Themes
Three main themes were identified from the interviews which described influences of cultural practices and beliefs on parent’s experiences after the death of a baby, the theme titles include direct quotes from participants. Collective support was illustrated in descriptions of families and friends ‘gathering round’ the bereaved parents; ‘it is against our custom’ described cultural constraints and prohibitions impacting parents’ behaviour and coping in the immediate aftermath of the baby’s death; spiritual, supernatural, and social beliefs surrounding the causes of stillbirth are summarised in ‘maybe it’s God’s plan or witchcraft’.
Gathering round
Families and friends played a central, and largely positive, role in providing emotional and practical support after the death of a baby by ‘gathering round’ mothers to care for them. Beyond offering condolences and comfort in the immediate period after the death, family members often took the lead in facilitating rituals, including arranging the funeral. This was often mandated by parents’ exclusion from involvement in burial of their own baby. However, some mothers, were physically unable to take part because of prolonged ill health resulting from pregnancy or birth complications. Family assistance ensured conventions could be followed and was highly valued by many parents:
“My family buried my child; they obtained a birth certificate, and they were able to bury him. I still appreciate what they did because I was in no position to attend the burial.” (Bibi, mother, peri urban Kenya)
Beyond the first days and weeks after the baby’s death, family and close friends continued to provide social and financial support to women, including help with domestic work, childcare, and provision of money to compensate for lost income. These networks were a crucial resource, allowing women and partners to focus on coping with the death of the baby and their own emotional recovery.
“My friends took care of me, even my family members sent me some money and we managed to survive...They used to cook for me food, they could give me that warm massage, such things. They used to keep me company at home. They could come and sleep with me here to console me... It strengthens you in a way; you slowly start to forget what happened because whenever you are alone, you spend the entire time crying, but when you are with someone, she can bring up stories and you chat, and even laugh a bit”. (Nansubuga, mother, semi-rural Uganda)
For male partners, the presence of extended family and female friends was additionally perceived as important in enabling them to return to employment and resume their primary role as provider for the family, as Maganda commented:
“Her female friends and neighbours would visit her and comfort her. When we came back here, I only stayed with her for only two days and resumed duty at work. Her female friends and neighbours came and gave her company.” (Maganda, father, urban Uganda)
Women living in urban settings in both Kenya and Uganda, particularly those who had migrated for employment or partners’ employment tended to describe feelings of loneliness and isolation more frequently after the death of their baby.
“I expected my husband to tell his family, but he didn’t, and I have one brother who lives far so I too didn’t want to tell him. We even spoke this morning, but I didn’t want to tell him about it.”
(Lilly, mother peri-urban Kenya)
Barriers to accessing family included distance, transport costs and availability of mobile phones. In these circumstances some parents sought alternative ‘communities’ to avoid isolation, religion was an important focus and church members/ groups were very prominent in filling gaps.
It is against our customs
Cultural norms were cited as a key influence on the behaviour and actions of both parents and health workers after the death of a baby. These perceptions affected opportunities for seeing or having contact with the baby after the birth, whether the baby was named, mourning and burial rituals.
I didn’t see his face
For some parents, decisions around whether to see or have contact with the dead baby immediately after birth were influenced by fears of going against ‘customs’ and potential negative effects. Fears around future fertility or recurrent pregnancy loss were commonly cited as specific reasons for not having contact. Despite this, several women expressed regret for not having the opportunity to see or hold their baby, among few opportunities to create memories of their existence.
“No, I didn’t. I didn’t get a chance to hold her. I think I was afraid, and I was not understanding anything, I was more confused and also it is against our customs to hold dead babies.”
(Joy, mother, peri-urban Kenya)
Assumptions of cultural prohibition meant that some health workers did not routinely offer the option of seeing or holding the stillborn babies to women. Others were conflicted in recognising the need to provide individualised care but had limited time and opportunity to support parents in making the ‘right’ decision that included being sensitive to cultural prohibitions. They expressed anxiety and uncertainty about whether their current practice was helpful:
“...someone tells you; in our culture we are not supposed to look at the dead baby. You will not, when you are trying to [show them the baby] … much as you know the importance of them looking at the baby... you try to respect their culture and let them do what they feel is right.”
(Lynette, health worker-Uganda)
They don’t take it as a person
Participants in both Kenya and Uganda related community views and perceptions that babies who were stillborn did not have the same status as individuals who were born alive. Angella, whose baby was stillborn explained:
“If it’s a stillbirth they don’t take it as a person, they do that only for a child who has at least cried after coming out of the womb. One who has cried is a human while the stillbirth isn’t regarded as a human since they haven’t heard its cry.”
(Angella, mother, urban Uganda)
This view of stillborn babies as ‘less human’ was further reinforced by use of the pronoun ‘it’ in some narratives and linked as a reason for the lack of normal rituals marking the baby’s existence. Although a few women, predominantly in urban Kenya, referred to their baby by name in the interview, naming a stillborn baby was relatively uncommon.
“The baby has to first be born and he stays for about 2 days, that’s when they give him a name. One whom God takes away from earth after being born is the one who gets a name...But with the other one [referring to a stillborn baby] remember, he is born already dead, that one doesn’t get a name, he doesn’t.”
(Obei, father semi-rural Uganda)
This reluctance to assign a name was often rooted in the practice of passing down family or traditional names. Using familial names for a dead baby was considered to likely bring bad luck to the whole family, consequently naming ceremonies and baptism were not extended to stillborn babies even where parents were religious.
We do it differently
Parents and health workers in both countries described mourning rituals and funerals as being different for stillborn babies as compared to other deaths. Babies were buried very rapidly, often on the day after the birth, with only a few mourners present and a lack of normal traditions.
“No condolence money is collected. No money is collected as condolence fee from the community members. After burial, no last funeral rites are done. No gathering and cooking is done after burial like for older people. They take it like as if you have not lost anyone.”
(Mugisha, father, semi –rural Uganda).
Participants associated rapid burial with secrecy and taboos surrounding stillbirth, one father in Kenya was told it was necessary to avoid the baby’s body being stolen and used for witchcraft. In some communities, fathers generally assumed responsibility for planning and conducting the burial:
“We buried it [baby] without informing anyone else; me, my friend and my dad plus my brother who stays in Mbale. We proceeded and buried at that time without letting the neighbours know”. …where you bury, the grave isn’t supposed to be seen; you bury and just dig around it to camouflage around. You can even plant there something. Only family members are supposed to know and not all [family members] even because if you know Shafik is a witch doctor and has a bad heart; you don’t show[him].’’
(Shafik, father, urban Uganda)
However, it was also commonplace for both parents to be excluded from funerals of stillborn babies. This was explained by concerns around future fertility or potential for recurrence of pregnancy loss. For example, women and partners were told that if a woman of reproductive age participates in the burial of a stillborn baby, she may never conceive again. Often, older relatives particularly women who were past childbearing age took the lead role.
“For us, when a child dies, we [mother] aren’t supposed to bury them anyway…it’s a family affair.”
(Hellen, mother, urban Kenya)
“In our culture, when a baby dies from the mother’s womb, we do it differently; it’s the elderly people that bury that baby, women who have reached menopause...”
(Ali, father, semi-rural Uganda)
Not being able to attend the funeral caused considerable distress for some parents. Amongst concerns was uncertainty as to whether the ‘necessary’ rituals had been performed and potential for future harm arising from omissions. For example, in central Uganda, traditions dictated that the umbilical cord should be cut off before burial of a stillborn baby and if this were not done, it was believed that the mother would not conceive again. Conversely, other women were forced by their circumstances to take a more active role in funerals than they wished. Lack of a willing partner, family support or resources to travel home meant women attending or conducting the burial personally. Failing to adhere to prescribed behaviour led to considerable anxiety around the potential impacts.
“I felt bad about it in that up to now, it still worries me. Because as you know, culturally, people allege that I might not be able to give birth again...the fact that if the mother buries their baby, she will never conceive again in her life.”
(Nalweyiso, mother, semi-rural Uganda)
The place of burial, an important and sometimes contentious issue, depended on the culture and marital status of the parents. Patriarchal traditions across Kenya and Uganda dictated that children should normally be buried at their fathers’ ancestral burial grounds. These were sometimes located a distance away from the parents’ current residence and some lacked resources to transport the baby’s body. Access to family burial grounds was sometimes denied to single or separated women who also lacked financial resources to secure an appropriate burial and place to commemorate the baby’s life and existence.
“...because they asked me where I was going to bury the child but I had nowhere, I didn’t have any single coin because even... So, there is a woman who had a banana plantation in the neighbourhood, and she said that a baby who hasn’t cried is buried in the middle of 2 banana plants. That was the only solution available at that time and I also didn’t have anything to do about it.”
(Nalweyiso, mother, semi-rural Uganda)
In urban Kenya, some facilities offered hospital-arranged funerals or access to public burial grounds for babies who were stillborn. These options were valued by parents facing financial pressures, geographical distance, and family disagreements over where to bury the baby, such as Jolly:
“Yes, but you know I buried the baby not at our home or anywhere but at the cemetery, because there was a disagreement between our families. It was like the baby had died and among the [ tribe], they have their own cultures and we have our own cultures. I am a lady who was not married by that time and I could not take the baby to our home, and I could not take the baby to the father’s place, so we had to bury the baby at the [district]cemetery.” (Jolly, mother-peri urban Kenya)
Maybe it’s God’s plan or witchcraft
Although participants acknowledged medical causes for stillbirth, spiritual, social and traditional beliefs were equally prominent. Religious beliefs featured conspicuously in most participant’s narratives and provided fundamental context for accounts of human experience. Stillbirth was frequently described in terms of ‘God’s plan’, with the lack of individual control over events offering comfort to women and partners, who often spoke of their ‘gratitude’ to God that the mother had survived.
“We believe that whatever happens is a decision from God because we did all that we could; the scanning was done properly, we went through antenatal, took medications, she used to sleep under a mosquito net.”
(Issac, father semi-rural Uganda)
Religious perspectives were also often invoked by health workers when they offered support or reassurance to parents in the immediate aftermath of the baby’s death.
“So [pause] I tell them that it’s not you who decided to get this pregnancy, it was God’s plan, he is the one who decided that you conceive and it’s the same God who has taken away this baby...” (Ritah, health worker, Uganda)
However, not all participants took comfort from the notion that the baby’s death was predetermined by a higher power, several described their faith being tested. In these cases, religious fatalism contributed to feelings of powerlessness and lacking control over their lives which added to hopelessness and despair:
“I thought about many things. I said, am I really the one who gives birth to children and they die? What did I do to you God?” (Evalyne, mother, urban Uganda)
Participants in both countries also related widespread beliefs in their communities that supernatural forces were responsible for poor health outcomes including stillbirth. These beliefs unpinned links between natural disasters and poor pregnancy outcomes held in some communities:
“Maybe even the earthquake which happened when I was pregnant. When one is pregnant and by any chance an earthquake occurs, you get a miscarriage and sometimes the baby dies in-utero. And when it occurs, many people lose their pregnancies.”
(Mariam, mother, semi-rural Uganda)
Stillbirths were frequently associated with witchcraft; this could occur directly as result of a woman’s involvement and her ‘possession’ by evil spirits, indirectly from ‘curses’ imposed by other ‘witches’, or failure to take herbal medicines. Having a stillbirth was often regarded as a bad omen, and some parents encountered suspicion and gossip in communities which added to stigma and isolation.
“You know this is not a common thing, when it happens everyone is questioning in their mind what would have happened and they are not comfortable talking about it... and you believe that maybe your wife is a bad omen or you have been bewitched”
(Ian, father peri urban Kenya)
In both Kenya and Uganda, stillbirth was also considered to occur as a consequence of parent’s immoral behaviour. There were strong views that stillbirths were associated with infidelity or extra marital affairs:
“This man went to see his wife and from there he went to see his ‘side chick’ [girlfriend] and she prepared tea for him and he took it to his pregnant wife in hospital and according to customs it is not right. And when you mix that way death must occur”.
(Eric, father peri-urban Kenya)
Several women and partners recalled hearing similar rumours circulating in their communities after the death of the baby which caused considerable distress. Some had heard of relationship breakdown and abandonment occurring as a result. Beliefs linking stillbirth with immorality were also shared by some health workers, potentially creating negative perceptions of parents experiencing the death of a baby:
“…
I understand that if you sleep with another man and you are pregnant then you will miscarry the baby or something bad will happen to the baby.”
(
Tamara, health worker, Kenya)