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Reducing barriers associated with maternal health service use, household water treatment, and improved hygiene is important for maternal and neonatal health outcomes. We surveyed a sample of 201 pregnant women who participated in a clinic-based intervention in Kenya to increase maternal health service use and improve household hygiene and nutrition through the distribution of water treatment products, soap, protein-fortified flour, and clean delivery kits. From multivariable logistic regression analyses, the adjusted odds of ? 4 antenatal care (ANC4+) visits (odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.9-4.5), health facility delivery (OR = 5.3, 95% CI = 3.4-8.3), and any postnatal care visit (OR = 2.8, 95% CI = 1.9-4.2) were higher at follow-up than at baseline, adjusting for demographic factors. Women who completed primary school had higher odds of ANC4+ visits (OR = 1.8, 95% CI = 1.1-2.9) and health facility delivery (OR = 4.2, 95% CI = 2.5-7.1) than women with less education. For women who lived ? 2.5 km from the health facility, the estimated odds of health facility delivery (OR = 2.4, 95% CI = 1.5-4.1) and postnatal care visit (OR = 1.6, 95% CI = 1.0-2.6) were higher than for those who lived > 2.5 km away. Compared with baseline, a higher percentage of survey participants at follow-up were able to demonstrate proper handwashing (P = 0.001); water treatment behavior did not change. This evaluation suggested that hygiene, nutritional, clean delivery incentives, higher education level, and geographical contiguity to health facility were associated with increased use of maternal health services by pregnant women.
In March 2011, we conducted a baseline cross-sectional survey of pregnant women to determine their use of maternal health services, water, and hygiene practices. The intervention was implemented in 25 health facilities after the baseline survey, and in March 2012, we conducted a follow-up survey with participants enrolled at baseline. Because of logistical and financial constraints, the surveys were limited to 12 of 25 health facilities, all within a 3-hour drive of Mbita, the district seat of government. To assess the reliability of the survey data, we also abstracted data for all patients from the antenatal registers in health facilities for 12 months preintervention (March 2010–February 2011) and during the 12-month intervention period (March 2011–February 2012). In collaboration with the Kenyan Ministry of Health and SWAP, we selected Suba and Mbita districts in Nyanza Province for the project because of poor reproductive health service use in these districts. We targeted 25 health facilities that together served approximately 2,000 pregnant women per year for program implementation. We excluded four health facilities from the review of antenatal register data: two on remote islands that were difficult to reach because of distance, time, and unreliable transport, and two that had no registry data for more than 6 months of the preintervention period. Based on previous health intervention studies in western Kenya, we assumed that confirmed water treatment would increase from 5% to 15%, with a confidence level of 95%, a power of 80%, and a design effect of 2 (for clustering of women by health facility), resulting in a sample size of 328 pregnant women.8–10 To account for a possible loss to follow-up of 20%, we increased the target sample size to 400 pregnant women. The median number of women projected to be enrolled per health facility was 13 (range 9–36). We attempted to enroll pregnant women ≥ 14 years of age presenting to antenatal clinic in the 12 selected health facilities, as pregnant women ≥ 14 years of age are classified as emancipated minors in Kenya. We aimed for the number of enrolled women per clinic to be proportional to the average monthly attendance per clinic relative to the entire sample of 12 clinics. Women who consented to participate were interviewed at the clinic, and then visited at home to observe their household water, sanitation, and hygiene practices at enrollment. They were also told that they would receive a home visit after approximately 12 months for a follow-up survey. Enumerators fluent in Dholuo and English used a standardized questionnaire at baseline to interview respondents during their first ANC visit about demographic and socioeconomic characteristics; current utilization of antenatal services; past utilization of antenatal, delivery, and postnatal services; water sources, storage, and treatment; and hygiene practices. We also made observations of water storage containers, water treatment products (if any), soap, and handwashing procedure (correct procedure was defined as using soap, lathering, and drying hands with a clean towel). We tested stored drinking water in all homes for residual chlorine using the N,N-diethyl-p-phenylenediamine colorimetric method (LaMotte Co., Baltimore, MD) as an objective measure of chlorination. Program implementation included several components. First, to help improve the quality of care at project health facilities, a 1-week training course on managing obstetric emergencies, neonatal resuscitation, patient-centered care, rapid syphilis testing and treatment, water treatment, and handwashing with soap was provided to nurses and clinical officers after the baseline survey. Second, each clinic received a bulb syringe for neonatal suctioning, an ambu-bag for neonatal resuscitation, and handwashing and drinking water stations. Third, to serve as incentives for attendance at maternal health services, the Kenyan Ministry of Health and SWAP gave free hygiene kits (WaterGuard water treatment solution or P & G Purifier of Water [Procter and Gamble Co., Cincinnati, OH], and soap) to mothers at their first and third ANC visits, protein-fortified flour at their second and fourth ANC visits, and a clean delivery kit (surgical gloves, a sterile razor blade, a clean cord tie, swaddling cloth, water storage container with a tap, and a hygiene kit) at the time of delivery in health facilities.11,12 Finally, all women were offered free screening with a rapid syphilis test kit and treatment of women testing positive during their initial ANC visit. By providing testing and treatment services that were not typically offered because of a lack of supplies, the syphilis program served as an incentive for women to attend ANC.13 The incentives described above were provided to pregnant women at antenatal visits, delivery in a health facility, and postnatal check-up. Women also received reproductive health education from local providers. Throughout the implementation phase of the program, we communicated with health facility personnel through weekly short message service (SMS) texting, telephone calls, and monthly clinic visits to monitor distribution of incentives and use of services. In March 2012, we conducted a follow-up home visit to women enrolled at baseline to assess their maternal health service use and household water treatment and hygiene practices. The follow-up questionnaire included questions from the baseline survey and several additional queries about maternal health service use and incentives received. To determine whether antenatal and delivery register data captured similar results to the survey, we abstracted data on the number of women with four or more antenatal visits (ANC4+), first recommended intermittent preventive treatment of malaria (IPT1), second IPT (IPT2), health facility deliveries, and postnatal check-ups from the antenatal registers in participating intervention health facilities for 1 year preintervention (March 2010–February 2011) and during the intervention period (March 2011–February 2012). Data from baseline and follow-up surveys were collected electronically using Visual CE software (Syware, Inc., Cambridge, MA) on personal digital assistants, entered into a Microsoft Access 2007 database, and analyzed using SAS software version 9.4 (Cary, NC). The primary outcomes of interest included ANC4+ visits, delivery at a health facility, postnatal care visits, visits for IPT1 and IPT2, WaterGuard use, and knowledge of correct handwashing technique. We did not assess P & G Purifier of Water use because distribution was initiated too late in the study to be captured by the survey. Primagravidas were excluded from analysis because there were no previous pregnancies as a basis of comparison. For women lost to follow-up, a χ2 test for independence was used to determine whether they were similar to those included at follow-up. Fisher’s exact P values were reported when a cell count was less than five. Baseline and follow-up survey data were summarized and compared using McNemar’s test for paired participant data. Preintervention ANC registry data were compared with postintervention data with a t test. Because over 97% of women in western Kenya have at least one ANC visit (ANC1), ANC1 was used as a proxy for the denominator of all pregnant women.1,14 Considering data from each health facility separately, we calculated the mean ratios of each outcome to ANC1 visits and compared the means for the preintervention and intervention periods. Multivariable logistic regression using generalized estimating equations were used to assess the association of the intervention (pre versus post) with ANC4+ visits, health facility delivery, and postnatal care visit, adjusting for demographic factors. The demographic factors included age (in years), education (did or did not complete primary school), distance to clinic (≤ 2.5 km and > 2.5 km), and socioeconomic status. As a proxy measure of socioeconomic status, reported household assets were used to calculate wealth index tertiles through principal component analysis.15 Distances from households to clinic were calculated using ArcGIS 10.3.1 (Environmental Systems Research Institute, Redlands, CA). Distance was calculated using the most direct route, and did not account for roads or terrain. A 2.5-km threshold was used to assess distance as a barrier to service use.16,17 Data on the distribution of hygiene kits, nutrition supplies, and clean delivery kits, and utilization of antenatal, labor and delivery, and postnatal services, were obtained through SMS texting, telephone calls, and clinic visits, and described. The institutional review boards at the Kenya Medical Research Institute (protocol 1898) and the Centers for Disease Control and Prevention (protocol 5996) reviewed and approved the study protocol. Informed consent was obtained from all study participants. Personal identifiers were kept in encrypted files and destroyed at the end of the study.
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