We interviewed 38 women, as the result of 32 individual interviews and 2 FGD, and 5 guérisseurs. In addition, JH was invited to attend a meeting held among guérisseurs and had the opportunity to pose additional questions on such occasion. The respondents, whose age ranged from 17 to 80, were representative of all local major ethnic groups in the area: Marka, Bwaba, Mossi, Peuhl, and Samo. The vast majority of women were uneducated, were married, and as a source of income, they engaged in small-scale commercial activities.
The presentation of the findings is organized in three sections. For each reported verbatim quotation, we indicate the respondent's age and ethnicity. We explicitly indicate when quotations report the guérisseurs' speech. In addition, we have included a case study, Salima's story [see additional file 1] with the aim of allowing the reader to gain a better understanding of how a typical woman in Nouna perceives and defines her lactating problem and how she is likely reach a decision regarding health care seeking. We wish to point out that Salima is a fictional name used to protect the identity of the woman originally reporting the story. Given that the woman was illiterate, consent to use the information she shared with us was obtained verbally.
Local illness concepts and indigenous nosography
Women perceived breast problems related to lactation to be highly prevalent. They indicated that every second breastfeeding mother experiences some sort of problem. They reported that the most frequently encountered problem is inappropriate lactation, defined as the production of insufficient quantities of milk. Women explained that such problems are addressed within one's community by modifying dietary habits or by resorting to the use of herbal infusions.
The emergence of one of several additional physical symptoms marked the differentiation between a resolvable lactation difficulty and an actual health problem which requires professional attention. Depending on the language they were most familiar with, respondents used a variety of words to define health problems of the breast related to lactation, " siindimibanaw " (Djoula), "biis-guija" (Mooré), and " dindin " (Bwamu), and clearly recognized their potential to constitute a threat to a woman's well-being. Both women and guérisseurs consistently described the same set of symptoms and the same sequence: (a) itching of the breast; (b) either a slow milk flow or a complete absence of milk flow or continuous dripping; (c) swelling of the mammary glands accompanied by an inflammation and at times by fever; (d) a painful breast abscess.
" I had an inflammation, then some milk dripping, then swelling, then an abscess, and in the end, a wound" (22, Marka)
"... the illness can persist leading up to death" (20, Samo)
"There are different forms of diseases of the breast among breastfeeding women. First, there can be little absence of milk... then a swelling of the breast... then, there can be an inflammation, which can even turn into an abscess" (Guérisseur 2, Mossi)
Both women and guérisseurs identified two sources of illness: (a) breast problems due to "natural causes" with an observed cause-effect relationship, and (b) breast problems resulting from the action either of another human being, a sorcerer or a marabou, or of a nonhuman "force", such as a deity.
"The illness might be natural...or might be caused by sorcery" (22, Marka)
The respondents indicated that "natural" breast problems can arise as the result of inadequate breastfeeding practices or of a parasitic contamination. Adequate breastfeeding entailed both ensuring that the child correctly sucks the whole nipple and respecting traditional norms and behaviours related to motherhood.
"If the child sucks the breast from the side (inadequately), this can cause the illness" (24, Marka)
"It seems that there are parasites that can cause these problems" (19, Marka)
In addition, both women and guérisseurs mentioned mental and physical distress as well as no respect of basic hygienic conditions as additional "natural" causes of breast problems. They recognised that awareness and respect of hygienic conditions represent a recent development.
"Before women took no hygienic precautions... Today, women take all precautions. When you return from town... you must wash your hands and your breast before breastfeeding" (30, Mossi)
Breast problems resulting from the action of another human being were explained in relation to unsettled jealousy or envy between people.
" In my case, (the breast problem) is a spell thrown by my old boyfriend. When I refused to marry him, he told me that I would have never had children and I would have died young. This has not happened, but with each delivery (each child), I have breast problems" (22, Marka)
"A sorcerer can induce any breast problem in a woman to hurt her" (Guérisseur 3, Bambara)
Health care seeking behaviour
To treat their breast problem, 17 women had consulted a guérisseur, 8 had gone to the hospital, 2 had used home treatment, and 11 had consulted several practitioners at different moments through their illness. Most women had first attempted to solve the problem at home, resorting to their family tradition of pharmacopoeia. In addition, women had adapted their breastfeeding behaviour preferring the sick breast above the healthy one as long as lactation was possible.
The choice of provider, traditional or modern, depended on the woman's socio-demographic profile, her economic status, and on her perception of the cause and the severity of the illness. Ethnicity played a role, with strict Muslim Mossi women preferring the marabou (the Muslim healer) above any other guérisseur. Younger women generally preferred modern above traditional medicine. Women consistently reported that breast problems which result from sorcery can only be treated by guérisseurs, while "natural" breast problems can be treated by both guérisseurs and modern health practitioners, leaving the choice to the woman's individual preference. They recognised, however, that the application of user fees often induces women to resort to traditional medicine even in instances when they would in fact prefer modern medicine. Women frequently reported seeking care at the hospital only once in need of a surgical intervention to remove the abscess.
"When it is a spell that someone threw on you, traditional medicine is more effective. When it is a natural disease, modern medicine is more effective" (22, Marka)
"Traditional medicine helped me a lot. Modern medicine only took care of the abscess" (30, Samo)
"I did not have the money to go to the hospital, so I did the incision at home and applied some traditional remedy" (35, Mossi)
In addition, women's choice of provider appeared to be heavily conditioned by the opinion and the will of other family members, in particular the parents and the husband.
"My parents refused that I consult the hospital, because they trust that traditional medicine is effective" (33, Marka)
"... because it is him (my husband) who cares for me, I can't decide to consult a guérisseur without his consent" (24, Bwaba)
Traditional prophylaxis and treatment remedies
The guérisseurs shared women's opinion that the cause of the breast problem determines the treatment to be applied. In particular, the guérisseurs insisted on the fact that if the breast problem is the result of an act of sorcery, only their intervention will resolve the matter. They recognised instead that "natural" breast problems can also be cured with simpler herbal remedies or with modern medicine.
"If it is through the action of another man that you fall sick, you cannot get better unless a very experienced guérisseur treats you. Otherwise, you will treat yourself in vain" (Guérisseur 3, Bambara)
Both women and guérisseurs recognised as a first measure to facilitate further treatment, to stroke the breast with the dried primary hand at specific times during the day. In addition, they indicated treating the swelling and the inflammation with a mixture of traditional medical plants such as Fugufugu or Datu (Bissap tree seeds) and Karité butter. They explained that a similar healing effect can also be obtained by using river-mud or termites, ants, termites soil, and wasp nests in the preparation of medicaments. Climbing plants are used for medicaments to normalize milk production.
"If the problem is natural, it will be enough to take a bit of termite soil, mix it with potash, and the problem will heal" (22, Marka)
Recognising the complementarities between traditional and modern medicine, the guérisseurs wished for a closer collaboration with modern health practitioners.
"Those who say that one is more effective than the other make a mistake, because traditional and modern medicine have same mother and same father" (Guérisseur 3, Bambara)
"We have looked for this collaboration. Some nurses have accepted, but many others have refused" (President of Guérisseurs)
Practices to prevent lactation problems are related to the belief that during pregnancy, in particular among primiparae, two bubbles are formed, one in each breast. If these two bubbles do not burst after delivery, breastfeeding will be difficult and breast problems will develop. Women and guérisseurs described both the custom of wearing a tight cloth around the breast and a practice, known as ecrasement or rungri, which consists of massaging and pulling the breast during pregnancy. To ensure proper lactation, this painful practice is intensified in the weeks following delivery, when the breast is further kneaded with hot water and Karité butter. Women and guérisseurs added that other traditional medicaments, primarily mixtures of local plants and Karité butter or baths with potassium, are also regularly applied during pregnancy to prevent breast problems. Furthermore, a few women reported wearing amulets close to their skin.
"There is a bubble in each of the two breasts. If these bubbles do not break, this causes the illness... To break these bubbles, young mothers must carry a cloth tight around their breasts. Unfortunately, mothers do not like to wear this cloth anymore and so they have problems" (Guérisseur de Goni)
"If this (ecrasement) is not done, the bubbles inside the breast will prevent the flow of the milk and this will provoke breast illness" (28, Marka)
In spite of their efforts to care for the breast during pregnancy and following delivery to avoid lactating and health problems, the respondents also acknowledged their incapacity to truly prevent illness. Most respondents in fact, referred to the fact that ultimately God alone can decide over a person's health.
"God alone protects me. Alone, I can do nothing to prevent illness" (21, Fulani).