Maternal mortality still unchanged despite 10 years of free care

The year was 2013, the post-election euphoria was settling and the president was sworn in. His first order of business was to turn the election pledge of providing free maternity to all mothers in the republic into a presidential directive.

As healthcare workers, we were given no warning. The order was simple — open the doors and take them all in! Working in the country’s largest public facility, we knew we were not ready! But we had to follow instructions. The doors were thrown wide open and mothers streamed in. 

The experience was equivalent to a person whose first swimming lesson involves being thrown into the deep end of the pool. We ran a labour ward designed to hold no more than 30 patients. This is because the labour ward is a high turnover unit where mothers walk in, deliver and are transferred to other units. However, it is also the emergency unit for all things maternity. 

On a good day, our labour ward unit held 50-60 patients at a time. It was served by no more than seven midwives per shift. The actualisation of the free maternity pledge did not give time for increasing the patient beds, nor the number of doctors or midwives in the unit. In the first week, the unit was worse than an open-air market.

The patients were all over the unit; sharing beds that were placed in the rooms, in the corridors and in any other open space available. When the beds ran out, some were on the floor. Many mothers waited for their turn on the ward benches while having contractions. The unit was completely ungovernable.

It is 10 years down the line. We have made progress. The numbers of health workers serving our mothers has increased, even if it is not yet commensurate to the number of patients; many hospitals have either built new stand-alone maternity units or expanded their maternity units; the government has made effort to streamline the financing of the service; and mothers now enjoy the privilege of walking into any public hospital assured of maternity care. 

This journey is one worth documenting in the books of history; how a third world country bit the bullet to ensure access to maternity care to its entire population. Why then, pray tell, is our maternal mortality ratio rising? The current estimate stands at 364 maternal deaths per 100,000 live births, a figure that is way off tangent from achieving the Sustainable Development Goal three of lowering this figure to 70 per 100,000. 

What are we doing wrong? What we have certainly done right is demand creation! Our mothers now know that they have a right to healthcare. They will seek care in the facilities without having to dip into their pockets to finance it directly.

For Nayima*, free maternity care did not save her from dying. Despite diligently attending her antenatal clinics as prescribed and taking her supplements, nothing prepared her for what was coming. She presented herself to the labour ward when it was time for delivery in a timely fashion.

Her labour progressed well and her little one was delivered safely. She was overjoyed to be called a mother. However, she knew something was definitely wrong when she felt the warm, wet sensation pooling under her sheets. She tried to call for help but there was no one nearby. By the time help arrived, the blood was steadily trickling down from her bed to the floor. 

The effort to save Nayima’s life was in vain. Her little one was left orphaned within hours. The maternal review done showed Nayima succumbed to the leading cause of maternal death, post-partum haemorrhage. The review further revealed that had Nayima received proper post-delivery monitoring and timely diagnosis of the complication, this could have been averted. 

Despite the common knowledge that postpartum haemorrhage is the leading cause of maternal death, it is not the only thing to fear. The Ministry of Health recognises the TOP FIVE causes of maternal death, with the other four being: pre-eclampsia/eclampsia ; puerperal sepsis; obstructed labour and abortion complications.

In the aftermath of the Covid-19 pandemic, almost every county in Kenya now has a critical care unit along with a functional renal dialysis unit. These are resources that have come in handy, especially for patients with severe pre-eclampsia/eclampsia, and those with sepsis, who may require critical care and dialysis. Unfortunately, availability of these units across the country has not demonstrated commensurate improvement in outcomes for these mothers.

For Nduku*, seeking maternity care did not ensure timely diagnosis of her obstructed labour. She remained in labour for 22 hours before she could be transferred to a facility that had the capacity to perform her caesarian section. Nduku lost her baby and she herself barely survived the harrowing experience, left with a fistula as a reminder. She is still in care to repair the fistula. 

From the audits done in these cases of maternal mortality, severe morbidity and the near-misses, the key findings remain uncannily similar across board. The inadequacies resulting in poor outcomes for our mothers are due to the weaknesses in the key pillars of health systems. 

The lack of commodities, inadequate human resources, poor management of health information systems, erratic financing of the services and poor governance are findings that have become like a broken record. It demonstrates to us that access to healthcare does not guarantee access to quality care! The institutional culture in most of our hospitals needs to also change. We must develop a new culture that holds the strong belief that women’s lives are worth saving! 

Our emergency response must be better coordinated. The healthcare workers must be continuously trained and mentored to increase their competence to handle emergencies. All facilities must demonstrate their emergency response protocols and regular drills to maintain teamwork and coordination.

The counties must strive to ensure the necessary human resource and medical supplies are available at all times while the exchequer, through NHIF as currently stands, must ensure timely release of funds to counties and health facilities happens for smooth running of things. All these efforts will secure the QUALITY of care provided to our mothers. This is the only way we can truly begin to feel the impact of free maternity care!

Dr Bosire is an obstetrician/gynaecologist