title: A community-based assessment of correlates of facility delivery among HIV-infected women in western Kenya.
abstract: BACKGROUND
  Childbirth at health facilities is an important strategy to reduce maternal morbidity and mortality, improve fetal outcomes, and reduce mother-to-child transmission of HIV. Although access to antenatal care in Kenya is high (>90%), less than half of births occur at health facilities. This analysis aims to assess correlates of facility delivery among recently pregnant HIV-infected women participating in a community-based survey, and to determine whether these correlates were unique when compared to HIV-uninfected women from the same region.
  
  
  METHODS
  Women residing in the Kenya Medical Research Institute/Centers for Disease Control and Prevention Health and Demographic Surveillance System, and who had delivered an infant in the previous year were visited at home in 2011. Consenting mothers answered a questionnaire assessing demographics, place of delivery, utilization of prevention of mother-to-child HIV transmission (PMTCT) services, and stigma indicators. Known HIV-positive women were purposively oversampled. Chi-square tests of proportions and multivariate logistic regression, stratified by HIV status, were performed to assess correlates of facility delivery.
  
  
  RESULTS
  Overall, 101 (46.8%) HIV-infected and 127 (39.9%) HIV-uninfected women delivered at health facilities. Among HIV-infected women, cost (42.8%), distance (18.8%) and fear of harsh treatment (15.2%) were primary disincentives for facility delivery; 2.9% noted fear of HIV testing was a disincentive. HIV-infected women who delivered at facilities had higher education (p = 0.04) and socioeconomic status (p < 0.005), initiated antenatal care (ANC) earlier (4.9 vs. 5.4 months, p = 0.016), were more likely to know partner's HIV status (p = 0.016), report satisfaction with delivery care (p = 0.001) and use antiretrovirals (87.1% vs. 77.4%, p = 0.063) compared to those with non-facility delivery. Stigma indicators were not associated with delivery location. Similar cofactors of facility delivery were noted among uninfected women.
  
  
  CONCLUSIONS
  Utilization of facility delivery remains low in Kenya and poses a challenge to elimination of infant HIV and reduction of peripartum mortality. Cost, distance, and harsh treatment were cited as barriers and these need to be addressed programmatically. HIV-infected women with lower socioeconomic status and those who present late to ANC should be prioritized for interventions to increase facility delivery. Partner involvement may increase use of maternity services and could be enhanced by couples counseling.
authors.affiliation: Department of Research and Programs/Department of Reproductive Health Kenyatta National Hospital, Nairobi, Kenya. kinuthia@u.washington.edu.
authors.forename: John
authors.initials: J
authors.lastname: Kinuthia
authors.affiliation: Global Health and Psychosocial and Community Health, University of Washington, Seattle, WA, USA. pkohler2@u.washington.edu.
authors.forename: Pamela
authors.initials: P
authors.lastname: Kohler
authors.affiliation: Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya. JOkanda@kemricdc.org.
authors.forename: John
authors.initials: J
authors.lastname: Okanda
authors.affiliation: Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya. golilo@kemricdc.org.
authors.forename: George
authors.initials: G
authors.lastname: Otieno
authors.affiliation: Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya. fodhiambo@kemricdc.org.
authors.forename: Frank
authors.initials: F
authors.lastname: Odhiambo
authors.affiliation: Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, WA, USA. gjohn@u.washington.edu.
authors.forename: Grace
authors.initials: G
authors.lastname: John-Stewart
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D016550:Birthing Centers / Q000706:statistics & numerical data*; D036861:Delivery, Obstetric / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000523:psychology / Q000628:therapy / Q000635:transmission; D006301:Health Services Needs and Demand; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D007630:Kenya / Q000453:epidemiology; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology / Q000523:psychology / Q000628:therapy; D011295:Prenatal Care / Q000379:methods; D057545:Social Stigma
chemical_list: D019380:Anti-HIV Agents