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Barriers, Delays, Died, Midwives, Medical intervention, Pregnant women, Unattended, Voices.
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Christinah Makhado L and Selina RN. “They delay them, and some died unattended.” Voices of midwives on barriers that delay pregnant women in seeking early medical intervention in Limpopo province of South Africa. [version 1; peer review: awaiting peer review]. F1000Research 2026, 15:1241 (https://doi.org/10.12688/f1000research.185514.1)
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Research Article
“They delay them, and some died unattended.” Voices of midwives on barriers that delay pregnant women in seeking early medical intervention in Limpopo province of South Africa.
[version 1; peer review: awaiting peer review]
PUBLISHED 28 Jul 2026
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Abstract
Corresponding author:
Langanani Christinah Makhado
Competing interests:
No competing interests were disclosed.
Grant information:
The research was financed by the South African Medical Research Council (SAMRC, Grant number 407)
This research was supported by the South African Medical Research Council (SAMRC) through its Division of Research Capacity Development under the Research Capacity Development Initiative funded by the South African National Treasury. The content and findings reported/illustrated are the sole views and responsibilities of the researcher and do not reflect the official position or sentiments of the SAMRC.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2026 Christinah Makhado L and Selina RN.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Christinah Makhado L and Selina RN. “They delay them, and some died unattended.” Voices of midwives on barriers that delay pregnant women in seeking early medical intervention in Limpopo province of South Africa. [version 1; peer review: awaiting peer review]. F1000Research 2026, 15:1241 (https://doi.org/10.12688/f1000research.185514.1)
First published: 28 Jul 2026, 15:1241 (https://doi.org/10.12688/f1000research.185514.1)
Latest published: 28 Jul 2026, 15:1241 (https://doi.org/10.12688/f1000research.185514.1)
This research was supported by the South African Medical Research Council (SAMRC) through its Division of Research Capacity Development under the Research Capacity Development Initiative funded by the South African National Treasury. The content and findings reported/illustrated are the sole views and responsibilities of the researcher and do not reflect the official position or sentiments of the SAMRC.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Introduction
Medical facilities are crucial for providing specialized care for mothers and children’s health. The primary goal was to further reduce maternal mortality rates. Unfortunately, few women, especially in the remote rural communities of South Africa, use the services provided by trained healthcare professionals, whereas most utilize services offered by traditional health practitioners.1 In communities, traditional health practitioners offer healthcare services tailored to address the population’s health requirements.2 Traditional health practitioners include elderly women, socially and culturally viewed as stakeholders and caregivers of PW immediately when a woman reports missed periods up until birth and again throughout the postnatal period to breastfeeding mothers (BFMs) at home.3 As a result, they have a significant impact at the community level, considering their role during pregnancy and childbirth based on their indigenous knowledge. According to,4 indigenous knowledge is information gained through personal experience or as an apprentice to the elderly. A large portion of the health advice provided by elderly women to (PW) is based on traditional, religious, and cultural views that might not be applicable to certain ailments or disorders that affect pregnancy, the mother, or the baby.5 Although some practices appear to be comparable to those advised by modern medicine, they have undesirable effects. For instance, recommending specific dietary habits, dressing, or behavioral patterns without medical or scientific evidence in support could harm PW or even babies.5 Now and then, taking traditional drugs to treat PW or newborn babies may be viewed as a desirable practice by elderly women, but it may have unintended repercussions that, even if medical help is sought subsequently, the harm may already have been done.5
Approximately, 300 000 women die worldwide due to pregnancy- and childbirth-related complications.6 Most of the maternal death were reported to occur in low and middle income countries.7,8 In South Africa, approximately 20% of maternal fatalities occur outside healthcare institutions, with the cause being nearly identical to that of maternal death in healthcare facilities.9 Maternal death rates decreased from 150 per 100,000 live births to 113 per 100,000 live births in 2019 but increased between 2020 and 2021 due to a shortage of human and material resources.10
Maternal mortality studies have suggested that the death of any woman during pregnancy, labor, or the postpartum period might be avoided if she received care from medical institutions.11,12,13 However, cultural beliefs and socio-economic factors, which may have an impact on women’s lifestyles, healthcare utilization patterns, and health status, are frequently linked to maternal fatalities. Furthermore, cultural norms that restrict PW from accessing the services offered by trained birth attendants in healthcare institutions include a lack of power in decision-making.5 They use advice from an elderly woman at home or the services provided by unskilled workers.14 A few studies have also shown that older women may assist with birth without formal training by drawing on their experiences.15
Some MWs believe that traditional delivery attendants should be prohibited because they are responsible for women’s poor adoption of hospital-based maternity care, which leads to an increase in maternal deaths. However, other midwives expressed their opinion that traditional birth attendants “cannot be phased out” due to their importance, particularly in isolated regions where access to traditional maternity care is limited by intractable structural problems.16 According to,17 midwives demonstrate a positive attitude toward collaborating with traditional delivery attendants at the level of prenatal care alone. The midwives were uncooperative regarding intrapartum and postpartum care. According to,18 in a study conducted in Zambia-Lundazi district, midwives alluded that mothers-in-law in Lundazi have a strong influence on pregnant women regarding the utilization of healthcare services, and because of their dictatorial role, some pregnant women died when forced to go to work unwell instead of seeking medical attention.
According to,15 elderly women who care for and assist in PW impact both the mother’s and the child’s survival. Essential choices about the start of Antenatal Care (ANC) are also made by elderly women, who have an impact on young pregnant women.19 Despite the critical role played by elderly women in maternal health, little is known about how they contribute to the lives of pregnant women. Therefore, this study was conducted to explore midwives’ views on barriers preventing pregnant women from seeking early medical intervention.
Methods
A qualitative approach with an exploratory, descriptive, and contextual research design was used.20 This approach enables researchers to explore and describe midwives’ views regarding the barriers that delay PW in early seeking early medical attention in Limpopo Province. The research methodology was selected to aid researchers in gathering detailed information regarding the experiences, feelings, and advice provided by elderly women to the PW. The participants in the Vhembe and Capricorn districts of Limpopo Province were able to clearly communicate the details regarding the roles of elderly women in participation in maternal and child health.
Setting
Primary Healthcare (PHC) in the Vhembe and Capricorn districts was chosen as the setting for this study. The Vhembe and Capricorn districts are situated in the Limpopo province of South Africa. Five districts comprise the province: Capricorn, Mopani, Sekhukhune, Vhembe, and Waterberg. The province is regarded as impoverished, with almost 80% of the residents living in rural regions.21 The Vhembe District has the largest population and the highest proportion of pregnant women,21 whereas Capricorn District has an escalating number of maternal mortalities reported.9
Study participants and inclusion criteria
Population
Midwives with at least two years of work experience working in the selected primary health care (PHC) of the selected study sites. All midwives who met the criteria were accepted, and those who were willing to participate were included. A total of ten midwives participated in the individual in-depth interviews. Non-probability purposive sampling was used to sample the participants. The sample size was 15 midwives with 2 years of working experience.
Data collection procedure
Unstructured, in-depth individual interviews were conducted to collect data. A qualitative data collection method was used to encourage participants to speak freely about the explored topic without any restrictions. Permission was obtained from the University of Venda Research Ethics Committee and approval was obtained from the Department of Health. Upon approval, midwives at the selected primary care facilities with at least two years of working experience were recruited. The researcher was given the opportunity to talk to the midwives, and an appointment was set for those who met the criteria and were willing to participate. Before starting the interviews, participants signed the consent form and permission to record was sought to ensure that no critical information was left out. The question that guided the interview was, ‘You are midwives working here at the clinic; kindly share with me regarding “the barriers that cause pregnant women and breastfeeding mothers to utilize health care services late.” Probing was conducted to encourage the participants to provide more information on the questions explored. During data collection, participants sought and granted permission to use the voice recorder to capture and record information. This was done to ensure that all information said by the participants was not missed. Collected data from recordings were translated into English by language experts or linguists, except that some of the interviews were conducted in the participants’ home language, that is, Tshivenda, which was then transcribed verbatim.22 Data saturation was achieved by the sixth participant. However, the researcher continued with the interview by adding another four participants to ensure that no new information was coming out. Data were collected for a period of four months, and the interviews focused on the barriers that cause delays for pregnant and breastfeeding mothers to seek early medical intervention.
Data analysis
Data analysis of midwives was guided by Tech’s eight steps in the coding process described by.23 This involved transcribing and translating information from the audio recorder into English from the vernacular in written words, assisted by language expectations. After transcribing, the researcher repeatedly read each transcript to familiarize themselves with the data and simultaneously sorted similar and different ideas. The analysis was conducted by a researcher with the assistance of a team of authors in a scheduled workshop. Qualitative information was classified into categories. Finally, the themes and subthemes were developed and refined. Promoters were independent coders who cross-checked categories, sub-themes, and themes to see if they were linked to what the participants said during the interviews. The interpretation of the findings was based on the researcher’s understanding of maternal health and the integration of various literature regarding the topic of study. Follow-up with the captured data to the participants was performed to verify that the information they provided was indeed what they said.
Measures to ensure trustworthiness
Measures to ensure trustworthiness were as follows:
Credibility refers to confidence in the truth of the data and the interpretation of the data.24 The researcher ensured that the participants were identified and described accurately to ensure their credibility. A trusting and mutual relationship was established between the interviewer and the participants by creating an environment in which the participants would feel free to express themselves in their home language. Prolonged engagement was ensured by visiting the participants repeatedly to ensure that more time was invested in the in‐depth individual interview for about 45 minutes to one hour. Member checks were performed to ensure that the participants recognized the findings as true and accurate in their experience. Promoters were involved throughout the study’s planning until the final stage of writing the report.
Dependability refers to the stability and reliability of data over time and under various conditions.24 The dependability of the study was ensured by recording all details regarding the in‐depth individual interviews and documentation for others to repeat the study with the same participants in a similar context. In addition, the researcher used a cocoder to ensure the consistency of the findings.
Conformability refers to the objectivity or potential for congruence between two or more people regarding the data’s accuracy, relevance, or meaning. This concerned establishing that data represented the participants’ information and that the inquirer did not invent the interpretation.24 An audio recorder was used during data collection to assist the researcher in transcribing and minimizing bias. Conformability was ensured by listening to audio recordings as much as possible to verify the interpretations, conclusions, and recommendations.
Transferability refers to the extent to which study findings can be transferred to others in similar situations in other settings or groups.24 Transferability was ensured by providing a clear, detailed description that involved the setting, participants, and methods used to collect data for other researchers to come up with the same findings and conclusions.
Results
Demographic data of the midwives interviewed in this study are presented in Table 1. The table presents the sample description of the participants in terms of the number of midwives who participated in the study, age, and gender.
Table 1. Demographic data of midwives.
Findings from the MW working in the selected primary healthcare facilities were collected through in-depth individual interviews. Ten participants were interviewed using a semi-structured interview. The data revealed two themes: barriers that delay PW and BFMs from seeking early medical attention, and the need for elderly women to be trained by health care professionals.
Theme1: Barriers that delay PW and BFMs from seeking early medical attention
The results are discussed based on this emerging theme from textual analysis. Three subthemes were generated: individual factors, religious belief/traditional factor/cultural influence, and social factors.
Individual factors
PW under the influence of elders at home tend to visit prophets or traditional healers to seek a second opinion after they have been told that they must go to the hospital for delivery due to some complications. However, the prophets inform them that they will give birth naturally; thus, they should not visit the hospital. This discourages them from seeking early medical assistance. The following excerpts support this statement:
“… I can say women don’t want to stay at the clinic for a long period of time, they are firstly progressed at home by the ones they stay with, they tell her that do not to rush to go to the clinic, the time you go there you will give birth immediately on arrival without any waste of time. So that is the influence coming from those people staying with the pregnant woman. …” (MW5).
“… when labor starts, she must first do some cultural or spiritual practices (u phetha ndaela) before she comes to the clinic so you will find that when she comes to the clinic she arrives late; in some instances, they first call pastors to pray for her so that she can come to the clinic. …” (MW10).
Another challenge experienced at the clinic is that some women delay visiting the clinic. Instead, they first progress themselves at home under the influence of the elderly, and sometimes they say:
“… I will never allow you to refer me to the hospital if you think you will refer me, I will stay at home and arrive here when I am about to give birth. …” (MW8).
“… I didn’t want to rush to the clinic and just stay here for long period, I wanted to spend a few hours here that’s why I first sit at home even if I was feeling pain, I really wanted to come when I am about to deliver ….” (MW7).
“… If I come early you will refer me to the hospital, whereas I don’t want to deliver at the hospital ….” (MW1).
Cultural/Religious/Traditional beliefs
This study revealed that cultural/religious/traditional beliefs prevent PW from receiving early medical intervention. The time of initiation of ANC services was started until around 20 weeks of gestation, upward in fear of being bewitched if initiated early. This belief could be a barrier to PW seeking early medical attention. The following quote supports this assertion.
“… Even if we tell them to book early but not all of them follow this health advise because in our culture we believe that if you tell people that you are pregnant when it is still early you will be bewitched. …” (MW4).
“Well, most of the people in this area tend to believe in the tradition, so when they are pregnant, they tend to hide their pregnancy because they are afraid that their neighbors or other people to see that they are pregnant and can make that pregnancy disappear. …” (MW6).
“Those who book late for ANC turn to hide the card in fear of others knowing that they are pregnant and they can disturb their pregnancy, as black people, we believe that witchcraft do exist so the pregnancy can be taken out. …” (MW3).
“… most of them consult from traditional healer or prophet who tells them that this time, this year you will deliver normally I have seen it from the bones or the spirit showed me, then on that case, she comes being fully dilated and she is previous caesarian section x2 you will see that it becomes a problem. …” . …” (MW5).
“We experience problems from the women who consult traditional healers and prophets, though some don’t tell us that they have consulted. We see that when we tell the woman to do this she doesn’t do it because she has already told you do this; for example, when I refer the woman to the hospital for an operation because I have noticed that it will not be possible for her to deliver normally, she will refuse and said she will normally deliver, because of little knowledge she had and trust what the prophet or traditional healer told her, she believes more in prophets or traditional healer than nurses ….” (MW9).
Social factors
The study found that older people’s decision-making on healthcare services by PW and BMs at home was more influenced by them as caretakers. This effect was considered a social component that makes the use of healthcare services more difficult. The following exceptions support this hypothesis:
“… I can say women don’t want to stay at the clinic for a long period; they are firstly progressed at home by the ones they stay with; they tell her not to rush to go to the clinic, the time you go there, you will give birth immediately on arrival without any waste of time. So that is the influence coming from those staying with the pregnant woman. …” (MW5).
“… it depends on the family because, in some instances, you find that it is an agreement from a particular family that you are not supposed to go to the clinic now. …” (MW2).
“… To show that there are some of the things that they do at home, you will hear the breastfeeding mother saying the problem is that the breast milk is less than is expected to feed the newborn and the newborn is crying because of hunger, and the caregiver at home said we must give the baby soft porridge it will work. …” (MW8).
Theme 2: Need for elderly women to be trained by healthcare professionals
This theme is related to the training needs necessary for older women to participate effectively in maternal health in the Limpopo province. One sub-theme emerges, which is discussed as follows:
Training needs
The results showed that elderly women need to be capacitated by healthcare professionals about their involvement in maternity health procedures. Older women were unaware of the value of immediately seeking early medical attention. The following quotation backed this:
“… even the secondary factors, the grannies at home and the elderly women even on the day of chronic, we can tell them about this topic of early booking so that they may help others, so when the grannies come here during the day of chronic, we can gather them here and educate them about this issue ….” (MW6).
This study found that elderly women have an impact on PW health and occasionally prevent them from seeking early medical attention. As a result, elderly women need to be capacitated about the significance of urging PW to seek early medical assistance. One participant articulated the following:
“Elders at home, if the woman was told at the clinic that the baby is not in a good position, that’s where the old woman at home influence taking, the woman to prophets or traditional healer to seek help and sometimes is an agreement from the rest of the family members. …” (MW4).
Other participants articulated that:
“I don’t think the issue will be resolved completely because information can be disseminated but a person can take what her mother or relative told her unlike what a nurse can say because she believes that a person who can assist her better is her mother or mother-in-law at home, for example when the woman is in labour and she report to the mother or mother in law at home they will tell her to wait and not to rush to the clinic and she will do as told. …” (MW5).
“Health education should be given to the old women and mother-in-laws because they are the caregivers of the pregnant women so when they have pregnant women at home they must encourage her to book early for antenatal clinic and again to tell the healthcare worker who assist us to go and do a home visit if they find pregnant woman they must tell her to start early booking for antenatal care ….” (MW7).
Discussions
Literature has shown that there is a need to comprehend and develop programs that incorporate indigenous knowledge. African traditional medicine is based on information that dates back thousands of years and is thought to preserve the lives of both the mother and baby.25 Despite the development of strategies and programs to lower maternal mortality centered on biological intervention, there is still a problem with the use of healthcare services that are impacted by customs and cultural beliefs. However, according to other studies,26 access to healthcare services is a barrier, particularly for women living in remote rural regions.
PW being cared for by elderly women at home tend to prefer the services offered by prophets or traditional health practitioners in search of a second opinion after hearing from a medical expert that they must go to the hospital for deliveries due to complications. They should not go to the hospital because the prophets tell them that they will naturally give birth. This deters them from seeking early medical interventions. Older women tend to favor services rendered by traditional healthcare providers because of their greater influence on maternal and child health. This finding concurs with that of,27 who conducted a study in Kenya. They stated that the availability and accessibility of TBAs were perceived as critical facilitators of home birth deliveries, especially during the night when the transport challenge is more evident. A study in Pakistan established that the use of TBAs is a social and cultural practice, particularly in rural areas.2829 further adds that in the household structure, mothers-in-law and husbands seldom allow women any power to make decisions regarding their own lives.
The fact that some women delay visiting clinics is another challenge faced by healthcare professionals. Culturally, PW tend to book late for ANC in fear of being bewitched, so it is believed that they should hide the pregnancy until it passes the period of miscarriage. During labor, they first progress themselves at home under the guidance of the elderly. Consequently, the opinions and values of older people, particularly older women, can significantly impact whether women use healthcare services to enhance maternal healthcare. To help reduce maternal mortality, maternal health practices can be influenced by critically analyzing the perceptions and beliefs of elderly women’s influence on maternity care in remote areas. This finding is consistent with,30 who of a study conducted in the Omaheke Region, Namibia, which stated that the majority of respondents reported initiation of ANC visits at four–six months of pregnancy to screen for pregnancy complications and information given on health-related matters through health education.
Cultural practices impact women’s lifestyles, choices about maternal health, and use of healthcare, which are influenced by beliefs, attitudes, and health behavior. The study found that older people’s decision-making on healthcare services by PW at home was more influenced by them as caretakers. Therefore, these women were untrained maternal care providers. Instead, they rely on cultural information handed down through the generations. This effect was considered a social component that makes the use of healthcare services more difficult. This finding concurs with,29 who concluded that the influence of an older close relative was a barrier to the utilization of healthcare services because it was believed that they had more experience in handling pregnancy issues rather than encouraging PW to seek early medical attention. However, the study revealed that training elderly women, especially in rural areas, is essential to reduce maternal mortality. According to31,32 agreed that training TBAs may be essential to facilitate prompt referral, which is more significant in reducing maternal morbidity and death.
Additionally,33 stated that training TBAs may assist in raising awareness of cultural traditions that cause delays for PW to utilize healthcare early services, leading to complications and death.
Conclusions
When it comes to PW, socioeconomic considerations, emotional responses, and a lack of understanding render them vulnerable, as they cannot assess the advice given; thus, according to the MWs, who acknowledge the elderly’s advice to some extent. Elderly women give maternal health advice based on cultural and traditional beliefs, which frequently takes precedence over advice given by medical professionals. This influence contributes to delays in obtaining timely medical attention during pregnancy, particularly in remote rural parts of Limpopo Province, South Africa. Addressing the role of elderly women in maternal decision-making is critical to improving maternal health outcomes and encouraging early use of healthcare facilities.
Strengths of the Study
• The study sheds light on how older women impact maternity health-seeking behaviors in rural settings.
• The study explores the relationship between cultural attitudes and maternal healthcare utilization, a topic that is generally overlooked.
• The findings provide context-specific knowledge to guide culturally sensitive maternal health treatments in rural South Africa.
Limitations of the Study
• The findings may not be generalizable to all rural communities in South Africa because the study was conducted in selected areas of Limpopo Province.
• The study focused primarily on the perspectives of MWs within a specific cultural context and may not capture the diversity of beliefs and practices across different communities.
• The study was conducted during COVID-19, which may have potentially affected the depth and quality of data collected.
Recommendation
Healthcare authorities and community health professionals should develop targeted educational and training programs for elderly women to enhance their understanding of maternal health concerns and the importance of early medical intervention during pregnancy. Integrating respected older women into maternal health promotion activities may help to bridge the gap between traditional beliefs and evidence-based healthcare practices, lowering wait times for proper medical care.
Ethical considerations
Ethical clearance was obtained from the University of Venda Research Ethics Committee (Reference number: SHS/20/PDC/35/2809; Date: 06.10.2020). Approval was obtained from the Department of Health, Limpopo Province Research Ethics Committee (Reference number: LP_2020_11_039; Date: 08.02.2021), and from the Vhembe district on 15.02.2021, the Capricorn district on 26.08.2021, and the nurse managers of the clinics. Ethical considerations were adhered to and in accordance with statutory ethical standards. Participants were assured that participation was voluntary for ethical reasons, that they could withdraw at any time without harm or penalty, and that no reward was offered for participation. Ethical principles were upheld before participation, and all participants were provided with detailed information about the study. Including its purpose, benefits, and the measures to ensure confidentiality and anonymity. Participants who agreed to take part in the study provided written informed consent by signing the consent form voluntarily; anonymity was maintained by using codes instead of real names to prevent participants from being linked to the data; and all participants completed the study. As the data collection was conducted during the COVID-19 pandemic, infection prevention and control measures were strictly observed. Participants were required to sanitize their hands before and after signing the consent form, and the researcher adhered to the recommended COVID-19 safety protocols throughout the data collection process to minimize the risk of virus transmission. Records were kept securely in password-protected devices, and a copy was available only to the researchers.
Institutional review board statement
The study was approved by the University of Venda Research Ethics Committee (Reference number: SHS/20/PDC/35/2809; Date: 06.10.2020).
Informed consent statement
Informed consent was obtained from all subjects involved in the study. However, before participation, all participants were provided with detailed information about the study. Including its purpose, benefits, and the measures to ensure confidentiality and anonymity. Participants who agreed to take part in the study provided written informed consent by signing the consent form voluntarily; anonymity was maintained by using codes instead of real names to prevent participants from being linked to the data; and all participants completed the study
Availability of data and materials
All datasets and supporting materials generated generated or analyzed during this study are publicly available in the Zenodo repository. These materials are available at https://doi.org/10.5281/zenodo.20776021.34
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how to cite this article
Christinah Makhado L and Selina RN. “They delay them, and some died unattended.” Voices of midwives on barriers that delay pregnant women in seeking early medical intervention in Limpopo province of South Africa. [version 1; peer review: awaiting peer review]. F1000Research 2026, 15:1241 (https://doi.org/10.12688/f1000research.185514.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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