Kathryn Linn Geurts

Kathryn Linn Geurts
Weatherhead
Resident Scholar 2000-2001

Culture and the Senses: Embodiment, Identity, and Well-Being in an African Community
When Kathryn Geurts first arrived in Ghana, West Africa, to study sensing among the Anlo-Ewe speakers, she took the five-senses model with her. "I assumed it would be meaningful to them," she recalls, but her questions about touch, taste, smell, sight, and hearing were puzzling to many Ewe people, especially those who spoke no European languages. "They had no over-arching term for those five modes of experience," says Geurts.
Through a structural analysis of the nearly thousand-year-old Anlo-Ewe language, Geurts eventually identified linguistic categories for the perception of experience that link emotion, disposition, and vocation to physical sensation. Many Anlo-Ewe people consider abilities such as speaking and balance to be "senses." In addition, Geurts explains, "they have a complex category called seselelame, translated as 'feel-feel-at-flesh-inside' or feeling in the body. In some contexts, it serves as a meta-sense uniting multiple sensory modes. In others, seselelame is used to describe specific experiences we might call 'intuition.'" Geurts notes that although research in cutting-edge science has come to recognize the limitations of the strict five-sense categories, "the validity of this model has not really been questioned as to its cross-cultural relevance."
In her book, Culture and the Senses: Embodiment, Identity and Well-being in an African Community, Geurts explores the relationship between sensory orientations and cultural difference in psychological functioning. "I argue that sensory orders are culturally relative and that child socialization involves the acquisition of culturally distinct ways of perceiving that play a vital role in how people experience and 'know' the world around them."
As an example, Geurts explains that balance, both literally and figuratively, is considered by many Anlo-Ewe people to be an essential component of what it means to be human. Infants are encouraged to "Do agba!" or "Balance" when learning to sit up, toddlers balance small bowls and pans on their heads, and school children carry books and desks on their heads—all progressing toward an adult orientation "in which balance is considered a defining characteristic of mature persons."
"That sort of analogical relationship—between sensory experiences cultivated at an early age, and perceptions of self and other, sensibilities about society, the world, and the universe—is the central subject of my book," says Geurts.

Well-Being and Birth in Rural Ghana: Local Realities and Global Mandates

(Paper presented at the Fifth Annual Penn African Studies Workshop, October 17, 1997)

byKathrynLinnGeurtsUniversity of Pennsylvania

Abstract
I.INTRODUCTION
II.SAFE MOTHERHOOD AND CHILD SURVIVAL STRATEGIES:MANDATES FROM AFAR AND GHANA'S RESPONSE
III.BIRTH IN A RURAL CONTEXT: LOCAL REALITIES
ESI AND AMENUVOR
AMI AND SENA
IV.ANALYSIS AND ISSUES RAISED
V.CONCLUDING REMARKS: ON THE ECONOMICS OF MODERNIZATION& THE POLITICS OF PROFESSIONALIZATION
BIBLIOGRAPHY

Paper prepared for the Fifth Annual African Studies Workshop "Cross-Currents in Africa" (organized by the Penn, Bryn Mawr, Haverford, and Swarthmore Consortium) for a panel entitled "Local Solutions and Existential Dilemmas" (University of Pennsylvania, October 17, 1997).

Field Research for this project was funded by a Fulbright-Hays Doctoral Dissertation Research Abroad Grant. A 1992 pilot study was funded by the University of Pennsylvania Department of Anthropology, The Explorers Club, and Sigma Xi Scientific Research Society.

Kathryn Linn Geurts

1997

c 1997

Abstract

This paper will examine conflicts between national and local strategies to utilize Traditional Birth Attendants (TBAs) to improve maternal and infant care in rural Ghana. In the 1980's and early 1990's the Ministry of Health recruited locally recognized village midwives to receive education, training, and basic materials to use in deliveries. The midwives then recieved certificates which bestowed upon them the title and designation of community TBA. Due in part to this process they developed a heightened sense of their own individual and collective importance in the national efforts toward family planning and safe motherhood, and although often labeled "illiterates" the TBAs were highly conscious and articulate about the significant role they played in primary health care. Despite their vital function, at the local level TBAs often experienced exclusion from the formal medical system and derision and disrespect from many local health officials; their clients rarely paid them, and local district councils did not support them with financial or material assistance. Unable to replenish the supplies in their kits and lacking adequate facilities, they sometimes reverted to unhygienic and dangerous practices which they recognized as threatening to the neonate, their clients, and themselves. Discouraged by these and other conditions, some began to withdraw their services from the community while others tried to organize for change. Based on ethnographic case studies from twenty months of fieldwork in southeastern Ghana, this paper will examine the critical and paradoxical role of traditional midwives and how they have yet to achieve their potential due to intractable political and economic obstacles at the local level.

I.INTRODUCTION

Between 1992 and 1995 I spent approximately 20 months in southeastern Ghana conducting ethnographic research among Anlo-speaking peoples. Anlo is a dialect and sub-set of Ewe-speakers who inhabit most of the Volta Region of Ghana and much of southern Togo, as well as residing in Accra and other areas throughout West Africa. Individual Ewe-speakers and their families have also migrated to locations all over the world. The coastal area from Anyanui to Keta or Kedzi, and north of the lagoon to Anyako, is typically considered the heart of Anlo-land, and Anlo-Ewe speakers have inhabited this homeland for more than three hundred years.

Many Anlo-speaking people view the arrival of a new child as a joyous event and as the return of an esteemed ancestor. Seven days after the birth, many families perform an outdooring ceremony to introduce the baby to relatives and to the universe. Anlo-land is therefore not a context in which infants are treated with ambivalence, despite the poverty in which many of these families live. Newborn babies are welcomed wholeheartedly. However, all this jubilation is at the same time tempered by the sobering reality that in rural contexts in Ghana, childbearing is still one of the most dangerous moments in a woman's life. Furthermore, families are acutely aware of the fact that for every six children that a rural woman bears, a high likelihood exists that only three will survive past the age of five or ten.

This paper focuses on the question of who controls and is responsible for this domain. Is the well-being of mother and child during the critical process of birth her own responsibility and that of her family? Are her lineage elders in charge of the situation? Should the state and the district public health team intervene? What role should older women in the village, who have often delivered dozens and even hundreds of babies, play in this ordeal? And if the mother or baby dies, who is to blame? In a context of rapid social change, breakdown of traditional forms of social organization, and an increasing dominance of the biomedical model organized around specialization, Anlo-speaking people are struggling with these questions on a daily basis, with the outcome often determining the life or death of a woman and her child.

One response by the Ghanaian state has been to identify and train specific individuals in rural communities to perform routine deliveries in the home and refer complicated cases to the hospital or local clinic. As simple and straightforward as this plan to utilize "traditional birth attendants" may seem, in reality it is fraught with complications. This paper will explore the social context of birth and look specifically at the role that traditional midwives play in reproductive politics and management of birth in a village in southeastern Ghana.

II.SAFE MOTHERHOOD AND CHILD SURVIVAL STRATEGIES:MANDATES FROM AFAR AND GHANA'S RESPONSE

There are few people in the western world who would not agree that "family planning" of some sort is a good thing. Most feel that limiting the number of children in a family enhances the quality of life and health status for all individuals involved. Secondly, many believe that each "planned child" deserves assiduous prenatal care, and should be closely monitored by someone qualified to manage pregnancy and birth. In fact, these two ideas underpin much of the policy and programming of both public and private sector international development agencies supplying aid to so-called third world nations such as Ghana (World Bank 1989:69-72). The philosophy is also at the center of the UNESCO and WHO campaigns aimed at "safe motherhood and child survival," and the government of Ghana has taken this mandate to heart.

Fertility and mortality statistics for the 1980's showed that out of 1000 live births in Ghana, between 77 and 100 infants would die (compared to 33 in Sri Lanka, 32 in China, and under 10 in most European nations) (World Bank 1989:65; Murdoch 1980:15; and MOH 1990:3). The maternal mortality rate was between 500 and 1500 per hundred thousand live births in Ghana, compared to under 25 per hundred thousand for countries in Europe (MOH 1990:3). In response to these conditions and with significant amounts of aid from international agencies, one tactic employed by Ghana's Ministry of Health was to aggressively develop and implement a program aimed at recruiting village midwives to upgrade their skills so that they could more safely manage routine births and refer complicated cases to various public health facilities at the district level.

This intensive "Traditional Birth Attendant" (henceforth TBA) training program was inaugurated in 1987 and targeted mainly rural areas throughout the country. Program goals included improving the delivery skills of the TBAs and equipping them to perform certain pre-natal and postpartum care tasks. In addition, they were educated about primary health care topics such as family planning, immunization, and oral rehydration therapy. The initial stage of this program involved a pilot study conducted in the Dangbe District, and then the national program was initiated in 1989 beginning with the Volta Region. In general their training included 12 sessions spread out over six weeks or up to three months. At the conclusion of the training each TBA received a certificate, an identity card, and a "kit" which contained two bowls (one medium, one small), a nail brush, soap and soap dish, packet of razor blades, hand towel, cord ligatures, plastic bag of cotton wool, contraceptives (condoms and foaming tablets), packets of Oral Rehydration Salts, a record book, and referral cards to send clients to the hospital or clinic (Ministry of Health 1990:14). After the initial training, follow-up supervision and monitoring was to be performed by the same health post staff member who conducted the TBA's sessions. This staff member was to "visit" the TBAs regularly and review basic practices, discuss recent cases, and collect statistics from the record books indicating deliveries and outcome. At the end of 1992, the Ministry of Health's records indicated that they had identified 1,385 TBAs (or "village/home midwives") in the Volta Region, and they had trained 529. Between 1992 & 1995 I conducted interviews with eleven TBAs and participant-observation based research with six TBAs in 4 villages in the southern Volta Region. The following account describes some of the effects of this program in one specific village, and highlights the uneasy confrontation between a biomedical model and traditional Anlo beliefs and practices concerning well-being and birth.

III.BIRTH IN A RURAL CONTEXT: LOCAL REALITIES

From the end of 1993 and into 1995 I lived in a village I will call Agbelidu, which was located west of Anloga and had a population of approximately 1500 people. In order to learn about childbirth, I tried to introduce myself to the various people in the area who were frequently consulted or called for a birth or during pivotal points in pregnancy. This small step itself was much more difficult than I anticipated, and a description of the process illustrates some important issues about how birthing gets negotiated in rural contexts. I learned that there were four women who had attended many of the births in Agbelidu for the previous fifteen or twenty years. Such women (and occasionally men) were referred to in the local language as vixela or afeme vixela which translates roughly as "home midwife." One vixela lived in the compound adjacent to ours, so I began by paying her a visit. As my assistant and I entered the compound, a man working on the roof shouted through the hole that "the white woman was coming" and the midwife quickly escaped out the back gate. This (or a similar) avoidance technique occurred each of the five or six times I attempted to make her acquaintance. While her tactics were less dramatic than the first vixela, the second midwife was conveniently never home when I called at her house. The third vixela patiently sat with me for half an hour or forty five minutes and answered most of my questions, though very curtly. She restricted her deliveries to members of a religious sect known as Blekete, and it was clear that she was not interested in allowing me access to that particular domain. The fourth vixela was the midwife designated to participate in the TBA training program. She was initially very eager to speak with me, and throughout the fifteen months I lived in Agbelidu she often visited my house, but she never once called me to one of her deliveries although I heard that she conducted at least three. Despite these seemingly insurmountable obstacles, I eventually established close connections with five additional TBAs in three adjacent villages, and attended approximately fifteen births during my stay. However, the situation within the context of Agbelidu is illustrative of some very important points.

Largely because of my status as an outsider and as a European or a white, many people assumed I was a doctor or a midwife and somehow connected to the district health team. Despite my efforts to change their minds, they could not imagine an outsider in any other category being interested in talking to them about birth. The vixela next door was therefore extremely reluctant to interact with me because she had been told by local public health officials to cease any involvement in delivering babies and refer all clients who approached her to either the hospital or to a designated TBA. Clearly she did not want to draw attention to herself, or to be reported (by me) to the hospital personnel, although my survey revealed that she continued to offer her services and attended a number of births while I lived next door. The second vixela who also avoided me had actually stopped delivering though not because anyone had instructed her to cease. She felt that clients ought to go to the designated TBA, and since she rarely received compensation for attending a birth, it was not worth her while to continue. The third vixela's religious convictions (which could be classified as a "secret society") constituted the reason she would continue to have clients as well as the reason I would not be granted access to her domain. The fourth vixela (who held the title of TBA) took a rather paradoxical relationship to me which directly mirrored her attitude about her own role.

Of the six TBAs in the four villages where I worked, Agbelidu's TBA was the most negative and cynical about their predicament. She said that she took her work as a TBA very seriously, and expected things to change once the formal program began. She attended the training sessions, and set up a special room within her own house. After Agbelidu's chief "beat the gong-gong" (to assemble the members of the village) and informed the community that she was the officially designated and trained TBA, she expected to receive a steady stream of clients. Instead, pregnant women continued to seek the assistance of the other three vixelawo (home midwives) which violated the goals she believed the program sought to achieve. Furthermore, even those clients who came to her usually failed to pay. She resorted to holding the woman and neonate hostage in the birthing room in her home, trying to force the family to pay for her services before they could retrieve the baby. This drama evidently lasted as long as three days, and since she had to feed the woman while they lodged with her, and the family still failed to pay, she found even this tactic useless. By the time I came to live in Agbelidu, she was turning most clients away. Those she did deliver were evidently familial relations so close that she was obligated to assist. So while she reported to me that no one was requesting her service, and she would promise that when they did she would call me to help, I knew from other sources that she was actually withdrawing from the TBA role. Her failure to call me during the few times she actually delivered was probably due to the close association she felt I had with the TBA program trainers and medical personnel.