Socio-cultural factors, adoption of continuum of care practices and occurrence of puerperal sepsis amongst mothers in Kericho County, Kenya

INTRODUCTION

Continuum of care is described as the integration of health services which are deemed appropriate, and which are accessed at a given time and place. This care should be availed throughout the lifecycle. As such effective continuum of care practices link several essential maternal and child health aspects. These include a chronology of periods from adolescence, pregnancy, childbirth, postnatal and new-borns periods respectively. However, these practices mainly focus on new-borns and their mothers. Therefore, functional continuum of care revolves around maternal and child health programs. Interventions geared towards saving the lives of new-borns and mothers are evidently cost effective when practiced within the continuum of care. On the same breadth, it is noted that enhancing postnatal care within 48 hours of birth and generally increasing completion rate of continuum of care are bound to save lives.¹

Puerperal infections also known as postpartum infections or puerperal sepsis are infections caused by bacteria of the female genital tract either during childbirth or miscarriage. It occurs anytime between placental rupture membranes and at the forty-two-day post-delivery. Puerperal sepsis is also said to be complications that are occasioned by postpartum infections and is one the major causes of postpartum mortality in the world. There exist various types of postpartum infections. These include infection of the uterine wall (endometritis), infection of the uterine muscle (myometristis), and infection of the areas around uterus (parametritis). Albeit the fact that, puerperal infections have reduced since the introduction of antiseptics and penicillin, there are bacteria such as Staphylococcus and Streptococcus which still cause these infections.²

According to a report by the Kenya Demographic and Health Survey (KDHS) for 2008 to 2009, Kenya experiences low postnatal care (PNC) and skilled deliveries. Low PNC services were attributed to low levels of education and lack of skilled delivery.³ In cognizance of the importance of continuum of care for mothers from pregnancy through delivery to post-delivery period, it is recommended in Kenya for all concerned mothers to make at least four ANC visits, deliver in health facilities where there is skilled care, and also visit the aforesaid facilities for PNC services for at least four times. It is important to note that more than 80% of health facilities in the country have the capacity to dispense adequate maternal package under the purview of the continuum of care.⁴ Insights from demographic and health surveys conducted in years, 2003, 2008/09 and 2014 on changes in optimal childcare practices underlined the importance of conceptualizing children’s care as a continuum that cuts across the life of a children before, during and immediately after birth.⁵ Child health promotional activities at local, regional and national levels are asserted to have played a considerable part in enhancing uptake of certain recommended childcare practices in Kenya. Against this backdrop, however, it is not sufficiently documented how or the extent to which the continuum of care practices influences occurrence of puerperal sepsis in Kenya.⁵ It is on this ground that this study was conducted with the objective of giving more insight into the aforesaid practices and puerperal sepsis with a special focus on postnatal mothers residing in Kericho County, Kenya.

Statement of the problem

Reducing infant and maternal mortality has been top of the global agenda of which Kenya is a signatory. The third goal of the Sustainable Development Goals (SDGs) which were adopted by all United Nations (UN) member states in 2015, advocates for good health and wellbeing. In particular, the goal seeks to reduce infant and mortality rate to less than70/10000 live births by 2030. Yet, it is admitted that the world and particularly less-developed economies like Kenya, are off-track to achieve the health-related SDGs.⁶

Maternal Mortality Ratio (MMR) in Kenya has remained unacceptably high at 362 per 100,000 live births.³ Though the MMR declined from 488/100000 as presented by the previous KDHS conducted in 2008/09, the decline was not significant.³ The national trend on these mortality rates paints a grim picture. Puerperal sepsis is a common problem that contributes to infant and maternal mortality in Kenya. Documentation of the number of cases is a problem as most of the cases go unreported. Prevention of its occurrence can, therefore, immensely contribute to the reduction in maternal mortalities and will ultimately have an impact in achieving the respective SDG’s. The findings of this study could hence provide informative insight for the policy makers and practitioners with regard to continuum of care practices and puerperal sepsis among postnatal mothers in Kenya.

Objectives

The objective of this study was to determine the socio-cultural factors that contribute to adoption of continuum of care practices among postnatal mothers in Kericho County and to examine the relationship between socio-cultural factors, continuum of care practices and occurrence of puerperal sepsis among postnatal mothers in Kericho County

Research hypotheses

H₀₁

There was no significant association between socio-cultural factors and adoption of continuum of care practices amongst mothers in Kericho County.

H₀₂

There was no significant association between continuum of care practices and occurrence of puerperal sepsis amongst mothers in Kericho County.

As illustrated in Figure 1, there exist three categories of variables, that is, independent, intervening and dependent variables. These are represented by socio-cultural factors, continuum of care practices and occurrence of puerperal sepsis respectively. According to the conceptual framework, the aforesaid factors that influence continuum of care were related to occurrence of sepsis, and this relationship was confounded by continuum of care practices. This study was conducted on this hypothesis. In the conceptual framework the Tuckman model has been adapted. It is an input, process and output model where the PNC follow up can be offered either at home or at the facility within 24 hrs and beyond 24 hrs. The process entails the health care worker visiting the mother at home or the mother visiting the facility for follow up. The output is the occurrence or non-occurrence of puerperal sepsis.

Overview of continuum of care practices and occurrence of puerperal sepsis

Postnatal care still remains critical to the mother as well as the neonate. Routine PNC will enable the treatment in case of complications resulting from child delivery together with providing the mother with maternal and neonatal care clinical information. Postnatal visits provide an opportunity to educate mothers and it is recommended that all women receive at least three to four postnatal check-ups as per WHO guidelines which consists of immediate (within 48 hrs), early (at week 2) and late periods (at week 6).⁷

The outstanding task at hand on occasion is excessively such that providers turned out to be too occupied to even think about giving data about the significance of having a postnatal. In numerous nations a woman may never get a registration until the point when she ends up pregnant again or except if she chooses to look for family planning. Most of nations need postnatal registers, so regardless of whether a medical attendant has a registration with PN mother, documentation is not finished. To manage this issue, the Ministry of Health in Kenya has as of late structured and actuated a list for three postnatal visits: one visit within 48 hours, the second within one to about fourteen days, and the third visit at about a month and a half since delivery. In Kericho County, hospital deliveries have gone up from 42-57%. It is estimated that 1in 10 women develop puerperal sepsis during pueperium and this is attributed to lack of PNC follow ups. In Kericho County hospitals deliveries are on the rise but still postpartum infections are still occurring which made it necessary to carry out this study.

Empirical review

A study carried out locally assessed the determinants of postnatal care use in Kenya.⁴ The objective of the study was to identify the determinants of PNC use in the country. Cross-sectional design was adopted for the study. The sample population comprised of 3,970 women who were selected using stratified random sampling. The study established that PNC use was low in the country. The findings noted that socio-demographic factors and health care delivery factors could explain PNC use among mothers in the country. That is women with education beyond primary school and women living in urban areas were more likely to use PNC visits. Moreover, the study observed that only women who developed complications were more likely to seek PNC services.⁴

Another local study examined the effectiveness of Kenya community health strategy in delivering community-based maternal and new-born health care in Busia County.⁸ The study aimed at evaluating the effectiveness of the strategy in improving maternal and neonatal health outcomes in the County. An interventional non-randomized pre-test and post-test study was used. The results indicated that community health strategy was effective in delivering the essential maternal and new-born care practices. The study further noted that the continuum of care was needed throughout pregnancy, childbirth and postnatal period so as to improve the health of mothers and new-borns as well as to reduce their morbidity and mortality.⁸

A study conducted in Nandi County, Kenya, assessed factors associated with puerperal sepsis among reproductive age women.⁹ The study aimed to determine the incidence and management of puerperal sepsis among the women of reproductive age. The study adopted cross-sectional study on 215 women who were diagnosed with the condition. The study also used 4 health care providers in charge of the sick patients. The study used purposive sampling technique. Datawere analyzed using SPSS version 20, Chi-square test and logistic regression. The results established that most of the mothers who developed puerperal sepsis were within the age of 20 to 29 years. Moreover, the health care facilities lacked adequate prerequisites to perform puerperal sepsis awareness.

METHODS

A cross-sectional research design was adopted since the study was conducted at a specific period in time.¹⁰ Participants in cross-sectional studies are selected on the basis of inclusion and exclusion criteria set for the study. The participants in this study included postnatal mothers in Kericho County. Additionally, mixed research approach was employed. Moreover, positivism paradigm was adopted. The study was carried out in Kericho County.

The study population constituted of all women who had given birth at least 6 weeks preceding the study and who were attending MCH clinic at the four Level Four Hospitals operating in Kericho County. According to the available respective hospital records, the mothers totalled 1479. The number was calculated from the annual deliveries of 12,816 divided by 52 weeks and multiplied by 6 weeks under consideration. In addition, two groups of health care workers working in MCH and postnatal were included in the study. (5-8 participants are recommended in a FGD). The study used 6 per unit thus 12 per hospital giving a total of 48 health care workers.

The sampling frame comprised all postnatal mothers of six weeks following delivery and all the health care workers working in MCH and postnatal wards of the selected hospitals. Purposive sampling was used to select Kericho County where the study was eventually carried out. Cluster sampling was then used to identify the level 4 hospitals offering comprehensive maternity services within the sub-counties constituting Kericho County. Simple random sampling was used on all the eligible participants for the study. Convenience sampling was used to identify the healthcare workers who participated in the study. In order to ensure fair and equitable distribution of respondents (postnatal mothers) stratified (proportionate) random sampling technique was adopted. This implies that after proportionately determining the number of mothers in each health facility projected to participate in the study, respondents were randomly picked from the selected hospitals. The sample distribution is illustrated in Table 1.

The Cochran’s formula was used to calculate a sample of 385 respondents.¹¹ Focus Group Discussion (FGD) was used to collect data from healthcare workers. The data was collected using a structured questionnaire and a data collection sheet.

The Statistical Package for Social Sciences (SPSS) programme aided data analysis using both descriptive and inferential statistics.

RESULTS

Proportion of postnatal mothers adopting continuum of care practices

Continuum of care describes the intervention maternal and child programmes extended mothers and infants during antenatal, delivery and postnatal periods. In this respect, the study examined the extent to which postnatal mothers had complied with the aforesaid continuum of care practices. The results to this effect are presented in Table 2. The scale SD, D, NS, A, and SA represent strongly disagree, disagree, not sure, agree, and strongly agree respectively.

According to descriptive results shown in Table 2, it is evident that majority of the postnatal mothers (70.2%) agreed that they had received postnatal care (PNC) services within 24 hrs after delivery. Similarly, 50.0% of these mothers strongly admitted that they delivered their babies at a health facility.

On average, the mothers were in agreement with the aforesaid assertions (mean=4.00) albeit the fact that they exhibited diverse opinions on the same (SD>1.000). On the contrary, the sampled postnatal mothers generally disputed that they did not receive PNC services for varied reasons (mean=2.49), they had attended antenatal care (ANC) (mean=2.20), and that they had attended all four recommended ANC visitations (mean=1.17). Although the views of the respondents varied significantly on the first two issues (SD>1.000), they were unanimous in strongly disagreeing that they attended all the four recommended ANC visitations. These results were supported by majority of the surveyed mothers disputing that they did not receive PNC services (disagreed=70.5), they attended ANC (disagreed=74.2%), and that they had attended all four ANC visitations (disagreed=95.2%).

Note: SD*-strongly disagree, D-disagree, NS-not sure, A- agree, SA-strongly agree, and SD-standard deviation.

Association between socio-cultural factors and adoption of continuum of care practices

The views of postnatal mothers drawn from Kericho County on socio-cultural factors and embracing continuum of care practices are as shown in Table 3.

The study, as shown in Table 3, revealed that most (97.2%) of the sampled postnatal mothers were in agreement that their communities had midwives who gave alternative childbirth services to delivering mothers. In general, the mothers were in agreement with this assertion (mean=4.47) while, at the same time, they were largely unanimous on the issue (SD=0.568). Although, it was generally agreed that the communities had a strong belief in women giving birth at home (mean=3.65) with 71.7% of the mothers concurring with this assertion, their views were evidently varying (SD=1.350). Despite the fact that majority of the sampled mothers (56.1%) disagreed that they were very religious, 37.5% were in agreement. This was reflected by their significantly varying views on their religious beliefs (mean=2.69, SD=1.262). It was generally disputed that the mothers’ religion encouraged them to attend prenatal and postnatal services in health facilities (mean=2.24) with majority of the respondents (70.9%) disputing the argument.

Note: SD*-strongly disagree, D-disagree, NS-not sure, A- agree, SA-strongly agree, and SD-standard deviation.

The results of cross-tabulation between socio-cultural factors and adoption of continuum of care practices are presented in Table 4. According to the results of chi-square test shown in Table 4, it is apparent that the χ2 value is 1819.850 with 360 degrees of freedom which resulted in a p value of 0.000. Given that 0.000 is smaller than 0.05 the respective null hypothesis was rejected and the study concluded that socio-cultural factors had an influence on adoption of continuum of care practices amongst mothers in Kericho County. Additionally, the association between the specific socio-cultural factors and compliance to the continuum of care practices was determined. The results to this effect are presented in Table 4.

Note- a-394 cells (98.5%) have expected count less than, 5- The minimum expected count is 0.00.

As indicated in Table 5, it is instructive to state that religious beliefs, community beliefs and availability of traditional birth attendants or midwives played a consider- -able role relative to compliance of mothers to continuum of care practices. All mothers (100.0%) who had strong religious beliefs complied with the continuum of care.

However, majority (72.3%) of those who had little or no religious belief did not comply with the COC. Inferentially, religion played a significant and positive role in persuading mothers to comply with the aforesaid practices (χ2=122.541, p=0.0001). Unlike religious beliefs, the beliefs by the community that women should give birth at home did not have significant effect on the compliance of continuum of care χ2=1.111, p=0.292) when the association between the two was measured at p value=0.05.

Interestingly majority of the mothers (58.8%) who believed that they ought to deliver at home also complied with the continuum of care. This implies that these mothers were ready to go against their beliefs by embracing modernity which advocates for COC. Mothers from communities with midwives were more inclined to embrace the continuum of care practices (56.4%) when compared to those of communities lacking birth attendants where there was no sampled mother (0%) gave an affirmative response.

Interpretatively, the midwives and/or TBA encouraged the nursing mothers to comply with the COC probably due to their understanding of the benefits associated with the aforesaid practices. It was further revealed that presence or availability of midwives or birth attendants played a significant role in compliance of COC (χ2=8.747, p=0.003).

Continuum of care practices

The study examined adoption of continuum of care practices by postnatal mothers attending PNC services across the four Sub-County hospitals in the greater Kericho County. In this respect, these mothers were asked to comment on several issues pertaining continuum of care practices. The descriptive statistics to this effect are presented in Table 6.

As shown in Table 6, it was revealed that most of the surveyed postnatal mothers agreed that they had never visited a traditional birth attendant (agreed=70.2%); they had received excellent care when giving birth (agreed = 71.8%); and that they delivered their babies either at a dispensary, health centre or hospital (agreed= 66.1%). In spite of the preference of mothers to give birth while at a health facility, earlier studies had reported disrespect and abuse of women during childbirth (Afulani, Kelly and Buback).

Although the mothers generally were in concurrence in respect of these assertions (mean=3.84, mean=3.83, and mean=3.68 respectively), it is apparent that their views varied significantly on these aspects (SD=1.616, SD=1.529, and SD=1.577 respectively). In spite of their views considerably varying, the sampled mothers generally disputed that they received exemplary antenatal care services (mean=2.15, SD=1.438); community health workers visited them at least once after delivery (mean=1.94, SD=1.040); and that the visits of the health workers, if any, were highly beneficial to them (mean=1.83, SD=1.074). These observations were supported by 75.0%, 88.3%, and 89.9% of the mothers disputing the aforesaid assertions respectively. Further observations indicated that almost all the sampled mothers (92.0%) disagreed that they had attended both antenatal and postnatal care services without fail.

This was in concurrent with the almost unanimous disputing of this argument by the mothers (mean=1.83, SD=0.867). Not only did 96.4% of the sampled mothers disagree that they were visited by either a doctor or a nurse while at home after delivery, but they generally strongly refuted the claim (mean=1.35) while simultaneously holding largely similar views on the issue (SD=0.754).

Note: SD*-strongly disagree, D-disagree, NS-not sure, A- agree, SA-strongly agree, and SD-standard deviation.

Occurrence of puerperal sepsis

The study further examined the occurrence of puerperal sepsis, that is, the infections or ailments associated with mother during antenatal, delivery and postnatal periods. On this issue, a sample of mothers drawn from a cross-section of postnatal mothers in Kericho County were asked to express their views on a number of issues revolving around occurrence of puerperal sepsis. The pertinent descriptive results are presented in Table 7. According to the results shown in Table 7, it is very clear that the sampled postnatal mothers wholesomely disputed all issues put across with regard to occurrence of puerperal sepsis (mean=2.00) except on only one issue where they generally exhibited a sense of indifference (mean=2.51). On the latter issue, it was revealed that while 31.0% of the mothers agreed that they sometimes experienced complications during their PNC visits, 68.9% others disputed. As earlier indicated, majority of the mothers disagreed that they sometimes experienced pelvic pain after delivery (disagreed=73.4%); they sometimes had a fever during postnatal period (disagreed=81.8%); and that part of the complications they experienced was foul-smelling discharge (disagreed=86.3%). Evidently, these issues attracted significantly divergent views (SD>1.000) which was illustrative of the fact that, a sizeable number of mothers concurred with these assertions. Not only did 95.6% of the mothers disputed that they had experienced delayed involution of the uterus, but they were largely unanimous in disregarding this argument (SD=0.799).

According to the foregoing findings, it is apparent that, in total, 89.9% of mothers admitted to have experienced various forms of puerperal sepsis from complications during PNC, pelvic pain, fever, foul-smelling discharge to involution of the uterus.

Note: SD*-strongly disagree, D-disagree, NS-not sure, A- agree, SA-strongly agree, and SD-standard deviation.

The results shown in Table 8 indicated that in order to change occurrence of puerperal sepsis by a single unit, continuum of care practices and socio-cultural factors had to be changed by 0.589 unit and 0.435 unit respectively while holding other factors constant.

It was further observed that the aforesaid practices (t=6.340, p=0.0001) and factors (t=4.424, p=0.0001) had a significant effect on occurrence of puerperal sepsis among postnatal mothers residing in Kericho County, Kenya.

DISCUSSION

The study revealed that postnatal mothers residing in Kericho had, to a large extent, received PNC services immediately after giving birth, that is, within 24 hrs after delivery. The mothers also preferred to giving birth at health facilities possibly due to the perception of these facilities being the safest for delivery to both the mothers and their infants. It was apparent that mothers in Kericho County valued postnatal care more than antenatal care. This is supported by the findings that majority of the surveyed postnatal mothers disputed to having attended ANC visitations while admitting to receiving PNC services. These results were a departure from the observations made in a previous study conducted in Cambodia that postnatal mothers (as opposed to antenatal mothers) had greater propensity of discontinuing the continuum of care.¹² The argument made by the study was the long distance to health facilities which deterred completion of continuum of care practices. Yet, this did not clearly explain how and why the mothers made the necessary ANC visitations and PNC visitations. Whereas, this study underlined the importance with which mothers attached to postnatal care contrary to antenatal care, a study conducted in Jordan had revealed that mothers perceived ANC to be more crucial than PNC.¹³

Whereas the study indicated that mothers visited health facilities for PNC services, an earlier study conducted in Nigeria indicated a different scenario. According to the latter study, only 5.8% of the mothers attended PNC services.¹⁴ This could have been linked to large numbers of unskilled working mothers in Nigeria as opposed to the Kenya’s context. The present study further contradicted a past study which had found that only women who developed complications were more likely to seek PNC services.⁴ The disparity in the results of the two studies (current study and the former) could have been explained by the fact that neither of the two studies clarified whether or not mothers sought PNC services when taking their infants for immunization and other clinics.

With regard to socio-cultural factors, communities in Kericho County were found to have traditional birth attendants, otherwise referred to as midwives. These TBAs gave alternative care to mothers mainly during childbirth. Contrary to most of the mothers delivering at health facilities, the communities in Kericho County had a strong belief in women giving birth at home where they could be attended to by TBAs. These results were a reflection of observations made by an earlier study conducted in Busia County. The study had indicated that community health strategy was effective in delivering the essential maternal and new-born care to mothers and their infants.⁸ Most of the Kericho residents were not very religious which implies that their religions played a small role in the choices they made with regard to adopting the continuum of care practices. This explained why the religion was not contributing factor to the mothers attending prenatal and postnatal care services.

A significant proportion of occurrence of puerperal sepsis could be explained by adoption of the continuum of care practices. Additionally, the practices were found to impact significantly on occurrence of puerperal sepsis. The results underline the importance of the foregoing practices in addressing occurrence of puerperal sepsis among postnatal mothers in Kericho County and beyond. This is important because it has previously been reported in a study conducted in India that severe puerperal sepsis results in significant maternal mortality by (Marwah, Topden and Sharma). Another study carried in Uganda further supported the importance of the continuum of care practices where it established that the major cause of maternal mortality was puerperal sepsis.¹⁶ Therefore, mitigating or averting occurrence of puerperal sepsis is very essential, a fact that underscores adoption of continuum of care practices given that the latter significantly influences the afore-stated infections.

CONCLUSION

The study infers that socio-cultural practices are deeply entrenched in communities residing in Kericho County. This is informed by the results that the presence of traditional birth attendants, who often are old women with the perceptible reputation of assisting mothers when delivering. Cultural entrenchment is further underlined by the strong belief among women to give birth at home as opposed to health facilities.

Therefore, the preference of the mothers to give birth at health facilities could be concluded to have resulted from fear of their safety and that of their new-borns during delivery. This implies that the foregoing fear overrode their belief in giving birth at home.

Recommendations

Community social workers should be integrated into civic and health education to mothers and the general population particularly on matters of continuum of care. Cultural practices, norms and beliefs which dissuade mothers from seeking modern health services ought to be discouraged. While appreciating the role played by traditional birth attendants, the county governments and the Ministry of Health are recommended to offer them free training on how effectively to attend to mothers prior to, during and after delivery. Churches and other religious gatherings should play a leading role in encouraging mothers to seek ANC, delivery and PNC services at health facilities. This is informed by the fact that, there are certain religions which prohibit their followers against embracing modern medicine and health practices. The national and county governments are advised to use the necessary approaches to deal with such religious sects.

ACKNOWLEDGEMENTS

We would like to acknowledge Dr. Caleb Kirui of Kenyatta University for his guidance during the compiling of this article.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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