Abstract
Religious rights as enshrined in the Zimbabwean constitution are sacrosanct, however, when church doctrine bars followers from seeking modern medical care, they start infringing on health rights especially of the ‘lesser beings’ the women and children who are members of these religious sects. The ‘lesser beings’ are bearing the brunt of high maternal and neonatal mortality as they depend on unsafe traditional birth attendants and unconventional medicine. This study is ethnographic and presents lessons learnt from a programme aiming to improve maternal, newborn and child health outcomes among the Apostolic Church of Johanne Marange members in Manicaland province, Zimbabwe. The findings show that despite the stringent doctrine and barriers placed on apostolic members who want to access conventional medicine, the women and children are using clandestine approaches to circumvent the doctrine and barriers. This article argues that a barrage of unconventional and conventional approaches can lead to changes in health-seeking behaviour of the apostolic church and ultimately maternal and child health outcomes. The article argues that the intransigence of the apostolic can only be overcome by covert approaches to providing health services and save lives.
Introduction
As a young boy living in the rural areas of Masvingo province in Zimbabwe in the late 1980s and early 1990s, there were so many things facilitating me about life in general. As a catholic young boy, I was more fascinated by a religious group called Apostolic Church of Johanne Marange (referred to in this study as the Apostolic church) which is part of African Independent Churches. The fascination was mainly because of three things, the first one was the financial benefits I used to accrue from the church, and this benefit was accrued as a result of the church’s annual two-week July church camp. During the church camp, we used to sell firewood to the congregants and when the church break camp after two weeks, we used to go and scour the camping area for dropped coins which had a better buying power during the late 1980s and early 1990s, the coins were a source of pocket money for us. The second and third points of my fascination form the basis and conceptual thinking of this study. The second fascination was the fresh infant graves which were always an additional feature at the cemetery allocated to the church by the local leadership. On average 10 fresh graves were noticeable after every annual July church camp meeting. The third point of fascination was the commotion which was created at the camping site when police and healthcare workers came to forcefully vaccinate the infants and children of the apostolic church members. What fascinated me, in this case, were the apostolic women running away with their infants, toddlers and children whilst the male apostolic member threatened to beat up the police and the healthcare workers. Being a catholic and vaccinated, I was curious why the apostolic would prevent their children from being vaccinated if it prevents death and other health complications. I did not understand that through religion, the members of the Apostolic church of Johanne Marange were bound to beliefs and customs which forbid them from using conventional medicine. As I grew up, I began to understand that the apostolic church has a strict doctrine which prevents its members from accessing and using modern medicine and medical devices.
More than 20 years later in my adult working world, I ended up working on a programme aimed at improving the maternal, newborn and child health (MNCH) outcomes in Manicaland province in Zimbabwe. This article presents lessons learnt from implementing conventional programmes to address health-seeking behaviour among Apostolic Church of Johanne Marange members. The article is part of a personal learning agenda set during maternal, newborn and child health programme implementation. The overall objective was to generate evidence which can be used to improve programmes to improve health-seeking behaviour and MNCH outcomes among the apostolic church. In Manicaland, 42% of the population are Apostolic and apostolic make up the majority of non-institutional deliveries (ZIMSTAT, 2017, p. 192).
Influence of Johanne Marange Church Doctrine on Health-seeking Behaviour
Apostolic Church of Johanne Marange originated in the 1930s in Manicaland province in Zimbabwe. The church is one of the African Independent Churches with its origins grounded in the failure of the Western and Missionary churches to accept traditional practices among its congregants (Adedibu, 2018). These churches regard themselves as led by the spirit, ‘teach faith-healing’, regard sickness in itself and the use of medical services (traditional or modern) as a sign of weakness of faith (Gregson et al., 1999, p. 188). The doctrine of Apostolic Church of Johanne Marange preserved the traditional African cultural elements that were regarded as devilish by mainline or missionary churches. Some of the traditional practices retained were the practice of polygamy, wife inheritance and child marriages. The apostolic have strong religious codes and regulations and regard the use of modern medicine as elevating the health practitioners, their medicine and medical devices above God (Chitando et al., 2014).
The apostolic church members are taught that sin causes sickness and the prophets have spiritual powers to know who has participated in immoral activities such as premarital sex and received modern medicine (Maguranyanga, 2011). The Apostolic church of Johanne Marange doctrine allows polygamy; men are allowed to have as many wives as long they can support them. Among the apostolic, polygamy is seen as an achievement and those with more wives are revered and assume an elevated status (Machingura, 2011). For polygamous men, the more wives they have, the more power and success they are believed to have (Chikwature & Oyedele, 2016). Among the church elders, polygamy is viewed as a strategy to grow the congregation as children from apostolic families are likely to remain within the church (Machingura, 2014), however, studies have shown that the children from polygamous families suffer greater disinvestment in education and health which limit their socio-economic outcomes (Machingura, 2011). Disinvestment in education and health also increases child marriages and poor investment in girl-child education, with the preference being given to boy children (Kambarami, 2006). This is exacerbated by the highly patriarchal nature of Apostolic Church of Johanne Marange. For adolescent girls, early marriages expose them to pregnancy complications which are the leading cause of death for 15–19-year-old girls globally (Neal et al., 2012).
Health-seeking behaviour among the Apostolic Church of Johanne Marange is also affected by the church doctrine which advocates for alternative medicines such as being prayed for by the church leaders or prophets, the use holy water/oil to treat any diseases or medical conditions and other concoctions prepared by the church prophets and leaders (Maguranyanga, 2011; Musevenzi, 2017). Such beliefs and practices have led to low uptake of MNCH health interventions such as ante-natal care, health facility-based deliveries and child health interventions such vaccinations especially among the more conservative members of the church (Musevenzi, 2017). The use of modern family planning methods is also prohibited and church members are encouraged to have more children (Kenneth et al., 2016).
To cater for ante-natal care and childbirth, the Apostolic Church of Johanne Marange have created their non-conventional maternity and delivery rooms manned by traditional midwives (Apostolic birth attendants/ traditional birth attendants) who are regarded as not tainted by the secular medical practices (Maguranyanga, 2011). The birth attendants are not formally trained and are community-based providers of care during pregnancy, delivery and the postnatal period for apostolic women. Studies have shown that the use of traditional birth attendants is associated with high maternal and infant mortality especially among groups who shun conventional medicine (Goodburn et al., 1995; Kayombo, 2013; Neal et al., 2012; Withers et al., 2018). Such informal health practices have resulted in confrontations/antagonistic relationship between government health services providers and the Apostolic Church of Johanne Marange leadership (Maguranyanga, 2011).
In bureaucratic government circles, the Apostolic Church of Johanne Marange is regarded as unsophisticated and backward because they resist the government policies on education and health (Vengeyi, 2011). This brings to the fore the conflict between religious rights and health rights; the conflict is exacerbated by the parents having proxy agency for their children. By exercising these religious rights, apostolic sects might be trampling on the human and developmental rights such as prevention of child marriages, the right to education and healthcare under the guise of religious freedom. The conflict is more pronounced among the more conservative apostolic groups, according to Maguranyanga the level of conservativism of the religious sector is a predictor of non-use of modern medical services (Maguranyanga, 2011).
Conceptual Framework
Studies by UNICEF (2011), Vengeyi (2011), Machingura (2014), Musevenzi (2017) and Maguranyanga (2011) shows that Apostolic Church of Johanne Marange’s beliefs and doctrine have succumbed to the impact and pressures of the demands of the contemporary modernising and changing world. This study is based on the understanding that although the apostolic church doctrine is used to be regarded as impenetrable, secular conscientisation and civic society packaging of information have resulted in an awakening among the apostolic women of the importance of accessing modern healthcare. However, this does not point to the direct reformation of the church doctrine but church members making decisions which they believe are beneficial to them even if these decisions go against church doctrine. The study conceptually posits that within these deviations and loosening the adherence to the church doctrine, there is an avenue which government and other stakeholders who are seeking to change the health-seeking behaviour of the Apostolic Church of Johanne Marange can use to both formally and informally address adverse MNCH outcomes among the church members.
When one examines the Apostolic Church of Johanne Marange one would find that the internal stratification is key to its survival as those with power use it against those without. In this study, religion is regarded as a catalyst for establishing moral order for the church, legitimise hierarchies within the church, set collective goals and religious boundaries. It is argued that although church doctrine among the apostolic is not changing, church members are changing their views and perceptions about modern medicine thereby gradually weakening the grip of the church doctrine. The article explores how this gradual weakening can be a catalyst to change within the apostolic and inform policy. At the policy level, this conceptual framework argues that health policy must be tailored around the ecological behaviour of the Apostolic Church of Johanne Marange.
Methods
The study adopted a quasi-ethnographic approach which is an ethnographic approach albeit with limited field visits and time—hence the term quasi-ethnographic study. Ethnography in this study is defined as a process of ‘searching for predictable patterns in the lived human experiences by carefully observing and participating in the lives of the understudy’ (Sangasubana, 2011, p. 567). As the researcher, I was involved in the implementation of a health programme with the objective to improve the maternal, newborn and child health outcomes especially in communities which are regarded as hard to reach (geographically and religiously) in Manicaland province in Zimbabwe. I had to make several field visits to communities and facilities which provide healthcare services and are located within the hard-to-reach populations in Manicaland province. This provided me with the opportunity to interact with various stakeholders on-site and in a naturalistic Apostolic Church of Johanne Marange setting. Field observations and interviews were carried out by the researcher on-site and in a naturalistic setting with various study participants within their community. In this case, the research process was inductive, holistic and focused on working with Apostolic Church of Johanne Marange members as compared to treating them as objects with no voice. This allowed the researcher to collect realistic data in a naturalistic setting.
During data collection, the researcher interacted with several stakeholders who are either apostolic church members or are involved in one way or another in health-seeking behaviour of the apostolic groups. The various stakeholders observed and interviewed are as follows: Johanne Marange members (leaders and ordinary members both males and females), local traditional leadership (in some cases these were Johane Marange members), Health Centre Committee members and health services providers (nurses and village health workers). Interviews and observations were done in a variety of settings which were realistic and naturalistic these included formal sit-down interviews. Other non-formal interviews and observations involved situations such as sharing rides with Johane Marange church members, interactions with domestic workers (church members) around my area of residence and frequent field visits during programme implementation and stimulating discussion around the use of conventional medicine. The interviews and observations were carried out from June 2018 to September 2019. Because it is impossible to obtain direct consent from all respondents in an ethnographic study (some, however, did give it in the context of a confidential interview), the study tries to abstract the knowledge gained and at times conceal identities completely and aim firstly to deliberate on abstract issues on health-seeking behaviour among the apostolic.
Data analysis was simultaneously performed during data collection. By performing interpretative data analysis during the data collection process of the study became organic and allowed the interactions between research questions, data collection and interactions. Data analysis involved coding fieldwork interview and observation notes and transcripts. The coded data were assigned to grouped labels/categories and later assigned to the themes which are presented in the results section.
Results
Church Doctrine, the Albatross Around Apostolic Believer’s Neck
Among the Johanne Marange Apostolics, the church doctrine and hierarchy has created strong beliefs and customs which shapes the social and cultural fabric of the congregants. The church leadership, prophets and family patriarchy decide on all health matters. The church elders also set the doctrine and the prophets and elders play a ‘spiritual’ role to unmask those congregants who do not comply with the doctrine. At the household level, the patriarchy plays a significant role in enforcing church doctrine as they are regarded as a moral and religious authority. Interviews with apostolic women have shown that the head of households (husbands) play a significantly influential role and act as a reference group when it comes to household health-seeking behaviour. In polygamous households, senior wives also play a policing and enforcing role to ensure that junior wives adhere to church doctrine and family norms. The apostolic community also as a collective plays a significant role in ensuring that their fellow brethren’s households adhere to church doctrine. With this three-tier system of the church, patriarchy and community checks, apostolic members who want to access conventional medicine find it difficult to circumvent the tiers. Representatives of the health centre committees and facility staff indicated that there is an appetite for health services among the apostolic communities mainly because the apostolic members know that their leaders secretly access modern medical services in times of need.
The general perception across all the various interviews and observations is that there are high instances of maternal and infant mortality among the apostolic. Statistically, this is difficult to prove because of the poor death notification among the apostolic and shunning of healthcare centres. When the researcher pressed the apostolic members especially those in the position of power and influence both religiously and socially, all attest to the superiority of their unconventional medical practises and their traditional birth attendants. Instances of maternal and infant deaths at formal health facilities are always referenced as examples of how bad conventional medical practices are. There is also an emphasis by church leaders that the apostolic birth attendants and prophets are trained by the Holy Spirit hence are more superior than ordinary healthcare workers who are trained by human beings hence cannot match the skills of those who have been spiritually trained. By labelling conventional health workers as less skilled than the church’s prophets and birth attendants, the church is casting doubts about the effectiveness of conventional medicine. In cases where infant mortality occurs at the traditional birthing place, the apostolic believe that it has been caused by immoral behaviour by the mothers or as a result of witchcraft within the family or community.
In instances where the church members break with the prescripts of the church doctrine, they face negative implications if caught at both individual and household level. Husbands and senior wives who have a ‘subject’ who has broken the church doctrine and accessed conventional medicine are socially and religiously shamed, regarded as weak and can receive sanctions from church elders. At the individual level, some of the female respondents indicated that they would seek conventional medical services help in extreme cases, however, they will do so clandestinely to circumvent the sanctions such as physical violence, being ostracised in marriage and some cases being divorced. Other apostolic women indicate that they would ‘rather let the infant/child die than losing their marriage’. The emphasis was that seeking conventional medicine without the blessing of the husband was courting marital troubles which might lead to divorce or being shunned by the husband especially in polygamous relationships. The perception among male members of the Johanne Marange church was that valuing the marriage, preserving one’s religious and social status far outweighed the benefits of conventional medicine for maternal and child health because ‘children are like bricks, they will just mould more’. In the case of maternal death, the husband will fill the void by marrying another wife or the other wives will shoulder the responsibility of the departed wife like caring for children.
Conversations with apostolic women have revealed that they believe that complications in labour such as prolonged labour, foetal distress and breech presentations, and sickness of children are regarded as caused by the mothers’ sins (immoral activities which invite evil spirits). In case of these labour complications, apostolic traditional birth attendants force the mothers experiencing these to confess so that the complications are spiritually resolved. According to the apostolic birth attendants, failure to confess will lead to either the death of the mother or the child. In cases where the mother ‘confesses’ but still experiences complications and even death, the church prophets and birth attendants still blame the mother for incomplete confessions and witchcraft. The church members believe that all the illness and complications are traced to spiritual weaknesses, which only the church prophets and hierarchy are inherently prepared to deal with.
Lack of proper information and knowledge about the benefits of MNCH conventional services also play a role in entrenching the role of religious doctrine, patriarchy and church hierarchy in the enforcement of the prohibition of conventional medicine. Among the apostolic, religious and social hierarchy play a filter role in how apostolic women access information about conventional medicine as church members are prohibited from attending healthcare services outreaches such as family planning, vaccination and other health information session outreaches. In cases where there is resistance to church and social leadership, physical violence and other sanctions are used as a tool for punishment and deterrence. The findings also show that despite the challenges in accessing information, the apostolic women are well aware of the benefits of conventional medicine, however, they do not have the power to formally push for its acceptance within the church because of their social status. Creating trustworthy friendships and groups of those who believe in conventional medicine is rife among the apostolic women. These friendships and groups form part of the support system of which those in need tap into when accessing health services.
Group behaviour among the apostolic is more aligned towards supporting social and religious structures and is unwilling to support those who seek help from health facilities. Group retribution such as being shunned and punished by the group is the norm once someone is known to have accessed health services. Despite the challenges faced by the apostolic women in accessing healthcare services in Manicaland, the findings of this study show that apostolic women are tenacious when it comes to accessing conventional health services and there are several creative initiatives by the apostolic women to access healthcare services. It is important to note that these initiatives are both supported formally and informally by the healthcare services providers in the province. The approaches which apostolic women use to access healthcare are presented below.
Clandestinely Seeking Conventional Health Services
Some of the Apostolic Church of Johanne Marange members highlighted that they seek healthcare services secretly. Conventional health services providers indicated that they also deliver services to religious objector through various clandestine ways. The success of this approach depends on the trust between the patient and the healthcare providers. Conversations with apostolic women and healthcare providers show that there is mutual respect and confidentiality between apostolic women and healthcare service providers. Some of the approaches that are used by congregants to secretly access services are presented in the next paragraphs.
To access child vaccination their children, apostolic women will visit the facilities or village health workers under the guise of collecting Plumpy’nut a nutritional supplement for their children as it is acceptable among the apostolic. In the process, they will then secretly ask the healthcare provider to provide the vaccination. Healthcare providers within apostolic communities crafted the requirement that for one to receive Plumpy’nut, the mother needs to bring the child, by doing so the healthcare workers will also have the opportunity to assess and screen for other child health issues. In cases where apostolic children are vaccinated, healthcare workers indicated that the apostolic women would ask the healthcare workers to keep their immunisation cards/records so that those in power (husbands, senior wives and church hierarchy) are not able to see that the children are accessing conventional medicine.
In some cases, apostolic women visit facilities and nurses’ residences under the guise of vending different products whilst the objective is to get medical services such as family planning methods without being detected by their husbands and church hierarchy. In more conservative areas healthcare workers highlighted that apostolic women visit the healthcare facilities at night to get primary care healthcare services. For apostolic women, who might have experienced persistent deaths of infants, they indicated that they choose to give birth at facilities which are far away from their communities, in most cases, they stay with their relatives who are more sympathetic to their situation in urban areas. This practice is facilitated by the availability of the mother’s maternity waiting homes at healthcare facilities, which are used by expectant mothers before they deliver. Healthcare workers highlighted that although this practice brings expectant mothers to the facility, this happens late into their pregnancy which makes the mothers miss critical ante-natal care milestones. Healthcare workers also highlighted that they normally use the remaining time to screen for complications and refer to higher-level hospitals those with complications for specialised care.
‘Encouraging’ Clandestine Access to Health
The supply side of the primary healthcare services in Manicaland is also providing approaches which try to accommodate the context of the apostolic members. These approaches are not well pronounced in the Zimbabwean health policy but are a localised adaptation tailored towards apostolic women. These approaches are more pronounced in those facilities that provide services to the apostolic communities. A few of the facilities have recruited or are in the process of recruiting village health workers (VHWs) who are apostolic. The argument is that if VHWs are apostolic, then their fellow apostolic sects’ members will be able to access the services clandestinely and confidentially from the VHWs. The village health workers can offer some healthcare services to those who want them. These services include encouraging pregnant mothers to visit facilities for antenatal care, postnatal care reminders, assessing danger signs in pregnant mothers and children and treating minor ailments and referrals to clinics and providing family planning services. These services although they are not a full set of services provided at the healthcare facilities, they are regarded as baby steps to encourage apostolic women and children to start accessing healthcare services.
In addition to recruiting apostolic VHWs, some of the facilities are recruiting apostolic members as health centre committee members. The approach has three objectives which are to incorporate the needs of the apostolic on the decision-making table, forge strong relationships with apostolic communities and create alternative social stratification of new leadership more aligned to conventional medicine acceptance. The expected outcomes are that the leaders will influence their communities to access conventional healthcare services. Some of the HCCs use the influence of local traditional leaders such as village heads and headmen to negotiate and encourage apostolic communities to access health services at the facility. Non-apostolic respondents suggested that local leadership such as village headmen and chiefs use their power to sanctions those who do not seek conventional medicine, especially for maternal and child health. However, the local leadership highlighted the resoluteness of the Johanne Marange members who do not listen to local leaders when it comes to the health issues.
Discussion
The findings of this study show that the Apostolic Church of Johanne Marange’s beliefs and doctrine are like an albatross around the necks of apostolic women and children who are affected the most by the prohibition of conventional medicine. The church doctrine paints a picture which insinuates that conventional health services are inferior to the church’s ‘superior’ unconventional medical practices ‘ordained’ by God. The elevated ‘spiritual superiority’ of unconventional medicine, plays a significant role in the lives of the apostolic church members. The religious and social stratification of the apostolic play a significant role in enforcing the doctrine and placing obstacles to church congregants who want to access conventional health services. However, despite the intransigence of the church leaders, many of the congregants seek healthcare services clandestinely.
Several interventions which seek to address Manicaland’s poor MNCH indicators performance are in place, however, these interventions are designed with the prevailing health policy in mind. The Zimbabwe Health policy is very specific on who can provide health services and at what location, this limits the options available for healthcare workers who might want to uniquely provide services to the apostolic. The interventions in Manicaland which focus on addressing the apostolic health-seeking behaviour are generic and are based on the premise that the apostolic groups will openly defy the church and seek medical services at primary healthcare facilities despite the repercussions of doing so. Such interventions do not factor in the reality and the context in which the apostolic women and children affected by the church doctrine live in. Waiting for the change in doctrine will result in more death of mothers and children from preventable causes.
This article argues that a continuous barrage of orthodox and unorthodox approaches targeted at delivering healthcare services to the apostolic can lead to saving lives and changes in health-seeking behaviour of the Johanne Marange apostolic church and ultimately maternal and child health outcomes. The objective of the policy and healthcare services providers should be to find approaches that make it easier for apostolic women and children to access healthcare services, such as MNCH and family planning whilst at the same time increasing the number of apostolic who are receiving such services. Such approaches might call for unconventional methods of delivering services. The availability of these services within the community does not necessarily mean that everyone in the community uses the services. As studies have shown, the more conservative the members are the more difficult it is for them to accept conventional medicine. However, evidence shows that the small steps of providing services clandestinely can influence the more conservative groups to use the services once they have seen how others have accrued benefits in using conventional medicine such as survival of children and better maternal outcomes. This article advocates for new thinking around the Apostolic church of Johanne Marange, the new thinking presented in this article is regarded as ‘eating the elephant one piece at a time’.
There are several approaches which healthcare providers can use to ‘eat the elephant one piece at a time’. Some of the approaches put forward here require relaxation of policies and positions from the apostolic and the healthcare providers. Approaches such as training apostolic birth attendants on basic midwifery skills and detecting danger signs in pregnant women and newborn babies are key to reducing incidences of maternal and infant mortality. This can be augmented by financial incentives targeted at the apostolic midwives who refer those with danger signs to conventional healthcare facilities. Also training apostolic birth attendants on infection control reduces puerperal sepsis which is one of the main causes of maternal mortality in Manicaland province. The success of such interventions depend on a dialogue between government, programme implementers and the apostolic leadership. Although the suggested interventions might be regarded as controversial by those providing conventional medical services because they seem like an act of endorsing unconventional medical practices. The objective should not be about adhering to policy or perception but to save lives in a context that is difficult to navigate.
These interventions can reduce maternal and infant mortality among the apostolic. In cases where these approaches are successful, this can stimulate interest, change perceptions and weaken the religious strong moral justification and support for using unconventional medicine. This can also bridge the gap created by the characterisation of us versus them. This assumption is based on the premise that ‘all cultures are inherently predisposed to change and at the same time, to resist change’ (Tivel, 2012). Cultural processes such as diffusion and acculturation, although slow will also help the process change among the apostolic. Acculturation is facilitated by serious cases/complications treated successfully using modern medicine which will create continuous use and in some cases, the affected individuals act as promoters of modern medicine among the Johanne Marange group.
Conclusion
The objective of this article was to share lessons learnt from implementing MNCH programmes among the apostolic religious groups. This study raises pertinent issues which arise from the exercise of religious rights by the apostolic church. The study argued that it is mainly the vulnerable members of the apostolic church (women and children) who are most affected by the church doctrine which prevents them from accessing health services. As I argued in the article, apostolic women and children use unconventional approaches to access modern healthcare services and these informal small informal steps which promote health-seeking behaviour among the apostolic saves lives of vulnerable women and children. Organisations implementing MNCH programmes should be cognisant of the religious barriers preventing apostolic women and children from accessing healthcare services and design programmes which address these barriers. As development practitioners, we should create an environment and policies that make it convenient, attractive and economical to make healthful choices, and then motivate and educate people about those choices. It would be fruitful also for these organisations to create learning platforms and feedback loops so that their approaches reach more apostolic women and children. At the policy level, there is a need for flexibility which will allow interventions to be tailored towards the context of the apostolic groups without not being necessarily confrontational.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was developed whilst the author was working for a USAID funded MNCH Mhuri/Imuli project in Manicaland province in Zimbabwe.