FGD: Focus Group Discussion; TBA: Traditional Birth Attendant

Maternal health is one of the components of the reproductive and child health interventions package focusing on improving quality of life of women and adolescent mothers [1]. According to WHO, maternal health care is the health of women during pregnancy, childbirth and postpartum period which is crucial for the well-being of a mother and new born baby. It includes antenatal care, delivery care and postnatal care. The use of antenatal, delivery and postnatal care services can be accessed through the number and timing of ANC visits, proportion of births delivered in health centers, attendants during delivery and antenatal care and number of postnatal visits [2].

In order to reduce maternal mortality rates and improve maternal health, women need access to effective interventions and high-quality reproductive health care. Many countries have implemented programs to expand access to interventions in order to reduce the level of unmet need for contraception, provide antenatal care during pregnancy and ensure delivery by a skilled birth attendant. However, in the case of Ethiopia the antenatal care given to pregnant women is very low specifically in rural areas. The antenatal coverage is about 34% but six in every ten Ethiopian women (57%) did not receive any antenatal care for their last birth. Moreover, there was significant variation of use of ANC service by residence. Women from Addis Ababa tended to exhibit the highest use of ANC (93.6%), followed by women from other urban (76%) and rural areas (26.4%) [3].

Furthermore, the recent data shows that only 10% of births are delivered at a health facility, this shows that nine women in every ten deliver at home. The %age of deliveries in a health facility doubled from 5% the 2005 EDHS, while home deliveries decreased slightly from 94% to the current level of 90%. 28% of births were assisted by a Traditional Birth Attendant (TBA) and 57% of births were assisted by a relative, or some other person. Besides, the urban births are notably more likely than rural births to be delivered in a health facility which is 50% to urban and 4% to rural. The % of births delivered in health facility ranges from less than 10% in SNNP, Afar, Oromiya, Somalia, and Benishangul-Gumuz regions to 82% in Addis Ababa [3]. Besides, studies showed that postnatal care is another component and measurement of maternal health however the level of postnatal care coverage is extremely low in Ethiopia. The great majority of women (92%) with a live birth in the preceding five years did not receive a postnatal check-up. Only 6% of women received postnatal care from a doctor, nurse, or midwife. Less than 1% of women received care from a HEW. 32% of women in urban areas received a postnatal check-up from a health professional compared with 2% of rural women [3].

The case of Tigray is not far away from this truth. Tigray is one of the nine regions and the northernmost regional state of Ethiopia. The poor health status of Tigray region is comparable to the rest of the country, showing high infant mortality rate, low institutional delivery, high HIV prevalence, and low family planning utilization [3]. The recent Ethiopian demographic and health survey report reveals that the ANC is 50.1%, Health facility delivery and PNC utilization was 11.6% and 2.8% respectively in Tigray. This shows that 87.8% of women in Tigray delivered at home without any assistance of skilled health providers. There are also low maternal health care services and maternal health seeking behavior in Raya Alamata district. Studies conducted by Fentaw [4] at Raya Alamata district revealed that 50.1% of rural mothers have ANC visit during last pregnancy. From the ANC attendants of the district only 33.8% of mothers have more than four ANC visits which fulfilled the minimum recommended requirements of WHO. Besides, rural women who delivered with assistance of skilled birth attendant were 13.9% in the district. This demonstrated that 86.1% of rural women delivered at home without skilled attendants. Almost three quarters of women gave birth at home without the help of skilled birth attendants. More than two-third were assisted by family members and mothers, followed by untrained traditional birth attendant. The postnatal care coverage is also low in Raya Alamata district. No more than 18% of women attended the PNC.

Many factors impede a woman from seeking care. Socio-cultural factors are among the reason responsible for non-utilization of maternal healthcare services. Some cultures still rely on traditional birth attendants. In some cultures as well women must get permission from their husbands in order to seek maternal healthcare. Religion also plays a role in women access and utilization to healthcare as some religious beliefs do not allow the women to accept certain medical procedures [5]. Gender is the socio-cultural factor that constrained women from access to and use of health care services [6]. Women have limited role and responsibilities in decision making on key resources. Women’s powerlessness and their unequal access to material and other resources, and their inabilities to make informed choices are the fundamental causes of maternal death and disability [7]. They traditionally enjoy little independent decision making on most individual and family issues, including the option to choose whether to give birth in a health facility or seek the assistance of a trained provider [8]. Further research indicated that the strong patriarchal system of the society and the prevalence of male dominated norms of the society, limited women’s autonomy and reduced their possibility to make independent decisions about their own reproductive health [9]. It has also prevented women from attending routine visits in health facilities.

The other determinant factors that have an effect on maternal health utilization are food taboo [10], abdominal massage [11], and confinement [12] which are carried out in the era of pregnancy, delivery and postnatal periods. Moreover, prior researches and statistics indicate that the main reason for poor health outcomes among rural women is the non-use of modern maternal health care service [13]. These are poor literacy, lack of awareness about services, low status of women, lack of family support; abject poverty and prevalence of culturally influenced practices [14]. The existing literature also showed that demographic factors like sex, age, type of illness, access to services and perceived quality of the services influences the maternal health seeking behavior of women in general and rural women in particular [15].

The issue of traditional maternal health beliefs and practices has attracted the interest of some researchers in Ethiopia. Yet the amount of researches and the knowledge obtained from those researches do not suffice to explain the traditional maternal health beliefs and practices that influence maternal health seeking behavior. Furthermore, a critical look at the findings in Ethiopia showed that they mainly concerned with identifying biological aspects that affect maternal health care service utilization. On the other hand, investigating the traditional maternal health beliefs and practices in inclusive manner has been given little emphasis.

Besides, reviewing related studies on maternal health in Ethiopia let alone in the study area, Raya Alamata district, prominently, overlooked the issue of traditional maternal health beliefs and practices and instead dealt with determinants of delivery care utilization. Hence, it could be said there is a place to conduct a study that assess the issue of traditional maternal health beliefs and practices. Therefore, this study tried to assess the traditional maternal health beliefs and practices in Southern Tigray: The case of Raya Alamata District.

The purpose of this study is to identify the major traditional maternal health beliefs and practices carried out by women during pregnancy, labor and delivery in Raya Alamata district and its influence on maternal health utilization. It is hoped that the results of the study is essential to policy makers to understand the traditional maternal health beliefs and practices and serve as a groundwork for any possible intervention aimed at improving the low utilization of maternity care services in the study area.

Description of the study area

Raya Alamata is located at 600 km north of the capital city Addis Ababa and about 180 km south of the capital city of Tigray Regional State, Mekelle. It is the south most administrative district of Tigray Regional State bordered in south with Amhara Regional State in east with Afar regional State in north-east with Raya Azebo woreda and in north with Oflla woreda. Alamata woreda has 15 Tabias (peasant associations) and 2 town dwellers associations. The number of agricultural households of woreda is approximately 17,597. The total population of the woreda was 128,872 in 2003/2004 [16]. Regarding the health infrastructure, the district had one hospital, six health centers and 13 health posts [17].

Research design

Research designs are types of inquiry within qualitative, quantitative, and mixed methods approaches that provide specific direction for procedures in a research design [18]. It is the plan or proposal to conduct research [19] which facilitates the smooth sailing of various research operations, thereby making research as efficient as possible yielding maximal information with minimal expenditure of effort, time and money [20]. The research undertaken for this study was qualitative. Qualitative research (specifically exploratory research studies) was appropriate for such studies because it is flexible enough to provide opportunity for considering different aspects of a problem under study [20]. Qualitative research has specific designs. One of the specific designs that were applied for this study was phenomenology. Phenomenology refers to the way in which we as humans make sense of the world around us. A phenomenological study describes the lived experiences of individuals about a phenomenon as described by participants. This description culminates in the essence of the experiences for several individuals who have all experienced the phenomenon [18]. This study design was an important one to describe and understand the meaning individuals or groups ascribe to maternal health beliefs and practices because thus was created from the perceptions and consequent actions of the society.

Methods of data collection

Three main methods of data collection were employed. These included

1. Focus Group Discussions (FGDs),

2. Key informant interviews and,

3. In-depth interviews.

The data were collected from three Tabias. These are Gerejale, Selam Beqalesi and Temuga respectively.

In-depth interview

In-depth interviewing is the most commonly used data collection approach in qualitative research which are designed to discover underlying motives and desires and are often used in motivational research. Such interviews are held to explore needs, desires and feelings of respondents [20]. This method enabled the researcher to generate highly detailed information and to have better understanding on the issue of traditional maternal health beliefs and practices. In doing so, in-depth interview were conducted with twelve women with the help of interview guide check lists (unstructured) to collect the necessary data for the purpose of the research. Hence, this phenomenological study concerns with meanings that people ascribe to phenomena; interviewees would be requested to stick with talking about their own work and/or experience with regard to overall conditions of motherhood and their lived experiences.

Key informant interview

Key informant interview was used to collect qualitative data from informants that have knowledge and experience on the issue of maternal health. This was helping to get in-depth information from informants. Interview guide with loosely structured conversation was used to collect data from informants. The researcher was prepared open ended questions that would help to generate information from informants on the topic of maternal health beliefs, practices and traditions. Subsequent to that the researcher asked the informants about their consent to take part the interview. Following the agreement of the informants to take part in the conversation, the researcher was held an interview by introducing the purpose and the ultimate use of the information to the informants. Therefore, nine model women (age range 35-49) were selected in consultation with health extension workers of the Tabia. To select the model women purposive sampling technique was implemented by taking into account the time and cost as well as homogeneity of the population. These model women are fully implementing the health extension package as well as they have full knowledge of the community. The interviews with model women were held at the Tabia Health Post office that was taken 30-45 minutes. This is because; Health posts are constructed at the appropriate distance from the villages which women live. The informants were provided detail and wide-ranging of data on the issues of maternal health. They had shared their experience and their knowledge. This enabled the researcher to understand their attitudes, feelings and opinions.

In addition to this, the researcher was selected six health workers by using purposive sampling method based on their experience and willingness to participate in the interview. Among these, three of them are health extension workers. One health extension worker was selected from each Tabias. The researcher was selected health extension workers as key informants in view of the fact that they have frequent contact and interaction with mothers. They have good knowledge and experience about mothers and their problems. Furthermore, two female midwives were selected from Garjale health center and Timuga health centers. Female midwives were selected due to the fact that most women speak openly their problems to them than male midwives. The female midwives were helping to identify the experience and problems of women related to antenatal, delivery and postnatal care. Besides, they were also provided information on the knowledge, attitudes and practices of rural women toward maternal health beliefs and practices. Finally, one health expert from the district health office was selected and interviewed. The health expert was selected based on their experience and job description. The person has worked for long period of time on maternity and related issues. Therefore, he had provided pertinent information issues of maternal health utilization and the factors that affect women to seek care. The interview with health extension workers, female midwives, and health expert of the district were held in the office after the normal working time that is suitable to them due to a matter of privacy. Finally, the researcher was selected six key informants from religious leaders. Three of them were selected from orthodox Christian and the other three were selected from Muslim leaders. The interview that was conducted with religious leaders was helped to generate information related to religion and maternal health beliefs and practices. It could also help to reveal the impact of religious doctrines and principles on women health seeking behavior. Moreover, the researcher also selected three community leaders one from each Tabia. These were selected purposively from the community.

Focus Group Discussion (FGD)

Focus groups are a form of strategy in qualitative research in which attitudes, opinions or perceptions towards an issue, product, service or program are explored through a free and open discussion between members of a group and the researcher [21]. It is useful data collection method which helps to generate qualitative data from the discussion by making group interaction between members of the target population. The FGD helps to capture more deeper and comprehensive information from respondents such as model women and males on the issues of traditional beliefs and practices during the time of pregnancy, delivery and postpartum periods. Therefore, the researcher was consulted with local people who are active in or have connections to the study population like health extension workers and ‘Tabia’ leaders to select focus group participants. Accordingly, the researcher asked the participants about their consent to take part on the discussion. Following the agreement of the participants to take part in the discussion, the researcher organized three FGDs one from each by taking in to account the time and cost of the researcher as well as similarity of the study population. Each FGD participants were selected based on purposive sampling and it had eight members consist of 24 participants. The two FGDs were held with women (both model and non-model) thus would help to share in common a wide range of knowledge and experiences on issues of traditional beliefs and practices related to maternal health. The third discussion was held with husbands/males specifically in the age category of 25-65. I believe that this age category is more preferable for FGD because it has the power to influence in the household issues. The conversation with the participants of the focus group were based on discussion guide that were structured around the key themes by using familiarize local Tigrigna language to avoid misunderstandings in the process of conversation and discussion. Besides, the moderator was sensitive to local norms and customs during discussion. Before the commencement of the discussion, the moderator specified the objective of the FGD to the participants. Then, break down the major topics into discussion points and the moderator was started to ask questions for FGD participants. During the discussion the moderator encouraged the participation of shy participants to speak and ensure the discussion would not be dominated by few individuals.

Moreover, in order to assure the privacy of the participants and to talk participants openly the researcher was arranged venue for the conversation at the time of discussion. School is the best place because it was readily available and free from trouble. Therefore, the researcher selected Rarehe elementary school because of its central position. Finally, one moderator and one recorder were assigned in each group to probe questions on the topic as well as to manage informant’s participation. Notes were taken and data were recorded by using smart phones. I was also taking notes simultaneously.

Methods of data analysis

Qualitative data analysis is conducted concurrently with gathering data, making interpretations, and writing reports [19]. This analysis helps to shape the direction of data collection, especially where you are following a more inductive, grounded approach. Accordingly, the qualitative data that were collected from respondent using FGD key informant interview and in depth interview were organized, categorized, synthesized, analyzed and finally interpreted. To do so, the researcher was listened all audio taped and read the field notes step by step to jot down all the information. After that the audio taped from FGDs, key informant interview and in-depth interview was transcribed verbatim, and translate from Tigrigna to English. Transcription of the audio-record was done by the investigator himself. Furthermore, the researcher himself was translated the audio record and field notes from Tigrigna to English cautiously. Finally, the investigator was organized and prepared the data and broken up to all audio taped and field notes into sections based on their themes. The interpretation of the interview transcripts and field notes was analyzed by using thematic analysis methods. During the interpretation stage the investigator was not mentioned the names of the informants; and try to used pseudo names of the informants.

Ethical consideration

Ethical approval was obtained from the respective School of Sociology and Social Work, and University of Gondar, Department of Sociology. A formal letter was also submitted to all the concerned bodies to obtain their co-operation.

Ethical issues in research command increased attention today. The ethical considerations that need to be anticipated are extensive, and they are reflected through the research process [18]. In the progress of research, researchers need to respect the participants and the sites for research [19]. Thus, due respect was given to the participants during the data collection process. Besides, the researcher has got get an informed consent from participants before the commencement of the interviews. This principle proves that participation in research was voluntary based. Respondents could be informed that they have the right to participate voluntarily and withdraw from the research at any time. The researcher was not pressurized the informants to participate for interview or FGD.

The researcher ensured anonymity and confidentiality throughout the research process. To ensure confidentiality and anonymity, the researcher could not mention the names of participants. Besides, the data that has receive from respondents lock by using passwords. After the completion of the analysis all the data could be destroyed. Information that had provided by informants could not be transferred to a third party or could not be used for any other purpose. The general ethical issue here is that the research design should not subject those you are researching (the research population) to embarrassment, harm or any other material disadvantage.

There are a number of traditional beliefs and practices that affect the maternal health seeking behavior of rural women specifically rural women. These are carried out by women during the period of pregnancy, labor and delivery. These cultural beliefs and practices include abdominal massage, food taboos, spiritual healing, confinement and restriction of mobility after delivery. These all are the perceived cultural barriers to maternal health seeking behavior.

Traditional antenatal care beliefs and practices

Traditional maternal health beliefs and practices reflect the values and attitudes held by members of a community over a period of time. The broad-spectrum of the population in general and women of the study area in particular has specific traditional cultural practices and beliefs. These traditional antenatal care beliefs and practices were associated with pregnancy such as abdominal massage, Mejilis and Dubarti and prohibition of food.

The beliefs and practices of abdominal massage

Abdominal massage is one of the culturally based healing systems which are used during the time of pregnancy and labor. It is a common customary method of healing and widely used practices among rural people specifically in Raya Alamata district. In the rural area, abdominal massage was used by pregnant women to get relief from pregnancy related complications. It is not common to go to antenatal clinics. Therefore, the majority of pregnant women get some kinds of admiration and support from traditional birth attendants, families and neighbors to carry out such practices to solve their pregnancy related problems. At this time, pregnant women may suffer from loss of appetite, vomiting, nausea and body weakness. Besides, they suffer from stiffness, pressure and cramping of abdomen. To relieve from this trouble, they seek help from traditional birth attendants, elder women’s, healers, families, communities, neighbors and a nearby available health care service providers.

The majority of pregnant women were requested assistance from traditional birth attendants or relatives to seek appropriate remedial during the occurrences of pregnancy related complication and symptoms. They seek help from traditional birth attendants, elderly and other relatives to carry out abdominal massage. The abdominal massage took place when a woman suffered from complication related to pregnancy. Thus, the abdomen of the woman had massaged with the use of butter either by traditional birth attendants, elderly women or other relatives to turn the baby position to normal circumstances. This is carried out if they thought that the baby position is abnormal. In supporting this idea, a key informant from Timuga health center noted that:

The majority women were coming to the health center after they are massaging their abdomen with the use of butter in their home by traditional birth attendants. I asked them the reason to massage their abdomen hence most women massaged their abdomen as they were stressed. When the labor was coming, the abdomen increased its contraction and size subsequently it become bulge. They consider it as constipation of the abdomen. So women carried out abdominal massage to soften the body of the women and this is based on the belief it helps the women to deliver easily. It also believed that this practice help the mother to have trouble-free labor during delivery (45 years of old key informant).

As the above story illustrates, many of the expectant rural women have trust on traditional birth attendants because they were experienced and give due respect to privacy of the laboring mother and their social acceptance. They also provide emotional and psychological support to the expectant women. Therefore, pregnant women would like first consulted and saw by traditional birth attendants before they went to the modern health institutions. If the pregnancy complication is very severe and upsetting, finally they decide to go to modern health care system as an alternative healing place. The traditional birth attendants and biomedical health services are in most cases utilized concurrently by the pregnant mothers.

The majority of the key informants and focus group participants agree with the positive side of abdominal massage. In accordance with this, participants said that abdominal massage has a lot of function for pregnant women. One of the central functions of abdominal massage is to decrease the pain and pressure of pregnancy related snags. Besides, abdominal massage also lessens the feeling of discomfort and embracement associated with pregnancy. Finally, abdominal massage is easily affordable as well as less costly healing system in the rural area.

In contrast to the above argument, some of the informants were verifying the negative side effect of abdominal massage on the overall life of the pregnant women. According to key informants particularly health extension workers the cultural practice of squeezing a woman’s abdomen with the intention of inducing labor may cause excessive bleeding, uterine rupture and incomplete placental separation thus leads to maternal morbidity and mortality.

The beliefs and ritual practices of Mejilis

Beliefs and ritual practices are an important and integral part of the social and spiritual life of the societies within the given culture. Mejilis is one of traditional ritual beliefs and practice which is performed by the people of Raya for a long period of time. This ritual practice was done by inviting Muslim devotees, and their followers, mostly male elders for the well-being of the woman. It has detrimental role as a cultural healing system. Findings of the qualitative data from the interviewee revealed that many of the pregnant women in Raya performed this ritual practices before their birth. They thought that it was helping the pregnant woman to deliver the baby without any hardship. In support of this idea, one of the informants during the interview argues the role of Mejilis as follows:

I used to believe the Mejilis than the modern health care during my pregnancy time. (The researcher has probed: why?) Because they are interlace between us and the supernatural who gave every fate that we have. Thus, I fully trust their prayer will help to resolve my problem than taking myself to the health center (45 years of old key informant).

However, the reality is far away from this belief. There are a lot of hardships and sorrow experienced by rural women related to pregnancy complications. Rural women preferred to conduct the ritual instead of visiting health facilities on the onset of the problems. They are delaying to visit modern health facilities. As the length of time increases without getting adequate treatment, the severities of the problem become harsh and threat the life of pregnant women.

The belief on the ritual practice of Dubarti

Dubarti is a communal prayer ceremony which is practiced in Raya Alamata. It involves praising and glorifying the sky-god and seeking his spiritual assistance to pregnant mothers. It is also one of the traditional ritual practices that are actively run by group of women in the study area. ‘Dubarti’ as a group practice run by females and serves as an emotional healing practice using praying to God/Allah to save the pregnant woman from any harm that is going to be induced during pregnancy. It renders different utilities, for instance: praying for peace and harmony, to have a good harvesting season and health in the commune.

The health utility of Dubarti relies on praying to make the area a safe haven from diseases and plagues. According to the FGD, participants and interviewee’s, the days of praying vary as per the request and utility that are deemed necessary by those whom request the service. For instance, Monday is for marriage related cases, Tuesday is for wealth related service, Thursday is suited to have a child and pregnancy related cases and Saturday is for conflict resolution purpose as per the traditional norms of the people in the area.

To be specific, health related Dubarti practices focus on group praying to have a good time of pregnancy that is safe from any disease and illness. The ritual act begins, as to the argument of informants, by begging God/Allah to rescue the mother from pregnancy related illness, disease and delivery related deaths by using Koti-a slight stick by the practice leader. To do so, the lead woman begins singing a special song called Erfo Meraba which carries messages to Allah/God. The celebration of Dubarti is mostly practiced on the Muslim community of Raya Alamata. One woman lead the team by beginning the song and the other women followed and repeat the song. This practice was carried out to beg God or Allah to easy her labor and make the pregnant woman safe from any harm.

Dubarti as a practice is performed on the specific occasion, as per the request of the individual or society at large. As a ritual start-up the leader with Koti- a slight stick begin her blessing and praying sitting in the green grass suited by those who arrange the ceremony. The green grass is considered as a symbol of health, as to the illustration given by FGD participants, and they thought something good will happen for the pregnant woman.

Dubarti as a ritual practice have multiple function- one among this function is its spiritual function to get a psychic relief to pregnant mothers. Moreover, it strengthens the social bond and social acceptance among those adhere it and go in line to the tradition. As to the argument of FGD participant, it also serves as care giving service and attention to the pregnant woman. Spiritually thinking, they claim, the religious performance like blessing and praying creates a sigh of relief which you don’t get in the modern health care. For it the prayer includes request, expression of thanks giving, confession of sin and praise among the practitioners. It can be said that Dubarti is a traditional ANC service looking its preemptive care before pregnancy.

Beliefs and practices of food prohibition

Food taboo in pregnancy is one of the socio-cultural beliefs and practices that banned expectant women from using some types of nourishing foods. They are discriminate from using some kind of foodstuff that is relevant to their health and well-being. This belief and practice is common tradition among the pregnant women of Raya Alamata. In this area, there were foods that are restricted to eat by the pregnant women. The findings from FGD, key informant interview and in depth interviews revealed that cultural norms and traditions restricted expectant women from eating certain types of foods. They believe that eating such prohibited foods by pregnant woman have negative impacts on the health of the mother and the fetus during pregnancy.

According to key informants and FGD participants there are a number of food taboos. These were brassica seed (Senafiche), pepper, sugar cane, milk, cheese, honey, meat, banana, tomato, onion, cactus fruit, chickpea (Shimbera), lentil (misir), roasted crops (kollo) were restricted to eat by expectant women during pregnancy. There were many reasons raised by the respondents to restrict to eat these foods. The reasons behind the food taboos were fear of difficulty in delivery, fear of prolonged and pain labor; fear of abortion and miscarriage, large fetus, and feeling of indigestion. In addition to this, other respondents also argued that foods such as milk and milk products are taboo because it sticks on the fetal head and face of the fetus. This spoiled the face of the fetus and resulted in delivering a child with ugly face. Generally, the respondents said that eating restricted foods were not good for both the mother and the fetus since it has dangerous outcomes.

Traditional delivery beliefs and practices

There are embedded cultural beliefs and practices during the labor and deliver. The kinds of belief and practices which are carried out during the periods of labor and delivery are Zarr spirit, coffee ceremony, social gathering, customary tasting, religious beliefs and fear of disclosing to the external things and high desire of confinement as well as the utilization of herbs.

The beliefs and practice of Zarr spirit

Rural people of the study area believed that spirits or supernatural being are the root causes of illness for most of the people. For instance if an individual is victim of spirits and being sick with disease, it simply attribute to the Zarr spirit. Zarr is possessed spirit it enables to relieve patient people from disease according to the idea of the informant’s. Some people still practiced the ‘Zarr’ spirits during labor and delivery even though today it has declined its role. ‘Zarr’ spirits are not only an illness but also a healing ritual that is treated by pacifying the intruding spirits.

According to some of the informants, given the belief there are nonhuman spirits and extra-human forces lying outside the physical control of human beings there is a common perception that pregnant women may be affected by these spirits. Thus, to prevent any negative result these kinds of practices are opted in the study area. They were believed and practiced Zarr spirit in the home of the birthing woman as an alternative healing mechanism.

By common sense it is believed, as to the argument of FGD participants, that Zarr spirit has the power to speed up the delivery process. They also believed that the woman has delivered in calm and peaceful mode but it is mandatory to be loyal to that spirit. A key informant from Gerejale argued that “some women are practicing the Zarr spirits during labor and delivery”. Similarly, another key informant added that “some women did not desire to take medicine like TTC because they believed that the Zarr dislikes any modern medicines. Then, they refuse to the medication”. According to the informants, this belief system has also the power to prevent women from utilizing modern maternal health services that is an essential one for the survival of women. It has harmful effect on the overall health and well-being of the mother that can also lead to long-term health problems.

In relation to this, key informants said there is a cultural practice of encircling of a hen around the birthing woman’s head which is called Miticha in local language. As the labor process of the woman become hardship and lengthy, they slaughtered the hen and encircle on the body of the labor woman. The purpose of this practice was to exorcise the bad spirit from the labor mother which regards as treatment seeking behavior nevertheless this practice deterred a woman from getting modern medicine aptly. Some of them did not also visit and utilized modern health services. They only made these traditional healing practices in their home.

The socio-cultural beliefs and practices

The socio-cultural beliefs, practices and perception held in the community affect institutional delivery. Rural women at Raya Alamata district were limited from getting professionally assisted delivery due to traditional practices held in the home. A key informant from district health office mentioned around four contributing factors for home delivery in the district:

One is the practice of coffee ceremony in relation to traditional practice during labor and delivery. The second contributing factor for home delivery was the gathering of relatives, neighbors and TBAs during labor. The third reason for home delivery is the practice of customary tasting practice (mekamesi) after delivery. Finally, rural women due to fear of disclosing to the external things and high desire of confinement they are delivering at home (44 years old key informant from district health office).

Some practices are related to traditional beliefs and practices during delivery. The practice of coffee ceremony carried out in the home of the birthing woman. They want to celebrate this coffee ceremony with their neighbors, families and other relatives. The aspiration of the all birthing women and their families were to get birth in the home in view of the fact that home delivery was accompanied with coffee ceremony and other traditional rituals. Many of them denied delivering at health facilities due to lack of such services. The absence of such services in the health facilities has detrimental consequence on rural women health seeking behavior because it has restrained from getting appropriate modern maternal health services. This is one of the cultural practices ending with risky deeds on the life of birthing woman.

The other reason for home delivery is the existence of social gatherings comprised of families, relatives, TBAs, elders and neighbors that are not present in the health facilities. They will come to and provide a gift like money for the birthing woman. Moreover, in the rural area, every labor and birthing women have the desired to get themselves with this kind of social gatherings. This encourages the social networks and strengthened solidarity. It has a pivotal role in increasing social interaction and relationships of the local community. Besides, the social gatherings enable to give emotional, psychological and physical support to the labor women. This helps the birthing woman to relief from pain. In with this, one of the informants elucidates the importance of social gathering as follows:

When I gave birth to my 4^th child I used to go to health center. However, when I gave birth to 5^th child I don’t want to go the modern health care because most of the females who gave birth at home have the opportunity to feel the social gathering and aroma which is important to the pregnant mother emotionally. However, in modern health centers there is no this traditional ritual of birth (38 years old key informant).

The social gathering consist of parents, families, neighbors, relatives, friends and traditional birth attendants in the home imposed women to deliver in their home. They were chosen home as place of delivery due to the absence of social gathering at health facilities. Therefore, rural women were delivered in their home without the assistance of skilled birth attendants. Hence, this situation exposed women to severe bleeding and retained placenta which is harmfully affects maternal health seeking behavior.

According to tradition of the community, the birthing women should eat and taste food like porridge immediately after delivery to protect from bad spirits. The absence of these traditional practices in health facilities is the cause of home delivery even though today the government strives to provide such services in the health facilities. In the Rayan culture in general and Raya Aamata in particular the practice of porridge ceremony is a common banquet which has carried out after a woman has delivered. After birth, hot porridge called Geat (porridge) is eaten by the birthing mother and other gatherings which are existed in the ceremony. The porridge ceremony was used to express their joy and happiness.

According to key informants and FGD participants eating porridge has many implications for the birthing woman. Firstly, it has increased the strength of the mother. Secondly, it enables the birthing woman to rehabilitate quickly to the normal condition since it has replaced the nutrients which has been lost during the time of labor. This indicates that most rural women maintained their health by the use of cultural feeding systems. It can be concluded that traditional feeding practices are the most important determinants of health seeking behavior and it has supported women to have good health.

The utilization of herbs

Rural women used traditional herbs during labor and delivery to save the life of the birthing women. This traditional herb is called Demketach thus had the power to drive out the placenta from the birthing woman. In corroborating the above idea, one religious leader from ‘Tabia’ ‘Selam Beklasi’ elucidated the situation as follows:

In our Tabia many women are dying during labor and delivery until we are searching Demketach from herbalists especially in the previous years. The medicinal plant are searching from village herbalists to save the life of the women yet many of them died before getting the traditional medicine. In addition to this, the traditional herbs made women to die in the home related to overdose of the medicine given for the mother (50 years old religious leader).

Herbs are an integral parts of rural societies and used for different purposes such as preventing and curing from disease. Hence, many of the rural people are using herbal medicines for different purpose. The use of Demketach helps to drive out the retained placenta from the cervix of the woman is one among the many purpose of traditional herbal medicine.

The absence of such herbs in the surrounding area of the community makes difficult to utilize the herbs at appropriate time. As a result many women in the rural area died before taking the herbs due to retained placenta according to the idea of the informants. Moreover, excessive use of herbal medicine has a lot of negative side effects on the life the birthing woman. Many of them die as result of excessive use of traditional drugs.

Religious beliefs and practices

Religious beliefs and practices are served as a source of psychological or emotional therapy for labor women in the study area. Rural women of the study area seek maternal health services from religious cults like church. These religious healing practices were given by Orthodox Christian clergies to labor and birthing woman. In line with this, one of the FGD participants reported the role of religious practices as follows:

A priest read Melikia Rufael and blessed the holy water during labor. After blessed the water, the priest ordered the birth woman to drink the holy water. They believe that this practice could help to cut down the prolonged labor of the mother. The priest also blessed holy water at the 7th days after delivery and ordered the woman to baptize the holy water (40 years old religious leader).

As the narrative of FGD participants indicated that the priest continued to bless the water until the mother has delivered. The birthing women were continued to sanctify by holy water instead of going to health facilities. However, the family of the birthing woman sought health institutions when the religious maternal health treatment failed.

In substantiating this idea, health extension workers revealed that these practice was contributed to delay to get timely modern maternal health services. It also contributed to lack of access to skilled medical care during childbirth thus increase the risk of a woman. As a result many of the rural women died before they have reached health facilities and others also lose their infant in labor and delivery.

Religious beliefs and values also determine whether or not women deliver at health care facilities. In substantiating this idea one of the FGD participants noted as follows:

Home delivery is related to religious beliefs. Accordingly, some women believed on the power of saint marry. Subsequent to this, they said that no bad thing was happened. Saint marry knows everything. Saint marries helps to deliver peacefully and no need of institutional delivery (30 year old FGD participant).

In line with this, another 35 years of old woman FGD participant revealed that “religious doctrine has influenced institutional delivery. This contributes women not delivered at health a facility that means it encourages home delivery ”. Moreover, other key informants also said that in the Muslim community there is belief system that restricts women from getting delivery care services. This belief system ordered women not to open her body except to her husband. It considers as sin disclosing her sexual body to male health professionals. In support of this, the following vivid account of the key informant can show the above concern and experience of Muslim women in health centre delivery:

I am afraid personally and thinking religiously to show my sexual organ for any treatment in the health center for male health workers including delivery. For it this is not viable to my religious creed (30 year old key informant).

Another Muslim religious leader from Selam Bekalsi has forward similar ideas and explains the effect of gender based religious belief on maternal health seeking behavior. According to the informant there were some debates which have made by religious leaders whether rural women were assisted with health professional or not. Accordingly, some of the Muslim trainees said that women should not assist with male midwives. They said that these were not permitted in our Islamic law. The women body should not disclose or naked to anybody.

In addition to this, home delivery at the rural area is related to traditional practice and beliefs of the community. In rural areas of Raya Alamata district particularly in the highland areas of the district, home delivery was much more than the lowland area. This is due to the influence of religious leaders, TBAs and mother in-law. In substantiating this, 24 years of health extension worker from Selam Bekalsi argued that “mother-in-law is an obstacle for institutional delivery. They have encouraged women to deliver in their home with the assistance of relatives, neighbors and TBAs”. The presence of older women in the village also discourages institutional delivery. So relatives was decided to keep stay the women at home under the assistance of older people. This practice put off the birthing woman and her infant at risk.

Concomitantly, rural women have problems related to utilization of modern technology. This is related to lack of awareness and traditional perception of rural women. In support of this, 48 years of midwife from Timuga noted that:

Rural women were unpleasant and dislike uplifting to the coach due to lack of knowledge. Most of the labor women from the rural area are disgust sleeping on back with legs lifted up on coach .

Some of the rural women dislike giving birth on the coach. They also refused to use coach during labor and delivery. This affects women’s delivery seeking behavior at health facilities. However, in order to reduce this awful perception of women toward coach, the health workers are invited ANC attendants to observe the delivery room, sleeping and bathing room.

Traditional postpartum beliefs and practices

Traditional beliefs and practices are carried out in the post-delivery periods due to different reasons. Some of the traditional postpartum beliefs and practices which had carried out in Raya Alamata district are confinement and restriction of movement. These traditional beliefs and practices had either positive or negative impacts on the health of the birthing mother.

The beliefs and practice of confinement/seclusion

Confinement or seclusion is one of the traditional practices that carried out to maintain the health and well-being of birthing women. Findings from key informant and FGD participants revealed that rural women are confined in a narrow place called Kuta. In the post delivery period, the majority birthing women were confined or stay in home for a minimum of one month and maximum of six months. In average, they were confined or stay in home for about two and half months. This means, the birthing women stayed indoors and enclose in blankets or wells made of woods or cane. Culturally, the birthing women were not recommended to stay out-of-doors before this length of days.

In the post delivery period, the birthing women were got especial kinds of treatment from their families or neighbors. The treatment is expressed by giving love, affection as well as by giving different types of gifts. Above and beyond, they were also provided culturally acceptable foods to encourage and promote healing or restore the health of the women to the normal circumstances. During this period, special types of foods are recommended as well as promoted to be taken by birthing women. To do so, throughout the confinement period, the birthing women eat culturally prepared food, hot liquids and offered enough time to get rest to reinstate to the normal condition.

Most of the respondents magnified the use of confinement (locally called Chagula) for birth woman this is the time of comfort for most birthing woman. The majority of FGD participants thought that woman during the pregnancy period did not get enough rest and loaded with different household activities this affects the overall health of the woman and undermined the physical potent of the mother. So that the birth women must take rest for prolonged period of time to compensate the lost energy during labor.

In addition to the above statement, the respondents added that the birthing women stayed for long period of time in confinement. The rational of the confinement is basically related to the beliefs and perceptions of the local communities. Accordingly, the community perceive that birthing women were untied their backbones due to labor and delivery. Hence, it must be rebuild and rehabilitate to the usual conditions by the use of confinement. Confinement serves as means of therapy for the birthing woman. This confinement also has another benefit to the birthing woman. As everyone knows, during labor and delivery women has discharged much fluid so it has placed during this period. In addition to this, the respondents believed that the confinement helps to accumulate energy as well as it would help to have a complete health.

Moreover, confinement could help birthing women to keep from unveiling to the external environment. According to the local culture, the birthing women were not desirable to disclose to stormy weather conditions. They perceive that the divulging to the external environment were dangerous to both the health of the mother and the child. Therefore, to keep the well-being of the birthing mother and her child it needs to protect from blustery weather conditions like sun and wind via confinement for prolonged period of time. Besides, the respondents added that confinement also helps birthing women to have excessive time to breastfed her child properly.

In opposite to the above notions, some of the respondents stated that confinement was a cultural practice that has carried out by Rayan women to keep the health of the mother and the child nevertheless this practice did not have any significance. In support of this idea, one of the key informants from Gerejale health center reported that:

Traditionally, women were confined for long period of time inside the home without disclosing to the horrific environment like sun and cold. During the confinement period women were eaten junky foods like meat to recovery from their problems but this affects health of birthing women negatively since it has exposed to chronic diseases (26 years old midwife nurse).

Postpartum restriction of movement

The other kinds of cultural beliefs and practices were the restriction of any movement in the post-delivery periods. In the study area, the birthing woman is not staying alone inside the home as well it is impossible to make any movement. As the respondents mentioned, there are different reasons for the restriction of the women not to move outside the home subsequent to delivery. One reason is the inability of the woman to control or manage their body as deficiency of power/ energy. The second reason is much bleeding because of delivery weakens the physical potent of the mother and did not recommend moving immediately after delivery.

In addition, people believed that the movements of women immediately after delivery were exposed to bad spirit thus affects the well-being of the mother. These are some of the cultural practices that are used by the local people to maintain the well-being and health of rural women. All these are a kind of culture bound health seeking behavior of rural women.

Moreover, the findings of qualitative data indicate that the new birthing women did not leave alone at home in the post-delivery periods. The birthing women are obliged to be accompanied by other people. If not, leaving the birthing woman without any guardian is one major factor to evil spirits/demonic forces. As a result, the birthing women were contaminating with evil spirits in the absence of their custodians. The contamination of the woman with evil spirits causes to illness like madness. Some of them also believed that leaving a woman at home without somebody after delivery might be caused to mental and psychological disorders.

Among the Christian communities women were not leave alone for seven days especially until the priest baptized the birthing mother with holy water (Tsebel). On the other hand, the Muslim community also practiced this tradition. The only difference was the practice of baptizing by holy water in the Christian communities which was not carried out on the Muslim communities. In addition to this, key informants reported that in the absence of somebody the birthing women recommend to hold or put any metal inside the sleeping room to protect from the contamination of evil spirits. The use of metal to protect from evil spirit is one of the mechanisms to maintain the health of the birthing woman by using their indigenous knowledge.

Abdominal massage is one of the culturally based healing systems which are used during the time of pregnancy and labor. It is a common customary method of healing and widely used practices among rural people specifically in Raya Alamata district. According to this study abdominal massage is a central part of the life of pregnant women which helps to get relief from pregnancy related complications. It also assists to decrease the pain and pressure of pregnancy related snags. Besides, abdominal massage also lessens the feeling of discomfort and embracement associated with pregnancy by providing emotional and psychological support to the expectant women. It is inexpensive and less costly healing system in the rural area. Moreover, this finding indicated that abdominal massage also carried out to change the position of the unborn infant to the normal circumstances. Studies conducted in Southern Nigeria also revealed that abdominal massage was carried out for the purpose of reposition and to keep baby well [22]. Besides, abdominal massage during pregnancy may have to late registration for the antenatal care as well as it causes varied complications in pregnancy but failed to identify the complications associated with abdominal massage [23]. Findings from this study revealed that abdominal massage as a cultural practice of squeezing a woman’s abdomen with the intention of inducing labor may cause excessive bleeding, uterine rupture and incomplete placental separation thus leads to maternal morbidity and mortality at the time of pregnancy and labor.

The other traditional belief and ritual practices is called Mejilis. It is one of the traditional ritual beliefs and practice which is performed basically to pray and wish for the pregnant mothers to have safe labor and delivery. However, there are a lot of hardships and sorrow experienced by rural women related to pregnancy complications. They preferred to conduct the ritual instead of visiting health facilities thus contributed to delay to visit modern health facilities. As the length of time increases without getting adequate treatment, the severities of the problem become harsh and threat the life of pregnant women. The other traditional ritual practice is Dubarti that serves as an emotional healing practice using praying to God/Allah to save the pregnant woman from any harm that is going to be induced during pregnancy. Dubarti as a ritual practice have spiritual function to get a psychic relief to pregnant mothers. Moreover, it strengthens the social bond and social acceptance among those adhere it and go in line to the tradition. Studies conducted by Abrha [24] in south-east Tigray and Ebrahim [25] in Jamma district of South wollo showed that prayer is one of the major functions of Dubarti during conflict resolution and unpleasant situations however it lacks to give details with regard to maternal health.

Taboo is a restriction or prohibition of something like food during pregnancy, delivery or in the postnatal periods [26]. It is one of the socio-cultural beliefs and practices that banned expectant women from using some types of nourishing foods such as brassica seed (Senafiche), pepper, sugar cane, milk, cheese, honey, meat, banana, tomato, onion, cactus fruit, chickpea (Shimbera), lentil (misir), roasted crops (kollo). Studies conducted in southern Ethiopia by Nejimu [27] show that almost half (49.8%) of the respondents avoid one or more food items during pregnancy. Linseed, honey and milk/yoghurt were commonly avoided food items. Likewise, another studies in Madagascar by Morris [22] found many foods and activities that are considered taboo during pregnancy such as eating peanuts or bananas, drinking milk, drinking standing up, and wearing things around the neck. Besides, Ezeama [28] found a good number of women who did not eat vegetables during pregnancy. The reasons behind the food taboos were fear of difficulty in delivery, fear of prolonged and pain labor; fear of abortion and miscarriage, large fetus, and feeling of indigestion. Similarly, Nejimu [27] found that pregnant women were restricting from eating certain food items because they belief that were plastered on the fetal head, makes fatty baby and difficult delivery, fear of abortion, evil eye, fetal abnormality. In corroborating, this finding revealed that foods like milk and milk products are taboo because it sticks on the fetal head and face of the fetus. This spoiled the face of the fetus and resulted in delivering a child with ugly face. In substantiate this, studies conducted by Ohnishi [29] in Tanzania found that a pregnant woman eats eggs during pregnancy but it will give birth to a baby without hair or with malnutrition hair, which is brown and thin. As a result, the negative practices of food taboos could deprive pregnant women of good nutrition and consequently could lead to maternal anemia, low birth weight and postpartum hemorrhage [30].

The Zarr spirits or supernatural being are the root causes of illness as the same time it also enables to relieve patients from diseases. Zarr spirits are not only an illness but also a healing ritual that is treated by pacifying the intruding spirits. In consistent with this, Solomon [31] found that the Zarr spirit would identify the troubling spirit, including Jinn and evil-eye spirits, diagnose the illness, and recommend a therapeutic solution. Spiritually inspired healers, using their clairvoyant powers, recommended various kinds of therapeutic modalities to the physically ill, the psychologically disturbed, and to those with scores of personal and social problems. However, Solomon [31] did not try to discuss the Zar-spirit in relation to maternal health. Further, the finding of this study revealed that Zarr spirit has the power to speed up the delivery process; and it would help a woman to deliver in calm and peaceful mode. The Zarr belief has also the power to prevent women from utilizing modern maternal health services like TTC. Besides, some of them used Miticha to exorcise the bad spirit from the labor mother which regards as treatment seeking behavior nevertheless this practice deterred a woman from getting modern medicine aptly.

The socio-cultural beliefs, practices and perception held in the community affect institutional delivery. Rural women at Raya Alamata district were limited from getting professionally assisted delivery due to traditional practices held in the home like gathering of relatives, neighbors and TBAs. In line with this, Genaye [32] in his study found that pregnant women were eagerly awaiting the traditional birth ceremony accompanying their delivery as much as they wait for their baby. In anticipation of the birth, the expectant mother and her friends celebrate together. Furthermore, this finding showed that the birthing women should eat and taste food like porridge immediately after delivery to protect from bad spirits. In substantiating this, Genaye [32] uncovered the common practice of tasting distinctive foods that the mother will eat after her baby is born. Another earlier study in Tigray also showed that due to the deep rooted cultural belief a mother must eat porridge after giving birth. If the mother does not have access to porridge, it is believed that evil things could happen to either the mother or the newborn. Hence, women prefer to give birth at home. There the Health Development Army has started to prepare porridge in health facility if a woman from their team is in labor [33]. Moreover, Fentaw in his study at Raya Alamata district found that health center are commencing providing and preparing porridge, coffee ceremony and others for mother who gave birth in health centers [4].

Herbs are the most common form of treatment given by traditional midwives [22] and the use of herbs is a key practice both during pregnancy and child birth [30]. In many communities traditional birth attendants and local healers use herbs to enhance fertility, to safe guard the pregnancy and the baby, accelerate contractions and limit bleeding during labor and delivery [34]. In conforming this, the findings revealed that traditional herbs are used by women during labor which is called Demketach thus had the power to drive out the placenta from the birthing woman and facilitate the process of labor. Morris [22] found that some women were taking herbs to speed what they regard as a prolonged labor. Moreover, Nyek [35] and Basazn [36] found that the use of herbal medicines during pregnancy associated with the belief that herbal medicines are effective and safe, and having ever used herbal medicines during previous pregnancies and for other reasons. Many users have confidence in the efficacy of herbal medicines as an alternative treatment, with oral ingestion being the major method of use. Many users have confidence in the efficacy of herbal medicines as an alternative treatment, with oral ingestion being the major method of use. Besides, this result indicated that the absence of such herbs and excessive use of herbal medicine has a lot of negative side effects on the life the birthing woman.

Religion is central to life in many parts of Africa along with the positive virtues of religion should be optimally exploited to promote maternal health [37]. In substantiating the above idea, the finding showed that religious beliefs and practices are served as a source of psychological or emotional therapy for labor women in the study area. On the other hand, these religious healing practices were contributed to delay to get timely modern maternal health services. As a result, many of the rural women died before they have reached health facilities and others also lose their infant during labor and delivery. Studies in Nigeria also showed that religious beliefs can cause several African women to ignore vital maternal health care services, refuse to be attended to by male health personnel, and prefer faith to quality medicine [37]. Similarly, in some Muslim community of this study area Muslim women were restricted from getting modern delivery care services. This belief system ordered women not to open her body except to her husband. It considers as sin disclosing her sexual body to male health professionals. The finding also revealed that religious beliefs and values also encouraged home delivery. The role of religious leaders, TBAs and mother in-law is a serious issue for the promotion of home delivery. Similarly, Fentaw [4] in his study found that older mothers and traditional birth attendants were more accepted by the community because of their experience, respect to privacy of the laboring mother and their social acceptance. Besides, having closer attention from family members, feel more comfortable, delivering at home being the women’s experience were the common reasons for home delivery [4,9]. Besides, findings of this study revealed that rural women have refused to use coach during labor and delivery. Correspondingly, studies showed that for rural women being naked (lift up on coach and sleep in lithotomy position expose to air and being visible to everybody) is considered as shameful action [4]. This affects women’s delivery seeking behavior at health facilities.

The nature of confinement practices varies considerably across cultures but all have restrictions on women’s movement. Behavioral restrictions were performed to protect their current health during postpartum and future health at old age [12]. Correspondingly, findings of this study revealed that confinement or seclusion is a traditional practice that carried out to maintain the health and wellbeing of birthing women. In the post delivery period, the majority birthing women were confined or stay in home for a minimum of one month and maximum of six months. In average, they were confined or stay in home for about two and half months. Similarly, another studies conducted by Shariffah [12] and Fadzil [38] indicated that the new mothers will observe the postpartum practice for at least 40 to 44 days. It is also common practice for postnatal mothers to be confined within the house for a period of 40 days after delivery in southern India. It is forbidden from going outdoors [39]. Another studies in south east Madagascar revealed that women were stayed indoors wrapped in blankets, with doors and windows closed, and sometimes with animal lard on their skin [22]. This means, the birthing women stayed indoors and enclose in blankets or wells made of woods or cane. Culturally, the birthing women were not recommended to stay out-of-doors before this length of days.

In the post delivery period, the birthing women were got especial kinds of treatment from their families or neighbors. The treatment is expressed by giving love, affection as well as by giving different types of gifts. Besides, they were also provided culturally acceptable foods to encourage and promote healing or restore the health of the women to the normal circumstances. During this period, special types of foods are recommended as well as promoted to be taken by birthing women. To do so, throughout the confinement period, the birthing women eat culturally prepared food, hot liquids and offered enough time to get rest to reinstate to the normal condition. In the same way, studies in Madagascar by Morris [22] also showed that birthing women were recommended to drink hot fluids, take hot baths and ingest a regimen of herbs. Most of the respondents magnified the use of confinement (locally called Chagula) because the birthing women at this time must take adequate rest for prolonged period of time to compensate the lost energy during labor. Parallel to this, Shariffah [12] found that traditional postpartum practices give the new mothers a chance to rest and recovering from the trauma of pregnancy and delivering. Moreover, Chythra [39] found that bones will be soft in the postnatal period; and taking rest will bring them back to normalcy. Likewise, this study also discovered the negative effects of birth on women anatomy. Accordingly, birthing women were untied their backbones due to labor and delivery. Hence, it must be rebuild and rehabilitate to the usual conditions by the use of confinement. Confinement serves as means of therapy for the birthing woman. Moreover, studies conducted by Shariffah [12] revealed that women in confinement also avoid the exposure to wind and cold. Birthing women wear stockings and warm clothes to avoid the wind. They also avoided strenuous household chores performing hard tasks such as fetching water and lifting heavy weights. Similarly, confinement could help birthing women to keep from unveiling to the external environment. They perceive that the divulging to the outdoor environment (like sun and cold) were dangerous to both the health of the mother and the child. Besides, confinement also helps birthing women to have excessive time to breastfed her child properly. Similarly, Chythra [39] found that exclusive breast feeding on demand is possible, as mother is always close to the baby during the time of confinement.

The other kinds of cultural beliefs and practices were the restriction of any movement in the post-delivery periods. In the study area, the birthing woman is not staying alone inside the home as well it is impossible to make any movement. As the respondents mentioned, there are different reasons for the restriction of the women not to move outside the home subsequent to delivery. One reason is the inability (weakens) of the woman to control or manage their body as deficiency of power/energy. The second reason is much bleeding because of delivery weakens the physical potent of the mother and did not recommend moving immediately after delivery. On the other hand, the findings indicate that new birthing women did not leave alone at home in the post-delivery periods. Some of them also believed that leaving a woman at home without somebody after delivery might be caused to mental and psychological disorders because of evil spirit. To prevent from bad spirits, birthing women among the Christian communities were not left alone for seven days especially until the priest baptized the birthing mother with holy water (Tsebel). In the absence of somebody, the birthing women recommend to hold or put any metal inside the sleeping room to protect from the contamination of evil spirits. The use of metal to protect from evil spirits is one of the mechanisms to maintain the health of the birthing woman by using their indigenous knowledge.

The research findings revealed that in Raya Alamata district many traditional maternal health beliefs and practices are carried out during the period of prenatal, delivery and postnatal periods. These are abdominal massage, Mejilis, Dubarti and food taboos are commonly held during the prenatal periods. Moreover, the socio-cultural beliefs and practices like believing on Zarr spirit, the practice of coffee ceremony, the demand of social gathering, customary tasting practice, religious beliefs and fear of disclosing to the external things and high desire of confinement as well as the utilization of herbs are carried out during the periods of delivery and postnatal periods. These traditional beliefs and practices have negative consequences on the utilization of maternal health services in the study area. As a result of these beliefs and practices, many rural women were expose to excessive bleeding, uterine rupture and incomplete placental separation thus leads to maternal morbidity and mortality. In addition to this, these beliefs and practices also play a pivotal role in delaying women from visiting modern health facilities. This aggravated the severities of the problem and threats the life of pregnant women. Many of them put into death. However these practices have served as alternative health care for the rural community and it has a psycho social function for pregnant women. Moreover, these beliefs and practices too cause to put off women from utilizing modern maternal health services like TTC. As a result, many of them decided to deliver at their own home without the assistance of skilled medical professional during childbirth, thus increase the risk of a woman to dangerous state of life. As a result many of the rural women died before they have reached health facilities and others also lost their infant in labor and delivery.

I am very grateful to University of Gondar College of Social Sciences and Humanities for technical and financial support of this study. I am also thankful to my study participants who gave me their full time, information and life stories with full interest during the research.