The state of maternal and newborn care
It emerged that health care providers and service users in Kitonyoni and Mwania are confronted with many infrastructural challenges in providing and accessing quality maternal and newborn care services. There was overwhelming consensus within and between the FGDs as well as the key informant interviews that the main challenges adversely impacting provision and access to quality maternal and newborn care include inadequate qualified health personnel, lack of adequate transportation and poor roads, lack of quality and adequate water and electricity as well as abject poverty in the communities. In each of the dispensaries that serve the two communities, there is one trained health personnel, supported by untrained health assistants (2 in Kitonyoni and 1 in Mwania). The trained health personnel in both facilities hold a Certificate in Nursing accredited as Kenya Enrolled Community Health Nurses. They are trained in the basic skills to manage normal pregnancies, childbirth and postpartum care as well as to educate and mobilise community resources to support health care provision at the local level. The facilities lack qualified doctors and highly qualified nurses to meet the challenging demand for high quality care, a situation reported to be adversely affecting provision and access to quality maternity and newborn care by both the service providers and users.
Both service providers and users reported the lack of capacity by the two health facilities to provide round-the-clock services due to inadequate staffing and lack of resources to operate at night. It was reported that the health facilities have to shut anytime the Enrolled Nurses attend meetings or when they are on annual leave. In case of the later, the facilities are sometimes shut for up to one month continually, a situation reported by service users as frustrating and inconveniencing as they are often forced to seek health care elsewhere:
“…like now if the nurse is on leave, the hospital here is closed for one month, so we have to travel all the way to Kitise and when it is an emergency we are referred to Wote. We go through many problems when transporting a patient to Kitise or Wote. If we do not do it, the person may die.” [Partner, FGD, 40–60 years, Mwania].
The inadequacy of health personnel affected service providers both professionally and socially as they were compelled to work extra hours to meet the demands of the community. This included working both during the day and also being called on at night or when on leave to attend to emergency cases arising in the community. It was easier for the service seekers in Kitonyoni to access services from the health worker in Kitonyoni, compared to those in Mwania, as nurse in Kitonyoni resided closer to the facility making it easier for the community to access her even at night. The service provider for Mwania however resided at Kitise, a distance of 5 km from Mwania, making it difficult for the community to access his services during out-of-office hours due to the unavailability of transport facilities.
These challenges sometimes compel service users to resort to alternative care, often from untrained Traditional Birth Attendants (TBAs). At times they opt for self-medication or decide not to seek care at all. Most women services users reported that seeking care from TBAs was a more desirable alternative because they are guaranteed the TBAs will always be available to provide care and support. However, the health personnel reported that the women sometimes encounter serious complications, which are often delayed because of dependence on TBAs. They reported that TBAs sometimes employ dangerous practices, such administration of herbal concoctions, manually changing the baby’s position in the womb which sometimes leads to antepartum haemorrhage as well as using very hot water to aid contractions, putting the life of both mother and child at risk.
Another major challenge highlighted by all those responding in this study is the lack of electricity, a situation that makes it difficult to provide round-the-clock services as well as many basic but essential maternal and newborn services. It was reported that the health facility in Kitonyoni generates lighting through the use of paraffin; there was no heating and onsite sterilisation facilities, while refrigeration was powered by Liquefied Petroleum Gas (LPG). The Mwania health facility on the other hand has no lighting facility, relies on LPG for heating, refrigeration and sterilisation of equipment. The cost of LPG was reported to be co-shared between the community and the District Health Office. However, stock outs were reported to be common due to bureaucratic protocol in releasing funds and also in cases where the community is unable to meet its share of the cost, particularly when health care fees collected from patients are inadequate.
The lack of electricity as reported by the health personnel poses a major challenge when conducting deliveries, particularly at night. They pointed out that they often have to rely on torch lights, lamps or feeble lights from mobile phones when performing deliveries. The health providers expressed their frustration of attending to birthing women at night in the captions below:
“At night, I usually place the lamp either on a carton box like this one, or on another bed or somewhere raised. It is very challenging because I cannot keep on calling relatives of the mothers to come and assist me like with holding the lamp, because I am all alone here” [Nurse, Key Informant Interview]
“…sometimes I use a torch. It is very difficult to hold it and sometimes I am forced to hold the torch in the mouth as I conduct the delivery. This is because, if you have gloved yourself ready to conduct a delivery, it is difficult to hold the torch at the same time” [Nurse, Key Informant Interview]
A recognisance of the dispensaries and discussions with the health personnel revealed that none of the nine signal functions were in place at both facilities to cater for maternal and newborn complications. The lack of electricity was cited as the main challenge to providing any of the nine signal functions. It was mentioned that although most antibiotics can be given orally, e.g. amoxicillin tablets, those that require intravenous administration including uterotonics were not available at the facilities since they are required to be stored at temperatures of between 2 and 8° Celsius to maintain their efficacy. The health facilities could not provide these services due to the lack of electricity for refrigeration. Resuscitation and assisted delivery could not be performed at the two facilities due to the lack of oxygen masks and suction machines which also require electricity to function. In addition, the health providers lack the skill to perform complex resuscitations. Instead, they resort to rudimentary and traditional techniques, as described by a health provider:
“I do not perform resuscitation here because we do not have oxygen masks. There is no electricity here to operate these machines. I can only use the local methods…locally we make noise near the baby so that the baby can be shocked into waking up. For complex resuscitation, this is given through the umbilical cord, so if needed I usually call for help from health workers from Kathonzweni Health Centre, but this is very far…” [Nurse, Key Informant Interview]
The magnitude of lack of apparatus to provide basic maternal and newborn care services in the facilities was further described by a service provider in the quote below:
“…there are too many problems in this hospital, like shortage of drugs, lack of working materials e.g. delivery kits, suction machines [forceps or a ventouse suction cup] for babies who are asphyxiated [tired when being born], we do not have machines to suck the secretions, we do not have stitching kits and autoclaves to sterilise used instruments” [Nurse, Key Informant Interview]
In addition, service providers reported that the health facilities are not able to provide regular routine services requiring refrigeration such as immunisations, where medicines are required to be stored in cold chains. Although both facilities had refrigerators, they were not in operation most of the time due to gas stock-outs. In such circumstances, vaccines are either transferred to nearest facilities with functioning refrigerators or discarded and mothers referred to other facilities for immunisation of their children. This results in feelings of frustration from service users as expressed:
“…we are not able to immunise our children, we are told the drugs have to be put in a fridge [require refrigeration] but here there is no electricity, so they cannot keep the drugs here so we have to go to another facility…“[Mothers, FGD, 25–39 years, Kitonyoni]
Acute water shortage particularly in the dry season was also reported by both the service providers and users as a major challenge to providing and accessing maternal and newborn care services. As indicated earlier, the main source of water for the two facilities is rainwater. It was reported that the health facilities harvest abundant rainwater during the rainy season, but storage facilities are limited thereby resulting in severe shortages during the long dry season. The dry period as reported is characterised by long trekking to water sources, reliance on poor quality water and purchasing of water at exorbitant prices to cater for the needs of their households. At the health facilities, health providers are often forced either to go without water, or use poor quality water as they are often unable to afford purifying chemicals. In addition, the scarcity of water poses serious hygiene and sanitation problems in the two facilities, especially during the provision of delivery services. It was reported that water shortages sometimes becomes so acute that it is difficult to get water for hand washing, cleaning delivery surfaces (which is a normal table that sometimes acts as a bed for examining patients) and cleaning cutting equipment, exposing mothers and newborns to infections, a frustration expressed by a service provider in the quote below:
“After delivery, this place gets really soiled, there is no running tap water in here to clean the room, there is no water for mothers to take a shower after delivery…” [Nurse, Key Informant Interview].
The lack of electricity and quality water also adversely impacts the recruitment and retention of qualified personnel at the health facilities. It was reported that qualified personnel are often not motivated to work in such deprived areas as the lack of electricity and water not only impacts their work at the facility but at home, they are often compelled to use alternative sources of energy and poor quality water.
Accessing maternal and newborn referral services
The deprived state of the Kitonyoni and Mwania health facilities necessitates that pregnant and postpartum women seek referral services in better-equipped health facilities in the case of complications. Infrastructural challenges including the lack of adequate transport facilities and poor quality roads act as serious impediments to seeking referral care, often with adverse outcomes. This is compounded by poor road connectivity characterised by hills and rivers during the rainy season. The nearest referral district hospital (Makueni District Hospital in Wote) although located only 27 km from Kitonyoni and 45 km from Mwania, it was reported that on average it takes about three hours to travel to the facility due to the poor nature of the connecting roads, particularly during the rainy seasons. Due to the fact that there is no motorised ambulance serving the dispensaries, patients often use a combination of commercial motorbike, mini-bus and taxi to make this journey. It emerged that mini-bus operations were infrequent (operates only twice during the day). Taxi services were said to be very expensive (between Ksh. 2000 and Ksh. 4000; equivalent of $23-$46 for a one way journey) and often has to be called from Wote where the district hospital is located. In such circumstances, the woman or her family were not only faced with delays in getting to the hospital, but were also often made to pay for the double journey. As one young mother described:
“…like now, there are transport difficulties, in case there is a need for referral, we do not have a vehicle here, we have to call for taxi from Wote and it is very far and expensive” [Mother, FGD, 18–24 years, Mwania]
The health providers bemoaned that the difficulties of seeking referral services sometimes lead to fatalities or near-misses, particularly where mothers delay in seeking hospital care, as indicated in the quote below:
“When I first started working here, there was a woman who had been in labour for 2 ½ days without delivering… we decided to refer her, but there was no transport and the family did not have money for taxi. I decided to use my money to take a taxi because there was no matatu [public transport] operating. There was so much rain and we got there too late. The woman died shortly after delivery, but the baby survived” [Nurse, Key Informant Interview]
Such occurrences do have a devastating impact on the family, as one husband who recently lost a wife iterated sorrowfully:
“When I lost my wife, I was left with the baby and this is very hard life because I have to be both the father and mother. Now the baby is bigger [grown] but things were difficult in the beginning because I had to buy milk for the baby and I do not have a job” [Partner, FGD, 18–24 years, Mwania].
The respondents also recounted that the poor road quality and lack of adequate transportation further lead to hikes in transportation prices, particularly at night and during the rainy season. This is further made worse if the health of the woman is so bad that she cannot walk and a commercial motorbike has to be hired to take her to the main road. The patient’s condition as was reported by mothers is often exacerbated by the discomfort of the motorbikes due to the rough terrain. Considering that the cost of taxi from the two study communities to Wote ranges between 2000 and 4000 Kenyan Shillings ($23-$46), very few are able to afford. This is reinforced by a woman respondent in this quote:
“From here to Wote we have to pay Ksh. 2000 for taxi just to take you there. We cannot afford this, so if there is no matatu [public transport], we just have to resort to other means [alternative treatment]” [Mother, FGD, 25–39 years, Kitonyoni].
The health providers iterated that one of the major complications they face which requires speedy referral care is severe bleeding. They noted that a woman experiencing severe bleeding could die within two hours if not attended to, even if she is in good health. They reported that the health facilities do not have blood transfusion facilities, neither are they able to store oxytocin (as they are most effective when stored in cold chains, given the aridity of the area) to administer after childbirth to effectively reduce the risk of bleeding. It was reported that this often leads to fatalities and near-misses, as even in cases where women are referred to the district hospital, they are less likely to get to the referral facility within two hours due to the poor roads, lack of transport and exorbitant transport costs.
Poor transport facilities ultimately impacts not just referrals, but also access to the necessary hospital supplies, often resulting in stock-outs of essential medicines. In such situations, the health care providers are not able to offer essential services. Sometime they have to access supplies themselves using commercial motorbikes, in which case the dispensary has to shut for the time the providers are away from the facilities.