Maternal and Perinatal Death Surveillance and Response Kisumu County, Kenya Dr. Elisabeth Ogaja

1. Maternal and Perinatal Death Surveillance and Response Kisumu County, Kenya Dr. Elisabeth Ogaja County Minister for Health Services and Promotion of Health Investments

2. Kisumu County Population: 1.1 million people, of which 47% live in poverty. The county has both rural and urban, including slum, settings and hosts Kenya’s 3rd largest city. Tropical climate. High prevalence of malaria (30%), and HIV (19.3%) High maternal mortality ratio (597 per 100,000 live births) KNBS, 2009

3. WHY KISUMU HAS PROGRESS ED IN MPDSR • GOVERNORS Communique, • Commitment by the top leaders to personally attend the meetings • Suffering many funerals in each meeting. • Need to know why women are still dying in high numbers • Kisumu: MMR = 597/100,000 Live Births (Kenya= 362/100,000 LB) • Kisumu is among the 15 Counties (out of 47 )in Kenya contributing 98.7% of total maternal deaths

5. Governors communique Below is the commitment that the 15 governors signed to: • 1.    Recognize that Kenya has made substantial progress to achieve the Millennium Development Goals, with the exception of MDG 5 (maternal health). We are concerned that the maternal mortality ratio for Kenya of 488 maternal deaths per 100,000 live births has not shown any improvement over the last two decades. • 2.    Recognize the urgent need for scaled-up action and targeted interventions by improving access to quality healthcare for women, newborns and child health, particularly in the high-burden counties but subsequently to be rolled out across the country-in order to accelerate progress on MDG 5. • 3.    Recognize that maternal, newborn and child health, and the survival of mothers and their newborns, are central to development; the empowerment of women to make informed choices are critical to improving the health of women, families and communities; and that adolescent girls have a higher chance of dying in pregnancy and childbirth and face grave barriers to life-saving information and services. • 4.    Recall the Consensus Statement of the Global Country Consultation on Targets and Strategies for Ending Preventable Maternal Mortality (EPMM) of April 2014 in Bangkok, Thailand, that recognized EPMM is within reach, and that necessary acceleration of progress can be achieved by positioning maternal survival in the context of every woman's right to healthcare and the highest attainable level of health across the lifespan. • 5.    Recall the World Health Assembly Resolution of May 2014 on the Global Newborn Action Plan (WHA67.10) that commits to end preventable newborn deaths, and preventable stillbirths, through investments in high-quality care before, during, and following childbirth. • 6.    Recognize the urgent need to scale up action by improving access to quality healthcare for women, newborns and child health irrespective of the geographic location. • 7.    Build on the momentum of the First Lady's Beyond Zero Campaign that is about saving lives of Kenyan mothers and children. • 8.    Recognize that adolescent girls must be at the center of our policies and programmes; and we have the largest youth generation and we must empower them to become agents of change. • 9.    Share innovative and best practices implemented across countries and key strategies that County Governments need to undertake to accelerate the reduction of maternal and newborn deaths. We commit to collectively scale up support to and strengthen reproductive, maternal and newborn health systems in our respective counties where needs are greatest and rea­rm our commitment to stay focused on this ‘un‑finished' MDG 5 agenda and reach those with least access - the most marginalized, disadvantaged populations, including women and girls. • 10. Enhance high-level advocacy and sensitize local authorities on the urgency to improved and equitable access to maternal, newborn and reproductive healthcare, including the elimination of harmful traditional and cultural practices.

6. Governors communique (contd.) • 11.  Increase county-level investments in healthcare and ensure adequate human and financial resources towards maternal and newborn health. • 12.  Uphold the principles of equity, human-rights, gender equality that guide the provision and access of high-quality maternal and newborn healthcare for all. • 13.  Improve the healthcare infrastructure to support the delivery of emergency obstetric and newborn care services. • 14.  Strengthen data collection, analysis, documentation and information use for evidence in tracking progress in the implementation of maternal and newborn morbidity and mortality. • 15.  Undertake a multi-sectoral approach for the improvement of infrastructure to support access to roads and transportation, clean water and sanitation, and appropriate nutrition. • 16.  Strengthen public-private partnerships at all levels to leverage resources for addressing maternal and newborn morbidity and mortality. • 17.  Invest in the health and development of adolescents and youth, with a particular focus on successful transition of the adolescent girl to secondary level education. • 18.  Recognize that investment in Family Planning is the most cost-effective intervention for the reduction of maternal deaths, and population development. • 19.  We commit, together with partners, to improve the health and well-being of women and children, reduce poverty and advance sustainable development.

7. Background • The National Reproductive Health Policy goal seeks to enhance the reproductive health status of all Kenyans by increasing equitable access to reproductive health services. • The Government of Kenya has established a goal to reduce the countrywide maternal mortality rate to 200 per 100,000 live births by 2030 • The global goal for the SDGs - By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births

8. Background Strategies in place to reduce MPDs: • Scaling up of Emergency Obstetrics and New-born Care training countrywide, • Free Maternity Services Initiative, the Beyond Zero campaign and • Instituting Maternal and Perinatal Death Surveillance and Response (MPDSR) mechanisms among others • Unreliable data on maternal and newborndeaths: • contributes to a lack of accountability and • limits the ability to make decisions for health. Better information could improve life-saving maternal health interventions and use of health resources.

9. Institutionalizing MPDSR in Kisumu County Every month a meeting of ~50 health professionals from all backgrounds discuss MPDs with follow up actions. Aim of MPDR All women in Kisumu County may enjoy safe pregnancies and deliveries, and experience motherhood with access to quality health care services including family planning. Objectives • All maternal and perinatal deaths are reported, reviewed and acted upon (achieved) • Improved access to quality maternal and neonatal health services (in progress) • Reduced number of preventable maternal deaths (unchanged, perhaps due to increased reporting) – also quality ending in reduced perinatal deaths

10. GIZ Support • Coordination with partners through County Reproductive Health TWG • Retrospective Review of maternal deaths between Jul – Dec 2014 • Capacity build staff of major hospitals in facility-based MPDR • Quality Improvement in 8 major public hospitals • Since May 2015, regular county MPDR meetings • Formulation of Kisumu County MPDSR Guidelines (Domestication) • Integrate MPDRS in county health planning and policy documents

11. Key Outcomes • Openness and trust to talk about MPDs during MPDR meetings • Health workers are not penalized (removal of health workers’ fear) • Focus on improving healthcare systems and quality of care. • MPDRS integrated in county planning and policy documents • Regular MPDR meetings on county, sub-county and hospital levels • Since July 2015, all MPDs are reported and reviewed • Involvement of Regional Blood Transfusion Unit, partners, private health sector (Agha Khan Kisumu, Nyabondo Mission Hospital, Maseno Mission Hospital) • Focus on Response: up to date, 64% of Action Points determined at County MPDR Meetings achieved

12. MDs, FSBs and NNDs Totals (DHIS2)

13. Kisumu County Maternal Death and number Audited (Jan 2015 – July 2016)

14. Kisumu County % Maternal Deaths Audited by Month ( Jan 2015 – July 2016)

15. RH related indicators % (DHIS2)

16. Conclusions While there has not been a reduction in MDs reported in DHIS, the regular MPDR meetings with collective response has facilitated readiness of health workers, health managers and partners to openly discuss deaths and respondcollectively. Lack of change in number of MDs reported in DHIS may also be linked to increased reporting. Vast majority of MDs occur at regional referral hospital located in Kisumu County • July 2016 first time zero MDs occurred at this hospital • DHIS2 data for August 2016 not yet complete (DHIS2 reporting deadline 15th of following month)

17. Challenges • Newly employed staff not capacity built on the data tools. • Lack of dissemination of the data tools. • Interoperability between the open source systems at some facilities and the DHIS 2 platform • Weak culture on data use and demand at the service delivery points • Primary facilities are relatively new in conducting deliveries and therefore need much capacity building for quality services. • Referrals not efficient

18. Challenges • Teenagers/ Adolescents pregnancies are on the increase. • Approaches to the ASRHR still require more buy-in at community level • High HIV Burden complicating pregnancies • No specific programmes on NCDs in the new dispensation. • TBAs are still operational and mothers seek their services • High poverty level among young mothers • Inadequate male involvement

19. Lessons learnt • MPDs occur as a result of the three delays in seeking care. Haemorhage, Sepsis, PET are leading causes. • Underlying causes for mortality include barriers such as ignorance, financial, geographical, security, infrastructural • Routine DHIS 2 data can be used to inform facilities of their performance as well as in advocacy with the legislators • Monitoring and evaluation through regular mortality data review is key to performance improvement

20. Lessons Learnt • Withdrawal of OBA financing led to a drop in skilled deliveries • Documentation of performance has proven to be a resourceful instrument to the Kisumu CHMT on making informed decisions • Integration of HIV/ RH services saves resources and time • Teamwork helps

21. Areas for Improvement • Constant mortality and near-miss analysis for use in the • Sensitization and dissemination of MPDSR data tools including improved knowledge of ICD10 coding • Allocate and prioritize resources towards building capacity of health care workers on critical skills such as EmoNCand BEmoNC • Encourage inter-facility learning within the county and between counties • Extra efforts to capture maternal deaths among adolescents • Mentorship for young doctors, clinical officers, nurses other staff.

22. Areas for Improvement • Assess the impact on training on improvement of service delivery especially EmOC, EMNC services and care, supplies and ultimately reduction in maternal and perinatal mortality and near misses • Multisectoral/ Intersectoral collaboration / partnership development • Rights based, Equity focussed approach to service delivery. • Cost efficiency and cost effectiveness analysis and action especially on post natal period. SOPS devt. • Referrals Management

23. Sustainability Strategy • Apply the health systems approach for continuous assessment and improvement including on the social determinants of health • Strengthen M&E TWG and incorporate reproductive health agenda in the meetings • Ownership and follow up of action tracking tool by all staff at county, sub county and facilities • Continuous coordination and collaboration of partners involved in reproductive health services

24. Sustainability contd.. • Initiate an intergenerational forum (partnerships) between the education , health sectors, mothers union (already interested) and the community to guide the adolescents by building rapport that closes the generation gap by enhancing communication and understanding. • Conduct joint meetings/ functions with parents, sectors and the teenagers participating in the activities.

25. Sustainability Contd… • Ensure facility, sub-county and county review meetings are held regardless of whether deaths occur or not • Share the information/ lessons from review meetings beyond facilities with county and national leaders • Ministers Round Table meeting with specialists i.e. OB/GYN, PAEDs • Strengthen Community level reviews(Verbal Autopsy) • Integrate the process into the performance management system

26. Asante Sana

27. Welcome to Kisumu County - Governor Jack Ranguma