Community and provider perceptions of traditional and skilled birth attendants providing maternal health care for pastoralist communities in Kenya: a qualitative study

Experiences of midwifery students and graduates in Somalia: evidence from qualitative data

Introduction

Midwives play an important role in maternal and newborn care, yet are in short supply globally. The shortage in midwives is particularly acute in sub-Saharan African countries, many of which are conflict-affected. Midwives face many challenges that impact their workforce participation and retention, and these challenges are often compounded in conflict settings. Somalia ranks among the countries with the highest maternal mortality rate, with an estimated shortage of 20,000 midwives compared to the WHO recommended standard. Yet, limited research has explored the lived experience of midwives in conflict. This qualitative study seeks to explore the experiences, plans, and aspirations of midwifery students and recent graduates from nine midwifery schools in Somalia and to understand how the safety and security situation impacts their educational experience and willingness to join the profession.

Methods

This is a sub-study embedded within a broader prospective multi-cohort study of midwifery students and early career midwives conducted in 2023 and which will continue until 2025. We invited graduates and students in their final year from eight schools in Mogadishu and one school in Galgadud to participate in the study. This study draws on findings from five focus group discussions conducted with midwifery students and graduates who were included in the parent cohort study, for a total sample size of 33 students and graduates. We conducted thematic analysis using a combination of inductive and deductive coding.

Results

Our data illustrates powerful motivation among midwifery students and graduates to join the profession. Motivation was mostly intrinsic, with participants describing their desire to help the mother-baby dyad and to reduce maternal mortality in their communities as the predominant driving force for joining the profession. Yet, participants cited several barriers to entering the workforce, including harmful gender norms that prioritize women's domestic roles over professional aspirations and societal mistrust toward young midwives. Participants stated that their age and gender undermined them professionally and noted the community's preference for older midwives and traditional birth attendants. Safety and security significantly impacted participants' acceptance of job placement in remote areas and students' ability to attend school regularly. In terms of perceived preparedness, graduates felt well prepared for their role but identified gaps in abortion care, neonatal resuscitation, and usage of basic ultrasound.

Conclusion

The challenges faced by midwifery students and newly graduated midwives have direct implications for the health outcomes of mothers and infants in conflict-affected settings. The recurring themes of inadequate training, security risks, and restrictive gender norms require holistic and systematic interventions that address these issues in order to improve motivation and workforce participation among this important health cadre.

Going the extra mile: Developing an interactive mobile application for maternal and infant care for tribal birth attendants

Background

Mobile health applications are an established tool for healthcare management, patient education, and even capacity building for healthcare providers. However, its use among traditional birth attendants (TBAs) is limited. The aim of this study is to explore the needs and bottlenecks of developing an interactive mobile application for maternal and infant care (MAI) of TBAs.

Materials and Methods

It is a qualitative study having in-depth interviews (face-to-face approach) conducted among the seekers of MAI services. Setting: This study is conducted in tribal and rural locations in the district Sirohi, Rajasthan. Participants: TBAs and tribal females of reproductive age in tribal-dominated areas have participated. The development of an interactive mobile application MAI has three phases: (1) a need-based approach to identify the needs on the ground; (2) identifying intervention bottlenecks and possible solutions; (3) design and development of the mobile application.

Results

Ninety-six tribal females of reproductive age participated in the needs assessment. Eighty percent of them were ≤ 30 years of age and 40% of them were uneducated. Most participants informed that lack of information (culturally/locally appropriate content), peer advocacy, affordability, lack of transportation, and the influence of TBAs are the significant factors for less uptake of maternity and child health services in the tribal and rural areas.

Conclusion

The MAI app has culturally/locally appropriate content and is prepared by the local TBAs and Accredited Social Health Activists, with full local character and clothing. MAI app has videos and audio in the local language (Marwari) with pictorial quizzes. Using the MAI app, TBAs may self-educate and guide tribal pregnant women about maternal hygiene and infant healthcare as needed at various stages of pregnancy and childbirth.

Strategies to increase rural maternal utilization of skilled health personnel for childbirth delivery in low- and middle-income countries: a narrative review

BACKGROUND

Skilled attendance at birth is considered key to accomplishing Sustainable Development Goal (SDG) 3.1 aimed at reducing maternal mortality. Many maternal deaths can be prevented if a woman receives care by skilled health personnel. Maternal utilization of skilled health delivery services in rural areas in low- and middle-income countries is 70% compared to 90% in urban areas. Previous studies have found community-based interventions may increase rural maternal uptake of skilled health delivery services, but evidence is lacking on which strategies are most effective.

OBJECTIVE

To review the effectiveness of community-based strategies to increase rural maternal utilization of skilled health personnel for childbirth delivery in low-and middle-income countries.

METHODS

We conducted a narrative review. PubMed, CINAHL, Cochrane Library, and PsycINFO databases were searched for articles from database inception through 13 November 2019. Key search terms were pre-determined. Information was extracted on studies meeting our inclusion criteria: cluster and randomized trials, rural setting, reproductive aged women, community engagement, low- and middle-income countries. Studies were considered effective if statistically significant (p < 0.05). A narrative synthesis was conducted.

RESULTS

Ten cluster randomized trials out of 5,895 candidate citations met the inclusion criteria. Strategies included home-based visits, women's groups, and combined approaches. Out of the ten articles, only three studies were found to significantly increase maternal uptake of skilled health personnel for delivery, and each used a different strategy. The results are inconclusive as to which strategies are most effective. Limitations of this review include heterogeneity and generalizability of studies.

CONCLUSIONS

This research suggests that different strategies may be effective at improving maternal utilization of skilled health personnel for delivery in certain rural settings while ineffective in others. More research is warranted to better understand the context in which strategies may be effective and under what conditions.

Nomadic pastoralists' experience accessing reproductive and maternal healthcare services in low and middle-income countries: A contextual scoping review

Globally, discriminately vulnerable and marginalized groups, such as nomadic pastoralist populations, have perhaps the least access to reproductive and maternal health services (R/MHCSs). Previous studies report that most nomadic pastoralist mothers use both traditional methods of childbirth (i.e. delivering at home and assistance by traditional birth attendants (TBAs)) and traditional methods of contraception. However, determining factors of R/MHCSs in these nomadic pastoralist communities remain scarcely explored and condensed. This study aims to analyse quantitative, qualitative, and mixed methods studies and summarize pastoralists’ experience accessing R/MHCSs in low- and middle-income countries (LMICs).

We employed a mixed method approach in conducting this scoping review by including studies applying quantitative, qualitative, and mixed methods retrieved from online databases (PubMed, Google Scholar, and JSTOR) as well as reviewing indexes of journals specific to the field by using a set of keywords related to R/MHCSs in LMICs. Thematic content analysis was performed to generate four themes and codes.

We retrieved 2131 articles and retained 25 that met our inclusion criteria. Of these, 6 were quantitative studies, 12 were qualitative studies, and 7 were mixed methods studies. We found that nomadic pastoralists face multi-faceted barriers in access to R/MHCS that can be broadly categorized into four themes: (i) physical (geographic isolation and access), (ii) political (discriminatory/marginalized status, poor transport system, lack of infrastructure, and little political status to improve their lives), (iii) economic (poor quality of service/lack of available resources in rural areas where nomadic pastoralists live, vulnerability, poverty/affordability of R/MHCSs), and (iv) socio-cultural (misconceptions, perception, gender roles in decision-making, low demand for R/MHCSs by nomadic pastoralists, autonomy for females to travel) factors. Therefore, to effectively address the needs of nomadic pastoralist populations, R/MHCSs must be available, accessible, acceptable, and affordable through political, economic, geographic, and socio-culturally sensitive approaches.

Low awareness of, and low access to, modern R/MHCSs and their benefits is a critical barrier to service utilization. Partnership with nomad communities through leveraging existing structures, networks, and decision-making patterns and involvement of nomadic women and girls, community leaders, male partners, and trained traditional birth attendants are key to R/MHCS access.

What is known about this topic?

What the study adds

The Addition of Traditional Birth Attendant Care to a Home-Based Skilled Nursing Program in Rural Guatemala: A Secondary Analysis from a Quality Improvement Database

INTRODUCTION

The use of traditional birth attendants (TBAs) in low- and middle-income countries remains controversial. The aim of this secondary analysis was to observe factors associated with visiting a TBA in addition to a skilled nurse for antepartum care and how this additional care was associated with birth characteristics and outcomes.

METHODS

The study included a convenience sample of women living in Southwestern Guatemala enrolled in a community nursing program between October 1, 2018, and December 3, 2019. This analysis describes the sociodemographic characteristics, antepartum care, birth outcomes, and postpartum behaviors of women who received antepartum care with skilled nurses only compared with women who received antepartum care with skilled nurses and a TBA.

RESULTS

Of the 316 enrollees, 259 had given birth and completed their postpartum visit at the time of analysis. Three women were excluded because of missing data. The majority of women in the study sample reported visiting a TBA over the course of their pregnancies (80.9%). Women who saw a TBA in addition to the nurse were similar to the comparator sample except that they were almost 3 times more likely to have 8 or more prenatal contacts with the nurse. In separate multivariable logistic regression models adjusted for number of prenatal visits, women who saw a TBA in addition to nurses had a reduced likelihood of cesarean birth, increased likelihood of birth with a TBA, and increased likelihood of breastfeeding within one hour of birth compared with women who only received antenatal care from nurses. Patient-reported adverse outcomes were not included in the analysis because of low prevalence and concern about data quality and missing data.

DISCUSSION

Among a convenience sample of women in the Trifinio community in rural Guatemala, a large proportion of women continued to seek the care of a TBA in pregnancy while using a skilled nursing program for antenatal care. Intentionally integrating the TBA into the maternity care workforce may be beneficial for improving pregnancy care quality measures.

Understanding Women's Choices: How Women's Perceptions of Quality of Care Influences Place of Delivery in a Rural Sub-County in Kenya. A Qualitative Study

BACKGROUND

Maternal mortality is still unacceptably high in Kenya. The Kenyan Government introduced a free maternity service to overcome financial barriers to access. This policy led to a substantial increase in women's delivery options. This increase in coverage might have led to a reduction in quality of care. This study explores women's perceptions of quality of delivery services in the context of the free policy and how the perceptions lead to the choice of a place for delivery.

METHODS

Our study site was Naivasha sub-County in Kenya, a rural context, whose geography encompasses pastoralists, rural agrarian, and high population density informal settlements near flower farms. Women from this area are from the lowest wealth quintile in Kenya. We conducted a qualitative study to explore the women's perceptions of quality of care based on their experiences during maternity care. The participants were women of reproductive age (18-49 years) attending antenatal care clinics at six health facilities in the sub-county. Six focus group discussions with 55 respondents were used. For inclusion, the women needed to have delivered a baby within the six months preceding the study. Interviews were recorded with consent, translated and transcribed. The interviews were analyzed using a thematic content approach.

RESULTS

Four broad themes that determined the choice of health facility for delivery were identified: women's perceptions of clinical quality of care; the cost of delivery; distance to the health facility and management of primary health facilities. An unexpected theme was the presence of home deliveries amongst pastoralist women. These findings suggest that in this setting both process and structural dimensions of quality of care and financial and physical accessibility influence women's choices for place of delivery.

CONCLUSION

This study expands our understanding of how women make choices regarding place of delivery. Understanding women's perceptions can provide useful insights to policy makers and facility managers on providing high quality patient centered maternity care necessary to sustain the increased utilization of maternity services at health facilities under the free maternity policy and further reductions in maternal mortality.

Community- based maternal and newborn interventions in Africa: Systematic review

AIM AND OBJECTIVES

This review analysed the implementation and integration into healthcare systems of maternal and newborn healthcare interventions in Africa that include community health workers to reduce maternal and newborn deaths.

BACKGROUND

Most neonatal deaths (99%) occur in low- and middle-income countries, with approximately half happening at home. In resource-constrained settings, community-based maternal and newborn care is regarded as a sound programme for improving newborn survival. Health workers can play an important role in supporting families to adopt sound health practices, encourage delivery in healthcare facilities and ensure timeous referral. Maternal and newborn mortality is a major public health problem, particularly in sub-Saharan Africa, where the Millennium Development Goals 4, 5 and 6 were not achieved at the end of 2015.

METHODS

The review includes quantitative, qualitative and mixed-method studies, with a data-based convergent synthesis design being used, and the results grouped into categories and trends. The review took into account the participants, interventions, context and outcome frameworks (PICO), and followed the adapted PRISMA format for reporting systematic reviews of the qualitative and quantitative evidence guide checklist.

RESULTS

The results from the 17 included studies focused on three themes: antenatal, delivery and postnatal care interventions as a continuum. The main components of the interventions were inadequate, highlighting the need for improved planning before each stage of implementation. A conceptual framework of planning and implementation was elaborated to improve maternal and newborn health.

CONCLUSION

The systematic review highlight the importance of thoroughly planning before any programme implementation, and ensuring that measures are in place to enable continuity of services.

RELEVANT TO THE CLINICAL PRACTICE

Conceptual framework of planning and implementation of maternal and newborn healthcare interventions by maternal community health workers.

Access to Maternal Health Services During the COVID-19 Pandemic: Experiences of Indigent Mothers and Health Care Providers in Kilifi County, Kenya

COVID-19 has spread rapidly in Kenya and has not spared pregnant women. Evidence from Kenya shows that during the COVID-19 pandemic, health systems have been either stressed to their maximum capacity or are becoming overwhelmed. However, the population is advised not to attend hospital unless strictly necessary, and this advice seems to apply to all, including expectant mothers. There is a dearth of information on how poor expectant mothers with low bargaining power cope during COVID-19 in Kenya, which this study addresses for those in Kilifi County. This rapid qualitative study draws data from an extensive literature review and from interviews with 12 purposively selected mothers who were either expectant or had newborn babies during the pandemic in Kilifi County. Five matrons-in-charge of maternal health services and four traditional birth attendants were also interviewed via mobile phone. Data were analyzed thematically and are presented in a textual description. It emerged that expectant mothers feared attending hospitals for perinatal care due to the possibility of contracting COVID-19. Therefore, there was an increase in home deliveries with the assistance of traditional birth attendants (TBAs)/traditional midwives, who were also overwhelmed with women who sought their services. Since most causes of maternal morbidity and mortality can be prevented by prompt, suitable treatment by qualified health practitioners, the health officials interviewed recommended training and integration of TBAs in emergency healthcare responses to help during crises in MHS because they are trusted by their local communities. Notably, such integration of traditional midwives should be supported and should also include additional training and monetary incentives.

Health interventions among mobile pastoralists: a systematic review to guide health service design

OBJECTIVE

Mobile pastoralists are one of the last populations to be reached by health services and are frequently missed by health campaigns. Since health interventions among pastoralists have been staged across a range of disciplines but have not yet been systematically characterised, we set out to fill this gap.

METHODS

We conducted a systematic search in PubMed/MEDLINE, Scopus, Embase, CINAL, Web of Science, WHO Catalog, AGRICOLA, CABI, ScIELO, Google Scholar and grey literature repositories to identify records that described health interventions, facilitators and barriers to intervention success, and factors influencing healthcare utilisation among mobile pastoralists. No date restrictions were applied. Due to the heterogeneity of reports captured in this review, data were primarily synthesised through narrative analysis. Descriptive statistical analysis was performed for data elements presented by a majority of records.

RESULTS

Our search yielded 4884 non-duplicate records, of which 140 eligible reports were included in analysis. 89.3% of reports presented data from sub-Saharan Africa, predominantly in East Africa (e.g. Ethiopia, 30.0%; Kenya, 17.1%). Only 24.3% of reports described an interventional study, while the remaining 75.7% described secondary data of interest on healthcare utilisation. Only two randomised controlled trials were present in our analysis, and only five reports presented data on cost. The most common facilitators of intervention success were cultural sensitivity (n = 16), community engagement (n = 12) and service mobility (n = 11).

CONCLUSION

Without adaptations to account for mobile pastoralists' unique subsistence patterns and cultural context, formal health services leave pastoralists behind. Research gaps, including neglect of certain geographic regions, lack of both interventional studies and diversity of study design, and limited data on economic feasibility of interventions must be addressed to inform the design of health services capable of reaching mobile pastoralists. Pastoralist-specific delivery strategies, such as combinations of mobile and 'temporary fixed' services informed by transhumance patterns, culturally acceptable waiting homes, community-directed interventions and combined joint human-animal One Health design as well as the bundling of other health services, have shown initial promise upon which future work should build.

Health services uptake among nomadic pastoralist populations in Africa: A systematic review of the literature

The estimated 50 million nomadic pastoralists in Africa are among the most "hard-to-reach" populations for health-service delivery. While data are limited, some studies have identified these communities as potential disease reservoirs relevant to neglected tropical disease programs, particularly those slated for elimination and eradication. Although previous literature has emphasized the role of these populations' mobility, the full range of factors influencing health service utilization has not been examined systematically. We systematically reviewed empirical literature on health services uptake among African nomadic pastoralists from seven online journal databases. Papers meeting inclusion criteria were reviewed using STROBE- and PRISMA-derived guidelines. Study characteristics were summarized quantitatively, and 10 key themes were identified through inductive qualitative coding. One-hundred two papers published between 1974-2019 presenting data from 16 African countries met our inclusion criteria. Among the indicators of study-reporting quality, limitations (37%) and data analysis were most frequently omitted (18%). We identified supply- and demand-side influences on health services uptake that related to geographic access (79%); service quality (90%); disease-specific knowledge and awareness of health services (59%); patient costs (35%); contextual tailoring of interventions (75%); social structure and gender (50%); subjects' beliefs, behaviors, and attitudes (43%); political will (14%); social, political, and armed conflict (30%); and community agency (10%). A range of context-specific factors beyond distance to facilities or population mobility affects health service uptake. Approaches tailored to the nomadic pastoralist lifeway, e.g., that integrated human and veterinary health service delivery (a.k.a., "One Health") and initiatives that engaged communities in program design to address social structures were especially promising. Better causal theorization, transdisciplinary and participatory research methods, clearer operational definitions and improved measurement of nomadic pastoralism, and key factors influencing uptake, will improve our understanding of how to increase accessibility, acceptability, quality and equity of health services to nomadic pastoralist populations.

Maternal and neonatal service delivery by traditional birth attendants in rural Benin: A case for integration?

The Republic of Benin faces high maternal, newborn and child (MNCH) morbidity and mortality. Traditional birth attendants (TBAs) continue to operate on the margins of the health system yet provide critical services to women and children. This study aims to further the understanding of TBA's scope of practice for developing appropriate strategies to strengthen MNCH services at the community-level. TBAs were identified and surveyed on education, training, system support and scope of practice including management of obstetric and newborn emergencies. TBAs were found to perform diverse preventive and health promotion activities, including antenatal and newborn care counselling, promotion of family planning and immunizations. Among 109 TBAs, 11,102 births were documented in the prior year with a maternal mortality ratio (MMR) of 790/100,000 and neonatal mortality rate (NMR) 12.2/1000. The scope of TBA practices is broad and rural communities rely on this cadre for services. However, TBAs report higher rates of adverse maternal events compared to national statistics. Better understanding is needed on community preferences, training and methods of participation of TBAs within the health system. This could improve identification and referral for emergencies, reinforce safer practices and increase preventive and promotive health activities at the community level.

'Leaving no one behind': a scoping review on the provision of sexual and reproductive health care to nomadic populations

BACKGRUND

Marginalized groups, such as nomadic populations across the world, have perhaps the least access to modern reproductive health (RH) services. This scoping review aims to identify barriers to access to RH services faced by nomadic populations from the existing literature and to highlight possible opportunities to address them.

METHODS

Key databases, including PubMed, Popline, Google Scholar, and Google Advanced were searched for relevant articles published between 2002 and 2019. A total 344 articles were identified through database online searches, and 31 were included in the review.

RESULTS

Nomadic people face complex barriers to healthcare access that can be broadly categorized as external (geographic isolation, socio-cultural dynamics, logistical and political factors) and internal (lifestyle, norms and practices, perceptions) factors. To effectively address the needs of nomadic populations, RH services must be available, accessible and acceptable through tailored and culturally sensitive approaches. A combination of fixed and mobile services has proven effective among mobile populations. Low awareness of modern RH services and their benefits is a major barrier to utilization. Partnership with communities through leveraging existing structures, networks and decision-making patterns can ensure that the programmes are effectively implemented.

CONCLUSION

Further research is needed to better understand and address the RH needs of nomadic populations. Though existing evidence is limited, opportunities do exist and should be explored. Raising awareness and sensitization training among health providers about the specific needs of nomads is important. Improved education and access to information about the benefits of modern RH care among nomadic communities is needed. Ensuring community participation through involvement of nomadic women and girls, community leaders, male partners, and trained traditional birth attendants are key facilitators in reaching nomads. However, participatory programmes also need to be recognized and supported by governments and existing health systems.

Adapting the 2015 Mother-Baby Friendly Birth Facility Guidelines for Semi-nomadic Pastoralist Communities in Laikipia and Samburu Counties of Kenya

Purpose To adapt the 2015 International Federation of Gynecologists and Obstetricians (FIGO), International Confederation of Midwives (ICM), White Ribbon Alliance (WRA), International Pediatric Association (IPA), and WHO auspiced Guidelines on Mother-Baby Friendly Facilities to a particular sub-population; seminomadic pastoralist communities of Laikipia and Samburu Counties, Kenya. We anticipate an increased utilization of childbirth services by improving their acceptability. Description We drafted a Pastoralist Friendly Birthing Facility Checklist based on the FIGO/ICM/WRA/IPA/WHO guidelines and previous research in this context. We employed mixed methods to finalise the adaptation: a workshop with 27 local stakeholders; interviews with ten health planners and skilled birth attendants (SBAs); and ten focus group discussions (FGDs) with health committee members, community health workers, mothers and traditional birth attendants (TBAs). A facility audit of dispensaries across five group ranches was also undertaken. Assessment The final Checklist was divided into: characteristics of care and the environment; care during labour and birth; post-partum care; and community staff relationships. It was endorsed by the Ministries of Health in the relevant counties, and by women, SBAs and TBAs. No facility currently satisfies all the criteria specified in the Checklist. Conclusion The FIGO/ICM/WRA/IPA/WHO Guidelines were successfully adapted and can be used to ensure health facilities meet the needs of pastoralist women.

Men's perception of barriers to women's use and access of skilled pregnancy care in rural Nigeria: a qualitative study

BACKGROUND

Greater paternal engagement is positively associated with improved access to and utilization of maternal services. Despite evidence that male involvement increased uptake of maternal and child services, studies show that few men are participating in MNCH programs. Community leaders have long been engaged in public health promotion in rural settings and have been shown to mobilize communities to enhance changes in cultural practices related to public health. With the ultimate goal of increasing men's involvement in maternal health, this study seeks to understand men's perceptions of community and health systems barriers to maternal access and usage of skilled care in rural Edo, Nigeria.

METHODS

This qualitative study involved the analysis of data collected from community conversations with male elders in Etsako East and Esan South East Local Government Areas of Edo State, Nigeria. Community conversations participants (n = 128) comprised of elders between the ages of 50-101. A total of 9 community conversations were conducted. Discussions were audio recorded, transcribed and imported into Atlas.ti 6.2 for content analysis.

RESULTS

Men's perceptions of barriers to maternal use of skilled care are presented in two overarching themes: community systems and health systems. Three sub themes were generated as community systems barriers to maternal healthcare use, they include: gender roles, traditional treatment and policy changes. Three sub themes emerged under health system barriers and they include: cost of health facilities, dissatisfaction with facilities and distance from facilities.

CONCLUSION

Findings suggest that community elders are not only in a good position to influence men's behavior, they are also a source of information to policy makers on strategies to overcome barriers to maternal health, especially at the community level. Furthermore, community elders need support to enact regulations that will promote men's involvement in maternal health, thereby increasing maternal use of skilled care.

Impact of the free healthcare initiative on wealth-related inequity in the utilization of maternal & child health services in Sierra Leone

BACKGROUND

As a result of financial barriers to the utilization of Maternal and Child Health (MCH) services, the Government of Sierra Leone launched the Free Health Care Initiative (FHCI) in 2010. This study aimed to examine the impact of the FHCI on wealth related inequity in the utilization of three MCH services.

METHODS

We analysed data from 2008 to 2013 Sierra Leone Demographic Health Surveys (SLDHS) using 2008 SLDHS as a baseline. Seven thousand three hundred seventy-four and 16,658 women of reproductive age were interviewed in the 2008 and 2013 SLDHS respectively. We employed a binomial logistic regression to evaluate wealth related inequity in the utilization of institutional delivery. Concentration curves and indices were used to measure the inequity in the utilization of antenatal care (ANC) visits and postnatal care (PNC) reviews. Test of significance was performed for the difference in odds and concentration indexes obtained for the 2008 and 2013 SLDHS.

RESULTS

There was an overall improvement in the utilization of MCH services following the FHCI with a 30% increase in institutional delivery rate, 24% increment in more than four focused ANC visits and 33% increment in complete PNC reviews. Wealth related inequity in institutional delivery has increased but to the advantage of the rich, highly educated, and urban residents. Results of the inequity statistics demonstrate that PNC reviews were more equally distributed in 2008 than ANC visits, and, in 2013, the poorest respondents ranked by wealth index utilized more PNC reviews than their richest counterparts. For ANC visits, the change in concentration index was from 0.008331[95% CI (0.008188, 0.008474)] in 2008 to - 0.002263 [95% CI (- 0.002322, - 0.002204)] in 2013. The change in concentration index for PNC reviews was from - 0.001732 [95% CI (- 0.001746, - 0.001718)] in 2008 to - 0.001771 [95% CI (- 0.001779, - 0.001763)] in 2013. All changes were significant (p value < 0.001).

CONCLUSION

The FHCI appears to be improving access to and utilization of MCH services, narrowing the inequity in ANC visits and PNC reviews, but is insufficient in addressing wealth- related inequity that exists for institutional deliveries. If Sierra Leone is to realize a significant reduction in maternal and child mortality rates, it needs to strengthen the effective implementation of FHCI considering incorporating a sector wide approach (SWAp) or a "Health in all Policy" framework to reach the less educated, rural residents and ensuring culturally sensitive quality services.

Repositioning traditional birth attendants to provide improved maternal healthcare services in rural Ghana

Following the World Health Organization's recommendation for developing countries to discontinue the use of Traditional Birth Attendants (TBAs) in rural areas, the government of Ghana banned TBAs from offering maternal health care services. Since this ban, community-level conflicts have intensified between TBAs, (who still see themselves as legitimate culturally mandated traditional midwives) and nurses. In this articles, we propose a partnership model for a sustainable resolution of these conflicts. This article emanates from the apparent ideological discontent between people from mainstream medical practice who advocate for the complete elimination of TBAs in the maternal health service space and individuals who argue for the inclusion of TBAs in the health sector given the shortage of skilled birth attendants and continued patronage of their services by rural women even in context where nurses are available. In the context of the longstanding manpower deficit in the health sector in Ghana, improving maternal healthcare in rural communities will require harnessing all locally available human resources. This cannot be achieved by "throwing out" a critical group of actors who have been involved in health-care provision for many decades. We propose a win-win approach that involve retraining of TBAs, partnership with health practitioners, and task shifting.

Pregnant Women's Intentions to Deliver at a Health Facility in the Pastoralist Communities of Afar, Ethiopia: An Application of the Health Belief Model

Despite the significant benefits of giving birth at a health facility to improve maternal and child health, the practice remains lower than expected in pastoralist communities of Ethiopia. Understanding the intentions of pregnant women to use health facilities for delivery predicts the adoption of the behavior, yet documented evidence of intention in the context of pastoralist populations remains scarce. The current study aimed to assess pregnant women’s intentions to use a health facility for delivery in the Afar region of Ethiopia using the framework of the health belief model (HBM). A community-based, cross sectional survey was conducted from April 1 to April 30 2016 among 357 randomly sampled pregnant women using an interviewer-administered, semi-structured questionnaire. Data were entered into EpiData and exported to SPSS version 20.0 for analysis. Principal component factor analysis was done to extract relevant constructs of the model, and the reliability of items in each construct was assessed for acceptability. Multivariate logistic regressions were applied to identify predictors of pregnant women’s intentions to give birth at a health facility. The odds ratio was reported, and statistical significance was declared at 95% CI and 0.05 p value. Three hundred fifty seven pregnant women participated in the study (104.6% response rate indicating above the minimum sample size required). Among the respondents, only 108 (30.3%) participants intended to use a health facility for the delivery for their current pregnancy. Higher household average monthly income [AOR = 1.23, 95% CI = (1.10 − 2.90), antenatal clinic (ANC) attendance for their current pregnancy [AOR = 1.41, 95% CI = (1.31 − 2.10), perceived susceptibility to delivery-related complications [AOR = 1.52, 95% CI = (1.30 − 2.70), and perceived severity of the delivery complications [AOR = 1.66, 95% CI = (1.12 − 2.31) were positively associated with pregnant women’s intentions to deliver at a health facility. Intention was negatively associated with participants’ perceived barriers to accessing a health facility [AOR = 0.62, 95% CI = (0.36 − 0.85). Conclusions: A low proportion of pregnant women in the sampled community intended to deliver at a health facility. Pastoralist communities may have special needs in this regard, with household income, antenatal care attendance, perceived risk of complications, and perceived barriers to accessing a health facility largely explaining the variance in intention. Community-based interventions providing counseling and messaging on danger signs in the perinatal period and emphasizing benefits of delivering at a facility are recommended, alongside improving access.

Community perceptions towards the new role of traditional birth attendants as birth companions and nutrition advocates in Kakamega County, Kenya

Delivery with skilled birth attendants is important for reducing maternal mortality in developing countries. However, traditional birth attendants (TBAs) are abundant in such settings, managing deliveries without the skills and resources necessary to prevent mortality in this situations. Interventions that have been proposed to mitigate the situation include redefining the role of TBAs to nutrition advocates and birth companions for pregnant women to health facilities. We thus explored community perceptions on these new roles of TBAs, as birth companions and nutrition advocates, and their influence on health facility deliveries in Kakamega County, Kenya. Qualitative data was collected through key informant interviews with health workers and focus group discussions with lactating mothers, pregnant women, husbands, community leaders, community health volunteers, and TBA. Content analysis was conducted; data was organized into subthemes and conclusions made from each subtheme using Atlas.ti software. TBAs adopted their birth companion role as the majority offered companionship to mothers delivering at health facilities. Mothers were happy with this role as TBAs continued providing companionship even after delivery. The community members were happy with the new role of TBAs and reported increased deliveries at the health facilities. In contrast, TBAs did not adopt the nutrition advocacy role sufficiently. We found that redefining the role of the TBAs into birth companions to support facility-based delivery is thus feasible and acceptable. Nutrition advocacy by the TBAs should be strengthened to maximize on the opportunity provided by the close association between TBAs and mothers and the community.

Childhood vaccination in Kenya: socioeconomic determinants and disparities among the Somali ethnic community

OBJECTIVES

Kenya has a significant refugee population, including large numbers of Somali migrants. This study examines the vaccination status of Kenyan children and sociodemographic predictors of vaccination, including Somali ethnicity.

METHODS

Using the 2014 Kenyan Demographic and Health Survey, we calculated the proportion of non-vaccinated, under-vaccinated, and fully vaccinated children, defining full vaccination as one dose Bacille Calmette-Guerin, three doses polio, three doses pentavalent, and one dose measles. We assessed associations among various factors and vaccination status using multinomial logistic regression and explored the effect of Somali ethnicity through interaction analysis.

RESULTS

The study sample comprised 4052 children aged 12-23 months, with 79.4% fully, 19.0% under-, and 1.6% non-vaccinated. Among Somalis, 61.9% were fully, 28.7% under-, and 9.4% non-vaccinated. Somalis had significantly greater odds of under- and non-vaccination than the Kikuyu ethnic group. Wealth and birth setting were associated with immunization status for Somalis and non-Somalis.

CONCLUSIONS

Disparities persist in pediatric vaccinations in Kenya, with Somali children more likely than non-Somalis to be under-vaccinated. Health inequalities among migrants and ethnic communities in Kenya should be addressed.

Vaccination timeliness and co-administration among Kenyan children

BACKGROUND

Timely administration of recommended vaccines requires children to have multiple vaccines co-administered in the first year of life. The objectives of this study were to estimate the proportion of timely vaccinations and the proportion of co-administered vaccines, and to assess the relationship between vaccine co-administration and vaccine timeliness in Kenyan children.

METHODS

Using the 2014 Kenyan Demographic and Health Survey (DHS), we calculated the proportion of children who received co-administered and timely vaccine doses. Co-administration was defined as doses administered on the same day with dates recorded on vaccination cards. Vaccines were considered timely if given within four days before to four weeks after the recommended interval for administration.

RESULTS

10,385 children aged 1-4 years in the Kenyan 2014 DHS dataset had vaccination cards which comprised the study sample. Analysis revealed wide a range for receipt of timely doses, from 90.2% for OPV0 to 56.0% for Measles. Co-administration of the 6-week dose was associated with 2.81 times higher odds of a timely Penta dose 1 (95% CI: 2.28, 3.46) and birth-dose co-administration was associated with a substantial increase in timely BCG vaccination: AOR 7.43 (95% CI: 6.31, 8.75).

CONCLUSIONS

Though vaccine coverage in Kenya was high, timely vaccination was markedly low, with resultant implications for population immunity and potential spread of communicable diseases in unvaccinated infants. Co-administration of vaccines, place of residence, wealth index, and child age were consistently related to the odds of timely vaccine receipt. These relationships reinforce the importance of dedicating resources to programs that educate low socio-economic groups about the importance of vaccine co-administration.

Women's perceived barriers to giving birth in health facilities in rural Kenya: A qualitative evidence synthesis

BACKGROUND

In Kenya, uptake of skilled care during birth remains lower in rural areas when compared to urban areas, despite efforts by the government to encourage facility-based births by abolishing maternity fees in public health facilities.

OBJECTIVE

To synthesise published and unpublished qualitative research that explores women's perceived barriers to facility-based birth in rural Kenya.

DESIGN

Qualitative evidence synthesis DATA SOURCES: Multiple electronic databases (MEDLINE, EMBASE, PsycINFO, POPLINE, CINAHL, Web of Science and ProQuest), grey literature searches, citation chaining and checking of reference lists.

REVIEW METHODS

Studies were screened by title, abstract and full text, after which a standardised qualitative checklist was used to assess study quality. Synthesis of extracted data followed the 'best-fit' framework method, enhanced with a pathway-based model for the improvement of maternal and newborn care.

RESULTS

Sixteen eligible studies were identified. Key themes were: (i) knowledge, attitudes and practices, including past experiences of health facilities and community beliefs about facility services; (ii) insufficient demand for professional care caused by the perceived advantages of seeking alternative care during birth and the disadvantages of facility-based births; (iii) limited access to services, especially in rural areas, because of poor infrastructure; (iv) misconceptions regarding labour characteristics and, (v) poor awareness of labour outcomes.

CONCLUSIONS

Important factors can be characterised as 'push' factors (those pushing women away from facilities) and 'pull' factors (those related to the relative advantage of facility-based births). However, key to an individual woman's decision are factors relating to knowledge, attitudes and practices and awareness of labour outcomes. While a critical tension exists between government policy and consumer choice, the prevalence of inadequate awareness and the dominance of past experiences and community beliefs offer significant obstacles to a woman in making an informed choice about her preferred place of giving birth.

Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population

BACKGROUND

Person-centered reproductive health care is recognized as critical to improving reproductive health outcomes. Yet, little research exists on how to operationalize it. We extend the literature in this area by developing and validating a tool to measure person-centered maternity care. We describe the process of developing the tool and present the results of psychometric analyses to assess its validity and reliability in a rural and urban setting in Kenya.

METHODS

We followed standard procedures for scale development. First, we reviewed the literature to define our construct and identify domains, and developed items to measure each domain. Next, we conducted expert reviews to assess content validity; and cognitive interviews with potential respondents to assess clarity, appropriateness, and relevance of the questions. The questions were then refined and administered in surveys; and survey results used to assess construct and criterion validity and reliability.

RESULTS

The exploratory factor analysis yielded one dominant factor in both the rural and urban settings. Three factors with eigenvalues greater than one were identified for the rural sample and four factors identified for the urban sample. Thirty of the 38 items administered in the survey were retained based on the factors loadings and correlation between the items. Twenty-five items load very well onto a single factor in both the rural and urban sample, with five items loading well in either the rural or urban sample, but not in both samples. These 30 items also load on three sub-scales that we created to measure dignified and respectful care, communication and autonomy, and supportive care. The Chronbach alpha for the main scale is greater than 0.8 in both samples, and that for the sub-scales are between 0.6 and 0.8. The main scale and sub-scales are correlated with global measures of satisfaction with maternity services, suggesting criterion validity.

CONCLUSIONS

We present a 30-item scale with three sub-scales to measure person-centered maternity care. This scale has high validity and reliability in a rural and urban setting in Kenya. Validation in additional settings is however needed. This scale will facilitate measurement to improve person-centered maternity care, and subsequently improve reproductive outcomes.

Knowledge, attitudes and practices of traditional birth attendants in pastoralist communities of Laikipia and Samburu counties, Kenya: a cross-sectional survey

INTRODUCTION

Current efforts to reduce maternal and newborn mortality focus on promoting institutional deliveries with skilled birth attendants (SBAs), and discouraging deliveries at home attended by traditional birth attendants (TBAs). In rural Kenya, semi-nomadic pastoralist communities are underserved by the formal health system, experience high maternal and neonatal mortality, and rely primarily on TBAs for delivery care, despite Government proscription of TBA-assisted births. This study examined the knowledge, attitude and practices of TBAs serving these communities to assess the potential for collaboration between TBAs and SBAs.

METHODS

A cross-sectional, interviewer-administered survey was conducted among 171 TBAs from Maasai and Samburu pastoralist communities in Laikipia and Samburu counties, Kenya, as part of a larger mixed-methods study in partnership with a local service provider.

RESULTS

BAs were relatively elderly (mean age 59.6 years), and attended an average of 5-6 deliveries per year. A minority (22.2%) had received formal training. They provided antenatal, intra-partum and post-partum care. Most TBA care was non-interventionist, but not necessarily consistent with best practice. Most had encountered birth complications, but knowledge regarding management of complications was sub-optimal. Most had previously referred at least one woman to a health facility (80.1%), were key participants in decision making to refer women (96.5%), and had been present at an institutional delivery (54.4%).

CONCLUSION

TBAs continue to be key providers of maternal and neonatal healthcare in regions where the formal health system has poor coverage or acceptability. Strengthening existing TBA/SBA collaborations could improve both community links to the formal health system, and the quality of care provided to pastoralist women, while remaining consistent with current Government policy.