Research Article: Interrupted time series analysis of free maternity services policy in Nyamira County, Western Kenya

Date Published: May 8, 2019

Publisher: Public Library of Science

Author(s): Henry Owuor, Asito Stephen Amolo, Sharon Mary Brownie.


The Government of Kenya instituted the free maternity services (FMS) policy to improve utilization of maternal healthcare services and thus improve maternal health. The aim of this study was to evaluate the effect of the FMS policy on the uptake of maternal health services in Nyamira County in western Kenya.

An interrupted time series study design was used to design the study and to analyze the collected data. Forty-two data sets were collected for each outcome variable i.e. 24 pre- and 18 post-intervention. Monthly data was abstracted from the District Health Information System-2 (DHIS-2) and verified using facility data. The collected data was then keyed into SPSS-17, cleaned and analyzed.

During the study period, there was a significant increase in births attended by skilled attendants up to the 12th month (p<0.05) and caesarean section up to the ninth month (p<0.05). There was a decrease in obstetric complications up to the 12 month (p<0.05). In addition there was a significant increase in institutional maternal mortality ratio (iMMR) in the 12th and 18th months (p<0.05) following the implementation of free maternity service policy. There was a significant increase in deliveries in hospitals from the 1st to the 18th month (p<0.05) whereas in primary health care facilities the increase in deliveries was only significant up to the 6th month (p<0.05). The FMS policy led to progress towards improving maternal health by improving access to maternal health services. The improved utilization of maternal health services was more marked in hospitals. There was a worsening of institutional maternal mortality ratio.

Partial Text

User fees are charges levied at the point of use of any aspect of health services [1]. User fees for health services were introduced or substantially increased in African countries following the 1987 joint World Health Organization/United Nations Children’s Fund Bamako Initiative whose aim was to address severe problems in the financing of maternity care [1]. User charges for essential drugs were also introduced to generate funds to improve the quality of health services and equity in access to these services [1]. However, user fees have seldom produced these intended benefits [2, 3]. Instead, they have been a significant barrier to access of maternal health care services in Kenya [2]. Studies done between 2003 and 2006 in three African countries (Burkina Faso, Kenya and Tanzania) found that the mean cost of a normal or a complicated delivery in Kenya was US$18.4 compared to US$ 7.9 and US$5.1 for Burkina Faso and Tanzania respectively [4]. This has made user fees a prohibitive barrier to access to essential services even in Kenya [5].

This study was approved by Jaramogi Oginga Odinga Teaching and Referral Hospital’s Ethics Review Committee, accreditation number 01713. Since this study involved data abstraction no written consent was obtained from the study participants for using their records. Participant reports/information was already anonymized and de-identified prior to data collection.

Table 1 depicts the population and service data before and after the FMS policy implementation. The populations shown represent the mid-period populations before and after the policy’s implementation. There was a 3.7% increase in the population and a 50.9% increase in deliveries attended by skilled health personnel. This was accompanied by increases in fourth ANC clinic visits and average number of CSs per month and a decline in the number of birth-related complications per month. However, there were no major differences in institutional maternal and neonatal deaths. There was an increase in deliveries attended by skilled personnel in all the sub-counties except in Borabu sub-county.

Since the start of the nationwide implementation of the free maternity services policy in June 2013, there has been progress towards improving maternal health, especially access to maternal health services, in Kenya. The improved utilization of maternal health services was more marked in hospitals. However, there is a worsening of iMMR and an insignificant decline in ANC attendance. Longer-term studies should be conducted to further characterize the effect of the policy. In addition, qualitative studies should be carried out to understand the barriers to hospital delivery in Nyamira County in the context of the FMC policy. Meanwhile PHCF should leverage on their accessibility to improve utilization of health services in these facilities.




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