Introduction

An estimated 303,000 maternal deaths occurred globally in 2015, with 66.3% of these deaths occurring in sub-Saharan Africa [1]. Kenya’s maternal mortality ratio is estimated at 362 deaths per 100,000 live births [2]. Some of the maternal deaths in Kenya have been attributed to childbirth outside of health facilities. The latest Kenya Demographic Health Survey (KDHS), showed a modest increase in the proportion of women delivering in a health facility from 44% in 2009 to 61% in 2014 [2]. Previous work suggests that poor quality of maternity care, including fear of abuse and disrespect perpetuated by health workers, is a potential reason for women’s decision to deliver outside of health facilities in Kenya [3,4].

Person-centered maternity care (PCMC) represents the interpersonal dimensions of quality of care, which is critical to experience of care. It refers to care that is respectful and responsive to the needs of women and their families [5]. PCMC emphasizes the patient-provider relationship, and highlights issues such as whether women are treated in a dignified manner, are communicated to effectively, and feel involved in decision-making about their care. It also includes emotional and social support during childbirth by health care providers [5]. PCMC extends prior frameworks such as that by Bowser and Hill (2010) on disrespect abuse and that by Bohren and colleagues (2014) [11] on mistreatment, to highlight that women’s childbirth experiences fall on a continuum from the best to the worst possible experiences [6]. Categories of disrespect and abuse such as: physical abuse, non-consented care, non-confidential care, undignified care, discrimination, abandonment, and detention in health facilities [7] therefore represent poor PCMC. Studies exploring perceptions and experiences of women and health care workers in diverse sub-Saharan African countries such as South Africa, Nigeria, Guinea, and Tanzania provide evidence that poor person-centered maternity care during facility-based childbirth is prevalent and is a growing concern [8–11].

Most studies examining women’s experience during delivery in Kenya use qualitative methods, which provide vivid descriptions of the manifestations of disrespect and abuse [4,12]. One study conducted in a small rural public hospital in Western Kenya, describes women’s experiences with the health system as unsatisfactory—with women expressing frustration with lack of confidentiality, lack of autonomy, abandonment by providers, and dirty maternity care settings [13]. A few quantitative studies also provide insight into the prevalence of disrespect and abuse in health facilities in Kenya. For instance, one study found that about 20% of women report some kind of undignified care, including non-confidential care, neglect, non-consented care, or physical abuse [14]. A mixed methods study in a rural county in western Kenya highlights poor PCMC across various domains, including poor communication and inadequate support during childbirth [6,15].

Although previous studies have examined PCMC in both rural and urban settings in Kenya [5,16], little work has been done in peri-urban settings. Peri-urban settings in Kenya are often close to cities, but lack access to basic amenities such as running water and adequate sanitation. The healthcare system within these settings has also been reported to be deficient and health facilities are known to provide varied quality of care [17]. Low income women in such settings often have high levels of mortality despite delivering in a health facility [18,19].

Recent qualitative work in a peri-urban setting in Nairobi documents mistreatment of women during childbirth, as well as perceptions by healthcare workers that the health system is weak and under-supported [20]. Studies in India also highlight how mistreatment of women living in urban slums affects decision-making for facility-based childbirth [21]. The poor PCMC in peri-urban settings places women at greater risk for not accessing health care, and encourages home deliveries that may pose health risks to women and their children [20]. Despite the qualitative evidence, there remains a dearth of quantitative studies that empirically assess the extent to which women receive person-centered care during childbirth in peri-urban settings.

Previous attempts to measure women’s experiences during childbirth use binary measures of disrespect and abuse. In order to better assess the quality of maternity care, Afulani et al. (2017) developed the PCMC scale to assess women’s experience of labor and delivery services along three dimensions: dignity and respect, communication and autonomy, and supportive care [5]. The 30-item scale was initially validated in rural and urban Kenya [5] and subsequently in India and Ghana [22,23]. Research based on this scale shows that across these settings PCMC is often suboptimal and the most disadvantaged women received the poorest PCMC [24]. The PCMC scale has also been used to assess the factors that affect PCMC as well as consequences of PCMC [16,25].

We intend to extend the literature in two ways. First, the PCMC scale is used to evaluate PCMC in a peri-urban setting, providing important data on PCMC in a new context. We hypothesize, based on previous qualitative work, that PCMC will also be low in this setting. Second, we examine sociodemographic and facility characteristics associated with PCMC, with the goal of better informing how practice and policy might advance maternity care in settings with significant development challenges. The findings provide an important contribution to the growing literature on PCMC, and will help guide quality improvement initiatives to improve women’s experience during facility-based childbirth.

Methods

Results

Sociodemographic characteristics

Table 1 shows the univariate and bivariate distributions of the respondent’s sociodemographic characteristics. About 74% of the respondents were under 29 years old, and 85% were ever married. The average parity was two, with only 14% of the women having four or more children. About 45% reported post-primary education, and almost half (49%) of their partners had post-primary education. Most (85%) of the women were literate and read very well. About a third (37%) belonged to the highest urban wealth quintile, although the majority (88%) are unemployed. About a quarter of were of the Luo tribe, with other Christian groups (apart from Catholic and Protestants) being the major religion (59%). Most (77%) delivered at a public or faith-based health facility, with only 23% delivering at private health facilities. About half (55%) were classified as having high empowerment based on the empowerment measures used, although 43% had experienced intimate partner violence. Most women reported that their deliveries were attended by a woman (72%) and most (96%) identified the highest skilled attendant present at their delivery as a doctor, clinical officer or nurse/midwife. A majority (74%) reported no complications during their pregnancy and delivery. Sixty-five percent reported having previously delivered at a health facility. Most of the interviews were conducted via phone (66%).

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Table 1. Respondent’s sociodemographic characteristics and bivariate associations with PCMC.

https://doi.org/10.1371/journal.pone.0257542.t001

PCMC.

The individual items in the PCMC scale and sub-scale are shown in Table 2. The average PCMC score was 58.2 out of 90 (SD = 13.7; Range = 11–85). The average sub-scale score was 14.7 (SD = 3.17; Range 2–18) for Dignity and Respect, 15.74 (SD = 4.9; range 2–27) for Communication and Autonomy, and 27.76 (SD = 7.2; range 4–45) for Supportive Care. The standardized scores are shown on Table 3. Some notable findings from the individual items regarding PCMC in this context include the presence, albeit low prevalence, of physical (5%) and verbal (10%) abuse. Further, the majority of respondents (74%) in this study reported that health care workers never introduced themselves and about one fifth (22%) reported that the health care workers did not call them by name. The presence of supportive care was also sub-optimal. In particular, a large proportion of respondents were not allowed to have a companion during labor (78%) and delivery (84%).

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Table 2. Distribution of the items in the PCMC scale by sub-scale domain.

https://doi.org/10.1371/journal.pone.0257542.t002

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Table 3. Sub-scale normalized scores.

https://doi.org/10.1371/journal.pone.0257542.t003

Multilevel model

The null multilevel model had an intraclass correlation coefficient (ICC) of 0.170 (95% CI 0.053–0.430), suggesting that there was significant variation in women’s reports of PCMC across facilities, and that nesting is required. The intraclass correlation coefficient in the final model was 0.144 [95% CI .024, .531]. After accounting for other factors (See Table 4), women who were literate reported significantly higher levels of PCMC than women who were illiterate or semi-literate (β = 5.76, p = 0.006). Women whose delivery was conducted by an unskilled birth attendant reported lower levels of PCMC than women whose delivery was conducted by a Nurse/Midwife/Clinical Officer (β = -8.96, p = 0.016). However, the number of observations for this variable is quite small (n = 12), hence need to be interpreted with caution. PCMC was also lower for women with delayed antenatal care, with those having their first antenatal visit in the second (β = -5.03, p = 0.006) or third trimester (β = -7.29, p = 0.003), reporting lower PCMC scores than women whose first antenatal visit was in the first trimester. Finally, women who were interviewed by phone reported lower PCMC scores (β = -7.54, p = 0.006) than those interviewed face-to-face at the health facility. Other variables did not demonstrate significant associations with the PCMC score. In addition, the random intercept suggested meaningful variation in women’s PCMC scores across facilities, but facility type (i.e., public, private, faith-based) was not a significant predictor of PCMC scores.

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Table 4. Multilevel model examining associations between PCMC score and selected factors.

https://doi.org/10.1371/journal.pone.0257542.t004

Discussion

This study sought to assess women’s experiences of PCMC and associated factors in a peri-urban setting in Kenya using quantitative methods. We found that PCMC was sub-optimal in this setting. The lowest scores were in the communication and autonomy domain, followed by the supportive care domain—with the highest scores in the dignity and respect sub-domain. The sociodemographic factors associated with PCMC was self-reported literacy, with higher PCMC among literate women compared to illiterate women. Other factors associated with PCMC were timing and frequency of ANC, delivery attendant, and location of interview. The results indicate the need for improvements in PCMC, as well as efforts to address disparities by sociodemographic factors.

The average PCMC score of 58.2 out of 90 found in this study is consistent with scores obtained from other studies in Kenya using the same scale: the scores from the rural and urban county used in the validation of the scale were 59.5 and 60.2 respectively [24]. It is encouraging that most women within the peri-urban setting reported being treated with respect most or all the time (84%; See Table 2). Additionally, the proportion of women reporting physical abuse (5%) and verbal abuse (10%) was low when compared to earlier studies that had estimated physical abuse at 20% [3]. This could be due to the implementation of interventions to improve respectful maternity care in Kenya in the last few years [30]. More work is however needed—especially in the other domains of PCMC.

The low scores in the communication and autonomy domain is also consistent with prior studies on PCMC conducted in Kenya. For example, most respondents (74%) in this study reported that the health care workers never introduced themselves, and about one fifth (22%) reported that the health care workers did not call them by name. This is similar to the findings from the rural and urban Kenya study, where 77% and 85% of respondents respectively reported that providers never introduced themselves; and 27% and 44% respectively reported providers never called them by name [15] Women in our sample were, however, more likely to be able to give birth in the position of their choice: 24% of women in our sample reported that they were never able to be in the birthing position of their choice, compared to 70% and 39% respectively, for women in the rural and urban Kenyan samples [16]. Reasons provided for poor communication in prior studies include the work environment of providers not allowing sufficient time to communicate, provider knowledge and assumptions, as well as women’s inability to demand or command effective communication and respect for their autonomy [31].

Supportive care was also sub-optimal. In particular, a large proportion of respondents were not allowed to have a companion during labor (78%) and delivery (84%). This is worse than that from other studies assessing companionship during labor and delivery. For example, Afulani, et al (2018) found that 32% of women were not allowed continuous support during labor (with 19% never allowed a companion during labor), while 70% were not allowed continuous support during delivery (61% were never allowed a companion during delivery) [15]. This study also found that although providers often denied women companions at the time of delivery, this was consistent with the preference of some women, who desired support during labor and after delivery, but not during the delivery [15]. Women’s reasons for not desiring a companion during their delivery included lack of privacy and not wanting to be seen in their most vulnerable moment by non-health care workers [15]. Further contributing to the sub-optimal supportive care is poor pain control, with about one third of respondents reporting that the health care workers did not do everything they could to control their pain.

Literacy, a proxy indicator for education, has been established as consistently and strongly associated with delivery in a health facility [24,32]. In the current study, literacy was also significantly associated with PCMC. Women who are literate may be more able to communicate effectively with health care workers and negotiate for better experiences at the health facility. Literate women are also more likely to be familiar with the health care provision infrastructure and able to navigate it better [32]. Further, health care workers may provide better treatment to literate women because they are more likely to be able to hold them accountable [31]. Receipt of higher PCMC by more literate women may therefore contribute to the higher facility deliveries among them. Women’s education is also associated with improved health-seeking behavior through health awareness, economic autonomy and the ability to make appropriate health decisions [33,34].

Timing and frequency of ANC reflect the level of engagement with the health care system. The later a woman’s first visit, the more negative her PCMC scores were, suggesting more negative experiences during childbirth. Other studies conducted in Kenya have similarly shown that ANC timing is associated with experience of care, with women who received ANC in the third trimester reporting poorer experiences [35]. Early ANC visits is associated with positive maternal health outcomes primarily because women receive timely care for preventing or identifying and managing complications [36]. Women who seek ANC early are also able to establish a relationship with their healthcare providers, which can contribute to a better experience during childbirth. Studies in Kenya and other LMIC settings have, however, demonstrated key gaps in quality of ANC, with low SES women having poorer experiences during ANC, which could affect their decision on where to give birth [35].

Births being assisted by non-skilled attendants in a health facility demonstrates a failure in the health system. Although this represented less than 4% of our respondents, other studies have suggested unskilled providers sometimes play clinical roles in facilities including assisting with births. This is sometimes due to overcrowding in maternity units and long wait times due to shortage of clinical staff [12]. Furthermore, that women who were assisted by unskilled providers received poorer PCMC may indicate poorer knowledge of PCMC among this cadre of staff leading to poor PCMC provision [31]. Prior studies have shown that while these unskilled providers may sometimes serve as advocates for women, they can also be perpetrators of abuse [37]. However, given the very small proportion of women who were assisted by unskilled providers in our sample, this finding should be interpreted with caution and explored further in future studies.

The findings based on location of interview seems to demonstrate that women who were on their “home turf” so to speak—a location where they feel more comfortable or empowered (home and community)—were potentially more honest or forthcoming about their negative experiences in the health care setting, when compared with women who were interviewed at the health facility. Women interviewed in the facility may be hesitant to speak negatively about their experience in the facility for fear of retribution by health care workers. This is consistent with other studies where women interviewed at home reported higher PCMC than those interviewed in health facilities, although interviews were face to face in both locations [6,16].

Conclusions

This study is among the few in low-resource settings on women’s perspectives on person-centered maternity care within a peri-urban setting. Our findings support evidence of poor PCMC across all domains but particularly with regards to communication and autonomy and supportive care. These results indicate the need for interventions to improve in PCMC at health facilities in peri-urban settings in Kenya. Given the unique context of peri-urban settings, it is important to examine interventions that are feasible and relevant in these settings. This will help ensure peri-urban women are not left behind in efforts to improve maternal and neonatal outcomes.

Supporting information

Acknowledgments

We would like to thank Christine Achieng, Edwina Ndhine, Florence Okeyo King and Joy Minyenya-Njuguna who participated in collecting the data for the study. We are grateful to the Ford program and the Kellogg Institute for International studies for supporting the study. We thank the leadership of the health department at Nairobi County for giving us permission to recruit respondents from the public health facilities under their supervision and the different counties within Embakasi where we collected our data. Most importantly we thank the women of Embakasi for sharing their birth stories with us and allowing us to conduct this study.