Talking about infertility in Malawi: A starting point for developing support for people with a fertility problem.

Edinburghsch_iihpub1359pu

Constructing infertility in Malawi: Management of interpersonal, normative and moral issues in talk

This study examines social constructions of infertility in Malawi. The literature on infertility consists of epidemiological studies, describing patterns of infertility in terms of its incidence, causes and health seeking behaviour; studies of the psychological correlates of infertility; and ethnographic studies which describe experiences, perceptions and management of infertility within specific socio-cultural contexts. In addition, some studies discuss social aspects of medical practice in relation to infertility. Overall, studies of infertility in developing countries emphasize its many serious psychological and social consequences, usually attributed to cultural norms mandating parenthood. There appear to be several lacunae in the literature: men with fertility problems are rarely included, an in-depth examination of practitioners’ views is missing, and no qualitative study has been conducted on infertility in Malawi, which has a considerable secondary infertility rate. Furthermore, although ethnographic studies highlight the interpersonal (related to others’ judgements), normative (related to ideas about what ‘ought’ to be) and moral (related to ideas about what is good or bad) issues involved in infertility, no study has investigated how these issues are managed in situ, in verbal interactions. However, it has been argued that ‘talk’ is a prime site for the management of issues such as blaming and deflecting responsibility. Hence, this study addresses several gaps in the literature. It focuses on Malawi, and includes a wide range of participants: women and men with a fertility problem, significant others, indigenous and (Malawian and expatriate) biomedical practitioners. Semi-structured interviews with 63 participants were recorded and transcribed, and translations were obtained of interviews in which interpreters were used. For the analysis, I used discourse analysis (DA), informed by conversation analysis (CA). This analytic approach, novel in infertility studies, examines the interpersonal functions of statements in interactions, such as blaming or justifying. Use of DA and CA has led to novel insights into how respondents construct infertility, its causes, solutions (sought and offered), and consequences, and how they thereby manage interpersonal, normative, and moral issues, revolving around accountability, blame and justification, and attribution of (problematic) identity categories. For instance, I have shown how respondents construct childbearing as a cultural, normative requirement, and how this can be used to justify practices like extramarital affairs, or polygamy, as necessary solutions. In addition, identifying causes appears to be problematic for people with a fertility problem due to certain interpersonal and interactional issues, such as the idea that they are not entitled to medical knowledge. Practitioners can be seen to work up and bolster an identity of professional, competent expert in constructions of causes of infertility, and by attributing problems in helping infertility clients to external factors, including patients’ intelligence. This study has several theoretical, practical, and methodological implications, although I discuss some thorny methodological issues, especially those concerning the use of translations and the transferability of the analytic findings. A first contribution pertains to methodological debates and developments in conversation analysis, and in studies of infertility and other health issues which rely upon people’s self-reports. Second, my study contributes to theoretical developments in health psychology and health promotion. My analysis points to the relevance of social and normative considerations for engagement in ‘risky’ behaviours, such as extramarital affairs. This challenges cognition models which treat health behaviour as the outcome of individualistic decision-making processes, and see providing information as the main way of changing people’s behaviour. Therefore, a third set of implications is of a practical nature: some of the findings can contribute to health promotion, as well as to improvement of health services. For example, practitioners’ attribution of failures and (communication) problems to their patients, may prevent them from reflecting critically on, and addressing, their own contributions to problems. Overall, this thesis shows that when one wants to ‘give voice’ to people who are suffering from infertility, it is valuable to examine what they say in detail, within its interactional context, and the concerns they themselves make relevant, in their own terms

Socio-cultural factors, gender roles and religious ideologies contributing to Caesarian-section refusal in Nigeria

Abstract Background: The death of women from pregnancy-related causes is a serious challenge that international development initiatives, including the Millennium Development Goals, have been trying to redress for decades. The majority of these pregnancy-related deaths occur in developing countries especially in Sub-Saharan Africa. The provision of Emergency Obstetric Care (EmOC), including Caesarean section (CS) has been identified as one of the key ingredients necessary for the reduction of high maternal mortality ratios. However, it appears that creating access to EmOC facilities is not all that is required to reduce maternal mortality: socio-cultural issues in Sub-Saharan countries including Nigeria seem to deter women from accepting CS. This study seeks to explore some of the socio-cultural concerns that reinforce delays and non-acceptance of CS in a Nigerian community. Methods: This is a mixed method study that combined both qualitative and quantitative strategies of enquiry. The hospital's delivery records from 2006-2010 provided data for quantitative analysis. This quantitative data was supplemented with prospective data collected during one month. Semi-structured interviews, focus group discussions (FGD) and informal observations served as the sources of data on the qualitative end. Results: In total, 22 % of maternity clients refused CS and more than 90 % of the CSs in the focal hospital were emergencies which may indicate late arrival at the hospital after seeking assistance elsewhere. The qualitative analysis reveals that socio-cultural meanings informed by gender and religious ideologies, the relational consequences of having a C-section, and the role of alternative providers are some key factors which influence when, where and whether women will accept C-section or not. Conclusion: There is need to find means of facilitating necessary CS by addressing the prevailing socio-cultural norms and expectations that hinder its acceptance. Engaging and guiding alternative providers (traditional birth attendants and faith healers) who wield much power in their communities, will be important to minimize delays and improve cultural acceptability of CS. 2015 Ugwu and de Kok.sch_iih12pub3976pub

From Global Rights to Local Relationships: Exploring Disconnects in Respectful Maternity Care in Malawi

Widespread reports of “disrespect and abuse” in maternity wards in low- and middle-income countries have triggered the development of rights-based respectful maternity care (RMC) standards and initiatives. To explore how international standards translate into local realities, we conducted a team ethnography, involving observations in labor wards in government facilities in central Malawi, and interviews and focus groups with midwives, women, and guardians. We identified a dual disconnect between, first, universal RMC principles and local notions of good care and, second, between midwives and women and guardians. The latter disconnect pertains to fraught relationships, reproduced by and manifested in mechanistic care, mutual responsibilization for trouble, and misunderstandings and distrust. RMC initiatives should be tailored to local contexts and midwife-client relationships. In a hierarchical, resource-strapped context like Malawi, promoting mutual love, understanding, and collaboration may be a more productive way to stimulate “respectful” care than the current emphasis on formal rights and respect

Role of male partners in the long-term well-being of women who have experienced severe pre-eclampsia and eclampsia in rural Tanzania:a qualitative study

Men can be essential sources of support in maternal health, even more so in case of severe acute maternal morbidity (SAMM), affecting 1-2% of childbearing women in low-resource settings. In a qualitative study using semi-structured interviews, we explored the perspectives of nine male partners of women who suffered from (pre-)eclampsia six to seven years earlier in rural Tanzania. Male partners considered their role to be pivotal regarding finances, decision-making in healthcare-seeking and family planning and provided physical and emotional support. After SAMM, households may be affected in the long run. Some men took over their female partner's household duties until up to two years after birth. Providing men with more information on complication readiness and birth preparedness would enable them to extend their role in maternal morbidity prevention. IMPACT STATEMENT What is already known on this subject? The essential role of male partners in maternal health in low- and middle-income countries is well-studied in relation to its impact on care-seeking behaviour. After childbirth, the long-term role of male partners has not yet been studied. What do the results of this study add? We demonstrated the important role of men during, but also after SAMM. Households may be affected years after women suffered from SAMM. For women with the most urgent support needs, this study suggest that at least some men feel responsible for their partner and have different pivotal roles. What are the implications of these findings for clinical practice and/or further research? Because of their motivation to support their female partner, strategies to reduce recurring complications in subsequent pregnancies should include targeting male partners, for example, by increasing birth preparedness and complication readiness. Further studies should confirm the results from our innovative but small-scale study, as well as investigate the long-term role of male partners after uncomplicated births. Other studies could investigate the separation of couples after SAMM, family planning decisions after SAMM and strategies for involving men and increasing complication readiness and birth preparedness

Maternal death review and outcomes : an assessment in Lagos State, Nigeria

Strong political will by hospital management and supervising government agencies are a prerequisite for effectively addressing the human and infrastructural deficits that predispose to maternal mortality in Lagos State. Failure to address the patients and facility-related causes of maternal mortality could account for the persistently high maternal mortality ratio (MMR) in the hospitals. Interventions aimed at redressing all causes identified in the reviews will likely reduce MMRs. The study investigates results of Maternal and Perinatal Death Surveillance and Response (MPDSR) conducted in three referral hospitals in Lagos State, Nigeria over a two-year period and reports outcomes and lessons learned

Discursive Psychology and its potential to make a difference

Hampshiresch_iihpub2403pu

`Automatically you become a polygamist': `culture' and `norms' as resources for normalization and managing accountability in talk about responses to infertility

In the developing world, infertility is a serious problem. It leads to both psychological and social hardship, in part because childless marriages often result in divorce, men taking another wife or extramarital relationships. Such responses have been attributed to cultural norms that mandate procreation. However, there are theoretical, methodological and moral issues with treating cultural norms as behavioural determinants. They have been insufficiently acknowledged in health research. Therefore, I demonstrate an alternative discursive approach, which examines how people actively mobilize 'culture' or 'norms' in interactions, and the interpersonal functions thereby fulfilled (e.g. blaming or justifying). Analysis is presented of interviews on (responses to) infertility in Malawi. I show how respondents construct polygamy and extramarital affairs as culturally and normatively required, 'automatic' and normal solutions for fertility problems and play down people's accountability for these practices. These accounts and constructions appear to facilitate engagement in affairs and polygamy when people face fertility problems, which seems problematic from a health and gender perspective. Thus, detailed analysis of how people use 'culture' and 'norms' in situ is important because it provides insights into its potentially undesirable consequences. Moreover, such analysis provides a starting point for culturally and gender sensitive interventions, since it highlights people's agency, and creates a space to re-construct and change practices. © 2009 SAGE Publications.NO DIVISION13pub717pub

Infertility and relationships: the importance of constructions in context

In low- and middle-income countries, infertility is a neglected but highly stigmatising condition, which often leads to extramarital affairs, polygamy and divorce. I conducted interviews in Malawi with women with a fertility problem and used discursive psychology to analyse how they described and constructed (extra)marital relationships. Surprisingly, several respondents constructed their relationships as good, and descriptions minimised the significance and blameworthiness of husbands' affairs. This contrasts with the literature's portrayal of conjugal relationship problems as among the main hardships that infertile women endure. Attention to participants' own orientations to relationship 'trouble' is important. Furthermore, discursive practices, such as not complaining or not blaming one's spouse for affairs, appear to limit possibilities for 'speaking out' and 'acting up'. Interventions could facilitate alternative accounts and constructions. This study illuminates local practices of family and intimacy, how people 'do' relationships and intimacy in interaction, and the shared expectations concerning marital relationships and social categories (eg, 'spouse') that the respondents draw on. This is important: sexual and reproductive health interventions should consider relationships and their context-specific meanings.sch_iih2(1)pub3216pub23-4

The role of context in conversation analysis: Reviving an interest in ethno-methods

This paper discusses whether and how cultural context can be used in studies using conversation analysis (CA) and ethnomethodology (EM). I start with inspecting CA and EM principles regarding the use of (cultural) context. There is a risk of treating participants as 'puppets' of socio-cultural forces, and contextual features should only be taken into account if observably relevant for specific interactions. However, I argue that CA is overly cautious in attending to cultural particulars, in part because identifying universal conversational 'rules' has become its end-goal. In the second empirical part I discuss how, in interviews about infertility in Malawi, participants make relevant the cultural context. Examination of the sequential context of references to the cultural setting demonstrates their interactional function. Thus, respondents actively build Malawi's cultural context in situ, for the purposes at hand. I conclude that, notwithstanding CA's and discursive psychology's dispreference for interviews, using such data is an appropriate way to remedy analysts' lack of cultural knowledge, as cultural particulars are brought to bear 'there and then'. Moreover, if CA shifts its focus from universal turn-taking procedures to cultural particulars, it revives EM's interest in 'ethnomethods': reasoning and accounting practices, shared by members of collectivities.sch_iih40pub1238pub