The results are presented in two parts: the sociodemographic characteristics of the participants and the sociocultural determinants of the utilization of assisted childbirth.
Sociodemographic characteristics of participants
We visited 35 nomadic camps and recruited 26 women. These women were found in 24 camps. The sociodemographic profile of these women includes their place of residence, their age, their occupation as well as that of their husband, and their number of pregnancies. We also noted the use or non-use of prenatal consultation (PNC) and assisted childbirth.
The camps visited are within a radius of 16 to 62 km from the nearest health center (Kaigourou). The study participants are 18 to 40 years old. Their age distribution is as follows: 18 to 25 years (n = 11); 26 to 35 years (n = 11); and 36 years and older (n = 4). Of the 26 participants, 19 (73.1%) claim to have received prenatal care (PNC) at least once at the health center, while only 11 (42.3%) have given birth there during their lifetime. Women in the youngest group report less use of assisted childbirth (7 out of 11 have not had recourse to assisted childbirth).
All the participants are married housewives, and their spouses are breeders. No woman has been to school. The distribution of the number of pregnancies ranges from one to nine pregnancies per woman. Two were primiparous, eight had two or three pregnancies, and 16 had four or more pregnancies. Most of them started to have children at a very young age (11 of the women before the age of 25).
In addition, during 3 months of non-participant observation, we were able to appreciate the social and living environment of the nomads. In the camps we visited, nomads usually live in family (couple and children) under a single tent of leather or cotton of about 20 square meters. The distribution of work within the family seems well codified. The animals are at the center and punctuate nomads’ life. In the daytime, men tend the livestock in the pasture and at night, the whole family gets involved in animal care. When milking is finished and the milk is distributed, families meet to exchange information around a fire. We participated in these exchanges, which, for the occasion, concerned the difficulties of resorting to health services. On the other hand, the life of nomads seems well organized. Their socioeconomic level is function of their social status but also the number of livestock they have. The elderly and the women are highly respected, which gives them several privileges. Also, their way of life allows nomads to be quite autonomous to the extent that they produce most of what they need to live (milk, meat, butter). Other food is often considered as a supplement or luxury that not everyone can afford. In case of illness, self-medication is used first, sometimes with modern medicines brought from the city. However, nomads seem very open to modern health. On the other hand, nomads perceive themselves as quite vulnerable because their whole economy is dependent on unpredictable rainfall. At the same time, they demonstrate resilience capacities under extreme conditions. These observations allowed us to better understand the sociocultural dimensions that directly or indirectly influenced their use of assisted childbirth.
Body representations and experiences of pregnancy and childbirth
Our findings show that the use of assisted childbirth is influenced by some dominant representations of their body that women develop during pregnancy, at the beginning of labor, and during childbirth.
For many participants, pregnancy is a normal, even unavoidable process. All eyes in the community are turned toward married women waiting for pregnancy: “Pregnancy is a normal phenomenon for us women. All women are supposed to get pregnant.” (Aicha, 22).
According to them, the femininity of women and their status as wives are confirmed only through their ability to get pregnant. But beyond that, the fact of not being able to get pregnant could even create problems within the couple: “Pregnancies are part of our life as a woman even if they make us tired. Married woman are expected to give birth. The opposite would be very frowned upon and could even be problematic.” (Ami, 38).
Paradoxically, the participants affirm that their pregnancy is often hidden, especially during the first months, because they feel ashamed of having gotten pregnant insofar as this implies the performance of a sexual act, which is a taboo topic of conversation, even with one’s husband:
Even if I am pregnant, I cannot talk to people; it is a source of shame otherwise. They must understand by themselves ... I do not tell my husband because I do not know what he may think. I do not know if he is aware of what happened to me; we do not talk about it. (Lalla, 20)
Several participants admit that the neighbors can imagine that a woman is pregnant when she shows some signs, but this will only be confirmed when there is a change in the parturient’s body (visible belly). Typical subterfuge includes keeping the pregnancy secret for several months, which can delay recourse to maternal care.
Once considered pregnant, the woman is viewed as fragile and vulnerable. As such, she receives special attention and measures including the use of healthcare facilities to protect her and enable completion of pregnancy: “Once she becomes pregnant, a woman is considered a fragile human being. People pay close attention to her so that the pregnancy will succeed. If we feel that she needs something, we must give it to her very quickly; otherwise she risks aborting.” (Mariama, 33).
However, women recognize the capacity and limits of their bodies to cope with pregnancy and childbirth, a recognition which determines their use of healthcare. Thus, some participants refer to knowledge or experiences related to their bodies, enabling them to deal with any pregnancy without seeking healthcare. They refer to a body that practices, learns, gets used to, and acquires its own abilities to take on pregnancy and childbirth without any assistance: “With each pregnancy and childbirth, you learn, and your body gets used to dealing with them.” (Tahouskat, 23).
In addition, other parturients, without questioning their abilities, recognize the limits of this body, especially when obstetric complications appear. In these cases, using healthcare is envisaged or desired by most participants to lessen their suffering: “You can suffer from illness at such a level that you cannot stand it anymore. One should then consider going to the health center to receive healthcare.” (Rokiatou, 30).
The beginning of labor
The beginning of labor is also an important moment for the participants. It is marked by several representations that tend to delay the use of care. When labor begins, some participants said they would hide the pains to make sure that this was indeed the beginning of the labor and thus avoid conveying false information to neighboring people: “I had pain for a day and felt that I should give birth, but I did not want to tell anyone about it until I was sure.” (Fadimatou, 30) Furthermore, to show their bravery, other women hide the beginning of childbirth as long as possible: “Our tradition is to hide the birth until the last minute so that the woman shows that she is strong.” (Fatimata, 27).
Once labor begins and the neighbors are informed, a small group of women come to stay with the parturient woman to support her. These women pray at a distance, but the parturient gives birth without any direct assistance: “I gave birth on my own. The women were there, but they did not help me. They cannot do anything, nor do they care to do so.” (Safietou, 20) A woman, more often than not the mother of the parturient, will intervene only to cut the umbilical cord: “I have always given birth at home with the help of my mother. Her assistance involves waiting until I give birth to cut the cord of the child and that’s all.” (Zeinabou, 32).
Childbirth is feared by nomadic women and their neighbors, as this proverb illustrates: “Before giving birth, every woman has her two feet hung in her grave until delivery.” (Zeinabou, 32) Indeed, childbirth is unanimously perceived by our participants as a period of danger, and the outcome is uncertain, entailing a high risk of dying: “The biggest fear for we women is the sinking of the genitals (genital prolapses).... In addition, we can have miscarriages or even die.” (Tafa, 22) Furthermore, delivery is sometimes feared because of the pain associated with it, although there are different perceptions of this pain among pregnant women. For many participants, giving birth in pain is natural, self-evident, and transient, making health services less relevant: “Women give birth every week, and deliveries are naturally painful, but it happens anyway and without the presence of health workers.” (Mamata, 22) Facing the magnitude of these pains, others have recognized their own limits when it comes to bearing pregnancy and thus say they are more favorable to using healthcare services, of which they recognize the effectiveness: “Delivery is very painful. Even if it is normal, we need help, and health services are very effective.” (Mariama, 33).
On the other hand, several emotions, combined with their personal experiences, also seem crucial for these women in deciding whether or not to use assisted childbirth. Women talk about their worries and their fears when they refer to the various consequences of a delivery that went wrong and could affect their womanhood and compromise their union. “I am always afraid because at each delivery, I can end up with a tedafé (vesico-vaginal fistula in Tamasheq) or other problems that can make me infertile.” (Taliat, 22) Also, experiences of anxiety or stress are conveyed when women recount cases of abnormal childbirth. “Imagine, when childbirth is impeded, you lose hope of living. You tell yourself it’s all over for you.” (Ami, 38) Facing these emotions, several participants prefer to turn to assisted childbirth.
Home delivery is the most common recourse for pregnant women, although it is not necessarily the first choice of the majority of participants. It is however a deliberate and assumed choice for some parturient women, who for the most part only know this type of childbirth: “I prefer to give birth at home.” (Taliat, 22) Their preference for home deliveries will only change if their lives are threatened or when they are no longer able to make a decision. “Personally, I would go to the health center only when I have no hope left, when people decide for me.” (Fatimata, 27) Some justify their preferences with a concern for adhering to a social standard or tradition that recommends giving birth at home: “For home deliveries, we found our parents doing so and we followed in their footsteps.” (Lalla, 20).
Assisted childbirth is of interest for the majority of participants, although some women gave birth at home:
I think it would have been better to give birth at the health center according to what I hear. Personally, I always gave birth at home, but that's because I had no other choice. People here are afraid to give birth at the health center; they do not know how it will happen. It is easier for me and my family to give birth at home. (Safietou, 20)
Women have found several benefits to assisted childbirth, including shorter labor hours and the lessening of pain: “When you give birth at the health center, with the drugs, the labor time is shortened, and you suffer less.” (Khadou, 35) Also, parturient women have confessed that health services are also very effective postpartum: “Since I gave birth at the health center, I’m doing everything to come back because the conditions are better there. You’re cared for and your child too.” (Mariama, 33) For these reasons, many women no longer consider giving birth outside of health centers: “Since I discovered delivery at the health center, I try to come back even when I am living far away.” (Khadou, 35).
Risks during pregnancy and childbirth
During our interviews, the women insisted on a vast array of simple and complicated risks to which they are exposed during pregnancy and childbirth and which determine their use of healthcare. They represent these risks in different ways according to their own criteria, with a great variability of interpretations. Almost all parturient women acknowledge having experienced various diseases/risks during their pregnancy and childbirth periods: “As soon as I get pregnant, I get sick. Abdominal pain with constant vomiting. I have to lie down all the time. During pregnancy and childbirth, we face a lot of risks.” (Lawal, 38) Others also refer to the ultimate risk, which could be death: “Risks during childbirth are many and various and may lead to death.” (Tahousket,23) They report that age and a high number of pregnancies (multiparity) add to these risks.
Given this strong perception of risk and the perceived effectiveness of assisted childbirth, the majority of women seek healthcare services: “I gave birth at home, but more and more women tend to seek care and to give birth at the health center because it seems really helpful for a quick recovery.” (Fatimata, 27) However, they turn to healthcare services only when they are facing complications.
The autonomy of nomadic women
Our findings also highlight three dimensions related to the low autonomy of nomadic women, all three constraining their use of assisted childbirth. These are autonomy of movement, of decision-making, and of economic agency.
Autonomy of movement
Most participants admitted that they did not have freedom of movement and that their movements were governed by rules. In this regard, a woman traveling alone would not be well perceived, and the authorization of the husband or a family member (father or brother) would be required for the use of assisted childbirth. Indeed, the Muslim woman owes obedience and respect to her husband, and as such, challenging his authority is perceived as a religious transgression: “We are Muslims; the woman cannot challenge instructions from her husband and travel to the center without his authorization as well.” (Rokiatou, 30) Moreover, for other participants, this is part of the education received from their parents that should be maintained: “We have always been taught that this is how it is and how our mothers behaved. We must get these authorizations and follow their example.”(Assietou, 29).
In addition, for most participants, a second requirement for assisted childbirth is that the parturient women be accompanied by a man. The reasons given are primarily pragmatic. The ailing woman needs sturdy arms to cope with the unsuitable mode of transport on damaged roads: “To go to the health center, you need to find companions first. How can I travel sick in a transport vehicle without being accompanied by a man, a member of my family? It’s not acceptable.”(Leila, 24) The company of a man during their evacuation was very much appreciated by the participants. However, men are not always available to accompany them, which sometimes makes it impossible to use assisted childbirth: “I was sick (childbirth), while no man was available to bring me to the health center. They were all busy with the animals.” (Salka, 30).
Also, once at the health center, the presence of a man would also be required to make decisions regarding expenses and hospitalization, or act as an intermediary between the woman and the health workers: “I have spoken very little with health workers. They talk to the man (husband) and give him the papers (prescriptions). Then he pays for the drugs.” (Fatimata, 27) For the participants, all these are elements that limit their mobility as regards recourse to assisted delivery.
Decision-making autonomy as regards the use of assisted childbirth
Participants explained a complex decision-making process that follows several stages in which various interactions between different people occur. This process highlights the low autonomy of women as regards decision-making.
A network of actors controlling the decision-making process
For the participants, decision-making is controlled by a network of actors essentially made up of men. For these women, it is primarily the husbands who would be at the forefront when it comes to making decisions: “I did not see how I could go to the health center while my husband was on a trip.” (Taliat, 22) Moreover, the parturient woman’s parents, in whose house she gives birth, would preferably be other important actors: “When the woman gives birth at her parents’ house, they are the ones who decide. This case is the most common one, especially for young people.” (Fadimata, 40) Sometimes, decision-making is extended to the community, particularly to the notables and especially to the head of the camp, who manages the problem and proposes solutions to the husband. Indeed, at an advanced stage of complications, it is often badly perceived for the husband to decide alone for his wife without referring to the notables: “It is the notables of the camp who decide ... it is sometimes badly seen for a man to decide alone for his wife.” (Leila, 24).
This interdependence among husbands, parents, and relatives is recognized by participants as being very valuable in facilitating decision-making.
In addition, some participants negotiated with their spouses to await their delivery in a family near the health center a few weeks before the pregnancy reached full term: “For deliveries at the health center, if I’m not too stuck by that time, I will live and wait with a family near the center.”(Khadou, 35) In these cases, the woman asks permission of the husband, who evaluates the suitability of the request, and the decision is made by mutual agreement of the two spouses. This decision is also facilitated by the presence of host families (parents, acquaintances, or friends).
In other cases, this process of negotiation between the spouses did not result in the use of assisted childbirth because the decision was made late, either due to issues of modesty or because the communication between them was incomplete. Despite the insistence of some parturient women, their husbands felt that there were not enough reasons for them to give birth at the health center, which led to their not using the services:
Once I tried to talk to my husband about going to the village and giving birth at the health center. But he thinks that I am in a good shape and that my deliveries have always gone well at home. So he did not want me to, and I gave birth at home. (Safietou, 20)
In most cases, the decision of the husband or parents is final, which limits the power of women to use assisted childbirth.
When there are complications, the decision is made without the parturient woman’s input
For many participants, the decision-making process is different, and for them childbirth entails other steps when there are obstetric complications. In such cases, their decision is determined by the seriousness of the parturient woman’s state of health, which is itself judged on the basis of two criteria. On the one hand, there is the duration of her extended labor: “The decision is made when the woman spends several days of labor, and the family realizes that she cannot give birth at home.” (Fadimatou, 26) On the other hand, there is damage relating to the physical health of the parturient woman (fainting, labor stoppage, etc.):
I had to pass out before my mother would ask my father to take me to the health center. I do not remember anything. My mother later told me how it went. Fortunately, I arrived at the health center in time. (Khadou, 35)
This decision-making process is subject to a series of negotiations and consultations and requires consensus among family members: “The decision is made in a concerted manner. There should be mutual agreement before the decision is reached.” (Fadimata, 40) As a first step, the parturient’s female assistants assess the seriousness and urgency of the situation and provide guidance for the use of the healthcare center. They then inform the men, who make the decision for her evacuation: “The women around you will recognize the complications. Then they will go to the men to find solutions.” (Fatimata, 27) For many participants, decision-making would depend heavily on the values and opinions of their husband or parents (father or brothers).
The majority of parturient women mentioned not having participated in this decision-making process, a reflection of their weak autonomy as regards their recourse to assisted childbirth.
Economic autonomy: Control of financial resources by men
Our interviews show that all the participants are housewives. They do not perform any paid work, which limits their autonomy to seek care. “We do not perform any paid work to earn money. We take care of the family, children, and old people. It’s already a lot of work. But how can we have money in our bush here? There is no trade or income-generating activity.” (Lawal, 36) In addition, participants acknowledged that men control family resources and decide on all financial issues. As such, they are responsible for the health of the family and it is up to them, regardless of their wealth, to cope with the expense of caring for their wives: “When I’m at my husband’s house, he’s the one who decides and gives me the means to go to the health center for care.” (Khadou, 35) The payment of expenses related to the care of women is therefore an obligation for men. As a result, the costs of care would sometimes discourage them from sending their women to the health center: “It is the men who decide about everything. Even if a woman has her property, she cannot decide for herself. Their authorization is therefore required to give birth at the health center.” (Lalla, 20) Women thus acknowledge that they have limited access to family resources and that their control by men would affect their decision-making power to seek care: “Maybe if women had their own means, they could decide on their own!” (Lalla, 20).