Determinants of access to and use of gestational diabetes mellitus services in Kenya: a multimethod case study protocol

Current state of knowledge and research gaps

Having access to contemporary and current maternal healthcare services (MHCSs) is crucial for ensuring high-quality health services and preventing illnesses and deaths among mothers and infants. However, the lack of availability, accessibility and underutilisation of MHCS in LMICs is a pressing issue and directly linked to inadequate health outcomes and fatalities. In the context of this research, an important and missed opportunity for GDM-related interventions.

Several studies have reported accessibility in terms of transport, place of residence and distance as barriers to MHCS in LMICs.22–28 A study in Kenya reported that the presence of a community health worker at the MHCS increased the rates of visitation but found no significant correlation of accessibility in terms of distance on the first antenatal check-up timing.25 Studies have reported lesser usage of MHCS among women in rural areas when compared with women in urban areas in the African region.24 28 29 Conversely, studies in the Asian region reported no statistical significance between the urban and rural regions.30 31 Significant barriers to MHCS in SSACs are transport associated obstacles such as poor road conditions, unsuitable transport, shortage of qualified healthcare workers (HCWs) and limited availability of the services.22 23 25 26 32 33 Discrimination, negative attitudes of healthcare providers and inadequate service quality have also been identified as barriers to accessing MHCS.22 26 28 30 33–35 Other studies have reported a positive correlation between patient satisfaction, continuity of the services and the quality of healthcare services with the frequency and use of MHCS.36 37

Multiple studies have documented that economic constraints serve as a significant hindrance to accessing and using MHCS. Studies from the West and South of Africa found that the high cost of services as a major barrier.22 26 27 38 39 Women with higher living standards and employment opportunities tend to access MHCS more frequently and earlier compared with those facing financial hardship and unemployment.23 25 30 39 Studies in LMICs have reported that perception of risk factors related to obstetric outcomes have an impact on MHCS-seeking behaviour. Women who had obstetric complications in prior pregnancies tend to initiate earlier antenatal care.24 40 A study in South Africa reported that women who had never had a previous obstetric complication felt no need to visit antenatal clinics and in a study in Zimbabwe reported that pregnancy-related shame was negatively associated with MHCS attendance.26 27 A study in Kenya reported positive association between comprehension of family planning and visits to MHCS.25 Other studies reported that uncertainty of being pregnant influenced late attendance to MHCS.25 27

The perception of the risks of women’s pregnancy and the relevance of attending MHCS has an impact on the usage of MHCS. A study reported that low perception of the benefits of MHCS influenced the timing of when women would visit the MHCS . Women with low perception would initiate visits late.27 In a study in Zimbabwe, women were not aware or convinced of the benefits of MHCS visits on their health or infant.26 Studies in East Africa reported that the women had no knowledge that MHCS served to monitor both their health and of the fetus. This lack of knowledge was found to be potentially linked to unemployment.32 41 Studies reported that MHCS visits were influenced by women’s apprehension towards HIV testing and bewitchment of the MHCS.22 23 42 Numerous women lack awareness of their entitlement to refuse medical examinations and they face various sociocultural obstacles that hinder their ability to make autonomous choices about their well-being. These factors further contribute to their tendency to postpone seeking healthcare during pregnancy.33 42

Suboptimal or delayed timely use of MHCS has been attributed to socioeconomic status (SES). Education has been reported by studies to be associated with the usage of MHCS. Women that presented levels of education also presented autonomic attitudes and therefore were more likely to initiate antenatal care visits earlier in their pregnancy and use MHCS at higher rates when compared with uneducated women.23 28 29 39 43–45 Studies in developing countries also reported a positive association between the level of husband’s education and frequency of visits to MHCS.23 46 47 Conversely, a study found that husband’s education was insignificant to the rates of visits of MHCS in Karnataka region, India. Low maternal education is noted as a significant barrier to timely and adequate visits to MHCS.48 Furthermore, studies have indicated that even when mothers with lower educational backgrounds have access to MHCS, they are less likely to use these services compared with their counterparts with higher levels of education.49 50

Other factors that determine the rates of visitation to MHCS are age, marital status, gravidity and preceding birth interval.25 43 51–53 Several studies have indicated that young, unmarried women tend to use MHCS less often compared with women who are over the age of 20 and married.23 25 28 On the other hand, a study in Zimbabwe reported that women younger than 35 years old visited antenatal clinics frequently when compared with older women who did not have concerns over their pregnancy.26 Other studies did not find any significant relationship between age and the frequency of MHCS visits.23 39 54

Women who had a gap of over 3 years between childbirths visited MHCS more often compared with women who had a gap of less than 2 years between their previous births.25 The size of the family was found to play a significant role in determining the frequency of visits to MHCS. It was observed that women with an average of seven children tended to visit MHCS less often compared with women with three or fewer children.25 Moreover, there was a clear association between higher parity and lower visitation rates to MHCS, as supported by various studies.24 29 40 55 Studies reported that unwanted pregnancies negatively influenced the rates of visitation to MHCS.24 25

When it comes to religion and ethnicity, different studies have observed different effects of ethnicity on the frequency and utilisation of MHCS. In a study conducted in Nigeria, it was found that religion within the Hausa culture had a negative correlation with the use of MHCS.38 Similarly, two studies conducted in East Africa revealed that certain religious and cultural beliefs discouraged women from seeking early or any MHCS.32 33 A study in Ethiopia reported that Protestants, Orthodox and Muslims used antenatal care services more frequently than traditional believers.29 In a study in Uganda, it was noted that Muslim women were reluctant to attend prenatal classes that were not exclusively dedicated to women.43 A study in Ghana found no association between religion and antenatal visits.39

Studies have reported that women with higher SES are more likely to access and frequently use MHCS when compared with women with low SES.25 54 56 Occupational status is also reported to have an influence on the frequency of use of MHCS. It has been observed that employed women are more inclined to make use of MHCS as compared with unemployed women and housewives.23 28 46 Conversely, a study in India revealed that housewives tend to avail prenatal services to a greater extent in comparison to employed women.57 Another relevant factor would be language. A study in Guatemala reported language as a barrier to use of MHCS among rural dwelling women.58

The use of MHCS has been reported to be positively associated with women’s autonomy. Studies in SSACs and Asia reported that dependence on husband’s decision and financial means could negatively discourage women from visiting MHCS.33 38 56 57 Social support was also reported to have an association on the usage of MHCS in studies in Asia. This study reported that mothers-in-law perceived MHCS as unnecessary and discouraged the usage of these facilities by their daughters-in-law in Bangladesh.50 Usage of MHCS was encouraged by travelling to the facilities with another adult in Pakistan.44 A study in Kenya revealed that disparities between genders and societal expectations, a preference for traditional birth attendants over healthcare services, the feminisation of poverty and the influence of the community on expectant mothers all significantly impact access to healthcare services.22

The late initiation and inadequate utilisation of MHCS can be attributed to various factors, including SES, patient and healthcare provider factors, awareness and attitude, social support and cultural and religious factors, among others. In SSACs, challenges related to transportation, limited availability of healthcare services, poor service quality and a shortage of qualified HCWs are significant barriers to accessing MHCS. Additionally, barriers such as maternal education, quality of social support, economic constraints, parity, family size, perception of risks, knowledge, attitude and beliefs of women and healthcare providers contribute to the challenges. The impact of religion and culture on access to MHCS varies, and there is limited evidence regarding the influence of ethnicity and language given the heterogeneity within developing countries. Further research is needed to explore the role of language as a determinant or barrier to accessing MHCS in multiethnic countries, as well as the intersections of feminisation of poverty and autonomy, religion, attitudes of healthcare service providers and clients, and policy measures related to GDM services in the SSACs.

Universal screening for GDM is highly recommended. Moreover, many high resource countries have clearly outlined GDM guidelines in their national policies, incorporating them as an integral part of antenatal care. However, in low resource countries, the absence of GDM guidelines and the lack of routine GDM screening are common. The question arises whether the universal screening guidelines can be practically and effectively implemented in low resource countries, considering their specific local context. Additionally, numerous studies have focused on examining single or isolated variables related to GDM, but adopting a postcolonial theoretical approach can offer a comprehensive framework for a profound analysis of this phenomenon. It is crucial to enhance our understanding of the determinants and barriers to GDM services within the local context of low-income countries. This knowledge will play a significant role in addressing the burden of T2DM and developing appropriate policies and interventions.

Frameworks

The analytical framework to be used in this project is the postcolonial theoretical approach. Furthermore, the health needs assessment (HNA) and knowledge attitude behaviour (KAB) frameworks in a tool like aspect for data collection would also be implemented in this project.

The implementation of the postcolonial framework involves two critical steps:

1. The critical examination of the barriers to GDM services by attempting to identify how and where oppression works. Critically analyse what structures are rooted in colonialism and neo-colonialism and how they contribute to barriers to access to healthcare.

2. Investigating the prevailing health doctrines that form the basis for using GDM services and assessing their potential influence on the availability of these services. This stage involves collecting qualitative evidence to delve into the sociocultural and political practices that play a role in shaping the individuals’ experiences. The personal accounts of these individuals serve as valuable sources of knowledge.