Pulling Together – A Harambee* for Safe Motherhood Services in Pastoral Kenya

Pulling Together – A Harambee* for Safe Motherhood Services in Pastoral Kenya

This is a guest blog post written by Derek Lee from Pathfinder International.

The donkey cart ambulances were built by local craftsman.

On October 15, 2010, dozens of Kenyan women in bright headscarves gathered beneath the acacia trees scattered outside Balambala sub-district hospital.  The area chief was in attendance, as were members of the local women’s livelihood groups.  Despite the oppressive heat, everyone was in jovial spirits because this sunny day marked a momentous occasion for their “Care for the Mother” project.

An intervention led by the USAID-funded Extending Service Delivery (ESD) Project (a partnership between Pathfinder International, MSH, Intrahealth, and Meridian Group International), the Care for the Mother activity is designed to increase the community’s use of facility-based family planning/reproductive healthcare services in this remote stretch of Kenya. In fact, one of its explicit tasks was to provide donkey carts to serve as ambulances for transporting women in labor to the local clinic. Moving pregnant women across vast and sandy pastures to the nearest health facility in this hot, arid climate is not only a difficult task, but a potentially dangerous one too. It was to great applause that two donkey carts designed to the women’s specifications by local craftsmen were presented to the two livelihood groups in a joyous ceremony. The women were so eager to have working ambulances they even brought their own donkeys to the event.

There was one problem, however. As soon as the applause died down, everyone realized that something essential was missing – the yokes to attach the donkeys to the carts. In the flurry of the project activities, this small but vital detail had somehow been overlooked. The assembled group quickly proposed a solution, one that illustrates just how resourceful, enthusiastic, and committed they are to bringing safe motherhood services to their region.

Spanning the length of the Somali and Ethiopian border, Kenya’s North Eastern Province (NEP) is home to approximately 1.3 million semi-nomadic pastoralists. In this conservative Muslim region, many miles often separate villagers from the nearest health clinic and only an estimated 40 percent of the population has access to healthcare services. The early age of marriage and infrequent use of contraceptives have led to women giving birth to an average of nine children – nearly double the national average. Both maternal mortality and infant mortality remain high by Kenyan standards. Only seven percent of births in NEP occur in a health facility, compared to 39 percent nationally (Kenya: DHS, 2003). Meanwhile, awareness of healthy practices like birth spacing and antenatal care is extremely low.

During the handover ceremony, members of the women’s livelihood groups huddled in the shade to protect themselves from the sun. The North Eastern Province of Kenya is known for its hot, arid climate.

ESD’s AIDS, Population, and Health Integrated Assistance (APHIA II) Project is a five-year umbrella project between the Government of Kenya and USAID/Kenya that engages local organizations to improve health care at the community and facility level across NEP.  The Care for the Mother activity asks local women’s groups, with support from religious and community leaders, as well as husbands, to actively participate in sustainable social change around maternal and infant care by increasing a community’s use of antenatal and postpartum care, family planning, birth spacing, and facility delivery.

To accomplish this ambitious goal, ESD partnered with four existing women’s livelihood groups in Balambala and Sankuru villages in Garissa district, relying on the social networks they have established in the area, to spread new ideas.  ESD supported education of the women’s groups on several important safe motherhood topics with the intent that the women would disseminate this information throughout their communities and refer pregnant women to the local health facility for quality services.  Training the group members was no small task, considering that most of the women are illiterate. Project staff worked with health workers and volunteers fluent in Kiswahili and Somali to translate the education materials into the local language. A referral form was designed with group members using pictures that women could easily understand and mark off when referring their female family members and neighbors to the local health facility.  “For example,” says Jeanette Kesselman, a Senior Advisor at ESD, “one picture represented ‘antenatal care.’ Another picture meant ‘delivery.’  Creating diagrams that everyone could understand was a real challenge.”

In addition to facilitating monthly meetings between the women’s groups and health clinic staff, ESD also agreed to provide each women’s group with a donkey cart to transport mothers to and from the clinic. “There are very few cars, motorcycles, bicycles or buses in the area,” explains Ms. Kesselman, “but everyone can get around by donkey.” Donkeys are commonly used to transport supplies and produce throughout the area.

ESD Senior Advisor Pauline Muhuhu, right, hands an official delivery note to the chairwoman of the Darkenley women’s livelihood group.

In Balambala, however, there was no getting around in donkey cart ambulances without yokes.  While the obvious answer was to simply wait until yokes could be purchased at a later date, the women wanted the carts operational immediately – they had waited long enough.  The ceremony chairwoman, Mrs. Zeinab Omar, suggested holding a fundraiser – or a harambee – on the spot.  James Oyieko, an APHIA II NEP Reproductive Health Coordinator and Pauline Muhuhu, an ESD Senior Advisor, rallied the women and the area chief so that every single attendee contributed to the necessary funds. 

Within ten minutes and amid boisterous ululations, Mr. Oyieko announced they had raised 2,200 Kenyan shillings, enough to purchase two yokes and axle grease to make the two donkey carts functional immediately.

The group’s quick action at the ceremony illustrates the dynamism and drive the community has demonstrated in support of safe motherhood.  “These women are very motivated,” says Ms. Muhuhu.  “They’re interested in making lives better for their sisters, their mothers, and their children.”  While end line data for this intervention are still being collected, Mr. Oyieko has observed that referrals at the facility originating from the livelihood groups are increasing.

Plans are underway to apply and scale-up the Care for the Mother model across the entire Northern Arid Lands region as an APHIA Plus extension, and it could even serve as a template for other countries which face similar challenges reaching conservative, pastoral populations. 

 Ms. Kesselman sees this as a positive development for both health and cultural reasons.  “If the women know more about their health and what health services to expect at the facility, they can not only seek out these services, but they can demand them too.  It empowers them.”

*Harambee means "pulling together" in Swahili and refers to Kenya's long history of community self-help events. It is the national motto of Kenya.