By positive traditional practices, both women and men understood an assemblage of social practices and values as well as the specific resources and practices that help women through pregnancy and childbirth. The most fundamental traditional practice articulated by women is the social “Solidarity" of family and community translated generously in pregnancy, birth, and in the succeeding days and weeks. These are periods of vulnerability and risk, and birth of a baby is a joyful event that is shared by couples, extended family and the community. Social assistance is manifest in visits and in gifts of foods, soap, clothing, advice and actual care of the newborn. Such social assistance strengthens social ties and community – and is couched, too, in religious practices whether Islamic, Christian and traditional religious practice according to region and community. A second element to social assistance are the mutual associations that the majority of women join and that provide a platform for economic activity, be it working, saving or sharing. These help women directly around childbirth and the social networks and economic support provide women some autonomy (empowerment).

Structures of education that prepare a girl for married and reproductive life extend into the wider community 11. Such education covers, for example, the rights, responsibilities and propriety of a responsible mother; the cleaning, feeding, parenting skills; the responsible behaviors in adulthood including endurance and perseverance in work and honesty; the moral education promoting modesty and dignity. It covers, too, the pitfalls of improper moral and sexual conduct and how these are thought to be associated with complications in pregnancy and birth and with the wider community. This moral and institutional order curbs prostitution, rape, sexual and domestic violence and other forms of violence against women, particularly those who are pregnant or breastfeeding. It also give attention to the quality of drinking water; to hygiene and basic sanitation-hygiene rules (including hand washing before eating and after defecation) and careful hygiene around menstruation 12. It includes a zero tolerance of psychoactive substances such as tobacco, alcohol and drug consumption by girls and women. For Muslims, Koranic instruction for women includes learning virtuous verses, providing psychological support, and fasting restrictions associated with Ramadan are lifted in pregnancy and for new mothers. This education is acquired in the course of everyday life, but is given especially by those involved in events surrounding women’s initiation that involves female genital cutting – FGC 13.

A second arena of practices concerns dietary enhancements during pregnancy, for birth and during breastfeeding. According to region, women consume special foodstuffs and recipes, using herbs such as kinkélibala (Combretum micranthum), pellitoro (Hymenocardiaacidaspp.), guile (Solanum verbascifolium), Siminyi [Grewiamalacocarpa], suukoran (medicinal plant used by mothers), Shea Butter (Vitellaria paradoxa), chicken, honey, lemon and other fruits and vegetables. These are taken to prevent or treat particular complications of pregnancy, childbirth or related diseases (malaria, parasitizes, diarrhea) that themselves would complicate pregnancy. New mothers are offered enriched porridge. Elder women suggest foods that stimulate and enhance lactation (including peanuts, porridges) as well as herbal medicines. Such consumption in some regions extends to geophagy; the eating of earth, usually of termite mounds or the nests of mud daubing wasps that are rich in the minerals for which many women in these regions are otherwise critically deficient 14.

A third area of practices concerns birth spacing. Both women and men describe the ideal age for marriage and first pregnancy to be after first menstruation, rather than by age per se, though suggest this is usually between 15 and 17. Health professionals considered 18 as the ideal. For men interviewed is inconceivable to talk about ideal age of pregnancy outside questions of marriage. Women, on average, expressed a preference for a spacing of two years between births (or miscarriage) and to breastfeed for about a year. Ideally family size would be 2 sons and 2 daughters. Men, however, expressed ideals for more children (average 2.7 sons and 2.3 daughters) but recognise too the practical challenges to provide for their food, education and health. Men articulated a preference for a slightly shorter birth spacing of 18 months after a birth, and a much shorter one of only a few months after miscarriage.

The most cited practices to the enabling the birth spacing that guards women’s health is the ‘maternal holiday’ in which women are able to abstain from sex for extended periods. In certain regions young mothers separate from their husbands and return to their parental home for some or much of this time. This period is usually associated also with the period of breastfeeding, which also supresses fertility. Indeed several studies indicate that women may abstain from sex whilst breastfeeding as it is considered to endanger the health of the new born 15. The amulets that women wear ‘to avoid pregnancy’ also suggest sexual inactivity. These practices are decided by the couple and their families along with the easing of domestic responsibilities and greater attention to the newborn and nursing mother. Of those interviewed, 58% of women reported using some assistance in birth spacing, with this higher in town, yet these local methods were considered to fail frequently by 51% of those reporting their use, and to be only weakly or moderately effective by a further 22%. Induced, ‘underground’ abortions are unacceptable socially. Table 2, Table 3.

Women did not report any adverse effects of traditional practices on maternal and infant health - nor any perceived disadvantages that would impede the use of them. Very few men, too, said that they had ever been present at discussions concerning adverse effects of traditional practices on maternal health. Men agree that the ease of access, low cost, negotiable payment terms, and selfless social assistance in the neighbourhood supports the use of traditional practices 16. They do not imagine that zero risk is possible, but understand that these positive practices reduce it. Indeed, for some, these practices have been used for a long time by ancestors in the past who had fewer health problems (in extent and gravity) than current generations 17.

Informants suggested that pregnant women and young mothers who seek care whether for themselves or their children are always welcomed by traditional care providers. A few quotations can provide a sense of this:

My child lost weight following a fever associated with diarrhoea, I took her to an elder woman (‘grandmother’) who gave me a root decoction. She told me to boil them and have the child drink the decoction and wash with it morning and evening. Three days later, the child returned to suckle the breast and laugh.”

"When I delivered my baby, he was small and weak, and the midwife helped me with food”

"Ahh! it is a feeling of joy and satisfaction after using traditional recipes."

For men as for women, the traditional practice promoting maternal and infant health include the set of values and resources used to prevent or restore the deteriorating health of the mother and child. This included support to breastfeeding, recipes based on medicinal plants and, indeed, recommendations to use health services. Again some quotations are indicative:

"We know the interest of positive traditional practices especially breastfeeding, complementary feeding and body and food hygiene for the health of children." (men, Soyah, Mamou)

"We are told by the elders of the importance of breastfeeding for the health and growth of children." (men, Kissdidougou)

"Of course, we always talked about the importance of breastfeeding and human warmth / kindness of the mother towards the child / maternal care and cleanliness; it is for the health and rapid growth of the child." (men, Baténafadji, Kankan)

"We are told by the elders of the importance of the use of Shea butter after bathing newborns for them to grow up healthy." (men, Kissdidougou)

Community leaders, too, highlighted the concept of ancestrally proven values in the preservation of women’s health during maternity. Positive practices, in their telling, range from forms of sexual abstinence, to the Muslim faith and to traditional herbal and dietary recipes. They emphasized how traditional practices are couched within their community’s socio-cultural values, are easily accessible (available day and night), and have benevolent payment terms 18. Such psychosocial determinants and empathy have heightened significance given difficulties of affordability in the context of context of growing poverty.

Issues of cost and availability came over strongly in the focus groups.

"Concerning the cost of traditional practices, sometimes we offer products for free or with payment terms easier: in kind, delayed, moderate prices". In comparison, the prices of medicines are high in pharmacies or the market.” (woman, Urban Commune of Mamou)

"Traditional products are either free or very affordable." (woman, Sangardo, Kissidougou)

"There are traditional products everywhere next to our homes and it costs nothing." (woman, Soyah, Mamou)

There is always someone around capable of dealing women’s and children’s health issues." (woman, Kissidougou)

"There is always someone to go to who can distribute a traditional product and give practical advice, whether in the family, among immediate neighbours or in the surrounding villages." (woman, Soyah, Mamou).

"Families can find someone in the village at anytime to discuss questions about nutrition and feeding of newborn and children."

The low costs with payment often deferred, waived or in kind; the ease of access to traditional practices; their easily understandable use; the ability to converse easily in commonly understood idioms and conceptual framings; the empathy about them, all rooted in widely shared values are all strong reasons why traditional practices remain so popular.

Yet women themselves also emphasize the importance of both the formal healthcare institutions alongside their traditional practices, and many engage with both. Indeed, both women and men are very aware that pregnancy monitoring and antenatal care is provided by both public and private health facilities as well as the community level, but only 21% of women surveyed reported using both. More women reported that delivery itself was in health facilities (whether public or private, but this was still less than half (49%). More men (57%) reported that births were in health facilities, and 77% of providers reported this, seemingly revealing interpretative bias among providers for their own significance. There is, thus, a very low use of antenatal care services and a low use of assisted delivery.

Qualitative evidence reveals that the majority tend to visit the formal clinics when faced by problems – for curative rather than for monitoring and prevention. "For me, simple cases are treated well by the wise women, but if the case is serious about the child becoming thin, smooth, with brown hair and bloated stomach, you have to visit hospital." (women, Baténafadji, Kankan).

"As our grandparents’ products and incantations are available in our community, older women and other healers take care of the health problems of children and women, or if they cannot, they ask us to go to the health center or to the hospital." (men, Soyah, Mamou).

"In most cases (we frequent clinics when), it is malaria / fever, diarrhoea, vomiting, weight loss or lack of vitamins, or birth." (Men, Ratoma, Conakry).

Those who do not visit reproductive health services describe how they are not adapted to their needs. For women, specific problems included difficulties with opening times (44%); cost (62%), the derogatory attitudes of health workers and their poor welcome and communication (indiscretion and lack of confidentiality by ‘indelicate personnel); (59%); distance (15%), beliefs and prejudices (11%). These issues emerged to be of wider significance that the lack of support by husbands (12%) and by family (13%), or the low availability of user-friendly services (10%). Concerns extend to the quality of service, for example:

"I found that traditional services are more satisfactory than the performance of health centers where medicines and vitamins are almost non-existent." (Urban Commune of Kindia). Men, too, expressed various reasons for avoiding modern maternal health services, reiterating the significance of the poor quality and range of their services; opening times, and the difficult access that formal healthcare has to health products (drugs etc.). Like women many men highlight the poor welcome, the indiscretion, and the lack of effective and sympathetic communication between those attending and the health professionals.

Women suggested that efforts to improve comprehensive sexual and reproductive health should focus on improving the quality of services and the conditions promote information sharing. In interviews, their answers extended to the Ebola epidemic – and concerns with hygiene in the use of health services. Men too made connections between the Ebola epidemic and the increased use of traditional / customary practices given concerns with hygiene during the epidemic and speculation about the epidemic’s origins.

Providers recognize the existence of traditional family planning, breastfeeding, modified diets, herbal remedies that prevent complications, and local care in pregnancy and birth - and admit that these are more accessible and affordable 19. They also did not list any factors impeding the use of traditional practices, as their opinion is generally favorable towards them. Their benefits are comparable to modern therapies, even though there are concerns that traditional practices may expose women to more or less severe health risks. And yet those working in the health centers (and higher level structures) were unequivocal that pregnancy care is ensured formally through the antenatal care in government health and private structures and only marginally at the community level through the use of positive traditional practices 20.

Significantly, no health workers interviewed had encouraged the use of positive traditional practices for monitoring pregnancy. Community based workers, by contrast (traditional birth attendants, community health workers) did advise on the use of proven positive practices.

Health workers suggest that among the reasons why their services are poorly frequented are the low availability and quality of services (opening times); their poor stocks of health products; the costs ; the poor reception visitors receive, the communication gap and lack of privacy. Awareness, too, that they are silent on traditional practices and do pay little attention to ‘beliefs’ and customs. The Ebola epidemic had had a negative impact throughout the health system, and the increased use of traditional practices.

Community leaders were also concerned by the lack of attention paid by the formal health structures in positive traditional practices – and in the lack of qualified and motivated providers; opening schedules; distance; costs (direct and indirect); attitudes of health workers towards patients, and lack of empathy and lack of communication between caregiver and treated, vocalizing concerns, even, with the disrespect and prejudice that women in labor perceived during childbirth 21.

Whilst similar issues emerged in people’s engagement with formal family planning facilities, lack of engagement with them concerned more their social acceptability. The reasons women gave about the low rate of use of modern family planning (averaging about 7% nationally) relate to fear of disapproval from their husband (41%) and from in-laws (33%), and from speculation about the hidden intent of family planning (45%). Only 14% of women suggested a lack of a perceived need (14%). They expressed reasons why their choice was focused on traditional methods of birth spacing and other traditional practices lay in (a) lack of access to family planning facilities (in terms cost and time) and (b) the lack of confidence they placed in the facilities for their discretion and (c) concerns with the efficacy of the method recommended.

Men had slightly differing views. The proportion of men who supported their wives to delay pregnancy or avoid pregnancy is relatively low (19%). Yet those expressing a lack of need felt by women was negligible (1%). Most men suggested that it was the unfavourable opinion of husbands (34%), fear of in-laws (21%), fear and prejudicial rumours about modern family planning (24%) that reduced its use. They also outlined, however, how women’s access is limited by opening hours and distance; by costs (direct and indirect); by the attitudes of health staff. Services were not considered ‘user friendly’ for young people's health needs, and operated poorly as centers for listening and advice 22. Leaders especially expressed a lack of user-friendly services tailored to the specific needs of adolescents that make them more vulnerable concerning, in particular sexual immaturity, unwanted pregnancies, socio-economic dependence, risk of STDs, HIV & AIDS).

Health care workers, by contrast, suggest that low levels of family planning are attributed to the lack of need felt by women, as well as their husbands’ opposition, and rumours about family planning. Questions concerning welcome and discretion were not articulated. Health workers said that few women of childbearing age confide in them about the effectiveness of natural or traditional methods of child spacing. Those who do speak about are concerned that their methods are ineffective because the failure rate is high 23. Women find information on family planning options through traditional birth attendants, older women, community health workers and health staff. Men tended to know of natural or traditional practices through their partner in nearly half the cases, and many quietly expressed a need for sex education 24.

Traditional support structures coexist with national maternal and child health services. Evidence provided here shows that women who use the latter integrate these in practice with their traditional maternal support. Conversely, however, whilst we find that those working in those structures appreciate the significance of traditional systems, there is neither policy nor practice that acknowledges and builds on the potential benefits of such integration 25. Health services and wider administrative forums debate the high levels of mortality of mothers and newborns, but there is no evidence that providers have been approached to dialogue on traditional practices on maternal and newborn health.

We have provided information on the underlying reasons behind the continued use of traditional and religious practices despite some "accessibility" to modern health services. It is not the case that the modern system is displacing traditional practices, but the specifics of their encounter help maintain both, as socially separate. To the extent that the separation is maintained by the national structures, these structures do not become ‘part of the community’. This is a missed opportunity for a variety of reasons, whether relating to efficacy, efficiency, sustainability or resilience 26. Whilst this paper renders visible these missed opportunities, our focus has been on an associated problem: by ignoring existing social support, knowledge, practices and ethics supporting maternal and child health, the formal medical structures can contribute to processes of disempowerment that undermine both their own goals concerning maternal and infant health, as well as broader development goals.

Without community involvement, it is illusory to think that the health service can improve mother and child health. Such a commitment necessarily entails the recognition and promotion of popular knowledge and positive traditional practices in preserving maternal and newborn health 27. The experience of disempowerment relates not to these experience of maternal health facilities (as demeaning in welcome and unsupportive in communication) but more broadly, to the lack of appreciation of what women and the wider social world is already doing in supporting maternal health 28. The latter is rendered all the more complex where these traditional support networks that are in some ways empowering, are associated too with social networks which also support more negative aspects – most significantly Female Genital Cutting – legislated against nationally and internationally as a human rights violation 29. Women’s poor experience of modern health systems and their dependency on community social networks thus creates a dependency, too, on the structures supporting FGC. The customs, worldview and values ​​of a community shape behavior. FGC exemplifies how the inherited dispositions and acquired habits (that sociologist Bourdieu call habitus) that are important in delivering health also involve the structure and identity of a community, and are thus resilient to change. Identity and identity politics is thus closely integrated with health practices. A first step to address FGC must be to empower and integrate women within modern maternal health structures.

The system of sharing information about these practices is currently disorganized, informal and poorly explored 30. Access to information on positive traditional practices is also hampered by taboos, prejudice and the lack of communication between all stakeholders. There are, however, precedents in the sub-region and elsewhere to create maternal health structures that are empowering 31 and for a more systematic integration. Work in Benin 32 has exemplified, for example, the potential for integrating positive traditional practices, and highlights the significance of community-based services (with their experience and knowledge of communities) as a key point of communication between citizens, health providers and policy makers 33. Study have found that those who perceive the formal structures as disempowering (as unwelcoming, with opening time not attuned to women’s lives, as demeaning and difficult to communicate with) tend to use them only in times of desperation – in antenatal care after complications have arisen for curative reasons, rather than as part of the support system that assists all mothers, prevents problems or identifies them earlier.

Modern health planning is increasingly focused on health performance and reducing maternal and infant mortality is a central agenda 34.Top of Form