Factors influencing the quality of antenatal care in public maternal and child health facilities in Nairobi Province, Kenya

Abstract

When implemented according to the set standards and guidelines, antenatal care (ANC) contributes greatly to better health outcomes for women and their infants. Despite the implementation of World Health Organisation (WHO) guidelines for focussed antenatal care (FANC) known to improve quality and high utilisation of antenatal care services in Kenya, maternal mortality rates remains unacceptably high at 414 per 100,000 live births. Only 42% of women deliver with a skilled provider indicating a deficiency in the quality of care provided. This descriptive-cross sectional study examined the factors influencing the quality of ANC in public maternal and child health facilities in Nairobi province of Kenya. Proportionate cluster sampling was used to identify facilities for study where 384 systematically sampled mothers meeting the inclusion criteria were interviewed to explore their views and experiences with care during pregnancy. Additional information was obtained using self-administered questionnaires with ANC providers, key informant interviews and focussed group discussions (FGDs). Univariate and bivariate analyses was done using excel and SPSS software and variables computed appropriately using chi-square tests. Content analysis was done for qualitative FGDs findings. Findings reveal missed opportunities in almost all items of care particularly in health education and promotion. Proximity to place of residence, affordability and perceived good services were the main reasons for ANC facility choice. Clients portray high level of satisfaction with care as shown by high overall rating of quality at 80.3% and overall satisfaction index being 82.7%. Dissatisfaction was shown on waiting time and client-provider interaction. Quality of care measured by client satisfaction was influenced by waiting time (χ2df=1, =9.980, p<0.002), responding to questions well (χ2df=2=12.315, p<0.002), treating clients with respect (χ2df=1=13.225, p<0.0001), number of ANC procedures received (χ2df=2 =21.262, p<0.0001), facility cleanliness (χ2 (df=2) =22.161, p<0.0001), and timing of entry to ANC (χ2 df=4=13.441, p<0.009). Over 79.5% of women delivered sought skilled attendance at birth. Seeking skilled care at delivery was associated with client satisfaction with care (χ2df=12=28.204, p<0.005). Only 14.9% of women book for ANC during the WHO recommended first trimester of pregnancy. Influences to quality ANC were timing of first visits, frequency of visits, waiting time, patient load, adherence to standards, adequacy of laboratory services and provider training. A synergistic approach targeting facility, care providers, ANC mothers and the community at large is needed in order to improve the adequacy of public ANC services in Nairobi. Findings from this study will go along way in strengthening the credibility of public ANC thus ensuring that mothers reap maximum benefits from care resulting in a decline in MMR and sustained use of ANC and delivery services.