DETERMINANTS OF UTILIZATION OF MATERNAL HEALTHCARE 

SERVICES AMONG WOMEN OF REPRODUCTIVE AGE (15-49 YEARS) 

SEEKING CARE IN KAPKOI HEALTH CENTER, TRANS NZOIA COUNTY

 

 

 

 

 

 

BY 

ADERO GODFREY OOKO  

 

 

 

 

 

 

A THESIS SUBMITTED TO THE SCHOOL OF HEALTH SCIENCE IN 

FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS 

IN EPIDEMIOLOGY AND BIOSTASTITICS OF JARAMOGI OGINGA 

ODINGA UNIVERSITY OF SCIENCE AND TECHNOLOGY. 

 

 

 

 

 

 

 

© 2023. 

 

 



i  

  

DECLARATION AND APPROVAL 

Declaration 

This thesis is my original work and has not been presented for an award of a degree or 

diploma in any other university or institution. 

 

ADERO GODFREY OOKO 

(REG.NO.H153/4023/2018). 

 

Sign.                           Date. 06/11/2023 

 

Certification by Supervisors 

This thesis has been submitted for examination with our approval as the University 

supervisors: 

 

Dr. Jane Owenga, PhD 

Department of Public and Community Health and Development, 

School of Health Sciences,  

Jaramogi Oginga Odinga, University of Science and Technology. 

Sign.         Date. 06/11/2023 

 

Dr. Fredrick Oluoch Okumu, PhD 

Department of Physical Sciences, 

School of Biological, Physical, Mathematics and Actuarial Sciences,  

Jaramogi Oginga Odinga, University of Science and Technology. 

 

Sign.                                      Date. 06/11/2023 

  



ii  

  

DEDICATION 

 

To my dear wife Agnes, your unwavering support and sacrifices have made this academic 

journey possible. I dedicate this study to you with deep gratitude for being my rock and 

my inspiration. 

In loving memory of my late sister Dorothy, her contribution to my undergraduate 

education will forever remian in my heart. I dedicate this study to her, a beacon of 

generosity and belief in my potential. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



iii  

  

ACKNOWLEDGEMENT 

 

I express my profound gratitude to my dedicated supervisors, Dr. Jane Owenga and Dr. 

Fredrick Okumu, for their invaluable guidance and unwavering support throughout the 

study period. Their mentorship was instrumental in shaping the various chapters of this 

thesis, and their encouragement propelled me to persevere despite challenging 

circumstances. I also wish to extend my heartfelt appreciation to my friends and 

schoolmates, particularly James Onyuro Oketch, whose constructive criticism proved 

invaluable. My deep thanks go to the research assistants for their exceptional work during 

the two-month exercise, as well as to the study respondents for providing the crucial raw 

data. Lastly, I acknowledge my workmates for their understanding, granting me 

uninterrupted time to conduct my research, including leave days for data collection and 

analysis. May blessings abound for all who played a role in this journey. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



iv  

  

TABLE OF CONTENTS 

 

DECLARATION AND APPROVAL .................................................................................. i 

DEDICATION ..................................................................................................................... ii 

ACKNOWLEDGEMENT ..................................................................................................iii 

TABLE OF CONTENTS .................................................................................................... iv 

LIST OF TABLES ............................................................................................................. vii 

LIST OF FIGURES ..........................................................................................................viii 

LIST OF ABBREVIATIONS AND ACRONYMS............................................................ ix 

OPERATIONAL DEFINITION OF TERMS ...................................................................... x 

ABSTRACT ........................................................................................................................ xi 

 

CHAPTER ONE ................................................................................................................ 1 

INTRODUCTION .............................................................................................................. 1 

1.1 Introduction .................................................................................................................... 1 

1.2 Background Information ................................................................................................ 1 

1.3 Statement of the Problem ............................................................................................... 4 

1.4 Research Objectives ....................................................................................................... 5 

1.4.1 General Objectives ...................................................................................................... 5 

1.4.2 Specific Objectives ..................................................................................................... 5 

1.5 Research Question .......................................................................................................... 6 

1.6 Justification .................................................................................................................... 6 

1.7 Significance .................................................................................................................... 7 

1.8 Limitation of the Study .................................................................................................. 7 

 

CHAPTER TWO ............................................................................................................... 8 

LITERATURE REVIEW .................................................................................................. 8 

2.1 Introduction .................................................................................................................... 8 

2.2 Maternal Mortality ......................................................................................................... 8 

2.3 Theoretical Literature Review ....................................................................................... 8 

2.4 Underlying Determinants of Maternal Health ............................................................... 9 

2.4.1 Socio-Demographic Determinants ............................................................................ 10 

2.4.2 Client Determinants .................................................................................................. 13 



v  

  

2.4.3 Health Provider Determinants ................................................................................... 15 

2.5 Barriers to providing optimum maternal care .............................................................. 17 

2.6 Improving Maternal Health through Sustainable Development Goal ......................... 18 

2.7 Gaps in current maternal health research ..................................................................... 21 

2.8 Relationship between determinants of maternal service utilization ............................. 22 

2.8.1 Socio-demographic determinants .............................................................................. 22 

2.8.2 Client related determinants ....................................................................................... 23 

2.8.3 Provider-Related determinants .................................................................................. 23 

 

CHAPTER THREE ......................................................................................................... 25 

METHODOLOGY ........................................................................................................... 25 

3.1 Introduction .................................................................................................................. 25 

3.2 Study Setting ................................................................................................................ 25 

3.3 Study Design ................................................................................................................ 27 

3.4 Study Population .......................................................................................................... 27 

3.4.1 Inclusion and Exclusion Criteria ............................................................................... 27 

3.5 Sample Size Determination .......................................................................................... 27 

3.6 Sampling Procedure ..................................................................................................... 28 

3.7 Study Instruments ........................................................................................................ 29 

3.7.1 Validity Test .............................................................................................................. 30 

3.7.2 Reliability Test .......................................................................................................... 30 

3.8 Data Collection Procedure ........................................................................................... 30 

3.9 Data Processing and Data Analysis ............................................................................. 31 

3.9.1 Data Processing ......................................................................................................... 31 

3.9.2 Data Analysis Method ............................................................................................... 32 

3.9.3 Ethical Consideration ................................................................................................ 32 

 

CHAPTER FOUR ............................................................................................................ 34 

RESULTS ......................................................................................................................... 34 

4.1 Introduction .................................................................................................................. 34 

4.2 Socio-Demographic Characteristics determinants ....................................................... 34 

4.2.1 Association between Socio-demographic determinants............................................ 35 

4.3 Client Determinants ..................................................................................................... 37 

4.4 Health Care providers‘ determinants ........................................................................... 38 



vi  

  

4.4.1 Time for Service Delivery ......................................................................................... 39 

4.4.2 Expertise of Health Care Workers ............................................................................ 39 

4.4.3 Post Care services ..................................................................................................... 40 

 

CHAPTER FIVE .............................................................................................................. 41 

DISCUSSION ................................................................................................................... 41 

5.1 Introduction .................................................................................................................. 41 

5.2 Socio-Demographic Determinants ............................................................................... 41 

5.3 Client Factors ............................................................................................................... 42 

5.4 Health care provider determinants ............................................................................... 43 

 

CHAPTER SIX ................................................................................................................ 45 

CONCLUSION AND RECOMMENDATION ............................................................. 45 

6.1 Introduction .................................................................................................................. 45 

6.2 Conclusion ................................................................................................................... 45 

6.3 Recommendations ........................................................................................................ 46 

6.4 Recommendations for further Research ....................................................................... 47 

 

REFERENCES ................................................................................................................. 48 

 

APPENDICES .................................................................................................................. 55 

Appendix I: Research Authorization .................................................................................. 55 

Appendix II: Research Authorization ................................................................................ 56 

Appendix III: NACOSTI Apporval ................................................................................... 57 

Appendix IV: Ministry of Health, Trans Nzoia ................................................................. 59 

Appendix V: Questionnaire Guide ..................................................................................... 60 

Appendix VI: Focus Group Discussion Guide .................................................................. 63 

 

 

 

 

 

 

 



vii  

  

 

LIST OF TABLES 

 

Table 1.1: Sub – county expected vs actual maternal uptakes and mortalities reported in 

2017 & 2018 ........................................................................................................................ 4 

Table 1.2: Maternal Health uptake among Health Centers in Kwanza Sub County ............ 5 

Table 3.1 Main Indicators of Kapkoi in 2019 .................................................................... 26 

Table 3.2: Summary of study population, selection criterion, sampling procedure and data 

collection method. .............................................................................................................. 29 

Table 3.3: Summary of data collected per week. ............................................................... 31 

Table 4.1: Socio-demographic aspects of the study respodents (n=266) ........................... 35 

Table 4.2: Relationship between socio-demographic determinants. (n=266) .................... 36 

Table 4.3: Relationship between clients‘ determinants and utilization of maternal 

healthcare services. (n=266) .............................................................................................. 37 

Table 4.4: Relationship between Healthcare provider factors and maternal healthcare 

utilization. (n=266 .............................................................................................................. 38 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



viii  

  

LIST OF FIGURES 

 

Figure 2.1: Conceptual Framework: Determinants of utilization of Maternal Services .... 24 

Figure 3.1: Map of Kapkoi Sub-Location, Kwanza Sub County ....................................... 26 

Figure 4.1: Chart showing time duration spent at the facility. ........................................... 39 

Figure 4.2: Chart showing summary of respondents on post care services ....................... 40 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



ix  

  

LIST OF ABBREVIATIONS AND ACRONYMS 

 

AIDS Acquired Immuno Deficiency Syndrome 

ANC Antenatal Care 

DEPAM Decentralized Education Programme for Advanced Midwives 

DOH Department of Health 

KDHS Kenya Demographic Health Survey 

KNBS Kenya National Bureau of Statistics 

MDGs Millennium Development Goals 

MMR Maternal Mortality Rate 

MOH Ministry of Health 

NCPD National Council for Population and Development 

NGO Non-Governmental Organization 

PHC Primary Health Care 

PMNCH Partnership for Maternal, Newborn and Child Health 

PNC 

PPE 

Postnatal Care 

Personal Protective Equipment 

SBA Skilled Birth Attendants 

SDGs Sustainable Development Goals 

SMR Saving Mothers Report 

SSA Sub-Saharan Africa 

TB Tuberculosis 

TBA Traditional Birth Attendant 

UN United Nations 

UNFPA United Nations Fund for Population Activities 

UNICEF United Nations Children‘s Fund 

WHO World Health Organization 

 

 

 

 

 

 



x  

  

OPERATIONAL DEFINITION OF TERMS 

 

Antenatal Care  Antenatal care is a set of healthcare services provided to pregnant 

women before childbirth. These services include regular check-

ups, medical examinations, and education about pregnancy and 

childbirth  

Chi-Square  The chi-square (χ²) statistic is a statistical test used to determine if 

there is a significant association or independence between two 

categorical variables in a dataset.  

Conceptual 

Framework 

 A conceptual framework is a structured representation of a theory 

or model used to explain or understand a particular phenomenon or 

set of relationships. It typically includes key concepts, variables, 

and their interconnections 

Health System  A health system is the combination of all organizations, 

institutions, resources, and individuals involved in delivering 

healthcare services to a defined population.  

Maternal Health  Maternal health refers to the physical, mental, and social well-

being of women during pregnancy, childbirth, and the postpartum 

period.  

Morbidity Morbidity refers to the prevalence of illness, injury, or health 

conditions within a specific population.  

Mortality Mortality refers to the number of deaths within a specific 

population during a particular time period.  

Postnatal Care  Postnatal care, also known as postpartum care, involves healthcare 

services and support provided to mothers and newborns in the 

weeks and months following childbirth.  

Postpartum 

Haemorrhage 

 Postpartum hemorrhage is a significant loss of blood from the 

genital tract after childbirth.  

Pre-eclampsia  Pre-eclampsia is a pregnancy complication characterized by high 

blood pressure and damage to organs, typically the liver and 

kidneys.  

Primary Healthcare  Primary healthcare is the essential and basic level of healthcare 

services provided to individuals and communities.  

Utilization  Utilization refers to the extent to which a healthcare service or 

resource is used by individuals or a community.  

 

 



xi  

  

 

ABSTRACT 

Maternal care is described as regular clinical and nursing care recommended for women 

of reproductive age during pregnancy, childbirth and postpartum. The maternal mortality 

rate in Trans Nzoia County, particularly at Kapkoi Health Center, was alarmingly high in 

2018, contributing to 19.5% of total maternal deaths in the county. A comparative 

analysis of health centres in the sub-county for 2017-2018 revealed that Kapkoi Health 

Center consistently had low maternal health indicators, with only 24% of women using 

antenatal care, 25% for skilled delivery, and 24% for postnatal care. The study sought to 

establish determinants of utilization of maternal healthcare services among women of 

reproductive age (15-49 years) seeking maternal healthcare services within Kapkoi 

Health Center. Specific objectives were socio-demographic, client and client 

determinants of utilization of maternal healthcare services among women of reproductive 

age (15-49 years).  The study adopted cross-sectional design. A simple random sampling 

technique was used to select respondents who visited the facility during the study period. 

The study sample consisted of 266 women of reproductive. The data was collected using 

simple structured questionnaire and focused group discussion guide. The descriptive 

result shows more the majority of study respondents had primary education 47.0% (125), 

a significant portion of the respondents were aged between 20-35 years 53.4% (142).The 

study used Chi-square test to determine associations between utilization of maternal 

services and demographic, client and health provider determinants. The significant 

demographic determinants of maternal healthcare services were education (χ2=1.5343 

df=3 p=0.037), age (χ2=18.143 df=2 p=0.016), gravidity (χ2=48.553 df=1 p=0.028), 

while no significant result were marital status (χ2=6.639 df=3 p=0.084) and occupation 

(χ2=3.010 df=3 p=0.536). The significant determinants of maternal healthcare services 

utilization for client determinants were religious practices (χ2=0.198 df=4 p=0.034), 

cultural practices (χ2=2.786 df=4 p=0.043) and perception (χ2=2,446 df=4 p=0.001), 

while no significant result were knowledge (χ2=0.198 df=4 p=0.978) and distance to the 

facility (χ2=6.315 df=4 p=0.177). Results provided by the respondents regarding 

healthcare provider determinants with significant results were quality of skilled personnel 

(χ2=17.897 df=4 p=0.046) and attitude of healthcare provider (χ2=6.345 df=4 p=0.026) 

while no significant determinants were availability of skilled personnel (χ2=14.567 df=4 

p=0.567). In conclusion, the study highlights the critical influence of skilled personnel 

availability, service quality, and healthcare provider attitudes on maternal healthcare 

utilization among women of reproductive age, with postnatal women showing more 

positive perceptions quality of service offered. The findings emphasized the need for 

healthcare facilities and policymakers to prioritize improving quality of maternal services 

by addressing variations in provider attitudes, and promoting patient-centred care to 

enhance maternal healthcare utilization and improve maternal and child health outcomes. 

More efforts should focus on enhancing healthcare provider attitudes and promoting 

patient-centred care during both antenatal and postnatal care to improve women's 

utilization of maternal healthcare services. Investment in the quality of maternal services, 

targeted information campaigns to address cultural and religious beliefs, awareness 

promotion of free maternal services, tailored interventions for antenatal and postnatal 

respondents, and addressing distance barriers to healthcare utilization are essential steps 

to enhance maternal healthcare access and quality of care.   



1  

  

CHAPTER ONE 

INTRODUCTION 

1.1 Introduction 

Maternal wellbeing is  the health of women during pregnancy, at childbirth and 

postpartum period. It entails the healthcare dimensions of family planning, 

preconception, both prenatal and postnatal care services to guarantee a positive satisfying 

experience, in most cases and reduce morbidity and mortality in other cases (Castella, 

2020). Maternal health revolves around the health and wellbeing of women, especially 

when they are pregnant and at the time they give birth, as well as the upbringing of the 

child. Despite the fact that motherhood has been considered a satisfying normal 

experience that is emotional to the mother, a high percentage undergo through difficulties 

where they suffer as a result of maternal health issue and a number of them even die as a 

result of maternal health complications (WHO, 2017).  

 

1.2 Background Information 

Maternal healthcare is a regular clinical and nursing care recommended for women of 

reproductive age during and after pregnancy (Cleland, 2019). Maternal care is a form of 

preventive measure with the aim of provision of routine medical check-up that permits 

healthcare workers and midwives to treat and prevent any potential medical conditions 

over a span of pregnancy and post-delivery period (Andersen, RM. & Newman, 2020). 

Antenatal healthcare offers women guidance and information on appropriate place to 

deliver, service to seek depending on condition of a woman (Ali, 2019). Likewise, it 

offers opportunity to inform women on possible danger that requires immediate attention 

from healthcare workers. Antenatal provides information which in turn assist in 

preventing severity of pregnancy related issues through follow ups, monitoring and 

treatment of illness and conditions during pregnancy such hypertension, malaria, anaemia 

which put at risk lives of both mother and the unborn baby (S.Banda, 2017). 

 

Complications associated with pregnancies and deliveries pose a major concern in the 

developing countries. It is also one of the major causes of death due to complication and 

disability among women of childbearing age in Kenya (Ochieng B.M, 2020). The main 

cause of maternal mortality and disability among women of reproductive ages are linked 

to puerperal sepsis, unsafe abortion, haemorrhage, and obstructed labor (UNICEF, 2017). 

Facility service provision has therefore become key part in utilization of maternal 



2  

  

services. There has been recommendation by World Health organization on women of 

reproductive age to carry case note to help in improving continuity and quality of 

care(WHO, 2017). 

 

The global maternal mortality ratio due to underutilization of maternal healthcare 

decreased from 385 deaths per 100,000 live births to 216 deaths per 100,000 live births, 

representing a 44% decline (UNFPA, 2017). This resulted in annual average reduction of 

2.3 %. Analysis done globally indicates that each continent has advanced in improving 

maternal wellbeing of every mother seeking healthcare services, despite the fact that level 

of maternal utilization remains unsatisfactorily high in Sub-Saharan Africa (UNFPA, 

2017). Any maternal death can be prevented as evidenced by huge gaps between the rich 

and the poor, lifetime hazard of maternal death in developed countries is 1 out of 3300 

compared to 1 out of 41 in third world countries (UNICEF, 2019).  

 

Report by UNICECF, 2019 indicates that the number of girls and women of reproductive 

age who die each year from maternal complications declined from 532,000 in 1990 to 

303,000 in 2017 (UNICEF, 2019). These deaths are associated with lack of utilization of 

maternal services. The report stated that for every woman who dies, estimated number of 

20 suffer from serious maternal injuries, infection or other forms of maternal disabilities. 

Close to all maternal complications and death occur in developing countries as a result of 

lack of quality maternal care (UNICEF, 2019).  

 

Maternal death and complication can occur any time without any sign at any given time 

when women do not seek the services at the right time (UNICEF, 2017). Most of the 

maternal deaths and complications can be avoided if done by skilled health professionals 

or midwives (Countdown to 2030, 2019). Complications require immediate access and 

utilization to quality obstetric services with fully equipped lifesaving drugs and oxygen, 

as well as the ability to provide blood transfusion needed to perform caesarean section 

and other surgical procedures (WHO, 2017).  

 

Globally 287,000 maternal mortality occurred in 2014, out of which 99 % (284,000) were 

from developing countries (WHO, 2017). Executing and guaranteeing utilization of 

maternal care is one of the most effective maternal health intervention for preventing 

deaths as well as maternal morbidity (Barrera, 2017). 



3  

  

In Kenya, most maternal deaths are directly related to lack of utilization of maternal 

services during pregnancy and childbirth, unsafe abortions, obstetric complication like 

severe bleeding (J.Kaggia, 2017). If women of child-bearing age fail to utilize maternal 

healthcare in good time, they may risk developing complications. The third goal of 

Sustainability Development Goals is aimed at increasing life expectancy by reducing 

some of the commonly known killer associated with child and maternal mortality 

(Countdown to 2030, 2019). This can be achieved by making progress towards achieving 

the target of less than 70 maternal deaths per 100,000 live births by 2030 consequently 

this would require improved skilled delivery, ensure healthy lives and promote well-

being for all age groups. The main goal is to reduce the global maternal burden; end 

preventable deaths of newborns and children. 

 

The government of Kenya through Ministry of Health, introduced free maternal services 

in 2013 through UHC in order to reduce high maternal mortality rate that was reported to 

be 488 deaths per every 100,000 pregnant mother, (KDHS, 2014).  Despite this 

intervention, only 62 % of births in Kenya were reported to be through skilled providers 

(KDHS, 2014). Similarly, 61 % of the deliveries were done at the health facilities 

(KDHS, 2014). The overall loss of pregnant mothers negatively affects the entire 

economy of a country in the long-term. To ensure effective policies and realization of 

Kenya‘s vision 2030 of a healthy population with low maternal mortality, there is need to 

study determinants of low maternal healthcare services uptake.   

 

In ensuring the quality utilization of maternal healthcare services, Kenya made various 

commitments; Recruitment and deployment of 20,000 primary health care workers, 

establishment of 210 primary health facilities to provide maternal and child health 

services and expand community health systems (MoH, 2019).  

 

The study on the determinants of low maternal healthcare utilization among women of 

reproductive age in Kapkoi Health Center, Trans-Nzoia County, Kenya, is necessitated 

by the consistently high maternal mortality rates in the Western regions, exemplified by 

an 8.1% maternal mortality rate (KHIS, 2018). This highlights a pressing public health 

concern with severe risks to the lives of women during pregnancy and childbirth, 

emphasizing the urgency of understanding the determinants contributing to limited access 



4  

  

to healthcare services and ultimately aiming to improve maternal and reproductive health 

outcomes in the region. 

 

Table 1.1: Sub – county expected vs actual maternal uptakes and mortalities 

reported in 2017 & 2018 

Facilities in Kwanza Sub 

County 

Expected 

Annual 

Maternal 

Uptake 

Actual 

maternal 

uptake (%) 

Annual Maternal 

deaths Reported in 

2017 & 2018 (per 1000 

population) 

2017 
             

2018 

Keiyo Health Center 588 60% 13 8 

Muungano Health Center 550 58% 9 7 

Kolongolo Health Center 500 65% 5 3 

Kapkoi Health Center 1786 36% 24 25 

Biketi Health Center 380 48% 16 10 

Source: Adopted and modified from KHS Report, 2018 

 

1.3 Statement of the Problem 

The high maternal mortality rate is a critical issue affecting women of childbearing age 

(15-49 years) in Trans Nzoia County, with a significant and alarming number of 

maternal-related deaths reported by the Ministry of Health (MoH, 2018) particularly at 

Kapkoi Health Center. These fatalities account for a substantial portion, representing 

19.5% of the total maternal deaths in the county. Furthermore, a comparative analysis of 

health centers within the sub-county for the period 2017-2018 reveals that Kapkoi Health 

Center consistently reports the poorest maternal health indicators, with antenatal, skilled 

delivery, and postnatal care utilization rates at just 24%, 25%, and 24%, respectively. 

Additionally, according to Trans-Nzoia County report at glance, County Health 

Management Team's site support supervision conducted in 2019, ranked Kapkoi Health 

Center as the lowest-performing facility among 11 health centers with same level as 

Kapkoi Health Center, specifically in terms of maternal services offered to the women of 

reproductive age (MoH, 2019). Despite concerted efforts by both the National and County 

Governments to enhance maternal health indicators and service accessibility, Kapkoi 

Health Center remains a facility with notably low maternal service uptake. Hence, this 

study sought to investigate the determinants influencing the utilization of maternal 



5  

  

healthcare services among women of reproductive age seeking care at Kapkoi Health 

Center. 

 

Table 1.2: Maternal Health uptake among Health Centers in Kwanza Sub County 

Maternal 

Service 

Keiyo H/c 
Muungano 

H/c 

Kolongolo 

H/c 

Kapkoi 

H/c 
Biketi H/c 

201

7 

201

8 
2017 

201

8 
2017 

201

8 

201

7 

201

8 

201

7 

201

8 

ANC 

Attendance 

38

% 

37

% 
34% 

40

% 
51% 

54

% 

26

% 

24

% 

38

% 

30

% 

Skilled Delivery 
35

% 

39

% 
44% 

44

% 
52% 

52

% 

27

% 

25

% 

35

% 

47

% 

Unskilled 

Delivery 

45

% 

44

% 
36% 

34

% 
36% 

28

% 

61

% 

58

% 

40

% 

38

% 

PNC Attendance 
43

% 

45

% 
38% 

42

% 
48% 

46

% 

27

% 

24

% 

40

% 

43

% 

Source: Adopted and modified from Trans-Nzoia Health, 2019 

 

1.4 Research Objectives 

1.4.1 General Objectives 

To find determinants of utilization of maternal healthcare among women of 

reproductive age seeking services at Kapkoi Health Center, Trans Nzoia county. 

 

1.4.2 Specific Objectives 

1. To identify socio-demographic determinants of utilization of maternal healthcare 

among women seeking services at Kapkoi Health Center, Trans-Nzoia County. 

2. To identify clients‘ determinants of influencing utilization of maternal healthcare 

among women of reproductive age seeking service at Kapkoi Health Center, 

Trans Nzoia County. 

3. To identify health provider‘s determinants of utilization of maternal healthcare 

among women of reproductive age seeking services at Kapkoi Health Center, 

Trans Nzoia County. 

 



6  

  

1.5 Research Question 

1. What are the socio-demographic determinants influencing utilization of maternal 

healthcare services among women of reproductive age seeking services at Kapkoi 

Health Center, Trans Nzoia County? 

2. What are the clients‘ determinants of utilization maternal healthcare service 

among women of reproductive seeking services at Kapkoi Health Center, Trans 

Nzoia County? 

3. What are the health provider‘s determinants influencing utilization maternal 

healthcare services among women of reproductive age seeking services at Kapkoi 

Health Center, Trans Nzoia County? 

 

1.6 Justification  

Maternal mortality remains a critical concern, and Kapkoi Health Center has consistently 

reported alarmingly high maternal mortality rates (MoH, 2019). By conducting this study, 

the findings aim aim to uncover the underlying socio-demographic determinants that 

contribute to low maternal healthcare utilization in the region. This knowledge is essential 

for policymakers, healthcare providers, and community stakeholders who seek to improve 

the quality and accessibility of maternal healthcare services. Understanding these 

determinants will enable targeted interventions and policy adjustments to mitigate the 

existing barriers and ultimately enhance the health and well-being of women in their 

childbearing years. 

 

Furthermore, addressing the issue of low maternal healthcare utilization at Kapkoi Health 

Center is critical in the context of broader national and international goals. Both the 

Kenyan government's Ministry of Health Plan (MoH, 2019) and the National 

Reproductive Health Strategy for Kenya (NRHSK, 2019) have set ambitious targets to 

reduce maternal mortality and improve maternal health services. Despite these efforts, 

Kapkoi Health Center continues to lag behind in terms of maternal service uptake. The 

study will align with these national objectives and seek to contribute meaningfully to the 

achievement of the 90% utilization target in maternal healthcare services for all counties. 

The findings will inform evidence-based policies and interventions that can serve as a 

model for other high-burdened facilities facing similar challenges. 



7  

  

1.7 Significance  

First, this study has the potential to improve maternal health outcomes by identifying and 

addressing the barriers that hinder women from accessing crucial healthcare services. 

High maternal mortality rates are a pressing concern, and this study's findings can pave 

the way for targeted interventions and policies that will contribute to saving lives and 

enhancing the overall quality of life for women in their childbearing years. The study also 

provides healthcare workers with additional knowledge and information on how best they 

should improve maternal clients attending antenatal visits in their facilities to minimize 

the low turnout during delivery and postnatal services. 

 

Lastly, the study's significance extends to the realm of policy and program development. 

The insights gained from this research can serve as a valuable resource for policymakers, 

healthcare administrators, and public health experts. By understanding the specific socio-

demographic determinants that influence maternal healthcare utilization, these 

stakeholders can make informed decisions and create tailored interventions to better meet 

the needs of women in the region. This research provides a foundation for evidence-based 

decision-making, which can lead to more effective and efficient solutions to a critical 

public health issue. 

 

1.8 Limitation of the Study 

Despite the contribution of the study to the literature on utilization of maternal healthcare 

services, the study had one limitation. The study was affected by Covid-19 outbreak. The 

researchers and participants were at risk of exposure. All those who participated in this 

research were provided with facemasks and sanitizers during the entire data collection 

period.  

 

 

 

 

 

 

 

 

 



8  

  

CHAPTER TWO 

LITERATURE REVIEW 

2.1 Introduction 

This section entails general oversight on utilization maternal burden, overview of 

maternal Care and its role and value in birth preparedness, overview of strategies of 

reducing maternal mortality, gaps in the current maternal health system and barriers to 

maternal health care at client, health care provider and facility level. From the review of 

various literature, theoretical and conceptual frameworks of this study were developed. 

 

2.2 Maternal Mortality 

Estimates of Maternal Mortality Ratio (MMR) from the Maternal Mortality Working 

Group showed that there were 536,000 maternal fatalities in 2018, or a rate of 402 deaths 

per 100,000 live births, with 50% of such deaths recorded in Africa (900/100,000 live 

births) and 46% in Asia (Hill et al., 2020). According to a recent report by the Maternal 

Mortality Network, South Asia and sub-Saharan Africa (SSA) has the highest MMR rates 

by far. The Maternal Mortality Network emphasized on how challenging it was to 

acquire precise estimates of maternal mortality and morbidity, partly due to the form and 

results of the measure in issue   (Annamama, 2016). 

 

 According to a study by Annamama on maternal and child mortality in Africa, 3000 

untrained midwives performed over 55% of deliveries and were utterly to blame for the 

high death rate (Annamama, 2016). Even in nations with highly developed health 

information systems, it is challenging to collect valid measurements when health 

information systems are poor (e.g., India and China). This study aims to provide readers 

with an overview of current research on birth attendants' impact on maternal health 

treatments and outcomes. It will summarize the critical findings of a significant study 

carried out in developing nations, paying particular attention to disadvantaged women 

and their families who reside in distant rural areas and are inaccessible to adequate 

referral health facilities (Chakraborty, 2017). 

 

2.3 Theoretical Literature Review 

Caregiving for pregnant women, young mothers, and infants have been traditionally 

perceived as a private matter, the purview of midwives and mothers. Maternal care began 

in Europe in the late 19
th

  century when claims that unhealthy children compromised their 



9  

  

aspirations for culture and the military began to view healthy mothers and children as 

economic, political, and military resources (Graham, W.J., Bell, J.S. & Bullough, 2016). 

Birth assistance was conducted by shepherds who had prior expertise with the delivery of 

sheep; caring for pregnant women and giving birth is similar to caring for an egg. When 

archaeologists utilized evidence of a woman crouching in delivery assisted by some other 

woman from behind, they showed that safe practices had been documented in Egypt as 

early as 5000 BC (Filippi V., 2018). 

 

In his first book on midwifery, published in 2019, William Wolfe noted that women often 

waited to seek medical attention until their labor that was hopelessly blocked, since in the 

event of pelvic deformity, this may result in both the mother and the child's death (Wolfe, 

2019). There is evidence from most research that maternal health care services use is 

related to variables including income, education, ethnicity, religion, culture, age, and 

degree of decision-making.  Customers seek health for two main reasons: as a consumer 

good and as a commodity. Healthcare needs are derived from health demand, while 

health demand is derived from utility demand. Health enters the client's utility function as 

a consumer good, but as an investment, it establishes the context of time and necessity 

(Graham, W.J., Bell, J.S. & Bullough, 2016). 

 

A regular time of labor and lack of transportation, the expense of treatment, spouses' 

preferences, attitudes toward health care personnel, and women's prior experience and 

habits are some of the elements that affect how often people use health facilities (Mwabu, 

2017). Research on travel costs, medications, bad roads, a lack of services at night, verbal 

abuse, a bad attitude among certain healthcare professionals, and long hours were 

conducted (Ochako, R.; Fotso, J. C.; Ikamari, L.; Khasakhala, 2019). 

 

2.4 Underlying Determinants of Maternal Health 

Health is more than merely a medical concern driven by biological elements and 

treatments. The environment we live in, the activities we engage in, the people we 

connect with, and the kind of relationships we have all impact our health (Abbas, R. K., 

2015). Thus, health results from how our biology interacts with the physical, 

socioeconomic, cultural, and political environments in which we live; in other words, it is 

socially driven. As a result, socioeconomic class inequalities and biological variances 

contribute to differences in people's health status. Socioeconomic class, clor, ethnicity, 



10  

  

gender and other social determinants including risk and suspectibility, health-seeking 

behavior, access to healthcare, and long-term health and social implications (Nicole et al, 

2018). Social determinants of health significantly influence women's capacity to attain 

maternal and reproductive health. The decision of a woman to seek medical attention 

may be affected by her partner or other family members, social norms, her education, her 

social standing, the distance between her home and the clinic. The severity of her illness, 

her prior experiences with the medical system and how she expects to be treated by 

medical professionals, her level of household decision-making power, and her access to 

credit, land, and income (Chepkoech et al, 2018). It is crucial to consider how social, 

cultural, economic, and health system issues affect maternal health and maternal 

mortality. The utilization of maternal healthcare services among women of reproductive 

age is a multifaceted issue influenced by various determinants. This theoretical literature 

review focuses on three specific objectives: socio-demographic determinants, client 

determinants, and health provider determinants. These objectives aim to fully understand 

the determinants that shape maternal healthcare utilization. 

 

2.4.1 Socio-Demographic Determinants 

The sociodemographic makeup of women, culture and the accessibility of services may 

influence how often women in underdeveloped nations utilize maternal health care 

(Manishimwe C, 2017). These determinants play a crucial role in influencing maternal 

healthcare utilization. Income, as a key socio-demographic determinant, affects a 

woman's ability to access and afford healthcare services. Lower income levels often 

result in reduced utilization due to financial barriers (Shiffman, J. J. & Sultana, 2019). 

Similarly, educational attainment is vital, as women with higher education tend to seek 

maternal healthcare more often, demonstrating the importance of health literacy. The 

majority of studies published by researchers focused on quantitative research to 

determine the relationship between sociodemographic characteristics and the use of 

antenatal care services (Cleland, 2019), while some qualitative research was discovered 

to be primarily focused on women's perceptions and barriers to improving maternal 

health care services (Chakraborty, 2017). 

 

A woman's level of education plays in shaping her healthcare-seeking behaviour. 

Research conducted by Harley (2019) establishes that a woman's educational attainment 

serves as a robust predictor of the frequency of maternity visits, consequently influencing 



11  

  

the likelihood of achieving the requisite number of antenatal care (ANC) and postnatal 

care (PNC) visits (S.J Harley, 2019). Furthermore, findings by Matthews et al. (2018) 

accentuate that women with higher educational backgrounds exhibit a propensity to 

initiate their maternity visits early, underscoring the link between education and timely 

healthcare access (Mathew et al., 2018). However, it is imperative to acknowledge 

regional variations, as a study in West Africa conducted by Rowland identifies no 

significant correlation between education and the utilization of ANC and PNC services 

(Rowland K.L, 2020) . 

 

Exploring into the regional context of Sagamu, South-Western Nigeria, Iyaniwura and 

Yusuf's study (2019), encompassing 392 women who had experienced at least one full-

term pregnancy, illuminates the profound impact of socioeconomic factors on maternity 

care patterns (Ajayi, O. & Jibowo, 2018). The research underscores that elevated levels 

of wealth and educational attainment wield a favourable influence on the utilization of 

essential maternity services (Ajayi, O. & Jibowo, 2018). An in-depth cross-sectional 

community-based study conducted in Munesa Woreda, Arsi Zone, Oromia Region, 

Southeast Ethiopia, paints a distinct picture. Among 1055 mothers who had given birth 

within 12 months prior to the study, only 18.3 percent experienced childbirth at 

healthcare facilities, highlighting the prevalence of home births (Amano et al., 2016). 

Intriguingly, this study reveals that the educational levels of both husbands and mothers, 

particularly those with secondary and higher education, significantly impact the provision 

of healthcare in institutions (Amano et al., 2016). 

 

Furthermore, a comprehensive cross-sectional community household survey conducted in 

the Luwero area of Uganda examines prenatal and postnatal attendance rates among 769 

women. The findings divulge a robust prenatal and postnatal attendance rate of 94.4 

percent (Kiwuwa et al., 2018). Notably, women with post-primary education 

paradoxically exhibit a lower likelihood of attending four or more sessions, shedding 

light on the nuanced influence of education on healthcare-seeking behavior (Kiwuwa et 

al., 2018). 

 

The significance of women's education extends beyond quantitative metrics and is pivotal 

in understanding the quality and impact of maternity care dispensed by ANC clinics, as 

revealed in qualitative data analysis by Mumtaz and Salway (2015). Furthermore, the role 



12  

  

of the husband's educational level in shaping the utilization of ANC and PNC services 

comes to the forefront in various studies (Muntaz N.Z & Salway G.F, 2015). While 

research conducted in Andhra Pradesh underscores the statistical significance of the 

husband's education level (Navaneetham & Dharmalingam, 2020), it is essential to note 

contrasting results from a Karnataka study, demonstrating the multifaceted nature of this 

relationship. Interestingly, the Philippines presents a unique perspective where husband 

education emerges as a more potent predictor compared to wife education (Filippi V., 

2018). 

 

The determinants influencing maternal healthcare utilization encompasses the education 

of mothers and its influence on healthcare worker-family interactions. A community 

situational analysis conducted in South Africa emphasizes that maternal education 

significantly shapes the dynamics of these interactions, thereby influencing healthcare 

access (Tlebere et al., 2017). Consequently, the study underscores the importance of 

evaluating and addressing the myriad obstacles preventing communities and families 

from actively participating in and utilizing maternity care (Tlebere et al., 2017). These 

collective findings underscore the multifaceted interplay of educational determinants in 

maternal healthcare utilization, urging the development of tailored interventions to 

enhance maternal and child health outcomes. 

 

Researchers discovered that maternal visits were substantially related to the sequence and 

spacing of births. Higher order births were attributed to the delayed or insufficient usage 

of ANC (Navaneetham & Dharmalingam, 2020). Women from nuclear families were 

much less likely to need maternity services than women from extended/joint families, 

proving that family size and structure were significant variables in this area (Matsumura 

& Gubhaju, 2019). Frequent maternity visits were made for births that occurred more 

than three years after the previous one than those that occurred within two years (Magadi 

et al., 2016). Furthermore, women whose pregnancies were "unwanted" had later 

beginnings and fewer visits, making the desire to get pregnant a statistically significant 

factor in determining how often they used maternity services, including ANC, PNC, and 

delivery (Magadi et al., 2016). 

 

The age of women upon marriage and pregnancy is positively correlated with the use of 

maternity care. The age at marriage was positively associated with access to or 



13  

  

attendance at maternity care in rural north India (Pallikwadha S., 2016). Maternal 

healthcare service  was not significantly correlated with age at marriage (Potter & 

Obbermeyer., 2017). Compared to teens and older women, most women in their thirties 

attend maternity care visits earlier and more often (Mathew et al., 2018). Younger 

women preferred frequent clinic visits to be reassured that the baby was developing 

typically and to understand its location. Still, older women with no difficulties were 

unconcerned with regular visits (Mathole et al., 2019). However, several research 

indicated that the use of maternal care was not significantly predicted by the age of the 

women (Kabir et al., 2018). 

 

2.4.2 Client Determinants 

Client determinants encompass a wide range of personal and cultural factors that 

influence maternal healthcare utilization. Cultural norms, beliefs, and traditions can 

significantly affect a woman's decision to seek healthcare during pregnancy and 

childbirth. Perceptions of the value and safety of traditional practices versus modern 

healthcare services can be pivotal. The use of maternal services was attributed to 

determinants such as proximity to the hospital, higher levels of formal education, higher 

travel expenses (affordability) to the closest clinic, and being single. The mother's or 

mother-in-laboring law's experiences heavily affected the decision to deliver at home 

(Peltzer et al., 2016). 

 

Schiller and Levin (2016) highlighted the influence of religious factors on healthcare 

utilization, noting a consistent association between religion and improved health 

outcomes (Gymah et al., 2017). Religion, as a significant social institution, plays a 

pivotal role in shaping individual and community health behaviours by impacting 

lifestyles, worldviews, and motivations (Benjamin et al., 2018). However, it's essential to 

recognize that different religious groups may hold varying perspectives on healthcare and 

health-related issues. For instance, among ultra-conservative Apostolic groups in 

Zimbabwe, faith healing and strict adherence to church beliefs often hinder modern 

healthcare seeking (Maguranyanga, 2019). Jehovah's Witnesses, another Christian 

denomination, discourage blood transfusions based on specific Biblical interpretations 

but are open to medical alternatives (Loma Linda University, 2018). Contemporary 

Pentecostal Christian groups generally have more liberal health-related teachings but 

often emphasize seeking spiritual counsel and faith healing before turning to medical 



14  

  

treatments (Oyedepo, 2017). Similar beliefs are held by some Muslim communities, 

where the causes of health problems may be attributed to a combination of medical and 

spiritual factors (Curlin S., 2018). The intertwining of spirituality and healthcare 

decisions significantly influences when individuals seek medical help and when they 

choose formal medicine. This aligns with the health beliefs of adherents of traditional 

religions who often resort to traditional remedies before considering modern healthcare 

services (Oyedepo, 2017). 

 

Despite the pervasive role of supernatural beliefs in explaining individual health 

situations, it's surprising that religion has not been extensively harnessed to promote 

maternal healthcare utilization in Nigeria. The National Population Policy for Sustainable 

Development encourages collaboration with religious organizations but primarily urges 

them to promote reproductive health services in accordance with their beliefs rather than 

devising religion-friendly programs to address the country's maternal health challenges 

(NPoC, 2016). 

 

This study's theoretical framework is based on functionalism views religion from the 

perspective views on maternal, societal needs and categorizes human society into 

"sacred" and "profane" worlds, with religion being an integral part of the sacred, 

influencing human actions and behaviors. Religion contributes to social cooperation, 

order, and control, essential conditions for societal progress (Durkheim R., 2017). 

Modifications to this perspective, such as Malinowski's and Parsons' contributions on 

maternal healthcare, further emphasize religion's positive contributions to society by 

providing general rules for human behavior and criteria for evaluating human conduct 

(Parson, 2018). However, it's essential to acknowledge that the functionalist perspective 

has limitations, particularly in accounting for the abnormal operations of religion, such as 

conflicts and insurgencies in various parts of the world. 

 

Contrary to the functionalist perspective, Marxists assert that religion serves the interests 

of the ruling class by fostering class ideologies and pacifying the oppressed. Marx and 

Lenin described religious beliefs as tools for promoting class ideology and maintaining 

the status quo (Haralambo et al., 2017). While these perspectives provide insights into the 

role of religion in society, the Nigerian context demonstrates that religion, both 

Christianity and Islam, plays a significant role in supporting positive maternal health 



15  

  

outcomes. Faith-based health institutions are widespread in the country, serving urban 

and rural areas. Additionally, religious organizations have actively aligned themselves 

with public health initiatives during health crises, such as the Ebola pandemic, by 

implementing measures to prevent the spread of contagious diseases. However, despite 

these contributions to public health, there is a significant gap in harnessing the potential 

of religion to enhance maternal healthcare utilization in Nigeria (NPoC, 2016). 

 

2.4.3 Health Provider Determinants 

The role of health providers in maternal healthcare utilization cannot be underestimated. 

The attitude, competence, and availability of healthcare providers significantly influence 

a woman's decision to seek maternal care. A respectful and supportive healthcare 

environment encourages utilization, while a lack of trust or negative experiences can 

deter women from accessing services. 

 

The location and infrastructure of healthcare facilities, along with the quality of care 

provided, are critical health provider determinants (Hill et al., 2020). Proximity to 

healthcare facilities, especially in rural areas, affects access. Additionally, healthcare staff 

shortages and lack of necessary equipment can hinder utilization (Hill et al., 2020). 

Services provided by qualified workers are generally seen as a critical approach to 

lowering maternal and infant mortality. The rates of skilled attendance at delivery are 

normally used as an indicator for monitoring the Millennium Development Goal of 

enhancing maternal health services. In certain countries, little progress has been achieved 

regarding raising competent attendance rates during deliveries. According to the 2014 

Kenya Demography Health Survey, the number of experienced midwives present during 

deliveries has decreased (KDHS, 2014). 

 

Given the difficulties confronting health care resources in most countries, the provision 

of health facilities offers women the chance to obtain support from qualified staff. Since 

many fatalities occur during and during labor, medical institutions ensure that the birth 

process runs smoothly and with the appropriate care. As a result, expert birth attendance 

is required (Bun et al., 2018). To encourage facility deliveries, the Kenyan government 

launched a program in 2013 that provided free maternity care in public health facilities 

(Bournamnais, 2018). Given that the government instituted free maternity care in 2013, 

the 2014 KDHS reported that 61 percent of women who had recently given birth 



16  

  

delivered in health facilities, which is relatively low compared to the anticipated number 

of births (KDHS, 2014). 

 

All women should have access to affordable, primary maternity care that includes high-

quality prenatal care, clean, safe deliveries, and postpartum care for both mothers and 

babies. It is essential to get high-quality treatment from qualified staff to avoid 

complications. Eligible staff must access necessary medications, equipment, and 

emergency care, which are only available in health facilities (UNICEF, 2019). 

 

There are substantial differences in service usefulness across the areas. In the world, 

trained medical proffesionals perform 68 percent of deliveries, which is a little low given 

that most nations have made significant investments in the health sector. Globally, 

trained proffesionals, compared to slightly over half of births in rural regions perform 87 

percent of deliveries in metropolitan areas. There are notable discrepancies in certain 

African nations, where women in urban areas are twice as likely compared to women in 

rural regions to deliver their babies with the help of experienced professionals (UNICEF, 

2019). 

 

Compared to 78 percent in the Western Region and 70 percent in other Kenyan 

metropolitan regions, only 48 percent of women in Western Kenya give birth in health 

facilities that meet at least the basic requirements (Chepkoech, 2018). Research 

conducted in the Nyanza province in 2007 showed that awareness of maternal health 

issues and complications did not lead to increased hospital deliveries (MOH, 2016). 

 

More than half of the incidents of maternal mortality included poor medical treatment, 

with the majority occurring at the primary health care level (Penn-Kekana, 2017). The 

main issue was that 40% of healthcare professionals failed follow the recommended 

procedures, particularly in level 2 hospitals (44%) (Penn-Kekana, 2017). Additionally, 

there were issues with the capacity of healthcare professionals to conduct an initial 

examination (24%) and identify problems (34%). Once again, this essentially happened 

at the primary healthcare level (49% and 50%, respectively) (Penn-Kekana, 2017). In 11 

percent of the instances (mainly at the primary level), the incorrect diagnosis was made, 

and 22 percent of the cases included inadequate patient monitoring and failure to react to 

anomalies in the monitoring (mainly at the secondary level of care). Health care 



17  

  

personnel's judgments to send patients (9% in 1998 rising to 17% in 1999–2011) and 

addressing 35 issues related to maternal health at the incorrect level of care showed a 

considerable worsening (9% in 1998 to 17 percent in 1999-2011). These issues may have 

arisen due to inadequate transportation, difficulties understanding the seriousness of the 

ailment, or the absence of a designated referral hospital that will take the patient (MOH, 

2016).  

 

Government and international organizations have identified measures to reduce maternal 

mortality as one area supporting women's maternal health. To promote health and reduce 

maternal mortality, a lot of strategies need to be considered. Concerns have been raised 

about women's rights and taking center stage to encourage safer pregnancy; this was 

thought to be one of the result  (OECD, 2018). Consider maternal mortality while 

promoting maternal and reproductive health rather than population control and fertility. 

 

Some international organizations have approved making maternal health one of the 

MDGs, intending to reduce maternal death by 75% between 1995 and 2017. This is in 

favour of promoting maternal health as one of the top issues that need be considered and 

handled (UNICEF, 2019). The overwhelming evidence of the significant burden of 

maternal fatalities led to this. The International Conference on Population Development 

urged the government, funders, and other health stakeholders to assist in lowering the 

number of maternal fatalities by 2020 (UNICEF, 2019). 

 

2.5 Barriers to providing optimum maternal care  

From 1991 to 2011, administrative issues caused 42 percent more maternal deaths than in 

1998, indicating a steady decline in maternal health services (UNICEF, 2017). Despite 

national maternity guidelines, the development of plans at the provincial level has been 

uneven. Only 62 percent of the 141 public health facilities that underwent a thorough 

evaluation in 2002 had access to maternity care guidelines (Smith & Houston., 2016). It 

is a concern that the lack of adequately trained staff accounted for 22 percent of the 

administrative issues, given that one of the main strategies for reducing maternal 

mortality is the promotion of skilled attendants at birth. Was it due to a lack of training, 

or were there other factors, as asked in the 2
nd

 Saving Mothers Report, that health 

workers did not follow the protocols? (UDHS, 2016). Several programs are in place to 

enhance the caliber of midwifery skills through in-service learning. The four-year 



18  

  

introductory course that now makes up nursing training includes a year of midwifery, 

whose caliber is well-known internationally. Still, the Perinatal Education Programme 

(PEP) and the Decentralized Education Programme for Advanced Midwives are the most 

significant (DEPAM). 

 

The ongoing priority is increasing staff capacity, but issues with brain drain, 

demotivation, insufficient staffing, frequent ward rotation, and unfavorable working 

conditions undoubtedly affect how well healthcare workers perform. Additionally, to 

address the skills gap in rural areas, the Department of Health recently made one-year 

community service a requirement for the registration of all doctors (Penn-Kekana, 2017). 

However, the issue of a lack of personnel was pointed out as a preventable factor. This 

might result from the staff considering insufficient staffing to be expected or the assessor 

not having enough information at their disposal to classify it as an avoidable factor 

(MOH, 2016). Transportation issues between institutions caused thirteen percent of 

maternal fatalities, this undoubtedly contributed to referral delays (17%) or patient 

management at an inappropriate institution (17%), with the latter two indicating issues 

with healthcare providers. Provinces experienced different transportation issues, with 

Gauteng and the Western Cape having the fewest issues and Mpumalanga and the 

Eastern Cape has the most (Tlebere et al., 2017). According to data from the 2010 

National Primary Health Care Survey, 23% of clinics lack access to an ambulance (Penn-

Kekana, 2017).11 percent of maternal deaths were caused by a lack of medical facilities, 

including intensive care units, blood transfusion services, drugs, and laboratory facilities 

(WHO, 2017). 

 

2.6 Improving Maternal Health through Sustainable Development Goal 

The third Millennium Development Goal is to safeguard everyone's health and wellbeing 

at all ages and in all environments, primarily humanitarian and vulnerable ones. The Goal 

encompasses all main health goals, including universal health coverage, access to quality, 

affordable medicines and vaccinations for everyone, sexual and reproductive health, 

maternity and newborn health, child and adolescent health, communicable, non-

communicable, and environmental illnesses. Additionally, it asks for more health-related 

research and development, expanded and diversified health finance, improved health 

workforce, and better health risk reduction and management capability across all nations 

(UDHS, 2016). The attainment of these objectives is mainly dependent on universal 



19  

  

health coverage (UHC). As the health emphasis shifts to deal with the dual burden of 

long-held priority in contagious illnesses, the unfinished MDG agenda, and emergent 

challenges, including NCDs and injuries, investment in all of the health-related goals in 

the 2030 agenda is a must. 

 

In 2015, the worldwide maternal mortality ratio (MMR) was 216 per 100,000 live births, 

meaning that around 303,000 women and girls lost their lives due to difficulties with 

pregnancy or delivery (WHO, 2017). Increasing the yearly decrease by at least 7.3 

percent, which is more than quadruple that achieved between 1990 and 2015. Because 

the relevant health measures are available and well understood, most maternal fatalities 

may be avoided (UNICEF, 2017). To prevent unintended pregnancies, it is crucial to 

improve pregnant women's and girls' access to high-quality care before, during, and after 

delivery. One of the most significant barriers to improved health for women and girls 

during pregnancy and delivery is a lack of trained care, which has been been due to 

worldwide scarcity of certified health professionals, notably midwives. Professionally 

trained midwives and other people with midwifery abilities have been essential to success 

in all nations that have reduced maternal mortality (UNFPA, 2017). 

 

Only 76% of women in developing countries get expert care during delivery (WHO, 

2017). This implies that millions of births take place without the help of a midwife, 

doctors, or nurses with training. The incapacity or delay in obtaining treatment continues 

to be affected by the uneven position of women and girls. In addition to health system 

interventions, societal impediments such as lack of information, decision-making, and 

financial power, often caused by discrimination in law and practice, violence against 

women and girls, and gender stereotypes, must be addressed (Piroska, 2017).  

 

Campbell et al. (2017) presented critical lessons from the pooled results in a 

comprehensive evaluation of tactics implemented to decrease maternal mortality (Campel 

et al., 2017). No one intervention (e.g., pharmacological treatments, health education) 

alone will lower the incidence of maternal death. Strategies will be successful if the 

component packages are efficient with high target group coverage. Prioritizing the 

intrapartum period is a requirement by the epidemiology of maternal mortality (Liu et al., 

2018). This finding is supported by the literature from various studies, where researchers 

promote health center intrapartum care as a beneficial tactic. There will be more chances 



20  

  

to prevent mother mortality during prenatal care, postpartum care, family planning, and 

safe abortion (Meija & Rezeberga, 2017). This supports the necessity for a continuum of 

care strategy that considers the full reproductive life cycle rather than just pregnancy. The 

main finding of this research is that a full range of services, including ANC, that are basic 

for birth preparation through delivery interventions and post-partum care. The most 

crucial time for prenatal care is during pregnancy, when difficulties might arise and can 

treated by trained medical professionals (WHO, 2017). 

 

In a review study, Koblinsky et al., (2017) commented on moving to scale with 

professional healthcare (Koblinsky & Marjorie, 2017). The researchers who referenced 

an examination of 40 nationally representative household surveys found considerable 

growth in doctor-assisted deliveries, with most births accounted for in the public sector 

that the rising trend of women using private facilities. Despite the promising rise in 

access to maternal health services, Kolinsky reminds us that one in four women remain 

without obstetric care. The study suggested that the biggest hurdle to scaling up maternal 

health care is the paucity of competent health professionals, insufficient health system 

infrastructure, inferior quality of treatment, and women‘s unwillingness to utilize 

maternal health services. Based on a meta-analysis of 40 household surveys covering 45 

percent of the developing nation populations, they extrapolate existing behaviours and 

outcomes for reproductive and maternal health (WHO, 2017). Some significant results 

include; Progress in maternal healthcare is hampered by stagnation in rural regions, 

primarily in sub-Saharan Africa, key contributing factors include low quality of 

healthcare and lack of access by impoverished rural women to services. Sustained 

healthcare during and after birth depends on training, deployment and retention of health 

personnel. Teams of midwives and midwife helpers working in facilities will enhance 

coverage by up to 40 percent by 2030 (Moyer, 2017). 

 

Political commitment is necessary to address the most pressing safety gaps for mothers. 

The authors of a review on human resources and access to maternal healthcare call for a 

substantial rethinking of the problem of human resources and the division of labor among 

the many cadres of health and community workers engaged in supporting maternity 

healthcare (Moyer, 2017). The conclusion transferred attention from the immediate 

assumption that lives are saved by direct involvement to that of the social and 

community, and even farther to the political arena, including; High political commitment 



21  

  

to improve maternal health, as shown in Sri Lanka, Egypt, and Malaysia, nations that 

have been effective in decreasing the MMR. Contributions to social and economic 

progress, particularly those towards gender equality. Strengthening health systems with a 

focus on establishing referral networks and access that do not have significant 

opportunity costs on women's access. 

 

A crucial set of evidence-based services includes family planning, risk-free abortion, and 

thorough obstetric care. Investing in human resources to the fullest, including hiring a 

team of trained midwives and birth attendants who can assist women before, during, and 

after delivery. No one measure alone contributes to a decrease in the high maternal death 

rates; all of the above factors must be present. Nonetheless, it is noteworthy that SDG 3 

has placed a greater focus on the availability of qualified birth attendants than on many 

other equally important factors. This may be ascribed to credible data from nations that 

have seen substantial reductions in maternal mortality. Some of the critical elements that 

have helped these nations achieve such noteworthy accomplishments include the 

availability of experienced birth attendants and their effective expansion of coverage in 

China, Jamaica, and Egypt, as well as the presence of births in  facilities in each of these 

nations (Koblinsky & Marjorie, 2017). The lengthy history of professional midwifery in 

Sri Lanka allowed for a high percentage of competent providers at the village level and 

the concurrent availability of operational emergency obstetric facilities (UNFPA, 2017). 

 

2.7 Gaps in current maternal health research 

In the area of mother and newborn health, most evidence are based on retrospective 

survey methods, quasi-experimental methods using randomized control trials, and future 

qualitative research in conjunction with data from healthcare facilities. Due to ethical 

concerns, randomized control trials are normally not used to evaluate TBA competence. 

Comparing data from intervention and control areas to assess the results for maternal 

health (Fantatum et al., 2019). The same is valid for competence assessment studies, 

which use knowledge and skill assessments based on anatomical models in simulated 

home delivery situations to evaluate birth attendants, as opposed to direct clinical 

observation. 

 

Few longitudinal research and intervention studies have examined home births and 

pregnancy and delivery outcomes. Although the body of data on facility-based products 



22  

  

is expanding, little is known about community-based interventions' contribution to 

maternal health and their long-term effects. (Smith & Houston., 2016) called for 

extensive community research and drew attention to the problem of how community-

based interventions are overlooked and underestimated. Numerous prospective 

community-based studies have been conducted on utilizing quasi-experimental methods 

over 12 to 24 months, particularly in Bangladesh and Indonesia (Smith & Houston., 

2016). 

 

Although some NGOs have utilized them extensively as part of community health-based 

programs, such as CARE in Bangladesh, there are few reliable analyses of the impact of 

birth preparation packages that have been put in place. The literature raised concerns that 

these birth preparation strategies would not have the expected outcome since there are 

insufficient referral services for emergency obstetric care (Sandall, 2017). Examples of 

the growth of SBAs in Indonesia have been mentioned; however, these attempts were 

thwarted by the simultaneous decline in demand for emergency obstetric care owing to 

high out-of-pocket expenses and a lack of cultural acceptance. Therefore, while assessing 

the impacts of a single intervention, such as the effects of SBA treatments on maternal 

health outcomes, studies must consider the correlation between all levels of care. Strong 

arguments are made against the one component, one cadre strategy, and in favor of a 

continuum of care approach that integrates both. 

 

2.8 Relationship between determinants of maternal service utilization 

The determinants which may affect maternal utilization were classified into five groups 

as follows: 

 

2.8.1 Socio-demographic determinants 

The framework for this study focuses on socio-demographic variables, including age, 

education, occupation, marital status, and parity, to analyse their influence on the subject 

of investigation. These variables will serve as key determinants, allowing the study to 

explore how each factor affects the research context. By examining the interplay of these 

socio-demographic variables, the study aim aim to gain a comprehensive understanding 

of their collective impact and individual contributions to the research objectives. 



23  

  

2.8.2 Client related determinants  

The framework of this study centers on client factors, specifically cultural beliefs, 

knowledge, and religious affiliations. These client determinants are essential in shaping 

and understanding the subject of interest. By examining how cultural beliefs, levels of 

knowledge, and religious backgrounds influence the research context, the study  aim to 

gain valuable insights into their impact on the research objectives. Analyzing the 

interplay of these client factors will provide a comprehensive view of their individual and 

collective contributions to the study. 

 

2.8.3 Provider-Related determinants 

The conceptual framework of this study also focuses on health provider determinants, 

encompassing the attitude, quality of care, time taken for service delivery and expertise 

of healthcare providers. These components are fundamental in shaping the research 

context, as they play a pivotal role in influencing the subject under investigation. By 

examining the attitudes, quality of care, and expertise of healthcare providers, the study 

aims to gain a comprehensive understanding of their combined effects and individual 

contributions to the research objectives. Analyzing these health provider factors will 

provide valuable insights into their significance within the study's scope. 

 

 

 

 

 

 

 

 

 

 

 

 



24  

  

Figure 2.1: Conceptual Framework: Determinants of utilization of Maternal 

Services 

This study's conceptual framework was changed and adapted from (WHO, 2016). The 

Framework outlines the elements that affect maternal service usage, including client, 

facility, service provider, care provided, and client sociodemographic characteristics.  

 

 

 

Source: Adapted and modified from WHO maternal and newborn framework, 2016 

 

 

 

 

 

 

D
ep

en
d

en
t 

va
ri

a
b

le
 

1
 

In
d

ee
p

en
d

en
t 

va
ri

a
b
le

s 

Intervvening variable  



25  

  

CHAPTER THREE 

METHODOLOGY 

3.1 Introduction 

This section outlines the procedure used in this research study. The section focuses on the 

study setting, research design, target population, sample size and sampling procedures, 

data collection techniques and lastly data analysis used. 

 

3.2 Study Setting 

The study was conducted in Kapkoi Health Center. The facility is located in Kapkoi Sub 

Location, Kwanza Sub County, Trans-Nzoia County. The study area is positioned the 

37
th

 of the 47 counties regarding the size. The study area borders the Republic of Uganda 

towards the West, Bungoma and Kakamega counties towards the South, West Pokot 

County towards East, Elgeyo Marakwet and Uasin Gishu counties towards South East. 

The county is situated in North Rift of the previously Rift Valley Province. The study 

area is home to Mt. Elgon the second highest Mountain in Kenya.    

 

Kapkoi Health Center lies roughly between scope 00  52   and 10  18   north of equator 

and longitudes 340  38   and 350  23   east of the incomparable  eridian. The facility 

serves the community coverage of an area approximately 15.6 square kilometres. The 

facility is among the five in the region, others being Kolongolo Health Center, Muungano 

Dispensary, Keiyo Dispensary and Biketi Dispensary. The facility was purposively 

chosen because it‘s the main primary healthcare for in the wider catchment area, 

represent study area. The the facility has also specific challenges like low utilization of 

all maternal indicators, high maternal mortality and low skilled birth attendance. On an 

average, the region has an elevation of 1800 meters above sea level. The altitude varies 

from 4300 meters above sea level in Mt. Elgon and continuously drops to 1400 meters 

towards the north. 

 

The health facility serves an estimated population of 9,230 (KNBS, 2019), out of which 

annual average of 786 women of reproductive age are expected to be receiving maternal 

services in the region (KHIS, 2018). Administratively, the region is sub-divided into five 

community units known as ―mlango‖. Each unit has at least two Community Health 

Volunteers attached. The main maternal indicators for the region include family 

planning, fertility rate, antenatal visits and prenatal visits. 



26  

  

Figure 3.1: Map of Kapkoi Sub-Location, Kwanza Sub County 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 3.1 Main Indicators of Kapkoi in 2019 

Indicators Value 

Area (km
2
)      15.6 

Population (Thousands) 9230 

Pop. Growth rate (%) 5.5 

Fertility per woman             6.1 

Life expectancy in years 70 

Literacy rate among adults (%) 40 

IMR 1,000 live births 56.0 

Under 5 MR/1000 live births      61 

Number of Healthcare work                                         9 

Number of CHVs                                      24 

Source: Adopted and Modified from KNBS, 2019 

 



27  

  

3.3 Study Design 

Cross-sectional study design and sequential mixed method approach was applied to help 

in giving best measurement for study population as well as identifying best relationship 

between variables.. Data collection took a period of two months. The questions were 

intentionally developed in a non-directive manner to facilitate the cross-verification of 

responses gathered from the study participants. 

 

3.4 Study Population 

The study population comprises women of reproductive age, ranging from 15 to 49 years, 

both antental and postnatal care who actively sought healthcare services at Kapkoi Health 

Center. This population was drawn from a total population of 4,716 women during the 

study period. 

 

3.4.1 Inclusion and Exclusion Criteria 

The study included both antenatal and postnatal women from Kapkoi Sub Location, who 

made their visits to the facility during the study period and consented to take part in the 

study. The study also considered all women of reproductive age and are visiting the 

facility at the time of the study.  Minors who were under age (15-17 years), and were 

maternal clients were considered mature minors and were allowed to participate in the 

study. 

The study excluded antenatal and postnatal women who were eligible but did not consent 

to take part in the study. The study also did not minors aged 15-17 years accompanied to 

the facility by their parent. Non-residents antenatal and postnatal care women were also 

not included in the study. Lastly, women who attended antenatal and postnatal care 

services at the facility during the study period but were mentally disabled were also not 

considered to participate in the study. 

 

3.5 Sample Size Determination 

The study used Slovin Formula (Slovin E., 1960) to determine the study sample size. The 

method is best used in a large population and where it is not possible to study whole 

population but the characteristics of the study population is known. This method is also 

suitable because it gives accurate sample size of large population and this help in 

avoiding under sampling and oversampling. Simple random sampling technique is also 



28  

  

applied. The formula allows researchers to sample the population within specific degree 

of accuracy (Stephanie L., 2016). 

n=  
 

Whereby; n     - Is the sample size drawn from a population 

N    - This is the  population size 

e – This is the level or precision, the margin of error that is allowed in the study, in this 

case 

5% 

The total number of women who received maternal services at Kapkoi Health Center 

between May 2019 and May 2020 were 4716 (MoH, 2019). This shows an average of 393 

maternal mothers visiting per month. Since data collection took a period of 2 months, 

therefore the estimated study population was; 4716/12 * 2=786 

N is less than 10,000(786) 

 

Therefore, the sample size arrived at was 

n=  

=  

=786/2.965 = 266 

Therefore, sample size was 266 participants 

By use of sampling proportionate ratio 3:2 which meant that for for antenatal women to 

postnatal women participants as follows; 

Antenatal      3/5 * 266 = 160, Postnatal      2/5* 266 =106. 

The study therefore involved 266 respondents. 

 

3.6 Sampling Procedure 

The study participants were identified by systematic sampling technique through 

approaching all eligible maternal mothers seeking either antenatal or postnatal services at 

the health facility in MCH unit. The srecruitment of the study participants was done by 

the Research Assistant with assistance from two Community Health Volunteers attached 

to the facility. 

 



29  

  

Participants were drawn from all antenatal women and all postnatal women who visited 

the facility between the month of June 2020 and July 2020 and were taken through 

consenting steps to enable them take part in the study. Postnatal respondents were 

recruited by identifying the number of days, weeks and months since conception. 266 

(160 ANCs and 106 PNCs) study participants were recruited to take part in the 

questionnaire. FGD participants were identified and recruited by the Community Health 

Volunteers upon completion of care services at the facility. 

 

Table 3.2: Summary of study population, selection criterion, sampling procedure 

and data collection method. 

Population Selection Criterion 
Sampling 

Procedure 

No. of 

Participants 

Data 

Collection 

Method 

Antenatal women 

aged 15 – 49 years 

Primary target for 

maternal service 

utilization in Kapkoi 

Health Center. 

Simple 

random 

sampling 

160 
Structured 

Questionnaire 

Postnatal women 

aged 15 – 49 years 

Primary target for 

maternal service 

utilization in Kapkoi 

Health Center 

Simple 

random 

sampling 

106 
Structured 

Questionnaire 

8 1 FGDs 

 

3.7 Study Instruments 

The study used structured questionnaire and Focused Groups Discussion guide with the 

line of study objectives. The questions were organized in a logical sequence for easy flow 

to the participants. The questionnaire was divided into three sections namely demographic 

information, client‘s factors, health care provider related factors. The study also used 

screening tool to identify particpants eligble for the study. The study also used informed 

consent forms to ensure that participants fully understand the nature of a procedure, 

treatment, or study and voluntarily agree to participate. 

 



30  

  

3.7.1 Validity Test 

Validity is  defined as the degree to which variable represents what is intended (Patience 

A. Afulani & Raymond Aborigo, 2019). In this study, the content validity of data 

collection instrument was determined by getting cross-checks, completeness of data 

collection tools, expert opinion, critique and advice from my supervisors, external 

experts‘ opinions and other classmates at the university. The advice and critics provided 

were in correcting the tools to meets the study purpose and objectives. 

 

3.7.2 Reliability Test 

This is defined as the measure of degree to which research instruments yields consistent 

results. The study reliability assessed for consistency by using test-retest technique. This 

is a measure of reliability in which two variables of interests that are measured twice to 

yield consistent results. Cronbach Alpha was used to correlate between study variable, 

Socio demographic variables, client‘s variables and health care provider‘s variables. 

Reliability coefficient of ≥ 0.7 was considered and the result showed ‗r‘ value of 0.897 

for Socio-demographic, 0.92 for client factors and 0.978 for health care providers. The 

results for Cronbach‘s Alpha based on standardized items indicated that values based on 

all standardized items were greater than the coefficient 0.7. This indicate that there was 

consistency in the study instruments (Mugenda, 2014). Training of the research assistants 

was conducted to improve on reliability of the study instruments. 

 

3.8 Data Collection Procedure 

In the data collection process for this study, a systematic approach followed to ensure that 

information collected efficiently and ethically from the women seeking healthcare 

services at Kapkoi Health Center. Community Health Volunteers (CHV) played a key 

role in the initial engagement, introducing the women to a Research Assistant (RA) who 

was part of the study team. The RA then proceeded to explain the study's purpose and 

objectives. Women who expressed interest in participating were screened for eligibility 

using specific criteria. Once eligibility was confirmed, the RA obtained informed consent 

from the women, providing detailed information about the study and their rights as 

participants. 

 

For quantitative interviews, the RA conducted one-on-one sessions with the women, 

guiding them through the research questions and facilitating their responses. Additionally, 

file:///C:/Users/Admin/AppData/Roaming/Microsoft/Word/methodology%20to%20irine.docx%23_Toc314638310


31  

  

for Focus Group Discussions (FGDs), women were scheduled for a date to participate on 

specific days. During these group sessions, the RA played a central role in leading the 

discussions and providing support when required, which included offering translation 

services if there language barriers.  

 

Table 3.3: Summary of data collected per week. 

Weeks 
Number of Antenatal 

Respondents 

Number of Postnatal 

Respondents 

1
st
 24 15 

2
nd

 26 17 

3
rd

 19 12 

4
th

 26 16 

5
th

 19 18 

6
th

 17 9 

7
th

 15 7 

8
th

 14 12 

Total   160 106 

                                                                                   

For qualitative data, one of the research assistant led in introduction from the study team, 

then participants were requested to sign consent form, The FGDs were done in local 

dialect ―Suk‖,  language that is best understood by all the participants, there was 

repetition of all the questions to make clear understanding during the discussion meeting. 

The two RAs swapped roles of both moderator and note taker. Notes were taken during 

the session to ensure standardization and uniformity. 

 

3.9 Data Processing and Data Analysis  

3.9.1 Data Processing  

The study involved a thorough data processing procedure for both quantitative and 

qualitative data collected manually. For the quantitative component, the data collected 

from individual interviews were meticulously recorded on paper-based survey forms. The 

initial step included data cleaning, where the collected information were reviewed for 

completeness and accuracy. Any missing or inconsistent data were identified and 



32  

  

addressed. Subsequently, the data were coded to ensure uniformity and consistency in the 

responses. 

 

Once the quantitative data were cleaned and coded, they were entered into a computerized 

database using statistical software for further analysis. The data entry process was 

double-checked for accuracy to minimize errors. After data entry, the quantitative data 

underwent validation, including range checks and logical consistency tests. For the 

qualitative component, the data processing steps were adapted to handle textual 

information. Transcriptions of the Focus Group Discussions (FGDs) and individual 

interviews were carefully prepared. The content of these transcripts was thoroughly 

reviewed and organized in a codebook for thematic analysis. Common themes and 

patterns in the qualitative responses were identified and categorized. 

 

3.9.2 Data Analysis Method 

After completion of data collection, responses were edited coded and entered using SPSS 

version 25.0. The study used descriptive test such as percentages and frequenciesto 

describe population characteristics in relation to socio-demographic variables. The results 

were presented in frequencies, tables and percentages. The study used Chi-square test (χ 

2) to assess associations between various demographic characteristics of women of 

reproductive age (15-49 years) accessing maternal healthcare services. Cross-tabulation 

was used to show the nature of association between various study variables. P-value of 

less than 0.05 was considered to be statistically significant, while p-value greater that 0.05 

was considered not statistically significant. For the qualitative study was done by use of 

thematic and context analysis. 

 

3.9.3 Ethical Consideration 

The study adhered to a stringent ethical procedure and obtained necessary approvals at 

multiple levels. Firstly, ethical clearance and approval for the research were obtained 

from Jaramogi Oginga Odinga University of Science and Technology (JOOUST) and 

University of East Africa,Baraton ethical review boards. These approvals ensured that the 

study adhered to the highest ethical standards throughout its execution. At the county 

level, the study received formal authorization from the relevant county authorities. This 

step was essential to ensure that the research is conducted in compliance with local 

regulations and guidelines. 



33  

  

 

Additionally, ethical considerations guided the interactions with the study participants. 

The principles of anonymity and confidentiality was strictly maintained throughout study 

period. To protect the identity of the participants, their personal information was 

anonymized and kept confidential. This guaranteed that individual responses could not be 

linked back to any specific participant. 

 

Voluntary participation was another key ethical consideration. All women of 

reproductive age at Kapkoi Health Center were informed about the study, and 

participation was entirely voluntary. They were provided with detailed information about 

the research's purpose and objectives, and informed consent was obtained before any data 

collection took place. This ensured that participants had the autonomy to decide whether 

to be part of the study without any form of coercion. 

 

Furthermore, due to the prevailing COVID-19 pandemic, stringent adherence to safety 

protocols and guidelines was essential. All data collection activities, whether quantitative 

or qualitative, was conducted in line with COVID-19 safety measures. This included the 

use of personal protective equipment (PPE) by the research assistants and maintaining 

physical distance during interviews. The safety and health of both the participants and the 

research team were of utmost importance. 

 

 

 

 

 

 

 

 

 

 



34  

  

CHAPTER FOUR 

RESULTS 

4.1 Introduction 

This section presents findings as per the study objectives. The study sought to investigate 

the determinants of maternal healthcare utilization services among women of 

reproductive age seeking services at Kapkoi Health Center, in Trans Nzoia County. 266 

clients were interviewed during their visit to the facility. Out of these, 160 antenatal 

clients and 106 postnatal clients participated and gave their responses which translates to 

100 %. Socio-demographic, client, healthcare provider and facility determinants were 

considered. 

 

4.2 Socio-Demographic Characteristics determinants 

The socio-demographic factors of the respondents interviewed includes education level, 

ages, gravidity, marital status and their occupation. Most of the study respondents 47.0 

%(125) had primary level of education slightly higher than secondary level 32.7 % (87). 

Fewer respondents had no formal education 10.1 %(29) whereas respondents with post-

secondary education were 9.4 %(25).  

 

More than half  53.4 %(142) of the respondents were  between 20 – 35 years of age, 

while 15– 19 years were 32.3 %(86) while only  14.3 %(86) of the study respondents 

were aged between 36-49 years.Almost all respondents, higher number had gravidity >1,  

79.1 %(209) while only  20.9 %(57) of the respondents were first time mothers visiting 

the clinic. On marital status of the respondents, 70.3 %(187) of the respondents were 

married, much higher compared to single women respondents 23.3 % (62), while 

respondents are who separated in their families were 3.8 %(10) higher compared to the 

widowed respondents 2.6 %(7).  

 

Lastly, in regards to occupation, majority of the respondents were unemployed 64.3 % 

(171) of the respondents, higher compared to those who are self-employed 24.4 % (65). 

Additionally, only 2.6 %(7) of the respondents were employed while 8.6 %(23) of the 

total respondents were students. 

 

 

 



35  

  

 Table 4.1: Socio-demographic aspects of the study respodents (n=266) 

 

4.2.1 Association between Socio-demographic determinants  

The study result indicated significant association between education ((χ2=1.5343; df=3; 

p=0.037), age ((χ2=18.143; df=2; p=0.016) and gravidity ((χ2=48.553; df=4; p=0.028) 

and utilization of maternal healthcare services.  

However, the finding of the study also indicated that no statistical association between 

maternal healthcare utilization marital status (χ2=6.639; df=3; p=0.084) and occupation 

(χ2=3.010; df= 4; p=0.536) of women seeking maternal service at Kapkoi Health Center.  

The table indicate the socio-demographic factors and utilization of maternal healthcare 

services. 

 

 

 

Variables Attributes Frequencies Percentages % 

Education 

level 

No formal 29 10.9 

Primary 125 47 

Secondary 87 32.7 

Post-Secondary 25 9.4 

Total 266 100 

Age 

11 - 19 years 86 32.3 

20 - 35 years 142 53.4 

36 - 49 years 38 14.3 

Total 266 100 

Gravidity 

0 57 20.9 

>1 209 79.1 

Total 266 100 

Marital 

Status 

Married 187 70.3 

Separated 10 3.8 

Single 62 23.3 

Widowed 7 2.6 

Total 266 100 

Occupation 

Employed 7 2.6 

Not Employed 171 64.3 

Self Employed 65 24.4 

Student 23 8.6 

Total 266 100 



36  

  

Table 4.2: Relationship between socio-demographic determinants. (n=266) 

Variables Attributes Utilization of Maternal Service 
Significa

nce level 

  

Antenatal Respondents N 

(%) 

Postnatal 

Respondents 

N (%) 

 

Education 

No formal 17 (11.2 %) 12 (10.6 %) 

χ2=1.534

3; df=3; 

p=0.037 

Primary 60 (37.9 %) 65 (61.1 %) 

Secondary 68 (42.8 %) 19 (19.4 %) 

Post-Secondary 15 (9.1 %) 10 (8.9 %) 

N 160 (100 ) 106 (100) 

Age 

11 - 19 years 60 (37.5 %) 26 (35 %) 
χ2=18.14

3; df=2; 

p=0.016 

20 - 35 years 75 (47 %) 67 (63.5 %) 

36 - 49 years 25 (17.5 %) 13 (11.5 %) 

N 160 (100 ) 106 (100 ) 

Gravidity 

0 17 (10.4 %) 40 (38.1 %) χ2=48.55

3; df=1; 

p=0.028 

>1 143 (88.6 %) 66 (62.9 %) 

N 160 (100 ) 106 (100 ) 

Marital 

Status 

Married 114 (70.7 %) 43 (40.6 %)  

 

χ2=6.639

; df=3; 

p=0.084 

Separated 4 (2.3 %) 6 (5.4 %) 

Single 40 (25.1 %) 22 (21.8 %) 

Widowed 2 (0.9 %) 5 (4.2 %) 

N 160 (100 ) 106 (100 ) 

Occupation 

Employed 5 (3.9 %) 2 (2.1 %)  

 

χ2=3.010

; df= 3; 

p=0.536 

Not Employed 108 (67.1 %) 69 (64.9 %) 

Self Employed 39 (24.4 %) 24 (22.9 %) 

Student 13 (7.6 %) 10 (10.1 %) 

N 160 (100 ) 106 (100 ) 

 

Focused Group Discussion conducted, three of the participants mentioned age as one of 

the factors that greatly affected maternal utilization. Participant 6, aged 21 married and 

parity 2 suggested that ―Just as my colleague has said I am too young to mix with other 

experienced mothe