Determinants of subnational disparities in antenatal care utilisation: a spatial analysis of demographic and health survey data in Kenya

Abstract

Background: The spatial variation in antenatal care (ANC) utilisation is likely associated with disparities observed in maternal and neonatal deaths. Most maternal deaths are preventable through services offered during ANC; however, estimates of ANC coverage at lower decision-making units (sub-county) is mostly lacking. In this study, we aimed to estimate the coverage of at least four ANC (ANC4) visits at the sub-county level using the 2014 Kenya Demographic and Health Survey (KDHS 2014) and identify factors associated with ANC utilisation in Kenya. Methods: Data from the KDHS 2014 was used to compute sub-county estimates of ANC4 using small area estimation (SAE) techniques which relied on spatial relatedness to yield precise and reliable estimates at each of the 295 sub-counties. Hierarchical mixed-effect logistic regression was used to identify factors influencing ANC4 utilisation. Sub-county estimates of factors significantly associated with ANC utilisation were produced using SAE techniques and mapped to visualise disparities. Results: The coverage of ANC4 across sub-counties was heterogeneous, ranging from a low of 17% in Mandera West sub-county to over 77% in Nakuru Town West and Ruiru sub-counties. Thirty-one per cent of the 295 subcounties had coverage of less than 50%. Maternal education, household wealth, place of delivery, marital status, age at first marriage, and birth order were all associated with ANC utilisation. The areas with low ANC4 utilisation rates corresponded to areas of low socioeconomic status, fewer educated women and a small number of health facility deliveries. Conclusion: Suboptimal coverage of ANC4 and its heterogeneity at sub-county level calls for urgent, focused and localised approaches to improve access to antenatal care services. Policy formulation and resources allocation should rely on data-driven strategies to guide national and county governments achieve equity in access and utilisation of health interventions.

Magnitude of antenatal care service uptake and associated factors among pregnant women: analysis of the 2016 Ethiopia Demographic and Health Survey

“…37 The uptake of ANC services among married women was higher compared with women living alone. This finding is consistent with the studies conducted in Ethiopia, 15 Kenya, 32 Rwanda 38 and Bangladesh. 35 The higher ANC uptake could be attributed to the psychological and economic support obtained from their husbands, plannedness and desirability of their pregnancy, and the societal acceptability and support of their pregnancy state when compared with their unmarried women.…”

Joint spatio-temporal modelling of adverse pregnancy outcomes sharing common risk factors at sub-county level in Kenya, 2016–2019

“…Our results suggest that disparities in the spatial extents of APOs may have been driven by demand-side barriers and supply-side challenges, with low-resource counties disproportionately vulnerable to adverse outcomes. Recent studies highlight a heterogenous timing and coverage of ANC4 across sub-counties in Kenya, with poorer/rural sub-counties in northern Kenya exhibiting low coverage levels [ 50 , 51 ]. The current guidance from the WHO suggesting at least four comprehensive and targeted visits [ 16 , 52 ].…”

Disrupted Service Delivery? The Impact of Conflict on Antenatal Care Quality in Kenya

“…Our findings did not qualitatively vary in a statistically significant manner, at the 5 or 10% level, on limiting our analysis to violent or non-violent conflict events, varying the facility catchment area radius, or adjusting for confounders. The determinants of gaps in access to high-quality ANC and other maternal health services are multifaceted, including poverty, lower educational levels, and physical distance from health facilities (35)(36)(37). In this study, we have demonstrated that conflict is also an important determinant of the quality of ANC that women receive in this context.…”

“…The determinants of gaps in access to high-quality ANC and other maternal health services are multifaceted, including poverty, lower educational levels, and physical distance from health facilities ( 35 – 37 ). In this study, we have demonstrated that conflict is also an important determinant of the quality of ANC that women receive in this context.…”

“…The coverage of ANC and SBA has remained low and inequitable in Kenya, with higher disparities in coverage for ANC (33,34). However, studies examining the determinants of subnational disparities in maternal health care use in Kenya have not considered an independent role for conflict (35)(36)(37). There are also no published studies estimating the impact of conflict on the quality of health care in Kenya.…”