Turkana ‘squatting stools’ curbing maternal deaths

Ms Faith Eyanai sits firmly on a ‘wooden stool’ covered with a cushion all over it and holds two steel handles fitted on the sides of the device.

Beside her is a midwife at hand to instruct and receive the child when born and offer an emergency medical care if need be.

This is a ‘squatting’ stool, a piece of innovation that has enabled many Turkana community women to give birth in hospitals, a practice they previously gave a wide berth due to myths associated with delivering while lying down.

“This is my third child, which I am about to deliver, and I have not been lying down and pushing as is the norm in most deliveries but with the help of a squatting stool,” she says amid bouts of labour pains in the maternity wing of the Lodwar County Referral Hospital in Turkana.

Like Ms Eyanai, most Turkana women prefer giving birth while squatting or kneeling as opposed to lying on their back as is the norm across many parts of Kenya.

“There is a lot of pressure when a woman squats to deliver and if there is no complication, one can deliver within a few minutes. This is an art passed from one generation to the other and the majority of rural women in Turkana prefer to squat while giving birth,” she states.

Home deliveries

For generations, women in the community have been socialised to give birth while squatting, an art that has been perfected by traditional birth attendants in the villages, making the majority of women prefer home deliveries and shun hospitals.

Home deliveries, in turn, resulted in increased maternal and infant mortalities. According to the National Council for Population and Development report, 2015, Turkana ranked third nationally with 1,594 maternal deaths per 100,000 live births. Infant mortality was also high at 140 deaths per 1,000 live births.

The infant mortality rate for Kenya in 2021 was 32.913 deaths per 1,000 live births, a 3.36 per cent decline from 2020, which had also declined by 3.24 percent from 2019.

Turkana health department report on pregnancy complications assessment between July 2019 and June 2020, indicated the county lost 352 children and 20 mothers. On average, one child died daily during childbirth in the county during that period.

The report indicated that eclampsia accounted for the largest number of deaths, claiming seven lives (35 per cent of the total fatalities). Obstructed labour, post-partum haemorrhage and rupture of the uterus were the other causes.

Ms Mariam Momanyi, a midwife at the county referral hospital, notes on many occasions, expectant mothers are unable to push when told to lie down to deliver.

“We have had cases of women climbing down the delivery beds to kneel or squat and deliver without an issue. Some even run outside the delivery room and give birth outside the compound because they dislike giving birth while lying down,” she discloses. 

Benchmarking

After seeing what the expectant mothers underwent, they innovated the squatting stool following a benchmarking mission in neighbouring Karamoja, Uganda, where the squatting stool is widely used in health facilities, hence low mortality rates in the region.

The midwife explains, “The device is like a normal stool but long with a curved upper part fitted with a cushion placed on the ground. The curved part is to allow the nurse access to the perineum, receive the baby and deliver the placenta.

“The two metallic handles on both sides are for the mother to hold onto tightly while pushing the baby. A piece of cloth is used to cover the laps for their comfort and privacy.”

She reveals that before the device was adopted by hospitals, most women in the county preferred home deliveries, but the case has now been reversed. She notes that delivering while squatting gives a woman enough pressure to push the baby out as compared to lying on bed, thus taking little time to deliver the baby.

“Squatting delivery was widely practised in Turkana County such that by the year 2016, 75 per cent of women giving birth in Turkana preferred home deliveries assisted by a relative, a traditional birth attendant, while others gave birth single-handedly,” says the midwife who has been at the facility maternity wing for over three decades.

This, in turn, jeopardised the lives of both the mother and her baby because in the event of complications, the mother or her baby, or even both, could die as there were no trained birth attendants by their side to intervene or refer them for specialised care.

She says most deaths are attributed to maternal postpartum haemorrhage (excessive bleeding after delivery), infection and high blood pressure (eclampsia).

Ms Mary Emase says that apart from making delivery easy and less painful, squatting offers them a form of privacy.

“There is privacy since a delivering mother sits down and covers herself, unlike when she lies down,” she says.

Ms Emase adds that they also shunned hospitals because of fear of the negative attitudes of health workers and long distances to health facilities.

County Health Chief Officer Augustine Lokwang said the squatting stool is one of the innovations based on the culture of the local community.

“It has created convenience and women now feel that delivering in hospitals is just like being at home because of the device. We wanted to create demand for women to come and deliver in hospitals to reduce both maternal and infant mortalities,” said the county official.

Increased hospital births

Following the introduction of the device, hospital deliveries have increased from 33 per cent in 2016 to 80 per cent currently.

“At Lodwar County Referral Hospital, for instance, 10,419 deliveries have been recorded in the past three years. We have curbed the socio-cultural attitude and through our community health volunteers, we have broken the cultural norms that women who deliver at home are strong. All of them now seek skilled deliveries and seek neonatal care,” he said.

At the facility, noted the chief officer, there is an average of 350 deliveries per month as compared to 150 recorded in 2016 before the introduction of delivery stools. The same is replicated at sub-county hospitals.

Women are also given gift packs both for her and the baby after leaving hospital, as well as those for their men.

“Our skilled delivery has improved from to about 60 per cent, thus greatly reducing the infant and maternal deaths, with immunisation rates increasing to 80 per cent from 40 per cent in 2013. We have also increased doctors from four to the current 70,” he said.

He said they have bridged the distance to nearby health facilities from the previous 50km to 20km.

According to the County Health Sector Monitoring and Evaluation Plan 2018/22 report, the county government seeks to increase the proportion of pregnant women attending at least four antenatal care visits from 38.9 per cent to 77.4 per cent and to eradicate facility-based maternal deaths.

The Kenya Health Information System (KHIS) shows that 53.6 per cent women seek antenatal care in Turkana.

The county government and some of its partners, including Amref Kenya, the International Rescue Committee, and USAID Imarisha Jamii, are always training county health workers. The most recent training was in focused antenatal care and emergency obstetric newborn care.

[email protected]