UCLA

Background: There is an urgent need to improve both the clinical and person-centered dimensions of quality during intrapartum care to reduce maternal mortality and morbidity and achieve health equity in Kenya. Substandard care has been identified in 9 of 10 maternal deaths in Kenya and evidence shows that women of lower social position (e.g., younger, less educated, unmarried) have poorer access to quality care. The World Health Organization (WHO) quality of care (QoC) framework for maternal and newborn health has identified women’s access to their preferred social and emotional support as one essential component of the experience of care, but facilitating social support tends not to be prioritized by providers and facilities. Many support persons (SPs) encounter policies barring their presence, endure negative provider attitudes, and lack means to interact with women and providers. However, a gap in the literature includes an examination of how health care systems can better facilitate the support that women need and want during maternity care.Moreover, integrating SPs into maternity care and facilitating their supportive roles improves how providers’ treatment and care for women. SPs can garner more respectful treatment and advocate on behalf of women, which is especially important in Kenya where women frequently encounter mistreatment and lack autonomy in their own health care. Although integration of SPs has been proposed to improve QoC, existing studies have narrowly focused on mistreatment and overlooked other elements of QoC (i.e., other experience of care measures, clinical quality), representing a major gap in literature. Theory: The theoretical framework for this study builds upon the World Health Organization (WHO) quality of care (QoC) framework for maternal and newborn health, incorporating concepts from the person-centered care framework for reproductive health equity. The framework uses a systems-approach by situating these concepts within the socioecological model. Purpose: This study aims to address these gaps and proposes a new concept in the support literature, the Person-Centered Integration of Support Persons (PC-ISP) into maternity care, which refers to the extent to which SPs are integrated into care that is respectful and responsive to women’s needs and preferences. This includes communicating information to SPs, facilitating decision-making support, making them feel welcome, and engaging with their questions and concerns. Methods: The objective of this study was to examine how PC-ISP in maternity care is associated with women’s and SPs’ reports of QoC. This research used novel data from the Strengthening Person-Centered, Accessibility, Respectful Care, and Quality (SPARQ) study in Kenya, which surveyed both women and SPs at six facilities in Nairobi and Kiambu counties about their experiences of maternity care. I developed survey questions based on the PC-ISP concept that were administered to both women (n=1,138) and SPs (n=606) to better understand women’s preferences for PC-ISP and women’s and SPs’ experiences of PC-ISP. I used multivariable regression models to examine PC-ISP by women’s social status and SP types, assess how PC-ISP is associated with QoC outcomes specified by the WHO QoC framework, and assess how facility factors relating to capacity modify those associations. Results: This study provides detailed evidence regarding women’s unmet need for support, showing that women wanted support from their SPs in different ways than previously measured: consulting on decisions, wanting SPs to know and understand their condition and care, and opportunities for SPs to engage with providers about their questions and concerns. But, in practice, a substantial proportion of women reported that their SPs were not integrated in these ways. I found disparities in SP integration; for example, women with low-income, low-prestige occupations were less likely to report that SPs were welcome to ask questions and male partners were less likely to report being given information about women’s condition and care compared to mothers/mothers-in-law. Facility factors, such as number of providers assisting delivery and SPs’ perception of crowding, were consistently positively associated with SP integration, while facility types (i.e., public hospital, private hospital, public health centre/dispensary) displayed inconsistent positive and negative associations with SP integration. Findings also highlighted how women’s experiences of PC-ISP is associated with women’s positive experiences of care, better clinical care experiences, higher satisfaction with care, and greater willingness to return to facilities for care, but mixed evidence of SPs’ experiences associated with QoC, finding positive associations with increased key practices and women’s satisfaction, but negative associations with willingness to return to the facility. Results also showed that associations between women’s experiences of PC-ISP and QoC were modified by facilities’ capacity: I found evidence of stronger positive associations between PC-ISP and Person-Centered Maternity Care (PCMC) and key practices at facilities with higher patient-volumes and higher patient:bed ratios (i.e., crowded). Conclusions: Findings from this study provide insight into how health systems can practically increase support for women, address disparities in who has access to SPs, and improve clinical and person-centered QoC. Particularly in crowded facilities with high-patient volumes, integrating SPs may help facilitate high quality care. Greater efforts are needed to integrate SPs in ways that keep women at the center of their own care, including developing methods to assess and respect women’s preferences for support during care, educating SPs in how to constructively provide support in conjunction with providers, training providers on how to integrate SPs in equitable yet standardized ways, and creating accountability systems to ensure policies and practices are implemented equitably. Interventions to better integrate SPs can be a low-cost and person-centered approach to improve QoC in maternity care in Kenya.