Christina H. Lefebvre ^1* Joseph R. Starnes ^2,3 Aleksandra Jakubowski ^4,5 Alyn Omondi ⁶ Janet Manyala ⁶ Jane Wamae ³ Ash Rogers ³ Sandra Mudhune ³ Vincent Okoth ³ Vincent Were ⁶ Julius Mbeya ³ Samantha V. Yap ⁷ Philip Omondi ³ Willys Ochieng ⁸ Tom Odhong ⁸ Carren Siele ³ Richard Wamai ^10,11,3,7,9

• ¹ Department of Biology, College of Science, Northeastern University, Boston, United States
• ² Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, United States
• ³ Lwala Community Alliance, Rongo, Kenya
• ⁴ Department of Health Sciences, School of Community Health and Behavioral Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, United States
• ⁵ Department of Economics, Northeastern University, Boston, MA, United States
• ⁶ Adaptive Model for Research and Empowerment of Communities, Kisumu, Kenya
• ⁷ Department of Cultures, Societies and Global Studies, College of Social Sciences and Humanities, Northeastern University, Boston, Massachusetts, United States
• ⁸ Department of Health, County Government of Migori, Kenya, Migori, Kenya
• ⁹ Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria
• ¹⁰ African Centre for Community Investment in Health, Nginyang, Kenya
• ¹¹ Integrated Initiative for Global Health, Northeastern University, Boston, MA, United States

Despite evidence of the beneficial effects of skilled birth attendance (SBA) on maternal health and childbirth outcomes, there are disparities in access across counties in Kenya. These include Migori County which has historically recorded high maternal mortality rates. In 2007, the Lwala Community Alliance was founded to improve health outcomes in this county. The objective of this study is to provide a baseline status of facility childbirth and SBA in Migori and to characterize the effect of Lwala intervention on these outcomes.A cross-sectional household survey was designed for a 10-year study to evaluate the effectiveness of Lwala initiatives. The 2019 and 2021 household surveys were conducted in Lwala intervention wards and in comparison wards with sample sizes of 3846 and 5928 mothers, respectively. The survey captured demographic, health, and socioeconomic data at each household, data on SBA and facility childbirth, and explanatory variables. A generalized linear model was used to determine factors associated with SBA. A secondary trend analysis was conducted to determine change over time in the explanatory variables and SBA. To determine the change in SBA rate due to Lwala intervention, controlling for background temporal trends, a difference-in-difference model compared SBA rates in intervention wards and comparison wards.SBA increased in all surveyed wards and across all explanatory variables from 2019 to 2021. The difference in difference analysis showed that the SBA rate increased more in Lwala intervention wards than in comparison wards (Adjusted Prevalence Rate Ratio 1.05, p<0.001, 95%CI 1.03-1.08). The 2021 survey found the highest rates of both facility childbirths (97.9%, 95%CI 96.5-98.7) and SBA (98.2%, 95%CI 97.0-99.0) in North Kamagambo, the oldest ward of Lwala intervention. Higher educational status, four or more ANC visits, marriage/cohabitation, and wealth were significantly associated with increased SBA.We provide the first quasi-experimental evidence that Lwala interventions are significantly improving SBA which may inform related initiatives in similar settings. The household-survey data provides a baseline for continued evaluation of Lwala programs, and the breakdown by ward allows for development of specific programmatic targets.