{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,11]],"date-time":"2026-11-11T16:18:16Z","timestamp":1794413896872,"version":"4.9.1"},"reference-count":39,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2019,9,18]],"date-time":"2019-09-18T00:00:00Z","timestamp":1568764800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2019,9,18]],"date-time":"2019-09-18T00:00:00Z","timestamp":1568764800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["OPP1106888"],"award-info":[{"award-number":["OPP1106888"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Pregnancy Childbirth"],"published-print":{"date-parts":[[2019,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>There is broad agreement that antenatal care (ANC) interventions, skilled attendance at birth and management of complications arising after delivery are key strategies that can tackle the high burden of maternal mortality in sub-Saharan Africa. In Kenya, utilisation rate of these services has remained low despite a government policy on free maternal care. The present study sought to understand what factors are leading to the low healthcare seeking during pregnancy, child birth and postnatal period in Siaya County in Kenya.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Six Focus Group Discussions were conducted with 50 women attending ANC in 6 public primary healthcare facilities. Participants were drawn from a sample of 200 women who were eligible participants in a Conditional Cash Transfer project aimed at increasing utilization of healthcare services during pregnancy and postnatal period. Interviews were conducted at the health facilities, recorded, transcribed and analysed using thematic analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Multiple factors beyond the commonly reported distance to health facility and lack of transportation and finances explained the low utilization of services. Emergent themes included a lack of understanding of the role of ANC beyond the treatment of regular ailments. Women with no complicated pregnancies therefore missed or went in late for the visits. A missed health visit contributed to future missed visits, not just for ANC but also for facility delivery and postnatal care. The underlying cause of this relationship was a fear of reprimand from the health staff and denial of care. The negative attitude of the health workers explained the pervasive fear expressed by the participants, as well as being on its own a reason for not making the visits. The effect was not just on the woman with the negative experience, but spiraled and affected the decision of other women and their social networks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The complexity of the barriers to healthcare visits implies that narrow focused solutions are unlikely to succeed. Instead, there should broad-based solutions that focus on the entire continuum of maternal care with a special focus on ANC. There is an urgent need to shift the negative attitude of healthcare workers towards their clients.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12884-019-2485-2","type":"journal-article","created":{"date-parts":[[2019,9,18]],"date-time":"2019-09-18T09:04:57Z","timestamp":1568797497000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":46,"title":["Barriers to formal health care seeking during pregnancy, childbirth and postnatal period: a qualitative study in Siaya County in rural Kenya"],"prefix":"10.1186","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0235-3155","authenticated-orcid":false,"given":"Caroline A.","family":"Ochieng","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aloyce S.","family":"Odhiambo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2019,9,18]]},"reference":[{"issue":"9726","key":"2485_CR1","doi-asserted-by":"publisher","first-page":"1609","DOI":"10.1016\/S0140-6736(10)60518-1","volume":"375","author":"MC Hogan","year":"2010","unstructured":"Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980\u20132008: a systematic analysis of progress towards millennium development goal 5. Lancet. 2010;375(9726):1609\u201323.","journal-title":"Lancet"},{"issue":"10017","key":"2485_CR2","doi-asserted-by":"publisher","first-page":"462","DOI":"10.1016\/S0140-6736(15)00838-7","volume":"387","author":"L Alkema","year":"2016","unstructured":"Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN maternal mortality estimation inter-agency group. Lancet. 2016;387(10017):462\u201374.","journal-title":"Lancet"},{"issue":"10017","key":"2485_CR3","doi-asserted-by":"publisher","first-page":"410","DOI":"10.1016\/S0140-6736(16)00099-4","volume":"387","author":"CH Hansen","year":"2016","unstructured":"Hansen CH, Schellenberg JRMA. Modest global achievements in maternal survival: more focus on sub-Saharan Africa is needed. Lancet. 2016;387(10017):410\u20131.","journal-title":"Lancet"},{"key":"2485_CR4","unstructured":"GOK. A price too high to bear: The Costs of Maternal Mortality to Families and Communities. https:\/\/www.who.int\/pmnch\/media\/news\/2014\/technical_brief.pdf ."},{"key":"2485_CR5","unstructured":"Sustainable Development Goals: 17 Goals to Transform Our World http:\/\/www.un.org\/sustainabledevelopment\/health\/ . UN. [Internet]. United Nations Sustainable Development. [cited 2017 Dec 7]. Available from: http:\/\/www.un.org\/sustainabledevelopment\/health\/"},{"issue":"7525","key":"2485_CR6","doi-asserted-by":"publisher","first-page":"1107","DOI":"10.1136\/bmj.331.7525.1107","volume":"331","author":"T Adam","year":"2005","unstructured":"Adam T, Lim SS, Mehta S, Bhutta ZA, Fogstad H, Mathai M, et al. Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. BMJ. 2005;331(7525):1107.","journal-title":"BMJ."},{"issue":"9463","key":"2485_CR7","doi-asserted-by":"publisher","first-page":"977","DOI":"10.1016\/S0140-6736(05)71088-6","volume":"365","author":"GL Darmstadt","year":"2005","unstructured":"Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L, et al. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet Lond Engl. 2005;365(9463):977\u201388.","journal-title":"Lancet Lond Engl"},{"issue":"9543","key":"2485_CR8","doi-asserted-by":"publisher","first-page":"1284","DOI":"10.1016\/S0140-6736(06)69381-1","volume":"368","author":"OMR Campbell","year":"2006","unstructured":"Campbell OMR, Graham WJ. Lancet maternal survival series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368(9543):1284\u201399.","journal-title":"Lancet."},{"issue":"2","key":"2485_CR9","doi-asserted-by":"publisher","first-page":"181","DOI":"10.1016\/j.ijgo.2004.11.026","volume":"88","author":"A Paxton","year":"2005","unstructured":"Paxton A, Maine D, Freedman L, Fry D, Lobis S. The evidence for emergency obstetric care. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2005;88(2):181\u201393.","journal-title":"Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet"},{"key":"2485_CR10","volume-title":"Antenatal care in developing countries. Promises, achievements, and missed opportunities","author":"World Health Organization, UNICEF","year":"2003","unstructured":"World Health Organization, UNICEF. Antenatal care in developing countries. Promises, achievements, and missed opportunities. Geneva: World Health Organization; 2003."},{"key":"2485_CR11","volume-title":"Making Pregnancy Safer: the Critical Role of the Skilled Attendant. Joint Statement by WHO, ICM and FIGO","author":"World Health Organization","year":"2004","unstructured":"World Health Organization. Making Pregnancy Safer: the Critical Role of the Skilled Attendant. Joint Statement by WHO, ICM and FIGO. Geneva: WHO World Health Organization; 2004. Proportion of Births Attended by a Skilled Attendant: 2008 Updates. 2008, Factsheet Geneva: Department of Reproductive Health and Research, WHO"},{"key":"2485_CR12","volume-title":"Opportunities for Africas newborns: practical data policy and programmatic support for newborn care in Africa","author":"J Lawn","year":"2006","unstructured":"Lawn J, Kerber K. Opportunities for Africas newborns: practical data policy and programmatic support for newborn care in Africa; 2006."},{"issue":"1","key":"2485_CR13","doi-asserted-by":"publisher","first-page":"e53747","DOI":"10.1371\/journal.pone.0053747","volume":"8","author":"C Pell","year":"2013","unstructured":"Pell C, Me\u00f1aca A, Were F, Afrah NA, Chatio S, Manda-Taylor L, et al. Factors affecting antenatal care attendance: results from qualitative studies in Ghana, Kenya and Malawi. PLoS ONE. 2013;8(1):e53747.","journal-title":"PLoS ONE"},{"issue":"9268","key":"2485_CR14","doi-asserted-by":"publisher","first-page":"1551","DOI":"10.1016\/S0140-6736(00)04722-X","volume":"357","author":"J Villar","year":"2001","unstructured":"Villar J, Ba\u2019aqeel H, Piaggio G, Lumbiganon P, Miguel Beliz\u00e1n J, Farnot U, et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet Lond Engl. 2001;357(9268):1551\u201364.","journal-title":"Lancet Lond Engl."},{"issue":"9730","key":"2485_CR15","doi-asserted-by":"publisher","first-page":"2032","DOI":"10.1016\/S0140-6736(10)60678-2","volume":"375","author":"ZA Bhutta","year":"2010","unstructured":"Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, et al. Countdown to 2015 decade report (2000\u201310): taking stock of maternal, newborn, and child survival. Lancet. 2010;375(9730):2032\u201344.","journal-title":"Lancet"},{"key":"2485_CR16","doi-asserted-by":"publisher","DOI":"10.31899\/rh4.1177","volume-title":"Acceptability and sustainability of the WHO Focused Antenatal Care package in Kenya","author":"H Birungi","year":"2006","unstructured":"Birungi H, Onyango-Ouma W. Acceptability and sustainability of the WHO Focused Antenatal Care package in Kenya. Washington, DC: Population Council, Frontiers in Reproductive Health; 2006. [cited 2014 Jul 30]. Available from: http:\/\/www.hrhresourcecenter.org\/node\/808"},{"issue":"3","key":"2485_CR17","doi-asserted-by":"publisher","first-page":"244","DOI":"10.1111\/j.1365-2648.2007.04532.x","volume":"61","author":"B Simkhada","year":"2008","unstructured":"Simkhada B, van Teijlingen ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. J Adv Nurs. 2008;61(3):244\u201360.","journal-title":"J Adv Nurs"},{"key":"2485_CR18","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1186\/1742-4755-10-40","volume":"10","author":"CA Moyer","year":"2013","unstructured":"Moyer CA, Mustafa A. Drivers and deterrents of facility delivery in sub-Saharan Africa: a systematic review. Reprod Health. 2013;10:40.","journal-title":"Reprod Health"},{"key":"2485_CR19","doi-asserted-by":"publisher","first-page":"71","DOI":"10.1186\/1742-4755-11-71","volume":"11","author":"MA Bohren","year":"2014","unstructured":"Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, G\u00fclmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health. 2014;11:71.","journal-title":"Reprod Health"},{"key":"2485_CR20","doi-asserted-by":"publisher","first-page":"26","DOI":"10.1186\/s12884-015-0453-z","volume":"15","author":"L Mason","year":"2015","unstructured":"Mason L, Dellicour S, Ter Kuile F, Ouma P, Phillips-Howard P, Were F, et al. Barriers and facilitators to antenatal and delivery care in western Kenya: a qualitative study. BMC Pregnancy Childbirth. 2015;15:26.","journal-title":"BMC Pregnancy Childbirth"},{"issue":"2","key":"2485_CR21","doi-asserted-by":"publisher","first-page":"237","DOI":"10.1080\/07399332.2014.908194","volume":"37","author":"Remare R. Ettarh","year":"2014","unstructured":"Ettarh RR, Kimani J. Influence of distance to health facilities on the use of skilled attendants at birth in Kenya. Health care for women international. 2016;37(2):237\u201349.","journal-title":"Health Care for Women International"},{"issue":"1","key":"2485_CR22","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1186\/s12884-018-1708-2","volume":"18","author":"CM Gitobu","year":"2018","unstructured":"Gitobu CM, Gichangi PB, Mwanda WO. The effect of Kenya\u2019s free maternal health care policy on the utilization of health facility delivery services and maternal and neonatal mortality in public health facilities. BMC Pregnancy Childbirth. 2018;18(1):77.","journal-title":"BMC Pregnancy Childbirth."},{"key":"2485_CR23","volume-title":"Implementing free maternal health Care in Kenya: challenges, strategies, and recommendations","author":"N Bourbonnais","year":"2013","unstructured":"Bourbonnais, N. 2013. Implementing free maternal health Care in Kenya: challenges, strategies, and recommendations. Kenya National Human Rights Commission http:\/\/www.knchr.org\/Portals\/0\/EcosocReports\/Implementing%20Free%20Maternal%20Health%20Care%20in%20Kenya.pdf"},{"key":"2485_CR24","volume-title":"Kenya demographic and health survey 2008\u201309","author":"Kenya National Bureau of Statistics (KNBS) and ICF Macro","year":"2010","unstructured":"Kenya National Bureau of Statistics (KNBS) and ICF Macro. Kenya demographic and health survey 2008\u201309. Calverton: KNBS and ICF Macro; 2010."},{"key":"2485_CR25","volume-title":"Kenya National Human Development Report 2009","author":"United Nations Development Programme, UNDP Kenya","year":"2010","unstructured":"United Nations Development Programme, UNDP Kenya. Kenya National Human Development Report 2009. Nairobi: UNDP Kenya; 2010."},{"key":"2485_CR26","volume-title":"Kenya - multiple Indicator cluster survey Nyanza region 2011","author":"Kenya National Bureau of Statistics (KNBS)","year":"2013","unstructured":"Kenya National Bureau of Statistics (KNBS). 2013. Kenya - multiple Indicator cluster survey Nyanza region 2011. KNBS and UNICEF."},{"issue":"1","key":"2485_CR27","doi-asserted-by":"publisher","first-page":"152","DOI":"10.1186\/s13063-019-3224-8","volume":"20","author":"CA Ochieng","year":"2019","unstructured":"Ochieng CA, Haghparast-Bidgoli H, Batura N, Odhiambo A, Shannon G, Copas A, et al. Conditional cash transfers to retain rural Kenyan women in the continuum of care during pregnancy, birth and the postnatal period: protocol for a cluster randomized controlled trial. Trials. 2019;20(1):152.","journal-title":"Trials"},{"key":"2485_CR28","unstructured":"Krueger RA, Casey MA. Focus Groups: A Practical Guide for Applied Research. India: SAGE Publications; 2014. p. 373."},{"issue":"2","key":"2485_CR29","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1191\/1478088706qp063oa","volume":"3","author":"V Braun","year":"2006","unstructured":"Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77\u2013101.","journal-title":"Qual Res Psychol"},{"issue":"6","key":"2485_CR30","doi-asserted-by":"crossref","first-page":"418","DOI":"10.1515\/zfsoz-1990-0602","volume":"19","author":"J Corbin","year":"2016","unstructured":"Corbin J, Strauss A. Grounded theory research: procedures, canons and evaluative criteria. Z F\u00fcr Soziol. 2016;19(6):418\u201327.","journal-title":"Z F\u00fcr Soziol"},{"issue":"4","key":"2485_CR31","first-page":"760","volume":"71","author":"SA Spangler","year":"2010","unstructured":"Spangler SA, Bloom SS. Use of biomedical obstetric care in rural Tanzania: the role of social and material inequalities. Soc Sci Med 1982. 2010;71(4):760\u20138.","journal-title":"Soc Sci Med 1982"},{"issue":"10","key":"2485_CR32","doi-asserted-by":"publisher","first-page":"838","DOI":"10.1034\/j.1600-0412.1999.781002.x","volume":"78","author":"OA van den Heuvel","year":"1999","unstructured":"van den Heuvel OA, de Mey WG, Buddingh H, Bots ML. Use of maternal care in a rural area of Zimbabwe: a population-based study. Acta Obstet Gynecol Scand. 1999;78(10):838\u201346.","journal-title":"Acta Obstet Gynecol Scand"},{"issue":"10","key":"2485_CR33","doi-asserted-by":"publisher","first-page":"812","DOI":"10.2471\/BLT.06.035659","volume":"85","author":"Lale Say","year":"2007","unstructured":"Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: Examining the scale of the problem and the importance of context. Bull World Health Organ. 2007;85(10):812\u201319.","journal-title":"Bulletin of the World Health Organization"},{"key":"2485_CR34","doi-asserted-by":"publisher","first-page":"360","DOI":"10.1186\/1471-2458-11-360","volume":"11","author":"C Wanjira","year":"2011","unstructured":"Wanjira C, Mwangi M, Mathenge E, Mbugua G, Ng\u2019ang\u2019a Z. Delivery practices and associated factors among mothers seeking child welfare Services in Selected Health Facilities in Nyandarua south district, Kenya. BMC Public Health. 2011;11:360.","journal-title":"BMC Public Health"},{"issue":"12","key":"2485_CR35","doi-asserted-by":"publisher","first-page":"1882","DOI":"10.1016\/j.socscimed.2012.02.008","volume":"74","author":"H Guliani","year":"2012","unstructured":"Guliani H, Sepehri A, Serieux J. What impact does contact with the prenatal care system have on women\u2019s use of facility delivery? Evidence from low-income countries. Soc Sci Med. 2012;74(12):1882\u201390.","journal-title":"Soc Sci Med"},{"issue":"9775","key":"2485_CR36","doi-asserted-by":"publisher","first-page":"1421","DOI":"10.1016\/S0140-6736(11)60177-3","volume":"377","author":"P Basinga","year":"2011","unstructured":"Basinga P, Gertler PJ, Binagwaho A, Soucat AL, Sturdy J, Vermeersch CM. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. Lancet. 2011;377(9775):1421\u20138.","journal-title":"Lancet"},{"issue":"8","key":"2485_CR37","first-page":"1091","volume":"38","author":"S Thaddeus","year":"1994","unstructured":"Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1982. 1994;38(8):1091\u2013110.","journal-title":"Soc Sci Med 1982"},{"issue":"11","key":"2485_CR38","doi-asserted-by":"publisher","first-page":"1239","DOI":"10.1111\/j.1600-0412.2011.01163.x","volume":"90","author":"A Faye","year":"2011","unstructured":"Faye A, Niane M, Ba I. Home birth in women who have given birth at least once in a health facility: contributory factors in a developing country. Acta Obstet Gynecol Scand. 2011;90(11):1239\u201343.","journal-title":"Acta Obstet Gynecol Scand"},{"issue":"1","key":"2485_CR39","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1007\/s10995-013-1240-y","volume":"18","author":"CA Moyer","year":"2014","unstructured":"Moyer CA, Adongo PB, Aborigo RA, Hodgson A, Engmann CM, DeVries R. \u201cIt\u2019s up to the Woman\u2019s people\u201d: how social factors influence facility-based delivery in rural northern Ghana. Matern Child Health J. 2014;18(1):109\u201319.","journal-title":"Matern Child Health J"}],"container-title":["BMC Pregnancy and Childbirth"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12884-019-2485-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/article\/10.1186\/s12884-019-2485-2\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12884-019-2485-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,9,28]],"date-time":"2022-09-28T19:54:19Z","timestamp":1664394859000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcpregnancychildbirth.biomedcentral.com\/articles\/10.1186\/s12884-019-2485-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,9,18]]},"references-count":39,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2019,12]]}},"alternative-id":["2485"],"URL":"https:\/\/doi.org\/10.1186\/s12884-019-2485-2","relation":{},"ISSN":["1471-2393"],"issn-type":[{"value":"1471-2393","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,9,18]]},"assertion":[{"value":"18 April 2018","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 August 2019","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"18 September 2019","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The study received ethical clearance from Maseno University Ethics Review Committee (Reference Number MSU\/DRPC\/MUERC\/00108\/14). The permission included utilisation of oral form of consent where participants, from a cultural perspective, demonstrate wariness in signing or putting their thumbprint on documents they are not able to read for themselves. Nearly all participants opted for oral means of consent which was audio voice recorded with their permission. Oral consent was acceptable in this study because it did not involve medical procedures and posed minimal risk to study participants. The verbal consent also minimizes the possible negative influence of a written consent on rapport between the researchers and respondents [\n                      \n                      ]. The identity of the participants and the facilities involved in the present study have been anonymized to ensure confidentiality.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"339"}}