A STUDY ON UTILIZATION OF SKILLED BIRTH

ATTENDANCE AMONG WOMEN OF REPRODUCTIVE AGE

ATTENDING BUSIA COUNTY HOSPITAL.

BY
SHARON NEKESA NYONGESA.
D/Nurs/19064/4859
NURSING DEPARTMENT.

A dissertation submitted to the department of Nursing in partial

fulfillment of the requirement for the award of Diploma in nursing
in Kenya Medical Training College.

5th JAN,2023.

1
Declaration page
This research project is my original work and has not been submitted for a diploma award in KMTC or
any other institution.

Name. Sign. Date

Sharon Nekesa Nyongesa ...................... .......................

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Supervisor's Approval page
This dissertation entitled “A RESEARCH ON UTILIZATION OF SKILLED BIRTH
ATTENDANCE AMONG WOMEN OF REPRODUCTIVE AGE ATTENDING BUSIA COUNTY
HOSPITAL "has been submitted for review with my approval as College Supervisors.

Sign ………………...................... Date ……………….

Department Of Nursing

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Dedication
I dedicate this research to almighty God for his dear support and guidance. I also dedicate it to My
husband and parents for their dear support.

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Acknowledgement
My first and foremost gratitude is directed to KMTC for the opportunity to persuade Diploma in Nursing.
I also thank my HOD Mr Situma and my research lecture , Mr Bruce Olindi for the knowledge and
guidance and for equipping me with enough knowledge on Research. I finally thank my husband for his
tireless support especially financially to ensure that the project is successfully accomplished.

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Abreaviation of terms

WHO - World Health Organization

SBA - Skilled Birth Attendance

MoH - Ministry of Health

F.P. - Family Planning

ANC - Antenatal Clinic

KHDS - Kenya Health Demographic Studies

BBA - Born Before Arrival

TBA - Traditional birth Attendance

SDG- Sustainable Developmental Goals

MPDSR - Maternal, perinatal Death Surveillance any Response

NRHPF-, National Reproductive Health Policy Framework

UNICEF- United Nations International Children's Emergency Fund

EJMeD - European Journal of Medical and health science

C/S-Caeserian section

SSA- Sub-Saharan Africa

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7
Abstract
Maternal mortality rate in Kenya is at 510 deaths per 10,000 deliveries annually. These are all related to
pregnancy and delivery complications. This is believed to be due to underutilization of SBA.Based on this
trend, the research aimed at determining factor influencing utilization of the SBA all of which were done
under 3 objectives namely; Barriers to utilization of SBA, Knowledge and awareness on importance of
SBA, and staff and facility influence on utilization of SBA.

Cross sectional discriptive study design was employed for the study . Simple random sampling method
was used where 22 respondents were selected for the study. Questionnaires were distributed to the
selected samples which they filled under guidance. Data collected were thereafter analysed and presented
in form of graphs, tables and charts.

Findings revealed that most of the respondents had adequate knowledge and awareness on SBA with most
of them mentioning CHA and MCH/CWC to be the main source of awareness. However, there was low
utilization which the respondents related to high poverty , inadequate staff in the facility especially in odd
hours and weekends, lack of basic medical equipment e.g gloves which they had to buy, harrasment by
the staff and total student involvement during delivery and other procedures to be the major causes of low
utilization.

Based on the above, the government through the MoH, the facility and the medical institutions must
work together so as to improve the quality of service delivered through employment of more staff,
supplying the facility with basic medical equipment, organizing induction training for the staff especially
on communication skills so as to eradicate the harrasment issue and also through ensuring there is a
clinical instructor wherever a student carries out any procedure.The findings also calls upon more studies
to identify the reason as to why poverty plays a role on underutilization of SBA yet the government had
initiated free maternal services through " Linda Mama initiative."

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Table of Contents
Declaration page..........................................................................................................................................2
Supervisor's Approval page.........................................................................................................................3
Dedication...................................................................................................................................................4
Acknowledgement.......................................................................................................................................5
Abreaviation of terms..................................................................................................................................6
Abstract.......................................................................................................................................................7
CHAPTER ONE........................................................................................................................................11
INTRODUCTION AND BACKGROUND...............................................................................................11
1.1 Introduction.....................................................................................................................................11
1.2 Background of the study..................................................................................................................11
1.2: Problem Statement..........................................................................................................................12
1.3: Justification....................................................................................................................................13
1.4: Research Questions.......................................................................................................................13
1.5: Objectives.......................................................................................................................................13
1.5.2: Broad objective............................................................................................................................13
1.5.2: Specific objectives.......................................................................................................................13
CHAPTER TWO:......................................................................................................................................14
LITERATURE REVIEW..........................................................................................................................14
2.1: Introduction....................................................................................................................................14
2.2 Barriers to utilization of SBA among of reproductive age...............................................................14
2.2.1 Introduction..................................................................................................................................14
2.2.2 Age...............................................................................................................................................14
2.2.3 Education......................................................................................................................................14
2.2.4 Economic status of the mother......................................................................................................15
2.2.5 Parity............................................................................................................................................15
2.2.6 Marital status................................................................................................................................15
2.2.7 Residence......................................................................................................................................15
2.2.8 Cultural belief and language.........................................................................................................15
2.2.9 Religion........................................................................................................................................16
2.2.10 Quality and number of ANC visits..............................................................................................16

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 2.2.11 Transport and insecurity.............................................................................................................16
2.3 Staff and Facility factor...................................................................................................................16
2.4 Level of knowledge on SBA............................................................................................................17
CHAPTER 3..............................................................................................................................................18
METHODOLOGY....................................................................................................................................18
3.1 Study design....................................................................................................................................18
3.2 Study area........................................................................................................................................18
3.3 Study population..............................................................................................................................18
3.3.1 Inclusion criteria...........................................................................................................................18
3.3.2 Exclusion criteria..........................................................................................................................18
3.4 Variables..........................................................................................................................................18
3.4.1 Independent Variable....................................................................................................................18
3.4.2 Dependent variables......................................................................................................................18
3.5 Sampling techniques........................................................................................................................19
3.6 Sample size determination...............................................................................................................19
3.7 Development of data collection tool................................................................................................19
3.8Data collection process.....................................................................................................................19
3.9 Pre-testing/piloting..........................................................................................................................20
3.12 Data analysis/ Manual method.......................................................................................................20
3.13 Ethical consideration.....................................................................................................................20
CHAPTER FOUR.....................................................................................................................................21
RESULTS.................................................................................................................................................21
4.1 Introduction.....................................................................................................................................21
4.2 Demographic and social characteristics of the respondents.............................................................21
4.3 Knowledge on importance of SBA..................................................................................................22
4.4 Sources of information on importance of SBA..............................................................................23
4.5:Dissemination of awareness on SBA...............................................................................................24
4.6 Degree of SBA Utilization among women of Reproductive age......................................................24
4.7 Frequency of Utilization..................................................................................................................25
4.8. Reasons for not fully utilizing SBA................................................................................................25
4.9. Reason for >90% utilization...........................................................................................................25
4.10. Score in a scale of 100% of the quality of service delivered to you during utilization of SBA....26

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 4.11 Willingness to utilize SBA in subsequent pregnancies and deliveries...........................................27
4.12: frustrations encountered during utilization that may hinder you from subsequent utilization.......28
4.13 Women's willingness to re-utilize SBA from the similar facility utilized before...........................29
4.14. Reason for not using facility in the subsequent pregnancy and deliveries....................................30
CHAPTER FIVE.......................................................................................................................................31
DISCUSSION, CONCLUSION AND RECOMMENDATION................................................................31
5.1 Introduction.....................................................................................................................................31
5.2 Discussion of findings.....................................................................................................................31
5.2.1. socio-demographic data...............................................................................................................31
5.2.2. Awareness and Knowledge on importance of utilizing SBA among women of reproductive
age.........................................................................................................................................................31
5.2.3. Staff and facility factor influencing utilization of SBA................................................................32
5.3 CONCLUSION..............................................................................................................................32
5.4 RECOMMENDATIONS.................................................................................................................33
APPENDIX 1............................................................................................................................................34
REFERENCE............................................................................................................................................34
APPENDIX TWO.....................................................................................................................................35
QUESTIONNAIRE...................................................................................................................................35
APPENDIX 3............................................................................................................................................37
Work Plan..................................................................................................................................................37
APPENDIX 4.......................................................................................................................................38
BUDGET...............................................................................................................................................38

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CHAPTER ONE.

INTRODUCTION AND BACKGROUND

1.1 Introduction.
SBA is the process by which a woman is provided with adequate care during labour, delivery and early
postnatal period.It is the single most effective intervention in reducing maternal and perinatal mortality
for 2 main reason; first; 60% of maternal and 30% of neonatal death occurs over the short period between
labour and the 24 hrs.; and second most maternal deaths are due to direct obstetric complications that are
unpredictable antenatally but treatable when detected during labour and after birth. Thus, location of
delivery, who conducts the delivery and how quickly the mother can be transported to the location where
emergency obstetric care is available are crucial factors to improving the inextricably linked maternal and
child survival.

In Kenya, SBA is restricted to doctors,. Nurses and midwives. TBA's are excluded fry the definition as
they lack basic formal training on delivery and management of pregnancy related complications (Wanjira
et Al, 2012

Antenatal care plays a crucial role in determining the the maternal and newborn outcome as it presents the
opportunity for the pregnant woman and unborn to receive evidence based interventions distributed over
at least four Individualized visit. The Benefits of these visits in developing countries is still in question
due to high mortality Rate despite of successful uptakes

The uptake may also be linked to low socio economic status and poor infrastructural development in the
developing countries as compared to developed countries. These factors may hav]e been contributing to
high percentage of TBA and BBA and indirectly resulting to high mortality Rate in developing countries
especially those related to pregnancy and birth complications .

In 2013, free maternity care program was introduced by the government of Kenya after
repo]Hrts ]Hrevealed that over 6000 women were dying annually from causes that can be prevented
during pregnancy and childbirth. This program was launched to prevent financial barriers that
are ]Hrelated]H to the usage of maternal health services and hence ensuring all Kenyan mothers have
access to maternity service in public facilities. This was expected to improve Utilization of SBA from
44% recorded by MoH in 2008 and improve the attendance and quality of postnatal care.

1.2 Background of the study.

Globally, approximately 830 women die from pregnancy or childbirth related complications everyday
accounting to 287000 mothers dying annually (WHO, 2015). Out of the above figures, developing
countries, Kenya being one of them, accounted for approximately 99% of all the cases reported.
(WHO,2015). An estimate of 2 million deaths arising from maternal, still birth and newborn deaths
annually is due to lack of skilled birth attendance at birth, (WHO, 2015). This is however said to be
highest in developing countries than developed once. For example, a woman's risk of dying from
preventable and or treatable complications of pregnancy is 1 : 22 in sub Saharan Africa as compared to
1:7300 in developed countries (Alkema et al, 2016)

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In Africa, 88% of the total global deaths occurs annually , (WHO, 2015). Sub - Saharan Africa suffers
highest maternal mortality ratio- 546 maternal deaths per 100,000 births or 201,000 deaths per year.This
is 66% of all maternal deaths per year globally (WHO , 2015)

In Kenya, the maternal mortality rate is at 510 per 100000 live births which is more than twice the global
rate of 216 per 100000 live births, ( WHO, 2015). This makes it to be among the top 10 countries with the
highest mortality in the world ( WHO, 2015) According to MoH journal produced in 2013, 21% of
deaths among women of Reproductive age are due to pregnancy related cases.

Dispite of this high perinatal mortality Rate in Kenya, there is reduced uptake of SBA with only 61% of
women seeking for these services (KDHS, 2014). This is much far from the global and National target of
above 90% Utilization as per Kenya Health Sector Strategic Plan and vision 2030.

The Kenyan government through its attempt to achieve it's strategic plan and vision 2030 and also to
achieve SDG-,3, has put into place various initiatives to ensure maximum Utilization including National
Reproductive Policy Framework in 2007, introducing Linda Mama to cater for user fee, Beyond Zero
camping , etc. All these has however not yielded much as per EJMED r]Heport of there research done in
2020 on the Utilization of SBA which found that only 58% of mothers met the 4 recommend ANC visit
and only 51% attended post natal clinic in 2 weeks, (EJMED, 2020).

In western region , there is significant underutilization of SBA with only 52% of the mothers attending
more than 4 recommended antenatal visits, 49%delivering in health facility, 48% deliveres at home and
3% delivering on their way to the facility. Only 63% of mothers are reported to be receiving post natal
care, 36% reporting their newborns for post-delivery checkup as scheduled.

In Busia county, 307 deaths per 100,000 live births is reported, (EJMED,2020). According to Busia
County fourth quarter Maternal and perinatal Death Surveillance Response review meeting of 2018/2019
reported 59.9% ANC attendance meeting the FANC requirement, 58.8% skilled birth deliveries and
maternal mortality was at 307 per 100,000 as the above. This is much higher than expected requirement
by the government which aims at reduction of the mortality rate to less than 70 per 100000 live births and
meeting SDG 3 by 2030. Achieving the above still remains mirage unless factors contributing to
underutilization of maternal Care services are investigated. Thus, the study seeks to assess determinants
of maternal health care utilization in the era of free maternity Services in Busia County to help in
achieving the SDG3 on maternal health by 2030.

1.2: Problem Statement

Kenya is among the top ten countries with the highest mortality rate in the world (WHO, 2015). 21% of
deaths in Kenyan women of reproductive age are due to pregnancy related causes ( MOH,2013). The
poor statistics was linked to underutilization of maternal health care services and hence ,most of these
deaths can be prevented by accessing skilled birth attendance (WHO,2017) Kenyan government has put
in place various interventions to curb the issue of underutilization including National Reproductive Health
Policy Framework in 2007,doing away with user fee in all primary health facilities through "Linda mama
" initiative , Beyond Zero Campaigns etc. but dispite of all these, only 58% of mothers meet the
recommended 4 ANC visits, 62% delivers under skilled attendance and only 51% attends Post natal clinic
after 2weeks ( EJMED,2020) . This is much lower than the anticipated target of 90% by 2030.

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Busia county records similarly high mortality rate of 307 deaths per 100,000 live birth with only 58%
attending skilled birth (EJMED,2020).This study is therefore essential to determine what exactly
contributes to this low utilization of skilled birth attendance in this era of free maternity services .

1.3: Justification.
SBA is important in reducing maternal mortolity. It is currently applied as a sub indicator to monitor
progress in reducing this. Dispite a global and national target of ensuring more than 90%of births are
assisted by a skilled personnel, more than 37% of births in Kenya still occurs at home (KDHS,2014).
Increasing the percentage of births under skilled personnel is important in reducing deaths arising from
complications of pregnancy.This study is essential therefore in addressing the issue of utilization of SBA
in this era of governmental effort to address poor maternal and neonatal health and accelerating the
realization of Kenya Health Sector Strategic Plan and Vision 2030.

1.4: Research Questions

This research was guided by the following questions;

What is the influence of staff factor in utilization of SBA among women of reproductive age attending
BCRH?

What is the level of knowledge among women of reproductive age attending BCRH on SBA?

What are some of the barriers towards utilization of SBA among women of reproductive age attending
BCRH?

1.5: Objectives

1.5.2: Broad objective

To determine factors contributing to underutilization of SBA among women of reproductive age
attending BCRH.

1.5.2: Specific objectives

To determine influence of staff and facility factor on utilization of SBA by women of reproductive age
attending BCRH.

To determine barriers to utilization of SBA among women of reproductive age attending BCRH.

To access level of knowledge about SBA among women of reproductive age attending BCRH.

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CHAPTER TWO:

LITERATURE REVIEW

2.1: Introduction
The literature review will be discussed in three sections align to the study objectives. Various literatures
from the past studies will be reviewed to confirm findings from related studies so as to form the basis of
comparative analysis with the current study findings. The objective to be discussed will be;

Barriers to utilization of SBA among women of reproductive age.

Staff and facility factors influencing uptake of SBA

Knowledge of SBA among women of reproductive age.

2.2 Barriers to utilization of SBA among of reproductive age

2.2.1 Introduction
According to KDHS 2014 socio-demographic factors forms a great barrier to utilization of SBA. Some of
which included in; age, marital status, Educational level, residence, parity, economic status e.t.c. Other
barriers included; Religion, culture, insecurity, poor infrastructure and number of ANC visits.( Carolyne
Et Al, 2018).

2.2.2 Age
It is a key factor in care seeking behavior . However, patterns regarding age utilization of SBA are some
what inconsistence with most study findings a positive association and few finding a negative association
( Faber Et Al, 2017). For example a study by Mony Et Al, 2016 found that most women over 25 years
were most likely to deliver under SBA , compared to younger ones. This was however inconsistence with
findings by Elphas Et Al. 2016 in his study where they found that 90% of those who sought for SBA were
aged between 20-24 years. This study is however consistence with another study done in 2014 which
found that high population that is 47.9% who utilizes SBA were those ageing between 20-24 years with
least in the age extremes ( Consolata Et Al,2014). KDHS in its study in 2014 also found that utilization of
SBA decelerates with increasing age with the least uptake in those aged between 35-49 years (51%).

2.2.3 Education
Low education level has been noted to form a major barrier towards uptake of SBA. Kitul Et Al in their
studies in 2016 found that education played a significant role in determining whether a pregnant woman
will seek SBA or not with those with low level of education. Similarly Nguhiu Et Al, 2017 in their study,
found out that utilization of SBA increases with mothers education and wealth e.g 20% of births to
mothers with no education are delivered in a health facility as compare to 84% of births to mothers with
secondary or higher education. It also noted that higher education among women sensitizes them about
their health care needs and hence enhances the probability of being effectively able to communicate with
their spouse, family members and even health care staff about any pregnancy related complications hence
having confidence in visiting health facilities ( Yadav ET AL,2020)

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2.2.4 Economic status of the mother
As evidenced from Sub-Sahara African Countries with low economic status experiencing lowest
utilization of SBA, maternal economic status plays a significant role on the uptake of SBA ( Barriers Et
Al, 2012).

This was also consistent with a research done in Nigeria which revealed that, despite of effects to reform
health sectors and improve the health status of the population, inequalities in health have increased,
within regions and this is highly related to different socio- economic status of individuals ( Timothy Et
Al, 2014). Fagbamigbe Et Al 2015, revealed that most of the women (68%) preferred TBA’s since it was
cheap as the traditional attendance could even accept non-cash payments ( e.g Chicken) unlike in health
facilities where you have to pay cash.

2.2.5 Parity
Delivery under SBA was less likely among women who had 2-3 deliveries and birth intervals of less than
24 months than those with first experience ( Singh Et Al,2012). This study is consistent with result from
other studies where parity was found to have a negative associate with delivery care with an increase with
birth order, the odds of delivery with a health profession compared to a preference category ( i.e one child
) decreased ( Rogan Et Al,2014). Women with higher birth order utilized professionals to a lesser extend
than first births. According to KDHS 2018, the child birth order was found to be associated with the type
of assistance and delivery. Those with higher birth order are more likely to deliver without SBA
compared to those with low birth order.

2.2.6 Marital status

Single women have high autonomy and does not depend on decisions from their husbands and in-laws
concerning the place of delivery and the attendant hence more likely to utilize SBA as compared to the
married one who depend on the decision by their spouse and in-laws ( Ochako Et Al, 2014).

2.2.7 Residence
KDHS 2018 found out that residence influence utilization of SBA where those I urban settings were more
likely to be assisted by medical personnel than those living in rural areas. The further the mother lives
from a facility the less likely they are able to utilize SBA ( Geubbels, 2016)

2.2.8 Cultural belief and language

Cultural belief forms a barrier towards uptake of SBA especially belief on cause of illness, final decision
maker especially in health seeking behavior and ability to communicate with others ( Webair Et Al, 2013,
Bin-gouth Et Al,2013). A study done in Maasai community reveal that women being not final decision
makers was a major barrier to health facility delivery ( Karanja Et Al, 2018). In another study done in SA
found out that , in ability of women to express themselves in a language of the skill birth attendants
among most women was associated with low uptake ( Hunter-Adams and Rother, 2017).

It was also noted that most women found it easier to express their health problems to TBA in their native
languages than they could in the facility due to language barrier and difference in cultural believe among
various communities ( Carter,2013).

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2.2.9 Religion
Religious is a significant determinant in uptake of SBA ( Seigh Et Al, 2012) . it is hypothesized that
religious influence can partly explain the disparities in sexual and reproductive health outcomes.
( Tochari,2018) The same study revealed that Muslims approach to health care is strongly on preventive
measures and they still look much to their religious heritage to an extend that they consider exposure of
the persons private parts as to any person other than their spouses is a taboo ( Tohari, 2018)

2.2.10 Quality and number of ANC visits

Number of ANC visits greatly influence the behavior of choosing the place of delivery ( Wingstone Et Al,
2022). It was noted the utilization of SBA increase with the increase with the number of ANC visits
( Nguhiu Et Al,2014). Another study done in SSA countries indicated that mothers who attended at least
four ANC visits were more likely to deliver in health facilities than those who attended fewer. The reason
was proposed to be as a results of information they get during ANC visits on the advantages of SBA
( Guder Et Al, 2016)

2.2.11 Transport and insecurity

This forms a key barrier as was reported by women who delivered at home in a study done by Damian Et
Al, 2020. They reported that if labor pain starts at night it was difficult to organize or get even a
motorbike which could facilitate them to reach the facility. They also reported that even if they get the
charges were to high that they could not afford. This was worsen by insecurity within the county
especially at night and poor road especially in rural areas.

2.3 Staff and Facility factor

The relationship between patient and service provider have been found to have an impact on the future
utilization of maternal services ( Mmnava Et Al, 2015). Issues like privacy, confidentiality and sensitivity
of the staff changes patient satisfaction on quality of services( Conversin Et Al 2015). It is reflected on
the willingness to return for same service in the forth coming pregnancy.

In Tanzania , a study associated with poor communication by health providers during ANC visit resulted
to low hospital delivery ( Mogoma Et Al, 2011). A negative bad experience has also been shown to have
a significant on the well-being and future choice of the mother on where to deliver (Smaradache Et Al,
2016). Likewise discourtesy by health workers and disrespect for local cultural values cause a resentment
among clients towards utilization of SBA (Mmanava Et Al,2016).

In another study done by Hunter Adam Et Al, 2017 found out that in ability of women to express
themselves in the language of skilled birth attendants was also associated with under utilization of
healthcare services. Other barriers noted were irregular opening hour, long waiting hours and language
barrier to relay health information to the client by the health worker in the simplest way for easy
understanding ( Konginyuy Et Al, 2019). The study also mentioned feeling of mistrust, lack of respect
and cultural insensibility among healthcare workers as some of the problems the client face in reference
to staff interaction during service delivery.

Shortage of health personnel has also greatly contributed to negative attitude towards seeking of SBA as
clients claim that they cannot access full concentration as in many cases one staff is to attend more than
ten client at a given time ( Inyang & Walker, 2015). This is similar to the findings by Enchil in his study

17
in 2015 who reported that most of the clients feels reluctant to go for health facility delivery because of
inadequate staff especially during weekends and at night and poor reception hence no one to attend them.

Lack of focused post- partum follow up by healthcare workers has also made the clients to prefer to TBA
as they were able to provide post-partum care and follow up visits to their home. (Bidhan Et Al, 2016).

The importance and functioning of health system can also not be over-emphasized in terms of need for an
enabling environment. The outreach and the organization of the health systems are critical to the success
of the strategy for the provision of SBA. Health policies that support the work of healthcare workers, the
standards and protocals that defines their work and the arrangement for ensuring the required supplies and
essential medicines and equipments are available for equally important ( WHO, 2014). A functional
health system also requires suitable buildings, enough staffs, the right management of professional skills
and satisfactory terms of employment. In addition, there needs to be in place referral system and effective
functioning supervision and training of staffs all of which must be put in place in order to ensure that
there is a strategy in place for the provision of skilled attendant (Liam Et Al, 2019).

2.4 Level of knowledge on SBA

In a study done by Okomo Et Al in 2017, 80% of women were aware of nearest health facility where they
could get SDA. However only 32% utilized SBA. In the same study only 37.9% knew the importance of
SBA while 62.1% thought health facility delivery was not important at all ( Okomo Et Al, 2017). This
findings are consistence with the findings by Okereko Et al in his study 2013 who found that over 90% of
women had poor knowledge on benefit of SBA and 80% displaying poor knowledge on the benefit of
ANC visits. The study also showed that more than 50% had poor knowledge on maternal danger signs.

In the similar study low maternal utilization of SBA in most rural community who believed that
pregnancy is a natural process requiring no medical intervention. This was associated with lack of
awareness in SBA ( Okereko Et Al, 2013). In another study women were found to have fear on utilization
of SBA due to possibilities of undergoing C/S as they perceive that there was no any clear indication set
fo C/S and any person sectioned. This was associated with lack of knowledge and awareness of safe
motherhood ( Yarzever & Said, 2013).

Impact of knowledge of SBA was summarized by Emelumadu Et Al, (2014) in his study findings, where
he found that knowledge on safe motherhood is believed to improve maternal healthcare service
utilization through increased level of health awareness and greater knowledge of available health services
among educated women. Increase in knowledge on benefits of maternal healthcare services improved the
ability of educated women to afford the cost of healthcare services and their enhanced level of
Autonomicity

18
CHAPTER 3
METHODOLOGY
chapter sets out research methodology that was used to meet the researcher's objective of the study. The
research design, population of interest, sampling procedures and data collection instruments and data
analysis techniques were as outlined.

3.1 Study design.

A descriptive cross sectional study design was used in the study as it helped to generate qualitative data
through self-administered questionnaires. It was also seen appropriate for the study since it involved fact
findings and inquiries.

3.2 Study area

The study was conducted at Busia County Refferal Hospital which is located in Busia County. The
hospital is located just a few kilometres away from Kenya - Uganda border hence serving the population
from both countries . The area is majorly inhibited by the Teso Community but also have Luos.

3.3 Study population.

The target population for this study was all women of reproductive age (15-49 yrs) who attended ANC
and those admitted in the Obstetrics and gynecological ward at BCRH.

3.3.1 Inclusion criteria

All women between 15-49yrs of age who attended ANC and those admitted in obstetric and
gynecological ward between 18 NOVEMBER 2022 and 26th NOV 2022

3.3.2 Exclusion criteria

All women above 49yrs and those below 15yrs who attended ANC clinic and all other women who came
to ANC and CWC clinic. or were admitted before or after the study period.

All women who did not conscent for the study

All women who were mentally challenged

All women who were very sick admitted before or after the study period

3.4 Variables

3.4.1 Independent Variable

-Women's awareness on importance of utilization of SBA

-Barriers to utilization of SBA

3.4.2 Dependent variables

Delay in utilization of SBA

3.5 Sampling techniques

Simple random sampling method was used to select the number of respondents.

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3.6 Sample size determination
To determine the number of respondents to be employed in the study, Andrew Fischer’s method was used
since the population was less than 1000. Where;

N=(z2pq)/d2

=[(1.96)^2×0.5×0.5]÷0.05^2

=384

Where; N-desired sample Size

Z - Std deviation (1.96)

q- 1-p

d -level of Statistical Significance

Being that the population under study is <10,000, the sample size estimate will be found by:

nf =n/1+n/N

Where nf -the disired sample size when the pop is <10,000

n- the desired sample size when pop is >10,000

N- Estimated pop size

The target population for year 2022 for mother's attending CWC at BCRH was 1050

Monthly target was 88

And weekly target was 22.

This gave a sample size of 22 respondent which formed a predetermined population.

3.7 Development of data collection tool

Questionnaires were used for collecting data. It included a set of questions demographic information and
questions that explored a specific objective. Both direct and indirect questions were used.

3.8Data collection process

All the respondents was explained to what the research entailed and why it was being performed and there
consent was taken. They were explained to what was expected from them to do and how to fill the
questionnaires. There questionnaires were then issued out and were filled under the researcher's guidance
without any biasness.

3.9 Pre-testing/piloting
Eight questionnaires were distributed randomly to the study population who attended the MCH clinic
between 4th August and 7th August to feel so as ascertain if there was any complexity that could be
encountered during the study and also to identify the duration that could be needed so as to completely
feel the questionnaire.

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3.12 Data analysis/ Manual method.
The appropriately filled questionnaires were collected, sorted, analyzed presented using

tables, pie charts, bar graph and frequency tables for easy interpretation.

3.13 Ethical consideration

The researcher observed the ethical principles of Autonomy, beneficience and confidentiality That before
undertaking the study the proposal was first approved by the department of Nursing,KMTC busia
campus. Further Permission was sort from the Nurse incharge, Busia -County Hospital and the in charge
MCH and Maternity section. Recruitment to the study was voluntary as informant consent was obtained
from the respondents. Regarding confidentiality, no names were included on the questionnaire instead
signature and study serial numbers of the participants was used. The data from respondents was kept
secret and was not shared whatsoever.

21
CHAPTER FOUR
RESULTS
4.1 Introduction
This chapter presents data findings from the field, its analysis and interpretation. This information was
gathered through questionnaire and analyzed using descriptive statistical analysis technique. There was
100% res]ponse rate realized since the questionnaires we're issued to the respondents where they filled it
instantly and were collected back after being filled. All of them were valid and reliable for the study as
they filled them under researcher’s guidance.

4.2 Demographic and social characteristics of the respondents

This section presents the results on background distinctiveness of respondents. It compromise of age,
education levels, marital status and occupation of the respondents. The results were as shown in table 4.1

Table 4.1

Background data Number %tage

15-25 6 27%

26-35 11 50%
Age
>36 5 23%

Total sample population 22 people 100%

Education levels Primary 6 27%

Secondary 12 54.5%

Tertiary 4 18.5%

Total 22 100%

Marital status Single 8 36.5%

Married 12 54.5%

Divorced 1 4.5%

22
 Separated 1 4.5%

Total 22 100%

Occupation Civil servants 10 45%

Unemployed 4 18%

Self employed 8 37%

Total 22 100%

Gravidity Primigravida 10 45%

Multigravida 12 55%

Total 22 100%

From the findings, majority of the respondents (50%) were between 26-35yrs and most of them (54.5%)
had secondary education level. A large number (18%) were the unemployed group.54.5% of the
population was married.

4.3 Knowledge on importance of SBA

The researcher was interested in knowing the women's awareness on importence of SBA and the results
were as in the fig 4.1 below.

Fig 4.1.A pie chart showing women's awareness on importence of utilizing SBA

From the findings, it is evident that a large population (91%) had awareness on importence of SBA with
only 9% of the respondents lacking sufficient awareness.

23
 Awareness on importence of SBA
Unaware
9%

aware
91%

4.4 Sources of information on importance of SBA.

The researcher also inquired on the specific sources of information from which those who were aware of
SBA got from and the results were as in the fig 4.2

source of information
CHW MEDIA H.facility fam/frie

12%

44%

36% 8%

From fig 4.2 above, it's clear that the major source of information and knowledge among women was
health facilities (36%). It was also realized that community health workers played a significant role in

24
dissemination of information on importence of utilizing SBA and it stood at 44%. Only 8% and 12% of
the respondents got information from printed media and neighbours respectively.

4.5:Dissemination of awareness on SBA

The findings on depertmental degree on creating awareness on importence of SBA to the respondents
within the facility were as shown in the fig 4.3 below

Fig 4.3 : A pie chart showing departmental dissemination of SBA

DEPERTMENTAL DISEMINATION
OPD MAT MCH/FP

6%

32%

62%

From the figure above, it's evident that most respondents (62%) got the information from MCH/FP,
followed by Maternity at 32% and OPD with lowest role at 6%.

4.6 Degree of SBA Utilization among women of Reproductive age

The respondents were asked if they had ever utilized SBA in there previous pregnancies or this was there
1st Utilization and the response was as below.

Respondent's status Number of respondents %tage

Respondents who had ever utilized 16 73%

Those utilizing in there 1st time 6 27%

Total 22 100%

Table 4.2: Degree of SBA Utilization.

From the table above, large portion (73%) had utilized SBA before with only 27% utilizing in there 1st
time.

25
4.7 Frequency of Utilization
The researcher wanted to know how many times the respondent who had ever utilized SBA was attended
to by skilled birth attendant.

Fig 4.4:A bar graph showing frequency of SBA Utilization.

60%

50%

40%

30%

20%

10%

0%
>90% >50% <50

From the findings, very few respondents (13%) had used SBA in more than 90% of all there pregnancies
and deliveries with most of the respondents (54%) had utilized it in more than half of there pregnancies
and deliveries.

4.8. Reasons for not fully utilizing SBA

Figure 4.5 showing reasons for not fully utilize SBA

Reaons for <90% utilization of

SBA Findings above reveals that most
of the respondents (63%) do not
unsatisfactory services financial constraints fully utilize SBA due to
distance factor others
unsatisfactory services received
33% 3% 1% during there previous

utilization.

63% 4.9. Reason for >90%

utilization.
The researcher inquired from the
respondents who had utilized SBA in more than 90% of there pregnancies and deliveries of what inspired
them to this. The findings were as in the pie chart in fig 4.5 below;

26
Fig 4.6 showing what inspired those who utilized SBA>90% to do so.

inspirations towards >90% SBA utilization

free services provision of baby packs
satisfactory service others
2%

5%

15%

78%

From the above findings, most respondents are inspired by free maternal services making them to visit
facilities so as to access SBA.

4.10. Score in a scale of 100% of the quality of service delivered to you during
utilization of SBA
Findings were as shown in the fig below.

score of service recieved

during utilization of SBA
100% 75%-99% 50%-74% <50%
2%
12%

4.11 52% Willingness to

utilize SBA 34% in subsequent
pregnancies and deliveries.

Fig 4.5:A pie chart showing women's

willingness to utilize SBA in subsequent pregnancies and deliveries.

From the above , large population of the respondents 51% were willing to re-utilize SBA while 48%
were not willing. 1% are un-dicided however.

27
28
4.12: frustrations encountered during utilization that may hinder you from
subsequent utilization
The researcher wanted to know what did not please the respondent during her previous SBA utilization
and the findings were as in figure 4.6 below.

Fig 4.6:A bar graph showing frustrations perceived by respondents during previous SBA utilization

50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
t re rs
cy ff en he
iva sta m ca t
fp
r y ve pp o
tb ol f
ko en in
v ko
lac sm ts al c
r ra den
ha stu

The findings illustrates that most of the respondents (57%) and 33% were frustrated by harassment by
staff and total student involvement during utilization.

29
4.13 Women's willingness to re-utilize SBA from the similar facility utilized before.
The researcher wanted to know whether the utilization is influenced by facility factors and services
provided by the staff .The findings are as below.

Fig 4.7:A pie chart showing women's willingness to re-utilize SBA in the previously used facility

not willing
36% willing

64%

From the findings, only 64% of the respondents were willing to utilize SBA in the facility previously
used. With 36% not willing..

30
4.14. Reason for not using facility in the subsequent pregnancy and deliveries
The researcher wanted to know of respondents' perceptions on which population are to be screened. The
results were as presented below.

Fig 4.8. Reasons for not using similar facility in subsequent pgs. and deliveries.

70%

60%

50%

40%

30%

20%

10%

0%
lack of inadequet staff others delayed referral irregular
equipments openning hrs

As shown in the figure above, lack of equipments and non-pharms plays a major role in determining the
place for up taking SBA.

31
CHAPTER FIVE
DISCUSSION, CONCLUSION AND RECOMMENDATION
5.1 Introduction
This chapter presents a summary of the study results in chapter four, conclusion that the researcher
reached as per the findings and the recommendations that the researcher made based on the results
obtained from the field.

5.2 Discussion of findings

5.2.1. socio-demographic data

As per table 4.1, most of the respondents were aged between 26-35years of age, most were married
(58%), and a large population (57%) had secondary education levels .Also , Most of the population (48%)
were civil servants with almost equal ration between primigravidas and multigravidas at 47% and 53%
respectively.

Some of the above findings are consistent with previous studies as other findings are inconsistent. For
example, findings on age as a determinant towards utilization of SBA is consistent with findings
published by Mony et al, (2016) which showed that high population utilizing SBA were above
25yrs.Lowest utilization was noticed among women aging >36yrs. This is also consistent with KDHS
Finding of 2014 which revealed lowest uptake of SBA among women aged between 35-49 years. The
findings of this study is however inconsistent with studies done by Elphas et al and Conceleta et al in
2016 and 2014 respectively which revealed otherwise.

Findings on marital status are inconsistent with Ochako et al ,(2014) findings which showed that high
utilization of SBA was linked to single mothers more than married once.

On level of education, the study findings are consistent with all previous study findings i.e ; Kitul et al,
(2016), Nguhiu et al, (2017) and Yadav et al,(2020), which found that degree of SBA utilization among
women of reproductive age increases with increase in level of education with the lowest utilization to be
amongst those with primary education.

On gravidity, the ratio of utilization among multigravidas and primigravidas is almost equal at 47% and
53% respectively with only a small difference (8%). This is consistent with study findings by Singh et al,
( 2012), rogan et al, (2014) and KDHS,2018, which all found out that mothers with secondary and above
markedly utilized SBA as compaired to those with primary education.

5.2.2. Awareness and Knowledge on importance of utilizing SBA among women of

reproductive age.
Most population were aware of the importance of SBA services (91%) with only 9% not aware. This
findings are inconsistent with findings by Okomo et al , (2017), and Okereko et al , (2016) which in
there study found out that only a small population , 37.9% as per Okomos findings and <10% as per
Okerekos findings, had knowledge on importance of utilizing SBA. Most of this information was from
the CHW at 44% and health facility at 33%. On further inquiry, it was found out that MCH/F/P played a
significant role in disseminating the information on SBA which was closely followed by Maternity at
32%.

32
5.2.3. Staff and facility factor influencing utilization of SBA.
Larger proportion of the respondents, 49%, were not willing to utilize SBA in there subsequent deliveries
and pregnancies siting a major reason being harassment by staff (48%) and total involvement of medical
students during service delivery without guidance and assistance from qualified staff, (33%). The finding
are in line with several study findings which sited out that , harassment, discourtesy and disrespect of the
clients by the health workers played a major role in determining possibility of SBA re-utilization.
( Magoma et al,( 2011),Smarandache et al, (2016) and Mannava et al ,(2016).) A significant population
(51%) were however willing to re-utilize SBA and the main reason was due to provision of free
maternal services and also provision of post- delivery baby packs.

For those who were willing to utilize SBA in their subsequent pregnancies, very large population 66%,
were not willing to visit the same facility reason being lack of basic equipments and medical supplies
especially non pharms which they had to buy before they could be attended to,(67%).Some (29%) also
sited inadequate staff to be a limiting factor towards re-utilisation.These findings are in line with study
findings by iyang et al, (2015), and Echil et al, (2016) who found out that inadequate staff especially at
nights and weekend which results in minimal post-partum care, making them not willing to visit similar
facility previously visited in their subsequent pregnancies and delivery.

5.3 CONCLUSION.
Study aimed at determining what could have been the cause of underutilization of SBA in BCRH . 22
Women of ages between 15-49years were issued questionnaires with questions set as per the research
objective and they filled it from which the findings were obtained. It was clear that knowledge had no
influence on utilization as most of the respondents had knowledge and Awareness on importance of
utilizing SBA. It was also clear that MCH/FP and Maternity played a major role in dissemination of
information on SBA as a large portion heard of it when they went for routine FP services in MCH and in
maternity during delivery.. It was also clear that in availability of major medical equipments and supplies
especially non pharms determined the place for utilization of SBA .Also shortage of staff and
medical/nursing/ clinical student involvement in procedures hinders utilization of SBA.Further more,
Staff approach to those utilizing SBA determined possibility of its re-utilization in subsequent
pregnancies and deliveries as most of the respondents were discouraged by harassment received from the
staff hence reluctant to visit the similar facility in subsequent pregnancies and deliveries.

33
5.4 RECOMMENDATIONS
MOH should empower MCH, maternity and CHA departments both financially, adequate staff and with
knowledge on importance of SBA as they are the major source of information to the respondents. This
will enhance dissemination of accurate knowledge on importance of SBA.

MOH and other organization including N.G.O.s should equip the facilities with sufficient medical
equipments, non – pharmaceuticals ( including gloves, gauze, cotton etc) and medical staff for
betterment of service delivery as this will ultimately improve utilization.

Training programmes should be organized by the facility administration for all staffs attending patients in
maternity and MCH/FP especially on communication skills so as to minimize patients harassment by the
staff as this has been revealed to be a key determinant of re-utilization of SBA in a similar facility.

34
APPENDIX 1
REFERENCE
1: Center for Infection Diagnosis Research in Zambia - CIDR2 (2014)

2: GoK/ MoH (2010); Review of the 2004-2008 Representative health Agenda and proposed 2010-2014
research agenda.

3. Health, 2014. 11-360. (http://ww.biomedcentral) accesed on18th Jan, 2015.

4: ISRN Obstetrics and Gynecology 2012.

5. Kenya National Bureau of Statistics (2012), Population Distribution by sex, number of households,
area, Density and administrative Unit. Nairobi.

6: Kenya Demographic and Health Survey 2012/2013

7: Kenya National Bureau of statistics (2013). Population Distribution by sex, Number of Household,
Area, density and administrative units . Nairobi.

8. Kistiana S.(2019). Socioeconomic and demographic determinants of maternal health care utilization in
Indonesia. Thesis; Flinders University of Australia.

9: Moore,M.,Copeland,R.,Chege,S.,Pido,D.&Griffiths,M.(2013).Griffiths,M.(2013).A Behavior Change

Approach to investigating foctors influencing Womens use of skilled care in Homabay District, Kenya.

10: Okonofua,F.E, Ezeanochie,M.C..,Olagbuchi,B.N & Agholor K.N.(2020)Attaing MDG5 in Northern

Nigeria:Need to focus on Skilled Birth Attendence .African journal of reproductive health 14(2):9-11.

11: Ochako ,R,Fosto,J.C..,Ikamari, L...,& Khasakhala, A ( 2013). Utilization of maternal health services
among young women in Kenya.Insights from KDHS,2018.BMC pregnancy and childbirth.
("http//www.biomedcenttal.com/4471-2393/11/1") accessed on 18th may 2012.

35
APPENDIX TWO
QUESTIONNAIRE
Questionnaires For data collection on factors influencing utilization of Skilled Birth Attendance

Section A: Bio-data

1: Study serial number..............................

2: Age.......................years

3: Level of education : ✓Primary. [ ]. ✓ secondary. [ ] Tertiary. [ ]

4: Gravidity. primigravida. ✓[ ]. ✓ Multigravida [ ]

5: Marital status. ✓ Married. [ ]. ✓ single. [ ]. ✓ Divorced. [ ]. ✓ Separated. [ ]

Knowledge and awareness on SBA

6:Have you ever heard of SBA?

✓Yes. [ ]. ✓ No. [ ] (If yes , answer 7, if NO, skip to section 3)

7: Where did you get the information from?

✓ CHA. [ ]. ✓ Health facility. [ ]. ✓ Media. [ ] Family and friends. [ ]

(If from health facility, answer question 8, if Not, skip to 9.)

8: From which department did you get the information from?

✓ MCH/FP. [ ]. ✓ Maternity. [ ]. ✓ OPD. [ ]. ✓ others..........

Barriers to utilization of SBA

9: Have you ever utilised SBA?

✓ Yes. [ ]. ✓. No. [ ]. (If yes, answer subsequent question, if No, skip to 13)

10: How many times have you ever utilised SBA?

✓ In all Pregnancies. [ ]. ✓ in >50% of all Pregnancies

✓ In <50% of all Pregnancies.

11: If you did not fully utilised SBA, what made you not to fully utilise it?

✓Unsatisfactory service received. [ ]. ✓ Financial constraints. [ ]

✓Distance factors. [ ]. ✓ others........

36
12: For those who utilised SBA in all their pregnancies and deliveries, what probed you towards this?

✓ Free service delivery [ ]. ✓ Provision of post delivery package. [ ]

✓Satisfactory service [ ]. ✓ Others ...........

13: Rate the service you received during your utilization out of 100%

✓>95%. [ ] ✓ >75%. [ ] ✓. <50%. [ ] Others, specify.........

14: Would you like to utilise SBA again?

✓ Yes. [. ]. ✓. No. [ ]

15: If No, why?

✓ Lack of privacy. [ ]. ✓. Harassment by staff. [ ].

✓ Full student involvement [ ]. ✓ Inadequate staff. [ ]

✓Others...............

37
APPENDIX 3
Work Plan

May Jun-July Sept Oct Nov Dec Jan

2022 2022 2022 2022 2022 2022 2023

Concept presentation

Proposal development

Approval of proposal

Data collection

Data analysis

Report writing

Report presentation and

submission

38
APPENDIX 4
BUDGET

ITEM QUANTITY UNIT COST TOTAL [ksh]

PENS 5 @20 100

NOTE BOOK 2 @100 200

INTERNET SERVICES 10 HOURS @100 1000

TYPING AND PRINTING PROPOSAL 30 PGS @35 1,050

TYPING AND PRINTING QUESTIONNAIRES 60 PGS @30 1,800

TYPING AND PRINTING OF DISSERTATION 50 PGS @35 1,750

PHOTOCOPYING THE DISSERTATION 50PGS 5 250

TOTAL 6150

39