One of the key findings of this study is that women’s lack of knowledge about PCC was a key determinant of the utilization of preconception care among participants, both in urban and rural settings. This is not only a lack of awareness of the existence of PCC but also awareness of the content and timing of PCC, as the latter two guide women to know whether and when they need PCC services (2, 3, 24). Awareness about the risk factors that may lead to poor pregnancy outcomes, and the existence of risk mitigation measures through PCC emerged as a key factor in determining if women are willing to use PCC. Some women in this study with pregnancy risk factors, though aware of PCC, may have opted not to use PCC if they felt that there was no way of mitigating the risk in order to better pregnancy outcomes. This key finding is comparable to findings in studies by Asresu et al (13) and Demisse et al (11) in Ethiopia and an Italian study by Bortolus et al (12) which also found awareness about PCC as a key determinant. Addressing lack of awareness therefore, should not only entail making known its existence but also making the public aware of potential pregnancy risk factors and the existence of the evidence based interventions that better pregnancy outcomes.
It is possible to postulate that there would be a difference between the PCC uptake in the rural and urban settings here, because of differences in access, educational levels and availability of resources (18). Although some of the respondents from the rural setting felt that their urban counterparts were more aware of PCC due to their higher education levels and exposure, a majority of the urban women were equally unaware of PCC. Thus being educated did not necessarily translate to being aware of PCC. It is possible that the women from the rural setting assume that higher education is associated with knowledge seeking behavior which would spill over to gaining knowledge beyond one’s area of training. Another possible assumption is that higher education is associated with higher income which in turn buys access to qualified medical advice.
Another instructive example of determinants revealed in this study include lack of awareness about the content of PCC among health providers. This chimes with several studies in literature which found PCC awareness to be an issue not only among women, but also among health providers (6, 25-27). Therefore, if PCC is to be effectively utilized, a key national health promotion target should be not only be to increase PCC awareness of the public but also of (primary) health care workers and women of childbearing age. Some enlightening ideas from the participants in this study on the most effective ways pf increasing PCC awareness includes use of broadcast and print media both of which are widely available in Kenya (18), and equipping all health providers with the same message on PCC concept . As an adjunct goal, health education programs should aim to also clear the existing misconceptions about the care, such as PCC aims to give supplements to help with conception and it is therefore only for those with fertility problems, which were also evident from this study.
A majority of the women in both study sites agreed that PCC was a very important form of primary health care that was desirable. However, due to its unavailability and various accessibility challenges, it was unreachable. Financial and time constraints were underlined as major players in limiting accessibility of PCC to those who desired it both in the urban and rural settings. Due to a myriad other competing financial demands, PCC was sacrificed over more pressing needs. A few women went as far as convincing themselves that they were too healthy to require PCC, simply because it was beyond their reach. Due to the demanding nature of some vocations, poor time keeping and long queues during hospital visits, appointments for PCC consultations could not be honored.
This is an interesting determinant that was uniformly spread in both study settings. Whereas the people in the urban setting generally have more financial muscle, the issue of time constraints due to hours spent in traffic jam, stringent work hours and long queues in hospitals are critical impediments. On the other, their rural counterparts’ challenge lies not only in the amount of time spent looking for daily bread and butter which wins over PCC, but also in the limited finances. Local studies have demonstrated that similar hindrances face other forms of maternal health services in Kenya (19, 20). Same barriers to PCC care uptake were also found in other studies in different parts of the world (25, 28-30). As suggested by a few women, incorporating PCC in the free maternity care program in Kenya and initiating distinct PCC clinics in health care facilities can help to address these barriers.
Participants, both rural and urban, had split opinions on whose responsibility it was to initiate PCC. Whereas some felt it was primarily the health care workers’ responsibility in view of the fact that they were the ones who were equipped with PCC information, others felt it was a woman’s job as they are the ones in need and others still, the role of the whole community. This means no one in particular is responsible for initiating the care, and could be attributed to lack of guidelines and strategies with regards to PCC delivery in Kenya. This results in a situation where the women who may be most in need of PCC cannot access it – as they rely on healthcare providers to initiate them into the care. This reflects the findings of several studies several studies in literature which also revealed a lack of guidelines on PCC responsibility (5, 6, 12, 25, 28). Further, studies done among health providers also revealed a lack of consensus on this (25, 28, 31). Public education to enable understanding of individual responsibilities and clear role definitions would clear the existing confusion. As proposed by some of the participants, incorporating PCC as a must have service during other hospital visits for all reproductive aged women would help health providers assume the responsibility of offering it to their patients.
Respondents from both sites recognized that their attitudes towards pregnancy and PCC, such as pregnancy planning, are important determinants of PCC utilization. Since some women believe that pregnancy is a natural phenomenon that is dictated by higher powers, PCC was seen as less relevant, as they believe one can never really plan or prepare for a pregnancy. Inability to plan for a pregnancy goes hand in hand with inability to seek PCC. Studies elsewhere in the literature reveal that some women believe that it was beyond their power to plan a pregnancy (25, 26, 28-32). The CPR level in Kenya is at 62% in urban and 56% in rural areas (15), and this may potentially augment the problem of PCC utilization. A few rural women held beliefs that PCC is a Western phenomenon, which makes it irrelevant to Africans. Others’ blame of witchcraft for poor obstetric outcomes shows that some traditional beliefs and practices may get in the way of effective PCC use. Use of trained, older women in the communities and community health workers who can identify with and reach the local women, is one way to address this barriers.
The study also explored the factors that enable or promote PCC use, which were prior poor obstetric outcomes and the need for information about better pregnancy outcomes in women with underlying health conditions. Conversely, good obstetric outcomes in the past led others to believe that pregnancies are smooth, natural phenomenon that did not require any enhancement or interventions. In addition, some parous women felt more knowledgeable and experienced in matters pregnancy such that they felt they did not require any PCC input. This is a fascinating finding as one would expect parous women to be more aware of how dynamic and unpredictable pregnancy and delivery can be, and as a result embrace PCC more. Women therefore need to be educated about the content of PCC and the fact that a woman’s risks are dynamic which doesn’t always guarantee perfect outcomes in view of good outcomes in the past.
The quest for information about what pregnancy entails and how best to prepare for it or to ascertain one’s health status prior to conception also drives others to seek PCC. Further, some receive PCC in view of either the presence of underlying health problems such as chronic and genetic diseases or infertility concerns. It is therefore possible to purport that both among the health professionals and the public, there are some individuals who are knowledgeable, understand the importance of and embrace PCC. This aligns with the findings in studies done in Ethiopia (13), Nigeria (9) and United Kingdom (6, 31). This comes in handy because social influences such as family, friends and social media play a remarkable role in PCC uptake. Therefore, public education on the concept of PCC to ensure that correct information is in circulation cannot be overemphasized. On the other hand, poor prior interactions with health providers serves as an impediment to not only seeking care, but to also accepting and implementing recommendations made thereafter. This, interestingly, was a dominant theme among the rural women and is echoed by findings from the Northern Nigeria study by Idris (semi-urban setting) (7). It seems self-evident that being poorly treated does not encourage patients to engage health providers. From personal observations, the submissive culture of some rural communities in Kenya towards people of authority places them in the vulnerable position of receiving instructions and admonition quietly and without questioning or demanding respect. The patient population in the rural parts of Kenya have less financial power, access and influence. Since health providers can play a crucial role in the delivery of PCC, this is an important barrier to address and rectify through feedback and communication training among health providers.
This study looked at the determinants of PCC in both urban and rural settings, as well as in private and public hospitals, in a single study. The comparison of the attitudes and experiences of women in rural and urban centres of care is a strength as it allows comparison of women who have different levels of finances and access to PCC.
Use of qualitative method allowed us to delve deeper into the contextual factors affecting PCC in Kenya. It also provided additionally solutions to the barriers of PCC from the patients’ perspective.
The weakness of this study was the homogeneity of the women from AKUH, N (all had tertiary education) and therefore, these findings may not apply to urban women with differing socio-demographic characteristics like those from the slums hence, a separate study in low resource urban areas may be helpful.