Ghanaian mothers hit by dueling health rules

One afternoon early in my fieldwork in the Upper East Region of Ghana, I accompanied a local nongovernmental worker and a community health nurse to visit a sick 3-year-old girl named Azuma, her mother, Abiiro, and their extended family. The nongovernmental worker had concerns not only about Azuma's poor health, but also about circulating rumors that the family suspected her of being a "spirit child," a malicious spirit from the bush with a grave intention of destroying the family. From the nongovernmental worker's perspective, Azuma was at risk because of her medical condition and the chance that family members would administer to her a deadly poisonous concoction. From the family's perspective, Azuma represented a risk to her mother, the family's livelihood and its continued existence in this and in the ancestral world. Upon arriving at the family's compound we sat in the shade of a baobab tree with eight slight children under the watchful eye of the family elder and waited for Abiiro. She soon emerged from her near-collapsing mud home, limping from a filariasis infection and carrying Azuma, to sit on a bench across from us with Azuma on her lap. Azuma, arms around her mother, regarded us with concern from an askew right eye as she breathed uneasily, mouth open. After we exchanged customary greetings with the family, the nurse examined Azuma and talked with Abiiro. As we spoke about her condition, Azuma made repeated attempts to breastfeed. Abiiro pushed Azuma away, mentioning that she had stopped producing milk several months earlier. Azuma's medical card, issued by the Ministry of Health at its free postnatal care clinic, indicated that the 3-year-old was consistently underweight, never exceeding 11 pounds. The nurse tried, to no avail, to get Azuma to stand unaided. Her lean legs bowed outward with each unsuccessful attempt. Constant Crying, Rarely Sleeping Abiiro estimated she was 34 years old, although she appeared much older. She had given birth four times and had three surviving children, including Azuma, the youngest. Abiiro's most significant complaint was that Azuma cried day and night, rarely slept and insisted on being carried in her arms, which interfered with her work. At subsequent visits with the family, it became apparent that she was greatly concerned about the disruption and impact of Azuma's condition on the larger family. Also, the family described an increase in interpersonal family conflict that coincided with Azuma's birth. These complaints were indicative of potential spiritual danger and ancestral displeasure. Other than her frailty, Azuma's most noticeable feature was a strabismus in her right eye. This "look" troubled family members. Wandering eyes are perceived as evidence that a child or adult is up to something spiritual and cannot be trusted. I was surprised that the nurse, after a brief examination, quickly pronounced Azuma fine and said Abiiro simply needed to provide her with "proper nutrition" and vitamins to stimulate her appetite. She prescribed vitamins, antibiotics for Azuma's respiratory infection and medication for a suspected malaria infection. "That wandering eye is caused by the child failing to get the proper eye drops during birth," the nurse explained. "The mother must have had gonorrhea when she gave birth. If she would have gone to the hospital to deliver, none of this would have happened." The nurse questioned Abiiro about Azuma's birth, stressing that all women should give birth in hospital. "Why didn't you call the midwife or go to the hospital to give birth?" the nurse asked. "You even had complications and still did not go." Abiiro said she was unable to send for the local midwife because she went into labor at night and lived a five-hour minibus ride away from the nearest hospital. Complex Set of Unofficial Risks While hospital and clinic births represent the Ministry of Health's official position aimed at reducing maternal risk, my subsequent visits with Abiiro and other community members revealed a complex set of unofficial risks that overshadowed sanctioned safe-motherhood messages. First, Abiiro had gone into labor after sunset. Although midwives employed by the Ministry of Health encourage families to contact them at all hours, Abiiro later revealed that she did not want to bother the midwife at night. Community members, particularly expectant mothers, rarely travel along paths at night because of the increased presence of dangers such as witchcraft, sorcery and various spiritual beings. Giving birth in the family compound is often preferred, since babies born along a road or path--a liminal, ambiguous and potentially dangerous place--may never fully integrate into the social/earthly world. Moreover, the local interventions for difficult delivery require the woman to be in the family compound connected to the uterine or agnatic kin, rather than in a depersonalized clinic. Several women also equated home birth with a valued ethic of endurance and strength. Finally, rumors of birth experiences in hospitals or clinics warned of nurses beating women who labor too slowly and of medical staff mishandling or dropping and thus injuring or killing infants. Abiiro's notion of responsibility for Azuma's condition was understood within an epistemology that emphasized the local social, ancestral and spiritually based perceptions of risk. The nurse redirected and focused on Abiiro's individual responsibilities as a mother disconnected from the social and economic realities of the kin system, a biomedical risk discourse that emphasized the importance of regular antenatal clinic attendance, family planning and birth spacing and improved nutrition. In this and other encounters I observed, it was apparent that biomedical health providers regarded mothers as individual agents who are responsible to make the choices, as communicated by health professionals and educators, that are in their best interests. During my research among the Nankani, the local ethnic group, I became interested in the disjuncture between and integration of traditional ways of knowing in relation to the transnational models incorporated in Safe Motherhood campaigns and biomedical programs. Cases like Azuma's spurred my interest in local subjective understandings of maternal risk and blame. Based on my early impressions, mothers appeared subject to a double burden of blame ensuing from both the biomedical and the traditional models. However, upon viewing blame from a processual framework--resulting from long-term relationships and ongoing case studies--a difference between biomedical and traditional models of blame emerged.