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Factors associated with quality of intrapartum care in Kenya: a complex samples analysis of the 2022 Kenya demographic and health survey

BMC Pregnancy and Childbirth volume 25, Article number: 496 (2025) Cite this article

Abstract

Background

The provision of quality intrapartum care increases women’s utilization of skilled birth attendants in health facilities and improves maternal and newborn health. This study aimed to investigate the factors associated with the quality of intrapartum care using the 2022 Kenya Demographic and Health Survey (KDHS).

Methods

Secondary data from the 2022 KDHS of 11,863 participants, who were selected by multistage stratified sampling, was used. Based on literature and the availability of indicators within the 2022 KDHS, the quality of intrapartum care was operationalized as receiving all the three clinical components of intrapartum care including a mother having a facility-based delivery, receiving skilled assistance during childbirth, and placing the newborn on the mother’s breast within one hour from birth by the skilled birth attendant. Univariate and multivariate logistic regression analyses were used to analyze the data using SPSS (version 20).

Results

Of the 11,863 women who had recently given birth, about 52.6% had received quality intrapartum care. As part of the intrapartum care, 88.2% gave birth in a health facility, 90.4% obtained assistance from skilled birth attendants, and 59.8% had their babies placed on the breast by a birth attendant within 1 h after birth. Women who had attained secondary education (aOR = 1.46, 95% CI: 1.23–1.90), were working (aOR 1.24, 95% CI: 1.00-1.53), had 3–4 living children (aOR = 1.31, 95% CI: 1.02–1.68), took 31–60 min to reach the health facility (aOR = 1.49, 95% CI: 1.41–1.95), were assisted during childbirth by doctors (aOR = 19.86, 95% CI: 2.89-136.43) and nurses/midwives/clinical officers (aOR = 23.09, 95% CI: 3.36-158.89) had higher odds of receiving quality intrapartum care compared with their counterparts. On the other hand, women in the richest wealth index (aOR = 0.64, 95% CI: 0.42–0.98), those who gave birth through cesarean section (AOR = 0.27, 95% CI: 0.20–0.36) and those whose current age of their child was ≥ 2years (AOR = 0.76, 95% CI: 0.60–0.96) were less likely to receive quality intrapartum care compared with their counterparts.

Conclusions

About half of the women received quality intrapartum care in Kenya, with demographic characteristics seeming to be the main drivers of quality intrapartum care. Although the Kenyan government abolished maternity services fees in all public facilities, there is still a need to empower women through increasing access to education and economic development initiatives for their economic independence. This will enable mothers to pay transport fares to health facilities for those in hard-to-reach rural settings and buy other hospital delivery requirements (e.g., surgical gloves) that may not be available in rural public health facilities, thus increasing access to skilled birth attendance and quality intrapartum care as a whole. Its also worth noting, since Kenya is moving towards provision of quality intrapartum care, more and proper indicators of clinical intrapartum care need to be captured in future DHS studies. This will enable comprehensive assessment of the quality of intrapartum in view of informing maternal health care policy in Kenya and other countries.

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Introduction

Although labor is a normal physiological process, its related complications account for some of the major causes of mortality and morbidity among women of reproductive age and their neonates in low and low-middle-income countries [1]. The intrapartum period is defined as the time from the commencement of true labor throughout the first, second, third, and fourth stages of labor [2]. The overall objective of intrapartum care is to enable a mother to give birth to a healthy child with minimum interventions while ensuring the mother’s safety [3].

Dimensions of quality intrapartum care may range from clinical to non-clinical care aspects. According to the World Health Organization (WHO), clinical aspects of intrapartum care include delivery at the health facility, skilled personnel assistance, regular monitoring during childbirth, pain management, choice of birth position, immediate kangaroo care and breastfeeding, delayed bathing of the baby until after 24 h, and continuity of care up to 24 h before discharge [3,4,5,6]. Non-clinical care aspects must accompany clinical intrapartum care [4]. Some of the non-clinical aspects of intrapartum care include respectful maternity care, emotional support during childbirth, effective communication, and companionship during labor [3,4,5,6].

Literature has highlighted the need to work towards providing quality labor through skilled birth attendance and improving delivery experiences as this influences client decisions about facility-based care in future pregnancies [4, 7]. Poor quality intrapartum care exposes mothers to negative childbirth experiences and is a predictor of adverse outcomes among mothers such as post-traumatic stress disorder, dysfunctional personal relationships, and poor maternal-infant bonding [8, 9].

The intrapartum period presents the most crucial period for the survival of the mother and neonate especially in circumstances when the quality of intrapartum care is not guaranteed [10, 11]. Research evidence from most low- and middle-income countries indicates that mothers and neonates receive suboptimal quality care during the intrapartum period [12, 13], as the care provided does not conform to the WHO standards on clinical and non-clinical aspects of intrapartum care [3]. The literature highlighted that only about 61–66% of the components of competent and respectful delivery care were performed in Kenya, indicating a substantial gap in the care [14].

Studies have found an association between poor-quality intrapartum care and increased maternal mortality rates (MMR) [15, 16]. A study in 81 low- and middle-income countries found that interventions during childbirth are the most critical and account for about 64% of the overall impact on the quality of maternal and child health care [17]. The study also found that MMR decreased by about 21–32% by addressing gaps in intrapartum care. Sub-Saharan Africa had the highest MMR in 2017 (542/100,000 live births) with Kenya among the 18 countries with the highest incidence [18]. Although the MMR in Kenya has decreased from 362/100,000 live births in 2014 [19] to 355/100,000 live births in 2022, this remains high when compared to global incidence rates [20]. According to the Lancet and World Bank report, the MMR incidence in Kenya is higher than the estimated global MMR of 223/100,000 live births [21, 22], an indicator of gaps in maternal and newborn care.

Notably, most maternal deaths in Kenya are caused by rather manageable maternal complications during labor [23] and are attributable to sub-optimal care [24]. Some of the associated factors to this sub-optimal care include the lack of knowledge and skills to recognize and address emerging intrapartum complications [25, 26], negative attitudes towards care among healthcare providers, low staffing levels and demotivation among healthcare providers, and poor adherence to patient management guidelines [27]. Socio-demographic factors associated with the quality of intrapartum care include the planned status of pregnancy, number of antenatal visits, duration of labor, presence of quality services by region, advanced maternal age, education level, and employment status [28,29,30]. Other factors include the type of facility, availability of routine supplies, distance to facility, in-service training, and supervision of health care providers [11, 31,32,33].

In 2013, Kenya joined other countries in responding to the call to reduce maternal mortality and morbidity by abolishing child delivery fees in all public facilities as per the presidential directive [34, 35]. Despite this directive among many other initiatives, the maternal mortality ratio in Kenya whose direct influencing factor is the quality of intrapartum care [16], remains higher than the United Nations (UN) sustainable development goal 3.1 target of 2030 of having a MMR of less than 70 per 100,000 live births [36]. Above all, there are currently no nationally representative studies in Kenya exploring the factors associated with the clinical aspects of quality of intrapartum care. Therefore, this study aimed to determine the maternal, health facility, and obstetric-related factors associated with the quality of intrapartum care (i.e., operationalized as receiving all the three clinical components of intrapartum care) using nationally representative data from Kenya. The findings of the study may provide insights to policymakers and other stakeholders on how to tailor strategies to address the consistently poor quality of intrapartum care in Kenya and other sub-Saharan African countries.

Methods

Data source, sample design, and collection

This study utilized the 2022 Kenya Demographic and Health Survey (KDHS) which employed a two-stage stratified sampling design. Using equal probability with independent selection, the first stage involved the selection of 1692 enumeration areas (EAs) or clusters out of a master sample frame of 129,067 EAs from the 2019 Kenya population and housing census [37]. This was followed by house listing to create a sampling frame that was used in the second stage to select 25 households per cluster. However, all households in a cluster were sampled if they were less than 25. In total, the survey was implemented in 1691 clusters. The Inner-City Fund (ICF) facilitated the pretesting of the study tools and the training of data collectors, and data was collected between February and July 2022. All women aged 15–49 years who were usual members of the selected households or those who had slept in those households the previous night before the survey were interviewed in Swahili or English language [37]. Out of 32,156 women who responded to the survey (95% response rate), 11,863 women had recently given birth within 5 years and these were included in this analysis [37]. We requested the 2022 KDHS dataset and obtained written permission for use from the MEASURE DHS website (https://www.dhsprogram.com/data/available-datasets.cfm). Although the dataset contains hundreds of variables, only those relevant and applicable to our study were considered and used.

Study variables

Dependent/outcome

Based on the literature and availability of the data in KDHS [37, 38], the primary outcome of this study was receiving the quality of intrapartum care, “operationalized” as a composite variable constructed from 3 variables, namely (1) facility-based delivery; (2) receiving skilled assistance during birth, and (3) the skilled birth attendant placing the newborn on the mother’s breast within one hour from birth [37, 38]. Facility-based delivery was further categorized as Yes (giving birth at a public, private, nongovernmental, and faith-based organization’s health facility or clinic) or No (others). Receiving skilled assistance was also grouped as Yes (receiving birth assistance from a doctor, and nurse/midwife/clinical officer) or No (others). Lastly, the skilled birth attendant placing the newborn on the mother’s breast within one hour from birth was categorized as Yes or No. Therefore, receiving quality intrapartum care meant a woman receiving all three elements of intrapartum care which was recategorized as a binary outcome (Yes/No).

Independent variables

The factors included in the analysis were categorized into three namely, sociodemographic, obstetric, and maternal health services, and health facility-related characteristics [30, 33, 38,39,40,41,42].

Sociodemographic factors

We considered ten sociodemographic factors that were included in the analysis. These factors included; age in years (15–19, 20–34, 35–49), education (none/primary, secondary or tertiary), wealth index (poorest, poorer, middle, richer, and richest), residence (rural vs. urban), working status (Yes vs. No), marital status (single, married, or separated/divorced/widowed), religion (Muslim, Christian, or others), region (categorized into the eight provinces of Kenya; Coast, Northeastern, Eastern, Central, Rift Valley, Western, Nyanza, and Nairobi), and household size (≤ 4 vs. ≥ 5 members). Maternal autonomy was assessed through two proxy variables namely, who heads the household (male vs. female) and who makes healthcare-seeking decisions for the mother/participant (self, partner, jointly with partner or another person, or others). The health and well-being of the mother’s health status (bad, moderate, good), telephone ownership, and exposure to mass media such as radio, television, newspapers, and internet (Yes vs. No) were also included in the analysis. The wealth index was calculated by 2022 KDHS from information on household asset ownership using principal component analysis [37].

Obstetric, and maternal health services related factors

Eleven obstetric, and maternal health services-related factors were included in the analysis such as gravidity (prime, multi, and grand multigravida), the number of children ever born, the number of living children (≤ 2, 3–4, ≥ 5), antenatal (ANC) visits (≤ 3, vs. ≥ 4), age at first birth in 5year age groups (≤ 19yrs, 20-24yrs, 25-29yrs, 30-34yrs, ≥ 35), the birth interval in months (≤ 24 vs. ≥ 25 ), wantedness of the pregnancy (Yes vs. No), mode of delivery (vaginal or cesarean), pregnancy outcomes (born alive, dead, miscarriage, or abortion), pregnancy loss (0 or ≥ 1), and current age of the child in years (≤ 1 vs. ≥ 2). The quality of antenatal care as a composite variable was also computed and included in the analysis. The quality of antenatal care was computed from multiple binary outcomes (Yes vs. No) which included whether the mother had received eight ANC services such as blood pressure measurement, urine and blood testing, fetal heartbeat monitoring, nutritional, pregnancy danger signs and breastfeeding counseling, and receipt of iron tablets. Receiving all the ANC services meant receiving quality antenatal care (Yes).

Health facility factors

Four variables related to the place of delivery were included in the analysis. These variables included the specific place of delivery (public, private, Non-governmental Organizational (NGO), and faith-based organization (FBO) health facilities or clinics), who assisted the mother during delivery (Doctor, Nurse/Midwife/Clinical officer, or Others), and being treated with respect at the health facility (all the time, sometimes, or not at all). Time spent to access the health facility before delivery which was measured in minutes (≤ 30, 31–60, ≥ 61) was also added to the analysis as a proxy indicator of geographical access to the health facility.

Statistical analysis

The complex samples package in SPSS (V20) was used to analyze the data, and this accounted for the complex sample design inherent in DHS data [43, 44]. The complex sample package provides valid estimates of parameters because during analysis it accounts for the sample weighting, clustering, and stratification that occurred during the sampling of the study participants [43, 44]. Additionally, to account for the unequal probability sampling in different strata and ensure the representativeness of the study results, DHS sample weights were applied on all frequencies computed [43, 44]. Before analysis, data was cleaned, and dummy variables were created. At the univariate level, descriptive statistics such as the frequencies were computed for all categorical variables. Univariate and multivariate logistic regression were used to obtain independent factors associated with the quality of intrapartum care. All variables with P-values < 0.05, were entered in simple multivariate logistic regression to establish the factors associated with the quality of intrapartum care while controlling for other variables. All variables’ odd ratios are reported at 95% confidence intervals. Multi-collinearity was also assessed among all the predictor variables in the model using a variance inflation factor (VIF) of greater than 10 as a cutoff [44]. None of the factors exceeded the cutoff.

Ethical consideration

No ethical approval to analyze the secondary data was needed because the data is publicly available. However, permission to access the 2022 KDHS datasets was obtained from MEASURE DHS (https://www.dhsprogram.com/data/available-datasets.cfm). Ethical approval to conduct the study reported in datasets was obtained from the Inner-City Fund (ICF) Institutional Review Board. The study was implemented by the Kenya National Bureau of Statistics in conjunction with other stakeholders.

Results

Demographic characteristics of the study participants

A total of 11,863 women who had recently given birth were included in this analysis (Table 1). Most were aged between 20 and 34 years (74.4%) with a mean age of 28.31 years (standard deviation = 6.52), were living in rural settings (61.4%), and were from the Rift Valley province (30.4%). Most had attained primary and secondary education (80.5%), were Christian by religion (88.5%), and married (80.2%). The majority of the participants were working (57.3%), belonged to the richer and richest wealth quintiles (43.9%), lived in male-headed households (71.5%), and belonged to households with more than five household members (79%). At the time of the interview, the majority described themselves as being in good health (80.3%) and made decisions to seek health care services jointly with either their partner or somebody else (44.9%). Many of the participants had exposure to the radio (74.3%) followed by the television (38.4%) and newspapers (17.2%). In addition, most of the participants had a mobile phone (81.1%) and nearly half of the participants had access to the Internet (47.9%). In terms of obstetrical characteristics, about half of the participants were multigravidas (53.6%) and had either ever given birth to utmost two children or had utmost two children currently alive (53.9%). The majority had attended at least four antenatal visits (67.2%) and had received quality antenatal care (61.2%). Most of the participants first became pregnant at less than 24 years (87.1%), had a pregnancy interval of at least 2 years following their previous birth (75.4%), and wanted to conceive their last or current pregnancy (91.2%). Many of the participants had undergone vaginal birth (82.9%), assisted by the doctors (62.2%), and delivered at public health facilities (65.2%). Most mothers had taken at most 30 min to access the health facilities (73.1%) and were always treated with respect during their stay at the health facilities (87.3%). Many of the mothers had previously given birth to live babies (88.1%), who were currently aged at most two years (68.1%) at the time of the interview. Overall, most of the respondents had never lost a pregnancy either through abortion or miscarriage (77.0%).

Table 1 Demographic characteristics of the study participants
Full size table

Quality of intrapartum care

Overall, about 52.6% (95% CI: 50.6–54.6) of the study participants had received quality intrapartum care (Table 2). As part of the intrapartum care, 90.4% (95% CI: 89.6–91.2) gave birth in a health facility, 90.4% (95% CI: 89.6–91.2) obtained assistance from skilled birth attendants, and 59.8% (95% CI: 57.7–61.8) had their babies placed on the breast, by birth assistants, within the first hour.

Table 2 Component of intrapartum care received by study participants
Full size table

Factors associated with the quality of intrapartum care

Table 3 summarizes the factors associated with the quality of intrapartum care in univariate and multivariate logistic regression analysis. After controlling for significant independent variables, multivariable analysis showed that the working status of the mother, type of delivery assistant, number of living children, minutes to the health facility, wealth status, current age of the child, and mode of delivery, were statistically significant predictors of receipt of quality ANC. Participating mothers who had attained at least secondary education were 1.46 (95% CI: 1.12–1.89) times more likely to receive quality intrapartum care than those with either none or primary education. Participants who were working were 1.24 (95% CI: 1.004–1.53) times more likely to receive quality intrapartum care than those who were not working. Participants who had received assistance during delivery from doctors were 19.8 (95% CI: 2.88-136.43) times more likely to receive quality intrapartum care than those who received assistance from other delivery assistants. Mothers who had received assistance during delivery from nurses were 23.09 (95% CI: 3.35-158.88) times more likely to receive quality intrapartum care compared with those who had received the care from other delivery assistants. Participating mothers who had 3–4 living children were 1.30 (95% CI: 1.02–1.67) times more likely to receive quality intrapartum care compared with those who had given birth to fewer children. Participating mothers who would access the facility within an hour were 1.49 (95% CI: 1.14–1.95) times more likely to receive quality intrapartum care compared with mothers who spent less than half an hour (Table 3).

Table 3 Factors associated with the quality of intrapartum care
Full size table

On the other hand, mothers from the richest compared with those from the poorest quintile and mothers whose children were aged ≥ 2 years compared with those aged ≤ 1 year were 0.63 (95% CI: 0.41–0.97) and 0.75 (95% CI: 0.59–0.95) times less likely to receive quality intrapartum care, respectively. Additionally, mothers who gave birth through cesarean section were 0.27 (95% CI: 0.20–0.35) times less likely to receive quality intrapartum care compared with those who had a vaginal birth (Table 3).

Discussion

This study aimed to establish the factors associated with the quality of intrapartum care in Kenya using the 2022 Kenya demographic and health survey. This study indicated that 52.6% of the study participants had received quality intrapartum care. This study finding is higher than the prevalence recorded in other studies in Ethiopia at 27.3% and 13% [11, 45]. As part of intrapartum care, 88.2% gave birth in a health facility, which figure is higher than the overall prevalence (66%) for Sub-Saharan Africa [46], and also higher than 81% recorded from a study in a slum of Nairobi, Kenya in 2020 [47], 39.8% recorded from a study in Guinea-Bissau [48] and 76.6% recorded in Uganda [49]. 90% (90.4%) of this study’s participants obtained assistance from skilled birth attendants which finding is somewhat comparable to one from a study in South Africa [50]. However, this study finding indicates a higher prevalence of skilled birth assistance when compared to figures across the sub-Saharan region (60.3%) [51], Tanzania (81%) [52] and Ethiopia (29.2%) [53].

We also found that 59.8% of the skilled birth assistants placed the baby on the mother’s breast within the first hour following childbirth. This finding related to the first-hour initiation of breastfeeding is lower than that from other countries in Sub-Saharan Africa like Uganda (68%), Ethiopia (81.8%), and Nigeria (61%) [54,55,56]. Overall, the seemingly improved quality of intrapartum care and its associated indicators recorded in this study could be explained by Kenya’s initiatives to improve maternal and child health outcomes that have been implemented over the years including decentralization of services [34, 35, 57].

In this study, participating mothers who had attained at least secondary education were 1.46 times more likely to receive quality intrapartum care than those with either none or primary education. This study finding is consistent with a study by Silwal et al. [58] that found that educated women have better birth preparedness practices as compared to their counterparts and are therefore more likely to receive quality intrapartum care. Literature suggests that educated women are likely to have optimal antenatal care utilization and make informed decisions about maternal healthcare utilization [28, 59, 60]. Mothers who have adequate antenatal care visits receive information and sensitization about preparedness and expectations during labor [61]. Frequent encounters with the health care system by mothers during antenatal visits enable early detection of most foreseeable complications during labor and therefore guide their readiness planning and improve their health-seeking behaviors [38]. Therefore, there is a need to empower women through increasing access to education.

Participants who were working were 1.24 times more likely to receive quality intrapartum care than those who were not working. This is in line with an European study by Reynolds et al. [62] that found that employed mothers as compared with housewives, had higher exposure to risk factors of poor intrapartum care such as unplanned pregnancy. Other studies suggest that working women have the capacity and resources to prepare for any necessities during labor and are therefore more likely to have a better experience of intrapartum care [63,64,65]. Therefore, there is a need to empower women through economic development initiatives for their economic independence.

On the other hand, this study found that mothers who were from the richest wealth quantile were less likely to receive quality intrapartum care as compared with those from the poorest wealth quantile. This finding concurs with a study by Saaka [66] which found that economically disadvantaged mothers exhibited better birth preparedness and complication readiness practices as compared with their richer counterparts, and are therefore more likely to receive good quality intrapartum care. This discrepancy in findings may be explained by the fact that richer mothers may not see the need to prepare early due to their perceived ability to access any kind of health facility, and are therefore more likely to be caught off-guard when labor sets in. Additionally, Women in the richest wealth quantile are also more likely to deliver in private hospitals which may not be up-to-date or may not adhere to new WHO guidelines on intrapartum care, given that private hospitals or facilities are semi-autonomous in how they operate.

Participating mothers who had 3–4 living children were 1.31 times more likely to receive quality intrapartum care compared with those who had given birth to fewer children. Considering the number of children as a measure of parity, a study by Kamineni et al. [67] found that high parity is associated with proper birth preparedness and complication readiness. Multiparous women have a lot more labor experience accumulated from their previous pregnancies, therefore, know what to expect, how to prepare for it in advance, and what to demand in terms of services. Contrary to this study finding, other studies have found that primiparous women are better prepared for delivery and its complications due to the excitement of having the first child [58, 68, 69].

Participating mothers who accessed the facility within an hour were more likely to receive quality intrapartum care compared with mothers who accessed the health facility within less than 30 min. This finding is inconsistent with those from many other studies that suggest that mothers who take long to reach health facilities due to long distances and transportation challenges are likely to receive poor-quality intrapartum care [11, 70]. This discrepancy in findings may be explained by the fact that mothers who take longer to reach the facility are likely to arrive in a poor health state with complications due to the delays and are therefore given more attention by the health care workers as compared to their counterparts who reach the facility when no complications have happened. Also, mothers who take a little longer to reach their preferred health facility could be seeking better health services and are therefore likely to receive quality care.

Study participants who had received assistance during delivery from doctors and nurses/clinical officers/midwives were 19.89 and 23.09 times respectively more likely to receive quality intrapartum care than those who received assistance from other delivery assistants such as traditional birth attendants, or relatives. Skilled birth attendance has been highlighted as one of the best strategies for improving maternal and neonatal outcomes during labor [71]. The World Health Organization has highlighted the need to increase access to skilled birth attendants to reduce maternal mortality resulting from intrapartum periods by preventing complications and timely interventions on those that arise [72]. Traditional birth attendants lack the basic knowledge, skills, and resources to handle complications during labor in addition to cultural practices like the use of herbal medicines which may not be safe, compromising the quality of intrapartum care provided [73].

On the other hand, mothers who gave birth through cesarean section were less likely to receive quality intrapartum care compared with those who had a vaginal birth. This may be because mothers delivered by cesarean section often experience surgery-related complications (e.g., excessive bleeding and abdominal pain), which may delay the health workers from placing the newborn on the mother’s breast within 1 h and the fact that private hospitals may have a higher cesarean section leading to low quality of intrapartum care [74, 75]. Additionally, in low and middle-income settings like Kenya, there may not be protocols like those in high-income countries to place the newborn on the mother within 1 h after cesarean section birth, which may affect the quality of intrapartum care provided. Therefore, health workers need to develop and advocate for mechanisms to ensure early bonding of the newborn with the mother following cesarean section delivery.

This study also found that women whose children were two years and above were less likely to receive quality intrapartum care as compared with those whose children were one year and below. This finding may be because Kenya has had many community-owned and participation initiatives over the years to improve maternal and child health care, which may have enabled mothers to gradually access quality intrapartum care [76], Therefore, those mothers who delivered recently might have interfaced with an improved healthcare system as compared to those who delivered some years back. In summary, these findings seem to suggest that demographic characteristics compared with other factors are the main drivers of quality intrapartum care.

Strengths and limitations of the study

This study’s findings were drawn from data of a nationally representative sample population. Few studies in Kenya had explored the clinical aspects of quality of intrapartum care, using a nationally representative sample population. Therefore, this study’s findings are generalizable to women who have given birth in Kenya and can be used to tailor interventions aimed at addressing gaps in the quality of intrapartum care at a national level. In addition, the use of a complex sample analysis ensured that the results presented were reliable.

However, the quality of intrapartum care was measured using a limited number of indicators when compared with the stipulated WHO indicators [77]. Above all, the 2022 KDHS did not provide information or data related to skin to skin contact as defined by WHO (i.e., provision of skin to skin contact immediately and for at least one hour). Thus in the measurement of quality intrapartum care, we used a proxy indicator which is “placing the newborn on the mother’s breast within one hour from birth.” Therefore, our results related to quality of intrapartum care may not be conclusive. Since, Kenya is moving towards provision of quality intrapartum care, more and proper indicators of clinical intrapartum care need to be captured in future DHS studies. This will enable comprehensive assessment of the quality of intrapartum in view of informing maternal health care policy in Kenya and other countries. This study also utilized a cross-sectional study design meaning that the findings confer association rather than causality. The study findings are also subject to recall bias because respondents were interviewed about their past childbirth events. Additionally, this study did not include non-clinical aspects of quality intrapartum care because of missing data on such variables. Such information may have enriched this study, and future studies need to consider it. Despite these limitations, this study provides useful information about the predictors of the quality of intrapartum care in Kenya.

Conclusions

In this study, only half of the women received quality intrapartum care in Kenya. Various socio-economic factors were associated with the high quality of intrapartum care, for example, secondary education, working status, number of living children, minutes to the health facility, and type of delivery assistants. Whereas the richest wealth quantile, the current age of the child and caesarian section delivery were predictors of low-quality intrapartum care. These findings seem to suggest that demographic characteristics compared with other factors are the main drivers of quality intrapartum care.

Although the Kenya government abolished maternity services fees in all public facilities, there is still a need to empower women through increasing access to education and economic development initiatives for their economic independence. This will enable mothers to pay transport fares to health facilities for those in hard-to-reach rural settings and buy other hospital delivery requirements (e.g., surgical gloves) that may not be available in rural public health facilities, thus increasing access to skilled birth attendance and quality intrapartum care as a whole. Support supervision and monitoring should be conducted in health facilities authorized to conduct deliveries by the caesarian section. In-service training of healthcare providers involved in the care of patients delivered by the caesarian section should also be carried out to improve and replenish their knowledge and skills to improve the overall quality of intrapartum care. Health workers need to develop and advocate for mechanisms to ensure early bonding of the newborn with the mother following cesarean section delivery. In the future, there is a need for DHS to capture or incorporate other quality indicators of intrapartum care as stipulated by WHO such as the non-clinical care aspects. Above all, since Kenya is moving towards provision of quality intrapartum care, more and proper indicators of clinical intrapartum care need to be captured in future DHS studies. This will allow a comprehensive analysis and conclusions to be made about the quality of intrapartum care, in Kenya and various other countries.

Data availability

The datasets generated by the survey research during and/or analyzed during the current study are available in the MEASURE DHS website (URL: https://www.dhsprogram.com/data/available-datasets.cfm).

Abbreviations

MMR:

Maternal Mortality Ratio

WHO:

World Health Organization

KNBS:

Kenya National Bureau of Statistics

UN:

United Nations

ANC:

Antenatal care

EA:

Enumeration area

FBO:

Faith based organization

aOR:

Adjusted Odds Ratio

KDHS:

Kenya Demographic Health Survey

CI:

Confidence Interval

DHS:

Demographic Health Survey

VIF:

Variance Inflation Factor

uOR:

Unadjusted Odds Ratio

OR:

Odds Ratio

SPSS:

Statistical Package for Social Science

NGO:

Nongovernmental organization

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Acknowledgements

We appreciate the DHS program for making the data available for this study.

Funding

There is no funding that was provided for this study.

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Authors and Affiliations

  1. School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda

    Lilian Nuwabaine, Ahmed Mohammed Sarki & John Baptist Asiimwe

  2. Faculty of Medicine, Mbarara University of Science & Technology, Mbarara, Uganda

    Earnest Amwiine

  3. Programmes Department, Relief International, Khartoum, Sudan

    Quraish Sserwanja

  4. Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China

    Joseph Kawuki

  5. Infectious Diseases Institute, P.O. Box 22418, Kampala, Uganda

    Mathius Amperiize

  6. Mbarara Regional Referral Hospital, Mbarara, Uganda

    Angella Namulema

  7. Family and Youth Health Initiative, Jigawa, Nigeria

    Ahmed Mohammed Sarki

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Contributions

L.N. and J.B.A. Conceived the idea, drafted the manuscript, performed analysis, interpreted the results, and drafted the subsequent versions of the manuscript. E.A., Q.S., J.K., M.A., A.M.S. and A.N. reviewed the first draft, helped in results interpretation and drafted the subsequent versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Lilian Nuwabaine or John Baptist Asiimwe.

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Nuwabaine, L., Amwiine, E., Sserwanja, Q. et al. Factors associated with quality of intrapartum care in Kenya: a complex samples analysis of the 2022 Kenya demographic and health survey. BMC Pregnancy Childbirth 25, 496 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07619-8

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BMC Pregnancy and Childbirth

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