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Focused Antenatal Care (FANC) is crucial to improving maternal and infant health. Despite the Government of Kenya’ efforts to reduce maternal and neonatal morbidities and mortalities, these conditions prevail in Murunga. The current study examined how individual, organizational, and policy factors influence the utilization of focused antenatal care services amongst women in the Gatanga sub-county, Murang’a County, Kenya. The cross-sectional survey data was collected between June and July 2019 from three sampled wards. A structured questionnaire was administered to 334 women of reproductive age, aged 18 years and above, who delivered within the past one year or above 38 weeks of gestation. Descriptive statistics and chi-square tests at a 5% level of significance were done using SPSS version 22. The findings indicated that 37.3% of respondents do not utilize FANC services. Level of education (X2 (3) = 16.05; p < 0.05), occupation (X2 (3) = 16.50; p < 0.05), level of income (X2 (4) = 15.53; p < 0.05), time taken to the facility (X2 (3) = 34.72; p < 0.05), and waiting time (X2 (3) = 14.17; p < 0.05) were found to significantly influence utilization of FANC services. Therefore, women should be empowered through education and economic activities to remain financially independent. The government should also improve access to health care, especially in rural areas, by building new health facilities to improve the utilization of FANC services. Besides, more health care providers should be employed to reduce the waiting time at the facility.
Study design: the study employed a cross-sectional study design conducted in the Gatanga sub-county, Murang´a County. The 334 study participants who meet the inclusion criteria were spread across the three randomly selected wards of Ithanga (101, 30.6%), Mitubiri (120, 36.4%), and Gatanga 109 (33.0%). The data was collected using a questionnaire between June and July 2019. Descriptive analysis was conducted followed by Pearson´s Chi-square test of association between selected predictors and measures of utilization of FANC. Setting: the target population consisted of all women of reproductive age (15-49 years) in the Gatanga sub-county, Murang´a County. The location was chosen since the utilization of the recommended four FANC visits in Murang´a county (27%) [16] is much lower than the national level (58%) [17]. The study sorted to determine the extent of Murang´a county integrated development plan (2018-2022) to increase skilled birth attendance and utilization of focused antenatal care. Gatanga sub-county comprises five-county administrative wards: Ithanga ward, Kakuzi/Mitubiri ward, Kihumbuini ward, Gatanga ward, and Kariara ward. Participants: multistage sampling was applied to recruit the 334 study participants aged between 18 to 49 years and must have delivered within the past one year or above 38 weeks of gestation. Women with abnormal pregnancies were not eligible for inclusion in the study. Additionally, women who migrated to this region within one year or otherwise received service outside the study area were not considered. First, simple random sampling was used to select three wards and three community units in each ward. Secondly, systematic sampling (k=6) was used to select households at the community units. The first household was randomly picked, followed by every 6th household until the quota was reached. A household was selected if a household member met the inclusion criteria otherwise, skipped. If more than one woman of reproductive age lived together in a household, a simple random sampling technique was used to pick one respondent. Outcome variables: this study dichotomised the utilisation of FANC into two sub-variables. First, we considered utilising the FANC package with two responses as either “utilised” if the women met the required four or more recommended FANC visits and “not utilised” for those who attended less than four FANC visits for their most recent pregnancy. Secondly, we considered the frequency of visits with four levels: 0 – 3 and 4 or more times. Age: maternal age at birth in completed years. The variable was categorical with five levels: below 22 years, 23-27 years, 28-32 years, 33-37 years, and above 37 years. Education level: no formal education, primary education, secondary or post-secondary education. Marital status: either married, separated, divorced, engaged or single. Occupation: four levels including formal employee, self-employed, casual labor or housewife. Income level: refers to the monthly income level and was categorized into; less than Ksh 5000, 5000-10 000, 10 001-20 000, 20 001-50 000 more than Ksh 50 000. Parity: refers to the number of live children born to a woman. The variable was categorized into four levels: 1, 2, 3, or 4 and more births. Time taken to reach the health facility: measured in total hours taken by the time taken by women from their homes to the health care facility offer antenatal care services. The variable had four levels: within an hour, half of an hour to 1 hour, 1-2 hours, and above 2 hours. Missed service: measures whether a woman received or missed a complete antenatal care package at the end of their FANC visits or not. Waiting time: time taken in the queue before receiving the antenatal services. The attitude of clients to health facilities: clients´ willingness to recommend to someone else to visit ANC unit after her experience. The variable assumes two levels: yes or no. Cost of FANC services: include fees or charges women receive when they visit the health care facility for antenatal care services. Source of funds: source of funds used to cater for antenatal care services which can either be from savings, borrowing, Linda Mama card, insurance, or free services. Ownership of Linda Mama card: asks whether a woman owns the Linda Mama Card hence has two levels: yes or no. Benefits of Linda Mama program: asks whether the Linda Mama program covers women when they receive the FANC services hence has two levels: yes or no. Data collection technique: a questionnaire was used to collect the required information from the respondents over the period between June and July 2019. Bias: questionnaire bias was minimized before and after the study. First, the instruments were well-reviewed to ensure that the level of each categorical variables was free from faulty scale with no overlapping intervals. During the administration of the questionnaires, the selected enumerators who had medical background were trained and familiarized with the various terminologies and definitions used in the study and how to collect the required data from households. The interviewer training also helped eliminate semantic bias, given the educational level diversity of the respondents. Sample size determination: probability proportionate to size sampling methodology was used as specified by Fischer 1998. The sample size n was obtained using the following formula; (1) Where: n is the sample size if the target population is more than 10,000; z is the standard normal deviate at the required confidence level; p is the proportion of women currently utilizing complete FANC package; q = (1- p); d is the desired level of precision. Given that the proportion of women attending four focused antenatal care visits in Murang'a County is 27% [16], n = (1.962 × 0.27 × 0.73)/0.052) = 303. The study added 10% of the sample size to care for non-responses. Thus, the sample size used in the study was 303 + 31 = 334 respondents. Quantitative variables: waiting time, in hours, was measured on a continuous scale. Yet, the test of independence using the chi-square test requires two categorical variables. Thus, the variable was categorized into four levels: within an hour, half of an hour to 1 hour, 1 to 2 hours, and above 2 hours. Similarly, the cost of FANC services was categorized into 350 and below, between 351 and 700, between 701 and 1500, and above 1500. Data analysis techniques: the data was analyzed using Statistical Package for Social Sciences (SPSS) version 22. Descriptive statistics and Chi-square test at a 5% level of significance were used to test the association of the stated factors and the utilization of FANC. Ethical considerations: the proposal was approved by the Kenyatta University Graduate School Ethical and Research Committee. A research permit was then obtained from the National Commission for Science, Technology, and Innovation (NACOSTI) before the commencement of the study. Permission and approval to carry out the household survey were obtained from the Murang´a county health department and the community leadership. Informed consent was also obtained orally from the study participants. Assured confidentiality of information gathered the study's participation was purely a voluntary process with no coercive methods or payoff to influence the participants.
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