Table 2.

Illustrative quotes by theme

Theme 1. “Everyday” challenges in maternal child care
Sub-theme 1.1. Cost of care	“Money can deter one not to go to hospitals. The strike may not be there, but most mothers will still opt to give birth at home because they do not have transport to take hospital… You know money is everything and without it you cannot do anything.” -FGD with women, Group 1, Participant 8 “We have challenges within the health sector and at the hospitals whereby as CHVs we refer women, and they get charged Ksh 500 (USD $5) or Ksh 1,000 (USD $10), yet they have Linda Mama insurance to cover both her health and that of the child. So, when I send a mother to deliver [in a public health facility] and she is charged, they say that I am lying and that they are actually asked for money when they go there... If you refer a person and [the health worker] asks for money [from the patient], yet I told them that the service is free. From there, the person will lose respect for you as a CHV.” -FGD with CHV, Group 2, Participant 3
Sub-theme 1.2. Acceptability of care	“When I was in labor pains, [a health worker] abused me badly and even went ahead and slapped me! Imagine with that condition someone treating you like that? They should be sensitized on how to handle expectant mothers. When I gave birth to my fist born, I concluded I will not be going to hospitals and instead I will give birth in my home.” -FGD with women, Group 1, Participant 7 “When we refer [women] to clinics, we require the nurses to treat them in a nice way so that they can be motivated to attend all ANC appointments and even deliver in a facility. When they are harassed and abused verbally, they are discouraged and their attendance drops. It also discourages us as CHVs because by the time you have convinced a woman into accepting that she is pregnant and going to the clinic, you would have done a great job that should not be in vain.” -FGD with CHV, Group 3, Participant 6
Sub-theme 1.3. Quality of care	“Because of the shortages, some of the services have not been rendered effectively, and then also the quality of care to the patient is not up to standard…There is no way one nurse can manage a ward and be able to manage all the needs of the patients in that ward…You know when a patient comes [they] expect to get the best but because of these challenges…there are patients who don’t feel like they are satisfied [with] the services.” -Interview with facility manager, Participant 3
Theme 2. Experiences of maternal child health care during strikes
Sub-theme 2.1. Poor pregnancy outcomes during the strike	“Pregnant women and children lost their lives. Many women lost their lives during delivery and this strike will be on our memories for a long time to come.” -FGD with women, Group 2, Participant 8 “A certain woman delivered at home with the help of a traditional birth attendant and she delivered a healthy baby. Unfortunately, she developed complications during delivery and she died. I was pregnant at the time and I was really worried that I would die during delivery but I thank God I delivered safely. During the strike women go through a lot of challenges.” -FGD with women, Group 2, Participant 3 “The strike really affected people from my community, especially the pregnant mothers because maybe she attended her first ANC visit but when she came back for her second, there was the strike. So, she didn’t come for the third, and she defaulted and never met the fourth ANC visit… There were mothers supposed to deliver in the facility accompanied by their birth attendant, but as soon as they heard of the strike, they opted to deliver at home and [this] really affected [their] health.” -Interview with facility manager, Participant 1
Sub-theme 2.2. Strategies to access care during the strike	“I also went through such an experience [during the strike] at the [traditional birth attendant] because one needs to be assisted. Sometimes the place can be dirty and she lacks equipment, but you just persevere because you need the help...I was very happy because she did not ask me for any fee and she did not harass me for coming at night. I thanked her very much.” -FGD with women, Group 3, Participant 1 “When I arrived in the hospital I only found the watchman who told me that there was a doctor and he went to wake him up. The doctor came, checked up on me, [and] told me that I will give birth at 7:30am. He opened the maternity ward for me and asked me to wait until then. When 7:30am arrived, the doctor came and gave me a condition that in order to treat me, I had to cough up Ksh 2,500 (~USD $250) because doctors were on strike. I told him we had the money as long as he helps me give birth with ease. After he helped me, I paid him the money. It was a government hospital, which we are not supposed to pay any amount since maternity services are for free, but I had to pay because of strike.” -FGD with women, Group 1, Participant 2 “I had to take the responsibility of taking her to a Mission hospital [during the strike], but I was told by the doctor in charge that there were no free services and we had to pay at least some money. Since I wanted to help her, I had to use my own money so that she could deliver safely… I had to help her because the community trust in me. When I help them in good and bad times, they will continue trusting in me just the way she did.” -FGD with CHV, Group 1, Participant 2 “Yes, we were overwhelmed. We also had to discharge most of our clients earlier than expected because we usually observe a mother for 24 hours after a delivery to ensure both the baby and the mother are stable. But we had to shorten this time to save space for those already in the queue because they kept streaming in.” -Interview with facility manager, Participant 8
Sub-theme 2.3. Impact on health care workers	“I really suffered as a person because there was so much suffering, and [patients] come to look at you, you are to solve everything…So me, personally I could not even sleep.” -Interview with facility manager, Participant 5
Theme 3. Strike-related inequities in maternal child health services
Sub-theme 3.1. Indirect economic impact of strikes	I spent four thousand shillings when I went to give birth. I sold the maize I had until I didn’t have food at home…Yes, I sold the food I had to pay the hospital bills.” -FGD with women, Group 2, Participant 4 “The strike came and even created poverty in the community because now the person is sick, they take their land and they lease, they lease the land even when the person lives there, there is no food at home, children are unable to go to school. This thing largely affected [the community].” -FGD with CHV, Group 2, Participant 2
Sub-theme 3.2. Vulnerability of poor, especially rural poor, communities	“It was hell in the community…Because most people affected are the common ones, the poor ones, the common “mwananchi,” [they] are the most affected because you will find the fairly well-off people are able to access services elsewhere. But now you find the local community suffers the most,” -Interview with facility manager, Participant 8 “The person that really suffers is the one based in the community because if you look at it, for us that come from the community these private clinics are not many compared to those in towns. For a mother that comes from the village, in order for her to get to the private clinic it will really cost her a lot and life here in the village is difficult. You can’t compare a mother from the village and the one from town because the one in town can easily access the private clinics during strikes as there are plenty of them, so the one being affected is the one from the community.” -FGD with women, Group 4, Participant 10
Sub-theme 3.3. Role of CHVs in health system	“Sincerely speaking, the CHVs have been abused. For example, I have been working as a CHV for the past 30 years, I have been working under the health sector, but I have never seen the benefits of this work, yet I have not been employed. I am just doing it out of heart…So, what I am saying is, don’t let me be your stepping stone yet you don’t want to help me.” -FGD with CHV, Group 1, Participant 6 “The CHVs are the people who work at the ground and yet those who are paid are in the offices. We walk around villages looking for those who have defaulted medications, and pregnant mothers who need to start their ANC visits... The government should recognize our work as CHVs and they should omit the V in Community Health Volunteer and replace it with the W to be Community Health Workers as it used to be…So, you need to remember us, because we are like your pillars. If we collapse, then you will also collapse.” -FGD with CHV, Group 1, Participant 2
Theme 4. Relational dimensions of strikes in the health system
Sub-theme 4.1. Impact of strikes on relationships and trust in health system	“During the strike, I lacked respect and value in the community. When I would visit a household and make a referral, they would not listen to me because there was no one in the facility to provide medical services. They told me I was of no help since the referrals I made were of no use, and I wasn’t providing money for them to attend private facilities. I felt dejected since many people were dying and yet our hands were tied. They were associating us with the doctors and claimed that we were also on strike. This caused an injury to the relationship we had with the people in the community since we are the link between the community and the hospitals. I couldn’t tell the people anything, I had no referrals to make, no drugs to offer; some told me not to step in their houses.” -FGD with CHV, Group 3, Participant 3 “When you work in a hospital, you create a relationship with the community…but when there is a strike, they don’t understand why you cannot assist…they tend not to trust us again…It really affected me. We have invested so much in community health…but because of the strike the relationship that we had built was broken, [and mothers] went back to the traditional birth attendants.” -Interview with facility manager, Participant 7
Theme 5. Perspectives on the legitimacy of strikes by health care workers
Sub-theme 5.1. Support for legitimacy of strikes	“The doctors were demanding what was rightfully theirs…We saw in the media that the government did not fulfill their end of the bargain.” -FGD with women, Group 2, Participant 5 “We could be putting the blame on our doctors, but they are working in unpleasant environments. Most of the times we put our focus on money issues, that the doctors need salary increment, yet they want a good environment at their workplace so that they could perform better and not to be blamed for deaths.” -FGD with CHV, Group 1, Participant 2 “Sometimes you have to demand for your rights and because now in Kenya, it is a tradition. If you want something you have to go on strike because if you negotiate, you will never get [it]. Going on strike is not a good thing, because let’s say for the nurses and doctors the impact of the strike was too much on the patient, and politicians who are well off go to private facilities. So, it’s like they go on strike, but the politicians can’t feel the pain.” -Interview with facility manager, Participant 4
Sub-theme 5.2. Lack of support for legitimacy of strikes	“The advantage of the strike is only felt by the doctors because they don’t lose their loved ones. They can treat them at home or even send them abroad for medication since they have money. The disadvantage of [the] strike is felt by us because we lose a lot of people in the community and there is nothing more painful than seeing someone fighting for their life and succumb before your own eyes…When the strike ends, the doctors return to work but the pain of losing someone because doctors decided not to save lives is a wound that never heals.” -FGD with CHV, Group 3, Participant 4 “I recommend that the government should investigate those doctors who have their private clinics waiting for strikes and then they recommend patients to go there [during strikes in the public sector].” -FGD with women, Group 3, Participant 4
Theme 6. Interventions to maintain maternal child health care during strikes
Sub-theme 6.1. Maintenance of minimum services	“I would ask the government, whenever the nurses working in maternity [wards] want to go on strike or whenever the strike is on, then they should consider salary increments for them so that they can help the expectant mothers and babies. Because when these babies are born, no one knows they can end up being presidents or even doctors. We should not lose lives. So, they should have a salary increment before the strike. And the nurses should take their grievances and complaints before striking so that the government can sort them as they continue working. They should never leave us stranded on the roads.” -FGD with women, Group 4, Participant 7 “I think the government could have prioritized pregnant women because strikes don’t normally last long so maternity services should be availed throughout as it might lead to death of the child or mother or both…the maternity wing of the hospital should always be open.” -FGD with women, Group 4, Participant 12
Sub-theme 6.2. Provide free services in public and private hospitals and clinics	“I can say these clinics should be free whether [they are] public or private facilities. The services you get in public should also be offered in the private facilities. Any test that is done in public [facilities] for free should also be free in private facilities…pregnant women should be recognized anywhere, both in public and private.” -FGD with women, Group 3, Participant 5
Sub-theme 6.3. Coordination with private and non-profit sectors during strikes	“Please work hand in hand from the community, even the private and the faith based [facilities] with public institutions [and] health facilities, so that in case there is another strike in the future…it is good to work hand in hand so that when there is a strike it is good to support these private people to work so that they may fill these gaps.”  -Interview with facility manager, Participant 5 “I would like to say this Beyond Zero [organization] is all about mothers and children. The government should look for qualified nurses from Beyond Zero so that in cases of strikes they are available and are deployed in every facility, so that when the mothers come at least they can be attended to easily. They can be employed by Beyond Zero and be like the Flying Doctors [organization]. So, when the Beyond Zero vehicle comes it should come with nurses on board to be dispersed in every facility to save these mothers.” -FGD with women, Group 4, Participant 1
Sub-theme 6.4. Corruption	“The issue of corruption has really been on a rise. You find that money for paying workers is released by the national government to the County government. But the County government diverts the money. Those giving services in these institutions [i.e., health workers] have children in schools and also some need to pay their rents…yet the money is delayed up to the 15thday of the money. So, corruption has also been a factor that contributes to strikes.” -FGD with CHV, Group 1, Participant 7