RPMM FEATURE

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Regional Prevention of Maternal Mortality Network
Kenya Team

A Determination Born of Despair

In Nyanza Province, the road to the hospital is a bumpy red streak. The soil is the only asphalt, dusty in the dry season, and impassable during the rains. Families living in separate villages often spend weeks without seeing one another after the skies open in the rainy season.

It is this road that pregnant women must take if they develop complications and need emergency treatment. Their choice of transport: the back of a bike, or as one of 20 passengers in a mini-van (matatu) built for 12, facing a surly driver worried about getting blood on his seats.

Even if she makes it to the hospital, there is no guarantee that the woman will find the emergency care she needs. As one community member put it with stark simplicity, "It is cheaper for our women to die at home. You make us send them to hospitals further and further away - sometimes all the way to the capital - and there they die. And then we have to pay to bring the body back".

Starting Up

The scene is a familiar one to practitioners working to prevent maternal mortality. For the Kenya PMM Team, which joined the Accra-based Regional Prevention of Maternal Mortality Programme soon after it was established in 1997, such roads were just one of many issues to face in Nyanza Province.

The Province is home to five million Kenyans. In addition to high maternal mortality, it has one of the highest incidences of malaria in Kenya, among other health problems. It was here that the Team decided to establish a base and carry out its activities to prevent maternal death and disability.

As is the case with teams that have joined RPMM from 16 other countries, the 10-person Kenya PMM team is multi-disciplinary, and includes obstetricians, community physicians, nurse-midwives, social scientists, and anesthetists. They are all volunteers who hold down regular jobs and try to integrate the PMM approach into their daily work.

RPMM itself was established as an African center of excellence by Professor Angela Kamara, following the conclusion of the 1987-96 Columbia University PMM operations research program. RPMM is now one of six partners implementing projects in collaboration with the AMDD Program, in addition to its regular program of activities.

Although it is a relative newcomer to RPMM - the three founding teams were from Ghana, Nigeria and Sierra Leone - word of the Kenya PMM Team's work is spreading to other provinces, and some of its first members have already moved on to high-ranking posts in the capital. They have taken the PMM philosophy with them, and remained attached to the Team as associate members.

Notwithstanding its present-day success, the Team almost decided to quit while it was conducting its needs assessment in 1998 due to the size of the problems faced. It had selected Siaya and Bondo districts because these had the worst health indicators in Nyanza Province. The Team then selected four facilities for their initiative based on case load, complications, infrastructure, staffing, supplies, equipment, and attitudes: Siaya District Hospital together with the Ukwala Health Center, and the Bondo District Hospital together with the Madiany Health Center.

Sizing Up the Problem

It was during the time-motion studies Team members conducted at these four facilities that the Team almost gave up. During her 24-hour shift at the Bondo health facility, Kenya PMM Team member Monica Oguttu, a highly professional nurse-midwife, watched helplessly as a woman who had delivered safely died from eclampsia. There were no drugs whatsoever, and no equipment; staff were completely unprepared to handle such a case.

During his 24-hour facility shift, obstetrician/gynecologist Solomon Orero, the Kenya PMM Team Leader, had to perform an emergency operation. Another Team member gave the family of a woman in difficulty the money for transport to the hospital, but the woman lost her baby by the time she got there.

"We met and talked about our experiences, and we were ready to give up; things just looked too bleak," Monica Oguttu recalled, in her office at the Kisumu Medical Educational Trust in the provincial capital. "But then, we became more determined to carry on. Most of us come from this Province, and these are our people. We had to find a way to deal with these issues".

Dealing With the Findings

In fact, they found several ways. First, the Team organized dissemination sessions on the findings to the community, health providers, government, and donors. Indeed, the community had insisted on feedback: "Are you going to tell us what your findings are, or just go off and use the material for your PhDs like other visitors?" one community member had demanded.

The community feedback proved to be invaluable, generating both spontaneous and sustained engagement. In a sense, the Kenya PMM Team helped the community analyze the problems they faced, something they are not trained or able to do given their daily workloads, and enabled them to identify priorities for action. "You mean to tell us our women are dying just because there is no money for machines to check their blood pressure", one man exclaimed, forking out enough for four machines on the spot.

Since then, the community has, in collaboration with medical staff at the facilities and the Kenya PMM Team, made contributions as diverse as water tanks (families had to get water from the river during operations), fuel for generators (at one facility the staff had to use lanterns), funds for some of the salaries, and well-supplied pharmacies in two out of the four facilities.

The Kenya PMM Team also briefed and engaged donors: the German aid agency GTZ helped to turn an old kitchen at Bondo District Hospital into an operating theater. The Swedish agency SIDA supported a youth center at Bondo. The Lions' Club will repair the Kenya PMM vehicle.

The Team also challenged Kenya Breweries to get involved in community service. Based on the needs assessment, Kenya Breweries decided to repair delivery beds and provide sterilization equipment for the entire province. If this succeeds, the Breweries plan to extend it nationwide. The broken beds are picked up from facilities and repaired at the Kisumu Central Hospital because the "artisans are there, but idle"; the facilities are pledged to provide the mattresses.

The next step is training, and the Kenya PMM Team has prepared a three-week curriculum on life-saving skills and other areas, including record-keeping. The course is being tested on providers from another province. Team members said they deliberately decided not to train staff on record-keeping on site, given frequent turnover, but to include this in the training sessions planned. Family Care International funded the cost of field-testing, while the RPMM Network provided additional funds for the training.

Blood banks, vehicles for emergency transport (doctors sometimes refuse to respond to emergency calls due to the dangerous roads and lack of security), and regular supplies of drugs are amongst the remaining challenges at different facilities. Once the facilities are up to par, the Team will support an information campaign in the community to encourage use of the facilities.

Meanwhile, the PMM intervention has already improved relations between the community and the health providers. In addition, as a result of the intervention, women have become energized, and have lobbied their leaders, threatening not to vote for them if they do not help the community. The dirt road to Madiany has been improved: the community demanded that the authorities provide equipment and workers, while citizens provided the funds.

Sustaining Results

Team members now find satisfaction in PMM results as well as in their personal growth through teamwork. Dr. Chris Oyoo at Kisumu Hospital noted that infections had gone down in Siaya, and referrals were no longer so late. Plus, "I'm now involved in continued education outside our provincial hospital. I first learned about 'social medicine' through PMM".

Part of the Team's success can be attributed to its dedication. Other factors include the existence of a firm but gentle organizing force and a base that can serve as an effective secretariat - Monica Oguttu and her Kisumu Office. A vehicle is also key, since no one would use their own cars on the dirt road. The PMM methodology has also underpinned rigorous needs assessment and good project design, as have the start-up funds and ongoing technical support from RPMM, and the opportunity the Network provides to share experience with other African teams.

The Kenya Team believes its biggest challenge is fund-raising, while maintaining a balance between international and local resources to ensure sustainability. Dr. Khama Rogo, a respected obstetrician/gynecologist who formed the team after meeting RPMM Director Angela Kamara at a Safe Motherhood meeting, also served for a time as sub-regional coordinator for RPMM, in addition to his many responsibilities in Kenya. He believes that a good balance between support and self-reliance is needed to enable local initiative to grow in order to avoid dependency: "Otherwise, rather than holding out their hand to partner, donors end up giving people a wheelchair".

But the balance is not always easy to find. Simply buying a new vehicle for the Bondo Health Center, for example, would not be sustainable; finding a way to maintain the existing vehicle might be. On the other hand, some members of the community and facility staff get disheartened: "You come and give us great ideas; can't you give us just a bit of money as well?" The answers to such questions are generated during the day-to-day work in the field.