Why Are Women Dying to Give Life and Children Not Surviving to Experience Childhood?
A recent article Changing Lives, One Woman at a Time: Maternal Heath in Kenya by Siddharth Chatterjee, the United Nations Population Fund (UNFPA) Representative to Kenya and Dr. Abbas Gullet the SG of the Kenyan Red Cross (KRCS) concluded with the words: "no woman should die giving life."
Kenya is a country of incredible contradictions. As the richest country in East Africa, with $840 income per capita, Kenya is the closest to meeting the international middle -income threshold of $1,000. This is a significant rite of passage, but that annual income is still less than $3 per day. The peaceful elections in 2013 and reforms enhancing security and governance have renewed investor confidence-economic growth, estimated at 4.9 percent in 2013 and expected to increase to 5.7 percent in 2014.
Much progress has been made in approaching some of the Millennium Development Goals -- examples include Kenya's poverty rate, which has declined from 56 percent in 2000 to 42 percent in 2009 (still a grotesque number). Primary school enrollment reached 84 percent in 2008-2011 (although we must remember this statistic does not account for quality of education, gender inequities in enrollments and secondary school outcomes). Certain health indicators have shown improvement -- immunization coverage rates in 201 ranged from 73 percent (newborn tetanus) to 93 percent (MCV) and use of improved drinking water sources reached almost 61 percent (82.7 percent in urban areas).
Yet this nation, which is hurtling towards "development," boasts some of the worst outcomes for maternal and child health in Africa and the world. In 2010, 360 women died out of every 100,000 live births, ranking Kenya 51st on the list of the 75 countries where more than 95 percent of all maternal and child deaths occur. This represents a negligible improvement from 1990 during which 400 women died out of 100,000 live births (and a far cry from the MDG goal of a 75 percent reduction between 1990 and 2015). According to Save the Children's 15th Annual State of the World's Mother Report, Kenya moved 13 places up in world rankings last year but still holds the shameful 143rd place out of 178 countries that report maternal deaths.
For children under five, mortality in Kenya is a much happier story, but not quite happy enough. Mortality decreased from 98.2 children per 1,000 live births in 1990 to 72.9 in 2012. On an absolute basis, Kenya is significantly off track of the MDG goal of a 75 percent reduction by 2015 but recently has seen a fall of more than 8 percent a year, almost twice the MDG rate and enough to halve child mortality in a decade. Still, "each day 15 women and 290 children die as a result of pregnancy complications -- including giving birth, HIV and several curable and preventable childhood diseases." Kenya ranked 33rd globally in under-5 deaths (with approximately 35 percent of all neonatal deaths due to severe infections, followed by asphyxia, preterm births and congenital anomalies). Two-thirds of under-5 deaths are post-natal and leading causes include pneumonia and diarrhea. Over 34,000 stillbirths occur a year and 1/3 of children under-5 are stunted, a sign of chronic malnutrition.
Gabriel Demombynes (World Bank Nairobi office) attributes Kenya's success in cutting the rate of infant mortality (deaths of children under one year old) more than any other country to the relatively healthy economy, a functioning democracy and the increased use of treated bed nets from 8 percent of all households in 2003 to 60 percent in 2008. Using figures on the geographical variation of malaria, he calculated that half the overall drop in Kenya's infant mortality can by explained by the huge rise in the use of ITNs in areas where malaria is endemic.
So what is behind this painstakingly slow progress on maternal health in Kenya, especially in light of the enlightened approach to many development issues, including infant mortality? Clearly abject poverty as alluded to above is an overwhelming issue especially in rural areas. With 42 percent of the country still living below the poverty line, access to adequate health care is more than a challenge. Maternal morbidity and mortality in Kenya results from the interplay of social, cultural, economic and logistical barriers, coupled with a high fertility rate (3.76 children born per woman as per World Bank) and inadequate and under-funded health services ($17 US per capita in 2012 according to WHO data). Inadequate water supply, sanitation and hygiene resulting in WASH related illness is the reason for over 50 percent of the hospital visits in Kenya. According to the Kenya AIDS Indicator Survey released by the government in 2009, approximately 1.33 million adults were infected with HIV and many more unaware of the illness. A disproportionate number of those infected by HIV were women (8.7 percent vs 5.6 percent for men), contributing to negative health outcomes.
Tens of thousands of Kenyan women and girls in Kenya suffer from obstetric fistula, a childbirth injury causing leakage of urine and feces, a direct result of inadequate health services. While approximately 92 percent of women giving birth received some antenatal care in 2010 only 47 percent had the recommended 4 or more visits and 56 percent of Kenyan women deliver their babies at home (more in rural areas). Only 44 percent of births were assisted by health care professionals, well below the target of 90 percent of deliveries by 2015, and these rates of antenatal care and skilled birth attendance have declined over the past 10 years, particularly among the poor. Traditional birth attendants assist with 28 percent of births, relatives and friends with 21 percent and in 7 percent of births, mothers receive no assistance at all.
Together with income, education also plays a major role in determining maternal health outcomes, including fertility rates, access to family planning and antenatal coverage. Women with higher education are much more likely to receive antenatal care from a medical doctor than are those with no education (36 vs 21 percent) and clearly the higher the wealth quintile, the more likely a woman is to get antenatal care from a doctor. Although the Constitution of 2010 permits abortions to protect the life or health of a mother, women in Kenya continue to turn to unsafe procedures by unskilled practitioners en masse, due to lack of awareness of the law, stigmas against abortion, resistance from health workers and fear of prosecution by police.
Kenya would do well by drawing lessons and inspiration from success stories in other countries. Today, more than ever, actors at all levels, from large government bodies to small local non-governmental organizations (NGOs) are innovating programs that can directly impact maternal and reproductive health, thereby bringing the MDGs into the reach of many poor and underserved communities. Successful programs in countries like Ethiopia, India and Bangladesh have focused on two key facts; one, often the poorest women who are in dire need of health care live in hard-to-reach rural areas and two, mobile phone technology has expanded at a rapid pace in developing countries.
Since 2000, Ethiopia has reduced the risk of maternal death by nearly two-thirds (from 1 in 24 to 1 in 67). The country's Health Extension Programme created access to preventive services as well as high impact curative interventions at the community level. The deployment of more than 38,000 health extension workers bridged the gap between the community and hospitals, In addition, the Ethiopian government built 3,525 health centers and 16,048 posts to increase access to essential services to communities across the country.
Saadhan in India is a helpline that poor customers can call to access information regarding reproductive health. The service is supplemented by Community Health Workers who can then make house calls, provide information on contraception and refer patients to doctors.
The Indian government's 'Boat Clinics' are aimed at reaching geographically isolated communities in the north-eastern state of Assam. Boats carrying doctors, nurses, lab technicians and pharmacists make regular visits by boat and work with local community health workers to provide mothers and children with necessary services like routine immunization of children 0-5 years and pregnant mothers, vitamin A supplementation, general health check-ups and provision of family planning information and education.
In Bangladesh, the Demand Side Financing Pilot Program provides subsidies and vouchers to pregnant women so they can cover travel costs for regular antenatal health check-ups, deliver their children in hospitals or community health centres and to pay for medication. A similar program also exists in Cambodia.
In Kerala, a study from the International Center for Research on Women revealed that strengthening women's land rights reduces women's risks of HIV, protects women from poverty and sexual violence, and promotes child nutrition and schooling
Lessons from these parts of the world also show cash subsidies, conditional cash transfers and vouchers are all effective tools to aid poor mothers in accessing much-needed maternal health services.
Social workers and policy analysts from developing countries are now extolling the virtues of public-private partnerships (PPP) with regard to maternal and reproductive health care. PPPs combine the reach and muscle of large governmental bodies with the flexibility and ground-level reality understanding of smaller, private institutions.
For example, in Zambia, Merck for Mothers took the step of asking mothers in poor communities about their experiences and what was lacking. This type of 'market research' enabled them to tailor their services to fit the community in question.
Kenya's challenge is now two-fold. It must expand access and information regarding health care and it must make maternal health care affordable. The commitment to the cause already exists in Kenya. What is needed now is smart and decisive action.
The First Lady of Kenya, Margaret Kenyatta launched launched the Beyond Zero campaign on January 24, 2013 to accelerate the implementation of the national plan towards the elimination of new HIV infections among children. This is an appropriate starting point to address the deep and complex factors that have resulted in Kenya's dismal maternal mortality rates.
UNFPA and Kenyan Red Cross in concert with the Kenyan government have an opportunity here to transplant and adapt these lessons from other developing countries in order to implement them in a Kenyan context. From there, successful examples could also be exported to other sub-Saharan African countries, making Kenya a true leader in the continent and an incubator for innovative social policy.
Indeed, "no woman should die giving life," anywhere in the world.
Dr. Annie Sparrow, a paediatrician and public health expert, is an Assistant Professor of Global Health and Deputy Director of the Human Rights Program at Icahn School of Medicine at Mount Sinai in New York City.