Measuring stage of pregnancy
When asked how they measured their pregnancy, most women said "by moon" and/or calendar months. They and their husbands monitored their menstrual cycle because they were not allowed to sleep with their husbands, pray or do other household tasks when menstruating. A men's focus group identified one of the problems of identifying stage of pregnancy when relying on calendar months: "There are some women who will see their period at the beginning of the month, others will see it around day fifteen, others will have it around day twenty five .... In a case where pregnancy reduces (ie the period occurs early in the month), some women may go up to 10 or 11 months before they deliver." [JKMFG-4].
Stages of foetal growth
Foetal growth was described following Islamic tradition as water, clot, piece of meat and human being. These stages were recognized by all men and women of different ages. Men were more consistent about the order of these events but not their timing. Among women there was little consensus about the timing or order in which these stages occurred (Table , a-d), and as an understanding of basic embryology was not part of TBA training, their views were similar to those of other older women. Adolescent girls were particularly vague about foetal growth stages. "Quickening" or the first movement of the foetus, which health workers partly relied on as an indicator for giving the first IPTp dose, was not consistently associated with any particular stage of pregnancy by women. The baby was described as kicking or "shaking" at various times after three months (Table , a-d). Generally the foetus was not regarded as human before the fourth month.
Description of stages of foetal growth by different groups
Effects of malaria on the foetus
Men and women were able to list the common signs of malaria such as shivering, fever, vomiting, joint pain, general body weakness. They knew it caused anaemia and pre-term birth and that bed nets offered protection. They had some idea of the mechanisms by which malaria caused illness in a pregnant woman and foetus. One man, recounting how his brother-in-law's pregnant wife had to go to hospital with malaria, had been told that malaria reduced the blood by 60%, but was puzzled and asked "How can that be possible?" My brother in-law said different parts of the body start pulling against each other, and that affects the blood." [JKMFG-3]
Malaria was considered to affect the foetus indirectly. When young women were asked, "Do foetuses get sick in the womb?", one replied "Yes, it gets sick. It may be that it does not have the parasites but if the mother is not eating good food, that can make it get ill." [MYWFG-1]
Perceived safety of medications during pregnancy
Women were able to understand the concept that some drugs were contra-indicated early in pregnancy. There was general agreement that a local herb (jambakasala) "cleaned the baby" in utero and was safe even in the first month of pregnancy unlike another herbal remedy (katijangkumou) which could not be taken till later. Women named chloroquine/nivaquine as a western drug to be avoided during the first trimester because it was bitter, a characteristic associated with abortifacients. Some of the men thought that paracetamol also caused abortion.
TBAs actively encouraged women to go to ANC in the first trimester, "because doctors like that, so that she (the mother) can start treatment." [DTBAI-1] Men uniformly advised along similar lines, noting "You should start taking your medication at one to two or three months. That way they (health workers) can help you." [JKMFG-4] Despite this injunction, men had very little knowledge of the drugs given to women, other than describing their colour, and some idea that red ones were for blood. One said,
"My advice is to go to the clinic to see a nurse. Those people will tell her what to do and they will give her some medication." [JKMFG-3].
A similar view was as follows:
"Well, as human being we take those drugs with the hope that they are useful. I don't think if they are useless, the woman will have any cause to take them" [JJMFG].
Women were equally unclear about the drugs they were given and accepted their safety if given by a nurse or doctor at ANC. One group of TBAs thought that women were given "an injection for Jarrara "(cerebral malaria) [JOLITBA-1], which presumably was the routine tetanus toxoid vaccination. When asked "What are the medicines for?" typical replies were:"I don't know, but they said if I take them, my dizziness and shaking will go away" [JKYWI-3] and "The red tablet is for blood increase. The white tablet is for good health and the yellow tablet also serves the same purpose – strength and good health." [JKYWI-4]
Knowledge of IPTp dosing schedules
The fact that malaria causes anaemia and that iron prevents anaemia led to some confusion about the difference between anti-malarial and iron treatments. When asked about the month when IPTp was first given, one comment was as follows:
"On one occasion I was at four months, some other occasions, if I bought a ticket (for ANC registration) and I had normal health, they wouldn't give it to me. But as time went on, they would check my blood to see whether it was going up or down. Then they would start giving it to me." [JK0WFG-1 Women's reports of how many doses of IPTp they had received were unreliable. Some older women claimed they had received as many as five doses. [JKOWFG-1] Younger women generally knew that they should get two doses, but even this was disputed, as shown in the following conversation:
"How many times do you take your malaria medication?"
"It was supposed to be three. If you take anti-malarial drugs during the first three months, the effects of the drugs lessen the severity even if you have parasites in your blood. The second dose provides you longer protection. If you complete the third dose, even if you have parasites in the blood, they will not harm you." [MdYWFG-1]
Women consistently said they did not know when to take IPTp.
"How did you know it is time for you to take the second dose?"
"I don't know. I went to the Health Centre. I was given it by them when the time was right."
"Did you know, or have any idea when you should take the anti-malarial drug?
"No idea." [JWYI-1]
When asked how she knew it was right time for IPTp, another said "When I came here for the first time they checked me and I was given the first dose. Then I came for the second, it was the same. I was given a second dose, but I cannot tell if it was the right time." [JWYI-2]