The respondents
Responding women were from a diversity of socio-demographic and livelihood backgrounds. Their ages ranged from 16 to 70, averaging roughly 39. Livelihoods for the bulk of them were based primarily on informal economic activities: petty trading, manual laboring, and craftsmanship. TBAs, full-time housewives, and women without personal income sources were also in the sample. Among slum dwellers in Nairobi, incomes are generally very low, with slum women often earning more poorly than their men counterparts[
18].
Respondents frequently self-reported as married. Only a handful of them were divorced, single, or widowed. While respondents' educational profile indicates that they mostly had primary-level schooling, a substantial number reported secondary-level education. Participants with tertiary-level or without formal education were marginal in the sample. The women we studied self-reported largely as Luos, Kikuyus, Luhyas, and Kambas. The other reported ethnicities were Somali, Taita, Gare, Kisii, Olakaye, Borana, and Kuria. Most respondents self-identified as Christians. They were also nearly uniformly distributed between the two slum sites.
Perceptions of maternal health in the slums
Study narratives unequivocally underlined the critical importance of maternal health. 'When a mother is unwell, the whole family is unwell'; 'Without a strong and healthy mother, everybody in the household will suffer", responding women regularly admitted. Women's health was described as key to children's survival, household wellbeing, and societal continuity. Good health reportedly equips mothers to more competently care for their children and households, bear healthy children, and contribute positively to family upkeep and wellbeing. Poor maternal health was, in contrast, reported as likely to sap family resources, lead to deficient child care, and foster household poverty. Interlocutors frequently noted that healthy mothers and women contribute more positively to the community, and participated more in neighborhood development and organization efforts.
In general, respondents considered maternal health in the slums to be very poor. 'Many women here have poor health...and many of them die during pregnancy and childbirth'; asserted one woman community leader. The respondents noted that maternal mortality and morbidity was common in their communities. Large numbers of women living in the communities reportedly die or take ill during pregnancy and the post-partum period. Pregnancy loss, fetal deaths, stillbirths, unsafe abortions, and HIV were also said to be very common in the slums. Most interlocutors themselves admitted to having suffered life-threatening maternal health problems; and several of them also knew at least one woman in the community who had a maternal health problem. 'It is common for women here to be sick during pregnancy, sometimes you will see them with swollen legs and others looking really sickly'; observed a responding TBA.
Hemorrhage, anemia, hypertension, malaria, placenta retention, premature labor, prolonged/obstructed labor, and convulsion/seizures (pre-eclampsia) were the commonly-mentioned maternal health problems in the study communities. These problems reportedly often resulted in fetal deaths, premature births, pregnancy loss, and maternal mortality, morbidity, and deformity. In the very apt language of one respondent:
In this community, most people are poor...the women are always sick and sometimes they do nothing about their health because they do not have money to seek treatment. It is common to see women here die from bleeding, convulsion, and premature labor and births. The other day, my neighbor almost died from prolonged labor. The baby died. She was in labor for days... and was delivering at home.
Traditional birth attendants (TBAs); private, missionary, and public formal facilities; itinerant peddlers of western medicines; chemists; herbalists; and religious and magical healers were identified as key providers of maternal health care in the slums. Each provider-type reportedly had its strengths and weaknesses. For instance, the availability of providers and equipment that could make pregnancy and childbearing safer was mentioned as the major benefit of hospital-based care. Hospital-based providers purportedly had the competency to make childbearing safer and hospital-based delivery put women under the care of skilled providers and ensured the ready availability of equipment for managing emergencies and difficult deliveries. Informal providers (e.g., TBAs) reportedly lacked these skills and tools. Martha, a respondent, admitted that hospital-based providers saved her life. She sought delivery services from a TBA and stayed two nights in the TBA's house writhing in labor pains. Finally, the baby arrived feet first. Martha was scared and asked to be transferred to a hospital, but the TBA refused, promising that she could handle the situation. However, Martha recognized she was in grave danger and crawled out of the TBA's house. She was lucky to find a taxi to take her to a hospital in the city. She passed out upon reaching the hospital and remembered waking up with a baby girl by her side. Martha is convinced that she would have died if she had remained at the TBA's home.
Yet, hospital-based deliveries were generally considered to be very expensive and often out of the reach of slum women. Hospital-based maternal care providers were also perceived as harsh and unsympathetic toward poor women. Noted one woman: 'Even those facilities belonging to government or churches and offering free or discounted services, it is not easy for us to make use of them. They may not even ask for anything from you, but ... the whole thing is not easy for us ... You still have to convey yourself there, pay for tests, and buy drugs ... sometimes; we just can't pay for all these because of poverty ... so we go to the TBAs'.
While respondents frequently admitted to the superiority of the hospital as a delivery site, they viewed it primarily as a birthing site for women anticipating or at risk of obstetric emergencies and difficult deliveries. Respondents tended to consider the management of uncomplicated deliveries to be the time-honored role of TBAs, who were depicted as naturally and divinely gifted to assist during deliveries. TBAs' inborn expertise and skills were also viewed as more effectual and reliable than the learned practice of hospital-based providers. One responding woman's view that TBAs were divinely-gifted with the abilities to help women received massive support among the participants. The same approving response greeted the view of a middle-aged FGD participant that "Many TBAs are better than hospital providers when it comes to handling deliveries. It is their work and many of them are really good at it." Another woman also noted: 'They (TBAs) may not be as good as the doctors and nurses, but they help us a lot'.
Self-treatment during pregnancy and the post-partum and self-assisted deliveries were also commonly reported by the women. One woman admitted that she does not go to hospitals or to TBAs for any pregnancy-related conditions. She self-treats by buying medicines from chemists. Another woman reported that she delivered all her last three children assisted only by her teenage daughter.
Poverty and adverse maternal outcomes
Respondents generally acknowledged their economic disadvantage and vulnerability, commonly commenting that: 'Most of us here are poor'; 'The poorest people in Kenya live here'; 'Only the poor like us live here'; 'Most people you see here are poor'; 'Here in the slums, you will find the poorest of the poor in Kenya'. Responding women widely associated poverty with key social problems, including insecurity, deprived housing conditions, poor nutrition, unsafe abortion, inability to educate one's children, alcoholism, drug use, crime, delinquency etc.
The narratives we collected strongly linked poverty and negative maternal outcomes, casting poverty as the major killer of women in the slums and a key hindrance to women's wellbeing and survival during pregnancy and the post-partum period. Of course, they linked poverty to decreased utilization of appropriate antenatal care and delivery services as well as to poor nutrition. Due to poverty, slum women were reportedly often undernourished, scarcely used quality maternal services, and delivered at home. Poor nutrition also reportedly left women with poor quality blood and insufficient nutrients to go through pregnancy and the period surrounding it. Starving, weak, or underfed mothers were said to be common sight in the slums. Such women usually die, get sick, or suffer complications during pregnancy and the post-partum. Poverty was also said to hamper slum women's access to quality care. Facilities that offer good services in the slums were often privately-run and charged exorbitant prices. They were thus beyond the reach of poor women. The cost of reaching quality public maternal health services located outside the slums also emerged as a major hindrance to women's access to quality care. Several responding women also frequently implicated poverty in their own problematic maternal outcomes and for the maternal complications of other women personally known to them.
Respondents admitted to seeking homebirths because of their affordability. During homebirths, women did not have to pay for transportation, registration, laboratory, and other costs, including bribes reportedly offered to formal providers to facilitate services. They also did not have to pay for supplies such as transfusion blood, syringes, needles, drugs, and sanitary materials, which would be incurred during a hospital stay. Josephina, a mother of four, brought into bold relief the implications of poverty for women's uptake of hospital-based maternal services. She gave birth to her first baby in a public health facility in Nairobi at a time when she was unemployed and her husband did not have a stable job. Josephina recalled going to the hospital numerous times for consultations and says that she spent a lot of money during the period. There were days she would trek to the hospital due to lack of transport fare. In addition to paying various amounts for minor services, she also regularly bribed hospital staff to ensure that she would receive swift attention in the hospital. Josephina also paid in advance for blood that she would be transfused with, although she never received any at delivery and was never refunded her money. She was also requested to buy her own supplies (e.g., sanitary towels, cotton wool, and syringes), which were deposited in the hospital. Labor began for Josephine at night and her husband had to pay about 600 Kenyan shillings ($10 U.S.) to hire a taxi to transport her to the hospital. While acknowledging the risks in homebirths, Josephine says, "unlike homebirths, hospital-based deliveries make poor people poorer...'
However, in the context of the slum, the women maintained that poverty engenders undesirable maternal outcomes not primarily by preventing women's access to quality nutrition and maternal services, but by exposing them to extremely heavy workloads during pregnancy, to intimate partner violence, as well as to inhospitable and poor treatment by service providers. In what seemed like the mind of most our interlocutors, 32-year-old Anna asserted that 'Women here are poor, but they also devotedly attend antenatal services and they try to eat well during pregnancy...but poverty still causes us to have problems during pregnancy because of other things'. In her longer narrative, Anna suggested that among slum women, poverty operates through dynamics, other than restricting women's access to quality services and nutrition, to cause adverse health outcomes among slum women.
The heavy workload which poverty reportedly pushes women into during pregnancy and the post-partum period was a prominent explanation offered for adverse maternal outcomes among slum women. For many responding women themselves, it was the heavy workload which they perform during pregnancy and the postpartum period that caused them adverse maternal experiences. Due to poverty, slum women reportedly continued to do so much hard work during pregnancy and the period surrounding it. They would work in construction sites as head-carriers and loaders, stay out late selling their wares, or go from door to door looking for work, etc. Hard work during pregnancy and the period surrounding it reportedly sapped women's energy and blood, leaving them weak and fragile. For the respondents, women worked harder during the period of pregnancy in order to save enough money to prepare for birthing. To be able to cater for their babies, some women also reportedly resumed heavy work immediately after delivery. Julie blamed heavy workload during her pregnancy for the severe anemia she suffered. Always exhausted, Julie said she never rested adequately and blamed it all on poverty: she needed to save enough money to prepare for the baby and the time she will spend at home after delivery. As she continued to toil during this precarious period, Julie got burnt out, and became anemic. Aloeci, a 27-year-olf mother, who reported that she nearly died 5 days after her delivery also linked her 'near-miss' experience to heavy workload. She worked as a cleaner till two weeks before her delivery and resumed her job 4 days after delivery. It was on her first day at work after delivery that she suffered heavy bleeding. 'I had to start working immediately or I would starve with my children. I would have stayed at home and rested. But now I needed money. I nearly died'. Women's workload also reportedly increased during pregnancy and soon after birthing because husbands never bring home enough for the upkeep of households. Some men also reportedly run away when their wives become pregnant. In the case of Moriga, her husband chased her out of the house when she became pregnant, saying he did not have the resources to have another child. To prepare for the delivery of the baby, Moriga said she took a job as a bar tender. However, she often worked late, rested little, and stood for long periods. One day, out of exhaustion, she collapsed at work and lost the baby.
Another frequently reported means through which poverty promoted adverse maternal outcome in the slums was by exposing women to experiences of intimate partner violence during pregnancy and the period surrounding it. Owing largely to poverty, hardship, and unemployment, men in the slums were reported as often extremely frustrated and desperate, and which lead them into violent behaviors toward their wives. The physical abuse of women by their male partners was reported as common in the slums, and held as a key issue in slum women's adverse maternal outcomes. Wanjiru admitted that she lost her pregnancy to the constant beating she received from her jobless and alcoholic husband. 'He used to be a good man before, but when he lost his job; he became frustrated and beat me all the time. Here, men drink a lot and go home to beat their wives". She asserted. In her longer narrative, Wanjiru noted that most poor men in the slum get worried when their wives get pregnant. 'Because of the burden children bring, they get frustrated and often vent their frustration on their wives. It is not uncommon for men to kill their wives here when they are pregnant. That's what poverty causes here'. One unemployed man reportedly beat his wife until he gave birth prematurely. Another alcoholic and jobless husband allegedly kicked his pregnant wife in the stomach, killing her. A respondent had a neighbor who started beating his pregnant wife when he lost his job, until she suffered a miscarriage. There was also an account of a woman who experienced 4 stillbirths following 5 years of unrelenting physical mistreatment in the hand of an abusive, alcoholic, and jobless husband.
A third major way mentioned by the women through poverty reportedly engendered adverse maternal outcomes among slum women was by exposing them to inhospitable treatment by service providers. Respondents agreed that though while most slum women were often very willing to use modern maternity and delivery services, they usually suffered poor treatment when they presented in these facilities. As the women's narratives stoutly implied, their poverty was to blame for this. Providers reportedly were uncharitable toward poor health seekers, often abandoning them or ignoring them when they present at formal facilities. Among other confirmatory narratives, a 27-year-old Korogocho mother observed that when poor women walk into hospitals with their inexpensive dresses, they are easily identified by nurses and doctors, some of whom even act towards them as if they smelled. She said, "Some of them are so wicked that they will not pay you any attention until you are dying''. Providers were said to be deferential toward well-off care-seekers, who offer tips and bribes. Poor women who cannot afford to give bribes and tips have to wait for long periods of time before receiving attention. Some poor women reportedly only receive attention when they faint in waiting lines or are almost dying. 'Sometimes you go to the clinic and you are in labor; they will just ignore you because you are poor. They know there is nothing you will give them; so they only come to you when you are on the floor, dying in your own pool of blood or water'. Many women here have problems because they are poor and providers mistreat them'. The poor treatment received by poor women when they present at the hospital reportedly also push them to use less efficacious services, such as TBAs. Martha (aged 34) also noted, "Child delivery costs a lot in the hospital and when poor people like us go there, we are treated shoddily''.