Category Archives: Family Planning

Is it time for a comprehensive Reproductive Health Act for Kenya?

A Presentation made at the Kenya Medical Association State of Maternal Mortality in Kenya Conference held at the Kenyatta International Conference Centre, Thursday 15th September, 2011

Evolution of Modern Obstetrics and Gynaecology Practice in Kenya

In a previous post it was opined that although Kenya has the capacity to train the nurse workforce it needs, the prevailing challenge is ensuring all trained nurses and midwives are employed and efficiently deployed. The State of World’s Midwifery[i] 2011 observes that appropriate employment and deployment of skilled midwives is essential for Kenya to make meaningful progress towards achieving MDG 5. The current post seeks to highlight some of the milestones in the evolution of modern practice of midwifery and midwifery training in Kenya.

In colonial Kenya and before the mid-1960s, obstetrics and gynaecology were practiced as separate services located in different facilities. Whereas gynaecology services were availed as sub-specialty within the department of Surgery at the King George VI Hospital (later renamed Kenyatta National Hospital), midwifery services were considered a separate service altogether, provided in maternity homes that were usually sited some distance away from the main hospital. The tradition of building maternity wards some distance away from the main hospital arose as a long-practised measure to prevent cross infection especially from surgical patients. It also reflected the colonial policy that whereas the Government undertook to provide Africans with what was described as ‘complete medical care’, this service did not extend to obstetric care, which was regarded as a responsibility of the local authorities, the Municipal Councils or in the reserves, the African District Councils[ii].

The initiative to develop midwifery services in urban areas of Kenya is credited to the East African Women’s League (EAWL)[iii] which, “out of concern for the lack of a maternity ward for African women”, and with the encouragement of Lady Grigg (Governor‘s wife), founded the Lady Grigg Child Welfare and Maternity League in 1926. By 1928 the Lady Grigg Maternity Home at Pumwani (now the Pumwani Maternity Hospital) had been built. Other maternity hospitals followed, in Mombasa- Lady Grigg Maternity Hospital Mombasa (now part of the Coast Provincial General Hospital), and in Nairobi- the Social Service League Ngara Maternity Home (sadly, this has since ceased to be a hospital).

The EAWL also advocated for the training of African nurses and midwives, and all three maternity hospitals mentioned above undertook the training of the early midwives in Kenya (to enrolled midwife level). Later on, in pursuit of primary health care following the Alma Ata Declaration of 1978, midwifery training was incorporated into nursing training to produce the Enrolled Community Health Nurse. Training at registered midwife level had to wait until registered nurse training had started in Kenya. Training at para-medical level in Kenya can be traced back to 1927 when the first group of students was recruited for training as Medical Assistants at the Native Civil Hospital, (later re-named King George VI Hospital and Kenyatta National Hospital). This cadre was trained to provide both Nursing and Clinical services. These are the forerunner of the Clinical Officer of today. In 1952 the first batch of Kenya Registered Nurses commenced training at the King George VI Hospital and the Medical Training Centre (now Medical Training College)[iv]. Registered nurses could then undertake a further year’s training in midwifery to qualify for registration as Registered Midwife.

By 1954 of the 12 full time specialists at the King George VI Hospital, only one, Dr Peter L Candler specialised in gynaecology[v]. According to Peter Candler, the most common gynaecological condition he dealt with at that time was vaginal fistula resulting from lacerations during childbirth. This was followed by complications of generalised pelvic sepsis and infertility. However, he reported that ‘attempted’ abortion was unlikely among Africans because of the strong desire to bear children! Nearly two decades later when we came into the scene, the pattern of gynaecology had changed little, except in the case of abortion which had since become a prominent gynaecological problem.

The expansion of obstetrics and gynaecology services in Kenya is largely attributable to the University of Nairobi’s Department of Obstetrics and Gynaecology. The medical school in Nairobi was established through a presidential directive shortly after 1963, the year of Kenya’s independence. To implement the directive, the Ministry of Health with British Government financing, invited the University of Glasgow to assist in preparing the KNH as a teaching hospital ahead of the launch of the University of Nairobi Medical School in 1967. Thus, a team from Glasgow arrived, and in September 1965, oversaw the opening of the Obstetric Unit at the KNH. Initially, patients were ‘borrowed’ from the Pumwani Maternity Hospital through a process whereby one of the consultants would select a couple of women in early labour and transport them to the Obstetric Unit at KNH for their management. In addition, the Department ran, on behalf of the Nairobi City Council, four antenatal clinics at the health centres in Riruta, Waithaka, Woodley, and Langata. This way it was possible to have enough clinical material for the medical students and student midwives from the School of Nursing. It should also be mentioned that the first medical students taught at KNH were actually ‘borrowed’ from Makerere Medical School! Initially these were Kenyan students who chose to spend an elective term at the KNH, but later the hospital provided refuge to students who fled Idi Amin’s tyranny in Uganda, including some students from other countries.

Establishment of gynaecology (gynae) as a specialty at KNH, separate from Surgery, was not without resistance and intrigues. There were those surgeons that felt there was absolutely nothing new to be gained by creating a department of gynaecology- after all, hadn’t they treated gynae cases all those years? A thorny area concerned the allocation of operating theatre space for a regular gynaecology list. We needed a theatre for emergencies such as ruptured ectopic pregnancy and incomplete abortion; as well as another theatre for elective (‘cold’) cases. I remember one senior surgeon openly saying incomplete abortion never required an evacuation- after all many occurred in the ‘bush’ where there were no doctors! He had always sent them away without any evacuation.


[i] The State of World’s Midwifery 2011, was launched in June 2011 by the United Nations Population Fund (UNFPA)

[ii] Letter written on October 20, 1954 by Robert F Gray to Mr Walter Rogers of Institute of Current World Affairs, 522 Fifth Avenue, New York 36, New York. http://www.icwa.org

[iii] The East Africa Women’s League is an organisation for white women who were born in, lived or worked in East Africa. It was founded in Nairobi in 1917, its main concern being the welfare of women and children of all races in the country then known as ‘British East Africa’. http://www.eawl.org

[iv] http://www.kmtc.ac.ke/public_site/webroot/cache/article/file/Nursing_log1.pdf

[v] Note: Dr Peter Lawrence Candler was admitted to the Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) in 1962.

 

Champions are Urgently Needed for Accelerated Reduction of Maternal Mortality in Africa

“It is my aspiration that health finally will be seen not as a blessing to be wished for, but as a human right to be fought for.” Kofi Annan, Former UN Secretary General

Introduction: overcoming resistance to change

There is an urgent need for champions to push for accelerated reduction of the shockingly high maternal death rates in African countries, the general improvement of maternal health in the region, and the attainment of the fifth Millennium Development Goal (MDG5). One of the major challenges for the champions will be overcoming resistance to change. Resistance to change is to be found among all levels of society, among health professionals, including obstetricians and gynaecologists; midwives; medical and nursing training institutions; statutory regulatory bodies; professional societies; health management and administration, as well as political leadership and community in general.

But why is there resistance to change? People fear change, and in medicine there is the familiar tradition of: “We’ve always done it this way.” People harbour doubts as to whether innovations actually work better than the traditional practices. There are legal obstacles, including roles and practices prescribed in laws and regulations. There are limited human, financial and infrastructure resources to sustain application of new practices; and there are socio-cultural factors, gender roles including the status of women in society, that function as barriers to change.

Maternal mortality

Recent assessments of maternal mortality show that across Eastern and Southern Africa, “the most basic and natural act of giving life causes the death of almost 10 women every hour” . In 2008, some 79,000 women died in the region in the process of pregnancy and childbirth, accounting for more than one fifth of all such deaths in the world. According to the 2011 UNICEF Report, the latest estimated figures for maternal mortality ratio in Kenya, Malawi, Uganda and Tanzania are 490, 810, 440 and 580 respectively . These unacceptably high levels of maternal deaths make it extremely doubtful that these countries will succeed in reaching all the indicators of achieving improved maternal health (MDG5) in the next 4 years.

There is need for intensified advocacy, especially towards the recognition of women’s constitutional right to life and health, and therefore their right to quality reproductive health services, which ensure that every pregnancy is wanted; all pregnant women and their infants have access to skilled care; and that every woman is able to reach a functioning health facility to obtain appropriate care in the event of complications. After all, going through pregnancy and childbirth safely is what every woman should expect.

We know that even though complications of pregnancy cannot always be prevented, deaths from these complications can be averted. Up to 75 percent of all maternal deaths can be averted if women received timely and appropriate medical care. Maternal deaths from obstetric complications can be markedly reduced if skilled health personnel and essential supplies, equipment and facilities are available. And yet, apart from Malawi, where 54 percent of births were reported to have been attended by a skilled birth attendant, in the East African countries nearly 60% of all births take place unattended by a skilled attendant. Among the poorest women the majority of birth take place unattended by skilled personnel, the proportions being 72 percent in Uganda, 74 percent in Tanzania, and as high as 80 percent in Kenya .

The direct causes of maternal deaths have long been known, and so are the interventions to prevent them. We know what works and what does not work. Clearly, what is lacking is the commitment, at all levels, to act; to make the reduction of maternal mortality a high priority; and to reflect this in resource allocations to health services, especially for reproductive health services. Professor Mahmoud Fathalla of Egypt once observed that: “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their [women’s] lives are worth saving.” When will our countries decide?

Maternal morbidity

It has been said (though there is want of data) that for every maternal death there are up to thirty times as many cases of pregnancy related illness or disability . The lack of or poor access to, obstetric care is responsible for a major burden of maternal morbidity in African countries. Among such morbidities are the obstetric fistulae, vesico-vaginal fistula (VVF) and/or recto-vaginal fistula (RVF) which are usually the result of neglected obstructed labour.

Let me again illustrate this with the case of one of my patients, by name Halima. During my time in the Department of Obstetrics and Gynaecology at the KNH, in the 1970s, I happened to be one of two gynaecologists with special interest in the treatment of urinary incontinence, the commonest cause of which was VVF. Urinary incontinence is one of the most frightful afflictions of human kind and often results in the sufferer becoming a social outcast. Yet, this condition, which arises mainly from prolonged obstruction of labour during childbirth, is a preventable problem if only all pregnant women had access to skilled care during labour and delivery. At any given time there were one or two such cases in my ward. Halima was one of two teenage girls transferred from the Wajir District Hospital in North-Eastern Kenya, with a very large VVF; almost the entire anterior vaginal wall was missing. We had to repair this defect in stages over several weeks using grafts from other parts of her body. The two girls almost became permanent residents of Ward 23 in the old KNH building, and to occupy them they were provided with knitting kits and encouraged to make whatever they fancied. One morning, as I conducted my ward round Halima presented me with a blue knitted sweater. I was deeply moved by this deed, and for several days pondered over it. I guessed this was her way of expressing gratitude, perhaps for our compassion towards her, because she was, as yet, not cured!

Several lessons can be learned from Halima’s case. Clearly, in terms of addressing her problem, our surgical treatment came at the tail end of a chain of events that resulted in a damage that should never have happened in the first place. Halima was barely 14, too young to be anyone’s wife and to have begun childbearing. She was subjected to the severest type of female circumcision (infibulation), and given off for marriage shortly afterwards. In both situations her human and reproductive rights had been denied; she had been abused by the societal norms she lived under. In fact female genital mutilation (FGM), forced early marriage, and coerced sex were tantamount to gender-based violence. Then when Halima became pregnant she was further denied the right to health care- an opportunity to have access to skilled attendance during the antenatal period, as well as care during childbirth. How sad it is to note that, today, four decades later, many African young women continue to live under conditions that pose as much reproductive risk to their lives and wellbeing as it was for Halima.

Abortion, a fertile ground for change

In Africa, despite the fact that induced abortion takes place among women from all levels of society, the brunt of abortion-related morbidity and mortality is borne almost exclusively by the young and poor women. This perhaps explains the dilatory approach to the prevention of such mortality, where leaders don’t want to take the obvious step towards prevention of unsafe abortion. After all, it does not affect their social class. As such unsafe abortion has continued to be a major contributor to the unacceptably high levels of maternal morbidity and mortality rates that prevail in Africa. It continues to be one of the formidable challenges to the achievement of MDG5 of improving maternal health by 2015.

Yet, it is obvious that stringent abortion laws have not deterred women in need from going through with an abortion; what such laws have achieved is to push many hapless women to undergo unsafe procedures with consequent high rates of morbidity and mortality. For such women, the desire to do away with an unwanted pregnancy can be so intense that they will avail themselves of this last resort despite the law, even the attendant risk to their lives. The procedure of medical termination of pregnancy is simple, short and safe when undertaken in the open, by trained persons; on the other hand clandestine abortion, usually performed by unskilled operators, is expensive, unsafe and life threatening.

The persistence of unsafe abortion in Africa is, ultimately, perpetuated by two key factors: (a) the restrictive laws against termination of pregnancy; and (b) the limited or lack of access to adequate abortion care services. Criminalisation of abortion in majority of African countries is something inherited from the colonial laws, despite the fact that the law has since decriminalised the procedure in the colonial “mother countries” (United Kingdom 1967; France 1975; Italy 1978; Spain 1985; Belgium 1990).

Increasing access to contraception is an effective primary intervention for the prevention of unsafe abortion. However, it is feared that induced abortion may continue being the only means of birth control for many women in some parts of Africa. These are women with very limited access to contraception, who include adolescents and youths who, supposedly on moralistic grounds, are denied not only the services but also information on sexuality.

“Abortion is legal but we just don’t know it”

Sadly, many of the women who suffer unsafe abortion live in countries where abortion is sanctioned under certain conditions, but they are unaware of this provision, or, because of various reasons, they cannot access safe abortion services in their countries. For example, the penal codes in Kenya, Uganda and Tanzania sanction abortion for the preservation of the mother’s life and mental health. The Constitution of Kenya (2010) has recognised legal abortion, even though abortion remains generally restricted in Kenya . It is therefore incumbent upon health care providers to ensure women do have access to what they are legally entitled.

The above notwithstanding, it is regrettable that women continue to go through unsafe abortion even when they qualify for legal termination of pregnancy. In many cases this can be blamed on the health service provider, for example, ignorance of the law, negative attitudes and biases, and conscientious objection to termination of pregnancy; or the lack of appropriate facilities including trained providers. Service providers need to recognise their ethical and legal obligations to provide women in need of abortion with appropriate information on where safe services may be obtained. Medical policies and practices can also serve to restrict access to legal abortion, for example, insistence on unnecessary procedures /practices such hospitalisation. Access to services can also be restricted due to community related factors, especially lack of awareness about the law and facilities that provide legal abortion services.

Conclusion

Clearly, time has come for a paradigm shift in the attitudes of health workers and all others who come in touch with women seeking termination of pregnancy, from the attitude driven by deep-rooted suspicion to one of considerate review of all evidence present in order to ensure women are not denied safe abortion services to which they are legally entitled. The realization of unlimited implementation of existing legal and policy provisions ought to be a key goal of advocacy groups, including the Champions for reproductive rights in Africa.

Women have the right to safe abortion services within the law

Kenya’s constitution confers to all citizens the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care (Article 43 (1a)). Further, Article 26(4) specifies grounds upon which abortion may be legally provided; specifically, “if in the opinion of a trained health professional there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law”. Safe abortion services, as provided by law, therefore need to be available, provided by well-trained health personnel supported by policies, regulations and a health systems infrastructure, including equipment and supplies, so that women can have rapid access to these services (WHO).

It is more efficient to provide legal safe abortion services within the context of Comprehensive Abortion Care (CAC) system that aims to reduce the risk of unwanted (unplanned) pregnancy. Morbidity and mortality related to abortion can be prevented at the following three levels: (a) Primary level- Prevent unwanted pregnancy by providing contraceptive information and counselling, and increasing access to contraceptive services. (b) Secondary level- Prevent unsafe abortion through provision of counselling in early pregnancy, respecting women’s informed choice, and ensuring access to safe medical termination of pregnancy for those who so choose. (c) Tertiary level- Provide post-abortion care (PAC) services: clinical management of complications of unsafe abortion, and prevention of future unsafe abortion through contraceptive counselling and services.
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Focus on providing safe abortion services, not post-abortion care.

In order to minimize the problem of unsafe abortion and its impacts there is an urgent need for a paradigm shift in strategic planning, from the present focus on ‘post-abortion care’ to provision of ‘safe abortion services’. The present challenge for Kenya under the new constitutional dispensation ought to be ensuring all women who are legally entitled to legal termination of pregnancy do access the services without unnecessary impediments.

Addressing the problem of unsafe abortion in Kenya should significantly contribute to the achievement of Millennium Development Goal 5 on Improving Maternal Health, considering that unsafe abortion is one of the major factors behind the high maternal mortality rates in the country. In addition, complications resulting from unsafe abortion contribute to serious sequelae for women’s reproductive health such as chronic pelvic inflammatory disease (PID) and infertility. The incidence of unsafe abortion generally reflects the magnitude of unwanted (unplanned) pregnancies in a particular community. Hence, the only sure way of effectively minimizing unsafe abortion is to ensure women have easy access to safe, effective and acceptable contraceptive information and services, backed up by policies that promote social justice and equality, enhanced status of women, as well as legislation that decriminalizes abortion.

The single, greatest challenge to addressing unsafe abortion in Africa is the lukewarm commitment on the part of governments to promote, protect and respect women’s reproductive rights, including the right to access safe and legal abortion services. This lack of political will affects the availability, accessibility, and quality of abortion-related care.

For several years there has been a mistaken notion that post-abortion care (PAC) services provide the solution to morbidity and mortality associated with unsafe abortion[i]. Consequently considerable resources have been expended on expansion of these services. Unfortunately, although PAC services can (and do) save lives, in many respects the intervention comes late, at the tail-end of the train of events that precipitated the tragedy in the first place, and as such they cannot be considered an efficient public health strategy for the prevention of abortion-related morbidity and mortality.

Prevention of unsafe abortion requires a paradigm shift in strategic planning, to a focus on provision of ‘safe abortion, not post-abortion care, services’.

‘Safe abortion’ services are those provided by trained health workers, supported by policies, regulations and a functional health infrastructure, including equipment and supplies[ii]. Performance of abortion outside these conditions constitutes ‘unsafe abortion’.

The new Constitution of Kenya, while maintaining the longstanding restrictive stance towards abortion, it nevertheless, does provide opportunities for enhancing the reproductive health and rights of Kenyan women. The Constitution is explicit in the chapter on Bill of Rights regarding circumstances when abortion may be legal. Article 26 (4) states: Abortion is not permitted unless, in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law. Although several questions arise from this statement, for example: Who is a trained health professional? Is there any emergency that does not threaten life or health of the mother? What definition of ‘health’ is implied here? etc., whatever the answers may be the Constitution has entrenched the right for a woman to have a legal abortion, though under certain conditions.  The present challenge for Kenya then is to ensure women who are legally entitled to legal termination of pregnancy can access the services without hindrance or delay.

Experience in other countries where abortion has been legalized shows that women are often denied safe abortion services to which they are legally entitled[iii]. The reasons for this include the following:

  • Provider related factors: lack of knowledge of the law, or failure to apply the law, by providers, negative provider attitudes, biases and conscientious objection, and lack of awareness (or neglect) among providers of their ethical/legal obligations to provide women in need with appropriate information on where safe abortion services can be obtained.
  • Medical policies and bureaucracy: insistence on unnecessary/outdated medical abortion techniques e.g. requirement for hospitalization, use of general anaesthesia, etc.; opposition to task-shifting, and other regulatory bottlenecks.
  • Other factors: lack of public information about the law; lack of awareness about facilities providing safe abortion services; lack of awareness (among women) of need to report early in pregnancy.

[i] Mati JKG J. Adolescent reproductive health in the era of HIV/AIDS: Challenges and Opportunities. Obstet. Gynecol. East Cent. Afr. (2005); 18: 1-18

[ii] World Health Organisation. (2003) Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva, World Health Organisation

[iii] World Health Organisation. (2003) Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva, World Health Organisation

How Kenya’s New Constitution is likely to impact on access to safe abortion services

Background:

The aim of this presentation is to contribute to the understanding of the provisions in the New Constitution as they relate to access to safe abortion services in Kenya, and to analyse areas of particular concern in the implementation of the Constitution. In order for Kenya to achieve Millennium Development Goal 5 on Improving Maternal Health, it is imperative that the issue of unsafe abortions is addressed, since this is a major contributor to the high maternal mortality rates in the country. In addition, complications resulting from unsafe abortion contribute to serious sequelae for women’s reproductive health such as chronic pelvic inflammatory disease (PID) and infertility.

 

The incidence of unsafe abortion generally reflects the magnitude of unwanted pregnancies in a particular community. Hence, the only sure way of effectively minimizing unsafe abortion is to ensure women have easy access to contraceptive information and services, backed up by positive legislation that decriminalizes abortion. According to UN data[ii], in most so-called developing countries like Kenya, there was a trend towards enactment of more restrictive abortion laws in the period between 1999 and 2007 (Figure 1). Whereas in nearly all countries abortion is permitted to save a mother’s life, only 60 percent and 57 percent respectively of the countries permit abortion to preserve a mother’s physical and mental health. Rape or incest, and fetal abnormalities are respectively considered in 37 percent and 32 percent of the countries; and in only 19 percent are economic or social considerations entertained. Abortion is available on demand in some 15 percent of developing countries.

 

Figure 1: Grounds on which abortion is permitted – percentage of countries

Source: (World Abortion Policies 2007 )

Constitutional provisions that are relevant to abortion services in Kenya

The new Constitution of Kenya, while maintaining the longstanding restrictive stance towards abortion[i], it nevertheless, does provide opportunities for enhancing the reproductive health and rights of Kenyan women, which if adequately implemented can significantly contribute to the reduction of the high maternal mortality rates prevailing in Kenya today, and the achievement of MDG 5. In particular, the Constitution of Kenya:

  • Is committed to nurture and protect the well-being of the individual, the family, communities and the nation[ii].
  • Guarantees reproductive health care as a right for all Kenyans[iii]
  • Commits the government to implement international conventions, and regional commitments that Kenya has pledged to support such as CEDAW[iv] and the Maputo[v] Plan of Action[vi],
  • Guarantees that every person has inherent dignity and the right to have that dignity respected and protected[vii], and
  • Guarantees equality and freedom from discrimination for every Kenyan[viii]

 

The Constitution of Kenya is explicit in the chapter on Bill of Rights regarding circumstances when abortion may be legal. Article 26 (4) states: Abortion is not permitted unless, in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law. In other words, abortion can be permissible if in the opinion of a trained health professional there is need for emergency treatment (as in cases of severe pre-eclampsia and eclampsia), or the life or health of the mother is in danger (as in the case of severe cardiac disease, or complicated diabetes mellitus that is not adequately responding to treatment).

 

To a certain degree Article 26 (4) has widened access to safe abortion in Kenya through the inclusion of danger to ‘health’ as a ground for abortion in addition to danger to ‘life’, of the mother previously provided in Section 240 of the Penal Code[ix]. As it stands today, the Code of Professional Conduct and Discipline published by the Medical Practitioners and Dentists Board mentions, in addition, the health of the baby: “There is room, however, for carrying out termination when in the opinion of the attending doctors it is necessary in the interest of the health of the mother or baby”.

 

Restrictive medical practices

The Code of Professional Conduct and Discipline (see above) goes on to provide guidance on how medical practitioners should proceed in cases where there is ground for termination of pregnancy (TOP): “In these circumstances, it is strongly advised that the practitioner consults with at least two senior and experienced colleagues, obtains their opinion in writing and performs the operation openly in hospital if he considers himself competent to do so in the absence of a Gynecologist”. This guideline can present a serious access barrier, for example for the solitary medical worker in rural areas, where a second opinion may be a considerable distance away. Similarly restricting performance of abortion procedures to hospitals is not only restrictive but may also be unnecessary, considering that modern techniques for TOP can safely be carried out on an outpatient basis.

 

In addition, quite often in order to establish the risk to the life of the woman, a psychiatric assessment is required. This is not only discriminative to those living far from urban centres where psychiatrists are to be found. In addition, it is a process that gives the woman a label of psychiatric illness, besides being expensive, time consuming, and in many respects completely unnecessary. It is an invasion of the inherent dignity of the woman (see above). In many respects these practices serves to discourage rather than facilitate access to safe abortion services.

 

Provision of Safe abortion services[x]

The World Health Organization defines ‘unsafe abortion’ as “a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both”[xi]. ‘Safe abortion’ services, on the other hand, imply the services are provided by well-trained health personnel and supported by policies, regulations and a health systems infrastructure, including equipment and supplies.

 

Almost all the deaths and complications from unsafe abortion are preventable through application of safe abortion practices. Termination of pregnancy (TOP) is a safe medical procedure when performed by trained health care providers using proper equipment, correct technique and ensuring infection prevention standards.

 

Regrettably, in many circumstances where women are legally entitled to have an abortion, safe services are not available to them due to a range of reasons, which include the following:

  • Provider associated problems and biases: a lack of trained providers (recruitment constraints; poor deployment and distribution); negative provider attitudes; stigmatization and other sanctions; conscientious objection among health workers.
  • Medical policies and practices: insistence on hospitalization; insistence on use of unnecessary or outdated techniques including use of general anaesthesia; opposition to task-shifting, and other regulatory bottlenecks.
  • Lack of knowledge of the law or lack of application of the law by providers; lack of public information about the law and women’s rights under the law.
  • Lack of awareness about facilities providing abortion or the need to obtain abortion services early in pregnancy.
  • Lack of awareness among health workers of their ethical and legal obligations to respect women’s rights, and to provide women in need with adequate information on where and how safe abortion services can be obtained.

 

Prevention of unsafe abortion and its complications

The Africa Union’s Maputo Plan of Action for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights (2007-2010) aimed to reduce the incidence of unsafe abortion, through the following strategies:

  • Enacting policies and legal frameworks to reduce incidence of unsafe abortion;
  • Preparing and implementing national plans of action to reduce incidence of unwanted pregnancies and unsafe abortion;
  • Training service providers in the provision of comprehensive safe abortion care services where national law allows;
  • Providing safe abortion services to the fullest extent of the law;
  • Educating communities on available safe abortion services as allowed by national laws;
  • Training health providers in prevention and management of unsafe abortion

 

On the whole, there is consensus that to effectively reduce the incidence of unsafe abortion women must have easy access to contraceptive information and services, backed up by positive legislation that decriminalizes abortion. Table 1 shows a suggested three-tier scheme for the prevention of unsafe abortion and the related morbidity and mortality.

 

Table 1: A three-tier scheme for the prevention of abortion related morbidity and mortality[xii]

Conclusion 

 

This review has shown that the new Constitution of Kenya, despite the restrictive stance on abortion, does at the same time provide opportunities for enhancing the reproductive health and rights of Kenyan women. Hence, to be effective in the provision of safe abortion services, it is imperative that health care providers do familiarise themselves with these provisions in the Constitution. This will avoid the introduction or continuation of unwarranted access barriers to what should be legally availed to women in need.

Unsafe abortion remains an important contributor to the unacceptably high levels of maternal morbidity and mortality that prevail in Kenya; it is a key challenge to the achievement of MDG 5, as well as attaining the health targets set out in Kenya’s Vision 2030. In addressing the issue of unsafe abortion particular focus should be on ensuring equity in access to health care, especially for the poor and marginalised communities. Despite the paucity of supportive data, it is highly possible that considerably more induced abortions occur among the wealthier and more mature women than among the poor young single women that are often reported from public institutions. However, it is the latter that protract Kenya’s high maternal mortality rates, and who create the stiffest challenge to the attainment of national and international goals, if they are left ‘out of the loop’. In any case, the Constitution guarantees equality and freedom from discrimination for everyone.

 

Related Links


[i] Japheth Mati, New abortion law is still bad for women. STAR Thursday 29 April 2010

[ii] Preamble to the Constitution of Kenya

[iii] Article 43 (1) (a) Every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care

[iv] CEDAW, the Convention on the Elimination of All Forms of Discrimination against Women, is an international agreement that affirms principles of fundamental human rights and equality for women around the world. It was adopted by the UN General Assembly in 1979 through Resolution 34/180.

[v] Maputo Plan of Action for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights 2007-2010

[vi] Art. 2 (6) Any treaty or convention ratified by Kenya shall form part of the law of Kenya

[vii] Article 28 Every person has inherent dignity and the right to have that dignity respected and protected

[viii] Article 27 on Equality and freedom from discrimination

[ix] “A person is not criminally responsible for performing in good faith and with reasonable care and skill a surgical operation upon an unborn child for the preservation of the mother’s life if the performance of the operation is reasonable having regard to the patient’s state at the time, and to all the circumstances of the case” Section 240 of the Penal Code, Laws of Kenya.

[x] World Health Organisation. (2003) Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva, World Health Organisation

[xi] World Health Organization. (1992) The prevention and management of unsafe abortion. Report of a Technical Working Group. Geneva, World Health Organization. (WHO/MSM/92.5)

[xii] Source: Mati JKG J. Adolescent reproductive health in the era of HIV/AIDS: Challenges and Opportunities. Obstet. Gynecol. East Cent. Afr. (2005); 18: 1-18


A commentary on population and development in Kenya

The theme of Kenya’s National Leaders’ Conference on Population and Development, November 15-17, 2010 is “managing population to achieve Kenya Vision 2030”. Vision 2030 is the national blueprint for long-term development which aims to transform Kenya into “a newly-industrialising, middle income country providing a high quality of life to all its citizens in a clean and secure environment”. The Vision is anchored on three key pillars: Economic; Social; and Political Governance. This conference comes in the wake of the release of the 2009 Population & Housing Census , in which Kenya’s population is estimated at 39 million, with the population growth rate calculated at 2.5 percent over the period 1999-2009. A lot of concern has been expressed on the revelation that Kenya’s population increased by about a million people annually over that period, and that the population is projected to reach 64 million by 2030.

Kenya’s population growth rate increased steadily from 2.5 percent in 1948, peaking at 3.8 percent in 1979, this being one of the highest growth rates ever recorded. In 1989 the population growth rate began to decline, to 3.4 percent and further down to 2.5 percent in 1999, a level that has been sustained to 2009. The current population growth rate (of 2.5 percent), is still considered to be high, and owing to the past growth rates the population is still youthful with nearly half being aged 18 years or below. This is what has been dubbed demographic momentum– a phenomenon of continued population increase despite reducing fertility rates, which is brought about by waves of large populations of young persons entering reproductive age in successive years. This may in part explain the addition of one million people annually to Kenya’s population, as referred to above.

From the above, it is indeed a disconcerting thought for family planning advocates; to realize that there is a limit as to what birth control per se can do to significantly curtail Kenya’s population increasing trend over several decades! Perhaps the attention should change to finding out how to take advantage of the population momentum to improve our economy, so as to provide a high quality of life to all Kenyans, as envisioned in Vision 2030. Nevertheless, family planning will continue to play a central role in measures taken to improve the economy.

Can Kenya make use of the demographic momentum; make it a source of strength, not a threat? This is exactly what the so-called Asian Tigers did. They were faced with a situation similar to Kenya’s- coming from decades of high fertility that had generated huge population momentum. With better planning and viable economic policies they were able to unleash a healthy and better-educated workforce with fewer children to support and no elderly parents totally dependent on them. It can happen here; with adoption of social, economic, and political policies that allow realisation of the growth potential of our youth across the country, Kenya’s large youthful population can become our boon not our bane. To that end, family planning will remain a key driver of Kenya’s sustainable economic growth now and in the foreseeable future.

The government statement that “critical investment will be required in family planning services, health and other social and economic sectors to improve the welfare of Kenyans” is welcome. However, it needs to be followed by a critical review of the factors that have interfered with the effectiveness of Kenya’s Family Planning Programme; there is need to ask ‘what went wrong? In my view, these factors fall in two broad categories: First, an uncertain environment for effective promotion of birth control measures (political commitment; gender equity; child survival, among others), and second, serious chronic institutional weaknesses that interfere with effectiveness of the family planning programme (coverage of FP services; commodity security; quality of services and care, among others). Hopefully, the Leaders’ Conference may address these issues.

Related link

Kenya’s Rapid Population Increase: Our bane, boon or both

What’s in the way of achieving improved maternal health in Kenya?

By Japheth Mati MD

Introduction

The purpose of this discussion is first and foremost to keep the torch burning on the unacceptably high rates of maternal deaths that persist in Kenya. It reviews where we are with regard to attainment of Millennium Development Goal 5 (MDG5), and examines some of the critical barriers to good progress in improving maternal health in Kenya. The views expressed in the paper are founded on respect for women’s constitutional right to life and health, and therefore their right to quality reproductive health services, which ensure that every pregnancy is wanted; all pregnant women and their infants have access to skilled care; and that every woman is able to reach a functioning health facility to obtain appropriate care in the event of complications. Going through pregnancy and childbirth safely is what every woman should expect. We know that even though complications of pregnancy cannot always be prevented[i], deaths from these complications can be averted. Close to 80 percent of all maternal deaths can be averted if women received timely and appropriate medical care. We have the knowledge of the causes of these deaths and how they can be prevented; we know what works and what does not work. It is now generally accepted that lack of skilled assistance[ii] during childbirth is the most important determinant of maternal mortality. What, in my view, is lacking is the commitment, at all levels, to act; to make the reduction of maternal mortality a high priority; and to reflect this in resource allocations to health services, especially for reproductive health care.

Background

On July 15, 2010 the Honourable Member of Parliament for Laisamis asked the Minister of Public Health and Sanitation (a) to provide the current statistics of maternal deaths in the country (Kenya) and (to) state the steps the Government has taken towards achieving MDG5; and, (b) what achievements the Government has made so far in terms of improving maternal health. I would like to believe this was not just a coincidence, and that it probably had a bearing on the Africa Union Summit that took place in Kampala, Uganda, July 19-27, and UN High-level Plenary Meeting on the Millennium Development Goals (MDG Summit) that was scheduled to take place in New York, September 20-22, 2010. Both meetings, at which Kenya was represented, had the major objective of reviewing progress towards the attainment of MDGs by 2015.

In his reply the Honourable Assistant Minister of Public Health and Sanitation relied heavily on the findings in Kenya’s Demographic and Health Survey (KDHS) of 2008/9 which reported a maternal mortality ratio of 488 per 100,000 live births. The Minister emphasised there were wide regional disparities, and that in some provinces the mortality ratio rises up to 1,000 per 100,000 live births. This translates to approximately 8,000 pregnant Kenyan women dying each year from pregnancy-related complications. Unfortunately, the Minister was not specific regarding the progress the Government has made so far in terms of achieving MDG5 of improving maternal health in Kenya. Fortunately, in this country we have serially compiled data which can be used to show trends in the attainment of the various indicators of improved maternal health. These are briefly reviewed below.

Review of the progress made in improving maternal health in Kenya

The targets for MDG5 (Improve maternal health) are two: 5.A- Reduce by three quarters between 1990 and 2015, the maternal mortality rate; and 5.B- Achieve, by 2015, universal access to reproductive health. The indicators to show attainment of these targets are as follows: 5A- Maternal Mortality Ratio and the proportion of births attended by skilled health personnel; and 5B- Contraceptive prevalence rate; adolescent birth rate; antenatal care coverage; and unmet need for family planning.

Maternal mortality ratio (Target 5.1)

According to the KDHS 2008/9 maternal[iii] deaths represent about 15 percent of all deaths to women age 15-49 in Kenya. The maternal mortality ratio (MMR) during the 10-year period before the 2008/9 survey was estimated at 488 per 100,000 live births, which, though not statistically significant, was higher than the figure of 414 per 100,000 live births, which was reported in the 2003 KDHS. This implies that in the period between the two surveys, the rate of maternal deaths had either stagnated more or less at the same level, or had actually risen. Clearly, these figures do not depict a reducing trend towards the target of 147 maternal deaths per 100,000 live births set for 2015.

Proportion of births attended by skilled health personnel (Target 5.2)

Skilled attendance at delivery is an important variable that influences the birth outcome and the health of the mother and the infant. One of the indicators of skilled attendance is the proportion of births that take place in health facilities. Skilled attendance can also be accessed through domiciliary or community midwifery. Proper medical attention and infection prevention practices during delivery can reduce the risks of obstetric complications that increase the risk of morbidity and mortality for the mother and her baby.

The KDHS 2008/9 showed that only about 43 percent of births in Kenya took place in a health facility, and that the decision on place of delivery was mainly influenced by factors related to ease of access to services- availability of transport to, and charges for services at, the health facility. The same survey also reported that, overall, only 44 percent of births in Kenya were delivered under the supervision of a skilled health provider (nurse, midwife or doctor). Contrary to the prevailing policy, traditional birth attendants (TBAs) assisted up to 28 percent of mothers at delivery (the same percentage as were assisted by nurses and midwives!).

In terms of progress made, the proportion of births assisted by medically trained personnel has increased only marginally, from 42 percent in the 2003 survey to 44 percent in 2008-09, this being far below the projected target of 90% for 2015. The proportion of mothers that received skilled attendance was, as would be expected, lowest in rural areas, and among women of lowest socio-economic status.

Contraceptive prevalence rates (Target 5.3)

Kenya’s Family Planning Programme was established in 1967, a pioneering step in sub-Saharan Africa, which saw the contraceptive prevalence rate (CPR) among married women in Kenya rise from 7 percent in 1979 to 17 percent in 1984, 27 percent in 1989, and 33 percent in 1993. However, during the period 1998-2003, CPR leveled off at 39 percent with wide regional as well as social strata differentials. The KDHS 2008/9 has demonstrated a rising trend, with CPR reaching 46 percent for use of any method and 39 percent for use of modern methods of family planning. While this trend is encouraging, CPR still falls short of the target for 2015 (of 70%), by more than 20 percentage points.

Adolescent birth rate (Target 5.4)

Besides being an important contributor to the overall population growth, adolescent fertility is a determinant of maternal mortality rate, as well. Complications of pregnancy and childbirth are the leading causes of mortality among women between the ages of 15 and 19, this to a large extent resulting from the lack of access to good-quality health care, including abortion services, antenatal care and skilled attendance at delivery. The World Health Organization estimates show that the risk of maternal death is twice as great for women between 15 and 19 years when compared with those between the ages of 20 and 24 years[iv]. In Kenya, the 2008/9 KDHS showed that there had been a reduction in the proportion of teenagers who had begun childbearing (adolescent fertility), down to18 percent from the figure of 23 percent reported in the 2003 KDHS, although wide regional disparities persisted. Further analysis showed that the proportion of teenage mothers had declined from 19 percent in 2003 to 15 percent in 2008-09, while the proportion of those pregnant with their first child had declined from 5 percent in 2003 to 3 percent in 2008-09. These are encouraging results, even though it is difficult to explain the apparent reduction in adolescent fertility at a time when there was a fall in CPR (any method), among women 15-19 years, between the two surveys (from 6.7 percent in 2003 to 5.9 percent in 2008/9). Could this be an impact of the “Nimechill” (“I am abstaining”)[v] campaign?

Antenatal care coverage (Target 5.5)

Antenatal care is a critical intervention for the promotion of maternal and child health. The goal of antenatal care is to maintain and improve the health of the mother and her baby in utero, so that both are brought to labour in a good state of health. Antenatal care aims to diagnose and treat abnormalities of pregnancy soon after their symptoms are apparent; and to screen women for other conditions which may be present, before their symptoms manifest[vi]. Although the majority of pregnant women in Kenya attend an antenatal clinic at least once, usually starting in the second trimester, the KDHS 2008/9 showed that only 47 percent made the minimum four visits, with only 15 percent doing so in the first trimester as recommended by the World Health Organisation.

Unmet need for family planning (Target 5.6)

Unmet need for family planning reflects the desire among Kenyan women (and their partners) to control their fertility. Usually, it is the proportion of married women who either want no more children or wish to delay their next birth by at least two years, and are not using a family planning method. The KDHS 2008/9 showed that there is widespread desire among Kenyans to control the timing and number of births they have (i.e. to plan their families). Almost 54 percent of all currently married women either did not want to have another child or had already been sterilized, while nearly 27 percent would like to wait two years or longer before their next birth. Overall, there have been only minimal changes in fertility preferences in Kenya since 1998, and unmet need for family planning continues to exist in roughly one-quarter of all currently married women. Levels of unmet need decline steadily with increase in the level of education and wealth status.

Impact of improved maternal health on achievement of MDG4

Improvement of maternal health (MDG5) will have an important bearing on the achievement of MDG4- Reduce child mortality, since Infant mortality rate is one of the indicators for its achievement (Indicator 4.2). Perinatal mortality is a good indicator of the state of health in general and the health status of the mother at the time of delivery; as such it is strongly associated with maternal mortality. The 2008/9 KDHS reported a perinatal mortality rate of 37 deaths per 1,000 pregnancies[vii], which was a marginal decline from the 40 deaths per 1,000 pregnancies recorded in the 2003 KDHS. In the same survey neonatal mortality rate[viii] was estimated at 31 deaths per 1,000 live births for the period 2004-2008, 35 for the period 1999-2003 and 25 for the period 1994-1998, which indicate that neonatal mortality rate has not shown significant declining trend in the last 10-15 years.

Summary of the progress

From the above review, it can be concluded that whereas considerable effort has been put to health policy and strategic planning, including the development of reproductive health policy, reproductive health strategy and the road map for accelerating the attainment of the MDGs related to maternal and newborn health in Kenya, these are yet to translate to actual reduction in maternal deaths. In terms of Target 5A, Kenya has not started showing any downward trend in MMR, or an increase in the proportion of births attended by skilled health personnel. However, in the case of Target 5B, if the recent rising trend in CPR can be sustained, there is possibility that the projected figure of 70 percent may just be attained by 2015. Otherwise, a lot more effort is needed to produce any meaningful gains as far as the other indicators are concerned. If the MDGs are to be achieved by 2015, not only must the level of financial investment be increased (see below) but innovative programmes and policies aimed at overall development and economic and social transformation nationwide must be rapidly scaled up. Parliament is in an enviable position to push this effort.

What is the way forward?

Kenya can benefit from lessons learnt and best practices, both at home and abroad, which can jumpstart the process of accelerating progress in improving maternal health in the remaining period to 2015. Four such lessons learnt are summarized below.

1. It is generally agreed that MDGs are inter-related; consequently, achievement of MDG5 is closely tied to the progress made in several other goals, especially Goal 1: Eradicate extreme poverty and hunger; Goal 2: Achieve universal primary education; Goal 3: Promote gender equality and empower women; and Goal 6: Combat HIV/AIDS, malaria and other diseases. There is accumulating evidence that the impacts of the AIDS epidemic are a strong counter force to efforts to lower maternal mortality in sub-Saharan Africa[ix]. High rates of HIV infection and AIDS-related illness among pregnant women will continue to contribute to higher rates of maternal mortality, unless current AIDS prevention and treatment programmes can be sustained and expanded. In many parts of the country food insecurity poses a serious challenge to the achievement of universal access to HIV treatment in Kenya (MDG Target 6b), the indicator (6.5) for which is the proportion of the population with advanced HIV infection with access to antiretroviral drugs (ARVs).

2. To accelerate progress on achievement of health related MDG including MDG5 requires not only a strengthened, but a radically transformed health system[x] Provision of reproductive health services (including maternal health care) cannot be considered in isolation, and generally, these services are strong where the health sector is strong, and vice versa. Service provision is one of the essential functions of a health system, and effective service provision can only take place where there is adequate infrastructure and human and material resources, which in turn require adequate financial allocation and sound management. In 2001, African countries pledged at Abuja to increase allocation to the health sector up to 15% of government expenditure. This was once again repeated in the African Union Summit in Kampala, 19 to 27 July 2010, where African leaders (including Kenyan), pledged to invest more in community health workers and re-committed themselves (yet again) to meeting the Abuja target. In the meantime, national budgetary allocations to health remain far below this target. For example, for the fiscal year 2010-11 Kenya allocated just about 5.5 percent of the total Government expenditure to the ministries of Medical Services and Public Health and Sanitation, a level of investment that clearly does not demonstrate high prioritization among the national priorities, of health care including prevention and reduction of maternal deaths.

3. In order to accelerate progress on achieving MDG5, emphasis ought to be on sustainable high impact interventions, which should incorporate strengthening community partnerships and initiatives that aim to empower women. These high impact interventions include access to skilled attendance at delivery; emergency obstetric and post abortion care; functional referral systems; and a functional interface between the community and health facilities. Countrywide expansion of health outlets staffed by adequately trained health service providers is critical to effective implementation of these interventions.

4. To have an impact on MDG indicators, interventions must target populations with the most need. As reviewed above, most reproductive health indicators portray big disparities between the poor and the better off with respect to access to health care services and health status. Generally, the poor lack access to health care in terms of availability, affordability, and acceptability. Hence, for interventions to achieve the intended impact they must target populations with the most need, in most cases these include urban and rural poor, the “hard to reach” groups and people with disabilities. Others ‘hard to reach’ are adolescents and youth, especially those out of school, migrant workers in industries and farms, internally displaced persons and refugees. These ‘marginalised’ sections of the population are frequently under-served by health services, in a large part because of poverty, as well as difficulties in accessing static health institutions, but most importantly, because their peculiar health needs are not adequately addressed in the planning of health services. Hopefully this may change in the near future under devolved county governments?

Conclusions

From the evidence reviwed above it is obvious that a lot remains to be done if Kenya is to get anywhere close to attaining the targets set for MDG5. There are areas where some progress has been observed, notably the recent increase in CPR, which, if sustained, may just make it close to target, particularly if the gaps in unmet need for family planning are addressed. Also, there are encouraging trends with regard to adolescent birth rate and antenatal care coverage which can be built upon. Otherwise the progress has been inadequate in almost all other indicators.  As stated above, we have the knowledge of the causes of maternal deaths, and how they can be prevented. We know what interventions work and which do not; what appears to be the main barrier is the lack of commitment to act; to prioritize reduction of maternal mortality, and to reflect this in resource allocations to the health sector, and to maternal health services, in particular. From available evidence it is obvious that MDG5 cannot be achieved without emphasis on equitable expansion of access to basic services for all. Finally, let me end with remarks oft-attributed to Professor Mahmoud Fathalla of Egypt[xi], “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their [women’s] lives are worth saving.” When will Kenyan society decide?

Professor Japheth Mati is a former Chairman of the Department of Obstetrics and Gynaecology, University of Nairobi, Kenya. This article was first published on blog.marsgroupkenya.org/?tag=mdg-5


 

[i] In at least 15% of pregnant women serious obstetric complication can occur that usually cannot be predicted or prevented in advance.

[ii] A skilled attendant as defined by the WHO, ICM and FIGO is “a health professional – such as a midwife, doctor, clinical officer or nurse- who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification , management and referral of complications in women and newborns” (The Critical Role of the Skilled Attendant: a joint statement by WHO, ICM and FIGO. Geneva, World Health Organisation, 2004)

[iii] A maternal death was defined as any death that occurred during pregnancy or childbirth or that occurred within two months of the birth or termination of a pregnancy, even if the death was due to non-maternal causes.

[iv] Locoh, Therese. (2000). “Early Marriage And Motherhood In Sub-Saharan Africa.” WIN News.’.’ Retrieved July 7, 2006. en.wikipedia.org/wiki/Teenage_pregnancy

[vi]Pregnant women should routinely receive information on signs of pregnancy complications and be checked for them at all antenatal care visits; this should include testing for HIV. In addition, they should receive prophylactic treatment against anaemia, and malaria where this is endemic, and be encouraged to make plans for the impending birth, including where it will take place and how to get there in case of emergency.

[vii] Perinatal mortality was defined as the sum of the number of stillbirths and early (first week) neonatal deaths divided by the number of pregnancies of seven or more months’ duration, expressed per 1000.

[viii] The probability of dying within the first month of life, which includes deaths in the first week of life (newborn deaths)

[ix] www.thelancet.com. Published on line April 12, 2010 DOI:10.1016/S0140-6736(10)60518-1

[x] According to the World Health Organisation a health system comprises all structures, institutions and resources that are devoted to producing actions whose primary intent is to improve health.

[xi] Past President of International Federation of Gynaecology and Obstetrics Societies (FIGO)

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