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Background: Kenya’s high maternal mortality ratio can be partly explained by the low proportion of women delivering in health facilities attended by skilled birth attendants (SBAs). Many women continue to give birth at home attended by family members or traditional birth attendants (TBAs). This is particularly true for pastoralist women in Laikipia and Samburu counties, Kenya. This paper investigates the socio-demographic factors and cultural beliefs and practices that influence place of delivery for these pastoralist women. Methods: Qualitative data were collected in five group ranches in Laikipia County and three group ranches in Samburu County. Fifteen in-depth interviews were conducted: seven with SBAs and eight with key informants. Nineteen focus group discussions (FGDs) were conducted: four with TBAs; three with community health workers (CHWs); ten with women who had delivered in the past two years; and two with husbands of women who had delivered in the past two years. Topics discussed included reasons for homebirths, access and referrals to health facilities, and strengths and challenges of TBAs and SBAs. The data were translated, transcribed and inductively and deductively thematically analysed both manually and using NVivo. Results: Socio-demographic characteristics and cultural practices and beliefs influence pastoralist women’s place of delivery in Laikipia and Samburu counties, Kenya. Pastoralist women continue to deliver at home due to a range of factors including: distance, poor roads, and the difficulty of obtaining and paying for transport; the perception that the treatment and care offered at health facilities is disrespectful and unfriendly; lack of education and awareness regarding the risks of delivering at home; and local cultural values related to women and birthing. Conclusions: Understanding factors influencing the location of delivery helps to explain why many pastoralist women continue to deliver at home despite health services becoming more accessible. This information can be used to inform policy and program development aimed at increasing the proportion of facility-based deliveries in challenging settings.
Data collection took place in five group ranches in Laikipia County (Chumvi, Naibor, Makurian, Morupusi, and Tiamamut) and three group ranches in Samburu County (Longewan, Kisima, and Kirimon). The project commenced with engagement of stakeholders and permission from community leaders. Semi-structured in-depth interviews and focus group discussions (FGDs) were conducted primarily between October 2013 and March 2014 – three additional interviews were conducted in December 2014. Fifteen interviews were conducted in Kiswahili, Kenya’s national language, by the study’s research officer. The interviews were with seven SBAs (five female and two male) located at local health facilities; and eight key informants (two male and two female Community Development Committee (CDC) members, two district health managers, and two health facility in-charge personnel). Local research assistants were recruited and trained in qualitative research methods and FGD facilitation. The research assistants conducted a total of 19 FGDs across the eight group ranches. The FGDs were conducted in the local Maa language and involved a range of respondents: four FGDs with TBAs; three with community health workers (CHWs); five with women who delivered in the past 2 years with a TBA; three with women who delivered in the past 2 years with an SBA; two with women who delivered in the past 2 years without a TBA or SBA; and two with husbands of women who delivered in the past 2 years. CHWs are women and men who have received brief intensive training, and are deployed in each group ranch through the Ministry of Health’s ‘Community Strategy’. A component of their role is to encourage women to attend health facilities for antenatal care and delivery. The interviews and FGDs took approximately 60–90 min to complete, and were audio-recorded, transcribed and translated from Swahili and Maa into English by the local research team. The topic guides (available from the authors on request) were developed taking into account existing literature and the purpose of the study, and were piloted and revised. They covered reasons for home based deliveries and facility based deliveries, access and referrals to facilities, strengths and challenges of TBAs and SBAs, and strategies for improved care and collaboration. Pictures representing pregnancy, birth, birth complications, and the different types of health facilities were created by a local artist and used as prompts to stimulate discussion during the FGDs with TBAs and community women. Following transcription of all interviews and FGDs, two researchers analysed the data (TC and AB) using a thematic analysis approach [20]. One researcher used NVivo and the other analysed the data manually. The initial analysis adopted a deductive approach using the topic guides to identify themes. A re-reading of the transcripts using an inductive approach identified emerging sub-themes from data; sub-themes were founded on recurring concepts in the data. The researchers met to review analysis outcomes and ensure thematic concordance. Transcripts were coded and thematically categorised. The data analysis steps are summarised in Table 1. Themes that emerged from FGDs and semi-structured interviews Following final analysis, interim findings were presented to CDC members from all group ranches to ensure that they accurately captured and reflected the experiences of their communities; all CDC members were supportive of the findings presented. Ethics approval was obtained from the Ethics and Scientific Review Committee (ESRC) of AMREF (Kenya) and the Human Research Ethics Committee (HREC) at the University of Melbourne (Australia). All study respondents were provided information regarding the study prior to all FGDs and interviews and verbal consent was obtained. Respondents were provided with a small payment in recognition of their time (~USD 4).
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