Sociocultural determinants of nomadic women’s utilization of assisted childbirth in Gossi, Mali: a qualitative study

Despite significant progress in reducing its ravages, maternal mortality remains a major concern for public health [1, 2]. Worldwide, the maternal mortality ratio (MMR) fell from 385 to 216 deaths per 100,000 live births between 1990 and 2015, a drop of 44% [3]. However, almost all of these maternal deaths (99%) occur in developing countries (DCs) [4]. Unlike other regions of the world, Sub-Saharan Africa (SSA), with about 62% of global maternal deaths [5], did not experience significant improvement [6]. Moreover, SSA still has the highest MMR in the world, with 546 deaths per 100,000 live births [7], and the World Health Organization (WHO) estimates the number of women living with untreated obstetric fistula to be over 2 million in Asia and SSA [6]. These high maternal mortality rates have severe health and social consequences for the survival of children and for the financial health of the family.

Despite the efforts made, the situation in Mali is not different from that of other SSAs. According to the latest Demographic Health Survey (DHS V), conducted in 2012, the MMR is 368 maternal deaths per 100,000 live births, while the WHO estimated it at 587 per 100,000 live births in 2015 [7]. These figures also mask significant disparities between income levels and between rural and urban populations [8, 9]. In particular, the risk for nomadic women of dying from maternal causes is very high [10].

There are multiple causes of this high maternal mortality [11]. In DCs, obstetric complications are the main cause of maternal death [12]. In fact, they will occur in about 40% of all pregnant women [13] and apparently cause about 80% of their deaths [14]. More than half of these deaths are related to direct causes, such as hemorrhage (27%), infections (10%), hypertension during pregnancy (14%), and abortions (7%) [15]. Next, indirect obstetric causes represent 27% of maternal deaths. It turns out that these obstetric complications cannot be predicted [16]. All women are therefore at risk of developing a life-threatening obstetric complication during pregnancy.

This high maternal mortality is not acceptable because most maternal deaths are due to preventable causes or modifiable behaviors [17, 18]. There is scientific evidence in particular regarding the potential for skilled care at birth as a means of preventing maternal deaths [14]. According to some estimates, it can reduce maternal mortality from 16 to 33% [19], which makes it the most effective intervention to save women’s lives [20].

Furthermore, if it is agreed that assisted childbirth is a relevant strategy for avoiding maternal deaths [21, 22], it is also clear that women do not have the same opportunities to use it because of their sociocultural and economic differences or differences in the places where they live. Indeed, several factors can delay the use of maternal healthcare or make its use impossible [17, 18]. For this reason, despite scientific evidence attesting to the effectiveness of assisted childbirth and the efforts made by several countries to make quality health services available, women continue to give birth at home. In fact, coverage for assisted childbirth is 66% worldwide, but is only 49% for SSA and South Asia [23], compared to 97–99% in high-income countries [24].

For nomadic pastoralists in SSA, the use of healthcare services is very limited when compared to the general population [25]. This is due to several constraints, on the one hand, stemming from their environment and their way of life and, on the other, from important social and spatial disparities. Although underestimated in demographic statistics [26], these nomadic pastoralists are numerous, comprising an estimated 20 to 30 million people in the Sahel [25]. They are defined by Wiese [27] as anyone living in a tent, taking care of livestock, and practicing transhumance. In Mali, nomadic pastoralists are mainly Tuareg, Moor, and Fulani peoples. They live more frequently in low-rainfall desert areas where they migrate throughout the year along well-defined and almost identical routes depending on their rights of access and use, as well as the availability of resources for themselves and their animals [25].

In Mali, the use of assisted childbirth was already limited among nomadic pastoralists, but further deteriorated with the conflicts in the north and center of the country where they live. In fact, in these regions, about 7% of health facilities in Timbuktu, 4% in Gao, and 69% in Kidal were still closed in 2016 due to the security situation [28]. Assisted childbirth proportions in Mali, while reaching 58.4% for the whole country, decrease to 2.6% in Timbuktu, 2.4% in Gao, and 3.3% in Kidal [29]. However, even before the outbreak of war in northern Mali in 2009, these proportions were 35% for Timbuktu, 29% for Gao, and 29% for Kidal, compared to 66% at the national level. In SSA, these trends are confirmed for nomads. In Tanzania, assisted childbirth rates among nomadic women of Dagota were lower than those of the sedentary Iraqw tribe [30]. Similarly, in Ethiopia, of 478 Afar nomadic mothers interviewed, 83.3% gave birth to their last child at home without skilled care [31].

The reasons why these nomadic women do not use assisted childbirth seem difficult to identify as they vary from one context to another. Several authors in SSA refer to determining factors, which could be geographical, economic, cultural, technical, social, or political [10, 27, 32‐34], whereas only a few studies explore them for Mali in particular. However, some studies, whose results will be discussed later, have been carried out in Mali [35], Chad [36], Ethiopia [31, 37‐40], Kenya [41], and Sudan [42]. These studies have identified some sociocultural, geographic, and financial determinants that could limit the use of maternal healthcare by nomadic women.

The objective of this study is therefore to contribute to this very limited knowledge in order to improve the use of assisted childbirth by nomads in Mali. More specifically, it aims to describe and reach an insight into the sociocultural determinants of the use of assisted childbirth by nomadic women in the commune of Gossi.

This study was guided by the conceptual model of determinants of delivery service use proposed by Gabrysch and Campbell [43], who were themselves inspired by that of Thaddeus and Maine [44], which seems to be the most operational and best-suited model to understand the determinants of the use of assisted childbirth. Furthermore, it is adapted to the context of DCs [45]. It has the advantage of taking into account not only the risks of complications, but also the normal situations of using maternal care (preventive for instance). For these authors, the factors involved in the decision to use preventive maternal care significantly differ from those determining research in emergency obstetric care in the case of complications. In the second case, the severity of the complication may prevail over cost or distance considerations. In the event of life-threatening danger, even those who consider that normal delivery does not justify expenses and travel to a health center may attempt to overcome these barriers, despite high costs [43]. However, for normal delivery or preventive care, the time might be longer and the decision-making mechanism different in such cases.

In addition, this framework seems to distinguish intention to use care from behavior, i.e. actual use of care. For Gabrysch and Campbell [43], four groups of factors influence intention and behavior with respect to seeking care in a health institution. They may be divided into two groups: sociocultural characteristics and perceived benefits/needs, which influence the intention to use care; and economic accessibility (affordability) and physical accessibility, which influence behavior. However, all these factors interact with one another. In this study, we are more specifically interested in the sociocultural characteristics pertaining to the use of assisted childbirth. However, these sociocultural determinants are not the only ones that influence the use of assisted delivery by nomads. They constitute the first part of the results of the doctoral thesis of the lead author (MAAA). The second part of our results will be presented in another publication and will focus on the determinants related to nomads’ perceptions of the quality and geographical and financial accessibility of health services.

The commune of Gossi (Timbuktu region) was selected as the setting for this research. It encompasses a total surface area of 15,000 km² for a population of 24,065 inhabitants, of whom 90% are nomads [46]. It is mainly inhabited by Tamasheq (or Tuareg) and Fulani [47]. The choice of this commune was based on its characteristics (nomadic); the presence of a functional health center (Kaigourou); and the feasibility of research (security conditions for accessing nomads).

The results are presented in two parts: the sociodemographic characteristics of the participants and the sociocultural determinants of the utilization of assisted childbirth.

This study provides important contextual information on a complex combination of determinants, the result of which is the use or non-use of assisted childbirth by Tamasheq nomads in matters of health in ​​the commune of Gossi in Mali. Most participants indicated that they prefer to give birth in health centers, but this is often impossible due to many constraints related to their sociocultural, health, and economic context. In this difficult environment, the use of assisted childbirth is more often an expression of pragmatic choices by nomads and its limitation is related to several determinants.

In fact, the relationship that nomadic women have with their bodies seems to be one of the important elements in explaining their use of assisted childbirth. It appears that this recourse is largely influenced by certain dominant representations that women have of their bodies, risks, pain, and emotions during pregnancy and childbirth. In this regard, our study is in line with several others in SSA that have achieved similar results [55‐65]. These studies emphasize, and sometimes differ on, the links between sociocultural determinants and the use of maternal healthcare. However, for the most part, their findings support the contention that these determinants would deter women from using obstetric care [60].

Also, the results of some studies in nomadic areas in SSA mainly match those of our study, namely how pregnancy is detected, the modesty that it entails, and the hiding of the women’s condition which limits their use of maternal healthcare [31, 35‐42]. According to these authors, pregnancy gives women a fragile and vulnerable status, more attention, and privileges. On the other hand, the women of Gossi seem to refer less to traditional healers, marabouts, and birth attendants than others in SSA. However, childbirth is also dreaded by all these women, and the rules regarding delivery in particular are similar. Recourse to healthcare is seen as useful only in the case of complications. These sociocultural barriers to the use of maternal healthcare sometimes seem more ingrained than other obstacles, such as those of a geographical or financial nature [36].

Apart from these studies on nomads, several authors in SSA have shown that the representations that women and the communities in which they live make in relation to pregnancy and childbirth largely guide their behavior in the use of healthcare. For most participants, pregnancy and childbirth are seen as “normal phenomena,” giving them the feeling that their bodies are competent to deal with whatever might arise. As such, they do not need to be provided with healthcare [66]. Therefore, this dominant perception of “normal” pregnancy prevents many women from seeking care for routine deliveries [67]. This is why in many contexts, paradoxically, women with access to care give birth at home. In line with our results, some authors conclude that it is not enough to have accessible care for the use of assisted delivery to be effective [67]. They consider that this recourse would instead depend to a greater extent on the relevance to and appropriation of services by the communities in question. On the other hand, if childbirth is often considered as not requiring the use of healthcare, this is not the case when obstetric complications appear. For many nomadic women in our study, only complications would warrant assisted childbirth. On the other hand, the impact of this late recourse on maternal mortality in obstetric emergencies is questionable given the time required to intervene and save women in distress. Some authors even associate it with a high maternal mortality [67].

In addition, the use of assisted childbirth in the Hausa area (Nigeria), for example, is also limited by the fact that unaided childbirth is seen as an act of bravery and pride [56]. Likewise, it is seen in Uganda as an endurance test to which the woman must submit, and maternal death is seen as an act of fate [62]. However, there seems to be an evolution in these beliefs. Presumably, many of our study participants, including those who have never used assisted childbirth, are increasingly recognizing its benefits, particularly to shorten labor hours and postpartum care. Also, the risks and pain associated with childbirth generate a number of emotions that may trigger a preference for assisted childbirth. On the other hand, nomadic women hide their pregnancy, but not for the same reasons mentioned in some studies in SSA. For the nomads, their condition is hidden because acknowledging the pregnancy would suggest the sexual act, which is a taboo topic of conversation. This is not the case, for example, in Cameroon or Zimbabwe, where women apparently hide their pregnancies to protect themselves from “evil spirits,” including witchcraft, to which they believe themselves more vulnerable [61, 66]. Similarly, in Nigeria, it is because of a belief called “Kunya” (meaning modesty) that the primigravida in particular would hide her pregnancy [56].

In several SSA countries, as in the case of nomadic women in our study, childbirth is often perceived as very risky, and this element of risk would justify going to the health center [68]. Indeed, the combination of fear of suffering or of dying during childbirth would largely justify women’s preferences for assisted childbirth. On the other hand, the happiness related to this process seems better expressed in other countries in SSA [69] than among the nomadic women we met.

Moreover, the analysis of participants’ discourse in our study also revealed a low autonomy of nomadic women, which seems to limit their use of assisted childbirth. This is in line with several other studies in SSA that identify three dimensions to judge the level of autonomy of women with respect to using maternal care [70‐74].

These authors evaluated the autonomy of women though their level of mobility, participation in decision-making, and finally their access and control of financial resources. Also, they defined autonomy as the ability of women to take control of resources and decisions that affect them and to act independently from the men or the society in which they live [75]. They agree that in SSA, more independent women are more likely to use maternal care [71]. For some authors, women in SSA do not always have freedom of movement [70], as we have observed with the nomads of Gossi. In fact, the consent of their mothers-in-law or their husbands appears to be required before they can seek care [70]. Without the consent of these agents, recourse to medical care is seen as a lack of respect. Furthermore, since the woman has to pay at the health center, she must discuss this matter with her husband or mother-in-law, which is badly perceived locally. On the other hand, when women have greater freedom of movement, they are more likely to use maternal care [70, 74].

Our results are also consistent with other studies having highlighted the low participation of women in decision-making related to assisted childbirth in SSA [70, 73]. As seen in our study, their lack of decision-making power would largely contribute to late recourse or non-use of healthcare [38]. For example, in Ethiopia, when women ultimately decide where to deliver, they are more likely to give birth in a health center than is the case where others make this decision for them [39, 73]. The same is true in Niger, Burkina Faso, or Zambia, where women with some decision-making autonomy are more likely to give birth in a health facility than women who do not have such power [70, 71, 74]. In these countries, women with a greater degree of autonomy are free to make the decision to seek care and are also better equipped to face the imposed constraints.

Another study in Malawi shows that decision-making processes for the use of maternal healthcare are dominated by the men who make the final decision, especially when it comes to obstetric complications [76]. Thus, faced with the opposition of their relatives, some women could not assert themselves and were unable to force their relations to take measures in favor of seeking care [76]. Moreover, the nomadic women in our study have no source of income, and family resources are controlled by men, which seems to limit their use of assisted childbirth. Studies in SSA indicate that maternal care is less important when expenditures are controlled by other household members [72]. In addition, when women have better control over their financial resources, they can then decide how to use them to pay for care.

Our results also match those of Hampshire [36] who found that most of the nomadic women in her study had limited economic power that did not allow them to cope with health costs without the help of others. Their use of healthcare depends on the availability and the good will of men. Furthermore, achieving access to the husband’s resources is different or variable depending on a woman’s marital status (single, geographically single, or married). However, this individualistic and atomistic conception of the origin of autonomy is subject to a certain degree of criticism [77, 78]. According to this conception, individuals are supposed to be sufficiently independent and rational to make their own decisions [77, 79]. It does not recognize people’s social character based on their relationships with others, their interdependence, and the mutual support that defines human lives [80].

According to several authors, this conception thus offers a poor or an incomplete vision of autonomy [80, 81]. Conversely, they put forward a more relational form of autonomy which asserts that individuals are never independent enough to make decisions alone. This alternative conception of autonomy places the individual in a socially integrated network [82]. Its attributes are relationships with the family, the community, and society, and thus mutual responsibility and interdependence are recognized as playing a major role in any decision-making process. Indeed, for any decision-making, including recourse to maternal care, the mutual responsibility and cooperation of women with spouses, parents, and relatives therefore play a determining role, as noted in our study. As a result, women’s social environment and their relationships are recognized as continually contributing to their autonomy [82].

To illustrate the importance of the social network, Gage said in the same vein that in rural Mali, it is not only where you live that is crucial for the use of maternal care, but also who your neighbors are [83]. This suggests that living close to women who have used maternal care is likely to mean more help offered by neighbors. As such, autonomy analyzed from an “individualistic” angle by several authors in SSA has limitations, particularly for the evaluation of the decision-making power of nomadic women encountered in the commune of Gossi regarding the use of assisted childbirth. Indeed, these nomads are organized within their camp and with their neighbors in a supportive community environment. This interdependence within a social network is crucial for their survival in often hostile environments far from urban centers where health services are located. For these nomadic women, the use of assisted childbirth can be seen as a collective process involving multiple actors who interact and share roles according to certain social standards and at different points in the decision-making process. In analyzing the discourse of our participants, we note that the logic of solidarity and mutual aid seems to have determined their use of assisted childbirth given the inaccessibility of health services for them. They described many roles in their social networks that allow them to seek care and, in particular, to exchange information on the services available, as well as to support and help each other and thus to facilitate such use. This information seems to be well appreciated and often considered as a priority for rapid decision-making as regards the use of assisted childbirth. In addition, studies in other contexts have shown the importance of these social networks and their links to the use of healthcare [84‐86]. Some authors argue that social networks are an important source of information [86]. For the nomadic women of our study, their social network, including friends or relatives, seems to play an important role in motivating them to seek care. Pregnant women were able to receive emotional support, counseling, or help with housework to enable them to visit health centers.

Our participants consider that recourse to assisted childbirth depends to a greater extent on the suitability of services provided and their appropriation by the communities. On the other hand, if childbirth is often considered as not requiring the use of healthcare, it is not so when obstetric complications ensue. For many participants, it is not enough to have accessible care for the use of assisted childbirth to be effective [67]. Similarly, other authors show that women are more likely to seek care when their networks are broader and more homogenous, and when the level of solidarity is more important [85]. In other words, a network made up of people who are closely related and with homogeneous family ties is stronger and more reliable, as is the case for the participants in our study. Nomadic women seem to appreciate the fact that they do not feel alone in dealing with complex and difficult decisions that require important means, community mobilization, and, above all, knowledge and initiative, to be shown while they are suffering and not always able to cope. They seem to perceive this solidarity and interdependence as a source of strength, an integral part of their identity, and a component of a strategy of support upon which they can rely in a hostile environment. Therefore, we can question the ability of nomadic women with little education to make decisions alone with respect to seeking care in this difficult environment.

This study helped to identify and understand a set of sociocultural determinants whose interaction influences the use of assisted childbirth by Tamasheq nomadic women in the health area of the commune ​​of Gossi, Mali. It shows that despite a certain evolution, this recourse stems from pragmatic choices and perceived needs, which themselves are determined, on the one hand, by representations and experiences from pregnancy and childbirth, and on the other, by their lack of decision-making autonomy. Moreover, despite the preference of the majority of participants for assisted childbirth, which is recognized as being effective, many of them continue to give birth at home.

Furthermore, interventions aimed at promoting the use of assisted childbirth by nomads should target these different sociocultural determinants. Such interventions should take into account the relationship that nomadic women have with their bodies and their capacity and limits to cope with pregnancy and childbirth. In addition, they would take into account women’s perceptions of the multiple risks recognized as punctuating their experiences of pregnancy and childbirth, as well as the unpredictable complications that strongly motivate demand for healthcare.

Similarly, the study describes the mobilization of a social capital that must be recognized to the extent that it seems a very valuable component in this decision-making process. Therefore, potential interventions should capitalize on the social network of nomadic women to support decision-making where the use of assisted childbirth is being promoted.