Opportunities and challenges in implementing community based skilled birth attendance strategy in Kenya

Background: Availability of skilled care at birth remains a major problem in most developing countries. In an effort to increase access to skilled birth attendance, the Kenyan government implemented the community midwifery programme in 2005. The aim of this programme was to increase women’s access to skilled care during pregnancy, childbirth and post-partum within their communities.Methods: Qualitative research involving in-depth interviews with 20 community midwives and six key informants. The key informants were funder, managers, coordinators and supervisors of the programme. Interviews were conducted between June to July, 2011 in two districts in Western and Central provinces of Kenya.Results: Findings showed major challenges and opportunities in implementing the community midwifery programme. Challenges of the programme were: socio-economic issues, unavailability of logistics, problems of transportation for referrals and insecurity. Participants also identified the advantages of having midwives in the community which were provision of individualised care; living in the same community with clients which made community midwives easily accessible; and flexible payment options.Conclusions: Although the community midwifery model is a culturally acceptable method to increase skilled birth attendance in Kenya, the use of skilled birth attendance however remains disproportionately lower among poor mothers. Despite several governmental efforts to increase access and coverage of delivery services to the poor, it is clear that the poor may still not access skilled care even with skilled birth attendants residing in the community due to several socio-economic barriers. This study was conducted between June and July 2011. We used a qualitative approach utilising in-depth interviews (IDI) and key informant interviews (KII) to explore and understand different actors’ perspectives of the community midwifery programme. Two topic guides were developed; these were the KII guide and IDI guide. The KII guide contained 12 major items which aimed to explore the views and experiences of key informants on the community midwifery programme and factors that enable or hinder the community midwifery programme (Additional file 1). The IDI guide on the other hand contained 18 key items exploring CMs experiences; performance; job satisfaction; opportunities; and challenges faced (Additional file 2). The topic guides were pre-tested for cultural relevance and appropriateness in the Webuye community in eastern part of Bungoma District, in Western province which was not included in the study (Topic guides are attached as additional files). Triangulation of data was done by using these two data collection techniques to increase the validity of the study findings [12]. All interviews were conducted in English and were recorded using a digital audio recorder to ensure that all discussions were captured. MTM facilitated each interview and to improve the depth of the data collected, she was assisted by a Kiswahili/English research assistant, who was acquainted with the norms and culture of the area. Venues for interviews included participants’ homes, fields, clinics and church halls. The interviews lasted around 45 minutes to ensure prolonged engagement with participants. Summaries of interviews were made at the end of each interview to give opportunity to participants to agree with contents of their statements [13]. Notes were taken during field visits and interviews. The notes were expanded upon immediately afterwards. The study participants included 20 CMs and six key informants. Key informants were selected from national, provincial and district levels of the Ministry of Public Health and Sanitation, and the Population Council. We used purposive sampling to recruit all key informants who were perceived to have knowledge about the community midwifery programme so as to generate useful data to respond to the key research questions [12]. Key informants for this study were the pioneers, funder, manager, coordinators and supervisors of the community midwifery programme. These include the programme coordinator based with the Population Council (funder), the programme manager within the Reproductive Health Division of the Ministry of Public Health, the two coordinators and two supervisors from both districts. The CMs were selected from the registers maintained by the district supervisors. We ensured the inclusion of all CMs irrespective of location (either hard to reach or easily accessible areas) within the districts. As at the time of data collection, each district had 10 functional CMs and all were included in the study. The study sites were Kakamega District in the Western province and Maragua District in the Central province of Kenya. Of the two districts, Kakamega is under developed, with few public health facilities and skilled workers compared to Maragua. The reproductive health status of women was extremely poor in the Western province as illustrated by low utilisation of SBA of 25.3%, high fertility rate of 5.6 which was above the national average. There was also a high incidence of teenage pregnancy of 15% compared with other regions [8]. In the Central province, although 73.8% of the women gave birth with the help of a skilled birth attendant [8, 14], there were areas within the province that had limited access to services. Contraceptive Prevalence Rate was high among married women at 67%, compared to a national average of 46% [8, 15] (Table 1). Key characteristics of the study districts Reproductive, Maternal and Child Health Indicators for Kakamega District and Maragua District, Kenya. During the study period, four non-governmental organisations were working in the two districts to support the government of Kenya in the field of maternal health. They were: The USAID funded AIDS Population Health Integrated Assistance II (APHIA II) programme; the Tunza project of Population Services International (PSI) on family planning; Essential Health Services and the Population Council. Ethical approval for this study was granted by the Liverpool School of Tropical Medicine Research and Ethics Committee and the Scientific and Ethical Review Committee of the Kenyatta National Hospital in Kenya. Permission for the study was also obtained from the Division of Reproductive Health and the Director of each District Health Management Team. Informed consent was obtained from all participants. They were informed about their right not to participate and to withdraw at any time. To maintain privacy, anonymity and confidentiality, names of places were coded and no names of participants were obtained [12]. All audio recordings were transcribed. Each typed transcript was checked against the audio tape. All transcripts were later crossed checked with the recordings by the research team. Data were analysed using a thematic framework [13, 14]. Issues related to study aims were identified and coded without predefined categories capturing the main themes and concepts. The coding process involved identifying major themes in each of the transcript. During data analysis, identified themes were compared across the transcripts and field notes to determine differences and similarities in the perspectives of the study participants. After coding, themes were developed and classified guided by a framework and a triangulation of data sources and methods. The process of triangulation was used to validate the findings. This involved comparing the identified themes from the IDIs and key informant interview transcripts [12]. Results were then written up thematically, organised around the main research questions. This qualitative study has adhered to the guidelines for Qualitative research review guidelines (RATs).