Address these challenges to save the lives of mothers and babies

A gynaecologist examines a pregnant woman with a stethoscope. [Getty Images] "In order to improve maternal health, we have to focus on improving all women's health and access to care - not just during labour and delivery, but before and after pregnancy, and throughout our lives."-Leana S Wen Investment in maternal and neonatal health contributes to reducing mortality and morbidity rates among children and women of child-bearing age thus improving the overall health and well-being of individuals and populations at large. This gives infants and young children an equal opportunity to realise their full social and economic potential and contribute optimally in society. When infants and young children receive adequate care from the start, they can thrive and contribute meaningfully to society better. Although Kenya has made important progress in increasing the coverage of facility-based services such as skilled deliveries and postnatal support, the expected reduction in maternal and neonatal deaths has not been fully realised. This shortfall is due to persistent challenges that hinder access to and the quality of care across the country. One of Kenya's most significant barriers to improving maternal and neonatal health is the Three Delays in accessing care. The first delay involves seeking appropriate medical help, often hindered by cultural beliefs, lack of awareness, and financial constraints. The second delay occurs when women attempt to reach a proper health facility but are slowed down by poor infrastructure and transportation systems, especially in rural areas. The third delay occurs at the health facility where women may face further setbacks due to staff shortages or inadequate medical supplies. Another major challenge is the critical shortage of skilled healthcare workers at primary healthcare facilities, including obstetricians and midwives. This shortage and staff absenteeism severely compromise the quality of care provided during pregnancy and childbirth. The result is that many women do not receive the timely, high-quality care that is essential for preventing complications and saving lives. Financial barriers further exacerbate these issues. High out-of-pocket healthcare costs deter many women from seeking necessary medical care. The economic burden, along with inadequate transportation systems, increases the risk of maternal mortality, particularly during emergencies when timely care is crucial. Poor sanitation and lack of clean water in many healthcare facilities compound these issues, which pose serious risks to both mothers and newborns. Even when healthcare services are accessible, the quality of care can be substandard. This substandard care is often the result of insufficient medical supplies, inadequate training for healthcare workers, staff shortages, and failure to adhere to clinical guidelines. Such shortcomings undermine the effectiveness of care and erode trust in the healthcare system. Another critical issue is the weakness of Health Information Systems (HIS). Effective maternal and neonatal health services rely on robust HIS to track progress, identify gaps, and allocate resources efficiently. Weak HIS hinders the collection and analysis of data necessary for planning and monitoring, making it challenging to implement targeted interventions that could significantly improve outcomes. Before the devolution of government in 2013, State-owned health facilities had greater autonomy to retain and use the revenue generated from user fees, government transfers, and health insurance reimbursements. This autonomy allowed facilities to address immediate needs such as procuring medical supplies and hiring staff. Post-devolution, the ability of these facilities to retain and utilise their revenue has become subject to the interpretation of the 2012 Public Finance Management Act across counties. A review of maternal mortality rates (MMR) and neonatal mortality rates (NMR) data between 2022 and 2023 suggests a correlation between health facility autonomy and health outcomes. Kajiado and Lamu, which confer greater decision space on finances to health facilities, showed improvements in MMR and NMR. In Kajiado County, the MMR decreased from 53.33 deaths per 100,000 live births in 2022 to 49.94 deaths per 100,000 live births in 2023, and the NMR remained stable with a slight improvement. Similarly, Lamu County saw a significant drop in MMR from 130.55 deaths per 100,000 live births in 2022 to 43.3 deaths per 100,000 live births in 2023 and a reduction in NMR from 3.86 deaths per 1,000 live births to 2.3 deaths per 1,000 live births during the same period. These examples highlight how financial autonomy can enable health facilities to respond more effectively to local needs, leading to better maternal and neonatal outcomes. When healthcare providers lack the autonomy to make timely, patient-centred decisions, they experience delays and an inability to adapt to individual patient needs. Centralization in decision-making processes hinders frontline health workers from responding effectively to obstetric emergencies, resulting in missed opportunities for life-saving interventions and inadequate postnatal care. The calls for health facility autonomy transcend monies to include decision space over procurement, management of human resources and operational efficiency. Health facility managers could be held to account considering that they have decision space on the day-to-day running of health facilities including creating an enabling environment, incentivising lay workers and optimising revenue generation. Ending preventable maternal deaths must remain a top priority. Increasing equitable access to quality care before, during, and after childbirth is essential for supporting the health of both mothers and newborns through pregnancy and the first year of life. This requires a multifaceted approach addressing the above-mentioned challenges while promoting greater healthcare facility autonomy. Ms Murerwa is the Regional Technical Manager at Amref Health Africa while Ms Mukii is the Monitoring Evaluation and Learning Officer at Amref Health Africa

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