The results are presented in two parts. The first part concerns the role of the mother-in-law in the family, particularly after childbirth. The second part concerns her role in PMTCT, particularly with regard to infant feeding.
The customary role of the mother-in-law
Responsibility after birth
Mothers living in a rural area were more likely to live with their mother-in-law than mothers living in an urban area (25.5% vs. 6.1%; p < 0.001). They were also more likely to report to meet their mother-in-law at least once a week (59.9% vs. 28.3%; p < 0.001) (Table
2). Approximately one third of mothers reported that they had moved in with their mother-in-law after giving birth to their last born child.
Table 2
The mother-in-law: living proximity and decision making in rural and urban areas
The mother-in-law lives | | | | |
Together with the couple | 46 (14.5) | 35 (25.5) | 11 (6.1) | *** |
Same/nearby village | 142 (44.8) | 54 (39.4) | 88 (48.9) | |
Far away | 129 (40.7) | 48 (35.0) | 81 (45.0) | |
Meet the mother-in-law | | | | |
> Once a week | 133 (42.0) | 82 (59.9) | 51 (28.3) | *** |
< Once a week | 184 (58.0) | 55 (40.1) | 129 (71.7) | |
Moved to the mother-in-law after birth | | | | |
Yes | 115 (36.3) | 49 (35.8) | 66 (36.7) | |
No | 202 (63.7) | 88 (64.2) | 114 (63.3) | |
The mother-in-law makes the decision on | | | | |
Clinical attendance | 1 (0.3) | 1 (0.7) | 0 (0.0) | |
Family planning | 2 (0.6) | 1 (0.7) | 1 (0.6) | |
HIV testing | 1 (0.3) | 1 (0.7) | 0 (0.0) | |
Infant feeding | 6 (1.9) | 6 (4.4) | 0 (0.0) | |
Primary confidant | | | | |
Male partner | 191 (60.3) | 81 (59.1) | 110 (61.1) | |
Mother | 59 (18.6) | 21 (15.3) | 38 (21.1) | |
Mother-in-law | 4 (1.3) | 4 (2.9) | 0 (0.0) | |
Sister/other | 63 (19.8) | 31 (22.6) | 32 (17.7) | |
Qualitative interviews confirmed that the custom of a daughter-in-law staying in the house of her mother-in-law after giving birth was still practised, particularly in rural areas. A grandchild was seen to belong to the lineage of the father. This gave the mother-in-law rights and obligations concerning her paternal grandchild. Her main responsibility was to make sure that the daughter-in-law was capable of caring for her grandchild, the new member of the lineage. Among the mothers and fathers, there were diverging opinions about the customary role of the mother-in-law. Some rural mothers and fathers expressed that they saw the role of the mother-in-law after childbirth as important.
We send our wives to the village or have our mothers come to our home because there are things that are required that she must do for her daughter-in-law, like massaging and cooking. These are things that I cannot do. (Rural father, FGD)
However, there was a tendency among urban couples to express a more independent position, evading this practice. Some fathers stated that they as fathers should take the responsibility customarily assigned to the mother-in-law.
It is just tradition. But you can take very good care of your wife. You can wash, cook... What do you need your mother for? She already brought you up. You as a father should play your role in the family. (Urban father, FGD)
Increasing tensions
In the survey the mothers were asked questions about their relationship with their mother-in-law and their partner. The mothers-in-law were given significantly lower scores than the partners on all questions (p < 0.001) (Table
3). The mothers ranked their mothers-in-law particularly low on the questions regarding trust and power. There were no significant differences between the responses from urban and rural mothers with respect to these questions.
Table 3
Comparison of mean scores in relationship questions regarding mother-in-law and partner
'Trust' | | |
I share all the information I receive at the antenatal clinic with my partner/mother-in-law
| 3.10 (2.68-3.51) | 8.88 (8.62-9.15) |
I would share my secrets with my partner/mother-in-law
| 2.68 (2.33-3.03) | 7.59 (7.28-7.89) |
'Power'
| | |
I need to do what my partner/mother-in-law wants me to do
| 2.06 (1.73-2.39) | 5.57 (5.23-5.91) |
I can only feed our infant in a way my partner/mother-in-law approves of
| 1.34 (1.07-1.62) | 3.19 (2.83-3.55) |
'Support'
| | |
If I were sick and confined to bed my partner/mother-in-law would look after me
| 6.40 (6.03-6.77) | 9.10 (8.87-9.32) |
If my mother-in-law/partner treated me badly, I could trust my partner/mother-in-law to support me
| 5.10 (4.73-5.47) | 7.58 (7.30-7.87) |
All groups of informants in the qualitative interviews were familiar with the tensions and potential disagreements between daughter- and mother-in-law, but in the in-depth interviews, the majority of the daughters- and mothers-in-law stated that they had a good relationship.
She is fine; she is just like my own mother. (Urban mother, in-depth interview)
I regard her as my own daughter, since whatever bad things I say about her would reflect badly on my son too. (Urban mother-in-law, FGD)
However, during the FGDs several daughters- and mothers-in-law mirrored the well-known tensions between them. The obligations to pay respect and to obey the advice and demands of the senior woman came out strongly.
You need to follow her [the mother-in-law's] rules, because if you disagree there will be no love. (Rural mother, FGD)
Several mothers-in-law expressed common frustrations regarding the relationship between a mother-and a daughter-in-law:
There are some daughter-in-laws who do not listen to what you are telling them, they want to wander about and when you ask her to cook or do her responsibilities she says "ah, I would have preferred a husband whose parents are already dead. I am married to my husband, not you." You as mother-in-law, try to tolerate this but in the end you get tired. You decide to leave and let her live alone with her husband. (Urban mother-in-law, FGD)
During the discussions it was evident that it was the male partner who would have the final say if he was involved in their disagreements.
My mother has no right to make decisions in my house, its mine and my wife's. (Rural father, FGD)
Expecting authority
Mothers-in-law, in their position as elderly women and grandmothers, generally saw themselves as responsible for family health. By adhering to their customary defined commitments, mothers-in-law would expect their daughters-in-law to disclose information from the clinic to them.
When your daughter-in-law comes back from the hospital she has to tell you first what she was told there, since here she does not have a mother, you are her mother. Your role now is to give her more advice. (Urban mother-in-law, FGD)
Mothers in the survey rarely reported the mother-in-law as being responsible for decisions concerning health issues in the family (Table
2). The minority who did were almost all living in a rural area. The majority of mothers and fathers in the qualitative interviews stated that decisions concerning health issues were made by the couple, together. They were generally averse to involving the mother-in-law and appeared sceptical of her advice.
Me and my husband make the decisions. Sometimes my mother-in-law can say something, but if it is not good we do not listen. (Urban mother, in-depth interview)
The mother-in-law's experiences concerning infant feeding were deemed outdated by many and the mothers and fathers would rather follow advice given at the clinic.
I would not trust my mother too much in matters of feeding. Matters of breastfeeding are under my wife's care and my own mother is not involved at all. (Urban father, FGD)
However, some mothers, particularly those living in a rural area, stated that the mother-in-law was an influential person with great power over her daughter-in-law.
She can ask you to do something against your will and you have to listen to her because she is who she is. (Rural mother, FGD)
The role of the mother-in-law in PMTCT
Attitude to the PMTCT programme components
Although mothers-in-law rarely escorted their daughters-in-law to the antenatal clinic, the majority knew about the PMTCT programme.
In the PMTCT clinic they advise the mothers on the importance of testing, to use condoms and to advise the husband to go for testing as well. If they are HIV positive they will receive medication. (Rural mother-in-law, FGD)
HIV testing for pregnant women, medication for HIV-infected mothers and delivery at a hospital were among the mothers-in-law perceived as important and beneficial and the participation in these components of the PMTCT programme was clearly supported. However, as guardians of customary infant feeding and of the survival and welfare of the infant, new infant feeding practises were met with greater resistance. The two infant feeding options for an HIV-infected mother, exclusive breastfeeding and exclusive replacement feeding, were both incongruent with the customary infant feeding practises in the Kilimanjaro region. Mothers-in-law encouraged and expected prolonged breastfeeding into the second year of life with early introduction of water and other nutrients.
Expectations to breastfeed
Breastfeeding was closely connected to the survival of the infant and was a very strong norm. If the daughter-in-law did not breastfeed, and in particular if she could not give a satisfactory explanation as to why she did not breastfeed, it would appear as incomprehensible and unacceptable to the mother-in-law who would commonly intervene.
I will not agree that my grandchild is denied breastfeeding without a good reason. (Urban mother-in-law, FGD)
If the daughter-in-law refused to give her an explanation she risked sanctions including being forced to breastfeed, not receiving postnatal care, being gossiped about or sent back to her husband in the middle of the confinement period:.
I will send her away to live with her husband since I can not live with a person who refuses to breastfeed her own child. (Rural mother-in-law, FGD)
However, a mother-in-law's anger was normally based on a concern for the health of her grandchild. Some would accept uncustomary feeding methods if they understood the rationale behind not breastfeeding.
I would probe until I know why she does not breastfeed, and if there is a reasonable reason then we will use alternative feeding methods. (Rural mother-in-law, in-depth interview)
Furthermore, mothers-in-law expressed great faith in health personnel. If they knew that clinical advice was behind not breastfeeding, they were unlikely to disagree.
I would completely disagree with her not breastfeeding unless she was given instructions by doctors. (Urban mother-in-law, FGD)
The mothers in the qualitative interviews would advice HIV-infected women who opted for exclusive replacement feeding, to inform their mother-in-law about their HIV status. The importance of communication with the mother-in-law was illustrated by the quote below:
If I had not shared with my in-laws that I am infected, I am sure that my mother-in-law would not want me to give formula. (Urban HIV-infected mother, in-depth interview)
Scepticism about exclusive breastfeeding
The concept and rationale behind exclusive breastfeeding was difficult for mothers-in-law to understand and accept, as it was incongruent with the information they had received when they themselves gave birth and breastfed:
Not giving water is very difficult. At the clinic they said that the baby should not be given water or milk other than the mother's. I was shocked! When we gave birth, the nurses used to encourage us to give baby water, saying that even the mother's milk causes thirst. And when we give water the baby drinks much. So, why should we not give them water? (Urban mother-in-law, FGD)
Some mothers-in-law stated that they would not have been able to remain passive if their grandchild was not given water. They would have been worried for the infant's health and would have given it water in the mother's absence.
You might make decisions if you see the baby is "drying up": I must protect my grandchild! If the mother is not there, I will give him water. (Urban mother-in-law, FGD)
Mothers and fathers were aware of the mothers-in-laws' scepticism about exclusive breastfeeding. A few rural mothers expressed a very submissive attitude towards their mother-in-law and would rather have given the infant water than opposing her. However, most of the mothers said that if they told their mother-in-law that it was clinical advice to breastfeed exclusively, she would accept it owing to her strong faith in health personnel. This was confirmed by some mothers-in-law.
I would not give water to him in his mother's absence, since his mother was told by a doctor not to give him water for the first six months. I am sure the doctors know better about these things. (Urban mother-in-law, FGD)
Mothers and fathers stated that if the partner was involved and accepted that his wife practised exclusive breastfeeding, he was likely to support her against his mother and have the final decision.
I would forbid my mother to give water because my wife should follow the doctor's advice. (Urban father, in-depth interview)
Disclosure and support
When asking mothers a hypothetical question concerning who they would have as their primary confidant if they were infected with HIV only 1.3% of the mothers, all residing in a rural area, would have chosen their mother-in-law (Table
2). The majority (60.4%) would have chosen their partner. When asking mothers the same hypothetical question in the qualitative interviews, they stated their husband as their first choice and secondly their own mother, sister or a close aunt. None of them mentioned their mother-in-law. She was often mentioned as the last person they would have told about a HIV positive test result. The mothers feared her reactions and did not trust her to be supportive.
I would not tell her because she would not understand me. She would think I brought it [HIV-infection] to her son and would send me away. (Urban mother, FGD)
Among the mothers-in-law, there were various views of how they would have reacted if their daughters-in-law had hypothetically been infected with HIV. Some said that they would have been obliged to support her.
I would support her and let her live with me. Where could I send her to, since she is my responsibility? (Urban mother-in-law, in-depth interview)
However, a minority admitted that they would have treated their daughters-in-law badly, and held her responsible for bringing HIV into the family. Two of the HIV-infected mothers, both of whom lived with their parents-in-law, reported to have experienced mistreatment by their mother-in-law. One of them was thrown out of the home after her husband died.
My in-laws chased me away, accusing me of infecting their son. (Rural HIV-infected mother, in-depth interview)
The following quote of the other HIV-infected mother illustrates the importance of a supportive partner:
My husband did not like the way his mother was treating me. So we decided to look for our own place and leave them alone. (Rural HIV-infected mother, in-depth interview)