Women's place of delivery and experience of quality in delivery care: A quantitative and qualitative study in Nairobi's informal settlements

Background and objectives. A key indicator towards achieving the fifth Millennium Development Goal of reducing maternal mortality is the proportion of births in developing countries that occur with a skilled health professional. In urban slums of Africa, private health facilities may make up for the community's lack of access to or use of government health facilities. The dissertation research objectives are to first, to describe, and second, to determine the factors associated with women's place of delivery, their quality experience of delivery care, and their satisfaction with delivery care in two informal settlements of Nairobi, Kenya.;Methods. A population-based, household survey and qualitative data are analyzed. The World Bank/APHRC Maternal Health Survey collected data from 1,926 mothers who delivered in 2004 and 2005 in two of Nairobi's informal settlements. Multivariate regression methods were used for statistical analyses. Exploratory and confirmatory factor analyses informed scale development. Focus group discussions and in-depth interviews were conducted with 58 women who delivered in health facilities.;Results. Survey respondents were more likely to deliver in private facilities (45%) than in government facilities (22%) or at home/with a traditional birth attendant (33%). Private facilities located in the informal settlements were closer to women's homes and less expensive than government hospitals.;Women's ethnicity and wealth level were associated with facility-based delivery, as were male partners' education and antenatal care characteristics. Women living in the slum further away from the city center had greater odds of delivery in private facilities compared to at home. More educated women, those who received higher quality antenatal care in government vs. private facilities, and those who had an obstetric complication had greater odds of delivery in government facilities vs. at home.;Women's experience of quality in delivery care was more positive in private than in government facilities on 8 of 10 survey items. In multivariate analyses, quality scale scores were higher for older and wealthier women, women of certain ethnic groups, and were elated antenatal care characteristics. Women discussed how they appreciated continuous care from providers, being treated with respect and receiving medicines, food, tea and water for bathing after delivery. However, some women delivered unattended and others were insulted by providers. At government hospitals, women complained of high costs, being detained for unsettled bills, and a shortage of beds.;Overall, 56% of the survey sample was "very satisfied" with delivery care. Satisfaction was strongly associated with providers' empathy towards women and whether the pregnancy was wanted or unwanted.;Conclusion. Recommendations are made to address the fact that the private sector is widely relied upon for delivery care in the slums, and that the quality of care differs according to women's characteristics. Governmental efforts to improve access to maternity care that meets existing national standards should integrate the private sector. During antenatal care and community outreach, women from underrepresented groups should he encouraged to deliver in health facilities. Furthermore, health providers should he involved in strategies to reduce disparities in use of and quality of care, and increase empathy towards laboring women.