Toward an Open-Access Global Database for Mapping, Control, and Surveillance of Neglected Tropical Diseases

Eveline Hü Rlimann
Department of Epidemiology and Public Health
Swiss Tropical and Public Health Institute
BaselSwitzerland

University of Basel
BaselSwitzerland

Nadine Schur
Department of Epidemiology and Public Health
Swiss Tropical and Public Health Institute
BaselSwitzerland

University of Basel
BaselSwitzerland

Konstantina Boutsika
Department of Epidemiology and Public Health
Swiss Tropical and Public Health Institute
BaselSwitzerland

University of Basel
BaselSwitzerland

Anna-Sofie Stensgaard
Department of Biology
Center for Macroecology, Evolution and Climate
University of Copenhagen
CopenhagenDenmark

Department of Veterinary Disease Biology
DBL-Centre for Health Research and Development
University of Copenhagen
FrederiksbergDenmark

Maiti Laserna De Himpsl
Department of Epidemiology and Public Health
Swiss Tropical and Public Health Institute
BaselSwitzerland

University of Basel
BaselSwitzerland

Kathrin Ziegelbauer
Department of Epidemiology and Public Health
Swiss Tropical and Public Health Institute
BaselSwitzerland

University of Basel
BaselSwitzerland

Nassor Laizer
University of Basel
BaselSwitzerland

Informatics
Swiss Tropical and Public Health Institute
BaselSwitzerland

The Open University of Tanzania
Dar es SalaamUnited Republic of Tanzania

Lukas Camenzind
University of Basel
BaselSwitzerland

Informatics
Swiss Tropical and Public Health Institute
BaselSwitzerland

Aurelio Di Pasquale
Department of Epidemiology and Public Health
Swiss Tropical and Public Health Institute
BaselSwitzerland

University of Basel
BaselSwitzerland

Uwem F Ekpo
Department of Biological Sciences
University of Agriculture
AbeokutaNigeria

Christopher Simoonga
Department of Community Medicine
University of Zambia
LusakaZambia

Ministry of Health
LusakaZambia

Gabriel Mushinge
Department of Community Medicine
University of Zambia
LusakaZambia

Christopher F L Saarnak
Department of Veterinary Disease Biology
DBL-Centre for Health Research and Development
University of Copenhagen
FrederiksbergDenmark

Jü Rg Utzinger
Department of Epidemiology and Public Health
Swiss Tropical and Public Health Institute
BaselSwitzerland

University of Basel
BaselSwitzerland

Thomas K Kristensen
Department of Veterinary Disease Biology
DBL-Centre for Health Research and Development
University of Copenhagen
FrederiksbergDenmark

Penelope Vounatsou
Department of Epidemiology and Public Health
Swiss Tropical and Public Health Institute
BaselSwitzerland

University of Basel
BaselSwitzerland

Toward an Open-Access Global Database for Mapping, Control, and Surveillance of Neglected Tropical Diseases
10.1371/journal.pntd.0001404
Background: After many years of general neglect, interest has grown and efforts came under way for the mapping, control, surveillance, and eventual elimination of neglected tropical diseases (NTDs). Disease risk estimates are a key feature to target control interventions, and serve as a benchmark for monitoring and evaluation. What is currently missing is a georeferenced global database for NTDs providing open-access to the available survey data that is constantly updated and can be utilized by researchers and disease control managers to support other relevant stakeholders. We describe the steps taken toward the development of such a database that can be employed for spatial disease risk modeling and control of NTDs.

Introduction

More than half of the world's population is at risk of neglected tropical diseases (NTDs), and over 1 billion people are currently infected with one or several NTDs concurrently, with helminth infections showing the highest prevalence rates [1,2]. Despite the life-long disabilities the NTDs might cause, they are less visible and receive lower priorities compared to, for example, the 'big three', that is malaria, tuberculosis, and HIV/AIDS [3,4], because NTDs mainly affect the poorest and marginalized populations in the developing world [3,5,6]. Efforts are under way to control or even eliminate some of the NTDs of which the regular administration of anthelmintic drugs to at-risk populations -a strategy phrased 'preventive chemotherapy' -is a central feature [7][8][9][10][11].

There is a paucity of empirical estimates regarding the distribution of infection risk and burden of NTDs at the national, district, or sub-district level in most parts of the developing world [12][13][14][15][16]. Such information, however, is vital to plan and implement cost-effective and sustainable control interventions where no or only sketchy knowledge on the geographical disease distribution is available. There is a risk of missing high endemicity areas and distributing drugs to places which are not at highest priority, hence wasting human and financial resources. Consequently, integrated control efforts should be tailored to a given epidemiological setting [14].

The establishment of georeferenced databases is important to identify areas with no information on disease burden, to foster geographical modeling over time and space, and to control and monitor NTDs. In 1987 the bilingual (English and French) 'Atlas of the Global Distribution of Schistosomiasis' was published, which entailed country-specific maps of schistosomiasis distribution based on historical records, published reports, hospital-based data, and unpublished Ministry of Health (MoH) data [17]. While recent projects like the Global Atlas of Helminth Infections (GAHI; http:// www.thiswormyworld.org) [18] and the Global Atlas of Trachoma (http://trachomaatlas.org) [19] offer maps on the estimated spatial distribution of soil-transmitted helminthiasis, schistosomiasis, and trachoma prevalence, they do not provide the underlying data for further in-depth analyses conducted by different research groups. An open-access global parasitological database for NTDs, which provides the actual data, is not available.

The Swiss Tropical and Public Health Institute (Swiss TPH) in Basel, Switzerland, together with partners from the University of Copenhagen, Denmark, and the University of Zambia (UNZA) in Lusaka, Zambia, were working together in a multidisciplinary project to enhance our understanding of schistosomiasis transmission (the CONTRAST project) [20,21]. One of the CONTRAST goals was to create a data repository on location-specific schistosomiasis prevalence surveys in sub-Saharan Africa. In this manuscript, we describe the steps taken toward the development of such an open-access schistosomiasis database which is currently expanded to a global scale and to include other NTDs (e.g., soiltransmitted helminthiasis and leishmaniasis) and that can be constantly updated based on new publications and reports, as well as field data provided by contributors.

Materials and Methods

Guiding Framework

We selected schistosomiasis as the first disease to establish a proof-of-concept and populate our global NTD database. Indeed, schistosomiasis affects over 200 million people worldwide, with more than 95% concentrated in Africa. Both urinary schistosomiasis (caused by the blood fluke Schistosoma haematobium) and intestinal schistosomiasis (causative agents: S. mansoni and S. intercalatum) are endemic in Africa [22,23].

In order to obtain a large number of geographical locations to which prevalence data can be attached to our database, we conducted a systematic review. The specific steps of the process from identification of relevant surveys to data entry in the database, including various data sources, search criteria, data extraction and entry procedures, and quality control measures, are visualized in Figure 1, and will be described in more detail in the following sections.

Data Sources

We systematically searched the following electronic databases with no restriction to date and language of publication: PubMed [24], ISI -Web of Knowledge [25], and African Journal Online [26]. Using specific search terms, we retrieved relevant peerreviewed publications with an emphasis on schistosomiasis prevalence data in Africa.

The keywords applied for our literature search on schistosomiasis in the electronic databases, as well as the terms for the future search strategy on other NTDs, usually consists of species names and disease expressions often abbreviated and supplied with an asterisk in order not to miss out any results due to the variety of different spellings. The search strategy can be generalized as follows: country name OR continent AND disease (alternative spellings were included). These keywords were combined with names of African countries, whereas also alternative or former country names were considered to have our search strategy as broad as possible. This approach enabled us to save literature search results on a country-by-country basis.

Along with articles from peer-reviewed journals, reports from health institutions (e.g., World Health Organization (WHO) and the Office de la Recherche Scientifique et Technique d'Outre-Mer (ORSTOM)/Organisation de Coordination et de Coopération pour la Lutte contre les Grandes Endémies (OCCGE)) and doctoral theses (so-called 'grey literature') compose an important literature source for schistosomiasis prevalence data. Grey literature is often restricted to internal use or is not available in an electronic format. Publication databases available from WHO [27] and the Institute de la Recherche pour le Développement (IRD, formerly ORSTOM) [28] offer at least partial access to such documents. Additional grey literature included was obtained directly via site visits by team members to African universities and health research and development institutions. Another important source for survey data is the direct communication with local contacts, i.e., collaborators and partners from different African countries, individual researchers, and staff from ministries of health. The majority of entries that can be retrieved in the database were extracted from peer-reviewed journals (46%), however 30.5% of the data was obtained from personal communication with authors and 23.5% from grey literature. The latter was usually more extensive in terms of survey locations than the former sources. Since the key terms we used for our systematic review were mainly species and abbreviated disease names (e.g., 'schisto*' and 'bilharz*') that are not language specific, we also extracted and included reports written in languages other

Author Summary

There is growing interest in the scientific community, health ministries, and other organizations to control and eventually eliminate neglected tropical diseases (NTDs). Control efforts require reliable maps of NTD distribution estimated from appropriate models and survey data on the number of infected people among those examined at a given location. This kind of data is often available in the literature as part of epidemiological studies. However, an open-access database compiling location-specific survey data does not yet exist. We address this problem through a systematic literature review, along with contacting ministries of health, and research institutions to obtain disease data, including details on diagnostic techniques, demographic characteristics of the surveyed individuals, and geographical coordinates. All data were entered into a database which is freely accessible via the Internet (http:// www.gntd.org). In contrast to similar efforts of the Global Atlas of Helminth Infections (GAHI) project, the survey data are not only displayed in form of maps but all information can be browsed, based on different search criteria, and downloaded as Excel files for further analyses. At the beginning of 2011, the database included over 12,000 survey locations for schistosomiasis across Africa, and it is continuously updated to cover other NTDs globally.

Toward an Open-Access Global NTD Database www.plosntds.org than English, including French (especially for West African countries), Portuguese, Italian, Dutch, Scandinavian and few in Russian and Chinese. Sources from literature and from personal communication were stored, labeled and managed with Reference Manager 11 [29].

Often, geographical information of the survey location was not given in the retrieved publications and reports (94%). Hence, we retrospectively georeferenced the locations. The majority of the coordinates was retrieved using the GEOnet Names Server (55%) [30], topographic or sketch maps (23%), and Google (14%) [31]. Personal communication with authors and local collaborators contributed another 5% of the retrospective geolocations, and only 3% were derived from other gazetteers and sources. Irrespective of the source of retrospective geolocation, we always mapped the coordinates in Google Maps to ensure that they are located in the study area and pointing to a human settlement. In general, we tried to adhere to the guidelines for georeferencing put forward by the MaNIS/HerpNEt/Ornis network to approach georeferecing in standardized manner [32].

Data Extraction

All data sources obtained (literature, data from personal communication, and field visits) were screened for relevance by applying defined inclusion and exclusion criteria. Studies were included if they comprised prevalence data of schistosomiasis, identified either by school-based or community-based surveys. We accepted different study designs (cluster sampling, random sampling, stratified sampling, systematic sampling, etc.) as long as the reported findings could be considered as representative for the population or a specific sub-group of the population (e.g., school children, women, fishermen) in a given area. Along with schistosome prevalence data, a minimal set of information was collected, such as survey location (school, village, and administrative unit), date of survey, and number of individuals examined and found schistosome-positive (irrespective of sample size). In case additional survey-specific data were available, such as infection status according to age and sex, or intermediate host snail species (i.e., Bulinus spp. for S. haematobium and Biomphalaria spp. for S. mansoni), such information was tagged, as it might be of relevance for subsequent data extraction.

Hospital-based investigations, case-control studies, drug efficacy studies, and clinical trials, as well as reports on disease infection among travelers, military personnel, expatriates, nomads, and other displaced or migrating populations were excluded from the database in order to avoid non-representative samples (e.g., individuals with symptoms or disease-related morbidity) were excluded. Thus, the data in the database reflect the actual spatial distribution of the disease at a given time point. In case baseline prevalence data were reported in the aforementioned study types, or if former migrant populations settled down and the given survey location was clearly defined, data were included. Although having taken these precautionary steps, the database might still include prevalence data influenced by migration, since mobility and migration patterns of the rural population in sub-Saharan Africa are quite common [33,34]. Based on our exclusion criteria, we rejected more than 70% of the articles retrieved from the literature search.

Once a source was identified as relevant, the data were extracted following a standard protocol with emphasize on (i) the source of disease data such as authorship, journal, publication date, etc.; (ii) description of the parasitological survey specifying the country, the survey date (year, month, season), and the type of survey (community-or school-based); (iii) survey location reported at the highest spatial resolution available; and (iv) parasitological survey data. If relevant source included malacological data, details on snail survey methods used, snail species collected, and infection rate of the Planorbidae were also extracted.

The Kato-Katz technique for S. mansoni and urine filtration for S. haematobium diagnosis are often considered as 'gold' standard methods [35]. If prevalence data were reported by different diagnostic methods, we only recorded in the database the results of the test with highest sensitivity and specificity. We applied the following ranking of diagnostic methods: (i) 'gold' standard; (ii) direct methods such as detection of eggs in urine/stool; and (iii) any other method such as antigen detection.

Database System

The data are stored and managed in a MySQL [36] relational database with a web-interface built in hypertext preprocessor (PHP) [37]. The process from prevalence data extraction to database entry is schematically depicted in Figure 1.

The database consists of six tables corresponding to the sections of data extraction. The system architecture supports two types of users: the administrators and the end-users [38]. Registered administrators can enter new data, edit, or delete existing entries under their username and password. In addition, administrators can temporarily mask confidential data as requested by authors contributing specific data. Then a summary measure is presented instead with the contact details of the data owner to enable direct communication between researchers. Users can search all records using different selection criteria, e.g., country, document category, disease, and journal. The user part was designed to fulfill the most common queries, e.g., all recorded data for a specific parasite species in a given country or region within a specified period. The user will be able to download all information stored in the database matching different search criteria in an Excel file through an export function.

Data Quality

To guarantee and improve data quality, the following measures have been taken. A first quality check is performed after data entry in the electronic database. For example, data extracted by assistants are always double-checked against the original source of information before becoming open-access, while data entries of senior staff are checked randomly. Data sent by contributors are inspected for completeness (e.g., in terms of study year and diagnostic technique), precise calculations (e.g., prevalence), and for correctness of coordinate information if provided. Additionally, we routinely screen the database for specific errors, i.e., by mapping survey locations and counterchecking whether the points Figure 1. Flow-chart showing the steps used to assemble the GNTD database. 1. PubMed [24], ISI Web of Knowledge [25], African Journal Online (AJOL) [26], Institut de Recherche pour le Développement (IRD)-resources documentaries [28], WHO library archive [27], Doumenge et al. [17]; 2. Dissertations and theses in local universities or public health departments, ministry of health reports, other reports and personal communication. 3. Proforma and MySQL database include: (i) data source (authors); (ii) document type; (iii) location of the survey; (iv) area information (rural or urban); (v) coordinates (lat long in decimal degrees); (vi) method of the sample recruitment and diagnostic technique; (vii) description of survey (community-, school-or hospital-based); (viii) date of survey (month/year); and (ix) prevalence information (number of subjects examined and positive by age group and parasite species). doi:10.1371/journal.pntd.0001404.g001

Toward an Open-Access Global NTD Database www.plosntds.org are plotted in the expected area, by summarizing prevalence data per location and survey date to check for duplicate records, by testing for entry completeness.

Together with correctness of data extracted and entered, we also aim at the integrity of survey data. To further improve completeness of our database (e.g., date of surveys, disaggregated data) corresponding authors are contacted by e-mail asking for missing information. Approximately half of all reports had missing information, and so far we were able to get in touch with more than a third of the authors. Finally, missing coordinates for specific survey locations were obtained by re-checking additional maps and gazetteer sources, by communication with authors, and by employing global positioning system (GPS) databases created by collaborators during field visits for specific countries (i.e., Uganda, Zambia).

Results

On 10 January 2011, our database contained 12,388 survey locations for schistosomiasis that are georeferenced from 35 African countries and 568 data points on intermediate host snails for 20 African countries, giving information on 25 different mollusk species. The database is constantly updated and subjected to quality control as the project moves along. Surveys are dated as early as 1900 and the historical references that are part of the Doumenge et al. (1987) [17] global schistosomiasis atlas are included by extracting data from the original source files. Since our main focus was on sub-Saharan Africa, the data currently included in the database covers all Western, Eastern, Middle and Southern African countries, according to UN Population Division classification [39]. Data extraction for Northern African countries is currently in progress. Survey coverage between countries shows considerable variation. Typically, larger numbers of survey locations were found in higher populated countries, but the amount of surveys also depends on existing national control or monitoring programs. In addition, temporal and spatial gaps in the survey distribution (as observed in Liberia, Rwanda, and Sierra Leone) might have occurred due to political instability and financial problems. The most widely used method for the diagnosis of intestinal schistosomiasis in the surveys that were fed into our repository is the Kato-Katz technique (76.7%, as single method or in combination). Stool concentration techniques accounted for a total of 13.3% (e.g., Ritchie/modified Ritchie technique (6.0%), concentration in ether solution (5.0%), merthiolate-iodine-formaline (MIF) concentration method (2.3%)) [40]. With regard to S. haematobium diagnosis, microscopic examination of urine after concentration (82.0%) such as urine filtration, urine centrifugation, and urine sedimentation, as well as reagent strip testing (12.8%) for the detection of blood in urine (i.e., microhematuria) or a combination of both approaches (2.3%) are most commonly employed.

Most of the surveys currently included in our database focus on school-aged children (70.1%), whereas less than a third (29.9%) of the surveys include all age groups. Furthermore, among the prevalence data of schistosomiasis collected, S. haematobium (54.4%) and S. mansoni (40.8%) were the most prevalent species. The third schistosome species parasitizing humans in Africa, S. intercalatum (4.8%), was only reported in surveys carried out in Cameroon and Nigeria, confirming that this species is restricted to some parts of West and Central Africa (Figure 2). Additionally, two zoonotic Schistosoma species were reported, namely S. bovis (0.02%) and S. matthei (0.01%), in the first cattle being the reservoir, while the latter is naturally affecting different antelope species (Table 1). Cooccurrence of multiple species was reported in 20.4% of the surveys, the majority of which (97.6%) was S. mansoni-S. haematobium co-occurrence. Currently, two schistosomiasis datasets in the GNTD database are confidential and about 100 datasets still await quality control. Hence, these data were masked and cannot yet be accessed by the database users.

The distributions of S. mansoni and S. haematobium are shown in Figures 3 and 4, respectively. The applied prevalence cut-offs of 10% and 50% were chosen based on WHO recommendations to distinguish between low (,10%), moderate (between 10 and 50%) and high ($50%) endemicity communities [35]. The compiled survey data in the database suggest that S. mansoni predominates in East Africa, whereas S. haematobium prevalence is higher than S. mansoni in many African countries.

Discussion

Data repositories are important tools for the development and validation of data-driven models to estimate the distribution and burden of NTDs, such as for malaria [41,42]. Model-based predictions based on the compiled survey data will facilitate mapping of disease endemicity in areas without data and spatially explicit targeting of control interventions and long-term surveillance. With regard to NTDs, progress has been made for helminthic diseases [18] and trachoma [19]. The information included in a database helps to identify where current information is missing, request feedback from endemic countries, and initiate the collection of new data at those areas. Here, we described our efforts toward the establishment of an open-access database for NTDs. The database (http://www.gntd.or) allows for subsequent mapping of the observed survey data in order to identify high risk areas and to produce smooth risk maps, as exemplified by Schur et al. (2010) [43].

Open-Access

The work presented here and the issue of open-access in relation to data, information sharing, and services, is not a new one. Indeed, we are following the successful implementations in different fields, e.g., open-access publishing (e.g., Public Library of Sciences (PLoS) and BioMed Central (BMC) journals), PubMed, genomic data [44][45][46], biodiversity [47], drug trial results [48,49], and entertainment technologies [50].

With regard to epidemiological research, mapping disability, mortality, and disease burden due to infectious diseases, two recent open-access georeferenced epidemiological databases include the Mapping Malaria Risk in Africa (MARA), which is reporting malaria survey data in Africa dating back to 1900 [42,51], and the Malaria Atlas Project (MAP) [41], which provides maps of raw and model-based estimates of malaria risk at a global scale and country level. Other examples are the WorldWide Antimalarial Resistance Network (WWARN) [52,53], the MosquitoMap, a geospatially referenced clearinghouse for mosquito species collection records and distribution models [54], and the Disease Vectors Database [55], which is a georeferenced database on the presence of vector species of Chagas disease, dengue, leishmaniasis, and malaria. The GAHI project created a database of schistosomiasis and soil-transmitted helminthiasis survey data [13,18], similar to our GNTD database, with the goal to provide open-access information on the global disease distribution and to highlight areas requiring mass drug administration. While the GAHI project focuses on mapping country-specific disease risk estimates, the GNTD database provides open-access to the mainly locationspecific survey data. Free access to the data enables the users to conduct analyses for their own purposes. The existence of both databases offers the opportunity to join forces and to move Toward an Open-Access Global NTD Database www.plosntds.org forward in a unified way. As a first step it would be interesting to validate the two existing databases, align and harmonize them into a single comprehensive data repository, and discuss ways of harnessing synergies. Involvement of partners at WHO and other organizations will be essential.

Limitations

Despite the benefits of free and public data repositories, data sharing is a challenge. Data owners may hesitate to provide their data, especially when they have not yet been published. However, confidential data can be masked through a special database feature as explained in the Methods section. As more and more data are included into the GNTD database, the current lack in the geographical extent of location-specific survey data across countries and regions will become less critical. Undoubtedly, a host of valuable information exists within countries, in the form of unpublished local archived sources. Efforts are ongoing to access this information with the help of our in-country scientific partners Toward an Open-Access Global NTD Database www.plosntds.org in ministries of health and research institutions by visiting the countries of interest to strengthen and further expand our global network of collaborators. Nevertheless, it is likely that there will remain significant areas with scarce data because no surveys have been conducted or data are not readily accessible or have been lost in the face of civil war, political unrest, or inappropriate archiving procedures. Such geographical lacks of survey data might be only known to local experts while the international community might not be aware.

Data from systematic literature searches or unpublished reports may contain different levels of reliability. For instance, snail identification is complex and without the guidance of experienced morphologists incorrect results may be reported. The quality of diagnostic methods must also be improved, for example through repeated stool and urine sampling over several consecutive days, since schistosome egg-output varies from one day to another. Unfortunately, only few surveys adopted such rigorous diagnosis due to generally limited financial and human resources [56,57]. Furthermore, historical surveys differ in study design and are heterogeneous in terms of the age groups considered, the diagnostic methods applied, and the survey dates. Heterogeneity is also present in the way data are reported. For example in the past, numerous studies often aggregated their results at province or district level [58,59], while currently information are frequently provided or shared at village or even individual level [60,61]. All these points form important limitations of database compilations of  Toward an Open-Access Global NTD Database www.plosntds.org epidemiological data. However, data are as limited as the sources from which they were derived. Developing standard NTD survey protocols, will enhance data comparability in the future [62]. Georeferencing historical surveys are not a straightforward undertaking. We have used a number of different sources to geolocate surveyed locations, the most common ones were described in the Data Sources section. However, several villages may have the same name within a single country. In such cases, information regarding the administrative boundaries of the village or its distance from nearby rivers, lakes, or towns is essential. A further complication is that administrative boundaries as well as region and district names may change over time. For instance, in Uganda, 23 new districts have been created in 2005 and 2006 [63].

In order to maintain high quality of the database, the entries are checked continually using systematic screening approaches as described in more detail in the Methods section. Additionally, we aim to further complement gaps (on date of survey, geographical coordinates, age group, number of people examined, etc.) and to obtain disaggregated survey data by contacting authors or Toward an Open-Access Global NTD Database www.plosntds.org collaborators, and by cross-checking new sources (maps, databases, and grey literature).

Summary and Outlook

Our database is a global, freely-available, public, online resource, which hosts information pertaining to the distribution of NTDs. At present, the database contains more than 12,000 survey locations with emphasis on schistosomiasis prevalence data across Africa. It is currently expanded with information on soiltransmitted helminthiasis from Latin American and Southeast Asian countries. Our short-term goal is to extend the database from schistosomiasis to include other NTDs (i.e., ascariasis, hookworm disease, trichuriasis, lymphatic filariasis, onchocerciasis, and trachoma). Future versions of the database will supplement prevalence information from other NTDs (Buruli ulcer, Chagas disease, cysticercosis, dracunculiasis, leishmaniasis, leprosy, and human African trypanosomiasis). The approach for inclusion of further NTDs, as well as the search strategy that is going to be applied, will be the same as described in this article. We are aware that data on soil-transmitted helminthiasis is often given alongside Toward an Open-Access Global NTD Database www.plosntds.org intestinal schistosomiasis data and could have been extracted simultaneously. However, the database evolved from the CON-TRAST project that focused on schistosomiasis. While screening for schistosomiasis, we labeled relevant references on other NTDs in our reference database, which will speed up future work steps, such as literature review and data extraction of relevant sources.

The structure of the database allows entering not only parasitological data, but also other attributes, like geospatially referenced data on the disease vectors. At present, our database has limited malacological survey information, and it does not include historical collections, however, we plan to add the georeferenced historical collection compiled by the Mandahl-Barth Centre for Biodiversity and Health in Copenhagen, Denmark, which holds information on about 7,000 georeferenced snail samples.

Our hope is to provide to scientists and policy makers, a userfriendly and useful platform which is continuously updated in order to facilitate data sharing, and retrieval of disease surveillance and epidemiological data. We welcome contributions from other researchers in possession of prevalence data from various NTDs. Users may contribute by download the template offered after registration and providing the required information. An administrator checks the data for quality and sends a confirmation e-mail before including the data in the database. Researchers who may not wish to share their data may only provide limited information about the data they possess (survey location, year, and amount of data) so that the database becomes a library of potential data sources. Furthermore, we plan to add an option for the GNTD database users to contact and interact with the contributors by providing a 'send e-mail to contributor' function.

Another immediate goal is to develop a web-based interface, which will combine raw disease data and spatial model-based estimates of disease burden at different geographical levels with country boundaries and geophysical information. The results will be accessed in geo-referenced kml format, which is displayed automatically on a Google Earth interface on the website [64]. This will allow users to obtain estimates of disease burden at different spatial resolutions (village, district, region, country, etc.) and to display model predictions including prediction uncertainties and raw data on the map.

A more distant option is to allow end-users to upload their own data, for instance regional and community-based health practitioners could directly upload disease prevalence to the MySQL database using hand-held smart phones with GPS functionality [65]. Success of the project will depend on active collaboration and contribution of researchers and disease control managers from around the world. We hope that our efforts will be recognized as a helpful tool contributing to the control and eventual elimination of NTDs.

Figure 2 .
2African map of schistosomiasis survey locations based on current progress of the GNTD database. Survey locations are represented by pink squares for S. matthei, blue diamonds for S. margrebowiei, yellow stars for S. intercalatum, green crosses for S. bovis, brown dots for S. mansoni and red triangles for S. haematobium. Surveys where subjects were screened for co-occurrence of multiple species are indicated with overlapping symbols. doi:10.1371/journal.pntd.0001404.g002

of survey locations of S. mansoni, S. haematobium, S. intercalatum, S. bovis, S. matthei and S. margrebowiei as of 10 January 2011. doi:10.1371/journal.pntd.0001404.t001

Figure 3 .
3Observed prevalence of S. mansoni based on current progress of the GNTD database in Africa. The data included 4604 georeferenced survey locations. Prevalence equal to 0% in yellow dots, low infection rates (0.1-9.9%) in orange dots, moderate infection rates (10.0-49.9%) in light brown dots and high infection rates ($50%) in brown dots. Cut-offs follow WHO recommendations[35]. doi:10.1371/journal.pntd.0001404.g003

Figure 4 .
4Observed prevalence of S. haematobium based on current progress of the GNTD database in Africa. The data included 5807 georeferenced survey locations. Prevalence equal to 0%, low infection rates (0.1-9.9%), moderate infection rates (10.0-49.9%) and high infection rates ($50%) indicated by a red scale from light red to dark red. Cut-offs follow WHO recommendations[35]. doi:10.1371/journal.pntd.0001404.g004

Table 1 .
1Number of Schistosoma spp. survey locations in the GNTD database in Africa stratified by country.Countries
S. mansoni
S. haema-tobium
S. inter-calatum
S. bovis
S. matthei
S. margre-bowiei
Total

December 2011 | Volume 5 | Issue 12 | e1404Toward an Open-Access Global NTD Database www.plosntds.org
December 2011 | Volume 5 | Issue 12 | e1404
www.plosntds.org
AcknowledgmentsWe are thankful to Nadine Köhler and Marco Clementi, who assisted with data extraction and software development, respectively.Author Contributions
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Problem statement
Published: 17 Dec. 2015

Mamagoro A Mogawane
Department of Nursing Science
Private Bag X1106
University of Limpopo
0727SovengaSouth Africa, South Africa

Tebogo M Mothiba email@example.com
Department of Nursing Science
Private Bag X1106
University of Limpopo
0727SovengaSouth Africa, South Africa

Rambelani N Malema
Department of Nursing Science
Private Bag X1106
University of Limpopo
0727SovengaSouth Africa, South Africa

Problem statement
Published: 17 Dec. 201510.4102/curationis.v38i2.1553Dates: Received: 11 May 2015 Accepted: 28 Sept. 2015Page 1 of 8 Original Research Correspondence to: T.M. Mothiba Postal address:
It was evident during physical examination in January 2012 that 20 pregnant women who came for routine ante-natal care (ANC) were using IPs, as razor blade cuts were observed on Background: Indigenous practices (IPs) are experiences generated by people who are living in a specific regional context and cultural group. IPs are shaped by cultural traits that are passed from one generation to the next. IPs practices are rooted and embedded in society and, therefore, the practices become part of the people's lifestyle. It is difficult to try and change these practices as people have adhered to them throughout their entire lives. The believe system plays a major role in health care seeking behaviour of individuals because they are informed by the IPs that are observed in their environment.Objectives: To explore and describe the IPs of pregnant women at Dilokong hospital in Limpopo province.Method:A qualitative, descriptive, explorative and contextual research design was used for the participants to describe the IPs used by pregnant women. Data were collected through unstructured one-on-one interviews.Results:The following four themes with sub-themes emerged from the data: IPs based on ancestral knowledge; IPs based on spiritual diviners versus church principles; restricted practices versus instructions followed during pregnancy; and labour and IPs during labour and delivery.Conclusion: IPs are regarded as an honourable health intervention by traditional health practitioners (THPs), families and pregnant women. IPs like cords around women's waists are still observed during physical examinations. However, there is a reduction of prescribed indigenous oral medication used to accelerate labour because of their potential toxicity.

Introduction and background

Indigenous practices (IPs) are expressed in songs, dances, beliefs, rituals, cultural values, myths, and the treatment of diseases by using herbs. IPs are still applied during pregnancy worldwide, for example, in Turkey and Africa where women's reassurance depend on the local context and meaning of pregnancy. Evidence suggests the possibility that following those traditional practices during pregnancy has both therapeutic and harmful consequences (Ayaz & Efe 2008:285).

The study conducted by Gracey and King (2009:69) in Australia points out that almost 400 million indigenous people in the world have a low standard of health. Therefore, there is a need to acknowledge IPs by creating increased awareness campaigns, as well as political commitment and recognition of those serious and complex problems that are experienced by pregnant women who are using traditional medicine. The Department of Health (DoH) (2005:36) states that traditional health practitioners (THPs) are providing health care services in South Africa but their competencies are not recognised. Therefore, there is a need for the health care system to learn more about IPs in order to create a platform for the integration of services between Western medicine and IPs. In South Africa the THPs and indigenous birth attendance have been legalised under the Traditional Health Practitioners Act, Act 22 of 2007(South Africa 2008. It is, therefore, imperative for midwives to understand the IPs of pregnant women. Mulaudzi and Ngomane (2003:23) indicate that 80% of black Africans depend on THPs for care because of poverty and inaccessibility to health facilities. The study conducted by Peltzer, Phaswana-Mafuya and Treger (2009:159) points out that THPs use IPs either to prevent or to heal childhood illness. With this background, the researcher was motivated to conduct a scientific research study about the indigenous practices (IPs) of pregnant women at the Dilokong hospital of the Greater Tubatse municipality in Limpopo province. their body, some were wearing robes made of animal skin around their abdomens, whereas some had smeared yellow egg yolk on the entire abdomen. Family members also brought them indigenous medication in cooldrink bottles and instructed them to drink which might be harmful to the unborn baby.

Research aim

The aim of this study was to determine the IPs of pregnant women.

Research objectives

To explore and describe the IPs of pregnant women at the Dilokong hospital in Limpopo province.

Significance of the study

Knowledge about these indigenous practices could be used to develop guidelines for health care professionals regarding the advice they could give to pregnant women regarding IPs which could be harmful to the baby and the mother.

Research methodology Design

A qualitative, explorative, descriptive, and contextual research design assisted the researcher to obtain complete and accurate information on IPs whilst providing care to pregnant women at the Dilokong hospital in the Greater Tubatse municipality of the Limpopo province. Brink, Van der Walt and Van Rensburg (2014:120) describe a qualitative research approach as a method to explore the meaning, and to describe and promote understanding, of the view of the participants in the context in which a particular action is taking place. Exploratory research is conducted to gain insight into the research phenomenon (Babbie & Mouton 2009:79;De Vos et al. 2006:144). Descriptive research presents specific details about a situation and social setting of the phenomenon studied (Babbie & Mouton 2009:271). Contextual interest by the researcher was aimed at understanding events of the phenomenon studied within the concrete, natural context of the participants in which the practice occurred; the pregnant women who were simultaneously making use of IPs whilst seeking health care at the Dilokong hospital in the Greater Tubatse municipality of Limpopo (Babbie & Mouton 2009:272). These pregnant women were between the ages of 18 to 38 years, 10 came from rural areas and 5 from semiurban areas.

Population and sampling

The target population was pregnant women who attended an ANC clinic of the Dilokong hospital in Limpopo during July and August 2013. A non-probability purposive sampling technique was used in this study. A purposive sample was achieved by including only the participants who had knowledge related to IPs during pregnancy. The participants included in the interview sessions were those who had evidence of razor blade cut marks, wearing robes around the abdomen, having being smeared with yellow egg yolk on the abdomen and also those who were found to be taking indigenous medication in cooldrink bottles. Data were collected from 15 participants until data saturation was reached (De Vos et al. 2006:328).

Research setting

The study site was the Dilokong hospital which is a first level hospital that provides care for, amongst others, pregnant women. It is situated in the Greater Tubatse local municipality of the Sekhukhune district, Limpopo province in South Africa. The hospital serves patients from 14 primary health care clinics, 1 primary health care centre, 18 mobile clinics, 3 mine clinics and 1 gateway clinic.

Data collection method

Unstructured one-on-one interviews (De Vos et al. 2007:292) were conducted during this study to determine the IPs of pregnant women at the Dilokong hospital. The following one central question was put in the same way to each participant: 'Will you kindly describe indigenous practices that are used during pregnancy that you know?'

The main question was followed by clarity-seeking questions to allow the participants to clarify areas where the researcher sought to increase and generate detailed data until saturation was reached (Brink, Van der Walt & Van Rensburg 2012:144). All interview sessions were recorded verbatim by using a voice recorder and field notes were written to capture nonverbal cues that were not captured by the voice recorder to supplement the data collected. Unstructured one-on-one interviews were conducted for a period of two months (July and August 2013) and the sessions lasted for approximately 30 to 40 minutes.

Data analysis

Tesch's inductive, descriptive coding technique (Creswell 2009:124) was used to analyse the data. The eight steps were used which included categorising, ordering, manipulating, summarising, and describing the data in meaningful terms. The final decision was then taken about the themes which emerged during data analysis. The themes and their subtheme were arranged in columns based on their similarities. An independent coder was requested to analyse raw data. A meeting was held between the independent coder and the researcher to reach consensus about the categories they had identified independently.

Ethical considerations

The ethical standards for nurse researchers as outlined by the Democratic Nursing Organisation of South Africa (DENOSA) (DENOSA 1998) were adhered to. Research ethical clearance was obtained from the Medunsa Research Ethics Committee (MREC). Permission for collecting data at the health facility was sought from the Limpopo Provincial Department of Health. Written informed consent was obtained voluntarily from each participant after the participants had been adequately given an outline of risks and benefits involved in the research project and before commencement of the interview sessions. To ensure confidentiality, participants were informed that the information that they provide during the interview sessions would not be revealed. No participants' names were used in naming files created in the voice recorder (De Vos et al. 2006:84).

Trustworthiness

The following strategies regarding credibility, dependability, confirmability and transferability, as described by Babbie and Mouton (2009:277) were adopted to ensure trustworthiness of data.

Credibility

Credibility was ensured by extensive engagement with the participants in the field whilst collecting data during unstructured one-on-one interviews over a period of two months, until data saturation was reached (Babbie & Mouton 2009:277). All the interview field notes were sent to an independent coder and a consensus meeting was held in order to agree on codes that were identified independently.

Dependability

The research methodology was described in detail to enhance the possibility of other researchers repeating the study.

Confirmability

An inquiry auditor was used to check and assess whether the conclusions, findings, and interpretations were supported by collected data.

Transferability

Transferability refers to the extent to which the findings could be applied in other contexts (Babbie & Mouton 2009:277) and it was ensured by purposive sampling of participants who had the knowledge about the phenomenon which was studied.

Results and discussion

Findings of this stud are presented with the support of literature to generate meaning which is based on existing relevant sources and previously conducted research studies. Themes and sub-themes that are reflecting IPs of pregnant women are presented with relevant quotations from the participants (Table 1).

Theme 1: Indigenous practices based on ancestral knowledge

The study's findings reflect that the participants had described different practices that they were engaged in related to IPs during pregnancy, labour, and delivery. Six sub-themes emerged under this theme; IPs after conception, restrictions during pregnancy, practices aimed at correcting malpractices, indigenous knowledge transferred from elders to young ones, outcomes of pregnancy based on one's beliefs, and the significance of IPs.

Sub-theme 1.1: Indigenous practice after conception

The findings of this study reveal practices which the pregnant women engage in immediately after conception. A story of indigenous practice after conception was indicated by a participant who said: '…[O]nce you become aware that you are pregnant, they will prepare for you for some solemn obligatory prescription (ditaelo) like Joko tea which is very weak so as to protect you from evil spirits and witchcraft.' Furthermore, a participant indicated: 'Yes, that you will always live with it and drink it to protect one to have abortion because of people who might be jealous.'

Beliefs in witchcraft are a contributory factor to the delay in the first attendance at the ANC as pregnant women are visiting the THPs immediately when they discover that they are pregnant (Banda 2013:7).

Sub-theme 1.2: Restrictions during pregnancy

The study's findings reveal the restrictions that pregnant women have to adhere to during pregnancy as indicated by the participants in their own words: 'Then, if you are pregnant and someone who is also pregnant but low with gestational age, shares drinking water with you, you wait for her to bath, so that you will be able to walk across her soiled used water to get rid of the consequences, like she denies helping me get rid of the consequences (makgoma) but you know her.' Peltzer et al. (2009:159) confirm that traditional healers are usually the first professionals consulted by people with health problems and the healers will tell them about the restrictions during pregnancy, as they are more accessible geographically and providing a culturally accepted treatment.

Sub-theme 1.3: Practices aimed at correcting malpractices

The study's findings reveal that there are practices which are aimed at correcting malpractices during pregnancy. The findings are supported by the participant who indicated:

'…The egg of the killed hen will be taken and will break it and split it on the middle of my head, and this will weakens the magic then I will be released.'

In support of the study's findings, Truter (2007:59) indicates that traditional medicine is the most common therapeutic method used by African traditional healers for protecting patients from any form of possible afflictions, such as miscarrying or birth complications.

Sub-theme 1.4: Indigenous knowledge transferred from elders to young ones

The findings of the study indicate that the indigenous knowledge is transferred from elders to the young. It was indicated by a participant who said:

'This is the information I have learnt from my elders of using some of this medicinal plants to protect my pregnancy.'

here is a potion that is added into [sic] the water which is put aside specifically to be drunk by a pregnant woman, when she needs water. Elders know and have taught us that.'

Many traditional practitioners are mostly elders without education, who have received knowledge of medicinal plants and their effects on the human body from their forefathers (Furber et al. 2009:672).

Sub-theme 1.5: Outcomes of pregnancy based on one's beliefs

The study's findings reveal that the participants displayed beliefs related to the outcomes of pregnancy. A positive belief was indicated by the participant who said:

'It depends on the beliefs of the pregnant woman. If she does not believe in indigenous practices, the child will be born a healthy baby. It will just be normal before and after birth. Some women believe that these rituals are genuine and indispensable that of course is helpful. Once they arrive at the hospital they bear their children with less labour.' Papen (2008:386) states that IPs take shape around the cultural traits that are passed from one generation to the next. These practices are deeply rooted and embedded in these societies and, therefore, they become part of the people's lifestyle. They are innate to such an extent that it is difficult to try and change these beliefs and practices, since people have adhered to them throughout their entire lives. Believe systems play a major role in the healthseeking behaviour of individuals (Shaikh & Hatcher 2005:52).

Sub-theme 1.6: Significance of indigenous practices

The study's findings indicate that IPs are significant to individuals which was confirmed by the participant who stated:

'Mmm! They also give us cords, which are white on which three small pieces of blue cloths are sewn, to protect from miscarriages.'

'Mm! when you are eight to nine months they will give you a boiled Klim which will protect you against witches, enemies, the people who want to bewitch you by taking your urine cannot be successful because you will be passing milk only.'

These findings were supported by the study conducted by Truter (2007:58) stating that herbal medication is the most common therapeutic method used by the African traditional healers for protecting patients from possible afflictions. Therefore, they prepare powders and earth ointments which comprise animal fat, clay, and ashes for their patients.

Theme 2: Indigenous practices based on spiritual diviners versus church principles

The study's findings reflect IPs which were based on the anomaly between spiritual diviners and church principles. Five sub-themes emerged under this theme, namely, different pregnancy protection practices, period of protection, rationale for utilisation of protection, significance of the practices towards pregnancy outcome, and rights to prescribe the protection.

Sub-theme 2.1: Different pregnancy protection practices

The findings of the study reveal that there are different pregnancy protection practices. It was indicated by a participant who said:

'At our church, we use these solemn prescriptions whether pregnant or not, but when you are pregnant we use these to protect us from curses or witchcraft, so that witches cannot bewitch you on the day of giving birth.'

'…[S]olemn tea, solemn Vaseline, salt, coffee, and all are solemnised at church by special people, with light tea we use to bath and drink, then we use salt after usual bath you use water which was not used then you draw in some salt and bath with solemn salt. We put fine particles of it in your shoes before putting them on.'

These findings are supported by the study conducted by Peltzer et al. (2009:158) that confirms that in the Eastern Cape, the THPs treatments prior to delivery vary from rubbing, medicine for bathing, ingestion, or referral to the traditional birth attendant for assistance.

Sub-theme 2.2: Period of protection

The study reveals that the THPs suggest a period of protection for their clients during pregnancy as indicated by the participant who said: The study's findings are supported by the study conducted by Choudry (1997:537) which confirms that THPs are considered knowledgeable and skilful in maternal care by people in communities when a gestational age is calculated by the position of the moon and the use of Ritlangi, which is a thread of grass tied around women's waists, that provides comprehensive input towards the management of pregnancy and birth.

Sub-theme 2.3: Rationale for utilisation of the protection

During data collection, it was found that the participants had knowledge related to important reasons for adhering to their traditional medicine in relation to their conditions. A participant said:

'… [S]o that you will not be delayed when you give birth to the baby. It also makes the process of giving birth less painful.'

'It depends on the neighbours, whether they are enemies for conjuring the demons to the pregnancy, can make it difficult for you to bear the baby normally but through an operation.'

In support of the study's findings Waiswa et al. (2008:14) state that pregnant women in Uganda consult the traditional birth attendant during ANC because they perceive them as effective caregivers, as they provide herbal medicine to take care of their pregnancies.

Sub-theme 2.4: Significance of the practices towards pregnancy outcomes

The findings of the study suggest that practices have significance towards pregnancy outcomes. It was evidenced by the response of the participant who said:

'In my first pregnancy, I consulted with the soothsayer of the St John Apostolic Church and she gave me some cords to use. Because I didn't like the cords, I used them for a short time and buried them among the underwear I seldom use. The cord had a knot which I was ordered to undo or unfasten when I was about to give birth, I could not unfasten the knot because I forgot everything. I did not remember that I had the cord.' Lau (2012:29) indicated that knowledge should only be considered if it does not hold any harm to pregnancy. Lau further stated that considering traditional practices for pregnant women might reduce the burden on public hospitals, allowing time and resources to be spent on problematic pregnancies when the practices are safe.

Sub-theme 2.5: Rights to prescribe the protection

The study's findings reflect that the rights to prescribe the protection rest with prophets in the church. That was indicated by the participant who said:

'Yes, you can go to the prophet. The prophet will prescribe (ditaelo) like tea from Moria with picture of our Bishop.' Another participant added: 'I am a member of the Zion Christian Church, but the elders tell us these cultural practices. Sometimes, the solemn prescriptions of churches surpassed by the power of the curses, then we consult with traditional healer so that they can give us the potions.' Participants maintained that, although some traditional birth attendants could not read or write, they had a sound knowledge of attending to birth. It was further stated that pregnant women relied on traditional birth attendants for management of pregnancy, based on the attendants' expert knowledge (Mulaudzi & Ngomane 2003:23).

Theme 3: Restricted practices versus instructions followed during pregnancy and labour

The findings of the study revealed that there are restricted practices versus instructions followed during pregnancy and labour where women experience pregnancy-related restrictions which are accepted as norms in their cultures. The sub-themes which have emerged under this theme which confirmed the practices, namely, spiritual consequences of not honouring instructions, physical signs and symptoms of not honouring instructions, and people's influence towards the outcomes of the pregnancy.

Sub-theme 3.1: Spiritual consequences of not honouring instructions

The study's findings reflect that some participants do not honour the instructions of spiritual practices as indicated by the participant who said: 'Tremendously! After I returned to the soothsayer to report what I had experienced, she opened the Bible and it was revealed to her that I did not unfasten the knot. It was the time that I remember I hid the cord among 'panties' which I do not wear when I am pregnant.' Moloi (2005:118) stated that spiritually ancestors must be respected and honour their instructions because it is believed that they are part of their people.

Sub-theme 3.2: Physical signs and symptoms of not honouring instructions

The study findings reveal that participants had knowledge about physical signs and symptoms of not honouring instructions as verbalised by one of participant who said:

'Yes, I was seven months pregnant; now I experienced a serious water-like discharge.' Original Research Another participant said: 'A pregnant woman will experience the taboo related diseases and physical discomfort generally as makgoma; examples of disease are swelling abdomen and flatulence. Sometimes, a miscarriage is possible.'

In biomedical science, the above precautions are not applicable because they are referred to as myths and they cannot be proved to be true or right. However, noncompliance with the ancestral instructions might result in individuals experiencing bad luck (Moloi 2005:121).

Sub-theme 3.3: People's influence towards the outcomes of pregnancy

The study reveals that outsiders can influence pregnancy outcomes as indicated by one participant who said:

'Evil people draw on the roads and if you can tread on them, you are cursed. If you put solemn salt in your shoes and used Vaseline, their curse is but nothing.'

In support of this sub-theme, Mathole et al. (2004:129) indicate that women in Zimbabwe feel that pregnancy has to be kept secret during the early stages for fear of witchcraft. The women further state that the pregnancy is protected from evil spirits that may be inflicted by jealous people who would bewitch the pregnant mother to give birth to a malformed infant or to have a miscarriage.

Theme 4: Indigenous practices during labour and delivery

The study reveals that the participants displayed engagement with IPs during labour and delivery. Five sub-themes emerged from this theme, namely, procedures executed for prevention of bad spirits, practices for precipitated delivery process, consequences of the woman not obeying instructions, consequences of disobeying instructions related to the infant and IPs after delivery.

Sub-theme 4.1: Procedure executed for prevention of bad spirits

The study reveals that participants believed that indigenous procedures executed during labour and delivery prevented bad spirits. One participant indicated: 'Yes, if the evil acts are strongly done to you and if you've got hairs on your head, the egg yolk will not flow down your head.' Another participant stated: 'Then, they will take that killed hen, burn its legs to ashes, then I eat that powder and, therefore, drink warm water, then I will be released.' Maimbolwa et al. (2003) state that traditional birth attendants advise pregnant women to use traditional medicine as a way of preserving pregnancy and chasing away bad spirits that can affect the pregnancy. Maimbolwa et al. (2003) further stated that participants show trust and faith in what their carers advise them to do during pregnancy.

Sub-theme 4.2: Practices for precipitated delivery process

The findings of the study indicate that pregnant women are given traditional medicine to assist with quickening the labour process. This was confirmed by the participant who said:

'They will take that killed hen, burns its legs to ashes, then I eat that powder and, therefore, drink warm water, then I will be released.'

'He instructed his wife to give me a certain potion which smells like the goat dumps in water; yes indeed you cannot ask what the potion is made up of.' Choudry (1997:537) indicates that traditional birth attendants are considered knowledgeable and skilful in maternal care; roots of Xirhakarhani (a traditional analgesic) are boiled and the water mixture is given to the woman in labour to drink to relieve excessive labour pains.

Sub-theme 4.3: Consequences of women not obeying instructions from THPs

The findings of the study indicate that there were instructions that the participants did not obey which led to negative results. That was confirmed by one of the participant who said: 'I delivered my baby with an operation', and, 'Yes, particularly when the doctor told me that the baby cannot be born normally and so I have to go to operation. The demons were conjured into me and managed to delay the process of delivery because I didn't follow instructions from [the] TH'. Another consequence was indicated by a participant who said:

'Her pregnancy duration may be extended; she may have miscarriage especially if the solemn cord was not used according to the beliefs of the Zion Christian Church.' It is believed that non-compliance with a rule might result in difficulties during delivery. Pregnant women should take responsibility for their health by reporting earlier to health care providers for the prevention of complications (Lau 2012:31).

Sub-theme 4.4: Consequences of disobeying indigenous instructions related to the infant

The study's findings reveal that the participants who did not obey the instructions related to IPs experienced bad consequences in relation to their new born infants. A participant verbalised this by saying: 'Sometimes, the baby is abnormal and present with disability of some kind, mmm! Or madness.' Another indicated that: 'You can either deliver prematurely, or lose the baby in the form of miscarriage, or sometimes it happens that few days after the baby is born, she/he dies.' These findings are supported by Camacho, Castro and Kaufman (2006:359) who indicated that when indigenous instructions are not obeyed, unfavourable perinatal and neonatal health problems occur to newborn infants. Camacho et al. (2006:359) believe that non-compliance with indigenous rules might result in difficult delivery or abortion, and further state that in communities, the consequences of these imbalances are specialist intervention to restore the balance by using herbs or rituals, depending on the causes that have created the problem.

Sub-theme 4.5: Indigenous practices after delivery

The findings in the study reveal that participants displayed beliefs related to IPs after delivery as verbalised by one of the participants who said: 'There are some traditional treatments that are applied on the new born babies, for the baby to become strong quickly, the elders smear Dupa which is a muti used to treat childhood illness, is applied on the skin of the monkey, and burn it in a closed room so that the baby can inhale the smoke.'

Another participant indicated:

'And also the Vaseline, Vicks, and cords (motlemo). We mix Vaseline and Vicks and apply it on the entire body and you will also use another prescription of solemn water with a bit of sand in it, which has been prayed for. After you have taken the usual bath with soap, then you drop of solemn water in the unused water then you bath.' Gracey and King (2009:71) indicate that perinatal and neonatal health outcomes -including deaths -are pressing issues, especially in developing countries. Several interventions could cost-effectively save many of the lives of the infants. These interventions include improved clinical care to poorly served groups, engaging families and communities, and improving home-care practices.

Conclusion

The study's findings indicate that IPs are regarded as an honourable health intervention by THPs, families, and pregnant women. The women show trust in methods used to preserve pregnancy, labour, and delivery. IPs by pregnant women still continue and, like cords around their waists, are still observed during physical examinations. However, there is a reduction of prescribed potions mixed with cooldrinks for use to accelerate labour and to prevent negative consequences, because the potential toxicity has been explained during the provision of health education. These findings call for health care professionals to emphasise training of and workshops for the THPs for effective implementation of IPs to enhance improvement of negative consequences during pregnancy, labour and delivery.

Recommendations

Communication and understanding of cultural practices by health care providers and THPs would increase knowledge of earlier attendance of pregnant women at the health facilities. South Africans should have global knowledge of, as well as respect for and accept the function of IPs as cultural beliefs. Health care professionals should respect and protect IPs by formulating programmes for ubuntu meetings with the THPs.

Training workshops and traditional awareness campaigns for THPs, church leaders, elders, and communities must be conducted to strengthen community involvement and active participation in issues pertaining to ANC. Health care professionals must collaborate with conventional clinical services during community-based programmes to minimise the negative effects. Policymakers should develop strategies to protect women by the intervention of specialists in restoring the balance between using prescriptions, religious rituals and biomedicine. Educational sessions during clinical service delivery should be provided, particularly during the physical examination of pregnant women for the promotion of a healthy life style. Churches should also promote change in food habits. Food supplements need to be provided in areas where a deterioration in the nutritional status of individuals is apparent. The council of the spiritual diviners and church leaders should be advised to formulate rules in collaboration with health professionals to ensure that the health and wellbeing of pregnant women and the unborn baby is ensured.

TABLE 1 :
1Themes and sub-themes reflecting the indigenous practices of pregnant women at the Dilokong hospital in Limpopo province, South Africa.Indigenous practices after conception. Restrictions during pregnancy. Practices aimed at correcting malpractices. Indigenous knowledge transferred from elders to young ones. Outcomes of pregnancy based on one's beliefs. Significance of indigenous practices.Spiritual results of not honouring instructions. Physical signs and symptoms of not honouring instructions. Peoples' influence towards the outcomes of the pregnancy.Procedures executed for prevention of bad spirit. Practices for precipitating delivery process. Consequences of the women not obeying instructions from THPs. Consequences of disobeying instructions related to the infant. Indigenous practice after delivery.Themes
Sub-themes

Indigenous
practices based
on ancestral
knowledge

Indigenous
practices based
on spiritual
diviners versus
church principles

Different pregnancy protection practices.
Period of protection.
Rationale for utilisation of the protection.
Significance of the practices towards pregnancy outcomes.
Right to prescribe the protection.

Restricted
practices versus
instructions
followed during
pregnancy and
labour

Indigenous
practices during
labour and
delivery

'You do not take them off [strings tied around the abdomen]. They must be part of your body. You only take them off when you are experiencing labour pains.'http://www.curationis.org.za
doi:10.4102/curationis.v38i2.1553

Another participant elaborated:

'What I can tell you is that I attended church and we use what
is prescribed by the church for us to protect our pregnancies so
that we can reach term.'

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