When the mast came

In 2013, Henry Kilonzo was part of a team from the M-PESA Foundation that was looking for a project to support, when he and his colleagues came across statistics on maternal and new-born mortality published by the United Nations Population Fund (UNFPA).

The numbers were depressing. While there had been progress in reducing Kenya’s Maternal Mortality Ratio, from 590 per 100,000 live births in the 1990s, to 362 per 100,000 in 2014, there was still a lot to be done. This ranking made Kenya one of the countries with the highest burden of maternal deaths in the world.

Despite being widely considered an East African economic powerhouse, Kenya – like many other developing countries – is not new to inequality. Glaring disparities exist in everything from infrastructure and education, to food security and mobile network access. But the gaps in access to quality, affordable healthcare are so bad, that according to the UNFPA data, 15 counties accounted for 98.7 per cent of all maternal deaths in Kenya in 2014.

The counties were: Mandera, Wajir, Turkana, Marsabit, Isiolo, Siaya, Lamu, Migori, Garissa, Nairobi, Nakuru, Kakamega, Homa Bay, Taita Taveta and Kisumu.

The natural reaction of anyone hoping to lower the maternal mortality rate would have been to direct resources towards these 15 counties, so why did the M-PESA Foundation team decide to focus on Samburu?

While it was not among the top contributors to Kenya’s high maternal mortality rate, Samburu was doing badly, at 480 deaths per 100,000 live births, way above the national average of 362 deaths per 100,000 live births. That’s 480 families left without a mother, a sister, a wife, a caregiver.

Just like the top 15, Samburu’s pregnancy-related deaths were as a result of delivery without skilled birth attendance, which is no surprise given that only about 39 per cent of deliveries in the country are carried out in health facilities.

The county also faced other challenges, like infrastructure so poor that an expectant mother would have to endure a bumpy two-hour motorbike ride to get to a health centre, almost no mobile connectivity, and little economic development following years of ethnic conflict.

This meant that pregnancy, rather than being a cause for celebration, could very well be a death sentence in Samburu. Or at the very least, a game of Russian roulette.

So in 2013, the M-PESA Foundation partnered with Amref Health Africa, PharmAccess Foundation and the Samburu County Government to launch a maternal care programme christened Uzazi Salama.

Amref brought to the table its expertise in the training and mentorship of community health workers, and worked with Safaricom to develop LEAP, an m-learning platform used to train the workers.

“We are using the mobile phone as a primary training tool to provide the volunteer community health workers with content on maternal and primary healthcare. This content is developed by our partners and approved by the Ministry of Health,” says Henry.

Once trained the volunteers are released into the community, where they visit households and teach expectant mothers the basics of self-care and what to expect post-delivery.

To encourage them to deliver their babies in health facilities where they can be cared for by skilled birth attendants, these community health workers make sure expectant mothers attend at least four antenatal clinics, and then stay in touch with them after delivery to ensure that new-born babies and infants receive the necessary immunisation.

An interesting aspect of the Uzazi Salama initiative is that engagement with expectant mothers and other members of the community goes beyond sharing of life-saving information to provision of basic items that could make the difference between life and death for a new-born.

The Mama Pack, distributed free of charge to new mothers, is a unique incentive that ensures that women visit health facilities. It consists of several essentials including a basin to bathe their babies in, soap, a leso, bag, baby clothes and diapers, and is only handed over to mothers once they deliver their babies in the health facilities.

In a county where employment is scarce and incomes often meagre, giving expectant women something that they know will be useful not just for their babies, but for themselves, no matter how basic it is, makes a difference.

Henry says the idea is simple: “When they go home, definitely there are a lot of questions from other women. They all want to know where the new mothers got the Mama Pack. Word goes round and more mothers come to the facilities to deliver their babies, so that they too can receive the care package.”

PharmAccess, the international non-profit, ensures that quality care is provided to expectant and new mothers through enforcement of SafeCare standards. This is a set of guidelines that cover clinical services and management functions, as well as the infrastructure and administration services required to keep health facilities in good running order, such as kitchen, laundry and cleaning services.

With the provision of healthcare a devolved function under the Constitution, all the dispensaries, health centres and hospitals in Samburu are under the county government, which made it necessary for the initiative to earn the support of the county.

This support came in the form of a signed Memorandum of Understanding that also saw the Governor join Uzazi Salama’s steering committee. In the last four or so years, the county government’s support has enabled the upgrade of 59 facilities, 15 of which can now handle complicated deliveries.

After a successful pilot in two health facilities, the programme went full-scale in 2014, and the results since then have been significant.

According to Dr. George Kimathi, Director of the Institute of Capacity Development at Amref Health Africa, the number of women attending the antenatal clinics has grown from less than 20 per cent to close to 50 per cent, while the number of children taken for immunisation increased to 70 per cent, up from less than 50 per cent before 2013.

He is optimistic that the next Kenya Demographic and Health Survey will show improved maternal health in the county. Yet it’s safe to assume that a lot of this would have been impossible if Safaricom had not set up the desperately required communication infrastructure in the area.

The company installed a base station at Barsaloi, a small town with only pockets of subscribers at the time, to provide access to a reliable mobile network so that community members could communicate with ease and notify healthcare providers of medical emergencies.

With the mobile network in place, Amref could run its LEAP m-learning programme, which facilitated the training of community health volunteers in Maralal and Wamba towns, as well as the surrounding villages.

“The most significant success is our work with community health workers,” says Dr. Kimathi of the training of close to 300 midwives and other health workers on the management of complicated deliveries.

“We see that capacity outliving the project because we are able to provide safe delivery to mothers who are coming to deliver at the facility beyond the project period,” he adds.

With phase one of the initiative complete, the partners are now working to scale and replicate its successes in other parts of the country.

“We have ambitious plans and are keen to scale up the model of partnership between the private sector and neighbouring counties that have similar challenges. It’s possible for other counties to borrow our model,” says Dr Kimathi.

There are also plans to take Uzazi Salama to Kenya’s coast, with Lamu County, one of the 15 counties with the highest maternal mortality rates, emerging as a possible target. The county, considered a favourite tourist destination for its rich cultural history and beautiful beaches, also faces challenges such as low literacy levels, high poverty, poor infrastructure and insecurity.

There, Henry says, the aim is to establish 13 community units, each with 15 volunteer health workers with an individual reach of 20 households. Already, the M-PESA Foundation has set up maternal shelters, where expectant mothers reside for a few weeks until they deliver and be taken care of by qualified healthcare workers.

“For the last three years, we have been building the ship before we can sail, meaning that we have been learning, implementing, and using these lessons to improve the outcomes of the project,” says Henry.

These outcomes are so far transforming the lives of mothers, children and entire communities, many of them made possible because of a telecommunications mast that is bridging the gap between need, and access to quality healthcare – and in the process, ensuring that more mothers live to see their children grow up.