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What does access to health care among the urban poor mean?

Factors associated with use of “appropriate” maternal health services in the slum

settlements of Nairobi, Kenya

By Jean-Christophe Fotso, Alex Ezeh, Nyovani Madise,

Abdhalah Ziraba and Reuben Ogollah

INDEPTH Network AGMNairobi, September 3-7, 2007

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Background: Maternal Deaths and Mortality Ratio(Deaths per 100,000 live births)

Source: WHO/UNICEF/UNFPA, 2004

529,000 deaths 527,000 deaths

247,000 deaths 11,000 deaths

0

200

400

600

800

1,000

1,200

World Developingcountries

Sub-SaharanAfrica

Kenya

Mat

ern

al M

ort

alit

y R

atio

(p

er 1

00,0

00)

3

Background (Ct’d)

Kenya resolved to reduce MMR by 3/4 by 2015. Kenya NRHSDS (1997-2010)

• Safe motherhood and child survival• Key pillars include clean and safe delivery.

Urbanization, poverty and health inequities in SSA• More than 50% of SSA population will be living in urban

areas by 2030.• About 7 out 10 inhabitants of Nairobi live in slums.• Growing inequities between the poor and the non-poor.• MDG-5: Attention to the growing urban poor populations

in SSA.

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Background (Ct’d)

In the slums co-exist:• Private, sub-standard

and often unlicensed clinics, with

• Well equipped public, religious or large NGO facilities, generally in the outskirts of the slums.

Preferable to deliver at home or at TBA’s?Misleading not to treat the two categories of HFs separately.

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Objectives

Improve understanding of maternity health seeking behaviors in resource-deprived urban settings • Identify the factors which influence the choice of

place of delivery among the urban poor;• Distinction between sub-standard and “appropriate”

health facilities;• Formulate recommendations aimed at improving

maternal health.

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Data and Methods Data from a DSS-nested MHP

• 1,927 who had pregnancy outcomes in 2004-2005• 25 HFs providing obstetric care

Dependent variable: Place of delivery• Public/religious/large NGO HF: coded 2• Private, sub-standard HF: coded 1• Not HF (home, TBA …): coded 0

Covariates• Socioeconomic variables• Biodemographic and health-related covariates• Slum residence (Korogocho, Viwandani)

Methods• Descriptive analysis• Ordered logistic - Partial proportional odds models

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Health facility deliveries in Kenya

(1): All types of HFs; (2): Appropriate HFs

70

48

78

33

0

10

20

30

40

50

60

70

80

90

Per

cen

tag

e o

f w

om

en (

%)

Nairobi slums (1) Nairobi slums (2) Nairobi Rural Kenya

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Multivariate results: Socioeconomic & Residence

†p<0.10; *p<0.05; **p<0.01

Education (Ref: Primary)None -0.275 0.034Secondary or higher 0.321 ** --

Working status (Ref: Not working)Currently working 0.330 ** -0.039

Ethnicity (Ref: Kikuyu)Kamba -0.968 ** --Luhya -1.463 ** --Luo -1.758 ** --Others -0.464 ** --

Household wealth (Ref: Poorest)Middle 0.238 * --Least poor 0.788 ** 0.354 **

Husband/partner's education (Ref: Primary)None/not in union 0.366 ** --Secondary or higher 0.576 ** --

Slum residenceViwandani -0.704 ** -1.839 **

All types of HF vs Not

HF

Appropriate HF vs (Inap or not HF)

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Multivariate results: Biodemo and health-related

†p<0.10; *p<0.05; **p<0.01

Parity (Ref: 1)2-3 -0.646 ** --4+ -0.844 ** --

Wanted index pregnancy then (Ref: No)Yes 0.203 † --

Antenatal care visits (Ref: 2-3)0-1 -0.636 ** -0.342 *

4+ 0.134 --Advised to deliver with a health professional (Ref: No)

Yes 0.403 ** --Age (Ref: 20-24 years)

<20 0.120 --25-29 0.075 0.326 *

30+ -0.236 0.277 †

All types of HF vs Not

HF

Appropriate HF vs (Inap or not HF)

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Multivariate results: Interactions

Interaction between Area of residence and Maternal education

Interaction between Area of residence and Household wealth

Interaction between Household wealth and Health advice

Interaction between Maternal education and Health advice

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Korogocho Viwandani

None vs (Inap & App)

Odd

s R

atio

None Primary Secondary+

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Korogocho Viwandani

None vs (Inap & App)

Odd

s R

atio

Poorest Middle Least poor

0.0

0.5

1.0

1.5

2.0

2.5

3.0

None Primary Secondary

None vs (Inap & App)

Odd

s R

atio

Not advised Advised

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Poorest Middle Least poor

None vs (Inap & App)

Odd

s R

atio

Not advised Advised

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Recommendations

Provision of health services to the urban poor:• Registration of private facilities and clinics – minimum criteria

• Provision of public health services in/near the slums

• Improvement of the quality of care (delays, attitude of staff) in public HFs

Health education campaigns• Antenatal care attendance

• Advice/counseling on delivery and postnatal care, and other pregnancy-related issues

• Target groups: Poorest, not educated, not working women Higher parity women

Access to FP and RH services

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Acknowledgements:• The World Bank• The Wellcome Trust

Thank you