Tag Archives: maternal and child health

How sad it is that inventors cannot control the eventual application of their work: The flipside of innovations in diagnostic and therapeutic technologies in medicine. Japheth Mati MD

It is fair to conclude that the technological revolution of the twentieth century was unprecedented in human history. Medicine was one area of tremendous progress, especially considering that at the dawn of that century Surgery, in particular, was a dicey procedure to undergo. It was before the arrival of safe anaesthesia, blood transfusion, antibiotics, and other life support paraphernalia we often take for granted. Admittedly, a lot of today’s surgical procedures predate the 20th century, but they were far from being safe. Take Caesarean section, for example, around 1860s the mortality rate associated with the operation in Great Britain and Ireland, was 85%[i]. Major strides in mortality reduction had to await advances, especially in three key areas: Anesthesia, Blood transfusion and Antibiotics.

Anesthesia: In the 20th century, the safety and efficacy of general anaesthesia was improved by the routine use of endotracheal intubation, advanced airway management techniques, and better anaesthetic agents that made “bite the bullet” become obsolete!  Blood transfusion: The discoveries by Karl Landsteiner, of human blood groups (1901) and the Rhesus factor (1937), markedly improved the safety of blood transfusion. Antibiotics: Antibiotics are a creation of the 20th century, starting with the sulpha drug Prontosil in1935; Penicillin[ii] (1942), Streptomycin (1943); Tetracycline (1955); Nystatin (1957); to be followed by others, including the semi-synthetic antibiotic Amoxicillin (1981).

As I marvelled over these and other 20th century great medical scientific and technological feats, one question kept nagging me: does the way we mainly use these inventions today conform to the original purpose of their creators?

Thinking slightly outside of medicine, one can for example compare the opposites in the employment of nuclear technology: on the one hand, its value as a source of efficient energy to drive industry, and on the other its use as a weapon of  mass destruction. Though not to the same degree of departure, in medicine, a considerable number of today’s most celebrated technologies are used in manner that is at variance with the inventor’s original intentions, to the extent that some inventors have had occasion to publicly express regret over the ‘misuse’ of their work.

It’s the intention in this post to review briefly selected diagnostic and therapeutic innovations that have exerted great impact on medicine in general, and the practice of obstetrics and gynaecology in particular, especially beginning the second half of the 20th century.

The review covers the following diagnostic and therapeutic techniques: amniocentesis and amniotic fluid sampling, prenatal cytological sex determination, prenatal blood DNA sex determination, obstetric ultrasound, and in-vitro fertilisation technique. Each one of the above innovations has performed beyond expectation, finding greater utilisation for purposes far removed from the original intention at the time of their discovery. These “other” uses are examples of what can be referred to as ‘the flipside of scientific and technological innovations in medicine’. In sympathy with their cause, we are left to wonder: “If only inventors were endowed with wisdom to foresee the ends to which their creation might end up being applied!”

 Amniocentesis

Amniocentesis is the process of removing a sample of amniotic fluid – the medium in which the fetus floats in the mother’s uterus, to be analysed for markers of certain disorders of the fetus. This procedure is credited to the work of Douglas Bevis, a British obstetrician and gynaecologist at St. Mary’s Hospital in Manchester in early 1950s. Later, following the discovery of ultrasound (see below) it became possible to undertake ultrasound-guided amniocentesis with greater accuracy and safety.

Amniocentesis ultrasound guided image

Ultrasound guided amniocentesis

Amniocentesis and amniotic fluid sampling (AFS) permits the monitoring of fetal wellbeing in utero, especially in the management of Rh-isoimmunisation. It is frequently used in the estimation of fetal lung maturation, and in the diagnosis of genetic disorders such as Down’s syndrome (mongolism) and sex-linked diseases such as haemophilia.

In 1949 Canadians Murray Barr and Ewart Bartram had discovered sex chromatin (a mass of chromosomes, also called “Barr Body”), which is found only in female cells. Thus, finding the sex chromatin in fetal cells obtained through AFS permitted identification of a female child. Later through tissue culture techniques it was possible to identify the actual male and female sex chromosomes in cells, thereby improving accuracy of sex determination using cytogenetic technique, which remains the gold standard. There are now over 500 hereditary diseases that can be diagnosed through amniocentesis and other diagnostic techniques[i].

The technique of amniocentesis reigned supreme till the tail-end of the 20th century when in 1997 Dennis Lo and colleagues (both in Oxford UK and Hong Kong, China) published their seminal paper[ii] reporting the presence of fetal DNA in maternal blood, thereby opening the door to a new non-invasive technique that avoided the risk (albeit very small) of abortion following amniocentesis. The new DNA test, which employs the more advanced Polymerase Chain Reaction (PCR), has the added advantage of being performed at an earlier gestational age- as early as 7 weeks, much earlier than was possible with ultrasound scan (see below) which could only demonstrate male fetus at 11 weeks earliest, and not so reliably. An important downside of DNA PCR test is the cost involved.

The potential to determine fetal sex has opened the door to abuse of these tests. The ‘flipside’ of prenatal sex diagnosis has been its utilization in selective abortion of female fetuses, to the extent sometimes, of posing demographic imbalance as has been feared for India[iii] and China[iv]. In this regard the test changes from enhancing the wellbeing of the fetus to selecting it for destruction. A complete turnaround!

Ultrasound scanning

Prof Ian Donald[v] (1910-1987), the Regius Professor of Midwifery at the University of Glasgow (1954 -1976), and a tough Scot who endured three open-heart valve-replacement operations, is the celebrated Father of Medical Ultrasound, a technology he pioneered beginning the late 1950s. His first major publication on the subject appeared in the Lancet in 1958, which contained the first ultrasound images of the fetus ever published[vi].

The potential to reveal information on the growing fetus in the womb was soon realised and the use of ultrasound spread quickly, improving the safety of pregnancy and childbirth, and allowing for the much more effective detection and treatment of fetal abnormalities. Since the 1970s ultrasound scanning has become a routine part of antenatal care. And as the science of ultrasound developed, so did its applications. Ultrasound scanning is now used in numerous other areas of medicine, with recent advances in technology enabling three-dimensional images to be produced.

Ian Donald hommedia

Professor Ian Donald

A less discussed dimension of Ian Donald’s work is what fundamentally may have driven him to develop the technology. In this regard, he seems to have considered obstetric ultrasound to be more than simply a means to visualise the fetus in utero; instead, he saw the technology as providing a chance to ‘individualise’ the fetus. The technology made it possible for the fetus to be recognised, or at least spoken of as, an individual, a reality. This view comes out clearly from the description he uses in the following 1978 presentation to a lay audience[i]:

Here’s the baby see how he jumps … This baby is about a 12 week pregnancy … She [the mother] certainly cannot feel these movements but there is no doubt about the reality, … now you see it move its hand up to its face you see his head is up here and his chest is down here then he throws his legs out and his arms … You see his hands come up like that. And you see his face here, the back of his head … It is rather like a child on a trampoline, tremendous strength, energy and vitality.)

Perhaps because of these experiences, Ian Donald came to hold quite strong views against abortion, being a lead campaigner against the 1967 Abortion Act in the UK. He is known to have employed the ultrasound imagery as a powerful persuasive resource in urging women to continue with their pregnancies. In his view the only indication for abortion was a very grossly deformed fetus; no consideration in cases of mild or moderate handicap. Indeed Ian Donald even went to the length of attempting to save a fetus in an ectopic pregnancy – a heroic surgical endeavour which failed miserably, but which nevertheless, justified an audience with Pope John Paul II, an occasion he described as ‘the crowning event of my life’[ii].

Personal idiosyncrasies apart, there is absolutely no argument that Ian Donald’s work has contributed immensely to better outcomes in many medical disciplines, away from his own field of obstetrics and gynaecology. However, in a rather ironical way, ultrasound scan happens to be the most reliable way of diagnosing not only early pregnancy, but also of ensuring the uterus has been completely evacuated, following both spontaneous abortion and induced abortion (especially medical termination of pregnancy).

By the 1970’s, Ian Donald had become aware of the truth, that the ends to which technology is put cannot be determined by its originators. He somewhat despairingly wrote, “My own personal fears are that my researches into early intrauterine life may yet be misused towards its more accurate destruction”[iii]. Indeed, Ian Donald had come face to face with the flipside of his own scientific and technological innovation in medicine!

 In vitro fertilization

Patrick Christopher Steptoe (1913 – 1988), a British obstetrician and gynaecologist, along with biologist/ physiologist Robert Edwards, were the pioneers of the technique of in vitro fertilization for infertility treatment. Louise Joy Brown, their first ‘test-tube baby’, was born on 25 July 1978, the product of great perseverance- it took them 10 years before they had their first successful birth. Edwards was awarded the 2010 Nobel Prize in Physiology or Medicine for this work, however because the Prize is not awarded posthumously, Steptoe was not eligible for consideration.

Since Louise Brown, there have been over 4 million babies worldwide conceived through IVF. Despite a steady stream of ethical and moral questions arising from IVF, to date, the lives of many women and couples across the globe have been enriched by a child conceived through one or other of the various modifications of the original IVF technique introduced by Steptoe and Edwards. This reproductive technology has made and continues to make tremendous advancements in basic reproductive biology and embryology. It has enabled us to understand the human reproductive processes and especially fetal development, in a way that has never been possible in the past[iv].

At the same time, the world of IVF almost everywhere has become a very competitive market-place, resulting in many treatment centres going to great lengths to ensure a pregnancy is achieved. The temptation is high to transfer large numbers of embryos to the uterus, which results in pregnancies of high multiples, some of which may be lost through spontaneous abortion, or subjected to ‘fetal reduction’ procedures (euphemism for abortion).

The technique of IVF has become an essential source of ‘spare embryo’ for stem-cell research, which gives hope to many people dying from today’s incurable diseases. But, still, this is far beyond Patrick Steptoe’s imagined application of their technique.


[i] I. Donald (undated but after 1978) ‘Predicting ovulation’, unpublished lecture, tape-recording in BMUS Archive).

[ii] Malcolm Nicolson, Ian Donald – Diagnostician and Moralist http://www.rcpe.ac.uk/library/read/people/donald/donald.php

[iii] I. Donald (1972) ‘Naught for your comfort’, Journal of the Irish Medical Association, 65, 279-89.


[ii] Lo YMD, Corbetta N, Chamberlain PF, Rai V, Sargent IL, Redman CW, et al. Presence of fetal DNA in maternal plasma and serum.Lancet1997;350:485-7.

[iv] en.wikipedia.org/wiki/Abortion_in_China

[v] Prof Ian Donald was my supervisor at the Queen Mother’s Hospital in Glasgow in 1969.

[vi] I. Donald, J. MacVicar, T. G. Brown (1958) ‘Investigation of abdominal masses by pulsed ultrasound’, The Lancet, 1, 1188-95.


[ii] Fleming, Florey, and Chain shared the 1945 Nobel Prize for medicine for their work on penicillin.

 

 

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What are the prospects of achieving ‘skilled attendance’ for all births in Africa?

Ensuring that every birth is attended by skilled health personnel by 2015 is what is expected of all countries if they are to achieve Millennium Development Goal (MDG) 5. But how feasible is this for most African countries? According to WHO, skilled attendance at birth remains drastically low in sub-Saharan Africa; only about 42% of the childbirths are assisted by a skilled attendant in the Africa region, some countries registering as low as 5%[i]. This is against the target of 80% of births being assisted by a skilled attendant by 2015 if the goal of reducing maternal mortality rate by three quarters (between 1990 and 2015), is to be achieved.

Skilled attendance at the time of delivery is an important variable that influences the birth outcome and the health of the mother and her infant. Skilled attendance can be accessed at health facilities or through domiciliary or community midwifery. At both levels appropriate medical attention can reduce the risks of obstetric complications that increase the risk of morbidity and mortality for the mother and her baby.

Figure 1: Maternal mortality ratio by country, 2008

Source: UNICEF, Progress for Children: A Report Card on Maternal Mortality, 2008

Who is a skilled attendant?

A skilled attendant is defined as ‘an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage uncomplicated pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns’[ii] This definition implies that the term ‘skilled attendant’ should refer exclusively to people with midwifery skills; people who are capable of managing normal deliveries and to diagnose, manage or refer complications. Midwifery skills are a defined set of cognitive and practical skills that enable the individual to provide basic health care services throughout the continuum of pregnancy, childbirth and postnatal period and also to provide first aid for obstetric complications and emergencies, including life-saving measures when needed. In 2006, a consensus was reached on what are essential competencies of the skilled attendant in the Africa Region of WHO[iii]. It should be noted that the definition of skilled attendant does not include Traditional Birth Attendants (TBA), trained or untrained.

Until the mid-1990s, the term “trained attendant” was commonly used in national statistics, which tended to lump both professionals and non-professionals (e.g. trained TBAs) together, as long as they had received some “training”. However, training does not necessarily guarantee the acquisition of the needed skills. From 1996 onwards, the word “skilled” has been employed to recognise competent use of knowledge[iv].

Effectiveness of ‘skilled attendants’ depends not just on their knowledge and competency, but also on the environment in which they function. Skilled attendance should therefore not be considered purely in terms of skills of the service providers but also the environment in which they work- physical space, equipment, supplies, drugs and transport for referral of obstetric emergencies. The political, policy and socio-cultural environment can also enable or prevent effectiveness of ‘skilled attendance’[v].

Does skilled attendance at birth lower maternal deaths?

There is no direct scientific evidence to show that skilled attendance lowers maternal mortality; however, comprehensive analyses of the factors behind the successful reduction of maternal deaths in countries such as Malaysia, Sri Lanka, Thailand and Honduras clearly indicate that a central feature in all of them was the presence of a skilled attendant at delivery. The experience from those countries is what is currently guiding maternal and neonatal health policy and programming; especially what was done to ensure high availability of skilled birth attendants, as well as the kind of environment that ensured their effectiveness[vi].

Two important lessons from these experiences are (a) achieving skilled attendance for all requires attention to the political, social and legal actions that address women’s human rights and equity, this being especially important if skilled attendance is to impact on the health outcomes of poor people; and (b) development of skilled attendants must go side by side with the creation of an enabling environment, including putting in place resources that are needed for emergency obstetric care and responsive referral systems.

Will skilled attendance result in reduced maternal deaths in Africa?

According to WHO ensuring skilled care at every birth can reduce the global burden of 536 000 maternal deaths, 3 million stillbirths and 3.7 million newborn deaths each year[vii]. Half of the 75 countries in which 97% of all maternal deaths worldwide occur are located in the sub-Saharan Africa. Within Africa, the eastern region has the lowest proportions of skilled attendance at birth (about 34%). In addition, enormous disparities exist within countries: poor women in rural and urban areas are far less likely than their wealthier counterparts to receive skilled care during childbirth. For example, the 2008-9 Kenya Demographic and Health Survey showed that women in the highest wealth quintile were nearly four times more likely to have been attended by a doctor or nurse/midwife, at their last delivery[viii].

The countries of sub-Saharan Africa are faced by numerous challenges in their effort to ensure skilled attendance at birth. These can be coalesced into the following two: developing the needed human resources for health, and creating an enabling environment for effective skilled attendance.

  • · Development of human resources for health- skilled attendants

Human resource for health is a key component of the health care system, which requires efficient mechanisms for recruitment, deployment, retention and supervision of the workforce, as well as ensuring accountability of service providers.

Five years ago, WHO estimated that to extend coverage of maternal and newborn care in the following 10 years (to 2015), 75 countries[ix] needed at least 334,000 additional midwives (or equivalent skilled attendants), as well as additional training for 140,000 existing professionals providing first-level care and of 27,000 doctors who are not currently qualified to provide back-up care[x]. According to these estimates the current health workforce in some of the most affected countries in sub-Saharan Africa would need to be scaled up by as much as 140% for the country to attain the Millennium Development Goals.

Health worker shortage in sub-Saharan Africa derives from many causes, including inadequate planning and investment for pre-service training, inadequate deployment, loss of trained personnel due to poor work conditions, internal and external movement, career changes among health workers, premature retirement, morbidity and premature mortality.  In some countries trained health workers remain unemployed for long periods because of inadequate budgetary allocations to ministries of health.

A recent study[xi] focused on 12 African countries[xii] has found alarming workforce shortages in all the countries, with the current rate of increase in health workforce density being much slower than what WHO considers necessary for achievement of desired levels of coverage of key health interventions[xiii] (a minimum density of 2.28 health workers per 1000 population). The study has suggested a variety of complementary, shorter-term responses if countries were to aspire to achieving international goals, among them, adoption of aggressive retention policies, e.g. improving the remuneration and working conditions of health workers; addressing current unemployment of trained professionals; and adoption of task-shifting[xiv] practices where necessary. However, all these should be viewed as stop-gap measures while countries further developed/expanded local pre-service training opportunities.

  • · Creating an enabling environment for skilled attendance

An enabling environment can be viewed more broadly to include the political, policy and socio-cultural context in which skilled attendance must operate (structure), as well as the more proximate factors such as pre- and in-service training, supervision and deployment, and health systems financing (inputs). Within the political and policy environment are considerations such as legislation/regulations which govern scope of professional activities, but more important is the level of government commitment and stability which are crucial to smooth functioning of health services. The social/cultural environment will include cultural factors which may influence acceptability and effectiveness of service providers and the services they provide; for example, Muslim societies may object to male skilled attendants (male doctors and nurses), examining women. Socio-economic status, gender and women empowerment are other important factors with strong bearing on the performance and effectiveness of skilled attendants. Finally, effectiveness of the service providers is enhanced by responsible management systems, functional infrastructure, equipment/ supplies, management and health information systems, communication and transport mechanisms. Above all, availability of the above depends on sound planning and financing of the health sector.

Conclusion

The countries of sub-Saharan Africa are faced by numerous challenges in their effort to ensure skilled attendance at birth, particularly the serious human resource shortages and weak health systems. Recent assessments of progress towards MDG 5 suggest that most sub-Saharan African countries have made only modest progress, with at least 8 countries[xv] demonstrating negative change[xvi]. These findings cast a lot of doubt as to whether many sub-Saharan African countries will achieve skilled attendance for all births in the remaining period to 2015. Factors such as limited funding for health services, and inequities in reaching all pregnant women irrespective of wealth status, are some of the major reasons for inadequate progress.

There is data to show that the current number of health workers in most countries is insufficient to meet population health needs[xvii]. Addressing this challenge will require expansion of pre-service training of nurses, midwives and doctors, with a view to increase health worker densities in order to meet the target level of 2.28 physicians, nurses and midwives per 1000 population. Considering that pre-service training is clearly a longer-term solution, a variety of complementary, shorter-term responses, (as discussed above), will need to be considered.

As a way forward African governments need to create health policies and necessary legislation in support of delivery of essential maternal health interventions. Such policies are important building blocks of a well functioning health system- including financing of health services, and ensuring equitable access to skilled attendants for all pregnant women. Despite the fact that total official development assistance (ODA) to maternal, newborn and child health programmes increased by 64%, from US$2.1 billion in 2003 to almost US$3.5 billion in 2006[xviii], expenditures on health in most African countries remain far less than the threshold below which it is difficult to ensure access to basic services (US$45 per person). As a result, out-of-pocket health expenditures in sub-Saharan African countries range from 6% in Namibia to 62% in Chad[xix]. Faced with heavy out-of-pocket expenses, many families either avoid seeking care altogether, or risk impoverishment when they do so. Under such scenario ill-health contributes to, and perpetuates, poverty in sub-Saharan Africa[xx].

Related links:


[i] WHO/AFRO. Consensus on Essential Competencies of Skilled attendant in the African Region Report of regional consultation, Brazzaville, 27th February-1st March 2006 WHO Africa Regional Office, 2006

[ii] WHO/UNFPA/UNICEF/World Bank Statement (1999). Reduction of maternal mortality: a joint statement. Geneva: WHO.

[iii] WHO/AFRO. Consensus on Essential Competencies of Skilled attendant in the African Region Report of regional consultation, Brazzaville, 27th February-1st March 2006 WHO Africa Regional Office, 2006

[iv] Starrs A (1997). The Safe Motherhood Action Agenda: Priorities for the Next Decade. New

York: Inter-Agency Group for Safe Motherhood and Family Care International.

[v] Wendy J Graham, Jacqueline S Bell and Colin HW Bullough Can skilled attendance at delivery reduce maternal mortality in developing countries ? Studies in Health Services Organisation & Policy, 17, 2001 pp97-129

[vi] Wim Van Lerberghe and Vincent De Brouwere Reducing maternal mortality in a context of poverty Studies in Health Services Organisation and Policy, 17, 2001

[viii] Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health

Survey 2008-09. Calverton, Maryland: KNBS and ICF Macro.

[ix] Half of these countries are in sub-Saharan Africa.

[x] WHO. 2005. World Health Report 2005. Geneva: WHO.

[xii] Central African Republic, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Kenya, Liberia, Madagascar, Rwanda, Sierra Leone, Uganda, the United Republic of Tanzania and Zambia

[xiii] World Health Organization, The world health report 2006.

[xiv] The shifting of certain tasks from professional that require longer-term training to those requiring less intensive training which may be more affordable, for example permitting midwives to administer perenteral drugs, to manually remove the placenta, to remove retained products of conception, and to resuscitate newborns.

[xv] Chad, Cote d’Ivoire, Kenya, Lesotho, Malawi, Nigeria, Senegal.

[xvi] Countdown to 2015, 2008 Report Tracking Progress in Maternal, Newborn & Child Survival New York, United Nations Children’s Fund, 2008.

[xviii] Note: The total amount of aid for maternal, newborn and child health-related activities represents just 3% of total ODA

[xix] Adam Leive, Ke Xu. Coping with out-of-pocket health payments: empirical evidence from 15 African countries. Bulletin of the World Health Organization Volume 86, Number 11, November 2008, 849-856

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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