Fish hooks and gumboots: the language of pregnancy prevention in northern Malawi

Language and metaphors are central mechanisms of the human mind and thought processes, and allow us to draw on existing social or physical experiences to make sense of novel concepts.¹ Metaphors are not simply linguistic tools; they are deeply rooted and structured in cultural backgrounds and can shape our understandings, perceptions and actions. Different cultures can have different views about the life-course, reproduction and preventing pregnancy,² and these views are reflected in the use of language when talking about contraception.

Our hypothesis is that the vernacular language used to refer to contraception in northern Malawi would not correspond to the English terms in content or tone, and that such mismatches in the language of public health initiatives could affect uptake. We propose that the discussion around English terms in reproductive health programming must understand and use the local vernacular in each setting, particularly when trying to promote family planning programmes, where cultural values will shape willingness to use contraception.

The English terms most commonly used to describe a method or device to prevent a pregnancy inevitably carry implicit allusions, meanings or imagery. Family planning and birth control bring about images of children and a consideration of family life which, for some women and men, may be far removed from their desire to have safe, pregnancy-free and enjoyable sex. Control, and to some extent planning, have connotations of order, restriction, constraints and rules, and birth control may have negative associations with population control. Contraception, from the Latin contra (against) and conceptio (conceive), does perhaps more accurately describe the actions of women and men who do not intend to have a pregnancy, but again, may have some negative undertones by use of the word contra. The importance of the connotations is widely discussed in reproductive health circles.³

Around 7100 known living languages are estimated to exist today,⁴ and yet, due to resource implications, global health communications are rarely translated widely. The World Health Organization, for example, has six official languages – Arabic, Chinese, English, French, Russian and Spanish – for their key scientific publications.⁵ In Malawi, English is the official language, Chichewa is the national language and yet about half of the population have an alternative first language. Chitumbuka is the language of the patrilineal Tumbuka people of Karonga district, northern Malawi. The language Chitumbuka contains fewer words than English, so in many cases words are used in multiple ways and the context or the tone are used to clarify meaning. English words are frequently recognizable in newer Chitumbuka words (for example, tabulu means table and pensulu, pencil), and English words are used directly in speech if there is no Chitumbuka equivalent. In the context of a qualitative study involving 19 in-depth interviews with Tumbuka-speaking women in this community on consistency of contraceptive use, we documented Chitumbuka (and where commonly used, Chichewa) terms relating to services and methods to prevent pregnancy. Five women were younger than 25 years. For the concepts related to family planning, the words were translated by an adult Tumbuka female interviewer fluent in English. For the literal meaning, the words were translated by a pre-teen (to avoid knowledge of the contraception associations) of British heritage who is bilingual in Chitumbuka and English and immersed in Tumbuka culture since birth – and who was blinded to the purpose of the study.

Kulera is a Chitumbuka and Chichewa verb used to mean to prevent pregnancy, but that literally means to look after or to take care of, and it includes all modern methods of contraception. Despite being commonly used in Malawi, traditional methods (withdrawal or rhythm) are not included in the term kulera. The Chitumbuka phrase kuthaska nthumbo is a more general term for preventing a pregnancy (nthumbo means abdomen, and kuthaska is only used in this context), and can include all methods, including traditional ones.

Sindano (injectable hormonal contraceptive) is the most commonly used modern method to prevent pregnancy in Malawi. Sindano literally means a needle, and so can be used to refer to other injectable substances as well, including vaccinations. As in English, where the meaning of injectable is clear when used in the context of contraception, no clarification is usually required. Similarly, because nthowa means road or pathway, and pakawoko means arm, nthowa ya pakawoko refers to the method that is on the arm (contraceptive implant). If someone were to say nthowa zaka 5, they would be referring to implants lasting five years. Mapilisi, literally pills (the singular pilisi is from the English word pill), refers to oral contraceptive pills, and saying mkumwa mapilis means drinking contraceptive pills and does not mean any other type of pills. An obvious similarity to the pill exists, where we understand it is the contraceptive pill, because of the context in which the word is used, and perhaps also because the article “the” is always used. Female sterilization or tubal ligation is known as kujara in Chitumbuka, which literally translates as closing. As nthowa means road, if someone were to say kujara nthowa, they would mean closing the pathway, although whether this is the road to parenthood or the road is the Fallopian tube is not known. For the intrauterine contraceptive device, Chitumbuka has borrowed the English word loop; a common alternative is mbeza, which means fish-hook. The names of these different methods are therefore mainly descriptive of how each method is applied, rather than relating to the contraceptive effects.

Mazuwa, or days, applies to days of the menstrual cycle, or days in a month. To prevent pregnancy, someone may be kuwerenga mazuwa, or counting the days (rhythm method). A couple may also practice kuduka (jumping), kuthira pansi (pouring out), or kuwa waka (falling down), all referring to the withdrawal method. Women may also attempt kukhama (squeezing out or milking), which involves breathing in very strongly after sex to rid the body of sperm, or use vyoto (ashes), that is, drinking an ash and water mixture after sex.

Condom promotion in Malawi has been very important as human immunodeficiency virus (HIV) prevention, and the two main socially marketed condoms use different branding techniques to encourage use. Chishango (marketed by Population Services International) translates as shield, and bears a picture of a traditional African shield, including spears, giving a pregnancy or HIV prevention a rather confrontational aspect. This branding contrasts to another condom brand Manyuchi (marketed by Banja La Mtsogolo), which translates as honey, representing the sweetness of sex, and with more seductive imagery aimed at men. This imagery is reflected in one of the metaphors commonly used to excuse non-use of condoms; “one cannot eat sweets with the cover on.”⁶ A more savoury metaphor, also negatively impacting on condom use, is the need for sex to be nyama ku nyama oro, (meat to meat contact), or sumbi ku sumbi (egg to egg).⁷ Sex as food is not just metaphorical in this culture, as semen is believed to provide nourishment to the woman, and thus to use a condom is to deprive the woman of that offering.

More abstractly, moyo, (life), may also be used to refer to condoms, perhaps as it preserves life, or, as moyo may also refer to the life-force of the sperm, the condom is catching that life-force.⁸ The most prosaic term is jumbo (plastic shopping bag or gumboot) and mdidi, which may be translated as rumble; used when someone is producing a heavy sound like an earthquake or running with a thudding noise.

Some translations demonstrate the social pressure to have many children; for example, kuzenga mudzi refers to increasing offspring, but the direct translation means building a territory. Kunya waka wana refers to giving birth to more children; the direct translation means making children. The societal disapproval of poor birth spacing is reflected by negative terms referring to a situation where a woman becomes pregnant while the previous child is still very young: kutinya and nthumbo ya chiwulira.

In Chitumbuka, many of the euphemistic words for contraception are similar to those used in English, whereas others are more descriptive of the appearance or application of the method and have different connotations. The wide range of Chitumbuka words associated with preventing pregnancy reveal that family planning programmes need to factor in how the terms (for example, family planning versus safe sex, free sex or preventing pregnancy) are adopted in local languages, and to ensure that they understand and address the connotations. This consideration is particularly important in preventive public health programmes such as contraception, vaccination and nutrition, where cultural beliefs are strong, sustained engagement is important, and the interventions address deep, culturally rooted behaviours. An alternative approach is to start with local terms. The discourse on how to positively spin family planning descriptors to be more attractive to different groups^3,9 not only needs to consider the local context and how sex is perceived and described, but also needs to recognize that adoption of terms into the vernacular may be challenging to achieve, given the range of vivid imagery already in use.

Although this analysis relates to a single region of Malawi, the use of imagery in the vernacular, which carries different implications from the intended programming language, is likely to be replicated across low-income settings where indigenous languages predominate. Carefully considering linguistic matters could ultimately increase the acceptability and success of family planning programmes and increase the uptake of contraception.