Effectiveness of Ng'adakarin Bamocha model in improving access to ante-natal and delivery services among nomadic pastoralist communities of Turkana West and Turkana North Sub-Counties of Kenya

Introduction Access to maternal and child health care services among the nomadic pastoralists community in Kenya and African continent in general is unacceptably low. In Turkana, only 18.1% of the women had seen a nurse or a midwife for antenatal care during pregnancy while only 1.3% of pregnant women reported delivery at health facilities in 2005. Ng'adakarin BAMOCHA model, based on migratory routes of the Turkana pastoralists and container clinics was adopted in 2007 to improve access to maternal and child health services by the nomads. Methods A cross-sectional study design was used to establish the effectiveness of Ng'adakarin BAMOCHA model on accessibility and uptake of ante-natal care and delivery services. A total of 360 households and 400 households were interviewed for pre-intervention and post-intervention respectively. The study compared the pre-intervention and post-intervention findings. Structured questionnaires and focus group discussion were used for data collection. Results There was no improvement in the fourth ante-natal care visits between pre-intervention and post-intervention groups at 119(51.5%) and 111(41.9%) respectively (p < 0.05). Knowledge of the community on the importance of ANC visits improved from 60%-72% with significance level of p < 0.05. There was a significant increase 6%-17% of deliveries under a skilled health worker (p < 0.05). TBA assisted deliveries increased from 7.5%- 20.2% with a p < 0.05. There was significant reduction in home deliveries from 89.5%-79.5% with a p < 0.05. Conclusion The Ng'adakarin Bamocha model had a positive effect on the improving maternal health care among the nomadic pastoralist community in Turkana.


Introduction
Access to health is one of the key human rights. This is enshrined in various international treaties and agreements such as Millennium development goals. In Kenya, health was identified as key pillar in developing the nation in vision 2030 and further enshrined in Kenya health policy 2012 -2030. The key elements of rights to health are the accessibility of services, availability of health services, acceptability of health services and quality of health care (WHO, 2007) [1].

Rural and nomadic pastoralist community health care access
Access to health care overall is a challenge to rural residents, who have a lower proportion of the population insured, a greater difficulty in traveling to primary, preventative, prenatal, and emergency care providers, and less diversity in health care resources to choose from. Rural residents are left without these services, increasing the physical barriers to quality and timely healthcare. The geographic variances in access lead to the conclusion that different strategies to address health disparities will have to be considered for rural regions (Jones Ian et.al., 2011) [2].
The disparities in health care access are more pronounced among the nomadic pastoralist communities of Sub-Saharan Africa.
Pastoralists migrate periodically with their herds to maximally exploit scarce resources (pasture and water), which they need for their animals and themselves and which are dispersed in time and space.
It seems likely that this seasonal movement is an important determinant of nomadic people's health (Sheik-Mohamed & Velema, 1999) [3].
Nomadic populations are defined as communities of people that temporarily or permanently move their residence and occupational activities from one location to the other. Nomads include nomadic hunter and gatherers, pastoralists and peri-pathetic communities (i.e. groups of people moving around settled populations and offering a craft or trade). Pastoralists can be further differentiated into a) trans-humans (nomadic groups migrating regularly between two grazing areas along well-defined routes), b) pastoralists migrating along conventional routes but also moving into different areas each year and semi-pastoralists with semi-sedentary residence and mobility patterns (Okeibunor et.al., 2013) [4].
Nomads are often at a disadvantage for receiving health care. In Somalia, for example, the national health plan [1985][1986][1987][1988][1989][1990] recognized that 90% of nomads were out of the reach of the national health services. This scenario is replicated in Turkana County where close to 80% of the population are nomadic pastoralists (AMREF, 2007) [5]. One study conducted among the settled and nomadic Rendille in Kenya revealed that all children over 12 months of age in Korr village had full immunization coverage which is in contrast to the nomadic community of the same area immunization coverage of zero (Nathan & Rot, 1996) [6].
A study among the Fulani nomads of Nigeria concludes that the nomads are currently disadvantaged in the provision of health interventions due to physical and psychological distance that exists between them and the sedentary population as well as health officials in the areas (Dao & Brieger, 1995) [7]. Ailou (Ailou, 2010) [8] argued that it is possible to organize PHC services for nomads.
The services should be capable of mobility matching that of the community they serve. They should establish seasonal circuits in accordance with the local patterns of population movements.
Similarly, Al-Omar and Bin Saeed, (1999) [9] emphasized the need to set PHC programmes for nomadic populations, especially in countries with limited resources and large nomadic communities.
Here, it is reasoned that health services for the nomads could be organized with their full involvement in the planning and implementation. Ailou, (2010) [8] further believes that despite intervention from the government, partners and other development agencies most of the interventions for nomadic communities are either not cost-effective or inefficient. Landmark series on child and neonatal survival suggests that the high mortality persists despite low cost solution being known and that almost 60-70% of these deaths could be prevented by making these interventions widely available (Darmstadt et.al., 1999) [10]. It is worth noting that these areas have the same basic ecological and socio-economic characteristics with the study area. The intervention measures intended to reduce the child morbidity and mortality are pegged Quantitative data was entered using Ms Access sheet. Data was managed and analyzed using SPSS version 21. Qualitative data was entered and grouped using Ms Excel. A bivariate analysis was carried out to relate socio-demographic variables to antenatal care use and other health-seeking behavior of the mother for her child between 0-23 months. Chi square test was used as appropriate with p-value set at the 0.05 level.
Study limitation: the study covers the nomadic pastoralist community that make up 80% of the population therefore excluding sedentary community. The study used convenience sampling to select half of Ng'adakarin reached with intervention because of inaccessibility of some of Adakar to be studied as they migrate, even, across international borders in search of pastures and water for their livestock.

Results
The mean age for pre-intervention and post-intervention respondents was 20.1 (Standard deviation 4.9) and 28.5 (standard In general study population for the pre-intervention and postintervention groups were from similar and comparable demographic background and therefore the results could be compared. Complete characteristics are shown in Table 1. Page number not for citation purposes 5 In the pre-intervention assessment, 148 (64.2%) respondents indicated that they attended ANC for their last pregnancy at least once compared 165 (62.5%) who attended ANC at least once in the post-intervention assessment. Considering that the respondents who indicated that they attended ANC in the pre-intervention, 6 (2.5%) could not give an indication of number of times they attended and hence the percentage attended at least once could be exactly the same for both the pre-survey and the postsurvey. Table 2 shows the number of ANC attendance.
Of the respondents who indicated that they attended ANC in the Knowledge on recommended at least 4 ANC When the respondents were asked whether they knew that a pregnant woman is supposed to attend ANC at least 4 times before they deliver, in the preintervention survey, 131 (59.6%) indicated that they knew about this while in the post-intervention survey, 191 (72.0%) indicated that they knew that a pregnant mother should attend at least 4 times before delivery. There is a statistical difference between this knowledge at the pre-intervention period and the post-intervention period (p<0.05). Figure 1 shows the proportion of respondents pre-intervention and post intervention who are aware of the recommended at least 4 visits to health facilities before delivery.

Delivery services
The pre-intervention survey established that only 22 (6.2%) of the deliveries were done in health facilities while 317 (89.5%) of deliveries took place at home through the help of friends, relatives, traditional birth attendants and/or by themselves. This is in comparison to 66 (16.5%) of deliveries in the post-intervention survey, which took place in a health facility compared to 318 (79.5%), which took place at home. This indicates significant increase in health facility delivery (p<0.05) where it has almost tripled between the time of the pre-intervention survey and the post intervention assessment. The summary of places of delivery for the respondent for the last pregnancy is shown in ( Table 2).
The pre-intervention survey established that 20(5.6%) of the births were delivered by a trained birth attendant compared to 65(17.7%) in the post-intervention survey which shows a significant increased in births assisted by trained medical practitioner (p<0.05). The  Table 3).

Findings from focused group discussions and Key informant
interviews were consistent with quantitative analysis deliveries.
Respondents reported Cost (medical and transport cost involved), walking distance to delivery health facilities and lack of capacity of nearest facility (including container clinic) in terms of infrastructure (delivery rooms) and personnel. It is interesting that culture is mentioned as a barrier to utilization of delivery services though most of the respondents agree that health information available to them has tampered its influence.

Discussion
The demographic result shows that the two samples of the These findings are consistent with results findings (Ailou, 2010) [8] where there was significant improvement in delivery under skilled care after intervention through implementation of community strategy. However the skilled delivery and health facility deliveries coverage in Turkana is still way below the national average of 44% and 43% respectively (AMREF, 2007) [5].
Traditional birth attendants continue to play an important role in deliveries in Kenya and Africa at large with high proportion of deliveries conducted by TBAs [5,9]. The study established significant increase in TBAs assisted deliveries despite their lack of capacity to manage top-five causes of maternal mortality (Darmstadt et.al., 1999) [10]. The communities' preference for TBA deliveries is due to their proximity in the community, low cost (transport cost and medical cost) and long walking distances to health facilities (NCAPD, 2010;WHO 2003) [11,12]. Low rate of skilled delivery can also be attributed to capacity of container clinics to provide only referral services for deliveries despite close proximity to the migratory pastoralist community.

Conclusion
The study results shows that the Ng'adakarin BAMOCHA approach  Table 1: Demographic information of respondents