Role of traditional birth attendants in providing pre and postnatal care to mothers in refugee camps: a case of Ifo Camp Dadaab Kenya

Access to skilled birth attendance is critical in improving maternal and newborn health. However, in low resource settings, rural and refugee camps, professionally trained staff are often in short supply hence women tend to rely on traditional birth attendants (TBAs) for delivery. Despite knowledge that a health care facility delivery is safer, many women from low resource environments continue to seek for the care of TBAs. In order to understand the care provided to refugee women during pregnancy and after birth, in a refugee camp, a study was conducted in Ifo Dadaab refugee camp in Kenya. The aim of this article therefore, is to document findings on participants’ perspectives on pre and post-natal care provided to women in refugee camps during pregnancy and after birth. This was a qualitative study conducted in Ifo refugee camp in Dadaab Kenya. Nine participants were purposively selected for the study to give their perspectives on the role of TBAs in providing caregiving support to refugee women during pregnancy and after birth. The participants included two married men, three traditional birth attendants, two Somali pregnant women and two refugee safe mothers. Data was collected through focus group discussions and interviews. The data was beefed up with feedback from dissemination of preliminary findings to stakeholders’ validation conference held at Kenyatta University. Findings revealed that TBAs play a critical role in supporting women during pregnancy and after birth. However, they are not able to attend to complications associated to delivery. Among the caring support cited include, guiding and counselling pregnant women, educating them on the importance of attending antenatal clinics, massaging women during labour, praying for the baby after birth, and escorting women to the health facilities to take their babies for immunization. It was also apparent that TBAs advise pregnant women on the herbs they should have in stock while pregnant. In addition, they advise women to breast feed their babies immediately after birth. While TBAs are able to assist un complicated births at home, it was apparent that it becomes challenging for them to provide support for women with complication during the birth process. In view of this, it will be more helpful for TBAs to be encouraged to guide and advise pregnant women to deliver in the health care facility, where they can escort them to get professional attention during birth.


Introduction
World Health Organization (WHO) estimates that about 140 million women give birth every year globally. 1,2 In 2016, about 50 million births took place outside a health facility. Majority of these cases were in Sub-Saharan Africa where nearly half of all births occurred at home without skilled birth attendants. 1 In low and middle income countries, majority of births are attended by traditional birth attendants (TBAs) who happen to be the only source of help women can rely on during delivery. 3,4 Skilled birth attendance Access to skilled care during pregnancy, childbirth, and postpartum should be prioritized to improve maternal and child healt. All women and babies need good maternity care during pregnancy, child birth and after delivery to enhance optimal pregnancy outcomes. 5 However, globally, a third of child births occur at home without assistance of a skilled birth attendant. World Health Organization, advocates for skilled care at every birth to reduce the global burden of 536000 maternal deaths, 3 million still births and 3.7 million newborn deaths each year. In Indonesia, interventions to enhance collaboration and partnerships between traditional birth attendants, skilled birth attendants and facility based staff, created relationships integrated into midwifery training. 6 Skilled birth attendants provide maternal care during pregnancy, childbirth and postpartum and newborn care at health centres. 5 During pregnancy, skilled attendants monitor the progress of the pregnancy, detect complications, provide preventive measures, develop birth and emergency plans with the woman and her family and advise women on health lifestyle and nutrition in pregnancy. During child birth, skilled attendants monitor the progress of labour, they are vigilant for complications, and they stay with the women and support them in many ways. They know how to manage abnormalities such as breech delivery, and they work in a team of professionals with obstetric, neonatal and anesthesia skills and are able to handle severe complications. 5 In the postnatal period, they provide care in various ways including helping mothers and babies in breastfeeding, managing severe postpartum bleeding, depression etc. They give timely Access to skilled birth attendance is critical in improving maternal and newborn health. However, in low resource settings, rural and refugee camps, professionally trained staff are often in short supply hence women tend to rely on traditional birth attendants (TBAs) for delivery. Despite knowledge that a health care facility delivery is safer, many women from low resource environments continue to seek for the care of TBAs. In order to understand the care provided to refugee women during pregnancy and after birth, in a refugee camp, a study was conducted in Ifo Dadaab refugee camp in Kenya. The aim of this article therefore, is to document findings on participants' perspectives on pre and post-natal care provided to women in refugee camps during pregnancy and after birth. This was a qualitative study conducted in Ifo refugee camp in Dadaab Kenya. Nine participants were purposively selected for the study to give their perspectives on the role of TBAs in providing caregiving support to refugee women during pregnancy and after birth. The participants included two married men, three traditional birth attendants, two Somali pregnant women and two refugee safe mothers. Data was collected through focus group discussions and interviews. The data was beefed up with feedback from dissemination of preliminary findings to stakeholders' validation conference held at Kenyatta University. Findings revealed that TBAs play a critical role in supporting women during pregnancy and after birth. However, they are not able to attend to complications associated to delivery. Among the caring support cited include, guiding and counselling pregnant women, educating them on the importance of attending antenatal clinics, massaging women during labour, praying for the baby after birth, and escorting women to the health facilities to take their babies for immunization. It was also apparent that TBAs advise pregnant women on the herbs they should have in stock while pregnant. In addition, they advise women to breast feed their babies immediately after birth. While TBAs are able to assist un complicated births at home, it was apparent that it becomes challenging for them to provide support for women with complication during the birth process. In view of this, it will be more helpful for TBAs to be encouraged to guide and advise pregnant women to deliver in the health care facility, where they can escort them to get professional attention during birth. treatment to babies with problems such as preterm birth or those with complications associated with birth. 6 Skilled attendants provide counselling on postnatal contraception to mothers. They advise mothers on preventing mother to child transmission of HIV. This advice starts with HIV testing, providing antiretroviral therapy, counselling on infant feeding and on safer sex practices including use of condoms as well as the importance of family planning.
Access to skilled birth attendant is thus critical in improving maternal and newborn. 7,8 However, in low resource settings, rural and refugee camps, professionally trained staff are often in short supply hence women tend to rely on traditional birth attendants (TBAs) for delivery. 9 Despite knowledge that a health care facility delivery is safer, many women from low resource environments continue to seek for the care of TBAs. 7,10

Traditional birth attendants
A traditional birth attendant is defined as a person who assist a mother during child birth and has acquired her skills by delivering babies herself or through apprenticeship to other TBAs. 3,7,9,11 TBAs provide care during pregnancy, child birth and postpartum period. They are well established and live in close proximity to the women who require maternity care in the community. They have detailed knowledge of the community norms and are paid in. 1,12 TBAs are often older, respected women who are part of the local community but do not have a formal education and are often illiterate. Apart from being nearby and available, TBAs are trusted by women and they provide culturally appropriate pregnancy care in line with the traditional expectations of the community.
Traditional birth attendants (TBAs) play a critical role in maternal healthcare in the rural and deprived communities where there are inadequate skilled birth attendants. 13 In a study conducted in Ghana focusing on TBAs' perspectives on their role indicated that, TBAs assist in conducting uncomplicated deliveries at home due to absence of skilled birth attendants. According to this study, TBAs perceived their roles to include; advising women to go to the health facility to deliver. However, sometimes women refuse to deliver in health facilities. 13 The study further revealed that TBAs provide health education on nutrition and natural family planning to women in their respective communities. Additionally, TBAs arrange for means of transport and accompany women in labour to the health facility to give birth. They offer the couple education on natural family planning. TBAs provide psychological support through counselling. It also emerged from the study that TBAs are paid in kind for the services they offer. 13 Traditional birth attendants have continued to be culturally and socially accepted in many societies despite their limitation in handling childbirth complications. 14 Globally, every year over five hundred thousand women die due to complications related to pregnancy, and childbirth. 14 The mortality rates are high in developing countries especially in sub-Saharan Africa. In sub-saharan Africa, maternal mortality rate is at 500/100000 compared to Asia 220/100000, while Caribbean and Latin America is 80/100000. 14,15 Most of the causes of maternal mortality are preventable through utilization of skilled care at birth (WHO, 2015a). However, in developing countries, many women attend antenatal care in the hospital but few of them deliver with skilled birth attendants. 16

Reproductive health services in refugee camps
The demand on reproductive health services is steadily growing and the increasing number of female migrants creates added pressure.
Many refugee and migrant women have additional economic, financial and social challenges that may interfere or compete with pregnancy care. Being refugee or migrant can be considered a risk factor in itself. 17 A systematic review of reproductive health programs in humanitarian settings in 2015 identified reports on 30 worldwide programs 25 of which were from Africa. The reports revealed that women with refugee backgrounds in general have greater risks of adverse pregnancy outcomes. 18 The review further revealed that women displaced from African countries with humanitarian crises have increased risks of still births, perinatal mortality and increased caesarean section rates. 18 The purpose of this article therefore, is to document participants' perspectives on the role of TBAs in providing pre and postnatal care for refugee mothers.

Methodology
This was a qualitative study that was conducted in Dadaab Ifo refugee camp in Kenya. Nine participants were purposively selected for the study including, two married men, three traditional birth attendants, two Somali pregnant women and two refugee safe mothers. Data was collected using focus group discussions and interviews to gain more insights on participants perspectives on the role of TBAs in providing pre and postnatal care to refugee mothers.

Data collection procedures
Informal meetings with community gate-keepers from Ifo refugee camp (a representative from each block) were held. They were explained, the purpose of the research team's presence and the importance of the research. Thereafter, they were accorded opportunity to express their feelings and to air their views and opinions in relation to the current study. They were also encouraged to ask questions, which they did with a lot of enthusiasm. The questions were answered by the research team leader. It was after they were satisfied with the answers that they allowed the research team to go ahead and conduct the research as planned. At this point, the research team leader requested them to appoint one of them, to be accompanying the research team to the field.
The research team was divided into two groups. For each group, a researcher was assigned to seek consent by reading the content of the consent form to participants. After understanding the content of the consent and agreeing to participate, they were requested to append their signature to the consent form. The next step was to introduce participants into the virtual reality (VR) headsets. The black rhino group explained what VR is all about and how it is used. Women participants got to experience what VR entails by wearing the headset. They were then asked to narrate their experience on the technology and explained how this technology would be used to document and improve their practices. This enabled TBAs to consent to the shooting of their activities during the birth process and after birth.

Research participants
Being a qualitative study, a total of 9 participants were interviewed. They comprised of 3 TBAs, 2 pregnant mothers, 2 men and 2 safe mothers/refugee midwifes. One of the male respondent, a 35-year-old, was from the hosting community and the other, a 60-year-old man, was a refugee residing in Ifo refugee camp. The 35-year-old man got married in 2016, and had 5 children and during the study period they were expecting their 6 th baby. The 60-year-old man had 5 children. Both men had attained tertiary level of education. The 35-year-old was a businessman, while the 60-year-old was a refugee camp village elder in Ifo. The three TBAs interviewed were between ages 50 to 69 years old. Of the two pregnant refugee mothers interviewed one consented to VR recordings while the other declined. One was 30 years old, the other was 25 years old. They were both married with three children each and expecting a fourth baby.

Data processing and analysis
Data from focus groups and interviews was transcribed and organized according to themes in readiness for analysis. This article presents data focusing on TBAs caregiving support to refugee women during pregnancy and after birth.

TBA's Perspectives on their role in caregiving support to refugee women during pregnancy and after birth
TBAs revealed that in addition to helping the pregnant mother deliver, they also help to wipe the baby and wrap it to keep it warm. They pray for the baby and observe it to ensure the baby is well. In the event the baby develops a cold, she is able to give the baby herbs and coconut oil. One TBA aged 50 years reported this by saying:

I have been helping mothers deliver for the last 20 years. In a week I help at least 3 to 4 mothers deliver. My support to mothers includes 1) helping the mother deliver and wiping and wrapping the new born baby. 2) Praying for the baby in the name of Allah. 3) Observing the baby after delivery. In case the baby develops a cold, I use a herb (Malmal) or coconut oil. I use Malma and Herbe Suda/ Black seed oil for the baby when cold symptoms emerge and for the mother to lessen muscle tensions. I also use coconut oil to massage the mother in labor. I help the mother know how to hold and feed the baby.
Additionally, TBAs, advise pregnant mothers on good nutrition through feeding on a good diet. They take care of the mother and child after delivery. In the event a mother develops complication during delivery at home, some TBAs accompany the mother to hospital. One TBA revealed this by saying: I have delivered 30 women and no one has ever died. I give advice on diet and the types of herbs the pregnant mother should buy and where to buy them. I also massage the pregnant mother. I take care of the mother and child after delivery. I accompany the pregnant woman to hospital. After birth, I burry the placenta. During labour, I encourage the delivering mother by assuring her that this is a natural process. I give guidance and counselling to the mothers. I pray for the woman before and after delivery, which appeases Allah. I advise and do referrals for delivering mothers who are potentially at risk to deliver in hospitals. We advise the expectant mothers which herbs to stock at home. We never carry any ourselves. virgin Coconut oil is used for massaging the tummy and the back. Black seed oil is used to massage the pelvic muscles to help in opening the way. Herbe Suda/ Black seed oil and malmal are rubbed on the infant's nose, ribs to protect and cure the baby against cold, bronchitis. We are always available during pregnancy, delivery and after delivery we stay with the mother and baby. we adhere to our culture, custom and religion when delivering the baby. We burry the placenta. We treat delivering mothers with a lot of dignity. We encourage and support the mothers even when they go to hospital. We work 24/7 day and night time …we offer our services. We are friendly, treat them kindly and with respect, we speak their language, we stay with the women from the onset of labour until she delivers. We feed her, sing and tell her encouraging words, we tell her that birth is a normal process and the pain will go once the baby is out, we listen to their worries, pain and concerns.

Safe mothers' perspectives on their caregiving support to refugee women during pregnancy and after birth
The trained safe mothers revealed that, through training they are able to support pregnant women deliver in times of emergencies, when dilation has happened and the woman cannot reach the health facility. However, their main task is to advise pregnant women on how to manage their pregnancies in relation to attending antenatal clinics and delivering in hospital. One save mother reported this by saying: I was trained to help mothers in times of emergencies by organizing to have them taken to hospital. If I find the mother has dilated too far I help her deliver first and then call for an ambulance to take her to the hospital for further checking and recording the birth.
I escort mothers to hospital. I advise the expectant mothers on how to manage the pregnancy and explain to them the importance of taking medicine from hospital because they believe that if they do so the baby will grow big and give them complications during delivery.
Another save mother pointed out that they help advise women with complications like blood pressure on how to manage the condition and take medication as directed by the doctor but also the importance of delivering in a health facility. They also advise women on the importance of breastfeeding the child and how to hold the baby when breastfeeding.
We advise the pregnant mothers, those who have delivered and those to deliver so that they come to hospital to be seen by a doctor. We also help pregnant women with other complications like high blood pressure, they are encouraged to take medicine as directed by the doctors. I assist those mothers who come to hospital to deliver. I give them treatment after they deliver and give them advice to breastfeed. We teach mothers how to hold a baby while breastfeeding.

Pregnant mothers' perspectives on TBAs' role in caregiving during pregnancy and after birth
According to Somali mothers, traditional birth attendants play a critical role in helping mothers deliver at home. In addition, TBAs escort pregnant mothers to the health facility for immunization of their babies and for birth registration since TBAs live within the same vicinity. One pregnant mother reported this by saying: TBAs help mothers deliver at home and escort them to hospital when need arise. They also escort mothers to hospital for immunization and birth registration. TBAs are near home in the blocks and they do not insult mothers like nurses when someone is taken to hospital during the shift changing hour.
Another pregnant woman revealed that TBAs are friendly and since they live within the community, they come in handy to support the pregnant mothers deliver at home. This according to her is advantageous as the mother remain with her children. TBAs advice mothers on the herbs to stock while pregnant that will be used during delivery and for the baby after birth. She revealed this by saying: First the TBA is my friend, I have known her since I was a little child. Second she has been attending to me and has delivered all my other kids without a problem. Third I have enough space here, in hospital you are restricted to your bed. Fourth, I will remain with my children and family, I don't have to worry on whom I will leave them with and whether they have eaten. Again I have my herbs with me for use anytime they are needed. I understand one is never allowed to carry these herbs to hospital. Also my friend the TBA lives in our neighborhood, I don't have to get out of my compound, she will come when I call her and will be with me until I deliver, she will also take care of us thereafter. Services I can't get in the hospital.

Men's perspective on TBAs' role in caregiving to refugee women during pregnancy and after birth
According to men, TBAs play a critical role in caring for the unborn baby and the mother during pregnancy. According to men, TBAs do this through massaging the pregnant mother's womb, which enables them to tell the birth date and even the size of the baby. Since TBAs come from the community, they know their customs and they are able to meet the pregnant woman's needs before and after delivery. One man aged 35 years revealed this by saying: "TBAs knows how to tell the birth date by massaging the baby in the womb. Our TBA through the 5 deliveries has never failed in her measuring the unborn baby size and estimate. That helps me to plan ahead. TBAs know our customs and take care of the mothers' needs before and after delivery".
It also emerged that men are confident that their wives will receive baby care support from TBAs, who are able to teach their pregnant wives about the customs and culture. TBAs also encourage pregnant women to attend antenatal clinics and after birth, encourages the mother to take the baby to clinic. However, during delivery, the pregnant mother consult the TBA. "As a man I'm assured my wife will receive baby care support after delivery and customarily teachings of mothers in our culture. First my wife goes to hospital for clinic. As her delivery date approaches she consults the TBA. After delivery she takes the baby to the hospital with her clinic card".
As part of caring for the pregnant mother, TBAs, offer social and psychological support through massaging, rubbing the back of a pregnant mother during labour pain, encouraging them through stories, to reduce anxiety. One man aged 56 years reported this by saying: "TBAs offer social and psychological support such as, massaging and patting the back of the delivering mother. They encourage the mother through giving encouraging stories and singing where sometimes women gather to encourage her to reduce anxiety. They encourage her that birth is a normal process".

Conference participants' perspective
In disseminating preliminary findings to stakeholders and reproductive health practitioners, participants in the conference were asked to share their views on how best TBAs, mothers and fathers can be encouraged to embrace skilled birth attendance. Participants revealed that in some hospitals, some mothers may find the environment to deliver not conducive, since the labour rooms are open which does not provide women the privacy they need during labour process. That during delivery, the woman is moved from the labour bed to the delivery room, which makes it uncomfortable to the woman hence the reason why women prefer home delivery. To mitigate this, participants, proposed that, to enhance privacy for the delivering mother, the labour bed should be made conducive to allow delivery to happen there. This may include having a curtain around the bed, as well as allowing delivering women to come with birth companions who could be their husband, TBA or a trusted mother or safe mother from the community. Participants revealed this by saying: The structures of our maternity needs to be looked into. The delivery room is a challenge especially where the woman is laboring. The bed where the woman comes into should be the delivery bed to avoid taking them into the delivery room that is separate from the laboring room. The bed should be covered to enable the delivering woman go through the labour process in privacy. This will accommodate the safe mother and even the husband to be close to the woman during labour. Letting someone stay with the delivering woman during labour is also critical. Allow the birth companions to come with the delivering woman. The birth companion can be anybody including a family member, husband, relative or TBA. This should be the person the woman is comfortable with.
Additionally, participants maintained that, in order to encourage young mothers to deliver in health facilities, there is need for health care facilities to organize tours for pregnant mothers to the maternity wards, when they come for antenatal clinics. This will help them familiarize with labour wards and develop confidence on what goes on in the labour wards to start appreciating the importance of giving birth in the health care facility. On the other hand, participants, maintained that using respected leaders in the community to sensitize mothers on the importance of delivering in a health care facility may compel more women to deliver with the help of skilled attendance. They revealed this by saying: There is need for pregnant women to have antenatal tours to familiarize themselves with what goes on in the maternity wards. Using respected leaders in the community to speak and sensitize mothers on the importance of giving birth in the hospital, will help more mothers deliver in hospital.

Discussions of the findings
The aim of this article is to document participants' perspectives on the role of TBAs in providng caring support to mothers during pregnancy and after birth among refugee women. It is apparent from all participants, that TBAs are preferred by women because they are readily available in the community. This finding is in agreement with findings from a study conducted in Migori County Kenya by Cheptum et al. 14 Cheptum et al.,14 in their study, revealed that, TBAs are preferred for various reasons including: being readily available in the community, offering individualized care to mothers unlike in the healthcare facility, and that they provide herbal medicine believed to quicken the labour process. 3,7,9,11,14 Findings from men's perspectives revealed that TBAs play a critical role in caring for the unborn baby and the mother during pregnancy. According to them, TBAs do this through massaging the mother's womb, which enables them to tell the birth date. In addition, the fact that TBAs are paid in kind, makes the whole process affordable for men. These findings are in tandem with findings from Cheptum et al., 14 study, where men revealed that having their wives deliver with the help of the birth attendant is affordable. Men further revealed that they are confident that their wives will receive baby care support from TBAs, who are able to teach them about the customs and culture. A part from providing pregnant women psychological support, TBAs also encourage pregnant women to attend antenatal and postnatal clinics for the mother and baby. [15][16][17][18][19][20][21][22] Pregnant mothers, on their part revealed that, they feel comfortable to be delivered by TBAs because they are able to be with their children at home which saves them a lot of anxiety, worrying about their children. Additionally, according to pregnant mothers, TBAs escort them to the health facility for immunization of their babies and for birth registration. This kind of support is perceived to create confidence on the recently delivered mothers. Save mothers through training they are able to support pregnant women deliver in times of emergencies and at the same time, they advise them on the importance of antenatal and postnatal clinic. In addition, they advise sickly mothers on the importance of taking medication as well as feeding well.