By Treezer Michelle

“A healthy pregnancy begins before conception and continues with prenatal care, along with early recognition and management of complications if they arise. Early initiation of prenatal care by pregnant women, and continuous monitoring of pregnancy by health providers, are key to helping prevent and treat severe pregnancy-related complications,” says Christine Naliaka, the Bungoma County Reproductive Health Coordinator and the Deputy Chief Nurse in Bungoma County.

The World Health Organization (WHO)estimates that more than 300,000 women die from pregnancy-related causes every year. That translates to 830 women every day with 94% of these deaths occurring in Asia and Sub-Saharan Africa.

This is partly attributed to the fact that many more babies are born in Asia and Africa than in other regions. But it is also largely the result of the much higher maternal mortality rates found in lower-income countries. Per birth, a woman in a developing country is more than 200 times more likely to die in pregnancy or childbirth than a woman in a developed country.

“The Maternal and Perinatal Death Surveillance Reviews (MPDSR) is a model that was founded by the United Nations Commission on the Status of Women in 2012 to call for the elimination of preventable maternal mortality. MPDSR is a system that measures and tracks all maternal deaths in real time, helps us understand the underlying factors contributing to the deaths, and stimulates and guides actions to prevent future deaths,” says Naliaka.

Christine Naliaka(right), The Bungoma County Reproductive Health Coordinator and the Deputy Chief Nurse Bungoma County. Christine is a member of the County MPDSR Committee.

Bungoma County has a Committee that runs the MPDSR activities at the County and sub-county levels with the primary goal of the MPDSR being to reduce future preventable maternal mortality through a continuous action and surveillance cycle of identification, quantification, notification and review of maternal deaths, she explains.

This is followed by the interpretation of the findings and the avoidability of the maternal deaths which is used for recommended actions that will prevent future deaths.

” Through MPDSR which is strongly institutionalized here in Bungoma County, the county has recorded a decrease in maternal mortality in the last three years. In 2019, Bungoma County recorded 44 cases of maternal mortality, 29 cases were reported in 2020 and 17 cases have been reported between January to September in 2021. We record maternal mortality cases quarterly,” says Naliaka.

Any time there is a maternal or perinatal death in any health facility in Bungoma County, the committee sits down to discuss the likely health and non-health causes of the death at the facility level.

At the end of the month, the data is channeled to the sub-county MPDSR unit. After the sub-county unit has received the maternal and perinatal mortality data per quarter (3 months), all the 10 sub-counties in Bungoma County send the data to the County MPDSR unit for discussion.

“In our reviews of maternal and perinatal deaths at the county level, we analyze the causes of death and come up with action plans or interventions. These interventions are meant to prevent similar maternal deaths in future. For example a case of a woman who dies because she was not able to recognize the pregnancy danger signs like ceasation of foetal movement early enough therefore she did not seek for medical advice,” Naliaka says.

“We identify what is missing, like in this case, we can attribute the death to knowledge gap. We decide on how to get the knowledge to the people by tasking a team of Community Health Volunteers (CHVs) to talk to the community either through door to door campaigns or small community gatherings.”

Members of the Reproductive, Maternal, Newborn, Child and Adolescent Health Network in a campaign to sensitive women on importance of attending 4 focused ANC visits.

There is a team responsible for every type of intervention that the committee decides on. For the case of maternal health education, the County Community Strategy Vocal person is responsible for that, she adds.

The person is responsible for mobilization of community strategy vocal persons at the sub-county level and the facility level to discuss exactly how the CHVs will conduct the community health education.

In a case where a maternal death is caused by blood related issues, the County Medical Lab Coordinator is tasked with the action plan of mobilizing his team to source blood mainly through blood donations from community members. This way, blood becomes available for the next maternal patient who needs blood.

The MPDSR committee members in Bungoma County consist of trained members. An avarage of 8 members are trained to work at the county level, 24 members at the sub county level and more than 2000 CHVs.

” The services offered by the  MPDSR team in Bungoma County is totally free for the residents of Bungoma County thanks to the Linda Mama initiative which allows access to free maternal care. The community based interventions are also free and the CHVs work on volunteerism basis with a little stipend of Ksh 2000 every month that is funded by the county government . The CHVs that we work with were elected by the community members themselves, they are people that are known and trusted in the community,” Naliaka says.

Margaret Mabonga, a CHV in Mainya village in Kalaba Ward, Bungoma County says that they have been tasked with advising expectant women who have not started their antenatal care to start as soon as possible.

” If we as CHVs are able to convince someone to start prenatal care, we issue them with a referral letter which they are to present to the hospital once they get there to show that they were directed by a CHV. We also take the expectant women through maternal health education which is always organized by the MPDSR officers at the county and sub county level,” she says.

 “It is advisable to attend at least four antenatal care (ANC) sessions so that the doctors can ensure that both mother and baby are fine and to detect and manage the early risk signs during the pregnancy. During prenatal care, mothers undergo a lot of tests to identify if there are underlying medical conditions that can cause maternal or perinatal death. Blood and urine tests are mandatory. This helps in knowing the HIV status of the mother and the presence of any other sexually transmitted infections (STIs).”

Mabonga adds that the expectant women are also given drugs and injections that are important during the pregnancy period and even during birth. The drugs include folic acid, iron tablets, anti-malaria injections and anti-tetanus injections.

Margaret Mabonga(right) and Rachel Ombati whom Margaret referred for ANC at Bungoma County Referral Hospital.

According to Naliaka, the County Government in conjunction with Save the Children was able to train all the CHVs in Bungoma County that are under the MPDSR Initiative. Some CHVs have also been equipped with skills on helping in delivering babies for emergencies though we do not encourage these deliveries because of the county’s zero home births policy.

Additionally, the CHVs have also been trained on detecting pregnancy danger signs. This helps them to know when a pregnant woman under their care needs medical attention.

There are pregnant women however who do not attend the required four ANC visits. The Reproductive, Maternal, Newborn, Child and Adolescent Health Network (RMNCAH) is also a part of MPDSR Initiative in Bungoma County.

The RMNCAH is a network of nurses in Bungoma County who deal with the tracing of pregnant women who skip and do not intend to complete the four focused ANC visits. The RMNCAH network activities are funded by the county government of Bungoma upto about 40% and the remaining part of the funding comes from external donors. They receive 4% of the total 30% funds allocated to health in the county.

According to RMNCAH database, only 56% of pregnant women who attended first ANC visit last year were able to complete the 4 required ANC visits in Bungoma County. The data further shows that 87% of pregnant women delivered by skilled health attendants coverage. This means that 44% of pregnant women  did not complete four ANC visits while 13% of pregnant women in Bungoma County did not deliver with the help of skilled birth attendants.

“Failure to attend the four focused ANC visits greatly contribute to maternal mortality. When a woman comes for their first ANC visit, we keep records of the name, address, contact information and date of the next visit. We constantly check our records to identity the names of the ANC defaulter,” says Grace Wanjala, the deputy nursing officer at Bungoma County Referral Hospital.

“We then contact them and advise them to come for their ANC visit. We also have records of the CHVs who are in-charge of every village. In a case where the pregnant women cannot be easily traced, we use the help of the CHVs in ANC defaulter tracking. Sometimes we also hold campaigns to sensitize women on the importance of attending all the four ANC visits.”

According to Praxiors Wasibuye, a CHV at Namaya village, one CHV is incharge of 80 to 150 households. The CHVs identify, educate and refer pregnant women for ANC in their area of service.

“We also do defaulter tracing in our area of operation. Sometimes we are contacted and instructed to find out why a pregnant woman has missed an ANC visit. A CHV and the pregnant women under her care have to identify a motorcycle rider that takes the women to the hospital any time there is a complication. Payment is done through the RMNCAH network,”  adds Wasibuye.

Lucy Makokha, a resident of Oldrex in Bungoma town is a CHV’s referral case. She attended 4 four ANC visits.

Makokha is glad to have delivered in a hospital because her baby, who is now five-months- old developed Jaundice (yellowing of a baby’s skin and eyes. It usually occurs because a baby’s liver isn’t mature enough to get rid of bilirubin in the bloodstream) at birth. The baby was treated and discharged together with the mother after nine days.

Gladys Okoyo was also referred by Wasibuye. At the time she was two months pregnant. She attended ANC until she was 10 months pregnant.

“My pregnancy was overdue when I started having contractions. She arranged for me to be rushed to the hospital. Unfortunately, I stayed for more than 36 hours before giving birth. The amniotic fluid had maconium(waste produced by an infant 24 hours after birth) because the baby had overstayed in the womb. I delivered through c-section. It’s fortunate that I delivered in a hospital and with the help of skilled health workers so they were able to counter the complications,”  says Okoyo, adding that after a week, she was released from the hospital.

Gladys Okoyo and her 3 weeks old son at their home in Namaya village.

Naliaka says that even though the MPDSR unit has managed to prevent and record a decrease in maternal deaths in Bungoma County, there are some challenges that still act as a setback to the initiative including lack of proper payment plan for the CHVs which has caused a number of them to become irresponsive and others have even stopped working with the MPDSR team.

“We as the MPDSR team have recorded a decrease in maternal deaths but there is no single quarter that we have recorded zero maternal deaths. Late interventions is also a challenge. Most expectant women ignore the pregnancy danger signs for too long so when they come to the hospital, it becomes too late to salvage the situation,” she says.

“The Sub-County hospitals also do not have ambulances that can help rush the patients to Bungoma County Referral Hospital when they develop complications during childbirth. Sometimes lives are lost because the patient was not rushed to Bungoma County Referral Hospital in time.”

Knowledge gap among Healthcare providers and inadequate skills also still contribute largely to maternal deaths, Naliaka notes.

A research conducted in 2017 revealed that Bungoma County was among the 13 counties in Kenya whose MPDSR committees were active. Additionally, the county was also ranked as the county which has made the greatest strides in Kenya, reviewing 59% of the perinatal and maternal deaths that occurred within the county in 2017. It accounted for 51% of all the perinatal and maternal deaths reviewed in Kenya in 2017.