1
FACTORS INFLUENCING UTILIZATION OF
POSTNATAL CARE SERVICES AMONG WOMEN OF
REPRODUCTIVE AGE ATTENDING CHILD
WELFARE CLINIC AT KISII TEACHING AND
REFERRAL HOSPITAL, KISII COUNTY, KENYA
INTRODUCTION
Background Study
Postnatal care (PNC) is the care provided to women and newborns in the first six
weeks after birth while Postnatal period is the time interval that starts from the
birth of the baby to six consecutive weeks with recommended time visit, that is 6-24
hours, day 3, week 2 and week six following childbirth (WHO, 2014). Postnatal
period is very crucial to the health and wellbeing of the mother and her newborn
(Landge et al., 2017).The ineffective utilization of PNC services has made both the
mother and the child vulnerable to morbidity and mortality in low and middle income
countries. Even though the health of the mother is highly regarded as the health of
the society, more than 289,000 maternal deaths occurred globally every year due to
pregnancy, childbirth or the postnatal period complications, of which two thirds
maternal deaths occur after delivery which shows the significance of postnatal
period. Maternal mortality remains unacceptable high across much of the developing
countries especially Sub-Saharan Africa and South Asia accounting for 87% of
maternal deaths (WHO, 2014), a large proportion occurring during the first 48 hours
after delivery with postpartum hemorrhage being the major cause.
Globally, more than half a million women die each year from complications of
pregnancy and childbirth, a large proportion of maternal deaths occur during the first
48 hours after delivery and accounting to 99% in developing countries(WHO,2013)
.The maternal mortality in sub-sahara Africa averages to 640 deaths per 100,000 live
births. Every year ,3 million neonates die within their first month of life, representing
40% of all deaths of children under the age five (WHO, 2014) .In Sub-Sahara Africa
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one in nine children dies before the age of five, which is more than the average
number of deaths in developed countries ( Lozano et al., 2011) .The care during
puerperium for the woman has influence on maternal deaths if the woman does not
attend post-natal care services and yet this is one of the most important maternal
health-care services for not only prevention of impairment and disabilities but also
reduction of maternal mortality ( UNICEF, UNFPA, 2010).
3
As a result, millennium development goal 4 and 5 focused on reduction of child
mortality by two-thirds and reduction of maternal mortality by three-quarters
between 1990 and 2015, respectively (Chola et al., 2015; Lancet, 2010). The United
Nations have set targets for 2030 to further reduce child and maternal mortality
(Kamau et al., 2015).
Considerable progress has been made globally in improving maternal health. Around
the world, 72% of women give birth attended by skilled personnel and the maternal
mortality ratio has decreased from 380 to 210 per 100,000 live births between 2000
and 2013. Yet in South-East Asia and Sub-Sahara Africa only 67% and 48% of
women give birth with the assistance of skilled personnel, respectively (WHO,
2014). Postnatal care reaches even fewer women and newborns: less than half of
women receive postnatal care visit within 2 days of childbirth (Lawn et al., 2014).
An analysis of demographic and health survey data from 23 Sub-Sahara African
Countries found that only 13% of women who delivered at home received postnatal
care within 2 days of birth (WHO, UNICEF, UNFPA, World Bank and UN
Population Division, 2014). Maternal Health is a challenge and efforts need to be put
in place to achieve the global goal of reducing the maternal mortality ration to less
than 70 per 100,000 live births by the year 2030 (WHO, 2015)
Postnatal care services can be defined as preventive care practices and assessments
that are designed to identify and manage or refer complications for both the mother
and the neonate in the first six weeks after birth (WHO, 2014). Typically, such
services include an integrated package of routine maternal and neonatal care as well
as extra care for the neonates that are considered particularly vulnerable because, for
example, they are preterm, have low birth weight, are small for gestation age or have
mothers infected with Human Immunodeficiency Virus (HIV) (WHO, 2006).
Possible interventions for the mother
Iron and folic acid supplementation for at least 3 months, Screening for-and
treatment of-infection, hemorrhage, thromboembolism, postnatal depression and
other conditions. Prophylactic antibiotics given to women who have third-or fourth-
degree perinea tear, Counseling on early and exclusive breastfeeding, nutrition, birth
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spacing and family planning options-including any available contraceptives (WHO,
2014).
Possible interventions for the neonate
Care of the umbilical cord. A special care for preterm, low birth weight and HIV
infected neonates (WHO, 2014), Screening, treatment of infections and postnatal
growth restrictions. Assessment of factors predisposing through infant anemia and
teaching the mother to seek additional care for her neonate if she notices danger
signs such as convulsions or problem with feeding.
Complications following the childbirth are more common and aggravated in
developing countries. The long-term maternal complications in the postnatal period
include chronic pain, impaired mobility, damage to the reproductive system and
infertility (Safe Motherhood, 2012), some women suffer genital prolapse after
bearing several children, this condition is extremely uncomfortable and can lead to
other complications in future pregnancies if not properly addressed in the postnatal
period (Koblinsky, Chowdhury, Moran, & Ronsmans, 2012).
Safe motherhood alert (2008) reported that the factors which prevent women in
developing countries from getting postnatal care include distance from the health
services; cost, including direct fees and the cost of transportation, multiple demands
on women‘s time, women‘s seek of power in decision-making within the family; and
poor quality of services including poor handling by the health service providers.
The picture is different in developed countries, according to the World Health
Organization (2012) 90% of mothers received postnatal care. Hode et al. (2011)
reported an increase in utilization of postnatal care services at six weeks by women
in developed countries and virtually all women and their infants received postnatal
care services, even though the nature and frequency of this care varies considerably.
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A study in Thailand by Suwankhong and Liamputtong (2015). pointed out that many
Thai women see their reproductive health problems as the consequences of
inadequate postnatal services from the health workers, although traditional
postpartum belief and practices of not attending postnatal care bound.
Poor rural women seem to hold on strongly to their traditions of not attending
postnatal care when compared with their urban counterparts.
The objectives of postnatal care services are to support the mother and the family in
the transition to a new family constellation, prevent, early diagnosis and treat
complications of the mother and infant, refer the mother and the infant for specialist
care when necessary, counsel on baby care, support breastfeeding, counsel on
maternal nutrition and supplementation if necessary, counsel and provide
contraception service and immunize the infant. With limited resources, contact with
the health care system at least during the first twenty four hours and before the end
of the first week would be the most effective strategy for reducing maternal and
neonatal deaths (www.pathfinder.com,assesed July 2016).
Despite the importance of the postnatal care it is the most neglected period in
developing countries even the need for care and support after birth is less recognized
and approximately one-third of women in sub-Sahara Africa give birth in facilities,
and not more than 13 percent receive postnatal care services within two days of the
delivery. Whether women deliver at home or in the facility, postnatal care services
are often absent. Moreover, if PNC services were available, often lack essential
elements of care required for the optimum health of the mother and her newborns
(WHO, 2010). However, it has been noted that many women who give birth at health
facility in the developing world are discharged within hours after childbirth without
any indication where they can obtain further care or support (Titaley et al., 2009)
Women should not die in child birth because the vast majority of maternal deaths can
be prevented or reduced if women had accessed to, or visited maternal health
services during pregnancy, childbirth and the first month after delivery, it also shows
that women living in sub-Sahara Africa has one in 16 chance of dying in pregnancy,
childbirth and after childbirth. In Tanzania, for instance, puerperal mothers in rural
6
areas with no education are thought to be more at risk of health problems than their
counterparts with formal education (UNISA, 2010).
In Ethiopia, the proportions of mothers attend PNC services are very much lower
than the sub-Sahara Africa. The great majority (92%) of women who had live birth in
the preceding five years did not receive PNC services. Among women who received
PNC services, 4% were examined within four hours, and 2% within 2-3 days of
delivery. Generally only 7% of women received PNC services within two days as
recommended (Berhan & Berhan, 2014).
In Kenya the maternal mortality ratio is at 362 deaths per 100000 live births (KDHS,
2014) with the risk of dying being 1:20 is still high and the recent estimates of WHO,
UNICEF, UNFPA, the World Bank Group and UN Population Division also
highlight insufficient progress. For every maternal death there are at least 30 women
who suffer short or long term disabilities (National Guidelines for quality obstetric
and perinatal care, 2010), with postpartum hemorrhage contributing to 34% of
maternal deaths and it is the most common cause of maternal mortality in Kenya
(WHO, 2010). 61% of live births where delivered in the health facility; 62% where
assisted by a skilled provider. 53% of women who gave birth in two years before the
survey received postnatal care checkup in the first two days after delivery. 38% of
women received postnatal care within four hours after delivery, 9% received care
within 4-23 hours, and 6% were seen 1-2 days following delivery. Overall 43% of
women did not receive a postnatal checkup within the first six weeks after delivery.
In the North-Eastern region, 80% of women did not have any postnatal care, Coast
43.3%, Eastern 34%, Central 23.7%, Rift Valley 49.6%, Western 60.8%, Nyanza
36.7% and Nairobi 25.1% (KDHS, 2014)
The infant mortality rate is 39 deaths per 1000 live births and the under-five
mortality is 52 deaths per 1000 live births (KDHS, 2014). At these levels, about one
in every 26 Kenyan children die before reaching age one, and about one in every 19
does not survive to his or her 5th birth day. Neonatal mortality has exhibited the
slowest rate of decline (33%). A child born in Nyanza region is almost twice as
likely to die before age five as a child born in central region. Nairobi has the second
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highest under-five mortality rate; following Nyanza (72 deaths per 1000 live births).
The neonatal mortality rate in Kenya is 22 deaths per 1000 live births, 1.4 times the
postnatal rate. The perinatal mortality rate is 29 per 1000 pregnancies (KDHS, 2014).
Infant and child mortality rates are also regarded as indices that reflect the degree of
poverty and deprivation of a population. Under-5 and infant mortality rates are two
indicators used to monitor child health under millennium development goal (MDG)
1. The government of Kenya is undertaking a number of interventions aimed at
reducing maternal and childhood mortality, targets for these programs, including
vision 2030 indicators, sustainable development goals and National expanded free
maternity services program dubbed ‗LINDA MAMA‘. Despite renewed focus and
recent progress in child survival, a lot of effort need to be directed at child health to
achieve the global goal of ending preventable deaths of newborns and under-five by
the year 2030 (United Nations Development and Program, 2015).
The Kenya Maternal and Newborn Health Model; the six pillars of maternal and
newborn include: pre-conceptual care and family planning focused antenatal care,
essential obstetric care, essential newborn care, targeted postpartum care, and lastly
post-abortion care. These services are underpinned by the foundation of the skilled
attendants and a supportive and functional health system (MOH, 2011)
The Model recognizes the potential role communities have in the promotion of their
own health. It reiterates the importance of strengthening the interface between the
community and health services, as well as promoting the human rights approach to
the health service delivery.
These elements are also identified by the National Health Sector strategic plan II
2005-2010 as the key areas of focus. (National guidelines for quality obstetric and
perinatal care, 2011). In Kenya postnatal care services are available and National
guidelines for postnatal care encourages all mothers to make use of postnatal care
services. Unfortunately, many women attend antenatal care clinics and give birth in
public facilities but the same women do not attend postnatal care clinics (MOHSS,
2011). There are consequences if mothers do not utilize postnatal care services or if
postnatal care services are not available.
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Statement of the Problem
Globally ,more than half a million women die each year from complications of
pregnancy and child-birth , majority within the first 48 hours post-delivery. It is
estimated that three quarters of women do not receive postnatal care and this leads to
a bout 60-80% of maternal deaths in this period (WHO 2013). In Africa, most
mothers and newborns do not visit the health institution following birth, indicating
that postnatal care programs are among the weakest of all reproductive health
programs. In sub-sahara Africa, maternal and child mortality remains unacceptably
high accounting for 87% of deaths (WHO, 2014). In Kenya 57% utilized postnatal
care, 43% being from rural areas compared with 65% from urban (KDHS, 2014).
Postnatal care consistently has among the lowest coverage of interventions on the
continuum of maternal and childcare, with a reported median for countdown
countries at 28% (Lancet, 2015).
The Government of Kenya launched national expanded free maternity services
program dubbed
―
Linda mama
‖
which was a great step forward towards improving
access and quality of maternal, newborn and child health care services in the country
as well as attainment of health goals as outlined in Kenya‘s vision 2030 and the
Sustainable Development Goals, these did not translate into adequate utilization of
postnatal care services. In Kisii Teaching and Referral Hospital, 88% of women
attended antenatal care, 47% of them delivered in the health facility and 10.42%
were reported to attend postnatal care checkups within six weeks after delivery
(MoH, 2015), from the above statistics and information ,PNC has been poorly
utilized and it is with these that the researcher found out that there is need for
determining the factors influencing utilization of postnatal care services among
women aged 15-49 years attending child welfare clinic at KTRH. In the absence of
postnatal visit puerperium mothers are at risk and could result in ill health therefore,
the time to unpack the‖ black box‖ of PNC service delivery is now.
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Justification of Study
Postnatal care coverage is on a decreasing trend in comparison to other maternal and
infant health services .Despite the fact that majority of maternal and newborn deaths
occur within the first week of postnatal period, (WHO, 2014) healthcare providers
across Sub-Saharan Africa continue to advice mothers to come back to the facility
for a first check-up only after 6 weeks; this is a visit for survivors (Charlotte et al.,
2006).
In Kenya, it is noteworthy that more than half of the infants born in the health facility
(52%) did not receive PNC services while in Nyanza region where kisii county falls
under had the highest post neonatal mortality 31/1000 live births (KDHS,2014).
Effective utilization of postnatal care is a key initiative towards attainment of the
United Nations Sustainable Development Goals ; goal 3 that aims to reduce maternal
mortality to less than 70/ 100000 and Neonatal mortality to less than 12/1000 live
births. Postnatal care is essential for treating and diagnosing complications arising
after delivery, Particularly, for non-institutional birth, If routine postnatal care
reached 90% by babies and their mothers, 10 to 27% of the newborn deaths could be
averted (WHO, 2014.The results of this study will bring out a better understanding
on the factors influencing utilization of PNC services in kisii county which will lead
to appropriate intervention that will improve utilization of PNC.
Objectives of the Study
Broad Objective
To determine the factors influencing utilization of postnatal care services among
women of reproductive age attending Child Welfare Clinic at Kisii Teaching and
Referral Hospital
Specific Objectives
i. To determine the Socio-demographic characteristics of women of
reproductive age attending Child Welfare Clinic at Kisii Teaching and
Referral Hospital.
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ii. To determine the proportion of women utilizing postnatal care services
among women of reproductive age attending Child Welfare Clinic at Kisii
Teaching and Referral Hospital.
iii. To establish the socio-economic factors influencing utilization of postnatal
care services among women of reproductive age attending Child Welfare
Clinic at Kisii Teaching and Referral Hospital.
iv. To identify health service provider and health facility factors influencing
utilization of postnatal care among women of reproductive age attending
Child Welfare Clinic at Kisii Teaching and Referral Hospital.
Research Questions
i. What are the socio-demographic characteristics of women of reproductive
age attending child welfare clinic at Kisii Teaching and Referral Hospital?
ii. What proportion of women of reproductive age are utilizing the postnatal care
services attending Child Welfare Clinic at Kisii Teaching and Referral
Hospital?
iii. What are the socio-economic factors that influence the utilization of postnatal
care services among women of reproductive age attending Child Welfare
Clinic at Kisii Teaching and Referral Hospital?
iv. What are the health providers and health facility factors that influence
utilization of postnatal care among women of reproductive age attending
Child Welfare Clinic at Kisii Teaching and Referral Hospital.
Conceptual Framework
In this study, the dependent variable is the utilization of PNC services; while the
independent variables are several socio-demographic characteristics, Socio-economic
factors and Health provider and facility factors. The framework also helps
understand the potential influences on an individual's decision to make use of health
services. The conceptual framework was adopted from the Anderson‘s Behavioral
Model. The model suggests that the use of health services is a function of the predisposition
to use the services, factors that enable or impede use and need for the service. Anderson
(1995) refers to demographic factors and household wealth status as the predisposing
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factors; while availability of services, cost of care and distance to the facility are seen
as enabling factors. Attitudes and knowledge that people have about health care
services also influence their subsequent perception of need and use of these services.
This coupled by a woman‘s previous exposure to healthcare services indicates a
strong predictor of her susceptibility to make use of available reproductive health
services. According to Anderson (1995), these are the need-based characteristics.
The purpose of the model is to discover the conditions that either facilitate or impede
utilization of postnatal care services1.6 Conceptual Framework
The conceptual framework illustrates the relationships between the dependent
variable and independent variables as shown in figure 1.1.
Independent Variable Intervening Variable Dependent Variable
Health provider and facility factors
Reception
Awareness
Utilization of PNC
Number utilized PNC
Socio-economic factors
Residence
Distance to health facility
Income
Socio-demographic characteristics
Age in complete years
Level of education
Marital status
parity
Attitude
Willingness
12
Figure 1.1: Conceptual Framework Source; Adopted from Behavioral Model of
Health Services Use (Andersen, 1995)
13
MATERIALS AND METHODS
Study Site
The study was conducted at Kisii Teaching and Referral Hospital, in Kisii County;
which was one of the forty seven counties in Kenya. It shares common borders with
Nyamira to the North East, Narok County to the South and Homabay and Migori
counties to the West. The county lies between latitude 0 degrees 300 and 1 degrees
South and longitude 34 degrees 380 and 35 degrees East. The county covers a total
area of 1,317.5 km2.The hospital was selected as an area of study because it offered
PNC to mothers and their newborns after discharge from the hospital and clients
from other health facilities within the region. The facility was located in
Southwestern Kenya and the County government of Kisii runs it. It had a catchment
area encompassing 1.3 million people from the entire Gusii region with daily
workload of 200 newly admitted in-patients and 400 outpatients.
Study Design
The study was a descriptive cross sectional design that utilized quantitative technique
for data collection. Cross-sectional studies are carried out at one time point or over
a short period. They are usually conducted to estimate the prevalence of the
outcome of interest for a given population. Such a design helps asses a sample at
one specific point in time, it was ideal since it is most suitable as the researcher is
intending to gain immediate knowledge and information on factors affecting
utilization of postnatal care services as they exist on the ground
Study Population
The study population targeted all mothers who attended Child Welfare Clinic with
children between 7 to 14 weeks of age at Kisii teaching and referral hospital. Study
population comprised of 900 mothers (KTRH, Monthly report, 2017).
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Inclusion Criteria
a) Mothers who attended Child Welfare Clinic at Kisii Teaching and Referral
Hospital with children between 7 to 14 weeks and who are biological
mothers.
b) Those mothers who gave informed consent to participate in the study with
babies between 7 to 14 weeks old.
Exclusion Criteria
c) Mothers with children aged 7 to 14 weeks attended child welfare clinic but
refusal to consent to the study.
d) Those mothers who had children requiring urgent medical attention.
Sampling procedure
Sample size determination
Going by the proportion of number of women attending maternal newborn and child
health clinic in a duration of 1 month, the sample size was determined as described
by (Fisher et al., 1998) for a large population of more than 10000.
1.962 X 0.53X 0.47
0.052
= 383
15
Applying Yumane‘s formula (1967); for population that is less than 10000 it is
necessary to do correction of minimum sample size determination so that the desired
minimum sample size is reduced.
n
_ = 383
n
1+ /N
= 268
383
1+( /900)
Where n= desired sample size
z = standard normal deviation that corresponds to 95% confidence interval
p = proportion to targeted population estimate
Sampling technique
Systematic random sampling was done based on the number of women attending
Child Welfare Clinic for duration of One month. The researcher identified the total
number of women that attend CWC daily and computed the desirable sample size;
consenting clients who met inclusion criteria were recruited.
The sample size was calculated against the total population to obtain the constant K
which was the sampling interval using the following formula:
Where n is the sample size, and N is the population size. The population of women
attending the MNCH clinic were put into a sequential order, ensuring the subjects
been studied were randomly distributed.
16
A random number for instance X_ was selected, between 1 and K (sampling
interval). The first sample size subject was the x-th then every k-th subject will be
selected.
Sampling population per day was 36 women
Data Collection
Data was collected using a pretested semi-structured interviewer administered
questionnaires via face to face interview, the questionnaires was first prepared in
English and later translated to Kiswahili and Ekegusii depending on the participant‘s
preferred language and back to English to ensure consistency.
Questionnaire administration
Questionnaires were pretested in order to establish if they captured all the variables
in this study. Content validity of the instrument was ensured through constructive
criticism from colleagues in the maternal health department who had an extensive
experience and expertise in questionnaires construction. The questionnaires were
revised and improved according to the advice and suggestions made.
The pretesting was done at Marani Sub-County Hospital of Kisii County by the
principal researcher where questionnaires were administered to 30 mothers who
attended the maternal newborn and child health clinic; the participants were not part
of the study. The necessary instruction in simplified medical terms was used to
ensure correct interpretations. The mothers were only interviewed after being
sampled, identified the respondent and informed consent was obtained by the
researcher, administer the questionnaire in the language they understand better.
17
Validity and Reliability
Care in development of the instrument was taken so that the wording did not have
any ambiguities; pretesting was done to find out if the respondents interpreted all
questions in the same way. Information from the pre-test was used to refine the tools
prior to the main study. Reliability was also ensured through selection and training of
one research assistant, engaging him in the pre-test and supervising him during the
data collection process. Completed questionnaires were checked daily and errors
were corrected.
Recruitment and Process of Obtaining Consent
Eligible mothers were approached by the principal investigator. The interviewer
explained to the potential study participants the purpose and method of the study.
Informed verbal and written consent using a predefine consent form was obtained
from the mother (Appendix II).
Data management
Data was entered using Microsoft Access Software by the researcher. Error was
minimized by cleaning and rechecking all data entries with the original data forms.
The data was imported to MS Excel which was used for coding and validation. Data
was coded and double entered in a password protected excel spread sheet by the
principal investigator. A back up of these data was done regularly to avoid any loss
or tampering. Hard cover books were also used to store data and any vital
information collected and observed during the study period. Data cleaning and
validation were performed to achieve a clean set that was then exported as a
Statistical Package for Social Sciences (SPSS) file. All data did not have
recognizable names and all study records were properly kept in lockable drawers for
confidentiality.
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Data Analysis
Data was transferred to SPSS software package (version 23.0 software) for analysis.
Fisher‘s exact test was applied to determine the significance of differences of relative
frequencies.
Bivariate analysis was performed using chi square to determine the association
between the dependent and independent variables. Multivariate logistics regression
using backward method was then performed. Only variables with a p<0.05 were
entered into the initial model. To remain in the model, a significance of p<0.05 were
required, the variables that remained in the final model were presented and odds
ratios were calculated for all other variables in this model.
Data Presentation
MS Excel was used to generate graphical presentation. The data was presented in
graphs, pie charts and tables for analysis.
Dissemination of Results
The findings of the study were presented to Jomo Kenyatta University, School of
Public Health as a thesis and report to Kisii Teaching and Referral Hospital.
The results were made available to policy makers in Kisii County and Health
workers within Kisii Teaching and Referral Hospital to facilitate the improvement of
health services (Utilization of PNC). Findings were also published on a medical
journal.
Ethical Consideration
The study was performed according to good clinical practices and to the modified
Declaration of Helsinki (WHO, 2001). Permission to conduct the study was obtained
from the hospital administrator in Kisii Teaching and Referral Hospital.
19
Clearance was obtained from Jomo Kenyatta University of Agriculture and
Technology-College of Health Science and Kenyatta National Hospital-University of
Nairobi Ethics and Research Committee (KNH-UON ERC) ,ref :KNH-ERC/A/99.
Participants were enrolled into the study only after voluntary informed consent
(Appendix II) after which the questionnaire (Appendix III) were administered by the
principal investigator. The clients were free to withdraw from the study at any time.
The respondent‘s privacy were respected and protected. There were no risks
associated with participating in the study. No monetary benefit was associated with
participation in the study. Prior to the study sensitization meeting with the MNCH
clinic health workers was held and the objectives explained. All information about
the client were handled with utmost confidentiality and only used for intended
purposes. The data was stored in electronic formats by restricted access and hard
copies were kept in lockable cabinets and the questionnaires were coded.
80
69.8
Age (Years)
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RESULTS
Demographic and socio-economic characteristics of the study participants
Distribution of study participants by age
A total of 268 participants attending the Child Welfare Clinic at Kisii Teaching and
Referral Hospital were recruited into this descriptive cross sectional study. The mean
age of the participants was 26.94 (± 5.74) years with median of 27 years (range 17 to
45 years). Majority, 187 (69.8%) of the participants were aged between 21 to 30
years followed by those aged between 31 to 40 years at birth of the last child,
(Figure 4.1; Table 4.1).
70
60
50
40
30
20
10
0
15 - 20 21 - 30 31 - 40 41 - 50
Figure: Distribution of study participants by age
Percentage (%)
17.2
11.9
1.1
21
4.1.1.1 Distribution of study participants by highest level of education
Most of the participants (59%) had secondary school education, with 26.9% having
post-secondary level of education. Only 35 (13.1%) participants had primary
education as shown in Figure 4.2.
Figure: highest level of education
Distribution of study participants by marital status
Figure 4.3 shows the marital status of the participants. Majority 88.1% of the study
participants were married (Figure 4.3; Table 4.1).
Primary
school
13.
1
Post-
secondary
26.
9
Secondary
school
59
None1.1
0 10 20 30 40 50 60 70
Percentage (%)
Highest level of
education
22
Figure: Marital status of the participants
Distribution of study participants by number of children
The mean number of children was 1.89 (±1.049) with median of 2 children (range 1 to 6
children). Approximately 122 (45.5%) of the study participants had 2 or 3 children, while
120 (44.8%) had only one child. Only 24 (9%) of the participants were from households
with 4 to 5 children while 2 (0.7%) of the participants were from households with more
than 5 children (Figure 4.4; Table 4.1).
50
45
40
35
30
25
20
15
10
5
0
44.8 45.5
12 - 34 - 5 More than 5
Number of children
23
9
0.7
Figure : Number of children per household
Table: Demographic characteristics of the study population
Demographic characteristics Frequency (N) Percentage (%)
Age (Years)
15 - 20 32 11.9
21 - 30 187 69.8
31 - 40 46 17.2
41 - 50
3
1.1
Highest level of education
No formal education
3
1.1
Secondary school 158 59
Post-secondary 72 26.9
Primary education 35 13.1
Marital status
Married 236 88.1
Single 30 11.2
Separated/divorced
2
0.7
Number of children
1
120 44.8
2 - 3 122 45.5
4 - 5 24
9
More than 5
2
0.7
Percentage (%)
24
Socio-economic characteristics of the study participants
Occupation
The findings showed that majority of the study participants, 174 (65.4%) were
unemployed followed by 65 (24.4%) who had formal employment. 27 (10.1%) of the
participants worked in the agricultural and retail sector (Figure 4.5; Table 4.2).
Figure: Occupation of the study participants
Place of residence
The study findings showed that majority of the study participants 115(43.2%) resided in the
semi-urban areas while some 90 (33.9%) reside in the rural areas, Whereas, 61 (22.9%)
participants resided in the urban areas (Figure 4.6; Table 4.2).
Unemployed 65.4
Agricultural/Retail 10.2
Formal
employment
24.4
0 10 20 30 4050 60 70
Percentage (%)
50
45
40
35
30
25
20
15
10
5
0
43.2
Occupation
Percentage (%)
25
Figure 4.6: Place of residence of the study participants
Accessibility to the health facility
The study findings established that less than a half of the participants 90 (34%) resided in
areas that were between 0 – 5 kilometers to the health facility while 85 (32%) resided in
areas that were between 6 – 10 kilometers to the health facility. Followed by 58 (21.9%)
resided in areas that were between 11 – 15 kilometers to the health facility. 32 (12.1%)
resided in areas that were more than 15 kilometers to the health facility (Figure 4.8; Table
4.2).
Figure: Distance from place of residence to the health facility
50
45
40
35
30
25
20
15
10
5
0
33.9
22.
9
Rural Urban
Place of
residence
Semi-
urban
More than 15 12.1
11 - 15 21.9
6 - 10 32
0 - 5 34
0 5 10 15 20 25 30 35 40
Percentage (%)
Distance from residence to health
facility
(Kilometres)
26
Table: Socio-economic factors of the study population
Socio-economic characteristics
Frequency (N) Percentage (%)
Occupation
Formal employment
65 24.4
Agricultural/Retail 27 10.2
Unemployed 174 65.4
Place of residence
Rural 90 33.9
Urban 61 22.9
Semi-urban 115 43.2
Residence distance from the health
facility
(Kilometers)
0 - 5 90 34
6 - 10 85 32
11 - 15 58 21.9
More than 15
32 12.1
Utilization of postnatal care services
Proportion of participants who utilized PNC
Figure shows the women who utilized postnatal services. Majority, 172 (64.2%) did
not utilize postnatal services while 96 (35.8%) of the participants were found to have
utilized the postnatal services (Figure 4.8, Table 4.3).
70 64.
2
60
50
40 35.8
30
20
10
0
YesNo
Utilization of postnatal services
Percentage (%)
27
Figure: Proportion utilizing postnatal services
Place of delivery
Over half of the participants 166 (61.9%) delivered their last baby in the health
facilities, while 102 (38.1%) delivered their babies at home. There was a significant
relationship between the place of delivery and the utilization of the postnatal care
services. (2 = 48.213; df = 1; P < 0.001) (Figure 4.9, Table 4.3).
Figure Place of delivery
Medical assessment after delivery
Nearly half of the participants 142 (53%) had their first medical assessment (health
of mother and baby) after delivery, while 126 (47%) did not have their first medical
assessment. There was a significant relationship between medical assessment after
delivery and the utilization of the postnatal care services (2 = 18.533; df = 1; P <
Home 38%
Health facility
62%
28
0.001) (Figure 4.10, Table 4.3).
29
Figure: First medical assessment after delivery
Attendance of the first medical assessment
Less than half of the participants 95 (35.4%) had their first medical assessment after
delivery conducted within hours. Approximately seventeen percent (17.2%) of the
participants had their first medical assessment after delivery conducted within days,
while 16 (11.3%) of the participants had their first medical assessment after delivery
conducted within weeks. Few of the participants 10 (7%) did not know whether they
had their medical assessment conducted after delivery. There was a significant
relationship between attendance of first medical assessment after delivery and the
utilization of the postnatal care services. (2 = 9.089; df = 3; P = 0.028) (Figure 4.11,
Table ).
Yes
53
%
No
47
%
30
Figure: Attendance of the first medical assessment
Knowledge on visits of postnatal care service within the first six weeks
after delivery
A total of 172 (62.4%) participants gave their suggestions on the number of visits for
their postnatal care service within the first 6 weeks after delivery, Majority of the
participants 95 (35.4%) suggested one visit for their postnatal care service within the
first 6 weeks after delivery while 46 (17.2%) suggested two visits of attendance for
their postnatal care service within the first 6 weeks after delivery. The participants
who suggested three and four visits respectively were 23 (8.6%) and 8 (3%). 96
(35.8%) did not give suggestions on when they had attended postnatal care service
within the first 6 weeks after delivery. There was a significant relationship between
knowledge on visit of postnatal care within the first 6 weeks after delivery and the
utilization of the postnatal care services. (2 = 8.676; df = 4; P < 0.001) ().
Do not
know
7
Week
s
11.
3
Days 20.
4
Hour
s
61.
3
0 1
0
2
0
3
0
4
0
5
0
6
0
7
0
Percentage
(%)
Duration of first medical assesment after
delivery
31
Figure: Knowledge on attendance of postnatal care service within the first six
weeks after delivery
Two weeks postnatal care services utilization
Majority of the participants 155 (57.8%) did not attend their 2 weeks postnatal care
services. Those participants who attended their 2 weeks postnatal care services were
113 (42.2%). There was a significant relationship between the attendance of two
weeks postnatal services and the utilization of the postnatal care services. (2 =
4.783; df = 1; P = 0.029) (Figure 4.13, Table 4.3).
Do not
know
35.
8
43
38.
6
217.
2
135.
4
0 5 1
0
1
5
2
0
2
5
3
0
3
5
4
0
Percentage
(%)
Knowledge on attendance of postnatal care
service within the first six weeks after
delivery
(number of times)
32
Figure: Two weeks postnatal care services utilization
Challenges incurred when receiving postnatal care services
Majority of the participants 235 (89.7%) said that they did not experience any
problem receiving postnatal care services. However, 27 (10.3%) said that they
experienced problems receiving postnatal care services during their clinic visits.
(Figure 4.20, Table 4.5).
Yes
42%
No 58%
33
Figure: Challenges incurred when receiving postnatal care services
For the participants who experienced problems that prevented them receiving
postnatal care services were, the following reasons were given:
―
T
he baby w
as
in neonatal unit”, “Distance”, “pain from episiotomy”, “Health workers were on
strike”, “I am a student”, “I had a perennial tear”, “I was unable to walk”, “I had
no fare to Kisii Teaching and Referral hospital”, “I had no money”, “I was doing
exams”, “I was held up tightly with work”, “I was sick”, “It was raining too much”,
“Poor weather condition”, “The baby was in the incubator”, “The baby was sick”.
Provision of postnatal care services
Majority of the participants 234 (90%) said that they were happy with the provision
of the postnatal care services. However, 26 (10%) said that they were not happy with
the provision of the postnatal care services. (Figure 4.21, Table 4.5).
Yes
10%
No
90%
34
Figure: Provision of postnatal care services Table
Health provider and health facility factors
Variable Unit
Frequency (N)
Percentage (%)
Very friendly
36 13.6
Friendly 174 65.7
Reception at the health facility
Hurriedly 23 8.7
Rude
5
1.9
Slow 27 10.2
Teaching about postnatal care during
Yes 127 47.7
ANC No 139 52.3
Excellent 28 21.5
Level of information you received
Good 73 56.2
No
10%
Yes
90%
Fair 26 20
Poor
3
2.3
Challenges preventing receiving of
Yes 27 10.3
post natal care services
No 235 89.7
Happy with provision of post natal
Yes 234 90
care services
No 26 10
35
Socio-economic factors influencing utilization of postnatal care services
Table 4.6 shows socio-economic factors influencing utilization of postnatal care
services. In bivariate analysis, participants who were employed were 2.1 times more
likely to utilize postnatal care services (OR 2.1, 95% CI 1.1 to 4.0, P=0.022).
Table: Socio-economic factors influencing utilization of postnatal care
services
Socio-economic characteristics N (%) Utilization of Postnatal care services
P
OR (95% CI)
No, N (%) Yes, N (%)
Occupation
Formal employment 65 (24.4) 49 (75.4) 16 (24.6)
0.022
2.111 (1.113 - 4.004)
Agricultural/Retail
27 (10.2) 18 (66.7) 9 (33.3)
0.462
1.379 (0.586 - 3.243)
Unemployed
174 (65.4) 103 (59.2) 71 (40.8)
Ref
Place of residence
Rural
90 (33.9) 43 (47.8) 43 (47.8)
0.226
0.701 (0.395 - 1.245)
Urban
61 (22.9) 43 (70.5) 18 (29.5)
0.653
1.175 (0.583 - 2.372)
Semi-urban
115 (43.2) 85 (73.9) 30 (26.1)
Ref
Residence distance from the health facility
(Kilometers)
0 - 5 90 (34) 62 (68.9) 28 (31.1)
Ref
6 - 10 85 (32) 46 (54.1) 39 (45.9)
0.392
1.353 (0.677 - 2.706)
11 - 15 58 (21.9) 36 (62.1) 22 (37.9)
0.346
0.721 (0.365 - 1.424)
More than 15 32 (12.1) 26 (81.3) 6 (18.3)
0.065
2.648 (0.942 - 7.448)
N - Number; (%) - Percentage; P - P value (level of significance <0.05); OR - Odds Ratio; CI - Confidence interval
Health provider and health facility factors influencing utilization of
postnatal care
Table 4.7 shows Health provider and health facility factors influencing utilization of
postnatal care. In bivariate analysis, participants who had a very friendly and friendly
reception were more likely to utilize postnatal care services (OR 8.5, 95% CI 2.4 to
11.5, P=0.006). Participants who were taught about postnatal care services during the
antenatal clinic were more likely to utilize postnatal care services (OR 2.3, 95% CI
1.2 to 4.4, P=0.008).
36
As for the level of information received and challenges incurred when receiving
postnatal care and being happy with provision postnatal care, none of these factors
were found to be associated with Health provider and health facility factors
influencing utilization of postnatal care.
Table: Health provider and health facility factors influencing utilization of
postnatal care
Health provider and health facility
Unit
N (%) Utilization of Postnatal care services
P
OR (95% CI)
N - Number; (%) - Percentage; P - P value (level of significance <0.05); OR - Odds Ratio; CI - Confidence interval
Suggestions on how postnatal care services can be improved
Below are the suggestions given by the participants on how to improve post-natal
care services?
Table: Suggestions on postnatal care services
Suggestions Frequency (N) Percent (%)
Employ more nurses 18 33.3
Buy more weighing machines 1 1.9
Bring services closer to the people 3 5.6
Create awareness 13 24.1
Improve services 19 35.2
Total 54 100
factors
No, N (%) Yes, N (%)
Very friendly 36 (13.6) 35 (97.2) 1 (2.8)
0.006
8.588 (2.433 - 11.242)
Friendly
174 (67.7)
138 (79.9) 35 (20.1)
0.054
2.336 (0.984 - 5.546)
Reception at the health facility
Hurriedly
23 (8.7) 19 (82.6) 4 (17.4)
0.13
0.794 (0.738 - 10.580)
Rude
5 (1.9) 2 (40) 3 (60)
0.347
0.392 (0.056 - 2.763)
Slow
27 (10.2) 17 (63) 10 (37)
Ref
Teaching about postnatal care during
Yes
127 (47.7)
110 (86.6) 17 (13.4)
0.008
2.347 (1.245 - 4.426)
ANC No
139 (52.3) 102 (73.4) 37 (26.6)
Ref
Excellent
28 (21.5) 26 (92.9) 2 (7.1)
0.19
6.5 (0.396 - 6.712)
Level of information you received
Good
73 (56.2)
65 (89.0) 8 (11)
0.274
4.062 (0.330 - 5.002)
Fair
26 (20) 20 (76.9) 6 (23.1)
0.697
0.667 (0.128 - 1.732)
Poor
3 (2.3) 2 (66.7) 1 (33.3)
Ref
Challenges incurred when receiving
Yes
27 (10.3) 18 (66.7) 9 (33.3)
0.079
0.461(0.194 - 1.094 0
postnatal care services
No
235 (89.7) 191 (81.3) 44 (18.7)
Ref
Happy with provision of post natal
Yes
234 (90) 192 (82.1) 42 (17.9)
Ref
care services
No
26 (10) 16 (61.5) 10 (38.5)
0.016
0.350 (0.148 - 0.825)
37
CHAPTER FIVE
DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
5.1 Discussion
5.1.1 Low utilization of postnatal care services
This study documented a low utilization of postnatal care services at Kisii Teaching
and Referral Hospital as only 35.8% of the respondents utilized postnatal care
services which is a far cry from the recommended universal access of maternal
services as advocated by the WHO (2013) and GoK (2016). These findings were
lower than the findings of the National average, Kenya Demographic Health Survey
2014/2015 (KDHS, 2014) with 57%. A study conducted by Akunga et al. (2014)
recorded 47% and in Kiambaa area of Kiambu county only 45.1% utilized postnatal
care (Njoka, 2015). The difference might happen due to the fact that the study was a
hospital set up with a small study population. In contrast, this findings is higher than
the study findings in Nyeri Provincial Hospital which recorded about 14.2% utilized
postnatal care, (Kinuthia, 2014).This may be attributed to the time differences that
there could be improvement in accessing and utilizing postnatal care through time.
Although the study was in line with a study conducted in Loma district of Ethiopia
whereby 36% utilized postnatal care services (Ergat, 2018).
A number of studies in third world countries have shown that demographic factors
such as age, education, and distance are associated with the use of postnatal care
services (Sharma et al., 2007).
5.1.2 Demographic and socio-economic characteristics
In this study, it was established that the majority about 70% of the respondents were
aged between 21 to 30 years. This is in line that young mothers have grown up with
more knowledge around ANC, delivery in a health facility and PNC and therefore
most likely to take advantage of these services in a medical health care system.
Similar studies (Dhakal et al., 2007; Workinet et al., 2014) showed that older age
was associated with less PNC utilization. The hypothesis that women above 35 years
38
have grown up with a mentality that pregnancy is not a disease and thus does not
require to seek care at a health facility during and after pregnancy (Fakadu et al.,
2014). The findings of this study is in agreement with a study done in Nyeri
Provincial Hospital on Factors Affecting Utilization of Postnatal Care Services in
Kenya, (Kinuthia, 2014) which showed that majority of the respondents were
between 21-30 years of age utilized postnatal care services. It is well recognized that
age plays an important role in women‘s utilization of maternal health services. Since
older and young women have different experience; and influence, their behavior on
seeking PNC also vary, younger women might have enhanced their knowledge on
modern medicine and are more likely to utilize modern health facilities than older
women. A study done in Nepal (Sharma et al., 2007) gave results that women over
35 years are less likely to utilize PNC services. In this study the pattern was similar,
11.9% were of those women below 20 years, 69.8% were of those women between
21-30 years, 17.2% were of those women between 31-40 years and 1% above 41
years utilized the services.
It is well known that a mother‘s education has a positive influence on PNC services
utilization. The findings of this study revealed that 59% attained secondary education
and 26.9% acquired post-secondary education showed that the higher the education
level the better utilization of PNC as compared to mothers of primary education
with13.1% and those with no education at 1.1%.
This result were inconsistent with a study done in Kenya on determinant of postnatal
use in Kenya, (Akunga et al., 2014) which suggested that women with education
beyond primary school, women living in urban areas, women attending ANC at least
4 visits and women delivering in health facilities are more likely to use PNC services
compared to other women. Also it is similar with findings from studies conducted in
Ethiopia, Indonesia, Uganda and India (Mekonnen, Yared & Asnaketch, 2002; Araya
et al., 2012; Worker et al., 2014). This could be explained by the fact education has
positive input in enhancing female autonomy and help women develop greater
confidence and capable to make decisions concerning their health. Thus, literate
women seek out higher quality health services and have greater ability to use health
39
care inputs that offer better health outcomes (Titaley et al., 2009; Annet, 2004;
Sahoo, 2012).
Although marriage is important and is the tradition in a society like that of Omogusii,
up to 88% of the births in the present study occurred among women who were
married. Marital status is an important socio-demographic characteristic of an
individual that affects the underlying tendency to seek health in Africa (Khan et al.,
2006).
Number of children is another obstetric factor found to be significantly affecting the
use of PNC. With respect to birth order, this study showed that with each additional
birth, utilization levels decreases. This finding is in agreement with evidence from a
study conducted among mothers in rural Nepal (Sulochana, 2007). The chances of
utilizing PNC decreased in mothers who get pregnant for fourth and above than
those with below three children. As the number of pregnancy increases the
probability of giving birth in health institution decreases, this implies that mothers
seek modern obstetric care for their first pregnancy than for the subsequent
pregnancies because they believe that they are now experienced and exposure in
matters concerning obstetrics.
The decline in PNC services among higher birth had also been shown in a study done
at Mbeere District (Mwaniki, 2002) which agrees with the results of this study as
women with higher birth more than fourth rarely attend PNC.
Interestingly, majority of the study participants 65.4% were unemployed in this
study, whereby employment is synonymous with empowerment, which may affect
family‘s wealth status that in turn motivates good health service utilization. This was
contrary with a previous study by employment status which was a determinant of use
of services and those in self-employment were 65% less likely to use the services
than those in formal engagement. Agriculture is a very significant contributor to Kisii
economy, primarily substance agriculture (KDHS, 2014) it is reasonable to assume
that households who depend on agriculture/retail business may be unable to attend
PNC due to time away from work affecting their food production and income, this
results are in line with a study done in Nepal (Vishnu et al., 2011).
40
In regard with place of residence, often rural – urban differences in utilization of
maternal health services reflect the existing differences in access to health services
and opportunities (Ruataremwa, 2012). The reason for rural urban disparity in
utilization of health services is not new phenomenon, and can be explained by
variations in access to maternal health resources, where urban and semi urban
locations often tend to be more privileged relatively to rural areas (Gabrych &
Campell, 2009). Our findings showed that majority of the study participants resided
in semi-urban, 43.2%, urban 22.9% and rural dwellers with 33%. This could be
attributed to in semi-urban areas mothers may have good awareness about the
advantage of postnatal care services and had a better educational status than the rural
residents. In addition, mothers in towns may get easy access to health institutions and
health care providers when compared with rural residents but this was contrary in
this study. Other studies have, however, highlighted poor maternal health outcomes
associated with urban poverty (Izugbara & Ngilangwa, 2010), especially in the poor
slum settlements associated with major urban centers.
Distance from health facility remains a major problem as shown in the previous
literature; utilization of health services is strongly associated with access to the
health facility (Titaley et al., 2010; Rahman, 2010; Warren, 2010), in this study,
those who travel a distance below 5Km where more likely to utilize PNC than those
from a distance above 15 Km. This may be inferred to the cost of travel in terms of
money and energy. From this study, distance to the health facility was found to
influence utilization of PNC because majority 34% resided in areas that were < 5
kilometers away from the health facility. This was in agreement with other studies
that documented distance to the health facility to be a barrier to uptake of services
(Mwanika et al., 2002; Kamau, 2014).
5.1.3 Utilization of postnatal care services
In this study a mother and her newborn is deemed to have utilized PNC services if
attended by a health care worker at least three times in the postnatal care period
(within 42 days). In this study, less than half of the women 35.8% attended PNC at
least three times as recommended by WHO (2014), GOK (2011) during the first 42
41
days post-delivery. This is far below the national figure of 57% who received a
postnatal checkup in their last live birth (KDHS, 2014). Although this was in line
with other studies conducted locally; in Nyeri general hospital 14.2% (Peter
Kinuthia, 2014), in Kiambaa area of Kiambu County 45.1% (Njoka, 2015) and one
conducted in Kenya 47% (Akunga et al.,2014). This is a confirmation that PNC
services are poorly utilized and the weakest in maternal neonatal continuum of care
compared to ANC attendance of 98% and delivery with skilled attendance of 70%
(KDHS, 2014). Honestly this is a far cry from the recommended universal access of
maternal services as advocated by (WHO, 2013) and (GOK, 2010). Poor rates of
PNC attendance have been previously reported in other settings within sub-Saharan
states, Lawn and Kerbe, (2006).
Ethiopian DHS reports that the attendance of PNC within six weeks after childbirth
was only 19% among the surveyed postnatal mothers (Mekonnen et al., 2002)
Results from a study conducted in Congo showed that only 34.6% of postnatal
women had attended PNC within 42 days following childbirth (Dramax et al., 2012).
The poor uptake of postnatal care services imply that for many mothers and their
infants the continuum of care is disrupted during this critical period when lack of
appropriate care could result in significant poor health and even death. Timing of
PNC visit is very important and in this study only 42.2% attended postnatal clinic
within two weeks, this is in line to a study done in Uganda reported 15.4% had
postnatal care within a week (Izudi et al., 2015).
Place of delivery was a major factor predicting PNC utilization in our study, mothers
who delivered their last baby in a health institution utilized PNC more when
compared with those who delivered at home. This finding is nearly in agreement
with evidence from India (Jat et al., 2012). Demographic health survey results in
developing countries (USAID ICF Macro., 2011) and in Nepal (Dhakal et al., 2007).
The association of PNC services utilization with place of delivery can be attributed to
the fact that women who gave their last births in health facility have greater
opportunity to get exposed to health education associates to PNC services at the time
of delivery and hence get access to learn about the types, benefits and availabilities
42
of PNC services during their stay in a health facility. This exposure increases health
care seeking behaviors to prevent maternal and infant complications compared to
those mothers who gave birth at home. Furthermore, those women who gave birth
at home belong to more traditional cohort and hence become less likely to use PNC
services (Tesfahum, 2014).our study findings were contrary with a study conducted
in Uganda (Rutaremwa et al., 2015) which indicated that, majority of the women
opted for home births, and about a quarter of them delivered at a health facility
(Kwagala, 2013).
Although majority of women 56% acknowledged the importance of PNC services in
broader sense but they did not know when should seek those services in practice the
visits were meant for immunization and monitoring progress of their young ones and
less so for women‘s health and this occurred after six weeks. Similar studies
conducted in Ethiopia found that those women who had got information about PNC
from health care workers and nurses were more likely to attend postnatal care
services compared to those women who got information from other sources
(Gabrysch et al., 2009). Many women reported that PNC services were for the
infants to receive vaccination when due. Women sometimes do ignore negative
health outcomes that can occur during puerperium which jeopardize their health;
therefore WHO, (2013) recommends PNC for all women and the young ones,
including those assessments of both physical and mental well- being. These findings
may lead to a conclusion that the PNC service uptake is highly influenced by the
knowledge of women on postnatal care benefits. There was perception that only
women and neonates with health problems need to receive postnatal care.
5.1.4 Health provider and health facility factor
Perceived quality of services was found to be predictive of PNC utilization with a
bias of good services. Respondents who rated reception at the health facility as
friendly were 65.7%. Those taught about PNC during ANC visit were 47.7% and
those who acknowledge the level of information received as good were 56.2% more
likely to utilize PNC as compared to those rated the services as poor. This is in
agreement with other studies (Onah et al., 2006; Mrisho et al., 2009; Kamau, 2014)
43
which highlighted that promptness of care, competence of health workers, desire for
privacy, perceived availability of equipment, friendliness of staff were all
determinants of utilization of health care services.
It was observed that where people have the choice between several facilities, they
sometimes travel further if they target a facility which is perceived to offer superior
quality care (Gabrysch & Campell, 2009). They further reported that even where
facilities were conveniently located, they were under used if their quality were
considered to be bad. From this study, it is evident that the mother experienced some
form of disrespectful care; thus consistent with other studies in Kenya that reported
undignified care (Centre for Reproductive Rights and Federation Women Lawyers,
2007). Disrespectful care also has been documented as a key barrier to the uptake of
services as noted by Bowser et al. (2010). 52.3% of the women were not taught or
informed about PNC during their antenatal visits, meaning many HCWs did not
inform the mothers about PNC services. Similar findings have been documented
elsewhere by Titaley et al., (2009), who reported that they did not receive
appointments for the services on discharge and therefore were not aware of them.
Besides, respondents reported were relational practices of health providers, a
situation often attributed to poor working conditions among health professionals
(Kruk et al., 2010). Previous studies have established that poor relationship between
women and health attendants‘ affects women‘s health seeking practices (Kiwanuka
et al., 2008; Yakong et al., 2010). This indicates that factors which influence
maternal health service utilization may not only be attributed to specific background
characteristics of users but also those associated with the attitude of health attendants
and the health systems in general. In a study of health system factors influencing
maternal health serves in four countries (Parkhurst et al., 2005) found that systems
issues notably those related to human resources influenced the access to and
utilization of services, quality of care provided and ultimately maternal health
outcomes. Opening hours of health facilities (usually operate between 9:00am-
01:00pm) only weekdays, may also hinder women from seeking postnatal care. This
conflicting time schedule may provide an explanation for the decreased likelihood of
PNC attendance amongst mothers. This suggests that greater attention to the users‘
and health providers‘ perspective needs to be considered for service improvement.
44
5.2 Conclusion
This study assessed factors influenced Postnatal Care utilization among women of
reproductive age at Kisii teaching and referral hospital – Kenya.
1. Morbidity and Mortality occasioned by majority (64%) who were found not
to have utilized PNC services will continue to pose serious challenges in
effort towards addressing maternal and child care. Place of delivery,
awareness of postnatal care and attendance at two weeks postnatal care were
key parameters that were associated with utilization of PNC services.
2. Socio-economic factors which were found to be associated with utilization of
PNC services was largely depended upon individual factors such as;
occupation, place of residence and accessibility to health facility.
Expectations of the family from women are high in stabilizing its members
regardless of their health status, among other socio-economic factors.
3. Health provider factors relating to behavior and general practices such as,
attitude, reception at the facility, teaching about PNC during ANC visit and
level of information received among others are key issues that directly or
indirectly influence women to the uptake of PNC services. However, there
are also health facility factors that were responsible for enhancing utilization
of PNC services, they include the number of healthcare workers, commodity
related issues, general quality of care given and the waiting time contribute to
a greater extent towards utilization of PNC services.
5.3 Recommendations
Based on the results of the study, the following recommendations were made.
1. County MOH and facility managers need to continue sensitize the communities
more so women on the importance of PNC through provision of easy to understand
self-help IEC materials.
2. Community linkages through community health extension workers and
community health workers should be strengthened and possibility of facility
45
outreaches for key populations (women) should looked into a system that would
continue to promote good PNC practices and professional supervision.
3. There is need to improve PNC related infrastructure. This includes increasing the
number of nurses in CWC, continuous capacity building of health care workers on
reproductive health with emphasizes on PNC services and client relation should be
enhanced, provision of tools and equipment and creating a lunch hour shift these may
help improve utilization of postnatal care services
4. Further research to compare postnatal care services given to women who delivered
in health facilities and those who had home deliveries in terms of services provided,
strategies and their outcomes.
46
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APPENDICES
Appendix I: Introduction Letter
MAYIEKA NICHOLAS ONGERA
P. O BOX 20895-00200
NAIROBI
TEL: 0721676933/0737509340
THRO,
THE MEDICAL SUPERINTENDENT
KISII TEACHING AND REFERRAL HOSPITAL
P. O BOX 52
KISII
Dear Sir/Madam,
REF:
PERMISSION
TO
CARRY
OUT
ACADEMIC
RESEARCH
IN
YOUR
INSTITUTION
I am a student of Jomo Kenyatta University of Agriculture and Technology pursuing
a Master Degree in Public Health. I am conducting an academic research on the
factors influencing utilization of postnatal care services. The purpose of this letter is
to request to be allowed to conduct this research in your institution.
I wish to state that I will strictly adhere to the code of conduct required with total
respect to confidentiality. All records and information obtained will be handled
discreetly and professionally, will remain confidential unless otherwise through your
content and of any other person involved.
Looking forward to your kind and favorable consideration.
Yours faithfully,
MAYIEKA NICHOLAS ONGERA
62
Appendix II (A): Informed Consent Form
Project Title: - Factors Influencing Utilization of Postnatal Care Services among
Women of Reproductive Age (15-49 years) attending Child Welfare Clinic at Kisii
Teaching and Referral Hospital-Kenya
List of investigators 1. Mayieka Nicholas Ongera – Principal Investigator
2. Prof. Gideon Kikuvi – Co-investigator
3. Dr. Daniel Mokaya – Co-investigator
Introduction: My name is MAYIEKA NICHOLAS ONGERA, an MSc student in
public health at Jomo Kenyatta University of Agriculture and Technology (JKUAT).
You are kindly required to participate in this study because you meet the basic
inclusion criteria for the study. I would like to collect information on factors
influencing the utilization of post postnatal care services among women of
reproductive age (15-49 years) attending a child welfare clinic.
Purpose of the study: the main aim of the study is to determine the factors
influencing utilization of postnatal care services among women of reproductive age
attending CWC at Kisii Teaching and Referral Hospital.
Procedure: If you volunteer to participate in this study both verbally and by signing
the section at the end of the form, you will be interviewed by trained personnel who
will fill the collected information into a questionnaire.
Potential risks and discomfort: Some of the questions might be uncomfortable and
you don‘t have to answer them if they are causing any form of discomfort.
Benefits of the study: there will be no monetary benefits associated with
participating in this study but only the information gathered will improve the services
clients receive in this facility.
Confidentiality of the records: any records relating to the clients will be treated with
the utmost confidentiality. Your names will not appear in any of the reports from this
study. Personal identifiers will not be included in the written questionnaires.
Basics of participation:
You are being requested to participate in this study.
Participation is entirely voluntary
You are free to withdraw the consent to participate in this study at any time.
63
You are free to ask any questions pertaining the study which may not be clear
to you after the consent has been explained to you.
Who to Contact
You are encouraged to ask any question to clarify any issues at any time during your
participation in the study. If you need more information of the study, you will contact
the following persons
Name Contact Institution Email address
You can also contact KNH-UON Ethics and Research Committee using the landline
number 020726300-9 or through the email address [email protected]
Consent
I the undersigned have understood the above information which has been read and
explained to me by the researcher and I voluntarily consent to participate. I have had
the opportunity to ask questions and all my questions have been answered
satisfactorily.
Respondent‘s name
Respondent‘s signature_
Date / /2018
Researcher‘s name
Researcher‘s signature
64
Apendix II (B): Kiambatisho Cha Pili: Fomu Ya Ridhaa
Mada ya Mradi: Vishawishi kwenye utafutaji wa huduma za afya za baada ya
kujifungua kwa wanawake walio kwenye umri wa uzazi (15-49) wanaotafuta
huduma za kliniki kwa watoto wao katika hospitali kuu ya rufaa ya Kisii
(KTRH).
Waliohusika Kwenye Utafiti:
1. Mayieka Nicholas Ongera- Mtafiti Mkuu
2. Prof. Gideon – Mtafiti Mwenza
3. Dr. Daniel Mokaya- Mtafiti Mwenza
Utangulizi: Kwa majina naitwa MAYIEKA NICHOLAS ONGERA, mwanafunzi
wa Shahada ya Uzamili ya sayansi (MSc) katika somo la afya ya umma katika Chuo
Kikuu cha Ukulima na Teknolojia cha Jomo Kenyatta (JKUAT). Unaombwa
kushiriki kwenye utafiti huu kwa sababu umetimiza vigezo vya kushirikishwa.
Ningependa kupata maoni yako kuhusu vishawishi kwenye utafutaji wa huduma za
afya za baada ya kujifungua kwa wanawake walio kwenye umri wa uzazi (15-49)
wanaotafuta huduma za kliniki kwa watoto wao katika hospitali kuu ya rufaa ya Kisii
(KTRH).
Kusudi la Utafiti: Sababu kuu ya kufanya utafiti huu ni kujua vishawishi vilivyoko
kwenye utafutaji wa huduma za afya za baada ya kujifungua kwa wanawake walio
kwenye umri wa uzazi (15-49) wanaotafuta huduma za kliniki kwa watoto wao
katika hospitali kuu ya rufaa ya Kisii.
Utaratibu: Ikiwa utakubali kushiriki kwenye utafiti huu, kwa mazungumzo na pia
kwa kutia sahihi sehemu ya mwisho ya fomu hii, utahojiwa na wataalamu ambao
watajaza majibu yako kwenye orodha ya maswali ya uchunguzi.
Uwezekano wa hatari na Usumbufu: Baadhi ya maswali yanaweza kuudhi. Hutalazimishwa
kuyajibu ikiwa yatakuudhi ama kuleta usumbufu wa aina yoyote.
Faida za Utafiti: Hutalipwa fedha kwa kushiriki utafiti huu ila maoni yako yatasaidia kuboresha
huduma wanazopata wateja wa hospitali hii.
Usiri wa Kumbukumbu/Rekodi: Taarifa zote zinazowahusu wateja zitawekwa kwa siri kubwa.
Majina yako hayatachapishwa kwenye ripoti yoyote ya utafiti huu. Vitambulisho vya ubinafsi
havitajumuishwa kwenye maswali ya uchunguzi.
65
Misingi ya Ushiriki:
Unaombwa kwa hiari yako kushiriki kwenye utafiti huu
Kushiriki ni kwa hiari tu
Una ruhusa ya kujitoa kwenye utafiti huu wakati wowote
Una ruhusa ya kuuliza maswali yoyote kuhusu utafiti huu, ikiwa kuna jambo
lolote hujalielewa
Utakao wasiliana nao
Unaruhusiwa kuuliza maswali kuhusu jambo lolote wakati
unahojiwa. Ukihitaji maelezo zaidi, wasiliana na wafuatao:
Jina Nambari ya Simu Taasisi Barua Pepe
1. Nicholas Mayieka 0721676433 JKUAT
2. Prof. Gideon Kikuvi 0725363151 JKUAT
3. Dr. Daniel Mokaya 0733704573 JKUAT
Aidha, unaweza kuwasiliana na KNH-UON, kamati ya Maadili na
Utafti ukitumia nambari ya simu: 020726300-9 ama kupitia barua pepe:
Saini
Mimi, msahihi nimeelezwa habari ambayo imesomwa na kuelezwa na mtafiti
kwangu, nina ridhaa kushiriki kwa hiari. Nimekuwa na nafsi ya kuuliza maswaki na
maswali yangu yote yamejibiwa kwa kuridhisha
Jina la mhojiwa Tarehe
/
/ 2017
Sahihi ya Mhojiwa
Jina la mtafiti Tarehe / / 2017
Sahihi ya mtafiti
66
Apendix II (C): Ensemo Ya Kabere: Efomu Yogwancherana
Eng’ana Emwamu: Amang’ana akobanyora abasubati bemiaka yoroiboro (15-
49) abwo bakorigia obokoreri bwobogwenia magega yokoibora, ekero bakoira
abana babo ekiriniki ase enyagitari enene y’erufaa ya Kisii (KTRH).
Abaunenki:
4. Mayieka Nicholas Ongera- Omounenki Omonene
5. Prof. Gideon – Omokonyi bw‘omounenki
6. Dr. Daniel Mokaya- Omokonyi bw‘omounenki
Omochakano: Ase amarieta nigo inkorokwa MAYIEKA NICHOLAS ONG‘ERA,
omworokigwa ogosomera edigirii ya igoro ya ‗Masters‘ ase esayansi (MSc)
yobochenu ase eyunibasiti yoboremi n‘etekinolojia ya Jomo Kenyatta (JKUAT).
Nigo inkogosaba osange ase obotuki obo ase engencho yoboikeranu bwao. Nigo
inganeti ebirengererio biao igoro ya amang‘ana akobanyora abasubati bemiaka
yoroiboro (15-49) abwo bakorigia obokoreri bwobogwenia magega yokoibora, ekero
bakoira abana babo ekiriniki ase enyagitari enene y‘erufaa ya Kisii (KTRH).
Ekerenga kiobotuki: Ekerenga ekenene kiogokora obotuki obwo, nokogani
komanya amang‘ana akobanyora abasubati bemiaka yoroiboro (15-49) abwo
bakorigia obokoreri bwobogwenia magega yokoibora, ekero bakoira abana babo
ekiriniki ase enyagitari enene y‘erufaa ya Kisii (KTRH).
Omochoko: Onye kogochia gwancha gosanga ase obotuki obo, goetera chinkwana
naboigo ase okobeka esei ensemo yomoerio yefomu eye, nigo ogochia kounenkigwa
na abaobisa babwate obamanyi obonene na magega yaye baichorie amachibu ao ase
risakara ria amabori.
Obokong’u n’okogechigwa: Amabori ande nabo arabaise gokogechia. Korende
tokobetererigwa koyairaneria.
Eng’eria yobotuki: Torigoakanwa ase ogosanga ase obotuki obo korende
ebirengereruo biao nigo birakonye gokinia obokoreri bokoenanwa ase enyagitari eye
gochia ase abananchi.
67
Obobisi bwe chirekodi: Amangana onsi igoro ya abatecha nigo agochia kobiswa
kegima. Amarieta ao boigo tarigochia goakwa echaba ase eriboti ende yonsi
yobotuki obo. Boigo amabori yogokomanyekania taiyo ase obotuki obo.
Oboroso bwogosanga:
Nigo ogosabwa obwaterane ase obotuki obo ase ogwancha kwao.
Torikobetererigwa gosanga ase obotuki obo.
Nobwate obosibore bwokwerusia ase obotuki obo ngaki ende yonsi.
Nobwate obosibore bwokoboria amabori ande onsi igoro ya aria otaraigwa
buya
Nobwate obosibore bwokoboria amabori chingaki ogendererete
kounenkigwa.
Baria moraborie
Koragani amaereso ande gochia ime, nabo ogokwana na‘bakobwatia:
Erieta Enamba yesimi Eyunibasiti Email
Boigo, nabo ogokwana nekomiti ye chimbwa nobotuki ya KNH-UON ase
enamba yesimi: 020726300-9 gose goetera email: [email protected]
Inee, kwang’ancheire ingenderere gokounenkia ase obotuki obo?
Chitariki / / 2017
Esei y‘oria Okounenkigwa
Chitariki / / 2017
Esei y‘oria Okounenkia
Rika chisa obotuki bwachagete
68
Appendix III (A): Questionnaire on Factors Influencing Utilization of Postnatal
Care
SECTION A.
Name of interviewer………………………………………..
Client code number………………………
Date……………………………..
Please put a tick [√] or a number in the box next against your response and where
applicable write the required response in the box or space provided.
SECTION B: DEMOGRAPHIC DATA
1. Please indicate your age in the appropriate box in complete years:
15 — 20 years
21 — 30 years
31 — 40 years
41 — 50 years
Above 50 years
2. What level of education did you attain?
None
Primary school
Secondary school
Post-secondary
69
3. What is your marital
status? Married
Single
Separated/divorced
4. How many children do you
have? 1
2 — 3
4 — 5
More than 5
SECTION C: SOCIO-ECONOMIC CHARACTERISTICS
5. What activities are you involved, in order to earn a
living? Employment
Agricultural
Others
6. Where do you
stay/live? Rural
Urban
Semi-urban
7. How far is your residence from the health facility in complete kilometers?
0 — 5 km
6 — 10 km
11 — 15 km
More than 15 km
70
SECTION D: PROPORTION OF WOMEN UTILIZING POSTNATAL CARE
8. Where did you give birth to your last
child? Home
Health facility
9. After you gave birth to (child‘s name) did anyone check on your
health? Yes
No
10. How long after delivery did the first checkup take place?
Hours
Days
Weeks
Do not know
11. This facility provides postnatal care services. Did you know the postnatal
services you are supposed to receive after delivery?
Yes
No
12. If yes to question 11, name the services……………………………………
13. Within the first six weeks after delivery how many times are you supposed to
attend postnatal care service?
1
2
3
4
Do not know
71
14. Did you attend the two weeks postnatal care services?
Yes
No
15. If yes to question 14 above, what postnatal services did you receive?
Treatment
Immunization
Family planning
Postnatal checkup for both the mother and the baby
Other specifies…………………………..
16. If you did not go for postnatal services, tick possible reason why you did not
use these services
Not aware these services are offered
Had no problem
Others, specify……………………………………
17. Have you ever heard about postnatal care services?
Yes
No
18. If yes to question 17 above, from where did you get the information about
postnatal services?
Friends
Media
Health workers
Other, specify………………………………………………………………
72
SECTION E: HEALTH PROVIDER AND HEALTH FACILITY FACTORS
19. How were you received at the health
facility? Very friendly
Friendly
Hurriedly
Rude
Slow
20. During your antenatal visit were you taught about postnatal care?
Yes
No
21. If yes to question 20 above, could you rate the level of information you
received?
Excellent
Good
Fair
Poor
22. Since you delivered, were there problems that you faced which prevented you
from going to receive postnatal care services?
Yes
No
23. If yes to question 22 above, please name them…………….…………………
…………………………………………………………………………………
73
24. If you had used the postnatal care services, were you happy with the way the
services were offered?
Yes
No
25. If yes to question 24 above, list the good things which made you
happy……………………………………..
…………………………………………………………………………………
26. If no to question 24 above, what weaknesses did you see in the way postnatal
care services were offered ………………………………………………..
27. Give suggestions how postnatal care services can be improved
i.
ii.
iii.
iv.
Thank you for your co-operation
74
Appendix III (B): Kiambatanisho Cha Tatu: Dodoso Kuhusu Mambo
Yanayoshawishi Utumizi Wa Huduma Za Baada Ya Kujifungua.
KIFUNGU CHA A:
Jina la mhoji ………………………………………..
Nambari ya mteja………………………
Tarehe……………………………..
Tafadhali kuweka alama ya vema [√] au nambari katika sanduku ijayo dhidi ya
majibu yako na ambapo husika andika majibu ya ziada katika nafasi iliyotolewa.
KIFUNGU CHA B: TAKWIMU ZA MHOJIWA
1. Tafadhali onyesha umri wako katika sanduku muafaka:
Chini ya miaka 20
Miaka 21 — 30
Miaka 31 — 40
Miaka 41 — 50
Zaidi ya miaka 50
2. Umefikia kiwango gani cha elimu?
Hakuna
Shule ya Msingi
Shule ya upili
Baada ya sekondari
75
3. Hali yako ya ndoa ni gani?
Umeolewa
Bado kuolewa
Kutengana/Talaka
4. Je, una watoto wagapi?
1
2 — 3
4 — 5
Zaidi ya 5
KIFUNGU CHA C: SIFA ZA KIUCHUMI ZA KIJAMII
5. Unajihushisha na shughuli ipi kujikimu kimaisha?
Ajira
Kilimo
zingine
6. Unaishi/unakaa wapi?
Kijijini
Mjini
Kwingine
7. Ni ubali gani kutoka kwa makazi yako na kituo cha afya ?
Kilomita 0 — 5
Kilomita 6 — 10
Kilomita 11 — 15
zaidi ya kilomita 15
76
KIFUNGU CHA D: IDADI YA WANAWAKE KUTUMIA HUDUMA ZA
UTUNZAJI BAADA YA KUJIFUNGUA
8. Ulijifungua mtoto wako wa mwisho
wapi? Nyumbani
Kituo cha Afya
9. Baada ya kujifungua (jina la mtoto) je kuna yeyote alichunguza hali yako ya
kiafya
Ndio
La
10. Je, ilichukua muda gani baada ya kujifungua kupata
huduma? Masaa
Siku
Wiki
Hamna
11. Kituo hiki kinatoa huduma za baada ya kujifungua. Je, ulijua huduma
utakazohitaji kupokea baada ya kujifungua?
Ndio
La
12. Kama ndio kwa swali nambari 11 hapo juu, taja huduma hizo ……………….
………………………………………………………………………………
77
13. Ndani ya wiki sita baada ya kujifungua ni mara ngapi wanatakiwa
kupata huduma?
1
2
3
4
14. Je, ulihudhuria wiki mbili kwa huduma baada ya
kujifungua? Ndio
La
15. Kama ndio kwa swali nambari 14 hapo juu, ni huhuma gani ulizozipata?
Matibabu
Chanjo
Upangaji uzazi
Uchunguzi kwa mama na mtoto
Taja iwapo kuna huduma zingine…………………………..
16. Iwapo Haukupata huduma, taja ni kwanini haukupata hizi huduma za baada
ya kujifungua.
Kutojua huduma zinatotolewa
Sikua na shida yoyote
Iwapo kuna zingine zitaje hapa……………………………………………
78
17. Je, umewahi kusikia kuhusu huduma za baada ya
kujifungua Ndio
La
18. Kama ndio kwa swali nambari 17 hapo juu, ulipata wapi habari kuhusu
huduma za baada ya kujifungua?
Marafiki
Vyombo vya habari
wahudumu wa afya
Kwingine
KIFUNGU CHA E: MTOA HUDUMA YA AFYA NA MAMBO YA
KITUO CHA AFYA
19. Ulipokewa vipi kwa kituo cha
afya? Kirafiki sana
Kirafiki
Haraka
Kijeuri
Vibaya
20. Wakati wa ziara yako ya wajawazito kwa kituo cha afya, je ulifundishwa
kuhusu huduma baada ya kujifungua?
Ndio
La
79
21. Kama ndio kwa swali nambari 20 hapo juu, ulipokea kiwango gani cha
habari?
Mufti
Zuri
Wastani
Duni
22. Tangu ujifungue, kulikua na shida zilizo kuzuia kwenda kupokea huduma za
baada ya kujifungua?
Ndio
La
23. Kama ndio kwa swali nambari 22 hapo juu, tafadhali zitaje……………..
……………………………………………………………………………
24. Kama wewe ulitumia huduma za baada ya kujifungua, je,ulifurahia huduma
ulizozipata?
Ndio
La
25. Kama ndio kwa swali nambari 24 hapo juu, orodhesha mambo mema ambayo
uliyafurahia……………………………………………………………………
…………………………………………………………………………………
26. Kama la kwa swali nambari 24 hapo juu, uliona udhaifu gani kwa huduma za
baada ya kujifungua ulizopewa
…………………………………………………………………………………
80
27. Toa mapendekezo jinsi huduma baada ya kujifungua zinaweza kuboreshwa
i.
ii.
iii.
iv.
Asante kwa kushiriki.
81
Appendix III (C): Ogokoorera Iii: Amairanerio Ase Aria Agochangera Okorigia
Oborendi Nyuma Y
’
okoibora
ENSEEMO YA (A)
Erieta riao………………………………………..
Enamba yomoborigwa………………………
Chitariki……………………………..
Koranche charokia [√] gose enamba ime y‘ebogisi ase okoiraneria gose oriike ase
ekonyarekana agwo ase ribaga erio oeire korwa motwe.
ENSEEMO YA (B): OKOBEKERANIA AMANG’ANA
1. Koranche ichoria emiaka yao ime ye
ebogisi: Inse y‘emiaka 20
Emiaka 21 — 30
Emiaka 31 — 40
Emiaka 41 — 50
Goetania emiaka 50
2. Ekerengo giechiseemi chiao
inkereki? Tinsometi
Esukuru y‘oboroso
Esekendari
Goetania Esekendari
82
3. Kwanyorire enka?
Nimbwate enyomba
Tindi na nyomba
Titomenyaini/Totigainete
4. Abana obwate mbarenga?
1
2 — 3
4 — 5
Goetania 5
ENSEMO YA (C): OBORENDI BW’OMOIBORI (OBORENDI ASE
OMOKUNGU OIBOIRE ERE AMO N’EKENGW’ERERE GOIKA EMIAKA
ETAN’OMO)
5. Ng‘ai kwaiborerete omwana oo bw‘omoerio?
Inka
Nyagitari
6. Nyuma yokibora omwana(Erieta riaye) onde nakoringoretie agwo
nyagitari? Ee
Yaaya
7. Mbwango ki kwairete koringorigwa nyuma yokoibora?
Insa ‗nkeigo
K‘amatuko aetire
Ase emekubio
Tinkoinyora
83
8. Enyagitari eye nkorwa ere oborendi ase abakungu bakoibora. Kwana
komanyigwa buna enyagitari nkorwa ere oborendi ase omokungu oiboire?
Ee
Yaaya
9. Onye kere boigo ase riborio namba 8 agwo igoro, atora aria gwakoreretwe
………………………………….………………………………………………
10. Ase emetienyi emetang‘ani yokoibora, aye nara karenga ogwenerete kogenda
ekiriniki kioborendi nyuma yokoiboira?
1
2
3
4
11. Nkwarenge ase amorokererio y‘oroiboro ase emekubio ebere
? Ee
Yaaya
12. Onye kwarengeo, ninki gwakoreretwe?
Okogwenigwa
Esindani y‘ogotanga
Ogotanga oroiboro
Okoringorigwa kw‘oroiboro ase omwana na ng‘ina
Teeba ayande …………………………..
84
13. Teeba egekogera otakorete aria
aganeirie Tinamanyetigwe kende
Tinyoreti mochando onde
Teeba ayande……………………………………………………………
OMOBARO BWABAIBORI BAGOKORERA OROIBORO RWA
NYAGITARI
14. Ng‘ai
omenyete?
Risabu
Etaoni
Agachiiro
15. Ngento ki ogokora ase okwenyorera chinchera
okoragera? Nindikire
Oboremi
Ayande
16. Kwana koigwa igoro yomoroberio bwokorendwa nyuma yokoibora?
Ee
Yaaya
17. Ng‘ai aye kwainyorete amang‘ana
ayio? Abasaani
Amarario
Abanyagitari
Teeba enchera ende
85
18. Mboare ki omenyete korwa ase
enyagitari? 0 — 5 km
6 — 10 km
11 — 15 km
Goetania 15 km
ARIA ABWATEKAINE NOMONYAGITARI ASE ENYAGITARI
19. Inaki kwaariganetigwe ase
enyagitari? Oboseera kegima
Oboseera
Omoayarero
Ogotogonyerwa
Okwerindoria
20. Nkwaorokereretigwe igoro yoborendi nyuma yokoibora ekero ore
morito? Ee
Yaaya
21. Teeba ekerengo kiobomanyi obwate ase amang‘ana
ayio Buya goetania
Buya
Buya akeigo
Tingokiri
86
22. Korwa oibora, mbokong‘u ki kwanyorete obwo bwagotangete tikwagenda
konyora obokonyi nyuma y‘okoibora?
Ee
Yaaya
23. Koranche yaatore………………………………………………………………
24. Nogokirie na aria gwakoreretwe ase oborendi nyuma yokoibora?
Ee
Yaaya
25. Atora aria akogogetie …………………………………………………..…..
26. Onye teri boigo, mboremerwa ki kwaroche ase chinchera chiobokonyi nyuma
yokoibora………………………………………………………………………
27. Karwe ebirengererio birakonye chinchera chioborendi
obuya v.
vi.
vii.
viii.
Mbuya mono ase amairanerio
87
Appendix IV: Ethical Clearence from Knh-Uon Erc
88
Appendix V: Clearance Letter for Conducting Research
89
Appendix VI: Authorization to Collect Data from KTRH
Appendix VII: Authorization Letter - Postgraduate School
90
