How Siaya cut maternal risks through strong community health strategy

At the Siaya County Referral Hospital, Lydia Adhiambo is delivering a health talk to a group of pregnant women who have visited the facility to seek antenatal care.

When Adhiambo is not in the village visiting households for disease surveillance, conducting malaria tests, making referrals, or carrying out community outreach programmes, she is posted to the nearest health facility. There, she supports other duties such as giving health talks to pregnant women and mothers who have brought their children for immunisations.

A resident of Karapul in Alego Usonga, Adhiambo has served as a Community Health Promoter (CHP) since 2018. She supports 235 households, covering a population of 750 people.

Her responsibilities as a CHP include acting as a liaison between the community and health facilities, offering health education and promotion, conducting disease surveillance, making home visits, and engaging in outreach and advocacy for community health.

Adhiambo states that since the beginning of the year, she has referred five expectant women from her designated households to the health facility to begin antenatal clinics.

She met these women during routine household visits, during which she also maps children under five years of age, ensuring they receive all required vaccinations, and identifies pregnant women to refer them to the health centre for antenatal care.

“When I visit a household and find a pregnant woman who hasn’t started antenatal care, I refer her to the nearest facility immediately. During my visits, I also educate them on the importance of attending clinic, and on the tests and screenings they undergo after pregnancy confirmation, for their own well-being and that of the unborn child,” she explains.

She adds: “We also teach them about danger signs during pregnancy and their consequences. We stress the importance of sleeping under mosquito nets and maintaining a balanced diet during pregnancy.”

Her colleague Judith Oloo, from Ndere village, serves over 400 people across 110 households and has worked as a CHP since 2011.

She recalls that when she began the role, she would attend public barazas (community gatherings) to educate women on the importance of skilled deliveries at health facilities. “With the help of village elders, we conducted outreach sessions and informed women about the dangers of delivering outside health facilities or failing to attend antenatal clinics,” she says.

“It wasn’t very difficult to convince expectant women, especially once they understood the risks of unskilled delivery. These days, women from my area come to see me as soon as they suspect they are pregnant. I begin counselling sessions straight away before referring them for tests and clinic visits,” she adds.

Oloo says her work even led a traditional birth attendant in her area to stop practising and instead begin referring women to her for education. “During one of our meetings with county health officials, we were asked to identify and document traditional birth attendants within our areas. They were later invited for training and sensitisation. One of them later came to my house and told me she had quit. In fact, her daughter-in-law recently gave birth at the Siaya County Referral Hospital, which is very encouraging,” she adds.

Oloo and Adhiambo are just two of the 2,170 CHPs in Siaya County who have committed themselves to improving maternal and child health at the grassroots level.

Years ago, giving birth in Siaya came with significant risk, as many women delivered at home without skilled birth attendants.

Today, thanks to concerted efforts, numerous reports and studies show a notable increase in the number of women accessing skilled birth services. Skilled birth attendance in Siaya has risen from 70 per cent in 2014 to 95 per cent in 2022.

Improved access

Health officials and experts attribute this remarkable improvement to the presence of emergency evacuation services, a vibrant community health strategy led by CHPS, an increased number of specialists at health facilities, and improved access to antenatal care.

According to the Kenya Demographic Health Survey (KDHS), skilled delivery rates in Siaya County have risen from 70 per cent in 2014 to 95 per cent in 2022. Additionally, the proportion of children fully vaccinated with basic antigens increased from 78 per cent in 2014 to 88 per cent in 2022.

The same data indicates that 99.1 per cent of expectant women in Siaya County received antenatal care from a skilled provider, while 65.1 per cent had four or more antenatal visits. Furthermore, 89.3 per cent of pregnant women took iron supplements as of 2022.

For 29-year-old Esther Sharon, a resident of Siaya, her antenatal visits at the County Referral Hospital have been a great source of encouragement during her pregnancy journey.

She is already a mother of one and, at nine months pregnant, is expecting her second child in a matter of days.

“The health facility has been a great motivator for me throughout this pregnancy. From the antenatal services to the availability of all the medication I’ve needed along the way, I haven’t had to spend any money on drugs, as everything has been provided for free. Every clinic visit has been exciting thanks to the health talks delivered by the CHPs and nurses. I’ve also toured the maternity wing in anticipation of delivery day, and I’m really impressed by the changes there,” she says.

Brenda Akoth, 35, a resident of Siaya town, is eight months pregnant with her fourth child. She says she went to the health facility for tests and screenings as soon as she suspected she was pregnant, and immediately began her antenatal visits. “In addition to the routine check-ups, the healthcare workers provide us with health talks, including nutrition,” she adds.

Siaya County Reproductive Health Coordinator, Pamela Josephine, says that in efforts to improve skilled deliveries across the county, a major focus has been placed on emergency evacuation services. “We’ve established a call centre to manage this challenge. Emergencies from rural health centres are responded to within 30 minutes using ambulances. Through public-private partnerships, we’ve also engaged rescue teams through the Mama Link initiative, allowing mothers to be evacuated free of charge. The number of gynaecologists has also increased from two serving the entire county to four, each stationed at Level Four hospitals to handle emergency cases,” she says.

She adds that during antenatal visits, pregnant women are screened to determine whether their pregnancy is high-risk or normal. They are also provided with mosquito nets, deworming services, and anti-malaria medication. Women living with HIV are enrolled into care and treatment programmes immediately.

Josephine says antenatal visits also serve as an opportunity to counsel women on the importance of skilled birth attendance. After delivery, women are enrolled in family planning services and continue receiving care through postnatal services at child health clinics.

She notes that one of the persistent challenges is that some women still begin antenatal care late in their pregnancy, which prevents them from completing the recommended eight clinical contacts before giving birth.

Josephine adds that in the last financial year, the county government recruited 700 healthcare workers across various cadres to support the county’s health system. “In previous years, one of our biggest issues was human resource. If we have too few staff members and they become overworked, this ultimately compromises the quality of care,” she says.

Dr Evans Ogoti, an obstetrician-gynaecologist and Medical Superintendent at Bondo Sub-County Hospital, says the county government has established a fully equipped and staffed maternity theatre specifically for handling maternity cases and pregnancy-related complications that require surgical intervention.

Specialised care

Additionally, the staff have undergone training, including medical officers pursuing specialised training to become consultant obstetrician gynaecologists.

“Nurses have also been sponsored for higher diplomas in specialised fields, such as critical care, while others are undertaking midwifery training. This has enabled the provision of more specialised care, leading to better outcomes for both mothers and babies. Consequently, the number of mothers referred elsewhere due to lack of specialised personnel has greatly reduced, as most cases can now be managed in Bondo,” he says.

He notes that through integrated outreaches and community dialogues in collaboration with CHPs, they trace defaulters of immunisations and antenatal care visits, offering services or encouraging hospital visits if complications arise.

“The community dialogues help us understand the challenges women face, including those within facilities, allowing us to identify areas for improvement. This has encouraged more women to attend hospital,” adds Dr Ogoti.

Data from the health department shows that deliveries have increased from about 2,000 per year to over 4,000 annually, including both normal and caesarean deliveries. “The county has played a significant role by posting more staff to the hospital and ensuring the supply of pharmaceuticals and other essentials. The maternal and perinatal death surveillance and response (MPDSR) process has greatly improved skilled birth attendance, contributing to reduced maternal mortality. CHPs, through defaulter tracing and links with facilities, have significantly increased hospital births, reducing serious complications from late community births,” he adds.

Dr Martin Konyango, Executive Member in charge of Health, attributes the improved skilled delivery rates to enhanced quality of care, including 24-hour availability of gynaecologists managing critical patients.

He also credits a vibrant community health strategy that has increased maternal contact through referrals from antenatal care to skilled delivery.

“Furthermore, the increase in comprehensive care centres offering assisted deliveries and caesarean sections has improved outcomes. For example, Ambira Sub-County Hospital has performed 406 caesarean sections since February 2024, while Madiany recorded 23 since September 2024. Functional ambulances have also increased from six to 11 and expanded imaging capacity with ultrasound services at facilities including Got Agulu, Sigomere, Ambira, Ukwala Sub-County, and Tingwangi,” he says.