Abstract
BackgroundQuality of healthcare is an important determinant of future progress in global health. However, the distributional aspects of quality of care have received inadequate attention. We assessed whether high quality maternal care is equitably distributed by (1) mapping the quality of maternal care in facilities located in poorer versus wealthier areas of Kenya; and (2) comparing the quality of maternal care available to Kenyans in and not in poverty.MethodsWe assessed three measures of maternal care quality: facility infrastructure and clinical quality of antenatal care and delivery care, using indicators from the 2010 Kenya Service Provision Assessment (SPA), a standardized facility survey with direct observation of maternal care provision. We calculated poverty of the area served by antenatal or delivery care facilities using the Multidimensional Poverty Index. We used regression analyses and non-parametric tests to assess differences in maternal care quality in facilities located in more and less impoverished areas. We estimated effective coverage with a minimum standard of care for the full population and those in poverty.ResultsA total of 564 facilities offering at least one maternal care service were included in this analysis. Quality of maternal care was low, particularly clinical quality of antenatal and delivery care, which averaged 0.52 and 0.58 out of 1 respectively, compared to 0.68 for structural inputs to care. Maternal healthcare quality varied by poverty level: at the facility level, all quality metrics were lowest for the most impoverished areas and increased significantly with greater wealth. Population access to a minimum standard (≥0.75 of 1.00) of quality maternal care was both low and inequitable: only 17% of all women and 8% of impoverished women had access to minimally adequate delivery care.ConclusionThe quality of maternal care is low in Kenya, and care available to the impoverished is significantly worse than that for the better off. To achieve the national targets of maternal and neonatal mortality reduction, policy initiatives need to tackle low quality of care, starting with high-poverty areas.
Highlights
A total of 564 facilities offering at least one maternal care service were included in this analysis
Maternal healthcare quality varied by poverty level: at the facility level, all quality metrics were lowest for the most impoverished areas and increased significantly with greater wealth
The quality of maternal care is low in Kenya, and care available to the impoverished is significantly worse than that for the better off
Summary
While the Millennium Development Goals (MDG) strategy was successful in expanding coverage of antenatal care (ANC) and skilled attendance at birth in low- and middle-income countries (LMICs), improvements in maternal and child health outcomes did not always follow.[1,2,3] In Kenya, for example, ANC coverage and presence of a skilled attendant at birth each increased twenty percentage points from 2000 to 2015, but maternal and neonatal mortality remain high (510 per 100,000 live births and 22.2 per 1,000 live births respectively, in 2015).[4, 5] One reason for this is shortcomings in the quality of health care available to women and children, an issue that is beginning to receive international attention.[6,7,8,9,10,11,12,13]The inverse care law posits that the availability of good medical or social care varies inversely with the need of the population served.[14]. Prior research has documented inequities in reproductive and maternal health care access and outcomes within countries.[15] In Kenya, the burden of under-five mortality disproportionately affects rural, poorer and less-educated families.[16] Compared to children whose mothers have higher than secondary education, children whose mothers are not educated are 46% more likely to die before age five.[17] The poorest women received fewer essential services during ANC care and were four times as likely to deliver without a skilled attendant as women in the wealthiest quintile, according to the 2008–2009 Demographic and Health Survey (DHS).[16] A recent study indicates heterogeneity in quality of ANC across and within Kenyan provinces but did not detect statistically significant variation in ANC quality by women’s education level.[18] there are limited data on equity in maternal health care quality, beyond ANC. We assessed whether high quality maternal care is equitably distributed by (1) mapping the quality of maternal care in facilities located in poorer versus wealthier areas of Kenya; and (2) comparing the quality of maternal care available to Kenyans in and not in poverty
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