UTILIZATION OF FREE MATERNITY SERVICES AMONG WOMEN

AGED 18-49 YEARS IN MACHAKOS COUNTY, KENYA

Maria

A RESEARCH PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE AWARD OF THE DEGREE OF
MASTER OF SCIENCE IN PUBLIC HEALTH SYSTEMS MANAGEMENT
AND APPLICATION IN THE SCHOOL OF PUBLIC HEALTH AND
APPLIED HUMAN SCIENCES OF KENYATTA UNIVERSITY

JUNE 2021
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DECLARATION

Student

This research project is my original work and has not been presented for a degree in

any other University.

Signature…………………………………………………

Date………………………………

Ngesa Alice Mukunzu

Q142/38397/2017

Supervisor

This project has been sub-mitted for review with my approval as the University

Supervisor.

Signature ………………………………………………….

Date…………………………….

Dr. Joyce Kirui

Department of Health Management and Informatics

Kenyatta University
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DEDICATION

This project is dedicated to my children Ryan and Jayden, my husband Kennedy, my

parents and siblings for their support, humble time, prayers and words of motivation
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ACKNOWLEDGMENT

First, I would like to thank the Almighty God for giving me good health, source of
knowledge and wisdom through which the completion of this project was made
possible.
My sincere gratitude goes to my supervisor, Dr. Joyce Kirui and the IMPACT course
coordinator Kenyatta University Dr. George Otieno for their generous contributions,
positive criticisms, advice and commitment in guiding me through the entire process
of developing this project.
Special appreciation goes to Kenyatta University, School of Public Health and
Department of Health Management and Informatics, especially my lecturers for their
maximum cooperation, extra devotion and help to successfully undertake this course.
I am also thankful to the IMPACT team Kenya for their invaluable support during the
study period.
Special appreciation to my site Mentor Dr. Muthama, Isaac Matheka my supervisor
and the entire Machakos County Health Management Team for their support during
my field placement. I am also thankful to the Masinga Sub County Health
Management Team for their support during the data collection exercise.
Finally, yet importantly, I am greatly indebted to my family, friends and relatives for
their moral and spiritual support without which this project could not have been
completed successfully.
I would finally wish to pay tribute to all those people who in one way or the other
participated in the completion of this piece of academic work.
God bless you all.
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TABLE OF CONTENTS

DECLARATION......................................................................................................ii

DEDICATION.........................................................................................................iii

ACKNOWLEDGMENT.........................................................................................iv

LIST OF TABLES...................................................................................................ix

LIST OF FIGURES..................................................................................................x

ABBREVIATIONS AND ACRONYMS................................................................xi

DEFINITION OF OPERATIONAL TERMS......................................................xii

ABSTRACT............................................................................................................xiv

CHAPTER ONE: INTRODUCTION......................................................................1

1.1 Background of the study.......................................................................................1

1.2 Problem statement.................................................................................................3

1.3 Justification...........................................................................................................4

1.4 Research Questions...............................................................................................5

1.5 Hypothesis............................................................................................................5

1.5.1 Null hypothesis...............................................................................................5

1.5.2 Alternative hypothesis....................................................................................5

1.6 Research Objectives..............................................................................................6

1.6.1 General objective...........................................................................................6

1.6.2 Specific objectives.........................................................................................6

1.7 Significance of the study.......................................................................................6

1.8 Limitation and Delimitation..................................................................................7

1.8.1 Limitation of the Study..................................................................................7

1.8.2 Delimitation of the study................................................................................7

1.9 Conceptual framework:.........................................................................................7

CHAPTER TWO: LITERATURE REVIEW.......................................................9

2.1 Global free maternal health services.....................................................................9

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2.2 Overview of Maternal Health Services in Kenya...............................................12

2.3 Individual characteristics and utilization of maternity care services..................14

2.4 Mothers awareness on free maternity services in public hospitals.....................16

2.5 Mothers attitude on free maternity services........................................................17

2.6 Organizational factors and their influence on free maternity services...............18

2.7 Satisfaction and free maternity services.............................................................18

2.8 Summary of Literature Review..........................................................................19

CHAPTER THREE: MATERIALS AND METHODS.......................................21

3.1 Introduction.........................................................................................................21

3.2 Study design........................................................................................................21

3.3 Study Variables...................................................................................................21

3.3.1 Dependent variable.......................................................................................22

3.4 Location of the study..........................................................................................22

3.5 Study Population.................................................................................................22

3.5.1 Inclusion criteria...........................................................................................23

3.5.2 Exclusion criteria.........................................................................................23

3.6 Sampling technique and sample size determination...........................................23

3.6.1 Sampling size determination........................................................................23

3.6.2 Sampling technique......................................................................................24

3.7 Research instruments..........................................................................................25

3.7.1 Pre testing of research instrument................................................................26

3.8 Data collection techniques..................................................................................26

3.9 Validity and Reliability of the study...................................................................27

3.9.1 Validity.........................................................................................................27

3.9.2 Reliability.....................................................................................................27

3.10 Data management and analysis.........................................................................28

3.11 Logistical and Ethical considerations...............................................................28

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CHAPTER FOUR: RESULTS...............................................................................30

4.1 Introduction.........................................................................................................30

4.2 Response rate......................................................................................................30

4.3 Sociodemographic characteristics of respondents.........................................31

4.4 Overall utilization of maternity services.............................................................33

4.5 Utilization of free maternity services.................................................................33

4.6 Individual client characteristics associated with utilization of free maternity

services......................................................................................................................35

4.7 Influence of mother’s level of awareness on utilization free maternity services

.................................................................................................................................37

4.7.1 Sources of information on free maternity services......................................37

4 7.2 Relationship between awareness and utilization of free maternity services38

4.7.3 Nearest public facility offering free maternity services...............................39

4.8 Influence of mother’s delivery experiences on utilization of FMS....................39

4.9 Organizational factors associated with utilization of free maternity services....42

4.10 Determinants of utilization of free maternity services.....................................48

CHAPTER FIVE: DISCUSSIONS, CONCLUSIONS AND

RECOMMENDATIONS...........................................................................................49

5.1 Discussions..........................................................................................................49

5.1.1 Utilization of free maternity services...........................................................49

5.1.2 Individual client characteristics....................................................................49

5.1.3 Mother’s level of awareness on free maternity services..............................52

5.1.4 Mother’s delivery experiences on free maternity services...........................53

5.1.5 Organizational factors..................................................................................54

5.1.6 Summary of Findings...................................................................................55

5.2 Conclusions.........................................................................................................57

5.3 Recommendations...............................................................................................58

5.3.1 Recommendations from the study................................................................58

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5.3.2 Recommendations for further study.............................................................58

REFERENCES........................................................................................................59

APPENDICES...........................................................................................................62

Appendix I: Machakos county map..........................................................................62

Appendix II: informed consent form........................................................................63

Appendix III: household questionnaire.....................................................................66

Appendix IV: Key informant interview guide..........................................................78

Appendix V: Focus group discussion guide.............................................................79

Appendix VI: Research approval from Kenyatta University graduate school.........80

Appendix VII: Research authorization from Kenyatta University graduate school 81

Appendix VIII: Research authorization from National Council for Science,

Technology and Innovation......................................................................................82

Appendix IX: Letter of permission from Machakos department of health and

emergency services...................................................................................................83
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LIST OF TABLES

Table 3. 1: Proportion of respondent’s selected from each ward.................................24

Table 3. 2: Rule of Thumb for Cronbach Alpha..........................................................27
Table 4. 1: Questionnaire response rate.......................................................................30
Table 4. 2: Socio demographic characteristics of the respondents (n=394).................32
Table 4. 3: The influence of individual characteristics on utilization of FMS (n=394)
..............................................................................................................................36
Table 4. 4: The influence of mother’s level of awareness on utilization of free
maternity services (n=394)....................................................................................39
Table 4. 5: Relationship between distance from facility and utilization of FMS........39
Table 4. 6: Relationship of mother’s delivery experiences on utilization of FMS
(n=320)..................................................................................................................41
Table 4. 7: Relationship of organizational factors and utilization of FMS (n=320)....44
Table 4. 8: Influence of organizational factors on utilization of FMS.........................47
Table 4. 9: Multivariate models for predicting utilization of FMS..............................48
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LIST OF FIGURES

Figure 2:1 Conceptual framework..................................................................................8

Figure 4. 1: Place of delivery among respondents........................................................33
Figure 4. 2: Utilization of free maternity services among respondents........................34
Figure 4. 3: Awareness on free maternity services among the respondents.................37
Figure 4. 4: Source of information on FMS among respondents.................................38
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ABBREVIATIONS AND ACRONYMS

ANC Ante Natal Care

CIDP County Integrated Development Plan

DHIS District Health Information System

FGD Focus Group Discussion

FMS Free Maternity services

KDHS Kenya Demographic Health Survey

KII Key Informant Interview

MDG Millennium Development Goal

MMR Maternal Mortality Ratio

RMNCAH Reproductive Maternal Newborn Child and Adolescent Health

SBA Skilled Birth Attendance

SDG Sustainable Development Goals

TBA Traditional Birth Attendant

UNICEF United Children’s Fund

UNFPA United Nations Population Fund

WHO World Health Organization

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DEFINITION OF OPERATIONAL TERMS

Acceptability - This is conformity to the realistic wishes and expectations of

health users and their families.

Accessibility – Extent to which a consumer or user can obtain a service at the

time it is needed.

Affordable –The measure of assessing if the services offered are

cost effective.

Appropriateness – Provision of health care based on client needs.

Attitude - An acquired tendency to exhibit certain reactions to specific

objects based on values, emotions, beliefs and character.

Awareness –knowledge gained through own perception or being informed

by being cognizant of current development in regard to free

maternal healthcare services offered in public hospitals.

Free maternal health care- non-payment for services offered to pregnant women i.e.

antenatal care, delivery and post-natal services.

Knowledge - Refers to a state of awareness of free maternal health care.

Maternal health - Refers to the wellbeing of a mother during pregnancy

and after delivery.

Quality maternal care-Refers to provision of minimum level of care to all pregnant

women and their newborn babies, and a higher level of

care to those who need it, obtaining the best possible medical

outcome of the mother and baby, providing care, which

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satisfies users and providers, and maintaining sound managerial and

financial performance.

Staff competence- Training and abilities of healthcare staff in terms of technical and

cultural aspects and ability to communicate effectively to clients.

Timeliness – The degree to which patients are able to receive care as quickly as

possible.

Utilization of free maternal services– Use of free delivery services by women

during pregnancy in public health facilities.

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ABSTRACT

Globally, the rate of maternal mortality is unacceptably on the rise. Maternal mortality
rates in Kenya remain high at 362 per 100,000 live births. Only 62% of women
deliver under the care of a skilled provider indicating a deficiency in the quality of
care. The government of Kenya introduced the policy of Free Maternity Services to
all women attending public health facilities in June 2013 to increase skilled birth
attendance and reduce inequality by making services available to all pregnant women.
Despite the introduction and adoption of the free maternity policy in all government
facilities, there is still low utilization of the free maternity services by pregnant
women. The study sought to establish the determinants of utilization of free maternity
services among postnatal women in Machakos County. A cross sectional study was
carried out in Machakos County. A sample size of 421 postnatal women was
proportionally selected from each ward through systematic random sampling and
interviewed. The study mainly focused on the individual client characteristics, the
client related factors and organizational factors related to utilization of free maternity
services, which encompassed use of both quantitative and qualitative data collection
methods. Both quantitative and qualitative data was collected. Necessary approvals
were sought from relevant authorities and informed consent obtained from research
participants prior to data collection. Descriptive data was analyzed using Statistical
Package for Social Sciences version 25.0. Frequency distribution tables, graphs and
pie charts were used for data presentation. Qualitative data was presented as direct
quotes or narrations from respondents and triangulated with quantitative results.
Inferential statistics were calculated using Fischer’s exact tests and chi-square test
(p<0.05) done at 95% confidence interval to establish the association between study
variables. The study found out that the overall utilization level of free maternity
services by respondents was 75.6%. Chi-square test showed significant statistical
association between marital status (p=0.006), parity (p=0.038), distance from facility
and utilization of free maternity services (p=0.000), satisfaction with maternity
services offered during labour (p=0.000), treatment of mothers by healthcare workers
during labour (p=0.000) provision of adequate food (p=0.005), maternity services
offered were of high quality (p=0.000), maternity ward was not congested (p=0.009).
Fischer’s exact test showed significant statistical association between cleanliness of
the maternity ward (p=0.000), respect to clients by health workers (p=0.001)
availability of bed/linen (p=0.002), satisfaction with labour ward services during
delivery (p=0.000) with utilization of free maternity services. The study concludes
that the utilization of FMS was optimal, organizational factors were majorly
significantly associated with utilization of FMS.The study recommends that the
department of health to support health facilities to offer FMS by providing the
necessary supplies. These findings would assist key healthcare stakeholders to design
strategic policies and initiatives to ensure sustenance of Free Maternity Services in the
country. This would further ensure that the Free Maternity policy leads to improved
quality of maternal service provision in all public hospitals thus increased utilization
among women of reproductive age.
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CHAPTER ONE: INTRODUCTION

1.1 Background of the study

Maternal mortality is unacceptably high in Sub- Saharan Africa (Alkema et al, 2016).

Every day, globally nearly 830 women die due to complications during pregnancy and

childbirth, which are preventable, and 99% of these deaths occur in developing

countries (Alkema et al., 2016). Maternal mortality ratio in developing countries in

2015 was 239 per 100 000 live births compared to 12 per 100 000 live births in

developed countries, (WHO, 2014). There are large disparities between countries, but

also within countries, and between women with high and low income and those

women living in rural versus urban areas (Alkema et al., 2016)

Sub-Saharan Africa and South Asia account for 88 per cent of maternal deaths

worldwide, (Nicole, 2013). The Sub-Saharan Africans suffer from the highest

maternal mortality ratio, 546 maternal deaths per 100,000 live births,(Nicole, 2013).

This is 66 per cent of all maternal deaths per year worldwide. In Kenya, the maternal

mortality ratio declined from 488 maternal deaths per 100,000 live births to 362

maternal deaths per 100,000 live births (Kitui, Lewis, & Davey, 2013).

Free maternity services refer to offering of medical and obstetric care to pregnant

women without any financial cost. Improving the quality of service delivery requires

adequate investments in infrastructure, medical commodities and human resource.

For the provision of maternity care to be effective, women need to be active

participants and accept responsibility for their own health (Mxoli, 2007).

The health care cost is among the barriers to utilizing skilled birth services in

developing countries (Arhinful & Ross, 2006). In June 2013 in line with the Africa

union resolutions, Kenya introduced a free maternity care policy through a

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presidential declaration to improve on maternal and neonatal health outcomes. This

was in favour of service user fees exemptions for pregnant women and children under

five years of age, (AU, 2010). In 2009 as per KDHS, Kenya’s maternal mortality rate

was 488 per 100,000 livebirths compared to developed countries such as Switzerland,

which by then had a maternal mortality rate of 5 per 100,000 live births, (AU, 2010).

A policy on free maternity services was introduced which was meant to enable the

country to increase use of health facility based services by mothers, achieve national

development goals, (GoK, 2010) and global health development goals. Between 2016

and 2030, as part of the sustainable development goal 3, target 3.1 is to reduce the

global Maternity Mortality Ratio (MMR) to less than 70 per 100 000 live births

(Alkema et al., 2016). This policy was however implemented without considering

other factors that can also directly affect pregnancy outcomes such as the staffing

levels , availability of commodities and access to quality health education in health

facilities (Alkema et al., 2016).

KDHS 2013/2014 estimated that about 61 percent of births in Kenya took place in a

health facility. In Machakos County as per KDHS 2014 skilled birth attendance was at

63 percent while home deliveries at 37 percent. Machakos County still recorded a low

proportion of births assisted by skilled attendants at 47.4% (DHIS, 2017). Women

giving birth under a skilled birth attendant and access to emergency obstetric care is

accepted as one of the most crucial intervention for reducing maternal and newborn

deaths (DHIS, 2017).

High quality health facility delivery services, globally have been recommended as a

solution to preventable maternal and neonatal deaths (McKinnon et al, 2015). In line

with the recommendation, several African countries either reduced or eliminated

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delivery fees to promote health facility delivery service utilization (De-Allegri et al,

2015). Kenya abolished delivery fees in all public health facilities through a

presidential directive signed into effect on June 1, 2013.

For the government at large and for the Ministry of Health Kenya in particular

maternal and child health has remained a high priority. Attendance of antenatal care

and skilled birth attendance are significant determinants of maternal health. All

women need access to maternal health services. The proportion of births attended to

by skilled health personnel is thus a benchmark used for monitoring progress towards

achievement of sustainable development goal 3 on good health and well-being. Free

maternity healthcare services have been adapted in several countries to increase

deliveries by skilled birth attendants and reduce mortalities.

Researchers have shown that focus has been mainly on financial barriers to maternal

health while strategies and policies on utilization of maternal health care services is

limited (Michael et.al, 2013). How accessible and effective free maternity services are

to mothers still remains a question to be answered. Evidence and causes of

underutilization of free maternity services is still minimal in most studies. The free

maternity services programme was expected to have important impact, which has not

been convincingly demonstrated and there are specific concerns that the

programmatic management of free maternity has led people to question to what extent

is the program actually free.

1.2 Problem statement

The government of Kenya started implementing the Free maternity services (FMS)

in June 2013. This was intended to reduce the financial burden and high costs for

maternity services thus encourage mothers to deliver under skilled birth attendant.
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The KDHS 2014 estimated the MMR at 362 per 100,000 live births, which is still

high and far away from the MDG target of reducing MMR to 147 per 100,000 live

births by 2015 (KDHS 2014& MOH, RMNCAH 2016.). The reduction in MMR has

not been as significant as it was documented to be 488 per 100,000 live births in

2008/09. (KDHS 2008/09).

Despite the several efforts that the country has put in place aimed at reducing

maternal mortality ratio for example free maternity program, scrapping of user fees in

level one and two health facilities the MMR remains high and the skilled birth

attendance low. (Kenya RMNCAH, 2016) The free maternal health policy was

initiated to reduce the inequalities in access to maternal health services and therefore

lead to increase in utilization of skilled birth attendance.

According to the Machakos County Integrated Development Plan (CIDP), data

showed that at least women who attended one antenatal care visit was 67.2% while

delivery by skilled birth attendant 47.4%. The skilled birth attendance is way below

the 90% target by WHO. In Masinga Sub County skilled birth attendance was at 22 %

in 2017 (DHIS, 2017) this is despite the free maternity program and the county having

increased the number of the healthcare work force in the recent past.

1.3 Justification

Births delivered by skilled birth attendants’ is a key indicator for achieving

sustainable development goal (SDG) target 3.1 and for improving the measurement of

SDG 3.2 (W.H.O, 2017). In the reporting years, 2013 to 2017 deliveries by skilled

birth attendant coverage for Machakos County have remained low below the WHO

target of 90% at 38.2, 46.5, 55.5, 56.8, and 47.4 respectively as per DHIS reports.

Masinga Sub County has the lowest proportion of women delivered by a skilled
 5

attendant in 2017 at 22 % (DHIS, 2017). This therefore prompts for interventions to

ensure the achievement of the WHO target. An assessment of existing services is

crucial to inform the top management and policy makers in order to strengthen

delivery of the free maternity services in future.

The study will contribute to identification of hindrances or enablers of the free

maternity program in Machakos County for improving utilization of the free

maternity program in line with the universal health coverage with Machakos being

one of the pilot counties in Kenya.

1.4 Research Questions

1. What are the individual client characteristics associated with utilization of

FMS among postnatal women in Machakos County?

2. What is the influence of mother’s level of awareness on FMS on utilization of

FMS among postnatal women in Machakos County?

3. What is the influence of mother’s delivery experiences with FMS on

utilization of FMS among postnatal women in Machakos County?

4. What are the organizational factors associated with utilization of FMS among

postnatal women in Machakos County?

1.5 Hypothesis

1.5.1 Null hypothesis

Mother’s level of awareness on free maternity services, delivery experiences and

organizational factors do not influence utilization of free maternity services

1.5.2 Alternative hypothesis

Mother’s level of awareness on free maternity services, delivery experiences and

organizational factors influence utilization of free maternity services

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1.6 Research Objectives

1.6.1 General objective

To establish the determinants of utilization of free maternity services among postnatal

women aged 18-49 years in Machakos County

1.6.2 Specific objectives

i) To describe individual client characteristics associated with utilization of FMS

among postnatal women in Machakos County

ii) To determine the influence of mother’s level of awareness on FMS on

utilization of FMS among postnatal women in Machakos County

iii) To establish the influence of mother’s delivery experiences on FMS on

utilization of FMS among postnatal women in Machakos County

iv) To identify the organizational factors associated with utilization of free

maternity services in Machakos County

1.7 Significance of the study

The study targets to benefit mainly the Department of Health, public health facilities,

other relevant stakeholders in health and women of reproductive age who are the main

beneficiaries of the free maternity services. This research would point out key areas

that need attention by policy makers, health administrators and healthcare service

providers in developing evidence-based strategies for improving the free maternity

program. Results from this study will be useful to other researchers and scholars, as it

would be a basis for further research and build on existing literature.

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1.8 Limitation and Delimitation

1.8.1 Limitation of the Study

The major study limitation was that maternal health services are offered in both public

and private health facilities but the study focused mainly on maternal health services

accessed in public health facilities. Respondent recall bias was another limitation

since mothers were required to remember their experiences during delivery.

1.8.2 Delimitation of the study

The study was carried out at the households in three wards in Masinga Sub County.

The study was bound to the 421 sampled postnatal women who had delivered within

the period of researcher’s interest. The site was ideal because it had the lowest skilled

birth attendance coverage in the county.

1.9 Conceptual framework:

The study aims to establish the determinants of utilization of free maternity services

and define the relationship between the dependent and independent variables. This

framework was adopted and modified from McCarthy& Maine 2002 model on

determinants of maternal mortality. Dependent variable: Utilization of free maternity

services will be measured by mother’s report of having delivered at a government

facility and not paying for the service. Independent variable: These are factors that

will affect utilization of the free maternity services, for example mothers awareness

on FMS, mothers’ delivery experiences with FMS and organizational factors.

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Independent variable Intervening variable Dependent variable

Individual characteristics
Age, Marital status, parity,
level of education, income,
occupation

Mother’s awareness on FMS

Awareness on FMS Utilization of FMS
Those who delivered in
Free maternity Policy
government facilities and
never paid for the services
Mother’s experiences on
FMS
Delivery experiences on FMS

Organizational factors
Availability of health care
workers, Availability of
commodities and equipment,
Facility cleanliness, waiting

Source: Adapted and modified from McCarthy& Maine (2002)

Figure 0:1 Conceptual framework

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CHAPTER TWO: LITERATURE REVIEW

2.1 Global free maternal health services

The rate of maternal mortality is unacceptably high globally. About 800 women are

approximated to die daily from complications related to pregnancy or childbirth

worldwide (Bitew et al, 2015). In 2017, there were about 295, 000 global maternal

deaths with 86% of these occurring in the developing countries of Asia and Africa.

The World Health Organization, advocates for utilization of SBA at every birth to

improve delivery outcomes. It recommends assessment of women’s satisfaction to

promote the quality and effectiveness of health care delivery (WHO, 2014).The

reduction of maternal and child mortality and morbidity rate is one of the key targets

of achieving the Sustainable Development Goal (SDG) number 3 of ensuring global

health and wellbeing (UNDP, 2015). In the more developed countries, SBA rate is

about 99.5% whereas that of Africa is 46.5% (Esena et al, 2013). Developing

countries have adopted measures to reduce the increasing rates of maternal and child

mortality to include free maternity services

The ability of pregnant women to find themselves in the presence of skilled birth

attendants during delivery, readily available medical care in case of an emergency and

effective communication and referral systems are important interventions in scaling

up maternal healthcare services utilization (Owiti, Oyugi and Essink, 2018).

Accessibility refers to the availability of quality healthcare services to ensure those

who need them can acquire them within a reasonable time, ease and other aspects of

service delivery that make them available when needed. Accessibility in maternal

healthcare services utilization can be classified into two main categories. These

include economic accessibility and information accessibility.

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Information accessibility refers to the right to solicit, receive or impart ideas and

information pertaining to health issues. Conversely, economic accessibility, also

known as affordability refers to the measure of an individual’s ability to cater for

health services without experiencing financial hardship.

Ghana adopted the policy of free maternity services in public hospitals in 2008. By

then, the utilization rate of SBA was 59% well below the World Health Organization

target of 85% by 2010 (Esena et al, 2013). The policy led to a steady rise in the

number of facility-based deliveries from about 300,000 in 2007 to 500,000 in 2011. In

the New Juaben Municipality, the policy achieved tremendous results including

reduced maternal mortality rates (Ameyaw, 2011).

The introduction of the policy ensured pregnant women with complications arrived in

health facilities earlier in Ghana. This was accompanied with very poor quality of

health care to clients leading to low utilization rates as well as low satisfaction levels

(Tornui et al, 2015). The basic delivery equipment, consumables and midwifery staff

were readily available although overstretched. Expectant mothers reported different

aspects of quality improvement in the public facilities, thus positively influencing

future health seeking behaviour, maternal service utilization and reduced maternal

morbidity and mortality (Tuncalp et al, 2012).

A research conducted by the Navrongo Research Centre (NHRC), on the

government’s free maternal health care policy in the upper Eastern region of Ghana,

indicated that hidden costs during delivery were often characterized by finances to

buy medicine, scan tests and laboratory services, either in the health facilities or

outside the health facilities. Other hidden costs include purchase of pads and

disinfectants. These discourage many pregnant women from going to the health

facilities to deliver leading to increased maternal and neonatal deaths. Health workers
 11

interviewed in this study reiterated that there was an urgent need to help address the

problem in order to achieve the government’s agenda to reduce maternal and infant

mortality.

In Nigeria a study conducted following the implementation of free maternal health

services indicated that inadequate staff, infrastructure, poor remuneration and out of

stock syndrome led to many doctors leaving the country for developed countries

where there was better pay (Abel et al, 2013). This led to underutilization with over

65% of pregnant women delivering at home.

In Asia, especially in the Pakistani context, studies done suggested that women’s

utilization of maternity care services was very minimal. The most important concern

was whether their service quality meets patient expectation levels (Ashraf Mariam,

Ashraf Fatima, Atif, & Rukhsana, 2012).

There are hidden costs that are attributed to the low utilization of free maternity policy

in government health facilities in Dhaka, Bangladesh. Further, it was found that 72%

of clients assessed were willing to pay a government levied user charge although this

was less prevalent in low-income families at 61% (Shamsun, 2018).

Nepal introduced the policy of free delivery in 2009 as a constitutional right (Witter,

Khadka, Nathi, & S, 2011). The use of free maternity services continues to improve

with increased deliveries in health facilities. The funds are adequate to cover free

maternal service delivery costs, with some surplus being invested in staff incentives

and improving services. This has promoted flexible use of resources and

reimbursement of funds without delay (Raj et al., 2015).

Nearly, a half (47.8%) of clients were satisfied with government provided free

maternity services in Nepal (Shrestha et al, 2010). However, understaffing is a key

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issue in some posts and areas. There is decreased general revenue for facilities due to

wider loss of user fee revenues. This explains the on-going charges for patients as

reported by both facilities and patients from some hospitals.

Wu et al. (2019), utilization of maternal health services has been reported as a

promising avenue in preventing complications related to pregnancy and delivery,

while improving the health of the newborns. Despite significant improvements in

maternal health services delivery, previous research has indicated that inequities, low

coverage and poor quality of essential maternal health services still remain a

drawback for most countries in the Sub-Saharan region. For example, on average less

than half of women in the reproductive age group in Sub-Saharan Africa give birth in

health facilities (Dimbuene et al., 2018). Ganle et al. (2014) argue that only 47% of

African women give birth through a skilled birth attendant.

Despite the hindrances in access to SBA and effective emergency obstetric care

provision, there has been some progress in reducing maternal mortality and morbidity

levels.

2.2 Overview of Maternal Health Services in Kenya

In Kenya, maternal and child mortality rates have been relatively high. The rate of

maternal mortality stands at 362 deaths per 100,000 live births (KNBS & ICF, 2014).

Further, for every woman who dies during childbirth an extra 20-30 women suffer

serious injury or disability due to complications related to pregnancy or delivery

(Ochieng, 2014). The high MMR has persisted irrespective of improvements in other

health indicators due to lack of access to quality maternal health care including

antenatal, delivery and post-natal services (GoK, 2014).

 13

Free maternity health care services, were introduced in Kenya in the year 2013. This

was in line with the health system objective of universal health coverage in the fifth

millennium development goal. This was seen as a major success in the fight towards

reducing maternal and child mortality. The aim was to increase skilled birth

attendance and reduce inequality by making services available to all pregnant women.

This is a major milestone towards universal health coverage as documented in the

Kenya Health Sector Strategic Plan (KHSSP) 2014-2018 (GoK, 2014). The idea of

abolishing user fees has been long running in subsequent governments with strong

resistance from proponents who believe that free health care may not make economic

sense given the increasing budgetary deficits.

Access to skilled delivery has been identified as a key factor in reducing the maternal

mortality ratio. Despite the introduction and adoption of the free maternity policy in

all government facilities, there is still low utilization of the free maternity services by

pregnant women.

Despite witnessed growth in health sector infrastructure recently, many mothers are

still unable to access quality maternal health services. In Kenya, only 62% of births

occur under supervision of a skilled birth attendant (KNBS & ICF, 2014). This was

well below the WHO target of 90% deliveries by the year 2015.

Traditional Birth Attendants (TBAs) continue to assist expectant mothers with 28% of

births; relatives and friends are estimated at 21%, while the rest (7%) of the mothers

deliver on their own (WHO, 2014).

 14

The Ministry of Health reported that ANC service utilization increased by 11% since

initiating FMS, with ANC re-visits accounting for 13% (GoK, 2015). Normal

deliveries increased by 22% while those of CS increased by 17%. The complications

related to maternal care dropped from 4.3% in 2012/13 to 3.8% in 2013/14. The rate

of obstructed labour declined greatly while other maternal complications remained

fairly the same (GoK, 2014). Overall, there has been a 10% increase in health facility

deliveries across the country, with a 50% increase in certain counties (Owino, 2013).

The increased demand for maternal health services has overstretched the available

resources and overloaded the limited human resources. This has affected accessibility

and availability of quality, equity and sustainable healthcare services (Bourbonnais,

2013). The policy has faced several challenges that need to be addressed. They

include insufficient funds and delayed reimbursements, limited investment in new

infrastructure, lack of adequate equipment and low staffing levels (GoK, 2015).

2.3 Individual characteristics and utilization of maternity care services

Individual client characteristics are some of the factors that may determine access to

and use of health services (Essendi et al, 2011). This consequently plays part in

assessing utilization with quality of service provision. However, there is inconsistent

relationship between utilization levels and the individual client characteristics as

pertained to utilization of maternity services (Leslie & Gupta, 2009).

The educational status of women may be associated with the rate at which they use

health care. This improves the health of women by providing them with skills training

for employment (Ebere, 2013). Education increases awareness levels among women

thus inspires their need for using skilled maternity services at their disposal. Clients

who have high educational level demand more information on quality of care
 15

provided and hence try to build trust with physicians (Beatrice, Arthur, & Theresah,

2016).

Income provides women with the ability to achieve improved nutritional status

(Philip, Alex, & Caroline, 2018) and adequate housing, which protect and advance

their health status (Leslie & Gupta, 2009). This enables them to access quality

services thus enhancing positive delivery outcomes. Other studies have found that

house wives/non-working women are more likely to use free maternal health services

compared to those employed (Christine, 2014; Shamsun, 2018). Studies done in

Ethiopia and Nigeria revealed that ANC use is based on economic status. Women

from richer households were six times more likely to use such services than their

poorer counterparts (Yusuf et al, 2013).

According to a study done in Nyatike and Muhuru Divisions, a higher proportion of

low-income earners utilized more of the free maternity services than higher income

earners. In fact, higher income earners may bear the cost of private facilities in the

region (Christine, 2014). The same study reveals that education enhances female

autonomy hence can make personal health decisions. Women with higher educational

levels have greater access and therefore utilize high quality maternity services from

private hospitals. On the other hand, those with little education and hailing from poor

backgrounds mostly rely on government-subsidized care.

The age and parity of the mother have been examined as determinants of maternal

health care utilization and repeated use. Mothers in the middle childbearing ages are

most likely to use more maternal services compared to their peers in the early or late

childbearing ages (Babalola & Fatusi, 2009). Women who get pregnant at tender ages

tend to face more complications during pregnancy and childbirth. Older women have

greater experience and confidence on matters related to maternal care. Women with
 16

higher parity, especially those with successful deliveries, have more confidence and

less fear for pain and risky pregnancy outcomes (Tsegay et al, 2013). Women with

higher parity have greater responsibilities within the household for childcare and thus

increase their level of health service utilization (Kwast & Liff, 2008).

Given low socio-cultural status of women in developing countries, it influences

negatively on women’s health status. It is a major barrier to improve health due to the

unequal status between men and women. Overall, lower education levels, age, and

marital status also contribute to women’s poor maternal health conditions. Those

married spend more time caring for their spouses and families imposing a strain on

their health (Marchie, 2012). It is further revealed that socio-cultural variables when

taken together contribute positively to maternal mortality.

2.4 Mothers awareness on free maternity services in public hospitals

Women identify awareness as a major structural variable that could influence the

decision on whether to utilize maternal health services or not. Women need more

information about maternal health services during antenatal period so that they can

make informed choices when to seek these services.

Jewkes (2015) cited lack of adequate information on maternal health services,

laboratory tests result findings and dangers of coming for antenatal care late or not

coming for antenatal care services at all as contributors to the poor utilization of

maternal health care services. Inadequate information about these services and the

benefits to both mother and baby may also negatively influence utilization of maternal

health care services.

There is a strong positive correlation between knowledge of mothers on maternal

issues on the utilization of maternal health care. In a study in Australia that explored
 17

the characteristics of women who utilized and preferred to use the government funded

maternal care it was found that all of them knew the meaning of maternal care, knew

what it meant by normal delivery, recognized the complications that were likely to be

experienced when delivery was administered using unqualified personnel and knew

where to refer to in case of problems arising during pregnancy. On the other hand,

women who did not utilize the maternal care services on the other hand had a low

understanding of these issues (Teate, Leap, Rising, & Homer, 2011).

2.5 Mothers attitude on free maternity services

Studies have revealed that the attitude of mothers has an influence on the utilization

of maternal care. Salam et al (2013) pointed out that mothers attitude towards the health

care is determined by the experience of the women with the health care or what they

observe other mothers going through in the maternal care. Studies previously conducted

indicated that expectant mothers may fail to utilize maternal health services because

of past mistreatment to them or fears of mistreatment as heard from others. An

important but little understood component of poor care that women receive during

childbirth in facilities is disrespect and abuse perpetuated by health workers and other

facility staff. (Jewkes, 2015) Fear of experiencing disrespect and abuse influences

women’s decisions to seek care at a health facility during labour and delivery. (Kruk,

2015) A Malawian study conducted in 2017 by Machira, K. et al showed that the

health care providers are very unfriendly during childbirth as compared to the

antenatal care and this was likely to affect utilization of maternal services. According

to Bowser (2010) abuse and humiliation of women during childbirth across the world

is a major barrier to access to free maternity services. This is due to negative attitude

and burn out attributed to shortage of skilled staff and increased demand of services

with inadequate supplies. The working environment is not conducive due to increased
 18

workload, poor remuneration, inadequate supportive supervision, equipment and

supplies. Unfortunately, too often pregnant women seeking maternity care receive

varying degrees of ill treatment, from subtle disrespect of their autonomy and dignity

to outright abuse- physical assault, verbal insults, discrimination, abandonment, or

detention in facilities for failure to pay. Evidence is now emerging that this fear of

being badly treated and abused in health facilities is holding women back from

seeking help. It is proving to be as big a deterrent as cost of care and transport.

(Rowdon, 2014)

2.6 Organizational factors and their influence on free maternity services

A study done by Erick Tama et al (2016) found out that while there was improved

access to maternity services due to the free maternity program, measures were not

taken to improve the health facilities’ capacity to adequately cope with the increased

number of clients. Health workers had to handle more clients, which led to increased

workloads hence burnouts. The increased workload influenced negatively on staff

motivation; in some instances, some nurses were hesitant to work in the maternity

department. The increased utilization strained facilities’ physical capacity for instance

ward space forcing hospitals to fit many beds in small spaces leading to congestion

and sharing of beds. In some health facilities, mothers were discharged earlier than

required to ease congestion in the maternity wards. The increased utilization affected

quality of care too, with nurses not being able to give mothers the attention required.

2.7 Satisfaction and free maternity services

Client satisfaction was isolated as a major determinant in the increased utilization of

health services and without major effects on perceived quality of care. It is the actual

measure of health care services being offered at the health care system. (Al- Abri and
 19

Al- Balushi, 2014). Determinants of client satisfaction with the services offered help

policy and decision makers in implementing programs tailored to patients’ needs and

expectations. (Aldana et al., 2002, Kelley et al., 2014). The patients are the best

judges of health care services since they assess services directly offered to them and

they can provide inputs, which can be of help in improving the quality of care.

Patient’s satisfaction and perception are useful measures to provide a direct indicator

of quality in health care, hence needs to be assessed frequently so that an evidence

based domesticated healthcare plan can be developed for adoption in the health care

sector. (Kelley et al., 2014). The following aspects are considered in assessing client

satisfaction timeliness, acceptability, accessibility, affordability, client centeredness,

staff competence and appropriateness.

2.8 Summary of Literature Review

Many declarations, resolutions and goals have been made in order to achieve

reduction of maternal mortality. The most recent was MDGs, which ended in

September 2015. The SDG on maternal health aims to reduce preventable maternal

mortality to less than 70 per 100,000 live births by 2030.Delivery by skilled birth

attendants is the solution to maternal mortality reduction. Many countries in the past

have introduced free maternity services to increase deliveries by skilled birth

attendants. This is in line with law of demand in economics, which states that there is

increase in demand of product when prices are lowered.

In Kenya, free maternity services were introduced in the year 2013.A study was done

on assessment of implementation of the policy. Few studies have been done on factors

affecting utilization of free maternity services. There is limited evidence on

 20

effectiveness of the policy and interventions to address equity and access to allow all

pregnant women deliver in facilities or by skilled attendant.

This gives the need to identify other factors that may be affecting utilization of the

maternity services even when provided at no cost. This study seeks to investigate

factors that hinder or enhance the utilization of free maternity services.

 21

CHAPTER THREE: MATERIALS AND METHODS

3.1 Introduction

This chapter describes the research design, variables, study location, target

population, inclusion and exclusion criteria, sampling techniques, sample size

determination, data collection techniques, pretesting, validity and reliability of the

study, data collection techniques, data analysis and ethical considerations.

3.2 Study design

This research adopted a descriptive cross-sectional study design approach based in

collecting data from the sampled research respondents (Kothari, 2008). It was

preferred because it ensured complete description of the situation making sure that

there was minimal bias in data collection. This provided an operational framework,

through which the facts were placed, analyzed and thus produced valuable outputs

(Ochieng, 2014). The design was justified as it captured information on utilization of

free maternity services as exhibited by postnatal women interviewed at the

households.

3.3 Study Variables

The independent variables of this study included

i) Individual client characteristics such as age, educational status,

occupation, monthly income, marital status and parity.

ii) Mother’s delivery experiences such as, waiting time, reception at the

maternity, satisfaction with services in the labour ward, recommendation

of facility to relative or friend and revisiting the facility for delivery.

 22

iii) Mother’s level of awareness on FMS to include source of information on

FMS,nearest facility offering FMS, governments efforts on informing

public on FMS and knowledge on FMS.

iv) Organizational factors including staff availability, staff treatment during

labour, cleanliness of maternity, privacy, respect to clients and provision

of information to clients by health workers.

3.3.1 Dependent variable

The dependent variable for this study was utilization of free maternity services.

Utilization of free maternity services was measured by mothers’ self-report of

delivering in a public health facility and not incurring any financial cost after delivery.

3.4 Location of the study

The study was conducted in Machakos County, Masinga Sub County. Masinga sub

county borders Yatta Sub County and mbeere in Embu County. It was selected

because it had the lowest skilled birth attendance coverage in the county and it has the

highest number of public health facilities. The study was conducted in three out the

five wards. The wards are Masinga central, Ekalakala and Kivaa. It was a household

survey.

3.5 Study Population

The study population comprised of all women 18-49 years who delivered within a

period of one year between September 2018- September 2019 in Masinga Sub

County. The study was carried out in three wards. Three public health facilities that

offer maternal and child health services were used for key informant interviews.
 23

3.5.1 Inclusion criteria

Participants for this study included all the women who had delivered in the past one

year. The women were of age 18-49 years. Those who consented participated in the

study.

3.5.2 Exclusion criteria

The study excluded all women 18-49 years who could not talk, mentally unstable

those who were sick thus unable to participate during the time of conducting this

study.

3.6 Sampling technique and sample size determination

3.6.1 Sampling size determination

Fisher’s formula (Mugenda 2003) was used to determine the sample size. To estimate

the proportion within + or -5% of the true value with 95% confidence interval, the

sample size(n) will be calculated as follows (for a population more than 10,000).

𝑍2𝑝𝑞
n= 𝑑2

n= sample size

z=normal deviate usually set at (1.96) which corresponds to the 95% confidence level

p= proportion of skilled deliveries in Machakos County

q= 1-p

d= degree of accuracy =0.05

Therefore at 95% confidence level and +-5 percentage precision and population

proportion of 50% the sample size will be

(1.96*1.96) 0.47(1-0.47)/0.05*0.05
 24

n=3.8416*0.47(0.53)/0.0025

n=383 (desired sample in a population greater than 10000)

n= 383+ 10% non-response= 383+38=421

n=421

10% of subjects were included to cater for non-responses thus 421 questionnaires

were administered. However, after questionnaire checking, cleaning and editing, 394

questionnaires were deemed fit for analysis.

Table 3. 1: Proportion of respondent’s selected from each ward

Sub Wards Households Sample size Kth Response

county proportion value
Masinga Masinga 1825 161 11 147
Central
Kivaa 1887 167 11 158

Ekalakala 1052 93 11 89

Total 3 4764 421 394 (93.6%)

3.6.2 Sampling technique

Masinga Sub County was purposively selected from the eight sub counties in

Machakos County because it had the lowest skilled birth coverage and it has the

highest number of public health facilities. Multi stage sampling technique was used to

recruit the 421 study participants. First, the three wards: Masinga Central, Ekalakala

and Kivaa/Kithyoko were randomly selected from the five wards used to recruit

participants. All the wards were listed down on small papers then the researcher

picked papers to identify the wards to participate in the study. From the three wards,

eight community units were purposively selected from the twenty community units.
 25

A probability proportional to size was used to determine the number of households

required in each ward. Finally, the women to be included in this study were sampled

from every 11th household. Women were eligible if they had delivered within one

year September 2018- September 2019 prior to the time of data collection. If a

household had two or more women who qualified for the study, the participant was

chosen through balloting. In order to obtain additional information two focus group

discussions were carried out and three key informant interviews. The FGD comprised

of 10 community members who were purposively selected based on their ability to

provide the required information. The in charge of the facility was` identified as key

informant. Key informants comprised of informed, knowledgeable and experienced

persons who were involved in managing the provision of maternity services (Otieno,

2014).

3.7 Research instruments

The study used semi-structured questionnaires (appendix II) for collection of

quantitative data from postnatal women in the households. The questionnaires were

administered in English, and translated in Kikamba where appropriate with the aid of

trained research assistants. They were adequately trained and familiarized with the

study area and topic of research before data collection. Focused group discussion

guides (appendix IV) were used to collect qualitative data from FGD sessions with 10

participants Additional qualitative information was also collected using key informant

interview guides (appendix III) through sessions held with the nursing officer in

charge of each selected facility. The data collection instruments comprised of

questions covering individual characteristics, health provider factors and

organizational factors.
 26

3.7.1 Pre testing of research instrument

Pretesting of the research instrument involved administering of the research

instrument to a small sample of respondents with the same characteristics as the actual

sample that was to be used during the study. Pretesting of data collection tools for

mothers was carried out at Kithimani community unit in Yatta Sub County. A total of

42 mothers representing 10% of the study sample was randomly selected. Focused

group discussion guides and key informant interview schedules were also pretested.

3.8 Data collection techniques

Quantitative data was collected using semi-structured research questionnaires. The

questionnaires were administered by the researcher and trained research assistants

who guided the participants to fill in their responses. They were monitored, guided

and supervised by the researcher. All filled questionnaires, were collected and kept in

locked cabinets throughout the study period and accessed by the researcher only to

ensure confidentiality and avoid data loss.

Qualitative data was obtained from focused group discussions held with community

members and community health volunteers in two FGD sessions in an area identified

by the participants. The researcher moderated the sessions. Voice recording of the

FGD sessions was done and notes taken by research assistants. This encouraged free

discussion among participants thus captured information, which was not achievable in

a one on one interview.

The researcher also conducted key informant interviews with three facility nursing

officer in charges to supplement information obtained from clients. The interviews

were done at their offices on appointment in each facility. Their views, opinions and

suggestions were taken into account.

 27

3.9 Validity and Reliability of the study

3.9.1 Validity

The validity of the research instrument was established through discussing with the

supervisor, monitoring and evaluation officer at the Machakos department of health,

to assess how well the respondents respond to the research questions. Construct and

face validity were assessed. The team ensured that the data collection tool questions

were in line with the research questions. Any ambiguities and inconsistencies were

checked and corrected. Pre testing of the questionnaire was done to check on its

validity.

3.9.2 Reliability
The variables that had Likert type items were subjected to the Cronbach Alpha. Six

items were entered. Variables that did not meet the threshold of 0.7 were assumed as

not reliable for further analysis. SPSS version 25 was used to determine the

Cronbach’s Alpha. After subjecting, the variables to the Cronbach Alpha only one

item had 0.6 and it was removed from the questionnaire to make it more reliable. The

rest had a score of 0.8, which was satisfactory.

Table 3. 2: Rule of Thumb for Cronbach Alpha

Rate Standard Rate Standard

≥ 0.9 Excellent ≥ 0.6 Questionable

≥ 0.8 Good ≥ 0.5 Poor

≥ 0.7 Acceptable <0.5 Unacceptable

 28

3.10 Data management and analysis

Quantitative data was entered and stored in Microsoft Excel program. Data cleaning

and editing was done where extreme, missing and inconsistent values were identified

and corrected. The researcher did data entry and cleaning. Coding and verification of

the data was done for easy manipulation, analysis and presentation. Data was then

exported to Statistical Package for Social Sciences (SPSS) software version 25.0 for

descriptive analysis. Frequency distribution tables, percentages, charts and graphs

were used to present quantitative results.

Inferential statistics were computed using Fisher’s Exact Test presented in cross-

tabulations. This was done at 95% confidence interval and p values of less than 0.05

were considered significant in testing the association between the independent and

dependent variables. Individual patient characteristics, mother’s level of awareness on

FMS, organizational factors and mother’s delivery experiences were subjected to

statistical analysis in relation to free maternity utilization. Qualitative data from the

FGDs and KII were presented as direct quotes or narrations and triangulated to

validate and enrich quantitative results.

3.11 Logistical and Ethical considerations

The researcher sought approval from Kenyatta University Graduate School (Appendix

V). A research permit was sought from the National Council for Science, Technology

and Innovation (NACOSTI). (Appendix VII), Research authorization was sought

from Machakos Department of Health (Appendix VIII). Permission was also sought

from the Sub County Health Management Team and local administrators before

actual data collection.

 29

The study sought informed consent from research participants before they were

interviewed. The study purpose was clearly explained and participants were informed

that their involvement in the research was voluntary without due coercion or

influence. Their identities were kept private and confidential by removing personal

identifiers, with the collected information used only for the purpose of this study. The

results would be submitted to the Machakos County Department of Health and

emergency services. The results would be disseminated through publication for future

reference and presented in conferences and workshops of relevant stakeholders.

 30

CHAPTER FOUR: RESULTS

4.1 Introduction

The findings of this study are presented in this chapter. These include the

demographic information, presentation of results and analysis based on the objectives

of the study and as explored by the questionnaires, employing descriptive statistics.

The presentation of the results is based on sections. Section 4.2 is description of the

socio demographic characteristics of the respondents, section 4.3 overall utilization of

maternity services, section 4.4 utilization of free maternity services, section 4.5

individual client characteristics associated with utilization of FMS, section 4.6

influence of mother’s level of awareness on utilization of FMS, section 4.7 the

influence of mother’s delivery experiences on utilization of FMS, section 4.8 the

influence of organizational factors on utilization of FMS, while section 4.9

determinants of utilization of FMS.

4.2 Response rate

The study targeted a sample size of 421 women who had given birth in public

hospitals in Masinga Sub County from which 394 questionnaires were filled and

returned accounting to a response rate of 93.6%.

Table 4. 1: Questionnaire response rate

Response rate Frequency Percentage

Response 394 93.6%

Non response 27 6.4%

Total 421 100

 31

4.3 Sociodemographic characteristics of respondents

Table 4.2 presents socio demographic characteristics of the respondents, slightly more

than half (55.3%, n=218) were aged between 20 and 29 years while one in three

participants (32.2%, n=127), were aged between 30 and 39 years. Majority of

participants were protestant Christians (52.6%, n=204) while (47.4%, n=184) were

Catholics Christians. The marital status of three in four of the respondents were

married (74.6%), n=294) while one in four of the respondents were single (25.4%),

n=100). Education wise, approximately half of the participants (48.3%, n=190) had

primary education while (39.9%, n=157) had secondary education. Regarding

occupation, majority of the participants were unemployed (44.4%, n=175) with

approximately one in five (23.4%, n=92) of the participants being farmers.

On monthly income, slightly more than half of participants (54.6%, n=215) earned a

monthly income of less than Kshs. 10,000/=, while one in three (n=104, 32.5%)

earned no monthly income. On parity half of the respondents (50.8%, n=200) had

between 2-3 children while (3.6%, n=14) of the respondents had more than five

children.
 32

Table 4. 2: Socio demographic characteristics of the respondents (n=394)

Variable Respondent response Frequency Percentage

Age group <19 43 10.9%
20-29 218 55.3%
30-39 127 32.2%
>40 6 1.5%
Religion Catholic 184 47.4%
Protestant 204 52.6%
Marital status Single 100 25.4%
Married 294 74.6%
Level of education None 4 1.0%
Primary 190 48.3%
Secondary 157 39.9%
University 7 1.8%
Diploma/tertiary college 30 7.6%
Others 5 1.3%
Occupation Employed/salaried worker 24 6.1%
Farmer 92 23.4%
Business/self employed 91 23.1%
Unemployed 175 44.4%
Others 12 3.0%
Income <10,000 215 54.6%
10,000-30,000 37 9.4%
>30,000 11 2.8%
None 131 33.2%
Parity 1 115 29.2%
2-3 200 50.8%
4-5 65 16.5%
>5 14 3.6%
 33

4.4 Overall utilization of maternity services

As shown in figure 4.1, out of the 394 respondents, (81%, n=320) utilized maternity

services in their last delivery in government facilities while (8 %, n=31) delivered in

private/mission facilities. The rest (11%, n=43) delivered at home.

Place of last delivery

TBAs home
Mission Hospital 4%
4% Own home
7%
Private Hospital
4% Govt. Hospital
Govt. Dispensary 25%
3%

Govt. Health
centre
53%

Figure 4. 1: Place of delivery among respondents

One key informant interviewee reported-

“Ever since the introduction of FMS, the number of deliveries in a month has tripled
as more mothers are now coming to deliver at the facility.

4.5 Utilization of free maternity services

As per figure 4.2, the study found out that of the 320 respondents who delivered in

government facilities (75.6 %, n=242) never paid for the maternity services while

(24.4 %, n=78) paid for the services, though the payments done were not official as no
 34

receipts were issued. Those who delivered in government facilities and never paid for

the services defined utilization of free maternity services. Monies paid by mothers

after delivery was considered as payment for services offered.

Payment for maternity services

24.4%

75.6%

Yes No

Figure 4. 2: Utilization of free maternity services among respondents

One FGD discussant commented that:

“we know that we are not supposed to pay for the maternity services, but some

health workers ask for money after a mother delivers, chai ya daktari,

kupanguza daktari jasho”and at times, when a mother does not have the cash

she is forced to leave behind her identity card until that time when she is able

to raise the money, others are not issued with birth notification forms until

that point when they bring the money.

 35

4.6 Individual client characteristics associated with utilization of free

maternity services
Table 4.3 presents the individual client characteristics associated with utilization of

free maternity services. The highest percentage of women who utilize FMS in

Machakos county were those in the age bracket 20-29 (n=172, 78.9%) followed by

those in the 30-39 age bracket (n=106, 83.5%). Slightly more than half of those

utilizing FMS were Protestant Christians while 47.5 % were Catholics. Majority (77.5

%) were married with 22.5% being single. There was a statistically significant

association between marital status and utilization of FMS with married persons being

more likely to utilize FMS (79.6%, n=234 (p = 0.006). Regarding education, 47.0%,

n=150) of participants utilizing FMS had primary level education with another two in

five (41.4%), n=132, having secondary education however, there was no statistically

significant association between one’s level of education and utilization of FMS.

The main occupation of those utilizing FMS was business persons/self-employed

(79.1%, n=72) and farming (75.0%, n=69) even so, majority were unemployed

82.9%, (n=145). However there was no statistically significant association between

occupation and utilization of FMS, p=0.871.

Based on income, (75.8%, n=163) of those utilizing FMS study participants earned a

monthly income of less than KShs.10,000/= while 88.9% earned between 10,000 and

30, 000 per month. However, there was no statistically significant association between

monthly income and utilization of FMS, p = 0.218. Majority of those utilizing FMS

had a parity of 2-3 children (79.1%), n=159) while approximately four in five had 4-5

children (81.5%), n=53) There was a significant statistical association between parity

and utilization of FMS, p = 0.038, with those who had low parity more likely to

utilize FMS.
 36

Table 4. 3: The influence of individual characteristics on utilization of FMS

(n=394)
Independent
Dependent variable
variable
Response Non utilization Utilization of P
Individual of FMS (N=74) FMS (N=320)
characteristics n % n %
Age <19 10 23.3% 33 76.7%
20-29 46 21.1% 172 78.9%
30-39 0.107
21 16.5% 106 83.5%
>40 1 16.7% 5 83.3%
Religion Catholic 32 17.4% 152 82.6%
0.183
Protestant 44 21.6% 160 78.4%
Marital status Single 18 18.0% 82 82.0% X2= 7.465
df = 1
Married 60 20.4% 234 79.6% p=0.006
Level of None 1 25.0% 3 75.0%
education Primary 38 20.0% 152 80.0%
Secondary 30 19.1% 127 80.9%
University 0.076
0 0.0% 7 100.0%
Diploma/tertiary college 8 26.7% 22 73.3%
Others 1 20.0% 4 80.0%
Main Employed/salaried
3 12.5% 21 87.5%
Occupation worker
Farmer 23 25.0% 69 75.0%
Business/self employed 19 20.9% 72 79.1% 0.871
Unemployed 30 17.1% 145 82.9%
Others 3 25.0% 9 75.0%
Monthly <10,000 Kshs 52 24.2% 163 75.8%
income 10,000-30,000 Kshs 5 11.1% 40 88.9%
> 30,000 Kshs 0.218
0 0.0% 3 100.0%
None 21 16.0% 110 84.0%
Parity 1 24 20.9% 91 79.1%
2-3 41 20.5% 159 79.5% X2 = 8.437
4-5 df = 3
12 18.5% 53 81.5%
p=0.038
>5 1 7.1% 13 92.9%

P statistical significance (two sided fishers exact)

 37

4.7 Influence of mother’s level of awareness on utilization free maternity services

Findings from the study, figure 4.3 found that that there was a 99.0% awareness on

free maternity services being offered in public health facilities in Machakos County.

The highest percentage of women, 9 in 10 were aware that delivery services in public

health facilities were provided free of charge.

Awareness on FMS

1%

no
yes

99%

Figure 4. 3: Awareness on free maternity services among the respondents

In one FGD discussion, a participant commented-

“Almost everyone in the community knows that giving birth in all government

facilities is free of charge”,

4.7.1 Sources of information on free maternity services

Majority of the postnatal mothers acquired information on free maternity services

from more than one source. Generally, 57.0% of responders, the information was

acquired from facility staff, followed by community health workers (45.0%), radio/

TV (39.0%), husband and close relatives (4.0%), while (1.0%) acquired the

information from others sources such as local leaders. The results are presented in

Figure 4.4
 38

60% 57%
50% 45%
39%
40%
30%
Population percentage

20%
10% 1% 4% 1%
0%

Source of Information

Figure 4. 4: Source of information on FMS among respondents

4.7.2 Relationship between awareness and utilization of free maternity services

Table 4.4 presents the relationship between mother’s level of awareness on free

maternity services and utilization of free maternity services. From the study

population, 99.0% of the respondents were aware of free maternity services being

offered in Machakos County. However, only (82.0%, n=315) of respondents utilized

the services, of which (50.0%, n=5) did not have knowledge about free maternity

services but still utilized it. (18.0%, n=69) knew of the service but did not utilize it.

There was no statistically significant association between awareness of FMS and

utilization of the service p = 0.589

 39

Table 4. 4: The influence of mother’s level of awareness on utilization of free

maternity services (n=394)

Utilized free maternity services

Study Variable Yes (N=320) No (N=74)
P-value
n (%) n (%)
Awareness of free No 5 (50.0%) 5(50.0%)
maternity services 0.589
Yes 315(82.0%) 69 (18.0%)
P statistical significance (two sided fishers exact)

4.7.3 Nearest public facility offering free maternity services

The study found a significant statistical association between utilization of free

maternity service and proximity to a facility offering free maternity service (p=0.000).

Table 4. 5: Relationship between distance from facility and utilization of FMS

Nearest facility offered

free maternity services P
No (161) Yes (233)

Yes 146 (45.6%) 174 (54.4%) X2 = 15.989

Utilized free
df = 1
maternity service
No 15 (20.3%) 59 (79.7%) p=0.000

4.8 Influence of mother’s delivery experiences on utilization of FMS

In table 4.6, mother’s delivery experiences on free maternity services was assessed

based on their reception at the maternity, time taken to be attended at the maternity, if

mother’s would recommend the facility where they delivered to a friend or relative or

if they would visit the same facility if need be, labour experiences and satisfaction

with the services offered in the labour ward.

In regards to the reception at the maternity, the study revealed that majority (83.3%,

n=115) of respondents who utilized the FMS rated the reception as excellent. There
 40

was significant statistical association (p=0.000) between client’s reception at the

maternity and utilization of FMS.

It took less than 15 mins to be attended at the maternity for the majority of mothers

who utilized FMS (77.0 %, n=147). However, there was no significant statistical

association (p=0.389) between time taken to be attended and utilization of FMS. (78.2

%, n=230) of the respondents who utilized FMS indicated that they would visit the

same facility for delivery if need be. There was a significant statistical association

(p=0.000) between visiting the same facility for delivery and utilization of FMS.

Majority of the respondents (78.3 %, n=231) indicated that they would recommend

the facility where they delivered to a friend or relative. There existed a significant

statistical association (p=0.000) between recommending facility to a friend or relative

and utilization of FMS.

In regards to satisfaction with services in the labour ward, the study revealed that

majority (80.2 %, n=219) of the respondents who utilized FMS indicated that they

were satisfied with the services rendered during labour, (79.9 %, n=226) were

satisfied with services offered during delivery while (80.3 %, n=232) were satisfied

with services offered after delivery. There was significant statistical association

(p=0.000) between satisfaction with services rendered in labour ward and utilization

of FMS.

The study found out that (75.9%, n=236) of mothers who utilized FMS did not

experience verbal abuse during labour though there was no significant statistical

association (p=0.460) between verbal abuse and utilization of FMS. Majority of the

respondents (76.5%, n=241) did not experience pinching/slapping/beating during

labour. There was a significant statistical association (p=0.014) between pinching and
 41

utilization of FMS. (75.6 %, n=236) of the respondents did not deliver alone without

assistance however there was no significant statistical association (p=0.620) between

delivering alone without assistance and utilization of FMS.

Table 4. 6: Relationship of mother’s delivery experiences on utilization of FMS

(n=320)

Utilized Free Maternity

Variable Response No Yes P
n % n %
Poor 1 50.0% 1 50.0%

Reception at the Fair 19 46.3% 22 53.7%

0.001
maternity Good 35 25.2% 104 74.8%
Excellent 23 16.7% 115 83.3%
<15mins 44 23.0% 147 77.0%
X2 = 3.018
Time it took to be 16-20 mins 12 20.7% 46 79.3%
df = 3
attended at the maternity 21-30 mins 9 26.5% 25 73.5%
p = 0.389
>30mins 13 35.1% 24 64.9%
Agree 64 21.8% 230 78.2%
I would visit the same 0.000
Neither agree or
facility for delivery if 11 64.7% 6 35.3%
disagree
need be
Disagree 3 33.3% 6 66.7%
Agree 64 21.7% 231 78.3%
I would recommend the
Neither agree or
facility for delivery to a 11 68.8% 5 31.3% 0.000
disagree
friend/ relative
Disagree 3 33.3% 6 66.7%
Satisfied 54 19.8% 219 80.2%
X2
=21.992
Satisfaction with labour Neither
ward services- during satisfied or 17 54.8% 14 45.2% df = 2
labour dissatisfied
p = 0.000
Dissatisfied 7 43.8% 9 56.3%
 42

Satisfied 57 20.1% 226 79.9%

Satisfaction with labour Neither

ward services- during satisfied or 18 64.3% 10 35.7% 0.000
delivery dissatisfied
Dissatisfied 3 33.3% 6 66.7%

Variable Response n % n % p
Satisfied 57 19.7% 232 80.3%

Satisfaction with labour Neither

ward services-after satisfied or 17 73.9% 6 26.1% 0.000
delivery dissatisfied
Dissatisfied 4 50.0% 4 50.0%

Experienced - Verbal No 75 24.1% 236 75.9%

0.460
abuse Yes 3 33.3% 6 66.7%

Experienced - No 74 23.5% 241 76.5%

0.014
Pinching/slapping/beating Yes 4 80.0% 1 20.0%

Experienced - Delivered No 76 24.4% 236 75.6%

0.620*
alone without assistance Yes 2 25.0% 6 75.0%

P statistical significance (two sided fishers exact), * one sided fishers exact

4.9 Organizational factors associated with utilization of free maternity services

The organizational factors were rated based on the general treatment from health care

workers, cleanliness of the maternity ward, availability of bed linen, state of the

bathroom and toilet, privacy, respect to clients and provision of information to clients

by health workers and essential services. Other factors that were rated included

provision of food, warm water, sharing of beds in maternity ward, adequacy of health

workers and quality of services.

 43

As shown in table 4.7, in regards to how the health worker treated the mothers during

labour, majority (85.0%, n=130) of respondents who utilized the FMS rated the

treatment as excellent. There was a statistically significant association (p=0.000)

between treatment by healthcare worker and utilization of FMS.

Majority (84.0%, n=137) of mothers who utilized FMS rated the cleanliness of the

maternity ward as excellent. There existed a significant statistical association

(p=0.000) between cleanliness of the maternity ward and utilization of FMS.

Availability of linen was rated as excellent by (82.3 %, n=135) of the respondents.

There was a significant statistical association (p=0.002) between availability of bed

and linen and utilization of FMS. The state of the bathroom and toilet was also rated

excellent by (85.6 %, n=131) and (84.0%, n=121) of the respondents respectively.

There existed a significant association (p=0.000) between state of the bathroom and

toilet (p=0.000) and utilization of FMS.

In regards to provision of client privacy, the study revealed that majority (82.6 %,

n=90) of respondents who utilized FMS rated the provision of privacy as excellent.

There was a significant statistical association (p=0.002) between provision of client

privacy and utilization of FMS.

Regarding respect to clients and provision of information to clients by health workers,

majority (86.0%, n=111) and (84.7 %, n=116) of the respondents rated the two as

excellent respectively. There was a significant statistical association (p=0.001,

p=0.000) between respect to clients, provision of information to clients by health

workers and utilization of FMS.

 44

Table 4. 7: Relationship of organizational factors and utilization of FMS (n=320)

Utilized Free Maternity

Variable Response No Yes p
n % n %
Treatment by health Poor 5 33.3% 10 66.7%
Fair 24 53.3% 21 46.7% X2 = 28.369
worker during labour
Good 26 24.3% 81 75.7% df = 3
Excellent 23 15.0% 130 85.0% p = 0.000
Cleanliness of the Poor 1 50.0% 1 50.0%
maternity ward Fair 17 56.7% 13 43.3%
Good 34 27.2% 91 72.8% 0.000*
Excellent 26 16.0% 137 84.0%
Availability of bed/ Poor 3 37.5% 5 62.5%
linen Fair 11 55.0% 9 45.0%
Good 35 27.3% 93 72.7% 0.002*
Excellent 29 17.7% 135 82.3%
State of bathroom Poor 8 57.1% 6 42.9% X2
Fair 11 42.3% 15 57.7% = 22.544
df = 3
Good 37 29.1% 90 70.9%
p = 0.000
Excellent 22 14.4% 131 85.6%
State of toilet Poor 9 60.0% 6 40.0% X2
Fair 10 34.5% 19 65.5% = 18.052
df = 3
Good 36 27.3% 96 72.7%
p = 0.000
Excellent 23 16.0% 121 84.0%
Privacy Poor 11 16.7% 55 83.3% X2
= 15.045
Fair 13 48.1% 14 51.9%
df = 3
Good 35 29.7% 83 70.3%
p = 0.002
Excellent 19 17.4% 90 82.6%
Respect to clients Poor 9 39.1% 14 60.9% X2
Fair 21 40.4% 31 59.6% = 17.686
Good 30 25.9% 86 74.1% df = 4
Excellent 18 14.0% 111 86.0% p = 0.001
Provision of Poor 3 37.5% 5 62.5% X2
information to clients Fair 26 45.6% 31 54.4% = 20.805
by health workers Good 28 23.7% 90 76.3% df = 3
p = 0.000
Excellent 21 15.3% 116 84.7%

P statistical significance (two sided fishers exact) * one sided fishers exact
 45

In regards to provision of adequate food, the study revealed that majority (82.9 %,

n=131) of respondents who utilized FMS agreed to having been provided with

adequate food during their stay in the maternity ward. There was significant statistical

association (p=0.005) between provision of adequate food and utilization of FMS.

Qualitative results also showed that provision of adequate food affected utilization of

FMS negatively.

One FGD discussant narrated her experience and said, “In my recent delivery in

September my relatives were asked to get me food after delivery because the facility

had ran out of gas making it impossible for them to provide food for mothers who

delivered”

The study results showed that majority (80.0 %, n=196) of the respondents who

utilized FMS were provided with warm water for bathing after delivery. There was a

significant statistical association (p=0.000) between utilization of FMS and provision

of warm water.

Regarding sharing of beds (78.9 %, n=206) of the respondents who utilized FMS

reported that they never shared a bed with another woman in the maternity ward.

Sharing of beds among clients signifies increased congestion and thus discomfort

among clients There was significant statistical association (p=0.014) between sharing

of beds and utilization of FMS.

The study results showed that majority (79.0 %, n=203) of respondents who utilized

FMS reported that the maternity ward was not congested. There was significant

statistical association (p=0.009) between congestion of maternity ward and utilization

of FMS.

The maternity services offered were of high quality as rated by the majority of the

respondents who utilized FMS (79.8%, n=209). There was significant statistical
 46

association (p=0.001) between quality of maternity services offered and utilization of

FMS.

The study found that (77.7 %, n=216) of the respondents who utilized FMS reported

that the health workers in maternity ward were adequate. There was significant

statistical association (p=0.003) between adequacy of health workers and utilization

of FMS.

The study results showed that (80.7 %, n=201) of the respondents who utilized FMS

were provided with bed net. There was significant statistical association (p=0.000)

between provision of net and utilization of FMS.

In regard to provision of basin, pads and bathing soap, the study found out that

(75.7%, n=237), 75.0%, n=222) and (75.5%, n=237) of the respondents who utilized

FMS were provided with those supplies respectively, however there was no

significant statistical association (p=0.131, p=0.617, p=0.094) between provision of

basin, pads and bathing soap with utilization of FMS.

 47

Table 4. 8: Influence of organizational factors on utilization of FMS

Utilized Free Maternity

Variable Response No Yes P
n % n %
Adequate food was Agree 27 17.1% 131 82.9%
provided X2 = 10.640
Neither agree or
6 46.2% 7 53.8% df = 2
disagree
p =0.005
Disagree 45 30.2% 104 69.8%
I was provided Agree 49 20.0% 196 80.0%
with warm water X2 = 17.327
Neither agree or
for bathing 11 61.1% 7 38.9% df = 2,
disagree
p = 0.000
Disagree 18 31.6% 39 68.4%
I never shared a Agree 55 21.1% 206 78.9%
bed with another X2 = 8.546
Neither agree Or
woman 4 44.4% 5 55.6% df = 2,
disagree
p = 0.014
disagree 19 38.0% 31 62.0%
The maternity Agree 54 21.0% 203 79.0%
ward was not X2 = 9.466
Neither agree or
congested 5 27.8% 13 72.2% df = 2
Disagree
p = 0.009
Disagree 19 42.2% 26 57.8%
The maternity Agree 53 20.2% 209 79.8%
services offered X2 = 13.717
Neither agree or
are of high quality disagree 13 40.6% 19 59.4% df = 2
p = 0.001
Disagree 12 46.2% 14 53.8%
There were Agree 62 22.3% 216 77.7%
adequate health X2 = 11.594
Neither agree or
workers 10 58.8% 7 41.2% df = 2
disagree
p = 0.003
Disagree 6 24.0% 19 76.0%
A bed net was Agree 48 19.3% 201 80.7%
provided during X2 = 15.933
Neither agree or
my stay in the 3 37.5% 5 62.5% df = 2
disagree
maternity p = 0.000
Disagree 27 42.9% 36 57.1%
I was provided Agree 2 28.6% 5 71.4%
with basin 0.131*
Disagree 76 24.3% 237 75.7%
I was provided Agree 4 16.7% 20 83.3%
with pads 0.617*
Disagree 74 25.0% 222 75.0%
I was provided Agree 1 16.7% 5 83.3%
with soap 0.094*
Disagree 77 24.5% 237 75.5%

P statistical significance (two sided fishers exact), * one sided fishers exact
 48

4.10 Determinants of utilization of free maternity services

Table 4.9 presents the multivariate analysis. Multivariate analysis was used to

establish the effect of independent variables or predictor variables on the utilization of

FMS. Logistic regression tests was used to develop multivariate models for predicting

utilization of FMS i.e. socio demographic characteristics, awareness of FMS,

mother’s experiences on FMS and organizational factors. Results of multiple logistic

regression indicated that mothers who had a monthly income were more likely to

utilize FMS (OR 1.132, CI 1.001-1.279) More results of binary logistic regression

indicated that mothers who were provided with adequate food after delivery were

more likely to utilize FMS (OR 0.276, CI 0.078-0.984). Mother’s reporting that they

were provided with a basin after delivery were more likely to use FMS (OR 3.550, CI

1.072-11.762). Adequacy of health workers in maternity ward was found to be

strongly associated with utilization of FMS (OR 3.011, CI 1.454-6.234).

Table 4. 9: Multivariate models for predicting utilization of FMS

Predictor 95% C.I.

Wald OR Sig.
variable Lower Upper
Socio Monthly income 3.927 1.132 1.001 1.279 0.048
demographics
Organizational Adequate food 3.942 0.276 0.078 0.984 0.047
factors and was provided
utilization of Adequate health 8.808 3.011 1.454 6.234 0.003
FMS workers in the
maternity
I was provided 4.298 3.55 1.072 11.762 0.038
with basin
 49

CHAPTER FIVE: DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS

5.1 Discussions

This chapter presents a summary of the study findings, what it means and how the

study compares with other similar studies done elsewhere.

5.1.1 Utilization of free maternity services

The study findings showed that the utilization of free maternity services was at

75.6%, considering the women who delivered in public health facilities in their recent

delivery and never paid for the service. This estimate was higher than the national

average of 62% but below the 90% target by WHO. This could imply that the fee

exemption policy by the Kenyan government encourages women to deliver in health

facilities.

5.1.2 Individual client characteristics

The study found out that more middle-aged women had slightly high utilization for

free maternity services compared to younger and older women. There were slight

differences in utilization levels across the various age categories. The finding was

similar to a study done in Ethiopia, which showed that most women in the middle

childbearing ages are most likely to use maternal services more compared to their

peers in the early or late childbearing ages thus increased level of utilization (Babalola

& Fatusi, 2009).

Educated mothers have a greater ability to easily access and make use of available

information to inform their delivery decisions, however the level of education did not

play a significant role in determining utilization of free maternity services among

respondents in this study. This study showed that most of the respondents with

primary education had high utilization of free maternity services compared to the rest.

Meeting expectations of clients by service providers boosts their utilization with

 50

maternal care delivery services. Education plays a significant role in demystification

of poor delivery outcome related beliefs. These results were contrary to other findings

of studies done elsewhere for example a study done in Kakamega County Referral

Hospital, found that most clients with higher educational level demand more

information on quality of care provided and try to build trust with physicians

(Beatrice et al., 2016). This was also in contrast to a study conducted in Nigeria,

which showed that education increases awareness levels for the need to use skilled

maternity services at women’s disposal (Ebere, 2013).

On parity, our study found that majority of respondents who utilized free maternity

services had two or three children. It was further observed that the level of utilization

increased with decrease in parity This can be explained by the fact women with high

parities have experience which makes them not to consider pregnancy as an illness

hence making them think that they can deliver on their own at their homes. (KSPA

2010). This could also be due to the high poverty level and hardship around the study

area, where women prefer to have a smaller number of children whom they can cater

for. These results are contrary to a study conducted by Kwast and Liff (2008) in Addis

Ababa, Ethiopia, which showed that majority of women with higher parity, have

greater responsibilities within the household for childcare. This increases health

service utilization (Kwast & Liff, 2008). These results were also inconsistent with

another Ethiopian study done in Tigray region, in which it was reported that most

women with higher parity, especially those with successful deliveries, have more

confidence and less fear for pain and risky pregnancy outcomes (Tsegay et al, 2013).

About religion, this study showed that majority of respondents with high utilization

for free maternity services were Christians. The level of utilization did not differ
 51

significantly across the various religious affiliations. However, the study revealed that

religion does not play a significant indirect role on pregnancy and delivery outcomes.

The current study found out that majority of married women utilized free maternity

services more. Marital status was significantly associated with utilization of free

maternity services. These results were inconsistent with a study done in Edo South

Senatorial District, Nigeria, which showed that majority of married women spent

more time caring for their spouses and families imposing a strain on their health thus

reducing their utilization of maternal services (Marchie, 2012). These results were

consistent with a study done in Western Uganda that documented higher utilization of

free maternity services among most married mothers. This was attributed to financial

support from their spouses and consequently greater access to quality maternal care

(Asiimwe, 2010).

The study showed that majority of respondents who utilized the free maternity

services were farmers and unemployed women. The level of utilization had significant

differences across the various occupational categories. Unemployed women lack

enough resources to finance their healthcare needs thus seem to enjoy free maternity

services provided by the government. This finding was consistent with studies done in

Nyatike and Muhuru Bay divisions in Nyanza region by Mugambi Christine (2014)

and in Bangladesh by Shamsun (2018) who found that more housewives/non-working

women are more likely to use free maternal health services compared to their

employed counterparts thus more utilization.

Income was not significantly associated with utilization of free maternity services.

The study found out that majority of postnatal women with high utilization were low-

income earners. The levels of utilization increased with decrease in income among

respondents. This could be because higher income earners have a greater ability to
 52

access/afford and use health care inputs from private facilities unlike their poorer

counterparts who mostly rely on government-subsidized care. Therefore, the income

earned by majority of postnatal women was insufficient to sustain their family needs

hence the utilization of the free maternity services.

The finding was similar to a Kenyan study, which revealed that higher utilization of

free maternity was exhibited among majority of low-income earners (Christine, 2014).

This finding was contrary to studies done in Nigeria by Ebere (2013) and in Ghana by

Philip et al. (2018) who showed; that income enables women to improve their

nutritional status thus improved delivery outcomes. This contributes to increased

utilization among majority of higher income earners.

5.1.3 Mother’s level of awareness on free maternity services

The study found out that women were aware of free maternity services being offered

in government facilities. People working at the facility contributed highly to

sensitizing the mothers on availability of free maternity services right from the

antenatal care clinic visits and this increased utilization of the free maternity services.

The study found out that majority of the facilities that were near to the respondents

were offering the free maternity services hence the increased utilization, however

those who were not near a facility offering free maternity services were never

hindered from utilizing the service and clients went to facilities where they could get

the service. The study however found no association between awareness and

utilization of free maternity services. The findings were contrary to a study conducted

in Australia (Teate et al., 2011), which revealed a strong positive correlation between

knowledge on maternal issues and utilization of maternal health care.

 53

5.1.4 Mother’s delivery experiences on free maternity services

The study found out that majority of women who utilized the free maternity services

rated the reception at the maternity as good or excellent, this may be because

friendliness enables women to create good rapport and establish trust with clinician’s

thus higher perceived quality of care. This result was supported by a study done in

Kenya by Ochako (2011) who reported that when mothers perceive care providers to

being unsympathetic and having poor attitudes towards women in labour creates

mistrust between them thus reducing their satisfaction levels hence affecting the

utilization of the services. Similar results were also reported by another Kenyan study

done in Pumwani Maternity hospital in Nairobi City County, which revealed that

provider friendliness is a predictor of client satisfaction hence utilization of service

among majority of patients (Margaret, Bella, & Rose, 2014).

The current study revealed that majority of the women would revisit the same facility

or recommend to a friend or relative if need be and this could be attributed to the way

the health workers treated the women during delivery. This was in agreement with a

study done in Kenya by Salam et al (2013) which revealed that mother’s attitude

towards healthcare is determined by their experience with the healthcare or what they

observe others going through in maternal care. The positive relationship, between

attitude and utilization of maternal health care was also experienced in Japan

(Heneck, 2003), explained that in Japan there was effective free maternal care, proper

management of maternal resources and well trained staff to administer the maternal

care services, this saw improvement in the number of women preferring to use the

free maternal care due to the good perception that had been created as result of the

administration of the maternal care. The reverse is true, poor attitude by women

translates to low utilization of maternal care.

 54

5.1.5 Organizational factors

The study showed that most of the respondents who utilized the free maternity

services rated the cleanliness of the maternity ward, availability of bed and linen, state

of the bathroom and toilet as good or excellent. Facility cleanliness had a significant

influence on maternal satisfaction. Perceived facility cleanliness is associated with

high quality service provision. Sheehy et al (2011) who argued that the physical

birthing environment in most cases, affects patient safety and health, effectiveness of

care and the morale of the care providers reported similar results. Overall satisfaction

with the facility’s physical and birthing environment is a predictor to women’s

positive experience during labour and eventual delivery (Foureur et al, 2010). This

was further supported by a report by the World Health Organization, which explained

that delivery in unhygienic conditions without the assistance of a Skilled Birth

Attendant might result in adverse health conditions of pregnant women consequently

reducing their satisfaction levels hence utilization (WHO, 2004).

The current study revealed that majority of women who utilized free maternity

services reported that the health workers ensured their privacy. Utilization of

maternity services increased with provision of privacy. This is because patients feel

valued as the health care workers respects their rights to dignity, privacy and

confidentiality. The results concur with a study done by Otieno (2014) who argued

that provision of patient privacy affects the health seeking behaviours and ultimately

the effectiveness of such care. Provision of patient privacy encourages more women

to use the available maternal services since they feel satisfied with service delivery

components at their disposal. The results also concur with a study done by Okoth

(2017) which revealed that there was a relationship between privacy in service

delivery and utilization of maternal and neonatal health care services.

 55

The study found that monthly income, provision of basin, provision of adequate food

and adequacy of health care workers were predictors for utilization of FMS.

5.1.6 Summary of Findings

The study found that the overall utilization of free maternity services in public

hospitals in Machakos County was above average (75.6%), however 24.4% of the

respondents indicated to having paid some money for delivery services.

The study sought to describe the individual client characteristics of postnatal women

associated with utilization of FMS. Generally, the study revealed that majority

(78.9%) of the participants were in the age bracket of 20-29, mostly (80.0%) had

attained primary level of education, largest proportion (79.5%) had between 2-3

children, most (82.6%) of the respondents were Catholics, majority (79.6%) were

married and largest proportion (82.9%) were unemployed. The study findings

indicated that marital status (p=0.006) and parity (p=0.038), had a significant

statistical association with FMS.

The study also sought to determine the association between mother’s level of

awareness on FMS and utilization of FMS. It was revealed that most (99.0%) of the

postnatal women were aware of FMS being offered in public facilities. Majority

(57.0%) reported of having heard about FMS from facility staff. Slightly more than

half (59.1%) of the postnatal women lived near a facility that was offering FMS.

The study results showed that awareness on FMS (p=0.589) had no significant

statistical association with utilization of FMS.

The study also sought to determine the association between mother’s delivery

experiences and utilization of FMS. It was revealed that, most (77.0%) of the

postnatal women who utilized FMS took <15minutes to be attended at the maternity.

Majority of the respondents 83.3% rated the reception at maternity as excellent,

 56

78.2% would visit the same facility for delivery if need be with 78.3% indicating that

they would recommend the facility where they delivered to a friend or relative.

Recommending the facility to others by majority of the respondents showed a sign of

improved service delivery. Concerning satisfaction with delivery services, 80.2% of

the respondents indicated that they were satisfied with the services rendered during

labour, 79.9% satisfied with services offered during delivery and 78.3% were satisfied

with services offered after delivery. Visiting the same facility for delivery (p=0.000),

recommending the facility to a friend or relative (p=0.000), satisfaction with services

offered in labour ward during and after delivery (p=0.000) and reception at the

maternity (p=0.000) were significantly associated with utilization of FMS.

This study identified organizational factors associated with utilization of FMS. The

findings indicated that (85.0%) of the respondents rated the treatment by health

workers as excellent, (84.0% indicated that the maternity ward was clean, (82.3%)

reported that the linen were available, (86.0%) reported that the health workers were

respectful to clients. It was further revealed that majority (82.9%) of the respondents

reported availability of adequate food, similarly more respondents (80.0%) indicated

that warm water was provided to them after delivery. (78.9%) of the respondents,

reported never sharing a bed with others, (79.0%) of the postnatal women reported

that the maternity ward was not congested. (79.8% ) of the respondents indicated that

maternity services offered were of high quality and (77.7%) reported that there were

adequate health workers in the maternity ward. Availability of adequate food

(p=0.005), provision of warm water (p=0.000), maternity ward was not congested

(p=0.009), health workers were adequate (p=0.003), cleanliness of the toilet

(p=0.000), privacy (p=0.002) and sharing of beds (p=0.014) among respondents were

significantly associated with utilization of FMS.

 57

The study established the determinants of utilization of FMS as monthly income (OR

1.132 CI-1.001-1.279), provision of adequate food (OR 0.276 CI 0.078-0.984),

adequacy of health workers (OR 3.001 CI 1.454-6.234) and provision of basin (OR

3.550 CI 1.072-11.762).

5.2 Conclusions

The study concludes that utilization of FMS in Machakos County public hospitals was

optimal though mothers who utilized free maternity services were still reporting

illegal payments. Individual client characteristics were not significantly associated

with utilization of FMS. The facility staff played a greater role in creating awareness

on FMS, however mother’s level of awareness was not significantly associated with

utilization of FMS

The study concludes that mother’s delivery experiences played a significant role

towards utilization of FMS. Reception at maternity, time taken to be attended at the

maternity and satisfaction with the services offered during labour, delivery and after

delivery determined future utilization of FMS by the mothers.

These findings conclude that organizational factors played a significant role towards

utilization of FMS. Provision of adequate food after delivery, provision of warm

water, quality of maternity services, adequacy of health workers in maternity,

cleanliness of the maternity, respect to clients and provision of information to clients

by health workers were associated with utilization of FMS.

Finally, the study established the determinants of utilization of FMS as monthly

income, provision of adequate food and adequate health care workers.

 58

5.3 Recommendations

5.3.1 Recommendations from the

study County department of health

1. The Machakos county department of health should ensure that all the health

facilities have adequate supplies of food to be offered to the clients during

their stay in the maternity ward.

2. The department of health should also ensure that the facilities have adequate

health workers deployed in the maternity ward.

3. The department should also ensure enforcement of the FMS policy since

mothers reported of making illegal payments for the maternity services

5.3.2 Recommendations for further study

i. A research should be conducted to determine the quality of Free Maternity

Services across public health facilities in Kenya.

ii. A study should be conducted to establish the impact of FMS on maternal and

child health in Kenya.

iii. A study should be conducted to identify challenges of not providing entirely

FMS in Kenya
 59

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Free Maternal and Child Health Care Programme Using Community Based
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Al-Abri, R. &Al-Balushi, A. (2014) Patient Satisfaction Survey as a Tool towards
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Aldana, JM., Piechulek, H., Alsabir, A., (2002) Client satisfaction and quality of
health care in rural Bangladesh. Bull World Health Organisation.2001, 79:
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Arhinful, R., & Ross, J. (2006). Effects of Free Delivery Policy on Provision and
Utilization of Skilled Care at Delivery: views from Providers and
Communities in Central and Volta regions of Ghana.
Ashraf Mariam, Ashraf Fatima, Atif, R., & Rukhsana, K. (2012). Assessing women’s
satisfaction level with maternity services: Evidence from Pakistan. Health
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Collaborative Research on Internal Medicine & Public Health, 4(11).
AU, A. U. (2010). Assembly of the African Union. Paper presented at the Fifteenth
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Bourbonnais, N. (2013). Implementation of Free Maternal Healthcare in Kenya
Health Sector Strategic and Investment Plan. Nairobi Act Press.
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Christine, M. K. (2014). Determinants of utilization of free maternal health care in

Muhuru and Nyatike Divisions, Nyatike sub-county, Kenya., University of
Nairobi, Nairobi.
DHIS, M. C. (2017). Machakos County Integrated Development Plan 2018-2022
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University of Aberdeen.
 62

APPENDICES

Appendix I: Machakos county map

Machakos county
 63

Appendix II: informed consent form

Introduction

My name is Alice Mukunzu Ngesa. I am Master’s student from Kenyatta

University. I am conducting a study on ‘Utilization of free maternity services in

Machakos County”. You are being invited to participate in this study because you

are among the sampled respondents believed to have useful information on the study

subject.

Purpose

The purpose of this study is to understand factors influencing utilization of free

maternity services. The information will be used by the CHMT and Ministry of

Health to inform strategies and opportunities for improving free maternity services in

Machakos County as well as other regions of Kenya.

Procedure to be followed

If you agree to be in this study, you will be asked to respond to some questions

through either interviewer-administered questionnaire, interview schedule or focus

group discussion guide.

Study time: Study participation will take a total of approximately 45 minutes.

Benefits

There is no direct benefit to you anticipated from participating in this study.

However, it is hoped that the information gained from the study will help to identify

strategies and opportunities for improving utilization of free maternity services.

 64

Risks/Discomforts

Some of the study instruments may make you uncomfortable or upset, but you are

free to decline to answer any questions you do not wish to or to leave the group at any

time.

Confidentiality

Your study data will be handled as confidentially as possible. If results of this study

are published or presented, individual names and other personally identifiable

information will not be used.

Rights

Participation in research is completely voluntary. You have the right to decline to

participate or to withdraw at any point in this study without penalty or loss of benefits

to which you are otherwise entitled.

Question /Contact information

If you have any questions or concerns about this study, you may contact Dr. George

O. Otieno on Mob. 0719506770 or Dr. Daniel W. Muthee on Mob. 0723934169 or

the Kenyatta University Ethical and Review Committee Secretariat on

[email protected], [email protected] or [email protected]

 65

Participant(s) statement

The above information regarding my participation in the study is clear to me. I have

been given a chance to ask questions and my questions have been answered to my

satisfaction. My participation in this study is entirely voluntarily. I understand that my

record(s) will be kept private and that I can leave the study at any time.

Participant's Name (please print)

Participant's Signature Date

Investigator’s statement

I, the undersigned, have explained to the participant in the language s/he understands,

the procedure to be followed in the study and risks and benefits involved.

Person Obtaining Consent

Person obtaining consent Signature Date

 66

Appendix III: household questionnaire

Instructions
The questionnaire has been formulated for the sole purpose of gathering information

for research project geared towards establishing factors that will influence

utilization of free maternity services in public hospitals in Machakos County.

A. WARD ...........................................................................................

B. COMMUNITY UNIT………………………………………………

C. DATE.............................................................................................

D. INTERVIEWER ...........................................................................

E. RESPONDENT CODE……………….

S/N Question Answer Mark

A. Socio-Demographic Characteristics

1. What is your age in years?

2. Religion Catholic 1

Protestant 2

Muslim 3

Hindu 4

Buddha 5

African traditionalist 6

None 7
 67

Other (please specify) 8

3. Marital status Single 1

Married Monogamous 2
Married Polygamous 3
Divorced/ Separated 4

Widow 5

4. Level of education None 1

Primary

Secondary 3
University 4
Diploma/ Tertiary college training 5
Others, specify 6

5. Main Occupation Employed/ Salaried worker 1

 68

Farmer 2

Business/ self employed 3

Unemployed 4

Others (specify) 5

6. Monthly income Less than 10,000 1

Between 10,000-20,000 2
Between 20,000-30,000 3
Between 30,000-40,000 4
Between 40,000-50,000 5
Over 50,000 6
None 7

What is the distance from Less than 2KM

7. your place of residence to 1

the nearest public health Between 2-5KM 2

More than 5+ KM 3
facility?
Don’t know 4

8. Mode of transport to the By foot 1

health facility By Bus/Matatu 2

By own vehicle 3
Boda Boda 4
Others (specify) 5
 69

UTILIZATION OF FREE MATERNITY SERVICES

9. Parity 1 1

2-3 2
4-5 3
>5 5

How many were delivered None 1

10. in a health facility? 1 2

2-3 3
4-5 4
5 5

11. Where did you deliver in Govt. Hospital 1

your recent birth? Govt. Health centre 2

Govt. Dispensary 3
Private Hosp 4
Mission Hosp 5
Own home 6
TBAs home 7
 70

Using the scale provided to 5 4 3 2 1

12. what extent, do you agree

with the following

statement?

I never paid for the

maternity services.

where 5= Strongly agree,

4= Agree, 3= Neither agree

or disagree, 2= Disagree

and 1= Strongly Disagree

APPLICABLE TO

THOSE WHO

DELIVERED IN

GOVERNMENT

FACILITIES

B. Mother’s Knowledge on free maternity services

13. Have you ever heard of the Yes 1

free maternity services? No 0

14. How did you get the Radio/ TV 1

information about the free Facility staff 2

maternity services? Community health worker 3

Multiple responses Local leaders 4

 71

possible. Husband/Relatives 5

SKIP IF ANSWER TO

11 IS NO

15. Do you think the Yes 1

government has done No 0

enough to inform the

public about the free

maternity services?

16. Does the nearest public Yes No

facility offer FMS? 1 0

17. Did you receive antenatal Yes 1

care services in your recent No 0

pregnancy?

18. Where did you receive the Government facility 1

service? Private facility 0

19. Using the scale provided

to what extent do you agree

with the following

statements where 1=

Strongly disagree

2= Disagree

3= Neither agree or
 72

disagree

4= Agree

5= Strongly agree

I was adequately given

information about the

usefulness of delivering

under a skilled birth

attendant during the ANC

C. Mothers Perception on free maternal services

How can you rate the Poor 1

reception at the maternity?

20. Fair 2

Good 3

Excellent 4

21. How long did it take for <15mins 1

you to be attended at the

16-20 mins 2
maternity?
17-30 mins 3

>30mins 4

22. Using the scale provided to Strongly disagree 1

what extent, do you agree

Disagree 2
 73

with this statement? where Neither agree nor disagree 3

5= Strongly agree, 4=
Agree 4
Agree, 3= Neither agree or
Strongly agree 5
disagree, 2= Disagree and

1= Strongly Disagree

I would visit the same

facility for delivery if need

be.

Using the scale provided to

what extent, do you agree

23. with this statement? Strongly disagree 1

I would recommend the

facility for delivery to a Disagree 2

friend/ relative Neither agree nor disagree 3

Agree 4

Strongly disagree 5

24. Did you deliver in the same Yes 1

facility where you attended No 0

your ANC?
 74

25. Express your level of satisfaction with the services in the labour ward.

4= fully satisfied, 3= Satisfied, 2= somewhat dissatisfied and 1= Dissatisfied

Rating 4 3 2 1

During labour

During

delivery

After delivery

26. During labour did you experience any of the following (tick all that apply)

Experience YES NO

Verbal abuse

Pinching/slapping/beating

Delivering alone without

assistance

D. Health system factors

27.. How would you rate the following?

4= Excellent, 3= Good, 2= Fair and 1= Poor

4 3 2 1

How the health

worker treated you

during labour?

Cleanliness of the
 75

maternity ward

Availability of bed

and linen

State of the bathroom

State of the toilet

Privacy

Respect to clients

Provision of

information to clients

by health workers

28. Using the scale provided, indicate to what extent you agree or disagree with

the following statements where 5= Strongly agree, 4= Agree, 3= Neither agree

or disagree, 2= Disagree and 1= Strongly Disagree

5 4 3 2 1

Adequate food

was provided

during my stay in

the maternity

ward.

I was provided

with warm water

for bathing after

delivery
 76

I never shared a

bed with another

woman in the

maternity ward

The maternity

ward was not

congested

The maternity

services offered

are of high quality

There were

adequate health

workers in the

maternity ward

A bed net was

provided during

my stay in the

maternity ward

I was provided

with the

following items

during my stay in

the maternity

ward
 77

Basin

Pads

Bathing soap
 78

Appendix IV: Key informant interview guide

Dear participant,

You are hereby invited to participate in a Key Informant Interviewee for a study on

‘Utilization of free maternity services among postnatal women in Machakos County’.

You have been chosen purposively due to the expected level of information and

knowledge you have on the study topic. You are requested to be honest, free and

active in your participation. Participation will be guided by use of FGD Guide. All

information gathered will be held under strict confidentiality and will be used for

purposes of this research only.

1. In your opinion, are mothers in this area aware of the free

maternity services? Expound

2. What is their attitude towards the free maternity services?

3. What is the average number of deliveries conducted in this facility per

month?..........

4. How does it compare with the deliveries before the free maternity

program?

5. In your opinion, does this facility have adequate capacity to handle the

free maternal health care? In terms of health workers, availability of

equipment and other commodities. Give your reasons.

6. What are the challenges faced in administration of the free maternal care

7. In your opinion, what do you think the department of health and

emergency services in Machakos County can do to improve the free

maternity services program?

 79

Appendix V: Focus group discussion guide

Dear participant,

You are hereby invited to participate in a Focused Group Discussion for a study on

‘Utilization of free maternity services among postnatal women Machakos County’.

You will be one of the members of a focused discussion group made up of 8 to 10

participants. You are requested to be honest, free and active in your participation.

Participation will be guided by use of FGD Guide. There will be an observer,

moderator and note taker for your focused group discussion. All information gathered

will be held under strict confidentiality and will be used for purposes of this research

only.

1. Are women in this community aware of the free maternity services? Expound

2. What do women and other members of the community say about the

free maternity services?

3. What factors influence utilization of free maternity services in

this community?

4. In your opinion, what do you think are some of the challenges facing

free maternity services program?

5. In your opinion what can the department of health do to improve

free maternity services program?

 80

Appendix VI: Research approval from Kenyatta University graduate school

 81

Appendix VII: Research authorization from Kenyatta University graduate

school
 82

Appendix VIII: Research authorization from National Council for Science,

Technology and Innovation

 83

Appendix IX: Letter of permission from Machakos department of health and

emergency services