Tag Archives: maternal deaths

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


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.


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

Access to legalised abortion is a key ingredient to improvement of maternal health in Africa

It is worrying to note that while most advocates of improved maternal health are greatly disturbed by the WHO report that rates of induced abortion worldwide remain high worldwide, and especially the finding that in the Africa region almost all (97%) abortions are unsafe, there are others who belittle the significance of these findings, stating: “Ireland, where abortion is banned, has one of the world’s best maternal health records. Legalised abortion does nothing to improve medical care.”

Whilst it may be possible that Ireland has one of the world’s best maternal health records, it is unrealistic to make that the yardstick, and to conclude that African countries, for example, should stick to their strict anti-abortion laws, and by some grace the high rates of unsafe abortion and maternal deaths will reduce. There is a world of difference between the circumstances under which an average Irish woman lives and that of the average African woman. The Irish woman is today enjoying a living standard above the average woman in the British Isles, and can with ease slip across the channel to obtain safe abortion if need be. All these benefits are beyond the reach of the African woman. The truth of the matter is that the high mortality is concentrated among the poor and marginalised. The wealthy women in Africa have easy access to very safe abortion in their countries or abroad, as necessary. To the rich African woman as it is for the Irish, perhaps “legalised abortion does nothing to improve medical care”; to the average woman in Africa, it can be a matter of life and death. Restrictive abortion laws do not translate to lower abortion rates, but unsafe abortion can be effectively minimized by ensuring women have easy access to contraceptive services, backed up by a positive legal framework that facilitates safe abortion.

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.


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.

Addressing the barriers that impede timely achievement of MDG5 targets is urgently needed in Kenya

In order to accelerate progress towards the timely achievement of MDG5 governments must take urgent action to address key obstacles to the attainment of improved maternal health, especially among populations with the most unmet need.

Women have 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. Up to 75 percent of all maternal deaths can be averted if women received timely and appropriate medical care. We know the causes of these deaths and how they can be prevented.

Kenya has already put considerable effort to policy development and strategic planning with the aim of accelerating the attainment of health related MDGs, however, these are yet to translate to actual reduction in maternal deaths. Despite the recent observation of an upward trend in contraceptive prevalence rate (CPR), which raises hope that if it can be sustained, there may be possibility of attaining Target 5B of MDG5 by 2015, the country has neither registered any downward trend in maternal mortality ratio (MMR), neither is there any convincing evidence of an increase in the proportion of births attended by skilled health personnel (Target 5A).

However, successive surveys and other evidence show several serious obstacles remain which interfere with effectiveness of reproductive health interventions, and which must be addressed as a matter of urgency. These include the serious disparities which persist in reproductive health outcomes, especially in relation to area of residence and socio-economic status. Reproductive health indicators deteriorate as the socio-economic status declines and vice versa; so is the case as the distance from the main urban centres increases. Generally, the poor lack access to health care in terms of availability and affordability.

A key barrier is the weakness in health system[i]: health infrastructure, trained human resources, and efficient operating systems. Provision of reproductive health services cannot be considered in isolation, and generally, these services are strong where the health sector is strong, and vice versa. The leading cause of the weak health system is inadequate funding of the health sector. Effective service provision requires an adequate infrastructure, and human and material resources, and ultimately, adequate financial allocation. This is why it is disconcerting that Kenya Government’s allocation to the health sector continues to lag way below what was promised at Abuja in 2001 and in Kampala in 2010. 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 does not demonstrate high prioritization of maternal death prevention and reduction among the national priorities.

The MDGs are inter-related, so that achievement of MDG5 is closely tied to the progress made in several other goals, especially eradication of extreme poverty and hunger (Goal 1), universal primary education (Goal 2), promotion of gender equality and women empowerment (Goal 3), and combating HIV/AIDS, malaria and other diseases (Goal 6). Clearly, if the MDGs are to be achieved by 2015, not only must the level of financial investment be increased, there is need for a rapid scale up of more innovative programmes and policies which aim at overall development and economic and social transformation, nationwide.

It is thus imperative to implement a deliberate effort to target populations with the most need; these in most cases include urban and rural poor, the “hard to reach” groups and people with disabilities. In Kenya, most reproductive health indicators clearly portray big disparities between the poor and the ‘hard to reach’ on the one hand, and on the other, the urban better offs. Health planners must ensure that health needs peculiar to the ‘marginalised’ are factored in, and adequately addressed, in the planning of health services.

Finally, the Constitution of Kenya (2010) provides opportunities for enhancing health in general, including reproductive health and rights of Kenyan women. Article 43 (1)(a) states: Every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care. In addition, Article 27 guarantees the right to equality and freedom from discrimination, which encompasses within itself the right of the poor and marginalised persons to adequate and quality health care.

[i] 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.

Postpartum Haemorrhage, that Crimson Barrier to Achieving MDG5

By Japheth Mati


Postpartum haemorrhage (PPH), antepartum haemorrhage (APH), and bleeding following an incomplete abortion are collectively referred to as obstetric haemorrhage. PPH is the single most important cause of maternal deaths worldwide.

The definition of PPH is somewhat arbitrary and problematic[i]. Postpartum haemorrhage is defined as blood loss of more than 500 mL following vaginal delivery or more than 1000 mL following delivery by caesarean section. A loss of these amounts within 24 hours of delivery is termed early or primary PPH, whereas such losses are termed late or secondary PPH if they occur 24 hours after delivery. Estimates of blood loss at delivery are subjective and generally inaccurate. Studies have suggested that caregivers consistently underestimate actual blood loss. Another consideration is the differing capacities of individual parturient to cope with blood loss. A healthy woman has a 30-50% increase in blood volume in a normal singleton pregnancy and is much more tolerant of blood loss than a woman who has pre-existing anemia, or other medical complications. The diagnosis of PPH is usually reserved for pregnancies that have progressed beyond 20 weeks’ gestation, even though bleeding related to spontaneous abortion may have causes and management in common with those for PPH.

Magnitude of the problem

United Nations estimates show that more than 500,000 women die each year worldwide due to complications arising from pregnancy and childbirth, which has been expressed as one woman dying every 7 minutes[ii]. In 2008 almost 99 per cent of all maternal deaths occurred in developing regions, with sub-Saharan Africa accounting for 57 per cent of all deaths. According to a UN report[iii] on “Trends in maternal mortality”, the number of maternal deaths globally had decreased by 34 per cent from an estimated 546 000 in 1990 to 358 000 in 2008. However, in sub-Saharan Africa, the decrease in maternal mortality was below average, being 26 per cent. The report concluded that although that progress was notable, the annual rate of decline (i.e. 2.3 per cent) was still less than half of what is needed (i.e. 5.5 per cent) to achieve the MDG 5 target of reducing the maternal mortality ratio by 75 per cent between 1990 and 2015.

In the sub-Saharan Africa, the main direct causes of maternal death are bleeding (34%), infection (10%), pre-eclampsia/ eclampsia (9%) and obstructed labour (4%). In Kenya, a national review of safe motherhood[iv] conducted in 1997, marking the tenth anniversary of the Safe Motherhood Conference held in Nairobi in October 1987, showed that haemorrhage, sepsis, pre-eclampsia/ eclampsia, ruptured uterus and complications of induced abortion were the leading direct causes of maternal mortality. Clearly, prevention and making accessible treatment of postpartum haemorrhage should be highly prioritised in the interventions to reduce maternal mortality.

Causes of and risk factors for PPH

Postpartum haemorrhage has many potential causes, but by far the most frequently encountered is uterine atony, a condition whereby there is failure of the uterine muscle to contract and retract following delivery of the baby. Besides primary uterine atony, other causes of bleeding may include: retained placental tissue; trauma to the birth canal, especially cervical tears; and occasionally bleeding may be associated with clotting failure (coagulation defect) [v]. Although in a large proportion of women experiencing PPH no risk factors can be identified, the following have been identified as significant risk factors for PPH in published data[vi]:

  • · Retained placental tissue
  • · Prolonged second stage of labour
  • · Placenta accrete (morbidly attached placenta)
  • · Lacerations of the birth canal
  • · Instrumental delivery, especially forceps delivery
  • · Large for gestational age (LGA) newborn
  • · Hypertensive disorders
  • · Induction of labour, and
  • · Augmentation of labour with oxytocin

Prevention of PPH

There is ample evidence, based on several randomized controlled trials (RCTs) and a Cochrane meta-analysis involving more than 6000 deliveries, which suggests that active management of the third stage of labour (AMTSL) reduces the incidence and severity of PPH[vii], and should be recommended and offered to all women[viii]. Active management involves interventions to assist in expulsion of the placenta with the intention to prevent or decrease blood loss. It is the combination of uterotonics, clamping of the umbilical cord, and controlled cord traction when the uterus is well contracted. Uterotonics promote uterine contractions and thereby prevent atony and speed up delivery of the placenta. In contrast, with expectant, or physiological, management, spontaneous delivery of the placenta is awaited, with subsequent intervention, if necessary, that involves uterine massage and use of uterotonics.

Generally, uterotonic drugs are used to induce (start) or augment (speed up) labour; facilitate uterine contractions following a spontaneous abortion; prevent postpartum hemorrhage during active management of the third stage of labor; treat hemorrhage following childbirth or abortion; and for other gynecological reasons. The three categories of uterotonic drugs used most frequently are the oxytocins, ergot alkaloids and prostaglandins. Uterotonic drugs may be given intramuscularly (IM), intravenously (IV), and as a tablet that can be given orally, vaginally, rectally, or buccally. The uterotonic agents that are listed in Essential Medicines List, and which are commonly used in East Africa include oxytocin, ergometrine, and Syntometrine (a combination of ergometrine and oxytocin), all of which have to be administered through an injection.

Misoprostol, a prostaglandin E1 analogue with uterotonic activity, is an attractive option for use in AMTSL because it is stable, active orally, and inexpensive[ix]. Besides, whereas ergometrine is contraindicated in women with a history of hypertension, heart disease, preeclampsia, or eclampsia, there are no known contraindications for use of Misoprostol as used in AMTSL. Where skilled attendance is not available, the International Confederation of Midwives (ICM) and International Federation of Gynaecology and Obstetrics (FIGO) recommend that in the context of prevention of PPH, if oxytocin is not available or birth attendants’ skills are limited, misoprostol should be administered orally soon after the birth of the baby[x]. There is sufficient research evidence to support use of misoprostol both for prevention and treatment of PPH, particularly in settings where the majority of births take place away from health facilities, where standard uterotonics are not available. Studies in Tanzania, Afghanistan, Nepal, and Bangladesh have shown that for prevention of PPH, pregnant women delivering at home without a skilled birth attendant can successfully self-administer misoprostol orally as soon as possible after their baby is delivered[xi].

Use of Misoprostol for prevention and treatment of PPH ought to be added to Essential Medicines List

In consideration of the above this author, along with others, recently supported applications[xii] to add misoprostol to the World Health Organization’s (WHO) Essential Medicines List (EML) for prevention and treatment of PPH[xiii]. The addition of misoprostol to the EML for PPH prevention and treatment has potential to contribute significantly to the efforts to achieve MDG5 target. This safe and effective drug has been shown to prevent and control postpartum bleeding suspected to be due to uterine atony. The drug’s wide availability, low cost, stability at room temperature and ease of use make it an ideal candidate to add to the package of interventions available to prevent PPH in low-resource settings. Meanwhile in Kenya, the Kenya Obstetrical and Gynaecological Society (KOGS) is also pushing for the registration of misoprostol, “as an effective intervention in controlling PPH, particularly in limited-resource settings”[xiv]. Currently misoprostol is registered in Kenya for treatment of gastric ulcer, and the fear has been that misoprostol might be used for purposes of procuring abortion. Nigeria, in 2010, became the first African country to register misoprostol, but, ironically, restricted it to obstetric use in medical centres only; this in a context where nearly75 percent of women give birth at home!

[i] John R Smith, Barbara G Brennan,  Postpartum hemorrhage http://emedicine.medscape.com/article/275038-overview

[ii] Potts M, Prata N, Sahin-Hodoglugil NN. Maternal mortality: one death every 7 min. Lancet 2010; 375: 1762–63.

[iv]Ministry of Health, Kenya. A Question of Survival? Review of Safe Motherhood, Division of Primary Health Care, June, 1997.

[v] A mnemonic for remembering the causes of PPH is “4 T’s”: tone, tissue, trauma, and thrombosis (coagulation defect).

[vi] Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Matern Fetal Neonatal Med. Sep 2005;18(3):149-54. [Medline].

[vii] Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev. 2000;CD000007. [Medline].

[x]International Confederation of Midwives (ICM), International Federation of Gynaecology and Obstetrics (FIGO). Prevention and Treatment of Post-partum Haemorrhage: New Advances for Low Resource Settings Joint Statement. The Hague: ICM; London: FIGO; 2006. Available at: http://www.figo.org/docs/PPH%20Joint%20Statement%202%20English.pdf. Accessed October 12, 2007.

[xi] Prata N, Mbaruku G, Campbell M, Potts M, Vahidnia F. Controlling postpartum hemorrhage after home births in Tanzania. Int J Gynecol Obstet 2005; 90: 51–55; Rajbhandari S, Hodgins S, Sanghvi H, McPherson R, Pradhan YV, Baqui AH,and Misoprostol Study Group. Expanding uterotonic protection following childbirth through community-based distribution of misoprostol: operations research study in Nepal. Int J Gynecol Obstet 2010; 108: 282–88; Sanghvi H, Ansari N, Prata JVN, Gibson H, Ehsan A, Smith J. Prevention of postpartum hemorrhage at home birth in Afghanistan. Int J Gynecol Obstet 2010; 108: 276–81; Potts M, Prata N, Sahin-Hodoglugil NN. Maternal mortality: one death every 7 min. Lancet 2010; 375: 1762–63.

[xiii] These applications have been submitted by Gynuity Health Projects and Venture Strategies for Innovations.

[xiv] Susan Anyangu-Amu Misoprostol Can’t Shake Bad Reputation http://ipsnews.net/news.asp?idnews=52385

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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.


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

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