title: Barriers and facilitators to antenatal and delivery care in western Kenya: a qualitative study.
abstract: BACKGROUND
  In western Kenya, maternal mortality is a major public health problem estimated at 730/100,000 live births, higher than the Kenyan national average of 488/100,000 women. Many women do not attend antenatal care (ANC) in the first trimester, half do not receive 4 ANC visits. A high proportion use traditional birth attendants (TBA) for delivery and 1 in five deliver unassisted. The present study was carried out to ascertain why women do not fully utilise health facility ANC and delivery services.
  
  
  METHODS
  A qualitative study using 8 focus group discussions each consisting of 8-10 women, aged 15-49 years. Thematic analysis identified the main barriers and facilitators to health facility based ANC and delivery.
  
  
  RESULTS
  Attending health facility for ANC was viewed positively. Three elements of care were important; testing for disease including HIV, checking the position of the foetus, and receiving injections and / or medications. Receiving a bed net and obtaining a registration card were also valuable. Four barriers to attending a health facility for ANC were evident; attitudes of clinic staff, long clinic waiting times, HIV testing and cost, although not all women felt the cost was prohibitive being worth it for the health of the child. Most women preferred to deliver in a health facility due to better management of complications. However cost was a barrier, and a reason to visit a TBA because of flexible payment. Other barriers were unpredictable labour and transport, staff attitudes and husbands' preference.
  
  
  CONCLUSIONS
  Our findings suggest that women in western Kenya are amenable to ANC and would be willing and even prefer to deliver in a healthcare facility, if it were affordable and accessible to them. However for this to happen there needs to be investment in health promotion, and transport, as well as reducing or removing all fees associated with antenatal and delivery care. Yet creating demand for service will need to go alongside investment in antenatal services at organisational, staffing and facility level in order to meet both current and future increase in demand.
authors.affiliation: Child and Reproductive Health, Liverpool School of Tropical Medicine, Merseyside, UK. Linda.Mason129@gmail.com.
authors.forename: Linda
authors.initials: L
authors.lastname: Mason
authors.affiliation: Child and Reproductive Health, Liverpool School of Tropical Medicine, Merseyside, UK. Stephanie.Dellicour@lstmed.ac.uk.|Kenya Medical Research Institute (KEMRI), Center for Global Health Research (CGHR), Kisumu, Kenya. Stephanie.Dellicour@lstmed.ac.uk.|Centers for Disease Control and Prevention (CDC), Atlanta, USA. Stephanie.Dellicour@lstmed.ac.uk.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Dellicour
authors.affiliation: Child and Reproductive Health, Liverpool School of Tropical Medicine, Merseyside, UK. Feiko.Terkuile@lstmed.ac.uk.
authors.forename: Feiko
authors.initials: F
authors.lastname: Ter Kuile
authors.affiliation: Kenya Medical Research Institute (KEMRI), Center for Global Health Research (CGHR), Kisumu, Kenya. Pouma@kemricdc.org.
authors.forename: Peter
authors.initials: P
authors.lastname: Ouma
authors.affiliation: Child and Reproductive Health, Liverpool School of Tropical Medicine, Merseyside, UK. Penelope.Phillips-Howard@lstmed.ac.uk.
authors.forename: Penny
authors.initials: P
authors.lastname: Phillips-Howard
authors.affiliation: Kenya Medical Research Institute (KEMRI), Center for Global Health Research (CGHR), Kisumu, Kenya. Fachieng@kemricdc.org.
authors.forename: Florence
authors.initials: F
authors.lastname: Were
authors.affiliation: Kenya Medical Research Institute (KEMRI), Center for Global Health Research (CGHR), Kisumu, Kenya. kel4@cdc.gov.|Centers for Disease Control and Prevention (CDC), Atlanta, USA. kel4@cdc.gov.
authors.forename: Kayla
authors.initials: K
authors.lastname: Laserson
authors.affiliation: Kenya Medical Research Institute (KEMRI), Center for Global Health Research (CGHR), Kisumu, Kenya. mud8@cdc.gov.|Centers for Disease Control and Prevention (CDC), Atlanta, USA. mud8@cdc.gov.
authors.forename: Meghna
authors.initials: M
authors.lastname: Desai
mesh_terms: D000293:Adolescent; D000328:Adult; D000554:Ambulatory Care Facilities; D001291:Attitude of Health Personnel; D005260:Female; D017144:Focus Groups; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D000068097:Maternal Health / Q000706:statistics & numerical data; D008875:Middle Aged; D008880:Midwifery / Q000379:methods; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology; D011295:Prenatal Care / Q000379:methods / Q000706:statistics & numerical data; D036301:Qualitative Research; D034121:Reproductive Health Services / Q000706:statistics & numerical data; D012959:Socioeconomic Factors