Kenya: A Maternal Health Case Study

 

Nada Boutros

Stanford University

Class of 2008

        Traditionally, the provision of adequate food, water, shelter and basic healthcare has been the main focus of international and local relief agencies during complex emergencies1. However, this form of aid does not address aspects of mortality and morbidity due to acute and serious medical, obstetric, and surgical problems or to chronic diseases that need specialist input2. In the mid-1990s, several events helped refocus attention on reproductive health among war-affected populations3.

Kakuma Refugee Camp, Kenya

        Kakuma camp in Kenya is one of the oldest and largest refugee camps in the world. The inhabitants of the camp suffer from poor relations with the local population, a near total lack of economic opportunity, frequent instances of gender-based violence, crime, and recurrent food shortages. The camp sprawls over the desert of northern Kenya4. Its 86,000 inhabitants come from nine different countries and dozens of different ethnic groups: Sudanese comprise about 70 percent of the refugees5. The local population—mostly Turkana—is outnumbered by the refuge
es. A large number of relief agencies and NGOs provide a broad range of services to refugees, but food, water, firewood, education, medical facilities, and social services are in perpetual short supply due to cramped budgets and the austerity of the environment6.

        Women within reproductive age comprise 40% of the total population of the camp. Prenatal and postnatal clinics, family planning services, and curative services for children and adults are provided by four family health clinics throughout the camp7. The clinics also provide a base for community outreach services, including AIDS home care and community-based counseling, as well as for the activities of traditional birth attendants (TBAs) and community health workers. While there is a central delivery unit with prenatal, postnatal, and labor wards, more than half of the deliveries in the camp take place at home, attended by trained TBAs. Emergency obstetric referral services are provided through the Lutheran World Federation (LWF) hospital in the refugee camp and through a mission hospital in Kakuma. TBAs recruited from within the camp, Kenyan midwives, and doctors are the backbone of the supposed ‘excellent’ maternal health care provided in the camp. Controversially, at the Dadaab refugee camp located less than ten miles away from Kakuma, the system is hampered by the lack of security and presence of banditry, so when one is taken by relatives to the camp hospital she has to wait until morning for referral to be done or for qualified medical personnel to take action.


The root of the problem

        Following the Cairo Convention which promoted reproductive health needs as basic needs8, child spacing was discussed as one of the major component of family planning that can facilitate women’s and the total families’ health.  The context of longer time breast-feeding, through use of the Biblical and Koran laws of breast feeding exclusively up to 2 years, use of traditional herbs, use of abstinence have all been utilized.  However, the problem of the camps being closely housed together and the idleness in the camps facilitate more frequent sexual relationship and that calls for more modern methods. The use of the pill, injectable Depoprovera and condoms have been advocated and used only by a minority. Frequent deliveries have therefore still continued to deplete the health of women.


 

A study – Enhancing the use of emergency contraception, Muia. E et al.9

            A baseline survey applying was conducted to assess knowledge, attitude and practice regarding emergency contraception in late 1999 in order to contribute to the improved quality of reproductive health services for refugees in the context of expanding family planning access. A total of 927 women of reproductive age residing in the refugee camps and 16 health care providers were interviewed for the purpose of this study. The survey was complemented by focus group discussions among opinion leaders, adolescents (male and female) and representatives from the women's support groups.

            The study found that of the sixteen health care providers in the camp, though 12 were female, only one doctor, a Kenyan male with 10 years experience, serviced the refugee population. Family planning services offered included contraceptive pills and condoms.  Information and/or supplies were provided, on average, to 2 clients per month for emergency contraceptives and only at the camp hospital. There was no consistency regarding the emergency contraceptive regimen offered. Furthermore, there were no educational materials on emergency contraceptives or standard service delivery guidelines available in the camp hospital. Most of the women respondents interviewed were either refugees from Sudan (50.5%) or Somalia (32.0%). Nearly 56% were unaware that anything could be done to prevent a potential pregnancy following unprotected sex. The most frequently reported option (25.7%) was to go to the hospital. Nearly 15% of women claimed to have ever heard of emergency contraception, nearly half of whom had heard about emergency contraceptives only recently. The majority of the focus group participants had not heard about emergency contraceptives despite their availability at the camp hospital. However, the community elders strongly advocated dissemination of emergency contraceptives through their active participation and support. The avenues for dissemination of information recommended included health facilities, youth and women support groups, drama and puppetry sessions, among others. Findings from this study reflected the lack of essential knowledge regarding emergency contraception both among health care providers and the refugee population and its restricted availability at the camp hospital. The results therefore suggest training regarding protocol regimens, counseling, provision of IEC materials at health facilities and dissemination of information via youth and women support groups be considered.


Discussion

            The case study chosen for this paper is a refugee camp in which the infrastructure and the facilities are advanced, especially in comparison with other refugee camps in Sub-Saharan countries. However, maternal mortality and morbidity still pertain at unusually large numbers, having long-term consequences, horizontally and vertically within the community. From the study, it is possible to see that infrastructure and equipment alone are insufficient in terms of providing maternal and reproductive health care to women in refugee camps. It is particularly important for NGO’s to emphasize education and raise awareness of the resources and possibilities available to them, within the camp and within a larger context as well.

Reproductive Health in Refugee Camps – Analysis within a larger context

            Women of reproductive age are about 25 per cent of the tens of millions of refugees and persons internally  displaced by war, famine, persecution or natural disaster. One in five of these women is likely to be pregnant. Neglecting reproductive health in emergencies has serious consequences, including unwanted pregnancies, preventable maternal and infant deaths, and the spread of STIs including HIV/AIDS. Yet, refugee women commonly lack the most basic elements of reproductive health care. The breakdown of health services worsens the impact of such diseases and the chances for treatment and escalates the risk involved in pregnancy. At many refugee camps most of those who become pregnant are considered to be in high risk groups—adolescents, women over 40, women with many existing children, and women who are physically and emotionally exhausted and undernourished10. As seen through the case study presented in this paper, infrastructure and resources are not the only elements missing to building a strong reproductive health facility within refugee camps. Education and awareness of reproductive health is essential to protect women in refugee camps from the issues aforementioned.

The International Conference on Population and Development affirmed that the right to reproductive health applies to all people at all times. Effective reproductive health programs safeguard human rights such as the right to health, to freely decide the number and spacing of children, to information and education, and to freedom from sexual violence and coercion11. Failure to provide for the reproductive health needs of populations affected by crisis, especially in the age of AIDS, can have tragic consequences not only for individual women, men and children. It can also undermine an entire nation’s stability and prospects for post-conflict reconciliation, reconstruction and development12.

            As in more stable settings, almost all women who develop pregnancy-related complications can be saved from death and disability if they receive treatment in time. In Kakuma and in other refugee sites in sub-Saharan Africa, UNFPA works with local partners to establish prenatal support and a referral system for obstetric emergencies. In Afghanistan, UNFPA responded with emergency supplies and equipment during the acute phase of the crisis, and has contributed to longer-term development as well, rehabilitating a maternal hospital and training health care workers, among other activities.

            A recent global evaluation by the Inter-Agency Working Group on Reproductive Health in Refugee Settings found that most refugee sites now offer at least some combination of prenatal care, assisted child delivery, management of obstetric emergencies, and newborn and post-partum care. Maternal mortality ratios in refugee camps in Kenya (Kakuma) have been found to be lower than in the host country overall or in the refugees’ home countries, which poses controversy and allows conflict to arise. While some components of maternal health care—particularly emergency obstetric support—still require a great deal of strengthening, a good start has been made since 1994, as seen in the case study discussed above13. However, a new global evaluation by the Inter-Agency Working Group on Reproductive Health in Refugee Settings warns that recent progress in this area is now threatened by stagnant or declining donor funding, compounded by the United States administration’s political opposition to some aspects of reproductive health14. Increased advocacy and funding are more critical than ever before, as geopolitical instability and increasing vulnerability to natural disasters threaten to increase the number of people in need in coming years15, 16.