National Maternal Health Advancement nearing the ditch after Global Gag Rule Executive Order

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After the promulgation of the Constitution of Kenya (2010), maternal health projects saw light and there was hope of finally acknowledging women and upholding their rights. This was seen as a step in the right path after the National Guidelines for reducing maternal mortality and morbidity from unsafe abortion in Kenya were instituted in September 2012.On the eve of Madaraka day in 2013, His Excellency the President declared free access to maternal services in all public health facilities which was a notch higher towards realizing global development.

However, on 3rd December 2013, the then Director of Medical Services withdrew the same guidelines under unclear circumstances which caused uproar among reproductive health advocates nationally. This marked the beginning on the bumpy industry as the providers were reluctant to provide comprehensive reproductive health services.

According to a study carried out by African Population and Research Center in 2012, an estimated 464,690 induced abortions occurred in Kenya in 2012, corresponding to an induced abortion rate of 48 abortions per 1000 women of reproductive age (15-49 years), and an induced abortion ratio of 30 abortions per 100 births in 2012. This high rates and complications from unsafe procedures accelerated maternal deaths nationally.

At the global arena, the former US President’s Administration was supportive of the maternal health programs but as expected by many reproductive health advocates, the Trump administration was to be a backlash. Little be told that, majority of the people around the world had expected Hillary Clinton to win the US elections and hence many were comfortable that there was to be a buy-in and continuation of the Obama Legacy. This meant that there was no contingent plan as what would be the next step in case the unforeseen happens, which indeed happened.

Every time there is a new administration in US, there is always that critical decision on whether or not to adopt the Mexico City Policy. First announced in Mexico City in 1984 by President Reagan’s administration, the policy requires all nongovernmental organizations operating abroad to refrain from performing, advising on or endorsing pregnancy by choice initiatives if they wish to receive federal funding. To date, support for the Mexico City Policy has been strictly partisan: it was rescinded by Democratic President Bill Clinton on 22 January 1993, restored by Republican President George W Bush on 22 January 2001 and rescinded again by Democratic President Barack Obama on 23 January 2009 and again restored a few days ago by President Trump.

The Global Gag Rule or Mexico City Policy stipulates that taxpayer dollars should not be used to pay for pregnancy by choice programs or related services (such as counselling, education or training). The impact of the Policy is an increase in maternal deaths and morbidities aggravated by unsafe abortions. This move will deny thousands of the Kenyan Women access to the comprehensive reproductive health services through the Ksh. 60 billion annual grant from the US government. As of today, 220million women from developing countries have unmet need for family planning in which Kenya is included.

Alternative avenues need to be portrayed for the women to have a voice in this world at this stage. Most recently the Canadian and Dutch governments have come in support for women and will fill the void left by USAID in the developing nations. More needs to be done across the globe

Counties with highest burden Maternal Mortality

 

COURTESY OF UNFPA Kenya

13th August 2014

Maternal mortality is one of the indicators of reproductive health status of the population. Efforts to reduce maternal deaths have for decades been a focal point of international agreements and a priority for women’s rights and health groups throughout the world because a maternal death is one of life’s most tragic outcomes. The irony is that almost all maternal deaths are entirely preventable given proper medical surveillance and intervention.

In the last round of censuses, the United Statistics Statistical Division (UNSD) encouraged many developing countries to include questions on pregnancy related deaths as a way of helping improve on the quantity and quality of data needed in the estimation of maternal mortality in the world. This was subsequently adopted in the 2009 Kenya Population and Housing census.   Respondents were asked to report any death in the household in the last 12 months prior to enumeration. These were subsequently named the recent deaths in the household.  Among the deceased females age 12 to 49 subsequent questions were asked on whether the female deaths were pregnancy related (i.e. during pregnancy, during delivery or within two months after delivery).

Measurement of maternal mortality

Several indicators are used to measure maternal mortality in order to display sources of different risks as well as interventions. In the first place, all maternal deaths as outcomes from pregnancy and the first definition ispregnancy-related death which is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.  When information on the cause of death is available, then we have maternal death, which is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

However, for comparison purposes between different contexts due to differences in the risk of pregnancy maternal mortality ratio (MMR) are often used. Maternal mortality ratio (MMR) is thus the number of maternal deaths during a given time period per 100,000 live births during the same time period. MMR captures the risk of death in a single pregnancy or a single live birth or in technical terms it measures the extent of obstetric risk.

In the entire country, a total of about 32,021 women of reproductive age were reported to have died out of which 6,632 died of pregnancy related causes. Out of the total number of women of reproductive age who had died, 21 percent was as a result of pregnancy related causes. Table 1 shows the ranking of top 15 counties by number of maternal deaths and maternal mortality ratio. Columns 1-3 are the ranks by number of   maternal deaths. It indicates that only 15 out of 47 counties account for 98.7 % of the total maternal deaths in the country. However, the number of deaths masks important considerations such as the size of women population in the region as well as the frequency of pregnancies, an alternative ranking is by maternal mortality ratio which takes into account the obstetric risk. This is provided from column 4 to 6. Mandera and Wajir still rank highest in terms of absolute number of maternal deaths as well as the increased obstetric risks.

 

TABLE 1: RANKING OF COUNTIES BY NUMBER OF MATERNAL DEATHS AND MATERNAL MORTALITY RATIO

Rank Region maternal deaths Rank Region Maternal mortality ratio (deaths per 100,000 live birth
KENYA 6,623 KENYA 495
1 MANDERA 2,136 1 MANDERA 3795
2 WAJIR 581 2 WAJIR 1683
3 NAIROBI 533 3 TURKANA 1594
4 NAKURU 444 4 MARSABIT 1127
5 KAKAMEGA 364 5 ISIOLO 790
6 KILIFI 289 6 SIAYA 691
7 NANDI 266 7 LAMU 676
8 BUNGOMA 266 8 MIGORI 673
9 HOMABAY 262 9 GARISSA 646
10 MIGORI 257 10 TAITATAVETA 603
11 KISUMU 249 11 KISUMU 597
12 SIAYA 246 12 HOMABAY 583
13 TRANSNZOIA 234 13 VIHIGA 531
14 GARISSA 208 14 SAMBURU 472
15 KWALE 203 15 WESTPOKOT 434
Other counties 85
Total 6,538
Percent of the total number of deaths 98.7

 

Although Nairobi, Nakuru, Kakamega, Kilifi, Nandi Bungoma, and Kwale rank higher in terms of number deaths, in terms of MMR they do not rank higher. In terms of the maternal mortality burden it is therefore important to include risks in number of deaths as well as obstetric risk. This is shown in Table 2. At national level nearly half of deaths (48 %) occur during delivery. In 5 counties (Lamu, Garissa, wajir, Mandera and Turkana) over half of deaths occur during delivery. The county with highest proportion dying during pregnancy is Marsabit. Siaya, Kisumu and Taita taveta have the highest proportion dying in the post-partum period. The implication here is that different factors influence the risk of maternal death in the different counties. Kenya is among the top 10 Countries with the highest number of HIV-associated maternal deaths and about 20 percent of maternal deaths is indirectly related to HIV. Thus HIV may be important in Nyanza region counties which have the highest prevalence of HIV while other factors may be important in Mandera, Wajir and Garissa with low prevalence of HIV.

 

TABLE 2: RANKING OF COUNTIES BY BURDEN OF MATERNAL MORTALITY

County Maternal deaths MMR Percent of deaths during
Pregnancy Delivery 2 months after delivery
Mandera 2,136 3795 28 56 16
Turkana 175 1594 24 54 22
Wajir 581 1683 28 60 12
Migori 257 673 24 45 30
Nakuru 444 374 28 40 31
Siaya 246 691 22 28 50
Kisumu 249 597 18 33 48
Nairobi 533 212 25 38 38
Homa Bay 262 583 22 34 43
Kakamega 364 316 20 44 36
Garissa 208 646 25 61 13
Marsabit 97 1127 30 47 23
TaitaTaveta 129 603 16 36 48
Isiolo 32 790 25 56 19
Lamu 52 676 10 65 25
Kenya 6,623 495 26 48 26

– See more at: http://kenya.unfpa.org/news/counties-highest-burden-maternal-mortality#sthash.tt7GUS3y.dpuf

Teenage Pregnancy: Who To Blame?

By IJEOMA POPOOLA
For fear of facing public reproach, Susan, a student, ran away with her three-month-old pregnancy to a village in the outskirts of Ibadan with the collaboration of her mother, the teenage girl relocated to her aunt’s house where she gave birth to a baby girl and nursed her for one year. Susan, thus, dropped out of school and took to petty trading to meet the needs of her baby, Ajoke.

Numerous Nigerian teenage girls suffer the same fate with Susan, as those considered brilliant among them have had to abandon their education while their future is jeopardised due to unwanted pregnancy. A medical doctor, Miss Martina Opara, says that unguided adolescents are easily impregnated because of the physiological developments taking place in them she explains that teenagers are easily excited sexually because of the biological changes in their bodies, including production of sex hormones. The doctor advocates that adolescents should be made to understand these physiological changes to avoid unwanted pregnancy, and notes that such pregnancies contribute to maternal and child mortality.

Opara explains that some of teenagers die during pregnancy because they are too young to have the babies, while others lose their lives because of the lack of care as the men who put them in the family way deny responsibility for the pregnancy in most cases. Analysts observe that some non-governmental organisations (NGOS), JP shown concern about teenage pregnancies and are tackling the menace. One of such organisations is the Association of Reproductive and Family Health (ARFH), which has launched campaigns on adolescent reproductive health in many parts of the federation. According to the President of ARFH, Prof. Oladapo Oladipo, teenage pregnancies can be reduced through intensive adolescent reproductive health education, proper parental guidance and peer education. During a visit by some journalists to the ARFH Comlex in Ibadan recently, Oladapo explained that sexual urge was natural, but noted that sex education of adolescents would enable them to understand the implications of early sex.

He advised parents to redouble their effort in guiding their teenagers properly and instilling sound moral values and discipline in them. Oladapo is worried that teenage pregnancy and its attendance unsafe abortion and maternal mortality are a threat to adolescent reproductive health which, he says, is the key to the attainment Millennium Development Goal (MDG) in the area of improved child and maternal health. According to him, ARFH has trained a large number of peer educators to carry the campaign against teenage pregnancy to every part of the country.
In addition, the organisation has established a Youth Rescue Club to support the campaign.
Members of the club are mainly teenagers who have formed opinions on teenage pregnancy as result of their experience in the advocacy campaign. A secondary school leaver and the Public Relations Officer of the club, Mr. Olatunde Adedeji, blames teenage pregnancy on poverty, ignorance and inferiority complex by adolescents. He says teenage pregnancies are more rampant in the rural areas ravaged by poverty and ignorance. But a 20-year-old undergraduate, Miss Bushrah Fagbohun, does not believe that teenage pregnancy is restricted to the poor and ignorant parts of the country, teenage pregnancy is celebrated; in fact it is to show that one is a ‘big’ girl. “It is common in both public private schools. It also occurs in the urban centres,” the medical student of the Ladoke Akintola University. Ogbomoso, argues.

She advocates abstinence from sexual intercourse as the best way to avoid teenage pregnancy and adds that peer educators should possess the persuasive skill to convince teenagers to abstain from sex. You have to hammer it so much before they will listen to you.”
But Oreoluwa Kolawole, also an undergraduate, does not believe that all teenager can abstain from sex.
He says that it is, therefore, very important” to educate teenagers proper on their reproductive health.
Kolawole suggests that reproductive health education be incorporated into the school curriculum at all levels. This, he says, will enable teenagers to know when they are likely to be pregnant if they have sex.
Another peer educator, Tosin Odekunle, wonders why some informed teenagers St’ fall victim of unwanted pregnancy, but 19-year-old Ben John explains that sexual urge can be irresistible when a person’s level of control is low.
“When you are attracted to a girl, the urge comes on,” he says, adding that urge is triggered mainly by the sight of a woman’s exposed body. John expresses dismay at the skimpy dressing among teenagers now a days saying that it contributes to teenage pregnancy.
He advises male teenagers attracted to their female counterparts to overcome sexual urge by keeping a distance from the girls.
For 18-year-old Miss Tomi Adepoju, teenagers and women generally are provocative their dressing, claiming that the women dress to satisfy their tastes but end up provoking the men’s sexual urge ultimately inflicting teenage pregnancy and its resultant effects on the society. Adepoju appeals to teenagers to dress modesty to avoid seducing the men into having sex with them. “Girls should not be selfish in their dress they should consider the feelings of the men,” she says. The teenager, however, does not blame the females alone. she points Out that men also harass the teenage girls sexually by deliberately pulling down their jeans trousers to the waist in the fashion mode known as “saggy” or “baggy” trousers.
She blames the indecent dressing on fashion trends, but urges teenagers to be careful.
Adepoju also appeals to parents to inculcate sound morals, including decent dressing, in their children and wards.

Another peer educator, Yemi Konigbagbe, 19, expresses concern that parents to longer create time to inculcate morals and discipline in their children because of their quest for money. ‘ . Parents do not have time to guide their children anymore. This leads to all kinds of indiscipline, including sexual intercourse, among teenager ‘’ he says.
For Miss Chinenye Nwokoro, teenage pregnancy is not only caused by poverty, ignorance, inferiority complex and parental failure, but is culture-induced. She describes the culture of teenage wives in some parts of the country as worrisome. Nwokoro also notes that the quest for male children by parents contributes to the menace, saying that some parents who do not have male children encourage their teenage girls to get pregnant so they can possibly bear male children.

According to a Senior Programmes officer of ARFH, Mr. Oladapo Adeyemi, sexual intercourse is like a recreation for teenagers in the rural areas due to the lack of recreational facilities in the hinterland.1 expresses regret that this has bloated the number of teenage pregnancies. The official also points out that regular intercourse between male adults and teenagers is rampant in the rural areas.
“In February 2009, there was a case of a step-father having regular intercourse with his step-child”.
Adeyemi says that the non-domestication of the child Rights Act in some states of the federation hinders the prosecution of such cases. As the trend is becoming increasingly worrisome, analysts are calling collective effort in eradicating teenage pregnancy to facilitate Nigeria’s realisation of the fifth MDG on improved child and maternal health.