STRUGGLING AND COPING WITH LIFE: MATERNAL EMOTIONAL DISTRESS IN A SOUTH AFRICAN TOWNSHIP by SARAH E. RUBIN Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Anthropology CASE WESTERN RESERVE UNIVERSITY August 2014 CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES We hereby approve the dissertation of Sarah E. Rubin candidate for the degree of Doctor of Philosophy* Committee Chair Eileen Anderson-Fye, EdD Committee Member Atwood D. Gaines, MPH, PhD Committee Member Vanessa Hildebrand, PhD Committee Member Kimberly Emmons, PhD Date of Graduation August 2014 *We also certify that written approval has been obtained for any proprietary material contained therein. Copyright © 2014 by Sarah E. Rubin All rights reserved for my parents i Table of Contents List of Figures vi List of Tables vii Acknowledgements viii Abstract xv 1. Introduction 1 1.1 THREE STORIES 1 1.2 INTRODUCTION 2 1.3 RATIONALE 7 1.4 WHY THE XHOSA? 10 1.4.1 THE TOWNSHIP CONTEXT 10 1.4.2 XHOSA MOTHERHOOD 11 1.4.3 STUDIES OF PERINATAL DEPRESSION IN THE TOWNSHIP 11 1.5 A STUDY OF MATERNAL EMOTIONAL DISTRESS AMONG XHOSA TOWNSHIP MOTHERS: THEORETICAL FRAMEWORK AND CONTRIBUTIONS 12 1.5.1 PSYCHOLOGICAL ANTHROPOLOGY: UNDERSTANDING MENTAL ILLNESS, SUFFERING, AND EMOTION THROUGH THE LENS OF CULTURE 12 1.5.1.1 CULTURE AND MENTAL HEALTH 12 1.5.1.2 SUFFERING AND SUBJECTIVITY 13 1.5.1.3 ANTHROPOLOGICAL WORK IN EMOTION AND MATERNAL EMOTION 14 1.5.2 REPRODUCTIVE ANTHROPOLOGY: THE IMPORTANCE OF REPRODUCTION AS A LOCUS FOR CULTURAL VALUES AND NORMATIVE SOCIAL ROLES 16 1.5.3 SOUTH AFRICAN STUDIES: IMPORTANCE OF GENDER AND MOTHERHOOD IN XHOSA CULTURE AND TOWNSHIP LIFE 16 1.6 RESEARCH AIMS 18 1.7 ORGANIZATION OF THE DISSERTATION 21 2. Research and Theoretical Context 23 2.1 INTRODUCTION 23 2.2 STUDIES OF PERINATAL DEPRESSION (PND) 23 2.2.1 HISTORY OF PND 24 2.2.2 “POSTPARTUM DEPRESSION” IN THE DSM 25 2.2.3 STUDIES OF PND IN SOUTH AFRICA 27 2.3 A BROADER APPROACH: PSYCHOLOGICAL ANTHROPOLOGY APPROACHES TO MENTAL ILLNESS AND WELL-BEING 28 2.3.1 CRITIQUES OF STUDIES OF CROSS-CULTURAL PND 28 2.3.2 APPROACHING BIOMEDICAL PSYCHIATRY AS AN ETHNO-PSYCHIATRY 30 2.3.3 UNDERSTANDING CULTURAL DIFFERENCES IN MENTAL HEALTH 32 2.3.4 ANTHROPOLOGY OF EMOTIONS 35 2.4 STUDIES OF MOTHERHOOD 40 2.5 SOCIAL SUFFERING: AN ANTHROPOLOGICAL APPROACH TO POVERTY AND SUBJECTIVITY 48 2.5.1 THEORETICAL APPROACHES TO SUBJECTIVITY 48 2.5.2 SUBJECTIVITY AS A WAY TO UNDERSTAND THE EXPERIENCE OF POVERTY 49 ii 3. Background 53 3.1 INTRODUCTION 53 3.1.1 TERMINOLOGY 53 3.2 KEY EVENTS IN SOUTH AFRICAN HISTORY 54 3.3 BRIEF HISTORY OF THE TOWNSHIP 58 3.3.1 KEY DATES AFFECTING TOWNSHIP FORMATION AND TOWNSHIP LIFE 61 3.3.2 WOMEN AND THE TOWNSHIP 61 3.3.3 CAPE TOWN’S TOWNSHIPS IN PARTICULAR 62 4. Methods and Methodology 66 4.1 THEORETICAL CONTEXT 67 4.2 RESEARCH LOGISTICS 71 4.2.1 ACCESS 71 4.2.2 RESEARCH ASSISTANCE 72 4.2.3 LANGUAGE COMPETENCE 74 4.2.4 TRANSCRIPTION AND TRANSLATION OF TRANSCRIPTS 75 4.2.5 LIVING AND WORKING IN OUR HOPE TOWNSHIP 76 4.3 STUDY PROCEDURE 78 4.3.1 SAMPLING AND RECRUITMENT 77 4.3.2 SUMMARY OF RECRUITMENT PROCEDURE 80 4.3.3 SAMPLE SIZE AND CHARACTERISTICS 81 4.3.4 REFUSALS 82 4.3.5 INTERVIEW TIMELINE 82 4.4 INTERVIEW SCHEDULES 84 4.4.1 SUMMARY OF INTERVIEW SCHEDULES 84 4.4.2 EDINBURGH POSTNATAL DEPRESSION SCALE 85 4.4.3 RISK FACTOR ASSESSMENT 88 4.4.4 STRUCTURED PRENATAL INTERVIEW: THE “MOTHERHOOD INTERVIEW” 88 4.4.5 SUBSEQUENT FOLLOW-UP INTERVIEWS 89 4.4.6 HOME VISITS AND OBSERVATIONS 89 4.4.7 THEMATIC SATURATION AND TRIANGULATION 91 4.5 DATA ANALYSIS PROCEDURE 92 4.5.1 DECIDING WHAT TO ANALYZE 92 4.5.2 DATA ANALYSIS 93 5. Everyday Life in the Township for Pregnant Xhosa Women and Mothers: Scarcity, Violence, and HIV/AIDS 96 5.1 PRELUDE 96 5.2 INTRODUCTION: EVERYDAY STRUGGLES OF TOWNSHIP LIFE 97 5.3 FOOD INSECURITY 99 5.3.1 FOOD AND LOVE: THE SOCIAL AND AFFECTIVE ASPECTS OF FOOD DISTRIBUTION 99 5.3.2 FOOD AND THE HOUSEHOLD: THE MORAL ECONOMY OF A XHOSA HOUSEHOLD 104 5.3.3 FOOD AND CHILDREN: A MOTHER’S RESPONSIBILITY 117 5.3.3.1 MOTHERS WORRY ABOUT THEIR CHILDREN’S NUTRITIONAL NEEDS 119 5.3.3.2 MOTHERS MUST PROCURE REGULAR AND SUFFICIENT CHILD SUPPORT 123 5.3.3.3 MOTHERS MUST “MAKE A PLAN” TO MAKE SURE THEIR CHILDREN HAVE ENOUGH FOOD 129 5.3.3.4 MOTHERS UNDERSTAND THE HIGH STAKES OF HUNGRY INFANTS 133 5.3.4 DISCUSSION: FOOD INSECURITY 144 5.4 VIOLENCE 146 5.4.1 IN THE NEIGHBORHOOD 147 iii 5.4.2 TOWARD FAMILY MEMBERS AND PARTNERS 151 5.4.3 GENDER VIOLENCE 161 5.4.3.1 INTIMATE PARTNER VIOLENCE 161 5.4.3.2 RAPE 166 5.4.3.3 ABUSE AT THE MATERNITY CLINIC 177 5.4.4 DISCUSSION: VIOLENCE, GENDER VIOLENCE, AND UMBILINI 187 5.5 HIV/AIDS 198 5.5.1 GETTING PREGNANT, GETTING TESTED 200 5.5.2 LIVING WITH HIV 203 5.5.3 DISCUSSION: HIV/AIDS 208 5.6 CONCLUSION 210 5.6.1 THE TOWNSHIP PARADOX 210 5.6.2 CHAPTER SUMMARY 211 6. Xhosa Motherhood: Concepts, Norms, and Relationships 214 6.1 INTRODUCTION 214 6.2 INIMBA: THE XHOSA CONCEPT OF MATERNAL 215 6.2.1 INIMBA IS A SPECIAL BOND THAT ENGENDERS MATERNAL COMPASSION AND EMPATHY 215 6.2.2 INIMBA MAKES MOTHERS CAPABLE OF “AS IF” MOTHERING 219 6.2.3 INIMBA CAN BIAS A MOTHER TOWARD HER CHILD MAKING HER UNJUST OR UNFAIR 224 6.3 LOVE IN THE MOTHER-CHILD RELATIONSHIP: WHAT “GOOD” MOTHERS DO 231 6.3.1 INTERPERSONAL MODE OF SHOWING LOVE 235 6.3.1.1 INITIATING DIALOGUE 235 6.3.1.2 INTERSUBJECTIVITY 237 6.3.1.3 MORALITY 240 6.3.1.4 DISCIPLINE 243 6.3.1.5 OPENNESS 245 6.3.1.6 LACK OF OPENNESS 250 6.3.2 MATERIAL MODE OF SHOWING LOVE 255 6.3.2.1 INTIMACY AND CARE OF PROVIDING 255 6.3.2.2 PROVIDING FOR ADULT CHILDREN 257 6.3.2.3 PROVIDING IN A CONTEXT OF SCARCITY 260 6.3.2.4 MOTHERS WHO DO NOT PROVIDE 264 6.4 DISCUSSION 267 6.5 CONCLUSION 271 7. Becoming a Xhosa Mother: Social and Emotional Transformations 273 7.1 INTRODUCTION 273 7.1.1 REPRODUCTIVE NARRATIVES 273 7.1.2 THE SOCIALITY OF PREGNANCY AND MOTHERHOOD 275 7.2 MAKING PREGNANCY PUBLIC 276 7.2.1 “I WAS SCARED TO TELL HER”: THE DISCOVERY AND DISCLOSURE OF PREGNANCY 276 7.2.2 THE MORALITY OF PREGNANCY 286 7.3 MOTHERS’ MOTHERS 289 7.3.1 “MY MOTHER WILL RAISE THIS CHILD”: THE EMOTIONAL IMPACT OF A MOTHER’S OR MOTHER-FIGURE’S PROMISE TO “HELP” 289 7.3.2 THE PAIN OF HAVING NO MOTHER TO HELP 290 iv 7.4 “MY BABY’S FATHER” 297 7.4.1 BABIES’ FATHERS’ ATTITUDES AND BEHAVIORS AND HOW THEY AFFECT WOMEN’S EMOTIONAL EXPERIENCE OF PREGNANCY 297 7.4.1.1 FATHERS’ UNHAPPINESS: EMOTIONAL AND PRACTICAL CONSEQUENCES 299 7.4.1.2 FATHERS’ HAPPINESS: EMOTIONAL AND PRACTICAL CONSEQUENCES 309 7.4.1.3 “MAYBE THE FATHER WILL CHANGE, YOU KNOW, WHEN THE CHILD IS HERE”: IMAGINING FUTURE SUPPORT 310 7.5 DISCUSSION 317 7.6 CONCLUSION 321 8. Creating an Empathic Community: A Xhosa Way of Coping 325 8.1 INTRODUCTION 325 8.2 UBUNTU: COMMUNALITY AND INTERCONNECTEDNESS IN XHOSA CULTURE 326 8.3 A XHOSA WAY OF COPING 328 8.3.1 IMMEDIATE CONSEQUENCES OF EMOTIONAL DISTRESS 328 8.3.2 THE COPING PROCESS 335 8.3.2.1 SHARING DISTRESS: “I AM FREE” 335 8.3.2.2 COLLECTIVIZATION 343 8.3.2.2 EMPATHY 353 8.3.2.2A INIMBA AS MATERNAL EMPATHY 360 8.3.2.2B ADVICE AS A MODE OF EMPATHY 361 8.4 DISCUSSION 365 8.5 CONCLUSION 372 9. Conclusion 374 9.1 SUMMARY OF FINDINGS 374 9.2 CONTRIBUTIONS TO ANTHROPOLOGY 378 9.3 FUTURE DIRECTIONS 381 9.4 THREE STORIES, REVISITED 383 Appendices 387 APPENDIX A. CHART SUMMARIZING LITERATURE ON PERINATAL DEPRESSION AMONG BLACK WOMEN IN SOUTH AFRICA 387 APPENDIX B. CHARACTERISTICS OF SAMPLE AT RECRUITMENT 388 APPENDIX C. TIMELINE SHOWING NUMBER OF INTERVIEWS PER PARTICIPANT PER MONTH 391 APPENDIX D. TIMELINE OF WHICH INTERVIEWS ARE INCLUDED IN STUDY ANALYSIS: MAY 2010-DECEMBER 2010 392 APPENDIX E. EDINBURGH POSTNATAL DEPRESSION SCALE, ENGLISH VERSION 393 APPENDIX F. EDINBURGH POSTNATAL DEPRESSION SCALE, XHOSA VERSION 395 APPENDIX G. RISK FACTOR ASSESSMENT, ENGLISH VERSION 397 APPENDIX H. RISK FACTOR ASSESSMENT, XHOSA VERSION 398 APPENDIX I. THE MOTHERHOOD INTERVIEW 399 Bibliography 400 v List of Figures FIGURE 1. POLITICAL MAP OF SOUTH AFRICA WITH CAPE TOWN DEMARCATED xvii FIGURE 2. MAP OF CAPE TOWN METROPOLITAN AREA WITH FIELDSITE DEMARCATED xviii FIGURE 3. MODEL OF THE INTERACTION BETWEEN CULTURAL CONTEXT, MOTHERHOOD, MATERIALITY, AND EMOTIONAL EXPERIENCE 6 FIGURE 4. SCHEMATIC OF “THE APARTHEID CITY;” C. 1981 (LEMON 1991:12) 60 FIGURE 5. SCHEMATIC OF SEGREGATION IN CAPE TOWN; C. 1991 (COOK 1991:31) 64 FIGURE 6. PHOTOGRAPHS OF INFORMAL SETTLEMENTS IN TOWNSHIPS NEAR CAPE TOWN; C. 2011 (PHOTOGRAPHS BY THE AUTHOR) 65 FIGURE 7. MODEL OF VARIOUS RESOURCES A MOTHER MAY BE ABLE TO MOBILIZE FOR HERSELF AND HER CHILDREN 146 vi List of Tables TABLE 1.