A total of 43 pregnant and nursing women, aged between 18 and 43 years, with parity ranging from one to six of diverse demographic characteristics, participated in the study. Using the PEN-3 framework, themes from the findings in the cultural empowerment domain include positive factors such as the system of communication. A positive factor, language of communication, was identified in this domain as a positive factor that influenced women’s use of MHS. An existential factor under this domain identified was religion. Additionally, negative factors that influence women’s use of MHS identified in this domain are prayer houses and lack of women’s autonomy. In the relationship and expectation domain, seeking belongingness and the belief in the supremacy of God were the perceptions identified in the study. A negative enabler identified is the use of traditional medicine. At the same time, nurturers in the findings include family support and factors influencing the use of contraceptives. See Fig. 1 for a Summary of the Themes and Subthemes Using the PEN-3 Cultural Model.

Fig. 1

Summary of the themes and subthemes using the PEN-3 cultural model

Cultural empowerment domain

In this domain, the authors first explored cultural and religious structures within the community that positively influence the use of MHS, and then those that are existential (harmless) are acknowledged. Finally, cultural and religious structures that are harmful or act as barriers to women’s use of MHS are explored.

Positive factor

Positive factors are those cultural systems or structures that promote women’s use of MHS.

Language of communication

Most women narrated that they grow, learn, and interact through the Indigenous Igala language, which allows them to communicate effectively within their context. In this study, women identified the use of Indigenous oral communication using the Igala language as a positive factor that influenced their use of MHS. Women recalled that the use of the Igala language contributed immensely to their oral expression, engagement in health education, understanding of health information and a reason for their continued use of the primary health facility of their choice.

They teach us in Igala, it makes us understand what they are teaching us very well… it is interesting…the Igala that they are teaching us will make us come back another day again (RA/IDI/07).

Because I am Igala by tribe and I was born an Igala, my mum and dad are Igala by tribe, so its sweet in my heart and it makes me very happy. The things that influence me, that make me understand is that, they didn’t use any language apart from that Igala. It makes me understand what they said (RA/IDI/08).

Yes, the dialect (Igala language) is beneficial; for instance, now, if they are not feeling fine, either the head or the stomach, they will explain to them, but if they tell them to speak English, none of them would be able to speak English. If they speak their dialect, they will understand it better than English….since they understand what they taught them through that dialect, the thing will motivate them; next time, they will rush to that hospital, to that health centre (UA/IDI/09).

Normally, you know some people do not understand English, so if you understand English, they will speak English to you; if you don’t understand, they will speak Igala.. someone will be there to interpret it for you (UA/IDI/07).

Participants also recounted that in most health facilities where health information is provided in English, health workers also take time to interpret the information in Igala and other languages for women who do not understand English to promote an in-depth understanding and engagement in maternal health.

Neutral/existential factor

Neutral behaviours are those cultural and religious structures in the community that do not significantly contribute to women’s use of MHS.

Religious system

Findings from the study showed that the most dominant religious systems in the communities are Christianity and Islamic religion. Results from the study show that both religious systems play diverse roles around childbirth. Some of the roles played by these religious systems could be significant support during pregnancy and birth. However, such support may not necessarily enhance the use of MHS. For Christians, such support ranges from prayers to monetary support at birth, as these women recount.

When I gave birth to my first issue, my pastor came down to the hospital to come and see me and prayed for me and other women that gave birth. and also gave us money and, helped me, transported me from the hospital back to my house (UA/FGD/01).

when you are pregnant it is not a spiritual matter. You only go to your pastor when you need prayers. It is just that from time to time, maybe in the church, the pastor will pray for all pregnant women, and then when you are in labour, they will even come physically with their wife to pray with you (RA/IDI/01).

The Islamic participants in the study also noted support from their religious leaders or Imams, ranging from prayers to the provision of Rubutu. Rubutu is the verses of the holy Quaran or spiritual prayer book, written on a board, which are then washed off and given to women to drink and rub on their private parts, believed to prevent pregnancy complications and evil attacks and enhance speedy birth. Rubutu is taken regularly to achieve an uneventful birth.

When I am pregnant, we usually go to Imam to pray for us, he will write that thing (robutu) on a wood, then we will wash it use water to wash it down. He will wash it down and give us to drink, you will use it to wash your belly down to your front…whenever you use it to wash the private part it will make it to open so that you can deliver freely (RA/IDI/07).

Women narrate that the support provided for women by these religious leaders is crucial and supports the cultural and spiritual expectations of women in communities. However, these supports do not influence or enhance women’s use of facility care.

Negative factors

Negative factors identified in the study are significant cultural and religious structures that influence the non-use of facility care or MHS. These negative factors are embedded in communities and are mostly viewed as protective factors that could enhance maternal health outcomes. Moreover, most women tenaciously hold on to these factors and are unaware of their negative consequences. The influence of prayer houses and lack of autonomy were the negative cultural and religious structures found in this study.

Influence of prayer houses

Prayer houses, also synonymous with healing homes and prayer ministries, are non-denominational, privately owned prayer homes which have proliferated not just in Igala land but throughout Nigeria. Women narrated that most prayer house owners claim they have the power to hear from God and to reverse health issues, including maternal health challenges. Given the cultural context, most people believe that pregnancy is a time when women are vulnerable to attacks from evil forces, which intensify the need to seek protection from the prayer houses. In most instances, women are made to undergo rituals and hibernation in prayer houses for weeks or months, even in the face of maternal health complications.

I was in the prayer house that she said I have to spent 14 days there, so that the pregnancy will be safe so that she will be helping me to pray, I was there when I had the last miscarriage (RA/IDI/04).

Some women are even told that stepping out of the prayer house to seek facility care would terminate the protection they have and predispose them to attacks from their enemies. The fear of losing their lives and their babies keeps them bound in such prayer houses, limiting their access to facility care, which could predispose them to maternal health complications.

They prayed for me and, anointed me with oil and told me not to go to the maternity because my mother-in-law was after my life. They said the moment I go to the maternity, the protection will be broken, and I will either die or my baby will die. I was afraid (Observation 1).

You go to the prayer house a times they will tell you that you should not go to the hospital, that they will give you anointing, that they will give you water, that you should take it that it will help you (RA/IDI/07).

Most women complain that they have become banks of many prayer houses, as they demand money ceaselessly from them. Additionally, women are presented with prayers and made to go through several rituals to ensure that their prayers are answered. These rituals mostly involve use of prayer artifacts such as candles, anointing oil, handkerchiefs, sand, salt and holy water, which are sold to these women in most prayer houses. Consequently, the money that could have been used for facility care is spent in these prayer houses, limiting women's access to facility care, given that facility care in most Nigerian communities is paid out of pocket.

They give us olive oil and, in some places, they pack sand for us, that sand we put it in water, some are salt and some are different medicine… and you will be bringing the money for them (prayer houses), and they will be using it to take care of their own family; you will be suffering and be looking helter-skelter for money (RA/IDI/03).

Even with all the promises from prayer houses, women complain that they do not see any change in their circumstances due to the high number of maternal health complications that are seen in most prayer houses. However, many women still go from one prayer house to another, looking for miracles, mainly when pregnancies are associated with complications. For some women, going to prayer houses is a multiplication of issues as they believe that many prayer house owners are possessed by evil spirits, which is then transferred to people who attend such places, which is the reason many say they do not access prayer houses for spiritual help around childbirth.

Women’s lack of autonomy

Lack of autonomy was one of the themes that evolved in the study, reflecting that patriarchy is a dominant system in Nigeria, where men control affairs in the home, including issues related to MHS use. Issues of patriarchy are openly related to couples during marriage where they are told that, henceforth, the man takes charge of decisions in the home. Consequently, men, in some cases, dictate if, when, how, and where women should seek facility care around childbirth, though most of the men do not engage in maternal health and do not have much knowledge or information about maternal health.

You can’t make decisions by yourself except your husband. Because he is the head of the house, if you are going somewhere and he says you are not going there, then you will sit down, you will not go to that place (UA/IDI/04).

In these contexts, apart from husbands, several other people, such as family members, are also involved in decision-making related to women’s use of MHS. Such an approach to decision-making is believed to be crucial in Igala land because if a complication or death occurs without prior notice to the woman’s family of an existing emergency, the husband would be required to provide explanations to the wife’s family. Consequently, decisions need to be obtained from the family of the woman in emergencies before such a woman could be transferred to a health facility for emergency care, delaying access to emergency health services that predispose women to maternal and fetal health complications.

This is my first time coming to this hospital, there is where I use to go, my husband said I should stop going there, I should come here even my mother supported here, my dad also supported here that I should come here that they normally take care of pregnant women here. That is why I’m here (UA/IDI/ 07).

You know, we believe here that every day you are married to your husband, he is not the one to take the whole decision. Like if a woman is to be operated on, some husbands, no matter how emergent the situation is, they will ask the woman to wait. Let’s inform your parents and see what they will say. And some parents will say bring back the woman to us. It happened to one of my friends. The husband was willing to sign but the father said bring her home (RA/IDI/01).

Many women interviewed stated that the cultural stigma attached to women making decisions limits them from taking such challenging steps. For example, women who make decisions in their homes are seen as stubborn and taking the place of their husbands. Such women are conceived as having charmed their husbands to occupy such a position of authority. The husband is also seen as a worthless man who is ruled and controlled by a woman.

They will say the woman is a strong woman, they will say the woman married the man, not the man marrying the woman; they will say it is the woman that is the head of the house. They will be scared of that woman; they will say you should avoid the woman that the woman is the husband, and the husband is the wife (RA/IDI/09).

Though a few women still maintained that decisions on the use of MHS are taken jointly by the couple, women narrated that, in some cases, decisions are delayed, especially during emergencies, which could delay maternal health access and result in preventable maternal and fetal health complications.

The relationship and expectation domain

In this domain, we explored women’s perceptions and views of some significant cultural issues that influence their use of MHS. Additionally, some cultural and religious structures within the communities that influence women’s use of MHS were explored. We also explored some intergenerational traditions as well as the family, kin and friends within these communities that continuously act as a force to enable, nurture or hinder women’s use of MHS.

Perception

Women’s perceptions that were found in this study were the non-observable beliefs and values that influence their use of MHS such as seeking cultural belongingness and relying on the supremacy of God.

Seeking cultural belonginess

Many women narrated that they ascribe tenaciously to intergenerational practices to have a deep connection and link with their environment, social groups, and individuals with whom they share a close relationship. Such a connection is a fundamental human need as they believe that disconnection from the culture would mean that they were not rightfully married into the community or that they are strangers or outsiders. Women were also afraid that disconnection from traditional norms in the community could result in death and/or calamity in the family.

It means a lot to me because…we take an oath that we will remain for our husband alone till death do us part. So that is an oath, so we respect the rules and regulations guiding our culture (RA/IDI/02).

…it means a lot, … because that is our belief, that is tradition, and it has to be respected. Because once you don’t believe in it you might end up dying young (RA/IDI/07).

Some of the women interviewed had contrary views stating that such connections to traditional norms and practices were insignificant as they were brought up differently. Additionally, some participants expressed that such an era of holding on to cultural values and norms to prove your rightful belongingness to the community has passed and women need to embrace the new way of life by seeking assistance from health facilities to limit maternal mortality.

To me, I didn’t believe in culture, I believe in almighty God. I will not be scared of any culture, I don’t believe in culture and culture didn’t see me and I didn’t see culture. I believe in God (RA/IDI/10).

Hm, actually some of my friends like me, I don’t observe them because I believe that era is passed – we are now in modern era and we should access modern facilities (RA/IDI/01).

Many women stated that the need to maintain peace and acceptance in the family and community keeps them from openly expressing their feelings and walking in disobedience to cultural expectations and demands. Most pains are borne in their hearts and find expression as they carry out their daily activities in the home.

Relying on the supremacy of god and prayers

“What God cannot do does not exist” was a phrase that was frequently stated by participants in this study. Several of the women believed in the supremacy of God, implying that God has the sole authority and power over their lives and that of the baby. Many women in the study believe that God put the baby in the womb and so is able to protect and keep the baby until it pleases God to bring the baby out. Consequently, many women mentioned that they depend on prayers and God to see them through pregnancy and birth. They further narrate that, while health facilities exist, God alone has the final decision of maternal health outcome.

We see God through our prayer.. because some of us see God as our helper…. the baby in our womb, we don’t know how the baby is. It is only God that know how the baby is in our womb, and again, that’s why I also call him, so God is our helper, He is the one that helped this pregnancy…. Prayer is the number one thing. I don’t joke with prayer. So, my advice to other women is that they should hold on to God when they are pregnant because that is when they need God the most (UA/IDI/01).

Women, irrespective of their religion, also narrated that their belief and reliance on God gives them peace of mind and strength throughout the journey of pregnancy and childbirth. Women narrate that their faith in God is activated through worship and prayers to God, who alone has the final say in their condition.

Enablers

We found that the alternative health system was a critical healthcare system that was used by many women in the communities where the data was collected. Many women use traditional birth attendants and herbalists who provide them with traditional medicines during pregnancy and birth.

Use of traditional medicine

Women narrate that the use of alternative medicine in Igala land is an intergenerational practice that has been proven to be effective in relieving and treating minor and major maternal health issues. Many women assert that traditional medicine can easily be obtained from herbalists and traditional birth attendants who have an in-depth knowledge of herbal medicine. Women also claim that some traditional medicines are used commonly as spices and vegetables in the community. Women narrated the different types of herbal medicine they use and what each one does for them. Most of the traditional medicine are cooked or pounded to extract the liquid before they can be used by women.

one they call ‘ogwu amaro’ if they give you that one it will protect the baby in your womb then if the time when you are in labour you …will be strong and you will deliver…. It will protect the mother too, if you to want to pee you will pee freely… you will not feel pain (UA/IDI/04)

If you are pregnant you will take native medicine, some of such native medicine or herbs are used to treat conditions such as ‘ofu’ (hemorrhoid), ‘ija’ (fibroid), and ‘utebie’ (prevent the blood coming out from your babies cord from turning black), they will cut these native medicines from the bush and we will cook and drink it so that it will help us during pregnancy (RA/IDI/06).

for the Igala people they call one ‘ogwu ija’ ….so that the baby will not be big in your tummy and comes down with…..different … sickness (UA/IDI/ 08).

whenever you go to the hospital at times they will tell you you don’t have blood. We have herb medicine, if you see it, it is like blood, They call it ‘ogwu ebie’. It is like blood, if you cook it, if any body tell you this is not blood, you will not believe it. We take that whenever the nurse say that we don’t have blood…it works (RA/IDI/ 07).

The medicines is ‘Ukpokpo’, ‘Ogele’, ‘Ishaoko’, ‘Scent Leaf’ and ‘Aluri’ …another one is Agbo, the leaf, with paw paw, the leaf, we add them together ….you cook it and you will be drinking it… when you deliver, you will have no problem (RAIDI/ 08).

Many women also narrated some of the local medicines that are provided for them during labour and birth to reduce labour pains, enhance quick birth, and reduce postpartum bleeding.

Yes, they call it “ogwu adaru” …it will not allow your blood to flow when you are delivering (UA/IDI/ 07).

Many women narrated the importance of herbal medicine and believe that, although Western medicines are effective, Western medicines may not be as potent as traditional medicines in addressing some maternal health issues. Consequently, with this belief, many women decide to use only herbal medicine when they are pregnant. Some narrate that they also combine both to get a holistic effect.

There are some women that don’t even belief in going to facility to register for antenatal, they say no, I will not go, that this woman said I should be coming there to collect herbs, that is what will be helping me till I put to bed (RA/IDI/ 04).

This herbal medicine is very important because they will ask you to take these herbal medicines and not to concentrate on hospital drugs alone. They will advise you take herbal medicine, because, number one, if you don’t take it maybe when you deliver, you will have a problem (RA/IDI/ 07).

While traditional medicine is commonly used among Igala women, many women stated that they do not use traditional medicine as it cannot be measured like Western medications and could predispose women to maternal and fetal complications, as a woman narrates.

Local medicine doesn’t have dose and if you take over dose, it will affect you.

Some it will make you to be vomiting or having hot temperature or some other things, even some local medicine even forces baby to come out before labour….

it will cause false labour… some local medicine normally affects the liver and other things (RA/FGD/02).

Many women indicated that, in most cases, their mothers emphasized the need for them to take herbal medicine. Women recounted that they are told that herbal medicine existed before Western medicine, and was used by their forefathers before their birth, and has helped many women navigate the route of pregnancy and childbirth. Thus, women are told that, even if they do not want to depend solely on herbal medicine, they could use both concurrently around childbirth by using Western medicine in the morning and traditional medicine in the evening or vice versa.

Nurturers

We explored some cultural norms within the family and communities that shape the use of MHS. The most significant factors found in this domain were family support and factors influencing the use of modern contraceptives.

Family support

We found that family support was both a positive and a negative nurturer in women’s use of MHS. Childbearing is an engendered role in Igalaland, where women oversee issues related to maternal health while men provide the needed finance for facility care, which was mostly how women were encouraged to use MHS.

My husband provides all the money that I spend here during my antenatal and delivery. Because he is a very busy person, he does not come to the facility with me, but he always reminds me of the dates for my visits and also makes sure I remember to take my drugs every day (Observation 02).

However, most women expressed their dissatisfaction with men’s engagement in maternal health, although women were happy with their husbands supporting them during labour. Many women narrated that pregnancy and childbirth was a period they could get extra money from their husbands to spend on themselves. So they were happy with the men supporting them financially and during labour. However, most women disagreed with men engaging in maternal health as they believed that would unravel the amount of money spent on facility care, which could limit their financial support and access to facility care.

The reason I don’t like it (men’s engagement in maternal health) is that, maybe when you are coming for antenatal today, your husband follows you to that place, he will know everything that they are doing in that place, the amount they are giving card, the drugs and everything. So next time he will not give you the amount that you need again because he already knows what they are doing in that place, and before you know, problem will start. So, me I don’t like him following me (RA/FGD/02).

Many women narrated that extended family support is important around childbirth enhancing women’s use of appropriate health facilities through financial and moral support. However, while many women welcomed their husbands’ support during labour, most women expressed dissatisfaction with some extended family members supporting them during labour and deliveries and asked for nurses to be aware of their situations.

I don’t like it. Like my own, they came, but I was not okay with it. Because they will be seeing you going through that pain, that kind of pain, I’m not, I was not comfortable. Maybe the nurses should drive them out. The nurses should close everywhere so that they will not see me. They should just be hearing any voice (UA/IDI/06).

However, another participant narrated that though she does not welcome extended family support in the labour room, family support outside the labour room may indicate a good relationship between a woman and the family.

Some of them coming they are not coming eehh with good intention, some come with evil intention. I feel good, I have someone that are supporting me outside, because if as a woman if you are in the labour room and there is no one …my sister, or my sister in law …It will look like maybe am I that bad to them (RA/IDI/04).

Some women also narrated that such family support could prolong births, and some extended family members may disclose what the woman said in the labour room to other women.

Maybe,..God said, deliver by 2 o’clock, some that are coming there with evil mind..they may prolong the time. And some you know, we women, during labour, we are bound to say all sorts of rubbish …is not everybody that is supposed to hear what you are saying because once they are from there (labour room) they go out, they say ehhh, during labour, this is what she is saying (RA/ FGD/02).

Some women narrated that men’s engagement in maternal health could promote their use of facility care and exhibit their support. Nevertheless, women recounted that the cultural interpretation of such support might portray a woman as a domineering and one who controls affairs in the home. Additionally, most women narrated that men engaging in maternal health could mean that such a man is stingy and engages in maternal health to pay the bill instead of trusting the wife with the payment of the bills. Based on these narratives’ most women prefer their husbands' support during labour and birth but not in antenatal care. Most women also narrated that support from extended family is crucial in women’s access to facility care. However, they emphasize the need for health workers and nurses to understand the boundaries to which such supports need to be provided. Women narrate that boundaries around childbirth are important, as they do not trust many close relations who may appear friendly, but may be harbouring plans to hurt or harm them physically or diabolically. They emphasized that such established boundaries would enhance their use of facility care.

Factors influencing the use of modern contraceptivesIbegwu

Findings from the study showed that women had limited use of modern contraceptives due to cultural and religious structures and norms that were dominant in the communities where data was collected. In one community, many women do not openly access contraceptives because it is forbidden due to a cultural belief that such could attract the anger of Ibegwu (ancestors), which could result in the death of the husband or the male children of the family, especially when the woman in question has been married traditionally. Women are encouraged to have all the children that God has given them, as indulging in contraceptives is regarded as killing a baby. Women recount that those who indulge in family planning, especially with their husbands’ knowledge or money, would see their husbands get sick and die because of their actions. Consequently, many women in the community are afraid to use contraceptives.

My parents, my mother inlaw all those people use to sit me down and be warning me not to do family planning…because of culture…they said that a married woman, is not good to go and do family planning, because of those Ibegwu (ancestors)…because the thing (ancestors) leads to the man’s death, being our husband. If you do family planning and your husband is aware of it the thing (Ibegwu) will lead to his death (RA/IDI/09).

Male child syndrome

Many women also narrated that one of the reasons they do not access contraceptives is due to the issue of male child syndrome. In Igala land, a male child is regarded as the heir to the family's wealth as female children do not inherit family wealth since they will marry and leave the family. A woman who does not have a male child will not consent to use contraceptives as culturally, she is seen as someone who has not really produced an heir in the family.

When you don’t have a male child, you can’t go on family planning because when you go on family planning, and you need the male child….you won’t see the male child again. A male child is very important in our own tradition here because, normally if you have a female child, your husband will not be very happy with you, because the male child, when they have any talk in their family, they will call all the male children to come and sit down or all those palm trees, maybe they want to share it in your family, and you don’t have a male child, they will not give it to you, they will say you have females…. they will give it to the people that have males. Like me now, I am feeling it all the time, but I keep on praying to God (RA/IDI/08).

Influence of religion

Many women, both Muslims and Christians also narrated their experience of how their religion influences the use of modern contraceptives. For example, many participants explained that as Muslims, their religion does not support modern contraceptive use. A participant explained that Islam looks at using contraceptives as committing abortion, and since the Islamic faith is against abortion, they are not allowed to use contraceptives.

Islamically, they will be preaching against it (modern contraceptives),.. because they believe doing that (using modern contraceptives) is as if you are also committing an abortion indirectly…. and Islam does not permit abortion…as if you don’t believe in your religion, you don’t believe in Allah, that the repercussion is hereafter (RA/IDI/04).

For most Christians, women narrated that the decision on contraceptive use stays between the husband and wife on the number of children to have. However, a participant narrated that the pastors encouraged women not to use contraceptives but to continue giving birth as it is for that reason they were married.

They will tell you to be giving birth, but don’t hide the babies in your womb; you should continue giving birth; that is why your husband married you; that is the advice they will be giving you: not to use any injection or drug (RA/IDI/02).

However, this was not the perspective of other Christian participants, who, along with Muslim participants, narrated that the reason for the non-use of contraceptives was as a result of the side effects associated with contraceptive use, such as bleeding, secondary infertility and the need for more children, especially male children. Nevertheless, many participants related that with the present economic state in Nigeria, the use of contraceptives to achieve a small family size is crucial given the need to provide quality education and a good standard of living for the family.