"If they were telling us to go, we will go": factors associated with effective postnatal care coverage before and after discharge - a mixed

Introduction Maternal and newborn health is a key area of focus within Kenya’s health system, reflecting the global commitment to improving health outcomes for mothers and infants. Despite progress in recent years, Kenya continues to face significant challenges in reducing maternal and newborn mortality, with 530 maternal deaths per 100 000 births in 20201 and stalled progress in reducing neonatal mortality. These deaths are largely avertable through provision of high-quality delivery and postnatal care (PNC), particularly during the first 42 days after birth, when opportunities to prevent adverse outcomes are the greatest.2 Such preventive measures include maternal and newborn physical assessment for complications, prevention of infections, and mental health and nutritional interventions provided within the first 24 hours, 3 days, 1–2 weeks and 4–6 weeks.3 Despite its importance, PNC in Kenya has received less attention than other elements of the maternal and newborn healthcare package. The Kenya Demographic Health Survey (DHS) in 2022 reported that 23% of mothers and 16% of newborns received no postnatal check-up within 2 days after birth, compared with just 2% of mothers who receive no antenatal care (ANC) at all (among women with a live birth or stillbirths in the preceding 2 years).4 There is also high geographical inequity in access to PNC across counties, with coverage rates ranging from 37% in Wajir County to 94% in Embu County. The COVID-19 pandemic has further exacerbated gaps in access to PNC.5–7 In April 2020, Kenya introduced a policy document, “The Practical Guide for Continuity of Reproductive, Maternal, Newborn and Family Planning Care and Services in the Background of Covid-19 Pandemic”, which sought to minimise physical contact with health system personnel. Low-risk mothers undergoing normal delivery were guided to receive their first PNC at 6 weeks, while mothers who had undergone caesarean delivery (CS) were recommended to have visits at 2 and 6 weeks. High-risk mothers were to receive individualised care, although specific guidelines based on risk stratification were not indicated8 (online supplemental Table S1). One result of this policy is that while it remained in effect, most mothers with normal deliveries would have no immediate postnatal contact. While these changes were understandable during the height of the pandemic, this policy has remained active. Previous observational and qualitative studies have highlighted additional barriers to PNC access for mothers and newborns in Kenya. At the individual level, rural residence, less than primary education, poverty and home delivery have been shown to be correlated with low PNC utilisation.9–11 Decision-making about care by other family members has also been shown to reduce PNC service utilisation.12 13 By contrast, mothers’ empowerment as principal decision-maker regarding health and knowledge of health danger signs were both associated with reduced delays in seeking PNC. At the health systems level, contextual factors such as nurse shortages due to strikes have also been shown to hinder PNC knowledge and uptake.14 A study in Kiambu and Nairobi counties also found that lower levels of trust in the health systems were associated with reduced PNC care seeking, especially after COVID-19.15 Going beyond PNC access, there is to date relatively limited research on quality of PNC throughout the 6-week postnatal period. Many existing studies overestimate coverage of PNC by measuring it as intrapartum care within 24 hours after childbirth,16 17 although comprehensive PNC, by definition, should occur throughout the postnatal period. Other studies have defined participants as having received PNC if they have received any check-up from a provider regardless of clinical content of care.17 18 For example, women may be considered as having received PNC even if they were not checked for vital signs during the visit. Relatedly, other studies have conflated postdelivery sick child visits with routine PNC visits. Moreover, research to date has primarily focused on demand-side determinants of receiving PNC, despite the multifaceted nature of this decision. Therefore, in this study, we seek to fill these gaps by providing a comprehensive assessment of barriers and facilitators to high-quality PNC access. This study assessed crude and quality-adjusted PNC—the latter serving as a proxy for effective PNC to better reflect potential health gains.19 For mothers, we measured crude and effective PNC coverage only during the immediate postnatal period (before discharge). For newborns, we assessed both crude and effective PNC coverage before discharge and again during the early and late postnatal period (after discharge) in Kakamega, Kenya. We used both quantitative and qualitative data within 60 days post partum to contextualise the determinants influencing PNC-seeking behaviours in this setting.