Accessing informal delivery services seems to be a common practice in the slums, but when complications set in the birthing mother is forced to seek formal emergency obstetric care. However, when these services are most needed, residents of these two slums face obstacles. The data collected suggest that the major barriers faced include the inability to identify danger signs in time, poor health decision making, unaffordability of health care seeking, poor physical access to formal care services, inadequately equipped health facilities, and poor attitude among health personnel.
Identification of the Danger Signs
Reaching a decision to seek medical care when a woman experiences an obstetric complication begins with the ability to correctly recognize the symptoms and signs. Failure to correctly and promptly recognize the symptoms that require a birthing mother to be referred to a formal health facility could act as a barrier or a source of delay. Many participants in the discussions reported that some women in labor take a long time before deciding to seek help. One participant (Women aged 20–29 years) noted that: “I had labor pains for almost a whole week [presumably due to the embarrassment of seeking advice or help to visit a health facility from neighbors]. I got the pain from Sunday to a Thursday. I became very black. I started to rupture on a Monday and kept ignoring until later because I know of some neighbors who are just on standby to see how you will behave when you are in labor pain. You have to be strong so that you don’t give them something to talk about.”. It emerged that a previous history of uncomplicated deliveries limit cause for alarm when complications start, contributing to a delay in deciding to seek help. Additionally, most women in the study areas were reported to seek delivery services from TBAs who live in the community, and TBAs are considered to be committed to the welfare of the community members and have earned their trust. As a result TBAs are considered key opinion leaders on birthing matters, and many women allow them to make decisions on their behalf especially if the husband, who typically considers himself the key decision maker, is unavailable. Many TBAs will promptly refer a case with complications, but in few reported cases the TBA insisted on handling the case, hoping that all would end well. As captured in the words of one TBA: “Some TBAs are also greedy. They keep the woman long past delivery time…they are supposed to refer such a case to hospital…” Also, although not widely reported, attributing curses to complications, also hinder prompt care seeking.
Poor Health Decision Making
Correctly recognizing symptoms of an obstetric complication does not automatically translate into positive decision making to seek necessary care. Decision making emerged as a complex issue. Without a supportive spouse, family, or social network, the decision to refer a birthing mother with complications takes a long time to reach. Depending on the structure of decision-making power, the decision could either be made by the woman or any other relative, including the mother-in-law and the husband. Women who rely on their husbands for financial support may not be in a position to make referral decisions without their partners’ permission. TBAs reported that they sometimes make referral decisions on behalf of the mother when other family members are absent or when the mother is not in the right mental state to make this decision. In a few of the discussions it emerged that whenever the husband or other family member is uncooperative in decision making, the village chief or headman is sometimes involved. Young women discussants pointed out that their husbands, as providers, are often unwilling to give money for these services, possibly because emphasis is put on allocating meager funds to purchase of food or other essential items.
Unaffordability of Health Care Seeking
Respondents in the study recognized poverty as a barrier to the uptake of formal delivery services utilization. They noted that most of slum households are poor and often unable to afford these services, although they want to access formal delivery services. One male respondent noted that most slum residents would want their children to be born in the hospital, however, the high cost of a hospital-based delivery prevents them from realizing this dream. An assessment of facilities accessible to members of these two communities revealed that most of them charge for services related to pregnancy and child birth
17. All facilities were reported to charge for delivery services, and the price ranged from Kenya Shillings (Ksh) 20 as payment for registration in the government facilities, to Ksh 5,500 in mission hospitals (US $1 = Ksh 80)
17. This was the amount charged for a normal vaginal delivery, whose average is Ksh 1,700. This fee is much higher for cesarean section, from Ksh 3,000 in a government district hospital to Ksh 30,000 in a private maternity facility. It becomes even more expensive if the birthing mother has to hire a taxi where the charges from the slum to some of the formal maternity services in the city of Nairobi can cost as high as Ksh 3,000–4,000. A respondent said that many households find it difficult to pay for these services, and the availability of funds plays a major role in health seeking or lack of it.
As a result, the only option available to most of these women is to seek informal services. Some deliver at home, in an informal facility, or with a TBA. TBAs are less skilled, as mentioned, but often come in handy. Aside from the availability of their services at night, their services are affordable and payment is flexible or free depending on the financial state of the mother. Responding TBAs mentioned that their charges vary, with some mothers being too poor to pay for their services such that the TBA even has to contribute to buying food for the mother if there is none in the house. The highest amount paid was reported to be Ksh 500 ($6.25). TBAs: “These women do not come to us because they really want to but because of their financial problems. When they think that they will be admitted, given delivery services, then retained at the hospital because they cannot pay the bill, they choose to come to us. It is not their wish really. We do understand and there are some cases, in fact many of them, we do for free [give free services] since they do not have any money.”
Lack of money to pay for transport or hire a vehicle to transport a pregnant woman to a health facility was highlighted as a major hindrance to accessing referrals. This, coupled with the cost of care, discouraged the community members from seeking emergency obstetric care. The total amount needed for such an expense is great compared with what an average member of the community earns. Female opinion leaders: “Another reason is money. Delivery services charges as at now is at minimum of Ksh 5,000 ($62.5) [at a hospital with obstetric services]. Maybe you have also hired a vehicle. You will spend almost Ksh 10,000 ($125) so she would prefer the nearest and cheapest instead of going all the way to [obstetric specialist hospital].” (Female opinion leaders)
The unreliable road network within the communities, caused by the haphazard springing up of the slums, emerged as the major infrastructural challenge faced by Korogocho and Viwandani residents. Women with obstetric complications or in labor have to walk or be manually carried to the nearest facility or to public transport out on the main road. It is even more challenging during the rainy season due to the impassable pathways in the slums. It was reported that the situation is worse if complications arise at night, when transport service providers raise their taxi or car-hire charges. Use of matatu (public transport) is affordable, but when not in operation at night, the only means available is use of taxi or car-hire services, which are expensive. Public vehicle operators may sometimes charge even more due to the fear of inconvenience either by having to detour from their route or the woman delivering in the car.
Although reliable and affordable, using public transport presents its own challenges since a pregnant woman still has to walk from the bus terminus to the hospital doorstep and sometimes even stand in the matatu when its full as well as endure traffic jams on the way, causing further delays in getting to a health facility.
With these transportational and financial hindrances, some women are forced to walk all the way to a health facility. This delay causes some to deliver before reaching the facility or to lose their or their babies’ lives.
Other factors, which respondents identified as constraining the use of formal emergency obstetric services, include insecurity–especially at night, unfriendly health providers, inadequately equipped health facilities, and cumbersome hospital procedures.
Insecurity at Night
Insecurity levels in the slums were reported to be very high, a situation that has instilled fear in people of venturing out at night. Loss of property, death, and disabilities arising from attacks by thugs make referrals difficult when a birthing woman experiences complications. Residents fear for their lives. In most cases, they opt instead to use TBA services, putting the lives of the mother and baby at risk from improper procedures. A male discussant (Males over 30 years) narrated his experience: “Like my neighbour last year…she started having labour pains at about 3 p.m. and she did not seem to have prepared anything…. So at about 12 a.m. I was called and found the woman had already given birth and the blood was trickling like water. This problem took me a long time to look for help because at that time Korogocho was very dangerous and you could not even walk at night. We did all we could and we found a certain health worker who finally helped this lady. Then the next day we took her to a major referral hospital in the city because she had lost so much blood.”
Unfriendly Health Providers
Fear of ill treatment from health workers often discourages women from accessing health facility delivery care. Most discussants cited health professionals especially nurses, midwives, and generally female health providers as having a poor attitude towards pregnant women. With regards to maltreatment during delivery, ownership of the health facility emerged as a major determinant. Participants in the discussions reported that health workers in the formal private facilities—those not owned or run by the government—were more hospitable compared with their counterparts in government facilities who abuse patients, a practice that discouraged women from seeking health facility services when in need. Most women therefore preferred care offered by male birth attendants, opting not to seek care in formal facilities, with the exception especially of Muslim women (because of their belief that it is an abomination to be unlawfully touched by a man). A young female discussant (Women aged 12–19 years) narrated her experience with a government health provider: “On my first visit at [a government clinic] when I was expecting, I was examined but did not wait for further treatment because the doctors [the term ‘doctor’ is often used to refer to any health care personnel] are very arrogant. I went back home and started going to a private [informal] hospital.”
Cumbersome Hospital Procedures/Requirements
Hospital procedures or requirements in most hospitals in the country insist on proof of antenatal care attendance and payment of deposit before admittance for care. Pregnant women usually go through the laborious process of registration before eventually queuing to await their turn to be served. It is widely expected by health facilities/providers that pregnant women will go for antenatal care so that in an emergency case, the attending health worker can easily refer to the medical history on the antenatal card. Without an antenatal card, women seeking delivery services are turned away. Further, all women seeking delivery services in health facilities are required to pay a deposit fee before being admitted, and in cases where complications arise an additional amount is charged. Discussants reported that a demand for deposit occurs in all types of health facilities regardless of ownership status. These procedures and requirements discourage women from accessing health services. Furthermore, the queues can sometimes be too long such that some women end up delivering while still in the queue. Long queues were blamed on inadequate health professionals at the facilities. Poor women without money to pay for services and those who fail to attend antenatal care stay away from these facilities, even when faced with an obstetric emergency. This quote (Women aged 30–54 years) captures the seriousness given to payment of deposit: “At [a mission hospital], a normal pregnancy requires one to pay a deposit of Ksh 3000 [$38]. They have put posters all over the place so you do not need to ask anyone. The risky thing is that whether you are their client or not, they cannot take you without the deposit. During admission, you just present the receipt. Be it day or night, you must pay their deposit or else you will just deliver on their doorstep and they will ignore you. I was surprised. With a receipt, the service is very fast….”
It emerged that sometimes these health facilities waive their rules and attend to women with serious emergency complications but detain them after delivery until the bill is settled. Some women have been detained for months, and most worry about being away from their families. This practice has mostly been reported in government health facilities, and although it is not legal, most patients are unaware of this fact and rarely take legal action.
Inadequately Equipped Health Facilities and Poor Accessibility to Referrals
The poorly equipped health facilities in the slums are unable to handle emergency cases, and women experiencing complications are referred to facilities away from the slums. Referral of birthing mothers to appropriate facilities for obstetric care is often a complicated process, characterized by communication and transport challenges where the woman and her family often lack the money to pay for transport to the health facility. Even after arriving at a health facility, one may still need to be referred to a better-equipped facility, causing delays in receiving the required services and further deterioration of the patient’s condition, thereby lengthening treatment time. The family also always incurs more costs when additional referrals are made. Sometimes the health facilities are equipped with ambulances, but the woman’s family is asked to fuel it before she is transferred to a better facility. It was also mentioned that due to frequent stock-outs of drugs in most health facilities, the mother or her family has to buy the prescribed medicines or carry essential delivery materials when going to the facility, failure of which prolongs delay to receive care.