About 21 pregnant women die every day in Kenya due to complications from childbirth. That's equivalent to two 10-seater commuter micro minibuses, known as matatus, crashing every day with the loss of all the passengers on board.
Pregnant women in Kenya die because they either do not receive appropriate care during pregnancy or are unable to deliver with the help of skilled health attendants.
The World Health Organisation recommends four antenatal visits and skilled care during and immediately after delivery. It also recommends emergency obstetric care in cases of complications as key to reducing maternal and neonatal deaths.
But the costs for antenatal care and skilled delivery are simply too high for many poor women in Kenya. Based on data collected before the maternity subsidy policy was introduced the costs associated with a normal pregnancy and delivery was more than 20% of the country's gross national income of USD$1,380 per capita.
The intention of the maternity fee waiver, implemented in 2013, was to remove out-of-pocket fees for skilled delivery in public health facilities across the country. This would enable thousands of pregnant women delivering at home to access proper services. The direct payments for normal and c-section deliveries was replaced by a national government budgetary allocation to reimburse health facilities for deliveries provided.
The effect of the new policy was immediate. There was a 22% increase in skilled deliveries in facilities between 2013 and 2015.
What the policy hasn't done is address the entrenched inequity between rich and poor women. In fact, women who are better off have benefited more than those with a low income. A national survey carried out a year after implementation showed that the use of skilled delivery services was about three times higher among the richest 20% of women as compared to the poorest 20% of women.
An added problem is that poor women in both urban and rural areas were still delivering their babies in private facilities. To close the gap, there must be a concerted effort to target free services at the poorest women who cannot otherwise afford care. In addition, proposed changes to expand the free service offering to some private health facilities need to be implemented urgently.
Public versus private
National survey data from 2014 shows that the proportion of the poorest women in urban settings who delivered at public health facilities had declined from 95% to 87% between 2008-09 and 2014. This suggests that more urban poor women sought and paid for services in the private sector despite the availability of free services in the public sector. Similarly, about 11% of the poorest rural women delivered at private facilities in 2014.
The reasons for this could be due to a deficit of public health facilities nearby, a lack of trust in the public health system, and shorter waiting times in private health facilities.
Changes are under way to expand the programme even further. Next year the maternity fee waiver will be implemented through the National Hospital Insurance Fund, a state-run fund established in 1966 to provide affordable and equitable social health insurance to all Kenyans. This will extend availability of free services beyond public facilities to include select low-cost private and faith-based health facilities.
The changes planned for next year also include an enhanced maternity package that goes beyond one-time labour and delivery. It will include antenatal care, postnatal care, deliveries, family planning and any hospitalisations arising from pregnancy related complications. The programme is currently being piloted under an initiative called Linda Mama, which means "protect the mother" in Kiswahili.
The additions to the policy will go a long way in expanding the choice of health facilities. This is especially the case in settings with limited number of public health facilities. Working with the National Hospital Insurance Fund will also benefit from well-established mechanisms for monitoring quality of care.
But there are additional measures that the government needs to take to promote universal and equitable access to maternal health services.
Closing the equity gap
Kenya has committed itself to leave no pregnant woman behind. Realising this commitment requires identifying areas of inequality, understanding the drivers of the inequalities, and monitoring the progress made at reducing them.
As the programme is expanded and placed under the National Hospital Insurance Fund, the government should take into consideration three important issues.
The first is increased awareness. A national campaign should be carried to ensure that more pregnant women, especially those in remote communities, register with the National Hospital Insurance Fund to access free services.
The second is robust monitoring and evaluation system as part of the national strategic plan. This will help in assessing improvements in coverage of services. This in turn will help uncover and target inequalities so that the most disadvantaged women have the same access to quality maternity care as the richest women.
The third is to implement additional non-health health interventions to encourage the poorest women to demand and access services. Multi-layered barriers combine and reinforce each other to undermine utilisation of maternal health services.
These include demand side barriers such as formal and informal fees, transportation costs and opportunity cost as well as education and health information. Supply side barriers include quality of care.
All these factors should be carefully considered to achieve real progress in utilisation of services among the poorest women.
Estelle Monique Sidze does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.