THE PERCEPTIONS OF MOTHERS ON THE USE OF NON- SKILLED MATERNAL HEALTHCARE IN KENYA

Jane Strapola Awuor -Mala^1† --- Careena Flora Otieno-Odawa² --- Alexina Mayumbelo Sitimela³

¹Great Lakes University of Kisumu and The Delta Centre, Kitengela, Kenya, ²Great Lakes University of Kisumu, Nairobi Learning Centre, Kenya , ³International United Nations Volunteer Midwife, UNFPA, Wau, Western Bahr El Ghazal State, Republic of South Sudan

Keywords: Perception, Non skilled maternal healthcare, Kenya. Skilled maternal healthcare, Luo traditional maternal healthcare, Mothers, Taboos, Abominations, Curses, Treatment regimes

Received: 13 April 2016/ Revised: 4 May 2016/ Accepted: 24 August 2016/ Published: 28 November 2016

Contribution/ Originality

This study is one of very few studies which have investigated the opinions of mothers on the use of non-skilled maternal health care. Most papers have focused on the use of skilled attendants and have not effectively interrogated the opinions of women on why they specifically use non-skilled care.

1. INTRODUCTION

Kenya is among the Sub-Saharan African countries that still has a large proportion of its population carrying the highest burden of ill-health (Ministry of Health, 2006; Kaseje et al., 2009). This includes maternal mortality rate of 590 deaths per 100,000 live births in 1998 (Ministry of Planning and National Development, 2005) down to 414 deaths per 100,000 live births in 2002 (Ministry of Public Health and Sanitation, 2009) up to 488 deaths per 100,000 live births (Kenya Demographic and Health Survey Report, 2010).

KDHSR (2010) indicate that less than 47 percent of pregnant women make four antenatal visits. For instance, 60 percent of pregnant women in urban areas make four antenatal visits compared to 44 percent in the rural areas. Only 15 percent obtain the four antenatal visits as recommended. Regional disparities are noted in antenatal coverage. While mothers in North Eastern province do not get antenatal care at all, Nyanza and Western provinces have low use of doctors for antenatal care compared with use of nurses, with Coast and Central provinces registering the reverse (Ibid, 115).

In the same report (Ibid: 120), it is indicated that 43% of deliveries in Kenya take place under the supervision of skilled attendants. This is indicative of a 3% increase since the year 2003 which registered 40%. However, provinces such as Nyanza in western Kenya still register lower proportions of facility deliveries (34 percent). However, the Tropical Institute of Community Health and Development in Africa and Kaseje et al. (2009) found that less than one third (30 percent) of mothers use health facility delivery in Siaya district in Nyanza province. Overall, the distribution of mothers that do not deliver under skilled supervision remain high in a number of provinces including North-Eastern (81 percent), Western (73 percent), Rift Valley (66 percent) and Nyanza (54.9 percent). Regarding the use of postnatal care ibid indicates that 37 percent of women receive postnatal care from medical professionals, with Nairobi having the largest proportion of mothers (78 percent) accessing postnatal care. The objective of the study was to examine the perception of mothers on the use of non-skilled maternal healthcare.

2. RESEARCH METHODOLOGY

The study employed a sequential exploratory mixed study design. Four methods of sampling were used. These were; multistage cluster sampling, purposive, stratified, and random sampling. A total of 1197 mothers who had home deliveries a year prior to the study were sampled in Uranga, North Alego and Karemo divisions of Siaya district. Another 11 key informants were interviewed comprising community specialists in the Luo traditional maternal healthcare medicine, skilled health workers serving in the facilities located in each of the three divisions; traditional Luo medicine men and religious maternal health care providers who also doubled as spiritual overseers within their divisions. The study was conducted in three phases. The first was the listening survey to establish the generative themes on the perceptions between the skilled and non-skilled maternal healthcare systems; the second was the collection of qualitative data derived from the generative themes; and the third and final was the collection of quantitative data whose themes and variable were derived from the qualitative data that were analyzed.

Frequencies and effect size of the selected indicators whose relationships were measured and indicated by the p value of the Wald statistics in a multinomial regression model were established. The Wald chi-square p value <0.05 indicated significant results. Qualitative data was manually analyzed where data was condensed by organizing responses in meta cards, then teasing them out into common themes and then clustering them in tandem with the objective of the study. Each cluster was partitioned and coded (from a code list, which the researcher and the team developed) then the emerging phrases were summarized. These were further compressed and assembled to draw conclusions and recommendations.

3. RESEARCH RESULTS

The study interviewed 1197 respondents drawn from Karemo (392), Uranga (424) and Boro (381) divisions in Siaya District. The respondents were mothers who had their last deliveries at home a year prior to this study. The highest proportion (39%) were between 21-29 years while 50 % had between 1-3 children with 2 percent having more than 10 children. Although the highest percentage (30%) who delivered at home ascribed to the African religious churches, Roman Catholic followers (29 %), Anglican and Pentecostal churches (19%) respectively were equally present.

Table-1. Characteristics of respondents

N=11

3.1. The Care Providers in the Non Skilled Maternal Healthcare System

The study found an array of groups that provided the most care to mothers during the last pregnancy. These were community health workers (39%), traditional birth attendants (29%), churches (14%) and relatives (11%). When these providers were asked why they offered care in the non skilled maternal healthcare system against the policy of the Ministry of Health, they explained that the policy was not privy to the strengths of the traditional maternal healthcare system which they also referred to as the non-skilled maternal healthcare. However, they offered the care in secrecy to avoid reprimand by the authorities.

Figure-1. Where did you get the most care during your last pregnancy?

N=1197

On the other hand, community health workers (48%) provided the most care to mothers during the last delivery followed by traditional birth attendants (24 %), churches (12%) and relatives (10%). The study found that the community health workers referred to here had both conventional skills in preventive health as well as traditional maternal healthcare skills that they often put to use when delivering pregnant women. However, the traditional birth attendants referred to here had no form of training except those passed on to them by their parents and grandparents.

Figure-2. Who provided you with care during the delivery of your last child?

N=1197

The study found that 83 percent (995) of mothers were aware of the benefits of using skilled prenatal care during pregnancy; 77 percent (917) knew the benefits of facility delivery and 86 percent (1023) were knowledgeable of the benefits of attending skilled postnatal care respectively. However, none of them delivered at the health facilities. This was because 722 (60 percent) of respondents had herbs for shortening the duration of labour within their communities. Of these, 28 percent used the herbs to shorten labour during the last pregnancy in addition to 773 (64.6 percent) who reported the existence of traditions (Chike Luo) that they were expected to follow during the last pregnancy, but which were not available in the health facilities.

Presence of traditional methods used for providing care to women in the first three months after delivery was also reported by 832 (70%) of respondents of which 614 (51 %) had used the methods after the last delivery. Another 410 (34 %) used traditional methods of child spacing after the birth of the last child. A significant relationship between the presence of herbs used to shorten the duration of labour by where the mother received the most care during the last pregnancy (p value= .001) was found. Subsequently, the study also reveals a significant relationship between the use of the traditional herbs for shortening the duration of labour and where the mother received the most care during the last pregnancy (p value=.000). However, there is no significant relationship between the presence of traditions (Chike Luo) that communities expect a new born baby to undergo; the presence of traditional methods used for child spacing after the birth of the last child by where the mother received the most care as both have a P value of 0.111 and .007 respectively.

Table-2. Percentage proportion of selected indicators on perceptions on non-skilled maternal healthcare

Source: Primary interviews

3.2. Pregnancy Management in the Non-Skilled Maternal Healthcare System

The non-skilled maternal healthcare system has remedies for managing complications during pregnancy in addition to the provision of traditionally acceptable meals to the expectant mother during the pre-natal visits. Although Okolocha et al. (1998) and Griffin (2006) had similar findings in Southern Nigeria and India respectively, meals served to pregnant mothers during their regular visits by the traditional maternal healthcare providers did not suffice as in the case of this study. These preferences are only found in the non-skilled maternal healthcare systems, a finding that supports (Annette, 2004).

Other aspects include the ability of the care givers to communicate with the spirits to determine the spiritual health of the pregnancy, provision of remedies in cases where pregnant woman suffers from spiritual related conditions, sponging of pregnant women with hot water to provide comfort and management of pregnant related ailments. These aspects endeared mothers more to the non-skilled maternal healthcare as compared to facility based care.

The hospitality of the healthcare providers in the non skilled system was commended by women for they do not quarrel with pregnant women as they attend to them during labour. Mothers mentioned the absence of caesarian section in the non-skilled maternal healthcare system which makes them comfortable to seek for care. They also noted that non-skilled maternal healthcare providers do not continuously insert their hands in the vagina of pregnant women who are in labour. The ability of the non-skilled maternal healthcare providers to determine when the unborn baby is in danger by simply touching the abdomen of the pregnant woman, privacy and asking her questions regarding her comfortability were reported by the respondents as having endeared mothers to the non-skilled maternal healthcare. Aspects such as privacy during delivery and language of communication that Annette (2004) brought to the fore were not the case in this study. The foregoing therefore challenges the skilled maternal healthcare system that as long as these preferences are not observed, then women will continue to utilize non-skilled maternal healthcare system.

Table-3. Treatment regimes during pregnancy

Source: Primary interviews with spiritual traditional maternal healthcare providers

3.3. Management of Deliveries in the Non Skilled Maternal Healthcare System

In the non-skilled maternal healthcare system, deliveries are managed with the comfort of the laboring woman in mind. This is done by ensuring that before delivery, the body of the woman is sponged using warm water and her preferred position of delivery is established and respected. To this end, squatting and kneeling positions were mainly preferred during delivery. The care provider then supports the woman to pace up and down the homestead to allow the baby to move towards the cervix, a process which stops as soon the woman begins to feel the baby’s head moving towards the vagina. The study further found that management of complications related to delivery are in many ways dependent on the nature of complication. For instance, in the event that there was delay in delivery of the baby or the placenta, the woman was asked to kneel down to allow the baby to move towards the vagina. While in the kneeling position, the woman is asked to open her mouth and a wooden cooking spoon (Oliho) or rosary, is placed in her throat. This is done to choke her so as to trigger vomiting. As she attempts to vomit, pressure is mounted from her stomach that pushes the baby or the placenta out.

They noted that although the health facilities view the placenta as a mere after birth, its disposal in the traditional realm determines whether or not the mother will conceive in the future. When asked why this was the case, respondents explained that there was a specific way that a placenta has to be disposed of. This involves rolling the placenta slowly in a hole while holding the tip of the umbilical code that was cut and when the entire placenta settles in the hole, the provider ensures that the tip remains in an upwards position. This signifies an open doorway to future pregnancies by the mother that has just delivered. If the tip is buried facing downwards then the mother will never conceive and /or give birth again. The placenta is also buried behind the house of the woman that has just delivered. Traditions do not allow one to cross over to the other side of the homestead (Nga’do dipo) to bury the placenta; such an action leads to inability of the woman to deliver other babies.

Reports from the mothers interviewed also indicated that the non-skillsed maternal healthcare providers do not stitch mothers to ensure that the perenial tears heal properly and the perineum returns to its normal shape after delivery. They said that the providers sponge mothers who have had perennial tears during child birth using hot water and salt, and during this process, the woman is asked to contract and relax at regular intervals the muscles around the vagina as though she is withholding and passing urine. Respondents explained that this process enables the muscles around the vagina to get toned back to the pre delivery state.

The absence of male care givers in the non-skilled maternal healthcare was noted by the respondents as having made the services free from sexual abuse. When mothers were asked to explain how they encountered sexual abuse in health facilities, they explained that male health care workers sometimes touched women’s external sexual organs without any professional justification. This case was strongly cited by mothers at Malanga and Nyajuok. The mothers said that such incidences do not happen under the care of the non-skilled maternal healthcare providers.

3.4. Post-Natal Care in the Non-Skilled Maternal Healthcare

Post-natal care was described by respondents to include feeding and care of mothers after delivery, removal of placenta in cases of retention, treatment of conditions that affect mothers after delivery and methods of child spacing. Regarding the feeding given to mothers after delivery, mothers reported that care givers in the non-skilled health system provide them with black tea mixed with lemon to help in removing the blood clots. In addition, they [mothers] are also massaged using a herb known as manyasi to force the placenta out in the event that the placenta is not expelled within the normal duration.

Besides the massaging to help the mothers to push out the placenta, it also helps the mother with bowel movement as well as treats a condition called Arip which occurs when the birth canal is blocked. When asked to describe Arip, the respondents said that the pain associated with Arip is felt around the vagina and is also characterized with needle-like pricking pain. Another condition described by respondents which was addressed through massage was Bunda (swelling of the body), which they said makes delivery difficult because a pregnant woman may not be able to push the baby during labour due to increase in weight as a result of the swelling.

The ability of the non-skilled maternal healthcare system to prevent pregnancy was reported by mothers as one of the methods that contributed to their satisfaction with the non-skilled system. Among these methods include Tweyo, a method which was reported as having no side effects on mothers because it involves taking the under wear of a women who has just delivered , then tying it with a piece of placenta. ems. The two tied items are placed over the traditional cooking place called Oyare to prevent the woman from conceiving. This procedure is known as Ngawo dhako (blocking the womb of a woman from conception) But when the woman is ready to conceive another baby, the item is removed from Oyare by the same traditional maternal healthcare provider who had performed the initial procedure. This act of removing the item from Oyare is a sign that the woman’s womb is ready to carry another pregnancy.

Other than the rituals mentioned above related to birth control, respondents mentioned a number of taboos that equally hinder pregnancy from taking place. These are associated with the cultural sanctions put in place to safeguard the planting and harvesting seasons; mourning period and the norms that couples are expected to observe during this period. During the planting season known as Chwiri, members of a homestead are not allowed to go to the farm and plant the first seeds ahead of the head of the homestead. The head of a homestead in this case is the man whose house stands directly facing the main gate (Rang’ach) of the home. Respondents said that the Luo community has a clear distinction between the main gate and Roth (an opening around the fence of the homestead). A night before the first planting day, the head of the homestead is expected to have sex with his wife as a sign of successful planting. This ritual is called Golo Kodhi. Any woman who goes ahead to have sex with her spouse who is not a homestead head cannot conceive. The same pattern is followed during the harvesting period. Additional taboos that women associated with blockage of conception included having sexual intercourse when a co-wife to a mother- in- law has died. The women noted that during the mourning period, every sexually active person in the homestead refrains from sexual intercourse for a period of one week, and that should this sanction be broken, then no pregnancy can occur. Finally, respondents reported that when a woman has delivered, the husband is not allowed to come closer to her because she still smells blood as a result of child birth (also called Nyaudo or Nyawiwo in Dholuo Language). For this reason, sexual relationship between women who have delivered and their husbands are less likely to occur. Although unborn babies and pregnant women suffered from conditions that could only be managed within the skilled maternal health care system, the key informants interviewed at the health facilities in Nyoderea, Kaluo and Siaya district hospital observed that the dialogue between the traditional and skilled maternal healthcare systems has remained weak.

Table-4. Treatment regims during delivery

Source: Primary interviews

Table-5. Relationship between perceptions on non-skilled maternal healthcare systems and where the mother received the most care during the last pregnancy

N=1197

4. CONCLUSION

The study has found a significant relationship between the presence of herbs used to shorten the duration of labor and where a mother received the most care during the last pregnancy (p value= 0.001); and between the use of the traditional herbs for shortening the duration of labor and where the mother received the most care during the last pregnancy (p value=0.000). Also revealed is the absence of relationship between the presence of traditions (Chike Luo) that communities expect a new born to undergo; the presence of traditional methods used for child spacing after the birth of the last child by where the mother received the most care during the last pregnancy as both have a p value of 0.111 and .007 respectively. The finding of this study suggests that the management of pregnancy using non-skilled maternal healthcare is viewed as superior because of various reasons including; ability to correct / reverse the taboos, abominations and curses; healing the spiritual part of the mother by providing prayers; administering concoctions to women and their spouses, massaging of pregnant women and ability to listen to the voices of the spirits in relation to the instructions given on a iven pregnancy, delivery and post natal care. The African traditional churches grant the traditional maternal healthcare service providers authority to deliver babies, but the ministry of health policy does not. This has created a contradiction because the traditional maternal healthcare system which is viewed by the African traditional churches as being capable of managing conditions that are beyond the capacity of the skilled maternal healthcare system but which is not granted permission. This study suggests that the non-skilled maternal healthcare is not only preferred during pregnancy and labour, but also during delivery. Among the aspects that make delivery in the non-skilled maternal healthcare more preferred included the sponging of pregnant women who are in labour with warm water; being supported to pace up and down the homestead to help with movement of the baby towards the cervix; remedies used to address complications during delivery such as prolonged labour and delay in the delivery of the placenta. Overall, the knowledge on the benefits of utilizing skilled maternal healthcare during pregnancy, delivery and post natal care is not sufficient to inspire women to seek skilled maternal healthcare. As long as the skilled maternal healthcare system remains ineffective in providing accepted remedies related to correcting and reversing taboos, abominations, curses and healing the spiritual being of the women , then women will continue utilizing the traditional system. Other critical offerings in the traditional systems include provision of prayers and communicating to the spirits and adhering to the directives, massaging mothers and managing labor and delivery in more natural ways.

5. RECOMMENDATIONS

It is evident from the findings of this study that the skilled maternal healthcare system cannot ignore the strengths of the non skilled maternal healthcare system. This is deduced from the premise that the skilled maternal health system cannot handle the maternal healthcare complications related to spirits, curses and abominations. ve .this prevailing perceptions require that the skilled and non-skilled maternal healthcare systems. dialogue to establish areas of interface. Key to this dialogue is how the skilled maternal healthcare system can work closely with the non skilled maternal healthcare system to address maternal health conditions related to spirituality, treatment of ancestral curses and abominations and other non biometric conditions that are better understood in the traditional maternal healthcare realm.

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