Traditional and health practitioners perspective on traditional medicine utilisation during antenatal care in Bulilima, Plumtree, Zimbabwe

Background: Traditional Health System has been reported to be the most accessible, affordable, and acceptable in resource poor settings particularly in Sub Saharan Africa (SSA). It is utilised for different health needs including pregnancy management. This study sought to explore traditional and health practitioner’s perspective on traditional medicine utilisation during antenatal care in Bulilima District, Plumtree, Zimbabwe. Methods: A qualitative cross-sectional survey was conducted on purposively selected health practitioners and snowballed traditional health practitioners who responded to unstructured interviews. Data was collected using a digital tape recorder, transcribed and thematically analysed on MAXQDA. Results: Findings reported that Eel Fish/Water snake, Donkey Placenta, Elephant Dung, Holy water and Holy tea were common traditional remedies used during pregnancy. Reasons for traditional remedy utilisation were reported to be: protection from witchcraft, chasing of evil spirits, preventing breeching, stabilisation of embryo and shortening of labour period. Health service expressed their scepticism on the safety of traditional medicine utilisation during pregnancy. Conclusion: Women utilise traditional medicines and remedies during pregnancy for different reasons. There are concerns regarding their safety from the health service providers though traditional practitioners do not concur. There is need for investing on research that would ascertain the safety of these traditional medicines in a cohort format as this system has been a cheaper alternative for those who cannot afford or access modern health services.


Introduction
In developing countries, over a million women die of maternity related causes each year 3 regardless of well-known interventions to curb most of the pregnancy complications (UNICEF., 2008). Despite the availability of modern health systems in developing countries, women continue seeking care from traditional practitioners during pregnancy (Kyomuhendo, 2003). These services are popular in SSA countries because of accessibility, affordability and being readily available in the communities where people live (Nunu et al., 2019). Negative publicity towards pregnant women who use traditional medicine have been raised by policymakers, government officials, orthodox health professionals and researchers on the efficacy, quality, reliability and safety (Tsui et al., 2001, Wambebe, 2009). Although there are concerns Traditional Medicine (TM) continue to be widely used (prevalence > 70%) by African women for maternal and reproductive health care (WHO/WHO, 2015). Frequent users of traditional medicine are pregnant women with no formal education, low income, and living far from public health facilities (Kowalewski et al., 2000).
Zimbabwe has two recognised health systems that were adopted after independence in 1980 (Nunu et al., 2020). These are: the traditional health systems that are mannered by herbalists, traditional healers and traditional attendants as guided by different cultural norms and practices (Nunu et al., 2020, Mposhi et al., 2013: the modern health system that is mannered by professionally trained health service providers and services obtainable in designated health facilities (Mposhi et al., 2013, Nunu et al., 2020, Nunu et al., 2019. It has been reported that most health service users prefer to utilise the traditional health system particularly in rural areas and other resource poor setting s in the country as it is cheap and readily available at their local communities (Magaisa, 2007).
In Zimbabwe the most users of the traditional health systems are those that are in rural areas where there is limited number of health facilities as well as existence of inequity in 4 as far as the health service provision is concerned (Sanders, 1990, Nyazema, 2010. Over 60% of the Zimbabwean population resides in rural areas which are characterised by underdevelopment in comparison to the urban setup (Nyazema, 2010, Sanders, 1990).
There has however been conflict between traditional health practitioners and modern health service providers about the boundaries and concerns of safety in as far as traditional medicine utilisation by patients is concerned leading to differing views and the parallel running of these services (Nunu et al., 2020, Mutambirwa, 1989, Waite, 2000.
This study therefore seeks to explore traditional and health practitioner's perspectives on traditional medicine utilisation during antenatal care among women in Bulilima District, Plumtree, Zimbabwe.

Study Area
Bulilima is located in Matabeleland South province and bordering with Botswana to the west in Region 5 which is prone to severe drought (Dube, 2015). It has 16 clinics, 22 wards and has a population of 94 361 with 54% females with Kalanga and Ndebele being the dominant tribes (David and Dube, 2013). The district has one main referral hospital with sixteen clinics that usual refer pregnant woman with complication to district hospital and has an average household size of 5 (David and Dube, 2013). The average distance that women walk to the nearest clinic is estimated to be 5-10km. The study area is illustrated on Fig 1.

Study Design
A qualitative cross-sectional survey was undertaken to explore traditional and health practitioners perspective of traditional medicine utilisation on antenatal care among women in Bulilima District. This design was adopted as it enabled rich data to be gathered and answer the research questions through provision of in-depth explanations (Creswell, 5 2013).

Target Population
This study targeted traditional practitioners (involved in offering services to pregnant women) who resided within the three km radius from the clinics. Traditional practitioners included but were not limited to traditional psychiatrists, Traditional birth attendants, herbalists, traditional surgeons or other relevant individual responsible for pregnancy management with the aid of traditional medicine. The study further targeted trained health service providers that were offering maternal health related services to pregnant women in the district.

Sampling
A total of nine traditional practitioners who met the inclusion criteria were snowballed as the researchers had no prior knowledge of their numbers. Purposive sampling was used to recruit ten health practitioners' who were responsible for maternal health service delivery within the sixteen health institutions.

Data Collection Tools
An interview guide was used to guide the data collection process so as to ensure that sufficient data was gathered to answer the research question. The guides were developed in English language and further translated to Ndebele which is the major language spoken in this district. The guide was pretested on two health service providers and two herbalists in Mangwe district which is the neighbouring district. There were no adjustments that were made to the guide. The interviews took between 15 to 30 minutes to be administered. The interviews were recorded using a digital tape recorder.

Trustworthiness
This is a process that is implemented to ensure that the whole inquiry process yields robust and accurate findings (Nunu et al., 2020). The following were taken into 6 consideration during the conceptualisation and implementation of the research inquiry:

Credibility and Dependability
To ensure that the research methods that were used would provide trustworthy information (Nunu et al., 2020), a research proposal was reviewed by the Department of the Environmental Science and the National University of Science and Technology where the research is affiliated to, independent reviewers reviewed the proposal and made recommendations that were taken into consideration (on the research, data collection and analysis tools). The proposal was further reviewed by the Ministry of Health and Child Care of Zimbabwe before permission was granted to conduct the study. Standardised data collection, analysis and interpretation methods were also adapted from different authors (Creswell, 2013, Tobin andBegley, 2004).

Conformability and Transferability
In research there is need that findings of qualitative studies be put into context and be confirmed by other authors (Creswell, 2013,Nunu et al., 2020, Tobin and Begley, 2004.
Though the findings of a qualitative study maybe unique, ideas could be applicable to other different study settings (Creswell, 2013,Nunu et al., 2020, Tobin and Begley, 2004.
High levels of objectivity and honesty were observed in collecting, analysing and interpretation of the data.

Data Analysis
Data collected was transcribed verbatim, coded and thematically analysed on MAXQDA Version 14. Obtained results were then presented in the form of themes and subthemes that were supported by direct quotes from the respondents.

Demographic Characteristics
From a total of nine traditional practitioners, seven were self-employed, eight had an experience of more than ten years treating people and their average age was 48. Of the ten health practitioners that took part in the study all of them were nurses, seven were married and all had an experience of less than ten years. Their average age was 37.

Traditional Practitioners Perspective on traditional medicines
Themes and subthemes that emerged from traditional practitioners are protective role, payments services, hygienic services, complications, beliefs and many more as they are presented below: (a) Protective Role: The following subthemes emerged as they play a crucial role in protecting the baby and mother from different reported aspects during pregnancy.

(i) Complications
Respondents reported that there are many complications that arise during pregnancy, labour and as well as different methods of managing them. Also one of the participants highlighted that when the baby is a breech they massage the stomach clockwise using petroleum jelly mixed with ash. Also the position of foetus is directed by eating porridge with couch grass which enable the baby's head to be in the right position. Traditional practitioners reported that during their care and administering herbs during pregnancy or labour there are no complications that occur to women u though they might occur during postnatal care when they are discharged. Participants highlighted that they have power to determine what is hindering the women from delivery. Furthermore respondent indicated that bleeding is controlled with the aid of elephant dung. The following quotes resemble how respondents manage pregnancy complications and labour: "we grind the donkey placenta into powder and mix with boiling water and woman will drink then after some hours the uterus will come out.
"….As pregnancy months increase the baby is supposed to turn head facing down but now 8 if it crosses thus when massaging is done using petroleum jelly mixed with white ash till in the right position".
"I can tell that there are problems inside the placenta such as bleeding, blisters or rush so we pray for them and that thing usual disappears".
"…what I know is that complications usual arise after birth when they are now at their homes when they are doing their rituals".
"We take white roots of uqethu (runner grass) and drink so that the foetus will turn head facing down".
"We use elephant dung as it is burnt and they stand apart the burnt dung so that you could sense and feel the smoke of dung".

(ii) Evil spirits
Respondents noted that evil spirits affect pregnant women and might lead to serious problems. One of the participant noted that they chase away these spirits in different ways in order for woman to deliver properly. Participants felt that evil spirits usual makes nurses to have negative attitude towards pregnant women. Respondents cited following response in chasing away evil spirits: "We also use Eucalyptus Oil whereby I put 3 drops that in water in the "name of the father, son and holy spirit" to chase bad air/evil spirit".
"We recommend them to buy petroleum jelly and mix with Ivimbela (white/red ointment) to chase evil spirits during the first months and massage the stomach with it so that nurses will not have negative attitude towards pregnant women".

(iii) Unexpected Delivery
Based on respondent perspective delivery can happen at any place and at any time especial when not controlled. Therefore they suggested different ways to ensure that delivery doesn't occur unexpected as noted by one respondent who said: "…they make her carry a small stone like a baby in her back until she reaches final destination and untie it/throw it away when one responsible for her to give birth".

(iv) Witchcraft and tying
Traditional practitioners highlighted ways to protect pregnant women from witchcraft and tying. Participants indicated that: "Firstly when people haven't realized that she is pregnant, she will take a portion of soil from her footprint and put it in a cloth and tie it. When she is about to deliver thus when she will untie and put in water then drink".
"During the first month pregnant woman mix soil and their urine then dry it and tie in a cloth and untie when they are about to deliver to protect woman from witchcraft and tying during the entire pregnancy".

(v) Smell
Respondents elaborated that pregnant women reacts different to either bad or good smell and can easily vomit if not prevented and managed. One of the respondent highlighted that: "They usual smell their armpits or put their hand under the armpit and smell that hand to neutralize bad smell".

(vi) Disease prevention and control
Participants highlighted that there are different ways that are done to prevent the spread of diseases especial when delivery is done at home. There are also recommended herbs when pregnant women are not feeling well. Participants eluded that: "Pregnant woman are told in advance to bring their own blankets, string to tie the umbilical code and razors so as to prevent transmission of diseases".
"Also if they had inyongo they drink Marula (umganu) as they put it in water and they will have running stomach and some come out through urine, there is also limit of umganu (Amarula) as overdose might lead to complications. Pregnant woman are not suppose ukuphoziswa (enema)".

(b) Shorten labour
Different herbs have been used to speed up delivery and shorten labour as revealed by traditional practitioners. Also they suggested that there are herbs used to lubricate the vagina for easy delivery.
"We burn donkey placenta and mix with water and we also take roots of isikhukhukhu (snuggle leaf) facing Eastern side and they drink it for fast delivery".
"We also use inkunzane (slippery herb) to wash the vagina to make it slippery during birth and this herb is strictly not used for drinking".

(c) Sexual Intercourse
Different views from respondents emerged regarding sexual intercourse during pregnancy.
Some suggested that sexual intercourse does not cause pregnancy related problems. In addition one participant also noted that sex depends with individuals and there are herbs used to clean the dirty caused by sexual intercourse to the baby. Traditional practitioners indicated that: "Usual when having sex you should not ejaculate inside but practice withdrawal so that you won`t mess the head of the baby. In our culture we say it removes her dignity/ status (ukumkhipha isthunzi)".
:"Sex does not have any effect on pregnancy……some man have high sexual desire and stops even just few days before labour and this makes nurses complain about dirty babies".
"It depends with people and their appetite differs but umthunduluka (sour plum) leaves clean everything before birth even sperms as it is believed that the baby will be carrying them using head".

(d) Payment for services
Respondents reported that not every pregnant women pay for their services.
"…pregnant woman they don't pay anything since majority will be stressed as other males deny pregnancy, others being impregnated by others husband and relatives".
"They pay isimbo (consultation fee) in the form of money, goats, grains depending with the pocket of a person. Also they pay umkhonto (token of appreciation) in form of goat when the child start having milk teeth to show appreciation".
"They pay money for the eyes of grandmother but with no specific amount but according to your condition/pocket but it`s just small might be $1 or $2 for appreciation".

(e) Embryo/foetus growth
Other respondents emphasized that the baby grows natural in her mother`s womb and nothing is given to them for growth purposes it`s just God`s work. Other respondents indicated that they use a certain herb to stabilize the embryo within the first three months so that it`s not easily destroyed. Also one respondent highlighted that there are herbs used to make the baby to be big during pregnancy or after pregnancy. This is revealed by respondents following views: "No! No! No! No one knows how to make the baby grow inside that one its "nature from God". The only way that can be done to is to eat things according to their stomach preferences' but I recommend food like Okra, dried vegetables".
"We usual give them uMqathuva (Red star apple) to make porridge and also bathing close to granaries which is ladies place to stabilize the embryo (ukubamba umthondo)".
"Baobab barks are taken and put in water overnight and then woman drink to make the baby to grow and to be strong as well like a baobab tree. Also if the baby is born slim we bath him with it to gain weight".

(f) Hygienic services
Respondent's highlighted cleaning mechanism used in order to ensure that the house was in order and clean for delivery purposed. This is shown by one traditional healer who said: "…grandmothers build a hut that is specifically for labour which is polished using dagga and cow dung and no one is allowed to enter that house to maintain its cleanliness".

(g) Beliefs
Participants revealed controversy in terms of beliefs of traditional medicine in managing preganancy. Traditional practitioners also indicated that mother and baby are directly connected and whatever scary things they see in the environment affects the child "Now biblical beliefs is against these medicines but majority of Christians use these while hiding them".
"When she see weird scary things like snakes, crazy people or funny things. She opens her chest and spit on top of the stomach to protect the baby from that bad thing so that the baby will not imitate that bad thing and it`s called Nodzela. For instance some kids cry like doves and goats when mother usually like seeing that."

(h) Power to heal
Participants indicated that they get their power to heal through training programmes that occur usual after 5 years to revive them. Other participants indicated that it`s natural to heal pregnant women as their power comes from God. Participants said: "We usual go for trano training that runs for 3 weeks fasting......... and will be given names for prophesying for example Obadiah Mjuda from your angels": "Its natural as I was born after 12 months and people used to consult me while I was kid. I use visions, dreams, and word in the form of voice can come to me and tell what to do and our power comes from God".

(i) Food
Respondents indicated that pregnancies usual have different food preferences. ". In 13 addition they suggested that women should eat thoroughly cooked food and that is natural. Practitioners eluded that: "The only way that can be done is to eat things according to their stomach preferences' but I recommend food like Okra, dried vegetables. Many pregnancies reject different types of food such as eggs and meat "She is not suppose to eat food that is not thoroughly cooked but we usual recommend natural foods such as African chewing gum (uxakuxaku), wild meldar (umviyo)".

(j) Birth place
Participants indicated that choice to give birth or place of birth depends whether the woman does have complication or not. Furthermore respondentsdenoted that there are ways done to ensure that women deliver in the right place when labour begins rather than delivering unexpected at any given place. This shown with their response: "If there are no complications it`s better to give birth at home but if there are complications such that she needs caesarian its better at hospital".
"…they make her carry a small stone like a baby in her back until she reaches final destination and untie it/throw it away when one responsible for her to give birth".

(k) Tradition versus modern system
Traditional practitioners indicated that there is no problem working in conjunction with hospitals as they noted that some problems are beyond nurses/doctors capabilities which need their intervention. Also one of the traditional practitioner indicated that was once having legal right to help pregnant women. This is supported by their response as they said: "I can work with hospitals because in most cases pregnant women that have been failed by the hospitals such as those failing to urinate and those with cancer usual come to me".
"I am a registered healer among top eight healers in Matabeleland South and was given the certificate to help pregnant delivery but now they don't want to renew it don't know why?".

Health Practitioners Perspective on traditional medicine
Different themes emerged from health practitioners that reveal their knowledge on traditional medicine utilisation during pregnancy such as appetite booster, labour reduction, complications, monitoring and cost:

(a) Counselling and Food
Counselling was noted as one of the activity done by health practitioners towards women who utilise traditional remedies. Participants also recommended food that have got all the required nutrients during pregnancy. Respondent highlighted that: "We give them counselling and health education but sometimes according to culture they belief that so there is no way we can prevent it".

"I think it`s best for pregnant women to eat food with all nutrients preferable vegetables
and they should avoid eating cold food".

(b) Appetite Booster
Health practitioner indicated that some woman take multi-vite to boost their appetite as highlighted that: "yes some woman usual take umdamoyo (multi-vite) to boost their appetite as majority will be not having appetite".

(c) Labour reduction
Participant indicated that these traditional medicines reduces the time of labour as one said: " If pregnant women takes that African Pitocin, labour last for 2hours or even 1hour and sometimes it leads to complications".

(d) Modern versus tradition
Some health practitioners are indeed against these traditional medicine use during pregnancy. Also other health practitioners indicated that they don't recommend crossing 15 of systems from modern to tradition. On the other hand, other respondents highlighted that it`s possible to collaborate and integrate with traditional system even though there are challenges. Their views are: "Those women who use African Pitocin will be having more complications since they don't have specific dose, you will find that the patient will come with 500ml bottle of concoction and will drink all".
"No we are not allowed to refer patients from hospitals to traditional healers unless some nurses who are talented they can tell that this problem is beyond their control and recommend secretively even though it`s not advisable".
"It is possible to work together with traditional system but the problem is that some traditional healers say their knowledge and training comes from Ancestors thereby making their services to be paid for which makes it difficult to work in conjuction".

(e) Research and safety
Based on health practitioner perspective, thorough research should be done regarding traditional medicine and other respondents noted that these medicines are not safe and cannot be recommended. This is supported by: "I think if their medicines have a proper dosage and also a lot of research is done on their use it can be used but I think for now they need thorough research".
"I think on safety I would not recommend, I say they are not safe for now unless there are proper recommendations as we can see more complications than good things".

(f) Complications
Partipants elaborated on modern medicine in managing complications for those women utilising traditional medicine. Participants also acknowledged that not all traditional medicine causes complications. Participants indicated that in order for woman to deliver normal there should be 3Ps (power, passage and passenger) but when traditional medicine are used it results in severe complications as the respondent said "We use our convectional medicines like Oxytocin, cytotec and we do fluid replacement depending on how much they have lost for instance if they have lost more than 400ml blood replacement is done as we do cross match and see how much is the haemoglobin then transfuse".
"Some traditional medicine are good it will be just smooth delivery but you never know what they have taken some mothers don't say anything but we can see as the contraction and dilation doesn't go hand in hand".
"In most cases African oxytocin make 3Ps not to correspond leading to uterus rupture either of too much power affecting dilation".

(g) Concoctions
A number of concoctions were mentioned by respondents based on their experience as they associate with pregnant woman on a daily basis. One of the respondent also highlighted that patients take different form concoctions from church. "Some they use elephant dung as they put it in water and drink the concoction to make them to deliver fast and some take placenta donkey and drink it and make them to deliver fast".
"You will find out that there are some church where elders particularly grandmothers that are responsible for pregnancy especial massaging (sirila) and giving of holy water and holy tea".
"Woman also use isihaqa when they feel stomach pain during pregnancy which is harmful depending with the season".

(h) Monitoring and cost
Health practitioners indicated that we monitor woman who are in labour and those delivered for about 72 hours. Participants indicated that there are no charges for maternal health as patients are treated for free in rural areas. Participants noted that: "We also monitor those woman with problems such as high blood pressure. We also monitor of post-delivery usually 72 hours but nowadays because of circumstances beyond our control we are no longer able to keep them for those hours".
"Maternal health is for free and currently there is an NGO (Global Fund) that is funding, us as nurses we are given US$10 per delivery service".

Merging Traditional and Health practitioners views
Common themes emerged from both (traditional and health practitioners), these are: shortening of labour, food, payment and controversy behind tradition and modern system as indicated in Fig 2

Traditional medicine and concoctions used during pregnancy
Respondents stated a number of traditional medicines used and their reasons. The most predominant are Nyeluka (water snake/fish), donkey placenta, elephant dung, holy water and holy tea as indicated in Table 1 4.0 Discussion Majority of traditional practitioners were self-employed and attained at least ordinary level and have experience of more than 10 years healing people while health practitioners majority have less than 20 years' experience in the health sector. Literature reveal that educational level of traditional practitioners varies as some have attained primary, secondary and tertiary level (Hillenbrand, 2006). Our findings are in contrary with other studies that showed experience of traditional health practitioners ranges from 5-10 years (Kadir et al., 2012).
Bleeding was one of the complication that traditional practitioners manage through fumigating elephant dung as pregnant woman stand apart from the smoke naked under their observation. In addition the study noted that elephant dung was mixed with water and drank to quicken delivery among pregnant woman These findings are similar with different scholars that revealed women use elephant dung in either managing bleeding or quickening labour (Panganai andShumba, 2016, Chamisa, 2013). Also traditional practitioners highlighted that pregnant woman easily vomit due to bad or good smell which is prevented by smelling their armpits. Studies are against the notion revealed by the results as they suggest traditional herbs and chemical methods as a way of controlling odour rather than smelling of armpits (Garrett et al., 2003, Ling et al., 2012. The study noted that traditional practitioners have capabilities to chase away evil spirits through usual make nurses to have negative attitudes towards pregnant women affecting delivery process. Some mechanisms of chasing evil spirits from the study are similar with studies conducted by (Aziato et al., 2016) who highlighted anointing oil, blessed water, sticker, blessed white handkerchief, blessed sand, Bible and Rosary. Furthermore studies conducted in Islamic tradition revealed that prayer is weapon to chase away evil spirits (Abu-Rabia, 2005). Findings show that witchcraft in the form of tying constantly appear which is prevented through taking of dried soil mixed with urine or footprints and tying in a cloth and untie during labour. This is supported by studies conducted by (Chamisa, 2013) who found out that urine with soil and footprint mixed with other herbs prevent pregnancy tying.
Health practitioners revealed that those who utilise traditional medicine resemble more complications than those in convectional medicines. Also health practitioners acknowledged that some woman who utilize traditional medicine deliver safe without any complications. Some studies highlight that traditional medicine leads to complications that results in maternal morbidity and neonatal death (Zamawe et al., 2018) while others show that they lead to safe and fast delivery (Panganai and Shumba, 2016).
Traditional practitioners noted that if there are no complications woman can deliver safely 19 at home but if there are complications they should deliver at hospital. The world health organization suggests that delivery at home is safe under a skilled well trained birth attendant (Organization, 2004). On the other hand health practitioners recommended birth place to be at hospital to manage unforeseen complications. This is supported by studies that reveal concerns towards home birth as they advise hospital births even though there is no law restricting home births (Lindgren et al., 2006, Nunu et al., 2019. A number of herbs were noted in the study that are used during pregnancy such as umganu (Marula: Sclerocarya caffra) and isihaqa (long tail cassia: Cassia abbreviate) to cure diarrhoea and inyongo (fever) but they indicated that overdose leads to complications. This is supported by study conducted by (Eloff, 2001) that found that inner barks of Marula have antibacterial activities towards microbes such as Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli and Enterococcus faecalis which are prime causes of diarrhoea (Eloff, 2001). The study showed that ukuphoziswa (enema) is strictly not allowed among pregnant women. Despite our results discourages enema, literature shows that some pregnant woman still practice it (Malan and Neuba, 2011).
Based on traditional and health practitioner perspective from the study isikhukhukhu (Snuggle-lea: Pouzolzia hypoleuca Wedd), donkey placenta and inkunzane (Boot protectors/devil thorn; Dicerocaryum species) where most predominately African oxytocin used to induce and shorten labour. Similar results were obtained by different studies which showed that donkey placenta and isikhukhukhu (Snuggle-lea: Pouzolzia hypoleuca Wedd) were used to induce labour (Panganai andShumba, 2016, Chamisa, 2013). Also health practitioners revealed that African Pitocin reduces labour to about one or two hours and in most cases those who utilise traditional medicine the dilation and contraction will be not corresponding. Studies reveal that these African Pitocin quickens and induces labour but without stating the exact timeframe (Panganai and Shumba, 2016). 20

Conclusion
Traditional and health practitioners acknowledge that traditional medicine are used during pregnancy for different purposes even though their perspective tend to differ regarding their utilisation. Most traditional remedies were used in the last trimester to quicken delivery. Health care professionals should routinely include herbal medicines when asking about the patient's drug use rather than recognising contraction and dilation that are not corresponding which aid in determining that someone used traditional medicine. Women are valuable asset in any nation, therefore this subject of traditional medicine should be treated as something delicate to foster better maternal health since there are concerns regarding their safety.

Ethical Approval and consent to participate
Permission to carry out the study was sought from relevant authorities that is Provincial Medical Director for Matabeleland South, District Medical Officer for Bulilima and National University of Science Technology particularly the department of Environmental Science Health. More over the research abides to the Nuremberg code and principles stated in the Helsinki Declaration for safety of participants involved in the study (Zion et al., 2000)

Availability of data and material
Not Applicable

Competing Interests
The authors declare that they have no competing interests.

21
The research was not funded.

Authors Contributions
NM conceptualised the research idea. The author also collected and analysed qualitative data. NM designed the methodology and data collection tools. The author also translated the data collection tool to Local language (Ndebele). WNN refined the idea and together with NM drafted the manuscript. The author also co-ordinated the manuscript writing process. WNN performed data analysis on MAXQDA. All the authors read and approved the final manuscript.

Acknowledgements
Not Applicable

Authors Information
NM is an MSc in Environmental Health holder at the National University of Science and   Figure 2 Merged qualitative results