In this post Hildah Essendi (PhD) discusses her research on access to maternal and newborn care in two rural communities in Kenya.
The efforts and commitments to accelerate progress towards the Millennium Development Goals for maternal and newborn health (MDGs 4 and 5) in low and middle income countries have focused primarily on providing key medical interventions at maternity facilities to save the lives of women at the time of childbirth, as well as their babies. However, in most rural communities in sub-Saharan Africa, access to maternal and newborn care services is still limited. Even where services are available they often lack the infrastructural prerequisites to function at the very basic level in providing essential routine health care services, let alone emergency care. Lists of essential interventions for normal and complicated childbirth do not take into account these prerequisites, e.g. consistent and reliable electricity and adequate water supply. The needs of most health facilities in rural communities of sub-Saharan Africa are thus ignored, although there is enough evidence that maternal and newborn deaths continue to remain unacceptably high in these areas.
Countries with high maternal and newborn deaths need to invest in universal access to essential Emergency Obstetric and Newborn Care (EmONC) services. The functionality of health facilities providing maternal and newborn care is assessed using a set of nine key life-saving interventions often referred to as “signal functions”. Some examples of these functions include administering parenteral antibiotics for maternal infection, performing neonatal resuscitation or performing surgeries (e.g. caesarean section and blood transfusion). Lower-tier health facilities in rural areas require only seven signal functions to be working to qualify as ‘functioning’, but all of these functions require multiple infrastructural support to be operational. Many facilities in these areas often lack electricity, water and adequate health personnel. Furthermore, rural areas in general, have poor roads that act as barriers to access maternal and newborn care, including referrals during emergencies.
Our research was based on qualitative interviews conducted in Kitonyoni and Mwania sub-locations of Makueni County in Eastern Kenya. Kenya was selected as one of the areas in sub-Saharan Africa as it still exhibits high maternal and neonatal mortality rates, as well as poor infrastructure in health facilities serving most of its rural areas. The research aimed to understand community and provider perceptions of the obstacles faced in providing and accessing maternal and newborn care at health facilities in their localities. To get a mix of perceptions to access to care, we interviewed mothers and partners, health care providers as well as community leaders. We find that respondents in the study perceive various challenges, most of which are infrastructural and include lack of electricity, water and poor roads. All these elements adversely impact the provision and access to essential life-saving maternal and newborn care services in the two sub-locations.
Poor access to affordable and clean energy and adequate water in health facilities in the study areas was found to be a major contributor to high maternal and child morbidity and mortality in the region. Lack of electricity makes it impossible to run cold chains that can store life-saving vaccines, while inadequate clean water impacts sanitation where infectious diseases may thrive and spread. This situation makes timely and affordable access to the crucial maternal and child health services a challenge. The lack of electricity poses a major challenge when conducting deliveries, particularly at night. The health providers interviewed pointed out that they often have to rely on torch lights, lamps or feeble lights from mobile phones when performing deliveries. They expressed their frustration of attending to birthing women at night in the captions below:
“At night, I usually place the lamp either on a carton box like this one, or on another bed or somewhere raised. It is very challenging because I cannot keep on calling relatives of the mothers to come and assist me like with holding the lamp, because I am all alone here” [Nurse, Key Informant Interview].
“…sometimes I use a torch. It is very difficult to hold it and sometimes I am forced to hold the torch in the mouth as I conduct the delivery. This is because, if you have gloved yourself ready to conduct a delivery, it is difficult to hold the torch at the same time” [Nurse, Key Informant Interview].
A lack of electricity is also an impediment to the provision of life-saving vaccines to newborns in the study, as expressed by mothers in the study:
“…we are not able to immunise our children, we are told the drugs have to be put in a fridge [require refrigeration] but here there is no electricity, so they cannot keep the drugs here so we have to go to another facility…“ [Mothers, Focus Group Discussion, 25–39 years, Kitonyoni].
The two study communities also experience shortages and unequal distribution of midwives, nurses and doctors, facilitating an inadequacy which puts a strain on the few health workers, overburdening and overstressing them and rendering them incapable of offering adequate and quality care. Respondents in the study articulated their frustrations at the shortage of staff, forcing them to seek health care elsewhere, thus:
“…like now if the nurse is on leave, the hospital here is closed for one month, so we have to travel all the way to Kitise and when it is an emergency we are referred to Wote. We go through many problems when transporting a patient to Kitise or Wote. If we do not do it, the person may die.” [Partner, Focus Group Discussion, 40–60 years, Mwania].
Acute water shortage particularly in the dry season was also reported by both the service providers and users as a major challenge to providing and accessing care services. As the main source of water for the two facilities is rainwater, the facilities often experience shortages during the dry periods during which time, health providers are often forced either to go without water, or use poor quality water. This poses serious hygiene and sanitation issues in the facilities, especially during the provision of delivery services. It was reported that water shortages sometimes becomes so acute that it is difficult to get water for hand washing, cleaning delivery surfaces (which is a normal table that sometimes acts as a bed for examining patients) and cleaning cutting equipment. These problems expose mothers and newborns to infections, a frustration expressed by a service provider:
“After delivery, this place gets really soiled, there is no running tap water in here to clean the room, there is no water for mothers to take a shower after delivery…” [Nurse, Key Informant Interview].
The findings and recommendations from this study are important for the attention of policy makers and programme managers. In order to improve the state of lower-tier health facilities in rural communities and to strengthen infrastructure it is crucial to make basic routine and emergency obstetric and newborn care services more accessible.
This blog post is based on the results of the baseline survey conducted to assess challenges faced in accessing maternal and newborn care by beneficiaries of the Energy 4 Development scheme in two rural communities in Kenya. Results of this study were published in the Reproductive Health journal, and is based on Hildah’s work done at the University of Southampton. The Energy 4 Development project focused on the impact of renewable off-grid electricity on the health, education and wellbeing of people living in countries of the sub-Saharan Africa. Hildah currently works as a Senior Research Manager with M&C Saatchi World Services, managing their East African research programs. You can contact her here: firstname.lastname@example.org.
[…] Regionally, we found that Kenya and Tanzania had the strongest patterns of spatial heterogeneity in the observed outcomes and generally lower probabilities of obtaining all types of care. The lowest probabilities observed were throughout rural districts in northern Kenya and central Tanzania. Conversely, we found Rwanda and Burundi to have generally higher probabilities of obtaining care, as compared to Tanzania, Kenya, and Uganda. This trend could be due in part to the relative density of facilities available, while more remote areas of Kenya and Tanzania have comparatively less facilities and primary or secondary road networks. This pattern also occurred sub-nationally, as we observed higher probabilities of obtaining care in urban versus rural districts, indicating infrastructure density is important in increasing maternal and newborn health-care coverage. Similar findings for Kenya have been reported before in this blog post. […]