This study aimed to establish what drives women’s decision making on delivery health facility in a rural sub-County. Our study showed that there was an overall increase in utilization of health facilities particularly the tertiary health facilities. Evidence shows that an increase in demand for delivery services related to policy may have led to the further deterioration of actual quality of care, with understaffed public health workers having increased workloads as experienced in various health facilities across settings in Kenya (Lang’at & Mwanri, 2015); (Karanja et al., 2018); (Gitobu et al., 2018);(Tama et al., 2018). Evidence from other sub-Saharan contexts have also shown that an increase in demand at health facilities due to removal of user fees might not necessarily lead to an improvement in maternal health and other outcomes;(De Allegri et al., 2011); (Dzakpasu et al., 2014); (McKinnon et al., 2015). Perceived quality of care in this setting resulted in the women opting to switch seeking services from primary health facilities, that were geographically close to them, to tertiary maternity health facilities, often in town centers. This phenomenon of bypassing close-by health facilities in the search for health facilities providing a higher quality of care has been previously documented in Tanzanian settings, where women deemed primary health facilities ineffectual for complex obstetric services(Danforth et al., 2009); (Kruk et al., 2014).
As part of perceptions of quality of care, a majority of the women mentioned process indicators, such as the interpersonal treatment of women by healthcare workers. Private health facilities in the area were described as providing a high quality of care that was respectful and caring towards the women. Public health facilities, on the other hand, were described as mistreating women and being disrespectful and abusive in their interactions with women. Our findings suggested that women identified nurses as critical healthcare providers, holding them responsible for varying modes of mistreatment. The women specifically identified night-shift nurses in public tertiary health facilities as having a bad attitude towards them and attending to them in disrespectful ways. Forms of mistreatment often included verbal abuse, neglect, and abandonment during delivery and denying them personal autonomy in the choice of their preferred delivery positions.
Quality of care standards require that women be treated in a respectful manner and in a way that upholds their dignity (WHO, 2016). Mistreatment at health facilities by healthcare workers is a topic that is gaining traction and has been described in many different contexts, particularly in sub-Saharan Africa. Bohren et al. (2014) in a systematic review identifies mistreatment a barrier to women taking advantage of facility-based delivery (Bohren et al., 2014). Mistreatment of women is also described in detail within the Kenyan context, (Okwako & Symon, 2014); (Warren et al., 2017);(Oluoch-Aridi et al., 2018). Some studies have even estimated its prevalence at 20% (Abuya et al., 2015). Other studies have documented the manifestations of mistreatment Other recent reports in other sub-Saharan African countries have reported on mistreatment during facility-based delivery (Balde et al., 2017) Nigeria (Bohren et al., 2017), and South Africa (Jewkes et al., 1998). Urgent international calls have been made for accountability for the mistreatment of women during labor and delivery (Jewkes & Penn-Kekana, 2015);(Afulani & Moyer, 2019)). Mistreatment should be addressed during regular supervision in all facilities, and quality assessments should ensure that a functioning feedback mechanism for respectful care during delivery is in place. Policymakers and program managers need to take note and work on solutions to improve the quality of care that women face at maternal health facilities. Professional associations also need to be involved in continuing professional development to change norms. Other health policy researchers have suggested retraining health workers and including a value transformation component to promote respectful care during delivery services (Warren et al., 2017).
The availability of physical amenities at the health facility was commonly mentioned by the rural women. Women would “opt for quality” by choosing a health facility that had the equipment like a functioning theatre and ability to provide cesarean sections in the event of a complicated birth. This was mentioned by a majority of women in the focus group discussions. The information was often obtained by word of mouth from a relational network of other women who had used the health facilities. Physical amenities also mentioned by the women were adequate space in the wards, suitable beds, and bedding, availability of hot water for bathing and sufficient food for eating after delivery. Other Kenyan studies identify the same trend in different Kenyan settings, such as peri-urban and pastoralist communities and coastal Kenya, where women have mentioned a shortage of essential physical amenities at health facilities (Lang’at & Mwanri, 2015) ;(Karanja et al., 2018). These findings have been reflected in other sub-Saharan counties, particularly in rural settings (Gebrehiwot et al., 2014); (Anastasi et al., 2015); (King et al., 2015).
Referrals struggled with delays because of the lack of ambulances, poor communication or weak linkages with higher-level facilities that were part of the system. This finding suggests that referral options at some low-cost private health facilities within peri-urban settings are weak. WHO standards advocate for referrals that are conducted in a timely fashion with a pre-established plan for delivery care and with relevant sharing of information between the concerned staff at the private health facilities (WHO, 2016).
The rural women also had concerns around costs specifically informal charges during delivery services. Women described situations where public health facilities were "free," but they were exposed to hidden direct costs during billing. Women were asked to pay extra fees at the point of discharge. Some of them mentioned incurring indirect costs after their coverage for the delivery had been exhausted and they had complications with the baby. They reported been asked to pay for these auxiliary costs out-of pocket. Costs, both direct and indirect, have been previously identified in studies assessing factors influencing place of delivery both in Kenya and other sub-Saharan African settings (Mwangome et al., 2012);(Karanja et al., 2018). Out of pocket costs have been reported to been known to impoverish Kenyans accessing health care services (Chuma & Maina, 2012).
The women in this setting identified distance to the health facility as a facilitator to delivery at tertiary health maternities in town centers. Despite the number of health facilities increasing with increased access, women still preferred a health facility that was close to their residence, and easily accessible preferably in a town Centre that had easy access to public transportation. This has been identified in other studies examining factors influencing place of delivery in Kenya and different sub-Saharan African settings (Karanja et al., 2018; Anastasia et al., 2015). Our findings suggest that geographical access still presents a significant challenge, particularly for some segments of the rural women. The Naivasha sub-County study setting included women who hailed from pastoralist backgrounds, and the distances to a health facility were vast. Pastoralist women in Kenya continue to face long distances to care, posing a significant barrier and a threat related to obstetric emergencies, as seen in other studies (Caulfield et al., 2016); (Byrne et al., 2016). Some studies suggest construction of maternity waiting homes as a solution to distance, especially in pastoralist communities, but cultural resistance continues to be a challenge to the uptake of such interventions (Karanja et al., 2018). Support for obstetric emergencies and functioning ambulances have been proposed as a solution to such challenges.