TABLE OF CONTENTS
DECLARATION…………………………………………………….. Error! Bookmark not defined.
DEDICATION……………………………………………………………………………………………. ii
ACKNOWLEDGEMENT………………………………………………………………………….. iv
TABLE OF CONTENTS…………………………………………………………………………….. v
LIST OF TABLES……………………………………………………………………………………… ix
LIST OF FIGURES…………………………………………………………………………………….. x
DEFINITION OF OPERATIONAL TERMS……………………………………………… xi
LIST OF ABBREVIATIONS AND ACCRONYMS……………………………………. xii
ABSTRACT………………………………………………………………………………………………. xiv
CHAPTER 1: INTRODUCTION………………………………………………………………… 1
- Background of the Study…………………………………………………………………….. 1
1.9 Significance of the Study……………………………………………………………………. 11
CHAPTER 2: LITERATURE REVIEW……………………………………………………. 13
- Introduction……………………………………………………………………………………… 13
CHAPTER 3: MATERIALS AND METHODS………………………………………. 30
- Introduction……………………………………………………………………………………… 30
3.5.2 Sampling Techniques……………………………………………………………………… 33
3.5.2 Sample size determination………………………………………………………………. 34
- Data Collection Tools…………………………………………………………………………. 35
3.10.1. Qualitative data analysis……………………………………………………………. 40
CHAPTER 4: RESULTS……………………………………………………………………………. 42
- Introduction……………………………………………………………………………………… 42
4.5.3 Availability of maternity services, transport cost and duration of operation…. 65
- Socio-Cultural Factors Defining the Utilization of Skilled Delivery Services 65 4.6.1 Knowledge, attitude and believes……………………………………………………………. 65
CHAPTER 5: DISCUSSIONS, CONCLUSION AND RECOMENDATIONS. 79
REFERENCES………………………………………………………………………………………….. 91
APPENDICES…………………………………………………………………………………………… 98
Appendix I: Household Questionnaire…………………………………………………….. 98
Appendix II: FGD Questions Guide: Traditional Birth Attendants……………. 107
Appendix III: FGD Questions Guide: CHVS and Male Partners………………. 109
Appendix IV: KII Question Guide -Health Service Provider………………….. 112
Appendix V: Study Area Map…………………………………………………………….. 113
Appendix VI. Research Clearance- Suna-Migori County……………………….. 114
Appendix VII: Research Authorization-NACOSTI………………………………… 115
Appendix VIII: Ethical Approval – Kenyatta University………………………. 116
LIST OF TABLES
Table 3.1: Proportion to size per administrative unit………………………………………………. 34
Table 3.2: Cronbach test of reliability………………………………………………………………….. 38
Table 4.1: Demographic characteristics of the respondents…………………………………….. 43
Table 4.2: Relationship between Age of respondents and type of delivery……………….. 46
Table 4.3: Influence of parity on type of delivery…………………………………………………. 47
Table 4.4: Influence of Parity on ANC attendance……………………………………………….. 48
Table 4.5: Influence of marital status on type of delivery………………………………………. 48
Table 4.6: Influence of education level on type of delivery…………………………………….. 50
Table 4.7: Influence of occupation of respondents on type of delivery……………………. 52
Table 4.8: Influence of occupation of respondent’s spouse on type of delivery…………. 54
Table 4.9: Influence of average monthly income on type of delivery……………………….. 55
Table 4.10: Mann–Whitney test results on distance from facility and place of delivery62 Table 4.11: Effects of distance covered on ANC attendance………………………………………………….. 64
Table 4.12: Cost to facility and number of HCWs at the facility…………………………….. 65
Table 4.13: Attitudes and beliefs………………………………………………………………………… 66
Table 4.14: Reasons for delivering at home………………………………………………………….. 71
Table 4.15: Relationship between ANC attendance and type of delivery during last pregnancy……………………………………………………………………………………………………… 75
Table 4.16: Risk estimated in ANC attendance and Home delivery………………………… 77
LIST OF FIGURES
Figure 1.0: Conceptual Framework………………………………………………………………….. 11
Figure 3.1: Map of the study area; source: google…………………………………………………. 32
Figure 4.1: Religion of the respondents……………………………………………………………….. 45
Figure 4.2: Number of full-time pregnancies of the respondent………………………………. 45
Figure 4.3: Occupational engagements of respondents………………………………………….. 52
Figure 4.4: Occupation of respondents’ spouses……………………………………………………. 53
Figure 4.5: Main source of livelihood of respondents’ household……………………………. 55
Figure 4.6: Maternity service availability……………………………………………………………… 59
Figure 4.7: Duration of operation of health facility……………………………………………….. 59
Figure 4.8: Percentage accessing skilled delivery by distance to health facility…………. 61
Figure 4.9: Proportion attending ANC services by distance to health facility…………… 63
Figure 4.10: Decision making on ANC attendance……………………………………………….. 69
Figure 4.11: Decision making on delivery type…………………………………………………….. 69
Figure 4.12: Reasons for delivering at a health facility………………………………………….. 70
Figure 4.13: Preferred place of delivery for next pregnancy…………………………………… 72
Figure 4.14: Reasons to prefer health facility……………………………………………………….. 72
Figure 4.15: Preferred delivery assistance during the next delivery…………………………. 73
Figure 4.16: Attendance of ANC during last pregnancy………………………………………… 74
Figure 4.17: Attendance of ANC for all pregnancies…………………………………………….. 76
Figure 4.18: Reasons for attending ANC…………………………………………………………….. 78
DEFINITION OF OPERATIONAL TERMS
Skilled delivery: Refers to delivery assisted by a trained health care worker -Doctor, Nurse or, Registered Clinical officer; with training in midwifery and proficiency in the skills necessary to manage normal deliveries and diagnose, manage or, refer obstetric complications (WHO).
Facility delivery: Refers to child birth conducted within a health facility environment and assisted by a trained health care worker- Doctor, Nurse or, Registered Clinical officer; with training in midwifery and proficiency in the skills necessary to manage normal deliveries and diagnose, manage or, refer obstetric complications (WHO).
Home Based delivery: A delivery that has occurred in a place not accredited as a health facility and does not have a trained mid wife to assist in delivery.
Maternal health: refers to health of a woman during pregnancy, delivery, childbirth and postpartum period.
Lactating Mother: Refers to a mother who has had a delivery within the past 24 months.
Obstetric complications: refers to the disruptions and disorders of pregnancy, labour and delivery, and the early neonatal period.
Still Birth: Defined as fetal death at or after 20 to 28 weeks of pregnancy. It results in a baby born without signs of life
Free maternal Delivery: Refer to the Government’s program, initiated in 2013 where the governments pays specific health facilities the cost of delivery for pregnant women at a fixed rate.
Gravida: Defined as the total number of confirmed pregnancies that a woman has had, regardless of the outcome.
Parity: Defined as the number of times a female is or has been pregnant and carried the pregnancies to a viable gestational age; usually of 20 weeks or more.
LIST OF ABBREVIATIONS AND ACCRONYMS
AIDS – Acquired Immune Deficiency Syndrome
AM – After Midnight
ANC – Antenatal Care
CHMT – County Health Medical Team
CHEW – Community Health Extension Worker
CHW – Community Health Worker
CHV – Community Health Volunteer
DF – Degree of Freedom
DHIS – Demographic Health Information System
FGD – Focus Group Discussion
HBM – Health Belief Model
HCW – Health Care Worker
HH – Household
HIV – Human Immune Virus
ICPD – International conference on population and development
KDHIS – Kenya Demographic Health Information System
KDHS – Kenya Demographic Health Survey
KII – Key Informant Interview
KM – Kilometer
KNCHR – Kenya National Commission of Human Rights
KNBS – Kenya National Bureau of Statistics
MAX – Maximum
MCH – Maternal and Child Health
MDG – Millennium Development Goals
MICS – Multiple Indicator Cluster Survey
MIN – Minimum
MNCH – Maternal, Neonatal and Child Health
MoH – Ministry of Health
MPH – Master of Public Health
M&E – Monitoring and Evaluation
PM – Past Morning
PPH – Post Partum Hemorrhage
RCO – Registered Clinical Officer
SBA – Skilled Birth Attendant
SDA – Seventh Day Adventist
SDG – Special Development Goals
SPSS – Statistical Package for Social Sciences
TBA – Traditional Birth Attendant
UNFPA – United nations Family Planning Association
UNICEF – United Nations Children’s Fund
UN – United Nations
USA – United States of America
WHO – World Health Organization
YOB – Year of Birth
ABSTRACT
Skilled delivery is a key intervention that greatly contributes to improvement of maternal and child health. By extension, skilled delivery is a component of maternal and childcare provided during pregnancy, at delivery and post-delivery. Irrespective of the quality of service provided during pregnancy, delivery process remains a risk and hence needs to be given relevant attention. Global data shows that in developed countries, over 99% of the women access skilled delivery as compared to low accessibility of below 50% in developing countries and 61.8% in Kenya. This study sought to investigate the factors that determine utilization of skilled delivery services among women of reproductive age in Suna-West Sub-County, Migori County, Kenya. The objective of the study was to establish the factors influencing utilization of skilled delivery services among women of reproductive health in Suna West Sub County. Mixed design model was used to assess the views of the study population. Quantitative data was collected through household questionnaires targeting women of reproductive age. Qualitative data, on the other hand, was collected through focus group discussions and key informant interviews among health service providers, traditional birth attendants and male partners. Independent variables, of the study, were; demographic, economic, socio-cultural, and physical factors; whereas, the dependent variable utilization of skilled delivery services. The analysis was done using the Statistical Package for Social Sciences (SPSS version 24) software and Ms. Excel (office 2010). Chi Square was used to test the relationships between variables. The findings showed that Suna West Sub-County has a higher rate of skilled delivery (74.6%) as compared to national average 61%. Key factors identified to determine utilization of skilled delivery services were parity, p<0.005, χ2=13; level of education, p<0.005, χ2=27.616 and ANC attendance p<0.00 χ2=30.706; though not statistically significant, distance to health facility, time of operation of the maternity and availability of services were identified to have an influence on type of delivery. In addition, the study found high level of maternal knowledge on risks of pregnancy and negative beliefs on utilization of skilled delivery services. On the other hand, level of household income or partner’s occupation had no significant relationship. The study recommends establishment of policies by the County government to enhance risk assessment and risk-based health education during pregnancy, both at the community and at the antenatal clinics. In addition, there is a need to invest in infrastructure and human resource to ensure the women are able to get the services at any time they visit the health facility.
CHAPTER 1: INTRODUCTION
Background of the Study
More than a decade ago, the global community adopted the UN millennium declaration that listed 8 critical goals for combating poverty and accelerating human development (UN, 2000). These 8 declarations were christened Millennium Development Goals (MDGs) among which, the 4th, 5th and 6th goals target reduction of child mortality, reduction of maternal mortality, combating malaria, HIV/AIDS and other diseases – respectively. Indeed, the three goals specifically target human health whereby two of the goals directly focused on reducing child mortality and improving maternal health. These point out to the importance of health factors in global development and poverty reduction (World Health Organization [WHO], 2003).
Skilled attendance at childbirth is crucial for decreasing maternal and neonatal mortality. Yet, many women in low and middle-income countries deliver outside of health facilities, without the help of skilled personnel (WHO, 2004). During childbirth, a woman needs a continuum of care to ensure the best possible health outcome for her and the newborn. To achieve this, care starts from the mother herself, the family (more specifically the spouse) and first level of health care at a health clinic or at home by a trained health personnel (WHO, 2004). World Health Organization recommends that successful provision of the continuum of care during pregnancy, requires a functional health care system with the necessary infrastructure in place. This includes; transport between the primary levels of health care, the referral clinics/hospitals with an effectively efficient and proactive
collaboration across all healthcare providers to pregnant women and newborns (WHO, 2004).
The WHO defines a skilled attendant as an accredited health professional such as a trained midwife, doctor, or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns. Skilled delivery is best chanced from the point of conception. This is because the earlier an expectant mother starts attending Antenatal Clinic (ANC) visits, the lower their risk of obstetric complications due to early detection and timely provision of medical assistance (Seljeskog, Soundby & Chimango, 2006). In other studies, it has been observed that high number of maternal deaths occur during the first day after delivery, emphasizing the need for a skilled birth attendant before, during and post-delivery (Abebe, Berhane & Girma, 2012).
Despite the overwhelming evidence from developed and developing countries on the value of skilled attendants in lowering maternal mortality ratio, this skilled workforce remains insufficient in many developing countries (WHO, 2015). Consequently, improvement of maternal and reproductive health has remained a major challenge in most low-income countries – especially Sub-Saharan Africa and Asia (WHO, 2015).Since the millennium declaration, there have been some improvements in the uptake of maternal health interventions such as Antenatal Care (ANC), Skilled Birth Attendance (SBA), and
facility-based delivery. However, it is hardly evident in any resource poor countries that bear the highest burden of maternal mortality.
These efforts have resulted in success among a few countries although progress in most countries, including Kenya, has been unacceptably slow. Experience from past projects and ongoing researches point to the importance of access to a functioning health care system as a key factor in reducing maternal mortality (WHO, 2004). During the International Conference on Population and Development (ICPD), a resolution was endorsed by many countries including Kenya and action plan was agreed that all countries must expand utilization of maternal health services. That all births should be assisted by skilled attendants, trained birth attendants (United Nation [UN], 1995).
In Kenya, maternal and infant mortality rate remained at disconcertingly high level; 488 deaths per 100,000 live births, and the lifetime risk of maternal death in 2009 was 1 in 39 women – making it one of the world’s highest (Kenya National Bureau of Statistics [KNBS] and ICF MACRO, 2010). Interestingly, most maternal deaths are caused by hemorrhage during childbirth, HIV/AIDS, malaria, unsafe abortions, and the low proportion of deliveries conducted by skilled birth attendants as well as poor staffing; among other causes (KNBS and ICF MACRO, 2010). The government of Kenya declared free maternal and child healthcare, in 2013, among other rhetorical commitments to women’s health. This has seen a reduction of the number of women dying due to pregnancy related complications from 488 to approximately 362 per 100,000 live births (KNBS and ICF MACRO, 2010; KNBS 2015). However, this
reduction was not statistically significant when compared to the preceding results of 2008/2009 survey.
