Understanding links between Traditional and Skilled Birth Attendants


By Pamela Onyo, Anglican Overseas Aid


The Road Less Travelled (TRLT) is a project supported within the Australia Africa Community Engagement Strategy (AACES). AACES is a partnership comprising the Australia government with ten Australian NGOs and their partners working across eleven African countries. Each year AACES releases an annual report and this year the Kenya partners decided that the theme should be the outcomes of research conducted under the auspices of TRLT.

The research sought to enable better understanding of the current care seeking behaviour of childbearing women in pastoralist communities of Laikipia and Samburu Counties. The two-year study has been conducted by TRLT partners Nossal Institute for Global Health at the University of Melbourne and the Mother’s Union of the Anglican Church Mt Kenya Diocese, in collaboration with Amref Health Africa. It has been funded through the Australian Development Research Awards.

What is the issue?
Kenya has an unacceptably high numbers of mothers and babies dying at the time of birth. This is particularly and especially true for the semi-nomadic pastoralist communities who are living in remote parts of the country where many women deliver their babies at home attended by a traditional birth attendant (TBA). These TBAs are generally highly respected and trusted members of their communities who have a personal relationship with the women they are caring for. However, they are not trained nor equipped to manage complications of pregnancy and childbirth, which occur in about 15% of cases, and contribute to the preventable deaths of mothers and babies.

The government of Kenya wants all women to deliver their babies attended by skilled birth attendants (SBAs) in health facilities such as dispensaries and hospitals and has put a target of 90% skilled birth deliveries by 2015. SBAs are doctors and nurses who are trained and equipped to respond in the event of complications. However, for a range of reasons, women from pastoralist communities are often reluctant or unable to attend these services.

Launching the AACES Annual Report
With the research now complete the findings were disseminated to local stakeholders from Laikipia and Samburu County’s, and also at the national launch of the Australian Africa Community Engagement Scheme (AACES) annual report. Over 200 people attended the national annual report launch including government representatives, community members, and NGO CEO’s.

The report was launched by the Australian High Commissioner, HE John Feakes, while the Archbishop of the Anglican Church of Kenya, HE Eliud Wabukala, was invited to deliver an address on the research report where he said: “If we are to reduce the incidence of maternal and neonatal mortality then we need to understand what the factors are that attracts or inhibits a woman from seeking professional support when giving birth … The report provides illuminating information on the situation for pregnant women in Laikipia and Samburu. This information gives a detailed picture about what it is like for a pregnant woman, the difficulties and challenges that she faces in bringing new life into the world.”

The Research Findings
The main findings from the study are that:

  • The pastoralist women knew about the free delivery care provided by the government, but for many, the distance to the health facility was too far to walk, and transport costs were a problem.
  • Both women and men acknowledged that delivery with an SBA in a health facility is more hygienic and safer because they can manage complications if they occur.
  • The women said that they were frightened of some medical procedures in hospitals, were concerned that their modesty would not be protected, found hospitals to be very cold places, and did not want to be separated from their families during the delivery period. Additionally, SBAs have a reputation for being unfriendly to pastoralist women. Some women thought that having a baby in a health facility was a sign of weakness.
  • According to pastoralist women, TBAs provide comfort and care in a warm and familiar place, and are locally available and affordable.
  • TBAs remain with the women for days to weeks after delivery to care for them and to take responsibility for household duties so they can rest.
  • The role of TBAs includes helping to mediate between the husband and wife, giving dietary advice (sometimes not very good advice), receiving the baby, massaging the woman, promoting breastfeeding, and if necessary, referring and accompanying the woman to the health facility.
  • TBAs are able to recognise the important complications of delivery, but refer rather late in the event of an obstructed labour. They do not really know how to manage a baby that is having difficulty breathing.
  • Actively including TBAs in programmes designed to improve better utilisation of SBAs in pastoralist communities will help to increase the number of SBA deliveries, and reduce the number of TBA deliveries, some of which are unhygienic and unsafe.

Conclusion and Way Forward

  • There is potential complementarity in the perceived strengths of SBAs and TBAs. TBAs are highly acceptable and accessible to women, and are valued for their supportive role and emotional and socio-cultural sensitivity, but are not trained or able to diagnose or manage most obstetric and neonatal risks and complications. SBAs are skilled in diagnosis and management of these risks and complications, but are not seen as very accessible, or acceptable, in their service delivery. This complementarily, and the strong support from all stakeholders for greater integration of the work of TBAs and SBAs, will lead to further consideration of potential models for collaboration and cross-learning.
  • When combined with results from the quantitative arm of the study, they informed options for collaborative models of care involving both TBAs and SBAs for more effective, efficient and contextually appropriate care, which will be developed in partnership with participants and other stakeholders. These models will consider the potential for collaboration across all stages of pregnancy, labour and delivery, and the neonatal period.

As a result of the research the TRLT project and research partners, in conjunction with the Ministry of Health, are investigating the possibility of piloting a ‘pastoralist friendly health facility’.

A pastoralist health facility would support shared care by traditional birth attendants (who are preferred by women to be their service providers) with skilled birth attendants (who are the providers with the skills to save maternal and newborn lives). Such a facility would be structured specifically to suit the requirements of pastoralist women and ameliorate the issues that inhibit them for attending. For example, it may have a traditional house with fireplace on clinic grounds where a woman may weight prior to going into labour, and her close friends and family can be in attendance. A TBA may accompany the expect mother and comfort her during the birthing process, while clinic staff are especially trained to respect the woman’s modesty and accommodate her cultural requirements. The clinic would build close links to the community so that they feel ownership and responsibility for it. The objective is to significantly increase the number of women who attend ante- and post- natal care, and deliver in a safe environment, therefore reducing maternal and neo-natal mortality.

You can watch a video on the AACES 2013-14 Annual Report at: https://www.youtube.com/watch?feature=player_embedded&v=UQJePZcIaKI

You can access the AACES 2013-14 Annual Report at: http://dfat.gov.au/about-us/publications/Pages/aaces-annual-report-2013-14.aspx

You can download a booklet where TBAs and SBAs who took part in the research tell their stories:Walking together book viewing version

Below is a video about TBAs and SBAs, and how they are working together to benefit communities.

Credits for the photo are: From Left – Mary, AACES program beneficiary, John Feakes, Australia’s High Commissioner designate to Kenya (left), Anna Dorney from DFAT, Eliud Wabukala, Kenyan Anglican Archbishop, and Patrick Amoth, Ministry of Health. Photo by Douglas Waudo, ACBF.

The Road Less Travelled: Update

As you are likely aware, this blog has been somewhat dormant over the past few months as we have transitioned its management from Australian Volunteers International (AVI) to the lead project partner, Anglican Overseas Aid.

Changes in Federal Government funding meant that AVI could no longer undertake the communications component of the project. We offer our deep gratitude to AVI, and particularly to Hannah Ford, for the amazing work they have done to run this blog. We highly recommend reading Hannah’s powerful final blog post ‘If these hands could talk’.

We regret that the transition has taken longer than expected, but we are looking forward to sharing a range of new stories over the coming weeks and months.

Of particular note, we recently completed our Annual Report for 2013-14, which outlines the progress made through the project. We will make it available here soon.

Over the coming weeks and months we will be sharing:

  • interviews with voluntary and professional health workers in Kenya
  • an article about cultural shifts among the pastoralists of Ethiopia and Kenya
  • video news stories about our work from National TV in Kenya
  • an article about small steps creating big changes through women’s empowerment
We hope you will continue the journey with us along The Road Less Travelled.

Overcoming the obstacles to basic healthcare access

This post was written by Chris McKeon, Writer and Production Assistant at Arete Stories.

When The Road Less Travelled project began, the newly-built Morupusi dispensary sat alone on an empty hill. Its metal roof shone but the dust that covers the region had already begun to settle on its walls. Mounds of rubble surrounded it, instead of the people who normally wait outside health centres. Inside, there was nobody. Its walls and rooms were bare. There were neither drugs, nor places to store them nor people to administer them. The dispensary looked abandoned, but it wasn’t – it had never been occupied.

It was built with funds from the local Constituency Development Fund to serve the 4000 Maasai pastoralists who live in the Morupusi Group Ranch, in northern Laikipia, Kenya. They were walking 10 kilometres to the nearest hospital at Doldol, where they would wait for hours to be seen; a return journey that would take up to a day.

Before the clinic opened, women from Morupusi would have to walk to Doldol carrying their children on their backs if they needed medicine.  Image: Matthew Willman / Anglican Overseas Aid

Before the clinic opened, women from Morupusi would have to walk to Doldol carrying their children on their backs if they needed medicine.
Image: Matthew Willman / Anglican Overseas Aid

“We wanted a dispensary here because of the distance,” explains Elizabeth Kaparo, a local Community Health Worker and Treasurer of the dispensary committee. “Women have to walk to Doldol carrying their children on their backs if they want medicine. So we applied to the Constituency Development Fund (CDF) for money.”

Attaining funding to build the clinic was only the first step on a long road to improving access to health services for the Morupusi community. Once it was built, because the Ministry of Health had not been notified about the clinic, there was no budget allocated for staff, and no medical supplies. The building stood empty, and the Maasai continued their long walk to Doldol.

When the Community Development Committee reached out to Anglican Overseas Aid and The Road Less Travelled for help, project staff saw immediate potential in the clinic to become a central hub for community health and education. They formed a three-way partnership with the community and the Ministry of Health.

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Providing water in Naibor: building businesses in return

This post was written by Loretta Pilla, an Australian volunteer who is currently working in Kenya as a Program Management Officer with Anglican Overseas Aid’s The Road Less Travelled project.

Jchabure Lengunya is a mother of six children between four and 16 years of age. In addition to her family responsibilities, she is also an active member of the Naibor Water Committee. With Jchabure’s youngest child wrapped tightly around her neck, we sit beneath the shade of an acacia tree 50 metres uphill from the recently built rock water catchment in Naibor group ranch, in Laikipia County of Kenya.

“We are now entering the wet season,” she explains, pointing at the vast red clay landscape stretching to the horizon. It is barely flecked with green foliage, with even less houses in between.

Before the water catchment was built the women of Naibor travelled long distances during the wet season to the Naibor open spring to dig for water, and even further during the dry season to the Nanyuki River.

Image: Loretta Pilla / Anglican Overseas Aid

Women of Naibor in Laikipia, Kenya, wait to collect water from the tank at the base of the rock water catchment built by the community with support from The Road Less Travelled project. Image: Loretta Pilla / Anglican Overseas Aid

Jchabure explains that the water committee is responsible for ensuring the sustainable use of water by community members. This is an important role given the pressures the harsh weather conditions and often extended dry seasons can have on water availability.

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The work of the community

This post was written by Chris McKeon, Writer and Production Assistant at Arete Stories.

About three hours north of Nairobi around a high, rocky hill is a collection of small huts. They are part of the Maasai community of Naibor, in Kenya’s Laikipia region.

As well as the mud huts, there is also a small primary school built of metal sheeting and a track, carved through the red dust, linking it to the towns of Nanyuki and Doldol. The odd goat grazes along the side of this track and women can be seen trudging through the red dust daily with water containers on their backs. The lack of water in the community becomes increasingly apparent the closer one gets.

The dusty track that links the Maasai community of Naibor to the towns of Nanyuki and Doldol.  Image: Matthew Willman / AOA

The dusty track that links the Maasai community of Naibor to the towns of Nanyuki and Doldol.
Image: Matthew Willman / AOA

“We were in difficulties with water,” explains James Supa as he sits on a rock near the roadside. “In the dry season, mothers have to walk to the river or Doldol or Nanyuki for water. It can take a whole day to fill their buckets with water.” (Read our earlier blog post about the effects of the water burden on women in Naibor.)

The little water they do find is often contaminated by animals or can only be reached by digging in the mud where the river used to flow, five kilometres from Naibor. Supa acts as a link person between The Road Less Travelled project (TRLT) and the Maasai, to ensure any development activities are locally-appropriate and meet the needs of the community. TRLT is a project of Anglican Overseas Aid, which works in partnership with local organisation the Mothers’ Union of the Anglican Church in Kenya (MUACK).

In Naibor, the community identified the chronic water shortage as a key development challenge.  Image: Matthew Willman / AOA

In Naibor, the community identified the chronic water shortage as a key development challenge.
Image: Matthew Willman / AOA

Women of Naibor at a community meeting. The new rock catchment will mean less time walking long distances to collect water for their households.  Image: Matthew Willman / AOA

Women of Naibor at a community meeting. The water shortage is a burden that is felt most heavily by women, whose task it is to walk long distances on a daily basis to collect their household’s water.
Image: Matthew Willman / AOA

The past few years have seen increasingly long dry spells in the Laikipia region, and the water shortages have worsened. When TRLT started and a community development committee was formed, the people of Naibor identified the chronic water shortage as a key challenge, and appealed for support from the project to alleviate the problem.

After community discussions, the suggestion was made to use the local environment and build a rock water catchment to store water during the rainy season. TRLT supported the initiative, which made use of local labour and resources to build two low walls along the hill’s bare rock face, as well as a storage tank. The walls channel the rainwater down the rock face and into the tank for use during the long dry season, when water is scarce.

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Community Health Workers drive sanitation changes amongst the Maasai

This post was written by Chris McKeon, Writer and Production Assistant at Arete Stories.

The Maasai of Laikipia region in northern Kenya face a number of health issues. With a history of nomadism they had never felt the need for toilets as the bush always sufficed. However, with the decline in size of the territory along with the erection of more permanent structures, safe disposal of fecal matter has arisen as a major concern.

Preventable diseases such as diarrhoea are widespread, and pose a significant threat to the health of the Maasai – especially that of infants and children under the age of five.

The problem stems from a lack of basic hygiene. “The Maasai aren’t used to using pit latrines,” says Daniel Kipishe, a Community Health Worker in the Morupusi area. “They just go in the bush.”

A traditional Maasai home in Morupusi Group Ranch of Laikipia County, Kenya. Image: Matthew Willman / AOA

A traditional Maasai home in Morupusi Group Ranch of Laikipia County, Kenya.
Image: Matthew Willman / AOA

Each year, around the world, more than 1.5 million people die from water, sanitation and hygiene-related diseases, according to WHO. Millions more suffer from preventable diseases such as diarrhoea and intestinal worms.

For the Maasai, the lack of adequate sanitation may be hindering progress in other areas of community development, including maternal and child health.

Simple health advice is the solution to stopping the spread of disease. Anglican Overseas Aid (AOA), along with the Mothers’ Union of the Anglican Church of Kenya, has trained 25 Community Health Workers in Morupusi to help overcome this problem. Their role is to provide basic health advice in the villages and report on the area’s health needs to the Kenyan Government. Although the health workers were selected from the population, initially the Maasai were wary of engaging with them.

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On the road to safer birthing practices

This post was written by Sarah Manyeki, Monitoring & Evaluation Officer for Mothers’ Union Kenya – Anglican Overseas Aid’s partner in The Road Less Travelled project.

In the remote Maasai community of Morupusi, in Kenya’s Laikipia County, the training and deployment of Community Health Workers (CHWs) is beginning to see positive results. Elizabeth Kaparo was trained as a CHW in 2012, an initiative of The Road Less Travelled (TRLT), a project that is committed to improving access to basic health care for nomadic pastoralist communities.

CHWs, people trained in basic health skills and who live within the nomadic pastoralist communities, are part of the Kenyan Ministry of Health’s (MoH) strategy to find local solutions to the barriers to accessing health services. TRLT partner the Mothers’ Union works with the MoH to facilitate the training of CHWs. This collaboration is an important step to bridge the gap between the traditional practices of these communities, and formal health facilities.

The efforts of TRLT-trained Community Health Workers are starting to have a positive effect on the health of mothers and children in the Maasai community of Morupusi.  Image: Matthew Willman / Anglican Overseas Aid

Mothers and children in the Maasai community of Morupusi are starting to benefit from the training of Community Health Workers, who provide a link between traditional practices and formal health services.
Image: Per Arnsäter / Anglican Overseas Aid

The project envisages the CHWs as a vital asset to their community, offering a cost-effective, accessible, and community-owned health resource.

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