Bypassing high-quality maternity facilities: evidence from pregnant women in peri-urban Nairobi.

Utilization of high-quality maternal care is an important link along the pathway from increased facility-based delivery to improved maternal health outcomes, however women in Nairobi do not all deliver in the highest quality facilities available to them. We explored whether women living in peri-urban Nairobi who live nearby to high-quality facilities bypassed, or travelled farther than, their nearest high technical quality facility using survey data collected before and after delivery from women (n = 358) and from facility assessments (n = 59). We defined the nearest high technical quality facility as the nearest Comprehensive Emergency Obstetric and Newborn Care (CEmONC) capable facility to each woman's neighbourhood. We compared women who delivered in their nearest CEmONC (n = 44) to women who bypassed their nearest CEmONC to deliver in a facility that was farther away (n = 200). Among bypassers, 131 (65.5%) women delivered in farther non-CEmONC facilities with lower technical quality and 69 (34.5%) delivered in farther CEmONCs with higher technical quality capacity compared to their nearby CEmONCs. Bypassers rated their delivery experience higher than non-bypassers. Women who bypassed to deliver in non-CEmONCs were less likely to have completed four antenatal care visits and to consider delivering in any CEmONC prior to delivery while women who bypassed to deliver in farther CEmONCs paid more for delivery and were more likely to report being able to access emergency funds compared to non-bypassers. Our findings suggest that women in peri-urban Nairobi bypassed their nearest CEmONC facilities in favour of delivering in facilities that provided better non-technical quality care. Bypassers with access to financial resources were also able to deliver in facilities with higher technical quality care. Policies that improve women's delivery experience and ensure that information about facility technical quality is widely distributed may be critical to increase the utilization of high-quality maternity facilities.

Accuracy of patient perceptions of maternity facility quality and the choice of providers in Nairobi, Kenya: a cohort study.

OBJECTIVES: This study aimed to assess the accuracy of pregnant women's perceptions of maternity facility quality and the association between perception accuracy and the quality of facility chosen for delivery. DESIGN: A cohort study. SETTING: Nairobi, Kenya. PARTICIPANTS: 180 women, surveyed during pregnancy and 2 to 4 weeks after delivery. PRIMARY OUTCOME MEASURES: Women were surveyed during pregnancy regarding their perceptions of the quality of all facilities they were considering during delivery and then, after delivery, about their ultimate facility choice. Perceptions of quality were based on perceived ability to handle emergencies and complications. Delivery facilities were assigned a quality index score based on a direct assessment of performance of emergency 'signal functions', skilled provider availability, medical equipment and drug stocks. 'Accurate perceptions' was a binary variable equal to one if a woman's ranking of facilities based on her quality perception equalled the index ranking. Ordinary least squares and logistic regressions were used to analyse associations between accurate perceptions and quality of the facility chosen for delivery. RESULTS: Assessed technical quality was modest, with an average index score of 0.65. 44% of women had accurate perceptions of quality ranking. Accurate perceptions were associated with a 0.069 higher delivery facility quality score (p=0.039; 95% CI: 0.004 to 0.135) and with a 14.5% point higher probability of delivering in a facility in the top quartile of the quality index (p=0.015; 95% CI: 0.029 to 0.260). CONCLUSIONS: Patient misperceptions of technical quality were associated with use of lower quality facilities. Larger studies could determine whether improving patient information about relative facility quality can encourage use of higher quality care.