Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, United States.
Health Systems and Research Ethics Department, KEMRI-Wellcome Trust Research Programme, Nairobi P.O BOX 43640-00100, Kenya.
Health Policy Plan. 2024 Nov 14;39(10):1099-1108. doi: 10.1093/heapol/czae088.
A health systems reform known as Service Delivery Redesign (SDR) for maternal and newborn health seeks to make high-quality delivery care universal in Kakamega County, in western Kenya, by strengthening hospital-level care and making hospital deliveries the default option for pregnant women. Using a large prospective survey of new mothers in Kakamega County, we examine several key assumptions that underpin the SDR policy's theory of change. We analyse data on place of delivery, travel time and distance, out-of-pocket spending, and self-reported quality of care for 19 127 women prospectively enrolled during antenatal care (ANC) and surveyed two times after their delivery. We analyze changes in womens' delivery location preferences in recent years in Kakamega, and over the course of their most recent pregnancy. We also evaluate travel time, out-of-pocket expenditures and patient satisfaction for women who deliver in public hospitals vs primary health centres. We find substantial changes in delivery location at the population level over time and for individual women over the course of pregnancy. Facility delivery has increased from 50.4% in 2010 to 89.5% in 2019; 70% of respondents deliver at a different facility than their reported intention at ANC. Out-of-pocket delivery expenditures are on average 1351 Kenyan shillings (Ksh) in hospitals compared to 964 Ksh in PHC (primary health care)s (P < 0.01). Transport expenditures are 337 Ksh for PHC level deliveries vs 422 Ksh for hospitals (P < 0.01). Self-reported average travel time is 51 min (PHC delivery) vs 47 min (hospital delivery) (P = 0.78). The average distance to a delivery location is 15.1 km for PHC deliveries vs 15.2 km for hospitals (P = 0.99). There were no differences in overall patient-reported quality scores, while some subcomponents of quality favoured hospitals. These findings support several key assumptions of the SDR theory of change in Kakamega County, while also highlighting important challenges that should be addressed to increase the likelihood of successful implementation.
一项名为服务交付设计（SDR）的医疗系统改革旨在使母婴健康的高质量分娩护理在肯尼亚西部卡卡梅加县普及，方法是加强医院层面的护理，并使医院分娩成为孕妇的默认选择。我们使用卡卡梅加县新产妇的大型前瞻性调查，检查了支撑 SDR 政策变革理论的几个关键假设。我们分析了在产前护理（ANC）期间前瞻性纳入的 19727 名妇女的分娩地点、旅行时间和距离、自费支出以及自我报告的护理质量的数据，在分娩后两次对她们进行了调查。我们分析了近年来卡卡梅加妇女分娩地点偏好的变化，以及在最近一次怀孕期间的变化。我们还评估了在公立医院和初级保健中心分娩的妇女的旅行时间、自费支出和患者满意度。我们发现，随着时间的推移，在人口层面和个体妇女在怀孕期间，分娩地点发生了重大变化。从 2010 年的 50.4%到 2019 年的 89.5%，设施分娩有所增加；70%的受访者在分娩时选择的医疗机构与 ANC 时报告的意图不同。与 PHC 相比，医院分娩的自费支出平均为 1351 肯尼亚先令（Ksh），而 PHC 为 964 Ksh（初级保健）（P<0.01）。PHC 分娩的交通支出为 337 Ksh，而医院分娩为 422 Ksh（P<0.01）。自我报告的平均旅行时间为 51 分钟（PHC 分娩）和 47 分钟（医院分娩）（P=0.78）。PHC 分娩的平均分娩地点距离为 15.1 公里，而医院分娩的平均距离为 15.2 公里（P=0.99）。患者报告的总体质量评分没有差异，而一些质量子成分则有利于医院。这些发现支持卡卡梅加县 SDR 变革理论的几个关键假设，同时也强调了应解决的重要挑战，以增加成功实施的可能性。
