KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya.
Department of Global Health and Population, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA.
BMC Womens Health. 2024 Mar 19;24(1):181. doi: 10.1186/s12905-024-02965-9.
Maternal and neonatal outcomes in, Kakamega County is characterized by a maternal mortality rate of 316 per 100,000 live births and a neonatal mortality rate of 19 per 1,000 live births. In 2018, approximately 70,000 births occurred in the county, with 35% at home, 28% in primary care facilities, and 37% in hospitals. A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya to improve the progress of these indicators. Research has shown that women's ability to make decisions (voice, agency, and autonomy) is critical for gender equality, empowerment and an important determinant of access and utilization. As part of the Kakamega SDR process evaluation, this study sought to understand women's processes of decision-making in seeking maternal health care and how these affect women's ability to access and use antenatal, delivery, and post-natal services.
We adapted the International Centre for Research on Women (ICRW) conceptual framework for reproductive empowerment to focus on the interrelated concepts of "female autonomy", and "women's agency" with the latter incorporating 'voice', 'choice' and 'power'. Our adaptation did not consider the influence of sexual relationships and leadership on SRH decision-making. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. A thematic analysis approach was used to analyze the data in NVivo 12.
The results revealed notable findings across three dimensions of agency. Women with previous birthing experiences, high self-esteem, and support from their social networks exhibited greater agency. Additionally, positive previous birthing experiences were associated with increased confidence in making reproductive health choices. Women who had control over financial resources and experienced respectful communication with their partners exhibited higher levels of agency within their households. Distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women's agency and autonomy. Finally, women who faced barriers such as long waiting times or limited staff availability experienced reduced agency in seeking healthcare.
Individual agency, immediate relational agency, and distance relational agency all play crucial roles in shaping women's decision-making power and control over their utilization of maternal health services. This study offers valuable insights that can guide the ongoing implementation of an innovative service delivery redesign model, emphasizing the critical need for developing context-specific strategies to promote women's voices for sustained use.
卡卡梅加县的母婴结局特点是孕产妇死亡率为每 10 万活产 316 例，新生儿死亡率为每 1000 例活产 19 例。2018 年，该县约有 7 万例分娩，其中 35%在家中，28%在初级保健机构，37%在医院。肯尼亚卡卡梅加县正在实施一项母婴保健服务提供重新设计（SDR），旨在重组孕产妇和新生儿保健服务，以改善这些指标的进展。研究表明，妇女做出决策的能力（声音、机构和自主权）对于性别平等、赋权以及获得和利用保健服务的重要决定因素至关重要。作为卡卡梅加 SDR 过程评估的一部分，本研究旨在了解妇女在寻求孕产妇保健方面的决策过程，以及这些过程如何影响妇女获得和利用产前、分娩和产后服务的能力。
我们改编了国际妇女研究中心（ICRW）的生殖赋权概念框架，重点关注“女性自主权”和“妇女机构”这两个相互关联的概念，后者包含“声音”、“选择”和“权力”。我们的改编没有考虑性关系和领导力对 SRH 决策的影响。我们在卡卡梅加县进行了关键知情人访谈、深入访谈、小组访谈和焦点小组讨论，受访者包括在产前诊所就诊的孕妇、分娩后的妇女、在产后诊所就诊的妇女以及男子。我们使用 NVivo 12 中的主题分析方法对数据进行分析。
研究结果在机构的三个维度上揭示了显著的发现。有先前分娩经验、自尊心高、得到社交网络支持的妇女表现出更大的机构能力。此外，先前良好的分娩经验与增加对生殖健康选择的信心有关。在家庭中能够控制财务资源并与伴侣进行尊重性沟通的妇女表现出更高的机构能力。距离关系机构能力展示了卫生系统因素和社会文化规范对妇女机构能力和自主权的影响。最后，面临长时间等待或工作人员有限等障碍的妇女在寻求医疗保健方面的机构能力降低。
个人机构能力、直接关系机构能力和距离关系机构能力都对妇女的决策权力和对其利用孕产妇保健服务的控制能力起着至关重要的作用。本研究提供了有价值的见解，可以指导正在进行的创新服务提供重新设计模式的实施，强调需要制定具体情况的策略来促进妇女的声音，以实现持续使用。
