Counties: How we got women to ditch home births

A nurse at Lodwar Referral Hospital in Turkana County demonstrates how pregnant women use the birth stool during childbirth. The stool is one of the approaches the county is using to attract pregnant women to deliver in hospitals. PHOTO| ANGELA OKETCH

Giving birth outside a hospital can be a risky gamble. Complications can arise and if not managed by a trained health worker, the expectant mother and her baby are put between a rock and a hard place, with injury or death as the options in the absence of specialised interventions to arrest them.

Obstructed labour, infections, haemorrhage (excessive bleeding), high blood pressure and other complications can be addressed in a hospital or the mother quickly referred to another facility for specialised care to prevent death.

Yet in 2012, 162,373 babies were delivered at home. The mothers had their reasons, ranging from lack of transport to go to hospital to high hospital fees that they couldn’t afford.

This was addressed in 2013 with the introduction of the free maternity programme, and the number of home births dropped to 159,494, while hospital births rose from 634,442 in 2012 to 711,105 in 2013.

Since then, hospital births have continued to rise (875,101 in 2016) while home births have continued to decline (73,223 in 2016).

While free maternity services have played a big role in taking away the financial burden that kept mothers from hospital delivery rooms, there were other factors keeping pregnant women away. Expectant mothers also shunned hospitals due to fear of the negative attitudes of health workers, long distances to health facilities, and cultural preferences, among other reasons.

With this in mind, counties came up with strategies to attract mothers to deliver in health facilities and in turn lower their risk of death before, during and after childbirth.

We take a look at the tactics four counties have used to increase health facility deliveries and uptake of other maternal and child health services such as antenatal clinic attendance, child immunisation and postnatal checkups, which in turn give mothers and their babies a better chance at life.

BIRTH STOOL WORKS WONDERS IN TURKANA

The year was 2016 and the Turkana County government was worried. More than three-quarters of women in the county were giving birth at home, and half of them were assisted by a relative or friend, while others gave birth unassisted.

Home deliveries were a risk – in the event of complications the mother or her baby, or both could die because there were no trained skill birth attendants by their side to intervene or to refer them for specialised care.

Health officials sought to find out why women were not trooping to hospital to enjoy free deliveries under the free maternity programme.

“The assumption was that hospitals were too far, but we were wrong on that,” says Dr Gilchrist Lokoel, the chief executive officer of the Lodwar Referral Hospital in Turkana County.

They discovered that first, women did not want to expose their private parts to strangers, and secondly, they favoured the home birth position for delivery.

A picture of traditional birth stool that most women prefer using rather than lying at their backs at Lodwar Referral Hospital in Turkana County. PHOTO| ANGELA OKETCH

In hospital, the woman would be expected to lie on her back, while she preferred the traditional squatting and kneeling, which makes it easier to push and makes delivery faster than when lying down.

To get women to deliver in hospitals, the county needed to adjust to their needs. The county borrowed a tip from Karamoja in northern Uganda and introduced a traditional birth stool to the delivery room.

And it has worked wonders, doubling health facility deliveries from 6,899 in 2013 to 12,743 in 2017.

Morever, the culturally acceptable and low-cost intervention has seen maternal mortality go down from 260 deaths for every 100,000 live births to 158 deaths for every 100,000 live births.

In addition to the birth stool, the county roped in traditional birth attendants who assist in 23 per cent of deliveries in the county as promoters of safe motherhood. This enabled them to refer mothers to health facilities for childbirth.

Half of the mothers who deliver at the facility use the birth stool and take about 10 minutes to give birth on the soft and comfortable cushion.

They use the modified squatting or kneeling position aided by the soft cushion.

The birth stool is made of three parts: the long, curved upper part, the cushion placed on the ground between the woman’s legs to receive the baby, and a stool that allows the nurse to view the perineum (area between anus and vulva).

There are two metallic handles on both sides for the mother to hold onto tightly while pushing and because most mothers do not like to expose their nakedness to strangers, a piece of cloth is used to cover their laps for their comfort.

The padded pillow allows a partially squatting position that mothers find comfortable for delivery.

TRANSPORT IS ALL WE NEED IN SAMBURU

In Samburu County where only 32 per cent of births were assisted by skilled attendants, with the rest happening at home assisted by traditional birth attendants, health officials discovered that the reasons for this state of affairs was that health facilities were far away, and this was worsened by poor road networks.

This obstacle needed to be removed to get mothers to hospital delivery rooms. In 2015, the Uzazi Salama project funded by the M-Pesa Foundation with Amref Health Africa as a partner sought to address this challenge by providing transport vouchers. When labour pains start, the woman can call an ambulance which arrives with a nurse and takes her to the nearest health centre for delivery.

Community health volunteers identify and enroll expectant mothers in their third trimester who are a month or less away from their expected date of delivery.

Nurses assist Alina Lekirau at Catholic Hospital Wamba in Samburu County. Mrs Lekirau, a first-time mother lives in Ngisiu Village, 60 kilometres away from the hospital and used a transport voucher to call an ambulance to take her to hospital to deliver her child.

The mothers choose a health facility, whose phone number they are given. The transport voucher – Sh3,000 – is deposited in their phone as an Mvoucher and the woman is given a PIN to use later.

When labour pains begin, she calls the hospital and an ambulance with a nurse is dispatched to pick her. Each ambulance has a till number that will be used to collect payments from the transport vouchers. At the hospital, the woman transfers the transport voucher  to the ambulance’s till number.

 After delivery, she is taken back home by the same ambulance. She is also given a pack with mother and baby items for free. If the mother had false labour, she is housed at the maternity shelter to wait for her due date.

If the mother fails to call an ambulance one month after the recorded expected delivery date, the money is reversed to Safaricom on the assumption that she gave birth at home.

MAKES THINGS EASIER

To make things even easier for pregnant women from the nomadic community, the county constructed maternal shelters where mothers-to-be can put up while waiting to give birth and circumvent the long arduous trip to hospital when labour pains begin.

These interventions have boosted maternal health indicators, with Acting County Executive Committee Member for Health Dorcas Lekisanya saying that skilled deliveries rose from 2,000 in 2016 to 4,000 in 2017; mothers dying during birth reduced from nine in 2016 to five in 2017, while neonatal deaths reduced from 49 in 2016 to 28 in 2017.

The intervention has not been without challenges. Sometimes demand for the ambulances is high which hinders some women from getting the transport service when they need it.

Moreover, some women forget the system-generated PINs for accessing the mobile transport voucher, leading to delays in activating the voucher.

There are also some communication difficulties with some health facilities due to mobile phone network problems, which means a woman cannot access the ambulance.

“We tell the women to write the PINs and identification numbers and keep them safe. We are also incorporating an ambulance command centre for effective scheduling and management of the ambulance service,” says Ms Lekisanya on how the county is addressing these challenges.

MONEY MAGIC IN KAKAMEGA

In 2014, Kakamega was doing badly. Half of its women were giving birth at home, and the county was ranked fifth among 15 counties with the worst maternal and neonatal health indicators in the country.

Maternal mortality stood at 316 deaths for every 100,000 live births, while newborn deaths were 19 for every 1,000 births.

Further, 64 children under age five out of every 1,000 were dying. Something had to change and in 2015, an initiative dubbed Imarisha Afya ya Mama na Mtoto was identified as the vehicle to bring that change.

The programme targets pregnant and breastfeeding mothers from poor households, who might shy away from maternal and child health services like antenatal and postnatal clinics, health facility deliveries and immunisation for infants due to the costs involved.

They are given Sh2,000 if they attend antenatal clinics or take their children for immunisation.

The money covers transportation costs to health facilities and helps them buy food and other necessities for their children.

The money is paid out in phases. The first amount upon enrollment during the first antenatal clinic visit, with subsequent amounts being paid out during the second, third and fourth clinic visit as recommended.

The woman gets the fifth tranche upon delivering in a health facility, and the sixth, during the post-natal check-up. There is a limit to the number of newborns that can be supported per household.

“We are not giving them money to give birth every year expecting to be paid for it. The money is to cover transport costs for the mother when going for check-ups and to take care of the baby’s nutritional needs.

“We support two babies per mother, then the woman ceases to be part of the programme,” says Kakamega Governor Wycliffe Oparanya on the programme that has a Sh100 million budget, and is supported by Unicef and the government of Sweden.

Last year, the county passed the Maternal and Neonatal Child Health and Family Planning Act that established a fund to support the initiative and sustain the programme in the long run.

So far, 44,500 women have benefitted from the programme which saw skilled deliveries rise from 33 per cent in 2013 to 69 per cent in 2016. Mothers attending four antenatal clinics rose from 35 per cent to 54 per cent and immunisation coverage rose to 81 per cent from 63 per cent.

KIT FOR MUMS IN GARISSA

Like Turkana, Garissa sought inspiration from Karamoja in Uganda to up the number of skilled deliveries and address maternal mortality in the county where 63 per cent of women were giving birth at home assisted by traditional birth attendants in 2014.

From Uganda, they brought back MAMA kits and incentives to traditional birth attendants. The MAMA kit containing basic essentials was given to mothers who attended antenatal clinics, while traditional birth attendants were given Sh200 for every woman they referred for a hospital delivery.

Moreover, mothers are given birth certificates for their babies if they delivered in hospital and ensured that their child got the measles vaccination.

Like Samburu, the county also has maternal shelters to host pregnant mothers who live far from the health facility as they inch towards their expected delivery date.

As a result, women attending four antenatal clinics as recommended rose from 30 per cent in 2014 to 40 per cent in 2015; hospital deliveries increased from 36 per cent in 2013 to 45 per cent in 2015, women attending postnatal clinics rose from 3,517 in 2013 to 6,646 in 2015.

This won the county recognition from the Ministry of Health for having implemented the best practice in service delivery in the health sector in the 2014/2015 financial year.