Sub-Saharan Africa (SSA) accounts for the largest global maternal deaths at 66%. Maternal deaths result from obstetric haemorrhage, non-obstetric complications, hypertensive disorders of pregnancy and pregnancy-related infections.
The World Health Organization (WHO) has developed strategies to fight preventable maternal deaths that include addressing the access and quality of sexual, reproductive, maternal and new-born health care services. In its guidelines for maternal health, the WHO recommends the promotion, prevention and protection of maternal and perinatal health through antenatal care, particularly, focused antenatal care (FANC). This provision enables health systems to constantly monitor a pregnant woman in a deliberate effort to address health challenges associated with pregnancy. Antenatal care (ANC) provides an opportunity to incorporate interventions that may strengthen maternal, neonatal and child health through delivery of essential interventions in the course of antenatal visits. Research has shown that ANC has the potential to promote skilled birth attendance, postnatal attendance and have a positive effect on neonatal mortality and neonatal health outcomes , .
ANC coverage has increased by 43.3% globally between 1990–2013 but marked disparity exists between the global north and south. Estimated coverage of ANC and early ANC care visits both stood at 81% in developed countries compared to 48% ANC coverage and 24% early ANC care visits in SSA. Moreover, majority of women in developed countries have their first ANC visit in their first trimester of pregnancy whilst most of their SSA counterparts start antenatal care in the second and third trimesters.
There is potential to improve the coverage and utilization of ANC services in the SSA region by giving special focus to rural, poor and uneducated women so as to reduce physical barriers, creating demand for services through public information system improving the quality of services in order to meet the potential demand, according to research from Ethiopia, Nigeria and Seirra Leone–.
Utilization of antenatal services in SSA has been linked to various factors affecting the demand and supply sides. Studies in Ethiopia  and Nigeria have reported financial constraints in paying for transport costs to the health facility, and paying for services at the facility as key barriers to utilisation of ANC services. Particular to Kenya, direct and indirect costs to accessing healthcare have been reported as the main barriers to the access and utilization of ANC. Pell et al. found different charges across health facilities required from pregnant women in order to access ANC care. Charges were levied for the ANC card and laboratory tests. Transport costs to health facilities is a barrier especially to women of low income status. Equally important are other individual factors such as age, the level of education, marital status, household income, higher parity, having a history of obstetric complications, religion, ethnicity and cultural beliefs that limit women from attendance to antenatal services–.
In Kenya, achievements have been noted towards ensuring better access to maternal services by women. First, a presidential directive on June 1, 2013 saw the abolishment of delivery costs in public health facilities with the aim of promoting utilization of maternal services in the health facilities and reducing maternal mortalities. Later in October 2016, the government launched the Linda Mama Program which expanded the free maternal services for women to include antenatal and postnatal care. Evidence generated immediately following the introduction of free maternal services for the period ending in 2014 showed improvements in skilled birth attendance from 44% in the previous period to 62% and in one time antenatal visits from 92–96%. When assessed for their attendance to focused antenatal care after the introduction of free maternal services, this was minimal with 58% of women being found to be adherent up from 47%, contrywide .
The improvements to one-time attendance of ANC ,  show the potential to achieve the recommended 4 + FANC visits if the barriers and limitations in the access and utilization of the services are addressed. Evidence available after the introduction of free maternal services in Kenya shows that the implementation of the policy leaned more towards free skilled deliveries more than all other maternal services. There was inadequate preparedness on the part of health facilities to manage the growing demands for services resulting in challenges with optimal service provision on the part of health facilities.
In order to have a positive impact on the maternal and neonatal mortality as defined by the Sustainable Development Goal 3, it is imperative to establish the levels of uptake of FANC and factors prohibiting use of these antenatal services following the removal of the user fees. Additionally, little is known about the constraints/challenges by health facilities in delivering free antenatal services.
This study assessed the uptake of antenatal care services and the factors affecting the use and provision of these services since the provision of the FMP, in a rural setting.