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January 21, 2019

Free maternity shunned for traditional birth attendants

Elgeyo Marakwet Governor Alex Tolgos hands over equipment bought by the county for the former Iten District Hospital, now a County Referral Hospital.
Elgeyo Marakwet Governor Alex Tolgos hands over equipment bought by the county for the former Iten District Hospital, now a County Referral Hospital.

With free maternity services not significantly reducing mother and child deaths at birth since their introduction in 2013, focus is turning to traditional birth attendants (TBAs) in the fight against maternal mortality.

Some 65 per cent of women in pastoralist communities still seek the services of TBAs instead of delivering at hospitals.

Health professionals and organisations fear that this will increase child and maternal mortality at a time when huge investments are being made by the national and county governments to improve health.


Long distances to hospitals, arrogance among trained midwives in hospitals and poverty have been identified as the major factors that scare away expectant mothers, who in turn seek the services of TBAs.

Other factors include fear of male doctors and of questions about FGM from inquisitive nurses.

Amref Kenya maternal and child health programme manager Peter Ofware says poor handling of the mothers by nurses and midwives in hospitals has forced most of them to give birth at the houses of “compassionate” TBAs.

Ofware said pregnant women are putting their lives at risk, since traditional birth attendants cannot respond to emergencies that arise at birth, given that some women don’t attend prenatal clinics.

According to Ofware, TBA-assisted deliveries are the biggest contributors to increasing child and maternal mortality in most pastoralist communities.

Ofware said many pregnant women in rural areas prefer to deliver at TBAs’ houses than giving birth in hospitals due to fear of ‘arrogant’ midwives in public hospitals.

He said the worrying trend has compelled Amref and other partners to begin a training programme that will equip hundreds of midwives in urban and remote areas of Marakwet, Pokot, Samburu and several parts of Northern Kenya with midwifery skills. They will be encouraged to quickly refer birth complication cases to hospitals for specialist medical assistance.

Ofware said insults by midwives and nurses are discouraging expectant women in such areas from delivering in hospitals.

He said: “Midwives take a long time to attend to pregnant women who come to hospitals to give birth. This scares the expectant women. They narrate the ordeals they go through in the hands of trained midwives and nurses in hospitals to other women, who also get discouraged and choose to visit TBAs.”

Speaking at Elgeyo Marakwet County Referral Hospital in Iten during the launch of a midwives training programme, Ofware said less than 35 per cent of women receive medical assistance during birth.

He said failure by women to deliver in hospitals is increasing child and maternal mortality rates.

“We are persuading traditional birth attendants to refer expectant mothers to give birth in health facilities. There are many reports of women bleeding to death due to complications while giving birth at traditional birth attendants’ houses,” he adds.

He said women are still charged to deliver in some public hospitals, despite the government abolishing the costs in 2013.

Ofware said Amref will train 15 traditional birth attendants from Elgeyo Marakwet and a similar number in neighbouring counties at a cost of Sh10 million per county.

He said the number of TBA and midwife trainees will be increased annually.

Amref US official Robert Geldy said the foundation is working in partnership with marathoners from the county to raise funds for the programme.


Siblina Cheserek, a traditional midwife from Bugar, Keiyo North subcounty, said the training programme will help midwives to detect birth complications and refer them to hospitals for specialist attention.

Cheserek, 65, said traditional birth attendants offer cheap or at times free services, hence attracting women in rural areas, where it is a taboo for expectant mothers to be helped by men during delivery.

“Our services are cheap, at times we charge nothing. We take good care of them at birth, unlike in hospitals where they are harassed by some nurses,” Cheserek, who is among 15 TBAs being trained in Iten, said.

She said she expects to receive training on hygiene and use of basic equipment and detection of complicated cases at birth during the 12-month training.

Cheserek recalled how a pregnant woman in her village in Bugar, 15km north of Iten, bled profusely two years ago as she assisted her to give birth at her house before she was rushed to Iten County Referral Hospital for specialised care.

Many expectant women, she said, keep flocking to her home at birth, despite the risks.

She attributed this to her tender care to the women who come calling when their days to deliver are due.

“They call me kogo (grandma). When their days are due, they come to kogo because they fear arrogant doctors in hospital,” Cheserek said.

In Marakwet East subcounty, Talaa Suter, a famous TBA in Kipkaner location, said expectant women will keep visiting TBAs at birth due to their availability and willingness to unconditionally help mothers.

Suter said women have a bad perception of trained midwives in hospitals.

“We often convince them to accept modernity and deliver at the hospital but they say they fear nurses and doctors,” she said.

Other pregnant women, Suter said, fear to be attended to by male doctors at birth.

She added: “Culturally, it is a taboo for men to assist women at birth.”

Suter said traditional birth attendance is a practice that cannot be carried out by any woman. She said it is practised by women from certain families and passed on to the families’ generations.

She said circumcised women fear to be asked why they have undergone FGM.

“To avoid answering difficult questions posed by nurses about their genitalia, pregnant women just keep off going to health facilities,” she added.


Susan Tangus, a nurse and midwife at the Iten County Referral Hospital, praised the training programme, saying it will go a long way to reducing child and maternal mortality.

Tangus defended doctors and nurses over failure to offer better services to pregnant mothers at birth, blaming this on inadequate facilities in hospitals.

She said there are not enough theatres ultrasound machines in most public hospitals, making it difficult to attend to expectant mothers quickly during birth.

“We don't have modern maternity rooms. These are rooms that are equipped with theatres, ultrasound machines, antenatal rooms, delivery rooms, postnatal and neonatal rooms,” Tangus said.

The TBA and midwives training programme has the support of several marathoners, who normally do their athletics training in the high altitude Iten. Notable examples include Wilson Kipsang, Abel Kirui and Mary Keitany.

Kipsang, in a speech during the launch of the programme, said he supports the programme to save the lives of mothers, since his mother succumbed to complications at birth when he (Kipsang) was young.

Keitany, a mother of two, said the programme will impact positively on how midwives deliver their services.

She said the programme will make midwives, especially those in public health facilities, more compassionate and able to detect problems that could complicate deliveries.


A report by Amref indicates that there is only one medical doctor per 62,000 people in Elgeyo Marakwet, compared to the national figure of one doctor per 25,000 people, putting it among the lowest in the country.

First Lady Margaret Kenyatta, while donating mobile medical clinic through her Beyond Zero Campaign in Iten in March 2015, urged county governments to increase resource provision to the health sector.

Elgeyo Marakwet became the 21st region to receive the medical equipment, aimed at eliminating mother and child mortalities.

Speaking at a recent TV interview, Deputy President William Ruto said the huge investments in health have saved 30,000 child deaths per year.

Citing free maternity and increased number of referral hospitals from two in 2013 to 94 in 2016, Ruto said maternal deaths have been reduced significantly.

The DP said 2,000 maternal deaths have been prevented annually since the start of free maternity in 2013.

Elgeyo Marakwet Deputy Governor Gabriel Lagat said the county has equipped more health centres with maternity beds to encourage women in the remotest areas to give birth at health facilities.

The deputy governor said women from neighbouring counties are also benefiting from Elgeyo Marakwet’s health investments.

He said community health workers have been deployed to remote villages to dispel cultural fears that discourage women from giving birth at health facilities.

According to the World Health Organisation, maternal mortality remains high at 488 maternal deaths per 100,000 live births. This is below the average of 640 deaths per 100,000 live births.

WHO identifies unsafe abortions, obstetric complications such as severe bleeding, infection, hypertensive disorders and obstructed labour as the major causes of maternal mortality during birth. 

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