By George Achia
Despite all the odds stacked against her, Mary Apondi, thought she was doing everything right. The 28-year-old woman was excited about delivering her first baby, and although she lives in Kibera, Kenya’s largest informal settlement, Apondi found a way to have consistent prenatal care to ensure safe delivery.
But Shortly after giving birth on December 22, 2019 at the Bahati Heath Centre in Kibera, she realised something was awfully wrong with her tiny son. “I noticed the child was not breathing well. I informed the doctors that the child had a breathing complication and they told me to just breastfeed him,” she recalls, holding back her tears.
Apondi says she kept complaining about her child’s condition to the doctors for a whole day with no action from the medics. Eventually, the child was referred to Pumwani Maternity Hospital the following day in a critical condition where he passed away while being attended to.
Doctors at Pumwani hospital told Apondi that if the infant had been referred sooner, he might have lived. Those words haunt her to this day.
Watching her son succumb to what the medics called ‘difficulty in breathing’ was a hard pill to swallow for her. Despite all the traumatizing experience she went through, Apondi remains thankful for few of her family members who stood with her during the trying moment.
“I am yet to come to terms with the death of my son. He died in my arms yet I could not do anything to save his life. I did everything required of me during the pregnancy for safe delivery only for my son to die thereafter. I want to heal first before considering getting another baby in the future,” she says.
Apondi’s case mirrors the situation for vast numbers of Kenyan women living in remote rural areas, or even in urban neighbourhoods when they cannot afford quality care. And as with Apondi’s son, the main tragedy is that simple, low-cost interventions like breathing machines or simple apparatuses that can stop women from bleeding to death are the only things standing between life and death for these women and babies.
Kenyan mothers and babies are dying unnecessarily because of a concoction of factors including negligence among health workers, poor access to skilled health workers and emergency care that have contributed to the increased death cases among new born babies and their mothers. However, there are ongoing concerted efforts by different players in the health sector to reverse this trend.
The rate of death among mothers during pregnancy, delivery and after childbirth has remained a steady high at 362 deaths per 100, 000 births in Kenya up from 488 cases, according to Kenya Demographic and Health Survey 2014. Yet in developed countries like Italy, there are 2 deaths per 100,000 live births, depicting huge disparity in maternal mortality between developed and developing countries.
According to Dr James Gitonga, the head of Maternal and Perinatal Death Surveillance and Response (MPDSR) at the Ministry of Health, more than half of these deaths can be prevented by an adequate prenatal care, qualified health workers during delivery and proper post-natal medical care for new mothers and their babies.
“Doctors, nurses and clinical officers routinely ignore clinical guidelines with inadequate skills to treat and manage complications arising after giving birth,” says Dr. Gitonga. He adds that lack of essential drugs and limited access to life-saving services are also undermining the well-being of first time mothers and their babies.
While most health providers get the diagnosis of post-partum haemorrhage (severe bleeding after giving birth) and neonatal asphyxia (deprivation of oxygen to a baby before, during or just after birth) correct, only a small proportion offer the right treatment, according to the Kenya Health Service Delivery Indicator Survey (SDI) 2018 released recently.
“The two conditions – post-partum haemorrhage and neonatal asphyxia – are the leading causes of deaths in first time mothers and their babies during birth,” says Dr. Gitonga.
In addition, about 9,327 newborns died from neonatal asphyxia within the first 27 days of their birth in Kenya in 2018, according to the World Health Organization (WHO). Severe bleeding during birth is the leading cause of maternal deaths, accounting for a third of them in sub-Saharan Africa.
According to the report done in 3,094 health facilities across Kenya, only 16 percent of doctors and clinical officers prescribed the right treatment for neonatal asphyxia even though 88 percent accurately diagnosed the condition. Likewise, less than half (43 percent) of health providers prescribed the correct treatment for post-partum haemorrhage while 90 percent gave an accurate diagnosis.
The actions of health providers are under the spotlight against a backdrop of growing complaints over misconduct by health providers. The report further notes that four in five expectant mothers who die in hospital receive poor care where a different health management could have saved their lives or that of their child.
Dr. Christine Musyimi, a research officer at African Academy of Sciences (AAS) says depression during pregnancy is yet another challenge facing mothers.
“Depression during pregnancy and in the postpartum period is associated with a number of poor outcomes for women and their children,” she says, adding that although effective interventions exist for common mental disorders that occur during pregnancy and the postpartum period, most cases in low- and middle-income countries go untreated because of lack of trained professionals.
In order to fast-track progress in addressing child and maternal deaths in the country, in 2013, the Government addressed high maternal death and the lack of access to quality maternal health services (including antenatal, delivery, and post-natal services) by waiving all user fees for maternity services at all public facilities.
Devolution of the health sector in Kenya provides an opportunity for counties to identify and address their health challenges, and with the devolved health care functions to county governments, maternal health has slightly improved, leading to the number of births recorded at home halving between 2011 and 2015 while the number in health facilities increasing by 60 per cent, according to a 2017 situation analysis report by UNICEF on mother and child.
The increase occurred in 43 of the 47 counties, with many of low coverage counties, such as Tana River, Wajir, Mandera and Kwale, showing dramatic increases.
In Turkana and Kitui Counties, investments in infrastructure through building of new facilities and incorporation of maternity services at dispensaries (lower levels of healthcare provision) have led to improvement in skilled birth attendance.
This has also been facilitated by the engagement of Community Health Volunteers, who follow-up with mothers during pregnancy, and the linkage with health facilities increasing the use of health services at the community level. In a number of cases, the process has been facilitated by the involvement of traditional birth attendants as birth companions, responsible for referring and accompanying mothers to the health facilities when their labour begins, and on a few occasions assisting nurses during the birth.
Significant commitments have been made to improve maternal, newborn and child health outcomes, including the introduction of Free Maternity Services, the First Lady’s Beyond Zero campaign, and several new national maternal, newborn and child health service delivery guidelines aligned to global standards. To better improve child and maternal health care to complement the government’s efforts, some innovations by different players in the sector have sprung up.
For example, Amref Health Africa has come up with a mentorship approach that is aimed at building the capacity of peer-to-peer health workers to help them acquire and retain new skills to ensure safe delivery.
In addition, the organisation is implementing health facility open days to create a platform for dialogue between health facilities and communities and address barriers to service uptake.
“Through such dialogue forums, the community members raise issues they face at the health centres and it also offers feedback to the facilities on areas they need to improve on to curb deaths,” says John Kutna, a project lead at Amref Health Africa.
At AAS, Dr. Musyimi notes that “The ENGAGE TBA” (Engaging Traditional Birth Attendants to reduce maternal depression in rural Kenya) project has trained TBAs to provide psychosocial interventions to pregnant mother with depression.
“TBAs screened a total of 1700 pregnant mothers for a period of one year in 2019, a third of pregnant women had depression with 75 per cent experiencing some form of intimate partner violence,” she points out.
Further, Linda Mama Initiative that was launched by the government in 2016 and later transitioned to National Health Insurance Fund to bridge the financial gap that stopped many women from accessing maternity services especially those from poor backgrounds.
These factors including increased use of mosquito nets among children, enhanced immunization programmes, improvement in accessibility of health facilities and engagement of Community Health Volunteers are behind the downward trend in childhood mortality.
In addition, other initiatives such as the “Beyond Zero Campaign” by the First Lady Margaret Kenyatta, has increased service provision including antenatal and postnatal services; HIV testing, treatment and care; immunization, basic treatment for common ailments, through the mobile clinics across the Counties.
With the progress being made in this area, health experts maintain that a gap still exist between policy and implementation with the health sector being a devolved operation. They suggest the need for a dialogue between national and county governments to allow domestication and popularisation of health policies and guidelines at the local levels.
Kenya’s progress in achieving key maternal, infant, and child health targets has been slow as set out in key national policy documents. For Kenya to make rapid progress towards Universal Health Coverage a health system needs to have skilled human resources, minimum inputs such as drugs, commodities and infrastructure, financing, leadership and governance, and health information systems.
