Abstract
Every day, 810 women die from preventable pregnancy-related causes, with 99% of these deaths occurring in low- and lower-middle-income countries. Despite a global decline in maternal mortality of more than 40%—from approximately 532,000 deaths in 1990 to an estimated 303,000 in 2015—rates remain unacceptably high in sub-Saharan Africa (SSA), where nearly a quarter of a million women die annually from pregnancy-related complications. Evidence shows that midwives, when well-trained, well-regulated, and supported in their workplaces, can significantly reduce maternal deaths.This dissertation investigates how professional midwifery training shapes the quality of obstetric care in Kenya, using ethnographic methods to move beyond physiological understandings of pregnancy and childbirth. It examines the dynamic interplay between health systems, training programs, and practice environments. Paper 1 situates current maternal health challenges within a longer historical arc—from colonial reproductive governance to contemporary global health imperatives promoting facility-based births—highlighting how these forces shape care provision in Kenya. Paper 2 draws on direct observations and in-depth interviews with midwives, instructors, and administrative staff to assess how training programs prepare students to provide care in both urban and rural facilities. Paper 3 examines the experiences of midwives, their supervisors, and birthing individuals in healthcare facilities across diverse settings, identifying the conditions that promote access, improve maternal and newborn outcomes, and strengthen the working environments of midwives.
By incorporating historical analysis, the study underscores persistent structural inequalities in healthcare delivery, including the long-standing disinvestment in rural regions that drives disparities in facility birth rates and quality of care. A comparative case study design enables a closer examination of how training and care provision diverge across urban and rural contexts, offering insights into how midwifery education and health systems might better support timely, high-quality care.
Finally, this study engages with critical global health scholarship that challenges the dominant focus on sustainability and cost-effectiveness metrics in SSA. Such approaches, often prioritized by international organizations, emphasize quantitative indicators while failing to address deeper social and structural determinants shaping health outcomes. By situating obstetric care within national and global systems of reproductive governance, this dissertation uses ethnographic methods to illuminate the broader forces that shape maternal health in Kenya today. These findings underscore the need for policies that move beyond narrow performance metrics to invest in strengthening midwifery training, improving rural health infrastructure, and creating regulatory and workplace environments that enable midwives to provide high-quality, respectful care. They also highlight the importance of integrating historical and structural analyses into maternal health policy design, ensuring that national strategies explicitly address entrenched regional inequities and the systemic disinvestment that undermines care quality in rural areas.