Existence and functionality of emergency obstetric care services at district level in Kenya: theoretical coverage versus reality

Among the 40 facilities assessed, three were hospitals, five were health centres while 32 were dispensaries. In terms of institutional deliveries, the numbers were higher in the government and hospital level facilities. Table 2 presents institutional deliveries in 2009 by facility ownership and level in the district.

In terms of existence of services, five of the 40 facilities assessed qualified as EmOC “minus one” (performing all nine signal functions except assisted vaginal delivery) [10]. These were the government hospital and two private hospitals, which qualified as comprehensive EmOC. Two government health centers qualified as basic EmOC. Table 3 shows the ratio of EmOC facilities to population size in Malindi District in 2010. With regard to the WHO recommendations, there should at least be five EmOC facilities for 500,000 inhabitants, with at least one being comprehensive. In this respect, with three hospitals and two health centres being EmOC, the WHO recommendation was met. However, going by the strict WHO definition of an EmOC facility, none of these facilities qualified since assisted vaginal delivery was not provided.

In terms of provision of signal functions, the least performed signal functions were administering parenteral antibiotics (2.9%) and parenteral anticonvulsants (5.7%). Uterotonic drugs (85.7%) and manual removal of placenta (40%) were most performed. Figure 1 shows the contribution to health care in provision of basic signal functions by the 35 non-EmOC facilities. The dominant reasons for least-performing signal functions were no cases and lack of supplies.

Figure 2 shows the geographical inequities in distribution of EmOC facilities in the district. All the three hospitals offering comprehensive EmOC services and one of the two health centres offering basic EmOC services were located in Malindi Division, the main urban centre and administrative headquarters in the district. This area is served by a relatively well functioning public transport system and relatively adequate roads. The second basic EmOC facility was located in Magarini Division, which borders Malindi Division. This area is connected to the major trunk road with regular public transport. The two vast and remote divisions, Langobaya and Marafa, were not served by any EmOC facility and are not connected to any major trunk road with regular public transport. The average distance to the nearest EmOC facility was five kilometres in the urban area. Urban was defined as the area covered by 10 kilometres or less from the comprehensive EmOC facilities. For the rural areas, the average distance to the nearest comprehensive EmOC facility was 30 kilometres. Rural was defined as the area covered by more than 10 kilometres from the comprehensive EmOC facilities. Overall, Malindi Division had 19 facilities offering delivery services, Magarini had eight, Marafa had seven while Langobaya had six.

A total of 539 and 687 forms were completed for women who underwent a caesarean section in the three comprehensive EmOC facilities in the district in 2008 and 2009 respectively. This amounted to over 90% of all surgical obstetric interventions performed in the hospitals in both 2008 and 2009. The most common indications for caesarean section were cephalopelvic disproportion and ante-partum haemorrhage. These accounted for 50.3% and 32% in 2008 and 54.6% and 27.7% in 2009, respectively.

The overall caesarean section rates were below the recommended level of 5%. These were 3.7% in 2008 and 4.5% in 2009. The rates were lower in the rural than in urban areas (2.1% vs. 6.8%; p < 0.001) in 2008 and (2.7% vs. 7.7%;p < 0.001) in 2009. Table 4 shows the caesarean section rates by division while Table 5 shows the rates by rural–urban residence in the district. A notable decrease in caesarean sections rates in divisions far from comprehensive EmOC facilities were observed.

This paper documents the application of EmOC process indicators to assess the actual existence, functionality and provision of life-saving obstetric services at district level in Kenya. Some limitations as well as methodological issues in the EmOC process indicators methodology were observed. The first limitation was related to the strict WHO categorisation of facilities as basic or comprehensive. This is based on the activities of a facility in the past three months. In this study, over 50% of facilities assessed had less than 60 deliveries in the previous three months. It is therefore not reasonable to presuppose that all seven signal functions would have been conducted within this period in these facilities. An extension of the period to six months would perhaps have given a chance to facilities that had the capacity to provide basic EmOC but did not qualify due to low deliveries. Secondly, the strict WHO criteria do not acknowledge the significant contribution to health care of facilities missing perhaps only one or two signal functions. Similar limitations in the EmOC process indicators methodology are documented elsewhere [21‐23]. Thirdly, this paper is mainly descriptive and may not adequately provide a rigorous statistical appraisal of the findings. This limitation is however within the acceptable WHO concept of assessing the availability of EmOC [10]. Further, description of service level as provided in this paper provides a simple and clear message to decision makers and users and, therefore, no need for sophisticated statistical tests than necessary. Finally, the use of GIS buffer tool to estimate the distance women had to travel to reach the comprehensive care facility was a major limitation. The technique can be extremely misleading since the buffer tool assumes straight line distance, not taking into account road conditions and various terrain barriers.

Health centres in Kenya are required to provide basic signal functions and are theoretically classified as basic EmOC facilities [17, 24]. The Ministry of Health therefore ‘automatically’ classifies the five health centre level facilities in the district as basic EmOC [17]. The reality on the ground as evidenced in this study is however different. Only two of the five health centres expected to provide basic EmOC services qualified. A similarity illustrating theoretical coverage of facilities versus reality is provided in Uganda where, in 2003, results of an EmOC assessment showed that 21 (65%) of the 32 hospitals were comprehensive, while only five (4%) of the 129 Health centres functioned at their intended level [25]. The Uganda study is cited in the WHO handbook to show the difference between the way a facility is supposed to function and what it actually provides [10]. This highlights the need to classify facilities after direct inspection as opposed to theoretical coverage, which can be extremely misleading. In Kenya, by not taking the real definition of EmOC into account, EmOC coverage is often an overestimate.

The EmOC certification level requires that all signal functions are present [10]. Findings from this study, however, show that none of the facilities were “strictly" EmOC in the absence of assisted vaginal delivery by vacuum or forceps. Similar observations, showing that assisted vaginal delivery is a rare procedure, are documented in other sub-national studies in Kenya [12, 13, 26‐28]. This is despite vacuum extraction being included in the minimum package for maternal health services at health centre and hospital level facilities [24, 29]. Lack of the procedure implies that women who might benefit from this intervention are delivered by caesarean section. It is not clear why assisted vaginal delivery by vacuum is not offered as per the Ministry of Health and WHO specifications, yet there are observations that experienced midwives and nurses can perform the procedure at a basic EmOC facility [30]. In addition, anaesthesia is not required as with caesarean section and the potential risks associated with major haemorrhage and prolonged hospital stay are fewer [31]. Vacuum and forceps are also less invasive and inexpensive options in many situations [30]. Considering that comprehensive EmOC facilities are not easily accessible to rural women, vacuum extraction would be a more suitable option than caesarean section for women requiring a life-saving procedure in Malindi District and similar settings in Kenya. In Rwanda, a study revealed that under adequate supervision and immediate caesarean section back-up, vacuum deliveries conducted by competent mid-level providers are safe, making life-saving services more accessible and affordable for low-income households and rural populations [32].

The finding on lack of assisted vaginal delivery in this study and similar observations in other settings in Kenya highlight the need for further research to assess the status of the intervention in the country. This is necessary to provide information that may guide a review of maternal health guidelines to remedy the lack of this life-saving intervention in Kenya. Bridging this gap will contribute to strengthening the health system capacity to treat obstetric emergencies. There is also need to revisit the training policy on maternal health, given that midwives and clinical officers in Kenya are not currently trained to perform assisted vaginal delivery [33].

Comparable findings on availability of EmOC are reported in Kenya. The two Kenya Service Provision Assessment surveys of 2004 and 2010 found EmOC coverage to be below the recommended levels [12, 13]. Similar to this study, adequate coverage in comprehensive EmOC facilities, but shortage of basic facilities was reported in North Eastern Province [26]. In the Nairobi’s informal settlements, among the facilities offering delivery services, only 40% were offering EmOC [27]. In West Pokot, although two facilities offered caesarean section and blood transfusion, no facility offered a complete set of signal functions in 2007 [28]. While the EmOC certification criteria is biased against facilities with capacity to provide EmOC but miss two or three signal functions perhaps due to few deliveries, their contribution should not be ignored. The analysis of signal functions by facilities that do not qualify the EmOC status as instituted in this study, not only illustrates the contribution to healthcare of these facilities, but also makes it possible to show which signal functions are not being performed adequately. This information can guide decision making on which areas require strengthening to achieve maximum gains in mortality and morbidity reduction. In this regard, the finding that signal functions were least performed due to low cases implies the need to determine whether it is because of low facility deliveries or if it a problem of access related issues, like costs and distance.

Equity in service provision, which entails fair distribution, access and use between population groups [34, 35] is regarded as a measure of health system performance [36, 37]. Although the optimal requirement of comprehensive EmOC facilities was met in this study, reaching them was a challenge for women in rural areas. While it is logical that such facilities are located in the urban areas [38, 39] because of population density and presence of good infrastructure, it is clearly unfair to rural women. Except if compensated by an effective referral infrastructure that includes adequate good roads, communication and emergency transport. In view of the urgency and unpredictability of maternal complications, the inequities in access to care facilities in this study portray serious implications for women living in the underserved areas. These women have to travel over 30 kilometres to reach a comprehensive EmOC facility. Consequently, their chances of surviving an obstetric emergency are greatly reduced. Travel delay also means that the women arrive at the facility in such severe conditions that it may be difficult to save their lives [34]. If indeed policy and decision makers in countries with high maternal mortality are committed to the statement that "no woman should die while giving birth", there is need to improve equitable access to life saving interventions for women in under served areas. Geographical mapping of care facilities as instituted in this study can guide decision making on which facilities may benefit from upgrading to achieve the optimal coverage in an area [37, 40]. Possibly, upgrading the health centre in Marafa Division to comprehensive and a dispensary in Langobaya Division to basic EmOC status or strengthening the referral infrastructure could contribute to fair distribution and access to obstetric care in the district. Upgrading should additionally involve providing the neccesary equipment and supplies to provide the services.

The relative lack of access to life-saving services for rural women as observed in this study is documented in other developing countries [21, 40]. Similar, analysis of EmOC in countries with high and moderate levels of maternal mortality show that even as EmOC facilities meet the recommended levels, concerns surrounding equity and geographical accessibility are raised [40]. Similarly in this study, the question whether EmOC services exist and function and if the services are geographically and equitably distributed cannot be answered affirmatively for the rural areas.

Caesarean sections are regarded as the simplest ways of measuring the need for critical life-saving services [7, 8, 41]. In this study, the overall caesarean section rates in the district were below the recommended levels. Similar findings on low caesarean section rates are observed in other developing countries [21, 27, 42‐46]. The differences in physical access to the comprehensive EmOC facility by women in the district undoubtedly explain the variations in caesarean section rates between the four divisions and urban–rural areas to a great extent. From the findings, a pregnant woman with a complication requiring caesarean section in the urban area was up to three times more likely to access the intervention compared to her rural counterpart. Perhaps by availing vacuum extraction, women with prolonged second stage of labor in the rural areas can benefit from the intervention instead of travelling long distances to access the comprehensive EmOC facilities. Findings on low caesarean section rates among women in the rural areas are reported in other studies in Kenya and Tanzania [44, 47, 48]. It is observed that caesarean section rates is a valuable process indicator for identifying gaps in obstetric care and may be used for advocating improvements for healthcare to the relevant authorities [42, 47]. Thus, the variation between caesarean section rates in urban and rural areas observed in this study may indicate the need to upgrade some facilities to achieve good coverage in the rural areas. This alone, may however not increase use of life-saving services for rural women given that in this setting, the proportion of home deliveries is 84 percent (REACT data, unpublished). Sensitising the community to promptly seek care in the event of obstetric complications may be necessary to achieve optimal utilisation of life-saving services in the district.