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

Abstract

Introduction: African countries facing conflict have higher levels of maternal mortality. Understanding the gaps in the utilization of high-quality maternal health care is essential to improving maternal survival in these states. Few studies have estimated the impact of conflict on the quality of health care. In this study, we estimated the impact of conflict on the quality of health care in Kenya, a country with multiple overlapping conflicts and significant disparities in maternal survival.Materials and Methods: We drew on data on the observed quality of 553 antenatal care (ANC) visits between January and April 2010. Process quality was measured as the percentage of elements of client–provider interactions performed in these visits. For structural quality, we measured the percentage of required components of equipment and infrastructure and the management and supervision in the facility on the day of the visit. We spatially linked the analytical sample to conflict events from January to April 2010. We modeled the quality of ANC as a function of exposure to conflict using spatial difference-in-difference models.Results: ANC visits that occurred in facilities within 10,000 m of any conflict event in a high-conflict month received 18–21 percentage points fewer components of process quality on average and had a mean management and supervision score that was 12.8–13.5 percentage points higher. There was no significant difference in the mean equipment and infrastructure score at the 5% level. The positive impact of conflict exposure on the quality of management and supervision was driven by rural facilities. The quality of management and supervision and equipment and infrastructure did not modify the impact of conflict on process quality.Discussion: Our study demonstrates the importance of designing maternal health policy based on the context-specific evidence on the mechanisms through which conflict affects health care. In Kenya, deterioration of equipment and infrastructure does not appear to be the main mechanism through which conflict has affected ANC quality. Further research should focus on better understanding the determinants of the gaps in process quality in conflict-affected settings, including provider motivation, competence, and incentives.

Multilevel analysis of quality of antenatal care and associated factors among pregnant women in Ethiopia: a community based cross-sectional study

“…That may be because of inequalities in access to ANC services and the views of populations about the importance of ANC 25. Moreover, in some of the East African countries, there is ongoing conflict and persistent political instability that played an important role in hindering the quality of the ANC; the scholars revealed that lack of safety played a major role in reducing the ANC, especially in remote areas 26 27…”

Armed Violent Conflict and Healthcare-Seeking Behavior for Maternal and Child Health in Sub-Saharan Africa: A Systematic Review

“…Of the twenty-one included studies, seventeen (81.0%) reported healthcareseeking behaviors for maternal health services in settings of armed violent conflict. The reported healthcare-seeking behaviors were antenatal care attendance, skilled birth attendance, postnatal care services, family planning uptake/contraceptive prevalence rate, health facility birth, caesarean section rates, unmet need for family planning, and HIV/AIDs care and treatment [19,20,39,41,45,47,[50][51][52][53][54][55][56][57][58][59][60]. Nine studies (42.9%) reported healthcare-seeking behaviors for child health.…”

“…Healthcare services and their quality were negatively affected by factors such as insufficient financing, shortage of healthcare personnel, and destruction of infrastructure [20,58]. Poor quality of healthcare services as well as past unpleasant experiences in health facilities, contributed to a lower demand for maternal healthcare usage [45,50,51]. Male partner's attitudes or their negative perceptions of healthcare services emerged as significant barriers to positive health-seeking behavior [45,55,57,60].…”

A woman's lifetime risk disparities in maternal mortality in Ethiopia

“…As similar studies indicated that without further efforts in the rural and poorest areas, where the majority of maternal mortality is reported, Ethiopia's effort to achieve the 2030 SDGs could be hindered [20]. In addition, as evidenced by other studies in Kenya, threatening factors, like the current COVID‐19 pandemic [40], and some unrest and conflicts in some parts of the country could worsen and disrupt the appropriate delivery of maternal health‐care services and sustain a woman's LTR disparities in maternal mortality [41].…”