Why do women choose private over public facilities for family planning services? A qualitative study of post-partum women in an informal urban settlement in Kenya

BACKGROUND: Nearly 40 % of women in developing countries seek contraceptives services from the private sector. However, the reasons that contraceptive clients choose private or public providers are not well studied. METHODS: We conducted six focus groups discussions and 51 in-depth interviews with postpartum women (n = 61) to explore decision-making about contraceptive use after delivery, including facility choice. RESULTS: When seeking contraceptive services, women in this study preferred private over public facilities due to convenience and timeliness of services. Women avoided public facilities due to long waits and disrespectful providers. Study participants reported, however, that they felt more confident about the technical medical quality in public facilities than in private, and believed that private providers prioritized profit over safe medical practice. Women reported that public facilities offered comprehensive counseling and chose these facilities when they needed contraceptive decision-support. Provision of comprehensive counseling and screening, including side effects counseling and management, determined perception of quality. CONCLUSION: Women believed private providers offered the advantages of convenience, efficiency and privacy, though they did not consistently offer high-quality care. Quality-improvement of contraceptive care at private facilities could include technical standardization and accreditation. Development of support and training for side effect management may be an important intervention to improve perceived quality of care

Factors influencing place of delivery for women in Kenya: an analysis of the Kenya Demographic and Health Survey, 2008/2009

Background Maternal mortality in Kenya increased from 380/100000 live births to 530/100000 live births between 1990 and 2008. Skilled assistance during childbirth is central to reducing maternal mortality yet the proportion of deliveries taking place in health facilities where such assistance can reliably be provided has remained below 50% since the early 1990s. We use the 2008/2009 Kenya Demographic and Health Survey data to describe the factors that determine where women deliver in Kenya and to explore reasons given for home delivery. Methods Data on place of delivery, reasons for home delivery, and a range of potential explanatory factors were collected by interviewer-led questionnaire on 3977 women and augmented with distance from the nearest health facility estimated using health facility Global Positioning System (GPS) co-ordinates. Predictors of whether the woman’s most recent delivery was in a health facility were explored in an exploratory risk factor analysis using multiple logistic regression. The main reasons given by the woman for home delivery were also examined. Results Living in urban areas, being wealthy, more educated, using antenatal care services optimally and lower parity strongly predicted where women delivered, and so did region, ethnicity, and type of facilities used. Wealth and rural/urban residence were independently related. The effect of distance from a health facility was not significant after controlling for other variables. Women most commonly cited distance and/or lack of transport as reasons for not delivering in a health facility but over 60% gave other reasons including 20.5% who considered health facility delivery unnecessary, 18% who cited abrupt delivery as the main reason and 11% who cited high cost. Conclusion Physical access to health facilities through distance and/or lack of transport, and economic considerations are important barriers for women to delivering in a health facility in Kenya. Some women do not perceive a need to deliver in a health facility and may value health facility delivery less with subsequent deliveries. Access to appropriate transport for mothers in labour and improving the experiences and outcomes for mothers using health facilities at childbirth augmented by health education may increase uptake of health facility delivery in Kenya

Determinants for HIV testing and counselling in Nairobi urban informal settlements

BACKGROUND: Counselling and testing is important in HIV prevention and care. Majority of people in sub-Saharan Africa do not know their HIV status and are therefore unable to take steps to prevent infection or take up life prolonging anti-retroviral drugs in time if infected. This study aimed at exploring determinants of HIV testing and counselling in two Nairobi informal settlements. METHODS: Data are derived from a cross-sectional survey nested in an ongoing demographic surveillance system. A total of 3,162 individuals responded to the interview and out of these, 82% provided a blood sample which was tested using rapid test kits. The outcome of interest in this paper was HIV testing status in the past categorised as "never tested"; "client-initiated testing and counselling (CITC)" and provider-initiated testing and counselling (PITC). Multinomial logistic regression was used to identify determinants of HIV testing. RESULTS: Approximately 31% of all respondents had ever been tested for HIV through CITC, 22% through PITC and 42% had never been tested but indicated willingness to test. Overall, 62% of females and 38% of males had ever been tested for HIV. Males were less likely to have had CITC (OR = 0.47; p value < 0.001) and also less likely to have had PITC (OR = 0.16; p value < 0.001) compared to females. Individuals aged 20-24 years were more likely to have had either CITC or PITC compared to the other age groups. The divorced/separated/widowed were more likely (OR = 1.65; p value < 0.01) to have had CITC than their married counterparts, while the never married were less likely to have had either CITC or PITC. HIV positive individuals (OR = 1.60; p value < 0.01) and those who refused testing in the survey (OR = 1.39; p value < 0.05) were more likely to have had CITC compared to their HIV negative counterparts. CONCLUSION: Although the proportion of individuals ever tested in the informal settlements is similar to the national average, it remains low compared to that of Nairobi province especially among men. Key determinants of HIV testing and counselling include; gender, age, education level, HIV status and marital status. These factors need to be considered in efforts aimed at increasing participation in HIV testing

Monitoring of Health and Demographic Outcomes in Poor Urban Settlements: Evidence from the Nairobi Urban Health and Demographic Surveillance System

The Nairobi Urban Health and Demographic Surveillance System (NUHDSS) was set up in Korogocho and Viwandani slum settlements to provide a platform for investigating linkages between urban poverty, health, and demographic and other socioeconomic outcomes, and to facilitate the evaluation of interventions to improve the wellbeing of the urban poor. Data from the NUHDSS confirm the high level of population mobility in slum settlements, and also demonstrate that slum settlements are long-term homes for many people. Research and intervention programs should take account of the duality of slum residency. Consistent with the trends observed countrywide, the data show substantial improvements in measures of child mortality, while there has been limited decline in fertility in slum settlements. The NUHDSS experience has shown that it is feasible to set up and implement long-term health and demographic surveillance system in urban slum settlements and to generate vital data for guiding policy and actions aimed at improving the wellbeing of the urban poor

Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya

In 2008, the global urban population surpassed the rural population and by 2050 more than 6 billion will be living in urban centres. A growing body of research has reported on poor health outcomes among the urban poor but not much is known about HIV prevalence among this group. A survey of nearly 3000 men and women was conducted in two Nairobi slums in Kenya between 2006 and 2007, where respondents were tested for HIV status. In addition, data from the 2008/2009 Kenya Demographic and Health Survey were used to compare HIV prevalence between slum residents and those living in other urban and rural areas. The results showed strong intra-urban differences. HIV was 12% among slum residents compared with 5% and 6% among non-slum urban and rural residents, respectively. Generally, men had lower HIV prevalence than women although in the slums the gap was narrower. Among women, sexual experience before the age of 15 compared with after 19 years was associated with 62% higher odds of being HIV positive. There was ethnic variation in patterns of HIV infection although the effect depended on the current place of residence

A cross sectional comparison of postnatal care quality in facilities participating in a maternal health voucher program versus non-voucher facilities in Kenya

Background: Health service fees constitute substantial barriers for women seeking childbirth and postnatal care. In an effort to reduce health inequities, the government of Kenya in 2006 introduced the output-based approach (OBA), or voucher programme, to increase poor women’s access to quality Safe Motherhood services including postnatal care. To help improve service quality, OBA programmes purchase services on behalf of the poor and marginalised, with provider reimbursements for verified services. Kenya’s programme accredited health facilities in three districts as well as in two informal Nairobi settlements. Methods: Postnatal care quality in voucher health facilities (n = 21) accredited in 2006 and in similar non-voucher health facilities (n = 20) are compared with cross sectional data collected in 2010. Summary scores for quality were calculated as additive sums of specific aspects of each attribute (structure, process, outcome). Measures of effect were assessed in a linear regression model accounting for clustering at facility level. Data were analysed using Stata 11.0. Results: The overall quality of postnatal care is poor in voucher and non-voucher facilities, but many facilities demonstrated ‘readiness’ for postnatal care (structural attributes: infrastructure, equipment, supplies, staffing, training) indicated by high scores (83/111), with public voucher facilities scoring higher than public non-voucher facilities. The two groups of facilities evinced no significant differences in postnatal care mean process scores: 14.2/ 55 in voucher facilities versus 16.4/55 in non-voucher facilities; coefficient: -1.70 (-4.9, 1.5), p = 0.294. Significantly more newborns were seen within 48 hours (83.5 % versus 72.1 %: p = 0.001) and received Bacillus Calmette-Guerin (BCG) (82.5 % versus 76.5 %: p \u3c 0.001) at voucher facilities than at non-voucher facilities. Conclusions: Four years after facility accreditation in Kenya, scores for postnatal care quality are low in all facilities, even those with Safe Motherhood vouchers. We recommend the Kenya OBA programme review its Safe Motherhood reimbursement package and draw lessons from supply side results-based financing initiatives, to improve postnatal care quality