ROLE OF SOCIAL NORMS ON PREGNANCY CARE AND INFANT FEEDING AMONG HIV-POSITIVE WOMEN IN RURAL MAPUTO PROVINCE, MOZAMBIQUE

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Rev. cient. UEM: Sér. ciênc. soc.. Vol. 1, No 2, pp 54-76, 2019

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ROLE OF SOCIAL NORMS ON PREGNANCY CARE AND INFANT

FEEDING AMONG HIV-POSITIVE WOMEN IN RURAL MAPUTO

PROVINCE, MOZAMBIQUE

Carlos Eduardo Cuinhane

Universidade Eduardo Mondlane (UEM), Mozambique

ABSTRACT: Social norms have been considered barriers to compliance of biomedical norms that prevent passing

HIV from mother to infants. However, little is known about how women adopt and reconcile the biomedical norms with their local social norms during pregnancy care and infant feeding. This study, therefore, analyses the role of social norms on compliance to biomedical norms during pregnancy and infant feeding among HIV-positive women in rural Maputo province. It applied a qualitative method, consisting in in-depth interview and focus group discussion with HIV-positive women and men; semi-structured interviews with nurses, community health workers, traditional healers and church pastors, and focus group discussion with grandmothers. Data was thematically analysed. Results show that participants used social norms to prevent the perceived harmful to their life or that of the babies, such as “bad spirits”, illnesses and malnutrition. Some biomedical norms are accepted and also guide participants in pregnancy care. Nevertheless, some social norms influenced noncompliance to some biomedical norms such as exclusive breastfeeding. In conclusion, these findings suggest that participants often complied their local social norms as a way to fulfil the expectation of their families and communities. They seem reluctant to comply with all biomedical norms that challenge the local normative behaviour. In this regard, nurses should also involve male partners, mothers-in-law or grandmothers in education about the recommended biomedical norms preventing HIV infection from mother to infant.

Keywords: Biomedical norms, HIV-positive women and social norms

PAPEL DAS NORMAS SOCIAIS NOS CUIDADOS DA GRAVIDEZ E

ALEITAMENTO INFANTIL ENTRE AS MULHERES HIV POSITIVAS

NA ZONA RURAL DA PROVÍNCIA DE MAPUTO, MOÇAMBIQUE

RESUMO: As normas sociais são consideradas obstáculo para o cumprimento das normas biomédicas

concernentes a prevenção vertical do HIV. Contudo, pouco se sabe sobre como as mulheres adoptam e reconciliam as normas biomédicas com as suas normas sociais durante a gravidez e amamentação. Este estudo analisa o papel das normas sociais no cumprimento das normas biomédicas durante a gravidez e amamentação entre as mulheres HIV positivas na zona rural da província de Maputo. Usou-se o método qualitativo baseado em entrevistas aprofundadas e grupos focais com mulheres e homens HIV positivo; entrevistas semiestruturadas com enfermeiras, agentes comunitários de saúde, médicos tradicionais e pastores das igrejas e, grupos focais com avós. Os dados foram analisados na base do método de análise temática. Os resultados revelam que as mulheres usam as normas sociais para prevenir-se dos espíritos maus, doenças e malnutrição que elas consideram prejudiciais para a sua saúde e do bebé. Algumas normas biomédicas são aceites e usadas pelas participantes durante os cuidados da gravidez. Entretanto, algumas normas sociais influenciaram as mulheres para não aderirem à algumas normas biomédicas tais como aleitamento materno exclusivo. Depreende-se que as mulheres aderem às normas sociais como forma de cumprir com as expectativas sociais da sua família e da comunidade. Elas tendem a não aderir às todas normas biomédicas que não estão em consonância com as suas normas sociais locais. O estudo sugere que as enfermeiras devem incluir os maridos das mulheres, sogras ou avós na educação sobre as normas biomédicas recomendadas para prevenir a infecção do HIV da mãe para o bebé.

Palavras chave: Normas biomédicas e normas sociais, Mulheres HIV positivas. ________________________________

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55 INTRODUCTION

Social norms such as values, customs and traditions (VOSS, 2001) have been described as barriers to compliance of biomedical norms regarding prevention of transmission of HIV from mothers to infants in developing countries (GOURLAY et al. 2013; HODGOSON et at. 2014; IWELUNMOR et al. 2014; BEZABHE et al. 2015; SEWNUNAN and MODIBA, 2015; ANÍGILÁJÉet al. 2016). These biomedical norms include adherence of couples to HIV testing before pregnancy, sharing pregnancy intention with healthcare providers, adherence to antenatal care and lifelong antiretroviral therapy, give birth at the health facility, compliance to antiretroviral therapy for the baby, exclusively breastfeed the baby for the first six months, and contraceptive dual method use (WHO, 2013).

In Mozambique, like in other sub-Saharan countries such as Tanzania (LESHABARI et al. 2006) and Uganda (NANKUNDA et al., 2006), several health education programs have been developed to boost awareness regarding prevention of mother-to-child transmission of HIV (MOZAMBIQUE. MISAU, 2002) and enhance the recommended biomedical norms of pregnancy care, childbirth (MISAU, 2011), breastfeeding and contraceptive dual method use (MOZAMBIQUE. MISAU, 2013). Nonetheless, the results have not been those expected due to several barriers.

Literature shows that patriarchal norms1 such as submitting women to live under their husband’s guidelines – the need of permission from husband for almost everything – and expectation of loyalty to mothers-in-law have influenced women to delay timing the first antenatal care and adherence to antiretroviral therapy in Swaziland (DLAMINE-SIMELANI and MOYER, 2016) and other developing countries (MAISON et al.

2015;MUSENDO et al. 2016; OSAMOR and GRADY, 2016).

Others studies (BUVÉ et al. 2002) also revealed that patriarchal norms contribute to the risk of HIV infection in sub-Saharan Africa through practices such as obliging women to have sex without condom (RAMJEE and DANIELS, 2013; LEKALAKALA-MOKGELE, 2016), subjecting women to polygamy relationships (UNAIDS, 2012), and forcing women to involve in sexual intercourse as a way to cleanse a widower (SOVRAN, 2013).

Moreover, patriarchal norms also influence negatively the disclosure of HIV-positive status and HIV treatment (NJUNGA and BYSTAD, 2010; HAMPANDA, 2013; GILL et al. 2017). For example, a study in Thailand, Brazil and Zambia showed that women preferred not to disclose their HIV-positive status and stopped taking antiretroviral drugs after breastfeeding due to the perceived stigma that associated HIV infection to sex workers and multiple sexual partners. As well, in Mozambique women are generally accused of infecting their male partners with HIV (MATSINHE, 2006). Thus, disclosure of HIV-positive status could put women at risk of losing their male partners and their houses since the dominant norm in most of African countriesis the submission of women to their male partners (OJIKUTU et al. 2016).

Social norms also influence the lack of compliance of exclusive breastfeeding2 among lactating mothers (MARINDA et al. 2017; LAWRY et al. 2017). Though breastfeeding is considered a custom in sub-Saharan countries (MOLAND et al. 2010; LESHABARI et al. 2006), studies have reported low rate of exclusive breastfeeding since mothers added other liquids such as water, traditional remedies and solid food before the baby completed six months of age (ARTS et al. 2011; NDUNA et al. 2015; CUINHANE et al. 2017; WANJOHI et al. 2017).

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The aforementioned social norms are learned and reproduced in the family and community. In Maputo province, families have long established their social norms about childbearing and infant feeding process (JUNOD, 1912). Conversely, with the introduction of modern medicine – biomedical norms – familiesare expected to abandon their common practices such as unintended pregnancy3_{, home pregnancy} care practice, give birth at home, avoidance of mixed breastfeeding and unprotected sexual intercourse; and thereafter adhere to biomedical norms considered safe in maternal and child health.

However, the literature on reproductive health and HIV reveals that despite a wide implementation of health education on biomedical norms, women and their families continue following their social norms throughout pregnancy, birth and breastfeeding (TUTHILL et al., 2014; TUTHILL et al., 2015; RISENGA, 2017, LAWRY et al. 2017).Some practices, such as delaying to seek the first antenatal care and mixed feeding, associated to social norms could put infants at risk of acquiring HIV from their mothers. Nonetheless, up to date, little is known about whysocial norms are still favoured, how mothers deal with and adopt the biomedical norms and how they reconcile these biomedical norms with their local social norms concerning reproductive health. This study, therefore, aims at analysing the role of social norms during pregnancy, childbirth and breastfeeding in Manhiça and Namaacha districts located in Maputo province.

Social norms are stablished standards of behaviour learned and maintained by a society through which people are expected to act and do things (VOSS, 2001). They are used to evaluate and control people’s behaviour (FOUCAULT, 1995). Those who break the norms are subject to sanctions (FOUCAULT, 1995; OPP, 2005). Norms can be formal and informal. Formal normsare those that have been written down and state specific punishment for violators

(FOUCAULT, 1995); while informal norms are not written down, but specify how people should, may or must not and should not behave in their social interactions (SCHAEFER, 2010).In this study, we use the concept of norm to refer to biomedical norms, which are formal rules stablished by modern medicine and enforced by the hospital with regard to the process of sexual and reproductive health in the context of HIV4_{. Moreover, we also} apply the concept of social norm to describe a set of informal standards of behaviours culturally constructed and socially expected, which are perceived as customs and traditions that guide families or communities during pregnancy care, childbirth and breastfeeding.

In order to analyse the role of social norms on pregnancy and infant feeding, we use the theory of practice as underline by Pierre Bourdieu5_{(1977). This author argues that} people belong to different fields6_that aregoverned by historically developed rules and norms about how to act and interact. Throughout different socialisation processes, people develop a specific way ofperceiving, thinking, feeling, speaking, evaluating and actingin a certain way, which govern the social interaction of individuals in the society. However, norms and rules are subjected to change when those who produce them define new procedures that are socially homogenous to the members of the field (BOURDIEU, 1977).

From Bourdieu’s theory, we can consider that the healthcare system and the family and community7_{are historically relative} autonomy developed social fields (BOURDIEU, 1977; BOURDIEU and WACQUANT, 1992). The family and community, in both rural and urban areas, are still structured by cultural values, norms, ways of knowing and doing while the healthcare system relies on biomedical norms – scientific standards. In both fields, there are different assumptions about what to know, and how to behave. Thus,

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Role of social norms on pregnancy care and infant feeding among HIV-positive women in rural Maputo province, Mozambique

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Bourdieu’s framework enabled us to explain how social norms influenced women’s compliance to biomedical norms during pregnancy, childbirth and breastfeeding.

Understanding the reason why women continue relaying on their social norms could help to improve the current health education, and it could contribute to better healthcare and prevention of HIV from a mother to infant.

METHODOLOGY

Study design and study sites

This study is part of a broader research project about perceptions and practices regarding pregnancy care and infant feeding among HIV-positive women in rural Mozambique8_{. The study applied a} qualitative approach based on grounded theory (STRAUSS and CORBIN, 1994) to collect data in Namaacha and Manhiça rural districts of the Maputo province, located in the south of Mozambique. About 48 933 inhabitants lived inNamaacha district in 2017 (INE, 2019) and were assisted by 10 healthcare units, out of which 8 healthcare centres, 1 urban healthcare centre and 1 healthcare post (MISAU, 2018). Manhiça district had approximately 208 466 inhabitants in 2017 (INE, 2019), and operated 17 healthcareunits, out of which 14 were healthcare centres, 1 district hospital, 1 rural hospital and 1 healthcare post (MISAU, 2018).

Maputo province is one of the provinces with high prevalence of HIV/AIDS in the country. It is the second with the highest prevalence after Gaza province. A national survey conducted in 2015 on immunisation of malaria and HIV (IMASIDA) indicated that about 22,9% of people were living with HIV in Maputo province; out of which 29,6% are women and 15,8% are men (INS, INE, ICF, 2017). Both Manhiça and Namaacha districts are considered post of sentinel (posto de sentinela) for epidemiology surveillance of HIV. These

posts are located in the healthcare centres, where pregnant women have HIV testing and receive treatment for several diseases, such as syphilis and HIV (MISAU, 2011).

Sociocultural characteristics of the study sites

Both districts are rural and characterized by large families9_{. The average number of} children varied between 3 and 5 children. Beside children, families also lived with other family members such as grand-parents, uncles and nephews. (INE and MOZAMBIQUE. MISAU, 2013). The dominant type of marriage is monogamous, but there are also polygamy families (INE and MOZAMBIQUE. MISAU, 2013). Namaacha and Manhiça districts are patriarchal societies (LERNER, 1986). In these societies, a man generally occupies the dominant position – he is assigned a role of the head of the family, guardian of the children, breadwinner, provide security and food for the family (LERNER, 1986; FELICIANO, 1998; TVEDTEN, PAULO and TUOMINEN,2010). Women generally occupy the subaltern position – they are essentially housewives and they reproduce and take care of the children (ANDRADE et al., 1997). However, the family structure has been changing and women also look for and do a paid job (LOFORTE, 2000). Women also occupy the position of household head. The new national Census conducted in 2017 (INE, 2019) indicated that about 33,8% of all households (6.145.684 households), at a national level, were headed by women10_.

Under customs a mother-in-law or grandmother occupies dominant position in the family than her daughter-in-law. Grandmothers are considered the eldest and are expected to pass their knowledge about reproduction and infant care to their daughters-in-law (ANDRADE etal., 1997; LOFORTE, 2000).

The local inhabitants of both districts practice subsistence agriculture. There are

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some agricultural enterprises that employ some local people. However, most inhabitants do not often get a job in these enterprises. They often practice small informal business and others emigrate to Maputo city, South Africa and Eswatini (Swaziland) to look for a job (INE, 2012). The dominant religion in both districts is Christian Catholic (INE, 2019). Data from the previous surveys of Namaacha district (INE, 2012) and Manhiça district (2012) also revealed that most people were Christian Catholics in both districts, followed by Anglican Church, Muslim, and Christian Zionist Churches. In both districts there are also Assembly of God, Evangelic, Apostolic, Universal Church and Jehovah Witness (INE, 2019; 2012).

Recruitment of participants and data collection

Recruitment and interviews of study participants took place between 2015 and 2016 in 6 communities of both Manhiça and Namaacha rural districts. The 6 communities were selected using purposive method. The selected communities included Manhiça-sede, Ilha JosinaMachel, Taninga, Namaacha-sede, Mafuiane and Mahelane. Data collection consisted in 2 phases: the first phase took place in 2015, and it consisted in the recruitment and interview of both HIV-positive and HIV-negative women in 6 health centres located at each selected community. These healthcare centres were implementing the programme of prevention of mother-to-child transmission of HIV. The selected healthcare centres included Manhiça-sede healthcare centre, Taninga healthcare centre, Ilha Josina healthcare centre, Namaacha-sede healthcare centre, Mafuiane healthcare centre and Mahelane healthcare centre. Nurses working in maternal and child health service of each healthcare centre helped to identify and select the participants11_{. Nurses were also} interviewed in this phase. The second phase took place in 2016, and it included the

recruitment and interview of both HIV-positive women and men in the same 6 selected communities. Community health workers and local community-based organizations working with people living with HIV helped to identify the participants12_. _Grandmothers _who participated in the focus group discussion were also recruited in the same communities. Local community leaders helped to recruit the grandmothers who met the defined criteria. Community health workers, traditional healers and Church pastors were recruited and interviewed in 2016.

Participants for this study13_{consisted of a} purposive sample of 83 in-depth interviews with HIV-positive women, 12 HIV-positive men; semi-structured interviews with 6 nurses, 6 community health workers14_{, 4} traditional healers and 4 church pastors in both districts. These pastors included 2 from Christian Zion, 1 from Apostolic and 1 from Jehovah Witness Church. Additionally, focus group discussions were carried out with HIV-positive women and men and grandmothers in both districts. (Table 1). The inclusion criteria for HIV-positive women and HIV-positive men consisted of having a baby aged between zero to two years old and accepting to participate in the study. Only grandmothers15_or mothers-in-law who were living with a mother who had a baby aged between zero and two years old were included in the study. As well, the study included only nurses who were working in the program of prevention of mother-to-child transmission of HIV, and community health workers who were working with people living with HIV.

Both individual in-depth interviews and FGDs were conducted in Portuguese – the national language – for those who could read and write it. Tsonga, the local language, was used for those who could not understand Portuguese.

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59 TABLES 1: Summary of data collection tool and sample size

Data collection tool Participants Study sites Manhiça Namaacha

In-depth interviews HIV-positive women 47 36

HIV-positive men 5 7

Semi-structured interviews

Community health workers 3 3

Nurses 3 3 Traditional healers 2 2 Church pastors 2 2 Focus group discussions HIV-positive women 6 FGD (n=44) 5 FGD (n=55) HIV-positive men 1 FGD(n=4) 1 FGD (n=12) Grandmother 3 FGD (22) 3 FGD (19) Ethical procedures

This study obtained ethical clearance from the Faculty of Medicine of Eduardo Mondlane University and Maputo Central Hospital Bioethics committee, protocol number CIBS FM&HCM/73/2014. Verbal information about the objective of the study was provided, and a written consent was presented to each participant to make an informed choice on whether or not to participate in the study. All the participants agreed to participate. Those who could not read and sign, chose someone in their trust to translate the information into the local language and to sign on their behalf. During data analysis and presentation, some individual characteristics of the participants, such as place of interview, date of interview were not disclosed in the narrative of the participants. Only some relevant characteristics, which could not lead to identification of the participants, were presented in the quote of participants.

Data analysis

A thematic analysis approach (CHARMAZ, 2006) was applied to obtain key themes emerging from the data. The analysis involved 6 stages (BRAM and CLARKE, 2006). First, interviews were transcribed and then translated from Portuguese16_to English. Second, each transcription was read more than once, and initial codes were generated. Third, the codes were used to

identify and search various themes across the data. Fourth, the identified themes were revised according to research objectives. Fifth, the final themes were then defined; and in the sixth stage we developed this manuscript17_.

RESULTS

Demographic characteristics of participants

The majority of participants (71 of 95 interviewed) of both districts were between 18 and 35 years and 80 participants were living with a partner. About one third of the participants (31 participants) lacked formal education. A total of 69 participants were farmers and all participants had children. Participants were followers of different religious. Most participants were followers of Christian Zion, Apostolic and Assembly of God (Table 2). Women’s partners were mainly farmers (n=22), factor-workers (n=15), builders (n=), drivers (n=4), public servants (n=4), security-guard (4), involved in an informal small business in Mozambique, while other women (n=7) reported that their partners were working in South Africa. All men interviewed reported their wives were farmers.

The study’s findings consisted in 4 themes: 1) the role of social norms in pregnancy-decision-making, 2) the role of social norms

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during pregnancy care and childbirth; 3) the role of social norms on childcare and breastfeeding, and 4) the role of social

norms on compliance of antiretroviral therapy.

TABLE 2: demographic characteristics of the study participants

Characteristics of participants _Male Manhiça _Female _Male Namaacha _Female

Age range 18-35 3 39 1 28 36-45 2 6 2 8 46-55 2 0 2 2 Educational Level None 4 14 0 13

Less than primary education (1-6 years) 2 14 4 8

Primary education (7 years) 1 15 1 13

Secondary education (12 years) 0 2 0 4

Marital Status

Single 0 5 0 7

Living with a partner 7 38 5 30

Divorced/Widow 0 2 0 1 Number of Children 1-2 4 26 1 21 3-4 1 14 4 11 5-6 2 5 0 6 Occupation Factor worker 1 0 1 1 Farmer 5 34 1 29 Security 0 0 2 0 Tailor 1 0 0 0

Community health worker 0 1 1 2

Teacher 0 0 0 2 Housemaid 0 2 0 1 Own business 0 6 0 1 Student 0 2 0 2 Religious Christian Zion 5 16 4 12 Assemble of God 1 10 0 2 Christian Catholics 0 2 0 4 Universal Church 0 3 1 3 Apostolic 0 6 0 11 Evangelic 1 2 0 0 Muslim 0 1 0 0 Jehovah Witness 0 1 0 1

International Pentecostal Holiness 0 2 0 0

Alfa Omega 0 0 0 1

Anglican 0 0 0 1

No religious 0 2 0 3

The role of social norms during pregnancy decision-making

The main dominant norm was secrecy on pregnancy decision-making. Almost all

participants of both districts said that the decision on pregnancy was a private matter that involved only the couple. However, in case a woman failed to get pregnant, participants sought a traditional healer to

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get treatment following the decision of their mothers-in-law.

(…) After failing to impregnate several times, my husband decided to share our problem with his mother [mother-in-law]. She took me to a traditional healer who gave me traditional remedies, and after sometimes, I became pregnant. We did not think about consulting a health care provider and share this problem. (22 years old mother).

Some women also decided themselves to seek a traditional healer or consult their parents who could give them traditional medicine to treat the perceived infertility. Otherwomen sought a healthcare provider for advice or treatment of the perceived problem when they were trying to get pregnant.

Some women and men perceived that healthcare providers18_{should be involved in} the pregnancy-decision making. Healthcare providers were perceived as decision-makers regarding the safe moment to get pregnant, as one participant explained.

Things have changed due to the illness we live with [HIV]. We have to consult healthcare providers to know if we can have children. HIV-positive couple cannot decide alone to have children because they have to know their level of CD4 [types of white blood cells that protect the body from infection]. You can only impregnate your wife if your CD4 and hers is high (…) (men, 45 years old. FGD).

The majority of women (73 of 83 participants) and men (10 of 12 participants) of both districts said that they did not know there was a need to consult a healthcare provider prior to pregnancy. They also said that nurses did not advise them to consult a healthcare provider when planning to have children. Indeed, nurses said that they did not often advise women to

consult a healthcare provider prior to pregnancy. Nevertheless, some women who were advised to consult a healthcare provider, expressed their concern regarding consulting a healthcare provider prior to pregnancy because some male partners do not often accept to go to the healthcare centre for HIV-testing or HIV-treatment.

The role of social norms during pregnancy care and childbirth

All women attended antenatal care during pregnancy. As well, all men and grandmothers perceived antenatal care and childbirth at the healthcare centre as biomedical norm that pregnant women had to follow.

However, some social norms such as seeking church pastors’ prayers and traditional healers for spiritual protection before the first antenatal care and childbirth still guided some women during pregnancy and childbirth. Some women from both districts said that they sought traditional healers for spiritual protection of the pregnancy. Traditional healers said that they treated spiritual problems that could harm the pregnant women or the foetus, and then they advised pregnant women to go to the healthcare centre for antenatal care. Other women sought a church pastor for prayers. Some women said that Zionist pastors’ prayers helped them to treat illness such as back pain, pain of the belly and headache while others reported spiritual protection, prevention of miscarriage and, as a way of preparing childbirth. Women said that they sought prayers before timing the first antenatal care and before childbirth.

I sought for pastor’s prayers during my pregnancy because I was not feeling well, and I was afraid to miscarriage. A pastor helped me to prevent miscarriage because he prayed for me. This is common when someone hates you and can bewitch or wishes you not to get the baby (…). So, pastors prayed to prevent these bad spirits and jealous of people.

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62 The pastors tied my belly to prevent miscarriage: they prepared some lines and they gave me to put around my belly. When it was time to give birth, they took out the lines; and they prayed for me two weeks before childbirth. Then, I went to give birth at the health centre. (34 years old mother).

Indeed, pastors of Christian Zionist church said that they helped women of their church when they were pregnant. They prayed for pregnant women and then they advised them to go to the healthcare centre. Other pastors of Apostolic and Jehovah witness churches also reported praying for women during pregnancy, before childbirth and after childbirth. All pastors said that their payers helped women to “live in peace” during pregnancy and also helped to build confidence of the pregnant women before childbirth has they felt spiritually protected by God.

Some women believed that there were “bad people” who could harm the foetus or prevent a successful child birth. As well, some community health workers shared the same belief; as one of the participants explained it.

In my church, pregnant women receive prayers throughout pregnancy. They are advised to receive prayers before childbirth. Pastors say it is important because some women might have bad spirit or might be bewitched. So, they say prayers treat these bad spirits which the healthcare provider cannot treat. (53 years old, community health worker).

When women went to the healthcare centre for childbirth before pastor’s prayers, they requested their mothers or mothers-in-law to inform the pastors to pray for them. Some women said that sometimes, a church pastor visited and prayed for women at the healthcare centre, especially when they delayed to give birth.

Some nurses said that they had witnessed and allowed pastors and traditional healers to visit pregnant women at the waiting house located at the healthcare centre. They said that this was common for women who stayed at the waiting house between 1 and 2 weeks. Some nurses reported accepting these practices as a way of motivating women to give birth at the healthcare centre. One of the nurses recalled some of these practices, and she said:

Most pregnant women are accompanied by their family’s members when they come to give birth (...). When women delay to give birth (between 1 and 2 weeks), they bring their pastors and traditional healers to pray or purify them to take out bad spirit and, enable women to give birth. I did not want to accept these practices in the beginning. But then, I learned that accepting these practices would allow more people to give birth at the health centre. So, it is common to see family members bringing a pastor or traditional healer at the health centre. We accept praying or purification of pregnant woman, but we do not allow traditional healers to give traditional medicine because this can cause problem to women. For example, one day I went to examine a pregnant woman who was at the waiting house, and she was not there. I waited for her, and later on she came back with a traditional healer. She explained to me that she wanted the traditional healer to purify her because someone might have bewitched her, and that was probably the reason why she was delaying to give birth. I stood there, and after purification I examined her (…). Now and then, I never get worried when women disappear at the waiting house for sometimes because I know they had gone to look for a traditional healer. (Nurse).

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63 The role of social norms on childcare and breastfeeding

Confinement of the baby and the mother as a social norm

Women were confined in their houses after returning from the healthcare centre in both districts. A total of 66 out of 83 women, reported confinement between one week and two months. The confinement consisted in keeping the mother and the baby in a cleaned and warm place. Mothers were advised to rest and breastfeed the baby. The husband mostly informed and invited one of the closed members of the family – mother, mother-in-law, aunt or sister – to come to take care of the mother and the baby.

The duration of confinement varied according to the rules of the family regarding umbilical cord and the religious of the participants. Most participants of both districts said that their family’s rule was to stay in the house until the umbilical cord has fallen down and healed, which could take between one and two weeks.

Others women said that their church – Zionist church, Apostolic, God’s Assembly and Testimony of Jehovah – defined between two weeks and two months of confinement. Though, the umbilical cord had fallen and healed in one week, they had to remain confined until the predefined time was met according to the rules of each religious.

A Zionist church pastor confirmed that mothers with baby boys were confined two weeks and mothers with baby girls stayed four weeks. However, he said those were modern practices since the rule of the church based on the Holly Bible – book of Leviticus – predefined 33 days for a baby boy and 66 days for a baby girl. He said that rules have been changing as new mothers were working and they had not time to wait until two months. The Zionist church pastor explained the difference of time of confinement between girls and boys, as follows:

The baby girl takes long time confined because she will menstruate when she gets old. During menstruation, she will be confined again and again the house compound; while a baby boy will not be restricted when he grows up. He is free from the time he is born. (Pastor of Zionist church).

Other pastors of Apostolic Church and Testimony of Jehovah stated that the rules of their churches recommended that a mother should be confined two weeks until the umbilicus is healed regardless of the gender of the baby.

Among the participants who were not confined, some women said that their families did not inform them to do so, while others said their churches, such as Universal church, did not allow them as that was not the practice.

Taboos and treatment of umbilical cord

Participants of both districts said that only people who were taking care of the mother and the baby, such as mothers, mothers-in-law, aunts or the husband could enter in the room or touch the baby. They explained that most people could not enter in the room because they could harm the baby since they could be “hot people”. Participants explained that “hot people” were all men and women who were perceived to have engaged into sexual intercourse one day before or in the day of the visit. People who had recently lost their parents were also labelled “hot people”. They said if those people entered in the room or touched the baby, the umbilicus of the baby would bleed, it would delay to heal or the baby would get fever or diarrhoea.

Some women said that their mothers gave them traditional remedies to drink as a way to prevent the harm of the “hot people”. Nonetheless, few participants believed that the idea of “hot people” was a taboo. They said that nurses, who assisted the childbirth and treat the child in the postnatal might also be “hot people”. But, nothing happened

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to their babies whenever went to the healthcare centre.

During the confinement period, women were only allowed to go to the healthcare centre. They did not allow anybody to touch the baby on their way or at the healthcare centre, unless she or he was a nurse.

The majority of participants (75 of 83 women) treated the umbilicus at the healthcare centre. Nonetheless, few participants treated umbilicus at home despite advice of the nurses. Some participants said that they applied sugar while others put traditional remedies to heal the umbilicus. They said that their mothers or mothers-in-law advised them do so because the umbilicus was taking long time (2 weeks) to heal.

Traditional remedies as a social norm

The confinement period was also a moment of diagnosis, treatment and prevention of what participants perceived as “the illnesses of the black people”. These illnesses included perceived epilepsy seizures, green and yellow diarrhoea, infantile colic, fluid that comes out on the baby’s head and enlarge the head of the baby – hydrocephalus. Elderly female women such as mothers, mothers-in-law or aunt diagnosed and decided the treatment of the perceived illness.

However, some women diagnosed and decided the treatment themselves, after learning it from their mothers. Participants of both districts believed that the babies were born with those illnesses or they might develop during their growth. As well, they believed that the illnesses were not treated at the healthcare centre, but by using traditional remedies.

A total of 55 out of 83 participants of both districts reported using traditional remedies to treat the perceived illnesses before the baby completes six months of age. These remedies consisted in two types: the first was a remedy locally known as “vumba”, which consists of leaves of a plant that are

smashed and put in a shall of a snail. It is used to treat or prevent epilepsy seizures and stomach-ache. The second is locally known as “ximbitana”. This consisted on mixed roots of plants cooked and kept in a small clay pot or clay. It is used to treat the diagnosed or prevent illnesses such as infantile colic and hydrocephalus. The length of administrating these remedies varied from one to 24 months. However, traditional healers recommended 12 months for vumba and 15 months for ximbitana; while grandmothers recommended 12 months for vumba and 2 to 5 years for ximbitana.

Reasons for using traditional remedies

Women from both districts gave traditional remedies when they perceived their children had illness of “black people”, while others gave it to prevent future illnesses such as epilepsy and big belly. Most women from both districts perceived traditional remedies as the rule of their family. Nonetheless, most did not know what would happen if their babies did not take the remedies. They gave traditional remedies following their mothers-in-law’s advice.

I gave traditional remedies. I do not know what these remedies are for. I only gave to the babies because my mother told me to do so. She said the remedies were good and; that was the rule of the family. I am young to decide about that, and they know better about remedies than I do. (20 years old mother).

Some women said that they were willing to follow the advice of the nurses, but they were forced to use traditional remedies when their children got sick, and they could not get better even after using the pharmaceutical medicines prescribed in the healthcare centre.

Male participants and grandmothers of both districts claimed that traditional remedies were a mandatory since it was “the tradition” and, enhanced the growth of the

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baby. They said that the remedies should be given as soon as the baby was born. Traditional healers also said that traditional remedies would have an effect when they were given early in the first days after childbirth. They also said that babies who took these remedies were physically “stronger and healthier” than others.

Nurses and community health workers of both districts reported that women often gave traditional remedies despite hospital advice to avoid it. Nurses said that it was difficult to monitor it as women did not disclose about it. Moreover, some nurses who had children said it was very difficult to disobey the familial norms regarding traditional remedies as they also gave this remedy to their babies. One nurse narrated her experience as follows.

I gave traditional remedies to my baby. It was not easy to do it. I did not accept to give him soon after childbirth. Instead, I gave him Grip water. But when he completed six months, I noticed that he was biting his teeth. I told my husband but he did not believe it. I then told my mother, and she said I had to give traditional remedies. She said that situation was due to the moon, the moon was very strong for him. My husband and I did not accept it. But the baby continued biting his teeth. When my sister-in-law knew about it she told me to give traditional remedies. I talked to my husband, but he did not accept. Despite taking the baby to the healthcare centre, his situation wasted (…). When my sister-in-law who had a baby came to visit me, she brought traditional remedies of her baby, and she stayed at our house for sometimes. She told me to give the same medication to mine. I had to take a strong decision about it because my husband did not accept it. I started giving it, and the baby reduced the frequency of biting the teeth. I then told my husband,

and he authorized me to look for traditional remedies for the baby. We gave traditional remedies to the baby 2 times per day. After sometimes, the baby stopped to bite his teeth and he is fine. (Nurse).

Management of traditional remedies and modern medicine

Women received antiretroviral syrup from the healthcare centre for their infants for 6 weeks following childbirth. Antiretroviral syrup is a medication given to babies born from a mother living with HIV. It prevents the baby to acquire HIV from the mother. The majority of women (65 of 83 women) of both districts reported giving both antiretroviral syrup and traditional remedies to their infants. One of the participants explained how she managed it.

I gave both syrup and traditional remedies to the baby. I started with traditional remedies early morning, and after two hours, I gave syrup. I did not give both medications at the same time. My mother-in-law recommended me to do so when she brought the traditional remedies. (32 years old mother).

Grandmothers and men from both districts also said it was acceptable to mix the medication (antiretroviral syrup) from the healthcare centre and traditional remedies. Some perceived that both medications had to be given in the same day, but in different hours; while others said that they often interrupted traditional remedies whenever they gave pharmaceutical medicines prescribed from the healthcare centre. They often resumed traditional remedies after accomplishing the prescribed pharmaceutical medicines.

Traditional healers, however, advised women to use both traditional remedies and pharmaceutical medicine prescribed in the healthcare centre. They said that women should not interrupt or delay to give traditional remedies to the babies because it

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would not treat or prevent the perceived illness; as one of the traditional healers explained.

If you give traditional remedies after six months, it might not have the same effect because the illness would have developed. The norm is to give both the medicine from the healthcare centre and traditional remedies. But you must not give it at the same time [hour]. (Traditional healer).

Gripe water as substitute of traditional remedies

The women who did not give traditional remedies to their babies, said that those remedies were not used in their families, while others said that nurses advised not to use it. Some women from both districts, however, used Grip water – a pharmaceutical liquid used to realise infantile colic and gastrointestinal troubles in the infants (BLUMENTHAL, 2000). Women used Grip water as substitute of traditional remedies. They believed it has the same effect like traditional remedies. Grip water was used when women perceived illnesses such as infantile colic and stomach-ache; while others women gave it as a way to prevent possible illness in the future. Some women said that they used Grip water because it was recommended by the nurses while others reported learning about it with their family members, such as brothers, sisters and mothers.

Although some women who were using traditional medicines said that they would like to used Grip water, if it was available, most grandmothers and men from both districts did not perceive it as a substitute of traditional remedies. One man explained it as follows:

Grip water is not the same like traditional remedies. It may help to realise some infantile colic of the baby, but it does not cure it. Grip water is like

antiretroviral drug, they do not cure, but treat HIV only. If you want to cure the disease that the babies are born with, you must to use traditional remedies. (64 years old man).

Feeding the baby with water as social norm

A total of 76 out of 83 women from both districts fed water to their babies before 6 months. Some reported using water as a substitute for breastmilk. It was used as a way of wetting the throat of the baby while she or he could not access breastmilk. This was common when women had problem of producing breastmilk after childbirth. Moreover, water was used as a complement for insufficient production of breastmilk. Other women perceived the water was a “vitamin” that helped the baby to do digestion. As well, they said that water helped the babies to grow up and healthy. In addition, some women reported that the nurses advised them to feed babies with water when they had diarrhoea.

I gave water to the baby when he was 3 months because the baby had diarrhoea. I went to the healthcare centre, and the nurses advised me to give cool boiled water. So, I started to feed the baby with water to maintain his health. (30 years old mother).

Moreover, women also often gave water to the baby to satiate thirst. Women said that the environment was too hot (the temperature was very high), and they perceived that the baby needed water. Furthermore, some participants perceived breastmilk as “hot”, and it caused thirst to the babies.

I gave water to the baby when he was 3 months because my grandmother advised me to do it. She told me that breast milk was hot and water helps to minimize the heat and quench thirst. (19 years old mother).

However, women did not know why the breastmilk was considered hot.

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Grandmothers explained that breastmilk was hot because the mothers fed themselves on salted food. This passed to the breastmilk, and therefore, the breastmilk was hot. They perceived breastmilk alone could harm the baby. Hence, they often advised their daughters and daughters-in-law to also feed the baby with water to create an equilibrium in the body of the baby.

Some grandmothers said that they had heard that water should not be given to the baby. Nevertheless, they did not know why it was prohibited. Grandmothers also said that they would accept this advice if the nurses gave a liquid that would substitute water.

Perceptions of infant feeding

All participants perceived breastmilk as the natural and acceptable source for infant feeding. However, the majority of women, men and grandmothers of both districts reported that breastmilk alone was not sufficient to nourish a child up to the age of 6 months. Most participants perceived a child was able to eat some semi-solid food such as puree and soup from 3 or 4 months old.

Moreover, women faced challenges during breastfeeding, such as insufficient breastmilk for the baby due to biological problems – such as sickness of the mother– and lack of food for themselves. As well, women said that their babies had to be nourished to have “shining body19_{”, which} was a condition to show that they were “goodmothers”, and the baby was growing well.

Men and grandmothers of both districts also assumed women had to give food to the babies to ensure their weight was considered “good” at the healthcare centre. Furthermore, women struggled to maintain the perceived ideal weight of the baby to prevent disapproval of the nurses.

My baby started to feed on soup when he was 4 months old because breastmilk was not enough to nourish him. The

syrup that he receives from the health centre influence him to eat a lot, thus, breastmilk alone is not enough. Besides, he is going to decrease the weight if he is only fed on breastmilk. That is a problem because nurses get irritated with you if the weight of your baby decreases. They said you are not taking care of the baby very well. (31 years old woman). Social norms and compliance to antiretroviral therapy

The challenge of adherence to antiretroviral therapy was related to HIV-positive disclosure among women and men. A total of 44 out of 83 women disclosed their HIV-positive status to their husbands. As well, all men said they had disclosed their HIV-positive status and their wives were also HIV-positive. Some women reported it was difficult to disclose their HIV-positive status to their husbands as men generally perceived “HIV is a disease of women”. They feared to be accused of infidelity, stigma, discrimination and lose their relationships and their homes.

Furthermore, women perceived it was the task of men to do HIV-testing and disclose it to their wives. Some HIV-positive women did not disclose their HIV status when they started a new relationship after a divorce. Though, they had engaged into sexual intercourse with their new husbands without a condom, they said that they would not disclose their HIV status unless their husbands invited them to do a HIV-test together. They perceived that doing a HIV-test with their husbands would minimize stigma and discrimination.

Men, however, said that it was fearful to disclose HIV-positive status because their wives could accuse them of infidelity. They also perceived that women should disclose their HIV-positive status to their husbands as they often go to the healthcare centre and they are often HIV-tested during pregnancy.

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Among women and men who had disclosed HIV-positive status to each other, compliance to antiretroviral therapy was considered as a biomedical norm among the couples in both districts. Some participants labelled antiretroviral drugs as “sweets”. They reported taking the medication together consistently at the same time.

Despite this adherence to antiretroviral therapy, participants said that there was still stigmatization in the community. They reported that most people abandoned antiretroviral therapy due to stigma. Both HIV-positive women and men did not disclose their HIV status to their family members, such as mothers, mothers-in-law, brothers and sisters.

DISCUSSION

The findings of this study show that social norms such as customs and traditions guided participants throughout pregnancy decision-making, pregnancy care and childbirth, childcare and infant feeding. However, these social norms often conflict with the biomedical norms of the modern healthcare system. This conflict emerges because both family and community and modern health system fields have different norms and rules about sexual and reproductive health. Thus, the recommendations that women received from the health centre were not often applicable at their family and community context. According to Bourdieu (1977) this conflict is often expected when people do not recognise certain norms or rules as social norms that govern their practices or when the norms are too different and distant from those socially expected. As the data of this study highlight, some participants had information about the need to seek for a healthcare provider prior to pregnancy, but they did not follow the received advice. Despite the fact that nurses often recommended patients to follow biomedical norms, when women returned to their family and community, they faced rules that

were different from those received at the healthcare centre. Within this conflicting context, women seem often to follow the advice, and social norms of the family and community field rather than biomedical norms of modern healthcare system field. Similar findings have been documented across sub-Saharan Africa countries, such as Kenya (INYANGALA et al.,2016), Malawi (ROBERTS et al.,2016), Nigeria (SOFOLAHAN and AIRHIHENBUWA, 2012) and Mozambique (AGADJANIAN and HAYFORD, 2009; CHAPMAN, 2010). Agadjanian and Hayford (2009) also highlighted that HIV-positive women in the southern of Mozambique did not often follow the advice of the nurses with regard to contraceptive methods use because the advice conflicted with the local traditional culture of the clients.

Notwithstanding the conflict between social norms and some biomedical norms, the results of this study indicate that HIV-positive women attended antenatal care visits and gave birth at the healthcare centre. These practices suggest that participants accept and are supported to follow these biomedical norms. This result highlights that some participants are changing their values with regard to pregnancy care practices. Nevertheless, participants relayed in their social norms about pregnancy care and childbirth preparation, consulting the traditional healers and church pastors. Such a practice is also common in central region of Mozambique (CHAPMAN, 2010). Audetet al. (2014) also documented that HIV-positive persons often sought care from a traditional healer before presenting to the healthcare centre for treatment in rural Zambézia Province. This finding suggests that both social norms (customs and traditions) and biomedical norms play an important role in sexual and reproductive health as Chapman (2010) had also early documented. Thus, in practice there is not a strong border between biomedical and social norms; though modern healthcare system and family and community can be

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considered as relatively autonomy fields (BOURDIEU AND WACQUANT, 1992). The autonomy of the family and community field enables the people who supervise the accomplishment of social norms, such as grandmothers or mothers-in-law, to enforce HIV-positive women to follow rules which are not often similar to those recommended at the healthcare centre. Finding of this study showed that most HIV-positive women were enforced to follow social norms such as confinement, mixed feeding and giving traditional remedies and water to the baby in the family. Confinement practice and umbilicus treatment practices have also been documented in Tanzania

(THAIRU et al. 2008; DHINGRA et al.

2014), Uganda (WAISWA et al. 2008), Malawi (O’GORMAN et al. 2010), Mozambique (SAVE THE CHILDREN, 2007) and Bangladesh (WINCH et al. 2005). Moreover, other practices such as giving traditional remedies and water to the baby before completing 6 months old have also been previously documented in Mozambique (LUNET and BARROS, 2003; ARTS et al. 2011) and throughout sub-Saharan Africa (SCHAFER et al., 2016).

Mixed feeding – giving liquids and semi-solid food to the baby – responds to the reality mothers face in their everyday life in their family and community. As Bourdieu (1977) suggested, people often act according to the socially established and accepted norms that are less liable to sanction. Therefore, participants’ practices meet the wisdom and the social and culturally acceptable social norm. Lazarus et al. (2013) also noticed that mothers often practice mixed feeding to meet their own understanding of what is batter for their babies, and they respond to the normative pressure of their family and community. Nevertheless, both social norms and biomedical norms are not static as Bourdieu (1977) theorised. According to this author, practices are prone to change when those who produce social norms produce new

rules socially accepted and applied to all members of the community. Indeed, our study indicates that some participants avoided giving liquids such as water and traditional remedies to the babies despite advice of their mothers-in-law or grandmothers. This shows the possibility of changing of customs. However, an effective process of changing the local customs can only occur when the people supporting mothers, such as mothers-in-law, mothers and husbands are involved in the process of health education regarding biomedical norms. Therefore, compliance to biomedical norms is somehow influenced by local social norms, which guide the women about what and how to do regarding pregnancy care and infant feeding in the family and community. As well, biomedical norms are also susceptible to change in order to meet the expectations of the people. As Agadjanian and Hayford (2009) noticed, some medical advices are disconnected to cultural context of the clients, and this represents one of the barriers of the adherence of medical advice among HIV-positive people. The result of this study also shows some similar findings. It also highlights that some nurse’s advice and practices are in contradiction of medical advice. These practices reveal that nurses are aware of or share the same customs of the community, and they tried to help the patients to solve their problems. Nonetheless, the acceptance of some social and cultural practices, such as enabling traditional healers and church pastors to pray or cleanse the patients at the healthcare centre may represents one of the opportunities to close the gap between modern healthcare system and clients’ cultural context.

Limitation

Findings of this study are limited to the study setting and the selected participants. The study is also subjected to sample-bias because it did not include other HIV-positive women and men who had not children aged between zero and two years

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old. Moreover, the study did not include all participants who were not identified by the members of the local association working with HIV-positive people.

CONCLUSION

The study’s findings show that social norms influenced women’s compliance to biomedical norms throughout pregnancy decision-making, pregnancy care and infant feeding in both Manhiça and Namaacha districts. Despite following some biomedical norms, women acted according to the expectations of their family members, and they responded the situation faced in their everyday life following the norms and rules established in the family and community. The study suggests considering health education about biomedical norms for the family and community. Specifically, nurses should also involve relevant members of the family, such as mothers-in-law or grandmothers in health education about the recommended biomedical norms preventing HIV transmission from mother to infant.

ACKNOWLEDGMENT

This study was funded by a project grant from the DESAFIO, Development Program in Reproductive Health;

HIV/AIDS and Family Matters; Eduardo Mondlane University, Mozambique and Flemish Interuniversity Council (VLIR).

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