Internal Migration in Kenya: Implications for Maternal and Child Healthcare Utilization

Kenya has achieved impressive declines in maternal and under-five mortality over the last few decades; maternal mortality has dropped from 687 to 342 deaths per 100,000 live births and under-five mortality has decreased from 104 to 43 deaths per 1,000 live births. However, accelerated progress will be necessary if Kenya is to reach the Sustainable Development Goal targets of fewer than 70 maternal deaths per 100,000 live births and 25 under-five deaths per 1,000 live births by 2030. As many of these deaths could be prevented with access to healthcare during childbirth and early childhood, identifying factors leading to underutilization of care is a key strategy to reducing mortality. Research in low- and middle-income countries suggests internal migrants may be a particularly vulnerable group as the process of migration is disruptive and typically requires a period of adaptation before women can effectively engage with the healthcare system. This dissertation investigated the influence of maternal migration on the use of maternal and child healthcare services in Kenya. The first aim analyzed the relationship between maternal migration and receipt of recommended childhood vaccinations using nationally representative data from the 2014 Kenya Demographic and Health Survey. Migration status and migration stream (e.g., rural-urban) were used as exposures and two measures of vaccination status, full and up-to-date vaccination, were explored as outcomes. After accounting for selection and confounding biases using multiple imputation and inverse probability of treatment weighting (IPTW), relationships between migration and vaccination were statistically insignificant. These findings are an important deviation from previous literature that did not rigorously address important biases common to this area of research. The second aim examined how maternal migration into informal urban settlements (IUSs) in Nairobi, Kenya influenced childhood vaccination timeliness. This aim leveraged 2002-2018 data from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). The primary analysis explored the impact of migration status and secondary analyses of migrants examined whether migrant origin or previous experience living in the IUS differentially influenced timely vaccine receipt. There was no evidence that migration status or characteristics influenced vaccination timeliness in IPTW-weighted models. However, a considerable portion of both migrant and non-migrant children in the IUSs received their vaccinations late or not at all, indicating vaccination programs in the settlements should shift focus from simply increasing coverage to improving timeliness. Using 2004-2018 NUHDSS data, the third aim analyzed the relationship between migrant women’s adaptation to living in an IUS and use of recommended childbirth services. Heterogeneity in the relationship between adaptation and childbirth care was explored by characteristics of the migration experience. Use of recommended childbirth services was widespread in the IUSs but not associated with migrant adaptation. The relationship between adaptation and childbirth care did not differ significantly by a migration type, migration stream, migration companions, or reason for migrating. Collectively, these dissertation aims provide an in-depth analysis of the relationship between migration and utilization of maternal and child healthcare services in Kenya. Findings suggest that, in Kenya, characteristics enabling migration such as wealth and education, rather than the process of migration itself, drive differential healthcare use between migrants and non-migrants. As the public health community works towards further global reductions in maternal and under-five mortality the populations of women and children who don’t receive adequate healthcare must be clearly defined and targeted by outreach efforts.