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Community Based Approaches to Improve Equity in Nomadic Populations

Photo of Kenyan community health workers, Photoshare

Research Overview

Health inequities occur when certain groups of people, due to their gender, socio-economic status, ethnicity, geographic residence, or other characteristic, cannot access or use health services. For example, in the disadvantaged rural, semi-nomadic Kenyan population of Turkana, only 22.8% of deliveries were conducted by a skilled attendant, compared to the 62% national average. In order to improve equity and reduce maternal, newborn, and child mortality, disadvantaged groups must be targeted for services and interventions.

As part of a larger health project, AMREF Kenya launched the BOMA Model in 2005 to increase the use of health services in poor Maasai communities. The model established community health units and trained community health workers to provide services and educational outreach to households. Despite improvements in the quality of available facilities, there was not a significant increase in utilization of facilities for delivery. TRAction is supporting the development of a case study to identify facilitators and barriers to equitable access to and use of health facilities within the context of the BOMA project.

Project Location

Kenya: Magadi, Samburu, and Turkana communities

Research Objectives

The aim of this case study was to identify factors that influence the use of available facilities for delivery. TRAction and its research partners hoped to answer the following questions:

  • Why do some women deliver at home and others in a facility?
  • What can be done to increase utilization of facilities for delivery?
  • What are the equity characteristics of women who deliver at home versus a facility?

Study Approach

The study used both qualitative and quantitative methods to identify factors influencing use or non-use of facilities for delivery, and to determine the impact of current programs on equity.

Qualitative group and in-depth interviews were conducted with key informants in two villages: one close to the Entasopia Community Health Unit, and another that is located within one hour of the facility. From each study village, the sample included in-depth interviews with village elders, trained birth attendants, women who delivered at the health facility and at home, and key birth decision influencers (such as the husband or mother-in-law). Group interviews were conducted with midwives, nurses, community health workers, and health providers. Questions focused on facilitators and barriers to facility-based delivery, and factors influencing birth decisions.

A quantitative survey was conducted among women who have recently given birth in the Entasopia health center catchment area. The survey contained questions pertaining to the equity characteristics of women who recently delivered both at home and in a health facility. Standard wealth questions were supplemented with additional questions on livestock ownership, number of wives and children, household education, and type of dwelling structure. Data was analyzed to determine the extent to which disadvantaged populations are being reached by the health services.

Key Findings

This study revealed that 39% of women gave birth in a health facility. This is an improvement from end-term evaluation of the BOMA model intervention which revealed that skilled birth attendance was 24%. However, this level remains below the national average of 62% and far from the national target of 90% coverage by 2015. The qualitative findings revealed the barriers and motivators to health facility delivery. Barriers included women not being the final decision makers regarding the place of birth, lack of a birth plan, the gender of the health provider, unfamiliar birthing positions, disrespect and/or abuse, distance to the facility, negative attitude of health workers and lack of essential drugs and supplies. Motivators included proximity to health facilities, mother’s health condition, integration of TBAs with the health system, and health education/advice received.

Lessons Learned

Findings from this study point to an increase in health facility delivery in the Entasopia community after the implementation of the BOMA model. Unfortunately, this achievement is far below the national target and the mere implementation of the free maternity services may not salvage the situation, especially for women in hard to reach areas and women in the lower wealth quintiles. 

To increase the proportion of mothers delivering in health facilities and with skilled birth attendants, the health systems need to be functional with adequate supplies and motivated staff who work closely with TBAs to ensure referral of pregnant mothers to the health facilities. Actionable recommendations to increase uptake of health facility delivery include the establishment of transport mechanisms and intensive health education to increase awareness of the importance of skilled birth care, development of a birth plan and establishment of waiting homes.

Research into Action

This case study identified the contextual factors surrounding birth decisions. AMREF will apply the findings to future projects, and use the results to improve the BOMA model for scale-up. The findings will also be shared with Kenyan stakeholders and other country governments to inform decisions about health service delivery among nomadic and semi-nomadic populations. In addition, TRAction will synthesize the findings from this and 4 other equity studies to gain a global understanding of factors influencing equitable access and utilization of facilities for delivery. Experience from this study and other TRAction projects will also be used to develop qualitative research training tools.

Research Partners

African Medical Research Foundation (AMREF)

Principal Investigator: Sarah Karanja

Project Status


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