Facilitating factors and barriers to KMC accessibility and utilization
This study identified four major themes on facilitating factors and barriers that affected the accessibility and utilization of KMC service by the PLBWIs. The themes included; access (availability of KMC providers, place of delivery, strengthen referral systems, cost, health seeking behaviour, women empowerment and quality of obstetric care), buy-in (KMC knowledge, causes of LBWIs birth, advantages/outcomes of KMC, attitude towards LBWI and KMC, stigma towards mother with a LBWI and preference of LBWI care), medical issues (safety and maternal health) and traditional/cultural norms (social obligation and gender roles). The sub-themes for the identified four major themes grouped into availability, accessibility, acceptability and affordability of KMC service, personal behaviour and quality of care as shown in Table 2, to align to the parameters of utilization of KMC services. In this study the identified themes are described as follows; access-issues that enhanced or barred toobtain KMC service s, buy-in-issues that promoted or hindered KMC acceptance, medical issues-health factors that promoted or refrained to utilize KMC service and traditional/cultural norms-customary and/or habitually behaviours that facilitated or barred KMC utilization.
The trustworthiness of the results
To ensure trustworthiness of the study findings, the issues of credibility, transferability, dependability and conformability abided by as shown in the table 1.
Table 1: The trustworthiness of the study findings
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Credibility
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Transferability
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Dependability
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Conformability
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Description
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The research methodologies similar to the concept under study were incorporated. The participants of this study voluntarily participated to ensure recording honest information. Probing questions technique was used to ignite detailed information and, FGDs audio transcript results and notes were triangulated to verify some details
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The study results based on the understanding of community leaders’ perspective towards KMC utilization by PLBWIs, which ensured transferability to other settings using the methodologies of this study.
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The study protocol was used to conduct this study, in order, to achieve reliable study results
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The conformability of the results achieved by triangulating the FGD results and the notes
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Table 2: Socio-demographic characteristics of study population (N=12)
Demographics
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n (%)
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Age (years)
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Mean ± SD (range)
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41.9 ± 10.6
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25-34
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2 (16.7)
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35-44
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5 (41.7)
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45-54
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4 (33.3)
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>55
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1 (8.3)
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Marital status
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Single
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1 (8.3)
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Married
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11 (91.7)
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Education
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Never been to school
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1 (8.3)
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Some primary school
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1 (8.3)
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Incomplete primary school
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9 (75.1)
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Complete secondary school
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1 (8.3)
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Occupation
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unemployed
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1 (8.3)
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Self-employed
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10 (83.3)
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Employed
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1 (8.3)
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KMC knowledge
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Yes
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2 (16.7)
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No
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10 (83.3)
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Gender
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Male
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2 (16.7)
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Female
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10 (83.3)
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Table 3: Matrix of community leaders’ perspectives on facilitating factors and barriers affecting the accessibility and utilization of KMC service by the PLBWIs in MDH in 2018, identified themes and sub-themes grouped according to utilization[1] of KMC service.
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Availability of KMC service
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Accessibility of KMC service
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Acceptability of KMC service
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Affordability of KMC service
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Personal Behavior
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Quality of care
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Facilitating factors
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Access
Availability of KMC providers
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Access
Place of delivery: Hospital delivery
ü -Short distance to health facility
ü -Mandatory by CLs
ü -Community support by CLs
ü -Availability of hospital resources (human and material)
Strengthen referral systems
ü -CLs encouraging the community to see the midwives after home delivery
Buy-in
KMC knowledge
ü -Prior knowledge of KMC by the CLs
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Buy in
Knowledge on medical causes of LBWI birth
ü -accidents
ü -Gender Based Violence
ü -malnutrition
Perceived advantages/outcomes of KMC
ü -warmth
ü -enhance intelligence
ü -positive lived experience with KMC
Medical issues
Safety
ü -KMC perceived as a safe care
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Access
Cost
ü -KMC perceived as a cheaper service
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Access
Health seeking behavior
ü -Acting on health advice
ü -Acceptance of any pregnancy outcome
Women empowerment
ü -empowered in health decision making
Buy-in
Attitude towards LBWI and KMC
ü -Positive attitude towards LBWI and KMC
ü -Positive attitude towards mother practicing KMC
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Barriers
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Access
Non- availability of KMC providers
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Access
Place of delivery: Home delivery
ü -lack of ambulance services
ü lack of hospital material resources- Born before arrival[2]
ü -Cultural beliefs-selling of umbilical cords by health providers
ü -Health providers’ attitude-hostile behaviour
ü -Long distance to reach the nearest government health facility-Expensive to foot for transportation fare
-Geographical location of health facility (Hard to reach areas-cross the lake)
- Parents’ attitude
Buy-in
Lack of KMC knowledge
-No prior knowledge of KMC by pregnant women from Antenatal clinic
No KMC knowledge by CLs
Stigma towards mother with a LBWI
- Association of LBWI delivery to cultural taboos
-Fear of being ridiculed
Traditional/cultural norms
Social obligation
-Fulfilling gender roles
Medical issues
Maternal health
-Pains after delivery
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Buy-in
Perceived traditional causes of LBWIs delivery
ü -promiscuous
ü -extensive sexual intercourse
Preference of LBWI care
ü -Incubator care preference over KMC
Medical issues
Safety
ü -KMC perceived as a harmful care
Traditional/cultural norm
Cultural beliefs
-LBWIs not considered as not yet human beings
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Access
Cost
ü -KMC viewed as costly to use
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Access
Women empowerment
ü -Lack of women empowerment in health decision making
Buy-in
Attitude towards LBWI and KMC
ü -Negative attitude towards LBWI on KMC
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Access
Perceived poor obstetric care
ü -Slow response to community obstetric emergency
ü -Nurses negligence in providing obstetric care
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Availability of KMC service
Access: Availability of skilled KMC providers was the only sub-theme that emerged under the availability of KMC service as a facilitating factor to KMC utilization, as narrated below by the community leaders.
“Sometimes it depends on the way the nurse is telling the mother about kangaroo. If the mother is convinced by what the nurse is saying, the mother tends to agree to practice kangaroo, so that the child should be helped” CL 3
Accessibility of KMC services
Access (place of delivery, referral system), Buy-in (KMC knowledge and stigma), Traditional/cultural norms (social obligation and gender roles) and Medical issues(mother’s health) were the four themes that emerged under the accessibility of KMC service.
Access
Place of delivery: Hospital and home delivery came up as sub-themes under this theme.
Hospital delivery emerged as a facilitating factor to KMC utilization, which influenced by short distance to the nearest government facility, availability of hospital resources (human and material), mandatory and support by the community leaders.
“We are also lucky that this hospital is in our village and mothers access the hospital services without walking a long distance” CL 2
“Sometimes the woman can fail to deliver naturally the nurses take the woman to the theatre for delivery through an operation which in the village there is no operation” CL 1
“Us, community leaders, we have got the mandate to punish people if they give birth in the community, they pay a penalty. Because of this, most of the women are giving birth at the hospital” CL 9
“We encourage mothers to give birth at the hospital; we encourage them frequently through gatherings that women should give birth at the hospital and not in the village. Because it is at the hospital where mothers get adequate care” CL 12
Home deliveries and/or born before arrival[3] identified as the barriers to KMC utilization. The home deliveries were due to lack of ambulance services, lack of hospital material resources, long distance and geographical location of the nearest government health facility (hard to reach areas), cultural beliefs (selling of umbilical cords by health providers), health providers’ attitude (hostile behaviour), and parental non-health seeking behaviour, as indicated below.
“When they call for an ambulance they are told the ambulance does not have fuel, as such they do not give birth at the hospital due to challenges with transportation” CL 4
“In Mangochi, the only big government hospital we have is this Mangochi hospital. The hospitals that are around this community belong to either Roman Catholic or Anglican churches. So, what happens is mothers go to those church hospitals to giving birth. But, due to inadequate or few equipment at these hospitals, mothers are told that we don’t have equipment to help you with delivery, so you should go to Mangochi hospital, as such they may give birth on their way to the hospital” CL 7.
“Some mothers deliver at home due to lack of transportation from the village to where the hospital is situated. The town is far away from our villages, especially the village called Bala, which is across this lake” CL 10
“Women think that if they go to deliver at the hospital. The health workers will take other things like baby’s belly button and placenta and send them to other countries for money” CL 6
“Women are afraid that when they reach the hospital, sometimes, they have a warm welcome, most of the times they are shouted at in the labour ward. Female nurses insult the mother saying, ‘there! you should be doing what you were doing when you got pregnant, you should deliver there’… at the end women find it so good giving birth at home unlike being shouted at by the nurse at the hospital” CL 8
“Some women give birth at home willingly, although the community leader sensitized its community to give birth at the hospital. As such, they fail to go in time to the hospital so they deliver at home” CL 3
Strengthen referral system by referring newly home delivered mothers to the hospital identified as a facilitating factor to KMC utilization, as narrated below.
“When the mother has given birth at home…we encourage her to wrap the baby nicely and go to the hospital for care” CL 11
Buy-in
KMC knowledge: KMC knowledge by CLs identified as the facilitating factor to KMC utilization while no prior knowledge of KMC by mothers at antenatal care clinic and lack of Knowledge by the CLs emerged as a barrier to KMC utilization, as follows.
“When the baby is born before its time it is placed on its mother’s stomach the reason being the baby’s stomach and the mother’s stomach should contact each other” CL 1
“We are puzzled that the Health Surveillance Assistants (HSAs) who conduct scale (outreach clinic) they do not explain about kangaroo, why? We do not know about the care of kangaroo, why do they not teach these mothers? There we are puzzled, because HSAs could have been the ones teaching the mothers about kangaroo when they are doing scale. Because when mothers are taught they tell their husbands what they learnt, but we were not told anything” CL 5
“We haven’t had any education on Kangaroo, we are not interested in these children. This is our first-time hearing about these babies. In our community kangaroo for the baby born before its time is unknown and no one has no interest in kangaroo, we just stay” CL 12
Stigma to LBWIs by association of LBWI delivery to cultural taboos by the community brings fear to the mother of been ridiculed by the community, which was identified as a barrier to KMC utilization.
“In our village when a woman has given birth to a baby before its time, she does not publicise she keeps it a secret in fear of being ridiculed as people will be saying all sorts of things that lead to her giving birth before the baby’s time. With that sometimes we cannot know when it happens” CL 6
Traditional/cultural norms
Social obligations and gender roles identified as the barriers to KMC utilization, as CLs narrated.
“We, black people, have so many things that need to be done when the mother has given birth. The mother lies the baby on a mat and does house chores unlike baboons they can have their babies cling to them, but the human baby needs its mother’s care all the time, as such it is not possible to do kangaroo the whole day” CL 3
Medical issues
Mother’s health: Pain after delivery identified as a barrier to KMC initiation.
“Mother cannot start kangaroo as soon as after delivery as the mother will be in pains due to delivery, as such putting the baby to the tummy is torture” CL 4
Acceptability of KMC service
Buy-in (Knowledge on the causes of LBWI birth, Advantages /outcome of KMC and preference of LBWIs care), Medical issue (safety of KMC on LBWIs) and cultural beliefs were the four themes identified under acceptability of KMC.
Buy-in
Knowledge on the causes of LBWI birth: scientific based causes and traditional beliefs-based causes emerged under this theme.
Accidents, gender based violence and maternal malnutrition were identified as the scientific causes of LBWI delivery, that may facilitate the utilization of KMC,
“When a woman is beaten or has been involved in an accident she can give birth to a baby before its time” CL 9
“We believe that if the woman had inadequate food in her body, during her pregnancy, she can deliver early” CL 5
Promiscuity and extensive sexual intercourse were the identified traditional belief causes of LBWI delivery that may hinder mothers from utilizing KMC.
”This thing of babies born before their time started a long time ago. When it happens, elders were having ideas that either the man or the woman had extra marital affairs, so, they have mixed bloods from outside their marital home and the baby got sad and came out early” CL 3
“Sometimes elders say that when sleeping with a woman some men would do it so hard that they can perforate the uterus and the baby would come out early” CL 6
Preference of LBWIs care: preference of incubator care over KMC for a LBWI recognized as a barrier to KMC utilization.
“The box care [incubator care] will be good. In the box, there is warm air when the baby is breathing that it is as if the baby is still in its mother's stomach. When the baby is on its mother’s stomach, it breaths in cold air which is not good. That is why for mothers giving birth at the hospital is good so that baby should be put in a box” CL 10
Advantages /outcome of KMC: warmth, enhance intelligence, positive lived experience with KMC on LBWI and positive outcome with KMC service were the sub-theme identified to facilitating the utilization of KMC by the PLBWIs.
“When the baby is placed on its mother’s tummy it gets warm gets energy like a baby born mature, born with completed months” … at the end this baby, if God gives it chance to be well, it tends out to be an intelligent child more than children that were born with complete months” CL 5 & 6
“People tend to agree to utilize a health service if they see that the service helped someone then they have confidence to go and use it… sometimes the benefits of the care influence the decision maker to agree or to refuse the service” CL 2 & 9
Medical issue
Safety of KMC on LBWIs: KMC service perceived by some CLs as safe and some CLs perceived it as not safe for a LBWI.
Safety of KMC noted as a facilitating factor for KMC utilization, while non-safe of KMC identified as the barrier to KMC utilization.
“There is no danger in using KMC, that’s according to how the radio presenter narrated about kangaroo” CL 7
“IThere is a danger to the baby when it is on her mother’s chest, because the baby is squeezed unto its mother’s chest and denied of air to breath, which can cause suffocation and death” CL 5
Traditional/cultural norm
Buy-in; Cultural beliefs: the cultural belief of not considering LBWIs not yet humans shown as the barrier to KMC utilization.
“We think that they are good Samaritans because “According to our culture taking care of a baby born before its time will just waste mother’s time as she cannot do that for four months, others will just sleep on them” CL 3
Affordability of KMC service
Access (cost of KMC service) identified as theme under affordability.
Cost of KMC service: some CLs perceived KMC as a cheaper service to use, while some considered KMC as an expensive service to use, as narrated below.
“Because of poverty, some people cannot go and wait at the hospital since they will be buying firewood, food/relish, transport and more expenses…when a mother is at the hospital with the time spent, most of the things at home are stagnant. At the hospital the mother uses electricity and the nurse are on them instead of helping others” CL 1 & 4
“Kangaroo can be cheap if the mother takes care of the baby at home because the things that the mother uses in the hospital are also locally available at home” CL 9
Personal health behaviour
Access (Health seeking behaviour, women empowerment and attitude towards LBWI and KMC) identified as factors affecting KMC utilization under personal health behaviour.
Access
Health seeking behaviour: utilizing health advice and prior acceptance of any outcome of pregnancy emerged as the facilitating factors to KMC utilization, whereas parental attitude
“When you are ignorant on anything, it is good to listen to those that have knowledge on how to deal with the health problem at hand” CL 5
“It can happen that these pregnant women can give birth to a baby before its time due to different reasons” CL 2
Women empowerment in health decision making: Woman as a decision maker was identified as a facilitating factor in KMC utilization, whereas lack of women empowerment in decision making fell as a barrier to utilization of KMC, as reported below.
“The mother gives the authority to do kangaroo because she is the owner of the baby and she knows the importance of the baby hence she gives the care as for a man he only has the responsibility of buying things and the one taking care of the baby is a woman” CL 4
“The community has a hierarchy according to tradition. On the first position is the chief then cohorts, in the cohorts there are households in each household there is ahead of a family who has authority in making decisions of each and everything happening in the family” CL 7
Buy-in
Attitude towards LBWI and KMC: positive attitude towards LBWI on KMC and positive attitude towards mothers practicing KMC, whereas negative attitude towards LBWI on KMC emerged as a barrier to KMC utilization, as reported below.
“I do not think of anything about an under-weight baby [LBWI] and kangaroo, although I heard the issue on radio, presented so scanty, and this Kangaroo is new to us and I cannot associate it with anything bad, maybe my friends can” CL 4
“When we see a woman with a baby at the front and covered, we always think that the baby is dead. We do not think that the baby is alive because it is a strange thing. In our culture putting the baby in front and covering it, it means the baby is dead, so mothers that put their babies in front and covered we think they are caring a dead baby walking around, which is a taboo” CL 11
“When we see mothers with babies in front, we feel pity for them and culturally if we have something to give them we do, to assist them in taking care of the babies” CL 3
Quality of care
Access identified as the theme on quality of care due to perceived poor obstetric care; slow response to obstetric emergency in the community and negligence in providing essential obstetric care that merged as barriers to KMC utilization as shown below.
“When the ambulance is called to come pick up the woman in labour, the ambulance comes in late; sometimes it does not come at all. It is our plea, that ambulances should come in time so that the mother delivers in the hospital and starts kangaroo in time” CL 2
“The nurses leave the women struggling on their own in the labour ward. Nurses are angrily at the delivery ward, they are harsh to the pregnant women” CL 5
[1] Utilization of a service is described as availability, affordability, accessibility and acceptability of the service, personal behaviour and quality of care (18,25,26)
[2] BBAs (Born Before Arrival) are babies that are born on the way to the health facility for an assisted delivery with a skilled health provider (35)
[3] BBAs (Born Before Arrival) are babies that are born on the way to the health facility for an assisted delivery with a skilled health provider (35)