Norms and Practices of Gewata Community Toward Maternal and Child Health Services.

Background: World Vision Ethiopia is now implementing timely and targeted Counseling, Channel of Hope, Information, Education and communication on Basic Health Service Package using Faith Based Organization with the goal of Contribution in reduction of mothers and New born morbidity and death through further strengthening of the Supportive Supervision and Primary Health Care Unit. The community’s norms, practice, knowledge, accessibility and attitude towards of excellence of service delivered were signicant to making choice on utilization of Maternal and Neonate health services. These social gradients apply across family planning, antenatal care assisted delivery and post delivery services. Objective: To assess the norms and practices of Gewata communities toward MCH services during pregnancy, labour and post-partum, South West Ethiopia from March 29- April 20, 2019. Methods: Ethnography study design was employed to describe the norms and practices of Gewata communities toward MCH services during pregnancy, labour and post-partum time. Data were collected through non- probability technique namely in-depth interviews and FGDs. A Total of 14 in-depth interview were and 4 FGD were employed each have 8 members/participants among (Pregnant mothers, Lactating mothers, Health Extension Workers (HEWs) and Health Development Agent Leader (HDAL). Study participants were selected purposively based on maximum variation criteria-based selection. Findings: Currently, it is unhidden reality that the qualities of services, Religious principles, Educational level, Accessibilities of the services, Infrastructure facilities, religious leader perceptions and traditional views have an impact on norms and practice MCH services during pregnancy, delivery and post partum period. On the other hand, the Weradas’ Maternal and Child services are showing some improvements from previous with the improvement of Gewata woreda transportation which mainly indicate impact of infrastructure development on services utilizations. The main tasks ahead include integrating and networking religious healing with modern medical services, improving the underdeveloped medical service infrastructures, improving under developed transportation/road infrastructures and networks, make t medical services with culture of the community and rising the community’s consciousness of the advantages of Maternal and Child health services.

This study was identi ed the norms and practices of Gewata communities and help for the World vision use the ndings as next time planning and scale up the study for other Wold Vision health Traditional practice implementing MCH guidelines.
The study was undertaken in the Gewata woreda and considered the cultural beliefs, norms and practices of selected representatives in relation to key aspects of maternal and child health services utilization. The enabling factors that contribute to the uptake of MCH services, as well as any harmful traditional practices or other barriers that impede maternal and child health and utilization of related services were identi ed. We are grateful to the Gewata communities for the provision of the needed data for our study.
Although, thanks to all those who agreed to participate in this study, mainly the respondents, data collectors, and supervisors for the realization of these ndings.

Background
The global decrease in child and maternal deaths is one of the great achievements in international development in recent decades. The Child mortality rates have fallen by more than half, from 12.7 million under-5 deaths in 1990, to 5.6 million in 2016 (1, 2).
Low maternal and child health utilization remain a signi cant setback in developing countries.
Universally it is estimated that about 7.6 million children pass away before celebrating their age ve anniversary (3,4). According to World Health Organization (WHO) report maternal deaths reduced by 50% from 1990 to 2010 and also under-ve mortality rate were reduced by more than one fourth from 2000 to 2010.Still majority of the deaths take place in sub-Saharan Africa (5,6).
The proportion of maternal health services consumptions were vary from country to country and even inside the country itself in a lot of developing countries (7). In some rural area and some culture, there are challenges in utilization of maternal and child health care service largely as the decisions that guide women to utilize the MCH services seem to take place inside the circumstance of their marriage, household, mother-in-lawand family (8).
The health care services delivered after births essential to avoid complications after delivery. As literature indicates only 17% of postnatal mothers receive checkup within two days of giving birth, whereas 81% did not encompass a postnatal checkup inside forty days of giving birth. Simply 13% of newborns obtain a postnatal checkup within 48 hours of birth. The overall basic immunization coverage is surpassing double in Ethiopia within past 15 years (9, 10).
Separating Religiosity and health are very di cult in many communities as they highly inter-related mainly inside the African perspective where illnesses have been connected to divine belongings many years ago (11,12). Witchcraft is allied with disease inside the African perspective together with issues of childbirth (13,14). As literatures indicate in many countries pregnancy and childbirth are coupled with spiritual and long-established view point and practices (15)(16)(17). It is an incorporated component of the whole care provided to consumers and their families in all spheres of nursing and midwifery health care delivery (18-20). However, nothing is known about the Gewata women's experiences of spiritual, longestablished norms and practices during pregnancy, labour and post-delivery. Therefore, the study was investigated the norms and practices of Gewata communities toward MCH services during pregnancy, labour and post-partum time This study could help to identify the norms and practices of Gewata communities and help for the World vision use the ndings as next time planning and scale up the study for other Wold Vision health Traditional practice implementing MCH guidelines.
The study was undertaken in the Gewata woreda and considered the cultural beliefs, norms and practices of selected representatives in relation to key aspects of maternal and child health services utilization. The enabling factors that contribute to the uptake of MCH services, as well as any harmful traditional practices or other barriers that impede maternal and child health and utilization of related services were identi ed.

Study Area and design
The study was conducted in kefa zone of Gewata woreda the South Nation Nationalities and Peoples Region of Ethiopia from March 29-April 20, 2019.Ethnography study design was employed to investigate the norms and practices of Gewata communities toward MCH services during pregnancy, labour and post-partum time were adopted and employed.

Study participants
The study participants were selected purposively based on criteria to maximize maximum variation to achieve study objects at study area. A total of 14 In-depth interviews were done. The main theme of Indepth interviews and FGD is the same.

Data management and analysis
Transcribed data were cross checked for accuracy and completeness recorded audio. The principles of content analysis were applied where transcripts were read several times and coded. Similar codes were grouped and re-grouped as the study progressed. Verbatim quotes of participants' comments were given to support the ndings to allow for transferability of the ndings in similar contexts. Ethical clearance was obtained from the Jimma University ethical Review board. Permission was sought from the Gewata Woreda municipality.

Study participants
In-depth interviews data were collected from 14 participants. The participants' age was range from 20 years to 65 years with median age of 36 years. The FGD data were collected from 4 FGD group with each FGD group contains 8 participants with maximum variation.

Culture and religion of the Gewata community
The Gawata community is one of major community found in southern part of Ethiopia. The community is composed of different ethnic group like Kafa, Oromo, Amhara, Mazyangor and Maji. Within Gewata community more than four languages is spoken namely Ka cho, Amharic, Afan Oromo and mayzingo.
The Gewata community also believes with God even though they follow different religion. They also have respected religious and community leaders which lead the community for different spiritual and traditional ritual activities. In Gewata community there is no clear boarder between their religious ritual practice and cultural ritual practices.

Prenatal practices
The study participants underline that the uptake of prenatal care is directly related to acceptance of modern MCH ideas, good economic conditions, support from spouse, and support from mother-in-law, support from religious leader, support from elders and convenient means of transportation.
The majority of Women of Gewata communities have almost good awareness about the need for prenatal checks, so that many Gewata women go to modern health system for prenatal checks as they know they are become pregnant. The Gewata town and woreda health center, Health extension workers and Health Development Army Leader have publicized the bene ts of prenatal check-ups; their efforts have yielded good results in utilization of prenatal checkups. Few women only go to hospital when they are very unwell as their case is not handled at Health extension workers level and Health center level.
One pregnant woman stated: [Pregnant women] get out of health post /center after one or two hours as she gives birth to celebrate different cultural ceremony and ritual activities as their traditional beliefs and practice. In terms of food taboos, no special care for pregnant women was reported. Pregnant women eat what they want and continue their daily work until delivery. In addition, sour and spicy food, because diarrhea will avoid.

Delivery practices
There are three types of delivery among the Gewata communities: health facilities delivery, household delivery attended by traditional doctors/traditional birth attendant and household delivery supervised by the pregnant women's mother or mother-in-law using traditional methods.
At present, although health facilities delivery is free for all pregnant women, and relevant health authorities have publicized the bene ts of health facilities delivery, the results are not ideal. As study participants indicate, if delivery occurs according to traditional methods, the mother-in-law usually functions as a traditional birth attendant. The pregnant mother's family and religious leader basically provides prayer service and psychological assistance.
Even though the Health center, Health Extension and HDAL health promotion work to increase modern MCH service utilization, still there are mothers who give birth at home. One of the reasons for home birth the mothers and some communities believe that birth-giving is guided and attended by God as it is natural for women. Only pregnant women who sense exceedingly ill or something occurs suddenly visit up to date medicines and health services for a health check. Lack of infrastructures such as road and ambulance also put life of mothers and newborn in danger.

Postpartum practices
Within Gewata community mother who give birth practice six weeks con nement period, during this time they expected to stay at home? Some mothers depart their beds a week after birth but remain in their house. Eating of cold food, uncooked food, Vegetable and fruits prohibited for mothers recently give birth, as they believe it bring diarrhea to her newborn/ baby. Nowadays, some families have begun to let women to eat fresh fruits and cooked vegetables.
Usually, mother-in-law takes care of the mother who gives delivery, as mother who gives don't engage in hard activities within six weeks of delivery. If there is no mother-in-law presents the responsibility to take care of home activities is fall on shoulder of mothers who give birth. The mother who gives birth eats in her personal room. Food like porridge usually prepared for mother who gives birth is cooked separately.
There are a few other customs regarding postpartum women care. For example, postpartum women often do not have baths or brush their teeth after delivery, although this is not applied rigidly amongst all Gewata community. Most women understand that after delivery sex should be avoided for a certain period of time, as some women explain that they have sex with their partner until give delivery and start intercourse within three to four days while other start intercourse after 45 days of delivery as it varies from religion to religion.

Newborn care
During home delivery among the Gewata community, the newborn baby will be cleaned with clean water and soap, also ash is put on the umbilical cord. The newborn baby is then covered with the any clothes prepare for covering purpose even if it quality and cleanness level is not checked. Daily washing of baby will be continuing with warm water. Some women of Gewata community believe that colostrum (early breast milk) lacks nutrition and is even "dirty". Some parents feed their babies with cooked potato, water, cow milk and butter usually within a month after delivery, while other foods are gradually added. The Gewata communities believe eating fresh yak butter and barley soup is a blessing and the baby also needs food to grow strong. At the age of four to six months, almost the baby fed everything prepared in the house.
With regard to treatments for baby illnesses, many of the Gewata community believe it is better to go to hospital or any modern medical health facilities, while few parts of the communities think taking child to the traditional healer and religious leader for pray services.

Infant/child health, including immunization and nutrition
The communities mainly take their children to the hospital when they fall ill. In the survey some groups indicate that there are also times where rituals and praying are used to cure illness. Regarding immunizations, a 55-year-old community elder's man said: "I know that immunization can prevent measles and polio. Currently many children received immunization at the health center and health pos." There is no xed time for weaning breast in the Gewata community. Mothers who stay at home usually stop breastfeeding when babies are one to two years old. Mothers who go out for work usually wean earlier than those stay at home. However, villagers believe that feeding the baby rst with breast milk and additional feeding will make them strong and less hungry which means mothers will not be bothered during work.
If the baby gets a cold, some oil is put on the forehead. If the baby cries, parents often visit traditional doctors to get grass made medication. Some part of the communities mainly Christian protestant take their children to Church for pray if a baby's illness cannot be treated by the local health center, while some people will adopt traditional remedies. Some communities practice traditional ritual activities like when baby fall ill, rst the baby has to be present, as per traditional cultural ritual practices sacri ces like chicken (black in color), sheep and pork.

Identity and role of caregivers
All Gewata women/mothers carry their babies on their backs. They carry their babies no matter whether working or going outside for the purpose of easy care-taking. The responsibility of caregivers for child on mother shoulder as whole, this doesn't mean male never have any role caregivers for children. An older lady within family has also the responsibility of caregivers and engaged in household activities.

Gender dynamics
The Gewata communities' gender dynamics were generally in line with male responsible for eld work and female is responsible for home based (domestic) activities, even if it is di cult to say the male and female responsibility restricted to restrict to the above hypothesis.
The Gewata community live is rooted on traditional ways of living with limitation to meet basic needs for survival. Agriculturalists and pastoralists, engaged in small-scale economic activity are highly dependent on male labor. Even if it is di cult to measure the task burden on male and female based on their role as a whole, the community perceived males are dominant in Gewata community as whole.

Decision-making in the family
The survey indicates dominancy of male in decision making as male mainly engaged in eld work, government job and any activities bring income for the whole family. This brings male dominancy in exercise power related to economy related decisions.
In other hand the survey revealed decision related to services like of MCH services utilization, child caring and main home activity-based decision mainly carry out by mother-in-law and wives. In senior family member the male eldest child in the house has also pertinent role in decision making within the family.

Male involvement in family Life
The survey shows us "Male in charge of outside" refers to the fact that males in a family basically undertake eld work such as farming, government job and any activities bring income. However, female in Gewata community mainly engage in household activities even if that mean women are not excused from the eld work.
Regardless of age, religion and cultural difference men of Gewata communities except few government workers and high school students had little knowledge about MCH service utilization and showed little interest in gaining such knowledge. They generally hold that reproductive health is a matter for women, this make their involvement in family life speci cally related to pregnancy, delivery and newborn care is very low.

Control over family income
In Gewata community's male mainly engaged in eld work, seek government job, and they are source of income for family, while woman is responsible for home activities (i.e cooking, cleaning…) and take care of their children. This hypothesis brings the conclusion of male dominance and control over family income among the Gewata communities. Due to above raised reason men usually make decisions for his family on when and where the whole family visit modern utilization, depending on the circumstances as the communities mainly relate modern medicine with expenditure and the convenience of transportation. However, usually mothers-in-law have signi cant authoritarian decisions regarding pregnancy and delivery while wives mainly follow her husband's and mother-in-law decisions. Who makes decisions about child-care/ children's health?
Among Gewata community, in addition to the basic home activities raising and taking care of child is mainly the responsibility of women while the male involvement is imminent especially in rural area. When Gewata women go out for eld work additional to home activities many of them take their child with them on their back, while in rare case grandmothers take care of child until mother return from eld work.
Even if the mother and grandmothers have more rights in decision making along with community's elders for utilization of traditional medicine and treatment, the father play pertinent role on making decision of utilizing modern medicine. One reason is because of the women spent a lot of her time in home with her child. Another reason is those males is mainly engaged in eld work and begin to have their own income by working outside the home and also has decision power on income.

Child Sex Preference
In the Gewata community's context, child sex preference refers speci cally to the preference for male children. One of the FGD participants indicates the male sex preference of Gewata community as children are gifts of God. However, it is common in our community that family prefer boy/male. They give special name for boy's "KINDE" means considered as a supporter of the family. It is common for Gewata community asking for the sex of the newborn "boy/male or girl/female" before asking anything. If newborn is male the mother and newborn will be welcomed by the family as well as by the whole community at large. Even though majority of Gewata community at all have male sex preference, no one can't choose to have an abortion, or abandoning a baby, if the child is not the preferred sex (male sex) Different treatment of male and female children The cultural beliefs of "men outside" and "women inside" model of gender dynamics dictate from beginning of life how a family treats their males and females' children. Girls from a very young age stay at home helping their mothers, while boys, mirroring their fathers, have little involvement in housework. There is no general conclusion that men eat more food or less. However, there is a custom or tradition in our community that the wives always wait for their husband to eat food [they eat together after her husband test the food.
The other study respondents also explain it as there is a custom of giving food for husband rst then for children and mother. Mothers always feed the whole family but forget themselves. They consider themselves and get food at third stage after husband and children. Improvements in living standards and decreasing numbers of children in families enable parents to provide equal nutrition for their children, both boys and girls.

Perceived barriers to access and utilization of MCH services (users' perspective)
According to the survey results, the Gewata communities share certain common traits/personality that prevents people from gaining knowledge of modern MCH concepts. There is also educational level, and regional (rural and urban) differences. Regarding access to and utilization of MCH services, the local communities' Some Gewata know little about modern MCH concepts, the positive aspects of institutional delivery and relevant health services policies. This is especially a problem among people above40 years of age elders and those who are uneducated from rural area. Health professionals at health posts also provide different free services in the area of MCH to support our community. However, still villagers/community suffers from buying medicines/drug from private pharmacies even during delivery, vaccination and other treatments.
The 75 years old male Islam community and religious leader there are several complains e.g giving priorities for their relatives and close friends during treatments and counseling; and ignoring others. Many people are complaining about this and criticizing the government because there is no supervision or mechanism to stop these bad practices. There are also professionals misbehaving and miss handle patients especially not respect the culture of the community. MCH services providers' perspectives MCH services is unique and complex services provided for two separate individuals at once or in separate area, so improve facilities e.g supply all important resources and inputs in su cient level to deliver this service in standard level. The 30 years HEW explain level and constraints to deliver MCH services as …we have a shortage of inputs in health posts. e.g There is no BP apparatus, the balances in most health post is not functioning, shortage of HEWs, drug shortage and damaged drugs for FP and vaccinations are among many challenges and need improvements. There are many large Kebeles with large number of population but only one or two HEW. Hence it would be better to increase the HEW up to 4 per kebele so that they can provide services at health post as well as door to door.
The research nding identify the need of refreshment training for HEW and MCH services providers to overcome knowledge and experience problem seen on the health professionals. The need of training underlined by a 37 female HEW as follows. there should be refreshment courses or trainings for us so that we can update ourselves. There is no education opportunity for us, so the government must give attention on educational opportunities.
The research nding indicate that many change and improvement come in MCH services in the area with many positive impacts after world vision in Gewata woreda like construct many schools, health centers and posts were constructed in different kebeles of the Gewata woreda. So, Gewata woreda bene ted a lot from world vision on many aspects.
The world vision brings many tangible positive impacts to improve MCH services since the implementation in Gewata woreda. The world vision give training for the health professionals, HEWs, mothers and other stakeholders. This can improve the MCH services that the woreda health o ce provides.

Discussion
The nding in this study shows that women prayed and believe in God to have peaceful birth and prevent misfortunes as giving birth is natural. This claim is supported by study conducted in Ghana (30). Women in this lesson implored their God care for them from evil forces. They think their God is controlling and could prevent evil forces (31).
The few women who reported long-established beliefs and practices such as not eating or not drinking outside the home supported by preceding studies and suggests that such limitations may contribute to downbeat consequences for the woman and the unborn child (20,26).
Some of the study participants indicate that even though the MCH services is freely provided in public health facilities, still the services is not sociable and adequate, as the mothers and her family suffer a lot from lack of infrastructure, transportation cost and cost to buy drugs from private pharmacy. This problem is similar with one study conducted in china (32).

Conclusions
The Gewata community also believes with God even though they follow different religion. They also have respected religious and community leaders which lead the community for different spiritual and traditional ritual activities. In Gewata community there is no clear boarder between their religious ritual practice and cultural ritual practices.
The uptake of prenatal care is directly related to acceptance of modern MCH ideas, good economic conditions, support from spouse, and support from mother-in-law, support from religious leader, support from elders and convenient means of transportation. Gewata community women give birth at health facilities attended by skilled personnel, home birth attended by traditional doctors/traditional birth attendant and home birth supervised by the pregnant women's mother or mother-in-law using traditional methods.
Within Gewata community there is some change in social roles and taboos to follow during pregnancy and after delivery according their religion and norms. Some mothers depart their beds a week after birth but remain in their house. Eating of cold food, uncooked food, Vegetable and fruits prohibited for mothers recently give birth, as they believe it bring diarrhea to her newborn/ baby. Nowadays, some families have begun to let women to eat fresh fruits and cooked vegetables