Participant characteristics
A total of 29 new mothers aged between 18–34 years old participated in the study. Nearly 34% were between 25–29 years old with about 34% having college education. Among the participants, 68% were married. The majority of the participants (48%) had one child and 34% were from rural areas (Table 1).
Table 1
Demographic characteristics of the respondents
Code
|
Age
|
Education
|
Residency
|
Marital status
|
Employment
|
No of children
|
RP1
|
18
|
Primary
|
Rural
|
Single
|
Formal
|
1
|
RP2
|
23
|
Secondary
|
Peri-urban
|
Married
|
Formal
|
1
|
RP3
|
25
|
College
|
Rural
|
Married
|
Formal
|
1
|
RP4
|
30
|
College
|
Peri-urban
|
Single
|
self employed
|
2
|
RP5
|
19
|
Secondary
|
Urban
|
Married
|
self employed
|
1
|
RP6
|
31
|
Primary
|
Rural
|
Married
|
self employed
|
2
|
RP7
|
26
|
Secondary
|
Urban
|
Married
|
self employed
|
1
|
RP8
|
20
|
college
|
Peri-urban
|
Single
|
Formal
|
1
|
RP9
|
27
|
College
|
Rural
|
Married
|
self employed
|
1
|
RP10
|
32
|
Primary
|
Urban
|
Single
|
self employed
|
3
|
RP11
|
30
|
College
|
Peri-urban
|
Married
|
self employed
|
4
|
RP12
|
21
|
Secondary
|
Rural
|
Married
|
Formal
|
1
|
RP13
|
28
|
Primary
|
Urban
|
Married
|
Housewife
|
2
|
RP14
|
33
|
Secondary
|
Peri-urban
|
Married
|
Housewife
|
3
|
RP15
|
31
|
Primary
|
Urban
|
Married
|
Formal
|
3
|
RP16
|
22
|
Primary
|
Rural
|
Single
|
self employed
|
1
|
RP17
|
34
|
Secondary
|
Urban
|
Married
|
self employed
|
1
|
RP18
|
29
|
College
|
Rural
|
Married
|
self employed
|
1
|
RP19
|
25
|
Primary
|
Peri-urban
|
Married
|
Formal
|
1
|
RP20
|
23
|
College
|
Rural
|
Single
|
Formal
|
1
|
RP21
|
30
|
Primary
|
Urban
|
Married
|
Housewife
|
3
|
RP22
|
26
|
Secondary
|
Peri-urban
|
Married
|
Self employed
|
1
|
RP23
|
31
|
College
|
Urban
|
Married
|
Formal
|
2
|
RP24
|
24
|
Secondary
|
Peri-urban
|
Single
|
Housewife
|
2
|
RP25
|
27
|
Secondary
|
Rural
|
Married
|
Formal
|
2
|
RP26
|
32
|
College
|
Urban
|
Single
|
Housewife
|
3
|
RP27
|
28
|
College
|
Peri-urban
|
Married
|
Housewife
|
2
|
RP28
|
24
|
College
|
Rural
|
Married
|
self employed
|
2
|
RP29
|
29
|
Primary
|
Peri-urban
|
Single
|
self employed
|
2
|
Participant’s perceptions and experience regarding the quality of maternal healthcare services in the public health facilities in Kenya.
The study participants were asked about their perceptions and experiences regarding the quality of maternal healthcare services they received at the public health facility during their previous pregnancy and if it contributed to tokophobia. The quality of care framework developed by the University of Southampton was customized in this study and the interview guide was developed based on it. All the interviewed women revealed that indeed there were challenges regarding the quality of maternal healthcare and two themes with eight sub-themes were identified (Table 2).
Table 2
Themes and sub-themes that hampered the provision of quality maternal healthcare services in public health facilities in Kenya
Themes
|
Sub-themes
|
1. Participant’s perceptions and experience relating to provision of care
|
i. Inadequacies related to human and physical resources
ii. Inadequate referral systems
iii. Challenges with internationally recognized best practices
iv. Challenges in management of emergencies.
|
2. Participant’s perceptions and experience relating to actual experience of care
|
i. Lack of enough human resources for health and inadequate investment in physical resources
ii. Lack of cognition
iii. Lack of respect, dignity and equity
iv. Inadequate emotional support
|
Participant’s perceptions and experience regarding the provision of quality maternal healthcare in public health facilities
In-depth questions were asked about the participant’s perspectives and experiences regarding the provision of quality maternal healthcare services. From the collected data, 2 major themes emerged: 1) Participant’s perceptions and experience relating to provision of care and 2) perceptions and experience relating to the actual experience of care. Further details of these two themes and their corresponding sub-themes are subsequently highlighted below.
1. Participant’s perceptions and experience relating to provision of care.
The adopted quality of care framework identifies six elements related to provision of care namely: human and physical resources; the referral system; the appropriate use of available technologies; internationally recognized best practices; and management of emergencies. Although the interview guide had questions aligned to all the six elements, the responses from the study participants would conclusively elicit four elements (therein referred as sub-themes); namely: i) challenges with human and physical resources, ii) challenges relating with referral systems, iii) challenges with internationally recognized best practices, and iv) challenges with management of emergencies. The four sub-themes are explained below.
i. human and physical resources
The study indicated that most participants experienced challenges with patient flow at the maternity wing of the hospital, inadequate staffing at the maternity wing, unclear signage and/ or organizational management structure of labor, delivery and postpartum sections of the hospital, general infrastructure of the hospital’s maternity wing, and unclear/ less elaborate management structures.
Participants described their frustration on the manner in which the flow of patients was being handled. They noted that due to unclear patient flow, much time was wasted in finding their way within the hospital. This was commonly reported by women who were giving birth for the first time.
“I did not clearly understand the patient flow…this was my first pregnancy”. [RP22]
“During antenatal visits, the nurses should guide us on the flow of patients”. [RP12]
Participants identified staff shortages especially in maternity wings as a major challenge the health facility was struggling with.
“The nurses were very few compared to the number of women delivering” [RP7].
Participants reported that the hospital did not have clear signage written in the local language. Also, they noted that the direction to labor wards, delivery rooms and postpartum sections of the maternity wing was not labelled in the local languages, and this made it difficult for the first-time mothers to follow, more so those that were not able to read in English and Kiswahili.
“There was no clear signage, I got lost at first but the hospital staff assisted me” [RP2]
ii. Referral system
Participants reported that there were challenges with time taken to be admitted, timely examination and referral of a woman presenting with birth complications. Four participants experienced a very slow admission procedure, which led to delayed referral to a more advanced hospital.
“They are slow, I had complications, and my chances of surviving were low” [RP28].
Also, there were reports of challenges with reliable transport on a 24-hour basis. Participants mentioned that due to rough terrains particularly in rural settings, it was challenging to get means of transport more so at night. Although the hospital was reported to be having a number of ambulances, it was mentioned that they were unreliable. They also mentioned that due to their low economic status, it was expensive hiring private taxis and more often than not, the taxis were not available in the villages.
“Ambulances in the hospitals are unreliable, they do not respond on time,” [RP25].
It was reported that although the hospital had a hotline phone numbers, they were unreliable.
“I called and they said the ambulance had gone for another referral” [RP11].
In regards to the availability of staff, essential drugs and equipment at the local health facilities to stabilize expectant women with complications before referral, the participants reported that the local health facilities such as dispensaries were not operating on a 24 hours basis.
“Our dispensary is closed at night and during weekends” [RP20].
iii. Internationally recognized best practices
Allowing women to have social support of her own during labor and childbirth and assessment of women’s physical well-being throughout labor are among the globally recommended best practices. In this study participants reported that they were not allowed to be accompanied into labor and delivery wards by persons of their choice.
“The hospital does not allow anyone to be accompanied by a relative or family member to labor wards and delivery rooms” [RP15]
iv. Management of emergencies
Two participants mentioned that they were aware of three of their relatives who had birth complications and had lost their lives as a result of late reporting to the health facility which led to delays in managing the emergency. Also, they mentioned that unsafe abortion were common but the local health facilities did not have the capacity to handle emergency abortions as they do not operate on a 24 hours basis.
“There are women in our villages who have lost their lives due to unsafe abortions and other pregnancy complications because the hospital is far from rural areas” [RP13].
2. Participant’s perceptions and experience relating to actual experience of care
Based on the quality of care framework used for drafting the interview guide, the focus was on the Participant’s perceptions and experience related to their actual experience of care, namely: i) human and physical resources, ii) cognition, iii) respect, dignity and equity, and iv) emotional support. Participants noted a litany of challenges and inadequacies related to these factors. The challenges are discussed next.
i. Human and physical resources
The in-depth interviews were aligned towards the physical infrastructure, overall maternity environment, and contact time with qualified healthcare workers, cultural norms regarding gender of midwives and the competence of healthcare workers to offer quality maternal services. Concerns were raised over the state of wards, more specifically the quality of beds and bedsheets, hospital meals, toilets and bathrooms.
“There is a need to improve the quality of hospital linen and beds” [RP19]
“I wish they can improve the quality of meals they offer to inpatients” [RP14].
Regarding contact time with qualified healthcare workers, the majority of the participants noted that the hospital was understaffed.
“Only one doctor and about three nurses in the labor ward. We were seven” [RP10].
Cultural norms regarding the gender of midwives assisting women during delivery was mentioned by all study participants. All participants preferred to be assisted by female midwives and doctors but lamented that the hospital had mostly male healthcare workers.
“The hospital had only male nurses” [RP17].
ii. Cognition
In this study, participants noted that necessary information regarding their scheduled childbirth was not relayed effectively in a language they all understood. Equally, participants reported that they were not fully prepared for the childbirth process and they did not understand the existing options. Regarding postpartum care, the participants reported that they were not psychologically prepared for all possible outcomes of their pregnancy.
“They only looked at my maternity card and told me to go to the labor ward” [RP8].
“Although I had questions, I wouldn’t ask because I was worried” [RP23].
iii. Respect, dignity and equity
In the current study, fear of hostile treatment from midwives and nursing staff was echoed by study participants during the in-depth interviews. Their explanation for why women avoid facility-based deliveries were met with agreement by many of the other study participants.
“The nurses aren’t kind, compared to the traditional birth attendants” [RP18].
“Actually, most midwives do not treat women with dignity” [RP24].
In contrast to their often-negative impressions of facility-based midwives, participants largely submitted that the care provided by traditional birth attendants was of compassion, humility and absolute psychosocial support. They stated that traditional birth attendants encouraged them during labor and assisted them with tenderness and compassion.
“Traditional birth attendants will speak with you with kindness” [RP25]
“My experience was inspiring; the traditional birth attendant was empathetic” [RP3]
It was reported that the effects of not attending all the required antenatal care clinics during pregnancy created anxiety and fear among some study participants. Similarly, other participants explained how they had heard stories from women delivering in health facilities that caused fear and anxiety. In some cases, study participants confessed that these fears discouraged many of their peers from going for health facility deliveries
“There are stories of women being slapped at the hospital during labor” [RP26].
“I was not able to attend all antenatal visits; the nurse was very harsh on me” [RP1].
Participants also stated that the health facility did not have a designated office responsible for assessing socioeconomic and cultural needs of the expectant women. Also, most of the study participants felt that they did not receive appropriate respect from the healthcare providers. Participants noted that cultural practices that do not interfere with quality of care such as being assisted to give birth by a female healthcare worker should be practiced.
Participants noted that not all expectant women were treated with the same standard of care. They said that those who were well known by the healthcare workers received better treatment than the ordinary women.
“We were not treated equally, some received better treatment than others” [RP27].
“Some women were given special favors. This is common in public hospitals” [RP9].
iv. Emotional support
In the current study, participants were asked if: i) they were able to freely choose the social support they were comfortable with, ii) if they were treated with honesty, kindness and understanding, and iii) if the health staff were cognizant of their supportive role in the provision of care during labor, delivery and immediately postpartum period.
None of the participants reported having a companion of their choice during labor and delivery. The hospital was said to have strict protocols that would not allow such practices.
Participants reported that most midwives did not offer any physical, or emotional support during labor and childbirth, and this was largely as a result of understaffing.
“The nurses were overwhelmed. We were seven and they were only three” [RP4].