ASSESSING THE UPTAKE AND UTILIZATION OF FREE MATERNITY SERVICES

IN CLAY CITY WARD, KASARANI, NAIROBI COUNTY, KENYA.

BY

JOB WAFULA JUMA

Q126/4218/2018.

DEPARTMENT OF POPULATION, REPRODUCTIVE HEALTH AND COMMUNITY

RESOURCE MANAGEMENT.

A RESEARCH PROPOSAL SUBMITED IN PARTIAL FULFILMENT OF THE

REQUIREMENTS FOR THE AWARD OF BACHELOR OF SCIENCE POPULATION
HEALTH IN THE SCHOOL OF PUBLIC HEALTH AND APPLIED HUMAN
SCIENCES OF KENYATTA UNIVERSITY.

OCTOBER, 2022

DECLARATION
This research proposal is my original work and has not been presented for any academic
honor in any other university.

Signature…………………. Date …………………

JOB WAFULA JUMA.

Reg NO. Q126/4218/2018.

This research proposal has been submitted for examination with my approval as the
university supervisor.

Signature ……………………. Date………………...

Dr ISAAC OGWENO OWAKA.
Dept. of population, reproductive and community resource management.

TABLE OF CONTENTS

DECLARATION 1
ABBREVIATIONS 4
ABSTRACT 6
CHAPTER ONE: INTRODUCTION 7
BACKGROUND 7
STATEMENT OF THE PROBLEM. 8
JUSTIFICATION OF THE STUDY 9
RESEARCH OBJECTIVES 9
General objectives 9
Specific objectives 9
RESEARCH QUESTIONS 9
CONCEPTUAL FRAMEWORK 11
CHAPTER TWO: LITRATURE REVIEW 13
INTRODUCTION 13
CHAPTER THREE: MATERIALS AND METHODS. 14
METHODOLOGY 14
STUDY VARIABLES 14
Independent variable 14
Dependent variable 15
LOCATION OF THE STUDY 15
STUDY POPULATION 15
SAMPLING TECHNIQUE 15
Sample size 15
DATA COLLECTION TOOLS 15
Data collection techniques 15
DATA ANALYSIS 15
DATA RELIABILITY AND VALIDITY 16
ETHICAL CONSIDERATIONS 16
REFRENCES 16
APPENDICES 17
APPENDIX 1: QUESTIONNAIRE 17
APPENDIX 2: WORK PLAN. 20
APPENDIX 3: BUDGET. 21
APPENDIX 4: MAP 23

ABBREVIATIONS
SPSS- Statistical package for social sciences.
FMS- Free Maternity Services.
TBAs- Traditional birth assistants.
KDHS-Kenya demographic health survey.
MDG- Millennium developmental goals
SDG- Sustainable developmental goals.
GOK- Government of Kenya.
ANC- Ante-natal clinic.

ABSTRACT
Delivery with skilled birth attendance and access to the basic and emergency obstetric care is the
most crucial intervention for reducing maternal and new borne deaths.
Globally, the rate of maternal mortality is unacceptably high with Kenya recording a rate of 362
maternal deaths per 100, 000 live births (KDHS,2014). A significant proportion of women in
Kenya especially those in rural settings deliver at home alone or with the help of TBAs. Health
care charges are a significant barrier to access to skilled maternal health services. In June 2013
free maternal services were introduced in Kenya to encourage women to deliver in a public
facility.
Even with the introduction of this program only 62% of women deliver under skilled health care.
(KDHS,2014) which is relatively average. Initially the maternal mortality rate stood at 488
deaths per 100,000 live births as per (KDHS,2008). This shows there is some improvement in the
quest for the reduction and elimination of maternal mortality and neonatal mortality.
The cumulative loss of lives when giving birth affects the entire economy of the country in the
long term. In order to design effective policies to realize the Kenyan vision 2030 of a healthy
population with low maternal mortality. There is need to understand the factors associated with
utilization of free maternal health services in Kenya.
This study will aim to identify hindrances and enablers of (FMS) program in clay city.
The project will employ a cross sectional study design. The target population will be postnatal
women of child bearing age who had given birth between periods of august 2020 to august 2021.
Census will be used to sample the study respondents from three selected estates in clay city
ward. 421 women will be selected for the study. Primary data will be collected using self-
administered semi-structured questionnaires for quantitative data.
Descriptive data will be analyzed using statistical package for social sciences version 20.0 with
the aid of Microsoft excel program to generate frequency tables, graphs and pie charts.
qualitative data will be triangulated with quantitative data as direct quotes or narrations as
presented by key informants. To establish the association between study variables, the study will
employ Chi-square test done at 95% confidence interval with a margin of error 0.05 when p-
values of less than 0.05 will be considered significant.

CHAPTER ONE: INTRODUCTION

Background
Delivery with skilled birth attendance and access to basic and emergency obstetric care is the
most crucial intervention for reducing maternal and new born deaths.
Globally, the rate of maternal mortality is unacceptably high with Kenya recording a rate of 362
maternal deaths per 100 000 live births.
A significant proportion of women in Kenya especially those in rural settings deliver at home
alone or with the help of TBAs.
Health care charges are a significant barrier to access to skilled maternal health services. In June
2013 Free maternity services was introduced in Kenya to encourage women to deliver in public
health facilities.
Even with the introduction of this program only 62% of women deliver under skilled health care
services. (KDHS,2014).
Initially the maternal mortality rate stood at 488 deaths per 100 000 pregnant mothers as per the
(KDHS,2008). This shows there is some improvement in the quest for the reduction and
elimination of maternal mortality and neonatal mortality.
The cumulative loss of pregnant mothers when giving birth affects the entire economy of the
country in the long term. In order to design effective policies and realize the Kenyan vision 2030
of healthy population with low maternal mortality. There is need to understand factors associated
with the utilization of free maternal health care services in Kenya.

Statement of the problem.

maternal mortality continues to be a major health problem globally particularly in developing
countries like Kenya. Kenya did not achieve the millennium developmental goal number 4 and 5
targets to reduce the child mortality and improve maternal health by ensuring skilled birth
attendance as depicted by KDHS 2014 report.
women are having public health facility delivery but more are still delivering elsewhere or at
home or assisted by traditional birth attendants. There is poor utilization of public health services
during delivery in Nairobi County and in particularly clay city ward in Kasarani constituency. As
evidenced by the KDHS 2014 which showed facility delivery to be at 71.0%
among home deliveries 0.6% was by the help of TBAs. This study therefore seeks to assess the
uptake of the services.
Justification of the study
Without proper knowledge and understanding of the factors that impact the uptake and the
utilization of FMS. maternal mortality and child mortality rates will continue to increase.
Although this area has received significant interest in the recent past, there still exists gaps in
available literature describing the factors that hinder uptake and utilization of FMS. Especially
those women in urban and slum areas.
according to the study by UNFPA in 2014 on the burden of maternal mortality in Kenya, Nairobi
was ranked third out of 15 counties with the highest burden of maternal mortality. The maternal
mortality was 366 per 100,000 which is slightly higher than the national average of 364 per 100,
000 live births. Therefore, maternal health and child survival are identified as areas of concern.

Research objectives
General objectives
The purpose of this study is to assess the uptake and utilization of FMS in clay city ward,
Kasarani constituency in Nairobi Kenya.

Specific objectives
To determine: -
● the number of women with at least one ANC visit
● the number of births attended by skilled birth attendant
● number of pregnant women identified with obstrict complications and attended to or
reffered
● caecorean sessions of all births
● number of live births

Research questions
● What is the number of women with at least one ANC visit?
● What is the number of births attended by skilled birth attendant?
 ● What is number of pregnant women identified with obstrict complications and attended to
or reffered?
● What is caecorean sessions of all births?
● What is number of live births?

conceptual framework
Independent variables Dependent variable.
Social demographic x-tics i.e.
● age
parity
● religion
● marital status
● level of education
● main occupation
 Awareness of FMS

Utilization of FMS.
● High
● Low.

Nearest facility that offers FMS.

Mothers’ delivery experience

at the facility: -
● attitude
● time
● satisfaction
● Abuse

Multi-variated models for

predicting utilization of FMS.
● Adequate food
provided
● Adequate health
workers in the
 maternity
● Provision of a basin.

CHAPTER TWO: LITRATURE REVIEW

Introduction
The health status of mothers and children is an important indicator of the overall economic
health and well-being of country. In an effort to reduce maternal mortality the government and
international agencies are promoting maternal health care services hence mothers are able to
benefit as they freely access reproductive health education, vaccinations, pregnancy supplements
and lab services at no cost from public hospitals.
The international safe motherhood initiative was introduced in 187 in an attempt to reduce
maternal morbidity and mortality by half by the year 2000. This encompasses the need to
improve women’s status, educate communities and strengthen and expand core elements of
maternal health including antenatal, delivery and postpartum care at both community and referral
levels. A variety of programs were developed whose aim was to improve pregnant women’s
health status, improve access to health services during pregnancy and improving the quality of
care available to those who Experience complications during pregnancy and delivery.
provision of high-quality maternity care can make the difference between life and death by;
ensuring clean and safe delivery hence preventing obstetric complications from occurring,
providing treatment of pre-existing or emergent medical conditions and offering effective
management of complications once they arise. A continuum of care during pregnancy, labor and
delivery and the post-natal period results in reduced maternal and neonatal morbidity and
mortality.
according to the MDG 2013 progress report on Kenya, it was noted that challenges to improving
maternal care including inadequate skilled health personnel, most health officers lacked skills
along the continuum of care including family planning, midwifery, emergency obstetric and new
born care. There were also regional disparities among them in availability of health officers, poor
involvement of communities and households in maternal health due to social-cultural barriers,
lack of awareness on the benefits of skilled health care and reluctance to adopt good practices
(including preference of home delivery) as well as limited men involvement in maternal health
care practices. it is also noted that access to health facilities is constrained in many places due to
poor infrastructure and inadequate referral systems as many of the lower facilities do not offer
emergency obstetric care, post abortion and essential new born care.
The sustainable development goals were born in 2012 to replace the MDGs. Among the targets
was by 2030 to reduce the global maternal mortality ratio to less than 70 per 100,000 live births.

CHAPTER THREE: MATERIALS AND METHODS.

Methodology
This study will be a descriptive cross sectional study design. This design is deemed appropriate
because it enables precise profile of situations, events and persons hence considered the best
approach to address the study objectives (Aaker,2011).
The research design facilitates collection of data at a particular time with the aim of describing
the prevailing nature of conditions and securing evidence on the underlying phenomenon hence
the most appropriate for the study.

study variables
Independent variable
The independent variables of this study will include: - social demographic characteristics such as
age, religion, monthly occupation and parity, Awareness of FMS, proximity of the facility on
utilization of FMS, Mothers delivery experience i.e., attitude, time, satisfaction, abuse (verbal
and physical), multi-variated models of predicting utilization of FMS i.e., inadequate food
provided, Adequate health workers and being provided with a basin.
Dependent variable
The dependent variable will be the uptake and utilization of FMS.
Location of the study
The study location will be clay city ward which is located in Kasarani constituency in Nairobi
County. This study location is selected owing to the fact that it’s in the county that is among the
leading counties in Kenya having high maternal and neonatal mortality hence the most
appropriate to understand the factors that contribute to the rise of the maternal mortality rate and
neonatal mortality despite the introduction of FMS by the Kenyan Government.
Study population
The population of study will be postnatal women of child bearing age who had given birth
between periods of August 2020 to august 2021.
Sampling technique
Clay city ward will be purposively selected due to the fact that it is an area in Nairobi County
which has a high maternal mortality rate. Census sampling technique will be used to select all
Women of postnatal state who had given birth between August 2020 to August 2021 from three
selected estates in clay city ward.
Sample size
A total of 421 post-natal women of child bearing age will be purposively selected for the study.
Data collection tools
Primary data will be collected using self-administered semi-structured questionnaires for
quantitative data and key informant’s interviews for qualitative data.
Data collection techniques
The questionnaires will be client administered with the aid of a research assistant which will
enable the researcher to explain the purpose of the study and offer guidance to the respondents
on filling the questionnaires. The process will continue until the required number of
questionnaires are collected.
So as to ensure efficient and smooth data collection, the research assistants will undergo training
so as to be well equipped with adequate knowledge on how to approach and handle the
respondents and ensure comprehensive data collection.
Data analysis
Data will be analyzed using SPSS version 20.0 with the aid of Microsoft excel program to
generate frequency tables, graphs and pie charts. Qualitative data will be triangulated with
Qualitative data such as direct quotes or narrations as presented by key informants.
To establish the association between study variables, the study will employ Chi-square test done
at 95% confidence interval with a margin of 0.05 where p-values of less than 0.05 will be
considered significant.
Data reliability and validity
The questionnaires will be pretested and a group of 10 participants will be selected in the study
area. This will enable the researcher to test sustainability and conduct necessary collection of
data.
Ethical considerations
Consent will be sought from every study participant before the commencement of data
collection. Confidentiality will be maintained in handling the participants data.

REFRENCES
Kilowua, Lydia Munteyian, and Kennedy Ochieng Otieno. "Health System Factors Affecting
Uptake of Antenatal Care by Women of Reproductive Age in Kisumu County, Kenya."
International Journal of Public Health and Epidemiology Research 5.2 (2019): 119-124.
Masaba, B. B., & Mmusi-Phetoe, R. M. (2020). Free maternal health care policy in Kenya;
level of utilization and barriers. International Journal of Africa Nursing Sciences, 13,
100234.
Masaba, Brian Barasa, and Rose M. Mmusi-Phetoe. "Free maternal health care policy in
Kenya; level of utilization and barriers." International Journal of Africa Nursing
Sciences 13 (2020): 100234.
 Owiti A, Oyugi J, Essink D. Utilization of Kenya’s free maternal health services among women
living in Kibera slums: a cross-sectional study. Pan African medical journal. 2018 May
30;30(1).
Owiti, Angela, Julius Oyugi, and Dirk Essink. "Utilization of Kenya’s free maternal health
services among women living in Kibera slums: a cross-sectional study." Pan African
medical journal 30.1 (2018).

APPENDICES
Appendix 1: Questionnaire
PART 1: PERSONAL INFORMATION
1.Date
2.Age
3.Education level
◻ Non formal education
◻ Primary education
◻ Secondary education
◻ Tertiary education
4.Marital status
◻ Married(monogamy)
◻ Single
◻ Married(polygamy)
◻ Divorced/separated
5.Employment status
◻ Self employed
◻ Salaried
 ◻ Housewife
◻ Student
6.Monthly income
◻ Less than 5000
◻ Between5001-10000
◻ Between 10001-15000
◻ Over 15000
7.Distance to the health facility
◻ Less than 1km
◻ 1-2km
◻ 2-4km
◻ >4km
PART 2: SEXUAL AND REPRODUCTIVE CHARACTERISTICS
1.Age at last delivery
2.Have a stable partner
◻ yes
◻ No
3. Number of pregnancies(parity)
4.Number of live births
5.History of unwanted pregnancy
◻ Yes
◻ No
6.history of complications during pregnancy
◻ No
◻ Yes (specify)

PART 3: LAST ANTENATAL AND DELIVERY HISTORY

1.Did you attend ANC clinics during your last pregnancy?
◻ Yes
◻ No
2.If yes which facility. If No skip to question 9
◻ Public
 ◻ Private
◻ TBA
◻ Others (specify)
3. When did you start attending ANC clinic
◻ First trimester
◻ Second trimester
◻ Third trimester
4.Number of times
◻ Once
◻ 2-3 times
◻ 5-6 times
◻ >6 times
5.Were ANC profiles done?
◻ Yes
◻ No
6.If yes which ones (check in ANC booklet and indicate parameters)
◻ Hemoglobin level
◻ Blood group
◻ VDRL
◻ Serology
◻ Urinalysis
7.Who advised you to attend ANC clinic?
◻ Spouse
◻ Relative
◻ Friend
◻ Other
8. If No (Q1) why did you not attend ANC clinic?
◻ Financial constrains
◻ Lack of means of transport
◻ Had other sources of care during pregnancy
◻ Did not see the need
◻ Other (specify)
9. other sources of care during pregnancy
◻ TBA
◻ Religious leaders
◻ Herbalists
 ◻ Traditional healers
◻ Others(specify)
10.Do you know what free maternity services entails?
◻ Yes (specify)
◻ No

Appendix 2: Work plan.

Activity March April May June July August Sept October November December
2022 2022 2022 2022 2022 2022 2022 2022 2022 2022

Selection
Of research
Topic.
Concept
Paper
Writing

Research
Proposal
Writing

Proposal
submission

Collection
 of letter of
introductio
n
And begin
data
collection
and entry.
Writing and
submission
of a
research
project
report.

Appendix 3: Budget.

S/N Item Quantity Price Total

1 Transport 2000 2000

2 Printing 4500 4500

3 Binding 2250 2250

4 Research 1 1000 1000

assistants
5 Accommodation 8000 8000

6 Internet & 1000 1000

airtime

Total 18750
cost

Appendix 4: Map