Strikes threaten mothers' health as births by C-sections fall


Strikes threaten mothers' health as births by C-sections fall

Poorer mothers who cannot access the procedure face higher risk of fatal complications during labour

Births by Caesarean sections fell by 26 per cent in one month following the doctors’ strike, raising fears about the state of maternal in Kenya, health data seen by Nation Newsplex shows.

In November last year, 13,300 women gave birth using Caesarean section, as opposed to natural labour. The following month as doctors went on strike that number fell to 9,800, a 26 per cent decline. This suggests that about a quarter (3,500 women) of pregnant women who would have accessed C-sections in public facilities were unable to do so in non-public institutions.

The analysis shows that the number of women who died in childbirth doubled nationally in the first half of 2017 to 857, compared to 413 in the first half of 2016.

Unlike wealthier women who sometimes elect to undergo C-sections, poorer mothers who need the surgery for medical reasons but cannot receive it are at increased risk of fatal complications during labour.

Four in five Caesarean sections performed in the first six months of 2017 were done in faith-based health facilities, a Newsplex analysis of service data recorded daily in the Kenya Health Information System also reveals.

Usually, it is the reverse, with over two-thirds of C-sections being performed in public health facilities. But at one point during the doctors’ and nurses’ strikes, cases in government hospitals dropped to zero, with faith based hospitals taking up most of the load.

Patients who needed to undergo the procedure, which is usually done in government facilities for free under the free maternity program, had to dig deep into their pockets or go without it. That could be either because they lacked money to pay for the service in low cost, non-public health centres, or because faith based hospitals lacked the capacity to handle the numbers of emergencies and birth complications.

With nearly half of Kenyans living below the poverty line and because only a third of Kenyans (31 per cent) have health insurance, according to a 2016 survey by Twaweza East Africa, cost is one of the major factors that keeps women from accessing health services.

According to the survey, the main insurance provider was National Health Insurance Fund which covers 88 per cent of the insured. Other options included insurance coverage from employers (14 per cent).

ANTE NATAL CARE

With two-thirds of Kenyans having no health insurance, lack of access extends to other maternal and child health services such as family planning, antenatal care and vaccinations, with dire consequences. The analysis shows that the number of women who died in childbirth doubled nationally in the first half of 2017 to 857, compared to 413 in the first half of 2016.

Nationally, uptake of family planning services dropped by 14 per cent in the first half of 2016 compared to the same period last year.

But even before the strike maternal death rate in Kenya was already high at 362 maternal deaths per 100,000 live births, according to the latest Kenya Demographic and Health Survey (KDHS).

A C-section costs a facility a lot more than a normal delivery and requires, among other things, specialist personnel and an operating theatre. In FBOs, normal delivery costs around Sh10,000 and the C-sections cost about Sh20,000. But all types of deliveries are free in public facilities.

Most Kenyans opted for FBOs because private hospitals were way more expensive. In the more costly private hospitals, normal delivery costs between Sh40,000 and Sh95,000 while a C-section goes for between Sh140,000 and Sh220,000.

The nurses’ strike ended on November 2 after 151 days while the doctors’ strike that lasted for 100 days was called off in mid- March this year.

As the strikes persisted, St Mary’s Mission Hospital, Lang’ata, experienced an influx of patients. Many of the patients who sought treatment at the faith-based facility were pregnant mothers in the throes of labour pain, having been turned away in major government facilities, from the slums of Nairobi to Limuru and all the way from Thika, basically the Nairobi metropolitan area.

It was a nightmare for health workers at St Mary’s which has a reputation for quality, affordable care. When Newsplex first visited the hospital in January, we found all the beds at the maternity wing fully occupied.

Whereas those who deliver normally usually stay for two days, they were released the same day after the health workers gave them a clean bill of health. Those who underwent C-sections would stay for a day.

Dr Kimani Ngaruiya, the Medical Director at St Mary’s, says some women would be dumped outside the gate by their relatives, probably afraid that they might not get help, as in the other hospitals. “We had no respite but to take them in,” said Dr Ngaruiya.

This situation would persist for the better part of this year, for as doctors returned to work, they met protesting nurses at the gate. Dr Ngaruiya says take-up of all maternal health services at the hospital have increased.

BUNGOMA COUNTY

Bungoma County is a good case study on how events on the national stage were reflected within counties. There were 172 C-sections in public health facilities in the county and 40 in private and faith based facilities in November 2016, before the doctors’ strike started on December 4.
This means that 80 per cent of C- sections were performed in public hospitals before the doctors’ strike. But by January 2017, the number of C-sections in public facilities had dropped to 0 and spiked almost five-fold to 257 in private and faith based hospitals over the same period.

As the doctors strike ended in mid- March and doctors returned to work, the reverse happened. There was a two-thirds increase in C-sections in public facilities in April while the number of procedures in private and faith based facilities dipped by three quarters.

By May, the proportion of C-sections taking place in public facilities in Bungoma was almost back to the pre-doctors strike period with 200 (77 per cent) of surgeries conducted in public hospitals and 59 (23 per cent) done in private or faith based facilities.
However, in June as the nurses went on strike, the number of C-sections in private and faith based hospitals overtook those in public facilities once more. In June, 171 of 190 C-sections (90 per cent) were performed in private hospitals and FBOs, compared to 19 (10 per cent) in public facilities.

By July as the nurses’ strike persisted, almost 100 per cent, or 226 surgeries, were conducted in faith based or private facilities, compared to one in a public facility. The next month not a single C-section was done at a public facility in Bungoma.

Typically, over 90 per cent of deliveries taking place in health facilities occur in government facilities but due to the doctors’ strike, this dropped to 60 per cent in December 2016, and to less than 60 per cent during the nurses’ strike.

Nationally, uptake of family planning services dropped by 14 per cent in the first half of 2016 compared to the same period last year. According a source from the Ministry of Health, this was caused by the lack of nurses and midwifes to administer the family planning methods due to the strike.

The KDHS 2014 indicates that before the strikes one in six married women had an unmet need for family planning services, which means that the strikes made a bad situation worse. Unmet need for family planning refers to fertile women who are not using contraception but who wish to postpone their next birth or stop childbearing altogether.

Most antenatal care in health facilities is provided by nurses. During the doctors’ strike, access and use of antenatal clinic services dropped, but not as much as during the nurses’ strike.

Prior to the strikes, St Mary’s would get about 3,500 ante-natal care visits monthly, which steadily increased by 14 per cent to 3,999 by September.

Likewise, mothers seeking vaccinations for their children increased at St Mary’s. For instance, data on BCG vaccines (against tuberculosis) show previously they would do an average of 500 in a month. This number increased steeply to by 60 per cent to over 800 in October.

Before the strike, the Twaweza survey found that seven in ten Kenyans relied on public facilities compared to two in 10, who depended on private, faith based or NGO facilities.

In the 2017/2018 fiscal year the government allocated Sh4.3 billion to the free maternal healthcare program from a total budget of Sh2.6 trillion.