Intimate partner violence and postpartum healthcare access in Kenya: a cross-sectional study.

BACKGROUND: Intimate partner violence (IPV) impacts physical health, mental health, and healthcare use. IPV during pregnancy, in particular, is associated with lower rates of antenatal care, but no studies have assessed the association between IPV and postpartum healthcare. This study aims to examine the link between IPV (emotional, physical, and sexual) and two outcomes: postpartum healthcare use and access to family planning. METHODS: This study uses data from a cross-sectional survey of 859 women in Nairobi and Kiambu counties in Kenya who gave birth during the COVID-19 pandemic in 2020. RESULTS: In this sample, 36% of women reported ever experiencing IPV. Of those, 33% indicated the frequency of IPV stayed the same or increased during COVID-19. Nearly 17% of women avoided postpartum healthcare and 10% experienced issues accessing family planning. Those who experienced any form of IPV during pregnancy had approximately twice the odds of avoiding postpartum healthcare compared to those who did not experience any form of IPV. Compared to those who did not experience IPV during pregnancy, experiencing sexual IPV was associated with 2.25 times higher odds of reporting issues accessing family planning. Additionally, reporting fair or poor self-rated health was associated with both avoiding postpartum healthcare and reporting issues accessing family planning. Experiencing food insecurity was also associated with avoiding postpartum healthcare. CONCLUSIONS: To our knowledge, this is the first study to establish the link between IPV during pregnancy and postpartum healthcare access. During COVID-19 in Kenya, postpartum women who had experienced IPV were at increased risk of disengagement with healthcare services. Women should be screened for IPV during pregnancy and postpartum in order to better support their healthcare needs. In times of crisis, such as pandemics, policymakers and healthcare providers must address barriers to healthcare for postpartum women.

"It is not by choice that I gave birth at home": the social determinants of home births during COVID-19 in peri-urban and urban Kenya, a qualitative study.

BACKGROUND: The COVID-19 pandemic significantly impacted the provision of global maternal health services, with an increase in home births. However, there are little data on women's decision-making and experiences leading up to home births during the pandemic. The objective of this study is to examine the economic, social, and health system factors associated with home births in Kenya. METHODS: Community health volunteers (CHVs) and village leaders helped identify potential participants for an in-depth, one-on-one, qualitative telephone interview in Nairobi and Kiambu County in Kenya. In total, the study interviewed 28 mothers who had home births. RESULTS: This study identified a number of economic, social, neighborhood, and health system factors that were associated with birthing at home during the COVID-19 pandemic. Only one woman had planned on birthing at home, while all other participants described various reasons they had to birth at home. Themes related to home births during the pandemic included: (1) unmet preferences related to location of birth; (2) burdens and fear of contracting COVID-19 leading to delayed or missed care; (3) lack of perceived community safety and fear of encounters with law enforcement; and (4) healthcare system changes and uncertainty that led to home births. CONCLUSION: Addressing and recognizing women's social determinants of health is critical to ensuring that preferences on location of birth are met.

Can a quality improvement intervention improve person-centred maternity care in Kenya?

Few evidence-based interventions exist to improve person-centred maternity care in low-resource settings. This study aimed to understand whether a quality improvement (QI) intervention could improve person-centred maternity care (PCMC) experiences for women delivering in public health facilities in Kenya. A pre-post design was used to examine changes in PCMC scores across three intervention and matched control facilities at baseline (n = 491) and endline (n = 677). A QI intervention, using the Model for Improvement, was implemented in three public health facilities in Nairobi and Kiambu Counties in Kenya. Difference-in-difference analyses using models that included main effects of both treatment group and survey round was conducted to understand the impact of the intervention on PCMC scores. Findings suggest that intervention facilities' average total PCMC score decreased by 5.3 points post-intervention compared to baseline (95% CI: -8.8, -1.9) and relative to control facilities, holding socio-demographic and facility variables constant. Additionally, the intervention was significantly associated with a 1.8-point decrease in clinical quality index pre-post-intervention (95% CI: -2.9, -0.7), decreased odds of provider visits, and less likelihood to plan to use postpartum family planning. While improving the quality of women's experiences during childbirth is a critical component to ensure comprehensive, high-quality maternity care experiences and outcomes, further research is required to understand which intervention methods may be most appropriate to improve PCMC in resource-constrained settings.

Trust, Care Avoidance, and Care Experiences among Kenyan Women Who Delivered during the COVID-19 Pandemic.

We explore how the COVID-19 pandemic was associated with avoidance of, and challenges with, antenatal, childbirth and postpartum care among women in Kiambu and Nairobi counties, Kenya; and whether this was associated with a report of declined trust in the health system due to the pandemic. Women who delivered between March and November 2020 were invited to participate in a phone survey about their care experiences (n = 1122 respondents). We explored associations between reduced trust and care avoidance, delays and challenges with healthcare seeking, using logistic regression models adjusted for women's characteristics. Approximately half of respondents said their trust in the health care system had declined due to COVID-19 (52.7%, n = 591). Declined trust was associated with higher likelihood of reporting barriers accessing antenatal care (aOR 1.59 [95% CI 1.24, 2.05]), avoiding care for oneself (aOR 2.26 [95% CI 1.59, 3.22]) and for one's infant (aOR 1.77 [95% CI 1.11, 2.83]), and of feeling unsafe accessing care (aOR 1.52 [95% CI 1.19, 1.93]). Since March 2020, emergency services, routine care and immunizations were avoided most often. Primary reported reasons for avoiding care and challenges accessing care were financial barriers and problems accessing the facility. Declined trust in the health care system due to COVID-19 may have affected health care-seeking for women and their children in Kenya, which could have important implications for their health and well-being. Programs and policies should consider targeted special "catch-up" strategies that include trust-building messages and actions for women who deliver during emergencies like the COVID-19 pandemic.

Improving stigma and psychosocial outcomes among post-abortion Kenyan women attending private clinics: A randomized controlled trial of a person-centered mobile phone-based intervention.

OBJECTIVES: The objective of this study was to evaluate a person-centered abortion care mobile-based intervention on perceived social stigma, social support, mental health and post-abortion care experiences among Kenyan women who received abortion services at private clinics. METHODS: This randomized controlled study enrolled women who obtained an abortion from private clinics in Nairobi county, Kenya and randomized them into one of three study arms: 1) standard of care (follow-up by service provider call center); 2) post-abortion phone follow-up by a peer counselor (a woman who has had an abortion herself and is trained in person-centered abortion care); or 3) post-abortion phone follow-up by a nurse (a nurse who is trained in person-centered abortion care). All participants were followed-up at two- and four-weeks post-abortion to evaluate intervention effects on mental health, social support, and abortion-related stigma scores. A Kruskal-Wallis one-way ANOVA test was used to assess the effect of each intervention compared to the control group. In total, 371 women participated at baseline and were each randomized to the study arms. RESULTS: Using Kruskal-Wallis tests, the nurse arm improved mental health scores from baseline to week two; however this was only marginally significant (p = 0.059). The nurse arm also lowered stigma scores from baseline to week four, and this was marginally significant (p = 0.099). No other differences were found between the study arms. This person-centered mobile phone-based intervention may improve mental health and decrease perceived stigma among Kenyan women who received abortion services in private clinics. CONCLUSIONS: Nurses trained in person-centered abortion care, in particular, may improve women's experiences post-abortion and potentially reduce feelings of shame and stigma and improve mental health in this context.

Effects of the COVID-19 pandemic on antenatal care utilisation in Kenya: a cross-sectional study.

OBJECTIVE: The aim of this study was to assess the effects of COVID-19 on antenatal care (ANC) utilisation in Kenya, including women's reports of COVID-related barriers to ANC and correlates at the individual and household levels. DESIGN: Cross-sectional study. SETTING: Six public and private health facilities and associated catchment areas in Nairobi and Kiambu Counties in Kenya. PARTICIPANTS: Data were collected from 1729 women, including 1189 women who delivered in healthcare facilities before the COVID-19 pandemic (from September 2019-January 2020) and 540 women who delivered during the pandemic (from July through November 2020). Women who delivered during COVID-19 were sampled from the same catchment areas as the original sample of women who delivered before to compare ANC utilisation. PRIMARY AND SECONDARY OUTCOME MEASURES: Timing of ANC initiation, number of ANC visits and adequate ANC utilisation were primary outcome measures. Among only women who delivered during COVID-19 only, we explored women's reports of the pandemic having affected their ability to access or attend ANC as a secondary outcome of interest. RESULTS: Women who delivered during COVID-19 had significantly higher odds of delayed ANC initiation (ie, beginning ANC during the second vs first trimester) than women who delivered before (aOR 1.72, 95% CI 1.24 to 2.37), although no significant differences were detected in the odds of attending 4-7 or ≥8 ANC visits versus <4 ANC visits, respectively (aOR 1.12, 95% CI 0.86 to 1.44 and aOR 1.46, 95% CI 0.74 to 2.86). Nearly half (n=255/540; 47%) of women who delivered during COVID-19 reported that the pandemic affected their ability to access ANC. CONCLUSIONS: Strategies are needed to mitigate disruptions to ANC among pregnant women during pandemics and other public health, environmental, or political emergencies.

The economic toll of COVID-19: A cohort study of prevalence and economic factors associated with postpartum depression in Kenya.

OBJECTIVE: The aim of the study is to examine the risk of postpartum depression (PPD) among women who delivered during the COVID-19 pandemic compared to women who delivered before the COVID-19 pandemic and how economic challenges are associated with PPD. METHODS: Data were collected from 2332 women. This includes 1197 women from healthcare facilities in 2019 who were followed up at 2-4 and 10 weeks postpartum. Additionally, we recruited 1135 women who delivered from March 16, 2020 onward when COVID-19 restrictions were mandated in Kenya in the same catchment areas as the original sample to compare PPD rates. RESULTS: Adjusting for covariates, women who delivered during COVID-19 had 2.5 times higher odds of screening positive for PPD than women who delivered before COVID-19 (95% confidence interval [CI] 1.92-3.15). Women who reported household food insecurity, required to pay a fee to cover the cost of PPE during labor and delivery and/or postnatal visit(s), and those who reported COVID-19 employment-related impacts had a higher likelihood of screening for PPD compared to those who did not report these experiences. CONCLUSION: The COVID-19 pandemic has greatly increased the economic vulnerability of women, resulting in increases in PPD.

Person-centered maternity care and postnatal health: associations with maternal and newborn health outcomes.

BACKGROUND: Limited evidence exists on how women's experiences of care, specifically person-centered maternity care during childbirth, influence maternal and newborn health outcomes. OBJECTIVE: This study aimed to examine the associations between person-centered maternity care and maternal and newborn health outcomes. STUDY DESIGN: Longitudinal data were collected with 1014 women who completed baseline at a health facility and followed up at 2 weeks and 10 weeks after birth. A validated 30-item person-centered maternity care scale was administered to postpartum women within 48 hours after childbirth. The person-centered maternity care scale has 3 subscales: dignity and respect, communication and autonomy, and supportive care. Bivariate and multivariable log Poisson regressions were used to examine the relationship between person-centered maternity care and reported maternal complications, newborn complications, postpartum depression, postpartum family planning uptake, exclusive breastfeeding, and newborn immunizations. RESULTS: Controlling for demographic characteristics, women with high total person-centered maternity care score at baseline had significantly lower risk of reporting maternal complications (adjusted relative risk, 0.63; 95% confidence interval, 0.42-0.95), screening positive for depression (adjusted relative risk, 0.55; 95% confidence interval, 0.38-0.81), and reporting newborn complications (adjusted relative risk, 0.74; 95% confidence interval, 0.56-0.97), respectively, than women with low total person-centered maternity care scores. Women with high scores on the supportive care subscale had significantly lower risk of reporting maternal and newborn complications than women with low scores on these subscales (adjusted relative risk, 0.52 [95% confidence interval, 0.42-0.65] and 0.74 [95% confidence interval, 0.60-0.91], respectively). Significant associations were found between all 3 subscale scores and screening positive for depression. Women with high total person-centered maternity care scores were also more likely to adopt a family planning method than those with low scores (adjusted relative risk, 1.25; 95% confidence interval, 1.02-1.52). In particular, women with high scores on the communication and autonomy subscale had significantly higher odds of adopting a family planning method than women with low scores (risk ratio, 1.15; 95% confidence interval, 1.08-1.23). CONCLUSION: Improving person-centered maternity care may improve maternal and newborn health outcomes. Specifically, improving supportive care may decrease the risk of maternal and newborn complications, whereas improving communication and autonomy may increase postpartum family planning uptake.

Person-centred care for abortion services in private facilities to improve women's experiences in Kenya.

Globally, access to good quality abortion services and post-abortion care is a critical determinant for women's survival after unsafe abortion. Unsafe abortions account for high levels of maternal death in Kenya. We explored women's experiences and perceptions of their abortion and post-abortion care experiences in Kenya through person-centred care. This qualitative study included focus group discussions and in-depth interviews with women aged 18-35 who received safe abortion services at private clinics. Through thematic analyses of women's testimonies, we identified gaps in the abortion care and person-centred domains which seemed to be important throughout the abortion process. When women received clear communication and personalised comprehensive information on abortion and post-abortion care from their healthcare providers, they reported more positive experiences overall and higher reproductive autonomy. Communication and supportive care were particularly valued during the post-abortion period, as was social support more generally. Further research is needed to design, implement and test the feasibility and acceptability of person-centred abortion care interventions in community and clinical settings with the goal of improving women's abortion experiences and overall reproductive health outcomes.

Bypassing high-quality maternity facilities: evidence from pregnant women in peri-urban Nairobi.

Utilization of high-quality maternal care is an important link along the pathway from increased facility-based delivery to improved maternal health outcomes, however women in Nairobi do not all deliver in the highest quality facilities available to them. We explored whether women living in peri-urban Nairobi who live nearby to high-quality facilities bypassed, or travelled farther than, their nearest high technical quality facility using survey data collected before and after delivery from women (n = 358) and from facility assessments (n = 59). We defined the nearest high technical quality facility as the nearest Comprehensive Emergency Obstetric and Newborn Care (CEmONC) capable facility to each woman's neighbourhood. We compared women who delivered in their nearest CEmONC (n = 44) to women who bypassed their nearest CEmONC to deliver in a facility that was farther away (n = 200). Among bypassers, 131 (65.5%) women delivered in farther non-CEmONC facilities with lower technical quality and 69 (34.5%) delivered in farther CEmONCs with higher technical quality capacity compared to their nearby CEmONCs. Bypassers rated their delivery experience higher than non-bypassers. Women who bypassed to deliver in non-CEmONCs were less likely to have completed four antenatal care visits and to consider delivering in any CEmONC prior to delivery while women who bypassed to deliver in farther CEmONCs paid more for delivery and were more likely to report being able to access emergency funds compared to non-bypassers. Our findings suggest that women in peri-urban Nairobi bypassed their nearest CEmONC facilities in favour of delivering in facilities that provided better non-technical quality care. Bypassers with access to financial resources were also able to deliver in facilities with higher technical quality care. Policies that improve women's delivery experience and ensure that information about facility technical quality is widely distributed may be critical to increase the utilization of high-quality maternity facilities.

Perspectives on implementing a quality improvement collaborative to improve person-centered care for maternal and reproductive health in Kenya.

OBJECTIVE: To understand perspectives and experiences related to participation in a quality improvement collaborative (QIC) to improve person-centered care (PCC) for maternal health and family planning (FP) in Kenya. DESIGN AND SETTING: Semi-structured qualitative interviews were conducted with members of the QIC in four public health facilities in Kenya. PARTICIPANTS: Clinical and nonclinical public health facility staff who had participated in the QIC were purposively sampled to participate in the semi-structured interviews. INTERVENTION: A QIC was implemented across four public health facilities in Nairobi and Kiambu Counties in Kenya to improve PCC experiences for women seeking maternity or FP services. MAIN OUTCOME MEASURE: Semi-structured interviews with participants of the QIC to understand perspectives and experiences associated with sensitization to and implementation of PCC behaviors in maternity and FP services. RESULTS: Respondents reported that sensitization to PCC principles resulted in multiple perceived benefits for staff and patients alike, including improved interactions with patients and clients, deeper awareness of patient and client preferences, and improved interpersonal skills and greater job satisfaction. Respondents also highlighted system-level challenges that impeded their ability to consistently provide high-quality PCC to women, namely staff shortages and frequent turnover, high patient volumes and lack of space in their respective health facilities. CONCLUSION: Respondents were easily able to articulate perceived benefits derived from participation in this QIC, although they were equally able to identify challenges that hindered their ability to consistently provide high-quality PCC to women seeking maternity or FP services.

The Extended Role of Health Facility Cleaners in Maternity Care in Kenya.

CONTEXT: A growing body of evidence indicates that nonclinical health care facility staff provide support beyond their traditional roles, particularly in low- and middle-income countries. It is important to examine the role of health facility cleaners in Kenya-from their perspective-to better understand their actual and perceived responsibilities in maternity care. METHODS: In-depth, face-to-face interviews using a semistructured guide were conducted with 14 cleaners working at three public health facilities in Nairobi and Kiambu Counties, Kenya, in August and September 2016. Results were coded and categorized using a thematic content analysis approach. RESULTS: Cleaners reported performing a range of services beyond typical maintenance responsibilities, including providing emotional, informational and instrumental support to maternity patients. They described feeling disrespected when patients were untidy or experienced bleeding; however, such examples revealed cleaners' need to better understand labor and childbirth processes. Cleaners also indicated a desire for training on interpersonal skills to improve their interactions with patients. CONCLUSION: Cleaners' direct involvement in maternity patients' care is an alarming symptom of overburdened health facilities, insufficient staffing and inadequate training. This key yet overlooked cadre of health care staff deserves appropriate support and further research to understand and alleviate health system shortcomings, and to improve the quality of maternity health care provision.

RESUMEN Contexto: Un creciente conjunto de evidencia indica que miembros del personal no clínico de las instituciones de salud proporcionan apoyos que trascienden sus roles tradicionales, particularmente en países de bajos y medianos ingresos. Es importante examinar el rol del personal de limpieza de las instituciones de salud en Kenia­desde su perspectiva­para comprender mejor sus responsabilidades reales y percibidas en cuanto a la atención materna. Métodos: Se condujeron entrevistas personales en profundidad utilizando una guía semiestructurada con 14 miembros del personal de limpieza que trabajaban en tres instituciones de salud pública en los condados de Nairobi y Kiambu, Kenia, en agosto y septiembre de 2016. Los resultados fueron codificados y categorizados mediante un enfoque de análisis de contenido temático. Resultados: El personal de limpieza reportó que realizaba una variedad de servicios además de sus responsabilidades típicas de mantenimiento, que incluyeron la provisión de apoyo emocional, informativo e instrumental a las pacientes de maternidad. Describieron un sentimiento de falta de respeto cuando las pacientes estaban desaseadas o experimentaban sangrado; sin embargo, tales ejemplos revelaron la necesidad de que el personal de limpieza comprendiera mejor los procesos de trabajo de parto y parto. El personal de limpieza también indicó su deseo de recibir capacitación en habilidades interpersonales para mejorar su interacción con las mujeres. Conclusión: La participación directa del personal de limpieza en la atención a pacientes de maternidad es un síntoma alarmante de sobrecarga de las instituciones de salud, de personal insuficiente y de capacitación inadecuada. Este grupo de personal de atención a la salud, clave pero ignorado, merece apoyo apropiado y se necesita mayor investigación para comprender y mitigar los defectos del sistema de salud y mejorar la calidad de la prestación de servicios de salud materna.

RÉSUMÉ Contexte: La documentation et les données indiquent de plus en plus que le travail du personnel non clinique des structures de soins de santé s'étend au-delà du rôle qu'on attendrait ordinairement de lui, en particulier dans les pays à revenu faible ou intermédiaire. Il importe d'examiner ­ de leur point de vue ­ le rôle des effectifs de nettoyage des structures sanitaires du Kenya si l'on veut mieux comprendre leurs responsabilités réelles et perçues dans les soins de maternité. Méthodes: Des entretiens en personne approfondis, suivant un guide semi-structuré, ont été menés avec 14 membres du personnel de nettoyage de trois structures sanitaires de l'État dans les comtés de Nairobi et de Kiambu (Kenya), en août et septembre 2016. Les résultats ont été codés et catégorisés selon une approche d'analyse de contenu thématique. Résultats: Le personnel de nettoyage interrogé a déclaré effectuer des services allant au-delà des responsabilités d'entretien types, y compris l'apport d'un soutien affectif, informatif et matériel aux patientes des services de maternité. Il estimait subir un manque de respect lorsque les patientes présentaient une allure peu soignée ou saignaient. Ces exemples révèlent cependant la nécessité pour le personnel de nettoyage de mieux comprendre les processus du travail et de l'accouchement. Le personnel interrogé a également exprimé un désir de formation en matière de compétences interpersonnelles, en vue d'une meilleure interaction avec les femmes. Conclusion: La participation directe du personnel de nettoyage aux soins de maternité des patientes représente un symptôme alarmant de structures sanitaires surchargées, d'effectifs insuffisants et de formation inadéquate. Cette catégorie d'effectifs sanitaires, essentielle mais généralement négligée, mérite un soutien approprié. Une recherche approfondie doit être entreprise pour comprendre et combler les lacunes du système de santé et pour améliorer la qualité de prestation des soins de maternité.

Association between person-centered maternity care and newborn complications in Kenya.

OBJECTIVE: Despite the recognized importance of person-centered care, very little information exists on how person-centered maternity care (PCMC) impacts newborn health. METHODS: Baseline and follow-up data were collected from women who delivered in government health facilities in Nairobi and Kiambu counties in Kenya between August 2016 and February 2017. The final analytic sample included 413 respondents who completed the baseline survey and at least one follow-up survey at 2, 6, 8, and/or 10 weeks. Data were analyzed using descriptive, bivariate, and multivariate statistics. Logistic regression was used to assess the relationship between PCMC scores and outcomes of interest. RESULTS: In multivariate analyses, women with high PCMC scores were significantly less likely to report newborn complications than women with low PCMC scores (adjusted odds ratio [aOR] 0.39, 95% confidence interval [CI] 0.16-0.98). Women reporting high PCMC scores also had significantly higher odds of reporting a willingness to return to the facility for their next delivery than women with low PCMC score (aOR 12.72, 95% CI 2.26-71.63). The domains of Respect/Dignity and Supportive Care were associated with fewer newborn complications and willingness to return to a facility. CONCLUSION: PCMC could improve not just the experience of the mother during childbirth, but also the health of her newborn and future health-seeking behavior.

Accuracy of patient perceptions of maternity facility quality and the choice of providers in Nairobi, Kenya: a cohort study.

OBJECTIVES: This study aimed to assess the accuracy of pregnant women's perceptions of maternity facility quality and the association between perception accuracy and the quality of facility chosen for delivery. DESIGN: A cohort study. SETTING: Nairobi, Kenya. PARTICIPANTS: 180 women, surveyed during pregnancy and 2 to 4 weeks after delivery. PRIMARY OUTCOME MEASURES: Women were surveyed during pregnancy regarding their perceptions of the quality of all facilities they were considering during delivery and then, after delivery, about their ultimate facility choice. Perceptions of quality were based on perceived ability to handle emergencies and complications. Delivery facilities were assigned a quality index score based on a direct assessment of performance of emergency 'signal functions', skilled provider availability, medical equipment and drug stocks. 'Accurate perceptions' was a binary variable equal to one if a woman's ranking of facilities based on her quality perception equalled the index ranking. Ordinary least squares and logistic regressions were used to analyse associations between accurate perceptions and quality of the facility chosen for delivery. RESULTS: Assessed technical quality was modest, with an average index score of 0.65. 44% of women had accurate perceptions of quality ranking. Accurate perceptions were associated with a 0.069 higher delivery facility quality score (p=0.039; 95% CI: 0.004 to 0.135) and with a 14.5% point higher probability of delivering in a facility in the top quartile of the quality index (p=0.015; 95% CI: 0.029 to 0.260). CONCLUSIONS: Patient misperceptions of technical quality were associated with use of lower quality facilities. Larger studies could determine whether improving patient information about relative facility quality can encourage use of higher quality care.

Providers and women's perspectives on person-centered maternity care: a mixed methods study in Kenya.

BACKGROUND: Globally, there has been increasing attention to women's experiences of care and calls for a person-centered care approach. At the heart of this approach is the patient-provider relationship. It is necessary to examine the extent to which providers and women agree on the care that is provided and received. Studies have found that incongruence between women's and providers' perceptions may negatively impact women's compliance, satisfaction, and future use of health facilities. However, there are no studies that examine patient and provider perspectives on person-centered care. METHODS: To fill this gap in the literature, we use cross-sectional data of 531 women and 33 providers in seven government health facilities in Kenya to assess concordance and discordance in person-centered care measures. Additionally, we analyze 41 in-depth interviews with providers from three of these facilities to examine why differences in reporting may occur. Descriptive statistical methods were used to measure the magnitude of differences between reports of women and reports of providers. Thematic analyses were conducted for provider surveys. RESULTS: Our findings suggest high discordance between women and providers' perspectives in regard to person-centered care experiences. On average, women reported lower levels of person-centered care compared to providers, including low respectful and dignified care, communication and autonomy, and supportive care. Providers were more likely to report higher rates of poor health facility environment such as having sufficient staff. We summarize the overarching reasons for the divergence in women and provider reports as: 1) different understanding or interpretation of person-centered care behaviors, and 2) different expectations, norms or values of provider behaviors. Providers rationalized abuse towards women, did not allow a companion of choice, and blamed women for poor patient-provider communication. Women lacked assurance in privacy and confidentiality, and faced challenges related to the health facility environment. Providers attributed poor person-centered care to both individual and facility/systemic factors. CONCLUSIONS: Implications of this study suggests that providers should be trained on person-centered care approaches and women should be counseled on understanding patient rights and how to communicate with health professionals.

Development of a Person-Centered Family Planning Scale in India and Kenya.

Despite recognition that person-centered care is a critical component to providing high quality family planning services, there lacks consensus on how to operationalize and measure it. This paper describes the development and validation of a person-centered family planning (PCFP) scale in India and Kenya. Cross-sectional data were collected from 522 women in Kenya and 225 women in India who visited a health facility providing family planning services. Psychometric analyses, including exploratory factor analysis, were employed to assess the validity and reliability of the PCFP scale. Separate scales were developed for India and Kenya due to context-specific items. We assessed criterion validity by examining the association between PCFP and global measures of quality and satisfaction with family planning care. The analysis resulted in a multidimensional PCFP scale, including 20 items in Kenya and 22 items in India. Through iterative factor analysis, two subscales were identified for both countries: "autonomy, respectful care, and communication" and "health facility environment." This scale may be used to evaluate quality improvement interventions and experiences of women globally to support women in achieving their reproductive health goals.

Measuring The Impact Of Cash Transfers And Behavioral 'Nudges' On Maternity Care In Nairobi, Kenya.

Many patients in low-income countries express preferences for high-quality health care but often end up with low-quality providers. We conducted a randomized controlled trial with pregnant women in Nairobi, Kenya, to analyze whether cash transfers, enhanced with behavioral "nudges," can help women deliver in facilities that are consistent with their preferences and are of higher quality. We tested two interventions. The first was a labeled cash transfer (LCT), which explained that the cash was to help women deliver where they wanted. The second was a cash transfer that combined labeling and a commitment by the recipient to deliver in a prespecified desired facility as a condition of receiving the final payment (L-CCT). The L-CCT improved patient-perceived quality of interpersonal care but not perceived technical quality of care. It also increased women's likelihood of delivering in facilities that met standards for routine and emergency newborn care but not the likelihood of delivering in facilities that met standards for obstetric care. The LCT had fewer measured benefits. Women preferred facilities with high technical and interpersonal care quality, but these quality measures were often negatively correlated within facilities. Even with cash transfers, many women still used poor-quality facilities. A larger study is warranted to determine whether the L-CCT can improve maternal and newborn outcomes.

Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population.

BACKGROUND: Person-centered reproductive health care is recognized as critical to improving reproductive health outcomes. Yet, little research exists on how to operationalize it. We extend the literature in this area by developing and validating a tool to measure person-centered maternity care. We describe the process of developing the tool and present the results of psychometric analyses to assess its validity and reliability in a rural and urban setting in Kenya. METHODS: We followed standard procedures for scale development. First, we reviewed the literature to define our construct and identify domains, and developed items to measure each domain. Next, we conducted expert reviews to assess content validity; and cognitive interviews with potential respondents to assess clarity, appropriateness, and relevance of the questions. The questions were then refined and administered in surveys; and survey results used to assess construct and criterion validity and reliability. RESULTS: The exploratory factor analysis yielded one dominant factor in both the rural and urban settings. Three factors with eigenvalues greater than one were identified for the rural sample and four factors identified for the urban sample. Thirty of the 38 items administered in the survey were retained based on the factors loadings and correlation between the items. Twenty-five items load very well onto a single factor in both the rural and urban sample, with five items loading well in either the rural or urban sample, but not in both samples. These 30 items also load on three sub-scales that we created to measure dignified and respectful care, communication and autonomy, and supportive care. The Chronbach alpha for the main scale is greater than 0.8 in both samples, and that for the sub-scales are between 0.6 and 0.8. The main scale and sub-scales are correlated with global measures of satisfaction with maternity services, suggesting criterion validity. CONCLUSIONS: We present a 30-item scale with three sub-scales to measure person-centered maternity care. This scale has high validity and reliability in a rural and urban setting in Kenya. Validation in additional settings is however needed. This scale will facilitate measurement to improve person-centered maternity care, and subsequently improve reproductive outcomes.

Do active patients seek higher quality prenatal care?: A panel data analysis from Nairobi, Kenya.

Despite poverty and limited access to health care, evidence is growing that patients in low-income countries are taking a more active role in their selection of health care providers. Urban areas such as Nairobi, Kenya offer a rich context for studying these "active" patients because of the large number of heterogeneous providers available. We use a unique panel dataset from 2015 in which 402 pregnant women from peri-urban (the "slums" of) Nairobi, Kenya were interviewed three times over the course of their pregnancy and delivery, allowing us to follow women's care decisions and their perceptions of the quality of care they received. We define active antenatal care (ANC) patients as those women who switch ANC providers and explore the prevalence, characteristics and care-seeking behavior of these patients. We analyze whether active ANC patients appear to be seeking out higher quality facilities and whether they are more satisfied with their care. Women in our sample visit over 150 different public and private ANC facilities. Active patients are more educated and more likely to have high risk pregnancies, but have otherwise similar characteristics to non-active patients. We find that active patients are increasingly likely to pay for private care (despite public care being free) and to receive a higher quality of care over the course of their pregnancy. We find that active patients appear more satisfied with their care over the course of pregnancy, as they are increasingly likely to choose to deliver at the facility providing their ANC.

The Relationship Between Distance and Post-operative Visit Attendance Following Medical Male Circumcision in Nyanza Province, Kenya.

To date, there is no research on voluntary medical male circumcision (VMMC) catchment areas or the relationship between distance to a VMMC facility and attendance at a post-operative follow-up visit. We analyzed data from a randomly selected subset of males self-seeking circumcision at one of 16 participating facilities in Nyanza Province, Kenya between 2008 and 2010. Among 1437 participants, 46.7 % attended follow-up. The median distance from residence to utilized facility was 2.98 km (IQR 1.31-5.38). Nearly all participants (98.8 %) lived within 5 km from a facility, however, 26.3 % visited a facility more than 5 km away. Stratified results demonstrated that among those utilizing fixed facilities, greater distance was associated with higher odds of follow-up non-attendance (OR5.01-10km vs. 0-1km = 1.71, 95 % CI 1.08, 2.70, p = 0.02; OR>10km vs. 0-1 km = 2.80, 95 % CI 1.26, 6.21, p = 0.01), adjusting for age and district of residence. We found 5 km marked the threshold distance beyond which follow-up attendance significantly dropped. These results demonstrate distance is an important predictor of attending follow-up, and this relationship appears to be modified by facility type.