Persistent barriers to the use of maternal, newborn and child health services in Garissa sub-county, Kenya: a qualitative study
Authors: Kisiangani Isaac , Elmi Mohamed , Bakibinga Pauline , Mohamed Shukri F. , Kisia Lyagamula , Kibe Peter M. , Otieno Peter , Afeich Naïm , Nyaga Amina Abdullahi , Njoroge Ngugi , Noor Rumana , Ziraba Abdhalah Kasiira 
Published: May 2020

Abstract
Background
North Eastern Kenya has persistently had poor maternal, new-born and child health (MNCH) indicators. Barriers to access and utilisation of MNCH services are structural, individual and community-level factors rooted in sociocultural norms. A package of interventions was designed and implemented in Garissa sub-County aimed at creating demand for services. Community Health Volunteers (CHVs) were trained to generate demand for and facilitate access to MNCH care in communities, while health care providers were trained on providing culturally acceptable and sensitive services. Minor structural improvements were made in the control areas of two facilities to absorb the demand created. Community leaders and other social actors were engaged as influencers for demand creation as well as to hold service providers accountable. This qualitative research was part of a larger mixed methods study and only the qualitative results are presented. In this paper, we explore the barriers to health care seeking that were deemed persistent by the end of the intervention period following a similar assessment at baseline.

Methods
An exploratory qualitative research design with participatory approach was undertaken as part of an impact evaluation of an innovation project in three sites (two interventions and one control). Semi-structured interviews were conducted with women who had given birth during the intervention period. Focus group discussions were conducted among the wider community members and key informant interviews among healthcare managers and other stakeholders. Participants were purposively selected. Data were analysed using content analysis by reading through transcripts. Interview data from different sources on a single event were triangulated to increase the internal validity and analysis of multiple cases strengthened external validity.

Results
Three themes were pre-established: 1) barriers and solutions to MNCH use at the community and health system level; 2) perceptions about women delivering in health facilities and 3) community/social norms on using health facilities. Generally, participants reported satisfaction with services offered in the intervention health facilities and many indicated that they would use the services again. There were notable differences between the intervention and control site in attitudes towards use of services (skilled birth attendance, postnatal care). Despite the apparent improvements, there still exist barriers to MNCH services use. Persistent barriers identified were gender of service provider, insecurity, poverty, lack of transport, distance from health facilities, lack of information, absence of staff especially at night-time and quality of maternity care.

Conclusion
Attitudes towards MNCH services are generally positive, however some barriers still hinder utilization. The County health department and community leaders need to sustain the momentum gained by ensuring that service access and quality challenges are continually addressed.