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Background: Disrespect and abuse or mistreatment of women by health care providers in maternity settings has been identified as a key deterrent to women seeking delivery care. Mistreatment includes physical and verbal abuse, stigma and discrimination, a poor relationship between women and providers and policy and health systems challenges. This paper uses qualitative data to describe mistreatment of women in Kenya.Methods: Data are drawn from implementation research conducted in 13 facilities and communities. Researchers conducted a range of in-depth interviews with women (n-50) who had given birth in a facility policy makers health managers and providers (n-63); and focus group discussions (19) with women and men living around study facilities. Data were captured on paper and audio tapes, transcribed and translated and exported into Nvivo for analysis. Subsequently we applied a typology of mistreatment which includes first order descriptive themes, second and third-order analytical themes. Final analysis was organized around description of the nature, manifestations and experiences, and factors contributing to mistreatment.Results: Women describe: their negative experiences of childbirth; frustration with lack of confidentiality and autonomy; abandonment by the providers, and dirty maternity units. Providers admit to challenges but describe reasons for apparent abuse (slapped on thighs to encourage women to focus on birthing process) and 'detention' is because relatives have abandoned them. Men try to overcome challenges by paying providers to ensure they look after their wives. Drivers of mistreatment are perpetuated by social and gender norms at family and community levels. At facility level, poor managerial oversight, provider demotivation, and lack of equipment and supplies, contribute to a poor experience of care. Weak or non-existent legal redress perpetuate the problem.Conclusion: This paper builds on the expanding literature on mistreatment during labour and childbirth -outlining drivers from an individual, family, community, facility and policy level. New frameworks to group the manifestations into themes or components makes it increasingly more focused on specific interventions to promote respectful maternity care. The Kenya findings resonate with budding literature - demonstrating that this is indeed a global issue that needs a global solution. [ABSTRACT FROM AUTHOR]

Background: Kenya's high maternal mortality ratio can be partly explained by the low proportion of women delivering in health facilities attended by skilled birth attendants (SBAs). Many women continue to give birth at home attended by family members or traditional birth attendants (TBAs). This is particularly true for pastoralist women in Laikipia and Samburu counties, Kenya. This paper investigates the socio-demographic factors and cultural beliefs and practices that influence place of delivery for these pastoralist women.Methods: Qualitative data were collected in five group ranches in Laikipia County and three group ranches in Samburu County. Fifteen in-depth interviews were conducted: seven with SBAs and eight with key informants. Nineteen focus group discussions (FGDs) were conducted: four with TBAs; three with community health workers (CHWs); ten with women who had delivered in the past two years; and two with husbands of women who had delivered in the past two years. Topics discussed included reasons for homebirths, access and referrals to health facilities, and strengths and challenges of TBAs and SBAs. The data were translated, transcribed and inductively and deductively thematically analysed both manually and using NVivo.Results: Socio-demographic characteristics and cultural practices and beliefs influence pastoralist women's place of delivery in Laikipia and Samburu counties, Kenya. Pastoralist women continue to deliver at home due to a range of factors including: distance, poor roads, and the difficulty of obtaining and paying for transport; the perception that the treatment and care offered at health facilities is disrespectful and unfriendly; lack of education and awareness regarding the risks of delivering at home; and local cultural values related to women and birthing.Conclusions: Understanding factors influencing the location of delivery helps to explain why many pastoralist women continue to deliver at home despite health services becoming more accessible. This information can be used to inform policy and program development aimed at increasing the proportion of facility-based deliveries in challenging settings. [ABSTRACT FROM AUTHOR]

Background: The long-term impact of user fee removal policies on health service utilization in low- and middle-income countries may vary depending on the context in which they are implemented, including whether there are policy actions to support implementation. We examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys. Methods: Data are from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. A total of 5949, 6079 and 20,964 births were reported in respective surveys. We conducted interrupted time series analysis predicting changes in quarterly proportions of births occurring in public and private health facilities as well as at home before and after the 2004, 2007 and 2013 user fee policy shifts in Kenya. Results: There were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy. There was also a statistically significant increase in public facility deliveries among women from the two top quintiles, which was accompanied by a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time. Conclusion: The findings of this paper provide empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time. [ABSTRACT FROM AUTHOR]

Background: In 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. Methods: The 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. Results: Female 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. Conclusion: Newly 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. [ABSTRACT FROM AUTHOR]

Background: Universal Health Coverage ensures access to quality health services for all, with no financial hardship when accessing the needed services. Nevertheless, access to quality health services is marred by substantial resource shortages creating service delivery gaps in low-and middle-income countries, including Kenya. The Innovative Partnership for Universal Sustainable Healthcare (i-PUSH) program, developed by AMREF Health Africa and PharmAccess Foundation (PAF), aims to empower low-income women of reproductive age and their families through innovative digital tools. This study aims to evaluate the impact of i-PUSH on maternal and child health care utilization, women's health including their knowledge, behavior, and uptake of respective services, as well as women's empowerment and financial protection. It also aims to evaluate the impact of the LEAP training tool on empowering and enhancing community health volunteers' health literacy and to evaluate the impact of the M-TIBA health wallet on savings for health and health insurance uptake.Methods: This is a study protocol for a cluster randomized controlled trial (RCT) study that uses a four-pronged approach-including year-long weekly financial and health diaries interviews, baseline and endline surveys, a qualitative study, and behavioral lab-in-the-field experiments-in Kakemega County, Kenya. In total, 240 households from 24 villages in Kakamega will be followed to capture their health, health knowledge, health-seeking behavior, health expenditures, and enrolment in health insurance over time. Half of the households live in villages randomly assigned to the treatment group where i-PUSH will be implemented after the baseline, while the other half of the households live in control village where i-PUSH will not be implemented until after the endline. The study protocol was reviewed and approved by the AMREF Ethical and Scientific Review Board. Research permits were obtained from the National Commission for Science, Technology and Innovation agency of Kenya.Discussion: People in low-and middle-income countries often suffer from high out-of-pocket healthcare expenditures, which, in turn, impede access to quality health services. Saving for healthcare as well as enrolment in health insurance can improve access to healthcare by building capacities at all levels-individuals, families, and communities. Notably, i-PUSH fosters savings for health care through the mobile-phone based "health wallet," it enhances enrolment in subsidized health insurance through the mobile platform-M-TIBA-developed by PAF, and it seeks to improve health knowledge and behavior through community health volunteers (CHVs) who are trained using the LEAP tool-AMREF's mHealth platform. The findings will inform stakeholders to formulate better strategies to ensure access to Universal Health Coverage in general, and for a highly vulnerable segment of the population in particular, including low-income mothers and their children.Trial Registration: Registered with Protocol Registration and Results System (protocol ID: AfricanPHRC; trial ID: NCT04068571 : AEARCTR-0006089 ; date: 29 August 2019) and The American Economic Association's registry for randomized controlled trials (trial ID: AEARCTR-0006089; date: 26 June 2020). [ABSTRACT FROM AUTHOR]

Background: Person-centered reproductive health care is recognized as critical to improving reproductive health outcomes. Yet, little research exists on how to operationalize it. We extend the literature in this area by developing and validating a tool to measure person-centered maternity care. We describe the process of developing the tool and present the results of psychometric analyses to assess its validity and reliability in a rural and urban setting in Kenya. Methods: We followed standard procedures for scale development. First, we reviewed the literature to define our construct and identify domains, and developed items to measure each domain. Next, we conducted expert reviews to assess content validity; and cognitive interviews with potential respondents to assess clarity, appropriateness, and relevance of the questions. The questions were then refined and administered in surveys; and survey results used to assess construct and criterion validity and reliability. Results: The exploratory factor analysis yielded one dominant factor in both the rural and urban settings. Three factors with eigenvalues greater than one were identified for the rural sample and four factors identified for the urban sample. Thirty of the 38 items administered in the survey were retained based on the factors loadings and correlation between the items. Twenty-five items load very well onto a single factor in both the rural and urban sample, with five items loading well in either the rural or urban sample, but not in both samples. These 30 items also load on three sub-scales that we created to measure dignified and respectful care, communication and autonomy, and supportive care. The Chronbach alpha for the main scale is greater than 0.8 in both samples, and that for the sub-scales are between 0.6 and 0.8. The main scale and sub-scales are correlated with global measures of satisfaction with maternity services, suggesting criterion validity. Conclusions: We present a 30-item scale with three sub-scales to measure person-centered maternity care. This scale has high validity and reliability in a rural and urban setting in Kenya. Validation in additional settings is however needed. This scale will facilitate measurement to improve person-centered maternity care, and subsequently improve reproductive outcomes. [ABSTRACT FROM AUTHOR]

Background: The high rate of home deliveries conducted by unskilled birth attendants in resource-limited settings is an important global health issue because it is believed to be a significant contributing factor to maternal and newborn mortality. Given the large number of deliveries that are managed by unskilled or traditional birth attendants outside of health facilities, and the fact that there is on-going discussion regarding the role of traditional birth attendants in the maternal newborn health (MNH) service continuum, we sought to ascertain the practices of traditional birth attendants in our catchment area. The findings of this descriptive study might help inform conversations regarding the roles that traditional birth attendants can play in maternal-newborn health care.Methods: A structured questionnaire was used in a survey that included one hundred unskilled birth attendants in western Kenya. Descriptive statistics were employed.Results: Inappropriate or outdated practices were reported in relation to some obstetric complications and newborn care. Encouraging results were reported with regard to positive relationships that traditional birth attendants have with their local health facilities. Furthermore, high rates of referral to health facilities was reported for many common obstetric emergencies and similar rates for reporting of pregnancy outcomes to village elders and chiefs.Conclusions: Potentially harmful or outdated practices with regard to maternal and newborn care among traditional birth attendants in western Kenya were revealed by this study. There were high rates of traditional birth attendant referrals of pregnant mothers with obstetric complications to health facilities. Policy makers may consider re-educating and re-defining the roles and responsibilities of traditional birth attendants in maternal and neonatal health care based on the findings of this survey. [ABSTRACT FROM AUTHOR]

Background: A woman's health seeking behaviour during pregnancy has been found to have significant repercussions on her wellbeing and that of her unborn child. For example, the risk of poor pregnancy outcomes and maternal death is higher among women who do not receive antenatal care. Methods: The study described the characteristics of women who reported wanted, unwanted and mistimed pregnancies from their last birth at the time of the survey; the linkage between frequency of antenatal care visits and pregnancy wantedness and the relationship between timing of the first antenatal care visit and pregnancy wantedness since maternal morbidity and mortality are higher among women who do not receive antenatal care. The 2008-09 Kenya Demographic and Health Survey data is used and multinomial logistic regression and logistic regression informed the study analysis. Results: Results showed that women, who reported wanted pregnancy were more likely to receive antenatal care while those who reported unwanted pregnancy were less likely to receive antenatal care, but more likely to attend late the first time and have fewer than four antenatal care visits. Also, mistimed pregnancies were associated with low frequency of antenatal care visit and late timing of the first visit. Conclusion: Our findings confirm an association between pregnancy wantedness, frequency of antenatal care visits and timing of the first antenatal care visit. Women whose pregnancy was reported as mistimed and unwanted were more likely not to receive any antenatal care and when they did; they went for fewer than the recommended four visits with late timing. Health policy and strategies should ensure that all pregnant women regardless of their pregnancy status at the time of conception first receive antenatal care, and receive it in a timely manner and make at least four antenatal care visits before delivery. This will help to identify health complications that may arise during and after delivery and reduce maternal, new-born and infant mortality. Information, education and communication campaigns on family planning especially for spacing and matters related to antenatal care visits, timing and frequency should be intensified nationally. [ABSTRACT FROM AUTHOR]

Background: Sentinel surveillance for HIV among women attending antenatal clinics using unlinked anonymous testing is a cornerstone of HIV surveillance in sub-Saharan Africa. Increased use of routine antenatal HIV testing allows consideration of using these programmatic data rather than sentinel surveillance data for HIV surveillance.Methods: To gauge Kenya's readiness to discontinue sentinel surveillance, we evaluated whether recommended World Health Organization standards were fulfilled by conducting data and administrative reviews of antenatal clinics that offered both routine testing and sentinel surveillance in 2010.Results: The proportion of tests that were HIV-positive among women aged 15-49 years was 6.2% (95% confidence interval [CI] 4.6-7.7%] in sentinel surveillance and 6.5% (95% CI 5.1-8.0%) in routine testing. The agreement of HIV test results between sentinel surveillance and routine testing was 98.0%, but 24.1% of specimens that tested positive in sentinel surveillance were recorded as negative in routine testing. Data completeness was moderate, with HIV test results recorded for 87.8% of women who received routine testing.Conclusions: Additional preparation is required before routine antenatal HIV testing data can supplant sentinel surveillance in Kenya. As the quality of program data has markedly improved since 2010 a repeat evaluation of the use of routine antenatal HIV testing data in lieu of ANC sentinel surveillance is recommended. [ABSTRACT FROM AUTHOR]

Background: Kenya has a high burden of maternal and newborn mortality. Consequently, the Government of Kenya introduced health system reforms to promote the availability of skilled birth attendants (SBAs) and proscribed deliveries by traditional birth attendants (TBAs). Despite these changes, only 10% of women from pastoralist communities are delivered by an SBA in a health facility, and the majority are delivered by TBAs at home. The aim of this study is to better understand the practices and perceptions of TBAs and SBAs serving the remotely located, semi-nomadic, pastoralist communities of Laikipia and Samburu counties in Kenya, to inform the development of an SBA/TBA collaborative care model.Methods: This descriptive qualitative study was undertaken in 2013-14. We conducted four focus group discussions (FGDs) with TBAs, three with community health workers, ten with community women, and three with community men. In-depth interviews were conducted with seven SBAs and eight key informants. Topic areas covered were: practices and perceptions of SBAs and TBAs; rewards and challenges; managing obstetric complications; and options for SBA/TBA collaboration. All data were translated, transcribed and thematically analysed.Results: TBAs are valued and accessible members of their communities who adhere to traditional practices and provide practical and emotional support to women during pregnancy, delivery and post-partum. Some TBA practices are potentially harmful to women e.g., restricting food intake during pregnancy, and participants recognised that TBAs are unable to manage obstetric complications. SBAs are acknowledged as having valuable technical skills and resources that contribute to safe and clean deliveries, especially in the event of complications, but there is also a perception that SBAs mistreat women. Both TBAs and SBAs identified a range of challenges related to their work, and instances of mutual respect and informal collaborations between SBAs and TBAs were described.Conclusions: These findings clearly indicate that an SBA/TBA collaborative model of care consistent with Kenyan Government policy is a viable proposition. The transition from traditional birth to skilled birth attendance among the pastoralist communities of Laikipia and Samburu is going to be a gradual one, and an interim collaborative model is likely to increase the proportion of SBA assisted deliveries, improve obstetric outcomes, and facilitate the transition. [ABSTRACT FROM AUTHOR]

Background: Poor quality of care at health facilities is a barrier to pregnant women and their families accessing skilled care. Increasing evidence from low resource countries suggests care women receive during labor and childbirth is sometimes rude, disrespectful, abusive, and not responsive to their needs. However, little is known about how frequently women experience these behaviors. This study is one of the first to report prevalence of respectful maternity care and disrespectful and abusive behavior at facilities in multiple low resource countries.Methods: Structured, standardized clinical observation checklists were used to directly observe quality of care at facilities in five countries: Ethiopia, Kenya, Madagascar, Rwanda, and the United Republic of Tanzania. Respectful care was represented by 10 items describing actions the provider should take to ensure the client was informed and able to make choices about her care, and that her dignity and privacy were respected. For each country, percentage of women receiving these practices and delivery room privacy conditions were calculated. Clinical observers' open-ended comments were also analyzed to identify examples of disrespect and abuse.Results: A total of 2164 labor and delivery observations were conducted at hospitals and health centers. Encouragingly, women overall were treated with dignity and in a supportive manner by providers, but many women experienced poor interactions with providers and were not well-informed about their care. Both physical and verbal abuse of women were observed during the study. The most frequently mentioned form of disrespect and abuse in the open-ended comments was abandonment and neglect.Conclusions: Efforts to increase use of facility-based maternity care in low income countries are unlikely to achieve desired gains if there is no improvement in quality of care provided, especially elements of respectful care. This analysis identified insufficient communication and information sharing by providers as well as delays in care and abandonment of laboring women as deficiencies in respectful care. Failure to adopt a patient-centered approach and a lack of health system resources are contributing structural factors. Further research is needed to understand these barriers and develop effective interventions to promote respectful care in this context. [ABSTRACT FROM AUTHOR]

Background: Globally, there are increasing efforts to improve maternal health outcomes including the reduction in maternal mortality rates. Improved access to skilled care utilisation during pregnancy and delivery has been one of the strategies employed to improve maternal health outcomes. In Kenya, more than half of the women deliver without the assistance of a skilled attendant and this has contributed to high maternal mortality rates. The free maternal healthcare services policy in all public facilities was initiated as a strategy to improve access to skilled care and reduce poor maternal health outcomes. This study aimed to explore the perspectives of the service providers and facility administrators of the free maternal health care service policy that was introduced in Kenya in 2013. Methods: A qualitative inquiry using semi-structured one-on-one interviews was conducted in Malindi District, Kenya. The participants included maternal health service providers and facility administrators recruited from five different healthcare facilities. Data were analysed using a thematic framework analysis. Results: Free maternal healthcare service provision was perceived to boost skilled care utilisation during pregnancy and delivery. However, challenges including; delays in the reimbursement of funds by the government to the facilities, stock outs of essential commodities in the facilities to facilitate service provision, increased workload amidst staff shortage and lack of consultation and sensitisation of key stakeholders were perceived as barriers to effective implementation of this policy. Conclusion: Free maternal healthcare services can be one of the strategies to improve a range of maternal health outcomes. However, the implementation of this policy would be more effective if; the healthcare facilities were upgraded, equipped with adequate supplies, funds and staff; the community are continually sensitized on the importance of seeking skilled care during pregnancy and delivery; and inclusivity and collaboration with other key stakeholders be fostered in addressing poor maternal health outcomes in the country. [ABSTRACT FROM AUTHOR]

Background: Increases in the proportion of facility-based deliveries have been marginal in many low-income countries in the African region. Preliminary clinical and anthropological evidence suggests that one major factor inhibiting pregnant women from delivering at facility is disrespectful and abusive treatment by health care providers in maternity units. Despite acknowledgement of this behavior by policy makers, program staff, civil society groups and community members, the problem appears to be widespread but prevalence is not well documented. Formative research will be undertaken to test the reliability and validity of a disrespect and abuse (D&A) construct and to then measure the prevalence of disrespect and abuse suffered by clinic clients and the general population. Methods/design: A quasi-experimental design will be followed with surveys at twelve health facilities in four districts and one large maternity hospital in Nairobi and areas before and after the introduction of disrespect and abuse (D&A) interventions. The design is aimed to control for potential time dependent confounding on observed factors. Discussion: This study seeks to conduct implementation research aimed at designing, testing, and evaluating an approach to significantly reduce disrespectful and abusive (D&A) care of women during labor and delivery in facilities. Specifically the proposed study aims to: (i) determine the manifestations, types and prevalence of D&A in childbirth (ii) develop and validate tools for assessing D&A (iii) identify and explore the potential drivers of D&A (iv) design, implement, monitor and evaluate the impact of one or more interventions to reduce D&A and (v) document and assess the dynamics of implementing interventions to reduce D&A and generate lessons for replication at scale. [ABSTRACT FROM AUTHOR]

Introduction: Skilled birth attendance (SBA) and measles immunization reflect two aspects of a health system. In Kenya, their national coverage gaps are substantial but could be largely improved if the total population had the same coverage as the wealthiest quintile. A decomposition analysis allows identifying the factors that influence these wealth-related inequalities in order to develop appropriate policy responses. The main objective of the study was to decompose wealth-related inequalities in SBA and measles immunization into their contributing factors. Methods: Data from the Kenyan Demographic and Health Survey 2008/09 were used. The study investigated the effects of socio-economic determinants on [1] coverage and [2] wealth-related inequalities of SBA utilization and measles immunization. Techniques used were multivariate logistic regression and decomposition of the concentration index (C). Results: SBA utilization and measles immunization coverage differed according to household wealth, parent's education, skilled antenatal care visits, birth order and father's occupation. SBA utilization further differed across provinces and ethnic groups. The overall C for SBA was 0.14 and was mostly explained by wealth (40%), parent's education (28%), antenatal care (9%), and province (6%). The overall C for measles immunization was 0.08 and was mostly explained by wealth (60%), birth order (33%), and parent's education (28%). Rural residence (-19%) reduced this inequality. Conclusion: Both health care indicators require a broad strengthening of health systems with a special focus on disadvantaged sub-groups. [ABSTRACT FROM AUTHOR]

Background: Healthcare worker absenteeism is common in resource limited settings and contributes to poor quality of care in maternal and child health service delivery. There is a dearth of qualitative information on the scope, contributing factors, and impact of absenteeism in Kenyan healthcare facilities.Methods: In-depth semi-structured interviews were conducted between July 2015 and June 2016 with 20 healthcare providers in public and private healthcare facilities in Central and Western Kenya. Interviews were audio-recorded, transcribed, coded, and analyzed using an iterative thematic approach.Results: Half of providers reported that absenteeism occurs in both private and public health facilities. Absenteeism was most commonly characterized by providers arriving late or leaving early during scheduled work hours. The practice was attributed to institutional issues including: infrequent supervision, lack of professional consequences, limited accountability, and low wages. In some cases, healthcare workers were frequently absent because they held multiple positions at different health facilities. Provider absences result in increased patient wait times and may deter patients from seeking healthcare in the future.Conclusion: There is a significant need for policies and programs to reduce provider absenteeism in Kenya. Intervention approaches must be cognizant of the contributors to absenteeism which occur at the institutional level. [ABSTRACT FROM AUTHOR]

Background: Maternal and perinatal mortality is a major public health concern across the globe and more so in low and middle-income countries. In Kenya, more than 6000 maternal deaths, and 35,000 stillbirths occur each year. The Government of Kenya abolished user fee for maternity care under the Free Maternity Service policy, in June of 2013 in all public health facilities, a move to make maternity services accessible and affordable, and to reduce maternal and perinatal mortality.Method: An observational retrospective study was carried out in 3 counties in Kenya. Six maternal health output indicators were observed monthly, 2 years pre and 2 years post- policy implementation. Data was collected from daily maternity registers in 90 public health facilities across the 3 counties all serving an estimated population of 3 million people. Interrupted Time Series Analysis (ITSA) with a single group was used to assess the effects of the policy. Standard linear regression using generalized least squares (gls) model, was used to run the results for each of the six variables of interest. Absolute and relative changes were calculated using the gls model coefficients.Results: Significant sustained increase of 89, 97, and 98% was observed in the antenatal care visits, health facility deliveries, and live births respectively, after the policy implementation. An immediate and significant increase of 27% was also noted for those women who received Emergency Obstetric Care (EmONC) services in either the level 5, 4 and 3 health facilities. No significant changes were observed in the stillbirth rate and caesarean section rate following policy implementation.Conclusion: After 2 years of implementing the Free Maternity Service policy in Kenya, immediate and sustained increase in the use of skilled care during pregnancy and childbirth was observed. The study suggest that hospital cost is a major expense incurred by most women and their families whilst seeking maternity care services and a barrier to maternity care utilization. Overall, Free Maternity Service policy, as a health financing strategy, has exhibited the potential of realizing the full beneficial effects of maternal morbidity and mortality reduction by increasing access to skilled care. [ABSTRACT FROM AUTHOR]

Background: An understanding of the association between adolescent nutrition, adolescent pregnancy and their quest for healthcare services may elucidate a basis for intervention and formulation of programs that enhance post-partum and increase the lifespan of the newborn, improve the quality of life and bridge morbidity, mortality and healthcare-associated cost. However, the nutritional needs of pregnant and lactating adolescent girls aged below 10 years resident in Trans Mara East Sub-County, Kenya remained unestablished. The objective of this study was to assess the nutritional needs of pregnant and lactating adolescent girls (under 19) when accessing and utilizing nutritional advice and services in Trans-Mara East Sub-County, Narok County.Methods: The study adopted a cross-sectional approach that employed mixed methods with both quantitative and qualitative research approaches. Cochran formula was applied to arrive at a minimum of 291 households. Probability proportionate to size sampling techniques using cluster and simple random methods were used to practically access adolescents who are pregnant or lactating. Data was collected using questionnaires, in-depth interview and Focus Group Discussion. Quantitative data was analyzed descriptively using frequencies and inferentially using odds ratio and z-test. Framework analysis was employed to analyze qualitative data. p ≤ 0.05 was considered statistically significant.Results: The study revealed that access of pieces of nutritional-related advice represented by 67.8% was significantly higher than expected frequency of 50%. Nutrition supplementation, food fortification or blending and complementary feeding were significantly below the expectant frequency (p < 0.01) of 50%. Nutrition service areas such as provision and collection of vitamin A and IFAS were significantly lower than expected frequency (p < 0.01).Conclusions: The most widely utilized were nutrition services that falls within the preventive-focused services followed by curative-focused services. Nutritionist and nurse more likely to increase overall utilization of nutrition services. [ABSTRACT FROM AUTHOR]

Background: Globally, there has been increasing attention to women's experiences of care and calls for a person-centered care approach. At the heart of this approach is the patient-provider relationship. It is necessary to examine the extent to which providers and women agree on the care that is provided and received. Studies have found that incongruence between women's and providers' perceptions may negatively impact women's compliance, satisfaction, and future use of health facilities. However, there are no studies that examine patient and provider perspectives on person-centered care. Methods: To fill this gap in the literature, we use cross-sectional data of 531 women and 33 providers in seven government health facilities in Kenya to assess concordance and discordance in person-centered care measures. Additionally, we analyze 41 in-depth interviews with providers from three of these facilities to examine why differences in reporting may occur. Descriptive statistical methods were used to measure the magnitude of differences between reports of women and reports of providers. Thematic analyses were conducted for provider surveys. Results: Our findings suggest high discordance between women and providers' perspectives in regard to person-centered care experiences. On average, women reported lower levels of person-centered care compared to providers, including low respectful and dignified care, communication and autonomy, and supportive care. Providers were more likely to report higher rates of poor health facility environment such as having sufficient staff. We summarize the overarching reasons for the divergence in women and provider reports as: 1) different understanding or interpretation of person-centered care behaviors, and 2) different expectations, norms or values of provider behaviors. Providers rationalized abuse towards women, did not allow a companion of choice, and blamed women for poor patient-provider communication. Women lacked assurance in privacy and confidentiality, and faced challenges related to the health facility environment. Providers attributed poor person-centered care to both individual and facility/systemic factors. Conclusions: Implications of this study suggests that providers should be trained on person-centered care approaches and women should be counseled on understanding patient rights and how to communicate with health professionals. [ABSTRACT FROM AUTHOR]

Background: Maternal and neonatal survival are key components of population health and may be particularly vulnerable in humanitarian contexts of civil unrest and displacement. Understanding what factors contribute to poor health outcomes throughout the reproductive life cycle and across the continuum of care is crucial for improving health programming in acute and protracted refugee settings. Methods: We undertook a mixed-methods baseline assessment of factors related to maternal and neonatal health among refugees living in the Dadaab refugee complex in eastern Kenya. The qualitative component included 23 focus group discussions with 207 community members and 22 key informant interviews with relevant UN and non-governmental organization staff, community leaders, health managers, and front-line health care providers. We analysed qualitative data for content and themes using inductive and deductive techniques. Results: Taking a life course perspective, we found that the strong desire for large families and the primary social role of the woman as child bearer impacted maternal and neonatal health in the camps through preferences for early marriage, low demand for contraception, and avoidance of caesarean sections. Participants described how a strong fear of death, disability, and reduced fecundity from caesarean sections results in avoidance of the surgery, late presentation to the health facility in labour, and difficulty gaining timely informed consent. Mistrust of health service providers also played a role in this dynamic. In terms of newborn care practices, while breastfeeding is culturally supported and women increasingly accept feeding colostrum to the newborn, mixed feeding practices and application of foreign substances to the umbilicus continue to present risks to newborn health in this community. Conclusions: The findings from our study showcase the role that specific sociocultural beliefs and practices and perceptions of health care services have on maternal and neonatal health. An in-depth understanding of how these factors impact the utilization of biomedical health services provides valuable information for targeted improvements in health service provision that are tailored to the local context. [ABSTRACT FROM AUTHOR]

Background: Research suggests that birth companionship, and in particular, continuous support during labor and delivery, can improve women's childbirth experience and birth outcomes. Yet, little is known about the extent to which birth companionship is practiced, as well as women and providers' perceptions of it in low-resource settings. This study aimed to assess the prevalence and determinants of birth companionship, and women and providers' perceptions of it in health facilities in a rural County in Western Kenya.Methods: We used quantitative and qualitative data from 3 sources: surveys with 877 women, 8 focus group discussions with 58 women, and in-depth interviews with 49 maternity providers in the County. Eligible women were 15 to 49 years old and delivered in the 9 weeks preceding the study.Results: About 88% of women were accompanied by someone from their social network to the health facility during their childbirth, with 29% accompanied by a male partner. Sixty-seven percent were allowed continuous support during labor, but only 29% were allowed continuous support during delivery. Eighteen percent did not desire companionship during labor and 63% did not desire it during delivery. Literate, wealthy, and employed women, as well as women who delivered in health centers and did not experience birth complications, were more likely to be allowed continuous support during labor. Most women desired a companion during labor to attend to their needs. Reasons for not desiring companions included embarrassment and fear of gossip and abuse. Most providers recommended birth companionship, but stated that it is often not possible due to privacy concerns and other reasons mainly related to distrust of companions. Providers perceive companions' roles more in terms of assisting them with non-clinical tasks than providing emotional support to women.Conclusion: Although many women desire birth companionship, their desires differ across the labor and delivery continuum, with most desiring companionship during labor but not at the time of delivery. Most, however, don't get continuous support during labor and delivery. Interventions with women, companions, and providers, as well as structural and health system interventions, are needed to promote continuous support during labor and delivery. [ABSTRACT FROM AUTHOR]