Pergamon S0277-9536(96)00052-4

So,". Sci. Med. Vol. 43, No. 11, pp. 1561-1567. 1996 Copyright © 1996 Elsevier Science Ltd

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PRESERVING THE POT A N D WATER: A TRADITIONAL CONCEPT OF REPRODUCTIVE HEALTH IN A

Y O R U B A C O M M U N I T Y , NIGERIA

JACOB 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 womb or pregnancy. The first category represented the small proport ion 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 edu- cational 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 proport ion 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 On- wudiegwu'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.

THE 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 allo- pathic 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

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 qualifica- tions 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 woman 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,

of reproductive health 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 tra- ditional 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

SSM 43,11 C

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. Conceal- ment 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 supernatu- ral 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 tradition- ally done by herbal doctors. In the community that

A traditional concept of reproductive health 1565

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 under- five children in this community was 71% in 1991, compared to a national average of 54% in 1990 [14].

Another concept, which I stumbled upon serendip- itously 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 meaning- ful 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

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 encour- aged 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.

A traditional concept of reproductive health 1567

REFERENCES

1. Streatfield K., Singarimbun M. and Diamond 1. Maternal education and child immunization. Demogra- phy 27, 447, 1990.

2. Ant ia-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 communi ty 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 woman 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 IRD/Macro 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 Number

Health statistics Hospital 2 Maternity center I Local government dispensary I Private clinics 3 Patent medicine stores (chemists) 13 Faith clinics 7 Quack medicals 10

Educational stati.~tics Kindergarten 2 Primary schools 9 Secondary schools 5

Places of worship (modern) Catholic churches 2 Protestant (orthodox) 4 Christ Apostolic 12 Other African churches 10 Pentecostal/evangelical (Gospellers) 7 Jehovah's Witness Kingdom hall 1 Mosque 1

Other social amenitie.s Police stations 2 Bank 1 Post office 1 Fire service station I Customary court I

Source: Community-level data from the fieldwork in Efon Alaaye, 1991.