Maternal mortality in the informal settlements of Nairobi city: What do we know?

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Study Justification:
– Maternal mortality ratios in Kenya are high, with estimates at least as high as 560 deaths per 100,000 live births.
– The situation is expected to be worse in slum areas due to pervasive poverty and lack of quality health services.
– Effective monitoring of maternal mortality in developing countries is challenging due to the lack of reliable data.
– This study aims to estimate the burden and identify causes of maternal mortality in two slums of Nairobi City, Kenya.
Study Highlights:
– The maternal mortality ratio for the two Nairobi slums, from January 2003 to December 2005, was 706 maternal deaths per 100,000 live births.
– Major causes of maternal death included abortion complications, hemorrhage, sepsis, eclampsia, and ruptured uterus.
– Only 21% of maternal deaths had assistance from a health professional during delivery or abortion.
– Verbal autopsy interviews captured more abortion-related deaths compared to health care facility records.
– There were 22 late maternal deaths, mostly due to HIV/AIDS and anemia.
Study Recommendations:
– Urgent need to address the burden of unwanted pregnancies and unsafe abortions among the urban poor.
– Strengthen access to HIV services alongside maternal health services, as HIV/AIDS is becoming a major indirect cause of maternal deaths.
Key Role Players:
– African Population and Health Research Center (APHRC)
– Nairobi Urban Health and Demographic Surveillance System (NUHDSS)
– Medical epidemiologists
– Obstetricians
– Health care facility personnel
Cost Items for Planning Recommendations:
– Training for field workers and interviewers
– Verbal autopsy tool development and implementation
– Health care facility survey
– Data collection and analysis
– Ethical approval and permissions
– Transportation and logistics for field work
– Reporting and dissemination of findings

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is fairly strong, but there are some areas for improvement. The study provides specific data on the maternal mortality ratio in two slums in Nairobi City, Kenya, and identifies the major causes of maternal death. The study also highlights the challenges of monitoring maternal mortality in developing countries due to the lack of reliable data. However, the abstract does not provide information on the sample size or the methodology used to estimate the burden and identify causes of maternal mortality. Including this information would strengthen the evidence. Additionally, the abstract mentions the use of verbal autopsy interviews and a survey of health care facilities, but it does not provide details on how these data were collected or analyzed. Providing more information on the data collection and analysis methods would improve the transparency and replicability of the study.

Background. Current estimates of maternal mortality ratios in Kenya are at least as high as 560 deaths per 100,000 live births. Given the pervasive poverty and lack of quality health services in slum areas, the maternal mortality situation in this setting can only be expected to be worse. With a functioning health care system, most maternal deaths are avoidable if complications are identified early. A major challenge to effective monitoring of maternal mortality in developing countries is the lack of reliable data since vital registration systems are either non-existent or under-utilized. In this paper, we estimated the burden and identified causes of maternal mortality in two slums of Nairobi City, Kenya. Methods: We used data from verbal autopsy interviews conducted on nearly all female deaths aged 15-49 years between January 2003 and December 2005 in two slum communities covered by the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). In describing the distribution of maternal deaths by cause, we examined maternal and late maternal deaths according to the ICD-10 classification. Additionally we used data from a survey of health care facilities that serve residents living in the surveillance areas for 2004-2005 to examine causes of maternal death. Results: The maternal mortality ratio for the two Nairobi slums, for the period January 2003 to December 2005, was 706 maternal deaths per 100,000 live births. The major causes of maternal death were: abortion complications, hemorrhage, sepsis, eclampsia, and ruptured uterus. Only 21% of the 29 maternal deaths delivered or aborted with assistance of a health professional. The verbal autopsy tool seems to capture more abortion related deaths compared to health care facility records. Additionally, there were 22 late maternal deaths (maternal deaths between 42 days and one year of pregnancy termination) most of which were due to HIV/AIDS and anemia. Conclusion: Maternal mortality ratio is high in the slum population of Nairobi City. The Demographic Surveillance System and verbal autopsy tool may provide the much needed data on maternal mortality and its causes in developing countries. There is urgent need to address the burden of unwanted pregnancies and unsafe abortions among the urban poor. There is also need to strengthen access to HIV services alongside maternal health services since HIV/AIDS is becoming a major indirect cause of maternal deaths.

The study was conducted in two slums in which the African Population and Health Research Center (APHRC) is implementing the longitudinal Nairobi Urban Health and Demographic Surveillance System (NUHDSS) since August 2002. The surveillance system monitors vital events such as births, deaths, and migration on over 58,000 individuals in two slum communities, Korogocho and Viwandani. The two slums are located about 5–10 km from the city centre and occupy an area less than one square kilometer in size. The main means of transport is by commuter mini-buses which drop and pick-up passengers at the periphery of the slums but do not go inside the slum settlements as there are no paved roads and there is heavy human traffic on the available paths. The informal nature of slums underscores their non-permanence with lack of public infrastructure and social services. There are very few public health facilities serving the two slum communities, and these are mainly located on the outskirts of the slums and are therefore inaccessible at night due to security concerns. The residents are from over 15 ethnic backgrounds with the majority being Kikuyu (28%), Luhya (24%), Kamba (21%) and Luo (15%). In Viwandani, the population mainly comprises labour migrants working in the neighboring industrial area, while the Korogocho population consists mainly of long-term settlers working in the informal sector. We used data from verbal autopsies conducted on nearly all female deaths aged 15–49 years between January 1, 2003 and December 31, 2005 in the NUHDSS. We also used data from a health care facility survey conducted in 2006 to assess maternal health experiences as captured by the health management information system (HMIS) in health care facilities during 2004–2005. The health care facilities were identified from reports provided by women who participated in the household survey component of the project. As part of the NUHDSS routine procedures, verbal autopsy interviews are conducted using a questionnaire adapted from the verbal autopsy tool developed by the World Health Organization [20]. All deaths in the two slum communities are captured through a death registration form completed by a field worker. A detailed verbal autopsy interview is then conducted by a field supervisor trained to conduct verbal autopsy interviews. All verbal autopsy interviewers must have a minimum of 12 years of formal education and are familiar with the slum setting. They are trained on the verbal autopsy procedures for at least one week and retrained at the beginning of each data collection round. Interviews are conducted after making an appointment with the bereaved household normally after the funeral but within approximately 6 weeks of registering the death. Respondents are typically members of the household who cared for the deceased prior to death or have good knowledge of the symptoms or events that led to death and they must consent to be interviewed. Three physicians independently review the completed verbal autopsy forms and assign cause of death using the tenth revision of the International Classification of Diseases (ICD-10) [21]. If two or more concur, the result is then taken as the probable cause of death. Where agreement is not reached, the three physicians meet and discuss the case in order to reach a consensus. If consensus is not reached, the cause of death is coded as unknown. In this study, women who died between January 1, 2003 and December 31, 2005 were identified from the NUHDSS database. Three physicians (a medical epidemiologist and two obstetricians) independently reviewed the verbal autopsy records in order to ascertain the cause of death. The purpose of having the verbal autopsies reviewed again by two obstetricians was to ensure that any maternal deaths that could have been missed by the routine DSS coding were captured. The ICD-10 definition of maternal death, “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes”, was used. Further, we considered late maternal deaths defined by ICD-10 definition as “death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy” [21]. We categorized maternal deaths into direct and indirect causes. Direct obstetric deaths are defined as maternal deaths resulting from obstetric complications of the pregnant state (pregnancy, labor, and the puerperium), interventions, omissions, incorrect treatment or a combination of any of the above while indirect obstetric deaths are those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but was aggravated by physiologic effects of pregnancy [21]. A health care facility survey was conducted in 2006 and targeted facilities that are commonly used by pregnant women living in the two slum communities for obstetric care. A total of 25 health facilities where women delivered between 2003 and 2005 were identified. Selection of health facilities was based on information provided by women who had had a pregnancy outcome between 2003 and 2005 and had been interviewed in the household survey which was part of the larger maternal health project. Some of the health facilities assessed were located in the two slums while the rest were in other parts of Nairobi. We sought ethical approval from the Kenya Medical Research Institute (KEMRI) Ethical Review Committee, which is one of the Institutional Review Boards authorized to give ethical approval for research in Kenya. We also obtained permission from the Ministry of Health and from the Medical Officer of Health in-charge of the Nairobi City Council before visiting the health care facilities. Appointments were made with the respective health care facility personnel to explain the details of the survey after which consent was sought to carry out the interview. Structured interviews were carried out by one clinical officer who underwent three-day training for this exercise. Data on causes of deaths for 2004 and 2005 were extracted from the medical records. Descriptive statistics were used to describe the maternal mortality levels and causes of maternal death in the two slums.

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Based on the information provided, here are some potential innovations that could improve access to maternal health in slum areas:

1. Mobile health clinics: Implementing mobile health clinics that can travel to slum areas, providing essential maternal health services such as prenatal care, vaccinations, and postnatal care. This would help overcome the lack of public health facilities in these areas and improve access to healthcare for pregnant women.

2. Telemedicine: Introducing telemedicine services that allow pregnant women in slum areas to consult with healthcare professionals remotely. This could involve video consultations, remote monitoring of vital signs, and access to medical advice through mobile applications. Telemedicine can help bridge the gap between healthcare providers and patients in areas with limited access to healthcare facilities.

3. Community health workers: Training and deploying community health workers in slum areas to provide basic maternal health services, education, and support. These workers can conduct home visits, provide health education, assist with prenatal and postnatal care, and refer women to healthcare facilities when necessary. Community health workers can play a crucial role in improving access to maternal health services in underserved areas.

4. Improving transportation infrastructure: Advocating for improved transportation infrastructure in slum areas, such as paved roads and better public transportation options. This would make it easier for pregnant women to access healthcare facilities, especially during emergencies or when they require specialized care.

5. Strengthening data collection systems: Investing in the development and implementation of reliable data collection systems to monitor maternal mortality rates and identify causes of maternal deaths in slum areas. This would help policymakers and healthcare providers make informed decisions and allocate resources effectively to address the specific challenges faced by pregnant women in these areas.

These innovations, if implemented effectively, could help improve access to maternal health services and reduce maternal mortality rates in slum areas.
AI Innovations Description
Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Strengthening healthcare facilities: Improve the availability and accessibility of healthcare facilities in slum areas, such as Korogocho and Viwandani in Nairobi City. This can be done by establishing more health centers within the slums themselves, rather than on the outskirts, to ensure that pregnant women have easy access to quality maternal healthcare services.

2. Mobile healthcare clinics: Implement mobile healthcare clinics that can reach the slum communities and provide essential maternal health services. These clinics can be equipped with trained healthcare professionals and necessary medical equipment to offer antenatal care, postnatal care, and emergency obstetric services directly to the residents of the slums.

3. Community health workers: Train and deploy community health workers within the slum communities to provide education, support, and referrals for pregnant women. These community health workers can play a crucial role in identifying and addressing maternal health issues at an early stage, as well as promoting preventive measures and healthy practices among pregnant women.

4. Awareness campaigns: Conduct targeted awareness campaigns within the slum communities to educate residents, especially women of reproductive age, about the importance of maternal health and the available healthcare services. These campaigns can include information on antenatal care, safe delivery practices, family planning, and the risks associated with unsafe abortions.

5. Collaboration with NGOs and local organizations: Collaborate with non-governmental organizations (NGOs) and local organizations that are already working in the slum communities to leverage their resources and expertise in improving access to maternal health. This can involve partnerships to provide funding, training, and infrastructure support for maternal health initiatives.

By implementing these recommendations, there is a potential to improve access to maternal health services in slum areas, reduce maternal mortality rates, and ensure better health outcomes for pregnant women in Nairobi City.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health in the slum areas of Nairobi City:

1. Increase the number of health care facilities: Establish more health care facilities within the slum areas to ensure that pregnant women have easy access to maternal health services. These facilities should be located within the slums to address the issue of inaccessibility at night due to security concerns.

2. Improve transportation infrastructure: Develop paved roads within the slum settlements to facilitate the movement of pregnant women and improve access to health care facilities. This will address the current challenge of limited transportation options within the slums.

3. Strengthen community health workers: Train and deploy community health workers within the slum communities to provide basic maternal health services, education, and referrals. These community health workers can play a crucial role in identifying complications early and ensuring that pregnant women receive appropriate care.

4. Increase awareness and education: Conduct awareness campaigns and educational programs within the slum communities to raise awareness about the importance of maternal health and the available services. This can help overcome cultural barriers and encourage more women to seek timely and appropriate care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators to measure the impact of the recommendations, such as the number of pregnant women accessing maternal health services, the reduction in maternal mortality ratio, and the increase in skilled birth attendance.

2. Collect baseline data: Gather data on the current status of maternal health in the slum areas, including the number of health care facilities, transportation infrastructure, and maternal mortality rates. This will serve as a baseline for comparison.

3. Develop a simulation model: Create a simulation model that incorporates the recommendations and their potential impact on improving access to maternal health. This model should consider factors such as the number of additional health care facilities, the improvement in transportation infrastructure, and the effectiveness of community health workers.

4. Run the simulation: Use the simulation model to project the potential impact of the recommendations over a specific time period. This can be done by adjusting the input variables and running multiple scenarios to assess the range of possible outcomes.

5. Analyze the results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. This can include assessing the changes in key indicators and identifying any potential challenges or limitations.

6. Refine and validate the model: Continuously refine and validate the simulation model based on new data and feedback from stakeholders. This will ensure that the model accurately represents the real-world situation and can be used for future decision-making.

By following this methodology, policymakers and stakeholders can gain insights into the potential impact of the recommendations and make informed decisions to improve access to maternal health in the slum areas of Nairobi City.

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