Free Maternity Services Research Articles

English

The study aim to determine the factors that make women deliver at home after attending antenatal care, to determine the awareness of women on risks associated with home delivery, to determine the type of birth attendants’ available during home delivery, and to explore the opinions of women on various strategies to prevent home delivery. A non- experimental cross-sectional design was used, with a target population of 960 people and systematic random sampling technique was employed to select the sample of 132 subjects out of the target population. Participation was voluntary and the principle of informed consent was ensured. Questionnaire was used as an instrument for data collection but only 121 were retrieved and analyzed, using SPSS Version 23. The findings of the study revealed that, women deliver at home due to cost of hospital services, male attendant during delivery, distance of the health facility from their home, poor attitude of health care provider and fear of surgical procedure. Also, according to the findings, the strategies of preventing home delivery includes provision of free maternal and child services, good health care provider attitude, health education on danger associated with home delivery, and adequate man power. In conclusion, majority of respondents were aware on factors that make them deliver at home. Recommendations were made that, health services should be subsidized and made available to women of child bearing ages and health education as well as improvement of community awareness on the importance of institutional delivery should be planned and implemented. Key words: Determinants, home-delivery, antenatal care.

Client’s satisfaction with maternal child health services in tier three public health facilities, Kisumu county, Kenya

Purpose: The declaration of free maternal and child Health services by the government of Kenya was meant to address some of the systemic service access challenges and increase the number of clients using MNCH services, consequently reducing maternal and neonatal deaths. However, persistent poor maternal and child health indicators in Kenya even with free MNCH services as evident in Kisumu County portends considerable concern hence the reason for this study. There was need to identify factors or factor combinations that affect MNCH service quality in Kisumu County.Methodology: This was a descriptive analytical study whereby data was collected from a sample of 284 mothers seeking MNCH services in Kisumu tier three public health facilities using structured questionnaires and data was analyzed using the Statistical Package for the Social Sciences. Univariate statistics was used to assess patterns of responses to the client satisfaction questionnaire items. Bivariate logistic regression was used to assess association between client satisfaction and dimensions of their characteristics; p-values of less than 0.05 were considered significant.Results: Mothers aged 30-39 years were more likely to report being satisfied with maternal, newborn and child health services as compared to those aged 15-19 years (aOR=0.52, 95%CI=0.28-0.96, p-Value=0.035). The clients who had 1 pregnancy (aOR=2.29, 95%CI=1.04-5.05, p-value=0.040) and 2 pregnancies (aOR=3.22, 95%CI=1.54-6.70, p-Value=0.002) were more likely to report being satisfied with maternal child health services in public health facilities. Similarly, there was significant increased odds of being satisfied among those who resided in rural areas (aOR=2.24, 95%CI=1.05-4.79, p-Value=0.037), those who use vehicles as means of transport (aOR=6.87, 95%CI=1.38-34.28, p-Value=0.019) and those who use motorbike as means of transport (aOR=7.79, 95%CI=1.61-37.77, p-Value=0.011) and maternal child health services satisfaction.Unique contribution to practice and policy: The feedback from this study can be used by national and county governments, state agencies and other health stakeholders in designing communication and advocacy strategies for targeted groups or populations both at the community and health facilities to increase access and acceptability of MNCH services.

The Effectiveness of Counselling on Knowledge, Acceptance and Choice for Postpartum Intrauterine Contraceptive Device (PPIUCD) among Primi mothers

Background: Post-partum contraception is the best evidence based intervention in prevention of pregnancy and abortion related maternal morbidity and mortality in the developing countries. The spacing for contraception among women in the postpartum period can be effectively fulfilled by post partum insertion of PPIUCD, in a single visit under the Government scheme of providing free maternity services during institutional delivery. Despite optimal efforts by family planning program, very few primi mothers are opting for spacing method and lack of awareness has resulted in discontinuation of family planning method particularly PPIUCD. This study is designed to PPIUCD and causes for discontinuation at follow up in our hospital. The objectives of the study were study PPIUCD practices at Talera hospital and Akurdi hospital, Pune; causes for discontinuation of PPIUCD. Research Methodology: Research Approach: Quantitative approach, Research design-Quasi experimental design one group Pre-test Post-test design, Population–primi mothers, Sample–The sample of the study comprised of Primi mothers, Sample size: 60 primi mothers, Sampling technique: Simple Random Sampling Technique was used. Setting: the selection of the study setting is on the basis of the feasibility of conducting study and availability of sample. Study will be conducted in Talera Hospital and Bhosri Hospital, PCMC, Pune. Result: In pre-test, majority of 91.7% of the primi mothers had poor knowledge and 8.3% of them had average knowledge regarding PPIUCD. In post-test, majority of 86.7.7% of the primi mothers had average knowledge and 13.3% of them had poor knowledge regarding PPIUCD. This indicates that the knowledge among primi mothers regarding PPIUCD improved remarkably after individual counselling. Researcher applied paired t-test for effectiveness of individual counselling on knowledge among primi mothers regarding PPIUCD. Average knowledge score in pre-test was 8.4 which increased to 11.9 in post test. t-value for this test was 12.2 with 59 degrees of freedom. Corresponding p-value was small (less than 0.05), the null hypothesis is rejected. This is evident that the knowledge among primi mothers regarding PPIUCD improved significantly after individual counselling.

Inequalities in access to birth by caesarean section in the context of user fee exemption for maternal health services in southwest and north central Nigeria.

BackgroundUser fee exemption for maternal healthcare services was introduced with a focus on providing free maternal health services, including caesarean sections (CS), in Nigeria. This policy has had a positive impact on access to facility-based delivery; however, the extent to which inequality in access to CS exists in the context of user fee exemption is unclear. The objective of this study was to examine inequalities in access to birth by CS 5 y after the implementation of the user fee exemption policy.MethodsData were obtained from 1227 women who gave birth between 2011 and 2015 and were selected using cluster random sampling between May and August 2016 from two of the six main regions of the country. Adjusted and unadjusted binary logistic regression models were performed.ResultsAn overall CS rate of 6.1% was found, but varied by income, education and place of residence. Women who earned a monthly income of ≤20 000 naira (USn}{}{}150) were 50% less likely to have a birth by CS compared with those who earned more. Compared with women who were educated to the tertiary level, women who had a secondary education or less were 51% less likely to give birth by CS.ConclusionsThis study shows that inequality in access to CS persists despite the implementation of free maternal healthcare services.

"I couldn't buy the items so I didn't go to deliver at the health facility" Home delivery among rural women in northern Ghana: A mixed-method analysis.

BackgroundMaternal mortality remains a major challenge to health systems in low and middle-incoming countries. Some pregnant women develop potentially life-threatening complications during childbirth. Therefore, home delivery is a precursor for maternal mortality. In this study, we aimed at not only estimating the percentage of deliveries occurring at home and examining the factors associated with home delivery, but we also explored the reasons for home delivery among women in rural Ghana.MethodsThe study was conducted among mothers with delivery experience in selected communities in the Builsa South district located in the Upper East Region of Ghana. Both quantitative and qualitative data were collected using semi-structured questionnaires and Focus Group Discussion (FGD) guide respectively. A total of 456 mothers participated in this study. Regression models were used in the quantitative analysis whereas a thematic analysis approach was used to analyze the qualitative data.ResultsOf the 423 mothers in the quantitative research, 38.1% (95% CI: 33.5–42.8) delivered their index child at home. In adjusted analysis, women who were not exposed to information (AOR = 13.64, p<0.001) and women with 2 (AOR = 4.64, p = 0.014), 3 (AOR = 4.96, p = 0.025) or at least 4 living children (AOR = 9.59, p = 0.001) had higher odds of delivering at home. From the qualitative analysis, the poor attitude of nurses (midwives), lack of, and cost of transportation, cost of delivery kits, and traditional beliefs and practices were cited as reasons for home delivery.ConclusionDespite the government’s efforts to provide free maternal care services to women in Ghana, a significant proportion of rural women still deliver at home due to other ‘hidden costs’. Addressing poor staff attitude, transportation challenges, and negative traditional beliefs and practices through awareness creation may contribute to improving health facility delivery by rural pregnant women in Ghana.

Perceptions and management of postpartum haemorrhage among remote communities in Lao PDR.

In Lao People's Democratic Republic, despite a policy to provide free maternal health services in healthcare facilities, many rural women continue to deliver at home, without a skilled birth attendant. These women are at high risk of postpartum haemorrhage, the leading cause of maternal mortality in the country. While women in remote areas continue to be unable to access facility-based birthing, interventions to reduce postpartum haemorrhage are a priority. This requires an understanding of how women and their families recognise and manage postpartum haemorrhage in home births. The purpose of this study was to understand community perceptions and management of postpartum bleeding during home births in remote Lao communities. Five focus group discussions with a total of 34 women and their support networks were conducted in five remote communities in Oudomxay, a province with high rates of maternal mortality. Villages were selected with district health officials based on (1) known cases of postpartum haemorrhage, (2) travel time from the provincial capital (2-4 hours), (3) distance to the district health service (>4 km), and (4) population (50-150 people), with the five selected villages being the farthest from the district health service. The focus group discussions were complemented by qualitative, community-based key informant interviews (n=9). All interviews were conducted in Lao, English or the ethnic language most suitable for the sample and simultaneously translated by native speakers. All transcripts were translated into English, back translated and checked against interview recordings. The qualitative data were coded into key themes while moving between the data and the coded extracts. Interpretation of the data themes and coding was an ongoing process with codes and themes checked by the research team. Women described postpartum bleeding as a normal, necessary cleansing process. Some women felt it was critical in order to expel 'bad blood' and restore the mother to good health. Participants were able to describe late symptoms of postpartum haemorrhage but did not describe any methods to accurately estimate the amount of blood loss that required intervention. Traditional remedies were the first courses of action, potentially delaying treatment at a healthcare facility. When asked about the acceptability of taking oral medication immediately following home births to prevent postpartum haemorrhage, most women felt it would be acceptable provided it would not stop normal bleeding, and its usage, benefits and side-effects were clearly explained. While women continue to home birth in remote communities without skilled birth attendants, an informed understanding of traditional management of postpartum haemorrhage can assist in designing culturally responsive interventions. To support a reduction in morbidity and mortality from postpartum haemorrhage, tailored interventions are needed to raise awareness among women and their families to reduce delays in seeking health care. Women felt it would be acceptable to take oral medication to prevent postpartum haemorrhage. As such, community-based distribution of misoprostol that can be administered by lay people would provide an effective and acceptable prevention strategy. Other strategies should include promoting birthing plans, delivery by skilled birth attendants and early initiation of breastfeeding.

Free Maternal Health Care Policy in Kenya; Level of Utilization and Barriers

ObjectivesThe present study aimed to explore the level of utilization and barriers to the free maternal service (FMS) policy, introduced in 2013 in Kenya. MethodsLiterature search was on biomedical databases of the most recent available electronic data published, in English. That is between January 2014 and April 2020. The populations for eligible studies were health care providers, stake holders and mothers who sought maternal care in the specified hospitals. All studies eligible were strictly those conducted in Kenya. ResultsThe search generated 20,638 articles of which only 27 articles met the inclusion criteria. Qualitative analysis was done. The findings and discussion were presented and organized under thematic domains. ConclusionThe major findings of this review show that free maternal services has increased utilisation of the skilled birth attendant among the women who dwell close to the hospitals and who could not afford for the services initially. However there still exists a challenge to the utilization of FMS among the poor women in remote areas. To further improve the efficiency and utilization of FMS, it is recommended 1) more funding to the program, 2) putting in place adequate material/infrastructure and human resources, 3) improving road network in the remote areas and providing incentives to the rural poor women.

Socioeconomic inequalities in the use of caesarean section delivery in Ghana: a cross-sectional study using nationally representative data

BackgroundInappropriate use of Caesarean Section (CS) delivery is partly to blame for Ghana’s high maternal mortality rate. However, previous research offered mixed findings about factors associated with CS use. The goal of this study is to examine use of CS in Ghana and the socioeconomic factors associated with it.MethodsData from the nationally representative 2014 Ghana Demographic and Health Survey (GDHS) was used after permission from the Monitoring and Evaluation to Assess and Use Results (MEASURE) Demographic and Health Survey (DHS) program. Univariable and multivariable logistic regression models were fitted to examine the socioeconomic inequalities in CS use. The independent variables included maternal age, marital status, religion, ethnicity, education, place of residence, wealth quintile, and working status. Concentration index (CI) and rate-ratios were computed to ascertain the level of CS inequalities.ResultsOut of the 4294 women, 11.4% had CS delivery. However, the percentage of CS delivery ranged from 5% of women in the poorest quintile to 27.5% of women in the richest qunitle. Significant associations were detected between CS delivery and maternal age, parity, education, and wealth quintile .ConclusionsThis study revealed that first, even though Ghana has achieved an aggregate CS rate consistent with WHO recommendations, it still suffers from inequities in the use of CS. Second, both underuse of CS among poorer women in Ghana and overuse among rich and educated women are public health concerns that need to be addressed. Third, the results show in spite of Ghana’s free maternal care services policies, wealth status of women continues to be strongly and signtificantly associated with CS delivery, indicating that there are indirect health care costs and other reasons preventing poorer women from having access to CS which should be understood better and addressed with appropriate policies.

The relationship of socio-demographic, economic factors among postnatal women with status of Free Maternal Services Implementation in Public Hospitals in Nyanza, Kenya

The relationship of socio-demographic, economic factors among postnatal women with status of Free Maternal Services Implementation in Public Hospitals in Nyanza, Kenya

Impact of the community healthcare plan and the free maternity services programme on maternal and child healthcare utilisation in rural Kenya: a dairy farmer population-based study

Access to and utilisation of quality maternal and child healthcare services is generally recognized as the best way to reduce maternal and child mortality. We evaluated whether the introduction of a voluntary family health insurance programme, combined with quality improvement of healthcare facilities [The Community Health Plan (TCHP)], and the introduction of free access to delivery services in all public facilities [Free Maternity Services programme (FMS)] increased antenatal care utilisation and use of facility deliveries among pregnant women in rural Kenya. TCHP was introduced in 2011, whilst the FMS programme was launched in 2013. To measure the impact of TCHP, percentage points (PP) changes in antenatal care utilisation and facility deliveries from the pre-TCHP to the post-TCHP period between the TCHP programme area and a control area were compared in multivariable difference-in-differences analysis. To measure the impact of the FMS programme, PP changes in antenatal care utilisation and facility deliveries from the pre-FMS to the post-FMS period in the pooled TCHP programme and control areas was assessed in multivariable logistic regression analysis. Data was collected through household surveys in 2011 and 2104. Households (n=549) were randomly selected from the member lists of 2 dairy companies, and all full-term pregnancies in the 3.5 years preceding the baseline and follow-up survey among women aged 15-49 at the time of pregnancy were eligible for this study (n=295). Because only 4.1% of eligible women were insured through TCHP during pregnancy, any increase in utilisation attributable to the TCHP programme could only have come about as a result of the quality improvements in TCHP facilities. Antenatal care utilisation significantly increased after TCHP was introduced (14.4 PP; 95% CI: 4.5-24.3; P=0.004), whereas no effect was observed of the programme on facility deliveries (8.8 PP; 95% CI: -14.1 to +31.7; P=0.450). Facility deliveries significantly increased after the introduction of the FMS programme (27.9 PP; 95% CI: 11.8-44.1; P=0.001), but antenatal care utilisation did not change significantly (4.0 PP; 95% CI: -0.6 to +8.5; P=0.088). Access to the FMS programme increased facility deliveries substantially and may contribute to improved maternal and new-born health and survival if the quality of delivery services is sustained or further improved. Despite low up-take, TCHP had a positive effect on antenatal care utilisation among uninsured women by improving the quality of existing healthcare facilities. An alignment of the two programmes could potentially lead to optimal results. The study was funded by the Health Insurance Fund (http://www.hifund.org/), through a grant from the Dutch Ministry of Foreign Affairs.

The social determinants of health facility delivery in Ghana

BackgroundMany women still deliver outside a health facility in Ghana, often under unhygienic conditions and without skilled birth attendants. This study aims to examine the social determinants influencing the use of health facility delivery among reproductive-aged women in Ghana.MethodsNationally representative data from the 2014 Ghana Demographic and Health Survey was used to fit univariable and multivariable logistic regression models to estimate the influence of the social determinants on health facility delivery. Andresen’s health care utilization model was used as the conceptual framework guiding this study..ResultsOnly 72% of deliveries take place at a health facility in Ghana. The results of the adjusted model indicate that place of residence, financial status, education, religion, parity and perceived need were significantly associated with health facility delivery. First, urban women had a higher likelihood of health facility delivery than rural women (Adjusted Odds ratio [AOR] =2.21; 95% Confidence interval [CI] = 1.53–3.19). Second, middle-class and rich women were 1.57 (95%CI = 1.18–2.08) times and 6.91 (95%CI = 4.12–11.59) times, respectively more likely to deliver at health facility compared to the poor. Third, women with either at least secondary education (AOR = 2.04; 95%CI = 1.57–2.64) or primary education (AOR = 1.39, 95%CI = 1.02–1.92) were more likely to deliver at health facility than women with no education. In terms of parity, first time mothers were 1.58 (95% CI = 1.18–2.12) times more likely to deliver at health facility than those who had given birth three or more times before. Finally, regarding perceived need, women who were aware of pregnancy complications were 1.32 (95%CI = 1.02–1.70) times more likely to use health facility delivery than those who were not informed about pregnancy complications.ConclusionsFirst, in spite of Ghana’s free maternal health services policy, poorer women were much less likely to have a health facility delivery, which points to the need to understand the indirect costs and other financial barriers preventing women from delivering at a health facility. Second, many of the identified variables influence the demand and not just the supply for health care services, and highlight the importance of the social determinants of health and investments in interventions that extend beyond improving physical access.

\u201cWe are called the et cetera\u201d: experiences of the poor with health financing reforms that target them in Kenya

BackgroundThrough a number of healthcare reforms, Kenya has demonstrated its intention to extend financial risk protection and service coverage for poor and vulnerable groups. These reforms include the provision of free maternity services, user-fee removal in public primary health facilities and a health insurance subsidy programme (HISP) for the poor. However, the available evidence points to inequity and the likelihood that the poor will still be left behind with regards to financial risk protection and service coverage. This study examined the experiences of the poor with health financing reforms that target them.MethodsWe conducted a qualitative cross-sectional study in two purposively selected counties in Kenya. We collected data through focus group discussions (n = 8) and in-depth interviews (n = 30) with people in the lowest wealth quintile residing in the health and demographic surveillance systems, and HISP beneficiaries. We analyzed the data using a framework approach focusing on four healthcare access dimensions; geographical accessibility, affordability, availability, and acceptability.ResultsHealth financing reforms reduced financial barriers and improved access to health services for the poor in the study counties. However, various access barriers limited the extent to which they benefited from these reforms. Long distances, lack of public transport, poor condition of the roads and high transport costs especially in rural areas limited access to health facilities. Continued charging of user fees despite their abolition, delayed insurance reimbursements to health facilities that HISP beneficiaries were seeking care from, and informal fees exposed the poor to out of pocket payments. Stock-outs of medicine and other medical supplies, dysfunctional medical equipment, shortage of healthcare workers, and frequent strikes adversely affected the availability of health services. Acceptability of care was further limited by discrimination by healthcare workers and ineffective grievance redress mechanisms which led to a feeling of disempowerment among the poor.ConclusionsPro-poor health financing reforms improved access to care for the poor to some extent. However, to enhance the effectiveness of pro-poor reforms and to ensure that the poor in Kenya benefit fully from them, there is a need to address barriers to healthcare seeking across all access dimensions.

The differential effect of the free maternity services policy in Kenya.

BackgroundThe Government of Kenya introduced the free maternity services (FMS) policy to enable mothers deliver at a health facility and thus improve maternal health indicators.AimThe aim of this study was to determine if there was a differential effect of the policy by region (sub-county) and by facility type (hospitals vs. primary healthcare facilities [PHCFs]).SettingThe study was conducted in Nyamira County in western Kenya.MethodsThis was an interrupted time series study where 42 data sets (24 pre- and 18 post-intervention) were collected for each observation. Monthly data were abstracted from the District Health Information System-2, verified, keyed into and analysed by using IBM-Statistical Package for the Social Sciences (SPSS-17).ResultsThe relative effect of the policy on facility deliveries in the county was an increase of 22.5%, significant up to the 12th month (p < 0.05). The effect of the policy on deliveries by region was highest in Nyamira North and Masaba North (p < 0.001 up to the 18th month). The effect was larger (46.5% vs. 18.3%) and lasted longer (18 months vs. 6 months) in the hospitals than in the PHCFs. The increase in hospital deliveries was most significant in Nyamira North (61%; p < 0.001). There was a medium-term effect on hospital deliveries in Borabu (up to 9 months) and an effect that started in the sixth month in Manga. The relative effect of the policy on facility deliveries in PHCFs was only significant in Nyamira North and Masaba North (p < 0.001).ConclusionThe effect of the FMS policy was varied by region (sub-county) and by facility type.

Interrupted time series analysis of free maternity services policy in Nyamira County, Western Kenya.

IntroductionThe Government of Kenya instituted the free maternity services (FMS) policy to improve utilization of maternal healthcare services and thus improve maternal health. The aim of this study was to evaluate the effect of the FMS policy on the uptake of maternal health services in Nyamira County in western Kenya.MethodsAn interrupted time series study design was used to design the study and to analyze the collected data. Forty-two data sets were collected for each outcome variable i.e. 24 pre- and 18 post-intervention. Monthly data was abstracted from the District Health Information System-2 (DHIS-2) and verified using facility data. The collected data was then keyed into SPSS-17, cleaned and analyzed.ResultsDuring the study period, there was a significant increase in births attended by skilled attendants up to the 12th month (p<0.05) and caesarean section up to the ninth month (p<0.05). There was a decrease in obstetric complications up to the 12 month (p<0.05). In addition there was a significant increase in institutional maternal mortality ratio (iMMR) in the 12th and 18th months (p<0.05) following the implementation of free maternity service policy. There was a significant increase in deliveries in hospitals from the 1st to the 18th month (p<0.05) whereas in primary health care facilities the increase in deliveries was only significant up to the 6th month (p<0.05).ConclusionsThe FMS policy led to progress towards improving maternal health by improving access to maternal health services. The improved utilization of maternal health services was more marked in hospitals. There was a worsening of institutional maternal mortality ratio.

Ectopic pregnancy: A 5-year review of cases in a secondary health facility in Delta State, Nigeria

Background: Ectopic pregnancy and the associated risk factors remain a public health concern, with attendant maternal morbidity and mortality. Due to the reported increase in prevalence in several studies across Nigeria in the last few decades, periodic review of management is of relevance for institutional comparison. Aim: The aim of the study was to determine the prevalence, risk factors and management of ectopic pregnancy in Eku Baptist Government Hospital, a secondary health facility providing free maternity services, and compare these with an earlier study in the same facility and other parts of Nigeria. Methods: A retrospective study of cases of ectopic pregnancy managed at Eku Baptist Government Hospital in a 5-year period: 1 January 2013–31 December 2017. Data analysis was done by SPSS version 22 (IBM). Results: The institutional prevalence rate of ectopic pregnancy was 2.7%. Ectopic pregnancies constituted 12.2% (113/926) of gynaecological admissions. The mean age of participants was 29 ± 5.5 years, and 69.5% of them were married. The highest (59.1%) risk for ectopic pregnancy was previously induced abortion. The most frequent (94.3%) complaint at presentation was a lower abdominal pain. Ruptured ectopic accounted for 97.1% of cases. All the patients had laparotomy including three unruptured cases. There was no fatality in this study amongst participants. Conclusion: This study established a lower prevalence of ectopic pregnancy and zero mortality, with the introduction of free maternity service, compared to an earlier study. This findings suggest earlier presentation of patients with ectopic pregnancy. Prevalence and outcome of ectopic pregnancy can be further improved by effective contraceptive enlightenment and use, provision of postabortion care, provision of facilities for early detection and management.

Effects of free maternity service policy in Kenya: an interrupted time series analysis

Abstract Background In Kenya, more than 6 000 maternal deaths, and 35 000 stillbirths occur each year. In June, 2013, the Government of Kenya abolished user fees for maternity care in all public health facilities under the Free Maternity Service (FMS) policy, to make maternity services accessible and affordable, and to reduce maternal and perinatal deaths. This study aims to establish whether the FMS policy has influenced use of, access to, and quality of maternity care in Kenya. Methods We did an observational retrospective study in three counties in Kenya. We used daily maternity registers in 90 public health facilities to extract monthly observations for six maternal health indicators in the time period 2 years before and 2 years after the introduction of the FMS policy. We used interrupted time series analysis with a single group to assess the effects of the FMS policy. Standard linear regression using generalised least squares model was used to run the final results for each of the six variables. We calculated absolute and relative changes using model coefficients. Findings A total of 82 962 women from Kilifi, Turkana, and Wajir counties were included in the study. Data were collected between June, 2011, and July, 2015. After policy implementation, there was an increase in antenatal care visits, health facility deliveries, and livebirths of 98% (p=0·0008), 97% (p Interpretation The 2013 introduction of free maternity services in Kenya saw an immediate, and then sustained, increase in the use of skilled care during pregnancy and childbirth. This sharp rise in the uptake of services suggest that the hospital cost is the main expense incurred by most women and their families when seeking maternity care services and that this cost is, therefore, a barrier to uptake of maternity care. Funding Afya Bora Consortium fellowship career development award.

Initiation and continuity of maternal healthcare: examining the role of vouchers and user-fee removal on maternal health service use in Kenya.

This study explores the relationship between two health financing initiatives on women’s progression through the maternal health continuum in Kenya: a subsidized reproductive health voucher programme (2006–16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the voucher programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the voucher programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women’s timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum.

Modeling the Effects of Contraceptives as a Control Strategy in Human Population Dynamics

The population size of every country or government is very important in planning on effective service delivery. The cost of conducting population census yearly is of great significance to the country’s budget and many countries conduct population census once in a decade. This makes planning and provision of services to be based on mere approximation. Provision of free maternity services, estimation of national hospital insurance fund premium for medical care, and provision of retirement benefits, payment of allowances to the aged require accurate demographic statistics. In this study, population dynamics is described using a stochastic model, where population is put into distinct and disjoint age classes: Juvenile, sub-Adult, Adult, Resting-Adult, Senior Citizens and the Aged. These structures are assigned intra and inter group transmission rates which form the elements of transmission matrix and presented in form of a Leslie model. The model was modified to allow stochastic variation of transition parameters which is affected by demographic and environmental factors, specifically the effect of contraceptives to control population. It was found that intermittent implementation of control strategy at 50% and 70% efficacy yields a steady population growth rate of λ=1.39 and a steady population distribution of P=(23%, 10%, 23%, 18%, 23%, 20%, 6%)T.

Exploring mistreatment of women during childbirth in a peri-urban setting in Kenya: experiences and perceptions of women and healthcare providers

BackgroundIn Kenya, indirectly caused maternal deaths form a significant portion of all maternal deaths within the health system. Many of these deaths are avoidable and occur during delivery and labor. Poor quality health service has been a recurring concern among women in Kenya, with women reporting interactions with healthcare workers that are often demeaning and abusive. This paper explores the experiences and perceptions of both female patients and healthcare workers regarding mistreatment during childbirth. This study aims to provide recommendations on how dignified care can be made the norm, specifically focusing on a peri-urban setting in Kenya.MethodsThe research was accomplished using qualitative research methods with focus group discussions and in depth interviews with women and healthcare workers. The aim was to gain a deeper understanding of the manifestations of mistreatment within the context of a peri-urban setting in Kenya.ResultsFemale patients reported different forms of mistreatment, such as verbal abuse, physical abuse, neglect, discrimination, abandonment, poor rapport and failure of the health system to uphold professional standards. The healthcare workers described a health system that was weak and fragmented with poor policy support particularly for the new free maternity services policy leading to the mistreatment of women.ConclusionNewly formed County Governments need to provide resources for a functioning health system to ensure an enabling environment for the provision of high quality maternal health services. This process can include feedback loops with maternity clients to ensure woman-centered services. Policy makers need to strengthen oversight for the implementation of the free maternity services Community health volunteers can be trained to provide this information. Professional associations that govern the standards of quality care for healthcare workers need to address the mistreatment through retraining and norms transformation.

The perceptions, health-seeking behaviours and access of Scheduled Caste women to maternal health services in Bihar, India

The caste system is a complex social stratification system which has been abolished, but remains deeply ingrained in India. Scheduled Caste (SC) women are one of the historically deprived groups, as reflected in poor maternal health outcomes and low utilisation of maternal healthcare services. Key government schemes introduced in 2005 mean healthcare-associated costs should now be far less of a deterrent. This paper examines the factors contributing to this low use of maternal health services by investigating the perceptions, health-seeking behaviours and access of SC women to maternal healthcare services in Bihar, India. Eighteen in-depth, semi-structured interviews were conducted with SC women in Bihar. Data were analysed using Framework Analysis and presented using the AAAQ Toolbox. Main facilitating factors included the introduction of accredited social health activists (ASHAs), free maternal health services, the Janani Shishu Suraksha Karyakram (JSSK), and changes in the cultural acceptability of institutional delivery. Main barriers included inadequate ASHA coverage, poor information access, transport costs and unauthorised charges to SC women from healthcare staff. SC women in Bihar may be inequitably served by maternal health services, and in some cases may face specific discrimination. Recommendations to improve SC service utilisation include research into the improvement of postnatal care, reducing unauthorised payments to healthcare staff and improvements to the ASHA programme.