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Abstract
Increasing high temperatures, severe drought, altered rainfall patterns, and floods weaken essential infrastructure and services, increase risk of diseases, and disrupt women’s access to antenatal care. In Kenya, 2024 was the hottest on record with above normal rainfall, resulting in prolonged flooding. This paper describes the influence of adverse weather patterns on access to antenatal care in Kisumu and Migori Counties, adjacent to Lake Victoria. Qualitative data were primarily collected through focus group discussions (n = 16) with women aged 15–24 years (n = 62 participants) or 25–49 years (n = 87 participants), who had given birth in the last two years. Most participants recognize prolonged shifts in weather patterns, including unpredictability of rainfall, heavy rainfall and floods, prolonged dry spells, and rising temperatures which are increasingly affecting their daily lives. This includes damaged crops, loss of livelihood, financial challenges with food prices escalating, lack of safe drinking water, homes destroyed and loss of effects (due to flooding). Others reported how roads and bridges get washed away preventing women from accessing health care services resulting in poor uptake of antenatal care services. Climate change presents a complex and significant threat for vulnerable groups such as pregnant women. Mitigation strategies must focus on integrating women’s voices in climate-health policies to ensure continued access to healthcare, and reduce adverse health outcomes associated with climate change.
Citation: Matanda DJ, Warren CE, Okoth O, Otieno B, Nakuya Z (2026) ‘Water is a good thing, but when it destroys it is not good’: The influence of changing weather patterns on access to antenatal care services in Western Kenya - A qualitative study. PLOS Clim 5(3): e0000882. https://doi.org/10.1371/journal.pclm.0000882
Editor: Stefan Wheat, University of Washington, UNITED STATES OF AMERICA
Received: December 28, 2025; Accepted: March 10, 2026; Published: March 27, 2026
Copyright: © 2026 Matanda et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The raw data supporting the conclusions of this article is available by the authors, without undue reservation. It can be freely accessed at Havard Dataverse platform using this link: https://doi.org/10.7910/DVN/3NQWRO.
Funding: The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This study was produced by the Revive IPTp project which is part of the European and Developing Countries Clinical Trials Partnership (EDCTP-2) programme supported by the European Union (grant number CSA2018HS-2521). The views and opinions of authors expressed herein do not necessarily state or reflect those of EDCTP. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Changing weather patterns have increased over the last three decades threatening to reverse progress made in global public health and sustainable development [1]. In Kenya increasing high temperatures, severe drought, altered rainfall patterns, and floods weaken essential infrastructure and services, and create challenges for women’s access to health services as well as food and water security [2,3]. The year 2024 was the hottest on record in Kenya with above normal rainfall. Forty-one (out of 47) counties were affected by heavy rainfall resulting in prolonged flooding during the long rains of March - May 2024 including parts of the Lake Victoria basin that remained inundated at higher levels than in 2020 [4].
Changing environmental conditions have increased the geographical range and areas conducive for the transmission of vector borne diseases such as malaria (Plasmodium falciparum) [1]. Areas adjacent to Lake Victoria in Kenya have reported highest malaria prevalence at 19% [5]. Malaria in pregnancy (MiP) is associated with maternal anaemia, stillbirth, preterm delivery, and low birth weight, contributing substantially to neonatal mortality. Sulfadoxine-Pyrimethine (SP) for intermittent preventive treatment of malaria during pregnancy (IPTp) is a proven medical intervention for the prevention of MiP within the broader antenatal care (ANC) [6]. Despite Kenya’s adoption of this intervention in national malaria and maternal health policies and guidelines, stating that “All pregnant women living in moderate to high malaria transmission receive IPTp as part of ANC services” [7], uptake of the recommended 3 or more doses of SP- IPTp remains low. Only a quarter of pregnant women received 3 or more doses of IPTp in Kisumu and Migori counties [8].
Previous research has documented how extreme weather events such as floods, droughts, and heat stress pose growing risks to maternal health, particularly through their effects on social determinants and health-service access [2,9,10]. The 2024–2029 Kenya Climate Change and Health Strategy highlights that pregnant women and newborns are among the most vulnerable populations when it comes to the effect of climate change, especially extreme heat exposure and its association with adverse outcomes such as preterm birth, low birth weight, gestational hypertension, and stillbirth [11,12]. Extreme weather events increasingly disrupt women’s access to health facilities including ANC attendance. A household survey conducted in western Kenya in late 2024 found a significant proportion of mothers (70%) who reported that their households had been negatively affected by adverse climate events in the preceding 12 months, which prevented them from reaching a health facility for maternal health services [13].
Important gaps remain especially on the lived experiences of pregnant women and their access to health services during extreme weather events. There is a need for in-depth qualitative work to unpack how extreme weather affects decisions around access to ANC. This study addresses these gaps and provides locally grounded evidence to inform climate-resilient maternal health planning and targeted interventions, including malaria prevention, in Western Kenya.
Methods
Ethics statement
The study was reviewed and approved by the Population Council Institutional Review Board. (Protocol 962) and AMREF Ethics and Scientific Review Committee (AMREF-ESRC P886/2020). The study was granted administrative permission by the Kenya National Commission for Science, Technology and Innovation (NACOSTI/P/24/41134). All research materials were securely stored during data collection and reporting, and recorded audio files were deleted after transcription.
Design and participants
This was a qualitative study designed as part of a larger implementation research to develop and test community-based approaches to address low uptake of IPTp in Western Kenya [14,15]. This paper describes the influence of weather patterns on access to maternal health services from the perspective of women, health workers and health related stakeholders (community and county).
Study site
This study took place in two counties (Migori and Kisumu) in Western Kenya. Migori County is primarily rural, whereas Kisumu County includes Kisumu - Kenya's third-largest city as well as semi-urban and rural areas. These counties are in the Lake Victoria basin and part of the lake endemic malaria region, which has the highest burden of malaria in Kenya. Malaria risk in Kenya is heterogeneous, and is influenced by altitude, rainfall patterns, and temperature. Kisumu and Migori counties are susceptible to seasonal flooding, and other climate-related hazards during periods of heavy rainfall and drought.
Globally an estimated 14% maternal deaths (most in Sub Saharan Africa) are attributed to malaria in pregnancy. Malaria infection during pregnancy has a devastating impact on the health outcomes of mothers and infants including spontaneous abortion, severe maternal anaemia, low infant birth weight, preterm delivery and stillbirth [16]. The Ministry of Health/WHO recommends that all pregnant women living in malaria endemic areas, use three+ doses of Sulfadoxine-Primethamine for intermittent preventive treatment (IPTp-SP), appropriate case management, and distribution of insecticide treated nets as part of routine ANC. In Kisumu and Migori counties less than two thirds of pregnant women had 4 or more of the WHO recommended ANC contacts (63% and 59% respectively) with skilled health providers and only 25% of pregnant women received 3 or more doses of IPTp [8]. While the majority of pregnant women give birth with a skilled health worker in Kisumu county (97.9%) and Migori county (92.6%), the overall neonatal mortality rate remains high at 21/1000 live births [8].
Data sources
Data collection for this study took place between 15 November 2024 and 18 December 2024. Data for this study came from focus group discussions (FGDs) with women who had given birth in the preceding two years. Participants in FGDs were purposively identified in the community with the help of community health promoters (CHPs) who are part of the community health team, and sub-county malaria coordinators, with approximately 8–12 participants per group. CHPs familiarity with their communities enables them to support pregnant women including educating them on the importance of ANC. Women living in the study catchment areas who had given birth to a live baby within the two years preceding the study were invited to take part in FGDs. Seven FGDs were conducted with women aged 15–24 years (total of 62 participants), and nine FGDs were conducted with women aged 25–49 years (total of 87 participants). Each FGD was facilitated by two trained research assistants, conducted in Kiswahili or Dholuo, and held in private locations that were convenient for participants. The exact location of the interviews varied but mostly included private rooms in nearby churches, schools and health centres. Questions ranged on their experience of accessing ANC including for uptake of IPTp3 during pregnancy and specifically for this paper on how extreme weather events including flooding, heavy rainfall, drought and extreme heat affected their lives.
Data processing and analysis
Research assistants had sociology or anthropology backgrounds with experience in conducting qualitative interviews. All participants invited to take part in an interview or group discussion were informed about the purpose of the study and procedures. Their contributions were anonymized to protect confidentiality. During data collection, written informed consent was obtained from all participants before conducting interviews. Those who could not write were asked to nominate someone to sign on their behalf. For minors aged below 18 years, parent/guardian consent was obtained followed by individual assent. All sessions were audio recorded with consent of the participants, transcribed verbatim (from Kiswahili or Dholuo) and the transcripts translated into English, formatted in Microsoft Word, and analysed using NVivo version 12. A thematic approach guided the analysis, with initial codes derived from study objectives and data collection tools. Inductive analysis identified emerging themes and patterns across participant groups. Transcripts were independently coded by the data analysts. The coded outputs were then compared for areas of convergence and divergence using an intercoder reliability test. The data analysts achieved over 90% agreement on the coding, indicating a high level of coding reliability.
Reflexivity statement
The research team comprised Kenyan and international researchers with expertise in maternal health, malaria prevention, and qualitative research. Several team members are based in Kenya and have longstanding professional engagement with maternal and reproductive health programs in western Kenya, including Kisumu and Migori counties. Their familiarity with the local health system and community contexts facilitated culturally appropriate study design, data collection, and interpretation. At the same time, the researchers acknowledge that their professional backgrounds in public health and program implementation may shape how climate-related challenges to antenatal care are interpreted. To mitigate potential bias, the study incorporated multiple participant’s perspectives and used team-based coding and intercoder reliability checks during thematic analysis to ensure diverse perspectives informed the findings.
Results
Findings are presented thematically, incorporating illustrative quotes and examining thematic similarities, differences, and relationships around extreme weather events previously identified in the literature. Table 1 summarizes first order themes experienced by women related to heavy rainfall and floods, and extreme heat and drought. Overall perceptions around climate change in general are described first, followed by details of participant experience of extreme weather events that impact on daily life and access to services. Second order themes include how climate change can exacerbate financial hardship, influence access to and uptake of ANC, increase waterborne diseases and result in poorer health and nutrition outcomes for pregnant women.
Women’s overall perceptions of climate change and the impact on daily life
Shifting weather patterns affect daily lives and health. Most participants recognize climate change as a shared challenge and includes prolonged shifts in weather patterns, including extended and unpredictability of rainfall, heavy rainfall and floods, prolonged dry spells or droughts, and rising temperatures which are increasingly affecting their region in southwestern Kenya.
“There have been lots of changes. I came to Kisumu in 2020 and ever since rainfall patterns have become unpredictable.” FGD_Kisumu_25–49 yrs
“The changes that I have seen is that there is a lot of rain, but earlier on there was scorching sun and people thought they would die.” FGD_Migori_15–24 yrs
Women who participated in FGDs in both Kisumu and Migori counties reported that changes in weather patterns have disrupted agricultural cycles and daily life. Some farmers have had to shift to drought-resistant crops like cassava, while others struggle with food shortages due to destroyed crops and failed harvests.
“Most people start planting maize in late August, when it gets to September, the crops are just sprouting from the ground… But the crops have not done well because the rains were short, and the sun shined a lot, and this wasn’t the sunny season; it was supposed to be a rainy season.” FGD_Migori_15–24 yrs
“Yes, it happens, when rains start late, that has made people to change from planting maize to planting cassava, coupled with extreme heat at night.” FGD_Migori_25–49 yrs
Women also reported that the unpredictable weather has disrupted access to water and was a major concern, with some women explaining that they must travel further to fetch water, adding to their daily burden.
“Water is a good thing, but when it destroys it is not good. During drought there is no water even to drink, but during the rainy season it messes up.” FGD_Migori_25–49 yrs
Heavy rainfall and floods
Financial hardship.
Several people described how heavy rainfall and floods exacerbates financial hardship.
Heavy rains have really affected everyone in the community. If it rains continuously nobody will operate their usual businesses, therefore there will be no money to cater for the family needs.” FGD_Kisumu_15–24 yrs
Often extreme rainfall results in people losing their homes and effects due to floods and in Kisumu County they are forced to move to camps.
“Last year, in April when there were floods, my house got swept away and I lived outside as I built another one. Even now, the rainfall we are experiencing now has destroyed my house again.” FGD_Migori_15–24 yrs
Transport challenges during heavy rains and floods.
In addition to affecting crops, and safe water, heavy rains and flooding have destroyed roads.
“The change in climate … has damaged a lot of roads, and the roads have become difficult to pass through.” FGD_Migori_15-24 yrs
“When it is raining heavily, it becomes difficult to come to the clinic because some of the roads are impassable.” FGD_Kisumu_25–49 yrs
Women from Migori (the more rural county) described that the extended rainfall and flooding also destroyed roads making them impassable, restricting movement to markets, schools, and health facilities. The local motorbike taxis also refuse to carry pregnant women.
“Due to poor roads, the riders of motorbikes refuse to carry pregnant women for the fear of causing accidents.” FGD_Migori_25–49 yrs
Reduced access to health services.
Access to healthcare is severely affected during extreme weather events. All participants shared stories of families struggling to reach health facilities due to flooded roads and increased transport costs.
Some facilities only provide ANC clinics during specific times reducing the opportunities for women seeking services.
“Sometimes it rains from morning till afternoon, and at that time you cannot go to the clinic because clinic services are usually done in the morning hours.” FGD_Migori_25–49 yrs
Additionally, health workers described how many women just could not reach the facilities for ANC. Many women reported floods destroyed their homes with loss of personal belongings including losing their ANC and child health booklets. They missed ANC because the heavy rain made travel unsafe.
“Sometimes heavy downpour accompanied with extreme cold may prevent one from accessing health services.” FGD_Migori_15–24 yrs
“Climate in change has led to the damage of our roads, and that may hinder pregnant women from going to the facility in their locality if they want to because floods spoilt roads.” FGD_Migori_15–24 yrs
Some women recounted experiences of challenges reaching hospital to give birth. One woman from Migori recalled when she was in labour and trying to reach the hospital at night. She tried to cross the river at 3 different inundated bridges before managing to do so.
It affected me when I was going to deliver. It was raining and there is this bridge…let me start with the bridge at xxx; it was eight at night, the xxx bridge was full and the water had over flown, we turned back and went to try the bridge at xxx. When we got to the xxx bridge, it was over flown too, we turned and went to xxx bridge…and remember, all this time I am having labour pains, I almost gave birth in the water…” FGD_Migori_15–24 yrs
Impact on waterborne diseases and other communicable diseases.
Health care workers are aware of the risk of increase in communicable diseases including an upsurge of malaria in flood prone areas. Some of the health workers recognized the need to intensify administration of preventive strategies including providing ITNs and IPTp to women who have had to leave their homes due to floods and stay in the displaced people camps.
Following major rains, and floods, people seek shelter in nearby hospitals that may become flooded later. This reduces the availability of services. Floods prevent delivery of essential medicines and other supplies, and staff who live off site cannot reach the facilities, forcing women to seek costly alternatives.
Many participants noted an increase in disease burden during the prolonged rainy seasons. Contaminated water sources include stagnant floodwater and create breeding grounds for mosquitoes, increasing malaria and other waterborne diseases such as cholera and typhoid.
“We are also getting sick because of mosquitoes as well as diarrhoea and typhoid because of dirty water.” FGD_Kisumu_25–49 yrs.
Pneumonia and other upper respiratory tract infections also rise during the cooler extended rainy seasons. One community health officer from Kisumu described how three quarters of his community had to move away due to the floods and was expecting an upsurge in health conditions. However, it appears that mosquito nets and other basic facilities (hand washing and drinking water) are provided in the camps.
Extreme heat and drought
Heat/drought increases financial hardship, reduced source of clean water and increased likelihood of poor pregnancy outcomes.
Financial hardship.
In addition to financial hardship faced by pregnant women from excess rain, extreme temperatures and drought may also present significant challenges limiting the ability to work outside as well as increase in the cost of living due to food shortages.
“I have witnessed changes; especially the hot weather. Life has become difficult… and some of us have slept hungry for lack of food. At times we just eat porridge because we have maize flour, and we don’t have vegetables.” FGD_Kisumu_25–49 yrs
Reduced access to clean water.
During heat waves and drought, women often have to walk farther to find clean water, and frequently the water has been contaminated by animals.
“I have seen it personally, because earlier on, when there was drought, you could even fail to obtain drinking water. When there is drought, people have problems fetching water, so they mix with animals while using the same water. So, that brings a lot of diseases, and when one person is infected, the rest of the family members can easily get infected. FDG_Migori_25–49 yrs
Poor health and nutrition outcomes.
Food insecurity rises due to unreliable seasons. Destruction of crops, or poor yields increase food prices and can affect pregnant women’s nutrition with detrimental effects on her baby.
Many women reported struggling to reach the health facility due to the heat.
“During the dry season many women find it very hot and difficult for the pregnant women to walk to their clinics.” FGD_Migori_25–49 yrs
“There was too much heat, and I was unable to go to the clinic because I could not walk in that sun.” FDG_Kisumu_15–24 yrs
Women also reported feeling unwell during heat waves.
During drought, the temperatures were so high, and this brought about headaches and nose bleeding, which affected our bodies. FDG_Kisumu_25–49 yrs
Changes in seasons have impacted on agriculture leading to poor harvests and undernutrition. In 2024, a drought was experienced in the study area leading to crop failure and lack of food.
“The sun started shinning-from June until November such that most people didn’t harvest anything…Crops were ruined because they farmed during the season as usual knowing that it would rain from September, but unfortunately the sun shinned like that and even when the maize needed the rain, they didn’t get until now is when it has started raining again. So, you find that right now, we are going to lack food.” FGD_Migori_15–24 yrs
Discussion
This paper explores qualitatively how extreme weather events affect access to ANC services including malaria prevention in Kisumu and Migori Counties in western Kenya. The study aimed to unpack climate change factors influencing women’s access to ANC services as a nested study within larger implementation research on expanding access to prevention of malaria in pregnancy. Around a third of Kenya’s population live in malaria endemic zones, and malaria continues to be a significant health challenge accounting for 15 percent of outpatient contacts [5,8]. The impact of climate change is substantial to maternal health with evidenced from a systematic review showing that even slight temperature increases can significantly impact malaria transmission by accelerating mosquito vector and parasite development [17]. Such changes, especially in areas with non-immune populations have major implications for maternal health as pregnant women are at high risk of complicated malaria [18].
Women from both Kisumu and Migori Counties described how changes in predictability of weather patterns had impacted on their daily life and access to health care services. These experiences range from poor harvests, poor nutritional status, rising food and other costs. Floods force internal displacement, following loss of their homes and personal effects, and an increase in communicable/waterborne diseases including malaria. Moreover, many women recalled challenges in reaching ANC and other services either due to being confronted with impassable roads destroyed by floods or traveling in extreme heat. Climate change exacerbates existing threats that many pregnant women in low and middle income countries (LMICs) already face, including unmet nutritional needs, infections, heavy physical labour, and underlying chronic conditions such as hypertension and diabetes, which in turn may complicate pregnancy outcomes [19].
Many women in SSA have limited protection against extreme heart events during pregnancy and face heightened risks due to specialized health needs and pregnancy-related morbidities because of climate change. Many pregnant women continue to do physical work late in pregnancy including fetching water and firewood [20]. In low-resource settings, many women struggle to maintain a healthy diet during pregnancy, particularly during the hunger season, traditionally between May and September in Kenya. Food insecurity and undernutrition during pregnancy is associated with maternal micronutrient deficiencies and malnutrition [21]. Poor nutrition can lead to poor foetal development and risk of miscarriage. As food security continues to diminish because of climate change, the situation is expected to get worse [20,22]. Elsewhere in East Africa, food insecurity was reported due to weather changes and unpredictable seasons affecting crop yields. Evidence from qualitative research in Kenya showed that droughts and floods exacerbate food insecurity, compromise household income, and disrupt access to health services, leading to coping strategies that further endanger reproductive and maternal health [23]. Overall resilience to climate change is low in many parts of SSA [20].
Disruptions caused by climate change threaten access to and quality of health care services. The frequency intensity and duration of extreme heat events, extreme rainfall, flooding and prolonged drought are projected to increase in many regions of the world and are major factors adversely affecting maternal and newborn health outcomes [24,25]. In sub–Saharan Africa, maternal mortality remains high, with risks like hypertensive disorders (pre-eclampsia and gestational hypertension), gestational diabetes, premature birth, amid rising temperatures [26–28]. Higher temperatures also increase the risk of dehydration, and fainting. High ambient temperatures increase rates of infections and affect healthcare seeking as well as health worker performance [28].
Additionally, essential infrastructure, such as health facilities, is often destroyed during floods, leaving pregnant women without access to adequate healthcare. For instance, in 2024 during the long rains between March and May 2024, 41 counties in Kenya experienced significant rainfall, which caused widespread loss of lives, population displacement (approximately 300,000) and property disruption including at least 64 health facilities. Elsewhere, in 2023, more than 300 health centres were destroyed by Cyclone Freddy in Malawi, Madagascar, and Mozambique [29,30]. Few countries have policies on climate and health and if they do, there is very limited information on maternal health. Implementation of maternal health policies (including those related to malaria and other communicable diseases) are weak and few consider strengthening of health systems including mitigation plans to adapt to extreme weather events. There is a need to improve geographic and financial access to maternal health care as well as service quality for strengthened health system resilience [19]. Equally important is the need to institutionalise availability of information about climate change and its effects on women’s health. Potential sources of information may include local media (radio and community broadcasts), public health messaging, engagement with community health workers, and information shared through local administrative or civil society forums.
Limitations
Although this qualitative study provides deep insight from women’s perceptions of climate change and the impact on their daily life including access to ANC services, several limitations warrant consideration. First, the study’s geographic scope was confined to two sub-counties in Kisumu and Migori Counties. While these areas are vulnerable to increasing number of adverse weather events, findings may not capture heterogeneity across other Kenyan regions. Second, the FGD setting may have influenced women’s readiness to share differing ideas. However, this is among the first studies to understand the lived experience of women who are affected by climate shocks on their access to ANC care including prevention of malaria using IPTp₃ + uptake in a high-transmission African setting.
Conclusion
Climate change and maternal health are inextricably linked. Kenya is highly susceptible to extreme weather events, due to its varied topography, diverse climatic zones and reliance on natural resources. Vulnerable groups such as pregnant women, are disproportionately affected, experiencing elevated risks to their own health and that of their newborns. Addressing these multifaceted challenges requires comprehensive, integrated strategies that encompass environmental management, healthcare system strengthening, and social support initiatives. Strategies must focus on building community resilience, improving access to healthcare, and reducing adverse health outcomes associated with climate change.
Acknowledgments
We are indebted to our study respondents who volunteered to participate in the study. Special thanks to research assistants who traversed the two counties to collect data. We appreciate the support provided by Daniel Lango, Florence Thungu, Lilack Achieng Odhiambo, and Teresa Atieno Bange in transcribing the interviews.
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