KENYA
The Making it Happen Programme
The aim of the Making it Happen Programme (MiH) is to reduce maternal and newborn mortality
and morbidity by increasing availability and improving the quality of Skilled Birth Attendance (SBA)
and Emergency Obstetric and Newborn Care (EmONC).
Between 2012 and 2015, the MiH Programme will be delivered in 11 countries: eight in Sub-Saharan
Africa (Ghana, Kenya, Malawi, Nigeria, Republic of South Africa, Sierra Leone, Tanzania and
Zimbabwe) and three countries in Asia (Bangladesh, India and Pakistan).
The Making it Happen Programme has five outputs:
Output 1: Increased health service provider capacity to provide Emergency Obstetric and Newborn
Care (EmONC)
Output 2: Increased availability of EmONC for mothers and babies
Output 3: Strengthened accountability for results with increased transparency
Output 4: Strengthened capacity to sustain improvements in maternal and newborn health service
delivery
Output 5: Evidence generated by programme disseminated in order to inform national, regional and
global agenda
The programme includes three major interventions:
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Emergency Obstetric & Newborn Care training courses
Making it Happen with Data (Monitoring & Evaluation framework)
Quality Improvement
The Centre for Maternal and Newborn Health (CMNH) at the Liverpool School of Tropical Medicine
(LSTM) serves as the global coordinating centre for the MiH Programme.
The Making it Happen Programme in Kenya
The Making It Happen Programme is implemented in Kenya in cooperation with the Ministry of
Health. The following specific interventions are covered under the log frame for MIH Kenya:
Emergency Obstetric & Newborn Care Training Courses: 6,400 in-service health care providers, 240
pre-service health care worker and 180 master trainers will be trained in Emergency Obstetric and
Newborn Care (EmONC).
Making it Happen with Data: 166 health care providers and manager will be trained in the
collection, aggregation and use of routine data to inform practice.
Quality Improvement: 180 health care providers will be trained in quality improvement
methodology, including audit and death reviews (MPDSR).
BASELINE SURVEY RESULTS AND GRAPHS:
Under the Making it Happen Programme (MiH) baseline surveys were conducted in 2012 and 2013
for 120 health care facilities. Of these, 26 health care facilities are designated to provide
Comprehensive EmONC and 94 are designated to provide Basic EmONC services. The survey
identified that 3/26 CEmONC facilities (11.5%) were able to provide all nine required signal functions
and only 7/94 BEmONC facilities (7.5%) were able to provide all seven required signal functions. The
total number of deliveries was 25,050 (BEmOC=7,811 and CEmOC=17,239) in the previous 3 months
of the baseline surveys. The total number of Health Care Providers working in maternity area was
1,692 (BEmOC=1,172 and CEmOC=520). The Case Fatality Rate in all the facilities was 2.01
((BEmOC=2.56 and CEmOC=1.94). The Still Birth Rate in all the facilities was 2.45 (BEmOC=1.44 and
CEmOC=2.90).
Graphs:
Figure1: Number of facilities surveyed; facilities identified for intensive M&E:
Number of facilities
Number of facilities surveyed
100
80
60
40
20
0
Type of facility
Facilities for
intensive M&E
BEmOC
CEmOC
Type of facility
Figure 2: Number of deliveries in the facilities:
Country information
The Kenya is divided into 47 counties. Each county is further subdivided into sub counties
districts and there are a total of 46 sub counties in Kenya. Following the new constitution from
2009, devolution was implemented in 2013 from eight provinces to the 47 counties with
decentralized local governments which will take greater responsibility for the administration of
health care.
Kenya has a population of about 41.6 million (World Bank, 2011)1 and was ranked as 145 out of 172
countries in 2012 in the (Human Development Index 2013)2.
Approximately 76% of the population in Kenya live in rural areas (World Health Statistics 2013). The
average life expectancy is 61 years for women and 58 years for men (World Health Statistics 2013).
In 2012 HIV-prevalence in Kenya was 6.1 (UNAIDS)3.
Key MNH Indicators
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Maternal Mortality Ratio: 360/100,000 live births (2010)*
% Skilled Birth Attendance: 43.8 (2008)**
% Contraceptive Prevalence Rate: 45.5 (2009)**
Total fertility rate (per woman): 4.7 (2011)***
Ante-Natal Care (at least one visit): 91.5 (2009)**
*: WHO statistics, 2013 http://apps.who.int/gho/data/kenya: Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and the
World Bank. Geneva, World Health Organization, 2012 (http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf).
**: Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health Survey 2008-09. Calverton, Maryland:
KNBS and ICF Macro.
***: World Population Prospects: the 2010 Revision. New York, Population Division, Department of Economic and Social Affairs, United
Nations Secretariat, 2011.
1World
2
3
Bank data. 2011. http://data.worldbank.org/country/kenya (accessed June 2013).
Human Development Index 2013 (http://hdr.undp.org/en/media/HDR2013_EN_Summary.pdf, accessed November 2013).
UNAIDS (http://www.unaids.org/en/regionscountries/countries/kenya/, accessed November 2013).
Map of Kenya illustrating target regions and distribution of health care facilities for MiH
The Making it Happen Programme in Kenya will be implemented in fifteen counties between 2012
and 2015 (formerly Western Province, Nyanza Province and Central Province):
Western Province
Nyanza Province
Central Province
Kakamega
Kisumu
Nyeri
Bungoma
Homabay
Muranga
Busia
Nyamira
Kiambu
Siaya
Kisii
Kirinyaga
Vihiga
Migori
Nyandarua
Organisation of Health Care Delivery
The major health care implementing agencies in Kenya are the Ministry of Health. The public
delivery system is organised in a traditional pyramidal structure. First-level care is provided at
dispensaries and medical clinics. The next level comprises health centres and sub-district hospitals.
Third-level care is provided at district hospitals and provincial general hospitals (KDHS, 2009)4.
Human Resources for Health
The Kenya government places a high priority on staff training at all levels of health care provision in
the Kenya Essential Package for Health through its key initiative - The National Health Services
4
Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health Survey 2008-09. Calverton, Maryland:
KNBS and ICF Macro.
Strategic Plan. Various cadres of health care workers in Kenya provide maternal and newborn care:
These include obstetricians, medical doctors, clinical officers and nurse-midwives. 70.4 % of all
government employed medical staff work in hospitals (of which 7 are Provincial and 132 are
District/sub-district hospitals). Most health centres are understaffed; 48.6 % of them have fewer
than 3 nurses/midwives, which makes it difficult to provide continuous Emergency Obstetric and
Newborn Care services (KDHS, 2009)2.
Maternal & Newborn Health Situation
Total fertility rate was 4.7 children per woman in 2011 with a contraceptive prevalence of 45.5% in
2009 (World Health Statistics 2013). 92% of mothers used a health care professional at least once for
antenatal care for their most recent birth in 2008 (MDG Global Data Base, as above).
The reduction of maternal and neonatal mortality is one of the key goals of the Millennium
Declaration. An important part of reaching this goal is the provision of skilled attendance and
essential (or emergency) obstetric care (EOC) for pregnant women during labour, delivery and the
immediate postpartum period.
Hogan et al estimated the maternal mortality ratio (MMR) as 413 (236–678) per 100,000 Live births
(regional MMR 508 (430–610) (Hogan et 2010)5. WHO estimates MMR as 360 (230 – 590) per
100,000 Live births (World Health Statistics 2013, WHO, UNICEF, UNFPA, World Bank (2012) Trends
in Maternal Mortality: 1990 - 2010). Under-Five mortality rate was 73 per 1,000 Live births and
Neonatal Mortality Rate was 27 per 1,000 in 2011 (World Health Statistics 2013). The stillbirth rate
was estimated as 22 per 1,000 Live births in 2009 (World Health Statistics 2013).
Skilled Birth Attendance and Emergency Obstetric and Newborn Care
92 % of women in Kenya receive antenatal care from a medical professional, either from
doctors (29 %), or nurses and midwives (63 %). A very small fraction (less than 1 %) receives
antenatal care from traditional birth attendants, and 7 % do not receive any antenatal care at all.
Trends in use of antenatal care show that the proportion of women who received care from a
trained medical personnel rose from 88 % in 2003 to 92 % in 2009 (KDHS 2009).
Increasing the proportion of babies that are delivered in health facilities is an important factor in
reducing the health risks to both the mother and the baby. 43 % of births in Kenya are delivered in a
health facility, while 57 % of births take place at home (KDHS 2009).
Overall, 44 % of births in Kenya are delivered under the supervision of a skilled birth attendant,
usually a nurse or midwife. Traditional birth attendants continue to play a vital role in delivery,
assisting with 28 % of births (the same percentage as assisted by nurses and midwives). Relatives
and friends assist with 21 % of births, and for 7 % of births, mothers do not receive any form of
assistance (KDHS, 2009)2.
An Emergency Obstetric and Newborn Care Assessment was performed in Kenya (EOC&NC, 2011)6.It
showed that in 80% of all health facilities not all signal functions of EOC were performed. This was
especially prominent for the use of magnesium sulphate, assisted vaginal delivery, manual removal
of placenta and retained products and these especially in level 2 and 3 facilities.
In order to standardize and harmonize efforts of the Ministry of Public Health and Sanitation and its
partners to attain MDG4 and 5 in Kenya Family Health Division (FHD) together with a technical
5
Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Makela SM, Lopez AD et al. 2010. Maternal mortality for 181 countries, 1980-2008: a
systematic analysis of progress towards Millennium Development Goal 5. Lancet; April 12: 1-15.
6
A Murage, L Kizito. 2011. Emergency Obstetric and Newborn Care Assessment. Kenya: Report to Ministry of Health.
working group developed a 5-day curriculum for Emergency Obstetric and Newborn Care to be used
by all agencies for training from 2013 onwards. This curriculum was field-tested and adapted during
EmOC&NC courses under the Making it Happen programme in 2012 and 2013. A review workshop
chaired by the Family Health Division has recently reviewed the timetable and training material.
Kenya is one of the countries implementing the United Nation’s Maternal (and Perinatal) Death
Surveillance and Response (MDPSR) intervention to improve accountability and reporting on
maternal and perinatal deaths. In the 15 MIH counties, this intervention is implemented under the
quality improvement component of the programme together with Reproductive and Maternal
Health Unit under the Division of Family Health. The MPDSR trainings and interventions will target
health care workers at facility level as well as managers at Sub County and county level. Follow up on
reporting of maternal and perinatal deaths reporting as well as verbal autopsies will be linked to the
quarterly MIH data follow up visits.