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Pergamon

So,". Sci. Med. Vol. 43, No. 11, pp. 1561-1567. 1996
Copyright 1996 ElsevierScience Ltd
Printed in Great Britain. All rights reserved
S0277-9536(96)00052-4
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P R E S E R V I N G THE POT A N D WATER: A T R A D I T I O N A L


C O N C E P T OF R E P R O D U C T I V E HEALTH IN A
YORUBA COMMUNITY, NIGERIA
J A C O B A. A D E T U N J I *
Macro International, Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, U.S.A.
Abstract--Within the background of the outcome of the 1994 Cairo Conference, this paper describes a
traditional conceptualization of prenatal care in a Nigerian community and draws their implication for
effective delivery of reproductive health services in the area. The data used were from qualitative interviews
during 2 field trips to the community in 1988-89 and 1991. The finding of the study highlights a local
metaphor that likened the risks of pregnancy and child birth to a group of women that trekked to a local
brook to fetch water with their earthen pots: some fell, broke their pots; some missed steps and spilt their
water but kept their pots, and others returned without any mishap. The first group represented cases of
maternal mortality; the second group were cases of miscarriage, still-births or infant deaths, and the third
group represented successful outcomes for both pregnancy and the resultant baby. Various steps that were
traditionally taken to ensure that the mother neither lost her pot nor spilled her water are described. The
implications of these findings for policy and research are discussed in the paper. Copyright 1996 Elsevier
Science Ltd

Key words--prenatal care, reproductive health, health services use, Nigeria, Yoruba

INTRODUCTION
In a Nigerian community, pregnancies were likened
to pots containing water. The situation of maternal
and child health in the study area was likened to a
group of women who carried their earthen pots and
trekked to a local brook to fetch water. The pathway
from the brook was considered narrow and the
terrain difficult; a few fell and broke their pots; some
staggered but kept pots even though the water spilled,
and the majority of the people returned home
successfully with their pots and water. This metaphor
o f pot (or gourd) is one of the Yoruba ways of
thinking about the w o m b or pregnancy. The first
category represented the small proportion of women
who may unfortunately die in the course of
pregnancy and for pregnancy-related causes. The
second group represented those who might have
miscarriage, stillbirths, or lose their infants. Because
the risk of breaking the pot or spilling the water was
high, the traditionally established procedure for
averting or minimizing such risks was called ideyun
(pregnancy care), which aimed to ensure that each
pregnancy was carried to term, successfully delivered
and that the resulting baby was given a head-start for
life. The objective of this paper is to provide a
detailed description of the ideyun process in the place
o f study and to highlight for further research some
policy-relevant themes that apparently emerged from
the traditional belief system.
*Fax No: (301) 572-0993.

This topic is relevant especially now that the 1994


Cairo Conference has drawn renewed attention to
reproductive health. To reach women effectively in
the traditional setting, there is a need to understand
their belief system and target health education at
those practices that are dangerous to health. Past
studies have indicated that where the health message
is correctly communicated and accepted, the educational differentials in health services use among
women could be removed [1] and that poor use of
immunization services in some parts of Nigeria had
a link to people's poor knowledge of the services [2].
The need to reach the local women with correct
health education and service is also urgent in Nigeria,
given the recent observation that there has been a
drastic reduction in the already low proportion of
users of modern prenatal health services in the
country in the past decade [3-5]. For example, the
study by Ekwempu and his colleagues, which was
based on hospital records, reported that between
1983 and 1988, there was a decrease of 46% in the
number of babies delivered in their University
Teaching Hospital in northern Nigeria. In Onwudiegwu's [5] (p. 312) study in southwest Nigeria,
which was also based on hospital records from 1980
to 1989, it was observed that between 1980-84 and
1985-89, antenatal bookings dropped by 66%,
obstetric admissions decreased by 54% and hospital
deliveries by about 58%. It is perhaps more
worrisome to note that between 1980-84 and
1985-89, despite the drop in all these utilization
indicators, maternal mortality rate in the same
1561

1562

Jacob A. Adetu~i

hospital rose by about 73% (from 6.4 to 11.1 per


thousand deliveries) and perinatal mortality by about
58% (from 52.8 to 83.3). Although the current paper
does not directly address the question of maternal or
prenatal mortality risks, the likelihood that many
people who shift away from modern prenatal care
would resort to traditional prenatal care makes it
necessary to understand what goes on in the
traditional setting.
T H E DATA

The information used for the current paper was


derived from a two-phase study of a Yoruba
community, referred to as Efon Alaaye Micro Studies
1 and 2 (EAMSI and EAMS2). The first of the
studies, EAMS1, was of a smaller-scale and was
carried out between December 1988 and January
1989. The major focus of that phase was prenatal
care, health beliefs and response of parents to
childhood diseases, especially diarrhea, measles,
whooping cough, tetanus and fever. Thirty-one
respondents were interviewed in that study, made up
of 1 male medical doctor, 6 female nurses and
midwives, 2 herbalists (male and female), 3 traders
(female), 2 teachers, and 1 male and 16 female
farmers. Details of the sampling procedure have been
published elsewhere [6]. Interviews were conducted by
the researcher using an interview guide and the local
language. About 90% of the interviews were
tape-recorded and were later translated to English
and written out.
The second, larger round, EAMS2, was conducted
in the same location between February and July,
1991. It included in-depth interviews with about 53
respondents who were purposively selected from a
survey of 838 women and were interviewed for
specific topics. Women selected included those with
high or low proportion of children dead, those with
children that were currently ill or had very recent
illness, users and non-users of modern health care
services and adolescent mothers. All the in-depth
interviews were also conducted by the researcher
and were mostly tape-recorded while field-notes
were also kept. The tape-recorded ~interviews were
later written out in English. The focus of the analysis
in this paper is on traditional prenatal care in the
study area.
The study site is a semi-urban place in Ondo State,
southwestern Nigeria. The town is about 120 km
northeast of Ibadan and is situated on an
irregularly-raised land surrounded by mountainous
ridges. The estimated population of the community in
1991 was about 135,000 [7]. Most of the people of the
town were farmers, growing food crops such as yam,
rice, maize, peas and cassava. Some farmers also
planted cocoa and kolanut. About 95% of the
respondents in our baseline sample survey were
Christians and Christian missions have played
important roles in the provision of schools and health

facilities in the town. All of the 9 primary and 4 out


of the 5 secondary schools were built by churches,
and the first major hospital in the town was built
by the Catholic church in 1974. The African
churches, predominantly CAC operated 7 faith
clinics in the town in 1991 and were responsible
for delivering about 43 of the pregnancies in the
community [8]. Details of the available health
and social facilities in the town at the time of the
second survey are presented in Appendix Table 1 and
it shows that quack medicals and informal drug
stores outnumbered modern medical facilities in the
area.

RESULTS AND DISCUSSION

Pregnancy care in this community can be divided


into 3 types: traditional, faith clinics and modern
allopathic care. The traditional method of pregnancy
care is home-based and deliveries are supervised by
women relatives and herbal doctors. Faith clinic
care is church-based, and deliveries are supervised
by mission-trained midwives, while modern allopathic care is hospital-based and deliveries are
supervised by modern nurses, midwives and doctors.
The following section of the paper focuses on
traditional pregnancy care mainly because the type
of care provided in the modern health clinic
and maternity center is fairly typical of standard rural
maternal care in Nigeria, and faith clinic care has
been described in detail elsewhere [8] (pp. 1173-1175).
In describing the traditional pregnancy care method,
its meaning and processes are stated, and its apparent
underlying philosophy is highlighted relative to the
modern health care system.

Pregnancy care process


As has been mentioned earlier, the traditional
method of pregnancy care involved a process locally
known as ideyun or oyun dide. The primary objective
of this process was to ensure that the fetus remained
healthy and was safely delivered. A secondary
objective was to ensure that the child had some
immunity at birth against common diseases that
could kill in the first few days of life. The ideyun
process included the preparation of a traditional
herbal medicinal soup that the pregnant woman was
supposed to eat every morning before beginning
her daily domestic chores. This medicinal preparation
was an ajesara (literally "ingested to the body"
in anticipation). The process may also involve
preparation of a medicinal soap to be used by
the pregnant woman for baths. Traditional herbal
doctors and diviners were responsible for
the medicinal preparations and the process was
expected to start when the pregnancy was about 5
months advanced. Most pregnant women waited
till the fifth month before commencing prenatal
care in this community mainly because of the

A traditional concept of reproductive health


secrecy that tended to surround the issue of
pregnancy, especially in its early stages. The belief
was that pregnancy was better seen than talked
about. Pregnancy becomes very visible to outsiders
usually around the fifth month, and so efforts are
made to counteract the malicious intentions of the
wicked who might want to harm the fetus or its
mother.
The care giver. The first step in the ideyun process
was the selection of a traditional doctor; advice about
who to choose might be sought from parents,
relatives and friends. Since the enemies at stake might
use supernatural powers, the care-giver's qualifications would include ability to protect the mother and
the fetus from both natural and supernatural
enemies. Therefore, preference tended to be given to
a care-giver who was both a herbalist (onisegun) and
a diviner (babalawo). However, a relative or a
herbalist who knew little about divination might be
chosen if no serious mystical foes were anticipated.
This situation would not occur if the woman had had
difficulty conceiving or lost many infants. Once the
choice of a care-giver was made, the pregnant woman
was escorted to the doctor for traditional registration
by her husband, mother, mother-in-law or any
relevant individual. The traditional doctor might then
consult the oracle (if a diviner) and prescribe the type
of ingredients that should be fetched for the necessary
medicinal preparations. The doctor prepared the
medicinal soup for the w o m a n and gave instructions
on its usage.
The symbolic soup. During the field-work,
questions were asked on the ingredients used by the
traditional herbal doctor in preparing the ideyun
soup. A 51-year-old mother and traditional herbal
doctor, Mrs Ada [9], reported the following:
We use either tortoise or snail meat for the ideyun process.
The meat is cooked with some medicinal herbs to form a
vegetable soup. The pregnant woman has to eat a spoonful
of the soup with the meat each morning until the day of
delivery. If this is done, the child will be born strong and
healthy.
Another herbal doctor, a male aged about 70 years,
said:
There are various tree barks and herbs which are ground
together as the medicine for the ideyun. Some of the herbs
and barks are cooked with snail or tortoise meat, and some
with antelope or ekiri (deer) meat. These make the child
healthy when it is born and ensure easy treatment if the child
becomes sick in the postnatal period. Besides, as the time of
delivery draws near, we prepare awebi (i.e. bathing for
delivery) soap for the woman to bathe with for easy delivery.
Asked why the meat of tortoise and snail was used,
the traditional herbalists replied that it was because
parents wanted their children to be as safe and strong
inside their mothers as a snail or tortoise was safe and
strong inside its shell. The shell in this case represents
the pregnancy. Other animals whose meat is used in
the ideyun process tend to possess some attributes
that parents want their babies to possess. Antelope,
SSM 43,11

1563

for example, is swift, healthy and good-looking, and


ekiri is strong and smart. The barks and herbs that
are also used are selected for their curative efficacy,
and are an ajesara especially targeted at childhood
ailments like tetanus, rashes and measles.
Asked whether the delivery was expected to take
place under the supervision of the herbalist who did
the ideyun, Mrs Ada replied:
May God not give us a bad pregnancy. When labor pangs
seize a woman, the child could come out any time,
anywhere. It is that simple. Only difficult cases attract the
attention of herbalists or hospital doctors.
I asked how often a woman would use, and what
kinds of women used, the traditional method of
pregnancy care. The 2 herbal doctors (one male)
replied that many women still patronized them,
especially those who had become pregnant in their
early teens and were afraid of complications at the
time of delivery. The man said that although these
women attended modern clinics, they mixed traditional methods with modern care. Other categories
of users that were reported were mothers whose
children did not walk at the appropriate age, or
mothers who unintentionally became pregnant when
still nursing babies at the breast. At the time of
field-work, no respondent below age 40 reported
exclusive use of the traditional pregnancy care
method. One of them, Victoria, who had no
schooling, but a mother of five, said,
Those herbalists who help me to do the ideyun when 1 am
pregnant also provide the nursing medicines. The medicine
used for the ideyun process determines the type that will be
used to take care of the newborn. So, when the child is sick.
we take our teapots to them for appropriate herbal
combinations.

Proscribed behavior
Traditional pregnancy care involved some food
taboos and other things to be avoided. During the
fieldwork I asked mothers about this. A woman
farmer, Adun, aged 46 with no schooling, a mother
of four, said that pregnant women ought to avoid
cocoa-based beverages, milk and similar foods that
could make the fetus big. Similarly, she said that cold
food and iyan-kasi (stale pounded yam) should not be
eaten so as to give birth to clean-bodied babies. A
43-year-old woman with no schooling, and a mother
of four, 2 of whom were dead at the time of interview,
replied:
Each pregnancy comes with its different demands. I eat
whatever I like when I am pregnant, but I abstain from
cassava and pounded yam.
Another woman aged 37 with 5 years of schooling
and a mother of seven (6 alive) replied:
I know that pregnant women should not eat some animals
killed by hunters, such as snakes, porcupine and newt. Other
food taboos are family-specific. There is none in our family.
Pounded yam and cassava meals are high-density
carbohydrate foods. Women reported that they

1564

Jacob A. Adetunji

avoided these foods while pregnant because they


made them heavy and sluggish. Other foods that were
to be avoided were sugar-cane and walnuts (awusa).
Sugar-cane was believed to cause jedi, a disease that
presents as hemorrhoids, dysentery or even rectal
prolapse. Awusa nuts were believed to cause the baby
to throw up coagulated milk and draw saliva.
Moreover, it was mentioned during interviews in
Efon Alaaye that pregnant women should avoid
walking in hot afternoons, walking alone at night,
eating or buying banana in the market place and
allowing people with disabilities to cross their
outstretched legs. The reason for not allowing people
with disabilities to step over one's legs was to prevent
bearing children with disabilities. Walking in the dark
or in the hot afternoons and eating in the market were
risky because they could invite evil spirits lurking in
those places to follow a pregnant woman home (i.e.
would replace the original soul of the fetus). The
belief in abiku (babies who die early in childhood, so
that they could be born in the next pregnancy) must
have made the observance of this taboo very rigid in
the past, Today, infant mortality rates have declined
and the fear of the abikus is not as strong as it used
to be. Pregnant women who had to trek long
distances using foot-paths to the farms would
probably not go on hot afternoons or in the dark,
whereas those who were employed in government
jobs and had to trek home in the hot afternoons
found ways of circumventing the effects of this taboo.
One way was to have a young boy or girl walking
behind them or to tie a knot at the hem of their
garments.
Some scholars have observed a few other food
taboos among pregnant Yoruba women. For
example, Maclean [10, 11] reported in a study of
Ibadan and Idere, Nigeria that such women were
warned not to eat large plantains with clefts so as not
to have babies with ridged skulls. It has also been
found in Ile-Ife, a nearby university town in Nigeria,
that many traditional healers did not encourage
pregnant women to eat snake, snails and okra soup
[12]. On the beliefs about the abikus, Maclean [10]
(p. 176), [11], (p. 51) also found in her study that
women tied knots on the edge of a woman's wrapper
to escape the attention of abiku spirit, if they were to
go out in the dark.
The use of snails in the preparation of the
medicinal soup has been noted by an earlier study [10]
(p. 175), [11], (p. 50), although the explanation
provided by that study misses the cultural symbolism
of snail and its shell; it rather linked the use of snail
to the advantages of snail meat as an important
source of protein for pregnant women. The current
study found that while the nutritional value of snail,
tortoise, deer, or any other meat used cannot be
discounted, it seems that this was more of the
unanticipated consequences of their symbolism. The
symbolism of a tortoise and snail in Yoruba culture
goes beyond the protein in their meat. Tortoise is

traditionally presented as cunning, diplomatic and


elusive, and stories abound on this in the local
folklore. Similarly, snails symbolize ease, comfort,
gentleness and peace. These are desirable attributes in
children and are probably major reasons why they are
used in the ideyun process.

Emerging themes in the traditional concept of prenatal


care
From the general account of prenatal care practices
obtained during the fieldwork in this community,
some central themes of the philosophy guiding
prenatal health seeking behavior could be deduced.
In this section, those that seemed to me to be most
apparent are discussed. Attempts are made to point
out ways that each theme might help effective delivery
of health services in the area, if confirmed by further
research. They are termed principles here for lack of
a better concept.

(I) Principle of anticipation and preparation.


Irrespective of whether a pregnancy was deliberately
planned and expected or accidental and unexpected,
its occurrence in this traditional setting tended to
elicit some responses in preparation for the unborn
baby. One important element of that preparation is
the identification of potential sources of danger to the
fetus and its mother, either immediately or in the long
run. In most cases, the expectant mother could see the
immediate sources of harm as jealousy from her
rivals, the barren, the witch and other malevolent
forces who might cause a "leakage" or destroy the
unborn baby through miscarriage (isfnu). Her first
defensive action needed no outside help. She would
simply hide the pregnancy from outsiders. Concealment could last only until the fourth or fifth month
before a protruding belly betrayed the woman. Once
it was possible for outsiders to see the pregnancy, the
defense strategy had to change. The woman then
sought ways to do the ideyun (which could be literally
translated as "binding up" of pregnancy [13]). That
was when the traditional doctors were approached
for the necessary ajesara. The traditional health care
provider had the duty of protecting the mother and
the fetus from the dangers of disease and supernatural attacks as well as laying the infrastructure for the
long-term well-being of the pregnancy outcome.
This pattern of behavior was still apparent in the
community even among those who were educated.
Prenatal health care from outside sources usually
began around the fifth month, and some never
registered in an antenatal clinic until the seventh
month or more of the pregnancy. Moreover, the
Yoruba concept of ajesara seems to be the same
under both modern and traditional medical systems.
In fact, the Yoruba term for immunization is abere
ajesara (syringe/needle taken in anticipation),
suggesting that the modern immunization might be
considered a hospital version of what was traditionally done by herbal doctors. In the community that

A traditional concept of reproductive health


was studied, ajesara was to be traditionally taken
before the targeted illness struck; it was usually a
symbolic prophylactic. Different preparations were
targeted at illnesses or common conditions that were
potentially dangerous. There was no limit to how
many of the ajesara that one could take, except where
one did not have the resources to pay for their
preparation. Thus, with regards to immunization
beliefs, there seems to be no clash between the
traditional philosophy of pregnancy care and the
modern prenatal care program in this community.
Given that this is true, it might be argued that
immunization would be popular among mothers that
choose to use it since they might see it as an
alternative to the traditional ajesara. A survey
conducted as part of this study indicated that
prenatal tetanus immunization coverage for underfive children in this community was 71% in 1991,
compared to a national average of 54% in 1990 [14].
Another concept, which I stumbled upon serendipitously during my field-work, that could make
postnatal vaccination of children popular among
mothers is the traditional concept of Madarikan
(touch me not). Madarikan is a type of traditional
medicine that traditional doctors prepared for people
to ward off the evil eye and machinations of the
wicked. The postnatal immunizations for children
might be creatively promoted by employing this
concept in addition to ajesara as the modern way of
saying "touch me not" to killer diseases like measles,
tetanus, polio, whooping cough and diphtheria. If
these culturally-relevant concepts are employed in
promoting effective use of prenatal health services, it
seems reasonable to hypothesize that their use would
make communication and education more meaningful to the local Yoruba people in Nigeria. The
problem of low utilization of prenatal tetanus
immunization in parts of southeastern Nigeria (24%
compared to national average of 52%) was linked to
poor knowledge and poor implementation strategies
employed [2].
(2) Principle of continuiO'. The belief that the
herbalist who did the ideyun was usually the most
appropriate person to handle postnatal care seems
useful. The belief was that the foundation of a child's
response to specific medicinal treatments and herbal
combinations was laid during prenatal care; future
treatment "superstructure" was supposed to follow
the foundation so as to prevent a mis-match. This
might mean in modern times that parents who
wanted to use modern prenatal health services would
continue to use them after delivery, given that no
traditional herbalist was appropriate for her child's
postnatal care. To this end, it might be expected that
mothers who shifted from traditional practices to
modern, hospital-based care for their prenatal care
would continue to use modern care for their children
in the postnatal period. A likely hypothesis from this
is that those who combine more than one source of
prenatal care will use more than one source of

1565

postnatal care for their children, while those who


stick with a single source of prenatal care will do the
same for postnatal care, all things being equal. My
experience in the field suggests that only a very small
proportion of women used just one source and
nothing else, although the proportion of one-source
users might be higher in cities than in towns and
villages. It seemed as if many mothers wanted
children who could respond to both modern and
traditional treatment. This is especially so because
most people in this community believed that some
diseases like malaria could be properly cured by
traditional methods only the modern drugs were
usually taken for symptomatic relief.
(3) Principle qf maximizing protection. This is
summarized in the local phrase: "ona kan ko woja"
(i.e. a market receives shoppers from more than one
pathway). This principle concerns the idea of
multi-focal response to problems that had multiple
sources. The objective of a traditional health care
provider was to provide medicinal preparations that
could combat many potential sources of danger to the
client so as to give maximum protection. In fact,
whatever the woman got from her care provider was
supplemented where possible with home remedies.
In this community, women rarely wanted to use
only one source of health care. Some women
criss-crossed between faith clinics, maternity center
and modern hospital. They tended to register at more
than one of these sources. In the particular case of
women who registered at both faith clinics as well as
in the modern maternity clinic, the motivation for
their behavior seemed to be the urge to get both
natural and supernatural protections from real or
imagined foes. One major goal of mixing sources of
prenatal care therefore was to maximize protection.
Having combined sources or care, where these
women finally delivered their babies depended on
how they felt during labor, or who was readily
available. Some delivered at home or on the farm
because they saw no danger signs. However, if they
had unforeseen complications, they assumed they had
access to higher levels of care, and laced no fear of
being rejected or badly castigated; they would only be
blamed for delaying. For example, a 25-year-old
mother of 2 boys, a secondary school graduate
married to an electronics repairer, reported that she
attended both faith clinic and modern maternity
center for prenatal care; faith clinic to obtain the
blessings of God and benefits of prayer, maternity
center to remove the "mouth of the world" and have
access in case of emergency. When she was in labor
pains for her younger boy, she went first to the faith
clinic, but the midwife was not in, so she crossed over
to the maternity center. A school teacher even
registered for antenatal care at 2 separate towns,
because she was not sure which of the 2 would be
nearer to her when labor pains set in, Given this
situation, then it might be expected that the same
would occur during postnatal care.

1566

Jacob A. Adetunji

(4) Principle of preserving gourd and water. This


relates to scaling the allocation of priority to the
health of the expectant mother and that of the fetus.
It also resolves the issue of whether the traditional
prenatal care services put more emphasis on the
mother than the child or vice versa. The emphasis was
on both the mother and the fetus. The health of the
mother has to be maintained to ensure the viability
and safety of the baby she bares: it is known that
broken pots waste water. In a situation of high infant
and child mortality levels, such as was the situation
in this community in recent past, the first objective
during pregnancy was to have a healthy baby that
survived to adulthood. Hence, maternal health was of
utmost importance. First, it was realized that
carrying a pregnancy was like carrying a gourd (or
earthen pot) containing water: the gourd (or pot) was
considered fragile and breakable on impact, and the
fetus was the water inside. For a woman to die in the
course of pregnancy was considered a triple tragedy
that merited a communal effort to atone and
eliminate. It involved the loss of both the pot and
water and also of the person carrying them. If there
was a miscarriage or infant death, the usual
traditional parlance to express it was: "Omi lo danu,
akengbe o fo" (meaning "only the water has spilled,
the gourd is intact"). The joy of the unbroken gourd
was that it could still bring home many more rounds
of much needed water. The traditional support
system recommends those who are not carrying the
pot and water--husbands, parents-in-law, relatives
and friends--should stand by and watch for those
carrying them. They are to watch out for, point out
and remove possible sources of danger along the way,
thereby contributing to the safety and enjoyment of
the trip.

(5) The principle of begging the healer and the


client. This concerns the issue of dual responsibility
for health care effectiveness. It was recognized that
the herbalist-diviner had an important role to play in
ensuring the desirable health outcome. In the
traditional setting, it was possible for the healer not
to give his/her best by rationing care according to
client's ability to pay. It is in recognition of this fact
that the healer was "begged" to give his best. In
addition, client compliance is an important element
since no medicine can work unless it is used
appropriately. The appeal to the client is to comply
with the healer's instruction. This principle has
important implication for the delivery of health
services in this community. There is a need to appeal
to the providers to give their best in terms of facilities,
essential drugs, affordable prices, warm and caring
attitudes of workers and accessibility; there is also the
need to appeal to users not only to comply with
instructions, but also to use the services effectively by
reporting early any signs of disease, by coming for
postnatal check-ups and immunizations, and by
cooperating with health care workers in every way
possible.

CONCLUSION

In this paper, the traditional prenatal care practices


in a Nigeria community have been described and
some underlying themes that seem relevant to the
current concern with reproductive health have been
discussed. The 5 themes that have been identified are
by no means exhaustive, but they seem to influence
the pattern of use of modern health services in the
study site. From the findings presented here, a few
conclusions seem to emerge. The first is that there is
an existing concept of prenatal care and reproductive
health in this community. The reproductive health
described conceptualized both maternal and child
health care as inseparable, and that maternal health
is inherently important for child health. Therefore,
many aspects of the traditional concept of prenatal
care in this community are not contradictory to the
modern emphasis of reproductive health. The
traditional prenatal care included immunization and
it identified both the mother and the fetus as targets
of care. However, the traditional prenatal care
included the idea of physical as well as metaphysical
sources of illness and tried to combat both, whereas
the modern care focuses only on the physical.
Although the basis of this study is narrow and
more research is needed, the findings of this study
suggest that many of the emerging themes in prenatal
care could be built upon to reach effectively the
women in rural communities with health information.
Among the themes that are potentially useful, given
more research, are the principles of continuity, of
protecting the pot and water, and of anticipation and
preparation. If studies confirm them in other
communities, these ideas could be made the
foundation of culturally acceptable promotion of
reproductive health in the post-Cairo era. Moreover,
given the understanding that these people value
maximum protection, it seems that practices such as
healer shopping in prenatal care would not cease in
this community until people believe that the modern
health care system alone is sufficient to provide them
the level of protection they desire. Therefore, while
education can change people's belief about the cause
and course of disease or illness, there is the need to
increase people's confidence in the type of care
available at the rural prenatal health care center.
Only by doing this can we expect people to stay with
the modern health care system and thereby facilitate
the reproductive health agenda now being encouraged in similar communities in Nigeria and in Africa.

Acknowledgements--The author would like to thank the


following people for their assistance in the course of
carrying out this study: Professors A. G. Hill, A. O. Lucas,
Professor and Mrs J. C. Caldwell, Dr D. W. Lucas, Dr L.
Corner, and Dr P. K. Streatfield. I also thank the
Population Council, the MacArthur Foundation and the
Harvard Center for Population and Development Studies
for their support in doing this analysis. Comments from a
reviewer are also gratefully acknowledged.

1567

A traditional concept of reproductive health


REFERENCES

1. Streatfield K., Singarimbun M. and D i a m o n d 1.


Maternal education and child immunization. Demography 27, 447, 1990.
2. Antia-Obong O. E., Young M. U. and Effiong C. E.
Neonatal tetanus: prevalence before and subsequent to
implementation of the expanded programme on
immunization. Ann. Trop. Paediat. 13, 7, 1993.
3. Ekwempu, C. C., Maine D., OIorukoba M. and Essien
E. S. The structural adjustment and health in Africa.
Lancet 336, (8703), 56, 1990.
4. Owa J. A., Osinaike A. 1. and Costello A. M. Charging
for health services in developing countries. Lancet 340,
(8821), 732, 1992.
5. Onwudiegwu U. The effect of a depressed economy on
the utilization of maternal health services: the Nigerian
experience. J. Obstet. Gynaecol. 13, 311, 1993.
6. Adetunji J. A. Response of parents to five killer diseases
in a Yoruba community, Nigeria. Soc. Sci. Med. 32,
1379, 1991.
7. There was a census in Nigeria in November 1991, but
as at the time of writing, the local census figures are not
yet available. So, the estimated population for the
c o m m u n i t y is projected from the 1963 census figure of
67,090 assuming an annual growth rate of 2.5%. At this
growth rate, the population of the town would be
149,300 in 1995. These, of course, are just estimates.
8. Adetunji J. A. Church-based obstetrics in a Yoruba
community, Nigeria. Soc. Sci. Med. 35, 1171, 1992.
9. Names used in this paper are pseudonyms and not the
real names of the respondents.
10. Maclean C. M. U. Traditional healers and their female
clients: an aspect of Nigerian sickness behavior. J. Hlth
Soc. Behav. 10, 172. 1969.
11. Maclean U. Magical Medicine: A Nigerian Case-study.
Allen Lane the Penguin, London, 1971.
12. Odebiyi A. 1. Food taboos in maternal and child health:
the views of traditional healers in lie-Ire, Nigeria. Soc.
Sci. Med. 28, 985, 1989.
13. A question might be raised here: if the womb is thought
to be a pot or gourd, why is ideyun (literally, "'pregnancy
binding") the term for pregnancy care rather than
plugging or use of stoppers? First, it must be realized

that only leaking pots and gourds need stoppers; as a


leaking pot does not retain water, so a leaking womb
retains no pregnancies. Once a w o m a n was pregnant
and the pregnancy stayed until the fifth month, it was
apparently assumed that her womb (the pot) had no
inherent leakage. Efforts were then made to ensure that
none was metaphysically introduced. To this end,
protective pads were symbolically bound around the
pot. Hence the term ideyun.
14. FOS (Federal Office of Statistics) and I R D / M a c r o
International. Nigeria Demographic and Health Survey
1990. I R D M a c r o . Columbia, MD, 1992.

APPENDIX

Table I. Description of the services available in Efon Alaaye, 1991


Amenities

Health statistics
Hospital
Maternity center
Local government dispensary
Private clinics
Patent medicine stores (chemists)
Faith clinics
Quack medicals
Educational stati.~tics
Kindergarten
Primary schools
Secondary schools
Places of worship (modern)
Catholic churches
Protestant (orthodox)
Christ Apostolic
Other African churches
Pentecostal/evangelical (Gospellers)
Jehovah's Witness Kingdom hall
Mosque
Other social amenitie.s
Police stations
Bank
Post office
Fire service station
Customary court

Number
2
I
I
3
13
7
10
2
9
5
2
4
12
10
7
1
1
2
1
1
I
I

Source: Community-level data from the fieldwork in Efon Alaaye,


1991.