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Background: Skilled attendance at delivery is recognized as one of the most important factors in preventing maternal death. However, more than 50% of births in Kenya still occur in non-institutional locations supported by family members and/or traditional birth attendants (TBAs). To improve this situation, a study of the determinants of facility delivery, including individual, family and community factors, was necessary to consider effective intervention in Kenya.Methods: This study was conducted to identify the factors which influence the place of delivery in rural western Kenya, and to recommend ways to improve women’s access to skilled attendants at delivery. A community-based cross-sectional survey was carried out from August to September 2011 in all 64 sub-locations which were covered by community health workers (CHWs). An interviewer-administered questionnaire on seventeen comprehensive variables was administered to 2,560 women who had children aged 12-24 months.Results: The response rate was 79% (n = 2,026). Of the respondents, 48% of births occurred in a health facility and 52% in a non-institutional location. The significant determinants of facility delivery examined using multivariate analysis were: maternal education level, maternal health knowledge, ANC visits, birth interval, economic status of household, number of household members, household sanitation practices and traveling time to nearest health facility.Conclusions: The results suggest that the involvement of TBAs to promote facility delivery is still one of the most important strategies. Strengthening CHWs’ performance by focusing on a limited number of topics and clear management guidance might also be an effective intervention. Stressing the importance of regular attendance at ANC (at least four times) would be effective in enhancing motivation for a facility delivery. Based on our findings, those actions to improve the facility delivery rate should focus more on pregnant women who have a low education level, poor health knowledge and short pregnancy spacing. In addition, women with low economic status, a large number of family members and a long distance to travel to a health facility should also be targeted by further interventions.
This study was conducted from August to September, 2011 in all 64 community units covered by community health workers (CHWs), who have been identified as Level One of the health system in Kenya since 2006 [24] and had been volunteering since May, 2011 in Siaya, Ugenya, Gem and Kisumu West districts, Nyanza Province, Kenya. The MOH identified a six-tier health system, in which the Community Unit (level 1) is the proximal implementation unit to promote primary health care services. The range of the population in each CU was from around 2,000 to 10,000 according to the geographical context. The dispensary and health centers (levels 2 and 3 of the Kenyan health system) are engaged in both preventive and curative care. The higher-level hospitals (levels 4, 5 and 6) put more focus on curative and rehabilitative aspects than other levels [25]. The facilities at level 2 and higher provide health services for childbirth. Twenty-four-hour health services are provided at level 3 and above in the Kenyan health system. CHWs were selected and endorsed by the Community Health Committee, which was democratically elected as a governing body of the Community Unit. Their main activities are door-to-door canvassing to teach health-related preventive methods and collect health-related data from each household. This area is mainly inhabited by subsistence farmers and fishermen. The main ethnic group is Luo and their principal language is the Luo language, followed by Swahili and English. The research population consisted of all mothers who had children aged 12–23 months in this research area. The sample size was calculated assuming the following points: that 80% power to demonstrate an odds ratio of 1.4 to be significant at the 5% level, if the ratio exposed: unexposed is 1:1 and the prevalence of the outcome is 42.6% in the unexposed. This calculated a sample size of 1,120. In addition to taking the cluster design effect and missing data into consideration, the final sample size was 2,560. A community-based cross-sectional survey was conducted from August to September, 2011 as a benchmark for the impact assessment of the interventions by the JICA SEMAH project under authorization from MOH, Kenya. A total of 11,906 mothers who had children aged 12–23 months were identified by CHWs in the 64 sub-locations in August, 2011. Forty mothers in each sub-location were selected using random-sampling methods. Finally 2,560 mothers were targeted and were asked, using an interviewer-administered questionnaire, to assess their socio-economic status, their health-seeking behavior and their sanitation practice. Social capital was measured by the standard questionnaire [26]. Most of the variables were mentioned in the study [6]. In addition, the mothers were asked about the number of times CHWs visited their household and their satisfaction score regarding these visits, to generate an indicator of the CHWs’ performance. The research assistants, not CHWs, were recruited from each sub-location. All were high school graduates (12 years of education) and had previous similar experience of data collection. Furthermore, one day of intensive training, including guidance in data-collection procedures and pre-testing the questionnaire, was conducted. The outcome variable in this study was the place of delivery for pregnant women. While deliveries at any level of health facility (dispensary, health center and hospital or higher level) were considered institutional deliveries, deliveries anywhere other than an institution, including TBA or kinship homes, were considered non-institutional deliveries. To assess maternal health knowledge, the mothers were asked about the vaccination schedule, danger signs and risk factors in pregnancy and HIV/malaria preventive methods. After scoring by the Clinical Officer, this variable was classified into three levels: low, middle and high. The household wealth index was evaluated using three variables: household assets (e.g. cell phone, television, bicycle, etc.), house materials for the walls, floor and roof, and monthly salary. If they had more than three items out of six household assets, we scored one. If not, we scored zero. If the house materials for the wall, floor and roof were good, we scored one in each variable. This means the maximum score for household materials was three. The monthly salary was also scored in three levels as 0: less than 3,300 KSh; 1: 3,301-5,300 KSh; and 2: higher than 5,300 KSh. The sum of the three variables was calculated and divided into quintiles. An indicator on the CHWs’ performance was generated by using both frequency of visitation to households and the satisfaction score as reported by the target mothers. Frequency of household visitation was scored as follows:- 0: less than once per month; 1: once per month; 2: more than once per month. Mothers were also asked to specify their level of satisfaction with the CHWs’ performance using a five-point Likert scale, divided as low (0), moderate (1) or high (2). Finally, the variable of the CHWs’ performance was generated by adding the score of the household visitation and the score of satisfaction, and categorized into five quintiles as: poorest (0), poor (1), moderate (2), high (3) and highest (4). Social capital was measured using the standard questionnaire [26]. In this study, social capital consists of two main areas: informal social control, and social cohesion and trust. Each area was represented by a five-point Likert scale. The average score of 10 questions was calculated and classified as: lowest (0), low (1), moderate (2), high (3) and highest (4). Media and communication equipment was scored by possession of radio, TV and cell phone, and classified as: Possession of one piece of equipment or none (0), two pieces of equipment (1) and all three pieces of equipment (2). In addition, household sanitation practice was scored by using three indicators, i.e. having a toilet, hand-washing facility and a dish rack. They were grouped as: none (0), possession of one out of the three facilities (1), possession of two (2), and possession of all (3). Data were verified by a double-entry method and stored using Epi Info version 3.5. Statistical analysis was performed using STATA version 12 (STATA Corporation, TX, USA). The confidence level was set at 95%. Bivariable analyses were conducted in order to assess the association between their delivery place and the community, family, and individual variables. All 17 independent variables were entered into multiple logistic regression analysis and the final model was selected by a backward elimination strategy. The data was weighted with consideration of complex sampling design during the bivariable and multiple logistic regression analysis. Informed consents from all participants were obtained after full explanation of the study design and purposes. This research was approved by Great Lake University of Kisumu (GLUK) Ethical Review Committee (GERC) in Kenya.
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