Tag Archives: Millennium Development Goal 5

Evolution of Modern Obstetrics and Gynaecology Practice in Kenya

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

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

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

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

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

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

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


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

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

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

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

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

 

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Focus on providing safe abortion services, not post-abortion care.

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

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

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

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

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

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

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

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

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

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

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

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

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

Background:

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

 

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

 

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

Source: (World Abortion Policies 2007 )

Constitutional provisions that are relevant to abortion services in Kenya

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

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

 

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

 

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

 

Restrictive medical practices

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

 

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

 

Provision of Safe abortion services[x]

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

 

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

 

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

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

 

Prevention of unsafe abortion and its complications

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

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

 

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

 

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

Conclusion 

 

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

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

 

Related Links


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

[ii] Preamble to the Constitution of Kenya

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

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

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

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

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

[viii] Article 27 on Equality and freedom from discrimination

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

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

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

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


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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