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Evidence Based Midwifery

Understanding the phenomenon of dikgaba and related health practices in pregnancy: a study among the Batswana in the rural North

2012-02-27 04:38

Understanding the phenomenon of dikgaba and related health practices in pregnancy: a study among the Batswana in the rural North

The aim of this paper is to understand the phenomenon of dikgaba and related health practices in pregnancy. In-depth individual interviews were conducted to collect data from 20 key informants who are known to be experts and familiar with the phenomenon of kgaba-related health practices. Evidence Based Midwifery: March 2012

Antoinette du Preez PhD, RN, Adv M.
Senior lecturer, School of Nursing Science, North-West University, Potchefstroom 2520 South Africa. Email: antoinette.dupreez@nwu.ac.za

Fhumulani Mavis Mulaudzi DLitt et Phil, RN, RM
Associate professor, Department of Nursing Science, University of Pretoria, Arcadia 0007 South Africa. Email: mavis.mulaudzi@up.ac.za

Swinky Kgoadikgoadi RM, RN. Group superintendent, Employee wellness, Xstrata Alloys, 91 Riederstreet, Rustenburg 0300 South Africa. Email: skgoadigoadi@xstrata.co.za

Background. The use of traditional medicine during pregnancy and childbirth is common among the black traditional cultures of Southern Africa. A naturalistic and phenomenological approach was used to achieve the aim of the study from the perspectives of Batswana in the rural North West Province. Any pregnancy-related problem is believed to be somehow associated with dikgaba, a phenomenon that only indigenous healers are capable of managing through the use of kgaba (medicine for dikgaba). Midwives therefore need to know about traditional health practices, which can affect the mother and the baby during pregnancy and labour.
Aim. To understand the phenomenon of dikgaba and related health practices in pregnancy. In-depth individual interviews were conducted to collect data from 20 key informants who are known to be experts and familiar with the phenomenon of kgaba-related health practices.
Findings. The study revealed that understanding of dikgaba and the related healing practices in pregnancy and childbirth is common. The main categories were the description of dikgaba, management of social relationships, and management of dikgaba in practice and childbirth. Cultural beliefs and healthcare practices regarding dikgaba are entrenched among the Batswana.
Conclusions. Cultural accommodation, preservation and cultural re-patterning in rendering care to pregnant women is key. Culturally sensitive care methods must be taught in midwifery and nursing education.

Key words
: Dikgaba, kgaba, traditional medicine, pregnancy, health practices, evidence-based midwifery

South Africa is known for its diverse cultures of which the Batswanas living in the North West Province of South Africa are one of the populations and the focus of this paper. In South Africa about 70% to 85% of the population uses the services of traditional healers to manage and to prevent ill health, including pregnancy-related complications (Summerton, 2006). Consultation of healthcare practitioners and choice of healthcare options depend on the belief system of an individual. The beliefs, values and past experiences influence the pregnant woman in their selection among existing healthcare alternatives, based on socio-cultural interpretation of ill health (Chalmers, 1990). The use of traditional medicine in pregnancy has long been used by the black South African cultural groups, for example the use of isihlambezo by the Zulus (Mabina et al, 1997) and kgaba (medicine for dikgaba) by the Batswana (van der Kooi and Theobald, 2006). This practice has persisted, despite the ‘modern’ medicine usually prescribed by biomedical practitioners at the antenatal clinics to treat health problems identified during routine antenatal physical examinations. Indigenous healers provide a comprehensive service in the form of diagnostic, curative and preventive health care. Traditional health practices include use of medicines in the form of herbs and rituals aimed at restoring harmony and good health (Chalmers, 1990). 

According to Hammond-Tooke (1993), causes of diseases can be differentiated into those with natural causes and those with supernatural causes. Those brought about by supernatural causes are referred to as ‘diseases of the people’. They are often attributed to transgression of rituals and not following proper procedures expected in society, for example respect, mourning periods and appeasing of ancestors. There are also diseases caused by jealous people using sorcery or witchcraft. This phenomenon occurs throughout the lifespan of individuals, including pregnancy. There is a belief that diseases caused by supernatural powers and witchcraft can only be treated by traditional health practitioners.

In many cultural traditions, pregnancy remains a secret, as it is believed that revelation of conception, even to family members, could lead to jealousy. A study conducted by Ngomane and Mulaudzi (2010) in South Africa revealed that women attend antenatal clinic late due to fear of being bewitched, carrying a malformed fetus or giving birth to a physically or mentally impaired baby. The Batswana in the North West Province of South Africa believe that when a person is jealous of another woman’s pregnancy, he or she could evoke evil spirits to harm the pregnant woman or the fetus (Chalmers, 1990; van der Kooi and Theobold, 2006). This is known as ‘dikgaba’ or ‘kgaba’. The direct translation of kgaba is ‘harm or heartache others can cause’ (Ademuwagun et al, 1979). It is believed that dikgaba cause a complicated pregnancy, for example abortion, stillbirth, maternal death, prolonged or difficult labour. Some pregnant women use traditional and western medicine side by side (Banda et al, 2007) as they believe there are certain culturally explained conditions, such as dikgaba, that no western medical practitioner can cure. Indigenous healers manage dikgaba with potions or rituals (kgaba medicine/cures) aimed at ‘lifting off’ dikgaba (Kennett, 1976).

When an individual consults an indigenous healer, he or she diagnoses and prescribes the traditional cure (kgaba) for dikgaba. Consulting the traditional healers or herbalists usually occurs due to the belief that one is actually a victim of covert actions of a malicious family member, neighbour, friend or colleague (Edwards, 1985). Sources of knowledge regarding pregnancy-related traditional cultural practices, such as kgaba, are herbalists and older women who have acquired the knowledge through experience, having used such health practices themselves, either as traditional birth attendants (TBAs) or as consumers during their reproductive age (Mabina et al, 1997).

Theoretical framework
Midwives and other health professionals need to know more about dikgaba and related treatments or health practices used during pregnancy in order to provide comprehensive and culturally sensitive maternity care. The transcultural theory of Leininger was used as a theoretical framework to guide this study. According to Leininger and McFarland (2006: 3), “human care is what makes people human, gives dignity to humans and inspires people to get well and help others”. The theory identifies the following three modes of holistic care (Leininger and MacFarland, 2006).
• Culture care preservation and/or maintenance: This refers to supportive and enabling professional acts or decisions that help the cultures to keep, preserve and maintain beliefs about norms and values applicable in health and ill health. The research looked at how the Batswana preserve and maintain their norms and values regarding pregnancy-related ailments (Leininger and MacFarland, 2006)
• Culture care accommodation and/or negotiation: This implies assistive accommodating and enabling creative care actions or plans that help different cultures adapt to or negotiate with others for culturally congruent, safe and effective care for management of health, wellbeing and illness. Knowing about Dikgaba will assist nurse/midwives to make decisions on the care plan needed to assist their patients
• Culture care re-patterning or restructuring: This refers to enabling professional actions and mutual decisions that help people to change, modify or restructure their ways of life for better healthcare practices and outcomes. This research will help to evaluate if the belief system on dikgaba and health practices among the Batswana is harmful to pregnant women and enable midwives to assist women in making informed decisions (Leininger and MacFarland, 2006).

The framework served to guide the research in looking at how cultural accommodation, re-patterning and preservation can be practised to render cultural sensitive care.
Lack of research and published literature has led to a poor understanding of practices related to dikgaba in pregnancy by health professionals. Therefore, we sought to conduct a study to understand the phenomenon of dikgaba-related practices in pregnancy and childbirth.

Research design of the study

Phenomenology was used as an approach for this study. The approach focuses on perceptions and views of the participants to interpret their understanding of the phenomenon. In addition, the approach explains the way in which members of society make sense of their social environment and subjectively attach meaning to it (Holloway and Wheeler, 2002). This research project endeavoured to understand the phenomenon of dikgaba as experienced and understood by Batswana. The researcher explored the study phenomena using an interview that entails listening to, probing and observing interviewees. The focus was directed at lived experiences and meanings attached to dikgaba in pregnancy.

Population and sampling

The population used was the Batswana women and herbalists who are known to be experts in pregnancy and childbirth practices among the Tswana speaking communities of the rural district in the North West. The participants were identified from recognised birth attendants and older women who are greatly experienced in pregnancy- and childbirth-related practices, having gathered knowledge through personal observation and years of assisting pregnant and parturient women.

The snowball technique was used to reach potential participants (Rossouw, 2005) as it was not easy to identify all participants in advance. They were identified through referral by midwives in community healthcare centres. These midwives learn about these experts’ services during their interaction with pregnant and parturient women. Although traditional healers and herbalists are consulted in privacy, community members learn about them through testimonies of those that believe to have been successfully treated.

The potential participants were visited in their own homes to enhance trust (Brink et al, 2012). Every participant was requested to identify another potential participant according to knowledge and recognition of the relevant traditional health practitioner’s expertise and the service offered (Kennett, 1976).

The profile of the participants interviewed confirmed the notion that practices pertaining to dikgaba which belongs to indigenous knowledge systems rests with the traditional healers who are both diagnosticians and herbalists. TBAs, younger women who learned childbirth practices from their mothers (Peltzer and Mnqundaniso, 2008) and grandmothers, as well as those belonging to the interest group because of their keen interest in traditional affairs also contributed to this data. Of the 20 participants, 12 were TBAs, four traditional healers (TH), and four consumers (C) of kgaba remedies.

Data collection

Data were collected by individual in-depth interviews to ensure rich information that pertains to the topic (Brink et al, 2006).  The participants were expected to give a full description of the practices while, at the same time, the researcher was observing the non-verbal cues that come across during narration of the practices as the participants give account of their experiences.  Communication techniques such as minimal verbal response, clarification, reflection, encouragement, comments and listening to the interviews as described by Holloway and Wheeler (2002) were used. Field-notes were written after each interview. The main question posed was: “What is your understanding of dikgaba?” The following probing statement was used for each participant: “Tell me about the dikgaba practices used during pregnancy and labour”. The setting for data collection was a private place within the participant’s home, in order to prevent disruption or restlessness on the part of the participant. As a researcher, I was trying to be positive and relaxed and approach the interaction with respect, warmth, honesty and sincerity to make the interview successful (Rossouw, 2005).

Data analysis

The data were transcribed, organised and systematised to make analysis easier. The participants’ responses in the form of statements or phrases were classified into smaller, manageable units so that they could be manipulated and indexed for easy access. Related concepts were grouped together and then coded accordingly as and when they were identified. Data were then scrutinised and emerging concepts given codes and labelled for the purpose of categorisation (Burns and Grove, 2004). The whole process outlined was undertaken manually. A literature review was undertaken to gain insight from research, as well as other available literature, and research reports on the concepts identified. Key words used in the search strategy were ‘dikgaba’, ‘kgaba’, ‘pregnancy’ and ‘health practices’.

The need to give meaning to data generated by the interviews led to the researcher continuing to reflect deeply on the data to identify the patterns or themes. All data for the same question from different participants were grouped together by coding and concepts, terminology, ideas and phrases inherent in the text were cross-checked for consistencies or connectedness. 

Findings of the study

The main categories identified were the description of dikgaba, social relationships, and the management of dikgaba in pregnancy and childbirth.

Description of dikgaba

Participants gave different descriptions when asked about the understanding of dikgaba. These descriptions involved the definition, diagnosis, common suspects in dikgaba afflictions, and indicators of dikgaba in pregnancy and childbirth.

Definition of dikgaba

Participants were asked to explain their understanding of the phenomenon dikgaba. The findings revealed that dikgaba is understood by Batswana in the North West Province to be an affliction, a result of perceived act of malevolence by a family member, a neighbour or a friend directed to a victim. Lack of respect, bad behaviour or disobedience is identified as the factors necessary to evoke kgaba towards anyone exhibiting such unacceptable behavior based on cultural norms and values. The following quotes were captured regarding the participants’ definition of dikgaba:
“Kgaba is not witchcraft. Kgaba can be said to be a grudge or complaint against the person who is said to have it” (TH 1).

“It is not witchcraft, it is just a grudge, a favour denied, anxiety over a matter that causes kgaba to the woman” (TBA 2).

“The aggrieved person is capable of evoking dikgaba, the result of false utterances or insults directed to the elderly by the pregnant woman” (C 3).

The quotes concur with what Hammond-Tooke (1993) describes as the construction of the social reality of the illness. Most participants referred to dikgaba as an affliction suffered because of the victim’s failure in good social relations with her kin or due to ‘the envy of some ill-disposed individual’ (Hammond-Tooke, 1993: 197). Hammond-Tooke (1993) is also of the opinion that the illness can be properly comprehended and dealt with only when the meaning is imposed. The articulation of the meaning of the phenomenon by individual participants revealed the understanding they have of dikgaba, how this affects pregnancy and childbirth as well as the associated healing practices, is common:
“When you hear someone in the company of a pregnant woman softly mumbling a wish that the pregnant woman’s abdomen should rupture, the heart bewitches more than muti (the African term used for traditional medicine) can do” (C 2).

Diagnosis of dikgaba in pregnancy

The participants indicated that dikgaba is diagnosed by traditional healers using bone throwing. One of the traditional healers said:
“Sometimes the family comes to consult… I throw the bones first, the bones will tell me that this person is… and that is kgaba, then I would be able to prescribe a remedy guided by the divining bones” (TH 3).

Through the bones the traditional healers are also able to diagnose whether the woman will experience difficult labour or not. Hammond-Tooke (1993) reports that through the guidance of the ancestors the traditional healer throws the bones to get clues about what is suspected. One of the participants explained:
“In certain instances, the problem may be diagnosed before labour starts however in most cases it is only diagnosed during labour when birth becomes difficult, traditional healers are called and they will point out the existence of dikgaba” (TH 3).

The participant also explained that when women have dikgaba, they often consult traditional healers who will diagnose the type of dikgaba that they are suffering from, including exposing the person who afflicted the woman with the dikgaba:
“… this person consults the traditional healer who will explain that the woman is afflicted with dikgaba: ‘When we have called the traditional healer to determine which type of dikgaba it is, and it is identified to be the type she trod on…’” (C 3).

Common suspects in kgaba afflictions
The family is believed to be the significant origin of kgaba spells. The grandparents, parents, in-laws and siblings are all said to be capable of evoking kgaba spells in their individual positions in relation to the victim. A pregnant woman needs to be in a harmonious relationship with the family members at all times to avoid evoking dikgaba. The paternal aunt is singled out as the significant family member in the life of her brother’s children. Conflict with her is most likely to result in kgaba (Hammond-Tooke, 1993):
“According to Setswana, we have the great aunt, who it is believed is revealed by the divining bones (Kgadi e kgolo e e ntshiwang ke ditaola). When a person is afflicted with kgaba, we confront the great aunt about this” (C 2).

“At times the pregnant woman complains of this and that, and when you go to the aunt or uncle about the child’s health condition, you find their response negative”
(TH 2).

The frequent reference to the aunt as the significant person mostly implicated whenever a family member experiences kgaba-related problems during pregnancy or childbirth is noted. Most participants rated the aunt as the suspect in most instances of pregnancy and childbirth complications, as these Batswana believe this to be the evidence of a kgaba spell. Divination as the means of identifying some magical play perceived to be responsible for casting the kgaba spell does not involve mentioning of names and the suspect is only referred to in terms of relationship or status. This corroborates the notion that co-operative effort between the concerned parties during divination results in all referring to their knowledge of the patient and her social relationships with her kinsmen or neighbours to decide on the suspect (Hammond-Tooke, 1993).

Indicators of dikgaba in pregnancy and childbirth

According to the cultural beliefs of Batswana, any complication occurring during pregnancy and childbirth is said to have some form of connection with dikgaba. Participants believe that the existence of kgaba is suspected whenever a pregnant woman experiences problems that make it an uncomfortable or a life-threatening experience. All problems affecting the pregnant woman are therefore referred to the experts in kgaba illness so that a problem-free pregnancy can result in a smooth childbirth experience. Classified among the kgaba-related problems in pregnancy are various minor disorders, such as sleeplessness and backache. Batswana further believe that any factor that interferes with the process of labour is somehow related to dikgaba. The problems cited are prolonged labour, abnormal position and lie of the fetus as well as delay in delivery of the placenta (Hammond-Tooke, 1993). The quotes that follow relate to the effects of dikgaba, which in essence are the signs and symptoms indicating the need for traditional interventions:
“If, after childbirth, there are problems with the delivery of the placenta, this is suspected to be due to kgaba – in the absence of dikgaba, childbirth usually occurs normally” (TBA 1).

“If a person is afflicted by dikgaba in pregnancy, this is recognised if, after the baby has been born, the placenta remains inside, it is said that the woman is afflicted with kgaba, because of her father’s heartache; this is kgaba originating from the father. At times you hear it being said that it is ‘breech’, at times when the baby is born the cord is around the neck” (TH 2).

“When the baby is supposed to be born, it becomes a breech baby, that is, the baby is blocked from coming out, that too is kgaba” (TBA 10).

Most participants cited prolonged difficult labour as a common indication of the kgaba spell. This includes obstructed labour and retained placenta.

Management of social relations

The second category was the management of social relationships. Participants indicated that the way people manage their relationships in the family and community at large may influence the existence or affliction of dikgaba. Hammond-Tooke (1993) stated that dikgaba referred to a affliction suffered because of the victim’s failure to form good social relationship with her kin or due to ‘the envy of some ill-disposed individual’. Participants understand kgaba to be essentially an illness arising from broken social relationships between the afflicted and her family, friends or neighbours. They therefore believe that the cure for this is found in restoring the disturbed balance, thus ensuring a harmonious social life. The themes that emanated from this category are prevention of dikgaba, confrontation and resolution, and driving spirits away. Dikgaba is the result of disharmony between the pregnant woman and the significant person in her social relations stemming from being disrespectful, disobedient and slanderous.

As most participants believe that dikgaba is the result of conflict between the pregnant woman and the specific individual in her circle of social relations, they also strongly believe that deliberate efforts to interact harmoniously with others is the best prevention against dikgaba. Being respectful and obedient especially to the elders in the family and among neighbours was pointed out to be a desirable conduct significant to keep kgaba at bay. A study conducted in Botswana revealed that the young generation must be taught to respect the elderly. Failure to respect the elderly may result in misfortune, which manifests through dikgaba (Livingstone, 2005):
“The greatest thing is respect. If you are a young woman with respect, there will not be any slanderous talks against you that will hurt you” (C 2).

“It means now and then the family must have respect or manners to avoid kgaba from setting in… that is kgaba, but the greatest cause is lack of respect, kgaba does not happen to a person with good manners” (TH 4).

Prevention of dikgaba lies therefore in the social relationships characterised by sustained peace and harmony borne out of the attitude of respect for all (Hammond-Tooke, 1993).

Confrontation and resolution

According to some participants, resolution is achieved by having the two conflicting parties take part in negotiations for restoration of harmony. The person believed to have cast the spell explains the extent of heartache suffered. The pregnant woman will also need to show remorse and apologise to have the kgaba spell reversed. This is also achieved by having the person blamed for the kgaba spell voice the hurt caused by the victim and apologising for her wrongdoing. The kgaba spell is then broken on verbal command by the aggrieved party. The offending spirits are set to flee by the chanting of aggressive and rebuking words by the traditional healer or the family of the victim:
“When a person is believed to be afflicted with dikgaba, we confront the great aunt to ask what the problem is” (TBA 9).

“…this can only be achieved by the woman confessing and apologising for the wrong doing” (TH 4).

“If I tell her, ‘I have forgiven you my child’, this usually lifts off kgaba” (TBA 11).

Driving the spirits away

The practice of aggressively ordering kgaba out of the victim was mentioned by some participants. It is believed that using strong language makes the spirits associated with dikgaba feel no longer comfortable abiding with the victim and would immediately flee, relieving the victim of the curse:
“We then say to her ‘go give birth to the baby’. She will indeed deliver the baby thereafter, do you hear me? There is no better cure than this, Setswana, and that’s my story” (TH 4).

“Yes, it is shouted at and insulted, saying your mother’s this...your father’s... and it then goes away”
(TBA 7).

Management of dikgaba in pregnancy and childbirth
There is commonality in the herbal medicines used, the rationale behind usage and the rituals accompanying various treatment options mentioned. The procedures referred to are oral intake of herbal and non-herbal medicinal decoctions, burning of some herbal medicines to produce smoke to which the kgaba-afflicted is exposed, and boiling the herbs for inhalation of the resultant vapour by the woman undergoing treatment. Most of the traditional medicinal herbs used to manage problems of pregnancy and childbirth are chosen because of their inherent properties believed to be capable of producing the desired therapeutic effects (Kitula, 2007).

There was, however, no mention of enemas and emetics among the practices used against kgaba, even though the two are the forms of medication most commonly used by traditional healing practitioners (Kale, 1995). Although the traditional healers interviewed could easily refer to the kgaba medicinal herbs by names, they remained careful to not disclose the recipes they followed to prepare the remedies (Kale, 1995). This study confirms the fact that recipes of herbal remedies used are often kept secret, as documented in the study conducted by Kale (1995).

The frequent use of the ostrich eggshell as the kgaba remedy was identified by most participants. The finely crushed shell is mixed with water and drunk by the pregnant woman. Part of the mixture is added to the bathwater for cleansing. Some participants mentioned the mixture of water and soil collected from the junction of the footpaths as another remedy drunk, and also used for a cleansing bath. A wasp’s mud house or nest removed from the wall is mixed with water and this is drunk by the pregnant woman as a kgaba remedy too. This confirms the findings by van der Kooi and Theobald (2006). Blowing forcefully into a bottle to facilitate expulsion of the baby or the placenta, when labour is prolonged as a result of dikgaba, was identified as a common practice. This is done only at the point that kgaba as the cause of the problem is believed to have been ‘lifted off’: 
“…an ostrich egg. This is used during the first three to four months of pregnancy. You take a small piece and grind it very fine, put it in a mug and mix with a little cold water. The mixture is left for drinking, just a little bit at a time. This is a strong potion and can cause premature birth. So we put it away. When the pregnancy reaches the sixth or seventh month, you take this mixture, add to warm water and bathe the woman. Part of this mixture is left for drinking. When she reports the onset of labour pains, again you take the ostrich eggshell mixture and have her drink out of a calabash. When you often hear people saying ‘when I got to the clinic, the baby simply came out’, it is all because of the ostrich egg. It is painful because the pains are severe. It stretches you, that’s why it is not recommended for use by anyone because others use it carelessly” (TBA 6).

“After the woman has been relieved of kgaba, you need to assist her by giving her a bottle to blow air into so that the baby may be delivered. If this does not help and delivery is still delayed, that very soil from the wasp’s nest is…”
(TBA 12).

Kgaba remedies are commonly used in conjunction with rituals and other practices. The practices are meant to enhance the effects of the medicines used. Another non-herbal kgaba cure is the urine of the suspect in kgaba illness. The participants explained that it is mixed with water and offered to the victim to drink. It is indicated when childbirth is believed to be prolonged due to kgaba. The use of baboon’s urine was also mentioned by some participants, used to speed up the process of childbirth.

The participants who were interviewed in this study are authority figures in the community based on the knowledge they possess of this cultural issue, including the traditional healers who render care to those patients. The participants presented their understanding of the phenomenon based on their personal experiences and knowledge of those that have earned the respect of their communities for the role they play in providing healthcare interventions that are based on the people’s beliefs. The definitions of dikgaba and the understanding of the factors predisposing to affliction with dikgaba described from the understanding and perspectives of the participants, provided a logical point of entry into the focus of the study.

These findings clearly reveal that kgaba and the related healing practices will remain relevant and justifiable as long as the understanding of illness remains located and defined in the context of culture and society. Leininger’s theory as a framework was used, which emphasised cultural preservation and maintenance, cultural care accommodation or negotiation and cultural re-patterning or negotiation.

The first theme focused on the description of dikgaba – the definition, diagnostic methods, common suspects and afflictions and indicators in childbirth. The sub-themes that emanated from this showed that dikgaba is a condition that is associated with jealousy and that it can be diagnosed and prevented through maintaining good social relationships in the family. These results are commensurate with the issue of cultural preservation and maintenance, which emphasise the issue of ensuring that midwives are knowledgeable of such practice to be able to render cultural safe and congruent care.

Midwives are expected to also understand the management of dikgaba, which is well articulated in theme three and which also indicated how the condition can be treated by herbal and non-herbal medicine. Cultural re-patterning and negotiation can take place to ensure that there is no harmful treatment or care rendered to the pregnant woman. The midwife must show respect and find ways of communicating with the family and the patients using the principles described under cultural accommodation.

Traditional healing practices, such as those related to dikgaba, should be accepted as an integral part of client-centered midwifery care. This can be achieved by openness and mutual cooperation between the midwives, the client, her family and significant others involved in her care. Disclosure about the use of traditional medicine should be incorporated into the client’s antenatal records, including naming of the responsible traditional health practitioner.

The findings also highlight the value of cultural preservation by contributing towards the preservation of black African cultures by ensuring collaboration between modern medicine with custodians of culture, for example traditional leaders in the orientation of the nursing learners towards community midwifery services. Knowledge about kgaba and the related practices could be shared with custodians of traditional medicine, such as traditional healers, herbalists and TBAs whenever opportunities arise at workshops, symposia and conferences.

In addition, concientising people about culturally safe midwifery care in order to facilitate deeper understanding and acknowledgement of the legitimacy of cultural differences and cultural accommodation in the provision of midwifery care can be achieved through health education (van der Kooi and Theobald, 2006). Cultural healing strategies that could be made accessible to pregnant women preferring traditional midwifery care over biomedical obstetrical care should be investigated and formalised by means of protocols or guidelines for use to safeguard consistency and safety (van der Kooi and Theobald, 2006).

In South Africa, midwifery is an important component of the comprehensive curriculum for training of nurses. Therefore, findings of this study based on indigenous knowledge regarding cultural beliefs and practices, could inform midwifery and nurse educators to afford culturally safe and congruent midwifery care a place in the training curriculum.

Many of the traditional medicines commonly used in pregnancy and labour need to be investigated to determine their efficacy, safety and relevance through research. Findings of such studies would offer the rationale for further collaboration with practitioners of traditional healing systems in the management of pregnancy and childbirth. Cultural re-patterning or restructuring can be utilised by ensuring that the rights of the consumers of indigenous healing practices provided by traditional healers should be included in the Patients’ Rights Charter.


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