Background
Globally, almost 800 maternal deaths are reported each day in low and middle income countries. The increased lifetime risk of dying prematurely from pregnancy is one in 41 in developing countries, compared to one in 3300 in developed countries, making maternal mortality a social equity indicator [
1,
2]. Maternal morbidity from serious injury or disability due to obstetric complications is also significantly higher in developing nations [
2‐
4]. Maternal Mortality Ratio (MMR) is highest in Sub-Saharan Africa at 546 deaths per 100,000 live births [
2] . This MMR is below the 75% reduction required to achieve the Millennium Development Goal (MDG) five targets, and far below the Sustainable Development Goal (SDG) 3.1 target of less than 70 deaths per 100,000 live births [
2,
5,
6].
Kenya’s economic performance has seen it transform from a low to middle income country and despite the introduction of free maternal health services in June 2013 [
7,
8], recent WHO trends (1990–2015) have placed Kenya among the top ten countries with the highest maternal mortality [
2]. According to the 2014 Kenya Demographic Health Survey (DHS), although 96% of pregnant women received antenatal care (ANC) a significant proportion of women did not deliver at health facilities. The survey found an MMR of 362 (CI 254–471) [
9] compared to the 2008/2009 DHS which found a higher MMR of 488 (CI 343–696) per 100,000 live births [
10,
11]. As such, the MDG five target remains off track [
5,
6,
11].
According to the World Health Organization (WHO), 80% of maternal deaths are preventable, even in low-income countries [
3,
12]. Skilled attendance at delivery has been shown to be a surrogate marker for maternal mortality as approximately 16–33% of maternal deaths can be averted if supervised by a skilled professional [
4,
11,
13‐
15]. The proportion of births attended by skilled health personnel is thus a benchmark used to monitor progress towards the achievement of MDG five and maternal health in the post-2015 era [
6,
11,
13,
16]. Since service utilization is greatly determined by the perceived quality of care, it is crucial to comprehend the women’s perception of antenatal care (ANC) as an entry point into the continuum of maternal care and their level of satisfaction with the services provided [
17]. Several studies have examined factors that promote or hinder use of maternal health services. However, these studies assessed factors within specific age groups, in specific regions, quality of health care and mainly within public health institutions [
18‐
28]. Little is known of the demand for skilled birth attendance and which factors influence the choice of place of delivery. The choice of place of delivery affects if one receives skilled attendance at delivery, which in turn impacts maternal mortality. This study examined factors that influence the choice of skilled attendance at ANC.
Results
Of the 1445 participants, 99.2% (1397) were aged between 15 and 49 years. Characteristics of study participants are shown (Table
1). More than 90% had achieved primary level of education and above. Only 14% of the women had four or more ANC visits. 94.8% of women are likely to seek skilled attendance at delivery compared to 5% who are unlikely to seek skilled attendance at delivery.
Table 1
Characteristics of study participants
Age Median (IQR) 24 (21–29) | | | |
Education level✶ | | | < 0.001 |
No education | 122 | 8.7 | |
Primary and above | 1283 | 91.3 | |
ANC Visits✶ | | | 0.001 |
1 | 554 | 39.3 | |
2–3 | 656 | 46.6 | |
4 or Above | 199 | 14.1 | |
Sex of Provider✶ | | | < 0.001 |
Male | 311 | 21.5 | |
Female | 1134 | 78.5 | |
Regions✶ | | | < 0.001 |
Non- ASAL | 1168 | 80.8 | |
ASAL (Eastern & Northeastern) | 277 | 19.7 | |
In (Table
2), the logistic regression models for skilled delivery, classified by predictor factor shows cost, education level, ANC visits and sex of provider are strongly associated with client’s intention to deliver with a skilled birth attendant at delivery. In particular, women who reported having enough money set aside for delivery were 4.34 (
p < 0.002, 95% CI: 1.73; 10.87) times more likely to seek skilled attendance at delivery. Those with primary education and above had the highest odds ratio, which was 6.6 times higher than no education (
p < 0.001, 95% CI: 3.66; 11.95). Women with four or more ANC visits were 5.95 (
p < 0.018, 95% CI: 1.35; 26.18) times more likely to seek skilled attendance at delivery. The difference in odds ratios between male and female providers was 2.02 (
p < 0.014, 95% CI: 1.35; 3.53) in favour of females.
Table 2
Logistic regression models for skilled delivery, classified by predictor factor
Cost (has money for delivery) | | | | | |
No | 400 | Reference | | | |
Yes, enough | 457 | 8.99 (3.76; 21.44) | < 0.001 | 4.34.(1.73; 10.87) | 0.002 |
Yes, but not enough | 552 | 2.80 (1.64; 4.76) | < 0.001 | 1.90(1.07; 3.35) | 0.027 |
Opinion of ANC service | | | | | |
Very satisfied | 1161 | Reference | | | |
Not satisfied | 223 | 0.89 (0.47; 1.68) | 0.711 | | |
more or less satisfied | 22 | 0.97 (0.13; 7.40) | 0.977 | | |
Service Waiting time | | | | | |
< 30 | 751 | Reference | | | |
30–60 min | 255 | 1.55 (0.77; 3.12) | 0.224 | | |
61–120 min | 170 | 1.32 (0.60; 2.85) | 0.482 | | |
> 121 min | 233 | 2.40 (1.01; 5.70) | 0.048 | | |
Age of client | | | | | |
1 year | 1401 | 1.00(0.95; 1.04) | 0.69 | | |
Mother’s Education level | | | | | |
No education | 122 | Reference | | | |
Primary and above | 1283 | 11.20 (6.55; 19.13) | < 0.001 | 6.62 (3.66; 11.95) | < 0.001 |
Total number ANC Visits | | | | | |
1 | 554 | Reference | | | |
2–3 | 656 | 1.71 (1.04; 2.82) | 0.04 | 1.58 (0.92; 2.7) | 0.095 |
4 or more | 199 | 7.95 (1.90; 33.24) | 0.01 | 5.95 (1.35; 26.18) | 0.018 |
Sex of Provider | | | | | |
Male | 311 | Reference | | | |
Female | 1134 | 2.57(1.55; 4.25) | 0.00 | 2.02(1.35; 3.53) | 0.014 |
Geographical Region | | | | | |
Non- ASAL | 1168 | Reference | | | |
ASAL | 277 | 0.31 (0.19; 0.52) | < 0.001 | | |
Discussion
Our study shows that majority of women (94. 8%) had planned to deliver through a skilled attendant. Our results also found other significant differences in women’s intention to seek skilled delivery in relation to cost (those having enough money for delivery having higher odds ratio than those with no money), education (primary education and above having higher odds ratio), ANC visits (four or more ANC visits had higher odds ratio) and sex of provider (with female providers having higher odds ratio than males).
According to the DHS 2008/9 data, only 43% of women were attended to by a skilled professional at delivery [
11]. In Kenya, poverty, culture, and distance to health facility have been identified as factors that hinder women from utilizing skilled attendance at delivery. As our study focused on ANC attendees intentions, it is likely that many women in Kenya actually desire to be assisted by a skilled professional but they are constrained by these factors [
10,
35]. It is also possible that some women may have responded to the KSPA planning for skilled attendance due to the perceived social desirability of this answer by the community [
36].
Previous research has demonstrated a relationship between cost and access to maternal health care [
10‐
12,
15]. The DHS data has shown that the proportion of children born at home decreased as mothers wealth increased. Our findings are consistent with these results [
10‐
12,
15], whereby women who reported having enough money set aside for delivery were almost three times more likely to seek skilled delivery (
p < 0.022) than those who reported having no money set aside for delivery. To address this barrier the government of Kenya introduced free maternal services in 2013. The impact of this policy on skilled attendance at delivery will require further analysis. Evidence on the implementation of the free maternal policy from Malaysia and Sri Lanka, who have achieved the MDG targets, demonstrated the importance of sustained national commitment as a key component to their success [
37].
Education is a significant predictor of skilled attendance at delivery as shown by the differences between women with no education and those with primary and above. Educated women were almost 7 (
p < 0.001, 95% CI: 3.66, 11.95) times more likely to opt for skilled attendance at delivery than those with no formal education. Previous studies and the DHS have also highlighted this finding [
11,
18,
28,
38]. This finding points to importance of the role of education in the prevention of maternal mortality and morbidity. In order to achieve SDG 3.1, strong collaboration between the health and education sector is needed to ensure the achievement of SDG 4.1 which focuses on the education of girls [
16,
39].
Our study revealed that women with four or more ANC visits were almost 6 times (OR 5.95, 95% CI: 1.35, 26.18) more likely to seek skilled delivery than those with only one visit. This link between ANC attendance and skilled delivery is similar to those in previous studies conducted in developing countries such as Kenya, Ghana and India [
18,
26,
38,
40]. This supports the notion that antenatal care is a key pillar for safe motherhood because it offers an entry point into skilled care and the range of essential services that support the health of the mother and baby [
26].
Interestingly, we found sex of the health provider at ANC to significantly influence intention to deliver with a skilled birth attendant at delivery. In particular, women were twice as likely (
p < 0.014, 95% CI: 1.35: 3.53) to seek skilled attendance if attended to by a female provider than a male provider. Studies on gender preference have primarily focused on the doctor patient relations in obstetrics and gynaecology [
41]. A few studies focusing on the ANC experiences of women in Cuba, Saudi Arabia and Thailand found that female doctors were preferred by women because they were viewed to be easier to relate with on an emotional level and also more likely to provide gender-related preventive services [
41]. Very little data is available from developing countries, which are highly patriarchal and where gender concordance is necessary due to cultural and social practices that restrict physical contact between the sexes [
41]. Further research is required in this area.
Overall, our findings reflect those highlighted in the strategic framework for the Elimination of Preventable Maternal Mortality (EPMM) [
42]. In line with the framework, we support the need for a grand convergence of health and health enhancing sectors such as, education, social services and those focusing on gender empowerment for the achievement of SDG 3.1 of less than 140 maternal deaths per 100,000 live births in Kenya [
2,
42].
Limitations of the research
Several limitations should be considered. The cross-sectional study design employed by the KSPA means that causality cannot be established. This study was limited to only the facility audit questionnaires and ANC client exit interview, therefore the results cannot be extended to women who do not attend ANC. Certain demographic factors such as timing of first ANC, distance to health facility socio-economic status and urban/rural residence were not evaluated as they were not captured during the survey. Although traffic condition should be considered as a factor of the choice of skilled birth attendance, the KSPA dataset does not include such a question for analysis. Since the study utilized a secondary dataset certain variables were statistically insignificant possible due to low study power (service opinion, waiting time, age and region). We recommend that future KSPA surveys include a broader range of socio-demographic data in the ANC client exit interviews and consider the use of a similar unique identifier with the DHS to enable merging of service provision and household data.