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In sub-Saharan Africa, the unprecedented population growth that started in the second half of the twentieth century has evolved into unparalleled urbanization and an increasing proportion of urban dwellers living in slums and shanty towns, making it imperative to pay greater attention to the health problems of the urban poor. In particular, urgent efforts need to focus on maternal health. Despite the lack of reliable trend data on maternal mortality, some investigators now believe that progress in maternal health has been very slow in sub-Saharan Africa. This study uses a unique combination of health facility- and individual-level data collected in the slums of Nairobi, Kenya to: (1) describe the provision of obstetric care in the Nairobi informal settlements; (2) describe the patterns of antenatal and delivery care, notably in terms of timing, frequency, and quality of care; and (3) draw policy implications aimed at improving maternal health among the rapidly growing urban poor populations. It shows that the study area is deprived of public health services, a finding which supports the view that low-income urban residents in developing countries face significant obstacles in accessing health care. This study also shows that despite the high prevalence of antenatal care (ANC), the proportion of women who made the recommended number of visits or who initiated the visit in the first trimester of pregnancy remains low compared to Nairobi as a whole and, more importantly, compared to rural populations. Bivariate analyses show that household wealth, education, parity, and place of residence were closely associated with frequency and timing of ANC and with place of delivery. Finally, there is a strong linkage between use of antenatal care and place of delivery. The findings of this study call for urgent attention by Kenya’s Ministry of Health and local authorities to the void of quality health services in poor urban communities and the need to provide focused and sustained health education geared towards promoting use of obstetric services. © 2008 The New York Academy of Medicine.
The data are from a maternal health project carried out in 2006 by the African Population and Health Research Center (APHRC) in two slum settlements of Nairobi, Kenya. In these two areas, APHRC conducts a demographic surveillance system (DSS) covering about 60,000 inhabitants. These two areas are among a growing number of informal settlements in Nairobi that house more than 60% of the city’s population on less than 10% of the land. Like other Nairobi slum settlements, these two communities are underserved with regard to health infrastructure and services; they have high unemployment, poverty, crime, poor sanitation, and generally poorer health indicators when compared to Nairobi as a whole. The two communities, however, exhibit structural differences: Viwandani is bordered by an industrial area and attracts migrants with relatively higher education levels, while the population in Korogocho is more stable and show more co-residence of spouses. The specific data used in this study were collected through household interviews and a health facility survey. From the DSS database, all women who had a pregnancy outcome in 2004–2005 were selected and interviewed. The questionnaire, which was administered to a total of 1,927 women, covered topics including antenatal, delivery, and postnatal care; reproductive history; perceived access to and quality of care; obstetric complications; and antenatal, delivery, and postnatal expenditures. All health facilities (both within and outside the slum settlements) where women in the two communities go to deliver were assessed with regard to the number, training, and competency of obstetric staff; services offered; physical infrastructure; and availability, adequacy, and functional status of supplies and other essentials for safe delivery. A total of 25 facilities were surveyed. The first area investigated in this paper is the adequacy and quality of emergency obstetric care facilities serving the study population. They are described using distribution frequencies of data from the health facility assessment with focus on the type of care provided (basic or comprehensive emergency care), availability and adequacy of equipment and supplies, and physical infrastructure. The second issue of interest is antenatal care, analyzed both in terms of frequency (coded 1, 2–3, or 4 visits or more) and timing (initiation in the first, second, or third trimester of pregnancy). The association of timing and frequency of antenatal care with education, household wealth, parity, and slum location of residence is assessed using chi-square test. Principal component analysis was used to generate household wealth tertiles from household possessions, namely, presence of electricity, material of the dwelling floor, source of drinking water, type of toilet facility, and type of cooking fuel. The third issue analyzed is delivery care. Unlike in other studies, place of delivery is defined to account for the quality of care provided. From the health facility survey, health facilities were classified as either “appropriate” or “inappropriate”. As previously, the chi-square test is used to assess the association between education, wealth, parity and location of residence, and place of delivery. Age and ethnicity were also included in the study. However, due to space constraints, the results are not shown.
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