Antenatal Care Dropout and Maternal Mortality in Kenya: Policy Gaps Revealed by the 2022 Kenya Demographic and Health Survey

Background Maternal mortality remains a critical public health challenge in Kenya, with a maternal mortality ratio (MMR) of 355 deaths per 100,000 live births — five times higher than the Sustainable Development Goal 3.1 target of 70 by 2030. Antenatal care (ANC) is a proven platform for reducing maternal morbidity and mortality; however, Kenya faces a severe ANC dropout crisis in which near-universal first-visit attendance (97.9%) is not matched by completion of the recommended four or more visits (ANC4+) or the WHO-recommended eight or more contacts (ANC8+). The structural and policy determinants of this dropout, and their implications for maternal survival, remain insufficiently characterised in the current literature. Methods This study employed a cross-sectional design using secondary analysis of published estimates from the 2022 Kenya Demographic and Health Survey (KDHS 2022), a nationally representative household survey conducted across all 47 counties of Kenya with a women's response rate of 95% (n = 32,156). The analytical sample comprised 6,847 women aged 15–49 with a live birth in the two years preceding the survey. ANC dropout was examined by maternal age, education level, wealth quintile, residence type, and county of residence. Results While 97.9% of women initiated ANC with a skilled provider, only 66.0% completed ANC4 + and a mere 4% achieved ANC8+. ANC dropout was systematically concentrated among women with no formal education (ANC4+: 49.1%), women in the lowest wealth quintile (53.9%), rural residents (61.5%), and adolescent mothers (57.1%). County-level disparities were dramatic, ranging from 100% ANC4 + completion in Kajiado and Kisumu to 11.9% in Tana River, 35.0% in Turkana, and 40.4% in Mandera. Discussion ANC dropout in Kenya is driven by intersecting demand-side barriers and supply-side failures, compounded by the regressive impact of the recent NHIF-to-SHIF policy transition on maternity care access. This study proposes the MamaTrace USSD Platform — a novel, equity-centred maternal triage and ANC defaulter tracing system built on USSD technology — as a contextually appropriate intervention capable of reaching women with basic feature phones in remote, low-connectivity settings. Conclusion Kenya's ANC dropout crisis is a policy failure, not an individual one. Closing the gap between ANC1 initiation and ANC8 + completion requires restored universal financial protection for maternity care, targeted health system investment in high-dropout counties, a strengthened community health workforce, and deployment of innovative equity-focused digital solutions such as MamaTrace.