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We salute the Initiative by Kenya’s First Lady towards improved maternal and child health outcomes in Kenya. Japheth Mati MD

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The “Beyond Zero Campaign” launched on 24 January 2014 under the stewardship of Kenya’s First Lady, Margaret Kenyatta, seeks to improve maternal and child health outcomes in Kenya. Her enthusiasm and commitment to the success of the Initiative, including the pledge to raise funds for it through participation in the forthcoming London Marathon, is completely unprecedented in Kenya’s history. We salute this initiative by the First Lady of Kenya.

The Strategic Framework for the engagement of the First Lady in HIV control and promotion of maternal, newborn and child health in Kenya, which was unveiled on World AIDS Day 2013 focuses on the following five key areas: (i) Accelerating HIV programmes, (ii) Influencing investment in high impact activities to promote maternal and child health and HIV control, (iii) Mobilizing men as clients, partners and agents of change, (iv) Involving communities to address barriers to accessing HIV, maternal and child health services and (v) Providing leadership, accountability and recognition to accelerate the attainment of HIV, maternal and child health targets.

In an earlier post under the title “What’s in the way of achieving improved maternal health in Kenya” it was observed that there is sufficient knowledge of the causes of maternal deaths, and how they can be prevented. It is known which 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.

The health budgets in most African countries, Kenya included, do not demonstrate that health is rated as a high priority among other national needs. This is often the result of failure by governments to recognise the importance of health in development, so that expenditure on health is not perceived as a critical economic investment alongside spending on education, agriculture or industries. Yet, health is a critical resource, without which investment in all other sectors would go to waste. Further, poor health creates critical barriers to economic production.

Within the health sector, lack of equity in planning and distribution of resources for health results in inequitable access to health care services: Physical access (e.g. distance to the nearest health facility); Affordability (when fees charged for services are unaffordable); Acceptability (where people lack confidence in the services provided and decide not to utilise them). People who are denied access through the above barriers often turn to out-of-pocket expenditures on their health care. Ironically, evidence reveals that the poor bear the heaviest burden of out-of-pocket health expenditures, irrespective of where they seek health care.

From available evidence it is obvious that local and international health goals cannot be achieved without emphasis on equitable expansion of access to basic services for all. Policy makers and planners must begin to accept the existence of, and to act on, the vast inter- and intra-regional health disparities in Kenya. It was the expectation that devolution would create opportunities for better prioritization of needs at the grassroots, and, through better knowledge of community needs, formulate more focused interventions. 

Engaging with communities as envisaged in key area (iv) of the proposed Strategic Framework is indeed a critical focus, considering that proximity to health facilities and services, is no guarantee they will be utilised. For example, there are several areas in Kenya, both rural and urban, where communities will prefer traditional medicine as their first line of health care before modern drugs are sought. There is evidence to show that within certain communities in Kenya, majority of pregnant women will have consulted a mganga (traditional healer) who administered to them herbal preparations and potions to ward off evil spirits, before making their first antenatal clinic visit[1]. These women perceive antenatal care services available at health facilities- dispensaries and health centres, and those provided by TBAs and herbalists, to be complementary, and generally, they seek both types of care interchangeably. This may have negative effects, for example, due to delays in early diagnosis and management of antenatal complications, resulting in poor pregnancy outcomes.

https://africahealth.wordpress.com/2010/10/27/what%E2%80%99s-in-the-way-of-achieving-improved-maternal-health-in-kenya/

Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003 http://www.familycareintl.org/UserFiles/File/SCI%20Kenya%20qualitative%20report.pdf


[1]Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003 http://www.familycareintl.org/UserFiles/File/SCI%20Kenya%20qualitative%20report.pdf

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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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