Our study shows that majority of women (94. 8%) had planned to deliver through a skilled attendant. Our results also found other significant differences in women’s intention to seek skilled delivery in relation to cost (those having enough money for delivery having higher odds ratio than those with no money), education (primary education and above having higher odds ratio), ANC visits (four or more ANC visits had higher odds ratio) and sex of provider (with female providers having higher odds ratio than males).
According to the DHS 2008/9 data, only 43% of women were attended to by a skilled professional at delivery [11]. In Kenya, poverty, culture, and distance to health facility have been identified as factors that hinder women from utilizing skilled attendance at delivery. As our study focused on ANC attendees intentions, it is likely that many women in Kenya actually desire to be assisted by a skilled professional but they are constrained by these factors [10, 35]. It is also possible that some women may have responded to the KSPA planning for skilled attendance due to the perceived social desirability of this answer by the community [36].
Previous research has demonstrated a relationship between cost and access to maternal health care [10,11,12, 15]. The DHS data has shown that the proportion of children born at home decreased as mothers wealth increased. Our findings are consistent with these results [10,11,12, 15], whereby women who reported having enough money set aside for delivery were almost three times more likely to seek skilled delivery (p < 0.022) than those who reported having no money set aside for delivery. To address this barrier the government of Kenya introduced free maternal services in 2013. The impact of this policy on skilled attendance at delivery will require further analysis. Evidence on the implementation of the free maternal policy from Malaysia and Sri Lanka, who have achieved the MDG targets, demonstrated the importance of sustained national commitment as a key component to their success [37].
Education is a significant predictor of skilled attendance at delivery as shown by the differences between women with no education and those with primary and above. Educated women were almost 7 (p < 0.001, 95% CI: 3.66, 11.95) times more likely to opt for skilled attendance at delivery than those with no formal education. Previous studies and the DHS have also highlighted this finding [11, 18, 28, 38]. This finding points to importance of the role of education in the prevention of maternal mortality and morbidity. In order to achieve SDG 3.1, strong collaboration between the health and education sector is needed to ensure the achievement of SDG 4.1 which focuses on the education of girls [16, 39].
Our study revealed that women with four or more ANC visits were almost 6 times (OR 5.95, 95% CI: 1.35, 26.18) more likely to seek skilled delivery than those with only one visit. This link between ANC attendance and skilled delivery is similar to those in previous studies conducted in developing countries such as Kenya, Ghana and India [18, 26, 38, 40]. This supports the notion that antenatal care is a key pillar for safe motherhood because it offers an entry point into skilled care and the range of essential services that support the health of the mother and baby [26].
Interestingly, we found sex of the health provider at ANC to significantly influence intention to deliver with a skilled birth attendant at delivery. In particular, women were twice as likely (p < 0.014, 95% CI: 1.35: 3.53) to seek skilled attendance if attended to by a female provider than a male provider. Studies on gender preference have primarily focused on the doctor patient relations in obstetrics and gynaecology [41]. A few studies focusing on the ANC experiences of women in Cuba, Saudi Arabia and Thailand found that female doctors were preferred by women because they were viewed to be easier to relate with on an emotional level and also more likely to provide gender-related preventive services [41]. Very little data is available from developing countries, which are highly patriarchal and where gender concordance is necessary due to cultural and social practices that restrict physical contact between the sexes [41]. Further research is required in this area.
Overall, our findings reflect those highlighted in the strategic framework for the Elimination of Preventable Maternal Mortality (EPMM) [42]. In line with the framework, we support the need for a grand convergence of health and health enhancing sectors such as, education, social services and those focusing on gender empowerment for the achievement of SDG 3.1 of less than 140 maternal deaths per 100,000 live births in Kenya [2, 42].
Limitations of the research
Several limitations should be considered. The cross-sectional study design employed by the KSPA means that causality cannot be established. This study was limited to only the facility audit questionnaires and ANC client exit interview, therefore the results cannot be extended to women who do not attend ANC. Certain demographic factors such as timing of first ANC, distance to health facility socio-economic status and urban/rural residence were not evaluated as they were not captured during the survey. Although traffic condition should be considered as a factor of the choice of skilled birth attendance, the KSPA dataset does not include such a question for analysis. Since the study utilized a secondary dataset certain variables were statistically insignificant possible due to low study power (service opinion, waiting time, age and region). We recommend that future KSPA surveys include a broader range of socio-demographic data in the ANC client exit interviews and consider the use of a similar unique identifier with the DHS to enable merging of service provision and household data.
