Antenatal care services refering to intervention services

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ABBREVIATION

WHO-World Health Organization

UHC-Universal Health Coverage

MHCS-Maternal Healthcare Services

ANC-Antenatal Care

MOH-Ministry of Health

MDG-millennial Development Goals

SDG-Sustainable Development Goals

ASALs-Arid and Semi-arid Lands

NHIF- National Health Insurance Fund

KDHS- Kenya Demographic and Health Survey

KNBS-Kenya National bureau of statistics

HSSF-

CHAPTER ONE

1 INTRODUCTION

1.1 Background Information 

Antenatal Care (ANC) services refer to the interventions and services provided to pregnant women during pregnancy for their healthy being and that of the developing fetus. It includes medical, educational, and supportive services for pregnant women during regular check-ups, screenings, and health education. ANC services are integral to improving mother and child health outcomes (WHO, 2020; Barako et al., 2023). It is during the ANC visits that the medics monitor the pregnancy progress, identify and manage the potential complications, promote the adoption of healthy behaviors, and prepare the pregnant woman for childbirth. ANC is among the three components of maternal health services, and its inaccessibility can lead to high maternal and child morbidity and mortality rates (Dahab & Sakellariou, 2020).

Maternal health is essential for a productive populace. It is a precursor of healthy human capital formation that can be deployed in productive activities, thus stirring economic growth and development. The latter is among the critical considerations that make the subject indispensable in development policy formulation processes. Improved maternal health has been a goal for most countries. It has also remained an essential aspect in the United Nations’ former Millennium Development Goals (MDGs) and the current Sustainable Development Goals (SDGs), precisely SDG Target 3.1, where the former aimed at reducing the global maternal mortality ratio by 75% by 2015 and the present by less than 70 per 100,000 live births by 2030, respectively (WHO, 2018; WHO, 2024).

ANC is among the key recommended ways of reducing neonatal mortality risk in any community. Even though the under-five deaths have declined in absolute numbers, the proportion of deaths occurring in the neonatal period has increased – attributable to a slower declining neonatal mortality rate. According to Aranda et al. (2017), from 1990 to 2013, the neonatal under-five mortality rates increased from 37% to 44%, with low and medium-income countries accounting for over 99% of these deaths. Kenya was highlighted among the ten countries contributing to the most neonatal deaths globally (Arunda et al., 2017). Reducing the under-five mortality rates is mainly dependent on the reduction of neonatal deaths, and this can be successfully reduced by early detection of any potential ailments and complications during pregnancy by attending the required ANC clinics within the set intervals for check-ups.

1.1.1 Universal Health Coverage in Kenya

Universal Health Coverage (UHC) refers to a state where people have access to promotive, preventive, curative, rehabilitative, and palliative health services that they need in adequate and effective quality while not exposing them to financial hardship (WHO, 2019). UHC stemmed from the 58^th World Health Assembly of May 2005, where among the resolutions urged in the assembly was the plan by the member states to transition to universal coverage to contribute to meeting the populace’s health care (WHO, 2005). As a member state, Kenya had an obligation to gradually transition to the adoption of universal coverage, which also aligned with the Alma Ata Declaration of 1978 (III), which underpinned the importance of ensuring Health for All for sustained social and economic development. Further, Article 43 (1) (a) of the Kenya Constitution (2010) recognizes that every Kenyan has a right to the highest attainable health care, including reproductive health.

In this regard, Kenya has implemented various policies to improve health outcomes, with some aiming to enhance maternal health outcomes, including the Free Maternity Services Policy of June 2013 and Kenya Health Policy 2014-2030 (Pyone et al., 2017). These policies set the foundation for piloting the UHC, which the Ministry of Health (MoH) piloted in 2018 in Isiolo, Nyeri, Machakos, and Kisumu counties. The Ministry of Health (MoH) selected the four counties due to the high incidences of communicable diseases, non-communicable diseases, maternal and child deaths, and road accident-related injuries. Specifically, Isiolo was selected due to its arid and semi-arid conditions, low development rate, and high maternal mortality rates of 790 per 100,000 population (Njibu et al., 2023).

Another notable development in the UHC is the Makueni Care program, which Makueni County implemented in 2016. Makueni Care aimed to complement the existing forms of insurance. In this program, the residents paid an annual premium of KES 500, which was affordable compared to the KES 500 monthly NHIF premiums. The scheme covered a range of outpatient and inpatient services, with maternal and child healthcare services covered by the National Health Insurance Fund (NHIF) Linda Mama (Health Policy Plus, 2022).

1.1.2 UHC Implementation and Improvement of Access to ANC in Isiolo County

Isiolo County covers an area of 268,002 KM², out of which 25,700 comprise the Arid and Semi-Arid Lands (ASALs). Isiolo County has three sub-counties, namely Isiolo, Garbatulla, and Merti. The county has a population of

 

Though access to health care has substantially improved with the implementation of UHC in the four pilot counties, as of 2022, the number of women in Isiolo who had 4+ ANC visits during their pregnancy composed 53% of the pregnant women’s population, which was lower than the national average of 66% in the same period (KDHS, 2022), these statistics show that despite Isiolo County being among the UHC counties, it still lags in improving access to ANC services, a key variable in determining the state and direction of maternal care.

 

1.2 Statement of the Problem

Every woman has a right to access quality maternity services that respond to local needs and challenges. The provision and utilization of ANC services are subject to many different elements, such as lack of quality care; socio-demographic and sociocultural characteristics of patients, such as education, occupation, ethnicity, social relationships, and income level of the patients; logistical aspects, such as waiting for time and location of facilities; and lastly social perception of general health, illness, and diseases (Konlan et al.,2020). Deeply rooted cultural practices present a significant obstacle to women accessing maternal and neonatal health services and disempower women’s ability to make the right health choices(Christian Aid, n.d). Consequently, Isiolo County has been burdened with maternal health provision inefficiencies from sociocultural factors, inadequate resource allocation, barriers to accessing health facilities, and discrepancies between formal institutions and informal arrangements.

This study, therefore, seeks to examine the provision of antenatal care services in Isiolo County. In so doing, it seeks to investigate the extent of antenatal care utilization and the conditions that either promote or hinder maternal healthcare utilization in the county. Therefore, the study will evaluate the factors influencing antenatal care on five levels: at the individual level, focusing on a person’s attitudes and beliefs towards ANC; at the organizational level, focusing on the role of healthcare systems; at the community level, focusing on the various organizations in the area and at the policy level focusing on programs and policies.

 

1.3 Objective of the Study

1. To examine the extent of utilization of antenatal care services in Isiolo County.
2. To examine the factors influencing antenatal care services in Isiolo County.
3. To examine the measures that can be advanced to address the challenges facing antenatal care in Isiolo County.

 

1.4 Value of the Study

Cultural practices, health system structure, and health policies developed and adopted by the county and national governments play a role in determining the access and utilization of antenatal care in Isiolo County. Therefore, cooperation from all the stakeholders at all levels is crucial to foster the conditions necessary to promote the utilization of antenatal care in the county and contribute to the actualization of the Sustainable Development Goals (SDGs) target three, which aims at reducing global maternity mortality ratio to less than 70 per 100,000 live births.

This study will, therefore, be significant in giving a clear explanation of the extent of utilization of ANC in Isiolo County. In addition, it will contribute to the existing body of knowledge on access to maternal health services in Kenya and sub-Saharan Africa and the factors influencing the provision of the services.

2 Literature Review

2.1 Introduction 

The World Health Organization (WHO) 2002 created the first set of antenatal care recommendations consisting of one first visit during the first trimester and three subsequent visits. In November 2016, the WHO developed a guideline and recommendations on antenatal care, including an increase in recommended antenatal visits from four to eight contacts or more. To enhance the quality, appropriate timing, and maximum care impact, the WHO ANC model specifies that pregnant women should have their first ANC contact at 20,26,30,34,38, and 40 weeks of gestation. The recommendation aligns with goal 3 of the 2030 agenda for sustainable development to ensure healthy lives and promote well-being for all ages. Maternity care modes vary within and between countries, as there is no simple universal solution for providing maternity care(Koblinsky, 2016). Maternity care in each setting is partly a function of available resources, adopted policies, and existing infrastructure.

Three main conditions either promote or hinder healthcare utilization, including predisposing factors, enabling factors, and the need for care factors. Predisposing factors include the demographic structure, which consists of education and occupation, and health belief factors, which consist of value, which consists of healthcare service providers and health knowledge. Enabling factors refer to the resources or means that are available to an individual.

The need for factors refers to how an individual perceives their general health and functional condition and their familiarity with the signs and symptoms of ill health agony and concerns about their health.

 

2.2 The attitude of the pregnant women and the health providers

The availability of skilled health workers is a prerequisite for access to quality maternal health care. The shortage of these workers introduces a gap in the health workforce, thus limiting the utilization of antenatal care services, therefore resulting in high maternal mortality in the county. While efforts to increase the availability of health workers in low-resource settings through training, task shifting, and retention programs have shown promise, there are concerns that health workers’ performance remains sub-optimal due to poor access to proper training and supervision and the inability to apply the required knowledge and skills. Therefore, this presents a challenge in ensuring quality primary and secondary services since the healthcare providers may need to improve due to various factors that affect the utilization of the ANC. One of the significant underperformances is the adoption of a bad temper.

A good attitude is the most valuable precondition for any healthy behavior. Women with a positive attitude towards ANC have a higher proportion of ANC visits than those with a negative attitude. With improved knowledge about the benefits of ANC and the importance of a positive attitude toward it, these women will appreciate that medical procedures of ANC and interventions will do much to save their lives and improve their children’s health.

 

2.3 Cultural practices

Every woman everywhere has the right to access quality maternity. Women in Isiolo fail to seek care for numerous reasons, including sociocultural factors such as gender inequality, as the strong background of patriarchy within the communities residing in the county is a strong determinant of women’s health. Culture includes the beliefs encompassed in the behavioral, normative, and control beliefs constructed by the theory of planned behavior (LIBERMAN, PORTER, & SAMOVAR, 1994). Sometimes, women must seek their husbands’ permission before seeking antenatal care. The husbands sometimes overlook the total value of antenatal care and deny the wives permission to seek antenatal care to preserve their cultural practices. These occurrences are attributed to the low levels of education in the county; a total of 51% of Isiolo County residents lack formal education, while 36% of the population have only a primary level education, and only 13% of the population have a secondary level of education or above (KNBS,2017).

The level of education primarily reflects the income capacity of their families. Isiolo has a poverty index rate of 0.07%; hence, women from low-income families avoided antenatal care due to the costs that were out of their reach and the fear of being detained in the hospitals due to failure to pay the maternity bills. This trend has been eliminated by introducing the free maternity healthcare service, which has increased the number of antenatal attendance and deliveries in the county referral hospital, as evidenced in their records. In 2014, the Isiolo County referral hospital noted a 47.2% increase in hospital deliveries and a 44.2% increase in attendance at antenatal care clinics.

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