Abstract
Objectives: To examine the determinants of the continuum of maternal care from an integrated perspective, focusing on how key components of an adequate journey are interrelated.
Design: A facility-based prospective cohort study.
Setting: 25 health facilities across three counties of Kenya: Nairobi, Kisumu and Kakamega.
Participants: A total of 5 879 low-income pregnant women aged 13–49 years.
Outcome measures: Ordinary least squares, Poisson and logistic regression models were employed, to predict three key determinants of the continuum of maternal care: (i) the week of enrolment at the clinic for antenatal care (ANC), (ii) the total number of ANC visits and (iii) utilisation of skilled birth attendance (SBA). The interrelationship between the three outcome variables was assessed with structural equation modeling.
Results: Each week of delayed enrolment in ANC reduced the number of ANC visits by 3% (incidence rate ratio=0.967, 95% CI 0.965 to 0.969). A higher number of ANC visits increased the relative probability of using SBA (odds ratio=1.28, 95% CI 1.22 to 1.34). The direct association between late enrolment and SBA was positive (odds ratio=1.033, 95% CI 1.02 to 1.04). Predisposing factors (age, household head’s education), enabling factors (wealth, shorter distance, rural area) and need factors (risk level of pregnancy, multigravida) were positively associated with adherence to ANC.
Conclusion: The results point towards a domino-effect and underscore the importance of enhancing the full continuum of maternal care. A larger number of ANC visits increases SBA, while early initiation of the care journey increases the number of ANC visits, thereby indirectly supporting SBA as well. These beneficial pathways counteract the direct link between enrolment and SBA, which is partly driven by pregnant teenagers who both enrol late and are at heightened risk of complications, stressing the need for specific attention to this vulnerable population.
Design: A facility-based prospective cohort study.
Setting: 25 health facilities across three counties of Kenya: Nairobi, Kisumu and Kakamega.
Participants: A total of 5 879 low-income pregnant women aged 13–49 years.
Outcome measures: Ordinary least squares, Poisson and logistic regression models were employed, to predict three key determinants of the continuum of maternal care: (i) the week of enrolment at the clinic for antenatal care (ANC), (ii) the total number of ANC visits and (iii) utilisation of skilled birth attendance (SBA). The interrelationship between the three outcome variables was assessed with structural equation modeling.
Results: Each week of delayed enrolment in ANC reduced the number of ANC visits by 3% (incidence rate ratio=0.967, 95% CI 0.965 to 0.969). A higher number of ANC visits increased the relative probability of using SBA (odds ratio=1.28, 95% CI 1.22 to 1.34). The direct association between late enrolment and SBA was positive (odds ratio=1.033, 95% CI 1.02 to 1.04). Predisposing factors (age, household head’s education), enabling factors (wealth, shorter distance, rural area) and need factors (risk level of pregnancy, multigravida) were positively associated with adherence to ANC.
Conclusion: The results point towards a domino-effect and underscore the importance of enhancing the full continuum of maternal care. A larger number of ANC visits increases SBA, while early initiation of the care journey increases the number of ANC visits, thereby indirectly supporting SBA as well. These beneficial pathways counteract the direct link between enrolment and SBA, which is partly driven by pregnant teenagers who both enrol late and are at heightened risk of complications, stressing the need for specific attention to this vulnerable population.
| Original language | English |
|---|---|
| Article number | e050670 |
| Number of pages | 12 |
| Journal | BMJ Open |
| Volume | 12 |
| Issue number | 1 |
| DOIs | |
| Publication status | Published - Jan 2022 |
Bibliographical note
Publisher Copyright:© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Funding
Funding This work was financially supported by the Health Insurance Fund of the Dutch Ministry of Foreign Affairs, Children’s Investment Fund Foundation, MSD for Mothers, Stichting St. Antonius Foundation, Nationale Postcode Loterij and The Ministry of National Education of Turkey (internal project codes respectively 16001, 19005, 19019, 18011, 16020 and S29P78A3MACU9BC for funding of NA’s research time).
| Funders | Funder number |
|---|---|
| Health Insurance Fund | |
| Ministry of National Education of Turkey | 19005, 16020, 18011, 16001, 19019 |
| Meso Scale Diagnostics | |
| Children's Investment Fund Foundation | |
| Ministerie van Buitenlandse Zaken |
Keywords
- antenatal
- health policy
- public health
