Determinants of Skilled Birth Attendance and Postnatal Care in Kibera, Nairobi: Patterns, Predictors, and Policy Gaps

Background: Maternal morbidity and mortality remain high in Kenya, with disproportionate burdens among women in informal urban settlements. Despite the critical role of skilled birth attendance (SBA) and early postnatal care (PNC) in reducing adverse outcomes, utilisation remains suboptimal in resource-constrained settings such as Kibera, Nairobi. This study examined the determinants of SBA and early PNC utilisation, focusing on health system factors, individual-level barriers, and the role of male partner engagement. Methods: A convergent mixed-methods design was employed. Quantitative data were collected between March and May 2025 through a household survey of 423 women of reproductive age who had delivered within the preceding 12 months. A sub-sample of 87 male partners was purposively selected. Data were gathered using a digitalised structured questionnaire administered via handheld tablets by trained research assistants. Descriptive statistics, chi-square tests, and multivariate logistic regression were used to identify determinants of skilled birth attendance (SBA) and postnatal care (PNC) utilisation. Qualitative data were obtained through 30 in-depth interviews, 10 key informant interviews, and 4 focus group discussions. These were thematically analysed using a framework approach to explore structural, behavioural, and health system-related factors influencing maternal health service utilisation. Results: Utilisation of SBA was 71%, while only 38% of women received PNC within 48 hours postpartum. Predictors of SBA included maternal education, household income, parity, and proximity to health facilities. Early PNC utilization was associated with SBA use, autonomy in health service decision making, and prior ANC attendance. Among surveyed male partners, 35% reported involvement in birth preparedness, 54% contributed to delivery planning, and 32% were aware of recommended PNC timelines. Qualitative findings highlighted barriers including mistreatment by providers, hidden costs, and limited knowledge of postnatal schedules. Notably, male partners emerged as important enablers of care-seeking, offering financial, emotional, and logistical support. Conclusion: Improving SBA and PNC uptake in informal urban settlements requires a multifaceted approach that addresses structural, informational, and relational barriers. Male partner engagement represents a critical and underutilised strategy to enhance maternal health service utilisation. Interventions should leverage existing community strengths while targeting systemic issues, particularly provider training and motivation, health education, and gender-inclusive care planning to improve maternal health outcomes in urban poor settings. Further research is needed to explore the long-term impact of male involvement interventions on maternal and newborn health outcomes, assess the effectiveness of community-based postnatal outreach models, and evaluate the integration of informal care providers, such as traditional birth attendants, into formal referral and support systems. Additionally, longitudinal studies examining the behavioural and institutional effects of policy shifts—such as Kenya’s transition to the Social Health Insurance Fund (SHIF)—are essential to inform sustainable, equity-orientated strategies in similar urban contexts.