Exploring antenatal care experiences amongst pastoralist communities in Kenya: a focused ethnographic study

Background: Antenatal care (ANC) is a very important component of maternity care to ensure a healthy pregnancy and safer childbirth, particularly in areas where maternal health is poor. However, whilst progress has been made to reduce maternal deaths and increase ANC coverage globally, challenges remain in bringing ANC to specific remote or rural communities, such as pastoralist communities in sub-Saharan Africa. This PhD study focuses on ANC amongst a semi-nomadic pastoralist community in one part of Kenya. Pastoralist communities are herders of domesticated livestock, though some incorporate agriculture into pastoralism. Nomadic pastoralists organise their lives around the needs of their animals, which is characterised by migration depending upon weather patterns. In Kenya, there are at least 5.6 million rural pastoralists. Existing reports show that pastoralist communities tend to lack access to services and face long-standing marginalisation, poverty, and vulnerability. Further, in some African countries, including Kenya, gender norms mean that pastoralist women face double marginalisation in terms of decision making, access to education, and healthcare services. The research setting is Marsabit County in Kenya where 80% of the population is pastoralist. Marsabit has the fourth highest maternal mortality and morbidity rates in Kenya at 1,125 per 100,000 live births, and the highest teenage pregnancy rates. Pastoralist women’s access to and use of ANC services in Kenya has not been studied previously. Study aim: To explore the experiences of ANC amongst the pastoralist community in Marsabit County in Kenya in order to understand key barriers and facilitators of ANC service uptake. Specific objectives are: 1. To explore women’s knowledge, experiences, and perspectives on ANC services, and factors influencing ANC services use. 2. To understand men’s perspectives regarding factors influencing ANC and their suggestions for possible ways to enhance the use of ANC services. 3. To explore traditional birth attendants’ (TBAs) views about ANC, barriers to and potential facilitators for ANC use. 4. To explore nurses’ perceptions about the factors that influence the use of ANC services and to observe their practices at the clinic related to these. 5. To identify possible ways to enhance the use of ANC services amongst pastoralist community Methodology and Methods: This study adopted a qualitative approach, using a focused ethnographic (FE) methodology, underpinned by a philosophy of critical realism. Ethical approval was received from the University of Nottingham and Kenyatta National Hospital/University of Nairobi Ethics Research Committees (KNH/UoN). Fifty-eight participants were included. Methods of data collection included: (i) interviews with women (pregnant and postnatal); (ii) interviews with registered nurses; (iii) focus group discussions with men; (iv) focus group discussions with traditional birth attendants; and (v) observations of nurses’ interactions with women during ANC consultations. Data analysis adopted an inductive thematic approach, accompanied by a retroductive process to identify underlying causal mechanisms and structures that influenced ANC use. Data collection took place from January to June 2018. Findings: The pastoralist community is in a period of transition to contemporary healthcare service use. ANC services are only partially utilised due to two causal mechanisms that shape pastoralist women’s ANC experiences and health-seeking. First, government policy is shown to have a strong influence on ANC service utilisation through: (i) a patient record (a handbook), which emerged as a key mechanism that facilitates social inclusion and a gateway to accessing a range of government services; and (ii) re-framing the role of TBAs as referral agents, acting as conduits between community and healthcare services. The handbook acted as a strong incentive, compelling most women to attend ANC at least once, while the TBA’s referral roles created the potential to positively influence health-seeking behaviours around ANC. Secondly, there are multiple structural barriers that diminish women’s ability to access ANC. These include: (i) difficulties of pastoralist lifestyle and infrastructure challenges; (ii) social exclusion for women who experience out of wedlock pregnancy; (iii) health system limitations and women’s ANC experiences; and (iv) the nature of the relationship (in particular, a gap in information sharing) between nurses and women. Pastoralist women live in remote and hard-to-reach areas and the challenges related to their pastoralist lifestyle impact their ANC experience. In addition, accessing ANC services was hindered by normative cultural practices that made it hard for women with out of-wedlock pregnancy to disclose pregnancy, leaving them to endure social isolation and stigma. A new conceptual model of ‘partial utilisation’ of ANC was developed that encapsulates the key findings of this research. The model represents pastoralist women’s ANC use as partial rather than completely absent and the reasons for this. The notion of the community being in a transitional period between traditional and contemporary lifestyles further explains the observed patterns of ANC use. Implications: The existing model of ANC service organisation and delivery (where services are provided in static health facilities) do not address the ANC needs of pastoralist women. Therefore, in addition to existing aspects of ANC care, context-specific strategies should aim to: (i) provide a comprehensive ‘one-stop-shop’ ANC service during the initial visit; (ii) offer follow-up through mobile outreach services, and task-shifting by utilising available human resources e.g. community healthcare workers (CHWs) and TBAs; (iii) provision of outreach health promotion services for the community; (iv) sensitively engage with the community and address the cultural barriers related to out of wedlock pregnancy; and (v) address resource constraints in the health facilities and support for the nurses (e.g. skills development and commensurate remuneration). Implementation of these recommendations requires involvement of government, other stakeholders (e.g. NGOs, funders, donors) and community members (men and women). Conclusion: This is the first ethnographic study on ANC use amongst pastoralist communities in Kenya and East Africa. It provides novel information about ANC use in this under-researched population and its insights will be of relevance for similar populations globally. Eliciting the experiences and challenges of the pastoralist community provides a basis for developing services and policies that more realistically reflect their unique requirements