From the Department's safe motherhood lecture (photographed slides), with the Kenyan figures from the slides. Examiners love this topic because it joins clinical care to the health system.
The reasoning chain: why do women and newborns die → which deaths could have been prevented → at which of the three delays did care fail → which pillar of maternal and newborn health would have changed the outcome → how does the system (skilled attendants, referral, community, rights) make it happen.
1. Maternal mortality: definition and types
Maternal death (WHO): the death of a woman while pregnant or within 42 days of the end of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
| Type | Meaning |
|---|---|
| Direct | Result from obstetric complications of pregnancy, labour and the puerperium, or from interventions, omissions or incorrect treatment |
| Indirect | Result from pre-existing disease or disease that developed in pregnancy (not a direct obstetric cause) that was aggravated by the physiological effects of pregnancy: in our setting malaria, HIV/AIDS and anaemia |
The five major direct causes, in order of frequency: 1. haemorrhage, 2. sepsis, 3. hypertensive disorders, 4. complications of abortion, 5. obstructed labour. About 13% of all maternal deaths occur in adolescents, mostly from unsafe abortion.
Causes of maternal death in Kenya (slide figures)
| Cause | Share |
|---|---|
| Haemorrhage | 45% |
| Sepsis and infections | 13% |
| Hypertensive disorders | 12% |
| HIV/AIDS | 9% |
| Obstructed labour | 6% |
| Abortion | 5% |
| Other direct causes | 10% |
2. Maternal morbidity
For every woman who dies, about 30 more suffer long-term injury or illness from pregnancy and childbirth complications. Maternal morbidity is any symptom or condition resulting from or made worse by pregnancy.
Severe maternal morbidity ("near miss") is any pregnant or recently delivered woman (within 6 weeks of the end of pregnancy) whose immediate survival is threatened and who survives by chance or because of the hospital care she receives. Reviewing near misses teaches how to prevent deaths.
Common causes of morbidity: hypertensive disorders, stillbirth, preterm delivery, induced and spontaneous abortion, haemorrhage (antepartum, intrapartum, postpartum), anaemia, uterine rupture, obstructed labour, postpartum and antenatal depression, placental anomalies (praevia, abruption), gestational diabetes, ectopic pregnancy, premature rupture of membranes and perineal lacerations.
3. Newborn mortality
Maternal health and newborn survival are linked: lack of antenatal care, unskilled birth attendance and no postnatal care all raise newborn deaths.
- About four million babies die every year in the first four weeks of life (the neonatal period); many more are stillborn.
- Three quarters of neonatal deaths happen in the first week, and the highest risk is in the first 24 hours.
- About 99% of neonatal deaths occur in low- and middle-income countries.
- Top three causes in Africa: prematurity (29%), severe infections (28%) and birth asphyxia (27%).
- Kenya (slide, 2008): birth asphyxia and birth trauma 29%, prematurity 28%, neonatal sepsis 23%, congenital anomalies 7%, pneumonia 4%, diarrhoea 2%, tetanus 1%.
4. Why women and babies die: the three delays
(Thaddeus and Maine, 1994)
| Delay | Causes |
|---|---|
| 1. In deciding to seek care | Socio-cultural barriers, failure to recognise danger signs, failure to perceive the severity, cost |
| 2. In reaching a facility | Long distance, poor roads, no transport, cost |
| 3. In receiving adequate care at the facility | Shortage of staff, supplies and equipment, untrained personnel, user fees |
Fix them: birth plans and community education (delay 1), transport schemes and a working referral system (delay 2), and well-staffed, well-equipped facilities with emergency obstetric care (delay 3).
5. Interventions that reduce maternal mortality in Kenya
- ANC attendance (focused ANC) and postnatal clinic attendance
- Skilled birth attendance
- HIV testing, ART and PMTCT
- Family planning: more availability and uptake to cut the unmet need for contraception
- Competent providers in maternal and newborn health, and more health facilities for access
- Free maternity services (Linda Mama, NHIF cover)
6. The Kenya Maternal and Newborn Health (MNH) model: six pillars
Standing on a base of skilled attendants and an enabling environment, supportive health systems, community action, partnerships and male involvement, and equity and human rights for all:
| Pillar | Purpose |
|---|---|
| 1. Family planning and pre-pregnancy care | Information and services to plan the timing, number and spacing of pregnancies |
| 2. Focused antenatal care | Prevent complications where possible and detect and treat them early |
| 3. Essential obstetric care | Make care for high-risk pregnancies and complications available to all women who need it |
| 4. Essential newborn care | Care for newborns from birth to 28 days to prevent complications |
| 5. Targeted postpartum care | Prevent complications after childbirth, keep mother and baby healthy and prevent transmission of infection from mother to child |
| 6. Post-abortion care | Clinical treatment of incomplete abortion and miscarriage complications, plus counselling and contraception |
7. The foundations
Skilled attendance
Only two interventions have been shown to improve maternal health and reduce maternal deaths: skilled attendance at delivery (skills, numbers and an enabling environment) and availability of emergency obstetric care. A skilled attendant means a person with midwifery skills (doctor, midwife, nurse, clinical officer) trained to be proficient in managing normal deliveries and diagnosing and referring obstetric complications. A traditional birth attendant is not a skilled attendant. The skilled attendant needs an enabling environment: infrastructure, an effective referral system, and supplies, equipment, drugs, good management and supportive supervision.
Emergency obstetric care (EmOC): the "signal functions"
| Basic EmOC (BEmOC) | Comprehensive EmOC (CEmOC) |
|---|---|
| IV or IM antibiotics, uterotonics (oxytocin), IV anticonvulsants (magnesium sulphate), manual removal of the placenta, removal of retained products, assisted vaginal delivery, and newborn resuscitation | All of the basic functions plus caesarean section and blood transfusion |
WHO benchmark: at least five EmOC facilities per 500,000 people (including at least one comprehensive).
Community action, partnerships and male involvement
Involve women, families, providers and local leaders. Community education on obstetric complications, when and where to seek care, birth preparedness cards, and early recognition of complications. Male participation is essential (men are often the decision-makers and hold the resources), and it is critical in addressing the first and second delays.
Equity and human rights
A rights-based approach legitimises prioritising women's health, focuses attention on social, economic and geographic inequities and needs political support and national ownership. Safe motherhood is a basic human right: most maternal and newborn deaths are avoidable.
Referral systems
A functioning referral system is key: a telephone and/or vehicle with emergency funds or fuel, day and night; good records and detailed referral letters; communication between community providers and the referral facility; supportive supervision, feedback and in-service training; and telemedicine to reduce unnecessary referrals. Levels of care: community (level 1) → dispensaries/clinics (2) → health centres, maternities and nursing homes (3) → primary hospitals (4) → secondary hospitals (5) → tertiary hospitals (6).
Examiner questions
- Define maternal death and list its direct and indirect causes in Kenya.
- Explain the three delays and give one intervention for each.
- Name the six pillars of the Kenya MNH model.
- What are the signal functions of basic and comprehensive emergency obstetric care?
- What is a "near miss" and why do we audit them?
Practice questions
1. The commonest direct cause of maternal death in Kenya is: A. Sepsis · B. Hypertensive disorders · C. Haemorrhage · D. Obstructed labour · E. Abortion Answer: C. About 45%.
2. A woman dies after a 6-hour delay on a bad road before reaching the hospital. This is the: A. First delay · B. Second delay · C. Third delay · D. Fourth delay · E. Not a delay Answer: B. Delay in reaching a facility.
3. Which of the following is NOT a signal function of basic emergency obstetric care? A. Parenteral antibiotics · B. Oxytocin · C. Magnesium sulphate · D. Manual removal of the placenta · E. Caesarean section Answer: E. Caesarean section and blood transfusion are comprehensive EmOC.
4. The WHO definition of a maternal death uses a time limit of: A. 7 days · B. 14 days · C. 28 days · D. 42 days · E. 1 year Answer: D.
5. The leading causes of neonatal death in Africa are: A. Malaria, TB, measles · B. Prematurity, severe infection and birth asphyxia · C. Congenital anomalies only · D. Tetanus and diarrhoea · E. Injuries Answer: B.