When it comes to decision-making on the place of childbirth, women residing in peri-urban settings value health facility cleanliness beyond any other factor, followed by the availability of medical equipment and supplies.

This is according to a study done by fresh Ph.D. in Healthcare management graduate, Dr. Jackline Oluoch-Aridi and her supervisors – Prof. Gilbert Kokwaro, Dr.  Frank Wafula – both at the Institute of Healthcare management at Strathmore University Business School and Prof. Mary B. Adam of the maternal and child health department at A.I.C. Kijabe hospital. Together, they co-authored a publication that uses health economics to elicit women’s preference on place of childbirth that has since been published in a leading medical journal, PLOS ONE.

High maternal death rates

This study was a first of its kind in that it sought out the views of women who are key health care facility users in peri-urban areas on the factors they consider when making their choice for place of childbirth. Maternal death     rates continue to be high in Kenya and are reported to be particularly higher in informal settlements in cities where the urban poor reside. According to the WHO, in 2017, an estimated 295,000 women were reported to have died globally during and after childbirth. The vast majority of these women (95%) live in developing countries. Kenya’s maternal mortality ratio of 362 per 100,000 live births is relatively high for a lower middle income country. The ratios are particularly high across peri-urban settings. One study reported a maternal mortality ratio of 700 per 100,000 livebirths in two informal settlements in Nairobi. In spite of this, very little is known about what drives women’s choices on place of childbirth.

Dr. Oluoch-Aridi, currently serves as Ford Program’s Regional Research Programs Manager for East Africa, for the University of Notre Dame. Her research sought to examine this anomaly. She interviewed a total of 411 women selected to participate in the study conducted at Embakasi-North, a sub-county in Nairobi County with a population of 181,388 people and located about 10 km to the east of Nairobi City. The sub- county is home to Dandora, an informal settlement that houses the dumpsite for the entire city of Nairobi, and is characterized by low-income residential housing estates.

Discrete Choice Experiments

The study utilizes Discrete Choice Experiments – a quantitative stated preference methodology in that health economics that involves asking individuals to state their preference over hypothetical alternative scenarios. Each alternative is described by several attributes and the responses are used to determine whether preferences are significantly influenced by the factors and also determines their relative importance. The DCE methodology has been widely used in high-income contexts and is increasingly being applied in low- and middle-income countries as a tool to consider a range of policy concerns.

The study’s context is within a period when the Kenyan Government, in 2013, changed user fee policy and made maternity services free at all public and private health facilities for all women. This removal of user fees led to a substantial increase in the number of women accessing maternal health services. Consequently, the study was timely as it allows a critical understanding of what women value  when making decisions on place of delivery. it also allows policy makers at the County level to allocate resources efficiently and meet women’s preferences. “For instance, the strong preference for a clean health facility will dissuade expectant mothers from utilizing free services at offer in public health facilities forcing them to pay out of the pocket for alternative private  health care facilities, further impoverishing them ” Dr. Oluoch-Aridi says.

The value of cleanliness

The study also assessed the sociodemographic factors associated with these preferences and found out that younger women who were main income earners had the strongest preference for clean health facilities. Dr. Oluoch-Aridi continues to explain, “Due to their intrinsic belief in human dignity for all, the women value cleanliness, a commodity that may not be easy to come by in their environmental surroundings.” Older and married women on the other hand had stronger preference for availability of medical equipment and kind healthcare workers due to their vast experience with the health system as expected.

The article has been published at the high impact PLOS ONE Journal a peer-reviewed open access scientific journal published by the Public Library of Science since 2006. The journal covers primary research within disciplines in science and medicine.

A link to the article can be found here.