Data review process taking place at the Eldama Ravine Hospital.
From 2000 to 2017, the global maternal mortality ratio, deaths due to complications from pregnancy or childbirth, declined by 38 per cent down from 342 to 211 deaths per 100,000 live births. Though a substantive drop, it's less than half of the 6.4 per cent annual rate needed to achieve the UN Sustainable Development global goal of 70 maternal deaths per 100,000 live births.
In Kenya, the maternal mortality ratio and perinatal mortality rate are notably high in comparison, at 362 per 100,000 live births and 29 per 1,000 live births, respectively. Of the 47 counties in the country, fifteen contribute to 98 per cent of maternal mortality in the country. Among those, Turkana County faces challenges and barriers in reporting maternal and perinatal mortality data in the Kenya Health Information System (KHIS).
On its own, inadequate data might not seem like a problem.
However, preventive health measures rely on good data. National health surveillance guidelines recommend accounting for every maternal and perinatal death in a process of systematic tracking, identification of contributing factors, and addressing those factors to prevent avoidable deaths.
Improving Data and Lives at the County Level
In Turkana County, health officials didn't have to look far to start improving data processes. Lodwar County and Referral Hospital accounts for 75 per cent of all maternal and perinatal deaths in Turkana County. Yet, the hospital hadn't performed any perinatal death audits or input reporting in the KHIS tracker.
When hospitals fail to report maternal and perinatal deaths or perform audits, they're creating further gaps in the health system that can lead to more deaths. Without those audits, health providers can't address the issue and improve health services, and lack the data needed to advocate for additional resources.
To address these gaps, the county reproductive, maternal, newborn, child, and adolescent health coordinator and the County Health Records and Information Officer (CHRIO) engaged with the Tupime Kaunti Project to provide mentorship and training support to the hospital's maternity and newborn unit staff on maternal and perinatal death data. The training helped staff develop skills in maternal and perinatal death notification, review, and uploading data into KHIS.
"I am grateful for the support given by the Tupime Kaunti Project," says CHRIO Peter Etee. "Going forward, routine auditing and reporting of perinatal and maternal deaths will ensure reducing preventable deaths."
Ultimately, the hospital improved its reporting of perinatal deaths in the KHIS from zero between January and June 2020, to 28 perinatal deaths reported between July and November 2020.
Taking Preventive Measures
Tupime Kaunti provided similar support to Eldama Ravine Hospital in Baringo County to improve data verification and review. Hospital staff and local health officers now understand the importance of and connection between proper documentation and timely reviews of deaths and identifying actions to prevent further mortality.
"I now have the information and data needed to upload in the system," says Elsie Korir, Sub-county Health Records and Information Officer. "Before, it was an uphill task to get the information. Understanding the data process is key in cultivating a data culture among stakeholders."
With support from Tupime Kaunti, from January to June 2020, the stillbirth rate dropped to 17, down from 30 from July to December 2019. The rate then dropped to 16 in the summer of 2020.
Progress has also been made in Kisumu County, which had a maternal mortality rate of 495 per 100,000 live births—well above the national average. The County adopted and rolled out national guidelines for maternal and perinatal death surveillance response (MPDSR) in 2016. Since then, the Tupime Kaunti Project has supported committees of health workers and officials to identify causes of maternal and perinatal deaths and institute corrective actions. These committees meet regularly to focus on continued response per the national guidelines.
Kisumu County Hospital's response strategy now includes timely audits of maternal deaths and follow-up on the implementation of actions, leading to a decline in the Facility Maternal Mortality Rate from 512 in 2016, to 78 per 100,000 live births in 2019.
One of the more creative solutions to come out of the improved data processes in Kisumu is a consultant hotline for maternity nurses to use during an emergency to call a senior doctor or nurse. After death reviews in 2017 and 2018 revealed that most of the deaths occurred due to delays in clients seeing the facility's obstetrician, the hotline was established to cut through the previously bureaucratic process of getting in touch with the obstetrician on duty.
"It is a good thing to document our small achievements," notes Damaris Moraa, the Maternal and Neonatal Mentor and Deputy Nursing Officer at Kisumu County Hospital. "This will motivate the health workers to continue putting in effort to address challenges that contribute to maternal deaths."
Thanks to the teamwork and support supervision by the county MPDSR committee, responses to distress calls during emergencies have improved, and continued medical education and training on management of obstetric complications have improved health workers' skills to manage common obstetric complications.
Maternal Health is Global Health
Kenya still faces maternal health challenges, but the progress that's been made shows that through coordinated efforts and additional investments, it's possible to find solutions. But, finding those solutions and improving maternal and child health quality of care will only be evident through the data and usage of the health information systems.
As a country, improving the well-being of mothers and children is not only an important public health goal, but aligns directly to the broader focus of the UN Sustainable Development Goal 3, 'Ensuring healthy lives and promote well-being for all at all ages'.
These critical populations' well-being determines the health of the next generation and can predict future public health challenges for families, communities, and the country’s health care system.
Lillian Mageto is Chief of Party of the Tupime Kaunti Project. She has experience in statistical modelling, global and reproductive health, survey design, and capacity development. Lillian is a community and social services professional with a Master of Science degree in social statistics from the University of Nairobi.
Palladium implements Tupime Kaunti (also known as the County Measurement, Learning and Accountability Program, or CMLAP) for USAID. The project supports ongoing efforts to strengthen measurement, learning, and accountability systems to provide high-quality data and synthesized information for planning, implementation, and decision-making in Kenya.