Tag Archives: MDG5

Human Rights Issues in maternal health care in Kenya: Do Kenyan women enjoy the right to maternal health?

The findings of a recent Public Inquiry into violations of sexual and reproductive health (SRH) rights in Kenya highlight several factors which underlie the high and increasing rates of maternal mortality in Kenya. This inquiry undertaken by the Kenya National Commission on Human Rights (KNCHR) during 2011 had the overall aim to establish the extent and nature of violation of sexual and reproductive health (including maternal health) rights and to recommend appropriate redress measures.

‘The Public Inquiry Panel receiving evidence from a witness in Kitale’ 12-13 July 2011’

Source: knhcr.org

Maternal health’ refers to the health of women during pregnancy, childbirth and the postpartum period (usually up to 42 days). As such, the right to maternal health should encompass access to antenatal care services; delivery services, including delivery by caesarean section where necessary; essential newborn care services and postpartum care services especially during the first 48 hours of delivery. Provision of these services requires availability of trained service providers (midwives, nurses, doctors and clinical officers) at all times and the capacity of facilities to respond to emergency cases, adequate physical facilities, and adequate equipment and supplies including essential medicines and vaccines.

Improving maternal health is the fifth Millennium Development Goal (MDG5). It has two targets: 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 (MMR) and Proportion of births attended by skilled health personnel; and 5B- Contraceptive prevalence rate (CPR); Adolescent birth rate; Antenatal care coverage; and Unmet need for family planning. Analysis of the latest available data on Target 5A shows that MMR in Kenya remains high and has not started showing any downward trend, nor has there been an increase in the proportion of births attended by skilled health personnel. In the case of Target 5B, on the other hand, it is encouraging to note the recent rising trend in CPR which, if sustained, may get close to the figure projected for 2015.

The factors behind the high and increasing levels of maternal mortality in Kenya fall in the following broad categories: widespread poverty; limited access to health care services; limited availability of skilled attendance at childbirth including inadequate referral systems; and high prevalence of negative socio-cultural practices such as early marriage and FGM. A key cross-cutting factor is inadequacy of funding to the health sector, and disproportionate allocation for reproductive health services within the health budget.

The right to maternal health care services is recognized or implied in several international, regional and national instruments, which many African governments including the Government of Kenya have ratified. Among these are: The Covenant on Economic, Social and Cultural Rights (1966); The International Conference on Population Development Programme of Action (1994); The United Nations Millennium Development Goals (2000); The Maputo Plan of Action on Sexual and Reproductive Health and Rights (2006); Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) (2009); The Constitution of Kenya, 2010 (Article 43 (a); The National Reproductive Health Policy 2007; and The Prohibition of Female Genital Mutilation Act 2011.

In these, the State is obliged to fulfill SRH Rights ‘progressively’, depending on the resources available to them. The state is obliged to show that it is making ‘measurable progresses’ towards the full realization of the SRH Rights and to restrain from adopting ‘regressive measures’. At the same time, there are those rights for which the state is under obligation to effect immediately, for instance, the obligation to respect an individual’s freedom to decide freely if, when and how often to reproduce and the obligation to ensure freedom from discrimination and from degrading treatment.

The core obligations that are relevant to SRH Rights, which states are under obligation to fulfill immediately, include ensuring:

  • Access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups;
  • Access to essential drugs, as defined under the WHO Action Programme on Essential Drugs
  • Equitable distribution of health facilities, goods and services including trained health personnel;
  • Availability of reproductive health services including maternal and child healthcare;

A human rights-based approach to reproductive health care recognizes that all human rights are universal, interrelated, indivisible, and interdependent and are inherent in all human beings. It acknowledges that sexual and reproductive rights cannot be realized without the realization of other broader human rights, for example, the right to information, privacy and confidentiality and education.

The status of maternal health rights is determined by the effectiveness maternal health care services at all levels, namely in terms of: accessibility, availability, quality, affordability and acceptability. From the Public Inquiry findings the following conclusions can be made:

  • The physical accessibility of delivery services is an important issue of concern especially in the arid and semi-arid zones where significant percentages of the population must travel long distances to access health facilities.
  • Many facilities lack transportation support for maternity emergencies. There was evidence that most facilities in rural areas were ill equipped to handle emergency deliveries and women who needed C-sections in small facilities often died or lost their babies because they could not be transferred to a higher level in good time.
  • Lack of safe abortion services in Kenya has resulted in those seeking termination of pregnancy to resort to crude and unsafe methods, often with fatal consequences. There is a lack of awareness regarding provisions in the Constitution of Kenya 2010 (Article 26(4)) among healthcare providers and the general public.
  • The quality of maternal health services countrywide remains an issue of serious concern. Some of the key quality issues that have been highlighted are: lack of basic supplies such as cotton wool, pads, gloves, syringes, surgical blades, linen to wrap babies, anaesthesia, disinfectants, medicines, bed sheets, and blankets; dirty and unhygienic conditions; women forced to share beds or sleep on the floor; and the lack of food and hot water for bathing, etc. Overall, the factors that undermine the quality of maternal health services in Kenya were summarized as: (a) Lack of supplies and equipment; (b) Understaffing and lack of training and supervision; (c) Negligence and unethical practices by health providers; and (d) Weak Referral System.
  • Non-affordability of services is a serious impediment to accessing maternal health care throughout the country. Witnesses testified that the high cost of hospital delivery, especially the fees charged at level 4 and 5 facilities, was a key hindrance to accessing skilled maternal health services.
  • Acceptability of maternal health services- evidence from the Inquiry indicated that some communities did not utilize skilled delivery services because of cultural restrictions, mainly taboos regarding attendance by male nurses, which was prevalent among the Muslims in upper Eastern and North Eastern Kenya, as well as among the Sabaot of Western Kenya. These cultural preferences, together with the chronic shortage of skilled professionals in these areas, and the non-affordability of fees for services, come out as the main factors that perpetuate the demand for the Traditional Birth Attendants (TBAs).

Based on its findings the Public Inquiry concluded that women in Kenya continue to die or suffer disability due to preventable causes. The Inquiry notes that the causes of these deaths prevail against the backdrop of the myriad international and regional human rights frameworks and commitments that Kenya is a party to and the national legal, policy and institutional frameworks that are aimed at enhancing maternal health. From the foregoing therefore, the Public Inquiry concluded that Kenya is still far from realizing the maternal health rights and has made a number of recommendations to government and other stakeholders that are essential in working towards the realization of maternal health rights in Kenya, and the achievement of MDG5 and Vision 2030 goal.

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

Definition

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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