Background
Maternal and neonatal mortality has remained high in low resource settings despite progress in recent years. In 2015, about 303,000 women died from pregnancy-related causes and 2.7 million babies died during the first 28 days of life globally [
1,
2]. About 2.6 million babies were also stillborn [
3]. High quality antenatal care (ANC) can reduce maternal and neonatal morbidity and mortality and stillbirths through prevention, as well as early identification and management of pregnancy complications or pre-existing conditions [
4]. High quality ANC can also influence women’s health seeking behavior towards choosing skilled care at birth and helping them prepare to be able to access it [
5‐
7]. A positive experience during both pregnancy and childbirth are key to person-centered care and the right of every childbearing woman, as highlighted in recent World Health Organization (WHO) recommendations [
8‐
10]. While the specific recommendations for frequency of ANC has varied, WHO has consistently recommended that all pregnant women receive some ANC during their pregnancy [
4,
8,
11].
Kenya’s National Guidelines for Quality Obstetrics and Perinatal Care that were in use at the time of this work were based on the WHO recommendations on Focused Antenatal Care [
12], which recommended four comprehensive and targeted visits. The guidelines, however, urged providers to view each visit as if it were the only visit a woman may make. The recommended content of each visit includes blood pressure and fetal growth monitoring, urine testing, Iron and Folic Acid supplementation, Tetanus Toxoid immunizations, at least two doses of Intermittent Preventative Treatment for malaria in pregnancy in endemic malaria areas and deworming after the first trimester. The first ANC visit also includes a more in-depth medical history and physical examination, including head to toe examination, recording weight and height, blood group typing, HIV testing and counseling, and assessing needs for specialized care [
13]. The Kenya guidelines do not mention ultrasound scanning for routine ANC, but it is recommended for fetal assessment, including for dating, among women with preterm labor and those with complications. Early ultrasound increases the accuracy of gestational age assessments and current WHO guidelines recommend one ultrasound scan before 24 weeks of gestation [
8].
The Kenya guidelines also recommend comprehensive health promotion education, with a question and answer session also recommended during each visit. These guidelines also emphasize the importance of patient experience components such as communication, respect, and dignity. It states that
“Antenatal care should be simpler, safer, friendly and more accessible. Women are more likely to seek and return for services if they feel cared for and respected by their providers. This personalized approach requires health care providers to use excellent interpersonal skills since listening to client’s concerns is just as important as giving advice. It respects clients’ right to dignity, privacy, confidentiality, full and accurate information” [
13]
. Likewise, the most recent WHO recommendations
on antenatal care for a positive pregnancy experience, updated in 2016
, prioritizes person-centered care and overall well-being of the mother and baby [
8].
Until recently, most prior research on maternal health care focused on use of services with research on ANC mostly on timing and frequency of ANC visits [
14‐
17]. Increasing recognition of the role of poor-quality care to the poor maternal and neonatal outcomes has stimulated interest in assessing quality of maternal health service. However, most of the attention has focused on quality of care during childbirth. [
18,
19]. Little research thus exists on quality of ANC, and most of the studies on ANC quality have focused on the receipt of recommended ANC services [
20‐
22]. This is despite a global movement advocating for measurement and interventions to improve respectful maternity care. Only a few studies in Kenya, based on the Service Provision Assessment data at the national level, have examined multiple dimensions of quality of care. These studies suggest sub-optimal ANC quality in structural, service provision, and experience measures [
22‐
24].
More studies, including studies at sub-national levels examining multiple dimensions of ANC quality, are critical to (1) provide information on strengths and gaps in ANC quality and (2) guide interventions in specific areas to improve provision of services and person-centered antenatal care (PCANC). This paper extends the evidence in this area. We aimed to assess levels of quality of ANC, including both service provision and experience of care, in a rural county in western Kenya. Service provision here refers to receipt of recommended evidence-based services for ANC per WHO and Kenya guidelines. Experience of care captures items related to effective communication, respect, dignity, and emotional support per the WHO framework for quality of maternal and newborn health [
10]. These experience dimensions assess PCANC. We also examine factors associated with each dimension of quality of care to identify sources of disparities in quality of care.
Results
Descriptive
Table
1 shows the characteristics of the sample. The average age was 25 years, and about 17% were less than 20 years old. Approximately 79% were married, with average parity of 3; 30% had 4 or more children. About 60% had only primary education or less and 76% were literate (could read and write very well). Less than a quarter (23%) were gainfully employed (work for which they were paid). About two-thirds started ANC in the second trimester and received more than four ANC visits. Most women received ANC from a nurse or midwife (88%) and solely from a health center or dispensary (55%). About 10% received ANC solely from a private facility and 34% received some ANC from a hospital. Eighty-eight percent went for their first ANC visit for a checkup (routine ANC), but 46% experienced some complication during the pregnancy and 31% felt the problem they had was severe. Table
2 and Table
3 shows the distribution of individual ANC quality measures for both service provision and experience of care.
Table 1
Sample distribution
Age |
15 to 19 years | 177 | 17.2 |
20 to 29 years | 599 | 58.1 |
30 to 48 years | 255 | 24.7 |
Current marital statusa |
Single | 154 | 15 |
Partnered/Cohabiting | 4 | 0.4 |
Married | 811 | 78.7 |
Widowed | 48 | 4.7 |
Divorced/Separated | 13 | 1.3 |
Number of birthsa |
1 | 320 | 31.2 |
2 | 207 | 20.2 |
3 | 191 | 18.6 |
4 or more | 309 | 30.1 |
Highest education |
No school/Primary | 623 | 60.4 |
Post-primary/vocational/Secondary | 292 | 28.3 |
College or above | 116 | 11.3 |
Literacy: reading and write very well |
No | 244 | 23.7 |
Yes | 787 | 76.3 |
Employed with income |
No | 792 | 76.8 |
Yes | 239 | 23.2 |
Self or household member work in health facility |
No | 967 | 93.8 |
Yes | 64 | 6.2 |
Household wealth quintilea |
Poorest | 247 | 24.2 |
Poorer | 231 | 22.6 |
Middle | 159 | 15.6 |
Richer | 188 | 18.4 |
Richest | 197 | 19.3 |
Household wealth quintile |
Poorest/Poorer | 478 | 46.8 |
Middle | 159 | 15.6 |
Richer/Richest | 385 | 37.7 |
Current occupation |
Agricultural labor | 170 | 16.5 |
Casual labor | 63 | 6.1 |
Salaried worker | 97 | 9.4 |
Self-employed in petty trade | 189 | 18.3 |
Self-employed small-scale industry | 29 | 2.8 |
Unemployed/homemaker | 470 | 45.6 |
Other | 13 | 1.3 |
Partner’s occupationa |
Agricultural labor | 213 | 20.7 |
Casual labor | 185 | 18 |
Salaried worker | 157 | 15.3 |
Self-employed in petty trade | 144 | 14 |
Self-employed small-scale industry | 85 | 8.3 |
Unemployed/homemaker | 25 | 2.4 |
Other | 4 | 0.4 |
No Partner | 215 | 20.9 |
Partner’s educationa |
No school/Primary | 397 | 39.3 |
Post-primary/vocational/Secondary | 250 | 24.8 |
College or above | 147 | 14.6 |
No Partner | 215 | 21.3 |
Has health insurancea |
No | 866 | 84.2 |
Yes | 162 | 15.8 |
Tribea |
Luo | 696 | 67.6 |
Kuria | 239 | 23.2 |
Other | 95 | 9.2 |
Religious affiliation |
Catholic | 271 | 26.3 |
Protestant/Pentecostal | 233 | 22.6 |
Seventh Day Adventist | 299 | 29 |
Other Christian | 208 | 20.2 |
Muslim/other religion | 20 | 1.9 |
Attitude towards domestic violence |
Tolerant | 490 | 47.5 |
Intolerant | 541 | 52.5 |
Participation in household decisions |
Low participation | 531 | 51.5 |
High participation | 500 | 48.5 |
Experienced domestic violence |
No | 488 | 47.3 |
Yes | 543 | 52.7 |
Had any pregnancy complications |
No | 559 | 54.2 |
Yes | 472 | 45.8 |
Had severe pregnancy complications |
No | 709 | 68.8 |
Yes | 322 | 31.2 |
Had complications in prior pregnancy |
No | 894 | 86.7 |
Yes | 137 | 13.3 |
Received ANC in prior pregnancy |
No | 339 | 32.9 |
Yes | 692 | 67.1 |
Prior facility delivery |
No | 398 | 38.6 |
Yes | 633 | 61.4 |
Highest ANC facility |
Gov’t Hospital | 354 | 34.3 |
Gov’t HC/Dispensary | 571 | 55.4 |
Mission/Private facility | 106 | 10.3 |
Highest ANC Provider type |
Nurse/Midwife | 905 | 87.8 |
Doctor/Clinical officer | 115 | 11.2 |
Non-skilled attendant | 11 | 1.1 |
Reason for first ANCa |
Because of a problem | 112 | 10.9 |
Just for a checkup | 909 | 88.3 |
Can’t Remember | 9 | 0.9 |
Timing of first antenatal visit |
First trimester | 300 | 29.1 |
Second trimester | 634 | 61.5 |
Third Trimester | 97 | 9.4 |
Number of antenatal visitsa |
Less than 4 | 368 | 35.8 |
4 or 5 | 547 | 53.3 |
6 plus | 112 | 10.9 |
Place of interview |
Health facility | 421 | 40.8 |
In the community/a home | 610 | 59.2 |
Postpartum length |
less than 1 week | 81 | 7.9 |
1 week or more | 950 | 92.1 |
N | 1031 | 100 |
Table 2
Distribution of quality of antenatal care variables
Height measured |
No | 406 | 39.4 |
Yes | 616 | 59.7 |
Don’t know or can’t remember | 9 | 0.9 |
Weighed |
No, Never | 22 | 2.1 |
Yes, A Few Times | 93 | 9 |
Yes, Most Of The Time | 86 | 8.3 |
Yes, All The Time | 828 | 80.3 |
Don’t know or can’t remember | 2 | 0.2 |
Blood pressure taken |
No, Never | 99 | 9.6 |
Yes, A Few Times | 207 | 20.1 |
Yes, Most Of The Time | 122 | 11.8 |
Yes, All The Time | 594 | 57.6 |
Don’t know or can’t remember | 9 | 0.9 |
Did urine test |
No, Never | 223 | 21.6 |
Yes, A Few Times | 632 | 61.3 |
Yes, Most Of The Time | 31 | 3 |
Yes, All The Time | 139 | 13.5 |
Don’t know or can’t remember | 6 | 0.6 |
Did a blood test |
No | 35 | 3.4 |
Yes, once | 789 | 76.5 |
Yes, more than once | 207 | 20.1 |
Received a tetanus injection |
No | 130 | 12.6 |
Yes | 892 | 86.5 |
Don’t know or can’t remember | 9 | 0.9 |
Iron supplementation |
No | 98 | 9.5 |
Yes | 915 | 88.7 |
Don’t know or can’t remember | 18 | 1.7 |
Antihelminthes |
No | 379 | 36.8 |
Yes | 598 | 58 |
Don’t know or can’t remember | 54 | 5.2 |
Antimalarialsa |
No | 162 | 15.7 |
Yes | 849 | 82.4 |
Don’t know or can’t remember | 19 | 1.8 |
Ultrasounda |
No | 862 | 83.7 |
Yes | 167 | 16.2 |
Don’t know or can’t remember | 1 | 0.1 |
Total | 1031 | 100 |
Table 3
Distribution of quality of antenatal care variables
Told the results after weighinga |
No, Never | 103 | 10.2 |
Yes, A Few Times | 82 | 8.2 |
Yes, Most Of The Time | 104 | 10.3 |
Yes, All The Time | 711 | 70.7 |
Don’t know or can’t remember | 6 | 0.6 |
Told results after blood pressure measurementsa |
No, Never | 187 | 20.3 |
Yes, A Few Times | 134 | 14.5 |
Yes, Most Of The Time | 90 | 9.8 |
Yes, All The Time | 493 | 53.4 |
Don’t know or can’t remember | 19 | 2.1 |
Told results after urine testa |
No, Never | 115 | 14.4 |
Yes, A Few Times | 329 | 41.1 |
Yes, Most Of The Time | 46 | 5.7 |
Yes, All The Time | 303 | 37.8 |
Don’t know or can’t remember | 8 | 1 |
Told results after blood testa |
No, Never | 62 | 6.2 |
Yes, A Few Times | 304 | 30.5 |
Yes, Most Of The Time | 62 | 6.2 |
Yes, All The Time | 554 | 55.6 |
Don’t know or can’t remember | 14 | 1.4 |
Told about the signs of pregnancy complicationsa |
No | 537 | 52.2 |
Yes | 485 | 47.1 |
Don’t know or can’t remember | 7 | 0.7 |
Told where to go in case of complicationsa |
No | 445 | 43.2 |
Yes | 582 | 56.5 |
Don’t know or can’t remember | 3 | 0.3 |
Told what to expect during pregnancy and delivery |
No | 566 | 54.9 |
Yes | 458 | 44.4 |
Don’t know or can’t remember | 7 | 0.7 |
Birth preparedness educationa |
No | 233 | 22.6 |
Yes | 793 | 77 |
Don’t know or can’t remember | 4 | 0.4 |
Nutrition education |
No | 329 | 31.9 |
Yes | 691 | 67 |
Don’t know or can’t remember | 11 | 1.1 |
Breastfeeding educationa |
No | 365 | 35.4 |
Yes | 655 | 63.6 |
Don’t know or can’t remember | 10 | 1 |
Understood purpose of tests performed |
No, Never | 170 | 16.5 |
Yes, A Few Times | 178 | 17.3 |
Yes, Most Of The Time | 234 | 22.7 |
Yes, All The Time | 442 | 42.9 |
Don’t know or can’t remember | 7 | 0.7 |
Understood purpose of medicines received |
No, Never | 154 | 14.9 |
Yes, A Few Times | 167 | 16.2 |
Yes, Most Of The Time | 240 | 23.3 |
Yes, All The Time | 462 | 44.8 |
Don’t know or can’t remember | 8 | 0.8 |
Felt able to ask any questionsa |
No, Never | 178 | 17.3 |
Yes, A Few Times | 216 | 21 |
Yes, Most Of The Time | 195 | 19 |
Yes, All The Time | 434 | 42.2 |
Don’t know or can’t remember | 6 | 0.6 |
Asked if she had any questionsa |
No, Never | 306 | 29.7 |
Yes, A Few Times | 206 | 20 |
Yes, Most Of The Time | 153 | 14.9 |
Yes, All The Time | 358 | 34.8 |
Don’t know or can’t remember | 7 | 0.7 |
Felt treated with respect |
No, Never | 15 | 1.5 |
Yes, A Few Times | 82 | 8 |
Yes, Most Of The Time | 230 | 22.3 |
Yes, All The Time | 699 | 67.8 |
Don’t know or can’t remember | 5 | 0.5 |
Treated in friendly mannera |
No, Never | 25 | 2.4 |
Yes, A Few Times | 109 | 10.6 |
Yes, Most Of The Time | 247 | 24 |
Yes, All The Time | 646 | 62.7 |
Don’t know or can’t remember | 3 | 0.3 |
Could discuss issues in private |
No, Never | 316 | 30.6 |
Yes, A Few Times | 134 | 13 |
Yes, Most Of The Time | 139 | 13.5 |
Yes, All The Time | 438 | 42.5 |
Don’t know or can’t remember | 4 | 0.4 |
Felt the health facility was clean |
No, Never | 64 | 6.2 |
Yes, A Few Times | 126 | 12.2 |
Yes, Most Of The Time | 231 | 22.4 |
Yes, All The Time | 599 | 58.1 |
Don’t know or can’t remember | 11 | 1.1 |
Asked to give bribesa |
No, Never | 912 | 88.5 |
Yes, A Few Times | 64 | 6.2 |
Yes, Most Of The Time | 29 | 2.8 |
Yes, All The Time | 24 | 2.3 |
Don’t know or can’t remember | 1 | 0.1 |
Felt treated differently because of any personal attribute |
No, Never | 965 | 93.7 |
Yes, A Few Times | 36 | 3.5 |
Yes, Most Of The Time | 10 | 1 |
Yes, All The Time | 16 | 1.6 |
Don’t know or can’t remember | 3 | 0.3 |
Total | 1031 | 100 |
Bivariate
Table
4 shows bivariate statistics for the association between the summative ANC quality measures and receipt of an ultrasound with various potential predictors. Significant differences exist in the ANC quality measures by sociodemographic factors as well as facility types. The following associations had
p-values < 0.05. Not accounting for other factors, women who were older than 19 years and married women had, on average, higher experience of care scores than younger and unmarried women, respectively. Older women were also more likely to receive an ultrasound examination than younger women. Women with higher parity had lower service provision scores, including less likely to get an ultrasound. Compared to Luo women, Kuria women had higher experience scores and slightly higher service provision scores, but had lower odds of receiving an ultrasound.
Table 4
Bivariate regressions of antenatal care quality measures on various predictors, PQCC 2016/2017
Age |
15 to 19 years | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
20 to 29 years | 1.98** | [0.55 | 3.41] | 0.18 | [-0.25 | 0.61] | 2.40** | [1.34 | 4.32] |
30 to 48 years | 1.80* | [0.17 | 3.43] | -0.11 | [-0.60 | 0.38] | 2.84** | [1.51 | 5.31] |
Marital status |
Single | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Partnered/Cohabiting | -2.88 | [-11.0 | 5.27] | -1.59 | [-3.98 | 0.80] | 1.38 | [0.14 | 13.7] |
Married | 2.70*** | [1.21 | 4.19] | -0.17 | [-0.61 | 0.27] | 0.77 | [0.49 | 1.20] |
Widowed | 1.01 | [-1.82 | 3.84] | -0.33 | [-1.15 | 0.50] | 0.59 | [0.23 | 1.52] |
Divorced/Separated | 2.7 | [-2.13 | 7.54] | 0.18 | [-1.30 | 1.66] | 0.75 | [0.16 | 3.57] |
Number of births |
1 | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
2 | 0.05 | [-1.46 | 1.56] | -0.085 | [-0.52 | 0.35] | 1.4 | [0.91 | 2.14] |
3 | 0.16 | [-1.38 | 1.69] | -0.52* | [-0.97 | -0.069] | 0.53* | [0.31 | 0.91] |
4 or more | -0.65 | [-2.01 | 0.70] | -1.08*** | [-1.47 | -0.68] | 0.67 | [0.43 | 1.04] |
Tribe |
Luo | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Kuria | 3.96*** | [2.71 | 5.20] | 0.59** | [0.22 | 0.96] | 0.28*** | [0.16 | 0.49] |
Other | 1.2 | [-0.61 | 3.01] | -0.2 | [-0.75 | 0.35] | 1.05 | [0.62 | 1.80] |
Religious affiliation |
Catholic | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Protestant/Pentecostal | 0.77 | [-0.75 | 2.28] | -0.16 | [-0.60 | 0.28] | 0.58* | [0.36 | 0.93] |
Seventh Day Adventist | 0.55 | [-0.87 | 1.98] | -0.11 | [-0.52 | 0.30] | 0.99 | [0.66 | 1.48] |
Other Christian | -0.46 | [-1.99 | 1.06] | -0.58* | [-1.04 | -0.13] | 0.31*** | [0.17 | 0.57] |
Muslim/other religion | -2.48 | [-6.42 | 1.45] | -1.21 | [-2.42 | 0.0026] | 0.2 | [0.026 | 1.51] |
Education |
No school/Primary | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Post-primary/vocational/Secondary | 2.15*** | [0.96 | 3.34] | 0.66*** | [0.32 | 1.01] | 2.03*** | [1.35 | 3.04] |
College or above | 1.79* | [0.11 | 3.47] | 1.17*** | [0.69 | 1.66] | 9.22*** | [5.87 | 14.5] |
Literate | 2.28*** | [1.05 | 3.51] | 0.72*** | [0.35 | 1.08] | 2.57*** | [1.57 | 4.19] |
Employed | 3.66*** | [2.44 | 4.88] | 0.86*** | [0.50 | 1.22] | 2.14*** | [1.50 | 3.06] |
Household wealth quintile |
Poorest/Poorer | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Middle | 0.73 | [-0.80 | 2.26] | 0.45 | [-0.000034 | 0.90] | 1.67 | [0.93 | 3.01] |
Richer/Richest | 1.56** | [0.40 | 2.72] | 0.78*** | [0.44 | 1.12] | 5.03*** | [3.35 | 7.53] |
Current occupation |
Agricultural labor | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Casual labor | -0.71 | [-3.18 | 1.77] | 0.45 | [-0.29 | 1.19] | 1.86 | [0.76 | 4.53] |
Salaried worker | 3.16** | [1.02 | 5.30] | 0.79* | [0.17 | 1.42] | 8.51*** | [4.32 | 16.8] |
Self-employed in petty trade | 3.07*** | [1.28 | 4.85] | 0.53 | [-0.00080 | 1.05] | 2.10* | [1.07 | 4.12] |
Self-employed small-scale industry | 1.18 | [-2.17 | 4.53] | 0.28 | [-0.72 | 1.28] | 3.55* | [1.29 | 9.75] |
Unemployed/homemaker | 0.58 | [-0.94 | 2.10] | 0.19 | [-0.26 | 0.64] | 1.7 | [0.93 | 3.13] |
Other | 1.31 | [-3.92 | 6.54] | -0.017 | [-1.72 | 1.69] | 3.34 | [0.82 | 13.6] |
Partner’s education |
No school/Primary | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Post-primary/vocational/Secondary | 1.1 | [-0.26 | 2.46] | 0.3 | [-0.093 | 0.70] | 1.74* | [1.05 | 2.89] |
College or above | 2.22** | [0.64 | 3.81] | 1.25*** | [0.79 | 1.72] | 7.59*** | [4.67 | 12.3] |
No Partner | -1.54* | [-2.96 | -0.12] | 0.44* | [0.025 | 0.85] | 2.36*** | [1.43 | 3.89] |
Partner’s occupation |
Agricultural labor | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Casual labor | -1.68 | [-3.36 | 0.0057] | 0.15 | [-0.36 | 0.65] | 1.32 | [0.68 | 2.53] |
Salaried worker | 1.29 | [-0.45 | 3.03] | 0.91*** | [0.38 | 1.43] | 4.77*** | [2.68 | 8.51] |
Self-employed in petty trade | 1.69 | [-0.11 | 3.49] | 0.51 | [-0.029 | 1.04] | 1.01 | [0.48 | 2.12] |
Self-employed small-scale industry | -0.74 | [-2.90 | 1.41] | 0.6 | [-0.041 | 1.24] | 2.19* | [1.05 | 4.54] |
Unemployed/homemaker | -0.62 | [-4.21 | 2.98] | 0.17 | [-0.91 | 1.25] | 7.29*** | [2.85 | 18.6] |
Other | -4.75 | [-12.8 | 3.31] | 0.45 | [-1.92 | 2.83] | 1 | [1 | 1] |
No Partner | -2.23** | [-3.86 | -0.60] | 0.48* | [0.0028 | 0.97] | 2.19** | [1.22 | 3.94] |
Self or family work in health facility | 2.95** | [0.74 | 5.17] | 0.72* | [0.073 | 1.36] | 1.97* | [1.10 | 3.51] |
Has health insurance | 3.08*** | [1.66 | 4.50] | 0.86*** | [0.44 | 1.29] | 3.45*** | [2.36 | 5.05] |
High participation in household decisions | 1.30* | [0.25 | 2.35] | -0.011 | [-0.32 | 0.30] | 2.68*** | [1.88 | 3.81] |
Intolerant towards domestic violence | 1.59** | [0.54 | 2.64] | 0.86*** | [0.55 | 1.17] | 2.89*** | [2.00 | 4.18] |
Experienced domestic violence | -2.48*** | [-3.53 | -1.44] | -1.12*** | [-1.42 | -0.82] | 0.55*** | [0.39 | 0.77] |
Had any pregnancy complications | 0.84 | [-0.22 | 1.90] | -0.40* | [-0.71 | -0.092] | 0.65* | [0.46 | 0.92] |
Had severe pregnancy complications | 1.45* | [0.31 | 2.59] | -0.27 | [-0.61 | 0.061] | 0.73 | [0.50 | 1.06] |
Had complications in prior pregnancy | -0.53 | [-2.08 | 1.03] | -0.51* | [-0.98 | -0.047] | 0.93 | [0.56 | 1.52] |
Received ANC in prior pregnancy | -0.011 | [-1.13 | 1.11] | -0.51** | [-0.84 | -0.19] | 0.9 | [0.64 | 1.28] |
Prior facility delivery | 0.63 | [-0.45 | 1.71] | -0.25 | [-0.57 | 0.073] | 1.04 | [0.74 | 1.47] |
Reason for first ANC |
Because of a problem | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Just for a checkup | 1.69* | [0.033 | 3.34] | 0.077 | [-0.43 | 0.59] | 0.77 | [0.47 | 1.27] |
Can’t Remember | -4.45 | [-10.0 | 1.13] | 0.25 | [-1.48 | 1.99] | 0.51 | [0.061 | 4.31] |
Timing of first antenatal visit |
First trimester | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Second trimester | -0.48 | [-1.66 | 0.70] | -0.032 | [-0.38 | 0.31] | 0.87 | [0.60 | 1.25] |
Third Trimester | -3.31** | [-5.31 | -1.31] | -1.36*** | [-1.94 | -0.78] | 0.64 | [0.33 | 1.26] |
Number of antenatal visits |
Less than 4 | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
4 or 5 | 1.50** | [0.37 | 2.64] | 0.70*** | [0.36 | 1.03] | 1.57* | [1.07 | 2.29] |
6 plus | 2.34* | [0.53 | 4.15] | 1.24*** | [0.72 | 1.77] | 1.75 | [1.00 | 3.06] |
Highest ANC facility |
Gov’t Hospital | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Gov’t HC/Dispensary | 0.68 | [-0.46 | 1.81] | -0.52** | [-0.86 | -0.19] | 0.28*** | [0.19 | 0.41] |
Mission/Private facility | 3.48*** | [1.60 | 5.36] | 0.5 | [-0.045 | 1.05] | 1.62* | [1.01 | 2.59] |
Highest ANC Provider type |
Nurse/Midwife | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Doctor/Clinical officer | 1.37 | [-0.27 | 3.02] | -0.16 | [-0.66 | 0.34] | 0.69 | [0.38 | 1.24] |
Non-skilled attendant | 2.75 | [-2.66 | 8.15] | -0.051 | [-1.48 | 1.38] | 1.11 | [0.24 | 5.17] |
In the community/a home | -2.19*** | [-3.25 | -1.13] | -0.58*** | [-0.90 | -0.26] | 0.92 | [0.65 | 1.28] |
Postpartum length > =1 week | -2.97** | [-4.92 | -1.03] | -0.88** | [-1.45 | -0.31] | 1.12 | [0.59 | 2.12] |
Women who were more empowered, from high SES households, had someone in their household working in a health facility, and had health insurance, had on average, higher experience of care scores compared to less empowered women, women from lower SES households, women who had no one in their household working in a health facility, and women who had no health insurance, respectively. The significance and direction of the associations between service provision and the empowerment and SES measures are similar. College educated and women from the wealthiest households have over five times higher odds of receiving an ultrasound than women with less than primary education and those from the poorest households.
Additionally, compared to women who had never experienced domestic violence, women who had experienced domestic violence had lower experience and service provision scores and had lower odds of getting an ultrasound. Also, women who had a severe pregnancy complication and first presented for ANC because of a problem had lower experience scores than those who had no severe pregnancy complication and first presented for ANC for checkup. Women who had any complication, however, had lower service provision scores, with lower odds of receiving an ultrasound.
Women who started ANC in the first trimester, received ANC four or more times, and solely from private facilities have higher experience scores than those who started ANC after the first trimester, received ANC less than four times, and from government facilities, respectively. Similarly, women who started ANC in the first trimester and who received ANC four or more times had higher service provision scores. Service provision scores, however, did not differ between government hospitals and private facilities, but were lower for health centers. Additionally, compared to women who received ANC services in hospitals, women who received ANC in health centers had lower odds of receiving an ultrasound, while those who received ANC solely in a private facility had higher odds of receiving an ultrasound.
Multivariate
The multivariate models presented in Table
5 shows that, after controlling for other factors the following associations had
p-values less than 0.05. On average, women in the 20 to 29 age group still have higher experience scores and those older than 30 years have higher service provision scores than those younger than 20 years. Both age groups are also over two times more likely to have done an ultrasound test than the younger women. Women with four or more children have lower service provision scores than the primiparous women. Net of other factors, Kuria women still had higher experience scores and slightly higher service provision scores, but had lower odds of receiving an ultrasound than Luo women.
Table 5
Multivariate regressions of antenatal care quality measures on various predictors, PQCC 2016/2017
Age |
15 to 19 years | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
20 to 29 years | 1.72* | [0.088 | 3.35] | 0.47 | [-0.0069 | 0.96] | 2.17* | [1.06 | 4.45] |
30 to 48 years | 1.78 | [-0.35 | 3.91] | 0.67* | [0.034 | 1.30] | 2.92* | [1.21 | 7.04] |
Currently married | 2.94 | [-4.57 | 10.5] | 1.39 | [-0.81 | 3.59] | 0.55 | [0.043 | 6.91] |
Number of births |
1 | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
2 | -0.84 | [-2.45 | 0.77] | -0.015 | [-0.49 | 0.46] | 1.26 | [0.72 | 2.22] |
3 | -0.67 | [-2.41 | 1.08] | -0.36 | [-0.88 | 0.16] | 0.52 | [0.26 | 1.03] |
4 or more | -0.88 | [-2.74 | 0.99] | -0.71* | [-1.26 | -0.16] | 0.86 | [0.43 | 1.72] |
Tribe |
Luo | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Kuria | 4.97*** | [3.70 | 6.25] | 0.89*** | [0.52 | 1.27] | 0.37** | [0.20 | 0.69] |
Other | 1.57 | [-0.16 | 3.31] | -0.068 | [-0.59 | 0.45] | 1.3 | [0.70 | 2.41] |
Literate | 1.52* | [0.26 | 2.79] | 0.22 | [-0.16 | 0.60] | 1.35 | [0.76 | 2.38] |
Employed | 2.73*** | [1.46 | 4.00] | 0.56** | [0.19 | 0.93] | 1.01 | [0.64 | 1.59] |
Participation in household decisions | 1.24* | [0.14 | 2.34] | -0.16 | [-0.49 | 0.17] | 1.77* | [1.14 | 2.75] |
Household wealth |
Poorest/poorer | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Middle | 0.99 | [-0.49 | 2.47] | 0.27 | [-0.17 | 0.71] | 1.03 | [0.53 | 2.02] |
Richer/richest | 0.7 | [-0.64 | 2.04] | 0.13 | [-0.27 | 0.53] | 2.00** | [1.20 | 3.33] |
Partner’s education |
No school/Primary | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Post-primary/vocational/Secondary | 0.16 | [-1.21 | 1.52] | -0.062 | [-0.47 | 0.35] | 0.92 | [0.52 | 1.64] |
College or above | -0.46 | [-2.27 | 1.36] | 0.39 | [-0.15 | 0.93] | 2.40** | [1.29 | 4.46] |
No Partner | 1.42 | [-6.20 | 9.03] | 1.53 | [-0.71 | 3.76] | 0.94 | [0.072 | 12.4] |
Experienced domestic violence | -2.42*** | [-3.51 | -1.33] | -0.83*** | [-1.15 | -0.51] | 0.91 | [0.60 | 1.36] |
Had severe complications | 0.91 | [-0.19 | 2.02] | -0.24 | [-0.56 | 0.088] | 1.19 | [0.77 | 1.85] |
Timing of first antenatal visit |
First trimester | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Second trimester | -0.17 | [-1.32 | 0.98] | 0.16 | [-0.19 | 0.50] | 1.18 | [0.76 | 1.81] |
Third Trimester | -2.21* | [-4.28 | -0.15] | -0.75* | [-1.36 | -0.13] | 0.82 | [0.35 | 1.93] |
Four plus antenatal visits | 0.34 | [-0.81 | 1.49] | 0.38* | [0.033 | 0.72] | 1.1 | [0.70 | 1.74] |
Highest ANC facility |
Gov’t Hospital | 0 | [0 | 0] | 0 | [0 | 0] | 1 | [1 | 1] |
Gov’t HC/Dispensary | 1.99*** | [0.84 | 3.14] | -0.085 | [-0.43 | 0.25] | 0.33*** | [0.21 | 0.52] |
Mission/Private facility | 3.28*** | [1.48 | 5.09] | 0.48 | [-0.050 | 1.01] | 1.31 | [0.76 | 2.24] |
Interviews in the community | -2.41*** | [-3.44 | -1.38] | -0.55*** | [-0.86 | -0.24] | 1.08 | [0.73 | 1.61] |
Constant | 20.9*** | [13.1 | 28.6] | 9.38*** | [7.11 | 11.7] | 0.08 | [0.0056 | 1.16] |
N | 909 | | | 882 | | | 993 | | |
R-squared | 0.179 | | | 0.172 | | | | | |
After controlling for other factors, women who are literate, employed, and participate in household decisions also still have higher experiences scores, but only employment is significant for higher service provision, and those with higher participation in household decision making are more likely to get an ultrasound. Household wealth and partner’s education are significantly associated with getting an ultrasound, with women from the wealthiest households and those with college educated husbands having about two times higher odds of receiving an ultrasound than women from the poorest households and whose husbands have less than primary education. Controlling for other factors, women who had experienced domestic violence still had lower experience and service provision scores than women who had never experienced domestic violence.
Women who started ANC in the third trimester had lower experience and service provision scores, and those who received ANC four or more times received slightly higher service provision scores. Timing and frequency of ANC is not significantly associated with odds of getting an ultrasound. Additionally, compared to women who received ANC in hospitals, women who received ANC in health centers had higher experience scores but lower odds of receiving an ultrasound, while those who received ANC solely in a private facility had higher experience scores, but no difference in service provision scores or the odds of getting an ultrasound. The effect of location of the interview persists after controlling for other factors.
Discussion
This is one of the few studies to examine both service provision and experience dimensions of quality of ANC in a low resource setting, and to our knowledge, the first to do this at sub-national level in Kenya. We find that ANC quality is suboptimal in terms of providing recommended ANC services as well as ensuring women have a good experience. While many women receive basic ANC services such as blood pressure monitoring and urine test at least once during pregnancy, many are not receiving these consistently at every visit as recommended by the Kenya National guidelines [
13]. The situation is even more dire for more advanced services such as ultrasounds, which less than one out of every five women in our sample received, with women who had complications (the group for whom it is recommended) less likely to receive it.
Although there is increased attention to mistreatment and poor person-centered care in facilities globally, most of this work has focused on intrapartum care. In this paper we also draw attention to poor PCANC, which can affect women’s adherence to treatment recommendations and deter them from returning to a facility to give birth [
37‐
39]. The major gap in PCANC, which has been shown in other work for maternity care, is in the domain of communication [
40]: women are not given sufficient information during ANC about their care, hence do not understand the purpose of examinations and medicines, but are not able to ask clarifying questions. Most women felt respected by their health care providers, which is encouraging. However, that 1 in 10 women did not feel respected means there is room for improvement, given the internalization and normalization of disrespect which usually results in low reporting when compared to observations [
41‐
43]. We did not include survey questions on extreme forms of poor person-centered care such as verbal and physical abuse. But prior qualitative work in this setting suggests that verbal and physical abuse sometimes occurs during ANC [
44].
As in many areas of health care, the most disadvantaged and disempowered women receive the lowest quality ANC relating to both service provision and experience of care. The potential reasons why more empowered and wealthier women are more likely to receive high quality ANC and person-centered care is described in detail elsewhere [
20,
25,
40]. These reasons include being able to access care in facilities that offer higher quality care, being able to pay for higher quality care, and having the knowledge and ability to advocate for higher quality care. Studies in Kenya have shown that quality of care is poorer in low resource communities where poor women tend to live [
22]. In this paper, we also find that the SES and empowerment differences are more marked for the experience of care dimensions than for the provision of ANC services. This is potentially because the services included in the service provision index are basic services that are offered free of charge to most clients, thus requiring less knowledge or ability to advocate for them.
The exception is in getting an ultrasound where SES measured by household wealth and partner’s education is a significant predictor. This finding is not surprising given the limited availability of ultrasounds in many government facilities in this setting. At the time of this survey, even the referral hospital had no functional ultrasound. Ultrasounds are also not covered by the National Health Insurance funds. This required that women who needed ultrasounds obtain it at private facilities where they had to pay before getting the services. Ultrasound costs in private facilities in Kenya vary widely (between 600 and 4000 Kenyan shillings (about 6 to 40 dollars) because of lack of regulation [
45]. Furthermore, women with complications for whom ultrasound is recommended were less likely to receive an ultrasound than those with no complications. Therefore, those who need it the most may not be getting it because of cost due to systemic weaknesses. The higher odds of receiving an ultrasound among women who received some ANC in a hospital is likely because women receiving ANC in a hospital may have been referred there because of a complication, prompting providers there to request an ultrasound test. Ethnic differences between Luo and Kuria women in ANC quality might be due to biases against or in favor of certain ethnicities resulting in them receiving less services and being treated differently. We believe implicit bias plays an important role in quality of care differentials in this setting not just by ethnicity, but also based on SES and age, and thus account for some of those disparities too. Policies and interventions to improve quality of care therefore need consider how to address factors that contribute to these disparities.
The findings also suggest that certain high-risk women may not be getting key recommended services. For example, younger women (15 to 19 years) are less likely to get an ultrasound, in addition to being less likely have good PCANC. Given that this age group have high risk of complications, poor quality care may be playing a big role in their outcomes as complications may not be identified early or at all. In addition, perceptions of poor person-centered care may deter them from starting ANC early and attending frequently, further delaying identification of complications, and they may be less likely to deliver in a health facility where complications can be managed. Poor ANC quality in this group thus has detrimental consequences. Another high-risk group that was less likely to consistently receive the basic antenatal service was women with 4 or more children. This might be due to less attention to these women because of their prior childbirth experience, which could lead to adverse consequences for them if they receive less screening and preventative services. Other factors that account for differences in ANC quality are the timing and frequency of ANC. Both timing and frequency of ANC are important for the number of services one receives, but not for whether or not a woman gets an ultrasound. However, only timing is associated with experience of care, with women who received ANC in the third trimester reporting poorer experiences. This might be due to insufficient time for counselling and mistreatment from providers when women present for ANC late in the pregnancy, which we found in our qualitative work [
44].
In addition, the types of facility where one receives care affects the quality of care they receive based on different dimensions. In general, there was no difference in service provision scores by facility. However, women who received ANC at least once from a government hospital had lower experience scores, but had higher odds of getting an ultrasound. On the other hand, those who received care in a health center, had higher experience scores, but had lower odds of getting an ultrasound. Women who received care in only a private facility also had higher experience scores, but had similar odds of getting an ultrasound as those who were seen in the government hospital. The finding of higher experience scores in health centers and private facilities is consistent with prior studies on women’s experiences for antenatal and delivery care and for family planning services [
20,
40,
46,
47]. However, it raises the question of where the ‘best’ care for women might be during ANC [
25]. Most women, particularly poor women, do not have the option of receiving care in private facilities. While they may receive more advanced essential services in the higher-level facilities, which have more staffing and clinical infrastructure, they also stand the risk of being mistreated in these facilities. Women should not have to choose between receipt of essential services and good person-centered care. Thus, there is a need for targeted PCANC interventions in higher-level facilities, as well as equipping the lower level facilities to be able to provide the essential antenatal services.
Various reasons, ranging from structural factors to provider attitudes, account for the suboptimal ANC quality. Providers will be unable to take weight and blood pressure measurements or to do blood and urine tests if they do not have working scales and blood pressure monitors or functional laboratories, reagents and supplies needed for these tests. Similarly, they will be unable to give medications they do not have in stock. Thus, availability of necessary equipment, supplies, and medicines are key to providing good quality ANC. These reasons are much more relevant for service provision than experience of care, although the frustration and stress of providing care without all the necessary tools could also manifest in providers’ interactions with women. Lack of provider knowledge of service provision guidelines and their knowledge and willingness to provide person-centered care is also a potential reason for poor quality. It is notable in the distribution of the individual measures shown in Table
2 that women were far more likely to be given various services than to be given information and listened to. One reason is that in ANC clinics where one provider may be trying to attend to several women, it is faster to do tests and dispense medication than spending time explaining to women and answering their questions. Thus, poor communication may be because of time constraints or workflow. The implication of this is that women might not be adhering to treatments and recommendations for further tests because they do not understand why these are necessary. Providers therefore need to be able to prioritize effective communication even in busy health facilities.
Limitations
This study has potential limitations. Firstly, the measures of ANC quality are based on self-report. Recall bias is thus a potential limitation as women may not accurately remember whether or not they received a service. Second, although we assessed the appropriateness of combining the various items to generate the service provision and experience of care scores, the items are not from validated scales. Thus, there is a need for a more systematic process to developing validated scales for ANC service provision and experience of care. Additionally, in creating the summative scores, we coded ‘don’t know’/ ‘don’t remember’ responses as missing. But it is likely that women who said they can’t remember did not receive it, and if they don’t know, they likely weren’t told about it. Thus, we may have excluded women who received the poorest quality ANC, thus overestimating the actual levels of ANC quality. Social desirability bias is also potentially a limitation if women responded in a way that will please providers. This is likely a problem among women who were interviewed in a health facility and closer to the time of birth, as shown by the higher service provision and experience scores for women who were interviewed in a health facility and within a week of birth compared to women who were interviewed at home and after a week of birth. These are consistent with other findings on women’s experiences during childbirth [
25,
26,
48]. Furthermore, we used proxy measures of empowerment, which may only partially address cognitive and psychological empowerment, and we are unable to account for structural factors that affect quality of care. Finally, the results are not generalizable to all of Kenya, as data was collected in a specific county using a multistage approach which included convenience samples within randomly selected health units.
Despite these limitations, this study makes valuable contributions to existing research on ANC quality in Kenya and other low-resource settings. It is among the few studies to examine both service provision and experience dimensions of quality of ANC in a low resource setting, thus extending the evidence base for calls to improve quality of ANC and person-centered care. Measuring the different dimensions of quality of care with several items enabled us to identify key areas that need to be addressed to improve quality of care. In addition, the use of composite measures enabled us to include multiple aspects of care provision and experience to assess quality of ANC on a continuum. Moreover, the inclusion of women who received care from different types of facilities enabled us to highlight issues that need to be considered at the different levels and types of facilities.
Conclusions
This study adds to growing evidence on poor quality of maternal health care. We find that quality of ANC is suboptimal in both domains of service provision and experience of care, with disparities by demographic and socioeconomic factors as well as facility type. Much work is thus needed to improve both dimensions of quality of ANC at different levels of health facilities. In addition, disparities in quality of ANC based on demographic and social status need to be addressed in order to achieve the “no woman left behind” sustainable development goal. While it is still important to get women to health facilities, much more is needed to achieve the benefits of ANC, by ensuring that women consistently receive services required to prevent, identify, and manage complications. Furthermore, momentum for improving person-centered maternity care through the respectful maternity care movement should spread to ANC to ensure women are receiving person-centered care along the pregnancy childbirth continuum. As countries such as Kenya update their national guidelines for maternity care to align with new WHO standards, they must consider how to strengthen providers to provide person-centered care to all women in all types of facilities. Further research on the barriers and facilitators to providing high quality ANC will help guide further recommendations to improve quality of ANC and reduce disparities.
Acknowledgments
We are grateful to the PTBI fellowship leaders and the PTBI-East Africa and PTBI-Kenya teams for supporting the study. We thank the leadership of Migori County and the various sub-counties and health facilities, and the community health extension workers and community health volunteers, who facilitated our entry into the County, facilities, and communities. We will like to acknowledge Linet Ouma and Beryl Akinyi Ogola, the PQCC study coordinator and research assistant who coordinated the data collection. Finally, we like to express our gratitude to all our data collectors and study participants in Kenya.
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