Effects of the COVID-19 pandemic on antenatal care utilisation in Kenya: A cross-sectional study

BMJ Open, Volume 12, No. 4, Year 2022

Interpretation

Objective The aim of this study was to assess the effects of COVID-19 on antenatal care (ANC) utilisation in Kenya, including women’s reports of COVID-related barriers to ANC and correlates at the individual and household levels. Design Cross-sectional study. Setting Six public and private health facilities and associated catchment areas in Nairobi and Kiambu Counties in Kenya. Participants Data were collected from 1729 women, including 1189 women who delivered in healthcare facilities before the COVID-19 pandemic (from September 2019-January 2020) and 540 women who delivered during the pandemic (from July through November 2020). Women who delivered during COVID-19 were sampled from the same catchment areas as the original sample of women who delivered before to compare ANC utilisation. Primary and secondary outcome measures Timing of ANC initiation, number of ANC visits and adequate ANC utilisation were primary outcome measures. Among only women who delivered during COVID-19 only, we explored women’s reports of the pandemic having affected their ability to access or attend ANC as a secondary outcome of interest. Results Women who delivered during COVID-19 had significantly higher odds of delayed ANC initiation (ie, beginning ANC during the second vs first trimester) than women who delivered before (aOR 1.72, 95% CI 1.24 to 2.37), although no significant differences were detected in the odds of attending 4-7 or ≥8 ANC visits versus <4 ANC visits, respectively (aOR 1.12, 95% CI 0.86 to 1.44 and aOR 1.46, 95% CI 0.74 to 2.86). Nearly half (n=255/540; 47%) of women who delivered during COVID-19 reported that the pandemic affected their ability to access ANC. Conclusions Strategies are needed to mitigate disruptions to ANC among pregnant women during pandemics and other public health, environmental, or political emergencies. This study uses non-representative, cross-sectional data from two samples of participants: (1) women recruited within 7 days of delivery while admitted/on discharge at one of six participating facilities (three public hospitals, two private hospitals and one health centre) in Nairobi and Kiambu Counties from September 2019 through January 2020 (ie, prior to the onset of the COVID-19 pandemic; n=1197)17 and (2) women residing in catchment areas of these same six participating facilities, who delivered since pandemic-related restrictions were mandated in Kenya (ie, from March 16, 2020; n=1135).18 The latter sample was recruited with the specific intent of understanding the effects of COVID-19 on maternal and newborn health by leveraging the existing data among the sample of postpartum women surveyed just prior to the start of the pandemic. Additional information about both samples, including eligibility and recruitment procedures, can be found in previous publications.17 18 In short, eligible participants in both samples were those aged 15–49 years who had delivered a singleton birth within the specified timeframe and had access to a functional phone to allow for follow-up. Vaginal delivery was an additional eligibility criterion among the sample of women who delivered before COVID-19.17 The sample of women who delivered before COVID-19 were conveniently sampled in partnership with facility staff working in the postnatal wards. All women in the postnatal ward during working hours who were still admitted or at discharge were approached to learn about the study and determine interest and eligibility; among the 1357 women approached, a total of 1197 consented and enrolled (88.2%) in this previous study which assessed women’s receipt of person-centred maternity care and its association with maternal and newborn health outcomes. The sample of women who delivered during COVID-19 was conveniently sampled through engagement with community health volunteers and local village leaders and completed the survey in November 2020; among the 1182 women contacted by phone, a total of 1135 consented and enrolled in the study (96.0%).18 An experienced team of nine female enumerators participated in a 3-day, virtual training on the study protocol and survey tools. This was followed by a 1 day piloting exercise among 30 women for the enumerators to practice the study consent, assess and refine the survey flow and test study logistics and quality check procedures. Participants were contacted by phone for both the consent and a one-time, 30-min survey, though participants had the option for scheduling a separate time for the survey to be administered. For those unable to be reached, a total of nine attempts were made across different days and times. Participants received the equivalent of approximately US$1.00 (US dollar) of airtime as a token of appreciation. The primary outcomes of interest were: timing of ANC initiation, total number of ANC visits and adequate ANC utilisation. Items on the number and timing of antenatal visits were adapted from the 2014 Kenya Demographic and Health Survey.6 The timing of ANC initiation was measured by asking women approximately how many months or weeks pregnant they were when they attended their first ANC appointment. A categorical variable was then created to capture if ANC began in the first, second or third trimester. The total number of ANC visits was a categorical variable capturing whether women attended <4, 4–7 or ≥8 visits. Finally, information on the timing of ANC initiation and the total number of ANC visits was used to create a binary variable capturing whether women achieved adequate ANC utilisation, defined as initiating ANC during the first trimester and attending at least four visits (1=yes, 0=no). Among women who delivered during COVID-19 only, we explored whether women reported the pandemic to have affected their ability to access or attend ANC (1=yes, 0=no) as a secondary outcome of interest. We also included information on individual and household sociodemographic characteristics, including age, marital status, educational attainment, employment status, self-rated health and parity. Women who delivered during COVID-19 were asked about household food insecurity using the Household Food Insecurity Access Scale,19 and assigned a score (ranging 0–6) reflecting how many household food insecurity indicators were endorsed (Cronbach’s α=0.80). Women were also asked how the pandemic affected their ability to access or attend ANC. The analytic sample was first restricted to those with complete information on ANC measures (n=8/1197 missing among women who delivered before COVID-19 and n=13/1135 missing among women who delivered during COVID-19). To ensure that a substantial portion of the gestational period occurred during the pandemic (as opposed to a significant period of gestation occurring prior to the start of the COVID-19 pandemic and strictest lockdown measures) and would thus be vulnerable to potential COVID-related effects to ANC utilisation, the sample of women who delivered during COVID-19 was further restricted to those who delivered from July 2020 through the end of the study period in November 2020. This resulted in an additional 582 women who delivered from March 16 through June 2020 being excluded and a final analytic sample of 1189 women who delivered before and 540 women who delivered during COVID-19. Data were analysed using descriptive, bivariate and multivariable statistics using StataSE V.15. Pearson χ2 tests were used to examine differences in the distribution of demographic characteristics and measures of ANC utilisation across study samples. Multivariable logistic regression models were used to assess the relationship between study sample and timing of ANC initiation, number of ANC visits and adequate ANC utilisation, respectively, after controlling for individual level characteristics. Sensitivity analyses were conducted to examine the robustness of the models when restricting the sample of women who delivered during COVID-19 to those who delivered from August through November 2020 (n=372) and then September through November 2020 (n=234), respectively. These groups represent those whose gestational periods would have most significantly overlapped with the pandemic (ie, most or all of their pregnancy occurred after 16 March 2020). A multivariable logistic regression model was also used to assess factors associated with women reporting COVID-19 to affect accessing or attending ANC. The Institutional Review Boards at the University of California, Los Angeles (UCLA) and Kenya Medical Research Institute (KEMRI) approved all study procedures and all women provided verbal consent. Patients and members of the public were not involved in the design of this research; however, members of the public, including community health volunteers and local village leaders in study catchment areas, were involved in the recruitment of women who had delivered during the pandemic. These members of the public were also provided a policy brief of key study findings to disseminate to stakeholders within their communities.

AI Digest

Study Justification:

The study aimed to assess the effects of the COVID-19 pandemic on antenatal care (ANC) utilization in Kenya. This is important because disruptions to ANC can have negative impacts on maternal and newborn health outcomes. Understanding the barriers and correlates of ANC utilization during the pandemic can help inform strategies to mitigate these disruptions and ensure the well-being of pregnant women.

Highlights:

– The study found that women who delivered during the COVID-19 pandemic had higher odds of delayed ANC initiation compared to women who delivered before the pandemic.
– There were no significant differences in the odds of attending a sufficient number of ANC visits between the two groups.
– Nearly half of the women who delivered during the pandemic reported that the pandemic affected their ability to access ANC.
– The study highlights the need for strategies to mitigate disruptions to ANC during pandemics and other emergencies.

Recommendations:

– Develop and implement targeted interventions to promote timely ANC initiation among pregnant women during pandemics and emergencies.
– Strengthen health systems to ensure continued access to ANC services during crises, including improving transportation and communication infrastructure.
– Provide adequate resources and support to healthcare facilities and providers to meet the increased demand for ANC services during emergencies.
– Enhance community engagement and awareness campaigns to educate pregnant women about the importance of ANC and address any concerns or misconceptions related to pandemics.

Key Role Players:

– Ministry of Health: Responsible for developing and implementing policies and guidelines related to ANC during emergencies.
– Healthcare Facilities: Provide ANC services and need to ensure continuity of care during pandemics and emergencies.
– Community Health Volunteers: Play a crucial role in disseminating information and promoting ANC utilization among pregnant women in their communities.
– Local Village Leaders: Can help facilitate community engagement and support ANC initiatives.

Cost Items for Planning Recommendations:

– Transportation: Budget for transportation services to ensure pregnant women can access ANC facilities during emergencies.
– Communication Infrastructure: Allocate funds for improving communication infrastructure to facilitate timely and effective communication between healthcare providers and pregnant women.
– Training and Capacity Building: Invest in training programs for healthcare providers to enhance their skills and knowledge in managing ANC during emergencies.
– Community Engagement and Awareness Campaigns: Allocate resources for community engagement activities, including awareness campaigns and educational materials.
– Additional Staffing: Consider the need for additional healthcare staff to meet the increased demand for ANC services during emergencies.
Please note that the cost items provided are general suggestions and may vary depending on the specific context and needs of the healthcare system in Kenya.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional study design, which limits the ability to establish causality. However, the study includes a large sample size and provides statistical analysis to support the findings. To improve the strength of the evidence, future research could consider using a longitudinal design to track changes in antenatal care utilization over time and explore the potential impact of confounding factors.

Abstract

This study uses non-representative, cross-sectional data from two samples of participants: (1) women recruited within 7 days of delivery while admitted/on discharge at one of six participating facilities (three public hospitals, two private hospitals and one health centre) in Nairobi and Kiambu Counties from September 2019 through January 2020 (ie, prior to the onset of the COVID-19 pandemic; n=1197)17 and (2) women residing in catchment areas of these same six participating facilities, who delivered since pandemic-related restrictions were mandated in Kenya (ie, from March 16, 2020; n=1135).18 The latter sample was recruited with the specific intent of understanding the effects of COVID-19 on maternal and newborn health by leveraging the existing data among the sample of postpartum women surveyed just prior to the start of the pandemic. Additional information about both samples, including eligibility and recruitment procedures, can be found in previous publications.17 18 In short, eligible participants in both samples were those aged 15–49 years who had delivered a singleton birth within the specified timeframe and had access to a functional phone to allow for follow-up. Vaginal delivery was an additional eligibility criterion among the sample of women who delivered before COVID-19.17 The sample of women who delivered before COVID-19 were conveniently sampled in partnership with facility staff working in the postnatal wards. All women in the postnatal ward during working hours who were still admitted or at discharge were approached to learn about the study and determine interest and eligibility; among the 1357 women approached, a total of 1197 consented and enrolled (88.2%) in this previous study which assessed women’s receipt of person-centred maternity care and its association with maternal and newborn health outcomes. The sample of women who delivered during COVID-19 was conveniently sampled through engagement with community health volunteers and local village leaders and completed the survey in November 2020; among the 1182 women contacted by phone, a total of 1135 consented and enrolled in the study (96.0%).18 An experienced team of nine female enumerators participated in a 3-day, virtual training on the study protocol and survey tools. This was followed by a 1 day piloting exercise among 30 women for the enumerators to practice the study consent, assess and refine the survey flow and test study logistics and quality check procedures. Participants were contacted by phone for both the consent and a one-time, 30-min survey, though participants had the option for scheduling a separate time for the survey to be administered. For those unable to be reached, a total of nine attempts were made across different days and times. Participants received the equivalent of approximately US$1.00 (US dollar) of airtime as a token of appreciation. The primary outcomes of interest were: timing of ANC initiation, total number of ANC visits and adequate ANC utilisation. Items on the number and timing of antenatal visits were adapted from the 2014 Kenya Demographic and Health Survey.6 The timing of ANC initiation was measured by asking women approximately how many months or weeks pregnant they were when they attended their first ANC appointment. A categorical variable was then created to capture if ANC began in the first, second or third trimester. The total number of ANC visits was a categorical variable capturing whether women attended <4, 4–7 or ≥8 visits. Finally, information on the timing of ANC initiation and the total number of ANC visits was used to create a binary variable capturing whether women achieved adequate ANC utilisation, defined as initiating ANC during the first trimester and attending at least four visits (1=yes, 0=no). Among women who delivered during COVID-19 only, we explored whether women reported the pandemic to have affected their ability to access or attend ANC (1=yes, 0=no) as a secondary outcome of interest. We also included information on individual and household sociodemographic characteristics, including age, marital status, educational attainment, employment status, self-rated health and parity. Women who delivered during COVID-19 were asked about household food insecurity using the Household Food Insecurity Access Scale,19 and assigned a score (ranging 0–6) reflecting how many household food insecurity indicators were endorsed (Cronbach’s α=0.80). Women were also asked how the pandemic affected their ability to access or attend ANC. The analytic sample was first restricted to those with complete information on ANC measures (n=8/1197 missing among women who delivered before COVID-19 and n=13/1135 missing among women who delivered during COVID-19). To ensure that a substantial portion of the gestational period occurred during the pandemic (as opposed to a significant period of gestation occurring prior to the start of the COVID-19 pandemic and strictest lockdown measures) and would thus be vulnerable to potential COVID-related effects to ANC utilisation, the sample of women who delivered during COVID-19 was further restricted to those who delivered from July 2020 through the end of the study period in November 2020. This resulted in an additional 582 women who delivered from March 16 through June 2020 being excluded and a final analytic sample of 1189 women who delivered before and 540 women who delivered during COVID-19. Data were analysed using descriptive, bivariate and multivariable statistics using StataSE V.15. Pearson χ2 tests were used to examine differences in the distribution of demographic characteristics and measures of ANC utilisation across study samples. Multivariable logistic regression models were used to assess the relationship between study sample and timing of ANC initiation, number of ANC visits and adequate ANC utilisation, respectively, after controlling for individual level characteristics. Sensitivity analyses were conducted to examine the robustness of the models when restricting the sample of women who delivered during COVID-19 to those who delivered from August through November 2020 (n=372) and then September through November 2020 (n=234), respectively. These groups represent those whose gestational periods would have most significantly overlapped with the pandemic (ie, most or all of their pregnancy occurred after 16 March 2020). A multivariable logistic regression model was also used to assess factors associated with women reporting COVID-19 to affect accessing or attending ANC. The Institutional Review Boards at the University of California, Los Angeles (UCLA) and Kenya Medical Research Institute (KEMRI) approved all study procedures and all women provided verbal consent. Patients and members of the public were not involved in the design of this research; however, members of the public, including community health volunteers and local village leaders in study catchment areas, were involved in the recruitment of women who had delivered during the pandemic. These members of the public were also provided a policy brief of key study findings to disseminate to stakeholders within their communities.

Materials

Innovations

Based on the information provided, here are some potential innovations that could be used to improve access to maternal health:

1. Telehealth services: Implementing telehealth services, such as virtual antenatal care visits, can help overcome barriers to accessing healthcare during pandemics or other emergencies. This allows pregnant women to receive necessary care remotely, reducing the need for in-person visits and minimizing the risk of exposure to infectious diseases.

2. Mobile health applications: Developing mobile health applications specifically designed for maternal health can provide pregnant women with important information, reminders, and resources. These apps can offer personalized care plans, track prenatal visits, provide educational materials, and connect women with healthcare providers for virtual consultations.

3. Community health worker programs: Expanding community health worker programs can help bridge the gap between healthcare facilities and pregnant women in remote or underserved areas. Trained community health workers can provide essential antenatal care services, education, and support, ensuring that women receive the care they need closer to their homes.

4. Transportation solutions: Improving transportation options for pregnant women in rural or low-income areas can enhance access to maternal health services. This can include initiatives such as providing affordable transportation vouchers, establishing community-based transportation services, or partnering with ride-sharing companies to offer discounted rides to healthcare facilities.

5. Mobile clinics: Deploying mobile clinics to areas with limited access to healthcare facilities can bring essential antenatal care services directly to pregnant women. These clinics can provide prenatal check-ups, screenings, vaccinations, and health education, reaching women who may otherwise face challenges in accessing healthcare.

6. Public awareness campaigns: Implementing targeted public awareness campaigns can help educate pregnant women and their families about the importance of antenatal care and address any misconceptions or fears related to accessing healthcare during emergencies. These campaigns can use various channels, such as radio, television, social media, and community outreach, to disseminate information and promote the utilization of maternal health services.

It is important to note that the specific implementation of these innovations should be tailored to the local context and take into account the unique challenges and resources available in each setting.

AI Innovations Description

The study titled “Effects of the COVID-19 pandemic on antenatal care utilization in Kenya: A cross-sectional study” aims to assess the impact of the COVID-19 pandemic on antenatal care (ANC) utilization in Kenya, specifically focusing on women’s reports of COVID-related barriers to ANC and the factors influencing ANC utilization.

The study collected data from two samples of participants: (1) women who delivered in healthcare facilities before the COVID-19 pandemic (from September 2019 to January 2020) and (2) women who delivered during the pandemic (from July through November 2020). The participants were recruited from six public and private health facilities and their catchment areas in Nairobi and Kiambu Counties in Kenya.

The primary outcome measures of the study were the timing of ANC initiation, the number of ANC visits, and adequate ANC utilization. The study found that women who delivered during the COVID-19 pandemic had higher odds of delayed ANC initiation compared to women who delivered before the pandemic. However, there were no significant differences in the odds of attending the recommended number of ANC visits.

Furthermore, nearly half of the women who delivered during the COVID-19 pandemic reported that the pandemic affected their ability to access ANC. This highlights the need for strategies to mitigate disruptions to ANC services during pandemics and other emergencies.

The study also collected information on individual and household sociodemographic characteristics, such as age, marital status, educational attainment, employment status, self-rated health, and parity. Additionally, household food insecurity and its impact on ANC utilization were assessed.

The data were analyzed using descriptive, bivariate, and multivariable statistics. Multivariable logistic regression models were used to assess the relationship between study sample and ANC utilization measures, while controlling for individual-level characteristics. Sensitivity analyses were conducted to examine the robustness of the models.

The study was approved by the Institutional Review Boards at the University of California, Los Angeles (UCLA) and the Kenya Medical Research Institute (KEMRI). Verbal consent was obtained from all participants.

In conclusion, the study highlights the need for strategies to address the disruptions to ANC services during pandemics and other emergencies. These strategies should focus on improving access to ANC, addressing barriers faced by pregnant women, and ensuring the timely initiation and completion of ANC visits.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Telemedicine and virtual antenatal care: Implementing telemedicine and virtual antenatal care services can help overcome barriers to accessing healthcare during pandemics or emergencies. This would allow pregnant women to receive medical advice, consultations, and monitoring remotely, reducing the need for in-person visits.

2. Mobile health (mHealth) interventions: Utilize mobile health technologies, such as mobile apps or SMS messaging, to provide pregnant women with information, reminders, and support for antenatal care. These interventions can help educate women about the importance of ANC, provide appointment reminders, and offer guidance on self-care during pregnancy.

3. Community-based outreach programs: Establish community-based outreach programs that involve trained healthcare workers or community health volunteers who can provide antenatal care services directly to pregnant women in their homes or community centers. This can help overcome transportation challenges and ensure that women receive the necessary care.

4. Strengthening health systems: Invest in strengthening health systems, particularly in low-resource settings, to ensure that healthcare facilities are equipped with the necessary resources, infrastructure, and skilled healthcare providers to deliver quality antenatal care services. This includes improving access to essential medicines, medical equipment, and skilled birth attendants.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population group that will be the focus of the simulation, such as pregnant women in a particular region or country.

2. Collect baseline data: Gather relevant data on the current state of access to maternal health services, including indicators such as ANC initiation rates, number of ANC visits, and barriers faced by pregnant women.

3. Define the intervention scenarios: Develop different scenarios based on the recommendations mentioned above. For each scenario, specify the expected changes in access to maternal health services, such as increased ANC initiation rates or reduced barriers to accessing care.

4. Model the impact: Use statistical or mathematical models to simulate the impact of each intervention scenario on the chosen indicators. This may involve analyzing historical data, conducting surveys or interviews, or using existing simulation models.

5. Analyze the results: Evaluate the simulated outcomes for each intervention scenario and compare them to the baseline data. Assess the potential improvements in access to maternal health services, such as increased ANC utilization rates or reduced delays in ANC initiation.

6. Validate the results: Validate the simulation results by comparing them with real-world data or conducting additional studies to assess the feasibility and effectiveness of the recommended interventions.

7. Refine and iterate: Based on the simulation results and validation, refine the recommendations and simulation methodology as needed. Iterate the process to further optimize the interventions and their potential impact on improving access to maternal health.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the available data, resources, and context. Therefore, it is crucial to adapt the methodology to the specific research or implementation setting.

Author

Dima Health

Statistics:

Citations: 6

Identifiers:

DOI: 10.1136/bmjopen-2021-060185

Research Areas:

Community Interventions, COVID, Disparities, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Kenya

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female