Presentation at the Global Maternal Newborn Health Conference, October 20, 2015
Background: Trust in providers and a health facility is important to perceived quality and demand for facility-based maternity care. Barriers to maternity care-seeking include a range of financial, logistical, structural, environmental and experiential factors. Trust is a multidimensional concept that provides a distinctive lens for understanding health system responsiveness during the critical stage of labor and delivery. This study is one of the first to explore determinants of trust in a maternity setting through a range of local perspectives.
Methodology: A theoretically-driven qualitative approach drawing on appreciative inquiry and institutional ethnography was applied. Focus groups (n=8) with recently delivered women (RDW), pregnant women, and male partners; and in-depth-interviews (n=33) with RDW, providers, management, and community health workers (CHWs), were conducted in and around a public sub county-level hospital in a peri-urban area in Central Kenya. Interviews were audio-recorded, transcribed into Kiswahili and translated into English. Data were analyzed through inductive coding and memo-writing.
Results: Distinct maternity care user, provider, and management standpoints converge around a multi-faceted trust determinants framework that clusters around patient/individual, provider, health facility, community, accountability, and structural factors. The complexity of the framework lies in how determinants within factor clusters relate to one another and influence trust simultaneously. For example, a woman’s trust may be influenced by her perceived risk of facility-delivery; provider friendliness; hospital resources; her social network; whether she feels facilities can adjust to the ‘free maternity’ context, and her ability to speak in a normalized user-provider-management hierarchy.
Conclusions: The multi-faceted clustering of determinants in light of Kenya’s new constitution, devolved governance structure, and free maternity policy indicates the critical importance of perspective and socio-political context in understanding trust in the maternity setting. Cross-perspective findings further suggest a key role for communities and community liaisons in building trust and increasing demand for maternity care.