From Antenatal Care to Skilled Delivery: Examining the Drop-off Along the Maternal Healthcare Cascade in Kenya

Background Maternal mortality remains unacceptably high in sub-Saharan Africa, and Kenya has not achieved the reductions anticipated under the Sustainable Development Goals. A central challenge is that improving individual service indicators—antenatal care attendance, facility delivery rates—does not guarantee that women actually move through the full continuum of care. This study applies a cascade-of-care framework, adapted from HIV treatment research, to measure sequential loss along the maternal health continuum in Kenya. Methods We analysed data from the 2022 Kenya Demographic and Health Survey (KDHS), restricting the sample to women aged 15–49 who had a live birth in the five years preceding the survey (N = 10,391). We constructed a four-level cascade variable representing sequential progression from adequate antenatal care (4 + visits) through facility delivery to timely postnatal care within 24 hours. Sociodemographic predictors were examined using chi-square tests and survey-weighted logistic regression, with all analyses accounting for the complex sampling design. Results Only 40.3% of women completed the full cascade. The largest single loss occurred at the first stage: 37.6% of women did not attend four or more antenatal visits. Among those who did, a further 10.9% delivered outside a health facility. Post-delivery attrition—women who delivered in a facility but did not receive timely postnatal care—accounted for an additional 11.2 percentage points of loss. In multivariate analysis, higher education (OR 2.97, 95% CI 2.20–4.00) and belonging to the wealthiest quintile (OR 2.94, 95% CI 2.22–3.90) were the strongest predictors of full cascade completion. Rural residence lost significance once education and wealth were controlled. Conclusions The cascade framework reveals that Kenya's maternal health system loses women at every transition point, and that these losses are concentrated among the poor and uneducated—not primarily in rural areas per se. Interventions targeting the ANC entry barrier and the facility-to-PNC transition are most urgently needed. The cascade approach should be adopted more widely in national monitoring of maternal health systems.