Personal agency refers to the notion that the person has the capacity to make her or his own choices and exercise autonomy over personal life events and circumstances. During labour and delivery, although the women are in extreme pain and may be able to freely express themselves, they may elect to remain silent as a result of social control. The participants in this study described how women in Sudan are encouraged to be strong; physical courage is admired and weakness is ridiculed. Interpreting their words, the expression of pain through screaming and exhibiting distress during labour and delivery were associated with weakness in their culture, and because dominant norms exert considerable pressure in respect of social control, the women often demonstrate stoicism during labour and delivery rather than a true expression of feelings.
P11: And we have something also in our tribe. If you’re going to have the baby you don’t have to cry and do this all kind of this funny stuff, because they’re going to sing a song about you that you’re a chicken or something…You can’t cry. You can’t do this funny face and this kind of stuff…You have to be strong for it.
The participants expressed that Sudanese women are expected to cook, clean, and generally look after their husband and children even when pregnant. Beyond physical strength, Sudanese women are expected to be mentally healthy. According to the participants, depression is rare in Sudan; parenthetically postpartum depression is apparently not viewed with much sympathy.
P11: No, it’s normal. They know if you are women you have to get pregnant, you have to have kids. We don’t have like, I’m depressed because I am pregnant or something, no.
This quote implies sociocultural values of having many children and can be seen as one of the reasons that some people do not encourage contraception. The other significant issue is the role of males in family planning. The participants noted that men are very reluctant to use condoms or other forms of birth control. Women often have to hide the fact that they are using birth control. This topic as well as the constraints of patriarchy was expanded upon by many of the participants.
Sudanese women are expected to have children but sometimes take contraceptives secretly, for example, while at their mother's house (presumably with the mother's knowledge) or by hiding pills in their clothing. As one participant said, you use birth control if you are "strong for yourself". This participant delayed having children for four to five year after marriage. This may be interpreted as personal agency, and an empowering dimension through which women gain some control over family planning decisions.
P11: Sometimes you’re going to be in big problem with your husband if - you know, some women they do it secretly…They say, I don’t know why I don’t have the babies, and he worry maybe sometimes. But if you want to discuss he will immediately tell you no.
One woman also noted that several people in her community have had tubal ligations without their husband’s knowledge.
P11: He said, “Oh, what’s happened?” She said, “Oh, maybe God don’t give me children. I don’t know.”
I2: So you use family planning without their knowledge?
P11: Sometimes some women use this one -
I1: Injection. Yes, yes.
Resistance to patriarchy
In Sudan’s patriarchal society, women have few rights and may be constrained by their husbands and communities. Especially in rural areas, the women are expected even when pregnant to do all of the housework, cooking, and childcare. After birth, women are expected to breastfeed and in many areas of Sudan there is no access to infant formula. A woman’s main reason for breastfeeding can vary and it is not usually only to nourish the baby but also for use as a natural form of birth control. While breastfeeding their children (the length of which varies by tribe and may be from 40 days to two years) Sudanese women are not usually able to have conjugal relations with their husbands; this situation is mostly influenced and guided by older females in the family such as the woman’s mother-in-law. The rationale seems to be that the health of the newborn child is paramount; therefore if the new mother is feeding the baby but gets pregnant again, the baby might lack attention and get sick and die leading the community to accuse the woman of not being a responsible parent. Since polygamy is socially accepted and legal in the Sudanese communities where these participants have origins, the husband may bring another “wife” into the household during this period. One participant laughed when stating that her brother had 11 wives. Thus, in rural Sudan, a woman who gives birth faces a terrible dilemma: in order to be a responsible parent, she may risk personal loss – her husband may find another woman/wife, without any right to complain.
P11: Your husband have to move out from the house [during and after baby delivery]. For one year, two years. When you are breastfeeding? Yeah…
P7: Also then they look for another woman. He will have two wives at home or three wives…You have to accept it because you have the baby, you stay there with your baby and husband will go enjoy…we don’t have like the right to speak out.
However, the socio-legal environment in Canada which promotes equality between the sexes coupled with the availability of contraception, seems to be changing the power dynamics between husbands and wives and conjugal relations within in the Sudanese community in our study population. These women are now able to resume sexual relations (“enjoy” their husbands) shortly after their delivery, without this decision being guided by mother in-laws in Sudan. Sudanese women in Canada can ask their husbands to take responsibility for family planning and to help with childcare and housework, even if this request may not garner a positive response. However, when the women assert their rights in Canada or refer to the Canadian cultural norm of fairness, this can sometimes be viewed by their husbands or in-laws as disrespectful and cause tension in the family.
Resistance to health practices
The Sudanese women in the FGIs remarked that they had a great deal of experience with the birth process. Birth is seen as natural and a community event. Many of the participants indicated that even before having one's own child, one has much experience of caring for babies and small children including their younger siblings. Many of them had also been brought up (sometimes from the age of five years) seeing women give birth in their own communities in Sudan. Even when not related by family to the laboring woman, girls in the community are encouraged to participate by heating water, fetching cloths, and assisting with other small tasks. Community responsibility is modeled for them, and they also see the pain and reality associated with the birthing process.
P11: I don’t think so there is any different because they take it - because you already have the experience. Even when you are young you go always, if somebody have a baby, even young people, they will go there to watch… Yeah, to see how they deliver a baby
P7: Because, you know, when they come back they be there, it’s not because they want to be there. They send them [female child] with the stuff. Oh, you have to heat the water and bring it. You have to bring this one and this one.
Women in some villages in Sudan are unlikely to have doctors deliver their babies. Instead, they may have a midwife or even a traditional birth attendant who has had no formal training yet great experience with delivering babies. One woman’s mother was the local birthing specialist and delivered her daughter’s baby. These experiences may have led the women in the FGIs to conceptualize birth as a normal and natural process with which they have understanding and comfort. These conceptualizations may allow them to resist practices which they interpret as abnormal or unnatural, such as analgesia and delivery instrumentation.
Strength and knowledge in pain relief
In Canada, the participants still seem reluctant to have analgesia during labour (though they did report taking paracetamol/acetaminophen with codeine after a caesarean section). This may be because they are trying to be strong and stoical (as previously discussed); it may also relate to perceived negative side effects of the epidural anesthesia injections which were reported as bad headaches, losing hair, discomfort in the abdomen, and the risk of paralysis. One participant remarked that after initially refusing an epidural, she consented after three hard hours of active labour. As well, at least one other participant suggested that an epidural is not needed if the time of delivery is short (“less than 3 hours”).
Fear of caesarean sections
There appears to be a widespread belief for the participant women that women should not go to the hospital because the doctors will perform a caesarean section.
P11: Our people, they stay for a while because they say if you rush to the hospital they’re going to do for you c-section. We have that idea in our community. You have to wait until sometimes you deliver in the car or in the [ambulance].
These women’s reluctance to have caesarean sections may relate to their view of surgical births not being "natural" and thus representing medicalization of the process. Some participants described how they resisted their doctor’s advice to have a caesarean section. One participant said that she had to "try, try, try" to have a baby vaginally, and only had a caesarean section after several hours of labour:
P7: Yeah, but here they’re telling me, okay. I say, “You know what? I have to try, try, try,” but I couldn’t. Yeah, the last baby, the doctor told me, “Actually, you know, I don’t think you will have the normal delivery.” I said, “I have to try.” Okay, after I have the baby the second day he came over and he told me, “You know, I told you you don’t have a baby normal because you are small.
Resistance to other practices – delivery positions and relief for swelling
Even though the participants in this study generally complied with medical practices in Canada, there were many comments regarding an inconsistency between these practices and their own customs and perceptions. For example, Sudanese women had mixed feelings about delivery positions. In rural areas in Sudan, women are accustomed to kneeling or squatting to give birth. However, in urban hospitals in Sudan as well as hospitals in Canada, women are typically expected to deliver in the supine position. Participants reflected that a lying-down position is convenient because it is easier to clean up the blood and may be easier for the health professionals aiding the delivery. Although some participants had adapted to the supine position, other participants had a definite preference for the "rural" squatting position claiming this as easier and more comfortable. One participant stated, “Sitting this way, you get more pressure coming down, yeah, and help the baby to come out first”. Another participant indicated that for births in the hospital (where she was lying down), she was in pain and discomfort (“short of breath”).
P3: No, when you’re laying down it’s too much pain. If you walk it’s better.
Participants tend to follow their beliefs, even when they contradict evidence-based medicine recommended by Canadian health practitioners. A good example is that during the postpartum period they continue to put hot water on their swelling, despite the advice of nurses to use ice packs. As one participant said, "I have to do what I believe". This also illustrates the women’s agency - they are not cowed or intimidated by "advanced" Western health knowledge, and they will resist practices with which they do not feel comfortable.
P7: They told me that with c-section I have to put the ice with cloth but I go in the bathroom, take hot water with cloth. [laughter]…
I1: So do you think the hot water works on the wound?
P7: It’s my tradition. I believe in it, you know. . .I have to do what I believe.
Tradition related to hot and cold
There are also cultural norms associated with the consumption of food and beverages during maternity. As mentioned, in Sudanese villages, women in labour are not given any pain relief. However, great value is placed on "hot" things during labour, which are believed to reduce pain and speed delivery. Women drink hot liquids (water, tea), eat hot foods like porridge or soup, and are encouraged to take hot showers.
P2: Hot tea and hot drinks.
I1: Okay, so on the whole the hot things are thought to be good for labour?
P2: They mean to help you like help the baby go out.
Many of the Sudanese participants who had given birth in Canadian hospitals expressed dissatisfaction with the food. Although they appreciated being offered the option of a Halal menu, the women were often given cold food. According to their cultural beliefs, hot food after delivery is beneficial because it will reduce the blood in the stomach and benefit the baby. Some women said that they did not eat the hospital food but instead had food brought in by their friends and family.
P1: It’s mostly cold. Sometimes I don’t accept it. Sometimes I refuse it. Sometimes I take some like soup, hot soup I can, yeah, use it. I can eat it….
P3: Hot? Yeah. Because I know some people just after they have baby here in [Hospital], they never eat until they go home.
P11: For four day they don’t eat.
Bottle-feeding versus breast-feeding
Breastfeeding/bottle feeding the baby in the hospital arose as being an issue for some participants. As breastfeeding is associated with naturalness in Sudan, they are reluctant to engage in bottle feeding. Some of the women indicated that the hospital nurses did not ask about the new mother’s wish to breastfeed, or else ignored their expressed wishes to breastfeed. Participants also seemed a little wary of an apparent promotion of formula in the hospitals, as commented on at length by one participant who spoke through her own as well as shared experience.
P11: The only thing, sometimes they introduce bottle to the baby immediately, the nurses… They bring bottle, yeah. They don’t kind of like ask you to feed the baby…. Because I’ll sometimes go for labour support with the moms I see and they have that, they advertise about the formula. You couldn’t believe at the hospital. They have that all information on the formula and this one with this kind of good rich stuff on it, the formula, to give the moms interested to give it to the babies.