The analysis of data generated six themes. The findings from the theme, Policies and Infrastructure Influencing Postpartum Care will be discussed in this paper.
Knowing that the experience of childbirth is unique to every woman, nurse, and midwife in this study managed expectations of their clients during the postpartum period by promoting a trusted environment where their clients felt safe. Several policies and processes have been put in place to promote maternal and child health outcomes. These policies influence the day-day work of the nurses and midwives. They acknowledged that the policies and processes could achieve better health outcomes for the women and infants if adhered to. The findings will be discussed under three sub-themes 1) Free maternity services, 2) Adherence to perinatal care guidelines, and 3) Recruitment and retention of nurses and midwives.
Free Maternity Services (FMS)Policy
The Free maternity services (FMS) policy was introduced in all government facilities in 2013. This policy aimed to promote skilled perinatal services and eventually reduce maternal and infant mortality and morbidity. Most participants in this study acknowledge that there has been an increase in women seeking professional health services. However, it comes with its challenges, such as long wait times and lack of supplies at the healthcare facilities.
It's a bit challenging because as per now, most of the clients are aware of the “beyond zero programs” where we are supposed to provide free maternity services. Unfortunately, we lack supplies most of the time. So it becomes a bit challenging because you want them to come to deliver at the hospital, then when they reach the hospital set-up, there are no supplies, so they are forced to buy … some are not able to buy…So you hear comments from the people in the community, “if we go to the hospital, we will still be sent to buy this and that, we better move to our nearby midwife who can assist us and we pay back.” It’s a good initiative by the government whereby they want all mothers to deliver in the health center but the shortage of supplies makes it a bit challenging for us to do our work. (P022)
The participants reported missing opportunities for the women and infants to obtain care at the health facilities. This is disheartening for the mothers, given the many hurdles they face in accessing skilled health services.
We have many mothers coming to us especially with the free maternity being offered but sometimes they are too many for us to even see them and some end up going back home without being seen by the nurse. The mothers get tired of waiting in lines. Sometimes the babies are hungry, the mother is hungry too and so they prefer to go back home instead of waiting in line the whole day. (P016)
With the FMS, the national government is to reimburse health care facilities money for the cost incurred from maternity care services. However, participants reported compromised quality of care because of inadequate essential drugs, supplies and equipment at the health facilities due to the delayed reimbursement.
The government has promised to provide free maternity care, but apart from promising, there are some challenges we encounter…It is free, but we have encountered a lot of challenges in the provision of supplies. We cannot give good care if we don’t have the supplies. Because we depend on reimbursement of free maternity, we find that we encounter some challenges because the money is not paid. Although the government will was good, it is not as effective as we thought it could be. (P014)
Another issue that compromised the quality of care was the limited space in the health facilities. Despite the increase in mothers utilizing perinatal services, the building infrastructure remained the same. Women and infants are then forced to share the few available beds with others or sleep on the floor, posing a risk for infections.
For example, in our postnatal care unit, since they introduced the free maternity, we have more mothers coming and we don’t have enough equipment to help these mothers. We have fewer beds and it is not convenient for the mothers. For example, you could have like ten mothers and we have only five beds, so it is inconvenient, you find some mothers are sleeping on the floor. (P013)
The participants voiced concerns about privacy when caring for the women and infants. For example, this mother complained about sharing beds with other mothers.
Mothers and their newborns are sharing beds with other mothers with their newborns. The beds are also so small. There is no privacy for the mother when giving health education about her care. This also poses infection prevention problems because of sharing beds. (P010)
Although the FMS is an enabler for the use of skilled health care by women, several factors such as insufficient staffing ratios and lack of essential supplies lead to unsatisfactory care for the women. This has caused the women to abandon or delay seeking skilled healthcare, hence the potential risk for increased morbidity or mortality during the perinatal period.
Adherence to Perinatal Guidelines
Health care providers in Kenya are expected to follow the National Guidelines for Quality Obstetrics and Perinatal Care when providing perinatal services. Participants indicated that a copy of the document is available for reference in all facilities providing reproductive health services. All participants were aware of the postpartum guidelines. However, most participants indicated that implementing all aspects of the procedures was not always possible because of the shortage of staff and lack of appropriate equipment.
To my knowledge, I think the principles are there but implementing them is not sufficient. Yeah, so we are trying to implement these guidelines which have been made. But for them to be implemented, the government … should make sure that the services to the patients are upheld to some level … I told you earlier that they need to equip all the rural facilities both with the manpower and also with the equipment. (P013)
Nurses and midwives were knowledgeable on how to treat obstetric emergencies, and most of them had received training on emergency obstetric care. Yet, the lack of essential resources to provide care makes it difficult for them to attend to these emergencies.
Yes, we have standard operational procedures on the walls.… we have been trained on the Emergency obstetric care management. So it is easy to follow the operational procedures because we know … sometimes it is hard for us but we are trying (both laugh). We are trying because sometimes you know you are supposed to work according to the guidelines, but you are forced to improvise a few things. Most of the time we improvise because we don’t have the proper equipment and supplies. (P021)
They communicated to the women throughout the process to make informed decisions related to their health and well-being, such as family planning and infant spacing. These positive relationships promoted women empowerment and autonomy and enhanced positive health outcomes for the mother and infant.
You know, we see some of these mothers from when they are pregnant, during the antenatal clinics … Others come only to deliver … How we treat these mothers when we see them is important because if they are not happy with us, they will not come back to deliver the baby at the hospital … So, we get to know them, and they get to know us. We get to understand these women during the process…(P004)
The nurses and midwives assessed and provided appropriate postpartum care information to the women. They determined the vulnerability of the women and newborns by considering their age, parity, level of education, and general ability to take care of the infants. They provided emotional support to the women and maintained women's rights and dignity, and respect.
After delivery, the mothers are normally anxious, and some do not know what to do. During assessment, we encourage them. We listen to them. We explain the procedures that we are doing to them before we begin. We educate them and encourage them to ask questions. This way, when we ask them to come back after six weeks for postnatal care of the baby and for themselves, they come back because we provide good care. (P008)
A mother who has given birth is generally a happy mother. So, if you find otherwise, then you probe … You can also obtain the history from the relatives. Some will also tell you this mother is like this when she gives birth. Sometimes we must refer the mothers to the psychiatrist if we determine they need more help than we can offer. (P016)
Some participants acknowledged rushing through their assessments so that they can attend to as many women as possible, placing women at risk for impending complications.
So, we normally do quick assessments to these mothers and miss other things because we have to rush to the others waiting in line” (P016)
Participants indicated that on some occasions, women are discharged from the health facilities less than 48hrs following delivery due to lack of space in the health centres.
What we normally do, because of the congestion in the hospital, we don’t keep them for the two days that we are supposed to keep them. So they just stay overnight, and then the following day in the morning, if everything is stable, and the baby is OK, we just discharge them through the family planning and MCH which is the infant wellness infant clinic. (P012)
Further, the inconsistent availability of essential supplies probed unsafe organizational practices such as the rationing of basic supplies such as gloves, putting the women, infants, and nurses and midwives at risk of complications and infections. In most cases, participants reported that women were asked to purchase essential supplies required for their care at the health facility.
Sometimes we are just given two boxes of gloves and we are supposed to miraculously use them for three days before going back to the supply store to get more…many times, we run out of some important drugs like oxytocin. The mothers are asked to buy gloves so that we can use when assessing them. You know how important that drug is for a mother immediately following birth…We do not have a constant supply of water, the pump is down, like more than 50% of the time. So, in those instances …we have to get it from a small well outside and a few tanks outside that we have for reservoir …We need tap water, running water, you know, when fetching water with a jug (laughs), you don’t feel it’s enough hygiene especially if you have to clean up the place after delivery … Yeah. It is quite a challenge. (P012)
The integration of services, such as prevention of mother-to-child transmission (PMTCT), has allowed better uptake of the services and hampered the quality of care the women receive at the health facilities during postpartum visits. Participants were also concerned with the essential infrastructure in the health facilities.
We have so many programs like PMTCT that seem to have more priority than postpartum care. These programs have taken the space that we used to care for the mothers during postpartum care, and now all the mothers [antenatal and postpartum] are taken care of in the same ward. The bed is also too high for the mothers climb after delivering the baby. (P022)
On the other hand, women, especially those who are not first-time mothers, still delay seeking skilled health care services during the perinatal period. As such, they arrive at the healthcare facilities with complications such as postpartum haemorrhage, puerperal sepsis, or respiratory distress.
Those who have delivered many children assume it is normal to deliver at home on their own or with TBA. If it is precipitate labor, they deliver at home, they do not care what next. But then they find themselves with complications like sepsis, engorged breasts.
That is when they now come to hospital because of the complications. Sometimes we have to refer them to the county referral hospital. (P001)
Equipping healthcare facilities with better refan ambulance or access to the ambulance has improved the referral systems within the facility levels. However, there is still a need for basic supplies to manage emergencies.
With the introduction of ambulances, it has become better of but maybe the health centres should be equipped so that we can deal with emergencies. Sometimes you lack whatever you want for resuscitation no oxygen you get any child that is not breathing very well managing that child is a challenge at the health centres but at the district, I think they can manage. (P004)
Women expect quality and safe care for both themselves and their infants from the healthcare providers. The nurses and midwives in rural Kenya have appropriate education and a unique approach to providing respectful and dignified postpartum services. Utilizing the available resources, they promoted women and infant health outcomes through healthy relationships. However, all facilities need to be equipped with proper equipment, supplies, and human resources to succeed in postpartum guidelines.
Recruitment and retention of nurses and midwives
There was a consensus among all participants regarding the shortages of staff in health care facilities. "Our staffing ratios are so low, and it makes our work difficult" (P010), irrespective of the many qualified nurses without employment in Kenya.
One that we cannot get by is staffing…So I find that as a challenge that is almost beyond reach. Because first, we don’t have enough representation as nurses in the management positions … The solution to that one, I am not sure but because we have many trained nurses in the County who are not employed, just waiting for an opportunity, they should be hired even on contract … They just need to hire a few nurses on contract. Because when they hire on contract, it’s not a lot of money. It’s about half the salary. So they can just hire some of them on contract for a few years that will relieve the shortage. (P012)
Participants indicated that despite the shortages of nurses in healthcare facilities, some nurses remain unemployed. They recommended that the government increase the healthcare budget so that more nurses and midwives can be hired, especially in the health centers. Health centers are more likely to receive obstetric emergencies as they are closer to the communities than the referral hospitals.
There are so many qualified nurses out there looking for jobs… we are overworking. Especially the staffing in the health centers is worse than the referral hospital. Because at the health centers, you can find that there is only one nurse at work and maybe a clinical officer is [all that is] there. The night always has one nurse at some of the health centers. (P021)
The staff shortages hindered the effectiveness of the postpartum services in rural facilities because of the limited contact of nurses and midwives with their clients.
Staffing is more challenging. We have very few nurses attending to so many mothers. We don’t even have enough time to provide the education required to the mothers before they are discharged home because we are rushing to the next mother who has just delivered. (P002)
In some situations, a facility could have only a nurse/midwife on duty, with several patients to attend to. Such situations left the nurses helpless and demotivated.
Shortage of staff. Because we have only two nurses in the health center, sometimes you can find yourself working alone because the other nurse is sick. And there could be 4 mothers waiting to deliver. So you find it is difficult and you don’t even know what to do (P18)
And some a faced with situations where they must triage between two emergencies when they are the only skilled practitioners in the facility.
Sometimes you find you are alone and you have go round to all sections, immunization, outpatient, delivery room… you find there is another challenge where the two can collide let’s say another personal comes with bleeding abortion and comes and find another mother in 2nd stage labour…you will be running up and down which one will you help first? (P001)
This shortage of nurses and midwives in the health facilities has led to an informal increase in the scope of practice for the nurses and midwives. In addition to their work, they are now offering complex services that specialists would typically provide, causing role overload to the nurses and midwives and placing women and infants at risk.
Being in the health center or dispensary, you are doctor, you are the nurse, you are the subordinate, you are the everything … It affects one in such a way that you cannot do what you are supposed to do, like the observation in hourly or half hourly as per the guideline (P004)
It is essential to address the barriers to postpartum care in the healthcare facilities for women and infants to receive competently, quality, and safe healthcare services from the nurses and midwives. This entails equipping the healthcare facilities with the essential equipment and supplies required to provide adequate care, ensuring appropriate staffing, and ensuring nurses and midwives are regularly updated with the current postpartum care best practices.