The role of cultural safety and ethical space within postcolonial healthcare for Maasai in Tanzania

The history of the Maasai tribe in northern Tanzania is characterised by marginalisation, discrimination and political subjugation. Inequities, enacted through power relations, influence healthcare access, practices and outcomes among the Maasai. Cultural safety and ethical space provide lenses into social, political and historical influences on access to care, helping to understand the realities of historically marginalised populations such as the Maasai, and responses to health services. This study aims to examine Maasai experiences of accessing and uptake of health services within a postcolonial discourse in Tanzania. In an ethnographic study examining access and perceptions of healthcare services in Maasai communities, lead authors conducted participant observations and at health facilities to document experiences. Household interviews, a group oral history and interviews with NGOs working with Maasai communities, contributed to the data analysed. Inductive thematic analysis was used to understand healthcare experiences within a framework of cultural safety and ethical space. Despite trust in biomedicine, Maasai people have a strong desire for health services with particular characteristics. Quality of care, including facilities and diagnostics available and used, was important. A sense of fairness was a determinant in respecting services including 'first come first serve' system and transparency when unable to treat a condition. Trust in health services was also influenced by personal interactions with health workers, including provision of health information provided to patients and instances of being mistreated. These findings offer an understanding of ways in which spaces of healthcare can be more approachable and trusted by Maasai. Incorporating cultural safety and ethical spaces to understand healthcare access can help to reduce the power imbalance possibly resulting from a history of marginalisation. This can inform development of culturally appropriate programmes, used to educate healthcare professionals and advocate for improved healthcare services for marginalised groups.

Factors influencing adoption of facility-assisted delivery - a qualitative study of women and other stakeholders in a Maasai community in Ngorongoro District, Tanzania

Background

Tanzania’s One Plan II health sector program aims to increase facility deliveries from 50 to 80% from 2015 to 2020. Success is uneven among certain Maasai pastoralist women in Northern Tanzania who robustly prefer home births to facility births even after completing 4+ ANC visits. Ebiotishu Oondomonok Ongera (EbOO) is a program in Nainokanoka ward to promote facility births through a care-group model using trained traditional birth attendants (TBAs) as facilitators. Results to date are promising but show a consistent gap between women completing ANC and those going to a facility for delivery. A qualitative study was conducted to understand psychosocial preferences, agency for decision-making, and access barriers that influence where a woman in the ward will deliver.

Methods

In-depth interviews, focus group discussions and key-informant interviews were conducted with 24 pregnant and/or parous women, 24 TBAs, 3 nurse midwives at 3 health facilities, and 24 married men, living in Nainokanoka ward. Interviews and discussions were transcribed, translated, and analyzed thematically using a grounded theory approach.

Results

Most women interviewed expressed preference for a home birth with a TBA and even those who expressed agency and preference for a facility birth usually had their last delivery at home attributed to unexpected labor. TBAs are engaged by husbands and play a significant influential role in deciding place of delivery. TBAs report support for facility deliveries but in practice use them as a last resort, and a significant trust gap was documented based on a bad experience at a facility where women in labor were turned away.

Conclusions

EbOO project data and study results show a slow but steady change in norms around delivery preference in Nainokanoka ward. Gaps between expressed intention and practice, especially around ‘unexpected labor’ present opportunities to accelerate this process by promoting birth plans and perhaps constructing a maternity waiting house in the ward. Rebuilding trust between facility midwives, TBAs, and the community on the availability of health facility services, and increased sensitivity to women’s cultural preferences, could also close the gap between the number of women who are currently using facilities for ANC and those returning for delivery.

Adapting the capacities and vulnerabilities approach: a gender analysis tool

Gender analysis methodology is increasingly being considered as essential to health research because 'women's social, economic and political status undermine their ability to protect and promote their own physical, emotional and mental health, including their effective use of health information and services' {World Health Organization [Gender Analysis in Health: a review of selected tools. 2003; www.who.int/gender/documents/en/Gender.

ANALYSIS

pdf (20 February 2008, date last accessed)]}. By examining gendered roles, responsibilities and norms through the lens of gender analysis, we can develop an in-depth understanding of social power differentials, and be better able to address gender inequalities and inequities within institutions and between men and women. When conducting gender analysis, tools and frameworks may help to aid community engagement and to provide a framework to ensure that relevant gendered nuances are assessed. The capacities and vulnerabilities approach (CVA) is one such gender analysis framework that critically considers gender and its associated roles, responsibilities and power dynamics in a particular community and seeks to meet a social need of that particular community. Although the original intent of the CVA was to guide humanitarian intervention and disaster preparedness, we adapted this framework to a different context, which focuses on identifying and addressing emerging problems and social issues in a particular community or area that affect their specific needs, such as an infectious disease outbreak or difficulty accessing health information and resources. We provide an example of our CVA adaptation, which served to facilitate a better understanding of how health-related disparities affect Maasai women in a remote, resource-poor setting in Northern Tanzania.

Factors influencing implementation of interventions to promote birth preparedness and complication readiness

BACKGROUND

The recent WHO report on health promotion interventions for maternal and newborn health recommends birth preparedness and complications readiness interventions to increase the use of skilled care at birth and to increase timely use of facility care for obstetric and newborn complications. However, these interventions are complex and relate strongly to the context in which they are implemented. In this article we explore factors to consider when implementing these interventions.

METHODS

This paper reports a secondary analysis of 64 studies on birth preparedness and complication readiness interventions identified through a systematic review and updated searches. Analysis was performed using the Supporting the Use of Research Evidence (SURE) framework to guide thematic analysis of barriers and facilitators for implementation.

RESULTS

Differences in definitions, indicators and evaluation strategies of birth preparedness and complication readiness interventions complicate the analysis. Although most studies focus on women as the main target group, multi-stakeholder participation with interventions occurring simultaneously at both community and facility level facilitated the impact on seeking skilled care at birth. Increase in formal education for women most likely contributed positively to results. Women and their families adhering to traditional beliefs, (human) resource scarcities, financial constraints of women and families and mismatches between offered and desired maternity care services were identified as key barriers for implementation.

CONCLUSIONS

Implementation of birth preparedness and complication readiness to improve the use of skilled care at birth can be facilitated by contextualizing interventions through multi-stakeholder involvement, targeting interventions at multiple levels of the health system and ensuring interventions and program messages are consistent with local knowledge and practices and the capabilities of the health system.

Factors influencing place of delivery for pastoralist women in Kenya: a qualitative study

BACKGROUND

Kenya's high maternal mortality ratio can be partly explained by the low proportion of women delivering in health facilities attended by skilled birth attendants (SBAs). Many women continue to give birth at home attended by family members or traditional birth attendants (TBAs). This is particularly true for pastoralist women in Laikipia and Samburu counties, Kenya. This paper investigates the socio-demographic factors and cultural beliefs and practices that influence place of delivery for these pastoralist women.

METHODS

Qualitative data were collected in five group ranches in Laikipia County and three group ranches in Samburu County. Fifteen in-depth interviews were conducted: seven with SBAs and eight with key informants. Nineteen focus group discussions (FGDs) were conducted: four with TBAs; three with community health workers (CHWs); ten with women who had delivered in the past two years; and two with husbands of women who had delivered in the past two years. Topics discussed included reasons for homebirths, access and referrals to health facilities, and strengths and challenges of TBAs and SBAs. The data were translated, transcribed and inductively and deductively thematically analysed both manually and using NVivo.

RESULTS

Socio-demographic characteristics and cultural practices and beliefs influence pastoralist women's place of delivery in Laikipia and Samburu counties, Kenya. Pastoralist women continue to deliver at home due to a range of factors including: distance, poor roads, and the difficulty of obtaining and paying for transport; the perception that the treatment and care offered at health facilities is disrespectful and unfriendly; lack of education and awareness regarding the risks of delivering at home; and local cultural values related to women and birthing.

CONCLUSIONS

Understanding factors influencing the location of delivery helps to explain why many pastoralist women continue to deliver at home despite health services becoming more accessible. This information can be used to inform policy and program development aimed at increasing the proportion of facility-based deliveries in challenging settings.

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

Background

Kenya has a high burden of maternal and newborn mortality. Consequently, the Government of Kenya introduced health system reforms to promote the availability of skilled birth attendants (SBAs) and proscribed deliveries by traditional birth attendants (TBAs). Despite these changes, only 10 % of women from pastoralist communities are delivered by an SBA in a health facility, and the majority are delivered by TBAs at home. The aim of this study is to better understand the practices and perceptions of TBAs and SBAs serving the remotely located, semi-nomadic, pastoralist communities of Laikipia and Samburu counties in Kenya, to inform the development of an SBA/TBA collaborative care model.

Methods

This descriptive qualitative study was undertaken in 2013–14. We conducted four focus group discussions (FGDs) with TBAs, three with community health workers, ten with community women, and three with community men. In-depth interviews were conducted with seven SBAs and eight key informants. Topic areas covered were: practices and perceptions of SBAs and TBAs; rewards and challenges; managing obstetric complications; and options for SBA/TBA collaboration. All data were translated, transcribed and thematically analysed.

Results

TBAs are valued and accessible members of their communities who adhere to traditional practices and provide practical and emotional support to women during pregnancy, delivery and post-partum. Some TBA practices are potentially harmful to women e.g., restricting food intake during pregnancy, and participants recognised that TBAs are unable to manage obstetric complications. SBAs are acknowledged as having valuable technical skills and resources that contribute to safe and clean deliveries, especially in the event of complications, but there is also a perception that SBAs mistreat women. Both TBAs and SBAs identified a range of challenges related to their work, and instances of mutual respect and informal collaborations between SBAs and TBAs were described.

Conclusions

These findings clearly indicate that an SBA/TBA collaborative model of care consistent with Kenyan Government policy is a viable proposition. The transition from traditional birth to skilled birth attendance among the pastoralist communities of Laikipia and Samburu is going to be a gradual one, and an interim collaborative model is likely to increase the proportion of SBA assisted deliveries, improve obstetric outcomes, and facilitate the transition.

"We have been working overnight without sleeping": traditional birth attendants' practices and perceptions of post-partum care services in rural Tanzania

BACKGROUND

In many low-income countries, formal post-partum care utilization is much lower than that of skilled delivery and antenatal care. While Traditional Birth Attendants (TBAs) might play a role in post-partum care, research exploring their attitudes and practices during this period is scarce. Therefore, the aim of this study was to explore TBAs' practices and perceptions in post-partum care in rural Tanzania.

METHODS

Qualitative in-depth interview data were collected from eight untrained and three trained TBAs. Additionally, five multiparous women who were clients of untrained TBAs were also interviewed. Interviews were conducted in February 2013. Data were digitally recorded and transcribed verbatim. Qualitative content analysis was used to analyze data.

RESULTS

Our study found that TBAs take care of women during post-partum with rituals appreciated by women. They report lacking formal post-partum care training, which makes them ill-equipped to detect and handle post-partum complications. Despite their lack of preparation, they try to provide care for some post-partum complications which could put the health of the woman at risk. TBAs perceive that utilization of hospital-based post-partum services among women was only important for the baby and for managing complications which they cannot handle. They are poorly linked with the health system.

CONCLUSIONS

This study found that the TBAs conducted close follow-ups and some of their practices were appreciated by women. However, the fact that they were trying to manage certain post-partum complications can put women at risk. These findings point out the need to enhance the communication between TBAs and the formal health system and to increase the quality of the TBA services, especially in terms of prompt referral, through provision of training, mentoring, monitoring and supervision of the TBA services.