MOUNT KENYA UNIVERSITY ASSESSMENT OF FACTORS CONTRIBUTING TO UNSKILLED DELIVERY AMONG WOMEN OF CHILD BEARING AGE [15-49] WITHIN HABASWEIN SUB-COUNTY, WAJIR COUNTY ABDIWAHAB ABUKAR MOHAMED REG: DHRIT/2014/74385 A RESEARCH PROJECT SUBMITTED TO SCHOOL OF CLINICAL MEDICINE AND DEPARTMENT OF HEALTH RECORDS AND INFORMATION TECHNOLOGY IN PARTIALFULFILLMENT FOR THE AWARD OF DIPLOMA IN HEALTH RECORDS AND INFORMATION TECHNOLOGY OF MOUNT KENYA UNIVERSITY JULY 2017  DEDICATION I hereby dedicate this research to my loving family, friends and my Uncle Dr Adam Hajji Billow for the great concern, guidance moral support and financial support throughout the course of this research. DECLARATION I declare that this is my original work and that this research has never been submitted to any institution for learning or any other purposes. NAME: ABDIWAHAB ABUKAR MOHAMED REG. NO: DHRIT/2014/74385 Signature; ………………………………… Date; …………………………………………  ACKNOWLEDGEMENTS I would like to thank God for the endless grace and guidance since the inception of this project up to its completion. Also I acknowledge the department of Health Records and Information technology, Mount Kenya University, which through my able supervisor, Mr. Duncan Maina for the valuable advice and extensive support I received since proposing and drafting period of the project. I also would not forget my course mates and friends for the contributions towards the success of this project drafting. Deep gratitude goes to my Uncle Dr Adam Hajji Billow and my parents for the prayers, great care, concern and financial support throughout the hard times of the on developing this work to realization. APPROVAL The following project has been submitted with the approval of the following supervisors. The undersigned certify that he has read and recommended to the Department Of Health Records And Information technology for acceptance of research study entitled: Assessment of factors contributing to unskilled delivery among women of child bearing age [15-49] in Habaswein Sub-County, Wajir County Submitted in partial fulfillment for the award of diploma in Health Records and Information technology. SUBMITTED BY: Abdiwahab Abukar Mohamed REG NO: DHRIT/2014/74385 INTERNAL SUPERVISOR Mr. Duncan Maina Head of Department Masters in Health Information Management Phone No: 0723 167 027 Signature: …………………… Date: …………………………. EXTERNAL SUPERVISOR Madam Ann Opondo Lecturer Department of Public Health Phone No: 0706 587 626 Signature: …………………… Date: …………………………. TABLE OF CONTENTS ABBREVIATIONS AND ACRONYMS ANC Ante Natal Care DHM District Health Management Team Gravida 1 this refers to those pregnant women delivering for the first time deliver. Unskilled delivery child birth occurring outside a health institution and is conducted by non-skilled birth attendant. Infant mortality rates Number of deaths among the children of below 1 year in a given year per 1000 live births. Infants’ young born between the ages of 0-28days of life KDHS Kenya Demographics Health Survey Maternal death the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Premagravida women who have had successive deliveries during pregnancy TBA Traditional Birth Attendance Variables varying characteristics of something being observed or measured WHO World Health Organization ABSTRACT Maternal and infant morbidities and mortalities are major global public health concerns where impact is greater in Kenya and more so in all other developing countries. Provision of safe motherhood is of utmost importance in the reduction of maternal mortality and establishing a good health growth for the new born. Increasing the proportion of babies that are delivered in health facilities is an important factor to reducing the health risks on both the mother and the baby whereby in either way will affect the economy of a country. The main objective of this study was to assess the level of unskilled delivery and those contributing factors that drives woman to deliver outside health facilities within the premises of Habaswein Sub-County. The study was set to be a community based cross-sectional descriptive study on mothers of child bearing age within the 5 selected health centers which were recruited using the random sampling technique. Data was collected using a mix up questionnaires of structured and semi-structured questions which involved an interview of a total of 100 participants; both the healthcare providers and the target women in the selected health facilities and within the villages in the ratio of 1:4.Chi-square test and correlation analysis was be employed in the analysis to clearly show the existing relationship among the existing variables. The level of Significance of the study was considered to be at α=0.05. Of the 100 respondents, majority (89%) had the information on the availability of government subsidized maternal healthcare services but little of them appreciates and utilizes these resources. It is with clear indication that more than 90% of the 80 interviewed women believe on the culture and taboos of the society hence low turnout rates on the facility utilization. Though distance from and means of transport remains to be the strongest barrier to those who would have intended to access services, administration is highly needed to reduce the recently witnessed increasing complication, morbidities and mortalities associated to home deliveries.  CHAPTER ONE INTRODUCTION Pregnancy and childbirth related complications contribute to a significant number of pregnant women and childbirth related deaths and disabilities in the world especially in developing countries. The major causes of these deaths are prolonged or obstructed labor, complications from unsafe abortion, hemorrhage and malaria during pregnancy. Notably, most of this deaths and disabilities are preventable if women make good use of the available maternal healthcare services. Despite the government of Kenya and other stakeholders’ efforts to curb pregnancy related deaths and disabilities, maternal mortality rates (MMRs) have remained soaring high in the country. Safe motherhood initiatives such the provision of free maternity services are still being underutilized by many women in Kenya especially those in poor, rural and remote settings in the country. 1.1 BACKGROUND OF THE STUDY According to WHO, each year, more than five hundred thousand women die from complications related to pregnancy and childbirth, and nearly four million newborns die within 28days of birth (infants). “Currently Nigeria is rated to have the highest lifetime risk of maternal mortality than any other country in the world, where for 7 live births 1 is pronounced death within the first 28 days of life time (WHO, 2010). The figure is too high compared to those of developed countries where comparable risk for the infants 1 for every 8,000 live births. Dating back to the year 1990, when the MDG’s were formulated, an estimated 10 million women have died from complications related to pregnancy and childbirth, and some 4 million newborns have died each year within the first 28 days of life. Advances in maternal and neonatal health have not matched those of child survival, which registered a 27% reduction in the global under-five mortality rate between 1990 and 2007”, (UNICEF, 2010). Currently in Kenya, deaths occurring due to complications related to pregnancy and delivery during birth remains as high as 488 maternal deaths per 100000 live births per year due to high rate of unskilled birth attendance (Kenya Demographics Health Survey, 2011). This occurs as a result of unsafe deliveries which eventually develop complication hence claiming lives of many. The government of Kenya has raised great concern to solving the problem and working towards achievement of sustainable development goals. While 56% of Kenyan women deliver at home with home births being common in rural areas, only 44% are attendant by a skilled or trained midwife with approximately 35% of the new born not in for the postnatal clinical care (Mugweni, E., Ehlers, 2013 ) . Habaswein sub-county is a victim of this disaster and it is evident that Traditional birth attendance (TBA), cost of service, cultural practices, social class, and proximity to a health facility, poor road conditions and level of education are the common identified as a risk exposing factor to causing. Fight to attaining the 4th and 5th millennium Development Goals; reducing child mortality and improving maternal health, the government has subsidized the maternity fee effective from the year 2013. According to KDHS 2010, The proportion of women making the recommended number of antenatal care visits of 4 and above declined from 64 per cent in 1993 to 52 per cent in 2003 and to 47% in 2008/9, while the proportion receiving skilled care during delivery declined from 45 per cent in 1998 to 42 per cent in 2003. Skilled attendance at birth increased to 44% in 2008/9. Many researchers have carried out many studies to assessing various factors that contribute to complications during pregnancy and delivery by pregnant mothers where more than 50% of women living in the rural areas of sub-Saharan Africa are still on traditional practice (Wolde Michael K 2011). Findings show that 60% of deliveries were done at home as a result of resistance to cultural practices with an idea of distance between their places of residence to health facilities and poor means of transport. While the highest percentage of deliveries in urban are done by a skilled personnel in a health facility citing that level of education, income and accessibility to the facility are attributed to this. Still on rural, 11% of the cited the cost as the barrier, 18% for abrupt deliveries and 21% didn’t see any need to it (Amooti, K. B. 2010). More deaths are still evident on the sub-Saharan Africa where out of every 6 live births 1 dies before the fifth birthday. This rate still remains higher and much is needed or otherwise the development goals will remain unattainable by 2030 (Chiwuzie et al. 2012). According to the UNICEF The region as a whole only managed to reduce child mortality at an average annual rate of 1 percent from 1990-2007, and double-digit reductions will be needed during each of the remaining years (to 2030) if it is to meet SDG (the sustainable goal of reducing child mortality by two thirds 2015).” 1.2 STATEMENT OF THE PROBLEM Kenya’s health infrastructure suffers from urban-rural and regional imbalances, lack of investment, and a personnel shortage, with, for example, one doctor for 10,150 people (ministry of health- Kenya 2011). The alarming mortality rates are evident to be increasing the burden of dependence which specifically affects economy of the country. It is only through good foundation that a stable health person can grow to improving his own economy hence the country and therefore, the government of Kenya introduced the need for free maternity service program, postnatal care program, children nutrition program and free insect treated nets to help improve the life quality (V.J., & Roos, Janetta H. 2013). In the developing countries where Kenya; Habasswein Sub-County involve, is among those areas where most of registered births are from the adolescent group of age bracket 15-19 years; these category shy off the pregnancies hiding it from the public hence posing great risk to themselves and young ones to be born. This in turn has made the antenatal care services unattainable thereby increasing the risk to the concern (Ricardo C, Eads M, and Barker G 2013). According to WHO statistics, in 2013, 2.8 million babies died within the first month of life, which represents about 44% of all under-five deaths. About two-thirds of these deaths occurred in just 10 countries. While the number of neo-natal deaths has declined, progress has been slower than for the overall under-five mortality rate (Nuwaha, Fred. 2012). A better plan of action is needed to support the SDG strategies towards improving the health of the population hence economy. 1.3 JUSTIFICATION OF THE STUDY Habasswein Sub County is known to have very many health concerns and maternal mortality is one major concern globally. Some research has been carried out in Kenyan but information on facts about causes of maternal death is still limited. Most deaths of women and girls in childbirth in developing countries are preventable and the heath care needed to achieve this could be provided at relatively low cost. Empowerment of women and girls is vital in enabling them to access health care. Risks can be significantly reduced if problems in pregnancy can be picked up at an early stage and if women can deliver their babies in well-equipped health centers. 1.4 OBJECTIVES OF STUDY 1.4.1 BROAD OBJECTIVE To assess factors contributing to unskilled delivery among women of child bearing age within the premises of Habasswein Sub-County, Wajir County. 1.4.2 SPECIFIC OBJECTIVES To assess factors contributing to unskilled delivery among women of child bearing age within the premises of Habasswein Sub-County, Wajir County. To identify the leading determining factors that influenced the choice of place of delivery among the women of child bearing age at Habasswein Sub-County, Wajir County To assess rate of uptake and utilization of maternity services within Habasswein Sub-County, Wajir County. 1.5 RESEARCH QUESTIONS 1. What were the possible factors contributing to unskilled delivery among women of child bearing age within the premises of Habasswein Sub-County, Wajir County? 2. What were the leading factors that influence unskilled delivery among women of child bearing age within Habasswein Sub-County, Wajir County? 3. At what rate was maternity services utilized in all health facilities within Habasswein Sub-County, Wajir County? 1.6 SIGNIFICANCE OF THE STUDY The study was seen to cut through two levels of significance which are theoretical significance and practical significance. For theoretical significance, the study exposed the researcher into a learning experience where the theoretical class work will put into practice and appreciate the accumulated knowledge for application in other similar activities of this kind as well as for further studies. Secondly, the findings from this study were clearly interpreted and rationally use to help address the problems and consequences that arises from traditional birth attendance by unskilled personnel. Moreover, the information was used to advise the women of Habasswein Sub-County, on appropriate interventions towards improving safe motherhood services in the sub-county, (SCHMT) members in the sub-county towards proper formulation of strategies and effective Health education messages to help solve the problem of low deliveries in Health facilities in the sub-county. 1.7 THE SCOPE OF STUDY The study was conducted within the premises of Habasswein Sub-County, Wajir County as indicated in the map in appendix where the research will be tailored to assess those factors contributing to unskilled delivery among women of child bearing age in Wajir County; Habasswein Sub-County. Through which the identified factors will be tabled, recommended and action will be taken. 1.8 LIMITATIONS OF THE STUDY Research remains to be a complex field and therefore as a researcher challenges will be expected. While financial budgets will be limited, accessibility to some areas like Sabuli division will also became a challenge during data collection. At some instances, some of the respondents will fail to contribute sincerely due to unwillingness and barriers associated with the culture. For example, the culture will not allow the head count of the children but rather they consider to use a local say “ilmabathan” to mean many children. 1.9 DELIMITATION OF THE STUDY The study was limited to only Habasswein Sub County and will not go beyond the sub county. This was an advantage due to the fact that it was centrally located allowing easy collection of data from the respondents. CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Research Overview Maternal death as a fact is associated with considerable grief and depression. It directly affects child’s survival by increasing chances of new-born death by 2-4 times. The loss of a woman at the prime and productive part of her life also adversely affects family income and extent the impact of socio-economic burden on the spouse and children. Indeed, women’s economic contribution is essential to reducing poverty and building a strong health nation. Each year, research shows that out of an estimated 120 million pregnancies that occur worldwide, more than half a million women die during pregnancy and childbirth. For every woman who dies another 30 suffer long-lasting injuries and illnesses, for example the fistula, translating to more than 50 million women with complication as a result of pregnancy. Most maternal deaths are avoidable and can be prevented through empowering all the women of reproductive age on the proper decision on the place of delivery, ensuring good quality maternal health services, including antenatal and postnatal care, skilled care during childbirth, emergency obstetric care and prevention of unwanted pregnancies. Maternal health is directly linked to the survival of the newborn. Findings indicate that every year four million babies die in the first four weeks of life and a similar number are stillborn. Three quarters of neonatal deaths occur within the first week and the highest number registered within the first 24 hours of life. Almost all (99%) neonatal deaths occur in low income and or middle income countries (Rodeck, 2011). 2.2 Related studies Several studies have been done to determine the magnitude of health facility deliveries with correlational studies to assessing those factors that contribute to this. According to Amin A and Chandra-Mouli V; Reproductive Health 2014, the gender attitudes of both women and men are shaped by peers, family members, others in the community including community leaders, and societal institutions (e.g. media, sports, religious, military, schools) that validate masculine norms and identities and female subordination. It is to this respect that women are driven by their heads towards this humiliating situation by making decision for them on the controlled child birth, cultural practices and believes as well as decisions on the place of delivery Barbhuiya et al. (2011) in their study on prevalence of home deliveries and ante-natal care done in Gazipur Thana Bangladesh results showed that 83% of the respondents received ante-natal check-up throughout their last pregnancy and out of 505 respondents 91.3% of the respondents was found to have delivered at home while only 8.7% at health institutions. On the other hand, Kaguna et al. (2013) in their study on factors influencing choice of delivery sites in Rakai district Uganda noted that 44% of the sample delivered at home, 17% at traditional birth attendant’s place, 32% at public health units and 7% at private clinics. In Tanzania Demographic Health Survey (2011) described health facility delivery being 47% and home delivery being 50%. Another study done by Muranda (2013) in Zimbabwe reported that the adult literacy rate rose from 50% in the year 1985 to 95% 2011. Whereas ANC attendance rates were high however, the deliveries in the majority of cases did not take place at the hospital or planned place which was only 44.3% health unit deliveries with gravida 1 rating the highest percentage of 30.7%. Similarly, Godffrey and Sembatya (2013) in their study done in Mangachi district in Malawi in 1996 reported that although many mothers attend ante-natal clinics at various units in Malawi, less than one quarter of them actually deliver in the health Centre, which was 23% of all deliveries in the study. Mothers knowledge is an important factor in enabling them in attending ANC. Findings from a study by Ladfors et al. 2011 in a population based study Swedish Women’s opinions about ante-natal delivery and post-partum care reported that 81% of porous women answered that, checking blood and urine samples, fetal rate and measurement of fundal height were the most important procedures in ante-natal care. Mothers have also been reported to be having substantial knowledge on risk factors. In a study in Ekpoma Nigeria reported that the community was knowledgeable about hemorrhage in pregnancy and delivery, however because of the inability to recognize early warning signs they continued with traditional treatment even when clear evidence of danger existed (Chiwuzie et al., 2010). Mothers have a tendency to believe that, the more they deliver the less the complications and hence the less need to deliver in health facility. The TDHS (2010) discovered that in overall 45% of births were delivered in a health unit, while about half of the births were delivered at home. The proportion of births delivered in a health unit decreases with the mothers parity. The influence of distance cannot be underscored. According to Gabrysch (2011) on studies done in Zambia, she reported that due to geographical barriers there is limited access to emergency obstetric care. This is a key factor in explaining why most rural deliveries in Zambia still occur at home without skilled care. Addressing geographic and quality barriers is crucial to increase service use and to lower maternal and perinatal mortality. Linking datasets using GIS has great potential for future research and can help overcome the neglect of health system factors in research and policy. This study demonstrated that maternal complication rates are increased in areas where women are likely to arrive in the hospital, in a serious condition. This includes distance to the health facility and in adequate action by medical personnel. On the other hand Godfrey et al (2011) reported that among reasons given by mothers for not delivering in health units was distance to the health unit. Eighteen percent (18%) of the respondents in this study most of them prime gravida and grand multiparas had their confinement at home. Rizzuto et al. (2012) pointed out that in Africa; staffs often lack clinical and interpersonal skills. Facilities are in poor repair drugs and medical supplies and equipment are not existent or expensive. Problem of inadequately trained staff and supplies also came up in focus group discussions, in Ekpoma [Nigeria] it was noted that there was a negative perception of the quality of care available in which shortages of materials, adequately trained personnel and committed personnel in the modern health institutions serving the community (Chiwuzie et al., 2011). Brieger et al. 2009 described other factors which keep women away from higher level health facilities are costs of hospital delivery, unfamiliar practices, in appropriate staff attitudes, restrictions with regard to the attendance of family members before seeking institutional care. Other factors included negative perceptions of the quality care provided, related to bureaucracy, lack of drugs and other supplies, none functioning equipment, absence of doctors especially at night and apparently unfriendly attitudes of staff towards patients, also referral from one level of care to another was not well organized. Socioeconomic/cultural factors have significant influences on a place where delivery is to take place. WHO describes that poverty and level of education are clearly a high risk factors. It is also known that poor women are less likely to have formal education than wealthy women, and are less likely to be in good health and to seek or receive medical care (Maine, WHO 2008). Some studies done in Bachok district Malaysia and elsewhere noted that, child birth at home is perceived as a natural family event in which relatives support and comfort the mother while child birth in hospital on the other hand is an event from which families are to some extent excluded. Furthermore hospital delivery is not popular among rural mothers who are strongly influenced by traditions (Ahmad et al., WHO 2011). 2.3 CONCEPTUAL FRAMEWORK The framework aims at defining the underlying relationship between independent and dependent variables. In this research the independent and dependent variables are shown in the table below: Table . Showing dependent and independent variable. Independent Variables Dependent Variable Distance from facilities Age of respondents TBA practices Marital status Traditions and cultures Place of delivery Level of education Employment CHAPTER THREE 3.0 METHODOLOGY 3.1 Design of study This study was employing a descriptive cross-sectional study which concerns the determining frequencies with which unskilled deliveries occur within the premises. 3.2 Study area The study was carried specifically in a location known as Habasswein Sub-County, Wajir County. It is situated in the North- Eastern Province and according to the previous researches most women of child bearing age practice traditional birth attendance. 3.3 Study population The study target population will be women of child bearing age (15-49) within Habasswein Sub-County Wajir County. 3.4 Size and Sampling Procedures The target group was all women of child bearing age within Habasswein Sub-County. Five health facilities will be selected out of the ten facilities at random. The five facilities selected make half of the total facilities and produce accurate results (Graham W et al. 2011). The sample size of the women that was interviewed at both the facilities and the rural vicinities determine using the formulae below. n ═ NZ2 pq (E2 (N-1) + Z2pq) n = required sample size N = the population size (2000) Z = Standard normal deviate (1.96) P and q = Proportion of pregnant women delivering in Health facilities in Habasswein Sub- County (200/1673= 1/10) E = sets the accuracy of your sample proportions (=0.05) n = 2000*1.962*1/10 0.052* (1673-1) + 1.962*1/10 n = 100 The study therefore interviewed a total of 100 interviewees comprising both health workers and the target group members. 3.6 Data Collection Procedures The procedure involved identifying the area of study which was Habasswein Sub-County, Wajir County; get the necessary resources, permission from the university and local administration, designing a sample size, collecting data, analyzing and presentation of the findings. 3.7 Data collection instruments This was done using a mix structure and semi-structure questionnaires with both open and closed ended questions. 3.8 Data entry and cleaning With the use of Microsoft office access sheet data was entered and cleaned to ensure the quality before analyzing and presenting reports using the SPSS software. 3.9 Data Analysis Data obtained was analyzed using scientific calculator and computer packages, MS access and SPSS software to calculate percentages, averages, mean mode and frequencies. The results are presented in form of tables, graphs and charts as well as descriptions. 3.10 inclusion criteria The study was included all women of child bearing age within Habasswein Sub-County, Wajir County. 3.11 Exclusion criteria The study was not included all men, children and old women of age 50 and above within Habasswein Sub-County, Wajir County. 3.12 Ethical consideration Permission for this study was obtained from the local authority such as the area chief. Informed verbal consent was also obtained from the respondents and confidentiality of information was maintained. CHAPTER FOUR 4.0 RESULTS AND FINDINGS 4.1.0 Introduction This chapter presents analysis, interpretation and presentation of data. The study involves an interview of 100 respondents where 80 are women of child bearing age and 20 comprising of the healthcare providers within Habaswein Sub-County. The findings were based on the report collected using the questionnaires admitted and analysed using the scientific calculator and computer packages, MS access and SPSS package. 4.1.1 Social-demographic characteristics of the respondents (n=100). Table 1: socio- demographic characteristics of the respondents (n=100) Characteristic Frequency and percentage Age 15-19yrs 20-25yrs Above 26yrs (7) 8.8% (23) 28.8% (50) 62.5% Level of education Primary Secondary Tertiary (21) 26.3% (44) 55.0% (15) 18.8% Marital status Married Single Others (56) 70.0% (19) 23.8% (5) 6.3% From the research, the socio demographic information of the interviewed respondents within Habaswein Sub-County where 100 participants involved in the study, 92% were married with those above 26 years of age being 73.9%, 20-25years being 22.7% and the smallest group of 15-20 years having the least percentage of 3.4%. Married participants in the cohort consisted of 56 of interviewed 80 women making70% of the population reflecting the majority of the respondents. This is therefore translated to the level of education were out of the married population21% makes to the lowest level of education primary, 55% being majority to the secondary level and the remaining 18.8% making the learned top knowledgeable lot of women in the society. Figure : socio- demographic characteristics of the respondents (n=100) 4.1.2 Affordability and accessibility to the health services. Table : level of earnings by the respondents [n=80] Employment Yes No (35)42.5% (45) 57.5% Salary scale <ksh10000 ksh10000-20000 >ksh20000 (32) 40.0% (32) 40.0% (16)20.0% Employment and the distance from the individual’s home to the health care facility determine greatly the rate of service utilization in any given society. From the findings within Habaswein Sub-County, majority of the women are not in for any employment 60% of the 80 interviewed had no employment and depended mainly on the other sources such as business and pastoralist with 80% having a salary of less than Ksh 20000per month. Out of 100 respondents of whom 80% were women of child bearing age and the remaining 20% being the health care providers within the sub-county, majority of the women interviewed (82.5%) believed in the customs, traditions and beliefs surrounding the vicinity. While the level of education and that of income remains lower with 40% for both the low and middle class persons the accessibility to the health facilities remained to be a challenge where 67.8% of the respondents living in within the >3km away from the health facilities quoted walking, use of donkeys and motorbikes where passable to link the pregnant women to the health facility when need arises. The cost of transport from the home of the individuals and the income level were major predictors that determined the place of delivery and maternal medical care services preference for many. Figure : Level of earnings by the respondents [n=80] 4.1.3 Availability of traditional birth attendance Table . Respondents seeking assistance from traditional birth attendance Frequency Percentage Regular 58 72.5 Seldom 6 7.5 Sometimes 13 16.3 Not sure 3 3.8 Total 80 100.0 Presence and availability of the TBAs within the sub-county is known to almost all people with 72.5% of the population voting for the regular availability for the assistance. It was realised that 90% of all deliveries among the mothers who delivered were conducted by the TBAs where the remaining 10% were sub-divided among the healthcare provider’s husbands and other women not well recognized for the activity. In regard to the place of delivery, it was observed that, 72 out of the 80 interviewed women who either deliberately delivered at home, on the way to the hospital or accidentally as a result of unexpected earlier labour (abrupt unplanned delivery) 90 percent of them all were assisted by the traditional birth attendance. Figure : Respondents seeking assistance from traditional birth attendance 4.1.4 Beliefs and traditions related to the act of unskilled deliveries More than two thirds of the interviewed population were identified to have traditions and beliefs related to pregnancy and during birth of a child, 66 (82.5%) strongly had the values in them. 90% of them were bound to valued traditional ceremonies and practices after the child birth especially on the mother, child and placenta disposal. Table : Relationship between traditions and believes and the level of education. Traditions and beliefs and level of education Level of education Total Primary Secondary Tertiary Traditions and beliefs yes 20 36 10 66 No 1 8 5 14 Total 21 44 15 80 From the findings it was found that there was no statistical significance between respondents with formal and informal education in regard to traditions and beliefs regarding the maternal and child care (p>0.05). Also, 65(82.3%) women out of 80 interviewed respondents were below the secondary level of education as shown in the table 3 above. It was identified that majority of these respondents believed in the traditional mode of delivery which is always performed by the TBAs within their vicinity. 92% percent of them recommended that the services from the TBAs were satisfactory and that any complications in the process were regarded to be a bad omen. Courtesy and ethics was observed to be higher among the TBAs compared to that of hospital setting 4.1.5 Uptake and utilization of the maternal health services. During the research, a total of 20 healthcare providers were interviewed on the uptake of maternal healthcare by the women within the area pointing out the government’s role as well as the major factors that are believed to drive women to deliver outside health care facilities. Out of the 20 interviewed, 95% responded that the government has played its role in improving the maternal and child care quoting the subsidized maternity services which the government introduced in the year 2013. Focusing on the tradition and culture in relation to modern health care, 75% of the respondents said that it is against the modern healthcare and that the community is not satisfied with the modern healthcare especially during delivery. Also it was noted that over 50% of the women attend the prenatal and the post natal care services with less than 10% coming in for the maternity services. Moreover, 17 out of 20 respondents (85%) disagree on the ideas that the community was unaware of the services being offered but rather some of the factors shown in the table 5 below greatly determined on the choice of place of delivery among them. Table :Factors calling for unskilled delivery among the women Frequency Percent Valid Percent Cumulative Percent Valid 1 5.0 5.0 5.0 Traditions and beliefs 4 20.0 20.0 25.0 TBAs 3 15.0 15.0 40.0 Negligence 2 10.0 10.0 50.0 Distance to the health facility. 5 25.0 25.0 75.0 Lack of expertise and equipment in the facilities 5 25.0 25.0 100.0 Total 20 100.0 100.0 It was noted that distance from the health facility, lack of expertise and equipment within health facilities, among the many factors was the leading. 5 out of 20 (25%) of the respondents quoted that above the raised arguments, women deliver outside the healthcare facilities mainly as a result of build habits which has in turn grown to a norm. Figure : Factors calling for unskilled delivery among the women CHAPTER FIVE 5.1 DISSCUSION Unskilled delivery remains to be a major challenge among the child bearing age of women within Habaswein Sub-County as seen from the research. Building a healthy nation means a health foundation of individuals since inception so as to reduce the burden of disease hence improve on the building of economy. Unskilled delivery therefore becomes an important problem that requires special attention towards reducing maternal and infant’s complications and mortalities. 5.1.1 Distance and accessibility to health facilities for infant and maternal services. This study’s findings are consistent with the study done by Family Health International in Tanzania which identified that many women who lived more than 5km from the health facility lacked better means to allow them access the health care services adequately and efficiently. It therefore quoted that walking, use of motorbikes; animals like donkeys and carts were the only remedies though not always reliable. The findings also correspond to the study done by Mugweni, E., Ehlers, V.J., & Roos, Janetta H. (2013) in Zimbabwe where 87% of the women found challenges to accessing health facilities in spite that they were willing to go for maternity services. It also in agreement that these findings correlate with a study done in Zambia (2013) which clearly show that despite the availability of health services to the community, distance or its accessibility greatly determines its utilization where meeting the transport cost becomes a challenge. Noting on this research done by Barbhuiya (2011) Gazipur Thana Bangladesh it is consistent with this study where 94% of women who attended antenatal and post natal care only 7% delivered at the facility quoting cultural and beliefs to be influencing factor. These findings therefore clearly show that while the health facilities are being brought up in large numbers, strategic positions should be clearly identified to ensure ease and accessibility of the facilities in order to maximize the resource utilization where avoiding inconvenience and disturbance among those who would have otherwise been willing to utilize the services. This will become a better strategy to win the women’s decision on the choice of place of delivery and thereby having healthier and safe community with no risks nor threatening complications. 5.1.2 Existence of TBAs and their services. These findings are in agreement with other previous studies in Zambia (2013) where women in the rural African countries are described to have strong resistance traditions, taboos and culture such as traditional ceremonies during and after birth, use traditional herbs etc. From the findings where 80 women were interviewed 72.2% agreed that TBAs exist in their sub-county and that regular availability was 90%. Out of all the deliveries which had occurred in the sub-county over the recent past, 90% were conducted by the TBAs though it is not a safer and convention way. These findings are in agreement to a previous study by Chiwuzie, (2015) in Nigeria women cannot abandon the traditional birth attendance even when knowledgeable on the risks involved. It is risk in that the TBAs are only limited to uncomplicated normal deliveries and where complicated delivery occurs; death is the major outcome where both the mother and the newborn risk their lives. Although it is a dangerous exercise women more affiliated to the TBAs more than the health providers with reason that they have been close to each other over them hence familiarity. Also, it is noted that TBAs are polite and cheaper where it does not incur any cost and disturbance while seeking for transport services to the health facilities among other miscellaneous expenditure that would have occurred in maternity setting such as clothes, cotton wool among others. From the findings of this research it is predictable that the practice of TBAs will not end sooner despite the dangerous exposure and risks involved. Accessibility, friendliness and affordability will stand for its survival over the coming future as the modern health care diffuses in slowly. 5.1.3 Uptake and utilization of maternal healthcare services. This finding matches in the previous research by Brieger (1994) which describes factors that keep women away from higher level health facilities quoting costs of hospital delivery, unfamiliar practices, in appropriate staff attitudes, negative perceptions of the quality care provided, related to bureaucracy, lack of drugs and other supplies, none functioning equipment, absence of doctors especially at night and apparently unfriendly attitudes of staff towards patients, also referral from one level of care to another was not well organized. Many of the interviewed women in the research were seen to have confidence and trust on the TBAs keeping an explanation that the services are cheaper, affordable, does not involve any kind of disturbances especially transport mainly being the challenge. While majority of them 72 which is an equivalent of 90% had information on presence of government maternal care health facilities, uptake and utilization of the services where still rate poor among the interviewed healthcare providers. While the research found out that most of those who use the facilities were those who expected first deliveries mostly, the study found out that 90% of those few could not go back during their subsequent deliveries mentioning lack of courtesy by the healthcare providers who uses harsh language rendering the services unsatisfactory. 5.2 CONCLUSION AND RECOMMENDATION 5.2.1 Conclusion The study identifies unskilled delivery to be common in Habaswein Sub-County among women of child bearing age where the uptake and utilization of maternal healthcare services is still low. Although the uptake of ante natal and postnatal services is not badly off, there is need to call for hospital setting delivery as opposed to unskilled delivering. Distance from the homes to the equipped health facilities becomes the major identified barrier that is blocking the access as means of transport is becoming a disturbing agent to them. Moreover, culture and traditional believes surrounding the community is not friendly, therefore, empowering these women to change their attitudes and believes is wanting. Existence of traditional birth attendances (TBAs) is almost known to all women and more that 89% of the deliveries taking place within this sub-county is conducted by them at outside heath facilities. Also it is clear that taboos and cultural believes and practices which existed in the community are supported by all women with some of their husbands joining the exercise making the situation even worse as it totally diverges the attention from the modern healthcare. While TBAs are limited to normal deliveries with no other complications, when a cases of complicated presentation arises. It becomes a serious challenge posing danger to those delivering and death becomes the outcome. There is need therefore for Government to work through various organs in its jurisdiction to come up with interventions that will work out to solve the problems of these women of Habaswein Sub-County by considering all factors identified. 5.2.2 Recommendations: There is need to in collaborate TBAs into healthcare staff with some little stipend so as to motivate them and give strength to be a referral agents of the clients to the health facilities. TBAs practitioners should be trained and given some skill so that they can as well assist the community whenever an emergency that is not much complicated arise. The government should come up with laws and regulation that will as well guide and direct women to maximally utilize the subsidized maternal and child care and avoid posing risk to the innocent unborn and themselves by abandoning the traditions and culture surrounding the practice. There is need for government to equip the facilities with the materials required, retrain staff and ensure ease in the accessibility of the health care services by the community through extension of transport networks within the vicinity. The community need to be empowered on the risks and dangers associated with traditions and values within the society highlighting the disadvantage over the maternity delivery so as to diverge them to utilize the services. REFERENCES Amooti, K. B. (2013) Factors influencing choice of delivery in Rahai district Uganda.      Anyait, Agnes, Mukanga, David, Oundo, George, &Nuwaha, Fred. (2012). Predictors Biomed Central Ltd. Chiwuzie et al. (2012) Safe motherhood   causes of maternal mortality in a semi- urban Nigeria setting. World health forum International journal of health development. Facility delivery in Busia district of Uganda: a cross sectional study. (Biomed Central for health. Graham W. (2010) Criteria for clinical audit of the quality of hospital based-based Obstetric care in developing countries. WHO. The International Journal of public Health Page 614 - 617.  Ltd. Sustainable development goals.2015 (online) Available: UNICEF web site http://www.unicef.org /mdg/maternal/mortality. Addis Ababa University unpublished; Mugweni, E., Ehlers, V. J., &Roos, J. H. (January 01, 2008). Factors contributing to low institutional deliveries in the Marondera district of Zimbabwe.Curationis, 31, 2, 5-13. Mugweni, E., Ehlers, V.J., &Roos, Janetta H. (2013). Factors contributing to low institutional deliveries in the Marondera district of Zimbabwe. (Mugweni et al.; Factors contributing to low institutional deliveries in the Marondera district of Zimbabwe.) Curationis. Pradhan, P. M., Bhattarai, S., Paudel, I. S., Gaurav, K., &Pokharel, P. K. (January 01, 2013). Factors contributing to antenatal care and delivery practices in Village Development Committees of Ilam district, Nepal.Kathmandu University Medical Journal (kumj), 11, 41.) Ricardo C, Eads M, Barker G: Engaging boys and young men in the prevention of            sexual violence. Pretoria:  Sexual Violence Research Initiative and Prom undo; 2011. Wolde Michael K: Pregnancy out come in rural Ethiopia With emphasis to perinatal APPENDIX: I Questionnaires I am Abdiwahab Abukar Mohamed a student at Mount Kenya University, carrying out a research on factors contributing to unskilled delivery among women of child bearing age within Habaswein Sub-County. The information provided will be treated with confidentiality. Please give appropriate answer that best fit to the spaces provided below. Tick {√} the box where it matches your response to the question where applicable. Section 1: General Information How old are you? Tick on the appropriate bracket under which your age falls 15-19years [ ] (b) 20-25years [ ] (c) above 26 years [ ] What is your level of education? Primary [ ] (b) secondary [ ] (c) tertiary[ ] What is the level of education of your spouse? Primary [ ] (b) secondary [ ] (c) tertiary [ ] Are you married? Yes [ ] No [ ] Are you employed? Yes [ ] No [ ] What is your salary scale? tick where possible < ksh10000 (b) Ksh10000-20000 (c) >ksh2000 What is your marital status? Single [ ] married [ ] divorced [ ] Other specify .................................................... Which religious affiliation do you belong? Islam Christianity Hindu Traditional religion Have you ever had a baby? Yes [ ] No [ ] If yes, how many children do you have in your wedlock? 1 [ ] (b)2 [ ] (c) 3 [ ] (d) more than 3 Have you ever had any complication at any time during the pregnancy period? Yes [ ] No [ ] If yes give a description of the situation. …………………………………………………………………………………………………………………………………………………………………………………… Are there traditional birth attendances in your community? Yes [ ] No [ ] If yes, how often are they available to offer the service when needed? (a) Regularly [ ] (b) Seldom [ ] (c) Sometimes [ ] (d) Not sure[ ] Are there traditional rituals performed during pregnancy or after delivery by a pregnant woman in your community? Yes [ ] No [ ] If yes cite one experience. ………………………………………………………………………………………………………………………………………………………………………………. From your own point of view how do you view the culture and tradition of this community in regard to safe motherhood and child care? Is it friendly or too harsh? Justify your point. ………………………………………………………………………………………………………………………………………………………………………………………………Have you ever witnessed any complicated delivery conducted by the traditional birth attendance within your premises? What was the final outcome later? What is the approximate distance from your home to the nearest health facility? Less than 1KM b. 1-2 KM c. more than 2KM How often have you visited the hospital for the : Antenatal clinics [] (a) Regularly [ ] (b) Seldom [ ] (c) Sometimes [ ] (d) Not sure[ ] Maternity services (a) Regularly [ ] (b) Seldom [ ] (c) Sometimes [ ] (d) Not sure[ ] Postpartum services ( a) Regularly [ ] (b) Seldom [ ] (c) Sometimes [ ] (d) Not sure [ ] Do you understand the importance of attending these clinics during pregnancy? Yes [ ] No [ ] Section II: service delivery To what extend do you agree or disagree with following statements about the ministry of health in empowering and supporting women of child bearing age within your premises. (Strongly agree 2-Agree 3-Neutral 4- Disagree 5- Strongly disagree. Just tick on one) Statement 1 2 3 4 5 The government has played its role but the community is not embracing the government way The traditions and cultural values are against the hospital care delivery The community is unaware of the services provided in the health facilities What is the average number of deliveries registered within this Sub-County regardless of place of delivery? How many new born are registered dead annually within this health facility due to complicated deliveries? Are there any women who have suffered any complication related to pregnancy? If yes, how many survived? How many died? To what extend do you personally as a health care provider believe in the modern (conventional) medical practices? (Just tick on one) 1-Strongly agree [ ] 2-Agree [ ] 3-Neutral [ ] 4- Disagree [ ] 5- Strongly disagree [ ] From your own point of view what do you think the government should do to help you and women of child bearing to ensure safe delivery and care to all? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. For how many years have you served in the ministry of health as a health care provider? Since your career inception, are there any important remarkable steps that government has put in place to safeguarding the life of the newborns as well as the pregnant women? …………………………………………………………………………………………………………………………………… If so, how can you rate the implementation and uptake of the services by the community members?........................................................................................................ …………………………………………………………………………………………………………………………………………………………………………………..... From your own observation and experience in the field, what is your suggestion or your look towards ensuring a 100% hospital delivery and utilization of clinic services within Habaswein Sub-County.......................................................................................... …………………………………………………………………………………………………………………………………………………………………………………..... From the observation you have had over the years, what are the leading factors that drives the attention of women to deliver from their homes rather than hospital setting within this sub-county? …………………………………………………………………. …………………………………………………………………………………………………………………………………………………………………………………… APPENDIX II: RESEARCH BUDGET Number Activity Items Total Consideration of literature Library books and internet search Kshs 250 per day x days Kshs 3,000 Designing and developing research instrument Typing, photocopying of research instruments Kshs 1500 Pilot survey/pre-visit Maintenance Kshs 1500 Finalizing of research instruments 200 questionnaire x 30 days Kshs 6000 Main field data collection in two weeks Sustenance 10 days x 200 Kshs 1500 Purchase of stationery Pens, rulers and rubber Kshs 500 Training and payment of research assistant Kshs 200 x 10 days Kshs 2000 TOTAL KSHS. 16,000 APPENDIX III: RESEARCH WORK PLAN 2017 MONTH OCT 2016 NOV 2016 DEC 2017 JAN 2017 FEB 2017 MAR 2017 APR 2017 MAY 2017 JUN 2017 JUL 2017 AUG 2017 Topic selection Proposal development Data collection Report writing Data Analysis Report submission  MAP OF HABASWEIN SUB-COUNTY, WAJIR COUNTY ? 1