Factors associated with utilization of skilled birth attendance among women of reproductive age in North Horr Sub-County, Northern Kenya, 2021

Qabale Anna Duba^1,&, Elvis Omondi Oyugi², Paul Nyongesa³, Joseph Obiero Ogutu⁴

 

¹Kenya Field Epidemiology and Laboratory Training Program, Nairobi, Kenya, ²National Malaria Program, Ministry of Health (MOH), Nairobi, Kenya, ³Department of Reproductive Health, Moi University, Eldoret, Kenya, ⁴Department of Health and Sanitation, County Government of Siaya

 

 

^&Corresponding author
Qabale Anna Duba, Kenya Field Epidemiology and Laboratory Training Program, Nairobi, Kenya.

 

 

 

 

Nearly 830 maternal deaths occur each day globally as a result of complications associated with pregnancy and childbirth [1]. According to the World Health Organization (WHO), pregnancy-associated complications claimed the lives of almost 303,000 women of reproductive age in 2015 [1,2]. The bulk of maternal deaths–roughly 95% of all maternal deaths–occur in Sub-Saharan Africa and South Asia [3,4]. Nearly 85% of the global burden is shared between the two regions (Sub-Saharan Africa and South Asia), with Africa alone bearing more than 70% of the burden [4].

 

There have been significant setbacks in lowering maternal deaths in nearly all of the WHO regions, according to the report released by WHO[5]. According to a report by WHO [5], there were declines in maternal mortality between 2000 - 2015 on a national, regional, and international level. However, after 2016, more maternal deaths were reported. After 2016, improvements essentially stopped, or in some cases even reversed [5] Most maternal mortalities occur in the world's poorest regions and countries with active conflicts. Around 70% of all maternal deaths occurred in sub-Saharan Africa in 2020. In nine countries that were experiencing significant humanitarian crises, maternal mortality rates were more than double the global average[2,5].

 

Hemorrhage, puerperal sepsis, and abortion complications are the most frequent causes of these deaths, whereas indirect non-obstetric causes include tuberculosis, malaria, and HIV/AIDS [6]. According to the WHO, around 80% of all maternal deaths can be avoided completely even in low-income countries [4]. If under the supervision of a skilled professional, 16-33% of maternal deaths can be avoided [7,8]. The possibility of complications turning fatal is decreased by the presence of a trained specialist. Skilled birth attendance during childbirth is known to promote better pregnancy outcomes as well as contribute to maternal and newborn survival [9,10]. At the global stage, skilled attendance during childbirth constitutes 78% of all deliveries [4]. Countries with low utilization of skilled birth attendants are associated with poor maternal health outcomes [11,12].

 

Despite the deliberate efforts made by the government to improve maternal health, no major drop in maternal mortality trends has been realized in the past 15 years in Kenya. Initiatives such as the Linda Mama Programme, which provides mothers with free maternity care, and Universal Health Coverage have contributed to an increase in the availability of skilled birth attendants in Kenya. Investment in high-impact initiatives to support mother and child health has also been encouraged by the First Lady's Beyond Zero program, however, the proportion of women who give birth assisted by a skilled birth attendant is still very low in the arid and semi-arid areas of the country [13] . Every year, between 6,000 and 8,000 women in Kenya lose their lives while giving birth [14]. According to the Demographic and Health Survey (KDHS) of 2022, the maternal mortality ratio (MMR) for Kenya stands at 355 deaths for every 100,000 live births [13]. Disparities exist in Kenya: 15 of the country's 47 counties account for 99% of all maternal deaths. Nearly half of all maternal deaths among these 15 counties take place in just six counties. Kenya´s Northern region is home to five of the six counties. These counties experience limited access to maternity services presenting Kenya with the biggest obstacle to lowering maternal and newborn mortality.

 

The introduction of free maternity services and universal health coverage (UHC) in Kenya was expected to increase the utilization of skilled birth services by pregnant women [15]. On the contrary, an estimated 54% of deliveries are not attended to by skilled health professionals [8]. Due to the low utilization of skilled birth attendants, Marsabit County records 1,127 deaths per 100,000 live births, making the MMR for Marsabit County three times that of Kenya [16]. Home deliveries are still widespread in Kenya, despite the government's efforts to promote hospital deliveries. Compared to urban areas, the prevalence is higher in rural areas. According to the Kenya National Bureau of Statistics (KNBS) & ICF Macro, Marsabit County continues to rank among Kenya's lowest three counties with the fewest skilled deliveries, with about 40.7% of all births taking place at home [14]. Among the six sub-counties in Marsabit, North Horr, and Saku Sub-Counties had the lowest (26%) and highest (95%) percentages of pregnant women who had skilled birth in 2018 respectively [17]. We conducted this study to identify the factors that were associated with the use of skilled birth attendance services among the women in North Horr Sub-County, Marsabit County.

 

 

Study design and setting

 

This was a community-based cross-sectional study design conducted in North Horr Sub-County from November 2021 through December 2021. North Horr Sub-County comprises five administrative wards: Turbi, Maikona, North-Horr, Illret, and Dukana. According to the 2019 population census, the North-Horr Sub-County had a population of 71,447 (41,719 male and 29,726 female) of which an estimated 7,356 are women of childbearing age (15-49) years [18]. The Sub-County has 23 health facilities including hospitals, health centers, and dispensaries. North Horr Sub-County falls under arid and semi-arid areas in the northern region of Kenya with most of the residents being nomadic pastoralists (Figure 1).

 

Study population

 

The study population was women who were aged between 18-49 years from Turbi Ward, North Horr Sub-County. Only women who had at least one birth within the previous five years and had been a resident of Turbi Ward for not less than five years before the study were included. Women who declined to provide verbal or written informed consent or who were not able to respond were excluded. The study population was only limited to the biological parent (mother) of the child upon confirmation from the community health volunteer (CHP) and by asking the mother herself.

 

Sample size determination

 

We used the Fisher et al, formula [19, 20]to estimate the sample size required for the study. Assuming skilled birth attendance coverage of 25.8% for Turbi Ward, and a 5% level of precision the minimum sample size was 294 participants.

 

Sampling procedures

 

We used a multistage sampling technique to select the study participants (Figure 2). First, we ranked the wards in North Horr Sub-County and selected the ward (Turbi) which had the lowest coverage of Skilled Birth Attendance. All the 30 villages in Turbi Ward were included. We then calculated the sample size for each village based on the proportion of women of reproductive age (15-49 Years) with the lowest number of households assigned to a village being six households and the maximum being twelve households. The households were then selected using a simple random sampling technique. With the help of the Community Health Volunteers (CHVs), we determined the central point of each village during data collection. The first household to be visited and the direction of movement was determined by spinning a pen. The nearest household in the direction of the tip of the pen was used as the first household for the interview. The subsequent households were then selected using a simple random sampling technique until the desired sample size was arrived at. Where the selected household did not have an eligible study participant, or the household members were absent or declined to participate in the study, the closest neighboring household with an eligible participant was visited. However, the eldest participant was selected when a household had more than one eligible participant.

 

Data collection

 

We collected data from the study participants using a pretested structured questionnaire. The questionnaire was first created in English before being translated into the local Gabra language. We gathered information on the sociodemographic characteristics of the participants, antenatal care (ANC) attendance, the place of delivery, and the factors associated with the utilization of skilled birth attendant () services. The pre-testing of the questionnaire took place in the Shegel Location of Maikona Ward, which shared many similarities with the study area.

 

Data management and analysis

 

The collected data were entered into the Epi-info version 7.2.3 database for cleaning and analysis. Data cleaning was done by checking and correcting for duplicates and wrong entries. For the descriptive statistics, we summarized the respondents' demographic characteristics as frequencies (N) and percentages (%) for categorical data and mean and median (IQR) for continuous data. The utilization of skilled birth attendants (which was defined as giving birth assisted by a healthcare provider with midwifery skills) was the outcome of interest for the bivariate and multivariable analysis. In the bivariate analysis, we assessed the relationship between the utilization of skilled birth attendants and the sociodemographic and reproductive health characteristics of the study participants and calculated the crude odds ratios (COR). The variables that had a Chi-square test of p < 0.05 at the bivariate analysis were taken to the multivariable analysis where a forward stepwise selection logistic regression method was used to identify factors independently associated with the utilization of skilled birth attendant services. At the multivariable analysis, we computed the adjusted odds ratios (aOR) of utilizing skilled birth attendants among women with each variable of interest compared to the reference group and also presented the 95% confidence intervals (CI), and p-values for each. Those variables with p < 0.05 were retained in the final model and considered significantly associated with the utilization of skilled birth attendant services.

 

Ethical considerations

 

We obtained approval for the study from the Ethical Review Committee of Moi University/Moi Teaching and Referral Hospital (MU-MTRH IREC), approval number FAN:0003658. The participants were informed of the study's objective and methods before data collection, and their participation was gained by having them sign an informed consent form. The respondents were also guaranteed their voluntary participation and had complete freedom to quit at any time. By not giving any information gathered to a third party and removing personal identifiers during analysis, data confidentiality was carefully upheld.

 

 

Socio-demographic and reproductive health characteristics

 

A total of 294 respondents were interviewed. The mean age of the respondents was 28.5 years (Standard Deviation±5.89 years), approximately 46.1% (135/294) were aged between 18 - 27 years, and 58.5% (172/294) earned less than Ksh 1,000 as monthly income. A total of 284 (96.6%) were married, 50.3% (148/294) were Muslims, only 9.3% (27/294) had attended at least four Antenatal Care (ANC) visits and 8.8% (26/294) had attained at least basic/primary-level education. In addition, most of the women 90.8% (267/294) had two or more children (Table 1).

 

Utilization of skilled birth attendant delivery services

 

In this study, 124 (42.2%) of the women gave their last birth at a health facility under the care of skilled birth attendants. However, of the 57.8% (170/294) unskilled deliveries, 88.8% were conducted by traditional birth attendants (TBAs) whereas 2.9% gave birth on their own/unassisted ( Figure 3).

 

Factors associated with the utilization of skilled birth attendant services

 

The results in Table 2 show the factors associated with the utilization of skilled birth attendant services in the study area. According to the findings, women who identified as Muslims were more likely than non-Muslim women (Christians) to use skilled birth attendant services (COR 3.47; 95% CI: 2.12 - 5.67; p<0.01). Similarly, women who reported having a monthly income of more than Ksh 1,000 (USD 8) had higher odds of utilizing skilled birth attendant services (COR 3.71; 95% CI: 2.01 - 6.86; p < 0.05). Other factors that were associated with the utilization of skilled birth attendant services at the bivariate level included; living less than 10 Kilometers from a health facility (COR 3.71; 95% CI: 2.26 - 6.07; p < 0.01), attending four or more ANC visits (COR 12.89; 95% CI: 3.77 - 43.87; p < 0.01) and being accompanied by husbands (COR 5.59; 95% CI: 2.32 - 13.45; p < 0.01).

 

In the logistic regression model for factors associated with utilization of skilled birth attendance services, being Muslims (aOR 3.86; 95% CI: 2.15-6.91; p<0.01), having a monthly income of more than USD 8 (aOR 2.83; 95% CI: 1.28-6.27; p < 0.05), living less than 10 km from a health facility (aOR 2.39; 95% CI: 1.33 - 4.28, p < 0.01), attending four or more ANC visits (aOR 4.18; 95% CI: 1.03 - 17.18; p < 0.05) and being accompanied by husbands during clinic visits (aOR 9.45; 95% CI: 1.84 - 48.34; p < 0.05) were independently associated with accessing skilled birth attendant services (Table 2).

 

 

We found that the coverage of skilled birth attendance was 42.2%. Having a monthly income of above Ksh 1000, having attended more than four ANC visits, and living less than 10 kilometers from a health facility were associated with the utilization of skilled birth attendance among women. The utilization of skilled birth attendant services during delivery in the study area has significantly improved from 26% in 2018 [21] to 42.2% in 2022 as observed in the current study. The observed improvement over time could be attributed to the efforts and interventions initiated by the Ministry of Health, the county government, and other development partners towards the implementation of free delivery policy and in achieving universal health coverage (UHC) of which maternal and child health is among the six key programmatic areas [22].

 

There was an association between living less than 10 kilometers from a medical facility and a higher chance of using skilled birth attendant services. According to this study, women who lived less than 10 kilometers from a hospital had a twice as high likelihood of using skilled birth attendant services during childbirth than women who resided more than 10 kilometers away. This may be because one of the well-known obstacles to accessing healthcare, particularly in developing countries, is the distance to a medical facility. Living away from a health facility comes with both direct and indirect costs, including time and transportation expenses. The results are consistent with comparable earlier studies showing that a mother's decision to use a trained birth attendant at delivery is greatly influenced by the distance to a medical facility [8,23-25]. Distance to the nearest health facility is still a problem in the study area albeit this. To access skilled birth attendant services, over 80% of the respondents had to travel more than the recommended 5-kilometer radius to seek skilled birth attendant services.

 

According to this study, having more than four ANC visits was linked to higher-skilled birth attendant use during delivery. Compared to women who had attended fewer ANC visits, those who had attended four or more were 4 times as likely to use skilled birth attendant services during delivery. Studies carried out in Ethiopia, Kenya, Tanzania, and Sierra Leone showed similar findings [8,11,23,25]. This finding bolsters the idea that ANC is a crucial foundation for safe motherhood since it provides access to professional care and a host of other vital services that promote the mother's and baby's health. The latest WHO recommendations require women from developing countries to have a minimum of eight (8) ANC visits [26].

 

We noted a strong association between religion and the utilization of skilled birth attendant services. Compared to Christian women, Muslim women were more likely to use skilled birth attendant services at delivery. Due to their strong predisposition towards adhering to traditional beliefs, customs, and practices, studies have shown that women who are traditionalists are less likely to use skilled birth services [27-30]. However, to explore the causes of the religious differences in skilled birth attendant utilization, we advise conducting additional research utilizing a qualitative research approach since this is still a grey area.

 

The study revealed that women with monthly household incomes exceeding Ksh 1000 (USD 8) were more likely to utilize skilled birth attendant services than those with lower incomes. There could be several reasons for this, including financial difficulties stemming from the need to pay for extra supplies required during the delivery process and transport the mother to a health facility, or a lack of support for receiving skilled birth attendants because the poorest have other household or family responsibilities. In public health institutions in Kenya, skilled birth delivery services are provided without charge [31]; however, mothers may be required to purchase supplies that are not on hand at the moment of delivery. Sometimes these expenses surpass the direct cost of the service, which results in low utilization.

 

A key indicator that is substantially and strongly associated with women's use of skilled birth attendant services during childbirth is husbands' attendance at their wives' ANC visits. Our analysis confirms the results of earlier research [32-33] by demonstrating that women who had their husbands accompany them to the ANC clinic and during delivery had nine times higher odds of using skilled birth attendant services at birth than women who did not have their husbands with them. One possible explanation for this could be that men who accompany their to the ANC are more likely than men who do not to debate and decide together with their wives on the birth plan. The use of SBAs during childbirth may be aided by the concern of male partners and the presence of open communication between partners. This underscores the notion that a woman's social cycle, particularly her partner influences her decision to use the skilled birth attendant services.

 

Limitations of the study

 

This study was not without limitations. There was a possibility of recall and reporting bias. Social desirability may have occurred through the use of research assistants who were well-known to the community in the data collection process. Although this is acknowledged, we believe that the utilization of community members fostered a trusting environment among respondents, which enabled genuine responses.

 

 

Even though skilled birth attendance is free at government health facilities, the proportion of women using it is still very low. One of the main barriers preventing women from getting skilled birth attendant services during childbirth is the distance to health facilities. To provide pregnant women with access to skilled delivery, the stakeholders should consider the construction of additional health facilities and outreach programs, particularly in the vast region of the North Horr sub-county. Due consideration should also be made to educating the public about husbands' participation in ANC visits as there is a substantial association between their involvement and women's use of skilled birth attendants s during childbirth. This can be through the media, religious authorities, and community leaders.

 

 

The authors declare no competing interests.

 

 

Conceptualization and design: QAD, EOO, PN and JOO. Data Collection: QAD, JOO and EOO. Analysis, and Interpretation: QAD, JOO, PN, and EOO. Drafting and Review of Manuscript: QAD, JOO, EOO, and PN. All the authors reviewed and approved the final manuscript.

 

 

The authors express their gratitude to Moi University, Kenya Field Epidemiology and Laboratory Training Programme (KFELTP), Marsabit County, North Horr Sub-County, Turbi Ward, the community units, villages, and all those who participated in this study. Special thanks to Maurice Omondi Owiny for his mentorship throughout the writing process of this manuscript.

 

 

Table 1: Socio-demographic and reproductive health characteristics of the study participants, North Horr Sub-County Northern Kenya, 2021

Table 2: Factors associated with the utilization skilled birth attendance services among women of reproductive age, North Horr Sub-County, Northern Kenya, 2021

Figure 1: Map showing the study area and distribution of health facilities, Marsabit County, Kenya, 2021

Figure 2: Schematic presentation of the sampling procedure

Figure 3: Place of delivery and nature of assistance received during delivery

 

 

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