Factors associated with health facility delivery in Kitui County: a cross sectional study

Introduction

Globally, the maternal mortality rate has continued to increase leading to failure by countries to achieve the Millennium Development Goals (MDGs) that were set in year 1990 to 2015¹. This made it impossible to achieve the MDG 5² that aimed to reduce maternal and neonatal deaths (now Sustainable Development Goal (SDG) 3). However, maternal deaths have reduced from 546,000 in 1990 to 358,000 in 2015 in sub Sahara region representing a 34% reduction. Between 2016 and 2030, as part of the SDGs, the target is to reduce the global maternal mortality ratio to less than 70 per 100 000 live births³. In order to achieve, universal health care has been recognized as one of four pillars of government policy and is therefore receiving support from many quarters.

According to Safe Motherhood Initiative (SMI) introduced by World Health Organization (WHO), hospital deliveries were fewer than home deliveries in many regions of sub-Saharan Africa (SSA). The reason for this is that the initiative lacks a clear, concise realistic strategy⁴. As a result, a high number of still births (3.2 million), 4 million neonatal deaths and more than half a million maternal deaths, continue to occur. Most of these deaths are preventable⁴, and when skilled health personnel provide delivery services within health facilities to pregnant women, maternal and neonatal health outcomes improve⁵.

In Kenya, skilled birth attendance (44%). has remained far below the international target of 90% Skilled birth attendance during delivery is a benchmark indicator for safe motherhood⁶. Delivery by a skilled birth attendant reduces chances of maternal complications. A study by Nyongesa et al. found that the gender of a service provider, cost, number of antenatal visits and education level were strongly associated with client’s intention to deliver with a skilled birth attendant at delivery⁷.

In Kitui County, Kenya, skilled birth attendance has equally remained very low. Moreover, Mwingi North Sub county had recorded low number of deliveries in the health facilities. The district health information system (DHIS2) reported 1472 normal hospital deliveries in 2015 were 1472, 1594 in 2016, and 1194 deliveires in 2017⁸.

Even though delivery by skilled birth attendants have remained low, the immunization coverage at the country and the county level have remained above the national government rate, This means that immunization coverage is not proportional to the number of skilled birth attendants. According to the Kenya health information system (KHIS), the number of Bacillus Calmette Guillen (BCG) antigen doses administered in Mwingi North Sub county in 2017 was 3268, while the number of deliveries recorded by skilled birth attendants was 1154⁸. This means that over 65% of babies were delivered at home without the help of a skilled birth attendant, as BCG vaccines are administered within 6 weeks of birth.

Improving maternal delivery care is an essential element of attaining improved maternal health. In order to achieve improved maternal health, information about the rates and trends in maternal mortality is essential for resource mobilization, monitoring and evaluation of progress towards the SDGs. However, for this to be attained, maternal health programs should be based on quality evidence. Therefore, this cross-sectional study aimed to identify factors affecting health facility deliveries in Mwingi North Sub county, Kitui county. Kenya.

Methods

Results

Discussion

The percentage of women who delivered through the help of a skilled birth attendant is one indicator in meeting MDG 5 (now SDG3 – ensuring good healthy lives and promote wellbeing for all ages). In most countries where health professionals attend more than 80% of deliveries, maternal mortality rate is usually below 200 per 100,000 live births.

In Kenya, delivery by skilled birth attendants (health professionals) is available at very few births⁵. This study therefore considered factors affecting delivery in a health facility. The study has shown that that only 50.4% of the respondents had a delivery conducted by a skilled delivery attendant. Our results are slightly different from those from KDHS, whereby statistics for skilled attendants were 44% in Kenya.

Our study demonstrated that there is no significant relationship between age and delivery in a health facility. However, other studies, e.g. a study by Mrisho et al.¹⁰ in Tanzania, showed that a higher percentage of younger women deliver at health facilities in contrast to older women who often choose to deliver at home. A study by Bhattacharyaya et al. on factors associated with preference of a health facility delivery indicated that older women preferred health facility delivery as opposed to younger women¹¹. The reason given for this discrepancy according to studies in Zambia and Tanzania was that younger women were inexperienced and more afraid of birth complications than older women.

The present study showed that attendance of >4 ANC visits influenced the place of delivery. This study agrees with a study that indicated that women who attended >4 ANC visits were likely to deliver in a health facility than those who did less visits¹¹. In addition, the study by Bhattacharyya et al. indicated that marital status had little influence on the attendance of ANC during the mother’s last pregnancy and consequently on delivery in a health facility; in this study, single and married women mostly delivered either at home or at a government health facility. A study conducted in Myanmar¹² showed similar findings. In this study, the majority of divorced women delivered at home whereas widowed women delivered at either a private or government health facility. Women who make more than 4 ANC visits may have bad obstetric history or perhaps have started ANC visits at earliest gestation¹².

In our study, the number of children (parity) had a negative impact on delivery in a hospital. We found that women with higher parity and having more than two children in the family were more likely to deliver in their homes than their counterparts with low parity and one or two children. These study findings are similar to a study in Myanmar that indicated that women who have given birth more than once are less likely to seek maternal care at a health facility because they feel they can manage the birthing process without the assistance of a health care professional¹³. It was also shown in the present study that the respondent’s partners played a role in determining place of delivery; those women whose partners had formal jobs were more likely to deliver in a health facility as opposed to those whose partners’ job was casual or otherwise. The findings are similar to those of a study by Okang and Kaseje in Eritrea found that partners who had formal employment were more likely to deliver in a health facility than those with non-formal employment¹⁴.

Level of education is recognized as having an influence on the place of delivery. Women with non-formal education are more likely to deliver at home as opposed to a formally educated woman with a higher probability of delivering at a health facility¹⁵, as shown by studies carried out in Nepal, Columbia and Kenya¹⁶. Additionally a study by Feyissa and Genemo in Ethiopia showed that the level of education has a significant influence on health facility delivery¹⁵. Contrary to above, the results of this study in Mwingi North Subcounty show that education has little or no influence on the place of delivery. From the data obtained from our respondents, most of the women, irrespective of their level of education, delivered either at home or at a government health facility except for women with adult education who exclusively delivered at their own homes. This finding was in contrast to the anticipated results that would have shown a distinction in place of delivery depending on a woman’s educational attainment.

Similarly according to Addai¹³, in his study farming women were less likely to seek medical care at the time of delivery than women in other occupations. This was also influenced by the occupation of partners. This may be because partners with formal employment may be able to provide insurance cover; limitation of financial resources and poor access to health services are cited as the two reasons why farming woman give birth at home¹⁷.

Regarding health facility-related factors, most of the respondents in this study lived more than 10km from a health centre and therefore delivered at home due to the long distance from their homes to the heath facility. The number of ANC clinic visits were proportionately reduced; as distance increased the number of ANC visits decreased. Our study findings concur with Bhattacharyya et al.¹¹ whose findings in a study in India showed that women who gave birth at home would rather have delivered at a health facility but the long distance accompanied by transport challenges proved to be a hindrance. Moreover, a study in Nepal by Devkota et al.¹⁸ drew a similar conclusion, where they found that approximately 18% of women who had intended to deliver at a health facility ended up delivering at home. These findings are in agreement with Kenya’s KDHS that showed that most of the health facilities are over 5km radius from the consumers of services¹⁹.

Conclusions

Health facilities are the preferred sites for delivery regardless of the level of education, marital status and occupation of the respondents. Multiparous women are less likely to give birth at a health facility in preference of home deliveries. Long distance from the health facility is a hindrance to accessing health services and in turn maternal health care from qualified medical practitioners in Mwingi North Subcounty, Kenya.