Most Somali women fleeing to northeastern Kenya's Dadaab in northeastern Kenya have never visited an antenatal clinic, let alone given birth in a hospital.
"When I see an expectant mother or one with a small child, I ask them whether they have gone to the hospital. If they haven't, I refer them there," Miriam Ade, a community health worker in Dadaab's Ifo camp, told IRIN. "Many of these women have lived here but you find some do not even know that they can visit the clinic or some know where the clinics are but they don't want to seek such services, mostly for cultural reasons. It is my work to convince them."
Most of the 470,000 refugees in Dadaab are from Somalia, where about 80 percent of deliveries take place at home or with unskilled traditional birth attendants, according to the UN World Health Organization (WHO). With an estimated 1,400 maternal deaths per 100,000 live births, WHO describes maternal and prenatal health in Somalia as being "of pressing concern".
Fatuma Ali, a 27-year-old Somali refugee, delivered all her five children at home. When she fled Somalia for Kenya 10 months ago, she was pregnant; community health workers in Dadaab persuaded her to attend a local antenatal clinic.
"In my country there are no hospitals, and we don't even believe in going to the hospital... There are people who tell us it against our culture to go to hospital to give birth," she told IRIN. "After I was registered as a refugee here, I used to attend the clinic and they have even tested me for HIV; they have taught me how to feed my child and I received soap and sanitary towels soon after I delivered and went back home."
Ali was also treated for complications that the doctors attributed to the fact that she had undergone female genital mutilation/cutting when she was a girl, and gave her family planning advice.
"I am a refugee and I wonder how I can take care of many children... I have made a decision to stop giving birth," she said.
According to Beldina Gikundi, the reproductive health focal point for the International Rescue Committee (IRC) in Dadaab, community health workers have been crucial in boosting the uptake of reproductive health services among women in the camp.
"Many women still believe in home delivery and many more people still do not believe in discussing issues of sexuality that easily, but with the use of community health workers, we have been able to reach out to them to seek both reproductive health and HIV services," she said.
She noted that a number of women also sought rape and post-abortion counselling and treatment, as well as screening for sexually transmitted infections.
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However, limited health facilities at the camp are struggling to cope with the high demand for services. Thousands of Somalis continue to arrive in Dadaab daily, mostly women and children, but only the IRC and Médecins Sans Frontières have fully operational maternal health facilities in the camp.
"Many mothers either die or lose their children due to the poor conditions they give birth in at the camps... The facilities can only cater for so much," Gikundi said.
"The number of women seeking reproductive health and maternity services has increased over the past months and health facilities can hardly cope with the demand," she added. "At times, women are forced to share beds because occupancy is in the region of 110 percent."
MSF has a 170-bed hospital in the complex, while IRC has a 40-bed facility, which registers more than 310 births per month.
"The contraceptive rate is low, hence very high fertility rates putting pressure on resources at the maternity facilities. We are, however, doing everything to ensure the uptake of contraceptive use," Gikundi said.
The UN Population Fund is working with partners to provide refugees with reproductive health kits, including contraceptives.