The study was conducted from 16th October to 31st December 2012 during the third round of data collection within the KEMRI/CDC’s Health and Demographic Surveillance System (HDSS) area located in Siaya County in rural western Kenya. It has an estimated population of about 220,000 people [36]. Women of reproductive age (15-49 years) make up to 22% of the population and children under-five account for about 16% of the population [36]. The population is predominantly of Luo ethnicity and earns their living through subsistence farming and fishing [37]. HDSS area has high poverty levels and limited healthcare infrastructure. There are 36 health facilities; one district hospital, two privately owned hospitals, 11 health centers and 22 dispensaries [5]. According to the Kenya Essential Package for Health (KEPH) levels of care, Level one consist of the community; Level 2, dispensaries; Level 3, health centers, maternity/nursing homes/ clinics and Level 4, primary hospitals. Level 2 staff include enrolled nurses who can provide antenatal care and treatment for simple medical problems during pregnancy such as anemia, and occasionally conduct normal deliveries [38]. Level 3 is predominantly involved with preventive care, but also various curative services- safe motherhood, child health promotion and integrated management of childhood illnesses (IMCI), Malaria, HIV/AIDS/STI and TB control. Level 4 can handle at least basic emergence obstetric care [34].

The KEMRI/CDC HDSS collects data through house-to-house interviews by trained staff in three rounds every year running from, January to April, May to August, and September to December. Data collected include information on births, deaths, pregnancies, migrations, morbidity, educational and marital status. [37] Malaria transmission is high with seasonal peaks in May-July and October-November. HIV and TB prevalence in HDSS are some of the highest in the country [5].

As part of the Global Health Initiative [35] and in collaboration with the Ministry of health (MOH) and other partners in this area in 2011, we conducted a baseline reproductive health house to house survey of mothers with children 5 years and below at the time of interview. All households in the HDSS were targeted. Eligible participants were identified by community interviewers [39] as they visited households in the HDSS as part of the standard HDSS data round. Verbal consent was obtained for these additional service-related questions. As per standard HDSS protocol, individuals were fully aware that participation was voluntary and could opt out at any time during interview. Mothers were asked questions pertaining to the most recent pregnancy; ANC attendance, type of ANC service provider, place of birth. type of birth assistant, after delivery services provided which included PNC, FP and NBA. Data on a Health Facility (HF) check-up for babies born at home was also collected. Postnatal care was defined as service including any assessment given to a mother within 48 h of delivery. The national health policy in Kenya recommends that all women receive postnatal check-up at a HF within 2 days of delivery [2, 13]. PNC can range from simple general exam to and specific exams like blood pressure, breast exam, pain management, mental status exam and Caesarean Section incision site exams. The components and extent of this care is largely dependent on mode of delivery, complications at birth and complaints the mother may present with. Details of the specific service given were not obtained. NBA include early breastfeeding support, umbilical cord hygiene, keeping baby warm and immunization and identifying danger signs for severe illness like breathing difficulties, lethargy and inability to feed [20].

The child’s mother was interviewed; where the mother was not present at the time of interview, a proxy (the head of household or household administrator) was interviewed. Household administrator is the person who runs the household day to day affairs on behalf of a non-resident head of household [39]. When the mother or proxy was unavailable on a second visit, the household was excluded from the survey. Socio-demographic data collected a year prior was obtained from the HDSS database using the mothers’ Permanent Identification number issued by HDSS and useful in linking records of individuals across files [39].

This study employed quantitative analysis. Responses reported as “Don’t Know” or “NA” were excluded from analysis. Both descriptive and inferential analysis was done using Epi info. Continuous variables were described by medians, interquartile ranges, and standard deviations. Categorical variables were described as proportions. Associations for categorical data were determined using Pearson’s chi-square test or Fisher’s exact test. We evaluated factors associated with ANC, skilled birth attendance, PNC and NBA through bivariate analyses, using logistic regression. All tests were interpreted against a 5% significance level.

We enrolled 8377 mothers with at least one child who was under five at the time of interview. Using the HDSS permanent ID we linked mothers’ data with the youngest child and obtained 8260 mother-child pairs. Because of missing data the denominator for each variable was different. The median age of mothers was 27 years (range: 13-54 years) (Table 1).Table 1

Socio-demographic and clinical Characteristics

Complete data on ANC attendance was available for 89% (n = 8260) of mothers, 97% (n = 7387) of whom reported attending ANC. Data on number of ANC visits made was available for 89% (n = 7140); 4% (n = 6335) of mothers reported making only one ANC visit, 14% 2 visits, 31% 3 visits, 30% 4 visits, 14% 5 visits and the remaining 8% reported ≥6 ANC visits. Only 52% (n = 6335) of mothers completed the WHO recommended 4 ANC visits. Data on gestation month at first ANC visit was available for 94% (7140) of mothers; 14% (n = 6690) reported first ANC visit was in1sttrimester (0-12 weeks), 73% in 2ndtrimester (14-28 weeks) and 13% in 3rdtrimester (29-40 weeks) (Table 1). The median number of gestation months at first visit was 5. Skilled ANC service provider was reported by 98% (n = 7140) of mothers: 91% (n = 7002) a nurse/midwife and 9% a doctor. Non-skilled ANC care providers were reported as TBAs by 38% (n = 138), CHWs by 30% and “others” specified as co-wives, neighbors or relatives were reported by 33% of mothers.

The proportion of mothers attending ANC at least once and those making ≥4 ANC visits increased with level of education: 100% (n = 67) and 83% (n = 48) of mothers with post-secondary education and 87% (n = 31) and 44% (n = 9) with no education reported ANC attendance and completed ≥4 ANC visits respectively (Fig. 1).Fig. 1

Uptake of services according to education level

Only 49% (n = 8259) of mothers delivered in a HF, 48% at home, and the remaining 3% en route to a HF (Table 1). Of all mothers who reported a HF delivery, 84% (n = 4028) utilized a government-owned HF while the remaining delivered in a private HF. Types of government-owned facilities utilized for delivery included; Hospitals by 54% (1807), health centers by 31% (1038) and dispensaries by 16% (529). Types of private HFs utilized for delivery included; Mission Hospital by 62% (405), Private Hospitals/Clinics by 32% (211) and Nursing & Maternity Home by 6% (38) of mothers. Government hospital was the most utilized facility for delivery. Skilled birth attendants at delivery was reported by 52% (n = 8257) of mothers while the remaining 48% reported a non-skilled birth attendant. Skilled birth attendants were reported as nurse/midwife in 87% (n = 4323) and doctor in 13%. Non-skilled attendants were reported as TBAs by 41% (n = 3934), CHWs by 26% and other types of birth assistants by 33%. The “other types” were specified as; friends or neighbors 15% (n = 1316), relatives 12%, mother delivered on her own in 53% and in 20% data was missing (Table 1). The relatives were reported as sisters, co-wives or mother-in-law. Almost all the births assisted by CHWs and TBAs happened at home or en route to a HF, 94% (n = 1008) and 99% (n = 1610) respectively. However, 59 mothers assisted by CHW and 51 by TBA reported HF delivery. We did not evaluate whether these were mothers who started off with non-skilled birth attendant and were later referred to a HF or not. Likewise 3% (n = 4028) of mothers reporting HF delivery, reported a non-skilled birth assistant which may indicate mothers’ inability to identify the cadre of health service provider. Similarly, 11% (n = 3968) of mothers reporting home delivery, reported a skilled birth assistant.

The proportion of mothers reporting a HF delivery increased with the level of education and decreased with the age (Figs. 1 and 2). HF delivery according to marital status is shown in Fig. 3. Young age ≤ 34 years (OR 1.7; 95% CI1.5-2.0), Secondary vs primary education (OR 2.2; 95% CI1.8-2.6), post-secondary vs secondary education (OR 4.6; (95% CI2.0-10.8), post-secondary vs primary education (OR10.1; 95% CI4.4-23), single vs married, (OR 1.5; 95% CI1.3-1.7), single vs widowed, (OR 2.8; 95% CI2.1-3.6) were significantly associated with a HF delivery (Table 3).Table 3

Relationship between socio-demographic characteristics, antenatal care attendance and the place of delivery

About 51% (n = 7140) of mothers who reported ANC attendance also reported a HF delivery. Nineteen percent (n = 245) of women reporting no ANC reported a HF delivery. ANC variables strongly associated with a HF delivery included; ANC attendance (OR 4.5; 95% CI 3.2-6.1), HF as source of ANC (OR 2.9; 95% CI 1.4-5.8), first visit in 1st or 2nd vs 3rd trimester (OR 1.9; 95% CI1.7-2.2), first visit in 1st vs 3rd trimester (OR 3.0; 95% CI 2.5-3.7) and having completed ≥4 ANC visits (OR1.8; 95% CI1.7-2.1). There was a strong relationship between reporting skilled ANC provider (OR 2.8; 95% CI 1.9-4.0), first visit during 2nd vs 3rd trimester (OR1.8; 95% CI1.6-2.2), completing ≥4visits (OR 2.0; 95% CI 1.8-2.2), post-secondary vs primary education (OR 5.9; 95% CI2.9-12.0) and reporting a skilled birth assistant (Table 3).

We asked mothers whether they received any after delivery service namely, PNC and FP within 48 h of delivery. About 38% (n = 8260) and 17% of mothers reported to have received PNC and FP respectively. Only 40% (n = 7140) and 63% (n = 4028) of mothers who reported ANC and HF delivery respectively, also reported receiving PNC (Table 1). Of mothers who delivered away from HF, only 14% (n = 4232) reported receiving PNC. Thirty four percent (n = 4028) of mothers who reported a HF delivery and a mere 1% (n = 4232) of those who delivered away from HF also reported receiving FP. The proportion of mothers reporting PNC or FP increased with level of education and decreased with age. According to level of education: 67 and 37% (n = 73) of mothers with post-secondary education reported PNC and FP attendance respectively, 51 and 23% (n = 812) with secondary education, 38 and 17% (n = 2966) with primary education and 39 and 11% (n = 36) with no education. According to age: 41 and 19% (n = 1063) of mothers aged ≤20 years reported PNC and FP respectively; 39 and 18% (n = 5571) aged 21-34 years; 32 and 14% (n = 1462) aged ≥35 years. Despite coming into contact with health care worker 37% (n = 4028) and 67% (n = 4028) of mothers reported not receiving any PNC or FP respectively.

Young age ≤ 20 years (OR 1.5; 95% CI 1.2-1.7), secondary vs primary education (OR 1.7; 95% CI1.4-2.0), ANC attendance (OR 3.4; 95% CI2.4-4.8) and HF delivery (OR11; 95% CI 10-12) were significantly associated with increased uptake of PNC (Table 4). Mothers who delivered in a HF were more likely to receive FP compared with those who delivered away from HF, (OR34; 95% CI26-44) p-value = 0.001.Table 4

Relationship between socio-demographic characteristics and postnatal and the newborn care

We enquired from mothers if their newborns were assessed within 48 h after delivery. About 36% (n = 8259) of mothers reported NBA, 79% (n = 3007) of whom reported a HF delivery, 20% home delivery and 1% en route to HF. Only 37% (n = 7140) of the mothers who reported ANC attendance and 59% (n = 4028) who reported a HF delivery also reported NBA. Just like with PNC, the proportion of mothers reporting NBA increased with level of education and decreased with age. ANC attendance (OR 2.4; 95% CI 1.7-3.2), HF delivery (OR 7.8; 95% CI7.0-8.7) and having education vs none (OR 2.3; 95% CI 1.1-5.1) were significantly associated with reporting NBA (Table 4). Despite reporting a HF delivery, 41% (n = 4028) of mothers reported no NBA.

Sixty eight percent (n = 3966) of mothers who delivered at home, reported taking the newborn for a HF check-up. Less than 1 %, 0.3% (n = 2697) took the newborns for HF check-up the same day they were born, 1.6% were taken the following day, 28% within the first week, 77% by 2 weeks. Mean duration within which newborns were taken to a HF for check-up was 44 days. ANC attendance (OR 1.6; 95% CI 1.2-2.1) and HF delivery (OR 1.4; 95% CI 1.3-1.6) were significantly associated with increased likelihood of reporting a HF check-up (Table 4).

About 97% (n = 7387) of mothers reported having attended ANC during their most recent pregnancy, 51% reported both ANC attendance and HF delivery, 34% reported ANC, HF delivery and PNC attendance. Mothers reporting all services along the continuum of care; ANC attendance, HF delivery, PNC and NBA assessment were only 18% (Fig. 4).Fig. 4

Percent coverage of essential interventions along the continuum of care