Background
Traditional birth attendants (TBAs) are lay community members, mostly women, who assist with childbirth, and who are commonplace in many low-income settings. The story of TBAs in global maternal health programming has been characterised by both engagement and exclusion. In the 1970s and 1980s the efforts to reduce maternal mortality focused on training TBAs to provide safer delivery care. However, the impact of this strategy on maternal mortality was negligible as TBAs are not equipped to manage maternal complications, and risk screening for complicated deliveries is poorly predictive of outcomes [
1]. Consequently, the focus in the 1990s was on scaling up access to skilled birth attendants (SBAs), who are trained health workers such as nurses, midwives and doctors, able to manage complicated deliveries and resuscitate newborn babies, and who mostly work in health facilities [
2]. The shift to SBAs as the preferred provider of maternal health care was clearly reflected in the Millennium Development Goals, which nominated the proportion of deliveries attended by SBAs as the primary indicator of progress in maternal mortality reduction [
3]. The practices of TBAs were subsequently ignored, and in some places even proscribed by government. For complex reasons, many women in low-income settings are still cared for by TBAs rather than SBAs at the time of pregnancy and delivery [
4‐
6]. TBAs are valued by communities because they are accessible, inexpensive, and well-respected; abide by local traditions; and provide services that SBAs do not, such as in-home postpartum care [
4‐
10]. In recent years there has been some reassessment of the TBA role, and the potential for SBAs to collaborate with them to improve maternal and newborn health outcomes [
10,
11].
Kenya experiences a high burden of maternal and newborn mortality with a maternal mortality ratio of 488 deaths per 100,000 live births (95 %CI 333, 643), and a neonatal mortality rate of 30 deaths per 1000 live births [
12,
13]. As these rates were not improving with the passage of time, the Government of Kenya instituted health system reforms aiming to have 90 % of deliveries assisted by SBAs by 2015, a doubling from the 2008 level of 43 % [
12]. To achieve this goal, beginning in 2009, the Government deployed SBAs to level two health facilities (commonly referred to as dispensaries), which are mostly located in remote areas such as those populated by pastoralist communities. The Government also actively discourages TBA supported births. However, despite these initiatives, uptake of SBA services remains low, and inequitably distributed; for example, 89 % of women giving birth in Nairobi were attended by an SBA during 2008–09, while fewer than one in ten women birthing in remote pastoralist communities had an SBA present in 2012 [
12,
14]. A 2012 survey among the remote semi-nomadic pastoralist communities of Laikipia and Samburu counties in the Rift Valley region revealed that 92 % of births took place at home, and 57 % were assisted by a TBA. The remaining home deliveries were attended by family members or the woman delivered alone [
14].
Providing women in remote semi-nomadic pastoralist communities with maternal health care from SBAs is particularly challenging. Barriers include: more remote settings with fewer health facilities; mobile populations for whom static health services are less accessible; and strong traditions of using TBAs [
10].
The Government proscription of TBA assisted deliveries means that health planners no longer engage with TBAs, so little is understood about their current roles and practices in remote communities. The objectives of this qualitative study were to investigate and describe the: 1) roles and practices of TBAs and SBAs serving pastoralist communities in Laikipia and Samburu counties, Kenya; 2) attitudes of TBAs and SBAs regarding their own practices and those of one another; 3) communities’ attitudes in relation to care provided by TBAs and SBAs.
Methods
In order to better understand practices and perceptions of TBAs and SBAs providing maternal care in remote pastoralist communities in Kenya we undertook a descriptive mixed methods study. This paper reports on the qualitative phase of the study.
Study setting
This work was undertaken by a partnership between the Nossal Institute for Global Health at the University of Melbourne, Amref Health Africa, the Mothers Union of the Anglican Church in Kenya (MUACK), and the relevant County Health Ministries. The study builds on the existing health and development projects of MUACK with the pastoralist communities of Laikipia and Samburu counties of Kenya. These pastoralist counties are sub-divided into group ranches that consist of several villages, and each of these consist of a small number of homesteads (manyattas). The study sites were five group ranches in Laikipia (Chumvi, Morupusi, Makurian, Naibor, Tiamamut), and three in Samburu (Kirimon, Kisima, Longewan). Participating communities are mostly semi-nomadic; men migrate with cattle during dry seasons while women and children remain at home for most of the year caring for goats and sheep. The predominant language is Maa, although Kiswahili, English and other tribal languages and dialects of Maa are spoken. The health system comprises: dispensaries located in group ranches, which serve as primary care facilities mostly staffed by solo nurses; health centres and sub-district hospitals where medical officers and basic emergency obstetric care can be provided; and the district hospital where comprehensive emergency obstetric care is available.
Sampling
The qualitative data collection involved: focus group discussions (FGDs) with TBAs, community health workers (CHWs), and community women and men (Table
1). CHWs are local women and men who have received brief intensive training as part of the Ministry of Health’s ‘Community Strategy’; each group ranch has its own CHWs. A component of their role is to link pregnant women with health facilities. CHWs are ideally positioned to understand the perspectives of communities, TBAs and SBAs, hence their inclusion in the study. The number and range of FGDs was anticipated to be sufficient to achieve data saturation. We conducted individual semi-structured in-depth interviews (IDIs) with SBAs and key informants. IDIs were conducted with the seven SBAs (all dispensary level nurses) from the study sites because it was not logistically feasible to bring them all together in one place for an FGD; most would have to travel a long distance to participate in an FGD, which would involve leaving the dispensaries unattended. Purposive sampling was used to select the group ranches for the various FGD categories based on background knowledge of the sites. Specifically, the sampling approach ensured inclusion of people residing in places with and without a local health facility and SBA, and people who were close to and far away from health facilities. Sampling the FGD participants from within each study site was largely opportunistic.
Table 1
Summary of FGD participants and content
Traditional birth attendants (TBAs) | 4 | 46 | Experience & training; perceptions of quality care; rewards & challenges; managing complications; community preferences for care; options for TBA/SBA collaboration. |
Community health workers (CHWs) | 3 | 45 | Community preferences for care; reasons for this; decision making about care; accessibility of services; managing complications; perceptions of TBAs and SBAs. |
Women who have delivered with an SBA in the past two years | 3 | 27 | Care seeking choices and decision making; practitioner preferences; reasons for this; experiences of care; characteristics of good quality care; options for SBA/TBA collaboration. |
Women who have delivered with a TBA in the past two years | 5 | 59 | As above. |
Women who have delivered unattended in the past two years | 2 | 30 | As above. |
Husbands of women who have delivered in the past two years | 2 | 25 | Care seeking choices and decision making; practitioner preferences; reasons for this; characteristics of good quality care; options for SBA/TBA collaboration. |
A total of seven IDIs were conducted with SBAs (five female and two male; all were based in dispensaries) and eight IDIs with key informants i.e., dispensary managers (2), staff from the County Departments of Health (2), and male (2) and female (2) Community Development Committee (CDC) members. The topic areas discussed during the SBA interviews were similar to those identified for the FGDs with TBAs (see Table
1); and the topic areas for the key informant interviews were roles and relationships of SBAs and TBAs, and options for improved collaboration.
Data collection was undertaken from October 2013 to March 2014. The project commenced with engagement of stakeholders and permission from community leaders to proceed with the study in each of the group ranches. Interview guides for the FGDs and IDIs were drafted in English by the researchers based on the study objectives and the literature, and reviewed with the local data collection team who had in-depth knowledge of the communities. Interview guides were translated into Maa or Kiswahili language by local research team members, and back translated to English, piloted and revised. Pictures representing pregnancy, birth, birth complications, and the different types of health facilities were created by a local artist and used as prompts to stimulate discussion during the FGDs with TBAs and community women.
Data were collected by local research team members (two females, one male; two Maa speakers, one Kiswahili speaker) trained in FGD facilitation and IDI techniques, and supervised by study investigators. FGDs and IDIs were conducted in Maa, Kiswahili and English languages dependent on the preference of the participants. Participants were reimbursed for transport and lunch expenses, typically to the value of 400 Kenyan Shillings (approx. USD 4), consistent with the standard payment dispensed by NGOs active in the sites. All FGDs and IDIs were digitally audio-recorded.
Data analysis
All FGDs and IDIs were translated and transcribed verbatim by local team members and cross-checked for accuracy. The transcriptions were inductively and deductively thematically analysed by two of the researchers independently (AB & TC), and subsequently assessed for consistency and divergence [
15]. Analysis was undertaken manually by one researcher, and using NVivo 10 software by the other. The final themes were those that emerged from the data i.e., what participants said in response to questions from the interview guide, questions asked in order to probe responses, and questions asked to obtain clarity on what was being said. Our approach was more emic than etic in orientation. Following data analysis, interim findings were shared with representatives of group ranches to ensure that they resonated with the varied experiences and perceptions of the communities. The topic areas and themes relevant to this paper are summarised in Table
2.
Table 2
Themes that emerged from FGDs, semi-structured interviews, and key informant interviews
TBA practices |
- antenatal | Dietary and workload advice; abdominal massage; linking with SBAs. |
- delivery | Receiving the baby; giving comfort to mother; mediating with the husband; administration of special foods and herbs; abdominal massage; observing traditions. |
- post-partum | Keeping mother and baby warm; preparing special foods; cleaning the woman; disposal of placenta; assistance with domestic chores; encouraging breast feeding. |
- complications | Administration of herbs; food supplementation; inducing vomiting; referral to health facility. |
- challenges | Fear of becoming infected with HIV when women are ‘sick’; managing complications; difficulty obtaining transport for referrals |
SBA practices |
- antenatal | Checking vital signs of woman and baby; administration of medications/immunisation; making a birth plan; referral for laboratory testing; dietary and workload advice; promotion of bed nets. |
- delivery | Monitoring the mother and baby; encouraging the woman. |
- post-partum | Monitoring baby and mother; care of episiotomy/tear; encouraging breastfeeding; dietary advice; family planning. |
- complications | Transfer to higher level facility. |
- challenges | Trying to get women to attend health facility for delivery; doing deliveries at home; difficulty getting an ambulance in case of complications; lack of necessary equipment at health facility; being a lone practitioner. |
Perceptions of TBAs |
- strengths | Accessible and available; assistance with domestic chores; referral and accompanying to health facility; trusted and respected by community; valued traditional knowledge; courage. |
- concerns | Inability to manage complications; poor hygiene; unsafe practices. |
Perceptions of SBAs |
- strengths | Valuable technical knowledge & skills; provision of safety; access to equipment, medications & injections; ability to manage complications; able to refer easily. |
- concerns | Negative attitudes and behaviours towards women; leaving women alone; cold facilities; unwanted clinical procedures; staff absenteeism; restricted visitors; lack of equipment. |
Ethics
Ethics approval was granted in June 2013 from the Ethics and Scientific Review Committee of Amref Health Africa Kenya, and the Human Research Ethics Committee of The University of Melbourne, Australia. Informed consent was obtained from all participants, using written or verbal methods dependent on the participant’s level of literacy.
Discussion
The findings from this qualitative study describe the practices of traditional and skilled birth attendants providing care for pastoralist communities in Laikipia and Samburu counties, Kenya, as well as the perceptions of the value and limitations of SBAs and TBAs from a range of perspectives including those of the practitioners themselves, the communities they serve, and key informants from the formal health system and from the Community Development Committees.
TBAs are described as familiar, trusted and respected repositories of traditional knowledge, who are actively engaged with pastoralist women during pregnancy, birth, and especially post-partum. Several TBAs have built links with SBAs in their areas, and are encouraging women to attend the dispensary. However, despite these positive attributes, it is probable that some routine TBA practices are potentially harmful to women and their babies, especially dietary advice involving food restrictions, induction of vomiting, abdominal palpation/massage, administration of herbs, and inadequate personal and environmental hygiene. It is widely acknowledged by participants (including TBAs) that TBAs do not possess the knowledge, skills, or equipment required to recognise and manage obstetric and neonatal complications. When complications occur at home, arranging referral and transport to the health facility is a challenging process for all involved, likely to result in substantial delays.
SBAs are recognised by all categories of participants to have the technical skills and resources required to provide safe and hygienic deliveries. However, SBAs regularly encounter a number of challenges that potentially compromise the quality of care they provide. Clearly, many pastoralist women remain reluctant to deliver in the health facilities, even if they have engaged with antenatal care. The health facilities are thought to be cold, unfriendly and even frightening, which possibly deters women from attending. Similarly, the reputation of SBAs as uncaring, and even abusive, is likely to negatively influence the uptake of health facility services. There is growing international awareness of this problem and the urgent need to address it in order to increase the proportion of births attended by SBAs, as evidenced by the 2014 WHO statement on ‘The prevention and elimination of disrespect and abuse during facility-based childbirth’ [
16].
The SBAs are often practicing alone, which makes it difficult for them to staff the dispensaries at all times, and occasional absenteeism can be judged harshly by the community. Managing complicated deliveries as a solo practitioner is stressful, and arranging transfers to higher level facilities is not always a smooth process. Additionally, dispensaries are not always adequately equipped with essential items such as birthing kits and medicines. Despite these issues, there is ample evidence of mutual respect between SBAs and TBAs, and it is clear that some are already collaborating for collective benefit in the provision of care for women and babies in these remote settings. Creating greater collaboration between SBAs, TBAs and communities may maximise the strengths, fill the gaps and address the concerns regarding both SBA and TBA practices.
The development of a model for SBA/TBA collaborative care is likely to increase the uptake of SBA services [
4,
10,
17]. For example, in a rural county of Kenya, TBAs were trained to provide birth planning advice and given a financial incentive for referrals to SBAs, which resulted in a 113 % increase in facility-based deliveries [
18]. Evidence suggests that more collaborative models of care that collectively engage SBAs, TBAs and communities can improve the quality of maternal and newborn care and the utilisation of health services, as well as avert obstetric complications and perinatal, newborn and maternal mortality [
11,
18‐
21].
However, it is critical to recognise that other persistent barriers such as distance and accessibility, staff availability, cost of services and transport, informed decision making, social and cultural preferences, must also be addressed [
11,
19].
In the context of the pastoralist communities in Laikipia and Samburu, TBAs could, and in some places already do, escort women to dispensaries for antenatal care, refer them to the SBA at the onset of labour, provide them with support and comfort during delivery, and assist with domestic chores pre- and post-partum. Women may be more inclined to attend health facilities for maternal care if they are accompanied by a trusted, respected member of their own community, and the provision of continuous support to women in labour results in better obstetric outcomes and a more positive birth experience [
22]. Additionally, TBAs could assist SBAs, who are predominantly solo practitioners, at the time of delivery. TBAs would require basic training to facilitate this new role, and to eliminate some of their more unsafe practices. If TBAs escort labouring women to health facilities, their presence will ensure that women are not left alone. The approach of engaging female birth companions from local communities, such as TBAs, has been assessed in 13 randomised controlled trials and found to reduce the incidence of adverse birth events and improve satisfaction with facility-based delivery among mothers [
23].
This study has certain limitations that should be considered when interpreting the findings. Although data collection was designed to capture a range of perspectives from the sampled communities, as with all qualitative research, the findings are not representative of these communities, and cannot be generalised. Social desirability bias may have influenced some responses i.e., what participants actually believe, would do or have done may differ from what they reported. The SBAs in our study were based at dispensary level health facilities and therefore quite familiar with the communities and TBAs. Their views about TBAs may not be shared by SBAs based in higher level facilities such as district hospitals.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AB contributed to study design, data collection, data analysis, and led the first draft of the manuscript; TC contributed to data collection, data analysis, and development of the manuscript; PO contributed to data collection and development of the manuscript; JN contributed to data collection and development of the manuscript; AM contributed to study design and development of the manuscript; JN contributed to study design and development of the manuscript; MK contributed to study design, managed the project, and led revisions of the manuscript. All authors have given final approval for this version of the manuscript.