How has the standard of maternal-perinatal and under 5 healthcare in the public healthcare sector of Kenya been influenced by the policies being implemented by the Kenyan government

In today's developing world, healthcare is a cornerstone indicator of human development such as in the Human Development Index, a composite indicator that uses the dimension of a long and healthy life to denoted by the life expectancy index as a primary from of measuring healthcare (Nations U, 2022).

Due to the increasing cost of living, social and economic disparities within a population determines the standard of healthcare received. Despite the large improvements of the past decade in maternal healthcare, there are still substantial gaps in the various sectors of perinatal and maternal healthcare. There is a substantial gap in the quality and standardization of neonatal healthcare as well as continuing care for children under the age of 5. As neonatal mortality contributes largely to the rates of childhood mortality then the standard of perinatal care wholesomely is still unachieved in the state that I am observing, Mombasa Kenya. In regards to healthcare, similar to maternal healthcare there exists a positive correlation between low utilization of perinatal healthcare resources and the cost of healthcare (Keene et al., 2019).

In relation to maternal and neonatal healthcare, there are three sections in healthcare that refer to the health of infants globally. Maternal health refers to the health of women during pregnancy, there is the umbrella term known as perinatal health that covers two sections of infant healthcare, childbirth and the postpartum period which refers to health from 22 weeks of gestation until 7 completed days after birth. For infants, perinatal health is the most important period in infant healthcare as a healthy perinatal period heavily influences infancy, childhood and adulthood. (Maternal and newborn health, 2022).

When looking at Kenya from a contemporary lens from 2008 to 2009, the national demographics of maternal deaths were extremely high as the maternal mortality rate was 488 deaths for every 100,000 deaths per annum. It is debated that despite the Kenyan government's new policy which gave over 90% of women receive free maternal healthcare from medical professionals, over half of the annual births occur at home due to cultural stigma as well as lack of transportation access to hospitals resulting in at-home births (Health policy project, 2022).

However, the maternal healthcare policies in 2013 were amended and improved due to President and the ministry of health government, all maternity charges in public healthcare center’s to allow women to have access to maternal care and reduce all maternal deaths. Overall the policy has been effective in creating access to public maternal healthcare by reducing the cost margins, however, the gap in postpartum healthcare for children encompassing the first 4 years of the child's life is still unavailable to the majority of Kenyans due to the economic strain. (Gitobu, Gichangi & Mwanda, 2018)

Additionally, children under the age of 5 have a mortality rate that has decreased exponentially from 102 deaths for every 1000 live births in 1990 to 43 deaths for 1000 live births as of 2019. Despite this decrease in the mortality rate for children under the age of 5 in Kenya 64500 children still die under the age of 5 (3⁄4 of these deaths happen before 12 months of life). Oftentimes these deaths are a result of diseases and infections that are easily preventable which include but are not limited to diarrhea, pneumonia and neonatal complications. Such as These deaths are concentrated in the more rural areas of Kenya as a result of the lack of facilities in being able to cater for the whole county's population. (Health, 2022).

As a result of the evident gap in the standard of maternal, perinatal and under-5 healthcare, this paper will investigate the public healthcare system in Kenya. To be specific the investigation will highlight the standard of perinatal and infant healthcare and the way in which it has been impacted by the socio-economic disparities in the Kenyan population and by extension the Kenyan government. My interest in this topic arose during my internship where I shadowed different doctors and visited both public and private facilities, seeing the differences in the facilities and amount of people specifically, in the public facility there was an overwhelming amount of patients. I further choose the public healthcare system to which the government has autonomy because of the recent developments in the public healthcare system specifically in regard to maternal healthcare and increased accessibility to prevent maternal deaths, increasing the significance. Furthermore, because of the evident socio-economic disparities in Kenya, a less economically developed state, the privatized healthcare offered within the state is not accessible to the majority of the Kenyan population.

I choose to do the world studies; health and development guided by two of my higher-level subjects biology and global politics because it best illustrates the aspect of maternal- perinatal and under 5 healthcare and the effect on the standard of healthcare on the population (biologically) as well as the political aspect of the public healthcare system and its legitimacy in catering to the needs of the population as well as the effect of the public healthcare system on the overarching development of the state (politically) examined using the research question - How has the standard of maternal-perinatal and under 5 healthcare in the public healthcare sector of Kenya been influenced by the policies being implemented by the Kenyan government?

In maternal health nutrition during pregnancy heavily affects the perinatal health of the fetus as it is unable to provide itself with nutrients and oxygen and therefore is highly dependent on the mother to ensure its health and survival both during gestation and post-partum. Without the necessary nutrients and oxygen supply to the fetus during gestation results in malnutrition at such a critical stage of infant care, the malnutrition results in severe and permanent damage to the structure and function of the fetus and infant body. In medicine the study epigenetics which is the study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself has provided evidence that maternal nutrition can result in modifications to the fetal genome. Which can lead to various chronic diseases in the fetus including type 2 diabetes. (Gronert, 2006)

Maternal, perinatal and newborn health is viewed from state and non-state actors' point of view through a human rights and wellbeing perspective as it is used to evaluate the state’s standard of healthcare and living. An example includes the human development index which is a composite indicator that factors in infant mortality rates and increases the importance of the healthcare sector on the global stage.

Additionally, non-state actors such as the United Nations set out sustainable development goals (SDGs) in 2015 in order to create a progressive sustainable agenda to guide the development of states in the different sectors of the state (Maternal and newborn health, 2022). Within the SDGs, SDG 3 “Ensure healthy lives and promote well-being for all at all ages.” One of the main targets within this SDG, SD 3.1 aims to decrease the global maternal mortality rate to less than 70% for 100,000 live births by the reviewing period (2030). (Maternal and newborn health, 2022).

In Kenya, the current infant mortality rate in 2022 is 31.771 deaths per 1000 live births, a 2.47 decline from 2021, this is an improvement from the 2019 infant mortality rate which was 35.198 deaths per 1000 live births, which shows an evident decline in the infant mortality rate. (Kenya Infant Mortality Rate 1950-2022, 2022)

(Kenya (KEN) - Demographics, Health & Infant Mortality - UNICEF DATA, 2022)

Furthermore, the trends in under-five mortality rates have decreased exponentially from 102 deaths for every 1000 live births in 1990 to 43 deaths for 1000 live births as of 2019. This decrease in infant and maternal mortality rates can be attributed to the implementation of the free maternity service policy in Kenya in 2009. For the Kenyan government to gauge the effectiveness of their newly implemented policy, they observed three highly populated counties in Kenya monthly 2 years before implementing the policy and 2 years after the policies implementation with an average of 90 healthcare facilities catering to an estimated three million people over this period of time. (Kenya (KEN) - Demographics, Health & Infant Mortality - UNICEF DATA, 2022)

It was observed that the policy’s approach has been effective in reducing the risk of maternal and perinatal mortality rates in other states implementing similar policies to combat the same issue. However, the results in Kenya have been less successful as a pilot program due to only an average of 61.8% of the deliveries have been attended to by professionals. Despite the high cost of seeking maternal healthcare having a positive correlation with low utilization of maternal healthcare resources, especially in less economically developed countries with high maternal and perinatal mortality rates there is still the social factor that has not been accounted for as a reason for the high perinatal and maternal mortality. (Lang’at, Mwanri & Temmerman, 2019) In child healthcare similar to maternal healthcare there is a positive correlation between low utilization of perinatal healthcare resources and the cost of the healthcare as well as continued accessibility to healthcare below the age of five years. In a different pilot program such as the free maternity policy that has been implemented in Kenya, a country with similar economic issues, the increase in access to inpatient newborn healthcare has been identified as a potential source of improvement in child health and the infant mortality rate indicator. (Keene et al., 2019)

When collecting primary data, I choose to conduct an interview with the primary level 5 hospital in the Mombasa region with a healthcare official that has had personal experience in maternal- perinatal healthcare in order to diversify the perspectives included in my research. I had a set of interview questions for a healthcare official in a public hospital, the interview was guided by these general themes -

• What is the role of the antenatal clinic and post-natal clinics in guiding the maternal and perinatal periods.
• What are the necessary facilities in the labor ward for natural birth and is the hospital equipped to handle large quantities of women with the facilities available.
• Availability of cesarian section in the case of complications as well as post-partum care inclusive of the maternity ward and neonatal wards.
• General challenges faced by healthcare officials in day-to-day operations and the effect on staff and patients.
• Payment coverage by government bodies as well as NGOs
• In addition to the above data i used secondary sources, primarily journal studies that have been conducted in the same hospital I conducted my interview. As well as a journal study covering the post- natal period inclusive of the immunization period to the under 5 period. I choose to use information from journal studies as the information provided is qualitive and is controlled to the area that I am focused on.

I conducted an interview with Caroline Mapesa a healthcare official (i.e. nurse) at Coast General Hospital, which is the main level five public hospital in Mombasa. Nurse Caroline works in the labor ward which offers both natural delivery and cesarian section delivery which is used primarily when there are complications giving birth. Separate from the labor ward the hospital also has an antenatal clinic available to the public that provides medical checkups for pregnant women in order to monitor the health of the mother and child during pregnancy. The antenatal clinic also is responsible for recommending ways in which the women can keep a healthy lifestyle with recommendations on prenatal nutrition and vitamins. The hospital also has a postnatal clinic which is responsible for providing the necessary immunizations for the children 6 weeks after birth as well as checking the health of the mother (Mapesa, 2022).

Nurse Caroline primarily works in the natural delivery of the labor ward which receives on average 600-800 women per month and in July 2022 there were 850 deliveries. The hospital has the necessary facilities for a natural birth which include a delivery pack, blood pressure machine, portable light, oxygen machine, suction machine, ultrasound machine and a resuscitator machine (Mapesa, 2022). For cesarian section deliveries, there is a maternity ward where the mothers can be placed for a duration of time and monitored, and the babies have a neonatal baby unit which is primarily used in the cases of premature babies. In my interview with nurse Caroline, she denoted that despite the necessary facilities for gynecological and obstetric care being in place the ward is understaffed and therefore each person has to tend to multiple deliveries at a time which is very challenging.

Furthermore, when I asked about the effect of cost for delivery I found out that the delivery is covered for members of the National Health Insurance Fund in Kenya which is a government body/ corporation which provides health insurance to Kenya’s and charges monthly depending upon salary but is a minimum of 500 Kenyan Shillings monthly. This national insurance fund covers the majority of the healthcare costs in public hospitals or clinics. Additionally, if a mother does not have NHIF there are also subsidiary projects which work closely with hospitals in Kenya such as Linda Mama which is a part of the universal health scheme that the Kenyan government launched in 2018. The program Linda Mama is free health care for pregnancy, delivery and postnatal coverage that is targeted toward the vulnerable population who are unable to pay for NHIF, this program specifically covers maternal and perinatal costs to ensure that all women even in rural areas with no substantial income have access to the necessary material healthcare and further reduce the maternal mortality rates (MLEMWA, 2022).

In a study published in the journal of health, medicine and nursing done by Elizabeth Muthoki Kivuva, Dr Kezia Njoroge and Dr Wanja Tenambergen, done in 2021 a sampling of 376 pregnant women who delivered at coast general hospital which denoted the social demographic factors within the pool of sampling women that were sought delivery ministrations at Coast General Hospital (Kivuva, Njoroge & Tenambergen, 2021). The data is as follows -

From this data, it can be derived that majority of the women are within the normal age of the pregnancy and can be expected to have the facilities to care for a child, furthermore with the increased percentage of education in terms of secondary and tertiary education the women are well educated. However, the percentage of unemployed women can attribute to the economic status of the family as assumedly only one of the parents has a job resulting in income. The increased access to proper facilities for birth resulted in no maternal or infant deaths being recorded within this study. The obstetric history of the women who were used in this study also indicated that the pregnant women who have had children in the past (295 women) sought healthcare in primarily public hospitals with only 12% having had at-home births. This is an indicator of the free maternal health policy in Kenya being highly effective as it has reduced the number of at-home births, instead, the majority of the births have been done at hospitals which are equipped with the necessary facilities for safe delivery ensuring the health needs of the mother and infant are met

From a national level of analysis, the percentage of births that are handled by healthcare personnel has grown exponentially since the implementation of the free maternity service policy was made in 2009 which resulted in the increase from less than 44% of births being handled by healthcare personnel which indicates that the socio-economic status of the majority of Kenyans before the implementation of the policy was below average as they were unable to pay for healthcare services limiting the number of people with access to basic healthcare needs such as births. However, the implementation of the policy has resulted in 62% of all births being attended to by healthcare personnel as of 2014 which indicated that the policy has been effectively increasing access to maternal healthcare which covers both antenatal, delivery and post-natal care. ("Births attended by skilled health staff (% of total) - Kenya | Data", 2022).

Despite the implementation of the free maternity service policy being effective in increasing accessibility of maternal healthcare services to the majority of the Kenyan population, there is still a substantial gap between the standard of maternal care and the standard of under-five care. In a majority of the country as of 2014, the percentage of children within 12- 23 months that have received full immunization was 68%, the immunizations included 1-dose BCG, 3-dose DTP-HepB-Hib, 3-dose polio, 1-dose measles, and 3-dose pneumococcal vaccines (Allan, Adetifa & Abbas, 2021).

This geographical outline of areas that have higher full immunization rates showcases that the central and more developed areas of the country have more accessibility to vaccines needed for newborns within the first 12-23 months of life. The effect of not immunizing infants is that it opens them up to the risk of infection from vaccine-preventable diseases such as polio, measles, mumps and meningitis, whilst being vaccinated against vaccine-preventable diseases decreases the risk of a child getting an infection or spreading diseases to surrounding people. ("When parents choose not to vaccinate: Risks and responsibilities", 2022)

Another determining factor in the low percentage of fully immunized children is the lack of availability of these vaccines to the general public. Ideally, both the private and public healthcare sectors would have access to the same amount of vaccines, however, this is not the case in many public hospitals in Kenya as there has been a nationwide shortage of vaccines which has resulted in private hospitals having a monopoly over access to the vaccines which they procure from 3rd parties. However, the cost to receive the vaccines is very high and unattainable for the general public. This is illustrated in the contemporary case study of the polio vaccine shortage that was experienced in Kenya in 2019, the vaccines found only in private healthcare facilities resulted in the cost of the vaccine ranging from 8,000 Kenyan shillings ($80) to 20,000 ($200) ("Vaccine shortage in Kenya exposes thousands of babies to polio", 2019). The overarching poverty lines in rural and urban areas of the country are between KSH 3252- 5995 per month, per person ("Poverty & Equity Brief Kenya Sub-Saharan Africa", 2020). The cost to receive the vaccines which are largely available in private healthcare is unavailable to Kenyans with a lower income exemplifying substantial social and economic disparities within the healthcare systems of Kenya.

The United Nations Children’s Fund implemented a pilot program in 2019 to aid in increasing vaccination against these prevalent causes of under-five mortality in the regional areas of Kenya that were most affected by these cases specifically the northern and rural areas. UNICEF in cooperation with county governments and the ministry of health in Kenya has increased the percentage of children that are fully immunized from 84% in 2014 to 88% currently ("Health", 2022). The overarching issue of under-five mortality rates for which full immunization coverage is a contributing factor some of the other prevalent causes include birth asphyxia, preterm birth complications, pneumonia, malaria and diarrhea. 45% of these cases are further compounded by the underlying factor of malnutrition (Ng'ethe, 2017). Further, despite the decrease in under-five mortality rates in Kenya, 3/4 (64,500) of the deaths that have been recorded are still caused by preventable diseases to which healthcare intervention would have reduced the risk of death in cases such as diarrhea ("Health", 2022).

One of the benefits to the methodology that i used is that it i was able to get different perspectives from a local and national level of a analysis as the interview me to get a in-person account from a healthcare official in a level 5 public hospital. Compounded further with the journal study that was done provided more information of the patients and the social demographics in a randomly selected study which allowed me in the analysis to have more data of the various social situations of different citizens of Kenya. The primary and secondary sources gave information that guided the different areas of my analysis and helped me draw conclusions. One of the limitations in my methodology and analysis is that the other journal study that i used to guide my analysis of child immunization demographics as well as under- five healthcare was outside the region that I conducted my research on maternal and perinatal healthcare which broadens my analysis of the connection to under-5 healthcare and limits the connection between the various sources of information. Additionally, I could have diversified my interviewees by including the perspectives of patients which could have provided data from the Kenyan locals.

Overall, maternal- perinatal and under-five mortality is something observed in all countries worldwide, it is also used as a tool to gauge the standard of healthcare that is provided to the people by the government as an indicator of sustainable development within a nation. This essay has explored the public healthcare system in relation to maternal and perinatal healthcare specifically, in relation to the benefits that are being felt as a result of the free maternity service policy for the general population of Kenya as well as other systems in the government has fostered to improve the standard and cost of care for the general public using the research question - How has the standard of maternal-perinatal and under 5 healthcare in the public healthcare sector of Kenya been influenced by the policies being implemented by the Kenyan government? My research has also evaluated the gaps in the policies that have made improvements in specific sectors but have not improved the standard of care in others such as under-five healthcare as well as accessibility to full immunization. My findings highlight the positive effect of the free maternity service policy on maternal- perinatal healthcare and have highlighted the gaps in the continued health of children under the age of 5. These are similar to those I found in other literature reviews such as journals and publications used in the analysis above researching a similar topic through different lenses that have acknowledged the ways in which the free maternity policy has positively impacted access to healthcare and the overarching maternal and infant mortality rates in Kenya. As well as non-state actors such as UNICEF that have acknowledged the gap in under-five healthcare and are attempting to bridge it in various ways. An extension that can be done from this research includes investigating in more depth the benefits and limitations of the UNICEF programs being launched in various regions of Kenya and investigating the improvements that could be made to these programs to be spread out nationally in Kenya as well as other developing countries in Africa and Asia suffering from similar causes of death in children under 5 years. This extension would better equip the government to implement more policies and programs better suited to the large social and economic demographic of people in Kenya. As the populations of Kenya still endure large social and economic disparities as well as corruption within the government the advancements to be made that are still necessary within the current healthcare system still need to be fostered by both the state and non-state actors involved currently in order to ensure that the necessary medicinal and biological components are available to Kenyan population.and investigating the improvements that could be made to these programs to be spread out nationally in Kenya as well as other developing countries in Africa and Asia suffering from similar causes of death in children under 5 years. This extension would better equip the government to implement more policies and programs better suited to the large social and economic demographic of people in Kenya. As the populations of Kenya still endure large social and economic disparities as well as corruption within the government the advancements to be made that are still necessary within the current healthcare system still need to be fostered by both the state and non-state actors involved currently in order to ensure that the necessary medicinal and biological components are available to Kenyan population.

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