In total, 27 mothers and 25 nurses participated in the pre-intervention focus groups, and 42 mothers, 31 nurses, and 19 CHWs joined the post-intervention focus groups (Table 1). FGDs were held at healthcare facilities in the communities of Nyang’oma, Katito, Sondu, Masogo, Muhoroni, and Nyakach. Each focus group was well attended despite the late arrival of some participants.
Table 1. Timing, participant category, number of focus group discussions (FGDs), number of participants, and location of focus group discussions in western Kenya (2013-2014)
|
Number of FGDs
|
Number of Participants
(Range)
|
Facility Locations
|
Pre-intervention (2013)
|
|
|
|
|
Mothers
|
4
|
6 - 8
|
Nyang'oma, Katito, Sondu, and Masogo
|
|
|
|
|
|
|
Nurses
|
4
|
7 - 10
|
Katito, Muhoroni, Masogo, and Sondu
|
|
|
|
|
|
Post-intervention (2014)
|
|
|
|
|
Mothers
|
5
|
8 - 10
|
Muhoroni, Masogo, Nyang'oma, Katito, and Nyakach
|
|
|
|
|
|
|
Nurses
|
4
|
7 - 9
|
Muhoroni, Masogo, Katito, and Sondu
|
|
|
|
|
|
|
CHW
|
2
|
9 - 10
|
Awasi*, Katito
|
Note*: One post-intervention FGD was held at SWAP office in Awasi. All other FGDs were held at health facilities.
Table 2 summarizes a list of themes, sub-themes, and categories identified in pre- and post-intervention FGDs for mothers, nurses, and CHWs. Analysis of FGD data revealed three major themes: 1) quality of care; 2) barriers to antenatal care and facility-based delivery; and 3) SWAP and OBA interventions. The sub-themes of quality of care include perceived quality of care at healthcare facilities, perceptions on home delivery, challenges with providing quality care, and factors that make nurses better providers. The sub-themes of barriers to antenatal care and facility-based delivery include perceived barriers to ANC visits and facility-based delivery and perspectives on mothers and community health workers. The sub-themes of SWAP and OBA interventions include proposed topics for text messages, overall experience with SWAP and OBA, experience with group education, and experience with text messages. To summarize the unique perceptions and experience of mothers, nurses, and community health workers and their changes from pre- to post-intervention FGDs, each sub-theme is discussed by the timing of FGD and the participant group below.
Pre-intervention FGDs: Mothers
Proposed topics for text messages. The first major theme was SWAP and OBA interventions. In pre-intervention FGDs, the only intervention topic discussed was SWAP’s text messages. When FGD moderators asked mothers about health topics they would like to see addressed in text messages, participants expressed their interest in ANC appointment reminders, family planning, malaria, water treatment, nutrition, immunization, and HIV/AIDS. These responses informed text messages developed by SWAP.
Perceived quality of care at healthcare facilities. The second major theme was quality of care. At pre-intervention, mothers shared a variety of perceptions on the quality of care provided at ANC and delivery at healthcare facilities, ranging from positive to very negative. Positive perceptions of care included feeling welcomed and listened to by the nurses, and receiving a physical exam, medicines, and a clear, dated appointment for the next visit. Mothers also described a number of negative impressions of care that included being left to deliver on their own without any assistance and being slapped and verbally abused. One mother captured the uncertainty of the type of care they would receive, which could be determined by the provider assigned to them: “Hospital delivery is good but only if you get a good nurse. Some of them really mistreat mothers, they insult you, and so it only depends on the nurse that you get.”
Perceptions on home delivery: The majority of mothers shared their recognition of home delivery with traditional birth attendants as an unsafe practice or at least a suboptimal practice. For example, mothers commonly noted that complications from pregnancy and delivery could be managed better at healthcare facilities than at home. Some mothers also believed that HIV transmission during delivery could be better prevented at healthcare facilities than at home and that injections were available for bleeding and post-pregnancy pain. Based on these positive perceptions of healthcare facilities, most of the mothers expressed that they wanted to deliver the next child at healthcare facilities despite the concern of mistreatment.
Conversely, home delivery was viewed as a favorable option by a few participants who had either experienced or heard about mistreatment of mothers by nurses. As one mother stated about home delivery: “It is not safe but at least they don’t harass you the way the sisters [nurses] do.” Expressing a similar perspective regarding the kind of care given at home, other FGD participants said that local TBAs were “serious,” and were more likely to “pamper” and respond more quickly to the needs of laboring women than nurses in healthcare facilities. Some participants expressed their perspectives on the value of using traditional herbs to manage pain and facilitate delivery at home, believing that the herbs could help avoid surgery.
Perceived barriers to ANC visits and facility-based delivery. The third major theme that emerged from FGDs was barriers to antenatal care and facility-based delivery. Mothers listed a number of factors that inhibited women from visiting healthcare facilities for ANC visits and delivery, including lack of money, work, transportation, security and safety, fear of mistreatment by nurses, time, and shortage of supplies at healthcare facilities. Participants shared that people may not have money to pay for their first-time hospital fee of 100-150 Kenyan Shillings. For many women, work (e.g., drying maize at garden plots away from home) could prevent them from traveling to the hospital for ANC visits. More profoundly, one mother described how her concern about safety when traveling to the health facility at night would lead her to risk her health by staying home:
“When labor starts in the morning, then I will come and deliver here at [the health center]. If it starts at night, it can be very risky. We live next to the road and when it reaches at night, there is a lot of chaos…I would not like to risk. So, if it is during the day, I will just come to the hospital, but if it is at night, then I will have to deliver at home.”
Some mothers avoided ANC because many questions would be asked at the first ANC visit. The types of fear include HIV testing, injections, language barriers, and walking to the clinic while pregnant. A mother spoke about her fear of knowing her HIV status and explained that it delayed her timing of seeking care.
Pre-Intervention FGDs: Nurses
Among nurses, two themes emerged from pre-intervention FGDs: challenges with providing quality care and perceived barriers to antenatal visits and healthcare facility deliveries.
Challenges with providing quality care. Nurses described several important challenges to providing quality care at healthcare facilities, including inadequate training, limited equipment and supplies, and workforce shortages. Nurses expressed the need for, and importance of, training and clinic updates to help them provide the most effective care and avoid outdated approaches to care. On resource limitations, one nurse stated:
“Maybe you are in the labor ward, you have no delivery packs, and there is no water. Maybe there is somebody to be referred, and there is no vehicle. Maybe you are in the maternity, and you have no gloves. Those are some of the things that make my work difficult sometimes.”
Another nurse described an equally profound set of limitations in staffing:
“I feel understaffing is the most challenging because if you are alone and you are pressed with a lot of work to do, you cannot really provide your services effectively. You are one person. You want to attend to the mothers. You are attending to the children. There you are giving injections. You are giving the drugs, and you are competing with time.”
Perceived barriers to antenatal care and facility-based delivery. Nurses identified a list of barriers to ANC visits and facility-based delivery that coincided with obstacles identified by mothers. These included poor roads, HIV stigma, distance to healthcare facilities, geographic terrain (e.g., steep hills), and adverse weather. One nurse stated that stigma associated with HIV/AIDS prevented women from returning to ANC visits or delivering at healthcare facilities once they found out their positive status.
Post-intervention FGDs: Mothers
Under the theme of SWAP and OBA interventions, maternal FGDs included the sub-themes of perceptions of group appointments (SWAP only), text messages (SWAP only), and intervention effects (both SWAP and OBA interventions).
Perceptions of group appointments. Organizing a system of group ANC appointments required SWAP to coordinate efforts with each healthcare facility, which delayed full implementation for several months. Consequently, FGD participants attended group appointments only once or not at all. Mothers who were able to attend group appointments commented on the benefits. For example, one mother noted that the appointments helped her overcome cultural myths:
“Before I gave birth to my first-born, I used to hear people telling me that you are not supposed to buy clothes for the unborn baby. If you do that then, it is a taboo, and your child can die before it is born. So, I used not to buy clothes for the baby. When I came for those meetings, I was told that ‘those people are misleading you. Can you try and buy and then let us see if something will happen to the child?’ I bought the clothes, and there is nothing that happened to my baby. I also learnt how to take care of myself and the baby hygienically.”
Another mother shared that an additional benefit of the group appointments was the opportunity for social interactions:
“I also knew one woman the first day that I attended the meeting. So, we left together, and as we were chatting on the way, we exchanged numbers, and we always communicate. Of late she called and asked me whether I still go back to the clinic, and I said yes.”
Perceptions of text messages. The text message intervention also had several challenges in the early stages. A number of mothers reported that they did not get ANC appointment reminders. One participant shared that while reading in Luo was difficult for her, she could speak the language well. Another said that when she first got a message, she thought it was sent to her by mistake, but then she saw SWAP’s name at the end of the message. FGDs also revealed that health education messages sometimes reached the phone of husbands instead of mothers:
“I got my message through my husband’s phone. I was at home when the message arrived, and he was away from home. He told me that there was a message that he received from SWAP, but he accidentally deleted the message, so I did not get to read the message.”
Perceptions of intervention effects. Mothers shared their appreciation of both SWAP interventions and the OBA program:
“They [SWAP interventions and OBA] are both important. One helped me because I gave birth free of charge, and the other one, every time I came from the clinic, I could fill my bag with the item that I was given at the shop there.”
Some participants valued the OBA program more than SWAP interventions because it substantially lowered economic barriers to care: “They are both good, but I can say that OBA card was the best because it was catering for a lot of things that if we were to pay cash then maybe we wouldn’t.”
Perceived quality of care at healthcare facilities. At follow-up, mothers continued to comment on nurses’ rude attitude, arrogance, and violent behaviors, However, perhaps in recognition of the increased workload engendered by the SWAP and OBA interventions, at least one mother shared her sympathy for the multiple tasks that burden nurses: “There is only one nurse who is doing rounds in the wards, and she also wants to attend to you. If there could be at least more than one nurse, then things could be very easy.”
Perceptions on home delivery. Some participants continued to express negative views on home delivery, recognizing that TBAs cannot respond to complications quickly and safely. After the concurrent implementation of SWAP interventions and OBA program, participants reported that home delivery can be costly:
“What I can say about delivering at home is that it is not good because in the hospital, delivery is free unlike home. TBA wants to be paid. There is also some ashes that they give you when you feel labor to make the baby come out even when the time is not yet. This may make the baby die, and they end up taking your money as well.”
Perceived barriers to ANC visits and home delivery. Barriers to care expressed in post-intervention FGDs were similar to pre-intervention FGDs, with the exception of economic barriers. Women still expressed their concerns about lack of supplies, fears of maltreatment and travel at night, and cultural issues.
Post-intervention FGDs: Nurses
Experience with SWAP and OBA interventions. At follow-up, nurses identified positive effects and remaining challenges of SWAP interventions and spoke to how SWAP interventions enhanced their work and service utilization. For example, nurses noted how group education was useful for organizing mothers: “When I came to understand that we were going to book them as per the expected date of delivery, it really made our clinic to be organized.” Nurses also expressed appreciation for solar lighting that SWAP provided healthcare facilities that lacked electricity: “… in the night when we have a blackout, we simply use the solar system. So, this has improved our uptake and the clients are able to deliver at night even when we have a blackout.”
Another benefit of the SWAP program noted by the nurses was the training received on neonatal resuscitation, obstetric emergency response, water and hygiene, and education through listening (a behavior change intervention on patient-centered care).
At the same time, FGDs uncovered some unintended consequences of SWAP interventions. A nurse shared that mothers come to deliver at healthcare facilities with an expectation that they receive incentives, so they did not come with necessary supplies for baby care. Another nurse noted that the increased workload had implications for care they delivered:
“The negative part of it [increased clients] is that we have a high workload that sometimes cannot allow us to give quality service because we are struggling to finish the queue, and we miss giving some education to our clients. You find that when it comes to health talks like the danger signs, breast feeding education and other things, you find that time doesn’t allow us.”
Positive perceptions of the OBA program were also common among nurses. The program helped reduce nurses’ stress level during nights when they had difficult deliveries through increased availability of ambulance services to transport women to higher levels of care. Some nurses explained that the OBA program also provided additional financial resources for the healthcare facilities to conduct outreach activities and benefit people in remote villages.
The challenges with the OBA program described by nurses had less to do with the program itself and focused more on how the program magnified existing systemic problems, such as lack of equipment and supplies, and understaffing. By lowering economic barriers to care, OBA contributed to increased patient loads, which added to the stress of overworked nurses. Another challenge identified in FGDs was deficient transportation for referral: For now, OBA is giving us support. They have paid for transport, but still the ambulance is the same one. You call. It’s not there.”
Program sustainability. Most of the participants expressed their hope to continue SWAP and OBA intervention activities and shared some concerns about the potential consequences of ending them. One nurse shared that new programs often “come with support and staff, [and] upon exit [and removal of support staff], they integrate those services to the system… and leave it to nurses.” Nurses also discussed how CHWs may need financial incentives to continue providing antenatal education services after the program ends: “You know even those people in the community they also have their priorities, the community workers. They have to provide for their families, and some other added duties.”
Challenges to providing quality of care. As noted above, although nurses’ perceptions of SWAP and OBA were generally positive, many had concerns about their ability to provide quality care because of shortages of equipment and supplies and understaffing. These resource constraints, along with inadequate recognition, teamwork, and compensation, were mentioned as factors that discourage nurses and lead to suboptimal care. Furthermore, FGD responses emphasized understaffing as the major challenge faced by nurses: “It gives us a burnout, and even anger can flare out because expectation from outside is too much.” One nurse clearly summarized the consequences of these systemic problems:
“At times, we also have attitude which sometimes really make these mothers not to come and deliver in the hospital. Many times you find that these mothers are saying that they will be slapped…. Sometimes the nurse will ask so many questions that they don’t like, and they are going to be intimidated. So, we should be well-staffed, and then as nurses, we should work on our attitude. Like how you talk to them in that situation will also attract the others to the hospital, and we provide the care.”
Factors that enable nurses to provide better care. Nurses also identified a number of factors that can enhance nurses’ productivity at work, such as training, specialization, good supervision, adequate staff and supplies, and rewards (e.g., financial rewards, acknowledgment of efforts). Several nurses noted that having proper equipment and better working conditions were “most important” for working effectively, and that “there are places where nurses even work without gloves, without instruments, and even without the necessary essential drugs….I think so many nurses are demotivated.”
Community Health Workers
CHWs were included in post-intervention FGDs because they became important providers of care, moderating the group ANC appointments, providing educational talks, and handing out SWAP products as incentives. The sub-themes addressed in CHW FGDs centered on their experience with the SWAP and OBA programs, and their perceptions of the training they received.
Experience with SWAP and OBA interventions. CHWs discussed how SWAP and OBA interventions contributed to increasing ANC visits and hospital deliveries. One CHW noted that SWAP interventions made long waits worth their while: “even if it was getting late, [mothers] could still persevere and wait because of the good thing that they were going to get.” Another said that, before the SWAP program started “the ANC turn up was very low but when we started giving mothers vouchers, the deliveries went up, and the number we were seeing in the ANC also went higher. They could come in large numbers, something that was not happening before.”
The program was not without challenges because sometimes the incentives (health products) provided by SWAP ran out: “You find that the products are brought around the fifteenth there [and run out after] only two weeks,” so that women who had attended clinic after they ran out, “never got or [had] seen any product.”
CHWs reported that their group education sessions addressed nutrition, birth plans, malaria, and safe water practice (e.g., not carrying large amount of water). While a few challenges were identified, including late arrival of mothers and space limitation, the discussions uncovered how health talks benefited women and CHWs. Some CHWs paired up the mothers in the group sessions to share experiences, which helped even pregnant schoolgirls feel free to share their concerns.
CHWs also shared their experience with text messages, which included a similar challenge described by mothers in their FGDs:
“The major challenge that I have encountered is that some young women come here. They give us their telephone numbers…and when they are called [by CHWs], you find that the husband quarrels claiming that who gave you my number, and so it is not easy to schedule a health talk since they say that the husbands will not agree.”
Perceptions of training. CHWs discussed the training that they received prior to the SWAP intervention, and mentioned a list of topics, including record keeping, importance of hospital delivery, immunization, safe water, danger signs among pregnant women, nutrition, and basic business skills (e.g., reconciliation of product vouchers). A few CHWs shared that two days were not enough to understand record keeping practice and reconciliation, but many participants expressed their satisfaction with the training that they received from SWAP, and also the nurses:
“We get to even ask the nurses about certain things that make us as well gain knowledge as they also get knowledge. This is then happiness to both of us.”
Figure 1 illustrates a conceptual model to explain the impact of SWAP and OBA interventions on demand for, and supply of, ANC visits and facility-based delivery.