Being perceived as ‘a real woman’ or following one's own convictions: a qualitative study to understand individual, family, and community influences on the place of childbirth in Busia, Kenya

Abstract

Despite potentially playing a key role in improving maternal and child health, including the prevention of mother-to-child transmission (PMTCT) of HIV, health facility delivery rates remain low in Kenya. Understanding how place of childbirth is determined is therefore important when developing interventions to improve safe motherhood and childbirth outcomes. As part of a qualitative study, we conducted 25 in-depth interviews with mothers (13) and healthcare staff (12) and held 10 focus group discussions with traditional birth attendants (6) and female relatives (4) in Busia, rural Kenya. Our findings show that mothers prefer facility delivery; however, the choice is not theirs alone but involves both their family and the community. Furthermore, facility delivery poses a risk of being viewed as disloyal to tradition and not 'a real woman', which causes a strained relationship between healthcare staff, family and the community. Our interpretation of the findings is that mothers feel trapped between loyalty to sociocultural norms and awareness of the benefits of facility delivery. Also, we believe healthcare staff's disinclination to recognise certain traditional birth attendant services as a potential asset poses a barrier to increased facility deliveries. Interventions to link traditional birth attendants with formal healthcare combined with sociocultural sensitivity training for healthcare staff may increase facility delivery and PMTCT.

Access barriers to obstetric care at health facilities in sub-Saharan Africa—a systematic review

“…Women who used or intended to use maternity care services faced challenges such as inadequate facility opening hours [25, 157]; non-availability of services [111, 129, 158], poor (perceptions of) providers’ competence or clinical skills [64, 74, 76, 110, 111, 123, 151, 158–160] and knowledge [76, 158, 160–162]; inadequate staffing levels [48, 59, 67, 76, 82, 104, 106–108, 111, 153, 155, 157, 162–165] as well as previous experiences of unskilled birthing care from maternity care providers [29]. Generally, women expect to receive care promptly on reaching a health facility; therefore, long waiting times present a significant challenge to accessing health facility-based services [22, 29, 31, 53, 82, 87, 97, 107, 115, 123, 154, 155].…”

“…Costs of services were a deterrent to obstetric care utilisation for some service users [30, 33, 43, 55, 56, 65, 72, 74, 76, 83, 91, 100, 112, 114, 118, 121, 129, 134, 153], as was informal payments for services [110, 155]. Service costs is a particularly significant barrier for poorer rural populations which tend to be socioeconomically disadvantaged across sub-Saharan Africa.…”

“…Poor staff interpersonal skills, either perceived or from previous experiences [53, 65, 68, 74, 75, 103, 111, 121, 128, 129, 133, 154], impacted negatively on service use. Significant issues included a lack of respect for service users [66, 108, 131, 158, 167, 169, 170], a lack of trust/confidence in health professionals or more trust in alternative care [50, 60–62, 106, 114, 122, 156, 167] and mistreatment by health workers [22, 27, 28, 30, 33, 41–43, 55, 56, 83, 87, 89, 91, 103, 104, 106, 153, 170, 171]. Other negative attitudes of staff, which discourage service users from using maternity services, include a lack of commitment/motivation to work [31, 119, 165, 167], or for instance, expressing a desire to work abroad [152].…”

Mitigating the mistreatment of childbearing women: evaluation of respectful maternity care intervention in Ethiopian hospitals

“…An evidence synthesis of studies from 16 low-income and middle-income countries and China revealed that mistreatment during childbirth is a powerful deterrent to facility-based childbirth. 13 Additionally, studies from Afghanistan, 14 Bolivia, 15 Ghana, 16 Kenya, 17 18 Tanzania, 19 Malawi 20 and India 21 have clearly reported disrespectful care at birth as a key deterrent to facility-based childbirth.…”

Evaluation of a health promotion intervention associated with birthing centres in rural Nepal

“…Conversely, when women were included in decision, but were not the sole decision-makers about where to give birth, they were more likely to have a facility birth. Research has shown that although women want to choose their birthplace based on safety and other grounds [39], for many women the decision to give birth at a health facility is not their own but involves their family as well as the community [40]. The women sometimes find that their right to choose their birthplace is compromised because of cultural and traditional practices [41].…”