Understanding cultural beliefs and practices around pregnancy and vaccination
Our ethnographic study in Malawi—focused on understanding cultural beliefs and practices surrounding pregnancy and vaccination—was an enlightening journey. For six weeks, a team of experts delved into the lives of Malawian communities, learning about their perspectives, traditions, and the complex interplay of societal norms and healthcare practices.
The team was formed by Mandeep Kaur (EVI), Dr. Marion C. Kajombo (MUST), Mr. Chimwemwe Tewesa (MUST), and students from the Malawi University of Science and Technology (MUST).
This effort, made possible by European Vaccine Initiative (EVI) with funds from DGIS, sought to illuminate the nuanced realities of placental malaria and its impact on maternal and infant health. These chronicles document the stories, challenges, and moments of connection from the field from our colleague Mandeep Kaur.
1. Malawi: warm heart of Africa
Malawi, located in southeastern Africa, is known as "Warm Heart of Africa" for the genuine warmth and hospitality of its people. Before this study, I had never imagined myself in this land, but through EVI, I was privileged to join a project on advocacy for a potential placental malaria vaccine.
Malawi features breathtaking landscapes, from the shimmering waters of Lake Malawi, to the verdant tea plantations and rolling hills of Mount Mulanje.
Yet, beneath this natural beauty, lies the reality of public health challenges: high malaria prevalence, elevated maternal and child mortality, and inadequate healthcare access in rural regions.
Malawi’s deep-rooted culture, where traditions are passed through generations, plays a significant role in shaping health behaviours, particularly during pregnancy.
Through community engagement, interviews, and focus group discussions (FGDs) we have revealed stories of resilience and hope emphasizing the essential role of advocacy in promoting vaccines that protect pregnant women and their unborn babies.
2. Placental Malaria: the unseen challenges
Placental malaria, caused by accumulation of infected erythrocytes in the intervillous space of the placenta during malaria infection in pregnancy, was the focal point of our study. Despite its severe effects on maternal and infant health, it is a condition often shrouded in silence.
During discussions, many women shared their fears of malaria during pregnancy. One poignant story came from a woman who lost her first child due to complications caused by malaria: “I did not understand what was happening. I had fever for few days and then I started to have bleeding. When I reached the hospital, the doctors told me I had lost my baby.”
Healthcare workers also spoke of the difficulties in diagnosing and treating placental malaria, particularly in resource-limited settings. These conversations reinforced the urgent need for innovative solutions, like a placental malaria vaccine to safeguard maternal and child health.
3. The everyday life of Malawian women
Malawian women are the backbone of their families and communities, shouldering immense responsibilities with remarkable resilience. I had the opportunity to observe the demanding routines of Malawian women, who often begin their days fetching water, cooking, and farming and even running small shop business before attending antenatal appointments or caring for their children.
One woman reflected on this reality, which often leaves little time to rest: “Even when I am unwell, the work must continue”.
During FGDs, we also inquired about the influence of social norms on vaccination decisions. These stories highlighted the importance of involving entire households in health education efforts to foster better healthcare practices.
5. Lost in translation: bridging linguistic gaps in health terminology
Malawi's linguistic diversity added both richness and complexity to our fieldwork. While Chichewa is widely spoken, many rural communities use local dialects, often solely oral, requiring the support of interpreters to ensure accurate communication.
One significant hurdle was the translation of health and pregnancy-related concepts. For instance, participants often used idiomatic expressions to describe symptoms or beliefs, which do not have direct equivalents in English.
We used the local word malungo to refer to malaria (however, malungo in Chichewa refers to fever and encompasses more than just malaria). Participants linked malungo to various causes, such as rain exposure, mosquitos or consuming unclean food, which, as explored in Nkolokosa's (2023) research , it reflects some indigenous knowledge systems rather than biomedical definitions.
One can think, "are these conclusions completely wrong? How can they end up believing that just getting wet in rain or drinking contaminated water can cause malaria?". But we needed to reflect on the context.
The term requires careful probing and cultural interpretation to fully understand its meaning.
Malungo and malaria may be overlapping but can also be distinct phenomena with shared symptoms. Terms like malungo may carry cultural meanings and metaphors in different languages like ‘shaking in the knees’ in Ciyao, or ‘shivering and joints pain’ in Chinyanja. Understanding these linguistic and cultural nuances were vital for interpreting health beliefs and will be useful when designing effective interventions in the future, based on how different communities perceive symptoms and use health terminology.
5. Community engagement: building trust
Engaging with communities was one of the most rewarding yet challenging aspects of our fieldwork. In rural Malawi, community engagement begins with earning the trust and approval of local leaders, such as chiefs, village elders, and religious figures. Their endorsement was crucial for participant recruitment and fostering understanding of our study’s purpose. To ensure we respect local cultural dress standards, I was wearing traditional clothing.
One memorable moment happened during a meeting with a village chief. After explaining the purpose of our study, she not only gave her approval but also actively encouraged community members to participate in the study. These moments highlighted the critical role of community leaders as gatekeepers to meaningful research.
At times, our engagement extended beyond formal meetings. Sitting under the shade of a trees, sharing nsima and Casava with people, or listening to stories from elders offered an invaluable glimpse into the social fabric of Malawian life.
Research is not just about data collection but about building relationships rooted in mutual respect and understanding.
From left to right: (a) MUST team praying before eating lunch; (b) Mandeep Kaur and MUST Team enjoying lunch offered by village head; (c) Lunch offered to the team by Village Chief.
6. Vaccines and advocacy: bridging the gap
During the fieldwork we also found that despite the benefits of vaccination, misconceptions and fears persist. Some women worried that vaccines might harm their unborn children while others believed they were unnecessary if one adhered strictly to traditional remedies. One participant shared her hesitation related to vaccination, “I fear it would bring sickness instead of protection.”
Despite health campaigns and peer education, we still ought to address those concerns and create awareness about the benefits of vaccination.
The purpose of our study was to understand how people perceive malaria and especially placental malaria and its prevention, including emerging interventions such as placental malaria vaccines. To address these fears, we needed to connect with communities. Our goal extended beyond understanding community beliefs to advocating for interventions that protect future generations.
This journey through Malawi, guided by its people’s stories, has illuminated the path forward. Addressing public health challenges requires not only scientific innovation but also cultural understanding and trust-building at the grassroots level. Together, we hope to foster a healthier future for mothers and their babies.
You can follow the full story that will be delivered in 6 short episodes via EVI LinkedIn #malawichronicles. Follow us and stay tuned!
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