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Early Effects of Environment: A Comparison of Prenatal Care in South Africa and the United States

Carnegie Mellon University Research CMU Dietrich College Honors Theses Dietrich College of Humanities and Social Sciences Spring 2010 Early Effects of Environment: A Comparison of Prenatal Care
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Carnegie Mellon University Research CMU Dietrich College Honors Theses Dietrich College of Humanities and Social Sciences Spring 2010 Early Effects of Environment: A Comparison of Prenatal Care in South Africa and the United States Allison Piper Carnegie Mellon University Follow this and additional works at: This Thesis is brought to you for free and open access by the Dietrich College of Humanities and Social Sciences at Research CMU. It has been accepted for inclusion in Dietrich College Honors Theses by an authorized administrator of Research CMU. For more information, please contact Running Head: EARLY EFFECTS OF ENVIRONMENT 1 Early Effects of Environment: A Comparison of Prenatal Care in South Africa and the United States Allison Piper Carnegie Mellon University Humanities and Social Sciences Senior Honors Thesis Submitted as partial fulfillment of requirements for Psychology Honors Diploma Advisor: Dr. Sharon Carver Spring 2010 Early Effects of Environment 2 Table of Contents Acknowledgements...3 Abstract...4 Introduction...5 Methodologies...11 Results...15 Discussion...23 References...27 Appendices...30 Appendix A: Interview Questions, South Africa...30 Appendix B: Interview Questions, United States...31 Appendix C: Consent Form for Adult Respondents in English, South Africa...33 Appendix D: Consent Form for Adult Respondents in English, United States...34 Figure...35 Early Effects of Environment 3 Acknowledgements I am so grateful for all the guidance, support, and advice provided to me by numerous faculty members and community members throughout this project. I owe a huge debt of gratitude to my advisor, Dr. Sharon Carver, for her unflagging support throughout the project. For her selfless dedication of time, skill, and resources, I would like to thank Charlee Brodsky, who advised me on the photo essay composition and design. Thanks are also due to Cedric Nunn, for his photographic advice while in South Africa. Dylan Vitone provided assistance with book design, and Marie Norman provided assistance with ethnographic data. Both were very helpful, thank you. I would also like to thank the Undergraduate Research Office of Carnegie Mellon University for funding my South African photography with an International Small Undergraduate Research Grant (I-SURG), and the college of Humanities and Social Sciences for the opportunity to pursue this goal. Thank you to all of the community members who helped me to understand the communities with which I worked. I am so appreciative of Alice Maunz and Dr. Mark Meyer of the East Liberty Family Health Care Center for sharing their time and knowledge. Thank you to those in Impendle, South Africa who made my work possible: Mama Pumzile Zuma, Mama Regina Mhlango, Community Health Workers Ntombifuthi Molefe and Zanele Magwenyane. I would like to thank all of my project s participants. To the participants in Impendle, South Africa, thank you for inviting me into your homes, answering my questions, and allowing me to photograph you. Ngiyabonga kakhulu. To the participants in the United States, thank you for allowing me to witness your care, photograph you, and interview you. Thank you so much. Finally, I d like to thank my fiancé, Nik, for his patience, understanding, and support. Early Effects of Environment 4 Abstract Prenatal development has a critical impact on a child s life and is strongly affected by environmental factors, especially quality of prenatal care and home environment. Data was gathered in a South African village and a United States city through interviews, photojournalism, and archival data. A total of 14 women (10 South African, 4 American) were interviewed about their prenatal care and pregnancy experiences, and 12 were photographed in their surrounding environment. The photographs serve as a visual and emotional complement to the paper. The project showed that the extended family in South Africa provides a strong social support system for pregnant women, which serves to mitigate much of the lack of resources in the environment. In the United States, prenatal care typically assumes much of the education and social monitoring role, due to the smaller role of the American extended family and the cultural value placed on biomedical care. While the two environments are different, mothers and newborns in both environments generally have the necessary prenatal support. Early Effects of Environment 5 Prenatal and Newborn Environments: Photographs and Interviews from Rural Impendle, South Africa Introduction Prenatal care, both in the medical arena and in the home, is an essential component for promoting the health of newborns and the future on-track development of children. Culture affects the roles and priorities of prenatal care, and this paper examines cultures effects on prenatal care in two communities: Impendle, in rural South Africa, and East Liberty, in urban Pittsburgh, United States. Communal versus individualistic cultural beliefs, the size and role of the family, general community health, and attitudes of the community toward biomedical prenatal care, are examples of cultural factors contributing to the differing practices of prenatal care between the two countries. Urie Bronfenbrenner (1975) theorized that environmental influences, represented by gradually expanding rings radiating out from the child (Fig. 1), are the most crucial determinants of a child s development. A child s culture, including foods, socioeconomic status of the mother, prevailing lifestyle, and medical care, begins to affect a child at conception. Broader influences affecting the pregnant mother and consequently the fetus include the values of the culture, institutions such as schools and hospitals, media, government policy, and historical factors (for instance, South Africa s post-apartheid state, which influences what medical resources are available to whom), among others. It is important to examine culture, as every person is inextricably linked with his or her environment. Insert Figure 1 about here. Early Effects of Environment 6 United States Culture Cultural beliefs and practices are naturally different between South Africa and the United States. American culture places a high value on individualism and hard work (Tamis-Lemonda, C., & McFadden, K., 2010). The founding ideals of liberty, freedom, and equality are evident in the values of residents. U.S. capitalistic society also affords many opportunities for an individual s upward economic growth. The capitalistic system, however, has combined with historical factors and uneven population growth to result in an uneven distribution of wealth. The significant disparities in the availability of resources often fall along racial and socioeconomic lines. These disparities result in poor, often African-American women having less access to prenatal care (Kalmuss, D., & Fennelly, K., 1990). These urban, low socioeconomic status women and their experiences with prenatal care will be the focus of the U.S. investigation. South African Culture South African culture is much more communal and inter-dependent than the United States (Nasamenang, A. B., & Lo-oh, J., 2010). Where the typical United States home consists only of the nuclear family, this family structure is unimaginable for most Africans, who place a strong emphasis on extended family. Often several generations, as well as many children, will live in one household. South African society has a philosophy of Ubuntu, which translated means, roughly, humanity. Africans see themselves as part of a greater whole, and feel it is their duty to share what they can to support their fellow humans. This collective culture has an impact on childrearing and care of the pregnant mother. Family members (especially siblings) and neighbors work together to care for young children. As Africans tend to have higher reproductive rates than other countries, this communal atmosphere supports the wellbeing of both mothers and children. South African welfare, however, is in dire straits due to poverty, the Early Effects of Environment 7 HIV/AIDS crisis, low life expectancy, rampant malnutrition, and low standards of living (Day, C., & Gray, A., 2008). South Africa s maternal health has actually worsened in recent years. The UN estimated that the maternal mortality ratio (MMR) in 2000 to be approximately 230 deaths per 100,000 live births. In 2005, the MMR increased to approximately 400 deaths per 100,000 live births (Day, C., & Gray, A., 2008). Infectious diseases not related to pregnancy, such as HIV/AIDS or tuberculosis (TB) were responsible for the majority (38%) of maternal deaths. The United States, by comparison, had an MMR of 11 in 2005 (UNICEF, 2010). Infant mortality ratio (IMR), the number of deaths of children under one year of age per 100,000 births was 48 in South Africa in 2008 (an increase over previous years) and 7 in the United States the same year (UNICEF, 2010). South Africa does show a high prenatal coverage, with 94 percent of pregnant women attending at least one appointment. In addition, a skilled medical practitioner, such as a doctor, nurse, or midwife, was in attendance at approximately 91 percent of births in 2003 (Day, C., & Gray, A., 2008). In the United States, skilled medical practitioners were present at 99 percent of births (UNICEF, 2010). It is important to note the critical nature of the HIV/AIDS epidemic, especially in South Africa. The crisis has a strong bearing on what healthcare aspects are prioritized. In South Africa in 2007, approximately 5,700,000 people (approximately 11% of the population) were HIV positive. In the United States, about 1,200,000 people (approximately 0.4% of the population) were HIV positive. Poverty rates are highly dissimilar between the two countries. For comparison, the South African gross national income (GNI) per capita was $5,820 in In the United States, the Early Effects of Environment 8 GNI per capita was $47,580 (UNICEF, 2010). When examining the national poverty lines, though, it is important to note that even the Americans in the sample population have a high rate of poverty by national standards; 13.1% of Americans fall below the national poverty line (UNICEF, 2010). These two cultures were chosen for investigation because of their marked differences (rural vs. urban, communal vs. individualistic values), but comparability in some important dimensions (for example, each country has history of racial discrimination). It should be noted that South Africa and the United States are at very different stages in their development. It is more fair to compare South African health care standards to other African and developing countries and to compare the United States to other first world countries. The presentation of these two countries alongside one another is intended to illustrate the impact of culture on prenatal care, not to criticize the weaknesses of either country s prenatal environment. Prenatal development is important because of critical growth that occurs across the developmental domains. This growth continues in early childhood as the child s cognitive, linguistic, physical, social, and other abilities continue to expand and develop. If this growth is hampered, effects often can be seen throughout the person s adult life (Grantham-McGregor, et al., 2007; Walker, et al., 2007). Child health, consequently, is often used an indicator of national health. By examining the cultures of Impendle, South Africa, and Pittsburgh in the United States, conclusions can be drawn about the environments surrounding pregnant mothers as well as newborns. A large body of work has been conducted on the various facets of pregnancy and prenatal care. The reviewed selection covers topics relevant to this paper. Early Effects of Environment 9 Planning of the pregnancy prior to conception influences the pregnancy and experience of the mother. Previous work has shown that unplanned pregnancy is a major determinant in inadequate use of prenatal care (Delgado-Rodríguez, Gómez-Olmedo, Bueno-Cavanillas, & Gálvez-Vargas, 1997). Unplanned pregnancy also correlates with lower social class, lower education level, and lack of employment outside the home. Another related factor is teenage pregnancy, which tends to be unplanned in the cultures examined. In 1979, Gortmaker identified that inadequate prenatal care was strongly related to low birth weight. In addition, African American women were more likely to receive inadequate prenatal care, and consequently have a higher risk of negative birth outcomes. According to Gortmaker, this deficiency could be interpreted as the negative effects of poverty, which colors the environment of the pregnant mothers (Gortmaker, S., 1979). More recently, Barber (2006) found that high quality prenatal care among pregnant women in rural Mexico predicted skilled institutional delivery. Delivery in the presence of a skilled medical practitioner is a primary means of reducing maternal mortality. In 1996, McDuffie, Beck, Bischcoff, Cross, and Orleans recommended a schedule of nine prenatal visits in order for evaluation of the mother. The World Health Organization (WHO) discussed several priorities for appropriate prenatal care, including the medical roles of promotion of health and prevention of illness as well as the social role of education and care. The document included several barriers to access women may face, such as lack of transportation, lack of money, and language barriers, among others (World Health Organization, 2003). The WHO also discusses adequate nutrition and lifestyle for the mother, including discontinuing use of tobacco, alcohol, and other drugs (World Health Organization, 2003). The mother s experience during pregnancy is also influenced by the surrounding culture. Savage, Early Effects of Environment 10 Anthony, Lee, Kappesser, and Rose (2008) found that urban African American women commonly held an attitude that emphasized family support, concern over safety in the community, frustration with isolation and barriers to access, and confusion over unwanted pregnancies. These factors often made pregnancy a distressing experience for the women involved. Support structure and access to personal resources are a common theme during pregnancy (C. Rini, C. Dunkel-Shetter, P. Wadhwa, & C. Sandman, 1999). WHO generally recommends breastfeeding for mothers, but there are conflicting views in the literature over whether or not HIV positive mothers should breastfeed. This debate is especially high priority in South Africa, where the HIV/AIDS prevalence is at unprecedented levels. It is common knowledge that breast milk can carry the HIV virus. One view states, however, that exclusive breastfeeding for the first 6 months of life has the same risk as formula feeding (Coutsoudis, et al., 2001). In this theory, mixed feeding (feeding both formula and breast milk) irritates the infant s throat and stomach, opening opportunities for infection. Exclusive formula feeding reportedly the lowest risk, however, it is difficult to maintain in resource-poor areas. Exclusive breastfeeding is also difficult to maintain in practice (Saloojee & Pettifor, 2005). Other components of prevention of mother to child transmission (PMTCT) of HIV are HIV tests as a part of routine prenatal care, treatment with antiretrovirals for HIV positive mothers, and counseling. The project seeks to investigate the interacting roles of biomedical prenatal care and of the family in caring for the pregnant mother and the newborn. The project is implemented through a combination of academic paper and an accompanying body of photographs in documentary journalism style. This combination of art and academia was delicately undertaken, Early Effects of Environment 11 but has resulted in a work with complementary parts, which give a fuller image of the rural African environment and the urban American environment for prenatal development. -- Methodologies Presentation This project is presented in two halves: academic paper and documentary photographs. The pairing is intended to create a strong presentation on the topic of culture and prenatal care, with each half of the project adding unique strengths. The photographs provide visual illustration of culture and environment. By nature, they are more emotionally charged. The academic paper, by contrast, puts prenatal care in a larger context. It serves to describe both the prenatal care practices and of the communities as a whole, beyond the specific circumstances depicted in the photographs. The project was intended to compare the cultural differences seen in prenatal care in South Africa and the United States. Priorities in prenatal care as well as the surroundings of infants and pregnant women were investigated. South Africa Participants Ten participants were interviewed and photographed in South Africa. With the exception of one pregnant participant, all participants had recently delivered. Although the project was originally intended to focus on the experiences of pregnant women, finding willing participants who were currently pregnant proved difficult due to cultural constraints. Participants were all rural Zulu-speaking women of African (non-european) descent. Infants ranged in age from one week to six months old. In addition, three health care practitioners at the local clinic were interviewed. Early Effects of Environment 12 Participants were identified through a local Community Health Worker. The Community Health Worker is responsible for administering home-based health education, including sanitation, nutrition, and child health. The Community Health Worker was familiar with women in the area with newborns as a result of house calls throughout the pregnancy and after the child s birth supporting proper vaccination and welfare. The Community Health Worker served to make introductions as well as translate. She was, in turn, compensated for her assistance. Participants were all residents of the rural village of Impendle, South Africa. Impendle is situated in the Midlands of KwaZulu-Natal Province. The population of Impendle in 2007 was 39,397; 74.14% were unemployed in 2001 (Impendle Local Municipality, 2009). Procedure Interviews were conducted over the course of two weeks. Participants were visited in their homes. Community Health Workers provided translation, including explanation of project and consent form for participants, as well as translation of interviews. After introduction and explanation, the participants were asked a series of questions on their prenatal care experiences and their experiences with pregnancy. Finally, the mother and her newborn were photographed in a naturalistic setting. By photographing surrounding environmental conditions in the home, observations on the resources available to the newborn and mother were documented. Most audiences regardless of educational background can easily understand the photographs, which are presented in alongside this paper. The visual and emotional presentation allows for a more thorough exploration of the South African environment. In return for participation, participants whose photographs were used were given 8x10 prints of their photographs (about 1-2 photographs per participant). Materials & Design Early Effects of Environment 13 The interview was semi-structured. A list of basic questions can be found in Appendix A. Notes were recorded in a notebook and transferred to a password-protected laptop to ensure confidentiality. The language barrier limited the complexity of the interviews. The photographs were made in documentary photojournalistic style. Photographs were shot with a Canon A-1 35mm camera on Black and White Ilford HP5 film. Photographs were made in black and white following traditional photojournalistic methods. This presentation allows the viewer to focus on the environment shown in the photographs without the distraction of color. Film w
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