Objective: To explore the socio-cultural challenges in accessing antenatal care by pregnant Fulani women in Ibarapa Central Local Government, Oyo State, Nigeria

Methods: Qualitative research instruments were used to gather relevant data. All the participants were selected through purposive sampling. Twenty (20) in-depth interviews, two (2) focus group discussions and six (6) key informant interviews were conducted health officials, Fulani women and community leaders.

Results: Utilization of antenatal care is subject to socio-cultural factors which include cost of health services, attitudes of health workers, communication barrier, culture of pain suppression, patriarchy and culture of shyness.

Conclusions: Policies and interventions aiming at addressing the cost of health services must be formulated and well-implemented. Health workers should be culturally competent when carrying out their duties. The male’s role in reproductive health and other health issues should not be sidelined. Health campaigns, education and counseling need to be intensified to address the challenge of the culture of pain suppression and culture of shyness in the utilization of antenatal care services.

•    Antenatal Care
•    Challenges
•    Utilization

Ogundairo JA, Jegede AS (2016) Socio-Cultural Challenges in Accessing Antenatal Care by Pregnant Fulani Women in Ibarapa Central Local Government, Oyo-State, Nigeria. Ann Public Health Res 3(3): 1043.

Antenatal care has been noted to be of paramount importance to women during pregnancy. It’s utilization will have far reaching effects on achieving the target 1 of the Sustainable Development Goal 3 which is to “ensure healthy lives and promote well-being for all at all ages” [1]. The goal identified the crucial place of a woman’s health in the community and the nation at large as two (2) out of the thirteen (13) targets under the goals focus specifically on women. Target 1 is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 while target 7 aimed “by 2030, to ensure universal access to sexual and reproductive health care services including for family planning, information and education, and the integration of reproductive health into national strategies and programs”[1]. Target 7 of the SDGs is similar to the MDG target 5b which is to achieve, by 2015 universal access to reproductive health. One of the indicators under this target is antenatal care coverage (at least four visits) [2]. Several studies have linked increased accessibility and utilization of antenatal care to improvement of maternal and child health [3-6]. This can be explained by the accessibility to the services included in the antenatal care package. These services include early detection of high-risk pregnancies, routine measurement of weight and blood pressure, abdominal examinations, vaccination against tetanus and the prevention and treatment of HIV/AIDs [7]. Antenatal care attendance offers diverse opportunities to reach pregnant mothers with information on any labor related risks. It also acts as an avenue of promoting delivery with the assistance of a skilled health-care provider [8-10]. In Nigeria, the recommended four antenatal care visits by WHO was adopted by the health care delivery system. Each visit has different maternal and child health goals [7]. However, several issues have been raised in the utilization of ANC services in the country. Maternal mortality still remains a threat to the nation’s health care delivery system and the nation’s development despite several maternal health policies and programs that were introduced. There are reports of none or under-utilization of antenatal care services [11]. It should be noted that the provision of health services does not translate to utilization. The utilization of ANC is subject to many socio-cultural factors which include religion, culture, educational status, cost of services, location of facilities, poor knowledge of pregnancy and health facilities, age of mother, parity, social support, patriarchy, cultural beliefs and practices, religious beliefs and practices, social perception of pregnancy by pregnant [12-17].

Studies on the challenges in the utilization of antenatal care in Nigeria have not really focused on ethnic minorities in host communities. However, this is important because Nigeria is an ethnically diverse nation. There has been movement of ethnic group from one place to due to economic activities and other factors. In the utilization of antenatal care services, this ethnic diversity must be taken into consideration. Based on this premise, the objective of this study was to explore the socio-cultural challenges faced by pregnant Fulani women in Ibarapa Central Local Government, Oyo State, Nigeria. This is expressed within the assumption that the pregnancy experiences of this women, who are ethnic minorities, may differ from other women in the local government area (LGA). The Fulani women in this study comprise Bororo and Fulani who are two groups speaking major dialects of Fulbe Language in the LGA. The Bororos are mostly migrants from Chad, Niger and Cameroon while the Fulanis are mostly migrants from the northern part of the country. They own herds of cattle but not as large as that of the Bororos. Some of them are also farmers mostly on subsistence level.

This research is an ethnographic inquiry into the sociocultural challenges amongst pregnant Fulani women in Ibarapa Central Local Government Area, Oyo-State, Nigeria. Qualitative research methods were used to gather relevant data. All the participants were selected through purposive sampling. 10 (ten) settlements, including 8 Fulani and 2 Bororo settlements, were randomly selected out of over twenty (20) settlements in the local governments. Twenty (20) selected women were sampled from the settlements and they granted in-depth interviews. Two focus group discussions (with six (6) women each) were also conducted. Two community leaders, four (4) health practitioners granted key informant interviews. Interviews and focus group discussions were recorded with the use of an electronic recorder. The data collected was transcribed. It was analyzed using verbatim quotation, thematic and content analysis. Ethical approval for this study was sought from University of Ibadan Social Sciences and Humanities Research Ethics Committee. The UI/Social Sciences Committee assigned number is UI/SSHEC/2015/0008. All the participants consented to participate in the study.

Social challenges in the utilization of antenatal care

Health is needed for proper functioning of the body system. This will afford individuals the opportunity to indulge in various activities that will contribute to both personal and societal development. In order to meet the health needs of the society, health institutions were created. However, the availability of health facilities only does not guarantee its utilization; there is also the issue of affordability. In a country where most of the citizens leave below one dollar pay day, affordability of health services is a major issue. One of the informants explained that:

Sickness is not something that will tell you that it is coming. And it is not everybody that has money but anybody can fall sick at any time. So that is why here our treatment is very cheap. This makes many people to come. Apart from that, we give them facilities for credit. When they come and they do not have all the money, we give them the opportunity to balance later (KII/ Health Care Provider/ Igboora).

The flexibility in the mode of payment made it easy for the Fulani women them to utilize antenatal care in private hospital because it provides such service for them. One of the informants indicated that:

You cannot go to maternity or general hospital and tell them that you will balance your fee later. You have to pay everything at one. But in private hospital, we have access to credit facilities (KII/ Community Leader/ Ekuku Settlement).

However, some of the participants are unable to afford the cost of services even though there is credit facility. This made some to resort to the utilization of free traditional medicine. The use of traditional medicine is also influenced by proximity to nature. This was explained by one of the interviewees:

It is not that we do not know the importance of utilization of ANC services. But what will you do, if you do not have the money? It is for you and your husband to enter bush and collect herbs. Thank God we have them in abundance here. God is just merciful. He knows that we do not have money and he blessed us with herbs and roots (IDI / Cheese Producer/Apata Settlement).

Apart from cost of service, communication barrier is also a challenge. Language is one of the mediums of communication. It influences social interaction. It bonds people together. All the health workers interviewed agreed that there is communication barrier.

Another problem I have with the Fulani is language barrier. Fortunately, I can speak little Hausa but most of my staff cannot do that. When I am not around, there is usually problem of communication (KII/ Health care provider/Igboora).

One of the in-depth interviewee also explained that:

The Fulanis that cannot speak Yoruba fluently prefers to go to where the doctor can speak Hausa, even if it is little. You know, for better diagnosis, you need to express yourself clearly (IDI/ Cheese hawker/ Yidi Settlement).

There is also the challenge of negative attitude of health workers. The health workers, most especially the ones in the public sector, are reported to be harsh. Majority of the women argued that this unfriendly attitude was found to be a major challenge in the utilization of antenatal care services. According to one of the interviewees:

I do not use either public or private hospital during antenatal or delivery. The nurses are too harsh for my liking. They will be hitting you anyhow. They will be shouting on you... They will want to put their hands in your private parts. This is totally against my cultural value (IDI/ Cheese hawker/ Ekuku Settlement).

The attitude of the health workers is also reported to be laced with ethnocentrism. Culture defines man. It stipulates man’s behavior and action in the society. Culture differs from place to place and from society to society. Therefore, it is wrong to expect people from different cultures to act alike. It is wrong to believe that one’s culture is superior and therefore treat others as inferiors. In this study, ethnocentrism underlies the social interaction between the nomadic Fulani’s and the communities they reside even as it regards to the utilization of health facilities. This has influenced the women to utilize private hospital more than government hospital. One of the interviewees explained that:

As a person, I do not like public hospitals. They health workers are just too harsh. They see you as being inferior because you are Fulani woman. They talk to you anyhow. They do not treat our husband with respect. But in private hospital, we are welcome anytime any day. The nurses there are not harsh they don’t shout on you (IDI/Oniya Settlement/Cheese producer/2015).

Speaking on positive disposition to the women, one of the private health practitioners interviewed explained that:

On the attitude of health workers, we are always accommodating. They are rough, they have their own habits which government hospital will not be able to accommodate. If they do not go to public hospitals, salaries of the workers will still be paid. But we accommodate them because we know that if we chase them away we would not have our salaries. So we always tolerate them. By the time we are richer, we are going to build separate ward for them. But for the main time, we beg our people to tolerate them (KII/Health Care Provider/Igboora).

Speaking further, one of informants added that:

Our tradition here is that whether you are hausa, or fulani or any tribe you may be people are treated equally. In other places, they see them or most people consider them as being equal to animals. Not understanding the fact that it is the environment that they live in that influence their behavior and you only need a little time to educate them to see why they should not do certain things (KII/Health Care Provider/Igboora).

Cultural challenges

Fulanis are noted to be naturally shy. The culture of shyness most times does not make them to turn up for antenatal care and delivery early unless they have complications. One of the informants stated that:

We guard our genitals jealously. Strangers are not supposed to see them. I do not like antenatal care because the health workers will want to examine my private parts. It is against our culture (IDI/Cheese Hawker/Igboora).

Apart from the fear of being exposed unnecessarily, some of them are afraid of how they will merge in an unknown territory especially when they are referred to secondary or tertiary health institution. This was explained by one of the key informants:

Some do not come to hospital because they are shy most especially if they are referred to UCH in Ibadan for treatment. They will say I do not know how to get there, who will I meet? How do you want me to behave? I am a stranger. How will I do? What will I say? I am not a Yoruba woman. This is very common among the Fulanis (KII/Olugbon Medical Centre/ Nurse/2015).

Another cultural challenge is the culture of pain suppression. The Fulanis are known to have the ability to suppress pain until it becomes very unbearable. They hold the culture of pain suppression in high esteem. They see it as an advantage they have over ethnic groups. Most times, this makes them not to report for care or report late for treatment. One of the interviewees revealed that: Most of our women gave birth at home. We have the ability to suppress pain. It is part of our culture. It is a thing of pride. Sometimes, you don’t even know a woman is delivering next door until she finally delivered. So if you can deliver on your own, there is no need for antenatal care (IDI/Ekuku Settlement/ Cheese Hawker /2015). The Fulani society is a patriarchal society where decision making process is largely dominated by men in a patriarchal society. This has a very significant effect on the utilization of antenatal care services. Even after all the other factors have been taking care of, there is still need for the woman to seek for her husband’s permission. One of the discussants indicated that: It is the husband that has the final say. If he says I should not go, I cannot go. This means I have to make him see reason, plead with him to allow me go. But if he insists, I have no choice than to stay at home. But he gives me permission to go to hospital. Even if I do not want to go, I must go if he insists (FGD/Ekuku Settlement/Cheese hawker/2015). Another interviewee further stated that: During all my pregnancies, I did not attend hospital for antenatal, delivery or anything. Even for other sickness, I did not go to any hospital. This is because my husband is totally against it. I want to go like some of my fellow women do, but my husband said no. Now that he is dead, I attend hospital if I am not feeling fine, pregnant or not pregnant (IDI /Apata Settlement/ Farmer/2015).

Antenatal care is of sociological concern because social relationship and interaction underlies it. Findings from this study revealed diverse socio-cultural challenges faced by pregnant Fulani women in Ibarapa Central Local Government, Oyo-State, Nigeria. The study revealed that majority of the women took herbs during pregnancy. These findings are consistent with the findings of studies elsewhere [14,18]. This is linked to inability to afford the cost of health services. There is also the advantage of proximity to nature. The influence of cost of health care on utilization of health services have been confirmed in several findings [19-21]. However, none has mentioned the impact of flexible mode of payment on the utilization of health services. Due to the fact that most Fulanis store their money in form of their properties which is cattle, they do not readily have money for treatment when the need arises. The private practitioners, depending on the trust they have built over time, therefore offer credit facilities.

Furthermore, the study revealed that patriarchy also influence women’s health seeking behavior. Majority of the women said that they needed to get the consent of their husband before they seek antenatal care and other services at the hospital. This is consistent with the findings of a study in the northern part of Nigeria [22] and rural north India [23]. This is a reflection of the patriarchal structure of the society influencing social interaction between the women and the health facilities. The study also revealed that the culture of shyness and pain suppression influence the women’s utilization of antenatal services. The culture of pain suppression has also been confirmed in some studies [24,25]. Most of the women did not report early for antenatal care unless they have complication.

The influence of attitude of health workers on utilization of antenatal care was also emphasized by the study. This finding has also been confirmed by the several findings [26-30]. Majority of the women who utilized modern health facilities preferred private health facilities because the practitioners are accommodating no matter the ethnic background and cultural differences. Health workers are not expected to know about all cultures of their clients but they are however expected to use open communication, knowledge and respect when interacting with all clients [31]. Treatment was equally distributed among the women no matter the ethnic background. The study further revealed that communication barrier also affects utilization of antenatal care. This has been reported by [31] that women from a culturally and linguistically diverse (CALD) background in other cultures are less likely to access maternal and other health care services provided by health facilities due to language barrier.

Cost of health care services bars women from attending antenatal care. This places a burden on the government to provide alternatives to relieve the women of out-of –pocket financing of health services. The attitude of health workers goes a long in encouraging women, especially those from CALD background, to access health facilities. Therefore, health workers should be culturally competent when carrying out their duties. The impact of patriarchy on utilization of antenatal care cannot be over-emphasized. It influences social interaction between the women and the health facilities. This implies that the male’s role in reproductive health and other health issues should not be sidelined. Furthermore, health campaigns, health education and counseling needs to be intensified to address the challenge of the culture of pain suppression and culture of shyness in the utilization of antenatal care services.

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