In developing countries, more than nine million infants die every year before birth and in the first week of life as a result of complications occurring during pregnancy. Many of these deaths are preventable . In 2000 the United Nations (UN) made a declaration to include maternal and child mortality reduction as a target in its Millennium Development Goals (MDGs) . Maternal mortality is high throughout Africa, yet the ratios are particularly high in Kenya, where a woman’s lifetime risk of dying is one in 38 compared to one in 2000 in the developed world . The World Health Organization (WHO) reported that Kenya’s progress towards improving maternal and neonatal health is presently “insufficient” with little or no progress having been made over the past decade .
Of the more than 500,000 women who die each year as a result of complications arising during pregnancy, half live in Sub-Saharan Africa . Yet death is not the only outcome resulting from pregnancy complications. For every woman who dies, at least 30 others are injured and disabled. Globally seven million women are affected by health problems related to childbearing . Despite the inauguration of the Safe Motherhood Initiative (SMI) in Nairobi in 1987, Kenya has made limited progress towards improving maternal mortality.
Between 1980 and 2010, the national maternal mortality ratio (MMR) was 400–560 per 100,000 live births [1, 6, 7]. The ratios are higher for the major teaching and referral hospitals where obstetrics complications are concentrated. For example, the MMR in Kenya’s largest referral hospital, Kenyatta National Hospital (KNH), was 922 per 100,000 live births in 2004 . In Kilifi District Hospital in Kenya, the MMR was 250 per 100,000 live births between 2008 and 2010 . In nearby Sub-Saharan African countries, MMRs in teaching hospitals are also high. For instance, in Adeoyo Hospital in Nigeria, the MMR was 963 per 100,000 live births between January 2003 and December 2004 . The Neonatal Mortality Rate (NMR) in KNH from January to December of 2000 was 215 per 1000 live births . The NMRs are high in other African countries such as Nigeria, (53 per 1000 live births) and Ethiopia (51 per 1000 live births) .
Newborn deaths represent 38% of all deaths among children under five years of age . One in five women in Africa risks losing a newborn baby during her lifetime . Pre-term birth accounts for 29% of neonatal deaths globally and approximately 14% of babies are born with low birth weight . Early neonatal outcomes can be affected by nutrition, lifestyle and socio-economic status of mothers. “The best care in the world cannot save a woman’s life if she cannot reach it, cannot afford it, does not know it is there when to seek it, or is not permitted to use it” .
The Delay Model by Thaddeus and Maine [16, 17] provides a suitable conceptual framework for understanding risk factors associated with maternal mortality at a tertiary referral hospital. The Model identifies three types of delays. They are: delay in the decision to seek care, delay in arrival at a health facility and delay in the provision of adequate care . Some risk factors that have been linked to the delay model are: lack of funding, inaccessibility, poor infrastructure, inadequate staffing, inadequate equipment and supplies, lack of information, cultural issues, social vulnerability, and low socio-economic status .
Ensuring the continuum of care throughout pregnancy is an important requirement for the reduction of maternal and early neonatal deaths. There is evidence that a significant number of stillbirths and neonatal deaths could be prevented if all women were adequately nourished and received good quality care during pregnancy, delivery, and the postpartum period [14, 18]. The antenatal period helps the health care provider to assess risks and treat conditions that could affect both the mother and baby . It is essential that during delivery, obstetric emergencies are effectively managed to prevent complications which account for up to 58% of stillbirths and early neonatal deaths . Countries such as Thailand, Sierra Leonne, Libera, Pakistan, Sudan, Bosnia, Uganda, Tanzania, and Northern Kenya, have established intervention projects to improve the availability of emergency obstetric care (EmOC) . These projects include the use of signal funtions to assess whether their health facilties adhere to international standard operating procedures for the management of emergencies during pregnancy.
In the post-partum period, the provision of family planning advice after delivery is of vital importance, especially in settings where the birth rate is high and multiparous women are at repeated risk of pregnancy complications and adverse birth outcomes .
Health care infrastructure in Kenya includes two national tertiary teaching and referral hospitals as well as provincial hospitals, district and sub-district hospitals, health centres and dispensaries, or chemists. The private sector provides about one third of outpatient care and 14% of inpatient care. High-risk patients are managed in the tertiary hospitals where clinical resources are more specialized. A number of measures have been introduced to help meet the MDGs in Kenya. For example, Kenya's second largest referral hospital, the Moi Teaching and Referral Hospital (MTRH) has initiated 24 hour maternal and perinatal death reviews and monthly maternal mortality reviews for all maternal deaths. Over the past two years the MTRH has also established standard operating procedures for managing both direct and indirect maternal complications in pregnancy. However more work is needed to achieve progress in this area.
While there have been many maternal health studies in Kenya, little has been published specifically on maternal and early neonatal mortality [8, 11, 22–26]. The aim of this study is to measure the incidence of maternal and neonatal mortality in women who gave birth at MTRH and describe clinical characteristics and circumstances associated with maternal and early neonatal deaths following deliveries at MTRH. As one of only two teaching and referral hospitals in Kenya, the MTRH serves an important role in the country’s health system. MTRH is also the largest hospital in the rural western region of Kenya. High maternal and early neonatal mortality at MTRH has local and national implications and therefore requires investigation.