ABSTRACT

Postpartum care is an important link in the continuum of care for maternal health. The postpartum period is critical because most maternal deaths occur during this time, yet this is the most neglected period for quality care provision. Postpartum Care (PPC) services are essential in the first six weeks extending to six months. When not offered they lead to complications, poor outcomes like morbidity and mortality. The aim of this study was to assess utilization and factors influencing utilization of PPC services among women in Webuye West, Bungoma County, Kenya. The study adopted a descriptive cross sectional design. The study population was all women of reproductive age with living children aged 6-9 months. Six Health Care Workers (HCWs) were key informants. The study composed of a sample of 384 women. The sampling techniques were purposive and simple random sampling. Data collection tools were a semi structured questionnaire, focus group discussions and interview guide. Data was analyzed using Statistical Package of Social Sciences (SPSS) version 20.Statistical analysis was done using Pearson‟s Chi-Square test.On proportion of women utilizing postpartum care services only 33.6% utilized in the required timings and the attendance of mandatory visits was less than 40% which was below the recommended. All the four PPC visits were statistically significant to utilization. On socio cultural factors majority 85.8% of the women reported staying indoors during this period. Majority 55.7% of them had cultural beliefs and practices performed, both being statistically significant to PPC utilization. Religious beliefs and practices too were dependent on use of PPC (X2 p<0.011).On knowledge factors majority 70.6% of the women first knew the services during ANC from HCWs, awareness of first and fourth visits were statistically significant to PPC service use .On health facility factors majority 74.8% of the women reported availability of the basic services and majority 75.9% of HCWs were friendly and helpful. These influenced service utilization. Majority 51.0% paid for services and waited for 31-60 minutes.HCWs availability, friendliness, waiting time and service charges were statistically significant (p < 0.005) thereby influencing PPC utilization .In conclusion the proportion of women utilizing PPC service was low. Utilization of PPC services being statistically significant and dependent on various factors including , staying indoors, religious beliefs and practices , knowledge during ANC , availability of HCW,waiting time, HCWs helpfulness and friendliness and service charge ( p < 0.005). The study therefore rejected the null hypothesis. The study recommends that there is need to increase more awareness on PPC service utilization by HCWs and community volunteers. Community involvement and collaboration of teams to mitigate socio cultural beliefs and practices. The County MOH and facility managers to implement policies on PPC and continuous capacity building that emphasize PPC service utilization and maternal, neonatal, child health (MNCH) integration.

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CHAPTER ONE: INTRODUCTION

1.1 Background to the Study

The postpartum period biologically refers to the time immediately after birth to six weeks thereafter when the mother's body, including her hormone levels and uterus size, return to pre-pregnancy conditions (WHO, 2013). Postpartum care (PPC) is offered to a mother from the time of placental expulsion up to 6 weeks after delivery extending to six months. It involves health promotion, prevention, early detection and treatment of complications and disease, provision of advice regarding contraception, nutrition and immunizations, the Kenya Maternal and Newborn Health model (KMNH, 2009). Targeted postpartum care is an approach which defines a set of PPC services delivered to a mother in a minimum of four visits spread throughout the first six months following delivery (WHO, 2013). Globally, more than half a million women die each year from complications of pregnancy and childbirth, a large proportion of maternal deaths occur during the first 48 hours after delivery and account to 99% in developing countries (WHO, 2013). Postpartum care is an important link in the continuum of care for maternal health to prevent mortality and morbidity. In China coverage and quality of postpartum care is poor and these also applies to low and middle income countries Africa inclusive (Chen et al., 2014).

The same trend is found in Sub Saharan Africa most maternal deaths are due to causes directly related to pregnancy and childbirth extending to postpartum period. These

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includes unsafe abortion and obstetric complications such as severe postpartum hemorrhage, infections or puerperal sepsis, anemia, STI/HIV/AIDS, hypertensive disorders, embolism among others (Ukachukwu, 2009). The maternal deaths in Sub-Saharan Africa averages to 640 deaths per 100,000 live births and the leading cause for 34% of these deaths is hemorrhage, majority of which occurs in the postpartum period (WHO, 2013). The postpartum period is very critical for the newborn and the mother. This is so because most maternal deaths and complications occur during this time, yet this is the most neglected period for the provision of quality care (Erin et al., 2007). Postpartum care (PPC) is important for the mother to treat complications arising from the delivery, as well as to provide the mother with important information in promotion and safe guarding of her health (Abdella, 2010). Kenya experiences a very slow progression in maternal health during this period, despite efforts to increase PPC service delivery facilities from six out of ten in 2010 to eight out of ten in 2011 in every region (KSPA, 2011). In Kenya 51 % of women receive postpartum check and care, 43% being from rural areas compared with 65 % from urban KDHS, 2014).The 3rd Sustainable Development Goal (SDG) aims to reduce the maternal mortality ratio to less than 70% by the year 2030 ,the maternal mortality rate being 510 maternal deaths per 100,000 live births which is still high (WHO, 2015).Complications related to pregnancy, childbirth and delivery are among the leading causes of morbidity and mortality among Kenyan women (KNBS, 2010).

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To strengthen postnatal services in Kenya, the Ministry of Health (MOH) rolled out the Kenya Maternal and Newborn Health model, which outlines the Targeted Postpartum Care (TPPC). In the TPPC package the number of visits recommended in the postpartum period were increased to four. These include a checkup within 48 hours, within two weeks, six weeks and at four to six months respectively. This aims to prevent any complications to the mother occurring after childbirth and ensure that the mother is healthy and there is no transmission of infection from mother to child too (KMNH, 2009 & MOH 2008). The postpartum visits provide health care workers with an opportunity to identify health problems early enough in the mothers so as to offer early interventions successfully. This has resulted into increasing effort to promote PPC utilization, particularly in developing countries with high maternal mortality rates, Kenya being one of them (Nabukera et al., 2006).

1.2 Problem statement

Globally, more than half a million women die each year from complications of pregnancy and childbirth, majority of this during the postpartum period especially the first forty eight hours after delivery. It is estimated that three quarters of women do not receive postpartum care and this leads to about 60–80 % of maternal deaths during this period (WHO, 2013).

In Africa, most mothers and newborns do not visit the health institution following birth, indicating that postpartum care programs are among the weakest of all reproductive health programs .In Sub Saharan Africa, maternal mortality still remains unacceptably

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high accounting for 87% of maternal deaths (WHO, 2014).Locally, in Kenya 51 % of women receive postpartum check and care, 43% being from rural areas compared with 65 % from urban (KDHS, 2014).Majority of maternal deaths in developing countries occur in the immediate postpartum period (WHO, 2013). Postpartum care services in Webuye West are offered at facility level and the main referral hospital is Webuye County Hospital. Bungoma is among the top 15 counties with highest maternal deaths of 266 per 100,000 live births (UNPFA, 2014), Webuye West, reporting amongst the highest deaths of 67 in 100,000. Majority of these deaths occurring in the postpartum period, which is unacceptably high (DHIS, 2014).The use of PPC services among women in Webuye West remains low as compared to other maternal health services. From October 2014 to March 2015, attendance for PPC services in health facilities in the sub county was at 11% in comparison to other maternal health services, (DHIS, 2015 Webuye sub county Hospital). An audit done by the hospital MCH team on 50 MCH booklets (maternal part) for the PPC visits in relation to service utilization, in April 2015 showed no attendance within 48hours, 1st visit- for home deliveries) but 50% attendance for those with hospital delivery, non-attendance for 2nd visit (1- 2 weeks) for all women, 50% attendance on 3rd visit (4-6 weeks) and non-attendance on the 4thvisit (4months -6months).

This was followed up by report on incidences of complications leading to morbidity post-delivery from the post natal clinic and post natal ward at Webuye Sub county Hospital from January-April 2015 (DHIS 2015).The results showed that postpartum hemorrhage, puerperal sepsis, eclampsia /hypertension were ranked highest among other

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complications. Service utilization entails that a woman attends mandatory visits within the stipulated timelines where key elements in service delivery are offered. This in turn prevents the rising morbidity and mortality especially in the crucial periods within two weeks post-delivery where a woman is vulnerable. In Webuye West ,from the above statistics and information, PPC service utilization has been poor and it is with these that the researcher found out that there is a need for assessing and determining the factors influencing utilization of PPC services at the several points in time in the extended period of postpartum.

1.3 Justification

In Webuye West Sub County services to reduce maternal mortality and morbidity have been scaled up led by the main referral hospital of Webuye Sub County Hospital. This has been through the beyond zero program, availability of ambulances, refurbishment and upgrading of health centers and dispensaries to improving access and availability of PPC services. Also training of skilled birth attendants, HCWs, traditional birth attendants and community mobilization on utilization of PPC services .The public health team has also been incorporated in this.

The sub county has implemented the free maternity services introduced in 2013 by the government (MNHK, 2013) and Targeted postpartum care (TPPC) as a key in maternal health promotion (KMNH, 2009).These are to enhance and improve PPC utilization leading to improved and sustained health status of the women. Despite the above initiatives to address issues of safe motherhood, PPC service utilization is still poor in

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Webuye West. There has not been any study done in this sub county on utilization of PPC, and this study is intended to provide baseline information. Postpartum care promotes continuum of care to women thereby improving a woman‟s health and survival. When PPC is not offered as intended within this period it may result in maternal health complications leading to morbidity.

1.4 Research Questions

i. What proportion of women utilizes postpartum care services in Webuye West, Bungoma County?

ii. What socio-cultural and knowledge-related factors influence utilization of postpartum care services among women in Webuye West, Bungoma County?

iii. What health facility-related factors influence utilization of postpartum care services among women in Webuye West, Bungoma County?

1.5 Hypothesis

The null hypothesis (H0) was used. H01 Socio cultural factors have no influence on utilization of PPC services among women in Webuye West, Bungoma County. H02 Knowledge related factors have no influence on utilization of PPC services among women in Webuye West, Bungoma County.

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H03 Facility related factors have no influence on utilization of PPC services among women in Webuye West, Bungoma County.

1.6 Broad objective

To assess utilization of postpartum care services among women in Webuye West Bungoma County, Kenya.

1.6.1 Specific objectives

i. To determine the proportion of women utilizing postpartum care services in Webuye West.

ii. To determine socio-cultural and knowledge-related factors influencing utilization of postpartum care services among women in Webuye West.

iii. To establish the health facility-related factors influencing utilization of postpartum care services among women in Webuye West.

1.7 Significance

The findings from this study are to be used by the Webuye county hospital management team and Webuye West Sub County to be able to plan and formulate new strategies on ways of improving and promoting utilization of PPC services by women. In so doing this will improve the mothers‟ health, children and family at large. Policy formulation and implementation on utilization of PPC services by the team if implemented will help in reduction of maternal mortality and morbidity.

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The findings of this study will also benefit the health care workers (HCWs) in direct contact with these women as they will be able to come up with practical ways both in hospital and community on how to improve service delivery so as to scale up use of these services.

1.8 Delimitation and limitation

1.8.1 Limitation

The women‟s MCH booklets were used to confirm attendance and service offered .Some were not updated or well documented. Recalling events 6-9 months back by the women may have created recall bias. Majority of the women seek their own services at same time they take their children to child welfare clinic and utilize same booklet. So the child part was used as a point of reference whenever a woman did not exactly remember when they sought the service.

1.8.2 Delimitation

Since some of the information in the MCH booklets was not well documented, women were asked to recall the events and care given retrospectively. Quigley et al., (2007) found that maternal recall is reliable compared to medical records for certain pregnancy related and delivery events including complications among others.

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1.9 Conceptual Framework

Independent variables

Intervening variable Dependent variable

Figure 1.1 Conceptual framework (Adopted from Andersen &Newman, 1973)

Socio cultural factors influencing PPC Services (cultural beliefs, practices/rituals, family support religious beliefs/practices).

Utilization of postpartum care services among women in Webuye West, Bungoma County

Knowledge -related factors on PPC among women (What is, why, when, who) to use PPC, complications and barriers

Health facility related factors influencing PPC utilization (distance from facility, attitude of HCW and skills, access, charges & availability of PPC services, facilities and waiting time) time)

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The Andersen‟s Behavioral Model was used, in this study it demonstrates use of health services in accessing healthcare (Andersen, 1968) which later modified by his colleagues (Andersen &Newman 1973). According to this model, the use of the healthcare services is a function of three sets of individual characteristics namely predisposing, enabling and need. In predisposing characteristics: these were use of ANC, knowledge of mother on PPC and permission or family concern about the care, cultural beliefs, practices towards PPC. The predisposing factors reflect the fact that families with different characteristics have different propensities to use healthcare services. In enabling characteristics included: income, ease of access, and distance from facility. These reflect the fact that some families, even if predisposed to use health services, must have some means of obtaining them. The need characteristics were: expected benefit from care, skilled HCW/attendance, skills, attitude of HCW, availability of health facilities, postpartum care services and waiting time .The need factor is the most immediate cause of the use of health service. The need factor reflects perceived health status. These included, how people view and experience their own general health, functional state and illness.

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