Examining socioeconomic status disparities in facility-based childbirth in Kenya: role of perceived need, accessibility, and quality of care

Abstract

Background Giving birth in health facilities with skilled birth attendants (SBAs) is one of the key efforts promoted to reduce preventable maternal deaths in sub-Saharan Africa. However, research has revealed large socioeconomic status (SES) disparities in facility-based childbirth. We seek to extend the literature on the factors underlying these SES disparities. Drawing on the Disparities in Skilled Birth Attendance (DiSBA) framework, we examined the contribution of three proximal factors—perceived need, accessibility, and quality of care—that influence the use of SBAs. Methods We used data from a survey conducted in Migori County, Kenya in 2016, among women aged 15–49 years who gave birth nine weeks before the survey (N = 1020). The primary outcome is facility-based childbirth. The primary predictors are wealth, measured in quintiles calculated from a wealth index based on principal component analysis of household assets, and highest education level attained. Proposed mediating variables include maternal perceptions of need, accessibility (physical and financial), and quality of care (antenatal services received and experience of care). Logistic regression with mediation analysis was used to investigate the mediating effects. Results Overall, 85% of women in the sample gave birth in a health facility. Women in the highest wealth quintile were more likely to give birth in a facility than women in the lowest quintile, controlling for demographic factors (adjusted odds ratio [aOR]: 2.97, 95% CI: 1.69–5.22). College-educated women were five times more likely than women with no formal education or primary education to give birth in a health facility (aOR: 4.96; 95% CI: 1.43–17.3). Women who gave birth in health facilities had higher perceived accessibility and quality of care than those who gave birth at home. The five mediators were estimated to account for between 15% and 48% of the differences in facility births between women in the lowest and higher wealth quintiles. Conclusion Our results confirm SES disparities in facility-based childbirth, with the proximal factors accounting for some of these differences. These proximal factors – particularly perceived accessibility and quality of care – warrant attention due to their relationship with facility-birth overall, and their impact on inequities in this care.

Sub-national variation in indicators of maternal mortality in Kenya requires targeted interventions to fast-track SDG attainment

“…In Kenya, a disproportionate number of pregnant women (95.5%) attended ANC clinic, which is consistent with the global trends (86%) among expectant mothers [24]. ANC clinic is associated with increase in uptake of other health facility services such as health facility delivery and PNC clinic attendance; a trend which is associated with the trainings offered at the ANC clinics [46,47]. ANC clinic attendance is signi cantly in uenced by wealth quintiles and education attainment [24], and MMR was still highest in marginalized regions [48].…”

Can an integrated intervention package including peer support increase the proportion of health facility births? A cluster randomised controlled trial in Northern Uganda

“…Decisions on place of delivery are complex. Factors that may contribute to home delivery in Uganda and other similar countries include timing of the first antenatal care visit,5 lack of awareness of the time of delivery, lack of awareness of the importance of facility births,6 perceived poor quality of care at the health facilities,7 8 low maternal education,9 10 low socioeconomic status,7 11 rural residence and lack of transport 7 8 12…”