Kwale Kenya - Traditional Birth Attendants in Kwale County: A description of practices of traditional birth attendants and an evaluation of factors influencing women to deliver outside the formal health care system

Traditional Birth Attendants in Kwale County: A description of practices of traditional birth attendants and an evaluation of factors influencing women to deliver outside the formal health care system in Kwale

Executive Summary

Pregnancy and delivery are at the same time both natural, healthy processes and risky moments in the life of every woman and every “human to be”. With good quality care during pregnancy and delivery, serious illness or death caused by it are very rare. Where such is missing, illness and death take a heavy toll.

Many strategies have been put in place by governments worldwide to ensure safe pregnancy and delivery. Despite such efforts, in many countries including Kenya, serious illness and death due to pregnancy and delivery are still common. Over the past decades, the government of Kenya has encouraged antenatal care (ANC) visits and delivery in formal health facilities. It has discouraged women from delivering with traditional birth attendants (TBAs). A TBA is a person who assists the mother during childbirth and initially acquired her skills by delivering babies herself or through apprenticeship with other TBAs. Practices and experience of TBAs differ over various regions in the world and the relative importance of the various factors that have been found to influence whether a woman will deliver with a TBA of a formally trained health worker are not known.

Despite policies to discourage it, a large proportion of Kenyan women still delivers with TBAs, also in Kwale County. This mixed methods study consisted of a community-based knowledge, attitudes and practices (KAP) study with qualitative and quantitative components and six audio-recorded focus group discussions (FGDs). The KAP-study included 212 women who delivered outside the formal system in the last five years and investigated the knowledge, attitudes and practices of women in Kwale on pregnancy and delivery to understand the relative importance of various factors influencing the place of delivery. The FGDs with a total of 40 TBAs investigated the actual practices of TBAs in Kwale to better understand how they deliver their services. Data collection was done between September and December 2018 in Kinango and Matuga, two of the four sub-counties of Kwale County.

From the KAP-Study we found that the knowledge of most women on pregnancy and delivery is reasonably good, for example when it came to the general awareness of the importance of breastfeeding (85.8%), attending ANC (61.8%), eating a balanced diet (55.4%), and the awareness of danger signs during pregnancy (62.3% could mention correctly at least two danger signs). As much as they were aware of the importance of breast feeding, there was still doubt however whether it was better for the health of the baby than formula milk. Other areas with room for improvement of knowledge were family planning and awareness of the risks of delivery in very young women and those who have had have many children. In addition, the study brought out clearly that the attitudes of those women towards the formal system were positive, despite all of them having delivered at home. For example, overall the interviewed women agreed that a woman should plan in advance where to give birth, that delivering at home is risky, that babies are at a lower risk of dying when delivering in a facility and that formal healthcare workers are more experienced than TBAs. In line with these attitudes, the majority of the respondents in the KAP-study had not planned to deliver outside the formal healthcare system but ended up delivering at home because the formal system was not available or accessible. 72% of the women mentioned inaccessibility of the health facility as reason for home deliver, due to distance (55% indicated that the nearest facility is further than 1 hour walk away), limited opening hours (closed during weekends and at night), or absence of health workers (strikes and other reasons). The second most common reason mentioned by 52% of the women were costs related to delivering in a health facility. Only about a quarter (26%) had planned to deliver at home, 50% had planned to deliver in a health facility, and another quarter (24%) had not planned at all. Only about a quarter (26%) said they would go back to the same TBA next time despite almost all (96.5%) saying that they were satisfied with the services of the birth attendant during their delivery.



From the FGDs it emerged that the practice of TBAs is strongly embedded in family relations. Most TBAs had acquired their skills through first observing and assisting a female family member, mostly mother, grandmother or mother-in-law who was also a TBA. As elderly women in the community, they are expected to assist their daughters, daughters-in-law and grand-daughters during their deliveries. It also became clear that over the last 10 – 20 years, the delivery practice of TBAs has changed a lot moving away from a midwife role to a birth companion role. Changed government policies and emphasis on facility based, skilled delivery have resulted in older TBAs becoming attached to formal health facilities as community health volunteers (CHVs) and equally younger CHVs became recognized by the community as TBAs. The linkage to the health facility and increased emphasis on health education appears to have lessened the embedding in family relations. This reduced embedding in family relations and the change from a midwife to birth companion has changed the expectations of TBA for pay. They expect more, as actual costs are made when deliveries do not take place at home. However, the actual payments are less, as women appear to be less willing to pay for the supportive rather than the midwifery role. TBAs emphasized most that women like them for their availability and their kindness, caring and supportive attitude. Some practices still continue with massaging during pregnancy and at the onset of delivery still being common everywhere and, especially in more remote areas, the use of traditional medicine. Despite this on-going change of role, it also became equally clear that without improved access, the need for delivery services of TBAs continues to exist despite it not being line with the official government policies. In line with the findings of the KAP-study, lack of access to formal facilities and formally trained health workers is what still necessitates the presence of alternative care givers, TBAs, in the community. This can create tension, for example when it entails supplying TBAs with instruments and consumables to conduct unavoidable home deliveries viz-a-viz the official policy against home deliveries.

Based on the findings of the study, we can first of all recommend that the Ministry of Health (MOH) of Kwale County government should continue to improve access to essential obstetric care services 24/7 at less than 1 hour walk from peoples’ homes to improve the outcomes of pregnancy and delivery in Kwale. However until that has been fully achieved, the MOH should support bridging initiatives to assist women during delivery. This could be through supporting the TBAs or the pregnant women with requirements for emergency home delivery if they live far away from health facilities which are open 24/7. Alternatively, innovative ways of ensuring transport for women in labour anywhere, anytime might turn out to be a very efficient method to overcome the core factors leading to home delivery and will also address the core concern of additional expenses made by TBAs when accompanying women. Such bridging initiatives could help to strengthen the ties between TBAs and the formal healthcare system and reduce delays in reaching health facilities and referrals which too often result in maternal and infant morbidity or even death. Only when standard essential and emergency obstetric care services are available for everyone at any time at less than 1 hour walk, then it becomes relevant to focus on the minority which had other, more socio-cultural reasons, though often accompanied by concerns about access and costs, to deliver at home.