Too Hot To Thrive: Community perspectives on the effect of high ambient temperature on postpartum women and neonates in Kilifi, Kenya

doi:10.21203/rs.3.rs-3034548/v1

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Research Article

Too Hot To Thrive: Community perspectives on the effect of high ambient temperature on postpartum women and neonates in Kilifi, Kenya

https://doi.org/10.21203/rs.3.rs-3034548/v1

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Objective

To understand community perspectives on the effects of high ambient temperature on the health and wellbeing of neonates, and impacts on post-partum women and infant care in Kilifi.

Design

Qualitative study using key informant interviews, in-depth interviews and focus group discussions with pregnant and postpartum women (n = 21), mothers-in-law (n = 19), male spouses (n = 20), community health volunteers (CHVs) (n = 22) and stakeholders from health and government ministries (n = 16).

Settings

We conducted our research in Kilifi County in Kenya’s Coast Province. The area is largely rural and during summer, air temperatures can reach 37 degrees Celsius and rarely drops to 23.

Data analysis

Data were analyzed in NVivo 12, using both inductive and deductive approaches.

Results

High ambient temperature is perceived by community members to have direct and indirect pathways in pregnancy and postpartum periods, including on the neonates. The impact of direct pathways includes injuries on the neonate’s skin and in the mouth, leading to discomfort, and affecting breastfeeding and sleeping. Participants described babies as “having no peace”. These effects were perceived to be amplified by indoor smoke pollution and heat from indoor cooking fires. Community members believed that exclusive breastfeeding was not practical in conditions of extreme heat because it lowered breast milk production, which was, in turn, linked to a low scarcity of food and time spend by mothers away from their neonates performing household chores. Kangaroo Mother Care was also negatively affected. Participants reported that postpartum women took longer to heal in the heat, were exhausted most of the time and tended not to attend postnatal care.

Conclusions

There is a widespread perception that high ambient temperatures impact on postpartum women and their neonates through direct and indirect pathways. Discomfort makes it difficult for the mother to care for the baby. Multi-sectoral policies and programs are required to mitigate the negative impacts of high ambient temperatures on maternal and neonatal health in rural Kilifi and similar settings.

Heat

neonates

Kenya

exclusive breastfeeding

climate change

maternal health

infant care

Heatwaves have increased in frequency and duration across Africa in recent decades (1). In Kenya, this increase is notable in dry and arid areas of the East Coast and Eastern parts of Turkana, Garissa, Isiolo, Mandera and Marsabit counties (2). Kenya has also been experiencing a significant drought event that has reduced access to food and water supplies in many communities and caused extreme hardship. Exposure to high environmental temperatures and extreme heat events affects human health and activities, especially among vulnerable groups such as pregnant women and newborns (3, 4).

Epidemiological and physiological studies show that neonates are particularly susceptible to temperature extremes due to their ability to thermoregulate (5). Neonates are also extremely vulnerable and rely on care givers for adequate food (breastfeeding), comfort and physical protection (6, 7). Increased mortality among neonates has been reported during heatwave events (8, 9) and low temperatures are also known to increase the risk of acute neonatal mortality. However, there is a lack of epidemiological studies of the effects of temperature on neonatal mortality because in many hot, low-resourced settings, such deaths are significantly under reported (10). Heatwaves increase the incidence of hospitalization for renal disease, electrolyte imbalance, and respiratory causes in children (11, 12). Hyperthermia in infants may also lead to future health impairment (13). High temperatures may account for the sudden inexplicable deaths of infants, commonly known as Sudden Infant Death Syndrome, although the evidence is inconsistent (14, 15).

High ambient temperatures are also known to increase infection disease transmission, particularly for diarrheal diseases (16), and malaria (17) which are both leading causes of morbidity and mortality in infants. High temperatures can also coincide with drought events, and therefore effects will be felt in a population that has an increased burden of undernutrition and also dehydration if water supplies are limited.

Kilifi has one of the highest prevalence of undernutrition in Kenya and this has been made worse by the drought (18). World Health Organization (WHO) recommends frequent and exclusive breastfeeding for the newborn in the first six months after birth as breast milk contains the required fluids that neonates need, including antimicrobial factors that assist in reducing infant infections and disease (19). For mothers to perform exclusive breastfeeding, they require enough nutritious food and fluids to help in breastmilk production and an enabling environment (20, 21). A systematic review by Edney et al. found that breastfeeding is sufficient for infants even in hot weather, but this does rely on the mother having sufficient nutrition (22).

There has been limited research on breastfeeding and high temperatures. Breastfeeding practices vary seasonally as the mother may have less time during certain seasons (e.g., harvest). In Ethiopia, a study examining the time women spend planting and harvesting versus time spend engaging in exclusive breastfeeding found that women were unlikely to breastfeed when rainfall was higher (25cm of average monthly rain versus 5cm). This is because they spend most of their time farming, were unlikely to attend antenatal clinics, and are less likely to receive information on optimal breastfeeding behaviors (23). In a study of infant feeding practices in Burkina Faso, we found an effect of high temperature after adjusting for the effects of the season (a 23-minute reduction in daily breastfeeding duration per 10°C increase in temp) (24).

High temperatures are known to have effects on mental health and wellbeing. High temperatures are associated with increased anxiety (24), lack of sleep (26, 27) and irritability (28). Infant care is very important for newborns. Therefore, impacts on the wellbeing of the mother from extreme heat may affect the welfare of the newborn.

In sub-Saharan Africa, there is limited research on the effects of high ambient temperatures on mothers and their neonates. We undertook research to begin to close these gaps by examining how local communities are observing the effects of high ambient temperatures on women during pregnancy, postpartum and their neonates in Kilifi County, Kenya. The study forms part of the CHAMNHA transdisciplinary research project: Climate, Heat Maternal and Neonatal Health Africa. This paper focuses on the observed effect of high ambient temperatures on postpartum women and neonates.

Research Design

A qualitative descriptive study involving focus group discussions (FGDs), in-depth interviews (IDIs) complemented by key informant interviews (KIIs). In reporting these methods, we have used the Consolidated Criteria for Reporting Qualitative Research (COREQ): a 32-item checklist for interviews and focus groups (Appendix 1) (29).

Research Context

This study was conducted in Kilifi County in Kenya’s Coast Province, in the sub-counties of Kaloleni and Rabai, which have a total population of 304,778. Kilifi County has an annual crude birth rate of 26 per 1,000 population (30, 31). Literacy levels are low. The main economic activity is tourism, thanks to its beaches, diverse population, and desired climate for tourists. Socio-economically, Kaloleni and Rabai sub-counties are among the poorest constituencies in the coastal region, with 70% of the population living below the poverty line compared to the national rate of 47% (32). The county's maternal, neonatal and child health indicators are all below the national average (32, 33). Kilifi County also has one of the highest under–5 mortality rates in Kenya, with 87 deaths per 1,000 live births, despite the government policy to provide free facility-based antenatal, delivery and postpartum services for all women (33, 34). As a rural area, communities are geographically dispersed, and health facilities tend to be some distance from these communities (35, 36).

Study population and Sampling

We interviewed 98 participants across the Kaloleni and Rabai sub-counties of Kilifi, which included 10 IDIs with pregnant women and 11 with postpartum mothers. We conducted nine focus group discussions (FGDs) with mothers-in-law, male spouses, Community Health Volunteers (CHV) and 16 key informants, including individuals from the Ministry of Health (MOH), water, agriculture, department of meteorology, the local chiefs, public health officer, religious leaders, environmentalists and traditional birth attendants (TBAs). Interviewing a wide range of participants across the community helped elicit a heterogeneity of perspectives that supported rich triangulation of participants’ narratives. For instance, talking to pregnant and breastfeeding women and close family members and CHVs who help them along their delivery pathway provided a first-hand account of their lived experience. The sample sizes for IDIs, FGDs and KIIs were deemed adequate for answering study questions and providing a sufficiently diverse account of their experiences of high ambient temperatures.

Recruitment and Inclusion and Exclusion criteria

Aga Khan University has worked in Kilifi for the past six years and has built successful social networks with CHVs and facility health workers. We used these networks to recruit study participants. Based on the inclusion criteria, facility health workers and CHVs identified potential interviewees through the health facilities and in the communities.

Pregnant women who were at least 28 weeks into pregnancy, verified by the health care workers and postpartum women who had babies between 4 and 12 weeks old were recruited in the study. Mothers-in-law were recruited if they lived in the same homesteads with the postpartum woman who had given birth in the past year. CHVs were recruited if they had been in their role for the past two years and were actively involved in community work with pregnant and postpartum women.

Key informants were recruited if they held a key leadership role in the community or in relevant county ministries such as Health, Water, Agriculture, and Meteorology. An inclusion criterion for all participants was their willingness to provide informed consent to be interviewed and audio recorded. Participants who did not meet these criteria were not enrolled in the study. Following recruitment, interviews were scheduled at an appropriate time and date. Participants were screened by the field researchers prior to interviews to ensure that they met all the inclusion criteria.

Data collection

The research was designed by medical anthropologists (AL and FS) and reviewed by CHAMNHA team members with extensive research design experience. AL, a Kenyan social scientist, supervised field data implementation. Field researchers had extensive experience conducting public health and community research in Kilifi and received hands-on training that included role-playing using the study guide and feedback sessions.

The data collection tools were piloted in one FGD with CHVs, a pregnant woman, and a postpartum woman. This revealed that some terms used in the interview guides were likely to be misunderstood. For instance, the term ‘high ambient temperatures’ was sometimes confused with ‘fire’ or ‘drought’, and the word ‘facilities’ was assumed to mean ‘accommodation’. The field team discussed appropriate terminology to reduce confusion (for example, adding the word ‘health’ before facilities and using the local terms “Joto” or “Jua kali” (translated as “when it is extremely hot”).

Interviewing

IDIs and FGDs were conducted by AL, PK and SC at the closest health facilities to participants homes, either in a room or outside the health facility, under a tree. All FGDs consisted of between six and nine participants per group. Informed consent procedures were carried out at the start of the FGD, where the researchers verbally provided information in Kiswahili language about the study at the group level, and obtained consent for the interview and permission to audio record individually from each participant. Participants who could not write were assisted to consent with a thumbprint.

Interviews for key informants were conducted in their offices, which they considered most convenient. These interviews were conducted in both English and Kiswahili, as most of the participants in this group could read and write in English.

An open-ended, flexible topic guide was used to structure the discussions to encourage free-flowing dialogue. The IDIs and KIIs took at most one hour, while FGDs took one to two and a half hours.

The study guide had broad introductory questions and explored themes on both the direct and indirect effects of high temperatures on pregnant and post-partum women. Themes explored include indigenous knowledge and beliefs about how high ambient temperatures affect pregnant and postpartum women, the developing foetus and the neonate; local norms around strategies and practices to manage high ambient temperatures during pregnancy and in the postpartum period; the role of men and other family members supporting pregnant and postpartum women and their neonates; existing interventions and actions in the community to help vulnerable populations when it is very hot, and the usefulness of daily or seasonal climate forecasts.

Snacks and drinks were provided at the venue for all the participants, and transport costs for travelling to the venue were reimbursed. All participants were informed of COVID-19 preventive measures and the field team provided hand sanitizer and face masks.

Data management and analysis

Data transcription was done verbatim by a professional transcriber, assisted by study researchers.

All field audio recordings, transcribed data and field notes were saved on the Aga Khan University's data-protected password computer. For transcription accuracy, two researchers (PK and AL) checked the transcripts against the audio recordings. We followed Braun and Clarke’s (2006) thematic analysis framework to guide the analysis (37).

Data Familiarization

During data collection, study researchers (AL, PK and FS ) read all the field notes and discussed the key issues as they emerged in the data collection process.

Generating initial codes

A codebook was developed following open coding of a small sample of transcripts, using both deductive (topics that were derived from the interview guides) and inductive (findings emerging from interviewees’ narratives) analysis. Using both deductive and inductive approaches allowed us to have a more nuanced understanding of participants’ experiences of caring for neonates in extreme heat situations.

Searching for themes (categories)

AL examined data on the impact of high temperatures on postpartum women and their neonates by extracting and applying segments of the texts across the IDIs, FGDs and KIIs. This process entailed reviewing coding outputs and comparing them to identify salient patterns and themes for data interpretation. Categories were then charted manually in a matrix to help visualize possible relationships between themes, as illustrated in Fig. 1 below.

Reviewing themes

The data were checked and discussed with members of the larger team, to ensure saturation had been reached on the themes.

Participants’ socio-demographic characteristics

A total of 98 participants were interviewed including pregnant and postpartum women (n = 21), mothers-in-law (n = 19), male spouses (n = 20), CHVs (n = 22), and key informants (n = 16) from the Ministries of Health, Water, Environment, Housing, Meteorology, and Agriculture. The pregnant and postpartum women we interviewed were aged 17 to 39, had some primary education and the majority of them were unemployed, while a few participated in casual, informal work. Women under 18 years were considered emancipated minors if married. The mothers-in-law were aged between 35–63 years, the majority had no formal education, practised farming for economic activities and had relatively large families. The male spouses interviewed were aged between 24 to 63 years, were self-employed and had completed at least high school. Most CHVs had their own small businesses, worked between 10 to 30 hours per week and had been in the role for more than two years. The Key informants had worked at least for two years in their respective ministries in a senior role. All participants lived within the study area. Figure 1 (attached) summarises the socio-demographic characteristics of the participants. This paper focuses only on the effect of high temperatures on postpartum women and their neonates.

Summary: perceived effects of high temperatures on postpartum women and their neonates

Our findings from community members interviewed for this study suggest that high temperatures affect mothers and their neonates in multiple ways. Several health conditions in neonates were perceived to be a direct effect of the heat, including injuries on the skin and mouth, as well as impact on the wellbeing and behavior of the neonate (distress, crying). Heat impacts made it difficult to feed, interact and bath the neonate. In addition, the heat had significant effects on the postpartum women, including exhaustion, discomfort, and the inability for mothers to take care of themselves. These heat effects on the mother also have implications for infant care and wellbeing.

Several factors caused by heat and drought also affected maternal wellbeing. The post-partum women reported increased workload because water sources were farther away, and negative impacts on agriculture and shading around the home. This increased workload in the heat had increased the burden of exhaustion. Community members noted that some postpartum women re-commenced household duties such as fetching water and firewood and farming immediately after birth. Our participants linked these chores with longer periods of postpartum bleeding. In addition, heat and insufficient water led to reduced personal hygiene. The experience of heat is exacerbated by the fact that houses are often poorly ventilated. Participants reported that the indoor heat made it difficult to use mosquito nets, which would protect mother and baby from malaria. Many factors contributed to a reduced quality of care for the neonate, and these are explored in more detail below.

Low agricultural yields were associated with food scarcity and perceived to lead to low breast milk production, making it difficult for the mother to breastfeed exclusively. Moreover, mothers described both the indoor and outdoor environment as hostile when it was very hot, to the extent that they saw themselves as “having nowhere to escape”. Figure 1 summarizes the direct and indirect pathways of high temperatures on postpartum women and their newborns.

1. Heat-related skin problems in neonates

Participants described how they are beginning to see more neonates with damaged skin and attributed this to high temperatures becoming more common. Common descriptions of these injuries included “blisters’, “skin peeling off”, “heat rash”, and “skin patches”. Blisters were reported to develop immediately after birth, making it difficult to care for neonates.

The temperature was higher than usual [and] one week after delivering the baby had blisters ... You couldn't be able to undress the baby because those blisters were producing water, and in cases [where] they burst, they formed a wound because of the warm temperature.

IDI - Postpartum woman, Chalani

Male spouses shared similar sentiments about blisters developing into wounds on the babies’ skin.

The baby is normally affected because of hot temperatures. The baby gets blister like wounds …because of hot temperatures. And in most cases, the baby cries very often because of the heat.

FGD- Male CHVs, Kasemene,

CHVs reported seeing babies developing blisters all over their bodies including the head.

Also, these babies who are born normally develop ‘malenge lenge’ (blisters; Kiswahili). You can get a baby who has developed those malenge lenge all over the body. Even up to the head. That is due to the heat. Even if it is born at full term, some of them are normally born when they have already developed those malenge lenge.

FGD - Female CHVs, Ribe

Key informants and male spouses shared similar observations but described it as “heat rash”, “skin patches”, and “skin peeling off” rather than as “blisters”.

You will get people telling you that the baby has a fever, even if they [the babies] have a heat rash. What is worse is [that] they [babies] will be crying and scratching themselves, instead of breastfeeding.

KII - Ministry of Health Official, Kilifi

“... I even have experienced one of my children suffer[ing] skin rashes and something like the skin has some patches and when I consulted a clinician, definitely the answer was that this is heat rash, which is so extreme that even the child cannot sleep during the night, the child was crying and, in most cases, it is not treatable.”

KII, Public Health Official- Kilifi

The heat situation affects the baby's skin. … You may find the baby has rashes, then the peeling off (skin) and crying a lot.

FGD, male spouses, Gotani

A community chief who was a key informant for the study shared the same views and noted that local behavioral practices such as covering small babies with multiple layers of clothes may amplify the heat burden on the neonate’s already injured skin.

It [heat] really affects [the baby] and you would find that the skin of the young baby [is] peeling off, the first skin peeling off because of the heat. And as [in] my community [they] say that the baby must be totally covered, … so it has to be totally covered and so we totally cover the baby, and it is very hot, then the skin peels off.

KII, Chief, Kilifi

The chiefs’ reports aligned with field researchers’ observations that neonates were typically covered in many layers of clothes and/or blankets during the interviews.

2. Difficulties in caring for the neonate in the heat

The direct effect of heat makes babies uncomfortable, making it difficult for mothers to take care of them. Some male spouses described neonates as “having no peace”, “uncomfortable”, “crying all the time”, “cannot sleep”, or “can’t concentrate on breastfeeding”.

“…the baby has no peace in the night, hot temperatures make the baby to cry, the baby is never comfortable at all”.

Across our participants, there was a consensus on the difficulties postpartum women experienced taking care of their babies.

I would undress myself and the same to the baby; if the baby has blisters, you can't even breastfeed him, instead, [baby] keeps on crying.”

IDI, postpartum woman, Chalani

Male spouses interviewed in this study also alluded to mothers’ difficulties breastfeeding their babies due to the discomfort caused by the heat.

“The extreme heat affects the baby during breastfeeding, it affects the baby because she can't concentrate on breastfeeding... even breastfeeding she can't do it well. … the baby should be breastfed throughout, but when there is more heat, the baby is uncomfortable to breastfeed as he cries due to hot temperatures. It is really a problem.”

FGD, Male Spouses, Viragoni

Reports from community health volunteers and key informants from the ministry of health suggest that Kangaroo Mother Care (KMC), a method recommended to improve the wellbeing and development of low birthweight babies by maximising skin-to-skin contact, is challenging to perform in the condition of extreme heat. KMC was reported to increase perspiration in both mothers and babies, resulting in intense discomfort for both.

It will be a problem for the baby to be put in Kangaroo style. For you yourself [post-partum mother], you are already sweating all the time. So how will you put that baby into the Kangaroo style? Will you not be endangering the baby more? It will be trouble on top of trouble.

FGD, Female Community Health Volunteers, Rabai

Views from some stakeholders align with observations made by CHVs -however, for some key informants like the community health officers, hot temperatures’ effect on water supply implies that mothers may not bathe daily, affecting their bodily hygiene. Thus, they did not view KMC as beneficial due to the lack of hygiene in many mothers.

…, it is a good idea [KMC] but with aspects of hygiene, something needs to be checked and adhered to. Because we could be advocating for Kangaroo for the mother but looking at the hygiene status, the probability of having water – like how many times does that mother take bath? It is also an issue that needs to be considered, so it all goes around the hygiene and the whole benefit of Kangaroo.

KII, Community health officer, Rabai

Contextual factors that increase heat exposures and affect the care of the neonate.

Indoor heat in the poorly ventilated homes increased discomfort among the mother and the neonate making it cumbersome for the mother to breastfeed. Some participants said that the heat does not subside at night, which may harm both the mother and child.

When she [mother] is in that house, cooking is in there, everything in there, with a newborn baby, it is a must that it will affect the baby because of the smoke, dust, and hotness. Sometimes [baby] will be crying at night, and you wonder what the matter is, yet it is the house's condition as it is because it lacks windows, nothing, no coldness, it’s hot. It disturbs the child…

FGD, Mothers-in-law, Buni

Male spouses described how cooking with solid fuel in these homes intersects with high temperatures, and with there being not enough space to escape, causing sweating.

According to our living standards, you will find that as common citizens, we prepare food in a small house using firewood. The heat becomes too much inside the small houses [and] they start sweating. They wish to strip naked but cannot.

FGD, Male Spouses, Kamkomani

These conditions inside homes were said to make it difficult to use mosquito nets. It was reported that mothers refused to use mosquito nets because they heightened the severity of the heat.

During hot periods, they fold up their mosquito nets and put them on the hung line because they say sleeping under them increases the already high heat. So, sleeping is like that [sleeping without mosquitoe net]. So, it affects women and even newborns. Therefore, it now affects almost everyone.

FGD - Male CHV-Kasemeni

Further, our data suggests that mothers’ participation in household chores such as fetching water takes them away from their neonates for many hours. Participants had observed mothers getting stressed performing these chores and viewed this as hurting milk production.

…a postnatal woman has to walk about two kilometers searching for water. And maybe she must go with about two or three other people and if she has to make three or four trips, she gets very tired. And if she gets very tired, a neonatal baby won’t get enough breast milk because the mother is stressed up because of thinking about where and how to get water and other household essentials. And when they are stressed, breast milk production is not there.

FGD, Male Community Health Volunteers, Kilifi.

Spending many hours performing ADLs outside the home was also linked to mothers decision to introduce solid food to their babies prematurely, i.e. earlier than 6 months as reported by a key informant from the MOH.

It affects the mother because—due to the tasks that she performs in the sun—she will not produce enough milk to breastfeed the child. Therefore, the child is introduced to weaning before six months elapse. They (nursing mothers) have no (option) otherwise, and they have to ensure the child is full by the time they go to the farm or walk long distances to collect water. The child is forced early to eat things it should not, due to circumstance, and this is a risk to it and the mother. I think people [in Kilifi] do not understand [the dangers]. They think that [introducing solid food early] is the best.

Participants described how some villages have not harvested for three years, while in other areas, participants report low yields and animal deaths owing to water scarcity. Moreover, the interplay between high ambient temperatures, drought and food insecurity was potentially linked to low breast milk production, which in turn was seen as influencing mother’s ability to perform exclusive breastfeeding.

The support is needed because this woman who has no food and she is exclusively breastfeeding—you will find they [the babies] don’t reach the [age of] 6 months. That is the truth! You will find a woman has started feeding the baby on food, aaaha! You will ask her why she is feeding this baby, and he hasn’t attained that level [of development]? She will answer you that ‘There is nothing here [no milk in the breast]. Nothing is coming out [milk is not coming out of the breast], and the baby is crying.’ Another woman will say it: ‘[My baby] keeps breastfeeding. … I have to look for porridge, and that porridge— remember—it will be without sugar. There is a challenge [here], there is a challenge with [lack of] food. That is the truth! If we want people to be supported, there is a problem with food. There are people who are suffering…

FGD, Female Community Health Volunteers, Ribe

3. Exhaustion and delayed postnatal care

When asked how high temperatures affect postpartum women, community members reported that consequences for women included exhaustion and delayed postnatal care. Key informants for this study reported that the delay in post-natal attendance arises from the communal notion of the baby’s skin being delicate and not wanting to endanger the baby in the scorching sunshine.

There is a notion that is around, which is not a notion as such but a belief that the infant’s skin is a bit delicate and sensitive… so, if one thinks that ‘I have a few kilometers to get to the hospital for the post-natal clinic, then along the way I will be exposing my kid to the dust, direct heat and sun’ – which they feel is not good.

KII, Public Health Officer, Rabai

It [high temperatures] reduces [post-natal attendance] because you can’t walk too far, most of our facilities are too far from the villages, so you can’t walk to the facility, so most of them [postpartum women] will not attend the clinics.

KII, Community Health Officer, Kaloleni

Although distance to the health facility was described as one of the causes of a delay in or even reduced uptake of postnatal care, however, CHVs and community chiefs suggested that the fear of walking in the heat intersects with women's exhaustion from other activities of daily living such as fetching water early in the morning.

They will prefer not to go to the hospital after walking all that distance for water. Therefore, they will not be able to follow up on their progress with the clinics.

KII, Chief, Kaloleni

“Sometime as hot as it is and if one is very far from the dispensary or the health facility and she is supposed to go, before visiting the facility she has to make sure there is availability of water inside the house…. So, she may delay and decide not to go after fetching the water, being very tired and it is a distance to the health facility, she may decide either to attend late or not to attend at ,

KII, Chief, Rabai

In periods of high temperatures, postpartum women may prioritise fetching water as opposed to attending postnatal clinics. The views of community health volunteers below align with the chiefs and other community members’ observations.

Women in our place, they really fear these hot temperatures…maybe someone woke up in the morning to go look for water. Because the most important item in the house is water. She has taken two hours to fetch water. When she comes back, the temperature is already gone up. It is really “burning” very much. Do you think she can carry the baby? And maybe she doesn’t have even an umbrella. She will say, she will go tomorrow, and tomorrow and like that, like that because water problem is a daily routine. And when she comes, the temperatures are already gone up. She postpones again.

FGD, Community Health Volunteer, Ribe

4. Longer healing period for mothers

Male spouses and CHVs linked high ambient temperatures to prolonged postnatal bleeding and longer periods of healing in the postpartum

As for the mother, after delivery, she experiences unusual things, such as bleeding, she never gets dry fast.

FGD, male spouses, Kamokamani,

…The state of ability to heal will be there but it is slow. It won’t be that one which happens fast enough. It is because during hot temperature, the wound is normally watery, and this makes it not to heal fast.

FGD, Community Health Volunteers, Ribe

Similar sentiments were shared by the key informants who also associated extreme heat with slow healing in postpartum.

...It (high temperatures) can affect the healing for those who have C section … I think it can just affect the healing of the mother. Because of the wound, when you have a wound and when it is too hot, it doesn’t heal that fast.

KII, Community Health Officer, Kaloleni

Diverse participants in this study described poor health outcomes in neonates in Kilifi and attributed skin problems, discomfort and restlessness, and a reduced nutrition to high ambient temperatures in the County. The discomfort was said to be deepened by intolerable indoor home environments, which in turn were believed to make it difficult for the mother to provide care and for the baby to breastfeed and sleep. High temperatures affecting food production and many hours performing ADL away from home were presented as reasons why mothers did not have enough breast milk and introduced their babies to other foods before six months of age. It is not clear whether all the diseases mentioned by our respondents can in fact be attributed to the heat, however.

Breastfeeding

A World Health Organization (WHO) and a United Nations Children and Environment Fund (UNICEF) Global Breastfeeding Scorecard Report shows that worldwide, 41% of children under the age of 6 years were exclusively breastfed in 2019 (38). In Africa, more than 95% of infants aged six are breastfed, but the rate of exclusive breastfeeding (EBF) is low, with exceptions in Rwanda and Burundi where EBF is reported to be > 80% up to age 6 months (39). Under six months, rates of exclusive breastfeeding in Kenya are at 61% (40). Pre-lacteal feeding includes water and other liquids and is caused by factors such as maternal education, C-section, the sex of the child and home delivery (41, 42).

Community members in Kilifi identified low rates of EBF through three main mechanisms: 1) direct high ambient temperatures may cause blisters on the baby’s skin and in the mouth, which are uncomfortable for the baby; 2) low breast milk production linked to scarcity of food, and 3) raised temperatures in poorly ventilated houses exacerbating discomfort for both mothers and babies. These observed linkages require further scientific investigation.

Barriers to breastfeeding – including those related to heat – are interlinked and interventions must address them from a systems perspective. Firstly, there is a need to provide cool spaces where women can nurse when it is hot, both in the communities and in health facilities by equipping them with electricity for fans and cooling. Secondly, there is a need for programs and policies in settings such as Kilifi to provide the essentials, including supplies of clean water and nutritious foods for pregnant and nursing women, to overcome the problem of food and water insecurity for this vulnerable group. Thirdly, CHVs should be utilised as conduits to educate about the importance of breastfeeding during hot weather and the need to remain hydrated. Fourthly, improved guidance involves healthcare providers, who are critical for informing and guiding pregnant and postpartum women and their families on EBF as well as incorporating the involvement of partners and fathers (43, 44). Lastly, investments to improve the built environment are needed, which will require multi-sectoral coordination and innovative methods to cool indoor living spaces, especially in resource-constrained settings. Reducing indoor pollution by providing women with cooking eco-friendly stoves that have lower emissions, higher fuel efficiency and improved air quality may further contribute towards reducing the felt temperature in the homes.

Direct effect on the skin

Impacts of heat were perceived to cause a range of skin conditions in infants. Although clinically, there are skin conditions caused by heat (e.g. prickly heat,) it is difficult to interpret which skin conditions were more prevalent and the role of heat or sunlight. Researchers for this study observed heavy layering of neonates and key informants noted that this was a cultural practice to protect the baby from the ‘evil eye’. These practices are likely to add to the burden of heat on the neonate’s skin. An awareness-raising and behavior change and education intervention using key influencers such as the chiefs, CHVs, community elders and public health officers is required to help shift these harmful practices (45).

Kangaroo Mother Care

Skin-to-skin care is protective against a wide variety of adverse neonatal outcomes, especially in those born too soon, and facilitates close observation of the baby (46). KMC has the potential to prevent many neonatal complications and even improves exclusive breastfeeding. However, swaddling neonates when it is hot can be harmful because of the baby’s poor thermoregulatory capacity as they cannot dispose of the excess heat (47, 48). Sharing a bed with a newborn during periods of extreme high temperature is not recommended as it may result in child death (49).

Findings from this study suggest that mothers may be reluctant to practice KMC in the heat, owing to the discomfort involved. The need to improve community health facilities for KMC is key, considering that many Kilifian mothers give birth to underweight babies (50). Interventions such as solar-powered electricity to cool buildings and health facilities are warranted.

Delayed postnatal care and slower healing processes

Performing household chores in the heat led to exhaustion for mothers. Community education on the dangers posed by climate change and the effect of high temperatures on postpartum women and neonates is important for encouraging community members to support women in these positions – for example, through supporting them with daily chores. There is need to invest in health facilities closer home where women can access PNC easily when it is hot. Kilifi county office should also invest in improving transport to existing facilities.

STRENGTHS AND LIMITATIONS

Being the first study of its kind in East Africa, particularly in a region that experiences high temperatures throughout the year, these findings contribute to a much-neglected area. Our study participants were carefully selected to include community members who could speak directly about their observed experiences of the effects of high temperatures on women and their neonates. The study’s qualitative and anthropological approach to data collection enabled us to build a nuanced understanding of how extreme heat is impacting on neonatal health. The intersection between drought and food insecurity was a significant and dominating concern. Drought clearly exacerbates the heat risks, thus highlighting the importance of also looking at women’s experiences in non-drought situations.

There were also missed opportunities in the interviewing where themes such as dehydration and interactions between mother and baby were not adequately followed up and explored. Nonetheless, interviewing a wide range of community members who support women as they welcome their neonates into the world provided deep insights about their experience.

High ambient temperatures impact directly on neonatal health, bringing discomfort and skin problems while reducing women’s ability to exclusively breastfeed and undertake other aspects of infant care. Heat exposures are exacerbated by poor housing, in which indoor temperatures are raised by indoor fires and inadequately ventilated homes. High temperatures and drought increase the physical burden upon women by increasing the distances that need to be covered in the heat, and the drought has increased malnutrition in mothers and babies. These findings point to the need to initiate and implement multi-sectoral policies and programs to mitigate the negative impacts of extreme heat on maternal and neonatal health in rural Kilifi and similar settings. As the earth continues to warm over the coming decades, such interventions will become essential. While maternal and neonatal mortality has improved in the past 10 years, this study shows the emerging gaps that need to be addressed to maintain the progress that has been made in the last decade. Climate change is a threat to neonatal health and there is an urgent need to put strategies and interventions in place to support neonatal care in low-and-middle-income countries.

ACKNOWLDGEMENTS

We are grateful to all our participants in Kaloleni and Rabai sub-counties in Kilifi Kenya. We are grateful to Sophie Chabeda for assisting to collect some of the qualitative data.

DATA AVAILABILITY STATEMENT

Due to ethical reasons, we will not share the data.

ETHICS STATEMENT

This study received Ethics approval from the Aga Khan University Ethics Committee ref 2020/IERC-94 (v2) and National Commission for Science and Technology and Innovation Ref BAHAMAS ABS/P/20/7568, London School of Hygiene and Tropical Medicine Ref: 22685 and from Kilifi County Office ref DOM/KLF/RESCH/vol.1/66.

AUTHORS CONTRIBUTION

AL: Development of first draft, conceptualization, data collection, analysis and interpretation

FS: Conceptualisation, analysis, interpretation and revision of the original manuscript

PK: Data collection, analysis and interpretation

BN, SK, VF, NR, SL, MC, CP, KK and JH: Conceptualisation, data interpretation and revision of the original manuscript.

FUNDING

This work was supported by the Natural Environment Research Council (NERC) [grant numbers NE/T013613/1, NE/T01363X/1]; Research Council of Norway (RCN) [grant number 312601]; The Swedish Research Council for Health, Working Life and Welfare in collaboration with the Swedish Research Council (Forte) [grant number 2019-01570]; and the National Science Foundation (NSF) [grant number ICER-2028598]; coordinated through a Belmont Forum partnership.

CONFLICTS OF INTEREST

Authors declare that they have no conflict of interest.

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No competing interests reported.

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Too Hot To Thrive: Community perspectives on the effect of high ambient temperature on postpartum women and neonates in Kilifi, Kenya

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Abstract

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INTRODUCTION

METHODS

Research Design

Research Context

Study population and Sampling

Recruitment and Inclusion and Exclusion criteria

Data collection

Interviewing

Data management and analysis

RESULTS

Participants’ socio-demographic characteristics

Summary: perceived effects of high temperatures on postpartum women and their neonates

1. Heat-related skin problems in neonates

2. Difficulties in caring for the neonate in the heat

3. Exhaustion and delayed postnatal care

4. Longer healing period for mothers

DISCUSSION

STRENGTHS AND LIMITATIONS

CONCLUSIONS

Declarations

References

Additional Declarations

Supplementary Files

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