Association between social support and place of delivery: a cross-sectional study in Kericho, Western Kenya

An estimated 358,000 maternal deaths still occur worldwide each year [1]. Most of these deaths occur during labor, delivery, or the first 24 hours postpartum, and most complications cannot be predicted or prevented [2]. Where women deliver, who attends them, and how quickly they can be transported to referral-level care are thus crucial factors in determining the ability to successfully intervene [3]. The general pattern of utilization of maternal health services contributes to the incidence of maternal mortality and morbidity [4]. However, many women do not have access to the services they need for various reasons. Moreover, socio-economic factors, cultural traits, and local customs are associated with health-seeking behavior. For instance, there are places where services are available but women do not make use of them [3]. Women may prefer to stay at home for a delivery so that they can take care of family members such as young children or elderly relatives and manage their daily household chores [5]. Previous studies have shown that several factors are predictors of women accessing health services [6, 7]. It is important to identify which factors lead women to deliver at health facilities. Social support is also an important variable influencing health [8]. However, little attention has been paid to the possible association between social support and place of delivery. The aim of the present study was to determine the association between social support and place of delivery, and other factors influencing delivery location.

Socio-demographic characteristics and birth experience are shown in Table 1. Among the 303 respondents, age ranged from 18 to 41 years and median age was 23 years. Around 86% of respondents had some primary education. The most common occupation was farming. About 97% of women were Kipsigis, and more than 80% of respondents were married. In their most recent delivery, 58 (19.1%) women delivered at home and 245 (80.9%) delivered at health facilities. Just less than half of women who delivered at home were assisted by their mother-in-law, and the next largest proportion was assisted by neighbors.

Table 2 presents the associations between socio-demographic characteristics and place of delivery. Bivariate analysis indicated that facility delivery was more likely in younger women (P = 0.002), unmarried women (P = 0.008), primiparae (P < 0.001) and those with financial capability or high educational attainment (P < 0.001).

Table 3 shows associations between support for daily tasks and place of delivery among married women. Married women whose husbands supported them in farming and whose neighbors helped them fetching water were less likely to deliver at health facilities (P = 0.003 and P = 0.021, respectively) than those whose husbands and neighbors did not provide this support.

Table 4 shows associations between support for daily tasks and place of delivery among unmarried women. Unmarried women whose mothers supported them in housework and those whose sisters helped them fetch water were significantly more likely to deliver at health facilities (P = 0.002, P = 0.042, respectively) than those whose mothers and sisters did not provide this support.

Table 5 shows the associations between advice regarding facility delivery and place of delivery among married women. Married women who were advised by their mothers-in-law or by health staff to deliver at a health facility were more likely to do so (P = 0.015, P = 0.022, respectively) than those who were not.

Table 6 shows the associations between advice regarding facility delivery and place of delivery among unmarried women. There were no statistically significant differences between those who were advised to deliver at a health facility and those who were not.

Table 7 summarizes the results of multivariate logistic regression analysis of factors associated with the place of delivery in married women. Facility delivery was more likely among married women who were highly educated (OR = 2.5, CI: 1.0 − 6.1); who had financial capability (OR = 4.3, CI: 1.6 − 11.3); who had medical insurance (OR = 4.2, CI: 1.4 − 12.4); or who did not have previous birth experience (OR = 3.5, CI: 1.5 − 8.5). Facility delivery was also more likely among married women who did not have the support of sisters-in-law for fetching water (OR = 2.2, CI: 1.0 − 4.7), or who were advised to deliver at a health facility by family or neighbors (OR = 2.5, CI: 1.2 − 5.5).

The present study found that more than 80% of women delivered at health facilities, and less than 20% delivered at home. This is a high proportion of facility deliveries and low proportion of home deliveries in comparison to findings of the Kenya DHS (national estimate, 42.6% facility deliveries and 56.2% home deliveries) [9]. We believe this is because a large public health intervention focusing on maternal health had recently involved the current study site, thereby increasing the proportion of facility deliveries. Moreover, respondents were mothers who brought their babies to the health center for immunization. Thus we might have selected those who had already easy access to health facilities. However, a high proportion of facility deliveries is not unusual in urban areas within sub-Saharan Africa. Progress towards the professionalization of childbirth attendance in the urban population was already good in 1992 (>70% of births were attended by health professionals) and even better in 2000 [3]. A similar rise in facility deliveries would have accompanied this, since most professional assistance is provided in health facilities. On the other hand, rural sub-Saharan Africa showed no improvement; 32% of deliveries were attended by health professionals in the early 1990s and this proportion remained the same in 2000 [3]. While the present study site is not located in an area as urbanized as Nairobi, the capital of Kenya, some of its characteristics are more similar to urban areas than to rural areas because of economic development accompanying the tea industry.

Bivariate analysis showed that place of delivery was associated with age, educational level, occupation, marital status, economic status, medical insurance cover, parity, support for daily tasks, and advice regarding facility delivery. Many studies have investigated factors influencing place of delivery. For instance, a study in Kenya [22] and one in Burkina Faso [23] reported that a high education level was associated with a high proportion of facility deliveries. Another study in African countries including Kenya showed that favorable economic status was a significant predictor of the proportion of facility deliveries [7]. Moreover, the present study found that women who had medical insurance were more likely to deliver at health facilities, in agreement with a previous study conducted in Kenya [24]. In addition, primiparae were significantly more likely than multiparae to deliver at health facilities, as in previous studies [25]. Women who have not previously given birth tend to be more worried about complications than those who have had previous deliveries; therefore, they tend to choose facility delivery.

The current findings showed that types of support and the people providing this support were associated with place of delivery. Multivariate logistic regression analysis revealed that married women whose sisters-in-law helped them fetch water were less likely to deliver at health facilities. Bivariate analysis revealed that married women whose husbands supported them in farming and those whose neighbors helped them fetch water were also less likely to deliver at health facilities. These results are explained by the local cultural context. In the area of the study, women usually live near their husband’s family after marriage, and mutual aid and collaboration with neighbors is quite common [26]. Having support from sisters-in-law, a husband or neighbors indicates stable relationships within the marriage, and with the husband’s family and community. Our results showed that 44.8% of women who delivered at home were assisted by their mother-in-law (not TBA). Married women who had stable relationships with their in-laws readily received support to deliver at home, thereby decreasing their rate of facility delivery. Moreover, if a member of their husband’s family recommends a home delivery to a married woman, it is difficult to act against such advice, since married women are under pressure from this side of the family. This supports the previously reported idea that social support can include negative support as well as positive support [27]. Some married women deliver at health facilities because of positive reasons such as believing it is safer than home delivery. A previous study found that the perceived competency of midwives and better equipment were among the reasons women used childbirth services [5]. On the other hand, some married women who do not have a good relationship with their husbands or their neighbors might deliver at health facilities for negative reasons such as not having support for home delivery. Hence, facility delivery may be chosen for both positive and negative reasons.

The present study found that unmarried women whose mothers supported them in housework and whose sisters helped them fetch water were more likely to deliver at health facilities. Unmarried women are of course not subject to pressure from a husband’s family, and they can readily get support from their original family, so they are less likely to be influenced by traditional custom related to home delivery. As a result, unmarried women who had social support were more likely to deliver at health facilities.

The present multivariate analysis revealed that married women who were advised to deliver at a health facility by family or neighbors were more likely to do so than those who did not receive such advice. Bivariate analysis also showed that married women who were given such advice by their mother-in-law were more likely to deliver at a health facility than those who did not receive such advice. This suggests married women are more likely to be affected by advice from their mother-in-law than from any other family members. Mothers-in-law appear to be very influential regarding where their daughters-in-law deliver, and should therefore be involved with promotion of facility delivery. Moreover, married women who were advised by health staff to deliver at a health facility were more likely to do so than those who did not receive such advice, in agreement with a previous study [28]. However, the fact that women could receive advice from health staff suggests they already had good access to health services. Indeed, a previous study reported that professionals such as health care providers and counselors were not considered sources of social support by women [12]. Therefore, promotion of facility delivery should not accordingly be implemented only by health staff but also by close kinship.

In conclusion, our study found that social support was associated with place of delivery. This support took the form of instrumental support, such as support for daily tasks, and informational support, such as advice to deliver in a health facility. However, married and unmarried women differed in terms of the factors influencing their decision about where to deliver. Married women who had instrumental support were less likely to deliver at health facilities than those without this support. In contrast, unmarried women who had instrumental support were more likely to deliver at health facilities than those without this support. Married women who had informational support were also more likely to deliver at health facilities than those without such support. A woman’s mother-in-law was the most influential person regarding place of delivery. We therefore need to recruit as advocates not only women of reproductive age but also those in the same generation as their mothers-in-law. These findings can be used by policy makers, planners, and health care professionals to take into account social support issues in improving health facility deliveries. Increasing the awareness of women and their family members about the benefits of facility deliveries are recommended.