Objective: To assess the effectiveness of a traditional birth attendant (TBA) referral program on increasing the number of deliveries overseen by skilled birth attendants (SBA) in rural Kenyan health facilities before and after the implementation of a free maternity care policy. Methods: In a rural region of Kenya, TBAs were recruited to educate pregnant women about the importance of delivering in healthcare facilities and were offered a stipend for every pregnant woman whom they brought to the healthcare facility. We evaluated the percentage of prenatal care (PNC) patients who delivered at the intervention site compared with the percentage of PNC patients who delivered at rural control facilities, before and after the referral program was implemented, and before and after the Kenya government implemented a policy of free maternity care. The window period of the study was from July of 2011 through September 2013, with a TBA referral intervention conducted from March to September 2013. Results: The absolute increases fromthe pre-intervention period to the TBA referral intervention period in SBA deliveries were 5.7 and 24.0 % in the control and intervention groups, respectively (p < 0.001). The absolute increases in SBA delivery rates from the pre-intervention period to the intervention period before the implementation of the free maternity care policy were 4.7 and 17.2 % in the control and intervention groups, respectively (p < 0.001). After the policy implementation the absolute increases from pre-intervention to post-intervention were 1.8 and 11.6 % in the control and intervention groups, respectively (p < 0.001). Conclusion: The percentage of SBA deliveries at the intervention health facility significantly increased compared to control health facilities when TBAs educated women about the need to deliver with a SBA and when TBAs received a stipend for bringing women to local health facilities to deliver. Furthermore, this TBA referral program proved to be far more effective in the target region of Kenya than a policy change to provide free obstetric care.
We conducted a non-randomized controlled trial to investigate if women’s exposure to TBA referrals and a community education program changed their medical facility/SBA-seeking behavior for delivery. We hypothesized that enlisting the support of TBA referrals would significantly increase the number of women who choose to give birth in a health facility with a SBA present. The site of the study is in southeastern Kenya, in Yatta sub-county of Machakos County. The region is part of the arid and semi-arid lands of Kenya, populated by the Kamba tribe. Dry land rain-fed agriculture and small-scale animal husbandry are the primary source of livelihood for the non-urban population that is included in this study. Extreme poverty and geographic isolation of the population limit access to health care and contribute to a high child and neonatal mortality. The intervention facility was chosen because of its remarkably low percentage (2.4 %) of deliveries of antenatal care patients occurring in a facility with a SBA [16]. The Yatta sub-county has a female population of 141,075 and a total population of 273,519 [17]. A planning meeting was held with the Kisiiki Health Center staff in which the purpose and methods of the intervention were presented. After gaining the support of the clinical staff, they contacted TBAs known to them and recruited the assistance of the chief and the local community health workers to contact other TBAs who were active in the catchment area of the health center. The TBAs who were contacted were asked to attend a meeting with the investigators to discuss the project and request their participation and consent. In February 2013, we held a meeting with TBAs from the area surrounding the Kisiiki healthcare facility in Yatta sub-county to recruit them into the TBA referral program in order to expand the work of Tomedi et al. [16]. We met with the TBAs and encouraged them to educate or inform their clients about the potential complications that can occur for the mother and newborn at the time of delivery (with examples solicited from experienced TBAs), and why it is important to deliver at a health facility that can handle the complications or provide transport to a higher level of care (e.g. blood transfusion, C-section). Enrolled TBAs were told that they would be compensated with a per diem of KSH 200 (approximately $2.50 USD) for each pregnant woman that the TBAs referred to a facility for an SBA delivery. The Kenya government/Ministry of Health has emphasized the importance of health facility deliveries and that TBAs are not legitimate providers of health care (e.g. they are practicing without a license). The TBAs are aware of that, but in this and other meetings have stated that pregnant women continue to come to them requesting their assistance, and they feel an obligation to help. The lead author was told in preliminary meetings with TBAs (before the study was started) that they do not charge a fee for their services, but other community sources (e.g. the chief of some of the villages, local health staff) have said that they are paid by the client’s family, an amount that could range from KSH 200 to 500. Because of the government’s stated position regarding TBAs, they have been reluctant to refer the client when complications occur. The pregnant women, when asked about barriers to facility birth, have expressed a fear that they might deliver while traveling the long distance to a health facility. Therefore, in addition to providing the TBAs with an educational message for them to deliver to their clients, the meeting addressed other concerns and barriers. A Ministry of Health official in charge of maternity services for the district spoke of the important role of the TBAs to educate their clients and improve maternal outcomes. She and the hospital staff welcomed and encouraged the involvement of TBAs (up to the point of delivery). It was recognized that the TBAs would continue to be consulted by many families. They are asked to assess if a woman is in active labor, and if there likely is adequate time for the trip to the health facility. The TBA then accompanies the woman in case delivery should occur en route. The stipend paid to the TBA is considered a “per diem” to defray her personal expenses for the trip to the health facility. The amount of the stipend was chosen because the volunteer community health workers (CHWs) in the target area of the non-governmental organization that supports this project are paid a “per diem” of KSH 200 per day of work. The number of TBAs participating in the referral program was 38. The number of births from the Kisiiki area, which was estimated by the number of new PNC patients, was compared to the rural control facilities in the Yatta sub-county. Data from the Ministry of Public Health and Sanitation (MOPHS) facilities’ records was used to determine PNC visits and pregnant women who delivered at a rural health facility with or without a TBA. The control facilities consisted of 28 rural dispensaries and health centers within the Yatta sub-county that did not participate in the TBA referral program. The two intervention facilities for which results were reported in the previous study [16] were excluded from this analysis because we did not have data from them for each time interval. The two urban hospitals were also excluded, since the focus of this study is on rural health facilities. The number of first visits of PNC patients was used to estimate the number of pregnancies because the actual number of pregnancies cannot be determined from the available government statistics. Over 90 % of pregnant women are seen for at least one PNC visit, so the number of first PNC patient visits approximates the number of viable pregnancies. Informed consent was obtained from the participating TBAs. The pre-intervention data was collected from July 2011 through February 2013. In the control facilities, the number of new PNC patients and the number of deliveries were 2112 and 218 respectively. The intervention facility (Kisiiki) recorded 334 new PNC patients and 12 deliveries during the same time period. These pre-intervention figures were compared with post intervention data collected from March 1, 2013 through May 31, 2013 (prior to enactment of the policy where maternity services are free at health care facilities) and from June 1, 2013 through September 30, 2013 (after the enactment of the policy). Therefore, the post intervention period was divided into subintervals, one before the free maternity care policy was enacted and one after the policy went into effect. These periods were analyzed separately to assess changes in SBA-attended birth rates related to the effect of the change in the government policy. The University of New Mexico Human Research Protections Office and the Kenyatta National Hospital-University of Nairobi Ethics and Research Committee in Kenya approved the study. The SBA rate was calculated as a percentage of the prenatal care (PNC) patients who delivered at the facility, with the denominator being the number of first visit prenatal care patients and the numerator being the number of deliveries at the facility. The total number of the PNC patients and deliveries at all non-intervention rural facilities were used for the control percentages. Chi-square tests were used to test differences in percent of SBA (facility) deliveries between intervention and control groups for individual time periods: baseline rates (pre-intervention), for the rates during the entire 7-month intervention period, and for the rates during the two parts of the intervention period (before and after the implementation of the free maternity care policy). Differential changes over time between the intervention and control groups were tested using binomial regression with a term for the interaction between group and time. Statistical analyses were performed using Stata version 13 (StataCorp LP, College Station, TX, USA).
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