Reduction of Maternal Mortality in Kenya

Introduction

Maternal mortality is defined as demise of a pregnant woman regardless of the cause of death. This is according to the world health organization, WHO (2018). This is derived from the international classification of diseases (ICD 10). However, it was earlier excluding the causes from the accidental and incidental causes. Not so many countries have complete data when it comes to the epidemiology of maternal deaths but it is a very good indicator of country’s wellness (WHO, 2018).

Every day, as estimated 830 women die due to complications of pregnancy either during pregnancy, delivery period or within 6 weeks post-delivery. Most of these deaths can be prevented. An estimate that between 1990 and 2015, there was a reduction by 44% of the maternal mortalities with sub Saharan Africa reporting half the numbers within the time (WHO 2018). The reduction of the current numbers of the maternal deaths to around 70 deaths in every 100 000 live births is the target of the 2016 sustainable development goals that were adopted worldwide. There are disturbing data that show that the underage girls who are 15 years or less to die from the complications related to pregnancy is Sub Saharan Africa than in any other region of the world. This region accounts for half of the 99% of all the maternal deaths reported in the developing countries worldwide. This is contributed to by the high poverty levels (WHO 2018).

A study that was privy to the Kenyan Daily Nation in 2018 recorded that most of the maternal deaths reported in the country would have been averted if all the laid down procedures are followed by the implementers.  It also indicates that most of the deaths are not reported. The preventable factors include the fact that most of the deaths occur during weekends and at night when the hospitals are under staffed because they are not office hours. Third delays like delaying commencement of treatment for obvious complications by the health care workers who are inadequately trained or have less skills, inadequate use of the partograph as the monitoring tool for action, wrong diagnosis leading to wrong interventions or no treatment whatsoever. This independent study on the maternal death audits done shows in three quarters of the audits that there are health care worker related gap (Daily Nation 2018).

Nadia A. et al., (2016) notes that the poor resources that are experienced in refugee camp settings is a major contributor of very high number of maternal deaths reported in those areas. This is often compounded by the high rate of understaffing experienced in the health care facilities in these areas as well as for the displaced populations. There is reported reduced donor funding for the health programs due to donor fatigue consequent to protracted emergencies and this has a very big negative impact on the maternal health. This was according to a study done in Afghanistan.

There is an observation that malaria cases are very high especially in sub Saharan Africa and could be a big contributor to maternal mortalities in these regions. The refugee camps in these malaria endemic zones are noted to have reported malaria as a cause of death in mothers in these communities but more studies are needed to substantiate this (Rose M. et al., 2012).

Quality Improvement Methods

Maternal deaths prevention is one of the indicators tackled in the 17 Sustainable Development Goals (SDGs) that were adopted in 2015 as a guide for the development agenda 2030 for the United Nations. Countries having dropped the Millennium Development Goals (MDGs) after expiry. The 230 indicators were aligned to the 169 targets by the United Nations Statistical Commission created Inter-Agency and Expert Group on Sustainable Development Goals Indicators (Stephen S. et al., 2016).

Most of the deaths as mentioned earlier occur during the immediate post delivery period. There should be enough mentorship for the health care workers working in the delivery units on how to handle the complications. The mothers are also to be given health education on the possibilities so as to be ready with all the requirements as stipulated in the individual birth plan so as to ensure everything goes as per the plans during the whole process (Onesmus M. et al., 2016).

“Maternal death surveillance and response (MDSR) constitutes a quality improvement approach to identify how many maternal deaths occur, what the underlying causes of death and associated factors are, and how to implement actions to reduce the number of preventable stillbirths and maternal and neonatal deaths. This requires a coordinated approach, ensuring both national- and district-level stakeholders are enabled and supported and can implement MDSR in a “no name, no blame” environment. This field action report from Kenya provides an example of how MDSR can be implemented in a “real-life” setting by summarizing the experiences and challenges faced thus far by maternal death assessors and Ministry of Health representatives in implementing MDSR. Strong national leadership via a coordinating secretariat has worked well in Kenya. However, several challenges were encountered including underreporting of data, difficulties with reviewing the data, and suboptimal aggregation of data on cause of death. To ensure progress toward a full national enquiry of all maternal deaths, we recommend improving the notification of maternal deaths, ensuring regular audits and feedback at referral hospitals lead to continuous quality improvement, and strengthening community linkages with health facilities to expedite maternal death reporting. Ultimately, both a top-down and bottom-up approach is needed to ensure success of an MDSR system. Perinatal death surveillance and response is planned as a next phase of MDSR implementation in Kenya. To ensure the process continues to evolve into a full national enquiry of all maternal deaths, we recommend securing longer-term budget allocation and financial commitment from the ministry, securing a national legal framework for MDSR, and improving processes at the subnational level” ((Hellen S. et al., 2017).

In a quality improvement plan for health facilities, health workers in 21 public health facilities in Kwale analyzed data from the ANC in the facilities seeking to improve care for the ANC mothers. They regularly met to examine the performance gaps as well as develop a plan to improve. They looked at the data from 20 reportable indicators in the registers. The study found out that the mothers who had visited the facility for the 4 antenatal visits and had started the clinic during the first trimester had more improved and better outcomes during and after delivery. During the visits, all the recommended services were given (Michael K. et al., 2014). Therefore the Focused antenatal care is advised for all the service delivery points.

Critical Analysis

A research study carried out in 10 different countries from refugee populations showed that the use of the antenatal care clinics by the pregnant women improved the outcomes due to the fact that they get specific interventions in the visits that improve the pregnancy as well as getting the health education on the expectations and how to manage the minor complications in the antenatal period. In this study, delays in seeking health care was a problem and some mothers could not make decisions on their own to seek attention even when they are in a bad state. This made the time taken to get to a health facility immensely prolonged. There was no evident impediment to seeking care in the Kenyan Refugee Camps but the community based factors were noted. Delay by the health care providers to notice the danger signs or failure to fully examine and intervene early enough led to poor maternal outcomes as well in several cases. Other facility based factors observed includes lack of proper equipment for emergency interventions, inadequate or incorrect treatment given, limitations of a trained doctor to handle the obstetric complications (Michelle H. et al., 2012).

The offering of critical areas of care during the antenatal and postnatal period is vital in improving the care to the mothers. In the rural African settings, the availability of health care facilities in all areas is a problem and some mothers opt for the traditional birth attendants in the communities. “Therefore concentrating solely on adherence to clinical standards at points of care without deliberate attention to increasing utilization of critical services such as antenatal care (ANC), skilled delivery, prevention of mother-to-child transmission of HIV/AIDS (PMTCT), and early newborn care, among others, may not have a significant impact on population health outcomes in rural resource-poor settings” (Michael K. et al., 2014).

First, second and third delays are identified as the contributors to maternal deaths in Kenya. Onesmus M. et al., (2016) notes that failure of the mother to seek health care due to various reasons like lack to recognize the danger signs, ignorance of the available services and poverty is a first delay. The second delay is explained by the lack of transport of the mother to the heath care facility and the third delay is denoted by the delayed interventions, inadequate interventions or lack of the equipment and supplies as well as expertise in the health facility.

Some of the causes of poor maternal outcome especially during delivery are sometimes cultural and can be dealt with at that lower level. Negligence, abuse and mistreatment by the staff attending to them is something that the hospital administrations can deal with so as to improve the public confidence to utilize the services. In some areas, the culture dictates that the pregnant mothers are attended to by the female staff and not their male counterparts (Nicole Bourbonnais, 2013).

Emergency Obstetric care is one of the methods that are used to improve the outcome of the mothers during delivery and all the health care workers in maternities should be trained on it. “Ensuring the continuum of care throughout pregnancy is an important requirement for the reduction of maternal and early neonatal deaths. There is evidence that a significant number of stillbirths and neonatal deaths could be prevented if all women were adequately nourished and received good quality care during pregnancy, delivery, and the postpartum period. The antenatal period helps the health care provider to assess risks and treat conditions that could affect both the mother and baby. It is essential that during delivery, obstetric emergencies are effectively managed to prevent complications which account for up to 58% of stillbirths and early neonatal deaths. Countries such as Thailand, Sierra Leonne, Liberia, Pakistan, Sudan, Bosnia, Uganda, Tanzania, and Northern Kenya, have established intervention projects to improve the availability of emergency obstetric care (EmOC). These projects include the use of signal functions to assess whether their health facilities adhere to international standard operating procedures for the management of emergencies during pregnancy” (Faith Y. et al., 2013).

Governance Structures

Governance needs to be improved in the institutions offering health care as well as the organizations running them. In a review of maternal death audits done in Kenya for incremental progress and lessons learned in 2017, a few things were identified. “A national coordinating structure was established but encountered significant challenges including: (1) a low number of estimated maternal deaths identified that only included some occurring within facilities, (2) only half of those identified were reviewed, (3) reviewers had difficulties assessing the cause of death largely because of limited documentation in clinical records; and (4) resulting actions were limited. Successful implementation will require addressing many issues, including building support for the process lower down in the health system” (Hellen S. et al., 2017).

The poor infrastructure, staffing and equipment have for a very long time affected the public health system in Kenya. Only around 36% of health care facilities in Kenya offer delivery services and of these, the ones in rural areas are ill equipped to deal with complications which could exacerbate the maternal unfriendly outcomes.  According to the Kenya Health Sector Strategic and Investment Plan (2012-2018), Kenya has only 4 nurses for 7000 residents against the World Bank estimated needs for 14 for 4000. This is only around 17% met needs for the effective functioning of the system. It is also estimated that some areas are not given the equal number of health care workers just like other areas, straining further the services offered there (Nicole Bourbonnais, 2013). So, the human resources for health is a critical governance issue for improving of maternal health in all areas of the country.

There are several approaches that the government of Kenya has used to ensure the right governance for the issues of maternal and general reproductive health. “The United Nations Population Fund (UNFPA) has outlined the principles of the Human Rights Based Approach (HRBA) to sexual and reproductive health rights. The HRBA states that governments, as duty bearers, have three levels of obligation to right-holders (all persons): (1) to respect sexual and reproductive health rights (SRHR) by refraining from interfering with the enjoyment of these rights, (2) to protect SRHR by enacting laws that create mechanisms to prevent violations of these rights by state authorities or by non-state actors and (3) to fulfill SRHR by taking active steps to put in place institutions and procedures, including the allocation of resources, to enable people to enjoy these rights. In addition, Kenya has signed on to several regional mandates regarding health/reproductive health. Kenya participated in and committed to the 2001 Abuja Declaration, pledging to commit at least 15% of the national budget to health care. Kenya signed (but did not ratify) the Maputo Protocol on the Rights of Women of 2003, which recognizes reproductive rights and commits state parties to establishing and strengthening existing pre-natal, delivery, and post-natal health and nutritional services for women. As a member of the African Union, Kenya launched the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) in November 2010, reiterating the Campaign’s slogan that “no women should die while giving life (Nicole Bourbonnais, 2013).”

Focus on Outcomes and impact on inequalities

Prevention of high risk pregnancies according to Linda B. et al., (2017), proper management of the risky pregnancies, prevention of unwanted and untimed pregnancies through proper family planning as well as general improvements of maternal health could decrease the number of mothers dying from preventable causes in low income countries.

In a study done in Ethiopia in 2017, the results showed that most of the deaths occur within 24 hours post-delivery followed by during pregnancy though deaths are observed up to six weeks post child birth. This study also looked at the level of knowledge of mothers on the causes of deaths for the others of reproductive age. Education, occupation, social status, level of poverty and the monthly income all played a part in the likelihood of mothers dying during child birth. The higher the education and the other parameters being positive, the better the results (Fikreselassie G., et al 2017).

The issues of inequality affects the health of women generally. “The problem is driven, at least in part, by lack of access to quality maternal health services, including ante-natal, delivery, and post-natal services. Although health sector infrastructure has grown over the past decade, 4 many women still live at a considerable distance from health facilities, cannot afford to pay fees for maternal services, and/or face other barriers to accessing quality care. Access to skilled delivery is a particular challenge. Overall, only 44% of births in Kenya are delivered under the supervision of a skilled birth attendant, well below the target of 90% of deliveries by 2015. Traditional birth attendants continue to assist with 28% of births, relatives and friends with 21%, and in 7% of births, mothers receive no assistance at all.5 On June 1, 2013, the Government of Kenya took action to address this problem by initiating a policy of free maternity services in all public facilities, effective immediately.6 Health facilities soon began to feel the effect of this policy. On the day of the announcement, Pumwani Maternity Hospital delivered an unprecedented 100 births.7 By July, the Director of Public Health and Sanitation estimated a 10% increase in deliveries across the country, with increases of 50% in certain counties.8 In some facilities, these numbers have been even higher. According to representatives of Kenyatta National Hospital (KNH), within a month the number of pregnant women seeking maternal care had increased by 100 per cent” (Nicole Bourbonnais, 2013).

Conclusion

Most of the deaths in Kenya and the Sub Saharan Africa are caused by preventable direct causes and mostly occur after delivery of the babies. The systems of governance of the institutions, if well managed can be of great importance in averting the maternal deaths. Most of the deaths are related to human errors and can be prevented if the right interventions are taken in different levels timely (Daily Nation 2018).

References

Dorothy Otieno (2018) Several lapses in care contribute to deaths of over 80 per cent of expectant and new mothers. Daily Nation. https://www.nation.co.ke/newsplex/2718262-4322016-rpoc3c/index.html

Faith Y. et al., (2013) A retrospective analysis of maternal and neonatal mortality at a teaching and referral hospital in Kenya. International Journal for Equity Health. BMC.

Fikreselassie G. et al., (2017) Knowledge of Direct Obstetric Causes of Maternal Mortality and Associated Factors among Reproductive Age Women in Aneded Woreda, Northwest Ethiopia; a Cross-Sectional Study. The Pan African Medical Journal.

Hellen S. et al., (2017) Implementing Maternal Death Surveillance and Response in Kenya: Incremental Progress and Lessons Learned. Global Health: Science and Practice.

International Classification of Diseases (ICD) International Classification of Diseases, 10th Revision, Geneva, World Health Organization, 2004.

Linda B. et al., (2017) Progress and Inequities in Maternal Mortality in Afghanstan (RAMOS-II): a Retrospective Observational Study. Lancet Vol 5 May 2017.

Michael K. et al., (2014) Improving service uptake and quality of care of integrated maternal health services: the Kenya kwale district improvement collaborative. BMC Health Services Research.

Michelle H. et al., (2012) A Study of Refugee Maternal Mortality in 10 Countries, 2008—2010. International Perspectives on Sexual and Reproductive Health ? 2012 Guttmacher Institute.

Nadia A., et al., (2016) Achieving Maternal and Child Health Gains in Afghanistan: a Countdown to 2015 Country Case Study. Lancet Vol 4 June 2016.

Nicole Bourbonnais, (2013) Implementing free maternal health care in Kenya. Challenges, Strategies and Recommendations. KNCHR.

Onesmus M. et al., (2016) Trends in Health Facility Based Maternal Mortality in Central Region, Kenya; 2008-2012. The Pan African Medical Journal.

Rose M. et al., (2012) Effect of Early Detection and Treatment on Malaria Related Maternal Mortality on the North-Western Border of Thailand 1986-2010. PLOS.

Stephen S. et al., (2016) Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015. The Lancet.

WHO (2018) Health Statistics and Information Systems. Health Data and Statistics. World Health Organization, 2018 https://www.who.int/news-room/fact sheets/detail/maternal-mortality.