In individual IDIs, women were asked demographic questions about age, marital status, parity, and whether they were currently pregnant, followed by a range of questions about health seeking behavior including number of ANC visits they had attended, and whether they practiced family planning. Pregnant women were also asked about preparations they were making for their current delivery, where they preferred to have their delivery (and why) and which decision makers-were involved in that decision. In addition, all parous women (n=20) were asked where they had their last delivery, who attended and what their role was, what preparations were made, who made decisions for place of delivery, what position did they give birth in, and whether they attended a postpartum clinical visit after delivery. Some descriptive statistics for women surveyed are in Table 1.
Table 1: Descriptive Statistics of IDI participants (Source: IDIs)
# of women interviewed
Age range c
# of women interviewed who were married
# of parous women interviewed
# of currently pregnant women interviewed
# of currently pregnant women currently attending antenatal care
# of parous women who had last delivery at home
# of women who said they prefer to deliver in a facility
# of women who said they preferred facility delivery who delivered at home at last delivery
# of parous women who said decision about place of last delivery was their own
# of parous women who said decision about place of last delivery was 'God's' or chance
# of parous women who said place of last delivery was the decision of husband or others
# of parous women who attended a postpartum clinical visit within 1 week after delivery
Focus groups for TBAs and men were asked similar questions about birth preferences, their roles during pregnancy and delivery, and decision making around place of delivery.
Decision makers for place of delivery:
In response to questions about who decision-makers for place of delivery were, there was not uniform agreement between groups interviewed. One third of female participants expressed strong agency to make their own decision about the place of delivery.
"Safety is the only consideration, I decide. My husband and mother-in-law have no say."
" No one decides but me."
"Me and me alone." —3 female IDI participants
Only two female participants expressed a feeling of complete powerlessness to decide:
"I will be controlled by all." "Even if I say something, I am being told not to do it." —female IDI participant
Other women, who did not express a sense of personal agency in the decision to have a home delivery in their last pregnancy attributed the decision to "God", and explained that the unexpected onset of labor was the deciding factor to give birth at home in their last delivery regardless of personal preference.
"No one decided, I had labor pains then delivered at home. God decides, as facility is far."
"God plans for me. If it was up to me, I would have gone to hospital." —2 female IDI participants
Notably, most women who expressed both preference and agency for a facility delivery, ended up delivering their last child at home because of 'sudden onset of labor'. While distance and transportation were mentioned by some as reasons they decided not to go, even those who reported living within 30 minutes walking distance of the clinic decided to have a home delivery once contractions began.
The frequent report of sudden labor led to a follow-up question to women and TBAs about whether they thought a maternity waiting house near a ward clinic would help them get to a clinic on time. Although not all were familiar with the concept, when it was explained, all who were asked affirmed that it would be beneficial to them in their situation. Key informants from ward health facilities, including the ward health officer affirmed this potential solution as well.
Among TBAs there was a general consensus that husbands were the gatekeepers for a facility vs. home delivery. They attributed this to his control of the financial resources needed for transportation, as well as his preference for traditional norms:
"Not this way (facility birth). Maasai men don’t want to incur any cost."
"A man will deny (facility birth) to his wife because he says others have given birth at home so she can give birth at home too." —2 TBA’s FGD participants
From the men's FGDs, there were a few who affirmed that the husband is the sole decision-maker for place of delivery. Several also expressed an inability to pay the cost of transportation for a facility birth, especially to the tertiary care center in Karatu. More generally, however, there was consensus among men to affirm the role of the TBA in making a judgment about whether a facility birth was necessary based on their expertise about the progress of labor.
"TBAs are the ones to influence where a woman should give birth because they are close to the pregnant mother; I do not even touch her stomach because I am afraid of even being near her. She can tell me that a child is doing well and so she is the one to advise me to take her to hospital or not and I do listen to her because I trust her as I do not decide to take her to the hospital without the TBA’s word.” —Men’s FGD participant
Traditional Practices in a Home Delivery
Descriptions of practices around delivery preparation, ANC, and during labor in a home delivery were elicited from pregnant and parous women, TBAs, and husbands, to better understand rituals or services that are desired or expected in a traditional delivery.
Antenatal and postpartum clinical care
Pregnant and parous women were asked if they attended ANC visits during their last pregnancy or current pregnancy if they were pregnant. Every woman affirmed that she had attended ANC in the past and was attending ANC in her current pregnancy. TBAs also affirmed that they accompany women to their ANC visits.
Even women who said they preferred to have a home delivery, affirmed the importance of completing ANC visits and believed that they would be told if a hospital delivery was necessary by clinical staff. Several women provided the interviewer with the clinic cards they received showing the number of visits completed and estimated delivery date.
Men also affirmed the value of ANC visits prior to delivery and confirmed that the clinic does not allow a woman to come alone to her first ANC visit, but must be accompanied by her husband so they can provide counselling as well as HIV testing to the couple. This was confirmed by health facility staff except in the case where the woman was unmarried, or the husband was verifiably unavailable. Men's attitudes also reflected changing norms about the practice of going to antenatal care at a clinic:
"Due to the health education we’re receiving, we normally ask our wives to attend clinic or escort her and do the test together to know if you’re safe. So I advise her to go to the clinic until the time of delivery. In the past, TBAs were our clinics; they were the ones who knew how the child in the belly is doing until delivery."—men’s FGD participant
According to nurse-midwives, all three facilities in the ward promote 4+ANC visits and provide a minimum package of ANC services as defined by MoHCDEC. Midwives also provide counseling on a variety of topics including the importance of a facility delivery.
"We teach them about hygiene after delivery, family planning. We teach them proper breastfeeding. Also we remind them about the importance of facility delivery, and if there is a problem of transportation, we advise a mother to have her own saved bodaboda (motorcycle-taxi) phone number so when she has a problem, instead of waiting for a TBA she can call the bodaboda and come to the facility. We do this when we know the mother is coming for her last ANC visit" —nurse midwife at Nainokanoka clinic.
Women and TBAs were also asked about attitudes toward post-delivery care and if and how long they waited before going to a clinic post-delivery. The majority of women interviewed, who had their previous delivery at home, affirmed that they went to a clinic within 24 hours. Only one responded that she had not taken her last child at all to date. TBAs affirmed that it was common practice for them to escort women to a clinic within 24 hours of delivery.
Home Delivery Preparations
Notably, every woman, regardless of whether they expressed a preference for a facility or home birth, reported making preparations for a home delivery. Women identified several items for which they were responsible to prepare for a delivery in the home. The most common preparations mentioned were:
- Preparation of butter and ‘jelly’— Preparation of butter to feed the baby was mentioned by almost all women interviewed. Butter is given to the baby right after birth. Key informants explained that it is given just prior to breast feeding because of a belief that it will help the baby digest colostrum better. Women also prepare a local petroleum jelly which is used to rub on the baby's skin after birth and to massage her abdomen during labor.
- Preparation of firewood— All women prepare firewood for delivery. Key informants explained that firewood was important for cooking during the period after delivery when the mother is nursing and recovering from delivery.
Other items prepared for time of delivery included baby clothes, and several women mentioned food for the time of labor for themselves as well as the TBAs attending them. Foods mentioned included millet porridge, as well as black tea for energy during a long period of labor.
Prior to delivery, a man’s primary responsibility is to find and engage a TBA who will assist with the delivery and accompany his wife during her pregnancy—this includes taking her to ANC visits. TBAs affirmed that they were engaged by men, usually in the first trimester of a woman’s pregnancy. Most men also affirmed that they prepared meat for their wives for the postpartum period—particularly slaughtering a goat. Men also described preparations of meat for the 'birth ceremony'. Several men mentioned their role in supporting the practice of limiting their wives’ food-intake to assure a low birthweight baby which is considered to be easier to deliver.
"Our preparation starts when she is seven months pregnant, I do tell her to stop doing heavy duties and take some traditional herbs that make her vomit, I do engage a TBA and prepare a goat and a sheep for her.” –men’s FGD participant
The practice of limiting a woman’s food intake was mentioned by one other husband, specifically describing a role for his mother during pregnancy to limit eating by his wife which could cause a 'large baby' that would be difficult to deliver:
"There is one thing that my colleague haven’t said, for us Maasai when you see your wife is pregnant sometimes you may ask your mother to stay with her because it is prohibited for her to eat oily food which may cause a baby to become fat in the mother’s womb. This is because others use operations (episiotomies, c-sections) while we use the natural way. It is important for a woman’s mother or mother-in-law to stay near her so she cannot eat these kinds of food to protect her and the child." –men’s FGD participant
Key informants did confirm that the practice of limiting food consumption for pregnant women in the third trimester of pregnancy persists despite recommendations for a balanced diet during pregnancy from nurses during ANC visits.
Home Delivery Procedures
Women giving birth were asked about who was present at a home delivery and every one of them reported being attended by at least one, and up to four TBAs who helped them by preparing food, massaging them, rubbing oil on them, 'holding them during delivery, 'pulling out' the baby, and cutting the umbilical cord. All women reported giving birth in a kneeling or squatting position. Several TBAs reported women giving birth lying on their side, although others described moving to a kneeling position once the woman started pushing. One TBA described in some detail the way that multiple TBAs may work together to support a woman's birth position when she is pushing during a difficult delivery:
"Giving birth is hard. A mother may be in labor and fail to give birth, so several TBAs might help. The woman kneels on one TBA, and another sits between her legs—she is the main TBA to receive the baby. Others may sit at the back (of the mother)." TBA’s FGD participant
TBAs reported numerous responsibilities during birth. Those most frequently mentioned were:
- Feeding the mother— This was reported in all focus groups and was considered a major factor in assuring that a mother would have the strength for delivery. Preparation of black tea was also mentioned as a way to give her strength for delivery.
- Massaging the mother
- Receiving the baby, cutting the cord, delivering the placenta
- Cleaning the mother and the baby
All TBAs and women reported that mothers were given the infant immediately for breastfeeding after the child was cleaned, received butter, and rubbed with homemade petroleum jelly. TBAs were aware that breastfeeding helped reduce postpartum bleeding and mentioned it as a reason for giving the mother the baby for breastfeeding immediately. No man reported having a role in the delivery itself, or even being present in the home where delivery was taking place.
Nurse midwives interviewed about facility deliveries were asked about delivery procedures in clinics, particularly their ability to accommodate traditional birth practices. Responses were mixed, with nurse midwives interviewed at the two dispensaries expressing more flexibility around the roles TBAs would play in a facility birth than the midwife at the health center. All clinic midwives reported that TBAs escorting a woman to a clinic for a delivery outside of an emergency, such as obstructed labor or hemorrhaging, was rare. In those cases, patients were immediately transported by ward ambulance to Karatu for comprehensive emergency obstetric care.
In the rare case that a TBA did bring a woman in for a normal delivery, they were not generally invited to participate in the delivery during final stages of labor. At Bulati dispensary, a nurse said they would only allow a TBA to receive the baby after delivery. At Irkeepusi, a midwife said TBAs were allowed in the delivery room and could sometimes help with translating for them from Kiswahili to Maa, as many mothers did not speak Kiswahili. At the Nainokanoka health center, the midwife expressed skepticism about TBAs motives and suspected they were generally trying to ‘learn something they can use for a home birth by watching.’ She also suggested that TBAs represented a barrier to women choosing a facility delivery.
All nurse midwives interviewed also reported that birth position for deliveries in ward clinics was lying down (lithotomy position) and other positions could not be accommodated during the final stage of labor. One midwife did acknowledge one way in which her facility accommodates a traditional preference, which was to respect the Maasai taboo against episiotomies and the use of sutures to repair vaginal tearing during birth.
Obstetric Emergencies in a Home and Facility Delivery
Several parous women interviewed reported having a difficult delivery, and one was referred to Karatu for a C section in her last birth. Another woman described a bad home delivery experience in which she was held down and her abdomen was pressed down to force the baby out.
“You may give birth and get ill. At home they press your tummy like this. They hold you so you can't escape, they scare you during delivery.” —female IDI participant
TBAs were asked about how they contend with complications during a home delivery. Every one of them confirmed that if they were not able to help a mother deliver, they arranged for her to be transported to a ward health facility (from which they could be transported by ambulance to Karatu).
Prior to making this decision, TBAs reported massaging a mother’s abdomen during difficult labor, feeding her porridge and giving her black tea for energy to sustain pushing. One TBA claimed to have experience with successfully delivering babies no matter what the presentation. Another reported at least one unorthodox practice employed during a difficult delivery:
"If the baby has not come out you massage a mother and you put a baby cow beside the mother they may come together. And if you see the baby is coming you remove the baby cow and continue to massage the mother.” -TBA’s FGD participant
Nurse midwives at clinics reported capacity to deliver basic emergency obstetric services at any hour, seven days per week. Basic emergency care included repositioning a baby in the case of a breech birth and administering medications for eclampsia as well as oxytocin to prevent hemorrhaging. Other complications are referred to the Karatu hospital by the ward ambulance based at Nainokanoka Health Center.
Preferences and Barriers for Home vs. Facility Delivery
Home delivery preference
All female IDI participants were asked where they would choose to have their next child. Focus groups of men and TBAs were also asked the same question. Responses for all these groups were evaluated for convergences and divergences. Just under half of women interviewed expressed a preference for a facility delivery at their next birth. These responses, however, indicated some geographic variances, notably women from Nainokanoka sub-village, (who generally had the highest level of education as indicated by their ability to speak Swahili) preferred facility delivery, while most women in Irkeepusi sub-village said they preferred a home delivery, or did not consider it to be their decision.
Distance was not easy to assess as an access-limiting factor in itself. All women interviewed were asked about the time it would take to walk to a facility for birth; answers ranged from 30 minutes to 3 hours. There was no evident correlation between distance and delivery preference among those interviewed.
Those who reported having ‘no-preference’ when asked about where they would have their next child did not consider themselves to have agency: Either others would make the decision, or the place of delivery would be determined by ‘God’. Leaving the question to ‘God’ was considered a default preference for home delivery (in the absence of a complication during delivery) as it indicated an absence of a birth plan to reach a facility once labor began.
When women, TBA focus groups, and men's focus groups who preferred home delivery for their next child were asked why, responses generally fell into 3 sub-categories:
1) Preference for traditional rituals and care during a home delivery.
Female participants who expressed a preference for home delivery tended to emphasize the kind of care they and the baby received from TBAs. Psychosocial preferences included trust in TBAs and comforts of home, particularly being bathed, massaged, rubbed with petroleum jelly, and fed during the delivery. Lack of familiarity with the facility environment was also an expressed psychosocial barrier, although neither woman who had a facility delivery complained of a negative experience. Others who preferred a home delivery generally had a positive impression of clinics but saw it as a second-tier intervention if there were complications identified during ANC visits or during a home delivery.
Men were also divided in their preference, but those who preferred home delivery, tended to emphasize trust in TBAs, whom they considered to be as competent as a doctor to do a home delivery. Men also trusted TBAs to make a judgment about when transport to a facility would be necessary during a home delivery. One male participant made a specific reference to medical doctors ‘using a sharp object’ (episiotomy) which he felt was harmful to a woman and considered taboo among Maasai in Nainokanoka.
“For me I think it is better for a woman to give birth at home but it is important for her husband to be close to her just in case anything happens. Because if she goes to the hospital the doctor can delay treating her. A doctor can also use a sharp object to take out the baby and it is so painful. But there are women (TBAs) at home who could help her to deliver a child without excessive pain.” –men’s FGD participant
All TBAs in the focus groups affirmed, in principle, a preference for a facility delivery for which they reported being strong advocates in the face of family gatekeepers (husbands). More probative questions and reports from key informants suggest that TBAs may not be as supportive as they claim, particularly in light of their belief that overcrowding at clinics will result in a woman in labor being turned away.
2) Trust Gap in Facility Capacity
One of the most pervasive reasons given for a preference for home deliveries was overcrowding at facilities in the ward that had reportedly led to women in labor arriving at a clinic and being denied service. TBAs were particularly vocal on this issue and cited the problem of overcrowding in delivery rooms at clinics in the ward overwhelmingly as the reason they resist taking women for a facility birth. According to TBAs, at least 2 women, escorted by TBAs to a clinic, were told there was no space in the delivery room and had to return home only to deliver in the bushes. This story was shared in both TBA focus groups, and in men’s focus groups as well:
"When they have difficulties during birth, we take them to the facility, but a doctor denied one (interrupting voice; Two!) a place of delivery because there was not enough room....We want the facility to be larger with more health workers as now the country is big. We cried on the street that day. The birth attendant helped the mother to give birth in the bushes. It is hard to go to the community as they turn on you because that scandal of a doctor denying a pregnant mother at the facility door has spread. So it is hard to say ‘bring the mother for a facility delivery’ while we don’t have a place of delivery." –TBAs FGD participant
While this account was not first-hand and was not reported as a personal experience of any TBA who was present in the focus group, nor any female IDI participant, it is pervasive and does indicate a serious trust gap in facility capacity that warranted follow-up with key informants at all three clinics. Since the ward has averaged less than 5 deliveries per month at each clinic in the past 15 months, the problem of overcrowding in delivery rooms seemed incongruent with the data.
Clinical staff at all three ward facilities were interviewed and asked about the frequency of a woman in labor being turned away because of overcrowding. Midwives at the Nainokanoka health center and Bulati dispensary were not aware of this event ever happening in their facilities during their tenure. The nurse at the smallest dispensary (Bulati) also said that while they did have only one delivery room bed, they could accommodate mothers in labor in other beds in the facility and would not turn anyone away. She speculated that a birth might have happened on the way to a clinic, prior to arrival, but not as a result of being denied a space.
A nurse at Irkeepusi dispensary, however, believed that several women may have been turned away from there at a time in the past when a non-obstetrically trained health worker was covering a shift at the clinic—although not as a result of overcrowding. This was a significant finding. Such a breach of trust for any reason would certainly justify TBA skepticism about taking a woman to a facility for delivery if there was any risk of her being turned away during labor. This experience has likely led to the generalized belief that all clinics in the ward are understaffed and overcrowded.
3) Facilities only for emergencies
All participants (women, men, TBAs) who preferred a home delivery did consider a facility to be a second tier of assistance if there was difficulty during delivery. Women and men also mentioned relying on ANC visits to identify any potential warning signs and a recommendation for a facility delivery. Men who preferred home delivery acknowledged that going to a hospital was necessary and worth the transport cost in the event of an emergency. They expressed trust in TBAs to make that determination.
"Giving birth at home is my preference. TBAs are the same as doctors, when looking at the delivering woman they will know whether she will deliver safely or not. For a baby that cannot be delivered safely, TBAs would notice as early as possible and if there is a need of taking her to the hospital they recommend and advise us what is to be done. Therefore, we would like these TBAs to continue as caregivers for pregnant women while at home as long as they do go to the (antenatal) clinic until the day of giving birth." –men’s FGD participant
Health facility key informants noted that the practice of TBAs bringing women to the facility when they failed to deliver was the most common reason they came to a facility, and by that point, they were usually referred and transported to Karatu for comprehensive care.
Accessing facilities in the event of an emergency is consistent with findings that men, women, and TBAs do access the health care system and depend on ANC visits to give them information on the progress of the pregnancy and advise on risks. Other factors mentioned by men, to a lesser extent, were cost of transportation, although it was not always clear whether they were talking about going to a ward clinic or to the tertiary hospital in Karatu when they referred to it during focus group interviews.
Factors that have led some women (or key family decision makers) to change their delivery preference to a facility delivery
Facility delivery preference
Responses about preference for a future delivery indicate that there is a slow trend toward adopting facility delivery in principle. Specific reasons most-often cited by those who expressed a preference for a facility delivery were grouped into several sub-categories:
1) Changing Norms
Women, men and TBAs all acknowledged awareness of changing norms and a push by local health facilities and the EbOO project to encourage facility birth, especially during ANC visits. Several men referred to the way things have changed since the time of their fathers. TBAs and men’s focus groups were aware that there are expectations that women should deliver in clinics to be safe and some men acknowledged this change need not impede or contradict traditional practices surrounding a birth.
"Traditions and customs won’t prevent a woman from going to hospitals to give birth and even the traditional ceremonies can be done as soon as she comes back from the hospital usually after seven days." —men's FGD participant
2) Fear of 'new' complications
Several women, TBAs, and men, mentioned the need for facility delivery in light of 'new' complications that women experience nowadays. New diseases were mentioned as well, particularly HIV. Perceptions of new complications is likely a result of an increased awareness of risk and susceptibility rather than an increase in new risk factors in the recent past.
"A hospital is a good and safe place. In the past we were ignorant. We did not have anything to say. Now there are so many diseases and complications." – men’s FGD participant
"The world has changed not like past days. There are many risks of diseases and complications during and after delivery so it is better for me if I go to the hospital" – female IDI participant
3) Pain relief and control of bleeding
Several women as well as men specifically mentioned the benefit of receiving an injection for pain relief, as well as the ability to control bleeding and fully remove the placenta at the hospital as a reason why facility delivery is preferable.
"In hospital ... after delivery they clean you and they inject you with a syringe so you can not feel the pain and you are cleaned quickly. You can even wear your underwear right after birth. In a village it is not possible to clean you completely, you may have a discharge for over a month." — female IDI participant
4) Bad experience in a home delivery
A few women expressed a preference for facility deliveries in light of bad experiences in a previous home delivery. Excessive bleeding was the number one concern.
"You may give birth and get ill…or the placenta won't come out and they cannot do anything (at home) only to breastfeed the baby. Because if the placenta delays coming out, it is a disaster for mothers. That is why we like to give birth at the hospital" –female IDI participant