Front. Public Health Frontiers in Public Health Front. Public Health 2296-2565 Frontiers Media S.A. 10.3389/fpubh.2023.1064583 Public Health Original Research Prevalence of cultural malpractice during the perinatal period and its determinants among reproductive age women in southwest Ethiopia: A community-based cross-sectional study Tesfaye Diro Abinet 1 Abdissa Fufa Dinaol 2 Geremew Habtamu 1 * 1College of Health Science, Oda Bultum University, Chiro, Ethiopia 2School of Public Health, College of Health and Medical Sciences, Mizan-Tepi University, Mizan-Aman, Ethiopia

Edited by: Joao Sollari Lopes, National Statistical Institute of Portugal, Portugal

Reviewed by: Adera Debella, Haramaya University, Ethiopia; Gobopamang Letamo, University of Botswana, Botswana

 *Correspondence: Habtamu Geremew habteg29@gmail.com

This article was submitted to Life-Course Epidemiology and Social Inequalities in Health, a section of the journal Frontiers in Public Health

 17 03 2023 2023 11 1064583 21 10 2022 28 02 2023 Copyright © 2023 Tesfaye Diro, Abdissa Fufa and Geremew. 2023 Tesfaye Diro, Abdissa Fufa and Geremew

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

 Background

Cultural malpractices are accepted cultural norms and socially shared practices that have a negative impact on health. Cultural malpractices vary in type and number in different communities. This study aimed to determine the prevalence of cultural malpractice during the perinatal period and identify its predictors among reproductive-age women in rural communities of southwestern Ethiopia.

 Methods

A community-based cross-sectional study was conducted from May 5 to 31, 2019 in Semen Bench district, southwestern Ethiopia; among reproductive-age women who had experienced at least one prior delivery. A systematic random sampling technique was employed to select 422 women for the interview. After collection, the data were entered into EpiData and exported to STATA-14 for further analysis. Descriptive analyses were performed and presented in texts and tables. Besides, binary and multivariable logistic regressions were computed to identify determinants of cultural malpractice.

 Result

A total of 414 women completed the survey, resulting in a response rate of 98%. We found that 26.33% (95% CI: 22.15, 30.85%) had food taboos during pregnancy, 31.88% (95% CI: 27.42, 36.61%) delivered their last child at home, and 33.82% (95% CI: 29.27, 38.6%) practiced pre-lacteal feeding. Lack of formal education (AOR: 11.22, 95% CI: 6.24, 20.15), lack of ANC follow-up (AOR: 10.82, 95% CI: 5.46, 21.42), rural residence (AOR: 6.23, 95% CI: 2.18, 17.78), and avoiding colostrum (AOR: 21.94, 95% CI: 9.73, 49.48) were significantly associated with cultural malpractice during the perinatal period.

 Conclusion

The prevalence of cultural malpractice is notably high in the study area. Hence, community-based measures including expansion of education and promotion of maternal health services are important to reduce cultural malpractice during the perinatal period.

 prevalence cultural malpractice perinatal period reproductive age women Ethiopia Introduction

Different communities have socially shared practices that are deeply rooted in their culture and have an important association with their health (1). Cultural malpractices are accepted cultural norms and socially shared practices that have a negative impact on health (2, 3). The perinatal period, which includes pregnancy, delivery, and the post-natal period, is accompanied by various cultural malpractices that substantially affect the health of the mother and her children (4, 5).

Globally, several types of cultural malpractices have been reported (2, 6, 7). Ethiopia, as a multi-ethnic nation, is one of the countries where assorted cultural malpractices particularly during pregnancy, delivery, and post-natal period are practiced; among these, home delivery, pre-lacteal feeding, food prohibition, abdominal massage, and avoiding of colostrum were commonly documented (5, 8–11). Bench Maji Zone is also a home for such malpractices where home delivery, food prohibition, pre-lacteal feeding, and abdominal massage are commonly exercised (8, 12). These malpractices were found to have a significant association with residence, educational status, antenatal care (ANC) follow-up, gravidity, and distance from the health facility (5, 10, 13–15).

Cultural malpractices not only hinder women from utilizing maternal, reproductive, and child health services, but they also have a direct impact on the wellbeing and survival of both the mother and her offspring (2, 7, 16). Previously, studies have concentrated on the biomedical causes and management of maternal death; yet, they ignored cultural and traditional practices that can deter maternal morbidity and mortality (6, 17).

Maternal mortality is extremely high worldwide, accounting for 295,000 pregnancy-related deaths in 2017; almost all (94%) of these deaths occurred in resource-constrained settings (18, 19). Ethiopia is one of the nations where a higher number of maternal deaths are reported; a recent demographic and health survey estimated that there were around 412 maternal deaths per 100,000 live births (20). Various strategies, like improving access to reproductive health care and maternal death surveillance and response systems, have been implemented to reduce maternal mortality in Ethiopia; however, it persists as a major public health concern (21, 22). Cultural malpractices are among the important contributors to the high maternal mortality rate (23). It is estimated that about 5–15% of maternal deaths are due to cultural malpractice (6, 10, 24).

Cultural malpractices vary in type and number across different communities (8, 9, 25, 26). Thus, comprehensive evidence about the magnitude and determinant factors of cultural malpractices, especially during the perinatal period across different societies is crucial to reduce maternal mortality. Hence, this study was conducted to determine the prevalence of cultural malpractice during the perinatal period and identify associated factors among reproductive-age women in rural communities of Semen Bench district, southwestern Ethiopia.

 Materials and methods Study area, design, and period

A community-based, cross-sectional study was conducted from May 5 to 31, 2019 in the Semen Bench district. It is one of the ten decentralized districts in the Bench Maji zone, Southern Nation, Nationalities, and Peoples Region (SNNP) of Ethiopia. The district is composed of thirty-one Kebeles (the smallest administrative unit in Ethiopia), of which twenty-eight were rural. The estimated total population of the district was 159,480; of which 87,748 (51.26%) were females; the majority of the population in the district (152,973) are rural residents, with agriculture serving as their main economic source (27). There are four health centers and thirty-one health posts that provide maternal and child health services in the district.

 Study participants Source population

All reproductive-age women in the Semen Bench district who had experienced at least one prior delivery.

 Study population

All reproductive-age women in randomly selected kebeles of the Semen Bench district who had experienced at least one prior delivery.

 Inclusion criteria

All women who had experienced at least one delivery and were available during the period of data collection were included in the study.

 Exclusion criteria

Women who were seriously ill and/or had difficulties to communicate were excluded.

 Sample size determination and sampling procedure

The sample size was determined based on the single population proportion formula considering a 95% confidence interval, 5% margin of error, and cultural malpractice proportion of 50.9% from a previous study (28).

Thus, n=Z=(z α2)2d2p(1-p)

where,

n = is the desired sample size.

Zα/2 = the value of standard normal distribution corresponding to the significance level at α of 5%, which is 1.96.

P = is the proportion of cultural malpractice.

Therefore,

n=  ( 1.96)2(0.05)20.51(1-0.51)= (3.8416)0.00250.509(1-0.509) =384

Adding 10% non-response; n = 384 + (10*384/100) = 422.

Therefore, the final sample size for the study was 422 women of reproductive age.

Out of the thirty-one kebeles in the district, seven kebeles (one urban and six rural) were randomly selected. The study participants were recruited using systematic random sampling by considering household lists of randomly selected kebeles as sampling frames. For a household without eligible women, the next household was considered. Conversely, for households with more than one eligible woman, one of the women was selected randomly (Figure 1).

Schematic presentation of the sampling procedure to assess cultural malpractice during the perinatal period in southwest Ethiopia.

 Data collection tool, procedure, and quality control

A structured questionnaire (see Supplementary material), that was adapted from different literature was used (10, 11, 28). A face-to-face interview was employed to collect the data through house to house survey. The data were collected by seven midwives and they were supervised by two public health professionals. To assure the quality of the study, 2 days training was given to data collectors and supervisors about the objectives of the study and techniques of data collection. The tool was also pretested on 5% of the calculated sample size in one of the kebeles not included in this study. Furthermore, the collected data were checked every day for quality, completeness, and consistency.

 Operational definitions

Perinatal period: denotes the period during pregnancy, delivery, and postnatal period (5).

Cultural malpractice: accepted cultural practices that have a negative impact on health (5, 10).

Food taboo: avoiding certain foods during some occasions, like pregnancy, due to cultural beliefs (3, 10).

Pre-lacteal feeding: feeding the neonate something other than breast milk in the first 3 days after birth (29).

 Data processing and analysis

The collected data were entered into EpiData and exported to STATA version 14 for cleaning, categorizing, and further statistical analysis. Consequently, descriptive and inferential statistics were computed using the software. The bi-variable and multi-variable logistic regressions were employed to identify factors associated with cultural malpractice after checking for assumptions and assessing multicollinearity. Variables with a P-value < 0.25 during bi-variable analyses were chosen for subsequent multi-variable logistic regression. In the multi-variable analysis, significant statistical association was declared at a P-value < 0.05. Besides, the Hosmer-Lemeshow goodness-of-fit test and classification table were used to verify the fitness of the final models.

 Results Socio-demographic characteristics of participants

From the total calculated sample size of 422 reproductive-age women, 414 women completed the survey resulting in a response rate of 98%. Almost two out of every five women had no formal education. More than two-thirds of the respondents were rural dwellers. Most (84.3%) of the women were married, and the rest were either widowed (11.8%) or divorced (3.9%). More than half of the participants were housewives (Table 1).

Socio-demographic characteristics of study participants to assess cultural malpractice during the perinatal period in southwest Ethiopia.

Variable Category Frequency Percentage
Age 15–24 108 26.1
25–34 159 38.4
>35 147 35.5
Residence Urban 95 22.9
Rural 319 77.1
Marital status Married 349 84.3
Widowed 49 11.8
Divorced 16 3.9
Educational status No formal education 177 42.7
Primary and above 237 57.3
Occupation House wife 246 59.4
Merchant 78 18.9
Governmental employee 58 14.0
Othersa 32 7.7
Ethnicity Bench 242 58.5
Amhara 75 18.1
Oromo 44 10.6
Kefa 37 8.9
Othersb 16 3.9
Religion Orthodox 179 43.2
Protestant 161 38.9
Muslim 74 17.9

Othersa, students and private employees; Othersb, Sheka, Sheko and Dize.

 Obstetrical characteristics of participants

Among the participants, 178 had an antenatal care (ANC) follow-up. About one-third (35.3%) of the women had an illness during their last pregnancy. Most of the home deliveries were attended by families, and about one-fourth of women avoided feeding colostrum (Table 2).

Obstetrical characteristics of study participants to assess cultural malpractice during the perinatal period in southwest Ethiopia.

Variable Category Frequency Percentage
Gravida 1–2 158 38.2
3–4 159 38.4
>5 97 23.4
Illness during pregnancy Yes 146 35.3
No 268 64.7
ANC follow-up Yes 178 43.0
No 236 57.0
Who attended the delivery at home Family 62 47.0
Neighbors 33 25.0
UTTBA 25 18.9
TTBA 12 9.1
Colostrum feeding Yes 304 73.4
No 110 26.6

UTTBA, un-trained traditional birth attendants; TTBA, trained traditional birth attendants.

 Prevalence of cultural malpractice

Out of 414 women who completed this survey; 26.33% (95% CI: 22.15, 30.85%) had food restrictions during pregnancy, 31.88% (95% CI: 27.42, 36.61%) delivered their last child at home, and 33.82% (95% CI: 29.27, 38.6%) practiced pre-lacteal feeding on their newborn. Other cultural malpractices like abdominal massage, uterine massage, using an unclean blade to cut the umbilical cord, shaking of the abdomen or uterus, applying cow dung or butter on the umbilical stump, late initiation of breastfeeding, and avoiding the colostrum were also reported (Figure 2).

Prevalence of cultural malpractice during the perinatal period, by ANC follow-up status of women in southwest Ethiopia.

 Factors associated with cultural malpractice

Various factors were found to have a statistically significant association with the most commonly reported cultural malpractices (food taboo, home delivery, and pre-lacteal feeding).

Factors associated with food taboo: residence, educational status, and ANC follow-up were significantly associated with food taboo during pregnancy. Accordingly, rural dwellers were 2.25 (95% CI: 1.15, 4.38) times at higher risk of food taboo than urban residents. Similarly, women who did not attend formal education were having a 2.25 (95% CI: 1.15, 4.38) times higher risk of food taboo as compared to women who attended primary and above education. The odds of food taboo were 4.56 (95% CI: 2.61, 7.97) times higher among women who did not have ANC follow-up than among women who had (Table 3).

Factors associated with food taboo during pregnancy among reproductive age women in southwest Ethiopia.

Variables Category Food Taboo CR AOR (95% CI)
No Yes
Age 15–24 98 15 0.31 0.58 (0.27, 1.24)
25–34 111 46 0.83 1.28 (0.72, 2.280
>35 96 48 Ref Ref
Residence Urban 82 13 Ref Ref
Rural 223 96 2.72 2.25 (1.15, 4.38)*
Educational status No formal education 113 64 2.42 2.03 (1.18, 3.51)*
Primary and above 192 45 Ref Ref
ANC follow-up No 146 90 5.16 4.56 (2.61, 7.97)*
Yes 159 19 Ref Ref

AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio; *Significant at P-value < 0.05.

Factors associated with home delivery: marital status, educational status, and ANC follow-up significantly determined home delivery practice. Widowed and divorced women had a 5.97 (95% CI: 2.79, 12.78) times higher risk of home delivery than married ones. Women with no formal education were 11.22 (95% CI: 6.24, 20.15) times more likely to give birth at home as compared to women who attended primary and above education. Likewise, women who didn't have ANC follow-up were having a 10.82 (95% CI: 5.46, 21.42) times higher risk of home delivery than women who had ANC follow-up (Table 4).

Factors associated with home delivery among reproductive age women in southwest Ethiopia.

Variables Category Place of delivery CR AOR (95% CI)
Health institution Home
Residence Urban 77 18 Ref Ref
Rural 205 114 2.38 1.82 (0.88, 3.76)
Marital status Married 262 87 Ref Ref
Widowed/Divorced 20 45 6.78 5.97 (2.79, 12.78)*
Educational status No formal education 73 104 10.63 11.22 (6.24, 20.15)*
Primary and above 209 28 Ref Ref
ANC follow-up No 125 111 6.64 10.82 (5.46, 21.42)*
Yes 157 21 Ref Ref
Illness during pregnancy Yes 109 37 0.62 1.45 (0.8, 2.62)
No 173 95 Ref Ref

AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio; *Significant at P-value < 0.05.

Factors associated with pre-lacteal feeding: rural dwellers were 6.23 (95% CI: 2.18, 17.78) times more likely to practice pre-lacteal feeding than urban residents. Respondents who were Amhara in their ethnicity were 4.94 (95% CI: 2.09, 11.66) times more likely to practice pre-lacteal feeding than Bench ethnic groups. Similarly, women who didn't attend formal education had a 6.30 (95% CI: 2.67, 14.87) times higher risk of pre-lacteal feeding as compared to women who attended primary and above education. Women who had five or more gravida were 7.17 (95%: 2.95, 17.44) times more likely to practice pre-lacteal feeding than women who had fewer gravida. Likewise, women who didn't have ANC follow-up were having 6.73 (95% CI: 3.1, 14.61) times higher risk of pre-lacteal feeding as compared to women who had ANC follow-up. Women who avoided feeding colostrum to their newborns were 21.94 (95% CI: 9.73, 49.48) times more likely to practice pre-lacteal feeding than their counterparts (Table 5).

Factors associated with pre-lacteal feeding among reproductive age women in southwest Ethiopia.

Variables Category Pre-lacteal feeding CR AOR (95% CI)
No Yes
Residence Urban 80 15 Ref Ref
Rural 194 125 3.43 6.23 (2.18, 17.78)*
Ethnicity Bench 181 61 Ref Ref
Amhara 36 39 3.21 4.94 (2.09, 11.66)*
Oromo 24 20 2.47 2.56 (0.83, 7.87)
Others@ 33 20 1.78 0.69 (0.25, 1.9)
Educational status No formal education 74 103 7.52 6.30 (2.67, 14.87)*
Primary and above 200 37 Ref Ref
Gravida 1–2 137 21 0.38 1.36 (0.56, 3.32)
3–4 113 46 Ref Ref
>5 24 73 7.47 7.17 (2.95, 17.44)*
ANC follow-up No 121 115 5.82 6.73 (3.1, 14.61)*
Yes 153 25 Ref Ref
Colostrum feeding Yes 254 50 Ref Ref
No 20 90 22.86 21.94 (9.73, 49.48)*

AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio; @Kefa, Sheka, Sheko, and Dize; *Significant at P-value < 0.05.

 Discussion

This study was conducted to estimate the prevalence of cultural malpractice during the perinatal period and identify factors associated with it among reproductive-age women in rural communities of southwest Ethiopia. Consequently, the prevalence of food taboo during pregnancy, home delivery, and pre-lacteal feeding were 26.33, 31.88, and 33.82% respectively. Besides; residence, marital status, educational status, ANC follow-up, gravidity, and avoidance of colostrum were found to have a significant association with cultural malpractices.

We found that the prevalence of food taboo during pregnancy was 26.33% (95% CI: 22.15, 30.85%). This finding was higher than previous reports from different parts of Ethiopia (10, 11, 28, 30). The possible explanation could be due to differences in residence and period of study. Previous studies were conducted among urban dwellers whereas the current study mainly included rural women. Besides, this study estimated food taboos during pregnancy, whereas the previous studies investigated food taboos during delivery and the postnatal period. On the other hand, this finding was lower than previous researches from Ethiopia (5, 31), and Nepal (25). This could be partly because of socio-cultural variations.

Our study also found that the prevalence of home delivery was 31.88% (95% CI: 27.42, 36.61%). This result was higher than previous reports in Ethiopia (13, 15, 32). This might be due to the difference in the study setting; the previous studies were institutional based while our study was community-based. However, our finding was lower than studies conducted in the Afar and Benishangul Gumuz Regions of Ethiopia (33–36). The possible explanation could be due to the poor infrastructure in the underserved regions of the country, thus leading to poor access to health care.

Furthermore, this analysis indicated that the prevalence of pre-lacteal feeding was 33.82% (95% CI: 29.27, 38.6%). This finding is lower than previous researches conducted in the same country (37–39), this might be due to the difference in time of study; these studies were conducted in earlier times when access and quality of health care were relatively suboptimal. In contrast, our finding was higher than previous reports from various parts of Ethiopia (40–43). This might be attributed to the socio-cultural variation across the country.

Moreover, we also identified determinants of cultural malpractice among reproductive-age women in southwest Ethiopia. Accordingly, ANC follow-up and educational status had a consistent association with the identified cultural malpractices. In line with previous studies, women who didn't have ANC follow-up had a higher risk of food taboo, home delivery, and pre-lacteal feeding (5, 10, 34). This might be attributed to the effect of counseling and client education during ANC (43, 44). Similarly, women with no formal education were more likely to practice food taboos, home delivery, and pre-lacteal feeding than women with primary and above education. This association was documented elsewhere (5, 10, 13, 15, 29), and could be related to the lack of awareness about the harmful effect of cultural malpractices on the health of the mother and her offspring among women without formal education.

The results of this study indicated that residence is significantly associated with food taboos during pregnancy and pre-lacteal feeding. Rural residents were having a higher risk of food taboo and pre-lacteal feeding than urban women. This finding was also reported by previous studies (5, 10, 45). One possible explanation is that rural residents have limited access to health care and are less exposed to health information (42, 46).

Our study also identified that marital status is significantly associated with home delivery. Divorced and/or widowed women had a higher risk of home delivery as compared to married women. This association was also supported by previous reports (47, 48), and might be due to the enabling effect of partner support on improving maternal and reproductive health care service utilization (49, 50).

This study revealed that respondents who were Amhara in their ethnicity were more likely to practice pre-lacteal feeding than Bench ethnic groups. This could be partly due to the difference in socio-cultural attributes between the two ethnic groups. Consistent with previous studies, women who have had five or more gravidity were more likely to practice pre-lacteal feeding than their counterparts (5, 26). This could be due to the higher prevalence of cultural beliefs among older women. Lastly, we found that avoiding the colostrum was strongly associated with pre-lacteal feeding. This association was documented elsewhere (29, 43, 51) and might be due to the misconception among mothers that colostrum is non-nutritious and causes diarrhea (52).

 Limitations

The findings of this study should be interpreted considering the following limitations. Firstly, as we investigated events that occurred in the past, recall bias could not be ruled out. Secondly, the cross-sectional nature of the study makes it difficult to establish a temporal association.

 Conclusion

The prevalence of cultural malpractice is notably high in the study area. Educational status, ANC follow-up, residence, marital status, gravidity, and avoiding colostrum had a significant association with cultural malpractices during the perinatal period. Hence, community-based measures, including the expansion of education and promotion of maternal health services are important to reduce cultural malpractice during the perinatal period.

 Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

 Ethics statement

Ethical clearance was obtained from the College of Health Science, Mizan-Tepi University Ethical Review Board. Considering the non-invasive nature of data collection procedures, verbal consent was obtained from each woman who participated in the survey after a detailed explanation of the purpose of the research and the right to withdraw from the study at any time. For women who practiced cultural malpractice, detailed descriptions of possible health consequences and appropriate alternative measures were discussed by data collectors. Besides, confidentiality was assured by not recording personal identifiers and using the data only for the purpose of this study.

 Author contributions

ATD conceived the study. ATD, DAF, and HG designed the study, supervised data collection, analyzed the data, wrote the first draft, and critically reviewed the manuscript. All authors have read and approved the final manuscript.

We are thankful to Mizan-Tepi University, College of Health Sciences for granting the ethical clearance. We would also like to acknowledge the study participants, data collectors, and supervisors.

 Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

 Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

 Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2023.1064583/full#supplementary-material

 Abbreviations

ANC, antenatal care; AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio.

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