Accuracy of patient perceptions of maternity facility quality and the choice of providers in Nairobi, Kenya: a cohort study

Exploring the accuracy of self-reported maternal and newborn care in select studies from low and middle-income country settings: do respondent and facility characteristics affect measurement?

BACKGROUND

Accurate data on the receipt of essential maternal and newborn health interventions is necessary to interpret and address gaps in effective coverage. Validation results of commonly used content and quality of care indicators routinely implemented in international survey programs vary across settings. We assessed how respondent and facility characteristics influenced the accuracy of women's recall of interventions received in the antenatal and postnatal periods.

METHODS

We synthesized reporting accuracy using data from a known sample of validation studies conducted in Sub-Saharan Africa and Southeast Asia, which assessed the validity of women's self-report of received antenatal care (ANC) (N = 3 studies, 3,169 participants) and postnatal care (PNC) (N = 5 studies, 2,462 participants) compared to direct observation. For each study, indicator sensitivity and specificity are presented with 95% confidence intervals. Univariate fixed effects and bivariate random effects models were used to examine whether respondent characteristics (e.g., age group, parity, education level), facility quality, or intervention coverage level influenced the accuracy of women's recall of whether interventions were received.

RESULTS

Intervention coverage was associated with reporting accuracy across studies for the majority (9 of 12) of PNC indicators. Increasing intervention coverage was associated with poorer specificity for 8 indicators and improved sensitivity for 6 indicators. Reporting accuracy for ANC or PNC indicators did not consistently differ by any other respondent or facility characteristic.

CONCLUSIONS

High intervention coverage may contribute to higher false positive reporting (poorer specificity) among women who receive facility-based maternal and newborn care while low intervention coverage may contribute to false negative reporting (lower sensitivity). While replication in other country and facility settings is warranted, results suggest that monitoring efforts should consider the context of care when interpreting national estimates of intervention coverage.

Choice of home blood pressure monitoring device: the role of device characteristics among Alaska Native and American Indian peoples

BACKGROUND

Home blood pressure monitoring (HBPM) is an effective tool in treatment and long-term management of hypertension. HBPM incorporates more data points to help patients and providers with diagnosis and management. The characteristics of HBPM devices matter to patients, but the relative importance of the characteristics in choosing a device remains unclear.

METHODS

We used data from a randomized cross-over pilot study with 100 Alaska Native and American Indian (ANAI) people with hypertension to assess the choice of a wrist or arm HBPM device. We use a random utility framework to evaluate the relationship between stated likely use, perceived accuracy, ease of use, comfort, and participant characteristics with choice of device. Additional analyses examined willingness to change to a more accurate device.

RESULTS

Participants ranked the wrist device higher compared to the arm on a 5-point Likert scale for likely use, ease of use, and comfort (0.3, 0.5, 0.8 percentage points, respectively). Most participants (66%) choose the wrist device. Likely use (wrist and arm devices) was related to the probability of choosing the wrist (0.7 and - 1.4 percentage points, respectively). Independent of characteristics, 75% of participants would be willing to use the more accurate device. Ease of use (wrist device) and comfort (arm device) were associated with the probability of changing to a more accurate device (- 1.1 and 0.5 percentage points, respectively).

CONCLUSION

Usability, including comfort, ease, and likely use, appeared to discount the relative importance of perceived accuracy in the device choice. Our results contribute evidence that ANAI populations value accurate HBPM, but that the devices should also be easy to use and comfortable to facilitate long-term management.

Understanding Women's Choices: How Women's Perceptions of Quality of Care Influences Place of Delivery in a Rural Sub-County in Kenya. A Qualitative Study

BACKGROUND

Maternal mortality is still unacceptably high in Kenya. The Kenyan Government introduced a free maternity service to overcome financial barriers to access. This policy led to a substantial increase in women's delivery options. This increase in coverage might have led to a reduction in quality of care. This study explores women's perceptions of quality of delivery services in the context of the free policy and how the perceptions lead to the choice of a place for delivery.

METHODS

Our study site was Naivasha sub-County in Kenya, a rural context, whose geography encompasses pastoralists, rural agrarian, and high population density informal settlements near flower farms. Women from this area are from the lowest wealth quintile in Kenya. We conducted a qualitative study to explore the women's perceptions of quality of care based on their experiences during maternity care. The participants were women of reproductive age (18-49 years) attending antenatal care clinics at six health facilities in the sub-county. Six focus group discussions with 55 respondents were used. For inclusion, the women needed to have delivered a baby within the six months preceding the study. Interviews were recorded with consent, translated and transcribed. The interviews were analyzed using a thematic content approach.

RESULTS

Four broad themes that determined the choice of health facility for delivery were identified: women's perceptions of clinical quality of care; the cost of delivery; distance to the health facility and management of primary health facilities. An unexpected theme was the presence of home deliveries amongst pastoralist women. These findings suggest that in this setting both process and structural dimensions of quality of care and financial and physical accessibility influence women's choices for place of delivery.

CONCLUSION

This study expands our understanding of how women make choices regarding place of delivery. Understanding women's perceptions can provide useful insights to policy makers and facility managers on providing high quality patient centered maternity care necessary to sustain the increased utilization of maternity services at health facilities under the free maternity policy and further reductions in maternal mortality.

Bypassing high-quality maternity facilities: evidence from pregnant women in peri-urban Nairobi

Utilization of high-quality maternal care is an important link along the pathway from increased facility-based delivery to improved maternal health outcomes, however women in Nairobi do not all deliver in the highest quality facilities available to them. We explored whether women living in peri-urban Nairobi who live nearby to high-quality facilities bypassed, or travelled farther than, their nearest high technical quality facility using survey data collected before and after delivery from women (n = 358) and from facility assessments (n = 59). We defined the nearest high technical quality facility as the nearest Comprehensive Emergency Obstetric and Newborn Care (CEmONC) capable facility to each woman's neighbourhood. We compared women who delivered in their nearest CEmONC (n = 44) to women who bypassed their nearest CEmONC to deliver in a facility that was farther away (n = 200). Among bypassers, 131 (65.5%) women delivered in farther non-CEmONC facilities with lower technical quality and 69 (34.5%) delivered in farther CEmONCs with higher technical quality capacity compared to their nearby CEmONCs. Bypassers rated their delivery experience higher than non-bypassers. Women who bypassed to deliver in non-CEmONCs were less likely to have completed four antenatal care visits and to consider delivering in any CEmONC prior to delivery while women who bypassed to deliver in farther CEmONCs paid more for delivery and were more likely to report being able to access emergency funds compared to non-bypassers. Our findings suggest that women in peri-urban Nairobi bypassed their nearest CEmONC facilities in favour of delivering in facilities that provided better non-technical quality care. Bypassers with access to financial resources were also able to deliver in facilities with higher technical quality care. Policies that improve women's delivery experience and ensure that information about facility technical quality is widely distributed may be critical to increase the utilization of high-quality maternity facilities.

'We just look at the well-being of the baby and not the money required': a qualitative study exploring experiences of quality of maternity care among women in Nairobi's informal settlements in Kenya

OBJECTIVE

To examine how women living in an informal settlement in Nairobi perceive the quality of maternity care and how it influences their choice of a delivery health facility.

DESIGN

Qualitative study.

SETTINGS

Dandora, an informal settlement, Nairobi City in Kenya.

PARTICIPANTS

Six focus group discussions with 40 purposively selected women aged 18-49 years at six health facilities.

RESULTS

Four broad themes were identified: (1) perceived quality of the delivery services, (2) financial access to delivery service, (3) physical amenities at the health facility, and (4) the 2017 health workers' strike.The four facilitators that influenced women to choose a private health facility were: (1) interpersonal treatment at health facilities, (2) perceived quality of clinical services, (3) financial access to health services at the facility, and (4) the physical amenities at the health facility. The three barriers to choosing a private facility were: (1) poor quality clinical services at low-cost health facilities, (2) shortage of specialist doctors, and (3) referral to public health facilities during emergencies.The facilitators that influenced women to choose a public facility were: (1) physical amenities for dealing with obstetric emergencies and (2) early referral to public maternity during antenatal care services. Barriers to choosing a public facility were: (1) perception of poor quality clinical services, (2) concerns over security for newborns at tertiary health facilities, (3) fear of mistreatment during delivery, (4) use of unsupervised trainee doctors for deliveries, (5) poor quality of physical amenities, and (6) inadequate staffing.

CONCLUSION

The study provides insights into decision-making processes for women when choosing a delivery facility by identifying critical attributes that they value and how perceptions of quality influence their choices.

The predictive power of health system environments: a novel approach for explaining inequalities in access to maternal healthcare

INTRODUCTION

The growing use of Geographic Information Systems (GIS) to link population-level data to health facility data is key for the inclusion of health system environments in analyses of health disparities. However, such approaches commonly focus on just a couple of aspects of the health system environment and only report on the average and independent effect of each dimension.

METHODS

Using GIS to link Demographic and Health Survey data on births (2008-13/14) to Service Availability and Readiness Assessment data on health facilities (2010) in Zambia, this paper rigorously measures the multiple dimensions of an accessible health system environment. Using multilevel Bayesian methods (multilevel analysis of individual heterogeneity and discriminatory accuracy), it investigates whether multidimensional health system environments defined with reference to both geographic and social location cut across individual-level and community-level heterogeneity to reliably predict facility delivery.

RESULTS

Random intercepts representing different health system environments have an intraclass correlation coefficient of 25%, which demonstrates high levels of discriminatory accuracy. Health system environments with four or more access barriers are particularly likely to predict lower than average access to facility delivery. Including barriers related to geographic location in the non-random part of the model results in a proportional change in variance of 74% relative to only 27% for barriers related to social discrimination.

CONCLUSIONS

Health system environments defined as a combination of geographic and social location can effectively distinguish between population groups with high versus low probabilities of access. Barriers related to geographic location appear more important than social discrimination in the context of Zambian maternal healthcare access. Under a progressive universalism approach, resources should be disproportionately invested in the worst health system environments.

Why do women deliver where they had not planned to go? A qualitative study from peri-urban Nairobi Kenya

Background

In urban Kenya, couples face a wide variety of choices for delivery options; however, many women end up delivering in different facilities from those they had intended while pregnant. One potential consequence of this is delivering in facilities that do not meet minimum quality standards and lack the capacity to provide treatment for obstetric and neonatal complications.

Methods

This study investigated why women in peri-urban Nairobi, Kenya deliver in facilities they had not intended to use. We used 60 in-depth audio-recorded interviews in which mothers shared their experiences 2–6 months after delivery. Descriptive statistics were used to summarize socio-demographic characteristics of participants. Qualitative data were analyzed in three steps i) exploration and generation of initial codes; ii) searching for themes by gathering coded data that addressed specific themes; and iii) defining and naming identified themes. Verbatim excerpts from participants were provided to illustrate study findings. The Health Belief Model was used to shed light on individual-level drivers of delivery location choice.

Results

Findings show a confluence of factors that predispose mothers to delivering in unintended facilities. At the individual level, precipitate labor, financial limitations, onset of pain, complications, changes in birth plans, undisclosed birth plans, travel during pregnancy, fear of health facility providers, misconception of onset of labor, wrong estimate of delivery date, and onset of labor at night, contributed to delivery at unplanned locations. On the supply side, the sudden referral to other facilities, poor services, wrong projection of delivery date, and long distance to chosen delivery facility, were factors in changes in delivery location. Lack of transport discouraged delivery at a chosen health facility. Social influences included others’ perspectives on delivery location and lack of aides/escorts.

Conclusions

Results from this study suggest that manifold factors contribute to the occurrence of women delivering in facilities that they had not intended during pregnancy. Future studies should consider whether these changes in delivery location late in pregnancy contribute to late facility arrival and the use of lower quality facilities. Deliberate counseling during antenatal care regarding birth plans is likely to encourage timely arrival at facilities consistent with women’s preferences.