An Egyptian professor, Mahmoud F Fathalla, once observed, “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.” This statement remains true today especially in African countries as it was when the good Professor said it.
African countries contribute the greatest proportion of the world’s estimated 300,000 maternal deaths yearly. The average maternal mortality ratio (MMR) for Africa is about 400 per 100,000 live births. There is a huge variation in MMRs between African countries, with as high as 1,150 in South Sudan and as low as 37 in Egypt. Kenya’s MMR is estimated at around 355 per 100,000, according to the most recent census.
While most of the world has significantly reduced its maternal death burden, the rate of decline in most African countries, including Kenya, is slow. Women continue dying of preventable causes such as bleeding during and after childbirth, severe infection, blood pressure problems, unsafe abortion, and obstructed labour. Other common causes include complications from medical and surgical illnesses. What can we do about tackling preventable maternal deaths in Kenya?
A recent study published in the PLOS Global Public Health journal examined the factors reported contributing to maternal deaths in various African countries. The study found that the most frequently reported contributory factors were a delay in seeking help and recognising danger signs during pregnancy and after childbirth, suboptimal service delivery relating to triage, monitoring, and referral at the health facility and problems with transport to and between health facilities.
Reflecting on the findings of that study versus the Kenyan situation, there is an urgent need to address the problem of preventable maternal deaths using a systematic multi-pronged approach. Although everyone has a role in ensuring the best possible maternal health outcomes are met, the national and county governments bear the greatest responsibility. They should lead by declaring political commitment, providing adequate funding and eliminating corruption within the healthcare system which indirectly leads to suboptimal service delivery.
Governments should enact laws and policies that ensure respect for women’s rights and empowerment, improve physical infrastructures such as the transport system, fair number, and equitable distribution of health facilities. In addition, policies that enhance a country’s human development index are likely to also lead to improved maternal health outcomes. The human development index comprises life expectancy, education, and per capita income.
At the health facility level, urgent quality improvement is required in the processes that determine healthcare outcomes. Quite often, the focus has been on buildings. Such processes may address staffing (numbers, competence and presence), supply of high-quality medication and commodities and the development and implementation of clinical practice guidelines. Guidelines provide benchmarks for audit and reduce unwarranted variations in practice and maintenance of updated life-saving knowledge and skills by healthcare workers.
At the individual patient, family, and community levels, engagement with the healthcare system and participation in shared decision-making regarding obstetric care is essential. Awareness and paying attention to individual risk factors and implementing plans to mitigate their effects may help avoid preventable maternal deaths.
Members of the Kenya Obstetrics and Gynaecology society agree that bleeding during pregnancy and after childbirth is the most common cause of maternal deaths in Kenya, often made worse by the lack of blood transfusion capacity in many healthcare facilities. Kenyan obstetricians suggest priority interventions which could be useful in fast-tracking the reduction of preventable maternal deaths. These interventions include an investment in a reliable blood transfusion management system for all health facilities that offer maternal health services, investment in more numbers, and equitable distribution of obstetric consultants and midwives countrywide.
The availability of blood and blood products is central to managing obstetric-related bleeding, the most common cause of maternal deaths. Increased obstetric consultant presence will ensure better supervision and training of non-specialist doctors and the timely intervention with second-line surgical procedures that could save mothers’ lives in the event of intractable bleeding during pregnancy and after childbirth.
Finally, they suggest ensuring a constant supply of high-quality commodities and essential medications such as oxytocics, tranexamic acid, and intravenous fluids, which are vital in managing obstetric bleeding. In summary, the responsibility of saving our mothers by tackling the causes of preventable maternal deaths belongs to all of us.
-Dr Githae is a researcher based at the WHO Collaborating Centre for Global Women’s Health, University of Birmingham, United Kingdom