Exploring experiences with sensitivity to cultural practices among birth attendants in Kenya: A phenomenological study

Background Sensitivity to women’s cultural needs and expectations by care providers is essential. Skilled birth services for women are as essential as traditional birth services. Therefore, collaborative skilled and cultural care optimises childbearing experiences. Aim This study explored the experiences of birth attendants (BAs) with sensitivity to cultural practices (CPs) during pregnancy and birth among the Keiyo community in Kenya. Setting The study was conducted in the purposively selected public health centres and dispensaries offering maternity services and the villages in Keiyo South Sub County in Kenya. Methods A qualitative interpretive phenomenological study of BAs was conducted. Iterative and inductive interviews using a semistructured guide were conducted with 11 skilled BAs (SBAs) and eight traditional BAs (TBAs). Audio-recorded interviews were transcribed and analysed using ATLAS.ti software version 8.4.4 (1135), following Van Manen’s five thematic analysis steps. Results Three themes emerged: birth attendants’ cultural encounters, response to cultural encounters and collaboration. Birth attendants’ responses to different cultural encounters revealed their awareness of CPs. The response was experienced as a sensitivity to the need for a triad (woman, TBAs and SBAs) collaborative care, enabling collaborative, woman-centred and culturally safe care. Conclusion Birth attendants are exposed to cultural encounters, and their responses determine their awareness of enabling sensitive care for optimal childbearing experiences. The study illuminated the need for further collaborative engagements between the BAs and the community to facilitate positive experiences by women through woman-centred, culturally safe care.


Introduction
Every pregnancy and birth experience of a woman is different, and with each experience comes memories that she learns to appreciate or deny. 1,2 Childbirth experiences are etched in women's memories. The more pleasant they are, the better. 3 The physical, social and cultural environments that women navigate influence their experiences during pregnancy and childbirth. Therefore, women's experiences are a 'woven fabric' resulting from the interplay between these environments. 4 Maternal deaths remain high. Globally, 830 women die daily. Sub-Saharan Africa accounts for 546 per 100 000, 5 while Kenya has 362 maternal deaths per 100 000 live births, 6 yet 70 per 100 000 live births are expected by 2030 through the Sustainable Development Goals (SDGs). 7 Approximately 60% -80% of them can be prevented through early identification and intervention of obstetric complications by skilled care providers. 5 In Kenya, 95% of pregnant women attend prenatal care, but less than 40% utilise skilled birth services. These low rates of births at the health facilities are partially attributed to socio-economic and cultural factors. 8 Women's preferences for traditional birth attendants (TBAs) and cultural practices (CPs) remain a barrier to using skilled birth services, despite education on better pregnancy and birth outcomes when utilising skilled BAs (SBAs).
Specifically, the Keiyo rural community values such sociocultural practices throughout all childbearing stages. Most of these CPs involve food choices, herbs and cultural practitioners' utilisation. 9 Although culturally competent care is recommended by professional bodies, such as the International Confederation of Midwives 10 and the World Health Organization (WHO), and is included in the third SDG, 7 health services have not adequately embraced such care.
Intercultural sensitivity has been defined as an 'active willingness or self-motivation to understand and to be sensitive to the view of others from different cultural backgrounds'. 11,12 Cultural sensitivity should be a defining characteristic of a caring health practitioner, because women prefer healthcare facilities that provide culturally sensitive care. 13 Therefore, healthcare providers need education on cultural sensitivity to overcome the inadequate utilisation of skilled birth services by women. 14 Collaborative care between SBAs and TBAs has been suggested and implemented in other countries through the progressive integration of both services. 15,16 This collaboration builds partnerships that strengthen and enlighten SBAs concerning cultural care and TBAs with the necessary safety measures in caring for women. 15,17 Although cultural issues influence this kind of collaboration, it is acknowledged that healthcare systems should also address the shortage of skilled providers and lack of partner support and disrespectful maternal care. 18,19 According to the Kenya National Bureau of Statistics, 20 Kenya has 44 tribes with differences and similarities in CPs. Birth attendants engage with women from these diverse ethnic backgrounds during pregnancy and birth. Women in Keiyo, Kenya, receive care during pregnancy and birth from TBAs and SBAs. Traditional birth attendants continue to provide services in the community, with no formal collaboration with SBAs and no government policy to regulate their practices. 21,22,23 Despite the ethnic diversity in Kenya, there is limited evidence on the cultural challenges that BAs or childbearing women encounter during their engagements. Therefore, this study aimed to explore BAs' sensitivity to CPs during pregnancy and birth among the Keiyo community in Kenya.

Theoretical framework
The researcher utilised the cultural safety theoretical framework developed by Ramsden 24 to guide the study ( Figure 1). The framework was initially developed in New Zealand, where indigenous Maori people were affected by unequal representation in nursing schools and an increased disease burden because of discriminatory health care services. 25 Cultural safety has been defined as: [T]he effective nursing of a person/family from another culture by a nurse who has undertaken a process of reflection on their own cultural identity and recognises the impact of the nurses' culture on their own nursing practice. (p. 491) The definition was further adapted by the Nursing Council of New Zealand to 'relate to the experience of the recipient of care and extends beyond cultural awareness and cultural sensitivity'. Care without considering the woman's cultural identity diminishes, demeans and disempowers the woman during pregnancy and birth. 26 Cultural safety is considered an outcome of cultural sensitivity, requiring cultural awareness. 24 Further, Ramsden describes cultural awareness as the conscious effort by individuals to recognise and acknowledge cultural differences. Subsequently, Ramsden asserts that cultural sensitivity is achieved through self-reflection and self-awareness, leading to the acceptance of the legitimacy of cultural differences and mutual respect. Further, Ramsden 24 suggests the need to sensitise care providers to optimise culturally sensitive care.

Study design
The study adopted a qualitative design 27 and interpretative phenomenological approaches. 28 This type of hermeneutic phenomenology explores peoples' lived experiences about a phenomenon of interest. 28 People's lived experiences are identified and described, and the meaning of these experiences is interpreted. 29,30 This design was appropriate because the researcher is a SBA, born and raised in the Keiyo community and knowledgeable about the Keiyo culture. Therefore, prior understanding of the phenomenon enabled the researcher to interpret BAs' meanings attached to their sensitivity to CPs. The researcher was also part of the research instrument, and therefore there was no bracketing. 27,28 However, the researcher maintained an unbiased stance throughout data collection and analysis to ensure that the findings reflected interpretations from the participants' findings.

Study setting
Kenya has 44 tribes, making it one of the most culturally and ethnically diverse countries. The Kalenjin tribe is the third

Cultural safety
Is an outcome of nursing and midwifery educaƟon that enables safe service to be defined by those who receive the service.

Cultural sensiƟvity
Alerts students to the legiƟmacy of differences, and their own life begins a process of self-reflecƟon as the powerful bearer of their own life experience and realiƟes and the impact these may have on others.

Cultural awareness
Is a beginning step towards understanding that there is a difference. Many people undergo courses designed to sensiƟse them to formal ritual and pracƟce rather than to the emoƟonal, social, economic and poliƟcal context in which people exist. largest tribe, accounting for about five million people. 20 The Kalenjin are distributed mainly within the Rift Valley, with up to seven subgroups: Kipsigis (1 916 316), Nandi (949 835), Pokot (632 557), Keiyo (313 925), Marakwet (200 000), Tugen (109 906) and Sabaot (305 000). These subtribes share a common language, cultural beliefs and practices, geographical location and socio-economic activities. 31 The Kenyan government changed the constitution in 2010 and redefined the eight provinces as 47 counties, with further subcounties. 32 This study was undertaken in Keiyo South Constituency, a subcounty of Elgeyo Marakwet county. The population of Keiyo South is 120 750 out of a total Keiyo population of 219 750. 20 The Keiyo, a Kalenjin subtribe, predominantly occupy Keiyo South (Appendix 1). As illustrated in Figure 1-A1, 33 the Kerio highlands and escarpment, the hanging valley and the proper Kerio valley basin mark the Keiyo South boundaries within the Great Rift Valley (Appendix 2). 34 There are two health systems within the Keiyo community: the Ministry of Health's (MOH) allopathic health system and the traditional health system. The traditional health system includes the TBAs and traditional healers. Allopathic health services are provided through the MOH, faith-based and private health care providers. The MOH provides facilitybased services and coordinates community health workers (CHWs) and community health volunteers (CHVs) who coordinate health services in the community health units. These units consist of 5000 people or 1000 households. They form an extension of the main health facility as service delivery structures. 35 Dispensaries are managed by community health nurses who provide curative, promotive and preventive health services, including maternal, neonatal and child health. Clinical officers, community health nurses or midwives, public health officers, laboratory technicians and pharmacists run the health centres. These health centres act as referral centres for the community units and dispensaries. The services provided include minor surgical interventions and curative, promotive, preventive, maternity and birthing services. All these health facilities refer to the subcounty or county referral hospitals according to the severity of the cases.
The community is faced with challenges in accessing health services, especially those situated along the hanging valley and some parts of the proper valley basin because of rugged terrain and mudslides during the heavy rainy seasons. Nevertheless, with the recent introduction of motorcycles referred to as bodaboda, accessibility has improved.

Study population and sampling strategy
The study was conducted in two phases. In phase one, five health centres and five dispensaries were purposively selected from the 36 health facilities in the subcounty.
The researcher selected five facilities with an average of 20 or more births per month and five facilities below 20 births. During facility visits, SBAs on duty were approached and requested to participate. Out of the 10 facilities, one to two SBAs who had worked in maternal health units for at least six months were purposively sampled in liaison with the facility managers. This criterion enabled the inclusion of a maximum variation of SBAs, which provided data from the typical SBAs and extreme cases, especially from those who had worked for more than 20 years. An experience of at least six months was considered, as it could have exposed the SBA to the minimal basic experience with CPs in the community. An iterative interview and analysis process determined when saturation of data was obtained. Data saturation was achieved after analysing data from the first nine interviews, as the remaining two interviews did not elicit any new information.
In phase two, eight TBAs were purposively selected. Ten villages were identified with assistance from the local chief, the gatekeeper to the community. Some villages shared the same TBA. The initial TBA also assisted in identifying others through a snowballing process. The CHVs or CHWs assisted in locating the TBAs' homes for the interviews, which facilitated the initial meeting held between the TBA and the researcher, without the CHV or CHW's presence. The researcher and the participant agreed on the interview date and time. An iterative interview-analysis process was done. Data saturation was achieved after the sixth participant, while information from the two subsequent interviews was redundant.

Data collection
Semistructured interviews were conducted by the researcher (first author) in 2019 for the SBAs and 2020 for the TBAs. The researcher's personal experience and insight into this community's cultural beliefs and practices enabled the interviews to be conducted with awareness of cultural nuances. The researcher had not worked as a SBA in this community.
A semistructured interview guide was used for SBAs, with open questions to explore the following topics: CPs in pregnancy and birth, the role of CPs in the health services and SBAs' feelings regarding CPs during pregnancy. The semistructured interview guide for the TBAs included the following topics: TBAs' experiences with CPs, feelings regarding CPs during pregnancy and roles of CPs during pregnancy and birth in the community.
The researcher was fluent in English, Kiswahili and Keiyo, allowing the participants to express themselves in whichever language they felt comfortable. The researcher conducted interviews with TBAs at their home and with SBAs in their health facilities, which lasted between 1.5 h and 2 h. All interviews were audio-recorded with the participant's consent. http://www.phcfm.org Open Access

Data analysis
Iterative data collection and analysis led to emerging themes on cultural sensitivity. Transcription was done from the recorded language (English or Kiswahili). Each transcript was checked against the recorded interview to ensure that the transcription was accurate. The transcribed data was uploaded into ATLAS.ti software version 8.4.4 (1135) for data analysis, and Van Manen's five-step thematic analysis was used during the data analysis. 36 Firstly, the researcher uploaded the transcripts to ATLAS.ti, read and reread the transcripts, which gave the researcher insight into the emerging codes.
Secondly, progressive coding resulted in identification of categories (first-order constructs). The codes were organised into code groups that were labelled as categories. The researchers reviewed the codes and categories and reached a consensus regarding the essential codes. After the iterative reading of the transcripts and listening to the audiorecordings, new codes that were identified formed other categories or merged into existing categories.
Thirdly, steps 1 and 2 were repeated for the SBA interviews by analysing three interviews, six, nine and finally, all 11 transcripts. For TBAs, two interviews, four, then six and all eight transcripts were analysed. The analysis of initial transcripts identified issues that required further exploration in subsequent interviews and the creation of code categories. Related code categories were merged according to the emerging subthemes. This iterative process gradually developed a 'richer and deeper understanding' 28,29 of the BAs' experience with sensitivity to CPs as subthemes emerged from the ATLAS.ti-generated report and networks that elicited relationships in the subthemes.
Fourthly, second-order constructs, which were the emerging subthemes, were therefore merged into overarching themes, which were determined and agreed upon with the first author who had insight into the phenomenon under study. ATLAS.ti-generated reports and networks, which had all the quotations under each code, were used for interpretation.
Finally, the codes were summarised into categories which formed the subthemes and overarching themes presented in Table 3. Refining of the themes and interpretation of the meanings ascribed to sensitivity were further interrogated during the article writing process through consensus amongst the researchers. Findings are presented as an interpretation of themes, actual quotes from the interviews, integrating interrelated themes with cultural safety framework ( Figure 2) 24 and drawing on input from the literature. 27

Characteristics of participating birth attendants
Eleven SBAs were interviewed; five were male and six were female. They were between the ages of 23 and 55 years. All participants were fluent in both English and Swahili languages. They originated from the various Kalenjin subtribes, of which six were from Keiyo, three were from Tugen and two were from the Marakwet subtribe. Their work experience in maternal and child health ranged between one and 30 years, as indicated in Table 1. Ten of the participants had a diploma qualification, while one had a bachelor's qualification.
A total of eight TBAs were eligible to participate in the study. All eight TBAs were female, between 45 and 72 years, and they had between 10 and 40 years of experience. All eight were fluent in Keiyo; three of them also had a moderate understanding of Swahili, and three were fluent in Swahili. The TBAs were from the various Kalenjin subtribes: five from Keiyo and one from Marakwet, Kipsigis and Tugen (as indicated in Table 2).

Themes on birth attendants' sensitivity to cultural practices
Three interrelated themes emerged through exploring BAs' experiences with sensitivity to CPs during pregnancy and birth (Table 3). They are further described in the following subsections.

Encounters with cultural practices
Birth attendants recounted how they felt when they encountered a CP. Their encounters with CPs were conceptualised as either familiar or unfamiliar, as determined by the feelings evoked, such as fear, anxiety or fulfilment. Those BAs familiar with the CPs felt more confident in their care. This confidence made them feel that they provided sensitive care. However, some BAs expressed that an unfamiliar encounter with CPs triggered fear and anxiety. They were worried about the poor outcomes that might result from their care when they were unfamiliar with the CP.

Familiar encounters
Familiarity with encounters was based on whether the BAs had prior experience with the CPs. Such experience was common for TBAs. However, SBAs' familiarity with CPs was often because of their affiliation with a particular tribal origin. Because of their familiarity with the CPs, the BAs felt confident and in control, and they anticipated favourable outcomes for the childbearing women, caregivers and community. However, the familiarity did not necessarily mean that the birth attendants were entirely comfortable with the encounter, and some anxiety could still be felt.
One TBA narrated an experience where she encountered a mother with a swollen breast 5 days after birth. The TBA was familiar with this problem and felt comfortable and assured that she could handle the situation successfully: '… There was this woman whose breast was swollen after getting the baby; I was summoned … when I reached there, she was sitting down with no shirt … then I cut the breast to relieve the swelling; the breast was shiny. She was in pain … at once, I asked for water to be boiled. I sent a boy to the shop to buy a razor blade … I cut along a swollen vein and drained it out. By the time I left, she was eating her food …' (TBA 5, years of experience On the other hand, for SBAs, CPs that aligned with or complemented biomedical practices were experienced as familiar. For example, SBAs were familiar with the cultural value that women attach to having a companion (often a TBA) during their visit to the facility. Male companionship was also experienced as occurring more often now, as opposed to previous cultural expectations. The SBAs were confident that the companionship of women enabled womancentred sensitive care:   Additionally, SBAs encountered female genital mutilation (FGM) and dietary practices as familiar CPs because they were cognisant of the implications of these practices on pregnancy outcomes. For example, one SBA narrated their concern regarding a familiar CP of withholding protein foods for fear of birth complications. The SBAs were aware that the lack of proteins could lead to anaemia and therefore were prepared to provide haematinics to the women. Further, FGM and complications such as narrowing the birth canal, which led to bleeding because of tears, were encountered as familiar. The midwives would prepare episiotomies to ensure women received the care they needed:

Unfamiliar encounters
Birth attendants usually anticipated some level of control in the care they provided to women to optimise outcomes during pregnancy and birth. Their encounters with unfamiliar CPs caused discomfort because of the possibility of losing control and poor outcomes during pregnancy and birth. In this situation, BAs felt that they were more culturally insensitive.
Birth attendants expressed a lack of confidence in an encounter that was unfamiliar to them. Further, the unfamiliar encounter evoked fear and anxiety, which exacerbated the lack of confidence. A SBA felt unfamiliar with cultural beliefs about FGM's effects on libido and was uncertain about how to respond. On the other hand, a TBA was unfamiliar with how to handle a complication of labour, such as malpresentation, and was afraid of a poor outcome if they did not respond appropriately: Birth attendants interpreted cultural encounters based on how they felt about them. Further, the encounters enabled them to reflect on their actions and how these actions enabled their sensitivity. The anticipated outcomes of the encounters influenced their feelings of either confidence, fear or anxiety.

Response to cultural encounters
The BAs' responses to encounters as either repulsed or optimistic were based on the encounters' feelings.

Optimistic responses
Birth attendants expressed their response to CPs with optimism if they handled them comfortably, meaning that they were hopeful that the practice could be changed or incorporated into their approach to care and were more accepting of it.
They also had an optimistic response when they saw the potential for the woman or other BA to change their behaviour and be more closely aligned to their perspective on what was appropriate. In general, optimistic responses were regarded as culturally sensitive to familiar or unfamiliar CPs.
For example, one TBA narrated how she wished the SBA could allow the woman to walk around the ward or let the TBA be with her to guide her progress during birth. Although the SBA did not allow this, the TBA was optimistic that all was not lost, as her presence in the facility enabled her to provide support to the woman by sneaking in porridge to ensure the woman had some strength during labour: 'Imagine the mother labouring for many hours, and she is instructed to lie on one side since we arrived here last night. I did not even eat anything myself. I just sat there, but at least I sneaked in "uji" porridge in the morning … you see, if she could have come out and walked around or even kneel in a place like there [pointing a spot with grass], that baby could have been born "kitaaambo" [looong time ago …].' (TBA 2, E25, A68) Another example from the perspective of the SBAs was related to the use of herbs. While the SBAs did not support the use of herbs, they realised that the CP was part of the community's culture and expressed optimism that with education and advice, the practice would die off or the complications would be averted. The SBA considered that this response was culturally sensitive: Skilled birth attendants also had optimistic responses to women they perceived as suffering the consequences of CPs which were not their fault. One SBA narrated an example of FGM which was not the woman's choice and which therefore required a more sensitive response. Further, teenage abortion was forced on girls, who ended up with infections that were not their fault and needed to be treated more sensitively. This encounter led to an optimistic response from the BA, as they felt it was not the woman's choice to get the abortion, but rather the teenage girl was coerced into aborting the baby: , then rush to the hospital. Imagine, she was told not to mention anyone's name or else … so I imagined how she was feeling. So we just managed her like she was in real labour until she was strong enough to go home …' (SBA 6, F, A30) Skilled birth attendants saw optimistic responses as not necessarily doing away with CPs, but accepting the status quo or providing health education to change practice. The TBAs felt the need for the SBAs to alter their management of women, particularly during birth, and felt optimistic when they had the opportunity to influence the situation.

Repulsed response
Birth attendants felt repulsed by an encounter that made them feel uncomfortable. In this situation, SBAs compelled women to act in a manner acceptable to them and disregarded other models of care. Likewise, when seeing a woman in the community, the TBA would reject the SBA's recommendation and insist on the woman continuing with the herbs, as she felt the woman should not turn away from her tradition: Although SBAs recognised that they could not stop women from using herbs, they attempted to persuade women to postpone using herbs to minimise complications during labour. The SBA felt that there was no way of stopping the women from using the remedies, as they were caught in this mindset of using remedies during pregnancy and birth. In particular, the SBAs felt repulsed by educated women who continued using herbs. For example, one SBA recalled a university student who had a herb-induced abortion. She expected the girl to seek long-term family planning methods rather than becoming pregnant and then using herbs to induce an abortion: 'They are stuck with their herbal remedies; for me, I have been trying to inspire them to delay giving herbal medicine because I am part of them. I cannot refuse them to practice them, but we postpone. The moment we postpone, we minimise the complications.' (SBA 2, M, A32)

Collaboration
Some BAs felt that a more woman-centred model of care required collaboration between SBAs and TBAs, who were both vying for the woman's agreement with their plan of action. According to the BAs, health services that strive to be more woman-centred might encourage partnerships and avoid teamwork dissonance among BAs and other stakeholders within the health care environment. Such a model might be considered most sensitive to women's cultural needs and expectations.

Partnerships
The partnership is about creating an organisational environment that supports joint actions between SBAs, TBAs and other stakeholders in supporting women during pregnancy and birth. Such an environment requires integrating both biomedical and traditional models of healthcare.
These partnerships could enable appropriate responses to CPs that provide woman-centred care. For instance, one TBA appreciated the enlightenment they received from World Vision, a nongovernmental organisation, which educated them on the danger signs to look out for during pregnancy and birth. Further, the TBAs were rewarded by World Vision when they referred the high-risk women to the SBAs: Such a partnership model would support mutual respect between SBAs and TBAs to enable women to make informed and shared decisions about their care. Women would remain in control of their health care and make informed and mutually agreed-upon choices without coercion, ordering or instructing.
Skilled birth attendants narrated that, occasionally, they gave gloves to the TBAs and would encourage them to accompany women to the health facility. Although there are no clinical policies and guidelines that recommend the supply of protective equipment or the involvement of TBAs, the SBAs felt the need to enable this type of partnership to provide safe care: 'OK, we have embraced the issues … I mean the issue of TBA, by teaching about pregnancy and childbirth. Also, we have been distributing gloves, and we have encouraged them to come to the facility if a problem arises. We do not normally chase them. We encourage them to accompany the mothers to the facility. We usually talk to them nicely. We don't harass them and tell them, "Why did you deliver … I mean, why did you accompany the mother?" We usually embrace and support them.' (SBA 7, F, A30) According to birth attendants, partnership implied a strategy for organisational structures to support woman-centred negotiated care within the triad of TBAs-SBAs-women as they encountered CPs. Fostering relationships through sharing resources, providing free maternity services, involving mother-mentors as trailblazers of women's support groups and incentivising TBAs to refer women for SBA services were all seen by BAs as being sensitive to women's needs. However, there was no consistent or sustainable approach at present to developing such partnerships.

Teamwork dissonance
Teamwork emerged when most BAs made a concerted effort to foster a triadic team (woman-SBA-TBA) that would communicate what women needed to know about their care and agree on a plan. Traditional birth attendants hoped the SBAs could appreciate their experience with CPs, while the SBAs expressed the need for the TBAs to acknowledge their expertise. Therefore, BAs envisioned a situation where the community supported the triad by promoting safe CPs and involvement in public health forums and campaigns.
The TBAs were apprehensive of being removed from the birthing rooms while supporting the women, assisting with the baby and communicating with the relatives: 'When I go with the mother, some doctors [SBAs] will allow you to sit in the same room where the mother is labouring … Some [SBAs] do not chase you, but they take her in [birthing room]. I will be waiting close by with clothes for the baby. As soon as I hear the cry, they allow me to go and dress the baby while she [SBA] finishes up with the mother. It feels good to be of help there [facility] … my work is to dress the baby and escort the mother back to bed … I will rush to the shop to get her tea and bread to warm herself with. Then I will inform the people at home that they are sere The 'tug of war' between who had better education and expertise between the BAs shows the need for negotiated teamwork with clear roles agreed upon between the triad.
Teamwork dissonance could be avoided by sensitising the community to CPs that are not aligned to the biomedical model and are considered harmful. The SBAs acknowledged their role in understanding the CPs within the communities deployed. This approach emerged to enable the triad to engage with valuable and harmful practices and agree on what is feasible: 'The only way that we will incorporate [CPs] as health workers is that when you [SBA] are posted in a certain community, it is good to know their culture and taboos, then you do sensitisation … Some practices cannot align to current health care status … you will also try to weigh the positives and negatives of that culture.' (SBA 11, M, A55) Figure 2 summarises the key findings relating to Ramsden's cultural safety framework. 20 Birth attendants were aware that their encounters with CPs led to emotional reactions, depending on how familiar the BA was with the practice. These reactions influenced how the BA responded and their cultural sensitivity. More sensitive responses were seen as optimistic and more insensitive responses as repulsed.

Discussion
Further to enable cultural safety, reflective learning from the encounters and responses enabled the BAs to identify team dissonance as a problem and appreciate efforts for partnership and woman-centred culturally safe care. Birth attendants suggested the need for all stakeholders to create partnership (women, TBAs, SBAs, community, MOH and nongovernmental agencies) and enable collaboration in the triad (SBA-woman-TBA), the team most directly responsible for culturally sensitive care.
Achieving this ideal of collaborative woman-centred care emerged during data analysis as dependent on the ability of BAs to reflect on their experiences and learn from them. This cyclic experiential learning by the birth attendants can be viewed through the lens of Kolb's experiential learning theory as illustrated in Figure 3 (KELT). 37  anxiety, and the experience could evoke a repulsed or optimistic response. After reflecting on the encounter and their response, the researcher observed that the BAs could learn and create new self-knowledge about their cultural sensitivity. This new knowledge emerged in the data, influencing their approach to future encounters and enabling a more collaborative practice.
Kolb asserts that learning is a process whereby new knowledge creation is through experience and transformation of that experience. 37 During the initial stage of concrete experience (CE), there is direct engagement with the task or situation. In this study, the BAs had encounters with CPs during active involvement with the women, which evoked the experience of confidence with familiar encounters or fear and anxiety with unfamiliar encounters. In the second stage, reflective observation (RO), Kolb asserts that the individual connects with past experiences or understanding and reflects on their experience. This study highlighted that the cultural encounters compelled the BAs to reflect on their feelings and responses.
The reflections lead to abstract conceptualisations (AC), where Kolb highlights that reflections are refined into abstract ideas. The BAs, during the interviews, reflected on their responses to the encounters, and this awareness led to new ideas or insights into cultural sensitivity. Therefore, evaluation of the encounter led to an 'updating' of their prior knowledge or viewpoint.
Acquisition of this new knowledge enabled BAs to plan more collaborative approaches to care within a broader commitment to partnership with key stakeholders. Putting these plans into action and testing new ideas are highlighted in Kolb's cycle as active experimentation (AE). This collaborative approach emerged in the study as enabling woman-centred and culturally safe care. Such responsiveness to people's perceived health needs results in better health outcomes. 38,39 Therefore, creating cultural awareness is more than being familiar with CPs, but it requires engagement with a discourse to understand oneself. Cross-cultural representation requires self-reflection and historical awareness. 40 Cross-cultural engagement also requires negotiated and clear communication with people of diverse cultural backgrounds 41 and reflecting on interactions with other culturally diverse groups builds a better understanding of ways to engage them. 42 Engaging in self-reflection could challenge cultural norms that label people from other cultures as 'weird' or 'abrasive'. 42 Birth attendants needed to move from judging others based on their normative viewpoints to accepting the legitimacy of other viewpoints, even if they disagreed with them. It emerged that their responses were concerning their concept of self-versus the other. 43 Developing such cultural competency is a crucial proficiency in social work and midwifery. 40 Collaboration emerged as an area for AE by BAs. However, experimenting requires self-efficacy. 43 The foundation of collaborative engagement is shared decision making between the recipient and provider of care. 44,45 Shared decision making between the BAs was appreciated, while team dissonance was viewed as the reason for poor outcomes during pregnancy and birth.
Further, there is a need for the concept of partnership to be included in guidelines and policies that set direction and support for team-based approaches to care. 46 These organisational processes build a shared understanding between partners and build relationships within the team. Birth attendants identified the need for practice regulation to create such partnerships and avoid team dissonance.

Strengths and limitations
All BAs were from the Kalenjin tribe and shared a similar cultural background. The findings were interpreted based on the specific characteristics of the participants within their context. The transferability of the findings will depend on the participants and the study context in a different study.
Interpretation of data depended on the researcher's philosophical positioning. However, the researcher ensured that preconceptions of cultural and professional affiliation did not significantly influence the interpretations of the data. Supervisory guidance and reflections assisted in the interpretive character of understanding the BAs' experiences.
Limitations were related to methodology during data collection and analysis, which was time-consuming and tedious. But some of these were mitigated by involving a transcription assistant and the use of ATLAS.ti software for coding.

Recommendations
From the findings, SBAs need to develop cultural sensitivity, and continuing professional development should focus on this. Such education should facilitate experiential learning, critical thinking and reflection amongst midwives. Reflective learning on cultural sensitivity and culturally safe care should also be embedded in midwifery curricula. Trainers should also embody such cultural sensitivity.
Maternal care guidelines should explicitly address cultural sensitivity and safe care and promote an organisational culture that supports partnerships. An approach to collaborative practice that includes TBAs as part of the team will reduce women's feeling of giving 'birth in between' modern and traditional health settings.
Further studies should focus on developing such educational interventions and testing their effectiveness. The implementation of educational and organisational change should also be evaluated.

Conclusion
Birth attendants reacted to encounters with CPs with various feelings such as anxiety or confidence. These reactions appeared