Annika Launiala1, Marja-Liisa Honkasalo2Article : 26 AUG 2010 Medical Anthropology Quarterly: Volume 24, Issue 3, pages 399–420, September 2010
Findings from a study designed to discover how local understanding of malaria among Yao in Malawi relate to pregnancy risk definitions reveal that malaria in pregnancy is not perceived as a major risk. Using extended ethnographic field research and multiple methods, we argue a shift from narrow single-disease approaches to malaria during pregnancy is required and document women's concerns about exposure to multiple vulnerabilities during pregnancy, including witchcraft, extramarital affairs, and multiple dangerous illnesses. Four dimensions are implicated in Yao perceptions of risk: perceived adverse consequences in pregnancy; ease of treatment and cure; transmission and agency to control; and type of risk (social–medical). We discuss implications and consider malaria program features needed to address the complexity of perceived vulnerabilities and living conditions in resource-poor settings.
In April 2007, one of my Malawian research assistants phoned with news of, I (principle author) thought, the expected birth of a son. He and his wife had honored me by inviting me to choose the baby's name, and I eagerly awaited news. Sadly, he said that Onni (the name I chose, happiness in Finnish) had died, only four days after birth.
We expected Onni in late May or early June. On April 5 my wife complained of fever, whereupon I advised her to seek medical attention at the Lungwena health center. There she was given SP (sulfadoxine pyrimethamine), but her condition did not improve. After three days we started to think that the situation was bad, and on April 9 she went back to the health center. From there she was referred to St. Martin's mission hospital where she delivered after a hard struggle, just barely escaping surgery, but thank God she gave birth to a baby boy who weighed 2700g. Two days later she and Onni were discharged from the hospital. The problems started at home. My wife tried to breastfeed Onni, and at first it seemed to go well. But on the following night Onni became feverish and refused to suckle at her breast. In the morning we went to the Lungwena health center from where we were again referred to St. Martin's mission hospital. After some examinations the personnel found that Onni was suffering from malaria, and his temperature kept rising. Both my wife and Onni were given some treatment and admitted to the ward. I left for home around 4 pm and at that time Onni seemed to be improving. The following morning I was getting prepared to go to the hospital when they arrived with the corpse. They told me that Onni had died during the night, April 12.
Onni's untimely death propelled deeper reflections about my presumptions that malaria is perceived by everyone in Malawi as a major problem, one with dire consequences for pregnant women and young children. Despite, perhaps because of, my prior role as a UNICEF project officer responsible for malaria prevention activities, I had not questioned the disease focus. As the need is great to reduce the heavy burden of malaria in Malawi and sub-Saharan Africa where 25 million women become pregnant annually and are at risk of malaria, which significantly contributes to maternal and neonatal morbidity and mortality (Dellicour et al. 2010; Rogerson et al. 2007). Onni's death made me wonder what factors influence women's ability and motivations for malaria prevention during pregnancy, what kinds of local perceptions of pregnancy risks and vulnerabilities women have, how malaria during pregnancy is related to them, and more importantly how they match with the “at risk” approach used by international organizations and program planners.
This article examines the multiple dimensions in local perceptions of risk and shows why the Yao people of rural Malawi do not perceive malaria in pregnancy as a major risk. We do this by moving beyond the conventional single-disease approach and explore malaria in the context of pregnancy. We pay attention to the perceived vulnerabilities—witchcraft, extramarital relationships, multiple illnesses, and worries in pregnant Yao women's everyday lives—and examine how malaria is associated with these vulnerabilities. To reach a comprehensive understanding of risk perceptions, we investigate these issues from multiple perspectives among the Yao, including those of men, older women, pregnant women, and women of reproductive age as “it is the diversity in the experience and perceptions to risk that are important” (Nichter 2003:28). The following research questions guided our research: What kinds of vulnerabilities are pregnant women perceived to be exposed to in the communities? What local illnesses are perceived to be dangerous for pregnant women, why, and is malaria among these illnesses? What are the major worries among women and men related to pregnancy?
In international health, epidemiological approaches to risk dominate. Risk is calculated as a probability in terms of the odds that something will occur (or will not occur) within a given population exposed to specific risk factors relative to a reference population and perceived risk (Frankenberg 1993:229; Gordis 2004). Frankenberg describes the risk approach in epidemiology as a way of justifying a medical intervention (1993:233). Anthropologists criticize the epidemiological risk definitions for its neglect of the sociocultural settings where risk is understood and negotiated and for failing to account for heterogeneity and variations in meanings of risk among groups (Frankenberg 1993; Lupton 1999:24; Trostle 2005:161).
Mary Douglas's pioneering work (1992) galvanized medical anthropologists to deeply engage the notion of risk, also referred to as hazard, chance, uncertainty, and danger (Lupton 1999:8–9; Nichter 2008). Advances in our understanding of risk have come as studies pursue several perspectives. Some examine risk through the notion of uncertainty and its manifestations in everyday life (Bledsoe 2002; Haram 2005; Honkasalo 2006; Whyte 1997; see also Caplan 2000). Others demonstrate how social threats and risks influence treatment-seeking and prevention practices and how they can outweigh physical and biological risks (Bujra 2000; Chapman 2006; Nichter 2003:29, 2008:58–59). According to Nichter (2003:29), it is important to notice when social risks (“risk to valued relationship” as defined by Nichter 2008:58) outweigh biologized and medicalized risk categories prioritized in public health settings. This enables us to understand why certain preventive methods are accepted and others not. It is also important to note that risks are valued and prioritized differently based on their relevance at a given time, rather than actively considered simultaneously all the time. Nichter (2008:60) refers to hierarchies of risks: “how risk is judged in context as well as in relation to other risks rather than in isolation” (see also Day 2000). Furthermore, some medical anthropologists have emphasized that a comprehensive understanding of risk perceptions and factors affecting exposure to risk also requires examination of structural forces—poverty, inequality, and livelihood insecurity—that all impinge on access to health care. In other words, risk is located in the living conditions in which it occurs and investigated in a larger framework of vulnerability and agencies of power (Farmer et al. 2006; Obrist et al. 2007; Sommerfeld et al. 2002).
There is virtually no research exploring risk perceptions of and vulnerability to malaria in pregnancy. Instead, social scientists have focused more narrowly on malaria, its meaning and influence on illness experiences, treatment-seeking practices, and prevention among children under five (Ribera et al. 2007; Williams and Jones 2004). The few social scientific studies on pregnant women and malaria have examined treatment-seeking practices (Ahorlu et al. 2007), use of antenatal services (Launiala and Honkasalo 2007; Ndyomugyenyi et al. 1998), compliance with intermittent preventive treatment in pregnancy (Helitzer-Allen et al. 1994; Launiala and Honkasalo 2007; Mbonye et al. 2006; Mnyika et al. 1995), and perceptions of malaria in pregnancy (Launiala and Kulmala 2006; Winch et al. 1996). Yet, understanding experiences of vulnerability and perceived risks in a particular sociocultural and structural context are important as they influence how people respond to public health interventions such as prevention of malaria in pregnancy (Nichter 2008:11, 50).
http://onlinelibrary.wiley.com/doi/10.1111/j.1548-1387.2010.01111.x/full
Findings from a study designed to discover how local understanding of malaria among Yao in Malawi relate to pregnancy risk definitions reveal that malaria in pregnancy is not perceived as a major risk. Using extended ethnographic field research and multiple methods, we argue a shift from narrow single-disease approaches to malaria during pregnancy is required and document women's concerns about exposure to multiple vulnerabilities during pregnancy, including witchcraft, extramarital affairs, and multiple dangerous illnesses. Four dimensions are implicated in Yao perceptions of risk: perceived adverse consequences in pregnancy; ease of treatment and cure; transmission and agency to control; and type of risk (social–medical). We discuss implications and consider malaria program features needed to address the complexity of perceived vulnerabilities and living conditions in resource-poor settings.
In April 2007, one of my Malawian research assistants phoned with news of, I (principle author) thought, the expected birth of a son. He and his wife had honored me by inviting me to choose the baby's name, and I eagerly awaited news. Sadly, he said that Onni (the name I chose, happiness in Finnish) had died, only four days after birth.
We expected Onni in late May or early June. On April 5 my wife complained of fever, whereupon I advised her to seek medical attention at the Lungwena health center. There she was given SP (sulfadoxine pyrimethamine), but her condition did not improve. After three days we started to think that the situation was bad, and on April 9 she went back to the health center. From there she was referred to St. Martin's mission hospital where she delivered after a hard struggle, just barely escaping surgery, but thank God she gave birth to a baby boy who weighed 2700g. Two days later she and Onni were discharged from the hospital. The problems started at home. My wife tried to breastfeed Onni, and at first it seemed to go well. But on the following night Onni became feverish and refused to suckle at her breast. In the morning we went to the Lungwena health center from where we were again referred to St. Martin's mission hospital. After some examinations the personnel found that Onni was suffering from malaria, and his temperature kept rising. Both my wife and Onni were given some treatment and admitted to the ward. I left for home around 4 pm and at that time Onni seemed to be improving. The following morning I was getting prepared to go to the hospital when they arrived with the corpse. They told me that Onni had died during the night, April 12.
Onni's untimely death propelled deeper reflections about my presumptions that malaria is perceived by everyone in Malawi as a major problem, one with dire consequences for pregnant women and young children. Despite, perhaps because of, my prior role as a UNICEF project officer responsible for malaria prevention activities, I had not questioned the disease focus. As the need is great to reduce the heavy burden of malaria in Malawi and sub-Saharan Africa where 25 million women become pregnant annually and are at risk of malaria, which significantly contributes to maternal and neonatal morbidity and mortality (Dellicour et al. 2010; Rogerson et al. 2007). Onni's death made me wonder what factors influence women's ability and motivations for malaria prevention during pregnancy, what kinds of local perceptions of pregnancy risks and vulnerabilities women have, how malaria during pregnancy is related to them, and more importantly how they match with the “at risk” approach used by international organizations and program planners.
This article examines the multiple dimensions in local perceptions of risk and shows why the Yao people of rural Malawi do not perceive malaria in pregnancy as a major risk. We do this by moving beyond the conventional single-disease approach and explore malaria in the context of pregnancy. We pay attention to the perceived vulnerabilities—witchcraft, extramarital relationships, multiple illnesses, and worries in pregnant Yao women's everyday lives—and examine how malaria is associated with these vulnerabilities. To reach a comprehensive understanding of risk perceptions, we investigate these issues from multiple perspectives among the Yao, including those of men, older women, pregnant women, and women of reproductive age as “it is the diversity in the experience and perceptions to risk that are important” (Nichter 2003:28). The following research questions guided our research: What kinds of vulnerabilities are pregnant women perceived to be exposed to in the communities? What local illnesses are perceived to be dangerous for pregnant women, why, and is malaria among these illnesses? What are the major worries among women and men related to pregnancy?
In international health, epidemiological approaches to risk dominate. Risk is calculated as a probability in terms of the odds that something will occur (or will not occur) within a given population exposed to specific risk factors relative to a reference population and perceived risk (Frankenberg 1993:229; Gordis 2004). Frankenberg describes the risk approach in epidemiology as a way of justifying a medical intervention (1993:233). Anthropologists criticize the epidemiological risk definitions for its neglect of the sociocultural settings where risk is understood and negotiated and for failing to account for heterogeneity and variations in meanings of risk among groups (Frankenberg 1993; Lupton 1999:24; Trostle 2005:161).
Mary Douglas's pioneering work (1992) galvanized medical anthropologists to deeply engage the notion of risk, also referred to as hazard, chance, uncertainty, and danger (Lupton 1999:8–9; Nichter 2008). Advances in our understanding of risk have come as studies pursue several perspectives. Some examine risk through the notion of uncertainty and its manifestations in everyday life (Bledsoe 2002; Haram 2005; Honkasalo 2006; Whyte 1997; see also Caplan 2000). Others demonstrate how social threats and risks influence treatment-seeking and prevention practices and how they can outweigh physical and biological risks (Bujra 2000; Chapman 2006; Nichter 2003:29, 2008:58–59). According to Nichter (2003:29), it is important to notice when social risks (“risk to valued relationship” as defined by Nichter 2008:58) outweigh biologized and medicalized risk categories prioritized in public health settings. This enables us to understand why certain preventive methods are accepted and others not. It is also important to note that risks are valued and prioritized differently based on their relevance at a given time, rather than actively considered simultaneously all the time. Nichter (2008:60) refers to hierarchies of risks: “how risk is judged in context as well as in relation to other risks rather than in isolation” (see also Day 2000). Furthermore, some medical anthropologists have emphasized that a comprehensive understanding of risk perceptions and factors affecting exposure to risk also requires examination of structural forces—poverty, inequality, and livelihood insecurity—that all impinge on access to health care. In other words, risk is located in the living conditions in which it occurs and investigated in a larger framework of vulnerability and agencies of power (Farmer et al. 2006; Obrist et al. 2007; Sommerfeld et al. 2002).
There is virtually no research exploring risk perceptions of and vulnerability to malaria in pregnancy. Instead, social scientists have focused more narrowly on malaria, its meaning and influence on illness experiences, treatment-seeking practices, and prevention among children under five (Ribera et al. 2007; Williams and Jones 2004). The few social scientific studies on pregnant women and malaria have examined treatment-seeking practices (Ahorlu et al. 2007), use of antenatal services (Launiala and Honkasalo 2007; Ndyomugyenyi et al. 1998), compliance with intermittent preventive treatment in pregnancy (Helitzer-Allen et al. 1994; Launiala and Honkasalo 2007; Mbonye et al. 2006; Mnyika et al. 1995), and perceptions of malaria in pregnancy (Launiala and Kulmala 2006; Winch et al. 1996). Yet, understanding experiences of vulnerability and perceived risks in a particular sociocultural and structural context are important as they influence how people respond to public health interventions such as prevention of malaria in pregnancy (Nichter 2008:11, 50).
http://onlinelibrary.wiley.com/doi/10.1111/j.1548-1387.2010.01111.x/full
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