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Access to appropriate health care including skilled birth attendance at delivery and timely referrals to emergency obstetric care services can greatly reduce maternal deaths and disabilities, yet women in sub-Saharan Africa continue to face limited access to skilled delivery services. This study relies on qualitative data collected from residents of two slums in Nairobi, Kenya in 2006 to investigate views surrounding barriers to the uptake of formal obstetric services. Data indicate that slum dwellers prefer formal to informal obstetric services. However, their efforts to utilize formal emergency obstetric care services are constrained by various factors including ineffective health decision making at the family level, inadequate transport facilities to formal care facilities and insecurity at night, high cost of health services, and inhospitable formal service providers and poorly equipped health facilities in the slums. As a result, a majority of slum dwellers opt for delivery services offered by traditional birth attendants (TBAs) who lack essential skills and equipment, thereby increasing the risk of death and disability. Based on these findings, we maintain that urban poor women face barriers to access of formal obstetric services at family, community, and health facility levels, and efforts to reduce maternal morbidity and mortality among the urban poor must tackle the barriers, which operate at these different levels to hinder women’s access to formal obstetric care services. We recommend continuous community education on symptoms of complications related to pregnancy and timely referral. A focus on training of health personnel on “public relations” could also restore confidence in the health-care system with this populace. Further, we recommend improving the health facilities in the slums, improving the services provided by TBAs through capacity building as well as involving TBAs in referral processes to make access to services timely. Measures can also be put in place to enhance security in the slums at night. © 2011 The New York Academy of Medicine.
The study settings are Viwandani and Korogocho, two informal settlements located in Nairobi, the capital city of Kenya. In these two settlements the African Population and Health Research Centre (APHRC) operates the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) with about 60,000 registered inhabitants. The NUHDSS has monitored vital events like births, deaths, migration, and livelihood events of inhabitants of these two slum communities since 2001. Viwandani is located about 7 km southeast from Nairobi’s city center and is bordered by the city’s industrial area and the Nairobi River. It covers 0.52 km2 with a population density of 52,583 inhabitants/km2. Korogocho covers a smaller area than Viwandani (0.45 km2) and has higher population density (63,318 inhabitants/km2). It is located about 12 km east of the city center and is on reserve land of the City Council. Compared with Viwandani, Korogocho has less population disparity with regard to sex and age distribution. This study uses qualitative data from a maternal health project implemented in 2006 in the Korogocho and Viwandani slums. The purpose of the project, which is part of a multi-country study involving the Kassena-Nankana District in northern Ghana and the state of Uttar Pradesh in India, was to provide a better understanding of the delays and barriers to emergency obstetric care utilization in low-resource urban settings in Nairobi. This project was conducted within the NUHDSS, and data were collected through household interviews and a health facility survey. From the NUHDSS database, all women aged between 12 and 54 years who had a pregnancy outcome in 2004–2005 were selected and interviewed. From this group, those who had life-threatening obstetric complications and failed to seek health care were purposively sampled and participated in focus group discussions. The complications reported were similar across the slums and age groups. They included abdominal pain, headache and swelling of the feet, high fever, blurry vision, prolonged labor, and excessive vaginal bleeding. Their partners, opinion leaders, traditional birth attendants (TBAs), and older women were also purposively sampled and participated in focus group discussions (see Table 1). In total, 16 focus group discussions (FGDs) were held with each of the groups, formed along similar socio-economic and demographic characteristics. Groups of women who had complications were composed based on demographic and slum residence status. Opinion leaders were selected in consultation with the chiefs. Ethical approval of the study was obtained from the Kenya Medical Research Institute’s Ethical Committee and informed consent was obtained from participants before the discussions were held. Characteristics of groups purposively sampled for focus group discussions aOne group in Korogocho and another in Viwandani bHusbands/partners/boyfriends aged above 30 years whose wives/partners had a pregnancy with complications in the last 2 years (2004–2005) preceding the survey cHusbands/partners/boyfriends aged 30 years and below whose wives/partners had a pregnancy with complications in the last 2 years (2004–2005) preceding the survey Six trained field workers (3 male and 3 female) conducted the interviews in Kiswahili.1 The FGDs were conducted using an FGD interview guide. All the interviews were audio recorded and transcribed into English. The areas of investigation in this study included the respondents’ perceptions of formal delivery care services and the barriers that the community experiences to utilizing formal obstetric care services. Transcribed Word files were imported into NUD*ST 6 software (QSR International Pty Ltd, Australia) for coding24. This involved the continual reading of the transcripts and investigation of the themes emerging from the data for categories, linkages, and properties. In many instances, verbatim quotations were used to illustrate responses on relevant issues and themes.
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