Traditional Childbirth Visits and Their Relationship to Maternal and Child Welfare

In northern Ghana, it is a common practice for mothers to return to the household of a parent or other relative after childbirth.  This visit generally lasts anywhere from a couple of months to several years with the intended purpose of teaching new mothers to care for their child.  Higher rates of malnutrition and lower rates of exclusive breastfeeding during these stays suggests that the outcome of childbirth visits may counter their intent to improve mothers' skills to rear and nourish their children. 

The Savelugu-Nanton District and Our Sample
  The Savelugu-Nanton District lies in the Northern Region of Ghana and is noted for its poverty. Savelugu-Nanton's average per capita expenditure in 2004 was approximately forty-eight cents per day. Approximately 41% of children younger than five years of age were chronically undernourished, and 11% of their mothers are as well.1,2  The period of time between this farming nation's dry and wet seasons is a time of low food availability.  Our data was collected during this point in its "hungry season" when Ghana's households were running out of food.
  The majority of Savelugu-Nanton residents are of Muslim and Dagomba decent. Polygamous marriages are common and the society is largely patriarchal. People in Savelugu-Nanton generally live with their extended family in compounds of multiple huts or rooms that surrounds a central courtyard. The average household size for our sample is thirteen people.
  All data in this article is from a 2004 household survey conducted in Savelugu-Nanton to evaluate the diets of children three years and younger. A census was taken in sixty-four communities to identify all households with at least one child of that category. From each household, a child and its mother were chosen at random for more extensive interviewing. All information about mothers and their children in the article refers to the random sample.
The Childbirth Visit
  As part of a common cultural practice, called "dogi kuna" or "childbirth visit," a woman who has recently delivered a child will return to her parents' house (or the house of an older relative) with her child and any other young children. Women usually do not bring many belongings with them, although the child's father may send items like clothing or money to her during her stay. She will stay there anywhere from three months to three years.
  Mothers on childbirth visit are a significant portion of the population in Savelugu-Nanton. Approximately 16% of mothers of children younger than three years were on childbirth visit in 2004.

Who Participates in this Practice?
  Table 1 compares mothers on childbirth visit to mothers not on childbirth visit. Mothers on childbirth visit are typically younger and have given birth to fewer children than women who are not on this type of visit. Mothers on childbirth visit are on average twenty-six years old and have given birth an average of two times.  Mothers not on childbirth visit in comparison are on average thirty-one years old and have given birth four to five times.  Since the purpose of childbirth visit is to assist mothers and to teach them how to care for the child, it makes sense that these mothers are relatively younger and have fewer children. Both groups have less experience with breastfeeding and caring for infants and do not have the benefit of having older children to assist in caring for their siblings and to help with household chores.
  Nearly all the mothers on childbirth visit in our sample were of the Dagomba ethnicity. Dagomba is the majority ethnicity in Savelugu-Nanton with 84% of mothers being of this category. Of the 1,390 Dagomba mothers interviewed, 18% were on childbirth visit. Only 6% of the 251 women comprising the ethnic minority category were on childbirth visit, thus indicating that this practice is more common among the Dagomba people.

Where Mothers on Childbirth Visits Go
  Although we cannot say definitively, it appears that a majority of women who are on childbirth visit are living in the households of their parents or an older sibling. Approximately 42% were living in a household of which their father was the head, and 11% in a household of which their brother was the head. The remaining 47% were also likely living in households where their parents or other siblings lived but were not the main domestic figure.
  Table 2 shows several notable differences between the households being visited by mothers on childbirth visit and households not being visited. Households with visiting mothers tend to have more physical assets3  and cultivate more land (20 acres compared to 14 acres). They are also more likely to have higher quality housing materials such as a zinc roof or a concrete wall. Together, these observations suggest the households that mothers visit may have greater stores of wealth and be more economically established. Since the visited households are generally households of parents and older siblings, they have had more time to accumulate wealth. However, despite the indications of greater wealth, households with visiting mothers appear to have similar levels of expenditures and have similar diets.

Causes for Concern
  If the households where mothers go to visit appear no worse off (and possibly even better off) than other households, why should we be concerned about mothers going on childbirth visit? What might explain the differences we will see below in feeding practices, children's nutritional status, and mothers' autonomy? Mothers on childbirth visit undergo at least one of the following changes. First, the mother is no longer living in her own household as a wife with responsibilities of domestic management.  She rather acts as a daughter or younger sister to be taken care of. Second, the household where she is visiting may be in a different community than where she has been living. She may know fewer people in the community where she is visiting and therefore may have fewer sources of information about community events. The change in status or role within the household and any social isolation that may occur with the childbirth visit may negatively influence her autonomy or her access to information.
  Figures 1-3 compare the responses of mothers on childbirth visit to mothers who were not when they were asked about their role in making decisions about food and expenditures. For the most part, the decision-making power of the two sets of mothers is similar and it is encouraging that being on childbirth visit does not appear to diminish mothers' control over breastfeeding and weaning decisions. However, mothers on childbirth visit have a diminished role in determining household expenditures and how food is allocated within the household. It is possible then, that they may have less influence in determining their children's diets.
  In Table 3, we see that mothers on childbirth visit were less likely to know about nutrition education programs called "mother-to-mother support groups" that are targeted toward mothers of children two years old and younger. Mother-to-mother support groups meet weekly within a village and were designed to be informal and participatory.  They discussed breastfeeding and complementary feeding as well as other topics introduced by the mothers themselves. Mothers on childbirth visit who are there to receive support and informal training and tend to have fewer children, would seem to be a natural audience for mother-to-mother support groups. It is possible that having fewer sources of information about community events limited their awareness of these groups.
  Infants less than six months old whose mothers are on childbirth visit are less likely to be exclusively breastfed than infants of the same age whose mothers are not on childbirth visit, as in Table 3. The World Health Organization  recommends that children be exclusively breastfed for the first six months of life.4 Exclusive breastfeeding is associated with children having fewer infections and a lower risk of death in developing countries.5 Children who are exclusively breastfed are less exposed to pathogens in water and food.  Unfortunately, we cannot identify the reason why mothers on childbirth visit are less likely to exclusively breastfeed their child. The result in Figure 4 does not support the possibility that other household members are preventing the mother from exclusively breastfeeding. It is possible that older members of the household where the mother is visiting are advising the mother to give the child water, a common practice in Savelugu-Nanton. It is also possible that mothers on childbirth visit have less exposure or access to outside information about childcare and breastfeeding if they are visiting in an unfamiliar community.
  Children of mothers on childbirth visit are more likely to be chronically malnourished than children whose mothers are not. In Table 3, we see that 43.5% of children twelve to thirty-six months old of mothers on childbirth visit suffered from chronic malnutrition compared to 34.8% of children of the same age of mothers not on childbirth visit. While we cannot be certain of the mechanisms behind the association between childbirth visit and malnutrition, it is possible that the lower likelihood of exclusive breastfeeding in the first six months of life, the mother's relatively less control over food allocation and household expenditures, and possibly  lesser exposure to health and nutrition information may be contributing to the child's malnutrition.

Conclusion
  Further research is necessary to understand the mechanisms through which the practice of childbirth visit may influence children's nutrition and mothers' access to information and autonomy. However, regardless of the relationship between childbirth visit and child nutrition, mothers on childbirth visit and their children are identified as a potentially marginalized group in an already poor and malnourished population.

Endnotes
1. K. Simler et. al., "Food-based Approaches to Reducing Micronutrient Malnutrition: An Impact Evaluation of the UNICEF ICBD Program in the Savelugu-Nanton District of Northern Ghana," International Food Policy Research Institute in collaboration with UNICEF-Ghana and University for Development Studies-Tamale, (March 2005): 27-30.
2. Chronic undernutrition, or stunting, in children younger than 5 years old is measured by a height-for-age z-score which is calculated by subtracting from the child's height the median height of child of the same age and gender from a healthy distribution and dividing by the standard deviation of the distribution. Children with z-scores below -2 (whose height is more than two standard deviations below the median for their age and gender) are considered chronically undernourished or stunted.
Adults are considered clinically undernourished if their body-mass index is less     than 18.5. The body mass index is calculated as weight in kilograms divided by     the square of height in meters.
3. The survey measured asset wealth by asking each household member whether   s/he owned a particular asset that was in working condition. Since it is rare to own more than one of each of the listed assets, each type of asset owned counts as one point for each person. We sum the types of assets owned for each person, and then sum the scores over all household members to create a measure of household asset wealth. The listed assets include watch or clock, radio, cassette player, sewing machine, sofa or large padded chair, electric fan, television, bicycle, motorcycle, car, trunk, chop box, and makolle. A makolle is a light metal container with a lid where women keep their valuable items.
4. Michael S. Kramer, and Ritsuko Kakuma, The optimal duration of exclusive     breastfeeding: A systematic review (Geneva: World Health Organization, 2002),     19-20.
5. World Health Organization Collaborative Study Team. "Effect of breast-feeding on infant and child mortality due to infectious diseases in developing countries: A pooled analysis," Lancet Vol. 355, (2000), 451-455.

Bibliography

Kramer, Michael S. and Ritsuko Kakuma. The optimal duration of exclusive breastfeeding: A systematic review. Geneva: World Health Organization,     2002.

Simler, K., K. Jacobs, J. Mensah-Homiah, J. Randriamamonjy, D. Weismann, and A. Abdul-Razak. "Food-based Approaches to Reducing Micronutrient   Malnutrition: An Impact Evaluation of the UNICEF ICBD Program in the Savelugu-Nanton District of Northern Ghana." International Food Policy     Research Institute in collaboration with UNICEF-Ghana and University for Development Studies-Tamale, March 2005.

World Health Organization Collaborative Study Team. "Effect of breast-feeding on infant and child mortality due to infectious diseases in developing     countries: A pooled analysis," Lancet Vol. 355 (2000): 451-455.
Krista L. Jacobs is a Ph.D. candidate in the Agricultural and Resource Economics Department at UC Davis. Her research interests include economic applications to malnutrition in developing countries, food insecurity, and impact evaluation of nutrition and health interventions. In 2004, she spent six months living and working in Ghana's Northern Region as Research Manager in a project by UNICEF, International Food Policy Research Institute, and the University for Development Studies in Tamale, Ghana. She hopes to continue research on improving nutrition in Africa and Latin America.
 

---