What prevents pregnant women from adhering to the continuum of maternal care? Evidence on interrelated mechanisms from a cohort study in Kenya

Abstract

ObjectivesTo examine the determinants of the continuum of maternal care from an integrated perspective, focusing on how key components of an adequate journey are interrelated.DesignA facility-based prospective cohort study.Setting25 health facilities across three counties of Kenya: Nairobi, Kisumu and Kakamega.ParticipantsA total of 5 879 low-income pregnant women aged 13–49 years.Outcome measuresOrdinary least squares, Poisson and logistic regression models were employed, to predict three key determinants of the continuum of maternal care: (i) the week of enrolment at the clinic for antenatal care (ANC), (ii) the total number of ANC visits and (iii) utilisation of skilled birth attendance (SBA). The interrelationship between the three outcome variables was assessed with structural equation modeling.ResultsEach week of delayed enrolment in ANC reduced the number of ANC visits by 3% (incidence rate ratio=0.967, 95% CI 0.965 to 0.969). A higher number of ANC visits increased the relative probability of using SBA (odds ratio=1.28, 95% CI 1.22 to 1.34). The direct association between late enrolment and SBA was positive (odds ratio=1.033, 95% CI 1.02 to 1.04). Predisposing factors (age, household head’s education), enabling factors (wealth, shorter distance, rural area) and need factors (risk level of pregnancy, multigravida) were positively associated with adherence to ANC.ConclusionThe results point towards a domino-effect and underscore the importance of enhancing the full continuum of maternal care. A larger number of ANC visits increases SBA, while early initiation of the care journey increases the number of ANC visits, thereby indirectly supporting SBA as well. These beneficial pathways counteract the direct link between enrolment and SBA, which is partly driven by pregnant teenagers who both enrol late and are at heightened risk of complications, stressing the need for specific attention to this vulnerable population.

Prevalence and risk factors for delayed antenatal care visits in Rwanda: an analysis of secondary data from Rwanda demographic health survey 2019-2020

“…Surprisingly, age was not a risk factor for delayed ANC visit, contrary to other studies conducted in South Africa [ 27 ] and Kenya [ 24 ], where it was indicated that women below 20 years of age were more likely to have late ANC. These adolescent women may lack knowledge about the importance of ANC and consequences of delaying.…”

“…This study revealed that women with no formal education, primary and secondary level education were more likely to have delayed ANC visits compared to those with higher education levels. The same findings were reported in Tanzania [ 22 ], Ethiopia [ 23 ], and Kenya [ 24 ], where it was indicated that women with higher education levels will attend their ANC on time. This may be due to the lack of knowledge about reproductive health including the significance of timely ANC visits which is acquired with the higher-level education.…”

Maintaining Continuity of Care for Expectant Mothers in Kenya During the COVID-19 Pandemic: A Study of MomCare

“…For a more detailed investigation of pre-COVID utilization patterns in a comparable sample, we refer to Aksünger et al (2022). 35 …”

Key barriers to the provision and utilization of maternal health services in low-and lower-middle-income countries; a scoping review

“…The results of this review showed that women's poor knowledge of MH is the most frequent barrier (N: 56, 47.86%) to the utilization of MH services in LLMICs. The low level of specific knowledge on MH is reflected in three areas, including a lack of awareness of risk factors and danger signs [89,90,106], failure to receive special care and information in previous stages of care [26,87,138] and lack of awareness of available health services [27,55,122].…”