The socio-cultural context of maternal healthcare in Bondo District, Western Kenya: Implications for safe motherhood interventions.
This is a qualitative study of women's responses to pregnancy and childbirth among a selected sample of women in Nyang'oma division of Bondo district. In the study, close examination of the socio-cultural, economic, physical and service factors associated with low antenatal and postnatal health care services utilization patterns are examined. Pregnancy is put under a cultural microscope and the arena in which it is experienced examined. The analysis is based on one year's field work (July 2002-July 2003) funded by DANIDA through KEDAHR on maternal health care in a socio-cultural context. The research involved a questionnaire survey involving one hundred mothers who had given birth in the last one year prior to the survey and a maternal cohort of twenty five(25) pregnant women recruited in their 4th and s" months of pregnancy and followed initially weekly and later fortnightly beyond delivery and up to six weeks after delivery. The research also conducted key informant interviews, provider interviews, client-provider observations, direct facilities observations and the direct observations in the community on how pregnancy as a process is lived and experienced. The results reveal low antenatal health care utilization patterns and even more low postnatal health care practices. It is also apparent that the division has very low maternal health care coverage and few facilities. The low utilization of services is attributed to several factors key among them is the power relational dynamics and the negative effects of culture that limits the female choices and reduces the woman to a spectator in her own pregnancy, the cultural definition of pregnancy as a normal natural condition rather than a pathological one that requires medical care. Analysis of the qualitative data resulting from the longitudinal followup, case studies and the narratives amplifies the female voices and reveals a pattern where low antenatal care services utilization results from a variety of factors. These inciude poverty, low maternal education/awareness, provider based inefficiencies, the poor infrastructure and the availability of competing/complementing but familiar alternatives that / lend well to the cultural definitions of pregnancy. Equally emerging is the reinforcement of the fact that pregnancy and the whole question of reproduction is not solely a biological affair, but rather a socially constructed process Xl reinforced by the political and economic conditions prevailing in the environment in which it is experienced. The results from the previous Kenya Demographic Health Surveys (KDHS, 1993; 1998 and 2003) reveal a pattern of a very high antenatal attendance; however, the research indicates that the high cases observed in the surveys are examples of women who go to the clinics once for the sole sake of getting an antenatal card as 'security or passport to the unknown'. Most women cushion themselves against the possibilities of being turned away from health care facilities during delivery in the event of any obstetric complication, as the antenatal card is the passport to professionalized care. While the majority of women reported that they went for clinic at least once, there is a clear pattern of resistance that attempt to show women as conscious agents of their actions in trying to resist the medicalization of pregnancy and childbirth. The emergence of home deliveries as a common practice and the preferred place by most women amplifies further this resistance as women want to be in-charge of their destiny without the biological intrusion of the professionals (most likely men). Home deliveries are seen to accord women the control over their own bodies and the entire process is mostly in the hands of women- the parturient woman, her female kin and the midwives. Luo culture even discouraged the presence of the husband at birth. With respect to the safe motherhood interventions, the research recommends that the definition of reproductive health needs to be widened beyond the female person and beyond issues of pregnancy, delivery and contraception. The entire cultural arena in which conception happens, pregnancy is carried to term and delivery finally takes place needs to be revisited other than the present concentration in the improvement of antenatal health care facilities and the continued medicalization of pregnancy and training of health care personnel. An entirely holistic approach with the empowerment of women at the core and harnessing the beneficial aspects of culture are considered to be the best ways out of the maternal health burden.