Kenya has a maternal mortality ratio of 488 per 100 00 live births and a lifetime risk of maternal deaths of 1 in 38. Only 44% of deliveries are attended by skilled birth attendants. Therefore in an effort to increase women's access to a skilled birth attendants, the Kenyan government implemented the community midwifery programme in 2005.
This qualitative study identified the opportunities and challenges in implementing a community-based skilled birth attendance strategy in Kenya. In-depth interviews with 20 community midwives and six key informants were undertaken. The key informants were funders, managers, coordinators and supervisors of the programme. The study was conducted between June to July, 2011 in two districts in Western and Central provinces of Kenya.
The findings showed major challenges and opportunities in implementing the community midwifery programme. Challenges of the programme included: socioeconomic issues, the unavailability of logistics, problems of transportation for referrals and insecurity. Participants also identified the advantages of having midwives in the community providing individualised care; living in the same community as their clients making them easily accessible; and flexible payment options.
The community midwifery model is a culturally acceptable method to increase skilled birth attendance for women in Kenya. The use of skilled birth attendance, however, remains disproportionately lower among poor mothers, even with skilled birth attendants living in the community. This is due to socioeconomic reasons.
The community midwifery programme helped recognition of community midwives, recognising them as midwives and not nurses:
‘I feel recognised somehow because before they would not even recognise me as a midwife, in the community. They only knew me as a nurse but not as a midwife. So I feel that I am recognised being a community midwife, I am happy
The study offers implications for policy and practice to increase access to skilled birth attendance in Kenya.
Childbirth fear is reported to affect around 20% of women; however, the causes and factors associated with fear of birth are complex and multifactorial. This study aims to determine the prevalence of low, moderate, high and severe levels of childbirth fear in a large representative sample of pregnant women drawn from a large randomised controlled trial and identify demographic and obstetric characteristics associated with childbirth fear. The authors used a descriptive cross-sectional design, 1410 women in their second trimester were recruited from one of three public hospitals in south-east Queensland. Participants were screened for childbirth fear using the Wijma Delivery Expectancy/Experience Questionnaire Version A (WDEQ-A). Associations of demographic and obstetric factors and levels of childbirth fear between nulliparous and multiparous women were investigated.
The authors reported that the prevalence of childbirth fear was 24% overall, with 31.5% of nulliparous women reporting high levels of fear (score ≥66 on the WDEQ-A) compared to 18% of multiparous women. Childbirth fear was associated with paid employment, parity, and mode of last birth, with higher levels of fear in first time mothers (P< 0.001) and in women who had previously had an operative birth (P< 0.001).
The prevalence of childbirth fear in Australian women was comparable to international rates. Significant factors associated with childbirth fear were: being in paid employment, and obstetric characteristics such as parity and birth mode in the previous pregnancy. Firsttime mothers had higher levels of fear than women who had birthed before. A previous operative birth was fear provoking. Experiencing a previous normal birth was protective of childbirth fear.
The study identified that parity and mode of birth were statistically associated with fear of birth. The authors rightly point out that these findings support the importance of listening to women and keeping birth normal. In today's climate this extremely important finding as fear of birth has been linked to maternal request for caesarean section due to a previous poor birth experience. Midwives are in a prime position to provide women-centred care, improve the birth experience and potentially reduce the caesarean section rate.