Factors influencing deliveries at health facilities in a rural Maasai Community in Magadi sub-County, Kenya.

BACKGROUND: In response to poor maternal, newborn, and child health indicators in Magadi sub-county, the "Boma" model was launched to promote health facility delivery by establishing community health units and training community health volunteers (CHVs) and traditional birth attendants (TBAs) as safe motherhood promoters. As a result, health facility delivery increased from 14% to 24%, still considerably below the national average (61%). We therefore conducted this study to determine factors influencing health facility delivery and describe barriers and motivators to the same. METHODS: A mixed methods cross-sectional study involving a survey with 200 women who had delivered in the last 24 months, 3 focus group discussions with health providers, chiefs and CHVs and 26 in-depth interviews with mothers, key decision influencers and TBAs. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) using logistic regression were calculated to identify predictive factors for health facility delivery. Thematic analysis was done to describe barriers and motivators to the same. RESULTS: Of the women interviewed, 39% delivered at the health facility. Factors positively associated with health facility deliveries included belonging to the highest wealth quintiles [aOR 4.9 (95%CI 1.5-16.5)], currently not married [aOR 2.4 (95%CI 1.1-5.4)] and living near the health facility [aOR 2.2 (95%CI 1.1 = 4.4)]. High parity [aOR 0.7 (95%CI 0.5-0.9)] was negatively associated with health facility delivery. Barriers to health facility delivery included women not being final decision makers on place of birth, lack of a birth plan, gender of health provider, unfamiliar birthing position, disrespect and/or abuse, distance, attitude of health providers and lack of essential drugs and supplies. Motivators included proximity to health facility, mother's health condition, integration of TBAs into the health system, and health education/advice received. CONCLUSION: Belonging to the highest wealth quintile, currently not married and living near a health facility were positively associated with health facility delivery. Gender inequity and cultural practices such as lack of birth preparedness should be addressed. Transport mechanisms need to be established to avoid delay in reaching a health facility. The health systems also need to be functional with adequate supplies and motivated staff.

Lessons learned from implementing alternative rites in the fight against female genital mutilation/cutting.

INTRODUCTION: historically, programs aimed at making communities abolish female genital mutilation or cutting (FGM/C) consisted mainly of awareness campaigns on sexual reproductive health and rights and the enforcement of newly implemented laws. These types of programs or interventions appear to be only partially effective and sometimes yield unintended results, such as actually strengthening commitment to FGM/C or transforming it into a secret practice. A newer approach to change that is intended to account for the cultural meanings ascribed to FGM/C are alternative rites of passage (ARP). Amref Health Africa started adopting this approach in 2007. Since then, by a trial-and-error process lessons have been learned, that will be reflected upon in this paper. METHODS: desk research was conducted on organizational data regarding all Amref Health Africa's efforts to end FGM/C. Ninety-four in-depth formal interviews were held with members from Maasai and Samburu communities in Kenya targeted through maximum variation sampling. And participant observation of significative events as well as daily pastimes took place during school holiday season at the end of 2016. Furthermore extensive informal talks were held with project donors, activists, journalists, members of other non-governmental organizations, members of community services organizations, local government officials, high-ranking Dutch and US diplomats and senior members of the Anti-Female Genital Mutilation Board, which is part of the Kenyan Ministry of Public Service, Youth and Gender Affairs. On the basis of these data a framework on different positions on FGM/C was developed and published in early 2018. By reviewing the data again from a particular change management and public health perspective, by peer-debriefing within a multi-disciplinary research team and by explicating the lessons learned this paper adds to an overview that is of crucial importance to practitioners working to end FGM/C. RESULTS: risk of exclusion, perceived loss of cultural identity, changing meanings ascribed to cultural practices, lack of precise knowledge about subjective (sexual) experience and negative stereotyping are reasons not to adhere to anti-FGM/C programs. Areas of concern are the role confusion with following-up on policing, perceived outsider interference and the intended prolonging of the transition phase into womanhood not being explicated and embedded with ARP. Aspects to enhance to lever change more effectively are education and school curriculum development, male involvement, new stylization of love relationships, monitoring and evaluation and inclusive aspects of religion. CONCLUSION: changing a culturally embedded practice such as FGM/C is inherently complex. Because the cultural meanings ascribed to this practice are also evolving, any intervention that is effective at present might become superfluous in the future. A holy grail approach to change simply does not exist. Change needs to be levered in a variety of ways while working on the alignment of all these efforts by regular and thorough quantitative and qualitative assessments of effects and side-effects and reflections on lessons learned.