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nd: To improve perinatal outcomes, many countries in Sub-Saharan Africa are introducing universal access to maternal and newborn care. In June 2013the government of Kenya introduced free maternity services in all public health facilities to increase skilled birth attendance. Facility-related determinants of perinatal outcomes in the context of free maternity care have not been well documented in the study area. Methods: Data based on biological variables, access to and quality of services was collected from mothers attending antenatal clinic (ANC) at the 1st visit, 2nd and 3rd visits (which coincided with the 1st, 2nd and 3rd trimesters) up to 2 weeks post-delivery. Some variables such as distance to the facility were measured only at baseline while biological variables were monitored in each of the subsequent visits. Enumerators for the study were midwives at the selected facilities. The primary outcome was the final perinatal outcome (i. uneventful pregnancy, delivery and puerperium or ii).An abnormal perinatal outcome (stillbirth, neonatal ill health, maternal death, maternal ill health, maternal disability, birth injuries & trauma, normal baby/neonate). The secondary outcome was weight at birth. Frequency of facility factors against normal vs abnormal perinatal outcomes was compared by χ2 testing, the odds of perinatal outcome versus specific facility indicators were calculated using Logistic Regression tests and McNemar’s tests were used to compare relative means (of numeric variables) of different factors at different ANC visits. Results: Data from 287 mothers who attended all the 3 follow-up ANC visits was analysed out of the 365 mothers recruited during the first visit. Out of the 287 study subjects, 65% (187) of were drawn from public health facilities (Oresi & Kenyenya) while 35% (100) were drawn from non-public facilities (Christamarriane/CMMH and Tabaka). McNemar’s test statistic to check for the relationship between the distance to a facility and perinatal outcome show that perinatal outcomes were not with distance to facilities. No statistically significant differences were observed in public vs nonpublic hospitals among mothers who were served and delivered by skilled midwives and those who were attended to by non-skilled midwives (only 12 individuals were attended to by non-skilled midwives). Individuals who delivered at facilities with low midwife-client ratio had a 5% higher likelihood of having a normal perinatal outcome as compared to those delivering in facilities with high staffing ratios (OR =0.05, 95% CI 0.046-0.055, p=0.006)Conclusion: In free maternity care contexts, facility-level factors play a crucial role in positive perinatal outcomes. There is need to strengthen information dissemination by health workers, training and in-service support for midwives and ensure optimal staffing levels at health facilities.

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