Whose Knowledge Counts? : A Study of Providers and Users of Antenatal Care in Rural Zimbabwe

This thesis presents perspectives and experiences of different stakeholders and their ways of reasoning around pregnancy and pregnancy care. Data were generated from individual interviews with 25 health care providers, 18 women and 6 traditional birth attendants (TBAs) as well as 11 focus groups discussions with women, men and TBAs. The challenges experienced by health care providers in their provision of antenatal care, while attempting to change antenatal care through routines proven to have medical value, are highlighted. Changing some long established routines, such as weighing and timing of visits, proved difficult mostly because of resistance from the users of care, whose reasoning and rationale for using care did not correspond with the professional perspectives of care. Women also combined biomedical and traditional care. The women used the clinic to receive professional care and assurance that the pregnancy was progressing well and used TBAs, who are believed to have supernatural powers, for cultural forms of assurance and protection. The health care staff did not appreciate these aspects and discouraged women using TBAs. Midwives had problems to change routines of care because of their stressful working situations and the expectations of the women. In addition, they described the paradoxes in providing antenatal care in the context of HIV and AIDS. The caregivers were aware of the magnitude of HIV and AIDS and yet did not have any information on the HIV status of the women they cared for. This also caused fear for occupational transmission. HIV/AIDS is highly stigmatised in this area and women used various strategies to avoid testing. The study emphasised the need to broaden the conceptualisation and practice of evidence-based care to incorporate different types of evidence and include realities, knowledge and perspectives of not only the beneficiaries but also those implementing change as well as local knowledge. The necessity of reorganising the health care systems to accommodate the new challenges of the HIV/AIDS epidemic is also emphasised