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INTRODUCTION Background of the Study Every Day,

INTRODUCTION Background of the Study Every Day,

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INTRODUCTION Background of the Study Every day, 1500 women die from pregnancy or childbirth – related complications.

In 2005 (WHO), there were an estimated 536 000 maternal deaths worldwide. Most of these deaths occurred in developing countries, and most were avoidable. Improving maternal health is one of the eight Millennium Development Goals adopted by the international community at the United Nations Millennium Summit in 2000. In Millennium Development Goal 5 (MDG5), countries have committed to reducing the maternal mortality ratio by three quarters between 1990 and 2015. However, between 1990 and 2005 the maternal mortality ratio declined by only 5%. Achieving Millennium Development Goal 5 requires accelerating progress (WHO, 2005). The high incidence of maternal death is one of the signs of major inequity spread throughout the world, reflecting the gap between rich and poor. In addition to the differences between countries, there are also large disparities within countries between people of different cultures, with high and low income and between rural and urban populations. Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The four major killers are: severe bleeding (mostly bleeding postpartum), infections

2 (also mostly soon after delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labor. Complications after unsafe abortion cause 13% of maternal deaths (UNICEF 2004). Globally, about 80% of maternal deaths are due to these causes. Among the indirect causes (20%) of maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anemia and HIV. Women also die because of poor health at conception and a lack of adequate care needed for the healthy outcome of the pregnancy for themselves and their babies. The first step for avoiding maternal deaths is to ensure that women have access to family planning and safe abortion. This will reduce unwanted pregnancies and unsafe abortions (WHO 2005). The women who continue pregnancies need care during this critical period for their health and for the health of the babies they are bearing. Most maternal deaths are avoidable, as the health care solutions to prevent or manage the complications are well known (Basavanthapa, 2008). Since complications are not predictable, all women need care from skilled health professionals, especially at birth, when rapid treatment can make the difference between life and death. For instance, severe bleeding after birth can kill even a healthy woman within two hours if she is unattended. Injecting the drug oxytocin immediately after childbirth reduces the risk of bleeding very effectively (Wilson, 2006). Sepsis – a very severe infection – is the second most frequent cause of maternal death. It can be eliminated if aseptic techniques are respected and if early signs of infection are recognized and treated in a timely manner. The third cause, eclampsia, emerges as

3 pre-eclampsia, a common hypertensive disorder, which can be detected during pregnancy. Although pre-eclampsia cannot be completely cured before the delivery, administering drugs such as magnesium sulfate can lower a woman’s risk of developing convulsions (eclampsia), which can be fatal. Another frequent cause of maternal death is obstructed labor, which occurs when the fetus’ head is too big compared with the mother’s pelvis or if the baby is abnormally positioned (WHO, 2007). For women to benefit from those cost-effective interventions they must have antenatal care in pregnancy and in childbirth they must be attended by skilled health providers and they need support in the weeks after the delivery. According to the statistical data published by the National Demographic and Health Survey (2003), data show that less than two thirds (62%) of women in developing countries receive assistance from a skilled health worker when giving birth. This means that 45 million home deliveries each year are not assisted by skilled health personnel. In high-income countries, virtually all women have at least four antenatal care visits, are attended by a midwife and/or a doctor for childbirth and receive postnatal care. In low- and middle-income countries, just above two thirds of women get at least one antenatal care visit, but in some countries less than one third have this or, as in Ethiopia, just 12% (WHO, 2005). There are many reasons why women do not receive the care they need before, during and after childbirth. Many pregnant women do not get it because there are no services where they live, they cannot afford the services because they

4 are too expensive or reaching them is too costly. Some women do not use services because they do not like how care is provided or because the health services are not delivering high-quality care (Walton, 2000). Worldwide, over 500,000 women and girls die of complications related to pregnancy and childbirth each year (UNICEF, 2000). Over 99 percent of those deaths occur in developing countries such as the Philippines. But maternal deaths only tell part of the story. The Philippines’ maternal mortality rate continues at an unacceptably high level. While maternal mortality figures vary widely by source and are highly controversial, the best estimates for the Philippines suggest that approximately 4,100 to 4,900 women and girls die each year due to pregnancyrelated complications (DOH, 2007). Additionally, another 82,000 to 147,000 Filipino women and girls will suffer from disabilities caused by complications during pregnancy and childbirth each year (DOH, 2008). One of the Department of Health (DOH) National Objectives for Health is to ensure that 80 percent of mothers are provided with essential health care packages. The package includes: (a) tetanus toxoid immunization, (b) nutrition, including Vitamin A, folic acid and iron supplementation, (c) treatment of existing disease, if any, (d) recognition, early detection and management of complications before, during and after pregnancy, (e) clean and safe delivery, (f) promotion and support of breastfeeding, (g) information services for family planning, (h) STD/HIV prevention, and (i) dental care. The package is very comprehensive and most of these are provided during prenatal care of mothers

5 (DOH, 2007). Meanwhile, the basic premise of the Safe Motherhood Initiative is that childbirth must not carry with the risk of death or disability for the woman and her infant. Deaths due to pregnancy and childbirth are both too high in developing countries like the Philippines. To address this concern, the DOH provided several recommendations on maternal and child health as follows: (1) at least four times of prenatal visits, the first of which is on the first trimester; and (2) postnatal care should be given within two days after delivery, at most one week after. More recently, the DOH provided for seven visits for prenatal services throughout the pregnancy (DOH, 2007). The 2003 National Demographic and Health Survey (2003 NDHS) data show that seven in ten women made at least four antenatal care visit, while five in ten women made the first visit in the first trimester of pregnancy. Furthermore, women avail of prenatal services for curative rather than preventive reason (Landicho, University of the Philippines Population Institute, October 2006). In terms of delivery care, only 38 percent of live births were delivered in a health facility, and only 60 percent of all births were attended by a health professional. The delivery of postnatal care services is aimed at preventing the occurrence of maternal and infant morbidity and mortality in the country by checking whether there are complications arising from the delivery and providing the mother with information on how to care for herself and her child. In the 2003 NDHS, only one in three women who delivered outside a health facility followed the DOH recommendation, and a total of 65 percent received postnatal care.

6 The tragedy – and opportunity – is that most of these deaths can be prevented with cost-effective health care services. Reducing maternal mortality and disability will depend on identifying and improving those services that are critical to the health of Filipino women and girls, including antenatal care, emergency obstetric care, and adequate postpartum care for mothers and babies, and family planning services (UNFPA, 2003). Health care programs to improve maternal health must be supported by strong policies, adequate training of health care providers and logistical services that facilitate the provision of those programs. Once maternal and neonatal programs and policies are in place, all women and girls must be ensured equal access to the full range of services (DOH, 2003). According to Macmillian (2000), the interactions between traditional health practices and beliefs and modern health science and technology are of increasing importance to the developing world. Readiness to change develops so quickly in some areas as to overwhelm resources, while in others inexplicable resistances retard even the simplest activities. Perhaps the greatest value of this research is in providing a framework for interpretation of these interactions. Although essentially nothing new is recorded, the volume does provide a valuable synthesis of information from many sources. Even the almost excessive use of quotations is handled with sufficient care so that ideas are built rather than borrowed (Landy, 1999).

7 There are naturally minor points on which this health worker disagreed with the author's strongly anthropological orientation. For instance, in spite of the few instances cited, it is somewhat naive to really expect much cooperation from indigenous practitioners (Davidson, 2003). Many people have tried with great dedication and enthusiasm and failed, but results are never reported. As pointed out, however, it is tremendously important to continue to try to build maximum understanding of and with, local indigenous practitioners. Much can be learned from them that will aid in organizing health programs. Furthermore, cultural beliefs and practices play a significant role on the extent a pregnant woman from getting the care she needs. To improve maternal health, gaps in the capacity and quality of health systems and barriers to accessing health services must be identified and tackled at all levels, down to the community (Breslin, 2003). Both health and illness are concepts that are defined by an individual’s culture. What is “normal” in one society may be considered “abnormal” in another. Kaufert (1996) emphasizes the need to examine the universal process of a certain illness or disease within a social and cultural context instead of imposing allopathic standards of what is considered “normal” upon other societies. In the Cordillera, people are bounded by their own culture which includes their beliefs and practices. Many mothers stick to what they believe is good for them and practice cultural approaches that would seem fit to cure her illness. On the other hand, rural women often have difficulty accessing health care services. In today’s

8 world of managed care, community hospitals and rural health units may be of close distance, however, offer a decreased number of necessary services. One more concern is the multiple roles and role strain women experience in rural communities. Women are expected to be nurturers of the family without having anyone to turn to themselves. Self esteem may decrease as they are unable to fulfill the expectations of family and community, with depression as the end result. Bushy (1993) advises health care providers to help indigenous mothers recognize their strengths and incorporate their definitions of health and illness into the plan of care. Meanwhile, it is easier to have ideas about what culture is than it is to express them. The culture of a society denotes “traits which are shared by a significant number of individuals and which are transmitted from generation to generation within that society by teaching and learning.” This, however, does not take into account the possible biological variations of people within any society and how these may change its culture as a result of harmful influence or the onslaught of external biological or technological change (Watson, 2001). Indeed in any society, habits fostered by the prevailing culture, or to a lesser extent by the environment, can expose people directly to the risk of serious disease. Many people think of culture in an agricultural community as being limited to traditional habits and customs, particularly in relation to health and the farming cycle, because the very survival of the people depends on their fitness for work on the land. Some may also think that culture in an industrial country can be

9 equated with taste in the fine arts. Both ideas are quite erroneous. Culture is concerned with broad structure and development of a society and cannot be confined within narrower limits. Where culture is concerned, the health worker has, in fact, to come to grips with a subject much wider than a few traditional habits relating to disease. In the simplest societies, habits are developed for self preservation and the preservation of the tribe. Thus, various customs may accompany pregnancy, childbirth, and weaning, the aim being to ensure successful reproduction and to protect the life of mother and infant. Looked at from a modern, scientific point of view, however not all of these customs will be considered harmful. When a new form of healthcare is introduced to a society with an established culture, it immediately gives an alternative to traditional ideas about disease and its remedies. Whether people will choose the new or old will demonstrate their basic belief and hopes (Lucas, 2003). They will soon learn which modern treatment is effective and which is apparently ineffective or slow in producing results. They will make of the new system only for limited range of defined disorders, preferring their familiar traditional remedies and practitioners for everything else, chiefly because the traditional methods and remedies closely respond to the basic ideas of their society. Thus, this study will identify the cultural beliefs on maternal and newborn health care that are still being used at present. Moreover, the extent of practice of the cultural beliefs on maternal and newborn healthcare will be determined.

10 Conceptual Framework The structure of this study is based on Leininger’s Culture Care Theory (1991, 1995a, 1995b, 1997). Leininger (1991, 1995a) underlines the meaning and importance of culture in explaining an individual’s health and caring behaviour, and her Culture Care Theory is the only nursing theory that focuses on culture. (Rosenbaum 1997.) The roots of the theory are in clinical nursing practice: Leininger discovered that patients from diverse cultures valued care more than the nurses did. Gradually, Leininger became convinced about the need for a theoretical framework to discover, explain, and predict dimensions of care, and developed the Culture Care Theory as the outcome of studies performed in numerous Western and non-Western cultures. (Leininger 1997.) In her Culture Care Theory, Leininger states that caring is the essence of nursing and unique to nursing. (Leininger 1978, 1981, 1984, 1988, 1991, 1995a,b, Reynolds 1995.) Leininger (1997) actually criticizes the four nursing metaparadigm concepts of person, environment, health and nursing (Fawcett 1989.) First, Leininger considers nursing a discipline and a profession, and the term ‘nursing’ thus cannot explain the phenomenon of nursing. Instead, care has the greatest epistemic and ontologic explanatory power to explain nursing. Leininger (1995a) views ‘caring’ as the verb counterpart to the noun ‘care’ and refers it to a feeling of compassion, interest and concern for people (Leininger 1970, Morse et al. 1990, Reynolds 1995, McCance et al. 1997). When Leininger’s definition of care is compared to other transcultural scholars’ definitions, it

11 appears that her view of care is wider than, for example, that of Orque et al. (1983), who describe care as goal-oriented nursing activities, in which the nurses recognize the patients’ ethnic and cultural features and integrate them into the nursing process. Second, the term ‘person’ is too limited and culture-bound to explain nursing, as the concept of ‘person’ does not exist in every culture. Leininger (1997) argues that nurses sometimes use ‘person’ to refer to families, groups, communities and collectivities, although each of the concepts is different in meaning from the term ‘person’. Third, the concept of ‘health’ is not distinct to nursing as many disciplines use the term. (Leininger 1997.) Fourth, instead of ‘environment’ Leininger uses the concept ‘environmental context’, which includes events with meanings and interpretations given to them in particular physical, ecological, sociopolitical and/or cultural settings. (Leininger 1991, 1995a,b, 1997.) Care always occurs in a cultural context. Culture is viewed as a framework people use to solve human problems. (Orque et al. 1983, Leininger 1991.) In that sense, culture is universal. It is also diverse, as Leininger (1991, 1995a, 1995b, 1997) refers culture to the specific pattern of behaviour which distinguishes any society from others. Transcultural scholars define culture by stressing behavioral aspects as an explicit form of it. Leininger (1997, 38) states that culture refers to “the lifeways of an individual or a group with reference to values, beliefs, norms, patterns, and practices” and agrees that culture is learnt by group members and transmitted to other group members or intergenerationally. Leininger (1991,

12 1995a) distinguishes between emic and ethic perspectives of culture. Emic refers to an insider’s views and knowledge of the culture, while ethic means the outsider’s viewpoints of the culture and reflects more on the professional angles of nursing. Apart from culture and environmental context, ethno history is also meaningful when examining care from the cultural perspective. (Leininger 1995a.) The environmental context, which includes physical, ecological, sociopolitical and cultural settings, gives meaning to human expressions of care. Ethno history refers to the past events and experiences of individuals or groups, which explain human lifeways within particular cultural contexts over short or long periods. Leininger (1991, 1995a, 1995b, 1997) has formulated several theoretical assumptions and orientational definitions to guide nurses in their discovery of culture care phenomena. The assumptions and definitions are derived from the theoretical conceptualizations and philosophical positions of the Culture Care Theory, and they are used as guides to systematic study of the theory. Strictly constructed theoretical formulations would be incongruent with the purposes of the qualitative paradigm. The following assumptions concerning care/caring were significant when planning the study: • care (caring) is essential to curing and healing, for there can be no curing without caring

13 • every human culture has lay (generic, folk or indigenous) care knowledge and practices and usually some professional care knowledge and practices, which vary transculturally • culture care values, beliefs, and practices are influenced by and tend to be embedded in the worldview, language, philosophy, religion (and spirituality), kinship, social, political, legal, educational, economic, technological ethnohistorical, and environmental contexts of cultures • a client who experiences nursing care that fails to be reasonably congruent with his/her beliefs, values, and caring lifeways will show signs of cultural conflict, noncompliance, stress and ethical or moral concern • the qualitative paradigm provides ways of knowing and discovering the epistemic and ontological dimensions of human care transculturally Leininger (1997) states that orientational definitions are more appropriate in the qualitative research paradigm than the rigid operational definitions typical of quantitative studies. Orientational definitions are used as guides for studying the domain related to the theory. The following orientational definitions (Leininger 1995a, 1995b) structure this study: • cultural and social structure dimensions refer to the dynamic, holistic, and interrelated features of culture (or subculture) related to religion or spirituality, kinship (social), political (and legal), economic, education,

14 technology, cultural values, language and ethnohistorical factors of different cultures • professional care systems refer to formally taught, learnt and transmitted professional care, health, illness, wellness and related knowledge and practical skills that prevail in professional institutions lay care systems refer to culturally learnt and transmitted knowledge and skills used to provide assistive, supportive, enabling or facilitative acts towards or for another individual or group to improve a human life way, health condition or to deal with handicaps and death. The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals. The HBM is based on the understanding that a person will take a healthrelated action if that person: 1. Feels that a negative health condition can be avoided, 2. Has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition; and 3. Believes that he/she can successfully take a recommended health action (i.e., he/she can use condoms comfortably and with confidence). The HBM was spelled out in terms of four constructs representing the perceived threat and net benefits: perceived susceptibility, perceived severity,

15 perceived benefits, and perceived barriers. These concepts were proposed as accounting for people's "readiness to act." An added concept, cues to action, would activate that readiness and stimulate overt behavior. A recent addition to the HBM is the concept of self-efficacy, or one's confidence in the ability to successfully perform an action. This concept was added by Rosenstock and others in 1988 to help the HBM better fit the challenges of changing habitual unhealthy behaviors, such as being sedentary, smoking, or overeating (Raven, 2008). Culture Cultures are complex and multifaceted. As is apparent from the above discussions, cultures are complex “structures” that consist of a wide array of characteristics. The cultures of relationships or groups are relatively simple compared to those of organizations and, especially, societies. Edward Hall (1959, 1979) is one of the most significant contributors to the general understanding of the complexity of culture and the importance of communication to understanding and dealing with cultural differences at the societal level. Cultures are subjective. There is a tendency to assume that the elements of one’s own cultures are logical and make good sense. It follows that if other cultures—whether of relationships, groups, organizations, or societies—look different, those differences are often considered to be negative, illogical, and sometimes nonsensical. If, for example, an individual happens to be in a romantic relationship that is characterized by public displays of affection, that person might think that the behaviors of other people who have more reserved relational

16 cultures may seem strange, even inappropriate. The person might wonder why a romantic couple would not be more open in displaying affection to one another in public. The individual might even be tempted to conclude that the “reserved” relationship lacks depth and intensity. This phenomenon is true in a variety of situations. People who are used to informal meetings of a group might think that adherence to formal meeting rules is strange and stilted. Employees in an organization where suits are worn every day may react with cynicism and questioning when they enter an organization where casual attire is standard practice. Someone from a culture that permits one man to have only one wife may find it quite inappropriate that another culture allows one man to have multiple wives. With regard to culture, the tendency for many people is to equate “different” with “wrong,” even though all cultural elements come about through essentially identical communication processes (Kanitsaki, 2002). Cultures change over time. In fact, cultures are ever changing—though the change is sometimes very slow and imperceptible. Many forces influence cultural change. As indicated above, cultures are created through communication, and it is also through communication between individuals that cultures change over time. Each person involved in a communication encounter brings the sum of his or her own experiences from other (past or present) culture memberships. In one sense, any encounter between individuals in new relationships, groups, organizations, or societies is an intercultural communication event, and these varying cultural encounters influence the individual and the cultures over time. Travel and

17 communication technologies greatly accelerate the movement of messages from one cultural context to another, and in small and large ways, cultures come to influence one another through communication. Phrases such as “melting pot,” “world community,” and “global village” speak to the inevitability of intercultural influence and change (Bullivant, 2000). Cultures are largely invisible. Much of what characterizes cultures of relationships, groups, organizations, or societies is invisible to its members, much as the air is invisible to those who breathe it. Language, of course, is visible, as are greeting conventions, special symbols, places, and spaces. However, the special and defining meanings that these symbols, greetings, places, and spaces have for individuals in a culture are far less visible. For example, one can observe individuals kissing when they greet, but unless one has a good deal more cultural knowledge, it is difficult to determine what the behavior means in the context of the culture of their relationship, group, organization, or society. In other words, it is difficult to tell, without more cultural knowledge, if the kiss is a customary greeting among casual acquaintances or if such a greeting would be reserved for family members or lovers. As another example, beefsteak is thought of as an excellent food in some cultures. However, if one were a vegetarian or a member of a culture where the cow is sacred, that same steak would have an entirely different cultural meaning (Midgley, 1993). Health

18 Health is the general condition of a person in all aspects. It is also a level of functional and/or metabolic efficiency of an organism, often implicitly human. At the time of the creation of the World Health Organization (WHO), in 1948, health was defined as being "a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity". In 1986, the WHO, in the Ottawa Charter for Health Promotion, said that health is "a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities." Classification systems such as the WHO Family of International Classifications (WHO-FIC), which is composed of the International Classification of Functioning, Disability, and Health (ICF) and the International Classification of Diseases (ICD) also define health. Health is not only physical or mental health per se – health is also situated in a cultural context. The anthropological examination of health involves also norms, worldview, power structures, the role of beliefs, practices (Jocano, 2007). Nutrition Nutrition (also called nourishment or aliment) is the provision, to cells and organisms, of the materials necessary (in the form of food) to support life. Many common health problems can be prevented or alleviated with a healthy diet (Marcia, 2000). The diet of an organism is what it eats, and is largely determined by the perceived palatability of foods. Dietitians are health professionals who specialize

19 in human nutrition, meal planning, economics, and preparation. They are trained to provide safe, evidence-based dietary advice and management to individuals (in health and disease), as well as to institutions (McDowell, 2000). A poor diet can have an injurious impact on health, causing deficiency diseases such as scurvy, beriberi, and kwashiorkor; health-threatening conditions like obesity and metabolic syndrome, and such common chronic systemic diseases as cardiovascular disease, diabetes, and osteoporosis (Rudman, 2002). Hygiene Hygiene is the practice of keeping the body clean to prevent infection and illness, and the avoidance of contact with infectious agents. Hygiene practices include bathing, brushing and flossing teeth, washing hands especially before eating, washing food before it is eaten, cleaning food preparation utensils and surfaces before and after preparing meals, and many others (Eichner, 2005). This may help prevent infection and illness. By cleaning the body, dead skin cells are washed away with the germs, reducing their chance of entering the body. Hygiene is an old concept related to medicine, as well as to personal and professional care practices related to most aspects of living, although it is most often wrongly associated with cleanliness. In medicine, hygiene practices are employed as preventative measures to reduce the incidence and spreading of disease (Herman, 2003). Other uses of the term appear in phrases including: body hygiene, mental hygiene, domestic hygiene, dental hygiene, and occupational hygiene, used in connection with public health. The term "hygiene" is derived

20 from Hygeia, the Greek goddess of health, cleanliness and sanitation. Hygiene is also the name of a branch of science that deals with the promotion and preservation of health, also called hygienic (Mitchell, 2000). Hygiene practices vary widely, and what is considered acceptable in one culture might not be acceptable in another. Hygiene refers to the importance of cleanliness in maintaining health. Encouraging children’s personal hygiene habits is a day to day issue that parents and careers need to reinforce and practice so they and the children in their care can stay healthy and avoid illnesses and infections (Medibank, 2008). Effective personal hygiene habits in childhood are likely to establish an attitude to personal cleanliness that will extend into adulthood and help avoid common illnesses, so encouraging behaviors such as covering the mouth when coughing and using a tissue when sneezing can avoid spreading colds and flu (Stabler, 2006). Taking a proactive approach towards child hygiene is important. With many different illnesses and infections around at various times of year, the best preventative measure you can take in looking after your own and your children’s immune systems is to maintain high standards of personal and child hygiene (Evans, 2001). Children’s hygiene practices are everyday habits that need to be established and reinforced. Helping establish a child’s personal hygiene routine can be a rewarding experience, as a child learns responsibility over that routine.

21 Most children enjoy taking a bath or shower and helping children develop good personal hygiene habits can help them learn how important these habits are (Crane, 2000). Educating young children about children’s hygiene helps them understand the links between cleanliness and staying healthy. One important feature of children’s hygiene is the need to get into a routine of brushing teeth. Taking care with this ritual should help the development of healthy adult teeth. Children need to brush their teeth at least twice a day and so become aware of the importance of this aspect of hygiene for children in helping to prevent tooth damage and decay Evans, 2000). Another simple precaution that assists in child hygiene includes getting children into the habit of washing their hands after using the toilet, and into a regular habit of washing their hands after playing with pets, coughing or sneezing, and before eating or handling food (Crane, 2000). Children’s personal hygiene practices are simple and easy for young children to understand when they focus on things like washing hands. The most important feature of child hygiene is to make sure that good habits in personal health are encouraged, and children’s personal hygiene standards are met with approval. The habits formed in children’s hygiene routines early in life should help them stay healthy in the future (Clark, 2004). Maternal and Child Health Maternal and Child Health (MCH) refers to a package of comprehensive health care services which are developed to meet promotive, preventive, curative,

22 rehabilitative health care of mothers and children. It includes the sub areas of maternal health, child health, family planning, school health and health aspects of the adolescents, handicapped children and care for children in special settings (WHO, 2005). In addition, maternal mortality refers to those deaths which are caused by complications due to pregnancy or childbirth. These complications may be experienced during pregnancy or delivery itself, or may occur up to 42 days following childbirth. For each woman who succumbs to maternal death, many more will suffer injuries, infections, and disabilities brought about by pregnancy or childbirth complications, such as obstetric fistula. In most cases, however, maternal mortality and disability can be prevented with appropriate health interventions (Berlin, 2003). Some of the direct medical causes of maternal mortality include hemorrhage or bleeding, infection, unsafe abortion,

hypertensive disorders, and obstructed labor. Other causes include ectopic pregnancy, embolism, and anesthesia related risks. Conditions such as anemia, diabetes, malaria, sexually transmitted infections (STIs), and others can also increase a woman’s risk for complications during pregnancy and childbirth, and, thus, are indirect causes of maternal mortality and morbidity (Rogers, 2007). Since most maternal deaths occur during delivery and during the postpartum period, emergency obstetric care, skilled birth attendants, postpartum care, and transportation to medical facilities if complications arise are all necessary components of strategies to reduce maternal mortality.

23 These services are often particularly limited in rural areas, so special steps must be taken to increase the availability of services in those areas. Efforts to reduce maternal mortality and morbidity must also address societal and cultural factors that impact women’s health and their access to services (Swedo, 2006). Women’s low status in society, lack of access to and control over resources, limited educational opportunities, poor nutrition, and lack of decision-making power contribute significantly to adverse pregnancy outcomes. Laws and policies, such as those that require a woman to first obtain permission from her husband or parents, may also discourage women and girls from seeking needed health care services – particularly if they are of a sensitive nature, such as family planning, abortion services, or treatment of STIs. One traditional practice that affects maternal health outcomes is early marriage. Many women in developing countries marry before the age of 20. Pregnancies in adolescent girls, whose bodies are still growing and developing, put both the mothers and their babies at risk for negative health consequences (Jones, 2001). The consequences of maternal mortality and morbidity are felt not only by women but also by their families and communities (Patney, 2005). Children who lose their mothers are at an increased risk for death or other problems, such as malnutrition. Loss of women during their most productive years also means a loss of resources for the entire society.

24 Ensuring safe motherhood requires recognizing and supporting the rights of women and girls to lead healthy lives in which they have control over the resources and decisions that impact their health and safety. It requires raising awareness of complications associated with pregnancy and childbirth, providing access to high quality health services (antenatal, delivery, postpartum, family planning, etc.), and eliminating harmful practices. Maternal Health Maternal Health is now referred as “Reproductive Health” (RH). According to World Health Organization (WHO, 2001), it is defined as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity in all matters relating to the reproductive system and its functions and processes. It implies that people are able to have a satisfying and safe sex life, are informed about to have access to safe, effective, affordable and acceptable methods of family planning as well as other methods of their choice for regulation of fertility which are not against the law, are able to have access to appropriate health care services that will enable women to go safely through pregnancy and child birth and provide couples with the best chance of having healthy babies. Reproductive Health (Ras, 2006) is defined as “People have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and child birth safely, the outcome of pregnancies is successful in terms of

25 maternal and infant survival and well being and couples are able to have sexual relations free of fear of pregnancy and of contracting diseases.” Disease or Illness Management Disease management is defined as "a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant." It is the process of reducing healthcare costs and/or improving quality of life for individuals by preventing or minimizing the effects of a disease, usually a chronic condition, through integrative care (Kamalam, 2005). Disease Prevention Preventive medicine or preventive care refers to measures taken to prevent diseases, (or injuries) rather than curing them or treating their symptoms. The term contrasts in method with curative and palliative medicine, and in scope with public health methods (which work at the level of population health rather than individual health) (Gulani, 2005).


Independent Variables Cultural Beliefs • Maternal Health Care • Newborn Health Care Demographic Factors • • • Age Religion Educational Attainment • Occupation

Dependent Variables Extent of practice • • • Always Often Never

Figure 1. Paradigm showing the relationship of variables in the study.

Paradigm of the Study The paradigm of the study will comprise the independent, dependent and intervening variables.

27 The dependent variables in the study will be the extent of practice of cultural beliefs on maternal and newborn health care. On the other hand, the independent variables will comprise the cultural approaches which will include the beliefs and practices. Moreover, it will also include the respondent’s age, religion, educational attainment and occupation. Statement of the Problem Primarily, this study will determine the extent of practice of cultural beliefs on maternal and newborn health care. Specifically, it will seek to answer the following questions: 1. What are the cultural beliefs on maternal and newborn health care that are still being practiced at present? 2. What is the extent of practice of cultural beliefs on maternal and child newborn health care? 3. What is the difference on the extent of practice of cultural beliefs on maternal and newborn health care when the following variables are taken into consideration: a. Age b. Religion c. Educational attainment d. Occupation Hypotheses of the Study

28 Based on the problems of the study, the following hypotheses were formulated for testing: 1. The cultural beliefs on maternal and newborn health care are still being practiced at present. 2. The perceived extent of practice of cultural beliefs on maternal and newborn health care is often. 3. There is a significant difference on the extent of practice of cultural beliefs on maternal and newborn health care when the following variables are taken into consideration: a. Age b. Religion c. Educational attainment d. Occupation

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