Women's perceived barriers to giving birth in health facilities in rural Kenya: A qualitative evidence synthesis

Background: In Kenya, uptake of skilled care during birth remains lower in rural areas when compared to urban areas, despite efforts by the government to encourage facility-based births by abolishing maternity fees in public health facilities. Objective: To synthesise published and unpublished qualitative research that explores women's perceived barriers to facility-based birth in rural Kenya. Design: Qualitative evidence synthesis Data sources: Multiple electronic databases (MEDLINE, EMBASE, PsycINFO, POPLINE, CINAHL, Web of Science and ProQuest), grey literature searches, citation chaining and checking of reference lists. Review methods: Studies were screened by title, abstract and full text, after which a standardised qualitative checklist was used to assess study quality. Synthesis of extracted data followed the ‘best-fit’ framework method, enhanced with a pathway-based model for the improvement of maternal and newborn care. Results: Sixteen eligible studies were identified. Key themes were: (i) knowledge, attitudes and practices, including past experiences of health facilities and community beliefs about facility services; (ii) insufficient demand for professional care caused by the perceived advantages of seeking alternative care during birth and the disadvantages of facility-based births; (iii) limited access to services, especially in rural areas, because of poor infrastructure; (iv) misconceptions regarding labour characteristics and, (v) poor awareness of labour outcomes. Conclusions: Important factors can be characterised as ‘push’ factors (those pushing women away from facilities) and ‘pull’ factors (those related to the relative advantage of facility-based births). However, key to an individual woman's decision are factors relating to knowledge, attitudes and practices and awareness of labour outcomes. While a critical tension exists between government policy and consumer choice, the prevalence of inadequate awareness and the dominance of past experiences and community beliefs offer significant obstacles to a woman in making an informed choice about her preferred place of giving birth.