COPH Alumna Authors Article on Antenatal Care in Kenya

Dr. Eleanor Fleming, 2015 alumna of the Master of Public Health in Epidemiology program in the East Tennessee State University College of Public Health, has authored an article in the Journal of Health Care for the Poor and Underserved.  The article, “Can incentives reduce the barriers to use of antenatal care and delivery services in Kenya?” details a qualitative inquiry performed to understand pregnant women and nurses’ perceptions of incentives offered to seek antenatal care in the Nyanza Province in Kenya.

Kenya has high maternal and neonatal mortality rates, approximately 360 per 100,000 live births and 31 per 1,000 live births, respectively.  Among 15-49 year-old women, maternal deaths represent about 15% of all deaths. The Kenyan Ministry of Health recommends that expectant mothers attend a minimum of four antenatal care visits before giving birth to ensure the health of mother and child.

In 2011, the Kenyan Ministry of Health and a local non-governmental organization, Safe Water and AIDS Project, implemented a program in 25 health facilities in the Nyanza Province that included several interventions to motivate a greater number of mothers to attend four or more antenatal care visits, deliver in health facilities, and receive postnatal check-ups. 

To improve the quality of care at the health facilities, nurses received advanced training on emergency obstetrical care, neonatal resuscitation, rapid syphilis testing, and safe water and hygiene practices.  To increase care-seeking, pregnant women in the program received incentives at each visit including a hygiene kit, protein-fortified flour (unga), and a delivery kit.

An evaluation of this program showed statistically significant increases from pre-intervention pregnancies to post-intervention pregnancies in the percentage of women with four or more antenatal care visits.  The researchers performed a qualitative inquiry to understand pregnant women and nurses’ perceptions of the incentives. 

The team conducted 40 interviews to assess perceptions of these services. Mothers and nurses identified poor quality of care, fear of HIV diagnosis and stigma, inadequate transport, and cost of care as barriers. Nurses believed incentives encouraged women to use services; mothers described wanting good birth outcomes as their motivation.

While barriers to care did not change during the study, incentives may have increased service use. These findings suggest that structural improvements—upgraded infrastructure, adequate staffing, improved treatment of women by nurses, low or no-cost services, and provision of transport—could increase satisfaction with and use of services, improving maternal and infant health.

Co-authors include Dr. Fleming’s colleagues from the Centers for Disease Control and Prevention as well as individuals from the Safe Water and AIDS project in Kenya. 

Eleanor Fleming is a Lieutenant Commander in the United States Public Health Service and a Dental Epidemiologist for the National Center for Health Statistics of the Centers for Disease Control and Prevention.  She is the project officer for the National Health and Nutrition Examination Survey oral health component.