As countries in the African region intensify efforts to control the COVID-19 pandemic, health systems are being challenged. The consequential disruption of services on the already overstretched health systems, and the deviation of resources from essential sexual and reproductive health services (SRH) have increased the vulnerability of African women notably women in remote and rural areas and humanitarian settings.
Reductions in access to and utilisation of essential maternal and newborn health services during epidemics translate into important increases in the number of women and newborns who suffer complications or die during pregnancy, childbirth, and the postnatal period. Even a modest decline of 10% in service coverage during pregnancy and for newborns could result in an additional 28000 maternal deaths, 168000 newborn deaths, and millions of unintended pregnancies as family planning services face disruptions. The upsurge of the COVID-19 pandemic, that was first reported early 2020 in Africa, has resulted in reductions in access to and utilisation of reproductive, maternal, neonatal and child health (RMNCH) among other health services that are critical to the improvement of women’s health on the continent.
Status of RMNCH in Sub-Saharan Africa
The WHO defines reproductive health as “a responsible, satisfying, and safe sex life [with] capability to reproduce and the freedom to decide if, when and how often to do so”. Access to RMNCH is a determinant of maternal and child mortality, as well as many economic and social development indicators. Family planning, for example, prevents adverse outcomes and maternal and newborn deaths by reducing women’s exposure to high-risk pregnancies and helps to avoid unintended and closely spaced pregnancies.
Each year, nearly half a million women worldwide die as a result of complications in pregnancy and childbirth. Almost all (99%) of these deaths occur in developing countries, where pregnancy-related complications remain a leading cause of death for women in their reproductive years. Yet, most of these deaths are avoidable. Over the last 30 years, the global RMNCH burden has decreased significantly, but many countries are far from achieving the national-level goals for maternal and child health – particularly in sub-Saharan Africa. Approximately 300,000 women die from pregnancy-related causes every year – 74% from complications during delivery.
In low- and middle-income countries (LMICs), 218mn women have unmet need for modern contraception, contributing to 111mn unwanted pregnancies every year. This need is greatest among adolescents 15-19 years-old, who face increased socio-cultural barriers to access. As of 2019, 314mn women within the FP2020 countries (a group of LMICs committed to improving access to family planning services) used modern contraception methods. This is a significant increase from 53mn in 2012. However, estimates suggest that 230mn women and girls in LMICs still have unmet need for modern contraceptive methods.
Many of the countries with the highest maternal mortality rates, and child mortality rates are also those with the lowest use of family planning methods, such as Chad, South Sudan, Somalia, and Nigeria. Sub-Saharan Africa has the lowest modern contraception prevalence rates (mCPR) globally. However, sub-Saharan Africa is also the region that has experienced the highest recent growth in mCPR. Between 2012 and 2019, mCPR growth in East and Southern Africa was 1% per year on average, and 0.7% and 0.6% in West Africa and Central Africa, respectively. These rates are greater than all other regions, and at least double the growth of the next highest of Latin America and the Caribbean, and South Asia.
Kenya is no exception. While use of modern methods of family planning in Kenya has increased over the last decade, from 32% in 2003 to 60.7% in 2018, 13.8% of currently married women still have an unmet need for family planning services, and 31% of family planning users discontinue use of a method within 12 months. The most popular modern contraceptive methods used among all women are injectables (19%), implants (7%), and the pill (6%). Use of the intrauterine contraceptive device (IUCD) is low (2.3%). The public sector remains the major provider of contraceptive methods, with 60% of modern contraceptive users obtaining their contraception from a government source, 38% from the private sector, and 2% from other sources.
While the RMNCH landscape is complex and highly fragmented, including many health priorities, commodities, and key players, many organisations in collaboration with governments have demonstrated efforts to prioritise and improve RMNCH. Gaps in access are driven by numerous factors including issues with product quality and appropriateness, weak forecasting and procurement systems, and inconsistent political will and financing for products.
Overall, there is a need for greater market shaping and coordination support. In the family planning space, efforts are underway to explore how a market coordination mechanism could address commodity access issues in LMICs, but broader support across the RMNCH landscape is needed as well. There is also limited opportunities for scaling new RMNCH tools and interventions. RMNCH lacks global bodies that provide scale-up at the volume of other disease areas. Despite these complexities, governments in partnership with the private sector are empowering women through prioritising RMNCH strengthening.
Each year, nearly half a million women worldwide die as a result of complications in pregnancy and childbirth. Almost all (99%) of these deaths occur in developing countries, where pregnancy-related complications remain a leading cause of death for women in their reproductive years. Yet, most of these deaths are avoidable. Over the last 30 years, the global RMNCH burden has decreased significantly, but many countries are far from achieving the national-level goals for maternal and child health – particularly in sub-Saharan Africa. Approximately 300,000 women die from pregnancy-related causes every year – 74% from complications during delivery.
In low- and middle-income countries (LMICs), 218mn women have unmet need for modern contraception, contributing to 111mn unwanted pregnancies every year. This need is greatest among adolescents 15-19 years-old, who face increased socio-cultural barriers to access. As of 2019, 314mn women within the FP2020 countries (a group of LMICs committed to improving access to family planning services) used modern contraception methods. This is a significant increase from 53mn in 2012. However, estimates suggest that 230mn women and girls in LMICs still have unmet need for modern contraceptive methods.
Many of the countries with the highest maternal mortality rates, and child mortality rates are also those with the lowest use of family planning methods, such as Chad, South Sudan, Somalia, and Nigeria. Sub-Saharan Africa has the lowest modern contraception prevalence rates (mCPR) globally. However, sub-Saharan Africa is also the region that has experienced the highest recent growth in mCPR. Between 2012 and 2019, mCPR growth in East and Southern Africa was 1% per year on average, and 0.7% and 0.6% in West Africa and Central Africa, respectively. These rates are greater than all other regions, and at least double the growth of the next highest of Latin America and the Caribbean, and South Asia.
Kenya is no exception. While use of modern methods of family planning in Kenya has increased over the last decade, from 32% in 2003 to 60.7% in 2018, 13.8% of currently married women still have an unmet need for family planning services, and 31% of family planning users discontinue use of a method within 12 months. The most popular modern contraceptive methods used among all women are injectables (19%), implants (7%), and the pill (6%). Use of the intrauterine contraceptive device (IUCD) is low (2.3%). The public sector remains the major provider of contraceptive methods, with 60% of modern contraceptive users obtaining their contraception from a government source, 38% from the private sector, and 2% from other sources.
While the RMNCH landscape is complex and highly fragmented, including many health priorities, commodities, and key players, many organisations in collaboration with governments have demonstrated efforts to prioritise and improve RMNCH. Gaps in access are driven by numerous factors including issues with product quality and appropriateness, weak forecasting and procurement systems, and inconsistent political will and financing for products.
Overall, there is a need for greater market shaping and coordination support. In the family planning space, efforts are underway to explore how a market coordination mechanism could address commodity access issues in LMICs, but broader support across the RMNCH landscape is needed as well. There is also limited opportunities for scaling new RMNCH tools and interventions. RMNCH lacks global bodies that provide scale-up at the volume of other disease areas. Despite these complexities, governments in partnership with the private sector are empowering women through prioritising RMNCH strengthening.
Examples of selected case studies for RMNCH strengthening in Kenya:
- • The government of Kenya designed the National RMNCAH Investment Framework to prioritise coverage for RMNCAH services. Through the framework, the government has introduced new policies such as Free Maternity Services and Elimination of User Fee for Primary Care to address critical barriers. The First Lady is also spearheading the nationwide Beyond Zero campaign to ensure that no woman should die while giving life.
• In 2016, with funding from USAID, and in partnership with the Kenyan Ministry of Health (MOH), Maternal and Child Survival program (MCSP) built capacity for LARCs in public health facilities in Kisumu and Migori counties and used this platform to embed introduction of and learning about the potential of hormonal IUS within LARCs, using commodities donated by the International Contraceptive Access (ICA) Foundation. MCSP worked in close collaboration with the MOH to incorporate the hormonal IUS directly into the contraceptive method mix at select high-volume facilities.
• Kenya Association for Maternal and Neonatal Health (KAMANEH) is devoted to implementing sustainable, replicable, and cost-effective Maternal, Neonatal and Child health projects to reduce maternal/neonatal mortality in Kenya, through the Provision of preventive and affordable health care services, Community Midwives strengthening, women’s empowerment, male and community involvement, education, and advocacy work in both urban slums and rural communities of Kenya.
• The UN Joint Programme on RMNCH in ten counties with high maternal mortality burden (Mandera, Marsabit, Wajir, Isiolo, Lamu, Migori, plus four additional counties to be selected) enjoyed increased utilisation of integrated, quality reproductive, maternal, newborn, child, and adolescent health, HIV, and gender-based violence (GBV) services. The programme that ended in 2020 contributed to the reduction of maternal and newborn mortality in Kenya. While long-term investments in all the building blocks for health systems are required to address these issues, the joint programme worked on implementing evidence-based, equitable, and efficient high-impact interventions that were aimed at contributing to the long-term sustainability of the results achieved.
• FHI 360 is also working with the Kenya government through the Ministry of Health to provide technical support to family planning programs and helping to shape the national HIV/AIDS response. FHI 360 continue to collaborate with the Kenyan government to strengthen HIV prevention, care and treatment; reproductive health; and family planning services — through research and innovative approaches to improve service delivery and access.
Interventions needed to expand RMNCH
Despite this, progress in achieving maternal health targets has been slow, with 90% of countries not on track to achieve the Millennium Development Goal for maternal health (MDG 5). Policy harmonisation can help accelerate gains in maternal health by strengthening health systems and improving access to high-quality maternal health services before, during, and after birth. Use of family planning services not only prevents unintended pregnancy, but it can also protect the lives of many women who face increased health risks when giving birth at a young age.
The health interventions needed to prevent or manage complications are relatively straightforward and often inexpensive. Over half (60%) of maternal deaths could be averted if all pregnant women in developing countries had access to high-quality antenatal care and basic, and well-equipped, health facilities staffed by competent midwives. There should be a specific focus on improving access to, and quality of, integrated RMNCH services, increasing demand for quality RMNCH services, strengthening institutional capacity at county and national levels for planning and budgeting, coordination, supportive supervision, and monitoring and evaluation of RMNCH services. Addressing these key focus areas has the potential to drastically reduce maternal mortality.
The health interventions needed to prevent or manage complications are relatively straightforward and often inexpensive. Over half (60%) of maternal deaths could be averted if all pregnant women in developing countries had access to high-quality antenatal care and basic, and well-equipped, health facilities staffed by competent midwives. There should be a specific focus on improving access to, and quality of, integrated RMNCH services, increasing demand for quality RMNCH services, strengthening institutional capacity at county and national levels for planning and budgeting, coordination, supportive supervision, and monitoring and evaluation of RMNCH services. Addressing these key focus areas has the potential to drastically reduce maternal mortality.
Why expanding RMNCH is important
While many African countries have prioritised RMNCH strengthening, many are still falling short of the SDG targets set for RMNCH, and the situation has been made more challenging due to the COVID-19 pandemic and lockdown measures. Women’s and children’s health are acknowledged as critically important to the health and wellbeing of a population – both as an indicator of general population health, and as a determinant for achieving broader development goals, including those outside of the health sphere. Investments in women’s health, and particularly family planning, are considered “best buys” for global development in terms of value for money, generating savings through reduced maternal mortality, increased economic development, improved child health and education, and even decreased vulnerability to climate change.
Improving access to RMNCH fundamentally advances human rights by empowering women and girls with the ability to control if and when to become pregnant. Declines in fertility rates are associated with increases in women’s health, financial earnings, and educational attainment. It is for these reasons that investments in RMNCH are celebrated as catalytic to social development and equity.
Conclusively, Kenya like many other countries, has strong regulatory and policy frameworks for RMNCH. These frameworks provide many opportunities for advocacy, and for ensuring that the government, including specific offices, are held accountable for commitments made in the context of devolution. These policies continue to be revised without full dissemination and implementation. Through public private partnerships, we can realise the commitments made in these policy frameworks through market shaping and coordination support to expand access to RMNCH.
Improving access to RMNCH fundamentally advances human rights by empowering women and girls with the ability to control if and when to become pregnant. Declines in fertility rates are associated with increases in women’s health, financial earnings, and educational attainment. It is for these reasons that investments in RMNCH are celebrated as catalytic to social development and equity.
Conclusively, Kenya like many other countries, has strong regulatory and policy frameworks for RMNCH. These frameworks provide many opportunities for advocacy, and for ensuring that the government, including specific offices, are held accountable for commitments made in the context of devolution. These policies continue to be revised without full dissemination and implementation. Through public private partnerships, we can realise the commitments made in these policy frameworks through market shaping and coordination support to expand access to RMNCH.