Date of Award


Document Type


Degree Name

Master of Medicine (MMed)

First Supervisor/Advisor

Prof. Marleen Temmerman

Second Supervisor/Advisor

Dr. Abraham Mukaindo

Third Supervisor/Advisor

Dr. Jacob Shabani


Family Medicine (East Africa)


Introduction: At population level, a caesarean section (CS) rate between 10 and 15 percent is considered optimal for maternal and infant health outcomes and a useful process indicator of quality of care. However, that there has been a worldwide increase of CS rates in the past three decades. Compared to vaginal birth, questions abide of appropriateness, balance of risk versus benefit and cost implications to the health care system. Introduction of free maternity services (FMS) in June 2013has been known to increase health facility deliveries. However it may affect the quality of care offered in these facilities due to a strain in human and financial resources. Caesarean section rates and more importantly the potentially preventable CS can be used as a measure of quality of care as suggested by the World Health Organization (WHO).

Objectives: The primary objectives included a comparison of CS rates three years before and three years after FMS and to study the effect of FMS on indications particularly the rate of potentially preventable CS (Robson group 1-4) before and after introduction of FMS. The secondary objective was the effect of FMS on short term adverse maternal and neonatal outcomes of the CSs.

Methods: The study was conducted in Maragua Level IV Hospital in Muranga County, using a cross-sectional retrospective before and after study. The implementation of FMS services in June 2013 were used as the midpoint. The source was the obstetric database with the pre-implementation period being (June 2010 to May 2013) and post-implementation period (June 2013 to May 2016). A sample size of 1182 was calculated, distributed proportionally between the two arms; 264 in the pre-FMS and 918 post-FMS period. Proportionate sampling to ensure equal distribution of the sample proportional to the percentage of all CS in each year was used. A data collection tool based on the Robson Classification was employed to collect relevant data from the CS files. Maternal and neonatal outcomes were analysed. Comparisons of the change in variables were done by use of two sample test of independent proportion and Chi-square test as appropriate.

Results: The hospital deliveries increased from (n=4518) in the pre-FMS period to (n=8612) after introduction of FMS; 557 women (12.3%) had a Caesarean Section in the pre FMS period as compared to 1998 (23.2%) in the post FMS years, an increase of 10.9% (p<0.001) in CS rate. There were no significant changes in outcomes of maternal and neonatal mortality rate. There was a reduction in rates of potentially preventable CS deliveries (Robson groups1-4) from56.0% (n=148) in the pre-FMS period to 48.2% (n=443) in post FMS period (p=0.025) with an increase of unavoidable CS (Robson groups5-10) from 43.9 % (n=116) to 51.7% (n=475) since the introduction of FMS (p=0.025).

Conclusion: The number of hospital deliveries increased dramatically since the introduction of free maternity care in Kenya in 2013. The proportion of Caesarean section rate increased, mainly in the group of unavoidable indications (Robson group 5-10) suggesting more access to high level obstetrical care to women who needed the CS. The Robson tool is useful and could be adopted by maternity units for audit purposes due to its clarity, its applicability and a standardised way of communication between units. It is a platform for audit purposes.