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MEDICAL PLURALISM AND UTILIZATION OF MATERNITY HEALTH CARE
SERVICES BY MUSLIM WOMEN INT MOMBASA, KENYA
FATMA ALI SOUD
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
Fatma Ali Soud
This document is dedicated to my parents.
This research would not have been possible without the help of many people. I
would like to thank Dr. Abdalla Kibwana who was my first listener and consultant while
writing the proposal and questioning the feasibility of this study.
I owe a huge debt to the 300 women I interviewed and to the many others who took
time to answer my questions. I was invited into women's lives and entrusted with very
personal and intimate information. I owe great gratitude to Sister Asya Ahmed who
opened her home and birthing center and gave me a lot of her time to explain all the
social and cultural changes that had taken place in Mombasa. In addition, she took time
to re-introduce me to the many physicians, nurses (especially Sister Rumani Ahmed and
Mura Thabit), to the birth attendants Bi Riziki, and Amina AbdulGhania. To Dr.
Khadij a Shikeli for allowing me entrance into Coast General Hospital. To all the
administrative staff and nurses of MEWA, Sayyida Fatima and Al-Farouk hospitals who
took time to answer my questions.
My sincerest gratitude to Dr. Russell Bernard for his faith in me, his critical
counsel in research design, methods, editing and advice. I feel honored to have grown
academically under his tutelage. A very special acknowledgement to my committee
members, Drs. James Stansbury, Elizabeth Guillette, and Jeffrey Harman. Thank you for
your intellectual inspiration and professionalism. I had the privilege of guidance from
other professors who I would like to thank, Drs. Brian du Toit, Michael Chege, Leslie
Sue Lieberman, Sharleen Simpson and Maria Grosz-Ngate.
To my fellow student supporters, particularly the dissertation writing group, Roos
Willems, Antoinette Jackson, Elli Sugita and Alex Rodlach, thank you for tirelessly
reading, editing and providing input as the dissertation progressed. Special thanks to Alex
for his friendship, support and encouragement, and for listening as the dissertation took
many forms until it was written.
Deepest appreciation to my family in Mombasa, Faiza and Abdul Abdulbassit and
Aisha who invited my sons and me to live with them during fieldwork. To my sisters
Sabrina, Umi and Nasra for their love and encouragement. Last but not least to my sons,
Abraham and Adam Wilcox for their love and support and their ability to keep me
TABLE OF CONTENTS
ACKNOWLEDGMENT S .............. .................... iv
LI ST OF T ABLE S ............ ......_ .............. ix...
LIST OF FIGURES .............. ...............x.....
ACRONYM S ................. ................. xi..............
GLO SS ARY .............. .................... xii
AB STRAC T ......__................ ........_._ ........xi
1 LITERATURE REVIEW ................. ...............1...............
Introducti on ................. ...............1...._.._ ......
Theoretical Overview .................. ... ........... .... ...........6
Theoretical Models in Health Care Seeking Behavior............_..._ ............... ....6
Mother-to-chil d-tran smi ssi on (MT CT) of HIV ........................_. ............... 8
Prenatal care services ................. ........._. ... ...............10.....
What is adequate utilization of prenatal care? ................. ........._.._.......1 1
Utilization and access of prenatal care services .........._.._.._ .............. .....12
HIV positive women and the utilization of health care .........._..... ..............15
2 MOMBASA THE RESEARCH AREA .....__.....___ ........... ............1
Geography .............. .. ..... ._ ..... ...............18_
History: The Visitors and Administrators. .....__.....___ .......... .............1
The Coastal People Waswahili.............__ ...... ..__ .........__ ...........2
What Occupies Women's Time in Mombasa? Society and Culture ................24
3 MEDICAL PLURALISM INT MOMBASA. .......___......... .........___......30
Introducti on ............ _. .... ...............30....
Biomedical Health Care............... ...............3 1.
Traditional/ Folk Medicine ........._.. ...._._........._._. ............3
Islamic Heal ers .............. ...............40....
The Popular/ Lay Sector ................. ...............43........ .....
4 METHODS OF DATA COLLECTION................. .............4
Introducti on ................... .. ...... ...............45.....
Research Design and Obj ectives ................. ......... ...............45.....
Native Ethnography ................. ...............47....... ......
Sampling Design .............. ...............50....
Data Collection ................. ...............52....... ......
The Research sites ...._. ................. ...............57......
Statistical methods............... ...............66
5 RESULTS FROM THE DATA ANALYSIS .............. ...............67....
Introducti on ................. ...............67._ _._.......
A analysis .............. .......... ... .. .........6
Section A Socio Demographic Characteristics............... ............6
Section B Household Characteristics ........................................... 7
Section C Knowledge of Mother-to-Child HIV Transmission (MTCT)..........77
Obstetrical Characteristics.................... .................7
Section D Utilization of Maternity Health Care Services ............... ............._...80
Choice of a childbirth delivery center ................. ................. ................. .81
Reasons for using a facility for prenatal care or childbirth ................... .......82
6 ETHNOGRAPHY OF PREGNANCY AND CHILDBIRTH ................. ................87
Introducti on ................ ..... ...... .... ........... ... .... .... .. ... .......8
Menstruation and Puberty Rites Lessons On How to Safeguard Fertility ..............87
Infertility ........._. ...... .. ...............9 1....
Pregnancy Loss ........._... ...... ..... ...............95....
Perceptions of pregnancy ......_.. ............_ ........._.._......_._....96
Prohibitions in pregnancy............... ...............9
Illnesses in Pregnancy .............. ...............100....
Childbirth ................. .... .. ..............10
Postpartum period (Arubaini) ....._._._ ...... ._.. ....._. ...........13
7 SUMMARY AND CONCLUSION ............_. ....._. ....__ ...........18
Introducti on .........._........ ......_._. .. ._._ ........... ......... 1
Demographic and Obstetrical Determinants of Health Care.........._.._.._ ...............1 19
Household Characteristics and the Domestic Economy ................. ........._......123
Local and State Political Economy and Health Care............... .................12
Culture and Women's Health Beliefs............... ...............126
A DEMOGRAPHIC CHARAC TERI STIC S ...._ ................. .........__.. .....12
B QUESTIONNAIRE ................. ...............145...__ ........
C CODING FOR QUESTIONNAIRE ...._. ................. ............... 149 ....
LIST OF REFERENCES .........._.. ........... ...............158...
BIOGRAPHICAL SKETCH .............. ...............175...__.........
LIST OF TABLES
4-1 Interview sites .............. ...............52....
A-1 Section A Demographic characteristics ................ ...............136..............
A-2 Section B Household characteristics............... ............13
A-3 Section C Knowledge of mother-to-child- HIV transmission ................... ..........140
A-4 Use of maternity health care. ................ ............ ......... ........ .........141
A-5 Logistic regression model results of the determinants of using prenatal care ....143
A-6 Logistic regression model odds of choosing of a birthing facility as reported
by respondents ....._ ................. ........_ ..........14
E-1 Coding for Questionnaire ................ ...............149...............
LIST OF FIGURES
2-1 Map of Kenya situating Mombasa ..........._... ...___....... ..........1
4-1 Data collection sites .............. ...............51....
A-1 Percentage of respondents by ethnicity ........__............._. ............... 129 ...
A-2 Respondents' level of secular education .....___ ................ ........_.._. ......13
A-3 Respondents' knowledge about mother-to-child HIV transmission ......................131
A-5 Month biomedical prenatal care started .............. ...............133....
A-6 Respondents' number and frequency of prenatal care visits .........._.... ..............134
A-7 Percentage of respondents choice of birthing facilities .........._. ... ......_._. .....13 5
AIDS Acquired immuno-deficiency syndrome
HIV Human immunodeficiency virus
MCH Maternal child health
MOH Ministry of Health
MTCT Mother-to-child transmission
NGO Non-government organization
TBA Traditional birth attendant
STI Sexual transmitted infections
UNAIDS United Nations AIDS organization
UNFPA United Nations Population Fund
UNICEF United Nations Children's Fund
WHO World Health Organization
Swahili Culture of the people of East African coast from Mogadishu (Somalia) to
Mswahili The person (plural Waswahili or the people)
Kiswahili Language used by the Waswahili
Kenya shilling (Ksh.) Money used in Kenya the exchange rate was Ksh. 75-80 to the
dollar. Minimal wage ranged between Ksh. 8,000 to 20, 000.
Kanga/ Leso A rectangular piece of colorful cotton cloth, approximately three by one
feet with multi-purpose use, worn in pairs.
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
MEDICAL PLURALISM AND UTRLIZATION OF MATERNITY
HEALTH CARE SERVICES BY MUSLIM WOMEN INT MOMBASA, KENYA
Fatma Ali Soud
Chair: H. Russell Bernard
Major Department: Anthropology
This is a study of health-seeking behavior of pregnant Muslim women in
Mombasa, Kenya. Early initiation and attendance of prenatal care has been shown to
result in positive pregnancy outcomes. In addition, birth delivery assistance from a
trained and well-equipped provider is necessary to reduce maternal morbidity and
Kenya, among other countries in Africa has a high maternal mortality rate. The
maj or direct causes of mortality are hemorrhage, sepsis and hypertensive diseases of
pregnancy. Malaria, anemia, tuberculosis and HIV/AIDS as well weaken the immune
system and add to the toll of death during childbirth. Due to the HIV/AIDS epidemic,
Mombasa has an increasing rate of mother-to-child transmission (MTCT). In this study,
women' s knowledge of MTCT is assessed.
To address these above issues, Kenya developed a Safe Motherhood Initiative in
1987. This initiative was to identify poverty reduction strategies among women, improve
reproductive health and assure child survival. The research reported here adds to the
studies of the Safe Motherhood Initiative from the women' s perspective. I believe that
many of the findings of the research reported here can apply to urban areas across Kenya
and, indeed elsewhere in urban Africa where medical pluralism is the norm.
I investigated the available maternal health care services and how, when and why
women used or did not use them. I used participant observation followed by and a
questionnaire to collect data from 265 Muslim women. Logistic regression techniques
are used to estimate models of prenatal care use and choice of a birthing facility. Women
were interviewed during the postpartum period, while in the hospital, at home and while
attending the sixth week check-up. The results demonstrate the complexities of women' s
lives and the difficulties they face in accessing maternity health care. Their reasons for
not getting the care they need include cost, distance, lack of competence of health care
providers, and frequent shortages of essential equipment and supplies to provide basic
essential obstetrical care. In addition, their beliefs, knowledge and attitudes about the
efficacy of health care services and the curability of their condition affect their health-
This is a study of health-seeking behavior of pregnant Muslim women in Mombasa,
Kenya. Mombasa has an increasing rate of mother-to-child HIV transmission and a high
maternal morbidity and mortality. HIV-positive women transmit the virus to their infants
during pregnancy, during childbirth and while breastfeeding. HIV positive children fail to
thrive and have delayed motor development, with deceleration in mental health. These
children have a poor prognosis. Their health deteriorates at a faster rate due to AIDS, and
mortality is hardly past five years of age (Butlerys and Lepage 1998). In 2001 Kenya had
220,000 cases of pediatric HIV infection from mother-to-child transmission
(UNAIDS/WHO Epidemiological Fact Sheets 2002).
Kenya has a high maternal mortality. In 2001 it was estimated at 590 deaths per
100,000 births, and this is likely to be an underestimate since many maternal deaths are
not reported. The director of medical services in Kenya estimates that from 3300 to 6000
Kenyan women die each year of pregnancy related causes (Ministry of Health 1997). The
maj or direct causes of mortality are hemorrhage, sepsis, and hypertensive diseases of
pregnancy. Malaria, anemia, tuberculosis and HIV/AIDS weaken the immune system and
add to the toll of death during childbirth. To address these problems, Kenya developed a
Safe Motherhood Initiative in 1987. This initiative was to identify poverty reduction
strategies among women, improve reproductive health and assure child survival. The
Safe Motherhood Initiative was followed by a National Reproductive Health Strategy
covering the period 1997-2010. The strategy required all districts and provinces to a:
the causes of maternal and perinatal morbidity and mortality (Republic of Kenya 2001).
Pilot studies have been conducted across Kenya to assess the results of these safe
motherhood programs (Trangsrud and Thairu 1998). Findings reported here adds to these
studies of the Safe Motherhood Initiative. I believe that many of the findings of the
research reported here apply to urban areas across Kenya and, indeed, elsewhere in urban
Africa where medical pluralism is the norm.
This study was initially set to interview HIV-positive women, however when I
arrived in Mombasa, I was informed by clinicians that this would be difficult since most
of the women are not tested, and if tested women do not return for results. Previous
studies explain that women do not return for results due to fear of knowledge of an HIV
positive status. Another obstacle was women who knew that they were HIV-positive did
not want to reveal their status due to stigma. Although I questioned if a respondent was
tested for HIV, I did not inquire whether one is positive or negative. Knowledge of
testing and counseling for HIV is an important component in maternity health care
assessment. I re-formulated the hypotheses as follows:
1. Muslim women who have strong Muslim beliefs will go to Islamic institutions
and healers compared to women without similar beliefs;
2. Women who have knowledge about MTCT will seek more adequate maternity
health care than will women without similar knowledge;
3. Women who develop pregnancy related illnesses or complications will seek
Islamic healers compared to women without complications.
To explore these above issues, I investigated the available maternal health care
services and how, when and why women used or did not use them. I used participant
observation followed by a questionnaire to collect data from 265 Muslim women in
Mombasa, Kenya. Prenatal care services and parturition in a well-run biomedical
facility would improve maternal and child health. However, although most women do not
deliver at home, the facilities that they do use do not provide the kind of care that can
reduce mother-to-child transmission of HIV.
The results demonstrate the complexities of women' s lives and the difficulties they
face in accessing maternity health care. In relation to the hypotheses, women who had
economic means independent of their spouses or family had better access to health care
than women who did not irrespective of religious beliefs or educational status. Women
whose economic status was dependent on spouses, partners, and family members had
varied reasons for lack of or poor access to adequate maternity health care. Their reasons
for not getting the care they need include cost, distance, lack of competence of health
care providers, frequent shortages of essential equipment and supplies to provide basic
essential obstetrical care. In addition, their beliefs, knowledge and attitudes about the
efficacy of health care services and the curability of their condition affect their help-
In this chapter, I explain the different theoretical models used by medical
anthropologists in analyzing non-Western health care decision-making processes and
behavior. Kleinman's (1978, 1980) explanatory model is appropriate for this study, it
incorporates the individual's cultural response to illness and treatment. Furthermore, the
model refers to the patient' s and family's conceptions of the nature of a particular illness
episode, its causes and effects, expected and /or desired treatment and apprehensions
about the outcome .
In this chapter, I also explain the three routes through which a mother can transmit
HIV to her infant, and the preventive and curative methods to decrease or avoid
transmission. I also discuss the importance of prenatal care to illustrate what women
should be receiving when they get efficient care. From my personal experience as an
obstetric nurse, the expectations developed in the United States about what constitutes
adequate prenatal care are unrealistic for Mombasa. I present below some of the debate
on the adequate number of prenatal care visits. I also review the literature on the use of
prenatal care services by women with and without HIV infection and compare it with the
results from Mombasa.
Chapter 2 outlines the geography and history of Mombasa and offers a brief
overview of Muslim women' s life there. Mombasa has 750 years of recorded history and
it is unique on the African continent. The town's cultural and ethnic mixture comprises
the local Bantu with Arab, Indian, Portuguese, Chinese and British soj ourners, some of
whom remained in Mombasa to this day. "If a society or culture does not develop
procedures for healing and curing, it does not exist," says Rush (1996: 13 8) and indeed,
Mombasa' s fluid and plural medical system, developed from its turbulent history, as I
explain in Chapter 3.
Chapter 3 outlines the medical pluralism practiced in Mombasa. Kleinman's (1978,
1980) explanatory model divides medical pluralism into three sections: biomedicine,
traditional medicine, and the lay sector. Islamic health practices are found in all three
sectors. In Mombasa, biomedicine is respected by Muslims when treatment is required
for outbreaks of diseases such as typhoid. However, when the agent for an illness is
suspected to be supernatural, Muslims in Mombasa seek other means of healing. In this
way, they are similar to Christian Indians in Latin America (Crandon, 1986), Hindus in
India (Subedi 1989) and Buddhists in Thailand (Golomb 1988, Techastraisak and Gesler
1989). The dissatisfaction of one therapeutic system to heal or cure leads users to try
others until a remedy is achieved.
Chapter 4 explains the methods used in this research. I present the research design
and obj ectives, the advantage and disadvantages of native ethnography. In addition, I
illustrate the areas and methods of data collection and the sampling design.
Chapter 5 presents the major results from analysis of the 265 questionnaires. The
individual respondent's questionnaires provided information on the following:
demography, household characteristics, knowledge of mother-to-child HIV transmission
and use of maternity health care services. Logistic regression models the use of various
prenatal and natal health care options
The ethnography of pregnancy, childbirth and postpartum is presented in chapter 6.
I have included women's concerns of secondary infertility and pregnancy loss and the
herbal and ritual prohibitions and treatment to ensure fertility. Furthermore, I incorporate
illnesses that women perceive as risks for a pregnancy and the plural methods used to
treat these conditions. I finally narrate my experience of observing childbirth in a home-
In Chapter 7, I present the summary and conclusion using cultural materialism as a
theoretical tool to evaluate the different components that impede or assist women's
access to maternity health care. I divide these varied factors into the format of
infrastructure (demography, occupation, and obstetrical characteristics), structure
(education, domestic and political economy) and superstructure (values and beliefs). This
model takes into account that there is a relationship between all of these above elements
when women seek health care. The concept of reproductive health is a basic human right
and any of the above factors can help or infringe on this right.
Theoretical Models in Health Care Seeking Behavior
Medical anthropologists have offered five different frameworks for analyzing
decision-making about health care in non-Western societies. These are the determinant,
process, mental, systems and critical models. Although these models may provide
"overlapping, sometimes contradictory explanations of similar phenomena," (Ryan
1995:7) no single framework appears adequate for explaining a group's health-seeking
The determinant model attempts to account for intra- and intercultural variation in
health-seeking behaviors by examining the characteristics of illnesses, patients,
caretakers, households, communities and health care services, as well as the individual's
actions and willingness to seek care (Mechanic 1969, Colson 1971, McKinley 1973,
Foster and Kemper 1973, Fabrega and Manning 1979 and Stoekle et al. 1963). Friedson
(1960), Suchman (1964), Chrisman and Maretzki (1982), Igun (1979), and Young (1981)
emphasize that decision making about health care is a process rather than simply a
determined outcome. The process begins with awareness of an illness, followed by
diagnosis, selection among alternative therapies, and evaluation of the therapy. This can
lead to new choices and re-evaluation of outcomes. Nyamongo (1998) and Mbeh (2000)
found the process model to have more predictive power in assessing response to infant
diarrhea and malaria respectively.
Frackenberg and Leeson (1976), Feierman (1981), and Young (1981) describe the
systems model as the impact of social forces on the search for health care. This model
according to Janzen (1978) requires two levels of analysis, one at the micro level
(incorporating perceptions about an illness, the prevalence of the illness, and efforts to
diagnose, prevent, and cure an illness) and one at the macro level (incorporating
information about large scale social entities such as health institutions, economic and
political systems that dictate access to health care. Janzen (1978) points out that, in most
non-Western societies, the reaction to illness involves a "therapy management group"
comprising the friends, family and others in the social network of the ailing individual.
McKinlay (1973:275) adds that "the family, its kinship and friendship networks,
influence the manner in which individuals define and act (or fail to act) upon symptoms
of life crisis."
Kleinman (1978, 1980), Cominsky (1982), MacCormack (1982) and Good (1986)
formulated the mental models approach to health care seeking. This model focuses on
how people understand and experience their illness and that of others around them. This
understanding is, of course, a function of local culture. Kleinman's (1978:86) proposes a
theory using the explanatory model (EM) to describe illnesses in different sectors of the
health system. For each illness, according to the EM approach, there is a set of beliefs
about its etiology, onset of symptoms, pathophysiology, development, severity, and
treatment, as well as about appropriate roles for those afflicted. In addition, the EM
approach examines macro-level or external factors, such as the political, economic,
social, historical and environmental determinants in health care seeking behavior. Singer
(1990) has criticized Kleinman' s use of the EM approach and ignoring power relations
between social groups and between classes. I take this critique into consideration in
analyzing the data reported here. The EM approach, in theory, provides a way to make
cross-cultural comparisons of health-seeking behavior. Unfortunately, while many
scholars have done EM studies, systematic comparison for commonalities across cultures
has not yet been achieved. Indeed, I offer the research reported here as a contribution to
EM research, but leave for later the systematic comparison of models for seeking prenatal
and perinatal care.
The critical approach in medical anthropology focuses on how "political and
economic forces, including the exercise of power are used in shaping health, disease,
illness experience and health care" (Singer and Baer 1995:5). This model is "holistic,
historical and immediately concerned with on-the-ground features of social life, social
relations and social knowledge, as well as with culturally constituted systems of
meaning" ibidd: 81; see also Morgan 1987, Singer 1986, 1990, Singer et al. 1992). The
critical model focuses explicitly on macro-level forces to explain behavior rather than on
the individual, though the ethnographic data on which critical analyses are based are
often individual-level narratives (Scheper-Hughes 1992).
Mother-to-child-transmission (MTCT) of HIV
MTCT of HIV-1 can occur before, during or after birth. The contribution of each of
these routes has not been well identified, but it is estimated that two- thirds of potential
exposure occurs in utero and during birth while one-third occurs post-natally.
Understanding the risk of infection from these different routes has been important in
public health for the development of appropriate interventions. According to Newell
(1998), HIV can infect the placenta at all stages of pregnancy, and infected placental cells
may be passed to the fetus during childbirth. She concurs that when the amniotic sac is
intact, transmission may occur from the placenta to the fetus in fetoplacental circulation.
Studies to support intrauterine transmission have detected the "virus from fetal material
as early as 12 weeks' gestation, the intrauterine onset of symptomatic HIV disease, and
the identification of HIV in amniotic fluid" (Newell 1998:83 1). Infants have tested HIV
positive within days of birth, with some infections progressing rapidly, suggesting
intrauterine transmission ibidd).
HIV transmission during labor and delivery occurs in two ways. One is from direct
contact of the infant with infectious maternal blood and genital secretions during passage
through the birth canal. The other is through ascending infections from the vagina or
cervix to the fetal membranes and amniotic fluid through absorption in the infant' s
digestive tract. In either case, cesarean section is appropriate for prevention, with
immediate suctioning of oral and nasal secretions of the infant. The presence of HIV has
been identified in the birth canal, with higher levels in pregnant than in non-pregnant
women. Trials to assess reduction during delivery by antiseptic cleansing of the birth
canal have been conducted in Malawi (Biggar et al. 1996), but results showed no
significant impact on HIV transmission rates, except when membranes were ruptured for
more than four hours before delivery. Studies also suggest a reduction in the rate of
MTCT with the use of zidovudine (AZT) in pregnancy and at the time of delivery, though
the drug has little effect on the serostatus of the mother. AZT during pregnancy and
delivery has become the standard treatment in developed countries, producing a
transmission rate of fewer than 8% in regimen-compliant women. This is still not an
option in most of sub-Saharan Africa because of the cost of AZT and other
antiretrovirals. A single dose of nevirapine, however, given to the mother before she goes
into labor, and a single dose given to the baby within 72 hours of birth, has proven a cost
effective treatment to reduce MTCT in developing countries (Stringer et al. 2000), with
trials in Uganda (Guay et al. 1999) and in Zambia (Marseille et al. 1998). Other studies
done to improve care during delivery (Taha et al. 1997 and Gaillard et al. 2000) have
examined possible interventions to reduce MTCT by antiseptic cleansing of the birth
canal before parturition.
In the postnatal period, breastfeeding has been associated with increased MTCT.
The rates are higher in women who are newly infected compared to women with stable
infection. Present studies are not clear concerning the possibility of increased HIV in
colostrum. Mixed feeding practices also increases risk of infection, due to damage of the
infant' s intestinal tract from the early introduction of other foods. Some infants who
initially test negative at birth become infected at 3-6 months, and in the developed
countries, women on postnatal HIV therapy are discouraged from breastfeeding
Most studies done in Kenya have concentrated on voluntary counseling and testing
for HIV (Cartoux et al. 1996, Vollmer et al. 1999 and Sweat et al. 2000) specifically to
evaluate the acceptability and cost of testing.
Prenatal care services
The proper use of prenatal care services results in positive pregnancy outcomes by
reducing the risk of maternal and infant morbidity and mortality. Health care centers
offering prenatal care provide an informal risk assessment based on clinical judgment to
guide the providers appropriate monitoring and possible interventions during the
pregnancy (Aday and Andersen (1975).
Various factors ((previous medical and obstetrical history, screening laboratory
results, and intrapartum events that predict perinatal morbidity and mortality) are
assigned risk scores which, together, produce a probability of premature or low-birth
weight delivery. Prenatal risk assessment also assesses the probability of adverse
perinatal outcomes (Murata et al. 1992).
Prenatal evaluation continues with urine analysis and blood tests for rubella,
hepatitis B, gonorrhea, chlamydia, genital herpes simplex and HIV. Where available,
screening for congenital fetal disorders, like Down's syndrome, neural tube defects and
Rhesus isoimmunization are performed (Oldenetti et al 1996). Screening for anemia is
important in Mombassa because of the high prevalence of malaria and sickle cell anemia.
The diagnosis of common pregnancy complications, such as intrauterine growth
restriction, post-term pregnancies, pregnancy induced hypertension and gestational
diabetes, is necessary to prevent adverse outcomes. Reassessment of the mother' s well-
being continues throughout pregnancy along with education on the physical and
emotional changes associated with pregnancy. Women who follow through with prenatal
care also get information about childbirth, breastfeeding, and infant care classes. Despite
the measurable benefits of prenatal care, women in developing countries do not
adequately use the services (Berer 1999).
What is adequate utilization of prenatal care?
How much prenatal care is enough? With all the research, this is still a
controversial question. In Switzerland and Singapore (Sen et al. 1991), just three prenatal
care visits are considered adequate, while in the United States, 9-12 visits are
recommended (Kessner 1973, Kotelchuk 1994, Standards for American College of
Obstetricians and Gynecologists 1985). For over three decades, the Kessner Index
(Kessner 1973) has prescribed nine prenatal care visits for a normal pregnancy.
Kotelchuk (1994) Alexander and Cornely (1987) argue that the number of visits is less
important than the content and timing of visits. Adding to the confusion, Mahan (1996)
asserts that indices for judging the adequacy of prenatal care are not useful at all.
"Quality of prenatal care," he says "needs to be judged at the local level. Outcomes of life
or death or handicap are the ultimate measures of quality care" (1996:418).
The World Health Organization advocates, that maternity care should be a
"multidisciplinary, holistic, demedicalized, yet evidence-based approach that involves
women, and their families in decisions about their care" (Chalmers et al. 2001).
Fortunately, empirical evidence is available on this problem. Munjanja et al. (1996)
compared women in Harare, Zimbabwe, who had 12-14 visits with women who had six
visits. Among the 16,000 participants in this randomized field study, there were no
significant differences in pregnancy outcomes, at the aggregate level, for women in the
two experimental conditions. Based on this finding, I consider six visits as adequate
Utilization and access of prenatal care services
In 1998, a joint UNAIDS/UNICEF/WHO working group announced an initiative to
reduce perinatal transmission of HIV. The intervention was formulated to increase infant
survival, based on a package of six components:
-Early access to adequate prenatal care,
-Voluntary and confidential counseling and HIV testing for women and their
-A short course of perinatal antiretroviral treatment for HIV positive women
before delivery and the newborn at birth,
-Improved care during delivery,
-Counseling and support for safe infant feeding practices (Berer M 1999:872).
Many studies show that cultural, structural, and infrastructural barriers to prenatal
care all play a role in determining the rate of adverse outcomes of pregnancy. (See
Mabina et al. 1997, Lang and Elkin 1997, Goodburn et al. 1995, Campbell and Kelly
1995, Wall 1998, McCray 1982 and see Paredes et al. 2005, Romoren et al. 2005,
Manadhar et al. 2004, Nigenda et al. 2003, for recent examples. See Medley et al. 2004
for a review.)
The study I report here focuses on Muslim women's access to prenatal care and
their actual health-seeking behaviors in Mombasa. Pregnant women cannot get HIV
testing and counseling unless they go to a prenatal care health center that provides these
services. A positive HIV test is the entrance for perinatal intervention to decrease MTCT.
The challenge that health care providers and researchers face has been to understand
women' s rationale for not using preventative services even when they are aware of the
It is not necessarily the cost of services that prevents women from fully using
prenatal services, but living a "crisis existence and dealing with issues of financial
difficulties" (McKinlay and McKinlay 1972:377; and see Celik and Hotchkiss 2000,
Jelley and Madeley 1983, McKinlay and McKinlay 1972, Sargent and Rawlings 1991,
and Wilkinson et al. 2001). For example, user fees for preventative primary health care
were removed in South Africa in 1994 but this did not improve prenatal care utilization
(Wilkinson et al. 2001). By contrast, low-income HIV- positive African-American
women on Medicaid in New York improved their use of prenatal care (with concomitant
improvement in birth outcomes), once a program was implemented to enhance the
women's understanding of health-seeking behaviors (Turner et al. 2000).
Studies of African-American, Mexican-American and Puerto-Rican women in the
United States indicate an association of low socioeconomic status (SES) and
marginalization with low-birth weights, premature deliveries and adverse pregnancy
outcomes (Echavarria and Parker 2001, Gardner et al. 1996, Lia-Hoagberg et al. 1990,
Petitti et al. 1990, Turner et al. 2000). In Britain, Petrou and colleagues (2001) infer that
women of Pakistani and Indian origin made fewer prenatal care visits than attendance
made by white British women, possibly due to cultural and religious beliefs. Magadi et
al. (2000) in their study of frequency and timing of prenatal care in Kenya state that
women' s attendance was inconsistent, suggesting further research of traditional beliefs,
religious and cultural practices.
Other demographic factors included in most of the above studies included age,
parity, obstetrical histories and desire for the pregnancy. Teenagers and uneducated
women under-utilize prenatal care services (McCaw-Binns et al. 1995). There is also
documentation that prior adverse obstetric experience is a barrier to seeking early care
(Ivanov and Flynn 1999).
Lack of support from family and friends, particularly to assist with childcare or
transportation, is a structural barrier to the use of prenatal care (Winston and Oths 2000).
In some societies, women have to ask for permission from their partner, their in-laws or
their co-wife before leaving the household. The permission giver must therefore be an
advocate of biomedical health care. In Mombasa, the saying that "pregnancy is not an
illness" implies that women should not use the need for prenatal care as an excuse for not
fulfilling their familial and social obligations during pregnancy. The saying is clearly a
cultural artifact, but it belies a structural barrier, because so much of daily life (cooking,
cleaning, and taking care of infants, taking care of sick and frail relatives and friends)
depends on women's remaining active during pregnancy.
In terms of infrastructure, the sheer presence of low-cost, easy-to-reach clinics can
have an impact on the rate of use of prenatal care. Women often say that they are put off
by the long lines at clinics, inconsistent health care providers, the lack of female staff,
and a general lack of confidence with the health care system (Barnes-Josiah et al. 1996,
Handler et al. 1996, Ivanov and Flynn 1999, Mayer 1997, Petrou et al. 2001) Despite the
importance of these factors, all the evaluation studies just cited agree that strong rapport
between the pregnant woman and her health care provider increases women's health
HIV positive women and the utilization of health care
Good communication between health care providers and pregnant women with
HIV is all the more important because these women deal with the challenges of taking
care of themselves, their families and their children in an environment of fear, guilt,
"stigma, uncertainty, and limited access to information and health care" (Bunting and
Seaton 1996:563). Lack of privacy is a maj or satisfaction issue in health care centers in
Mombasa due to overcrowding. In order to create privacy, counseling rooms for HIV
positive women have been made available in a few facilities through Horizons Project of
the Population Council a USAID venture (USAID 2001). Unfortunately, unlike other
pregnant women, HIV positive pregnant women have an added concern while attending
prenatal care clinics the fear of disclosure of their HIV status to a spouse or boyfriend,
family member, neighbor or co-worker (Sobo 1995).
Walter et al. (2001) found that, though new mothers were not knowledgeable about
perinatal HIV transmission and did not trust health care institutions; this did not deter
some of them from seeking health care. Oldenetti et al. (1996) found that HIV positive
women believed that every woman should have the option of being tested but that HIV
testing should not be done unless counseling and treatment are available. Sobo (1995)
found that women trust clinicians who show empathy and a non-judgmental attitude and
who do not pressure women to disclose their HIV status. Given this, Sobo recommends
straightforward communication to reduce misunderstanding.
Ingram and Hutchinson (1998) reported that HIV positive women felt oppressed
and discriminated against by society and by the health care profession. These women,
they say, use various coping mechanisms in order to lead "normal" lives alternately
concealing their HIV status from strangers or looking for sympathizers in society. In a
follow-up study, Ingram and Hutchinson (1999) say that some women develop an attitude
of "defensive mothering" to protect their children against stigma. These mothers did not
hide their HIV status from friends and family and took extra precautions in their health
behavior and practices. The near-universal directive to reproduce provides a woman with
a different status during pregnancy. "Babies represent sources of love, acceptance, and a
legacy for the future," say Ingram and Hutchinson ibidd: 243) "even for a woman with no
sense of future for herself." Other studies show that guilt and the fear of dying and
leaving children behind can become an emotion that dominates women's reproductive
decisions (Sowell and Messner 1997, Williams 1990).
Much of the researches on cultural and social barriers to prenatal care for HIV-
positive women have been done in the United States. The MTCT problem is greatest,
however, in developing countries. The research I report here contributes to the research
called for by Reeves et al. (1999), among others, on HIV positive women's knowledge
about MTCT, and the barriers that prevent them from using available prenatal and
MOMBASA THE RESEARCH AREA
Mombasa is located off the coast of East Africa. As Kenya' s second city, it is the
main seaport and the capital of the coast province. Kenya has seven provinces; the coastal
province is one of them. The island of Mombasa adj oins the coastal hinterland; it is
symmetrically oval, three miles long and five-and-one-half square miles in area, lying on
a northwest-southeast axis (Stren 1978). The connection of the island to the mainland is
the Nyali bridge in the north, the Makupa causeway to the west, and a daily ferry service
in the south. The whole coastal region has a tropical climate with northeast and southeast
having monsoon winds. The harbor has deep waters providing excellent channels for
anchorage and access for large cargo ships, thus providing access for visitors from around
the world (Ntarangwi 2003).
Tanzaia Malindi Ocean
Figure 2-1. Map of Kenya situating Mombasa
History: The Visitors and Administrators
Strobel (1979:22) explains that "in the 750 years of its recorded history prior to
colonial rule, Mombasa absorbed one wave of migrants after another, each contributing
to its culture". Mombasa became culturally diverse due to traders from the Indian
subcontinent, Ceylon, China, and north and central Africa, and administrators from
Arabia, Portugal, and lastly Britain. These latter groups have left a lasting impression on
the society's politics, economy and culture.
Mombasa was an urban coastal settlement according to the geographers, al-Idrisi
and Ibn Batuta who visited the area in the twelfth and fourteenth century. Arabs and
Persians initially came to Mombasa to trade. The Arabs ruled the East African coast due
to wars among the existent feudal rulers at the coast. Conversion of the local inhabitants
to Islam was not an initial goal. According to Pouwels (1973) Islamization in Mombasa
took two phases, with a stronger conversion emphasis after 1300. This has been reviewed
extensively by Berg (1968), Davidson (1991), DeBlij (1968), Mazru'i (1995), Prins
(1961) and Salim (1973). The coastal people named Mombasa, "Mvita" or "Isle of war"
due to the many conflicts, instigated by the Arabs and the Portuguese, and later the Arabs
and the British, and the inhabitants against the intruders.
There was a long period of unchallenged Arab domination which ended when the
Portuguese arrived in Mombasa in 1498. The establishment of Portuguese power along
the coast was greatly facilitated by the tension between the various coastal city-states and
their Arab rulers. The period of Portuguese domination, lasted from 1500-1700, a time of
constant clashes with the inhabitants, with assistance by the Arabs. The Portuguese had a
reputation of greed, corruption and dishonesty (Kirkman 1964, Salim 1973).
Dissatisfaction led to a number of rebellions and revolts with the burning down of
Mombasa on two different occasions. Other than economic interests, the Portuguese
brought Augustinian missionaries to convert the inhabitants but they met with little
success (Freeman-Greenville 1980: xxvii). The Portuguese built forts and garrisons along
the coast in order to control this area of the Indian Ocean. The Portuguese culture and
language made a minor impact on the local Swahili culture (Abdulaziz 1995:144).
However, they introduced crops such as, maize cassava, cashew trees, avocado, guava
and tobacco (Salim 1973:4). The Portuguese withdrew to Mozambique after numerous
rebellions and riots (Kirkman 1964).
Mazru'i (1995:4) explains that there "was a power vacuum in East Africa during
the 18th century" and the early 19th century after the removal of the Portuguese. From
1698, the Yarubi dynasty in Oman placed the Mazrui family as governors of Mombasa,
and they ruled for 139 years. By 1812, the occupation of the Sultan of Oman was more
evident with the presence of a powerful naval and military force in the Indian Ocean,
incorporating the coast of East Africa as part of the Omani kingdom. Abdulaziz
(1995:145) asserts that this was the beginning of a "new era of political, cultural and
economic change" on the East African coast. Other immigrants were brought from other
countries, such as Hadhramut, Baluchi, and India to act as laborers, officials and soldiers.
The local culture and life-style became integrated with that of these immigrants in
language, dress and clothing, architecture and cuisine. The diversity was solidified
through inter-marriage with the local inhabitants. This was to become the Swahili culture
and the people who adopted the language, and customs became the Waswahili. Kiswahili,
the language has a Bantu structure; however Arabic is evident in 40% of its vocabulary,
and there are also a few Portuguese and Indian words. The word "Swahili" in Arabic
means "coast" and Waswahili means people of the coast.
The Arab domination of the East African coast coincided with the ivory and slave
trades Mombasa was a maj or slave receiving port, with some slaves remaining as
domestic and agricultural laborers (Strobel 1979:30). The effort to end the slave trade on
the Indian Ocean was one of the reasons that the British entered Mombasa. Although the
British abolitionists had humanitarian reasons to stop slavery, they also had political and
economic motives (Mazrui and Shariff 1994:31). British colonial rule began in 1895,
ending almost two hundred years of Arab domination. The British took administrative
responsibility from the Imperial British East African Company, and made East Africa its
protectorate with Mombasa as its capital. This changed in 1902 when the capital was
shifted to Nairobi. Roads, railways, and other governing infrastructure were built to
increase security and to improve the political and economic advantage of the British
administrators. These improvements not only altered Mombasa' s economy, but, as the
Mombasa' s importance as a port grew, it also brought an influx of immigrants from
upcountry (Ntarangwi 2003: 34). These new immigrants, whose ethnicities are Kikuyu,
Luo, Luhya and others, were different from the coastal people in culture, religion and
language. These immigrants were perceived by the established society in Mombasa to be
aggressive, and "uncultured" and there was initial resistance in accepting them into
Mombasa' s society (Foeken et al. 2000; Strobel 1979). Some of the so-called new
immigrants have intermarried and assimilated into the Swahili culture, including
converting to Islam, with their offspring becoming Swahili.
The Coastal People Waswahili
Many scholars have tried to determine the origin of the Swahili culture and its
people (Berg (1968), Chami (2002), Mazrui and Shariff (1994), Nurse and Spear (1985),
Salim (1973), Strobel (1979), Swartz (1991) and Willis (1993)). The prevailing theory
focuses on the fact that the initial groups of people in Mombasa called themselves the
"twelve nations" (ithna~shara taifa). These twelve nations are divided into two groups,
one group of three (miji tatu), comprising the WaKilindini, WaTangana and
WaChangamwe, and a group of nine (miji tisa), comprising the WaMvita, WaJomvu,
WaMtwapa, WaKilifi, WaPate, WaPaza, WaShaka, WaGunya and WaKatwa. Each
group, or nation (mataifa), had its own political representative who governed through
Arab and Portuguese rule. This system disintegrated, however, under the British.
Most of the people belonging to these groups referred to themselves by their
ethnicities and do not call themselves Waswahili (this occurred as well when I questioned
ethnicity in this research). According to Salim (1973:1-6) these groups are what
constitutes the Waswahili. He further defines the Waswahili as people of the coast with a
similar language--that is, Kiswahili--and having a culture influenced greatly by the
Muslim faith. He finally claims that "the Swahili do not form one tribe claiming one
ancestor. The Waswahili are the result of mixing and intermarrying between Africans and
Willis (1993:12) argues that "there is no single 'definition' of the Swahili: different
people, in different situations, may appropriate this ethnonym or apply it to others
according to their perception of their advantage". This argument stems from assessment
of the Waswahili in three areas. First, during British colonialism, for the enforcement of
taxation and other laws, the differentiation of "natives" and "non-natives" served as a
basis for people to define themselves to their economic or political advantage (Stren
1978:32). Secondly, after abolition of slavery, a freed slave became Swahili, by
converting to Islam, thereby acquiring status as a non-slave (muungwana). Thirdly, after
Kenya's independence, to be accepted into the new political arena as a mwananchi (a
term reserved for an indigenous African), people who had claimed Arab or Persian
ancestry now had to disassociate themselves from being anything other than African.
Another group of people in Mombasa are the Mijikenda, comprising nine Bantu
ethnicities; the maj or ones are the Digo (almost all Muslims) and the Giriama. The
Mijikenda have also intermarried with the Arabs and Waswahili, some calling themselves
Waswahili, although the maj orities have kept their ethnic identities. Some of the
Mijikenda were also added to this study because of the sharing of culture, particularly in
How has the history influenced society?: Among these ethnic groups in
Mombasa, some cultural practices are shared while others are not. For example, healing
for high blood pressure (mwajuu) in pregnancy is done by the Mijikenda, but Arab
women use the treatment.
During my fieldwork, I observed and listened to women as they complained about
demands on their time that kept them from taking care of things like preventative health
care. Some of these demands include visiting friends, neighbors and relatives; attending
ritual events such as weddings, circumcisions, births, and funerals; and religious studies.
While these activities take time, they also provide a network of emotional and practical
support, "access to jobs, goods and information" and "insurance against economic and
personal calamities" (Holmes-Eber 2003:9-10).
What Occupies Women's Time in Mombasa? Society and Culture
Visiting friends and relatives: Visits to friends, neighbors or family are made by
women mostly in the late afternoons, but can occur at any time during the day. These
visits are done after women have finished their other duties of cooking, cleaning and
childcare, or for those who work in the formal economy, after work. Fitting in a hospital
appointment for preventative care becomes difficult for some women who have to plan
for visits. The visits are informal without previous announcement and can be a quick
"just checking to see how you are" (nimekuja kukujulia hali) or a full day (kushinda)
depending on the purpose of the visit. Visits are considered social, cultural and a religious
obligation, particularly when visiting the sick. Depending on the duration of the visit,
drinks such as tea, coffee or soda may be served. On these visits, exchange of
information, chit chat or gossip takes place from the latest fashions, births, weddings or
funerals to be attended or checking on other family members. Holmes-Eber (2003) in her
research of women in Tunisia analyzes visits as important survival strategies for women.
In addition, she asserts that match-making and arranged marriages take place as young
people visit and meet at these social gatherings. There is no specific word in Mombasa
that describes the word "visit", except words that explain what the visit is about, for
example "I am going to visit the sick" (nenda kumtizamna mgonjwa) or "I am going to pay
my respect to the deceased family" (nenda ku~wapapole waliofiliwa).
Visits are reciprocated particularly for the sick. A woman who visits others also
receives visitors (atakaet~~~~tttt~~~~tttt watu na yeye hutatttttttt~~~~~~~kikana) when she or a family member gets
sick. A visitor will cook and clean and help with the general upkeep of the house.
Furthermore, if the sick is admitted, the visits continue at the hospital. Hospital
administrators and clinicians (especially those from up-country) voiced concern and
frustration due to these visits, because of the amount of people that come to see or stay
with the patient. Hospital rules that are strict and impose special times and number of
people by a patients bedside are criticized, at times creating conflict between hospital
personnel, relatives or friends. The hospital administrators, understanding the culture,
allow one relative to stay with a patient at all times, and leave this person to be the liaison
to the other relatives or friends not allowed in. The advantage to clinicians is having a
family member to assist in caring for the sick, especially when there is shortage of staff.
The disadvantage however, is the lack of privacy for other patients and taking time to
explain procedures to the patient and relative. Information about the patient's condition
and interaction with hospital personnel is relayed to other visitors. Even an infectious
disease does not deter a family member from staying with the sick. Desertion of a sick
family member is considered inhumane, leading to other community members criticizing,
scolding or ostracizing with comments such as, "how could you neglect your sick?" (vipi
mumemtupa mgonjwa wenu?). These comments are also made if a relative does not take
of a woman who has given birth. Having a sick family member obligates a woman
visiting others, or being involved in social activities. She is expected to take time c
work and stay home to take care of the sick. Other relatives take turns and participate in
the duties of caring. The help from other family members include when and how to seek
for health care providers.
Grandparents or older family members not living in the same household, as well
have to be visited and greeted whether daily or at least weekly, even when they live with
other family members who take care of them. Visits increase when the elderly get sick or
a sick person's condition deteriorates or at the time of death.
Funerals: Before death or when a person dies, the relatives and close friends
gather to pray and perform the last rites. Attending a funeral is assurance that an
individual will get a decent burial at death. A woman's last rites are performed by
women, and men's by men. The corpse is left in the house where she or he died, and if
the individual died at the hospital, the corpse is brought to his/her home for the last rites.
Following Islamic rules of the last rites, the body does not undergo post-mortem unless
foul-play is suspected and authorized by the law. The burial is conducted on the same day
or within twenty-four hours after death for example, a person dying in the night is buried
before sunset on the following day. A corpse that cannot be buried and has to be kept
overnight is left in her or his home. Relatives and friends gather in the deceased home
and Quranic text or special recitations for the soul of the departed are read. At times a
religious teacher (nawalinsu) and his students may be invited to conduct these recitations
during the day before or sometimes after the burial. The one who washes the corpse
(nzuosha nzaiti) can be a family member, neighbor or friend especially for women;
however for men a designated community member has this responsibility. A large ba
(in modern houses) is kept under a special bed without a mattress (kitanda cha nzwak
used just for washing the corpse. In homes that still have beaten earth or mud flooring, a
hole is dug underneath the bed where the water drains. Pregnant women are excused from
participating from performing funeral rites.
During this research, there was controversy about the performance of the last rites
in relation to people who die due to infectious diseases, such as AIDS. The community
was divided, with one group agreeing to adopt the recommendations of HIV/AIDS
activists and health care providers who wanted to implement the use of gloves and special
training to be given to the washers in how to handle infected body fluids. Those who
opposed such interventions argued that such practices would expose the family to the
stigma that their family member died of AIDS, and also dishonor the dead (kutuaibishia
maiti). It was decided that all bodies should be handled the same way whether the
individual died of an infectious disease or not. Wearing of gloves and careful handling of
body fluids is now widely adopted, but not by all.
Close relatives and friends spend three days after the burial at the deceased home.
Money for food is collected from all the attendants and the mourners are fed. On the third
or/and seventh day a gathering that includes neighbors and some community members
takes place to pray for the soul of the deceased (khitma) and a big lunch is done to feed
them. This practice is now discouraged as non-orthodox Islam by the religious leaders,
who argue of its significance, especially since at times it places a financial burden on the
mourners. Despite these protests, some people still continue with the practice.
Weddings: Traditionally marriages were arranged between families, and some
do since a marriage involves the couple, both sides of the family and their relatives.
Endogamous marriages are encouraged, following the Arab intermarriage system, with
parallel cousins being preferred. These are done to "reinforce kin ties, keep wealth in the
family and increase parental control and protection of daughters" (Holmes-Eber
2003:50). Women's education and occupation has increased exogamous unions and
getting more and more societal approval.
Wedding preparations can start months before the actual exchange of nuptials. The
arrangements are done by the relatives with each member volunteering to organize one of
the many festivities that fit into three to seven day. The men may have only one or two
days of organizing, which include the legal and religious aspect of the wedding. The size
of the wedding depends on the wealth of the extended kin. The women involved undergo
beautifying rituals such as removal of all body hair (except the head) through "waxing"
or "threading", plus decorative staining of the hands and feet with henna. These get
together parties might be held at either the bride or groom' s parent's home or at a family
member' s house.
Most of the women feel obligated to participate, as explained by one, "if you do not
get involved, then nobody will come when it is your time" (nisipolorenda, halafu hakuna
atakaekujat~~~ttt~~~ttt~~ nikiwa na langu). What used to be a neighborhood and community affair for
most areas, wedding practices have now changed, with families providing special
invitation cards to minimize the expense of weddings. Despite this change, many families
undergo financial hardship due to these elaborate arrangements. Sophisticated clothes and
expensive jewelry mostly gold are at times bought or ordered from Europe or the Middle
East. The more grand a function, the more status a family receives from the community. I
met women I had interviewed who had complained about not having money to pay for
health care, however they were adorned with very expensive jewels. When I questioned
the attire, one protested that "I do not want to embarrass myself' (sitakitt~~~~tttt~~~~ kujiaibisha). A
woman, who openly displays her inability to dress well or adorn herself with the latest
fashion and j ewels, makes a public statement of being poor (uma~skini), thus shaming her
husband and family. Salim (1973), Strobel (1979) and Swartz (1991) describe further the
details and responsibilities of the sexes, and the daily festivities for each day in a typical
wedding. Ntaragwi (2003) moreover illustrates the types of music for each occasion.
Some women prioritize their time differently, and are very selective of which
activities or visits to attend. These are mostly professional women who are busy and find
it hard to keep up with the day to day family and social activities. Another group of
women are those who attend religious classes (darsa~s). These women excuse themselves
from non-religious related activities in the community. These darsas~~~~ddddd~~~~dddd involve a lot of time
for the organizers and the participants. They take place mostly in the evenings, about
three times a week. I attended one of these meetings, just as I had attended weddings,
funerals, visited a relative's son after a circumcision and numerous visits to sick friends
and relatives. At the darsa, I was invited to talk about my research, and discuss my
evaluation of women' s health issues in Mombasa.
MEDICAL PLURALISM INT MOMBASA
Fabrega (1997: 12) has defined medical pluralism as a theoretical framework to
explain the differences between the dichotomies of disease/sickness and illness/healing.
Within medical anthropology, disease/sickness explains the biological or psychological
processes, diagnosed and treated within a Western biomedical framework. Illness/healing
on the other hand explain an individual's and his societal psychosocial interpretation and
management of sickness, (Fabrega 1997, Kleinman 1978, Waldram 2000, Young 1981).
Waldram (2000: 605) further argues that, "every medical system is a cultural system and
is engaged in both healing and curing". The practice of medical pluralism is universal
with the incorporation of alternative or complementary therapy, which may include
homeopathy, herbals, natural healing and holistic therapy. In non-Western societies, the
use of traditional medicine and some of the above practices are incorporated with
methods to include indigenous and religious healing rituals.
The word for health in Kiswahili is afya which is a holistic concept that goes
beyond that set by the WHO to include wholeness, safety and strength. "The healing
processes for ill health include attention to social relationships, emotions and religious
spirituality and conformity with tradition" (Boerma and Bennett 2000: 261). Ndege
(2001: 90) adds that being in good health not only includes the biological functions of the
body, but also embraces the political and economic forces that impact the body (Janzen
Each healing practice, according to the beliefs of pluralistic health systems, is
incomplete. For example, among the women I studied, biomedicine has antibiotics tl
can take care of respiratory infection, but the antibiotics can not take care of the wind that
might have caused the body's physical imbalance. If any given tradition is incomplete,
then pluralism makes perfect sense. In Mombasa, cultural healing practices include home
remedies, traditional/folk healers, herbal practitioners, Muslim and Christian spiritual
healers, charlatans, drug vendors, biomedical hospitals, and public and private health
Kleinman (1978: 86) asserts that illness is experienced and reacted to in three
sectors: the folk/traditional, the professional and the popular. He further explains that
groups have "cultural categories that they organize various types of illness and methods
of treatment" (Ware et al. 1989: 24) I have incorporated Islamic medicine and healing
practices within all these sectors since it is part of Mombasa' s pluralistic health care
Biomedical Health Care
Biomedical or clinical medicine in Mombasa is organized under the government' s
Ministry of Health (MoH), with headquarters in Nairobi (the capital of Kenya). The
government runs and owns about 5 1 percent of the health facilities countrywide (Owino
1998). Overseers assigned from the government headquarters implement health policies,
maintain quality standards of care and control all resource allocations to provincial and
district health activities. Nongovernmental, private-for-profit and mission organizations
run the rest of the facilities. For further details of the history of health care and the health
care infrastructure in Kenya see Beck (1981), Mburu (1981), Ndege (2001) and
Nyamongo (1998). In addition, Obonyo and Owino (1997), Owino (1998), and Owino et
al. (2000) have written on the financial and managerial challenges Kenya faced frc
independence (and continues to face) and guidelines needed to improve deliverance of
efficient health care services. Health care for all used to be free in Kenya until 1989
when cost-sharing programs were implemented after the introduction of structural
adjustment programs to assist the state with economic health management (Wanyande
The main maternity hospital in Mombasa, named Lady Grigg, is located at the
Coast General (Provincial) Hospital (CGH). The hospital's administrative responsibilities
are handled by the Provincial Medical Officer and his or her executive team. There are
two ways that women can get prenatal care: through CGH and from the health
department run by the municipal council. The CGH provides prenatal care services under
the preventative health care system. These services are also offered in seven department
health centers in Mombasa. These centers, however, are managed and financed by the
Ministry of Local Government, represented by the local Municipal Council. The
complexity of this system has been summarized well by Schaefer (1981:13 0) who states,
"often the government of the central city has no authority over other towns in the
conurbation, and rival local governments may pursue uncoordinated and contradictory
policies". This lack of coordination was especially evident in Mombasa for pregnant
women who presented with complications and needed advanced health care. Women with
complicated pregnancies are referred to CGH where there are advanced medical facilities.
Communication between clinicians who examine women at the health departments and
obstetricians at CGH is almost non-existent. CGH does not deal only with women with
complications from Mombasa Island, but also from the adj oining districts that comprise
the coast province. This province has a population of over two million. Despite the
inefficiencies at the municipal level, prenatal care services provided for women at the
CGH were well-organized, with formal educational classes given or televised while
women waited for services. The instruction given to women covered nutrition (for them
and for their infant), childbirth, infant care, breastfeeding, and prevention of malaria,
anemia and HIV. I did not observe these classes being offered at the non-government
The maj or private (for profit) hospitals in Mombasa are the Aga Khan, Pandya and
Mombasa. These hospitals have physicians who provide care for their admitted patients
and prenatal care in their offices or clinics. These hospitals are efficient and expensive,
charging approximately Kenya shillings (Ksh.) 20,000 to 40,000 (about $ 250-400) for
childbirth without complications, compared to the government hospital or birthing
centers that charge Ksh. 3000-4000 (about $30-50). Women who use the private facilities
are mostly insured, either by the National Hospital Insurance Fund (NHIF) or by private
insurance. In Kenya the NHIF is mandatory for all salaried employees earning taxable
income, though it reimburses only hospital care (Owino 1998).
The nongovernmental facilities include the African Medical and Research
Foundation (AMREF), UNICEF and various providers from religious charity
organizations. Furthermore, there are numerous for profit out-patient clinics manned by
one or two health professionals that charge reduced fees for health care services. In the
late 1980's, the Ministry of Health allowed health care workers such as nurses and
clinical officers (physician's assistants) to engage in private practice (Obonyo and Owino
1997). This government ordinance led to the opening of numerous out-patient health
centers, pharmacies and small hospitals that serve about five to twenty in-patients,
providing curative and preventative health services.
Christian- and Muslim-run not-for-profit charitable hospitals that charge minimal
fees are among these varied health care facilities. My research concentrated on three of
the Muslim-run establishments--the MEWA, Sayyida Fatima and Al-Farouk hospitals.
These hospitals were in neighborhoods where almost all the inhabitants were Muslims.
This proximity increased women's attendance when they needed maternity health care. In
addition, the cost for prenatal care and childbirth was almost a third less than that charged
at the other private institutions. These three hospitals had a total capacity of 80-100 in-
patients. Each had a small emergency room that managed minor cases of immediate care,
facilities for small surgical procedures, a pharmacy, a laboratory and an out-patient
facility. Moreover, they had qualified physicians (some worked privately, some were
employed by the hospital), nurses, midwives and other various hospital personnel. The
maj ority of the staff and their clients are Muslims, though there were a few non-Muslims.
The sense of familiarity that comes from receiving care from staff of similar religious
beliefs and culture increased encourages some women to use these facilities.
Nevertheless, I heard complaints from several women of nurses being unhelpful and
"arrogant." Criticism also stems from inflexibility of hospital staff in rej ecting certain
cultural practices, like the release of a corpse immediately after death. Islamic practice is
to bury within twenty-four hours. This becomes a problem since hospital rules (imposed
by the government) require that all the right documents be files or that a post-mortem be
done before a corpse is released. This tug of war between religion, culture and
biomedicine affects the relationship of the local community and clinicians. Quite a few
community members asked: "What is the use of having a Muslim-run hospital if they
cannot understand our needs?" The wide knowledge gap between health care providers
and their patients or kin at times created tension when they dealt with each other. Some
women offered these conflicts, created by the hospital administrative system, as their
reason for choosing home-based birthing centers.
Birthing centers are operated by nurses, midwives, clinical officers (physician's
assistants) or, occasionally, a physician. There one or two clinicians at these centers
employ a non-licensed assistant to help with management tasks. The volume of patients is
low--from five to twenty parturitions a month. Prenatal care is not efficient or consistent;
some of these centers have a small laboratory that can perform minor services, such as
hemoglobin levels and urine tests. Women are sent to private laboratories and pharmacies
for services if needed. Women who avoid hospitals because of rigidity assert that this
atmosphere is preferable. On the other hand, women who need advanced medical care do
not receive it at these centers, with detrimental consequences for their health. Basic
biomedical equipment is used during childbirth. Instruments are sterilized; birthing beds
are used with stirrups when needed. Minor surgical procedures such as episiotomies and
circumcisions (of male infants) are performed. One of the maj or complications of
childbirth is postpartum hemorrhage. Oxytocin, or ergometrine, a medication to stop
bleeding, and intravenous fluids are given to women who are beginning to hemorrhage
before they are rushed to a hospital that can provide advanced care.
The atmosphere in these centers is relaxed, jovial and comfortable. Women are not
rushed and services such as body massages are available for a fee. Biomedicine, home
remedies and traditional healing practices are combined. For instance, a woman
diagnosed with anemia is given iron pills, advised to drink a mixture of raisins and spices
(sikifabili), and receives advice in the form of a Quranic verse that she can recite to get
rid of ha~ssad (evil eye).
The health care network starts from these neighborhoods maternity facilities
moving up to the Lady Griggs / Provincial hospital where women are referred for
complications. The private hospitals and the CGH have more sophisticated diagnostic,
therapeutic and rehabilitative services. With the HIV/AIDS epidemic in Mombasa, most
of these other facilities do not have the training to assist HIV-positive women or their
infants in therapeutic care during pregnancy or at childbirth.
Traditional/ Folk Medicine
"Healers have for long been treated like trees on savanna farms not formally
cultivated, yet valued and used, particularly by women and children" (Chavunduka and
Last 1986:259). The traditional healer (mtabibu) has been defined as the witch-doctor
(mganga), diviner, medicine man, herbalist or sorcerer. In an urban area like Mombasa,
biomedicine is politically the only legitimate and acceptable form of health care service,
though the herbalists and diviners continue to practice publicly (Mburu 1992). Ataudo
(1985: 1345) describes African traditional medicine as "the totality of all knowledge and
practices, whether explicable or not, used in diagnosing, preventative or eliminating a
physical, mental or social equilibrium and which rely exclusively on past experience and
observations handed down from generation to generation, verbally or in writing".
Traditional healers in Mombasa are both male and female and they practice for
both sexes depending on ailment. However, pregnancy related illnesses are treated by
traditional birth attendants (TBAs) who have various degrees of knowledge in herbal
remedies. In addition, practices such as massage therapy are done only by women
healers. Healers as well use an "extensive system of classifying illnesses according to
signs and symptoms and suspected cause. Their system is dynamic and increasingly
incorporates biomedical knowledge" (Boerma and Bennett (2000: 262-263). This was
evident during observations and interviews with TBAs. Almost all TBAs stated that they
used gloves and dettol (antiseptic solution) while assisting in childbirth. I observed them
giving pain relievers such as (Panadol/Tylenol) and Chloroquin to treat malaria. In
Mombasa, TBA's are sent for educational training to the provincial hospital to learn
about complications in childbirth and prevention of HIV from contact with body fluids.
This has been promoted and encouraged by UNICEF. The TBAs who receive such
training are registered with the neighborhood chief. Mombasa Island has seven chiefs
who function under the administrative structure of the Municipal Council. These chiefs
have the responsibility to register births and deaths in their locations. They also keep a
log of all practicing TBAs. Not all women who give birth in the neighborhoods are
assisted by registered TBAs. Almost all of the TBA' s stated that they did not have formal
education or training, but had learned from observation. They stated that they received
their training to assist in births from their mothers, grandmothers and/or other female
relatives. A few TBAs stated that they had worked in hospitals as nursing assistants and
had learned from observation. There were two TBAs who declared that it was a spiritual
obligation, since they were "called" to healing. TBAs charge about Ksh. 2000 (about
$25). They do not demand payment before they render their services, and some barter for
other goods or services when financial payment is impossible. They are also flexible.
They go to women' s homes before a birth, and will stay to assist with the care of the
mother and baby if they are not called away for another birth.
During the interviews for this study I talked with 12 women who had assisted in
births, but I spent a lot of time with and directly observed two TBAs (see Chapter 4) who
were conducting the most deliveries in Mombasa. I also interviewed five male healers.
These interviews were not included in the quantitative analysis, but they added depth in
understanding healing in Mombasa. The purpose of healing, I was informed was to regain
'balance' or return the body to the state of 'wellness' by finding out what has afflicted the
body or interrupted or disturbed its function. These healers at times had their own herbs
and remedies which they prescribed and offered to their patients. Alternatively, they sent
their patients to herbalists with prescriptions.
Herbalists are important healers in Mombassa, they are mostly male, and their fees
vary depending on the ailment. The herbalists have an empirical knowledge of the
midicinal properties of selected leaves, barks, saps, roots and other natural products. The
use of herbal medicines begins at home in Mombassa. One tree, the muarubaini, was said
to be useful in the treatment of treat forty different ailments. Drinking a boiled potion
from the leaves of the muarubaini, treated fever associated with malaria, flu or
pneumonia. The herbalists in their shops or at the market prepared and sold what could
not be provided in the home. On the streets are also charlatans who claim knowledge and
competence in healing but prey on individuals who are desperate for treatment. There are
two types of herbalists, one who has a diagnostic and treatment center, while the other
sells his ware at shops or the market place (Beck 1981, Good 1986, Mburu 1992). The
most frequented herbalists in Mombasa are in two shops, one located in Old Town,
owned by an Indian healer. He stated the shop has been family owned since 1873, and
supplies the town with therapeutic treatments from India, China and the Middle East. The
second shop in Mwembe Tayari provides more local herbal remedies, though here, too,
non-local medicines are ordered from Tanzania and the Middle-East. The owners of both
stores explained that they did not diagnose or prescribe treatments. There are other
herbalists across Mombasa. Some sell their treatments at the local market. Others sell
along the road, where people stop to make purchases. Women herbalists who treat
pregnancy related conditions practice mostly from their homes, though a few have stalls
at the market (see Chapter 4).
Diviners are perceived to have a special "gift" or supernatural powers. They vary in
skill levels, specialization, knowledge and beliefs, the types and organization of therapy
they provide, and personal mannerisms. Diviners in Mombassa claim, and some are
believed to have the ability to diagnose and prescribe treatments, though do not offer
treatments. The diviner "gives the ultimate etiological conditions of a psychic, somatic or
psychosomatic disorder, interpersonal alliances and conflicts" (Mburu 1981:172). The
importance of balance in interpersonal relationships is part of being a moral person.
Fairness in the treatment of others protects a person from misfortune and illness. Wishing
ill or hostility on another person also brings harm to oneself (mchimba kisima huingia
mwenyewe). In addition, unresolved social relationships are viewed as causes of poor
health. For example, a pregnant woman's weight loss might be attributed to poor
nutrition, her relationship with her mother-in-law (who might not have accepted her) will
also be seen as associated with her poor health.
A common Swahili is that "daktard'~'~d~d'~'~d~d'i si M~ungu" (the "Western doctor is not God")
leads individuals to seek other local traditional/religious therapists. The incorporation of
Muslim diviners/healers differentiates the use of diviners from other non-Muslim groups.
The Muslim cleric, who is almost always a man, has a role as a diviner by using texts
from the Quran, astrology, numerals or rosary. He also divines through dreams, spirit
possession and necromancy (1980: 84).
"Islam affirms the power and will of Allah in all things, including suffering"
(Whyte 1997:47). Faith, illness and healing go hand in hand and it is common to hear a
sick person and his or her therapy managers to state that the outcome of the illness is
Allah' s will. Cure does not take place if not willed by Allah, and fatalism is the doctrine
sometimes adopted by believers (Feierman and Janzen 1992).
Islamic medicine in Mombasa dates from the 8th or the 10th century (Trimingham
1980), and is still practiced. Islamic healers incorporate Prophetic (Arabic) and Galenic
humoral medicine to view health and assess the body's response to illness. Humoral
medicine emphasizes on the hot/cold dichotomy, specifically in foods and the
environments. Greenwood (1981) and Morsy (1993) provide a detailed narrative on
humoral medicine in Morocco and Egypt which jibes with similar beliefs in Mombasa
(see Chapter 6). From a similar perspective, but adding women's knowledge about
pregnancy and the practices surrounding childbirth, Obermeyer (2000) has investigated
medical pluralism and humoral medicine in Morocco, while Mandersen (1981) describes
humoral practices and childbirth in Malay.
The imbalance demonstrated by disease is said in this system to be due to features
of physical and spiritual bodies. Physical imbalance can be caused by exposure to the
environment. Imbalance related to the environment is caused by the air or wind (upepo),
cold or hot temperatures. A woman complaining of having a fever (homa) could be
reacting to her body's discomfort to environmental heat or cold.
Food intake, lack of sleep or rest, and one's emotional state (Abdalla 1992: 182)
are related to certain illnesses. Emotional state is similarly linked to 'balance' or
'imbalance' of hot and cold. A hot tempered person suffers from headaches, while a cold
natured individual gets depressed (baridi ya bisi). Healing consists of rest, diets, fasting,
an array of medicines, and the extraction of impurity by bleeding, scarification or
branding, vomiting or use of enemas (Slikkerveerl990).
There is also a belief that spiritual beings cause illness. Morsy (1993: 1 11)
describes them as "subterranean beings" and assigns their effects into two categories,
direct and indirect. Direct spirits afflict individuals through possession, while indirect
beings are controlled or manipulated by others through sorcery. Waite (1992: 214)
explains that "spirits are believed to bring certain kinds of illnesses and other afflictions
to individuals, to families and to the whole communities". She specifically identifies
ancestral spirits, which represent the founders of an individual family. In Mombasa these
are termed nzajinni ya ukoo, and those of the community/territory (nzajinni wa nzji).
Spirits in Kiswahili are called jinni (plural nzajinni), pepo or ruhani. These are
mischievous and although they may cause discomfort, they do not cause serious illness or
death. For instance, a woman who has a ruhani can be pregnant for more than a year, (see
Chapter 6) and will not deliver until the ruhani is appeased.
Spirit possession can take many forms, from mild affliction (where a person
portrays physical discomfort) to altered social behavior. Serious symptoms of suffering
include body weakness, loss of appetite, loss of weight, headaches, and sometimes
shaking of the body. Sorcery accusations reflect strained social relations and could be due
to revenge. Sorcery can be used to create infertility, impotence or deaths of infants.
The "evil eye" (ficho) or ha~ssad, refers to harm inflicted on an individual due to
feelings of envy or j ealousy. In Islam, ha~ssad is "legitimized by reference to Quranic
descriptions of the malevolent power of the ha~ssid or possessor of the evil eye (Morsy
1993:110). Hassad is associated with creating misfortune, illness and even death. A
woman who says that someone else's baby looks healthy might be the target of blame if
that child suddenly becomes ill. Her eye, whether consciously or not, would be the cause
of ill-health. Women who have miscarriages or infant deaths might be asked if they are
obj ects of ha~ssad (fe umehusudiwa). Moreover, when a multitude of misfortunes occur in
a household, the inhabitants question if the home has ha~ssad, which. if true, would
require a healer to diagnose and remove the cause of the ha~ssad.
Hassad is different from sorcery which is associated with shirk or the acceptance of
a power greater than God--the gravest, most unpardonable sin in Islam (Feierman and
Janzenl992). Superstition and practices associated with it are slowly diminishing due to
Western education and culture on the one hand, and Islamic orthodoxy on the other.
Muslim women who still go to diviners or healers that believe in sorcery do so secretly.
This practice is associated with heretics and therefore sinful ibidd).
Sharifs are people who claim genealogical descent from the prophet Mohammed.
They assert, "or are imputed by their followers, to possess baraka or special blessings
from God, which can be used in healing" (Beckerleg 1994). Besides the sharifs, there are
also scholars of the Quran (maalims) with knowledge of Islamic law and Arabic medical
texts. This body of knowledge is taught locally or in the Middle East. The emphasis on
treatment for hassad or spirit possession is based on theories of balanced hygiene and
diet, and also, at times, exorcism. Portions of the Quran are prescribed, and written to be
worn as an amulet. It may also be written with food coloring on a plate, which is rinsed
out and given for healing or prevention. Although non-religious, some Muslim healers
use drumming (ngonza) for ritual therapy. Janzen (1978: 21) has studied healers and the
use of ngonza in central and Southern Africa and explains that ngonza is used for ancestral
worship, while divination and healing (ngonza za kutibu) are used for healing.
The Popular/ Lay Sector
Dean (1989: 117) defines self-care as the actions that "represent the range of
behavior undertaken by individuals to promote or restore their health". Kleinman (1978)
states that in both Western and non-Western societies, individuals self-treat 70-90% of
health problems in the home. These decisions to self-treat are made by laypersons who
face real symptoms and who seek to improve their health without medical supervision. A
layperson may choose to delay professional assistance until there is failure of home
remedies or worsening of symptoms.
The utilization of Western pharmaceutical and local herbal remedies is widespread
in the homes in Mombassa. Ethnicity, social class, education and gender play an
important role on influencing how home remedies are undertaken. Women and the
elderly tend to self-treat more than others. Geissler et al. (2000) found in Western Kenya
that the use of home remedies and self treatment starts with primary school aged children,
beginning with treatment of minor ailments, such as headaches, body pain, coughs and
malaria. This is also common in Mombassa. Added to home remedies are the prescription
and non-prescription medicines that are received from friends and relatives who work in
dispensaries or hospitals. With chronic illness, self-medication is at times in conjunction
with prescribed medicines. Individuals in a family share and use prescribed medications
without seeing a physician because the treatments are available at home and because it
decreases the hassles one has to endure at the local hospitals.
METHODS OF DATA COLLECTION
Methods in social research consist of observing, listening, asking and reading. In
this study, I used all of these general methods to study the meaning of health behavior
among some women in Mombassa. In this chapter, I explain the specific methods that I
used, including a questionnaire and participant observation, and how I selected the
sample of women I studied. As a native of Mombassa, I encountered some problems in
collecting data there, but I also had some advantages. I explain these problems and
advantages in this chapter as well.
Research Design and Objectives
One advantage of being a native of Mombassa is that I already am fluent in the
local language, Swahili. I was educated as a nurse in Nairobi and practiced in hospitals
there, plus in Mombasa for 6 years before coming to the United States. Over the years I
have maintained both family and contacts within the medical community in both places. I
have a few family members in Mombasa, during this research I lived with one of my
cousins and her family whose residence was in Mwembe Tayari which is in the middle of
town. This facilitated easy ambulation around town, and where places were not within
walking distance, public transportation (or the matatu) was easily available. With all of
this social support, I was able to conduct this study in six months, from June to
November 2003. l used Handwerker' s (2001) guide on how to perform an efficient and
"Quick Ethnography", plus Bernard (2002), and Patton (1990) on how to design and
perform fieldwork. During the summer of 2002, I went to Mombassa to reestablish
connections with people who would become my key informants, including physicians
and nurse-midwives who trained in 1977-1982 when I did my nurse/ midwifery training
in Nairobi, Kenya. These gatekeepers became my first informants and helped me to
determine what was feasible for my study. They told me which officials to contact when I
returned a year later for fieldwork, and they continued to help me with preparations by e-
mail and telephone after I returned to the United States to complete my proposal, develop
my initial questionnaires and received Internal Review Board (IRB) approval from the
University of Florida. Before leaving the United States, I as well mapped out a time
schedule and structure for data collection.
I spent the first two months in Mombasa building a foundation for fieldwork. This
consisted of initiating pertinent conversations, intense listening and informal interviews -
what Handwerker (2001:106) terms, "first and second order gossip." During these two
months, I also visited official and mapped out interview sites. Data collection and
recording, however, was continuous, from the time I arrived in Mombassa until the day I
left. I started with general, grand-tour questions, as Spradley (1979) called them: "Tell
me about problems that women have here with health care?" "Do you have any problems
with health care?" and so on. These questions elicited a lot of information very quickly
about health issues faced by women in Mombasa and helped me establish clear
My obj ectives were:
1. to describe Muslim women's knowledge and attitudes about mother-to-child HIV
2. to describe the health care decisions made by Muslim women during pregnancy
and to identify patterns of behavior in seeking prenatal health care
3. to identify and describe the health care facilities used by Muslim women during_
pregnancy and childbirth; and
4. to determine the factors that predict whether Muslim women make adequate use of
maternity care in Mombasa.
As a native going home to conduct doctoral research, I had some advantages, but
also encountered problems that outsiders would not have experienced. Clearly, native
ethnographers have a more difficult time maintaining obj activity than would someone
coming in fresh from the obj activity than would someone coming in fresh from the
outside. I realized as I did this research that there might have been cultural patterns that I
missed, taking them for granted patterns that, as Bernard (1996: 154) observes, an
outsider would see right away. On the other hand, as Bernard and Salinas Pedraza say
quite explicitly, (1989:5) "all ethnographies are subjective and selective. "The object in
social science is not to be devoid of an agenda. This is clearly impossible. The object is to
maintain standards of data collection that eventuate in credible work. Anthropologists are
enj oined to conduct research from a position of cultural relativism that is, to avoid
making judgments of the cultures we study. "Each way of life," we are told, "should be
evaluated according to its own standards of right and wrong" (Walbridge and Sievert
2003:2). I duly entered the preliminary stage of my research in 2002 without
preconceived ideas about what I would find, but I returned that year with obj ectives and
hypotheses. The participant observation data I collected were verified before leaving
Mombasa with key informants for variability and accuracy.
On the positive side, being a native of Mombasa made it possible for me to conduct
this research relatively quickly. I was accepted quickly by medical service providers as a
member of their community and by Muslim women informants as someone with whom
they could speak frankly in their native language, using the kind of idioms and discourse
cues that native speakers everywhere rely on for deep communication. As a result, I was
able quickly to understand the issues that were important to these women. A lot of the
nurses express pride in the fact that I was studying for an advanced degree, plus
impressed that I went back "home" to do this research. Many stated that once people
leave they do not want to get back. The acceptance and cooperation by some of these
nurses, particularly Sister Asya (as she was called by most of those who knew her) was
particularly important. She took me under her wing and introduced me to other clinicians
and key people in neighborhoods that I did not know personally or had forgotten about.
Sophia, another one of my cousins, helped me establish relationships with traditional
birth attendants, herbalists and Islamic healers whom Asya did not know. Michrina and
Richards (1996:75) observe that "there are two types of people in the field, those who are
knowledgeable and articulate, and those who can help you make contacts within your
group of study." Asya and Sophia had both of these qualities and were invaluable to my
research, but the point I want to make here is that my relationship with them was based
on the fact that I was one of them a Muslim woman health-care provider.
On the other hand, familiarity also breeds distrust. Concurrently with my study,
there was a study going at one hospital on a drug (nevirapine) to reduce mother-to-child
HIV infection. I was requested by the nurse in charge of the study not to interview the
HIV positive women, because the woman did not want their identity known by anyone
who might know them or their families. Other informants agreed to be interviewed, but
were clearly uncomfortable and guarded, also not wanting to disclose personal
information to someone who might know people in their families. For example, in one
interview with an acquaintance I sensed her discomfort from the very start when I asked
about her marital status. She had heard, she said, that her husband had taken a second
wife, but had not openly informed her, so she pretended not to know. She hoped, she
said, that I would keep this information confidential since, as long as her husband thought
she was not aware of his action, she would not have to share days with the other wife.
(Polygynous marriages are common in Mombasa and co-wives can demand to have the
husband share days between households). My first priority, of course, was to conduct my
work without doing any harm. This meant that I had to be alert to the need for
confidentiality at all times and for keeping informants plus advisors anonymous. Except
for some consenting individuals such as Asya and Sophia, pseudonyms replace names of
all informants in this study.
As I did my fieldwork, I ran into old friends and acquaintances. I accepted
invitations to weddings, was informed about funerals and social or religious activities.
Most of these events became information grounds for my research and also provided a
needed distraction from work. At these function with friends I was able to discuss
informally various issues surrounding women's health and particularly preventative care.
However, these outings were also a distraction because of the short time in the field and
eventually they became tedious. In addition, I lived in the middle of town with a relative
and her family in the neighborhood of the people I was studying. This was perfect as a
participant observation field site, although I did not encounter culture shock, there were
many changes in Mombasa since I left the island. I have lived in the United States for the
last twenty years, and although I have gone back every other year to visit, these short
visits had not prepared me for the changes I would find in my longer stay for fieldwork.
For example, public transportation workers found it strange when I asked them to tell me
when I needed to alight at my destination. The names of places were the same, but the
mode of transportation had changed. Public transportation was no longer with buses, as
had been the case when I lived there earlier, but with fast moving vans called matatus. Of
greater significance, despite the many benefits of native ethnography, I found myself
critically examining my relationship with both of my own societies, the one in Mombasa
and the one in the United States.
My obj ective was to interview between 250-3 00 Muslim women who had
delivered no more than eight weeks prior to the beginning of the study. According to the
Kenyan national census, there were approximately 48,000 women of reproductive age in
Mombasa Island in 1999. Figure 3.1 shows a map of Mombasa with 13 areas marked for
high concentrations of Muslims and six health care facilities used by Muslim women. I
screened potential participants for this study at each of the six facilities and also
interviewed some women at home to capture some of the 5% of women who do not
deliver at any of the health-care facilities shown in Figure 4. 1. There are three private
hospitals in Mombasa. I did not interview at these facilities because they are used mostly
by women of higher socioeconomic status and who are, therefore, likely to know about
and use effectively, all available health-care resources (Enderlein et al. 1994, Ivanov and
Flynn 1999, McKinlay and McKinlay 1972).
During screening, I sought to maximize variation in age; ethnicity, education,
parity and socio-economic status in order to maximize intra-cultural variation (see
Appendix 1 for the full questionnaire). Table 4.1 shows the distribution of the sample
across the seven venues. With this purposive sampling strategy, I was able to interview
280 Muslim women who had delivered recently, whether in a hospital or other health
facility or at home. Of the 280 interviews, 265 had complete information and consist of
women during their six weeks postpartum period. These interviews are the subj ect of the
analysis in Chapter 5. Additional information gathered during this study has been added
to explain women's health seeking behavior and add to the qualitative analysis in Chapter
3 and 6. In addition, I interviewed several clinicians, Islamic healers, traditional healers
and birth attendants, and Islamic religious leaders (Imams) about Muslim women's
maternity health, particularly in relations to HIV/AIDS.
8. Kidogo Basi
11. Mwembe Tayari
A. Coast General Hospital
B. Sayidda Fatima
E. Spaki Birthing Center
F. Kibokoni Birthing
Figure 4-1. Data collection sites
Table 4-1. Interview sites
Location of data collection Number of interviews conducted
Coast General Hospital 50
Sayyida Fatima Hospital 50
MEWA Hospital 50
Al-Farouk Hospital 20
Spaki Maternity Home 20
Kibokoni Maternity Home 20
Home visits 55
Interviews from the questionnaire: The content of my questionnaire is based on
studies of maternity care by Celik and Hotchkiss (2000) in Turkey, Chapman (1998) in
Mozambique, and Magadi et al. (2000) in Kenya. I added questions about knowledge of
HIV/AIDS and its prevention. To pretest my questionnaires, I contacted the owners of the
two home-based birthing centers in Mombasa and obtained a list of mothers in the two
respective neighborhoods who were clients. I interviewed ten mothers in their homes and
tested the questionnaires. I recited the informed consent protocol to each pretest
participant in Kiswahili, and each of them and received their permission to continue with
the understanding that I would hold their information in confidence. After ten interviews,
I learned what worked in the questionnaire and what needed rewording. I wrote the
questionnaire in English and translated it into Kiswahili, taking care to frame the
questions properly in the local idiom. For example, the question "did anybody help you
decide when to start prenatal care?" a direct translation would sound curt and provide a
yes or no answer. This would have to be followed with "whom?" However, rephrasing it
by asking, "mshauri wako ni nani ukitaka kwenda kupima?" ("Who assisted you in the
decision to prenatal care?), would provide both answers. A few of the respondents that I
pretested the questionnaire on were uncooperative, giving short, abrupt answers; some
were reticent because they felt embarrassed by the questions, while others were verbose.
After correcting the questionnaire (see Appendix D), maj ority of the respondents were
very cooperative. I controlled the interviews by leading and providing the appropriate
verbal and non-verbal feedback.
Structured interviews: The questionnaire consisted of structured and semi-
structured interviews. The structured component comprised a series of items on socio-
demographic features, and some questions on the availability of medical insurance.
Marital status a socio-demographic feature that usually elicits a simple answer was
quite complicated. During the pretest, I found that some women hesitated to answer a
query about their marital status and would not affirm or deny whether they were in a
monogamous or polygynous relationship. One woman responded: "How would I
know?,Maybe I am the only wife, and maybe I am not." Thus, in addition to the usual
"yes" and "no" answers for this question, I wrote side notes to include women's added
responses. The question on occupational status also caused some difficulty. A number of
women initially said that they were housewives, or provided one occupation. However,
with time I noticed some were involved in different trading practices from the home. I
reworded the question to include women's activities or jobs that supplement their
Education, both secular and religious, is an area of great concern to the women I
interviewed. They voiced their frustration at not being able to continue with their
schooling because of cultural or religious restrictions, either as understood by them or as
imposed by their families.
Other components of the structured questionnaire included education (both secular
and religious) of the spouse or partner, spouse' s occupation, and whether the spouse or
partner was employed in Mombasa or resides elsewhere (approximately 15% of partners
in this study live or work for prolonged periods out of Mombasa). I also asked about
whether the partner had medical insurance.
Finally, I assessed socioeconomic status with data about the status of the home. I
asked whether a woman owned or rented the home she lived in; whether the home had
electricity; and the source of water for the home. There were three sources of water: tap
water (from indoor plumbing), well water, and water bought from an outside source. I
observed women spending a lot of their day either collecting water or waiting for
someone to deliver water. Piped water in Kenya is state controlled, and when there is a
shortage, it is rationed to certain hours of the day. Water is sold from state-run
neighborhood stations that open from 6 a.m. to 5p.m. For a payment of a few Kenyan
shillings (Ksh.) 25 which is about U. S. 32 cents, water can be delivered to one' s home,
but if the deliverer is busy, waiting for water delivery could use up the whole day. The
house I lived in used well water for every other need, except drinking and drinking water
was bought twice a week. I had the experience of wasting most of a day waiting for
drinking water to be delivered. I understood when women complained and stated their
frustrations about access to water and their relief when water arrived.
Finally, a section of the structure was about women' s awareness of how HIV might
be transmitted from mother to child. If a woman said that she knew the manner of
transmission, then the next question was about the source of her knowledge: word of
mouth, school or college, a health care provider, or the media (television, newspapers, or
radio). A follow-up question probed whether the woman thought her knowledge had
changed her behavior. I assessed behavioral change by asking if the women had been
tested for HIV, and if the test was positive, if she had delivered in a medical facility that
offered procedures to prevent passing the infection to the infant. Although this last
question was placed under the structured interviews, it could as well belong to the semi-
Semi-structured interviews: The semi structured component of the survey dealt
with women's pregnancy and childbirth experiences. These experiences are private and
personal and were embellished and dramatized or downplayed, depending on each
woman' s circumstances and perception of those circumstances. I was able to interview
each woman only once and allotted up to two hours for each interview. I was, however,
sometimes unable to complete the work in this time. Some of the narratives were j oyous,
but the heartrending experiences of others were so emotionally wearing, on me as well as
on the narrators, that we often had to take breaks in the middle of the interviews. Some
women had complicated pregnancies and were strong narrators, while others were first
time mothers without complications. This, too, played a role in how much time was
needed to complete each interview. During the open-ended narratives, women expressed
their relief or frustrations about pregnancy and childbirth and mentioned people who had
participated in their j ourney to motherhood, including partners, family members, friends,
neighbors or health care providers.
In this section of the survey, I also developed pregnancy histories: number of
children, miscarriages, abortions, and stillbirths. I felt that many respondents answered
these questions truthfully, except the question about abortions. Abortion is illegal in
Kenya and it is forbidden in Islam, but it is widely known that Kenya has a high rate of
unwanted pregnancies that lead to abortion (Bauni and Jarabi, 2000). One of the leading
causes of hospitalization in Kenya in 19991 was admissions after abortions. Data on
abortion prevalence between provinces showed the Coastal province (including
Mombasa) had lower rates of number of admissions than all other provinces in the
country (Ministry of Health Report 1996-1999).
I inquired about the date of conception, when and where prenatal care was started
or continued, and who assisted or impeded these decisions. I asked about transportation
to and from the clinic and whether the woman liked or did not like the health care center
or provider. Women had a lot to say about the health care system (see Chapter 5). In this
final section, I explored health care decisions that is where, when and why respondents
had begun treatment when sick during the pregnancy. Answers provided were further
probed for diagnosis given, length of treatment and effectiveness. I was able to extract
from these data a taxonomy of the maj or illnesses or problems that are associated with
pregnancy, the type of healer used, and a description of the treatments The main
conditions that were consistently mentioned were homa (fever); anemia; shango (vaginal
discharge), possibly due to fungal or bacterial infection; body aches and pains; and
SThe updated Ministry of Health report for the years 2000-2003 were not published while I was collecting
mwajuu, with some symptoms that resemble high blood pressure in pregnancy. Some of
these names of illnesses, such as mwajuu and shango were unfamiliar to me, despite
having practiced nurse- midwifery in Mombasa from 1982 to 1983. I was also unfamiliar
with some of the treatments for illnesses that were mentioned, including some home
remedies, some traditional and Islamic healing practices, and even some treatments used
among various ethnic groups living in Mombasa. "Even the most experienced of 'native'
anthropologists," said Narayan (1993:683) about her ethnography in India, "cannot know
everything about his or her society."
The Research sites
As shown in Table 4.1, I did participant observation at four hospitals, two home-
based birthing centers, and visits to mothers in their homes. In the hospitals (Coast
General, MEWA, Sayyida Fatima and al-Farouk), I observed women as they came to
clinics at three different stages: (1) for prenatal check ups, (2) during postpartum
assessment, and (3) when they brought their infants for the six-week post-delivery
evaluation. The second and third stages were logistically feasible; for this study.
Coast General Hospital the waiting room: At Coast General, women brought
their babies for a six-week post-delivery checkup on Mondays, Wednesdays and Fridays
between 8a.m. to 1p.m. These hours were hospital policy and were rigidly enforced.
Women who came late did not find a clerk to give them a check-in card or see a health
care provider. The benches were full by 7a.m. and a quick hustle ensued to the clerk' s
desk as he sat. First, women had to register their babies into the hospital system and
receive a patient number. Next, they had to pay for services in another room. Then,
women waited in a second line for a nurse to check the baby's weight and temperature
and assign them a room or cubicle to see a clinician. This process, including the checkup
by the clinician, took from three to five hours. Many women grumbled and expressed
frustration or sighs of resignation during the course of a normal day at the clinic. Some
infants cried while others were continuously breast, or bottle-fed. Mothers changed
diapers while waiting to be seen. I found a quiet comer and called mothers aside for
interviewing. I asked the other mothers to reserve the informant' s space in line, so that
she would not miss her turn to be seen by a clinician. During these moments, I had the
opportunity to listen and observe the interaction between the women, the health care
providers and other hospital personnel.
This waiting to be seen by a clinician was for well and sick babies and there was
constant commotion as women moved from one area to the next. The whole area was
open except for walled partitions. Once, a mother began wailing as her child died in her
arms, waiting to be seen. I learned later from the matron-administrator of the clinic that
women were supposed to take very sick infants to the emergency room. This was not
something that was widely known or understood. In fact, I had to ask about this incident
to find out that it was possible for mothers with very sick infants to get quick treatment.
This event was so distressing to me that I stopped interviews for the day and went home.
Coast General Hospital the postpartum ward: This is part of the maternity
floor where women stay to recover after childbirth. Women stay for 2-5 days post-
delivery if there are no complications and leave after payment for hospital services. Some
are being given medication intravenously and some require blood transfusions due to
complication in delivery. Other women are well enough to walk around to visit each
other, or go back and forth to the toilet. Infants are either asleep, breastfeeding or having
their diapers changed in this area. The room was quiet, except for an occasional nurse
passing by on errands. I spent the mornings in the mother/baby clinic, and afternoons and
evenings conducting interviews in the post-partum area. I left during visiting hours to
allow family and friends to visit. I would inquire from the nursing staff which patients not
to disturb before interviewing.
MEWA / Sayyida Fatima and Al-Farouk hospitals: These hospitals were
designed to cater to a Muslim clientele. Although the administrators and health care
providers are Muslims, less than 15% of respondents stated that they chose these
institutions for religious reasons. As I will explain in the following chapter, these
hospitals were mostly chosen because of distance, cost, and the availability of specific
As with Coast General, I conducted interviews with mothers who brought their
infants for a well-baby check after six weeks and in the postpartum ward. Compared with
Coast General, service at these two Muslim hospitals was much quicker. The average
waiting period was about an hour and all procedures were done in the room with a nurse,
though a physician saw patients when necessary. I asked to conduct interviews with the
women before they left the hospital. I also spent time here observing how women
interacted with each other and with health care providers. I noticed that unlike the other
government clinics prenatal classes were not offered, and women left quickly after
receiving services. In fact, I had a hard time getting some women to stay for interviews.
Overall, though, I was able to interview most of the women who I approached. One
reason for my success, according to other nurses at these two hospitals, was that I dressed
in a bui bui or abaya, the black overcoat and scarf worn by almost all Muslim women in
Mombasa. Had I dressed as hospital personnel women hurrying to leave after being seen
would not have been as ready to linger and sit for an interview. My dress as a Muslim
woman was a cultural asset and helped me to develop rapport with potential informants
(see Warren and Hackney (2000:22) for more on the importance of dress in Hieldwork).
Time spent in the hospitals helped me develop close relationships with the
clinicians. In one institution, I was asked to assist with deliveries when the hospital was
short staffed. This would have allowed me to move entirely into the role of full
participant as observer, but I declined politely and disengaged in order to maintain a
different relationship with patients than that of the staff. I opted for more detachment and
less engagement, as Hayano calls it (1979: 113). Balancing multiple identities as nurse,
native and researcher was a constant in this study. Opting for a more engaged role as a
clinician might have produced more data, or different data, of course, than those I was
able to collect.
Spaki and Kibokoni maternity homes: In these two biomedical facilities, women
were observed as they came in for prenatal or postpartum visits. Others brought male
infants for circumcision, or pregnancy related problems. Deliveries ranged from one to
two a day, recitations from the Koran was done while the women were in labor, and
women were also encouraged to recite from the Koran in order to distract them from the
pain and provide spiritual comfort. I asked women specifically why they had chosen to
use these maternity centers. The environment was relaxed and j ovial, and if the women
had not stated their specific reasons for coming, one might assume they were there for a
friendly social visit. I did twenty interviews at each of these two homes and Hyve more in
each neighborhood to get opinions about these homes from women who did not use them.
I also interviewed the nurse, the assistant and the surgical technician about their
techniques and their rapport with the people they served. With my knowledge as a
clinician, I could not help but judge the care given to women. One of the two maternity
homes did not have a full-time qualified practitioner, and some of the decisions of the
practitioner on hand were not reassuring. Once, when a woman came in complaining of
premature labor, she was not referred to a hospital where she could receive urgent care.
Instead the patient was massaged and sent home. I provided general suggestions in my
discussions with the practitioner as we compared notes about different ways to assist
women and improve their health care in various conditions, but I did not intervene
directly with nursing or medical given.
Mama Msena and Bi Zuena Traditional birth attendants In comparison to the
home-based maternity clinics, where there was a semblance of biomedical influence,
these homes were regular living arrangements with a room assigned for assisting in
childbirth. The term for one who assists with childbirth is mkunga or mpokeaji which
translates as "one who receives" or assists. Both women were warm, motherly and were
referred to as 'mother', 'aunty' or 'grandmother' by their clients, as if these traditional
birth attendants were members of the clients' families. As I visited these homes, I
realized they were not only used for childbirth, but for advice on child rearing
(particularly of daughters) and for counsel on marital relations. It was definitely a
women's domain. Men who stopped in were on errands for their wives.
The birthing rooms in both homes were empty, except for a bed with a thin
mattress, covered in plastic, and a pillow. The patient had to bring her own wraps, or
khangas, which are colorful rectangular cloths, 1 by 3 yards in width and length. These
khangas had multiple purposes and were used as a bed covering, or as a body wrap while
the woman was in labor, or to cover the baby before going home. Women who came to
deliver were also instructed to bring their own surgical gloves (a recent practice that has
been encouraged since the advent of HIV/AIDS), cotton balls, a blade, tie string, and
disinfectant. Mama Msena kept her medicinal remedies in the courtyard, where she also
had a variety of herbs, and medicinal plants. She was petite, quick witted and full of
humor. Many women in the neighborhoods across Mombasa mentioned her name as I
conducted interviews. Mama Msena lived on the outskirts of Mombasa, but women came
to see her for different ailments, particularly infertility. Women stated that they respected
her because of confidentiality and generosity. Women came in for massage therapy,
particularly after delivery, and interviews were conducted after their visits in the
courtyard or by following women to their homes.
Women went to Bi Zuena for different reasons. She had worked in a hospital as a
clerk, before becoming a traditional birth attendant (TBA). She did not indulge in herbal
healing, although she performed massages. She stated that she was conducting less
childbirth deliveries with the intention to discontinue the practice. One of the main
differences between these homes and the biomedical facilities were the one-on-one
rapport between care-giver and patient. About thirty percent of women in this study used
home-based maternity services. From my interviews with these women, they understood
the dangers that this choice involved, should an emergency arise during delivery, but they
chose to overlook those dangers. I will revisit this issue in Chapter 6. Some women who
could afford the other biomedical facilities still attended the services of the TBA and
other healers for home remedies and massage therapy.
Traditional Healers: I reached the Maj engo market as directed to meet Bi Riziki,
a healer. I had been informed she had expertise in treating problems associated with
pregnancy. After crossing rainwater-fi11ed potholes on the path, and dodging human and
automobile traffic, I arrived at the entrance to the market. I asked for Bi Riziki and was
directed to her stall. She was standing by a shelf filled with a variety of herbs, roots and
some form of vegetation. Her son and also assistant was welcoming, but she looked at me
suspiciously, particularly when she saw I had a tape-recorder and camera. I assured her
that I was not going to use them without her permission. She relaxed temporarily, but was
on guard throughout this initial visit. I refrained from asking her or her clients questions
and instead observed their activities. On future visits, she calmed down, and I was able to
interview her and some of her female clients. She even allowed me to audio tape her and
take pictures, something I had not been able to do throughout this study. Women came to
Bi Riziki with complaints of gynecological and obstetrical problems. At times, she
walked away with them from the stall, for privacy, something that I also imitated when I
interviewed one of her female clients. Women also brought their partners and infants for
The second healer Bi ZamZam was from a different ethnic group from Bi Riziki.
She was more relaxed, and had no reservation in explaining her different types of
remedies. Women came to her mostly for treatment of anemia and for massage therapy.
She referred some of her patients to Bi Riziki and the hospitals when the ailments were
beyond her scope of treatment.
Home visits "Are you an American spy?": Conducting home visits was the
most difficult part of the data collection. I initially wanted to interview women in their
last month of pregnancy and do a follow up visit after they delivered. This proved to be
impossible because most women (especially those unemployed) moved to their mother' s
or in-laws' house for the forty days after delivery. This is a cultural practice called
arubaini (forty days) to help the mother and baby recuperate after the strain of labor. The
woman is considered unclean after childbirth, and is excused from household duties, until
after the forty days. The practice of arubaini varies in Mombasa' s different ethnicities
and economic status. I will return to this issue and how it affects the use of health care
services in Chapter 3.
To find women whom I might interview in their homes, I walked door to door
through the neighborhoods mentioned in Figure 4. 1 to inquire if there were any women in
arubaini. These neighborhoods are densely populated, with houses very close to one
another, and people are involved in each other's affairs. This made it easy to find mothers
in arubaini. On the other hand, home visits were time consuming, because it was difficult
to enter and exit immediately after an interview. Some people wanted to get to know me
and my work, and asked about life in America. I developed a short and uninteresting
narrative that I kept repeating and that would not prolong my stay. Most of the homes
consisted of extended families or had visitors to see the mother and new baby. One-to-
one interviews were difficult to conduct, with a lot of chit-chat before and during the
interview I avoided late evenings in order not to interrupt meal and family times. I also
excused myself when partners arrived home. I did this for two reasons. First, I understood
the culturally appropriate gender roles. Women are expected to cater to their partners
when the latter arrive home. Second, while I encountered few men during this study,
those whom I did meet were suspicious and questioned me about my research,
particularly when I mentioned that I was associated with a university in the United States.
This suspicion from men made the women uncomfortable and I knew that under these
circumstances, their answers to my questions would be inhibited.
The suspicion among men reflected anti-America sentiments in Mombasa. The
American invasion of Iraq started in March 2003 and I started home visits in August of
the same year. Various groups of Muslims in Mombasa, particularly young men, had
demonstrated against American involvement in Iraq. There was plausible suspicion that
some Muslims were involved in the Al Qaeda movement, which resulted in a joint effort
by American and Kenyan intelligence services to search Muslim homes in Mombasa.
This created an ambience of distrust and I was at times asked by men, during my home
visits: "are you an American spy?" or "how do we know that you were not sent to
investigate about terrorism?" The women did not question me, but once their partner had
created an air of distrust, women became wary and their answers to questions became
cautious. Warren and Hackney (2000: 17-19) observe that anthropologists have been
considered as spies from the United States government everywhere they have done
ethnography. They add, however, that men are more likely to be suspected of being spies
and indeed, in Mombasa I felt I was regarded with less mistrust because I was a woman.
Being a woman, I was perceived as having less power, and therefore not dangerous.
These interviews of Muslim women in Mombasa about their pregnancies and
childbirth experiences were, at times, cathartic. I found it hard to remain uninvolved,
emotionally, and to focus on data collection, but I did not let the need for obj activity stop
me from answering questions from my informants or assisting them with information
about women's or infant' s health, care of infants, breast feeding, mixed feeding, and so
on. Women disclosed their health problems to me and I provided advice within the scope
of my knowledge as a nurse practitioner. Some of my advice was practical, such as how
to position infants and prevent nipple soreness or breast engorgement. At times my
advice turned out to be impractical. For example, I counseled women to use canned infant
formula instead of diluting cow milk for feeding newborns. I later learned the difference
in cost. My twenty years' experience as a nurse and midwife helped me establish strong
rapport with my informants. There was a cost to this, as well as a benefit, for with that
rapport I heard many stories of pain and suffering.
The data from the 265 structured and semi-structured interviews were analyzed
using SAS and SPSS. The questionnaires and codebooks for the structured interviews are
in Appendix 1.
There are two dependent variables in this study, both of which involve the use of
maternity health care services. One is the use of prenatal care and the other is choice of a
birthing center. Since the dependent variables are binary, I used a logistic regression
model to estimate the probability of women' s behavioral choices, given a series of
The narrative data were analyzed with the help of Atlas/ti (scientific software -
version 4. 1). Analysis of women' s narratives about their use of maternity health provides
insight not obtained from the quantitative analysis.
RESULTS FROM THE DATA ANALYSIS
This chapter presents selected results from the structured interviews. The individual
respondent' s questionnaires provided information on the following: socio-demographic
characteristics, household characteristics, knowledge of mother-to-child HIV
transmission, and the seeking/utilizing of maternity health care. In answering the
question, "what factors impede or provide access to maternity health care?" I created a
number of variables, guided by the literature, about how women make health care
decisions. Any individual decision can be driven by more than one factor. For example, a
woman might have health care insurance (which would allow her to deliver at a hospital
at no cost), but decide to deliver at a home-based maternity facility for some personal
reason (like not wanting to be probed clinically by strangers
Since the two dependent variables are binary, I apply logistic regression. (Logistic
regression estimates the probability that the qualitative dependent variable has two
possible outcomes [Allison 1999:19, Agresti and Finlay 1997:575]).
The dependent variables are:
1. Did the informant get prenatal care (yes/no)
2. Did the informant use a birthing center (yes/no)
I used stepwise selection to determine the final list of explanatory variables in each
model. Considering the sample size, I included variables that were significant up to the
0. 1 level. The results of this exploration for the two models are shown in Tables 5-5 and
In Model 1 (Table A-5) the informant attributes with statistical significance are
education, partner' s Islamic education, telephone ownership, knowledge of HIV
transmission (in utero) and number of miscarriages.
In Model 2 (Table A-6) informant attributes with statistical significance are ethnicity,
health care insurance, respondent' s education, test for HIV, knowledge of MTCT(in
utero), previous childbirth, education and HIV test and previous childbirth and HIV test.
The reasons explored for using prenatal care or for a particular birthing center
were: the fact that the institution followed Islamic practice, distance, the presence of
health care providers, cost, the presence of services and a woman's particular health
problems. Tables A-5 and A-6 show the p-values and odds ratios for the nature and
strength of association between the dependent and these explanatory variables. In Model
1 explanatory variables with statistical significance were distance and health care
services. In Model 2, distance, health care providers and cost had statistical significance.
Section A Socio Demographic Characteristics
Age: As indicated in Table A-1, the respondent's ages averaged 26, with a range
of 16-47 years. Across the world, women younger than 20 or older than 35 experience
more obstetrical complications than do women between 24 and 34. Although not
statistically significant, younger women in my sample use health care services less,
particularly with their first pregnancy, although more deliver in a biomedical facility. As
well, lower socioeconomic status and lack of social support mean that younger women
have less access to health care than older women. On the other hand, women who have
more than two children use prenatal care less and take time before going to a facility to
give birth if they do decide to go at all. This relaxed attitude stems from experience of
Ethnicity: The largest ethnic group in Mombasa is the Mijikenda, who comprise
30% of my sample (N=80). The second largest group in my sample, at 27% (N=70) are
self-identified Arabs. Only 5% (N=14) stated they were Waswahili. Ethnic affiliation is
fluid in Kenya "situational, rational and changeable," as Cooper (2000:120) says. This
has long created confusion in Kenya, particularly during census collection ((Republic of
Kenya: Census 2001). For example, people of the East African coast, particularly those of
mixed ancestry such as Arab/African or Asian/African, are all identified as the Waswahili
by the Kenyan government (Middleton 1992). However, women categorize themselves
differently from how they are labeled. Ethnicity does not play a role in seeking prenatal
care (Model 1) but it plays a very significant role (p< 0.0001) in the choice of a birthing
facility (Model 2). There was higher probability that Arabs, Asians and some Waswahili
will choose biomedical childbirth facilities than the other ethnicities because of
affordability (OR= 12.17) (Table A-6). Marginalized ethnic groups use health care
differently from the dominant groups in societies. In observation as well, childbirth
assistance by a TBA was more common among the Mijikenda, Bajuni, Jomvu, and
Changamwe. In Mombasa, historically, the Arabs, Asians and some Swahilis, have had
resources deprived of the Mijikenda and other smaller groups (Mkangi 1995). This has
been shown as well in various other studies outside Africa, for example in Britain, Petrou
and colleagues (2001) infer that women of Pakistani and Indian origin made fewer
prenatal care visits than white British women. This above study claims cultural and
religious beliefs as plausible factors to decreased attendance. Similar studies in the
United States have indicated that African-American, Mexican-American and Puerto-
Rican women do not adequately use maternity health care (Echavarria and Parker 2001,
Gardener et al 1996, McCaw-Binns et al 1995, Lia-Hoagberg et al 1990, Petitti et al
1990). These studies stated that socio-economic status plays a role in access to health
care services leading to poor maternal/child health outcomes.
Education: Respondent' s education is highly significant in both models, use of
prenatal care (p=.001) and in choice of childbirth center (p=.02). There is a high
correlation between education and better health care. On evaluating respondent' s
education, about (N=3 1) 12% of women had never been to school (see Figure A-2).
Reasons for not attending school varied, the most consistent was inability to afford
schooling. Although school attendance had been free for this population, parents still had
to pay for uniforms and school supplies. The above 12% estimate of Mombasa Island
alone was slightly higher than the whole district' s estimate which was 8%. However, it is
lower in comparison to the country's estimate which is 3 5% (Republic of Kenya: Census
2001). More than half of the respondents (N=142) 54% had elementary or primary
education. The numbers decreased with secondary education to (N=89) 34% and only
two women had a college degree.
The probability of use of a biomedical facility increases when the woman or
spouse have higher education and subsequently increased socioeconomic status. The odds
of using a biomedical facility increased as women' s educational level increased (OR =
0. 11) (Table A-5) and (OR=0.01) (Table A-6). Although education was a factor another
component that was obvious on observation was respondent' s economic status.
According to literature, women's access to resources, including health care increases as
their personal socioeconomic status rises independent of their spouses and children
(Handwerker 1989). Assessing women's socioeconomic status was difficult because
women downplayed what they did both in trade schools as well as outside the home.
More than half of the respondents (N=139) 53% stated that they were "only" housewives.
Nevertheless, I observed the maj ority of women involved in many different home-based
trades. These j obs consisted of selling j ewelry, cloth material, fried potatoes, frozen
lollipops, and even selling water. Some women claimed that they were in sales, (N=56)
21%, they sold items door to door or to shopkeepers.
Islamic education: In Mombasa, Islamic education is started before secular
education and is not entirely free. Only 17 of the women (6%) had no Islamic schooling.
These few women were either recent converts or had parents who could not afford the
cost of Islamic education. Muslim clerics charge about 50-200 Kenyan shillings (about
one to three U. S. dollars) per month to teach Quranic classes. Sixty-three of the 146
women who had completed grade school said that they were continuing their education.
Women in this group also reported meeting with others for other non-religious
discussions, such as issues involving the community, health, education and politics.
Several of the women in this group were educators, conducting classes from home or
involved with madrasa~s.
Islamic education was not statistically significant in either of the two models.
Marital status and union: The overwhelming majority of the respondents were
married (N=257, 97%). Women who reported being separated or divorced stated that the
breakup of their marriage had occurred while they were pregnant. There was only one
unmarried woman and two women cohabiting under a common law relationship. Five
women stated that they had left their marital homes to go to their parents' homes after
childbirth and had not gone back.
Among those married, approximately 87% (228) stated they were in a
monogamous relationship, while about 11% (29) reported being in a polygynous
relationship. Some women in polygynous unions stated that their husbands alternated
households, dividing his days among the wives. This could, they reported, change in late
pregnancy, where the husband had to be available in case the wife went into labor. Only
one respondent stated she delivered at home, having been delayed in going to the hospital
while waiting for the husband to return from the other wife' s home The maj ority of the
respondents were married (N=257) 97%. There was only one unmarried and two
cohabiting under common law relationship. Women, who declared separation or
divorced, stated that the separation or divorce had occurred while they were pregnant or
during their postpartum period. Five women stated that they left their marital homes to go
to their parents' homes after childbirth and have not gone back.
Section B Household Characteristics
Health care advocates: According to the health care access literature as discussed
in Chapter 1, support from spouse, family or friends plays a role in how women use
biomedical health care. In this study, women's supporters and social network was
assessed through investigation of the household characteristics (see Table A-2).
Spouse's education: Men had more formal education than did their partners.
Male partners without formal education were (N=4) 2%, and elementary education was
about (N=85) 32%. The numbers with a secondary education were (N=153) 58%, and
(N=11) 4% had a college degree. Trade schools were attended during and/or after
secondary schooling. Although spouse's secular education did not have statistical
significance in the logistic regression models, educated men were more supportive of
their wife' s use of biomedical health care (OR=0.23).
Partners with an Islamic education encouraged their wives more to use biomedical
prenatal care (p=.07). Spouses with secondary secular education also had advanced
Spouse's occupation: Partner's education and occupation played an important
role in affordability of health care. Approximately (N=66) 25% of the respondent' s
spouses were drivers. Drivers in Mombasa operate private public transportation or vans
called matatus. The matatus transport commuters within the island for a minimal amount.
Other drivers moreover, transported goods from the island inland to other parts of Kenya,
or to other countries, such as Uganda and Congo. Approximately 35% of partners work
out of the country, and visit their wives in Mombasa after a few months, a year or even
after two years. Their wives stated that these visits lasted a month or two. Researchers at
the Coast General Hospital reported that, they had observed that the maj ority of their HIV
positive women had spouses who were drivers, both local and long distance. Extensive
research on the spread of HIV among truck drivers has been conducted in Africa. These
studies explain men's high risk sexual behaviors with prostitutes at truck stops to and
from their destinations (Rakwar et al. 1999, Nzyuko et al. 1997).
Other occupations included clerical office workers (N=46) 17%. Involvement in the
local tourism business, either on a full-time or part-time basis was explained as a maj or
source of income. Odd jobs to supplement income were explained as a survival approach
needed at a time of inflation and a poor economy.
Adults in the household: The number of people in the household played a role in
the acquisition of health care. The maj ority of the respondents lived in nuclear
households (N=169, 64%). About a third (N=87, 33 %,) had in their households three or
more family members that is extended family. In the survey there were some respondents
who reported living with sharing the household with many in-laws, up to four brothers-
in-laws and their wives. Advice and decisions about health care in such households was
complicated. As stated by one respondent, "I ask my husband where to go for prenatal
care; however my fellow sisters-in-law also help me make decisions. But our mother-in-
law has to approve before a final decision is made"
More than half of the respondents (N=136, 5 1%) stated they consulted their
husbands on when or where to initiate prenatal care and choice of a birthing center. A
few (N=39, 15%) made their own decisions, while the remainder consulted their mothers,
in-laws, or friends.
Women who lived with their in-laws stated that they felt obligated to seek advice
from their in-laws before making final decisions concerning health care. One respondent
said, "after all I now live with them, they are like my parents. I have to include them in
On a few occasions, women complained that their mother or sister-in-laws were not
as sympathetic as their own female kin. One informant protested, "My mother-in-law left
me in labor for two days before my mother came to escort me to the hospital". I observed
that a maj ority of women' s mothers were involved in caring for their daughters while in
labor and after childbirth, nonetheless the husband and his family had the final word on
Medical Insurance: Respondent's with medical insurance comprised a quarter
of the participants (N=69 26%). Availability of insurance had marked statistical
significance (p = .0008) in Model 2. Women with higher income (whether their own or
from spouse/family) were more likely to have medical coverage than were those with
lower incomes. Medically insured women had access to biomedical prenatal care
facilities and could afford to deliver at hospitals (OR=0.28). Even so, a few such
respondents complained that they did not use private hospitals. Some said that the
maj ority of the hospitals demanded user fees before rendering services. The government
run national hospital insurance fund (NHIF) was not trusted by many hospital
accountants and physicians for timely reimbursement. Respondents also asserted that the
NHIF and other insurance companies took too much time to reimburse them. Employer
sponsored private health insurance for workers were one of the primary sources of
coverage. Among the private sector firms, employers that offered insurance had varying
premiums by industry. Respondent' s reported that the maj ority of the employers of many
firms either did not offer or could not afford to contribute to the premiums. Most of the
uninsured did not have regular doctors, and moved from provider to provider in search of
affordable health care.
Water availability: Mombasa suffers many of the problems one finds in most
third world cities. The town's growth preceded the establishment of a solid, diversified
economic base to support housing and other infrastructure. Piped water, electricity and
sanitation are still inadequate and women spend a lot of their time getting water for daily
use. Although water was not statistically significant in Model 2, it was a maj or
component in health care and a time-consuming commodity when not easily available.
Unsafe water carries diseases, including typhoid, cholera, hepatitis, dysentery, amoebiasis
and intestinal protozoa. Approximately one-third of the respondents had complained of
suffering from typhoid while pregnant. I will discuss this issue further in the next chapter.
Electricity: The vast maj ority of the respondents (N=244, 92%) affirmed having
electricity. Power outages, however, are common in order to conserve fuel. For people
who have wells and water pumps, lack of electricity meant lack of power to extract water.
Women had to time the availability of electricity so that they could be home to fill water
into buckets or plastic cylindrical bins for later use. At times the period of no water or
electricity was announced on the radio, at times not. I observed quite a few births when
there was no electricity; attendants used kerosene lamps, flash lights or candles.
The approximate eight percent who stated they did not have electricity had
complaints about the power and lighting company not being efficient in reconnecting
electricity after disconnection.
Car ownership: Thirty-three (12.5%) women stated they had a car, but cars (or
lack of it) were important for all women when they needed to go to the hospital in a
hurry. A couple of home births occurred due to lack of transportation to take a woman to
the hospital. Car possession whether private or of companies were requested to transport
neighbors and friends to and from the hospital. Doing favors to transport the sick to
hospital was an everyday occurrence.
Telephone ownership: In the questionnaire, (N=175, 66%) of women reported
they had mobile telephones. Telephone ownership was a significant (p= .01) predictor of
a woman's using prenatal care services (OR=0.16). Some women stated they would
rather be without other household necessities but have enough minutes on their phones.
Even street vendors who could barely read or write had mobile phones. A few
interviewees who reported not having a phone stated that their husband or other family
member in the household had one.
Respondents with phones used them to inquire about health care providers and
services from others who have been to them. Some women reported going to a clinic and
being told to return another day because the blood pressure machine or the hemoglobin
testing instrument was not working. Women who had mobile phones said that they would
call ahead and make sure that there was a physician on duty or that certain services coulld
be performed. Telephone possession also increased convenience in making arrangeme
with relatives, friends or business acquaintances, providing time to attend the clinic fo
prenatal care. Mobile phones are not cheap. However, as the numbers indicate, women
value their phones greatly.
Section C Knowledge of Mother-to-Child HIV Transmission (MTCT)
The Kenyan government in conjunction with world health bodies has done maj or
campaigns to promote HIV/AIDS prevention and transmission. The vast maj ority of
respondents (N=249, 94%) stated their awareness of MTCT. Less than five percent
acknowledged being uncertain of modes of transmission, while less than two percent
declared being completely unaware (see Table A-3).
Also, the vast maj ority of women (N=245, 93%) (Figure A-3) confirmed that the
media was their main source of information. While conducting this study, I heard daily
public service announcements about HIV transmission, informing the public on the
importance of prenatal care and the possibility of MTCT. Information about HIV/AIDS
was also present in the newspapers almost daily.
Women could check more than one source of information for this question and
health care providers were listed by 113 respondents (43%). Various clinics held teaching
sessions with prenatal care attendees and informed them about MTCT. Posters were
evident in almost all clinics and hospitals.
In addition, women aged 16-25 reported getting information about HIV
transmission from schools. A few of these respondents stated that they belonged to
HIV/AIDS advocacy groups initiated from high school.
Only 41 women (16%) acknowledged open or informal discussions about HIV
awareness, let alone MTCT. Indeed, open discussions about HIV spread and preve
were never without reservations--such is the stigma and shame attached to the dis.
Many women who are aware of MTCT are aware all three modes of transmission: in
utero (N=207, 78%), during childbirth (N=185, 70%) and while breastfeeding (N=160.
60%). Women's response regarding MTCT in utero was significant (p=.03) in Model 1.
Similarly, in Model 2, (p=.0001) the probability of a woman attending or delivering in a
biomedical birthing center increased if aware that she was HIV positive (OR=0. 19)(Table
A-5) and (OR=0.22)(Table A-6). Though radio messages educated the public on the
importance of prenatal care and HIV testing while pregnant, the messages were not
specific about the three modes of transmission. Respondents may have been aware of
transmission during childbirth, but they did not say that it was important enough for them
to deliver in a level 2 or 3 hospital where there can be MTCT prevention.
Prenatal HIV testing: Prenatal HIV testing and screening has been
recommended for every pregnant woman by the World Health Organization. Over 70%
of respondents reported being tested for HIV were (N=189). HIV testing was highly
significant (p=.01) in the model for choice of a birthing center. The combination of
increased education and having been tested for HIV is significant in the model (p=.03)
(OR=1.11). That is, women who had increased secular education and had an HIV test
chose a biomedical birthing center.
In this study there was no confirmation whether those tested went back for results,
or whether the results were positive or negative. However, according to the literature, and
from my own observation, the maj ority of women tested for HIV do not go back for
results. In addition, lack of follow-through, particularly in a poorly established health
care infrastructure, leads to lack of counseling, diagnosis, and treatment for those how are
HIV-positive. This was evident in both the clinics and hospitals in Mombasa.
Number of children or parity: Previous childbirth experiences both good and
bad played a role in how women accessed maternity health care. Women with previous
childbirth formed the maj ority of the respondents at (N=166) 63%. There was marked
significance (p=.0001) in previous childbirth and choice of a birthing center, but not in
use of a prenatal care facility. First time mothers, plus women who have had more than
Hyve pregnancies are associated with using non-biomedical facilities (OR=0.29). First
time mothers mostly belong in the younger age group of 16-25, have lower
socioeconomic status, and at times lack the skills in dealing with health care providers. I
observed that the experienced mothers utilized social support more from their families
and the community, and had more experience in dealing with health care providers.
The combination of previous childbirth and HIV testing had a marked statistical
significance (p=.0009) in Model 2 demonstrating that the probability of a multigravida
who had had an HIV test delivering in a biomedical facility increased (OR=2.98).
Number of miscarriages and/ or stillborn: Women who had experienced bad
obstetrical outcomes in a previous pregnancy or pregnancies utilized maternity health
care early and frequently. This has also been documented by Ivanov and Flynn (1999)
their study of bad obstetrical experiences and use of prenatal care. Approximately (N=3 5)
13% of respondents had had one or more miscarriages. Most of these respondents had up
to 14-16 visits, compared to the average of seven (OR=0.58). Fear of losing another fetus
prompted women to seek prenatal health care more consistently after a previous bad
outcome (p=.03). Women, who had a stillborn and had not attended prenatal care, blamed
themselves for the loss, stating that they understood that a biomedical facility could have
provided other options of care.
Section D Utilization of Maternity Health Care Services
Prenatal care utilization: As is often the case in developing countries most of the
women in this study initiated prenatal care well into their pregnancy--after the fourth
month of gestation (Figure A-4). Despite this, 68.3% of them (N=181) (Figure A-5) had
more than six visits, which is considered adequate in most circumstances, (N=20, 7.5%)
had exactly six visits. Still, 21.5% (57) had less than six visits were and 2.6% (N=7) had
no visits. Reasons for inadequate or no attendance included lack of money to pay for
services, not having childcare, or simply not having problems with the pregnancy. To
further investigate causes that assist or impede the use of health care services, I
questioned women whom they consulted for advice in making maternity health care
Advisors: Informal advisors play an integral role in health care across the world
(McKinlay 1973, Janzen 1978, Feierman 1981). Over half (N=136) of the women
reported that they consulted their husband in deciding on whether to initiate prenatal care,
especially if money was needed to pay for the services or if permission was needed to
leave the household. Husbands were also consulted if they knew about health care
providers or could provide transportation.
Other family members were consulted, particularly when there were complications
to the mother or the baby, or if women needed help with hospital costs. Consultations,
however, could have bad outcomes. One woman reported that she had had prolonged
labor, and that the obstetrician had told her and the family that she had a big baby and a
narrow pelvis, requiring a cesarean section. The husband consulted with his mother and
mother-in-law to decide about surgery. They disagreed about it, and while they discussed
it, the child was stillborn.
Choice of a childbirth delivery center
There were five areas itemized in this study of where women chose to deliver their
babies (Figure A-6). These are:
1. Home with no assistance
2. Home with a traditional birth attendant (TBA)
3. Home with a clinician (nurse/midwife/physician assistant)
4. Level 1 biomedical facility (these levels are explained in detail in chapter 3)
5. Level 2 biomedical facility
6. Level 3 biomedical facility
Starting with the top levels which are 2 and 3, these hospitals were equipped with
urgent care services to care for both mother and baby. These hospitals had the capacity
among others, to care for an HIV positive mother and prevent MTCT to the baby.
Respondents who had attended such facilities were (N=118) 45%.
The level 1 hospital was almost similar to a woman delivering at home with a
clinician. Approximately (N=1 10) 42% of respondents used this facility, which dic
have the capability to prevent MTCT or mortality. During the interviews, the clinic
level 1 centers stated that they referred women with complications (HIV positive patients
included) to the level 2 or 3 hospitals. However, they sometimes received referred
women because they complained of hospital costs. In the next section, I will explain a
woman's other reasons for choosing health care facilities.
Some respondents, (N=34) 13% asserted preference of a home environment for
childbirth, with a traditional birth attendant (TBA). Most neighborhoods had a TBA or
were close to a clinic where medical personnel were at times called to assist with a
Reasons for using a facility for prenatal care or childbirth
Islamic medical institutions: Women had many reasons for choosing a facility. I
asked women to choose the five main reasons for why they would go to a particular
facility. The most commonly repeated reasons were itemized 1 to 5, (Table A-4) number
one being their most important reason, while five being the least.
Since this study was conducted within the Muslim community, I expected the
maj ority would prefer an Islamic run medical institution. I included this assertion as one
of my hypothesis. As stated earlier, only (N=3 1) 12% stated that they would make
religion as a deciding factor, there was no statistical significance in both models. Support
of an Islamic establishment or muungano wa Waislamnu (Islamic solidarity) was not a
reason of using a facility. The three Muslim run hospitals were built with the intention
of providing access to appropriate health care to those poor Muslims who could not
afford the private hospitals, and also as an alternative to government run hospital
Women often complained about their dissatisfaction with the above institutions wl
were mainly due to mismanagement and cost of attending them. Respondents who Ysltate
using Muslim-run facilities agreed that they used them for tohar or hygienic cleanliness.
Another factor named was stara, although this can simply be translated as the upholding
of one' s respect and virtue, the context enforces a health care provider the moral and
spiritual obligation to protect and honor the individual in their care.
Distance: Distance to a clinic or hospital has been described as a main factor
hindering women from accessing health care. In an urban area like Mombasa, where
transportation and health care facilities were not far from each other, approximately
(N=83) 3 1% of respondents reported distance as a reason for using maternity care.
However, distance had a statistical significance (p=.09), with the odds increasing by 74%
that a respondent made a choice of a prenatal care facility depending on distance.
There are numerous health care facilities at close proximity around Mombasa.
Transportation with matatus (transportation vans) was constantly available at a cost of
Ksh. 10 (equivalent to a United States penny). Women did not have to travel far to receive
care, however, when I questioned some women who had traveled further away from
centers closer to home, they stated that they were in search of either better facilities,
health care providers or shopping for affordable care.
When choosing a birthing center, there was statistical significance (p=.06), with the
odds increasing to almost 78% that a woman would choose a center due to distance.
Women chose facilities for childbirth closer to their homes, in the event that they went
into labor at night, where transportation may not be available.
Health care providers: Health care providers influence women's decision of
where to go for care. Respondents affirmed that they moved to different providers
search of good care. The physical and verbal abuse of women during pregnancy at
childbirth has been documented by Allen (2002), Fon et al. (1998), Okafor and Rizzuto
(1994) and Sargent and Rawlins (1991). Interviewees who chose attendants as reason of
choosing a health care facility were (N=115) 43%. There was no statistical significance in
model 1, indicating plausible flexibility while a respondent was pregnant. However, in
choice of birthing center there was statistical significance (p=.03) with the odds highly
increasing at 82% that health care providers was a maj or factor in choosing where a
women delivered their babies.
Cost: Shopping and paying for affordable maternity health care was a struggle for
many women in this study. Although only (N=101) 38% stated that cost was a factor
while they searched for affordable prenatal care, with many acknowledging that it was a
maj or factor for choosing a childbirth facility. Most women commented, ikiwa sina pesa
sendi clinic (if I don't have money I don't go to the clinic). Payment for preventative care
was a reason used for not using services, especially when other pressing financial needs
took precedence in the home.
Almost all the women (N=99%) did not have home-births, signifying that although
cost was a factor, compromises were made to pay for services or sometimes women were
not paying for services. In choosing a birthing center there was a high probability
(p=.0001) that cost was a maj or factor, with the odds being high that a woman will
choose a birthing center depending on affordability.
To deal with payments after birth, interviewees stated that other family members
were requested to help with contributions (mchango) to help pay for childbirth costs.
Women in most hospitals were retained after postpartum discharge until the bill was p
leaving husbands to raise funds to pay before the mother and baby could be released.
Nurses reported that at times women sneaked out of the hospitals leaving their babies
behind, later to return to claim their babies after paying the hospital bill. Attendants at the
home-birthing centers complained that they had to force women to pay a deposit before
childbirth with the fear that, that would be the only payment to be received after the
woman and the baby left. The balance with some women would be given in installments,
however with some there would be none.
Health care services: The choice of health care services went hand in hand with
health care providers, With the maj ority of the respondents (N=186) 70 % agreeing that
they chose a facility according to services provided. These services included the
interaction with providers, and the efficiency of the establishment in terms of delivery of
care. Interviewees stated that waiting period to be seen by a provider was important,
availability of medication, functioning equipment and laboratory. Although maj ority of
the respondents stated these services were very important, about (N=147) 55% of them
delivered in childbirth centers that could not provide emergency life saving services for
them or their babies. Millions of women globally have babies without problems, however
when there are obstetrical complications they are immediate and require swift action.
Obstetrical emergencies that could cause maternal morbidity are hemorrhage, obstructed
labor, sepsis, and eclampsia. Since this study also assessed women's measures to prevent
mother-to-child HIV transmission, any of the 55% of respondents who might have been
HIV positive would not be in facilities that could prevent MTCT.
In both models there was no statistical significance in choice of health care services
as a reason of choosing a health care facility.
Health problems: I inquired if women chose a health care facility depending on
health problems particularly in pregnancy. The maj or health problems mentioned during
pregnancy, although some are not pregnancy related were anemia (due to diet and/or
malaria), malaria, typhoid, pregnancy induced hypertension or pre eclampsia, and vaginal
discharge (due to reproductive or sexual transmitted infections). Respondents who chose
facilities due to any of the above health problems were (N=18) 7%, plus there was no
statistical significance in both models in women's responses to how they managed any of