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Mulaudzi FM, Lebese RT, editors. Working with indigenous knowledge: Strategies for health professionals [Internet]. Cape Town: AOSIS; 2022. doi: 10.4102/aosis.2022.BK296.06
Midwifery care has existed since time immemorial. Among indigenous Africans, giving birth was a normal process where females used to deliver at home under the care of birth mothers. However, this communal practice was displaced during colonisation and was replaced by midwifery that was conducted in hospitals under controlled environments and bureaucracy of the health care systems.
Indigenous midwifery care (mahlayiselo ya vasungukati) believes that the birthing process extends from before and during pregnancy to during and after the delivery. Successful outcomes of pregnancies depend on compliance with the practices and beliefs associated with the birthing process. To date, pregnant females still engage in indigenous practices and beliefs during pregnancy, labour and post-delivery. However, these practices sometimes clash with modern practices of midwifery.
This chapter reviews the African indigenous beliefs and practices during pregnancy, labour and post-delivery. These include practices such as indigenous measurement and monitoring of pregnancy till the expected day of delivery, delay of early labour and treatment of minor disorders of pregnancy. Religious beliefs during the prenatal period, labour and post-delivery, maternal nutrition and taboos to be avoided are discussed. Each section includes the implications for the health care practitioners.
Understanding the indigenous antenatal practices by health care practitioners will improve and contextualise cultural care towards pregnant females in clinics and hospitals; it will also assist in the return of indigenous practices.
Many countries have started promoting the use of traditional and indigenous midwives. Countries like Canada have seen a resurgence of indigenous midwives, skilled and knowledgeable females who assist young females during pregnancy, birth and postpartum. The rise is because of indigenous midwives’ understanding and respecting clients’ cultures, languages, beliefs, practices and traditions (Couchie & Sanderson 2007). However, in other countries, indigenous midwives are looked down upon and the word ‘traditional birth attendants’ has been coined to categorise them as inferior and undermine their practice. This is evident mainly in some of the African countries where they practice. The ignorance and marginalisation of cultural traditions in indigenous midwifery have brought a lot of challenges regarding maternal and newborn outcomes. The gap has been identified by the World Health Organization (WHO) (1992; Sibley, Sipe & Barry 2012). There is a realisation of the importance of acknowledging the role played by indigenous midwives in curbing maternal mortality rates globally. Policies have since been promulgated for countries to incorporate indigenous midwifery and traditional birth attendants as part of the primary health care team (Stoyles 2015):
Persons are not abstract entities but rather personified human beings in the world and that personhood depends on developing a history with other persons within families and communities with distinctive values and traditions. (p. 92)
In the above statement, Stoyles (2015) emphasises the value of pregnancy and the meaning of pregnancy loss captured in an African context. Physiologically a female is designated the role of carrying the pregnancy, but culturally, when a female is pregnant it involves the female, the husband, the external family and the community (Arghavanian et al. 2019; Ngomane & Mulaudzi 2012). The cultural beliefs and practices have designated roles for the husband, the external family in the form of the grandmother or mother-in-law and the community towards the successful outcome of the pregnancy. Thus, in understanding antenatal care from an African perspective, it is crucial to understand the indigenous practices relating to pregnancy, the female, the husband, the family and the community.
Indigenous practices of maendlelo ya ndzhavuko/ulwazi ngezemvelo nezendabuko (Idang 2015) impact decisions and activities of everyday living. It is therefore an important factor in the care of a pregnant female. Indigenous practices are expressed in the attitude and behaviour of a female as prescribed by her community (Zepro 2015). Understanding the dos and don’ts and the societal norms and expectations around pregnancy provide the midwife with tools that enhance the provision of culturally relevant care to the mother and unborn child (Swihart & Martin 2020).
Culturally, the beliefs and practices around a pregnant female are presumably geared towards a safe delivery. Many of the indigenous practices in Africa are linked to cultural and religious beliefs and values (Ndemanu 2018). Cultural beliefs shape people’s thinking, worldviews and, consequently, their practices (American Nurses Association 2020; Idang 2015; Ndemanu 2018). The colonisation of Africa by the Western world led to the forceful relegation of the culture as irrelevant and unimportant (Ntuli 2018). Colonisation changed the primary beliefs of African people to secondary beliefs and promoted Western practices as primary and better.
African scholars seek to promote and restore indigenous practices and beliefs. Given this, this chapter reviews African indigenous beliefs and practices during pregnancy. The beliefs and practices highlighted in the chapter are representative of various regions of the continent and include Southern Africa, Western Africa and Eastern Africa. Some of the practices are aligned with the expectations of modern midwifery practices, such as fundal height measurement and monitoring of pregnancy till the expected day of delivery, delay of early labour and treatment of minor disorders. Also covered in the chapter are religious beliefs during the prenatal period, maternal nutrition and taboos to be avoided when pregnant.
In Africa, pregnancy [ukukhulelwa/nyimba] is highly valued because children are seen as wealth, lineage progenitors and a retirement investment (Chimbatata & Malimba 2016; Naab, Lawali & Donkor 2019). They are a gift from the amakhosikazi akithi (the grandmothers and elderly females, who have passed menopause) (Brindley 1985). The understanding of pregnancy in Africa goes beyond the general understanding. It is understood as the period when a female misses her normal monthly menstrual cycle, and a baby starts to develop in the uterus of the female for nine months (Dyer 2007). It is viewed as sacred and should happen within the context of a marriage (Palamuleni, Kalule-Sabiti & Makiwane 2007). It is that period when a female’s status is about to change forever, as she would thereafter be known as a mother. Baloyi and Manala (2013) aver that a mother is regarded as a precious ornament, and a pregnant female will therefore guard her pregnancy by observing all the traditional practices to attain the status of motherhood. The high value placed on children and childbearing is expressed in the Yoruba culture through the different proverbs that show the value of children and how they should be cared for. Yoruba proverbs centred on children include omo laso (children are covering) and omo niyi (children are the prestige) (Omobowale, Omobowale & Falase 2019).
It is therefore a great joy for a female when she is pregnant within the first year of marriage and would do everything within her control to bear and keep the prestige of motherhood. The value of children in Africa and the link to the curse from the evil spirit or witches that are presumed to be the cause for their inability to have children may explain the subsequent need to protect pregnant females. The belief in the existence of witches and evil spirits that seek to harm the unborn baby leads to families seeking help from their ancestors for the protection of the unborn baby. This belief is one of the reasons why a pregnant female is expected to hide the pregnancy or keep the pregnancy a secret till it is visible or the signs of pregnancy are established. Though the female is expected to keep the pregnancy a secret from everyone, the pregnancy is made known to the mother-in-law or the granny of the house (Brindley 1985; Ngomane & Mulaudzi 2012).
Most of the traditional practices are therefore channelled to appease the ancestors to seek protection from evil spirits and witchcraft and ensure the safe delivery of the baby. Mothers-to-be engage in these traditional practices to ensure their safety and that of the unborn baby (Aziato, Odai & Omenyo 2016).
Practices and beliefs to protect the mother and the unborn baby differ from community to community. These include wearing protective amulets, use of herbs and observance of the stipulated rites in pregnancy (Aziato et al. 2016; Mogawane, Mothiba & Malema 2015).
Studies have shown that African females present late for antenatal care services in modern medicine. Understanding the concepts and values of pregnancy in Africa will help the midwife to recognise the reasons behind the late presentation and some behaviours of African females during pregnancy. It will also help the midwife to understand the importance of having a child and its link to the behaviours of pregnant females at the antenatal clinic or antenatal services. Thereby, the midwife will be able to treat every pregnant female as precious and subsequently administer the appropriate antenatal care measures.
Traditional diagnosis of pregnancy relies on the symptoms and signs seen in the pregnant monther (Oyebola 1980). One of the ways of confirming a pregnancy is when a female misses their menstrual cycle. Once the pregnancy is confirmed, the female reports to the mother-in-law or the grandmother of the house (Ngomane et al. 2012). In addition to missing the menstrual cycle, the elderly female notices changes in the female’s appearance and behaviour. For some females, pregnancy is confirmed by morning sickness, which is characterised by nausea and vomiting accompanied by a change in eating patterns and the missing of the period, which eventually confirms that the female is pregnant. Another way of confirming pregnancy is the palpation of foetal parts by the traditional birth attendants (Selepe & Thomas 2000). In ancient Africa, females were taught to participate in the measurement of the gestational age and monitor the growth of the pregnancy. The females were taught to mark the tree at the rise of each new moon and, at the ninth marking, prepare themselves for delivery. In addition, the birth attendants calculate the pregnancy with the moon, and it is expected that after the ninth moon, which is the ninth calendar month, the pregnant female is expected to deliver within the next four weeks (Larsen, Msane & Monkhe 1983). The birth attendants also monitor the foetal heartbeat with the use of a horn that resembles the modern fetoscope. Among Vatsonga, the female is given a grass known as ritlangi by the traditional health care practitioner to tie around her waist. As the foetus grows bigger, the grass is expected to become tighter around the waist of the female. This practice allows for participatory medicinal practice as the female grows to be conscious of herself and her weight. She can understand if the foetus is growing or not and it is a basic scientific way of diagnosing intrauterine growth retardation or any other maldevelopments of the foetus (Ngomane & Mulaudzi 2012; Selepe et al. 2000).
Many of the cultural beliefs on prediction centre around the throwing of bones and communication with ancestors. Determination of the sex of the baby also depends on the throwing of bones and the physical presentation and expression of the expectant mother’s appearance throughout the pregnancy (Steingo 2019).
Adherence to indigenous practices during pregnancy is central to the well-being of the unborn baby and the mother. One such practice is the use of herbs and indigenous medicines to maintain the pregnancy and prepare the female for safe delivery. These herbs are sometimes prepared on their own or with some other ingredients. They are administered to the pregnant in the form of mixtures, drinks, powder or food. The preparation of these herbs and indigenous medicines differs from community to community and region to region; however, most of the ingredients are similar. Some of the ingredients used are herbs from plants, products from animals, fish, clay, soil and metals (Illamola et al. 2020).
There are varied reasons for the use of indigenous medicine and herbs during pregnancy. The prevalent use of herbs among pregnant females is based on the indigenous background of the people. It makes the females feel connected to their cultural roots. In addition, the use of herbs and indigenous medicines is believed to wade off evil and protect the unborn baby from witchcraft. Pregnant females also make use of indigenous medicines and herbs, assuming that they are cheaper, easily accessible and pose no side effects (Duru et al. 2016).
There are common herbs used during different trimesters in pregnancy across the regions. The herbs discussed here are not exhaustive but rather common herbs. Many of the indigenous herbs and medicines are taken during pregnancy are targeted toward the first and third trimesters (Nergard et al. 2015).
The first trimester of pregnancy is usually a turbulent period for pregnant females. They are faced with minor disorders such as nausea, vomiting, backache, pica, heartburn, indigestion and many more. During these discomforts, many females resort to herbal treatment. These herbs are easy to find and affordable (Duru et al. 2016). According to Bayisa, Tatiparthi and Mulisa (2014), the sustained use of these herbs in Africa is because of the believed potency against these illnesses. The commonly used herbs include garlic, ginger, bitter leaf, palm kernel, cinnamon, jute leaves, aloe vera, lemon, and bitter kola (Mothupi 2014).
Bitter leaf is one of such common herbs used in West Africa in countries such as Nigeria, Malawi, Ghana and Sierra Leone; East African counties such as Uganda, Ethiopia and Tanzania (Oyeyemi et al. 2018). The herb is known for the protection provided against malaria and the help in fighting anaemia. The herb is boiled and taken as a tea and sometimes used as food (El Hajj & Holst 2020). Pregnant females in South Africa and West Africa consume sour plums/wild plums (Ximenia caffra) to improve appetite and combat nausea and vomiting. The fruits can be eaten whole, while the leaves are boiled and taken as a drink or inhaled (Nergard et al. 2015).
The third trimester involves the last three months of pregnancy. Traditionally, pregnant females prepare for the delivery of the baby. One of the popular preparations is the use of herbal medicine to induce delivery. The most popular and vastly researched herbal medicine used during pregnancy in South Africa among AmaZulu is isihlambezo (herbal decoction). Few studies have documented the use of traditional medicines during pregnancy and labour in South Africa (Hlatshwayo 2017; Illamola et al. 2020). The South African social anthropologist and pharmacologist Varga and Veale (1997, p. 911) define isihlambezo as a herbal decoction that is commonly utilised by many Zulu-speaking females as a preventive health tonic during pregnancy, which is also presumed to work in providing anaesthesia and analgesia during delivery. It is believed it will help a female have a smooth, painless delivery. Naidu (2013) defines isihlambezo as that which cleans. The term isihlambezo originated from the isiZulu verb ukuhlamba, which means to cleanse ceremonially for protection against evil spirits.
The traditional remedy isihlambezo is a decoction made from extracting salts and minerals of plants from areas such as roots, bark and wood. The extracts are then boiled and steeped for several hours, which the females will ingest the isihlambezo in the form of a tea (Naidu 2013). This decoction is taken specifically during the third trimester as an antenatal tonic medication with the belief that it promotes a favourable course of pregnancy and facilitates precipitated and uncomplicated labour (Naidu 2013). Many different plants can be used as isihlambezo ingredients, and the recipes vary depending on factors such as the traditional healer consulted, the condition of the female, the geographical area or residing community. The most cited composition of the decoction includes Clivia miniate, Agapanthus africanus, Pentanisia prunelloides and Gunnera perpensa (Illamola et al. 2020).
An understanding of the different types of herbal medicine used during the first, second and third trimesters of pregnancy will equip the health care practitioner with information that will aid in the right diagnosis and management of a pregnant African female.
The prenatal period is the period of foetus development from conception to birth and any alteration affects the outcome (Dean & Grizzle 2011). Africans believe the prenatal period is essential and sensitive and is the time when a pregnant female should receive all the love and care. There are diverse beliefs and practices held about this period that have been followed from generation to generation. One such belief and practice is sex during pregnancy. Beliefs relating to the expected sexual behaviour vary across culture in terms of duration, frequency and abstinence.
While some believe that sex should be avoided during pregnancy, others believe that sex can happen during pregnancy but depending on the trimester of the pregnancy. Avoidance of sex during pregnancy is associated with different reasons. According to Baloyi et al. (2013), in Botswana, one of the reasons for abstinence is related to the impurity associated with pregnancy. Baloyi et al. (2013) state that a pregnant female is impure from the time of conception till the baby is weaned and, therefore, should not engage in sex. They also stated that as bringing the baby to life is a sacred process, the female must not contaminate the baby’s innocence. Secondly, in some communities in Africa, it is assumed that engaging in sexual intercourse during pregnancy can lead to miscarriages and deformities of the baby. For instance, in the Ewe culture in Togo, males are not permitted to have sex with their wives to prevent miscarriage of the pregnancy (Kiemtorè et al. 2016). In the southwestern part of Uganda, not only are males not permitted to have sex with their wives, but they must also abstain from any form of infidelity till the wife has delivered. It is believed that engaging sexually with other females will bring misfortune to the mother and baby (Beinempaka et al. 2015). The Kalenjin in Kenya believe that a pregnant female must abstain from sex because the semen of the male harms the foetus and may result in the death of the baby (Riang’A, Nangulu & Broerse 2018). Similarly, in the Bohlabelo district of Limpopo, females are prohibited from having sex for the entire duration of the pregnancy to protect the unborn baby. Pregnant females are expected to sleep with their mother-in-law (Ngomane & Mulaudzi 2012).
In Madagascar, sexual activities are allowed in the first three months of conception and the last month of conception. Sex is not allowed in the second and last trimesters. It is believed that sexual activities during this period affect the formation of the baby and the baby may be born with a deformity (Morris et al. 2014).
Similarly, in Zimbabwe, the husband is expected to have frequent sex with the pregnant female during the first three months of the pregnancy to enhance the formation of the baby. This is also practised in the Zulu culture (Brindley 1985; Mutambirwa 1985).
Aside from abstinence during pregnancy, the state of mind of a pregnant female affecting the wellness of the unborn child is another prenatal belief that is equally important. Africans believe that the mood of the mother affects the unborn baby. Mutambirwa (1985) adds that the husband should shower his expecting wife with gifts to preserve a healthy and happy state of mind. The belief is that a happy female is a healthy female and happiness affects the attitude of the baby when born. Furthermore, during the prenatal stage, a pregnant female is encouraged to engage in minimal exercise to prevent abortion or malformation of the baby (Larsen et al. 1983). To prevent this, the female is given herbal concoctions to prepare and strengthen the uterus throughout the pregnancy.
These beliefs differ in contextual meaning from region to region. M’Soka, Mabuza and Pretorius (2015) affirm some social behaviours that are deemed acceptable during pregnancy. Faithfulness to one’s partner is considered an expected behaviour during pregnancy. It is believed that a pregnant female must be loyal to her partner to avoid obstructed labour and convulsion during delivery (Maimbolwa et al. 2003).
Cultural expectations from expecting mothers extend to the foods that can and cannot be eaten. Forbidden foods come in the form of food taboos in the communities. Food taboos are common globally for both females and children. Food taboos are restrictions on eating certain foods, and these are based on religious and cultural or ancestral beliefs (Getnet, Aycheh & Tessema 2018). The reinforcement of the food practices and beliefs is done by the elders in the family and community. According to Chakona and Shackleton (2019), pregnant females are forbidden from taking food that is of the most benefit to them and the unborn baby.
In addition, a group of nutritionists has reiterated the importance of a female planning to be pregnant consuming a healthy diet before conception. This is very important because pre-conception nutrition provides the initial nutrients that a foetus needs (Stephenson et al. 2018). Nevertheless, maternal nutrition at conception and pregnancy periods are equally or even more important because it affects the development of the baby, the state of health of the mother and the positive outcome of the pregnancy (Ugwa 2016). In medical terms, maternal nutrition should be rich in iron, protein and vitamins. Although these food beliefs sometimes differ from the standard prescribed in Western medicine for expecting mothers, the principle of ensuring that the mother and the unborn baby get the adequate needed amount of food remains the same (Hlatshwayo 2017).
The indigenous practices and beliefs on maternal foods in Africa can be both valuable and detrimental to a female and the unborn baby (Chakona & Shackleton 2019). Some of these beliefs also prescribe the amount and type of food to be taken that will lead to safe delivery (Ekwochi et al. 2016). African pregnant females adhere to their food beliefs and practices primarily as a form of respect and allegiance to their ancestors and for the safety of their babies (De Diego-Cordero et al. 2020). Some of these beliefs are good, while others are injurious to the pregnant females and the development of the foetus.
The indigenous beliefs and practices are similar across Africa, with only slight differences in the types of food depending on the accessibility and knowledge (Ekwochi et al. 2016; Ugwa 2016). For instance, in Zambia, pregnant females are forbidden from eating okra whereas, in Nigeria, pregnant females are to abstain from eating snails to avoid giving birth to a sluggish baby (Ekwochi et al. 2016). Common beliefs and practices include avoiding certain types of foods that can cause the foetus to grow too big, leading to prolonged and difficult labour; avoiding foods that can have a negative impact on the behaviour of the baby when born (Chakona et al. 2019; M’Soka et al. 2015; Ugwa 2016). For instance, there is the belief that pregnant females should avoid fatty food because it causes thick or excess vernix, which causes a delay in pregnancy. They are to eat indigenous plants and leafy vegetables. These enhance blood formation and when there is adequate blood in the female, she has the strength to push during delivery and contribute to a successful outcome of the pregnancy.
Food beliefs are similar in southern Africa. A study conducted by Chakona et al. (2019) in the Eastern Cape province of South Africa showed that females are forbidden from eating naartjies for fear of giving birth to a jaundiced baby. In the same study, females reported that they were told by elders not to eat fish, otherwise their babies would be born with skins that look like the scales of fish. Leftover foods must not be eaten for fear of having difficult labour and the baby suffering from difficulty in breathing. As established in the paragraph on the preciousness of a child, pregnant females practice these beliefs to secure the safety of their unborn babies. Similarly, a study conducted by Zinyemba (2020) among the Vatsonga revealed similar patterns; pregnant females were forbidden from eating food that was hunted and seafood and even potatoes. Among the Vatsonga, pregnant females are not allowed to eat eggs, while VhaVenḓa do not allow pregnant females to eat spicy foods as they believe the baby will be born with red eyes and sugarcane is also not allowed because the glucose will affect the skin of the baby.
In Kenya, the Kalenjin believe that an expecting mother should abstain from eating eggs, animal organs such as the heart, tongue and, sometimes, whole sections of animal meat. It is considered that when an expecting mother eats eggs the baby will grow up learning to steal and eat animal organs, and it is seen as a disrespect to males. In addition, to avoid large infants and potential caesarean sections, expecting mothers are to sparingly eat protein-rich food and high-energy-giving foods such as ugali, a mixture of corn flour, millet and sorghum.
The food beliefs among the Maasai are slightly different from the Knjin. The Maasais are traditionally known for their pastoral living, and this influences the type of food they consume. They eat meat only during special occasions in which a major part of the food goes to the fathers or males in the community (Oiye et al. 2009). They do not believe in farming the land for crops and this affects the amount of food available. In addition to these beliefs, most vegetables are left for livestock. These beliefs limit the value and amount of nutrition in the food available to pregnant females.
The food taboos in Uganda are mainly targeted at child-bearing females and children. Even though it is similar to those from Kenya, in Uganda, females are not allowed to eat animal products such as the back of the chicken or goats. It is considered disrespectful to the male and the female might die if she eats these (Riang’a, Broerse & Nangulu 2017). Pregnancy does not change the status quo; in reality, there are more food restrictions for a pregnant female with the associated belief of keeping her and the baby safe. These food restrictions involve avoiding milk intake during the rainy season to prevent babies from crawling or walking like a caterpillar. In addition, to prevent miscarriage, placenta retention or even death, pregnant females are not permitted to eat offal and ribs of goats and cattle (Riang’a et al. 2017).
Food beliefs also vary in western Africa. In Nigeria, expecting mothers are not allowed to eat snails, eggs, grass cutter milk, okra and fatty foods. It is believed that if expecting mothers ingest these prohibited foods when pregnant, the newborns will have excessive salivation.
In Ghana, the food beliefs are similar to that in Nigeria but differ based on the regions in Ghana. The northern part of Ghana prefers to have fermented food, while the southern part of Ghana prefers non-fermented foods. The ingestion of these foods is based on perception rather than facts (De-Graft Aikins 2014). For more food and nutrition relating to edible vegetables, refer to Chapter 13.
Understanding the health care education needs of an expecting mother is important for successful delivery. As established earlier, the expecting mother cannot be divulged from her beliefs and practices. The diet control of an expecting mother gets under way ahead of pre-conception, and it is often influenced by the cultural norms and practices of the community. It is therefore of utmost importance for midwives to understand the beliefs and practices around the diet of an expecting mother to ensure that appropriate advice is given.
Indigenous knowledge systems and practices in South Africa seek to acknowledge the contribution of traditional medicine in attempts to go beyond the biological aspect of the human body and also recognise the spiritual aspects (Mogawane et al. 2015). The authors recognise that very little attention is paid to indigenous cosmogeny with respect to the traditional practices related to pregnancy and childbirth. Indigenous practices during childbirth may include plants, animals, spiritual modalities and other techniques unique to the various cultures. Within the South African context, AmaZulu calls childbirth ukubeletha.
The WHO estimates that 60% of the population in developing countries utilises traditional medicines. Furthermore, 69.9% of expecting mothers prefer traditional medicine during childbirth because of its safeness, availability and efficacy (Mawoza, Nhachi & Magwali 2019).
During history-taking, the midwives need to identify females who use the pluralistic health care systems during pregnancy and childbirth. The identification will assist with the effective management of the female during her pregnancy and labour processes.
The WHO (2015) defines a traditional birth attendant as ‘an individual that assists the pregnant females during childbirth, and who initially acquired the skill of delivery by conducting births herself or through apprenticeship’. The traditional birth attendant/traditional midwives are responsible for the preparation of the female during the entire birthing process (Nwadiokwu et al. 2016). Firstly, the traditional birth attendant needs to clean the hut, which will be used for labour. Furthermore, make sure that there are clean clothes for the delivery process and clean, fresh water. In Zimbabwe, a fire is made to keep the delivery hut warm (Lefeber 1994; Makoae 2000).
As part of preparing for the labour process, the traditional birth attendant needs to be familiar with the expecting mother’s beliefs and customs concerning childbirth. The birth rituals practised for the actual childbirth process vary across ethnicities and cultures. Locations for homebirths are also different. Some births take place in the house of the expectant mother, the expecting mother’s maternal home or the traditional birth attendant’s hut (Nwadiokwu et al. 2016; Ohaja & Anyim 2021). In Udhuk, Ethiopia, the birth takes place on a stone to symbolise the mother’s hard work. However, in the Western parts of Ethiopia, females are expected to give birth in the bush on their own. They believe that others are not to see the blood of a female during childbirth because it is cursed. She can return home only when she is cleansed after delivery (Nwadiokwu et al. 2016).
Another perspective is that males and any other person in a state of impurity, such as menstruation, are forbidden to be present in the house where delivery is taking place. The reason for the practice is that the foetus will feel ashamed to be born, thus causing obstructed labour (Nwadiokwu et al. 2016; Treacy, Bolkan & Sagbakken 2018).
It is imperative for health care professionals to be knowledgeable of the cultural beliefs associated with the preparations of labour to be able to provide culturally appropriate care for females. Respecting and incorporating the female’s cultural beliefs should be adopted by the health care facilities. Skilled birth attendants are moving towards allowing birth companionship during labour; thus, a female should be given a choice.
The Vatsonga of South Africa use herbal medicine called xirhakarhani to ease labour and prepare for labour. The traditional birth attendant would prepare the xirhakarhani an indigenous analgesic, by boiling the plant and then giving it to the childbearing female to drink during labour (Ngomane & Mulaudzi 2012). Similarly, this is done by the Ndau people of Zimbabwe. They use the traditional medicine called demanhandwe for masuwo (childbirth). The demamhandwe is a plant that grows throughout the year but mainly during rainy seasons. The roots are bulbs resembling potatoes. It is then boiled and given to a birthing female. The main use of the herbal mixture is to widen the birth canal, promoting cervical ripening and dilatation during masuwo (Hlatshwayo 2017). Basotho in South Africa crush ostrich eggshells and administer them to expecting mothers to ease the childbirth process (Van der Kooi & Thepbald 2006).
The knowledge of preparation and practices needed before a birth is important to health care practitioners as this might explain the reasons behind some obstructed labour that defies scientific explanation. Thus, helping health care practitioners prevent further complications during labour and prevention of maternal and neonatal mortality is crucial.
Before the onset of uterine contraction, the following beliefs are known to hinder the delivery process. It is crucial to prevent bad spirits from affecting the mother as this is associated with poor progress of labour and is discussed further.
There is a strongly held belief that a pregnant female should not make it known to her neighbours or relatives that her labour has begun for fear of attracting evil spirits that might cause complications during labour (Maimbolwa et al. 2003). Furthermore, a study conducted in Ghana attested that the Ababeletisi, also known as traditional birth attendants, do not share the pregnancy status of a female. Secret signs of pregnancy, such as a growing abdomen, are obvious to protect both mother and baby from any bad spirits (Aziato & Omenyo 2018).
In some cultures, the expecting mothers are also given a herbal medicine called mbita (which constitutes boiled herbs). This mixture is consumed by expecting mothers in an effort to protect the unborn baby from any sorcery during labour. The mbita is also called Scerlocaya caffra in Western medicine (Ngomane & Mulaudzi 2012). In other studies, the females would use eucalyptus oil drops put in water or mixed with ivimbela (white ointment), as known in isiZulu culture, as a means to chase away the evil spirits (Mudonhi et al. 2021).
These findings suggest that childbearing females have beliefs associated with fear of evil spirits that may impede the childbirth process, thus also delaying seeking antenatal care. Thus, Western health care practitioners must know the possible reasons for delayed antenatal attendance and the increased rate of babies born before arrival (BBA).
During the first stage of labour, the traditional birth attendants will note that labour has begun. Once labour is confirmed, the traditional midwives would advise the childbearing female to bear down as soon as she feels the uterine contractions or labour pains are becoming stronger (Makoae 2000).
The practice of vaginal examination varies across cultures. Often the practice is conducted to determine and confirm how far the head is from the perineum. The traditional birth attendants in KwaZulu-Natal often insert two to three fingers, sometimes bare, into the vagina to feel for the lump which would indicate the foetal head (Makoae 2000). In Lesotho, the traditional birth attendants put fingers to determine the level of the head; if fingers go in completely, the head has not yet descended. In Ghana, the traditional birth attendants furthermore assess whether the membranes are intact or ruptured by checking if it is near the vaginal opening which indicates that the female will give birth soon (Aziato & Omenyo 2018). The authors note that the same practice of assessing cervical dilatation is practised in both traditional and Western practices. It is imperative to note the risk of infection and puerperal sepsis; thus, the health care professional should train traditional birth attendants on safe childbirth practices.
The females sometimes experience unbearable labour pains. The Vatsonga traditional birth attendants, in these instances, would prepare a medicine called Xirhakhari, where the herbs are boiled. This medicine helps relieve excessive labour pains (Ngomane & Mulaudzi 2012). In another study, it is suggested that the female should place the snuff on her doorstep as a practice that will inform the ancestors that she is about to go into labour (Masilo 2022). Furthermore, this practice is also believed to assist in ensuring that the females experience only mild uterine contractions throughout the stages of labour (Ngomane & Mulaudzi 2012). The practice of using the snuff is equated to the non-pharmacological management of pain that will reassure the females and promote pain relief. In Ethiopia, the traditional birth attendant applies butter to the female’s abdomen as a form of pain relief and to accelerate the labour process (Kitila et al. 2018). The females are also encouraged to dance as a way of facilitating the labour process and reducing the associated pain.
The findings suggest that health care professionals utilise non-pharmacological pain relief remedies during childbirth which allow the use of natural resources in efforts to improve the birthing experience of the female.
The second stage starts when the cervix reaches full dilatation (10 cm) and ends with the delivery of the baby. The following practices are performed by the traditional birth attendant in preparation for the birth of the baby.
In rural Uganda, the females express their concern regarding the mode of delivery utilised in the health care facilities (Atukunda et al. 2020). Most females prefer to choose their birth position; however, in health care facilities, they are restricted from adopting the lithotomy birth position. In contrast, during home births, they are allowed to adopt a birthing position that comes naturally to the female (Atukunda et al. 2020).
Studies support the notion that females should make an informed decision on the type of birth position of their choice; however, this right is sometimes overlooked within Western medicine (Mselle & Eustace 2020; Musie, Peu & Bhana-Pema 2019). Since ancient times females gave birth in various positions such as semi-sitting, upright position, squatting, kneeling, all fours position and left lateral position, as it was a common birth position that usually occurred in a home-delivery setting (Zileni et al. 2017, p. e2).
However, this is not the reality in health care facilities where the midwives who are considered skilled birth attendants are not giving the females the choice of birth position as highlighted by the maternal guidelines of South Africa. Midwives continue to routinely position females in supine positions during both the first and second stages of labour despite the evidence that supports various birth positions (Musie et al. 2019). Most traditional birth attendants use the upright, kneeling or standing birth position as it is associated with greater pelvic outlet diameters and improves the effectiveness of uterine contractions, allows labour to progress quicker and better neonatal outcomes such as good Apgar scores and reduces the risk of foetal distress (Currie 2016; Musie et al. 2019). It is about time midwives recognise the importance of traditional practices related to birth positions.
Some traditional birth attendants in Kenya indicate that the placenta with its membranes needs to be delivered within five minutes after the birth of the baby. If not delivered, they massage the mother’s abdomen (Lefeber 1994). Furthermore, in Ghana, delayed cord clamping is mainly performed to free the baby from spirits (Aziato & Omenyo 2018). This practice is also followed in Western medicine as an evidence-based practice that is associated with optimal neonatal outcomes. Further, the study added that the female should avoid wearing tight clothes during pregnancy as this will cause umbilical cord complications (Aziato & Omenyo 2018). It is imperative for health care professionals to know about the traditional practices and beliefs associated with the third stage of labour.
A study conducted in Ghana confirms that traditional birth attendants give females a bottle to blow in, as this helps with the delivery of the placenta. After the expulsion of the placenta along with its membranes, the female is given a choice to take the placenta for rituals and cultural practices (Aziato & Omenyo 2018). Most females, in respect of their traditional beliefs, take the placenta home and bury it in their yard. In contrast, other societies in Ghana indicated that the placenta might be burnt or discarded in the river (Aziato & Omenyo 2018). It is believed that practices of discarding the placenta should be practised with full caution, as acts of sorcery can be performed if the person comes in contact with the vaginal blood on the placenta. This could also cause premature death of the baby and future miscarriages (Aziato & Omenyo 2018). The placenta needs to be properly discarded. If this is not done, evil people may use the placenta to harm the baby. Thus, medical health care professionals need to give the female a choice of how to discard the placenta.
The Batswana females are given a herbal medicine called makgorometša to drink. This medicine results in the initiation of precipitated labour. This is to ensure that the females give birth rapidly. Other indigenous practices followed to induce labour include removing the expecting mother’s clothes from the wardrobe at home, as this might facilitate the labour process (Mogwane et al. 2015).
Batswana of the Northwest Province in South Africa believe that a person who is envious and jealous of someone’s pregnancy can invoke an evil spirit to cause harm to the female or the foetus, which is known as dikgaba (Chalmers 1990; Du Preez 2012; Van Der Kooi & Theobold 2006). The dikgaba means to harm or to cause heartache to others (Ademuwagun et al. 1979). The English dikgaba or kgaba is known as Rhoicissus tridentata. It is believed that dikgaba [a grudge] may cause complications such as abortion, stillbirth, maternal death and prolonged or difficult labour (Du Preez et al. 2012; Hlatshwayo 2017). The traditional birth attendant will then prepare a herbal decoction called kgaba to manage dikgaba (postdates and prolonged labour) (Van Der Kooi & Theobold 2006). Studies by Hlatshwayo (2017) and Van Der Kooi and Theobald (2006) indicate that the decoction is a mixture of the ostrich eggshells, baboon urine and herbs.
Practices to prevent prolonged labour include the husband of the pregnant female not tying a belt around the waist. The belief is that this may prolong the birth. The females are also advised not to sleep during the day nor accompany visitors when they leave, which is a prevalent practice in most African communities in South Africa, as this may also cause prolonged labour (Mothiba et al. 2015).
The VhaVenḓa say that prolonged labour is caused by the female not abiding by the following beliefs. Mudzadze onopfelekeza vhayeni means that the female is not supposed to bid farewell to the visitors (Mothiba et al. 2015). In the Limpopo province, traditional birth attendants advise the females to slaughter a chicken, burn its legs to ashes and then eat the powder and drink warm water. This practice is believed to assist females and initiate labour progress (Maimbolwa et al. 2003; Mogawane, Mothiba & Malema 2015).
It is imperative for clinical health care professionals to be aware of the traditional practices that may cause expecting mothers’ labour to occur rapidly. Detrimental practices can be addressed to avoid further harm to the mother and her unborn baby. Appreciation and reinforcement of positive cultural practices by health care workers will ensure compliance by pregnant females and their families.
Traditional birth attendants and family members play an important role during vutswedyani (after-birth care referring to the postnatal period) among Vatsonga. In this culture, vutswedyani starts immediately after the birth of the placenta and membranes (Ngunyulu & Mulaudzi 2009). The placenta and membranes are also called gula in Xitsonga and ungubo yomtwana in isiZulu. This period continues until the female has her first menstruation after birth. The duration of after-birth differs according to individual females’ menstrual cycles. Therefore, the after-birth period for the majority of females ranges between six and 12 weeks from an African perspective. The after-birth period is known, named and understood differently by people according to their cultural backgrounds and languages. For example, in Xitsonga it is called vutswedyani (postnatal period) and the postnatal mother is called ntswedyani or umdlezani in isiZulu.
Indigenous practices on how to care for the mother and the baby after birth differs according to countries, regions and even communities. Each country employs indigenous practices according to its cultural beliefs, norms and values. In rural KwaZulu-Natal, immediately after delivery of the placenta, the traditional birth attendants tie the cord with a clean string and cut it with a new razor blade (Ngunyulu & Mulaudzi 2009). Females are encouraged to bring their new razor blades for cutting the cord. This is done because sharing or reuse of razor blades is prohibited and can prevent cross-infection (Ngunyulu, Mulaudzi & Peu 2015).
Health care promotion is also called nsivela mavabyi in Xitsonga. Traditional birth attendants in some communities promote the health and well-being of mothers and babies during after-birth care. An hour after delivery, the mother and the baby are kept in the hut of the mother-in-law. The main purpose is to protect them from the evil spirits (infections), which are believed to be possibly brought by people coming to see the mother and the baby. As in most African cultures, community members, neighbours and close relatives usually visit the family once they receive the message that the baby is born. This is a common way of showing support. So, to reduce and control the number of people, they allocate the trusted traditional birth attendant to provide special care to the mother and the baby. The selected elderly female or traditional birth attendant should be aged 50 years or above and reached menopause. The traditional birth attendant should be known by the chief and the community as a person actively involved in the care of females during pregnancy vuyimani (labour), ku lumiwa (peuperium) vutswedyani (after-birth). Furthermore, she should not be sexually active because it is believed that might bring evil spirits (meaning that they are highly infectious) (Ngunyulu & Mulaudzi 2009). The selected granny is expected to assist the mother with household chores so that she gets time to rest and recover physically and emotionally from pregnancy, labour and birth injuries or stress. Similarly, in Nigeria, after-birth mothers are isolated and relieved from all household chores (Sulayman & Adji 2019). This helps to restore a female’s energy and ensure a speedy recovery. During the confinement period, the mother is also given warm food, including traditional soft porridge called xidlamutana in Xitsonga or umdoko in isiZulu, which is believed to promote milk production, crucial for baby feeding. This shows that the family members and traditional birth attendants know the value of health care promotion and disease prevention during the after-birth period.
It is crucial for midwives to be aware of the knowledge and skills of family members and traditional birth attendants so that they consider working with them during after-birth care.
For the uterus – known as xivelekelo in Xitsonga and isibeletho in isiZulu – to return to its normal state, some traditional birth attendants use a mixture of water, salt and munywana, which is also known as ‘young Jew’s mallow’ and perform ku thova; ukuthoba [warm water compresses] on the lower abdomen. This practice of warm compressions is done daily and is repeated until vaginal bleeding stops and the xivelekelo [uterus] returns to its non-pregnancy state.
Other traditional birth attendants advise the mother to closely observe and urgently report the bad smell of the vaginal blood during after-birth and continuously guard the mother’s body for changes in colour and general weakness. It is believed that before the uterus returns to its normal pre-pregnancy state, the mother is at risk of having ‘evil spirits’ (acquiring infection), which in most instances leads to makhuma [sub-involution], and consequently puerperal sepsis (Ngunyulu & Mulaudzi 2009). This shows that traditional birth attendants are aware of the importance of early identification of problems/risks and rapid response to prevent complications.
It is deemed crucial for the health care professional to be knowledgeable of the traditional management and prevention of sub-involution.
Traditional birth attendants know the different methods of preventing sub-involution and are experts in the management of pains that occur after the birth of the neonate. Once the female reports experiencing postnatal abdominal pains, they boil mukhusu, which is a dried indigenous vegetable for almost 30 minutes to an hour to ensure that the vegetable releases all the nutrients. After boiling, they allowed the boiled mukhusu to cool down until lukewarm; then the soup is drained and given to the postnatal female to drink every morning before she eats breakfast. She is advised to continue drinking until the after-birth pains stop (Ngunyulu & Mulaudzi 2009). Some traditional birth attendants prefer to use a mixture of water, salt and munywana; they boil the mixture first, then allow it to cool down until it is warm and do abdominal compresses twice daily until the after-birth pains subside (Ngunyulu & Mulaudzi 2009).
Indigenous practices advise females to delay the resumption of sexual activities for several reasons, which include giving the female the opportunity to recover completely from pregnancy and labour-related injuries and to return to the previous pre-pregnancy state without disturbances (Ngunyulu & Mulaudzi 2009). They believe that the uterus of the mother is still highly favourable for conception, should the couple decide to have sexual relations before the mother starts to menstruate after birth (Ngunyulu & Mulaudzi 2009). Furthermore, some cultures allow the after-birth female to return to her hut when she starts her first menstrual period after delivery. It is believed that the first menstrual period after delivery is a clear indication that the reproductive organ systems, more especially the uterus and the related structures have completely recovered from the pregnancy, labour and birth-related injuries (Ngunyulu & Mulaudzi 2009). When the mother starts to menstruate, she needs to communicate to the traditional birth attendant and the mother-in-law by waking up very early in the morning; in ancient times, the mother was supposed to smear cow dung in the hut where she resides. Smearing cow dung was the traditional way of keeping the huts clean and free from dust. When the allocated traditional birth attendant and mother-in-law see this, they know that the mother is ready to go back to her room.
Indigenous beliefs and practices among Africans are often at crossroads with Western practices. Fortunately, an African male cannot be separated from indigenous beliefs and practices. It is therefore important for health care practitioners to be aware of these practices and collaborate with traditional birth attendants to meet public health care expectations.
To meet the public health care expectation, midwifery curriculum and training content should have components of indigenous practices and cultural practices in addition to the existing Western health care practice, and it should be preferable to use both health care system approaches during training to produce midwifery graduates that are ready to meet the cultural health care needs of diverse pregnant females living in various African countries.
It is crucial for midwives to have adequate knowledge of indigenous practices to make a comprehensive clinical judgement when dealing with mothers and babies from diverse cultural backgrounds. This knowledge will enable midwives to identify indigenous practices that might place the health care of the mother and their babies at risk.
The chapter documented indigenous beliefs and practices during pregnancy, labour and after-birth in Africa, which are still in practice despite the overshadowing of Western practices. The documented practices provide insights into the many behaviours of females during pregnancy, labour and after birth. In addition, the knowledge of these beliefs and practices will equip health care practitioners with the needed tools to combat conflicts that may arise between health care practitioners and pregnant African females.
How to cite: Musie, MR, Anokwuru, RA, Ngunyulu, RN, & Lukhele, S 2022, ‘African indigenous beliefs and practices during pregnancy, birth and after birth’, in FM Mulaudzi & RT Lebese (eds.), Working with indigenous knowledge: Strategies for health professionals, AOSIS Books, Cape Town, pp. 85–106. https://doi
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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