Duncan Shikuku (Senior Technical Officer – Liverpool School of Tropical Medicine and Midwifery and Women’s Health Specialist
Kenya is not on track to meeting the SDG targets of less than 70/100,000 (currently at 362/100,000) maternal mortality ratio and 12/1000 (currently at 22/1000) newborn mortality rate by 2030. To achieve this, a functioning health system that includes “skilled health personnel” (SHP), previously known as skilled birth attendants, who are competent to provide care during labour and childbirth is essential.
The introduction of free maternity services in 2013 in Kenya has increased health facility delivery service utilization with no significant changes in the ratio of maternal mortality and the rate of neonatal mortality. With the prioritization of universal health coverage (UHC) by the MOH, this will likely increase the demand for health facility care and nursing/midwifery workforce as part of the efforts to achieving the ambitious SDG targets. However, the largely didactic nursing/midwifery training curriculum, nurse/midwife shortages and inequitable distribution in the country are challenges to achieving quality maternity care.
Definition of skilled health personnel
World Health Organization (WHO), International Confederation of Midwives (ICM) and International Federation of Gynecology and Obstetrics (FIGO) define a skilled health personnel as competent maternal and newborn health (MNH) professional educated, trained and regulated to national and international standards and competent to identify and manage or refer women and/or newborns with complications thus can perform all signal functions of emergency maternal and newborn care (EmONC) to optimize the health and wellbeing of women and newborns.
Emergency obstetrics care (EmOC)
An estimated 15 percent of pregnant women will develop a complication during pregnancy, childbirth or the puerperium, which will require EmOC. Emergency obstetric care is defined as the collective minimum set of medical interventions (or bundle of care) required to prevent or manage the main obstetric complications (haemorrhage, preeclampsia or eclampsia, sepsis, complications of obstructed labour or abortion) and newborn complications (birth asphyxia).
Critical role of midwives
Midwives can provide 87% of the needed essential care for women and newborns, when educated and regulated to international standards. They are the most cost-effective suppliers of midwifery services that could avert a total of 83% of all maternal deaths, stillbirths and neonatal deaths. In Kenya, the nursing and midwifery workforce plays a leading role in health service delivery, providing assistance during birth in 58% of all births (KDHS 2014).
Pre-service midwifery training in Kenya
Currently, there are seven programs for pre-service nursing and midwifery training that have been approved by the Nursing Council of Kenya (NCK) in the country at certificate, diploma and degree level. They are: 1-year certificate in Kenya Enrolled Midwifery (KEM), 3-year basic diploma in Kenya Registered Community Health Nursing (KRCHN), 3-year basic diploma in Kenya Registered Nursing & Midwifery (KRNM), 3-year basic diploma in Kenya Registered Midwifery (KRM), 1-year post-basic diploma in KRM, 4-year degree in Bachelor of Science in Nursing (BScN) and 4-year degree in Bachelor of Science in Midwifery (BScM).
The Nursing Council of Kenya (NCK) established by the Nurses Act Cap 257 of the Laws of Kenya ensures the delivery of safe and effective nursing and midwifery care, to the public, through quality education and best practices. As the only professional regulatory body for all cadres of nursing and midwives in Kenya, it accredits training institutions and programmes of study for the nursing and midwifery professions and prescribes the training syllabi used to develop the curricula for training at training institutions. It reviews training syllabi every 5 years. However, the midwifery (1-year post-basic diploma in Kenya Registered Midwifery (KRM), 3-year basic diploma in Kenya Registered Nursing and Midwifery (KRNM) and 3-year basic diploma in Kenya Registered Midwifery (KRM) were last reviewed over five years ago in 2011, 2013 and 2007 respectively. The updated definition of a skilled health personnel and the requisite competencies in provision of essential care needed for women and newborns creates an opportunity to update the midwifery training syllabi. This is timely to accelerate the drive towards the ambitious SDGs.
There is urgent need for competent nurses/midwives to drive the achievement of SDG MNH targets. To achieveequitable and adequate capacity to deliver the Kenya Essential Package for Health. Kenya requires additional 7,461 midwives and 15,931 to achieve the recommended 13,308 and 35,376 midwives and nurses capacity respectively (Towards Universal Health Coverage: The Kenya Health Strategic and Investment Plan, 2014 – 2018). Pre-service midwifery training like other medical trainings has been criticized of being overly didactic and lacking in the skills competency aspects for its graduates who require further exposure through internships and clinical attachments to acquire the necessary clinical skills. It is doubtful that midwifery graduates from the three training levels have the requisite competencies needed to function adequately as SHP in health facilities without direct supervision of an experienced midwife or medical doctor with midwifery skills.
A review and update of the midwifery training guidelines to reflect internationally recognized standard competencies by integrating the competency-based EmOC training at the pre-service level in MNH is essential. Liverpool School of Tropical Medicine – Centre for Maternal and Newborn Health provided both financial and technical support to NCK in updating the midwifery training syllabi to reflect the current SHP competencies integrating the EmOC and maternal and perinatal death surveillance and response (MPDSR) – key in achieving quality of care. This investment in nursing and midwifery workforce training is likely to accelerate achievement of the UHC agenda of the Government of Kenya