Understanding antenatal care use in pastoralist communities: a focused ethnographic study in Kenya

Abstract

Background/Aims The provision of high-quality antenatal care improves maternal and child health outcomes. Pastoralist communities face unique challenges in accessing healthcare associated with a nomadic, marginalised lifestyle, and have high rates of maternal morbidity and mortality. There is minimal evidence on antenatal care use globally among this group. To develop optimal services for pastoralist communities, there is an urgent need to understand pastoralist women's use of antenatal care services. This study's aim was to explore experiences of antenatal care among pastoralist communities in Kenya, to identify key barriers and facilitators of uptake. Methods This focused ethnographic qualitative study was underpinned by a philosophy of critical realism. A total of 58 participants (women, husbands, traditional birth attendants and nurses) were included. Data were collected using interviews, focus group discussions and observation. Data were collected for 6 months in six villages and five health facilities in a pastoralist region of northern Kenya. Inductive thematic analysis and retroduction were used to identify concepts, structures and mechanisms that influenced antenatal care use. Results Pastoralist women's antenatal care experiences and use were linked to two main themes. The first was government policies that incentivised antenatal care use by linking the provision of the baby's health and citizenship records to antenatal care uptake and encouraging traditional birth attendants to adopt defined referral roles. The second highlighted multiple structural barriers that impeded consistent antenatal care uptake, including the pastoralist lifestyle, cultural barriers, health system constraints and a gap in information sharing. The dissonance between these led to partial, sub-optimal use patterns of antenatal care. Conclusions Government policy created an impetus for the pastoralist community to use contemporary healthcare services. At the same time, multiple barriers impeded access to services. This explains the partial use of antenatal care services among pastoralist communities. The findings throw doubt on the feasibility of antenatal care guidelines that recommend eight contacts during pregnancy. There is a need to work collaboratively with communities to develop context-specific models of care.