Home delivery preference
All female IDI participants were asked where they would choose to have their next child. Focus groups of men and TBAs were also asked the same question. Responses for all these groups were evaluated for convergences and divergences. Just under half of women interviewed expressed a preference for a facility delivery at their next birth. These responses, however, indicated some geographic variances, notably women from Nainokanoka sub-village, (who generally had the highest level of education as indicated by their ability to speak Swahili) preferred facility delivery, while most women in Irkeepusi sub-village said they preferred a home delivery, or did not consider it to be their decision.
Distance was not easy to assess as an access-limiting factor in itself. All women interviewed were asked about the time it would take to walk to a facility for birth; answers ranged from 30 min to 3 h. There was no evident correlation between distance and delivery preference among those interviewed.
Those who reported having ‘no-preference’ when asked about where they would have their next child did not consider themselves to have agency: Either others would make the decision, or the place of delivery would be determined by ‘God’. Leaving the question to ‘God’ was considered a default preference for home delivery (in the absence of a complication during delivery) as it indicated an absence of a birth plan to reach a facility once labor began.
When women, TBA focus groups, and men’s focus groups who preferred home delivery for their next child were asked why, responses generally fell into 3 sub-categories:
1)Preference for traditional rituals and care during a home delivery
Female participants who expressed a preference for home delivery tended to emphasize the kind of care they and the baby received from TBAs. Psychosocial preferences included trust in TBAs and comforts of home, particularly being bathed, massaged, rubbed with petroleum jelly, and fed during the delivery. Lack of familiarity with the facility environment was also an expressed psychosocial barrier, although neither woman who had a facility delivery complained of a negative experience. Others who preferred a home delivery generally had a positive impression of clinics but saw it as a second-tier intervention if there were complications identified during ANC visits or during a home delivery.
Men were also divided in their preference, but those who preferred home delivery, tended to emphasize trust in TBAs, whom they considered to be as competent as a doctor to do a home delivery. Men also trusted TBAs to make a judgment about when transport to a facility would be necessary during a home delivery. One male participant made a specific reference to medical doctors ‘using a sharp object’ (episiotomy) which he felt was harmful to a woman and considered taboo among Maasai in Nainokanoka.
“For me I think it is better for a woman to give birth at home but it is important for her husband to be close to her just in case anything happens. Because if she goes to the hospital the doctor can delay treating her. A doctor can also use a sharp object to take out the baby and it is so painful. But there are women (TBAs) at home who could help her to deliver a child without excessive pain.” –men’s FGD participant.
All TBAs in the focus groups affirmed, in principle, a preference for a facility delivery for which they reported being strong advocates in the face of family gatekeepers (husbands). More probative questions and reports from key informants suggest that TBAs may not be as supportive as they claim, particularly in light of their belief that overcrowding at clinics will result in a woman in labor being turned away.
2)Trust Gap in Facility Capacity
One of the most pervasive reasons given for a preference for home deliveries was overcrowding at facilities in the ward that had reportedly led to women in labor arriving at a clinic and being denied service. TBAs were particularly vocal on this issue and cited the problem of overcrowding in delivery rooms at clinics in the ward overwhelmingly as the reason they resist taking women for a facility birth. According to TBAs, at least 2 women, escorted by TBAs to a clinic, were told there was no space in the delivery room and had to return home only to deliver in the bushes. This story was shared in both TBA focus groups, and in men’s focus groups as well:
“When they have difficulties during birth, we take them to the facility, but a doctor denied one (interrupting voice; Two!) a place of delivery because there was not enough room....We want the facility to be larger with more health workers as now the country is big. We cried on the street that day. The birth attendant helped the mother to give birth in the bushes. It is hard to go to the community as they turn on you because that scandal of a doctor denying a pregnant mother at the facility door has spread. So it is hard to say ‘bring the mother for a facility delivery’ while we don’t have a place of delivery.” –TBAs FGD participant.
While this account was not first-hand and was not reported as a personal experience of any TBA who was present in the focus group, nor any female IDI participant, it is pervasive and does indicate a serious trust gap in facility capacity that warranted follow-up with key informants at all three clinics. Since the ward has averaged less than 5 deliveries per month at each clinic in the past 15 months, the problem of overcrowding in delivery rooms seemed incongruent with the data.
Clinical staff at all three ward facilities were interviewed and asked about the frequency of a woman in labor being turned away because of overcrowding. Midwives at the Nainokanoka health center and Bulati dispensary were not aware of this event ever happening in their facilities during their tenure. The nurse at the smallest dispensary (Bulati) also said that while they did have only one delivery room bed, they could accommodate mothers in labor in other beds in the facility and would not turn anyone away. She speculated that a birth might have happened on the way to a clinic, prior to arrival, but not as a result of being denied a space.
A nurse at Irkeepusi dispensary, however, believed that several women may have been turned away from there at a time in the past when a non-obstetrically trained health worker was covering a shift at the clinic—although not as a result of overcrowding. This was a significant finding. Such a breach of trust for any reason would certainly justify TBA skepticism about taking a woman to a facility for delivery if there was any risk of her being turned away during labor. This experience has likely led to the generalized belief that all clinics in the ward are understaffed and overcrowded.
3)Facilities only for emergencies.
All participants (women, men, TBAs) who preferred a home delivery did consider a facility to be a second tier of assistance if there was difficulty during delivery. Women and men also mentioned relying on ANC visits to identify any potential warning signs and a recommendation for a facility delivery. Men who preferred home delivery acknowledged that going to a hospital was necessary and worth the transport cost in the event of an emergency. They expressed trust in TBAs to make that determination.
“Giving birth at home is my preference. TBAs are the same as doctors, when looking at the delivering woman they will know whether she will deliver safely or not. For a baby that cannot be delivered safely, TBAs would notice as early as possible and if there is a need of taking her to the hospital they recommend and advise us what is to be done. Therefore, we would like these TBAs to continue as caregivers for pregnant women while at home as long as they do go to the (antenatal) clinic until the day of giving birth.” –men’s FGD participant.
Health facility key informants noted that the practice of TBAs bringing women to the facility when they failed to deliver was the most common reason they came to a facility, and by that point, they were usually referred and transported to Karatu for comprehensive care.
Accessing facilities in the event of an emergency is consistent with findings that men, women, and TBAs do access the health care system and depend on ANC visits to give them information on the progress of the pregnancy and advise on risks. Other factors mentioned by men, to a lesser extent, were cost of transportation, although it was not always clear whether they were talking about going to a ward clinic or to the tertiary hospital in Karatu when they referred to it during focus group interviews.