How Kenya's Kisumu County reduced maternal mortality by 30% in just five years

Just five years ago, giving birth in Kenya’s Kisumu County carried substantial risk. One third of women, especially in rural communities, were choosing to give birth at home without the aid of a skilled birth attendant. The county’s maternal mortality rate was 495 per 100,000 live births, one of the highest rates in the country.

Now, that rate has decreased some 30% to 343 per 100,000 live births, according to the country’s latest national bureau of statistics health survey. Moreover, child mortality has also decreased from 54 to 39 per 100,000 live births.

This dramatic improvement has been due, according to the county’s minister of health, Dr. Gregory Ganda, to a combination of policies and interventions launched and executed in quick succession, including improving primary health care and service delivery and professionalizing community health workers. Now, more women, 9 in every 10, are giving birth at properly staffed and equipped health facilities.

Exemplars News spoke with Dr. Ganda about how Kisumu County reduced maternal mortality, is working to reduce it further, and ensuring its progress remains sustainable.

Could you tell us about your personal journey and how you came to work in public health and on maternal mortality in Kisumu County?

Dr. Ganda: I'm a gynecological oncologist by training, but now I'm the county executive committee member for health in Kisumu County, which means I'm the county's minister for health. Kenya has 47 counties, and each county is semi- autonomous in terms of being able to manage certain functions, including health. I oversee the department of health services within Kisumu County, which has a population of around 1.3 million. I advise His Excellency the governor on all health and health related matters as well as oversee the creation and implementation of health policies.

I initially had no interest in public health – I just found myself in this field through a twist of events. When I became a gynecologist, I was posted to a high-mortality area called Migori in the south-western part of Kenya. I often worked tirelessly beyond the normal office hours and into the deep of the night. The call of duty was quite demanding, and I even missed my master's degree conferment and graduation ceremony in Makerere, Uganda, because there was no one to cover my shifts. Despite my efforts, I remember arguing with a surgeon friend of mine about how hard we were working and how much impact we were having. I remember he told me, 'You know what? The area you're working in still has some of the highest maternal mortality rates." That was a turning point for me.

That changed my perspective. I started getting more interested in what was happening within the community and in public health.

We began implementing various interventions to try and reduce maternal mortality and address issues like gender-based violence. We also had high rates of teenage pregnancy, so we started a program to try and reduce teenage pregnancies, including creating a call center, offering mentoring sessions, and going to schools to talk with young people. That’s how I initially found myself in public health.

Eventually I left Migori to go back into gynecological oncology in Kisumu. But then we got a new governor – His Excellency Prof. Peter Anyang' Nyong'o – who had previously served as Kenya’s minister of medical services. He had tried to align the health sector's priorities. But it wasn't working. I was called upon to help set things up. I told them, 'I’ll do it for two years, and then I’ll go back to my clinic.' However, when I arrived, I realized that there was so much to be done. I told them, 'We need to radically shift the way we’re doing things.'

This approach aligned with the vision of the governor, who is a strong believer in the Cuban model of primary health care, and he tasked me with implementing that vision in Kisumu. As I continued this journey – learning, visiting other places, and engaging with different people – I found myself deeply involved in public health. It wasn’t a decision I consciously made; I simply found myself in this space.

Could you tell us about the previous maternal mortality situation in Kisumu. Why was the rate so high?

Dr. Ganda: Kisumu was one of the 10 counties with the highest rates of maternal mortality in the country. The mortality rate was above the national average at 495 per 100,000 people, according to a health survey in 2022.

The main problem was that many of our women were delivering at home. Our skilled birth attendance rate was at 69%, meaning that 3 in every 10 pregnant women were not delivering in health facilities. This was significant because we're mostly a city – but there's also a rural population that needs to be taken care of – and that rural population was not receiving adequate attention.

Another issue was that service delivery was disjointed. Community health and primary health facilities did not work together. We also had fewer health facilities, and the ones we had were not well-equipped and did not have enough personnel to take care of patients. This led to a vicious cycle where women who came to deliver in the facilities experienced poor outcomes, which discouraged others from coming to these facilities. As a result, many women, particularly those who could not afford to come to town, delivered at home and missed out on critical medical interventions. This significantly contributed to our high maternal mortality rate.

In addition, those who could afford to travel had to travel long distances to find facilities, causing significant delays in accessing care.

In your view, what are some of the most important initiatives and reforms that have been undertaken in Kisumu that have helped reduce maternal mortality?

Dr. Ganda: For me, the biggest thing we did was focus on primary health, starting with community health. By the time I came into this role, I had already discussed community health with the governor, who had the idea that we needed to do something in this area. He even identified a partner, Living Goods, who was doing some work on a small scale in another county.

We started professionalizing the role of community health worker, recognizing them as a professional responsible for providing services in the community. We identified the right people for these roles, created the necessary policies, and passed what we call the Community Health Act, which allowed us to formalize the role of community health worker in Kisumu.

We trained the workers. There were several training modules they had to go through and then they received the equipment needed to carry out their work. And I believe we were among the first counties to start paying them a stipend.

We were the first county to fully digitize community health work. We ensured that all community health work was digitized, creating a more efficient and effective system.

We also strengthened the primary health care system to support these efforts.

We hired more staff, doubling the number of technical staff from around 1,000 to 1,800. These additional staff members were deployed to dispensaries and health centers. Synergy between health facilities and community health workers was created by sensitizing the health workers and creating joint opportunities for health-related programming.

We bought more ambulances to ensure every area had access to emergency transport. We went a step further by establishing the first proper emergency operation center, a call center to manage ambulances and coordinate referrals centrally. Previously, the referral system was disjointed and inefficient.

We increased the number of facilities capable of performing cesarean sections, so women no longer had to travel long distances to receive comprehensive care.

Additionally, we focused on capacity-building, providing training for primary health care workers, particularly in emergency obstetrics.

We were fortunate to have the Transforming Health Systems for Universal Care program funded by the World Bank, which provided us with the resources to plan and execute these improvements. We prioritized getting our operating theaters operational, equipping them, and training our health care workers. These efforts, combined with the work done by community health workers, made a significant impact on maternal health outcomes in Kisumu.

Can you tell us more about the role community health workers played in reducing maternal mortality and keeping newborns healthy?

Community health workers have played a very big role in maternal health. First, they visit households and identify pregnant women early on. Even if a woman is not pregnant, they provide health education and counseling, encouraging women to attend antenatal clinics. When they register a pregnant woman, they ensure she goes to a facility for delivery. They even accompany women to these clinics and to the delivery itself. They also monitor risk factors, looking for danger signs like swollen legs or bleeding. They help women create individualized birth plans, discussing delivery options and ensuring they understand the importance of delivering in a hospital rather than at home. They also talk about how to finance the delivery, although in our case, delivery is free through the government’s Linda Mama program, which reimburses facilities for deliveries.

Another critical role community health workers play is monitoring the nutritional status of pregnant women. They use tools like the mid-upper arm circumference (MUAC) tape to measure a woman’s nutritional status. All this work by community health workers improved our situation – facility deliveries increased from around 65-70% to 94-98%. These numbers are significant because the preventive measures taken during delivery have the biggest impact.

They also monitor children’s wellbeing by assessing nutritional and immunization status to prevent and identify missed opportunities.

How has the establishment of primary health care networks changed health care for people in Kisumu, especially new mothers?

Dr. Ganda: The concept of primary health care networks is still relatively new in Kisumu, only about three years old. These networks aim to ensure that facilities in a given region work together to serve the population better. While it’s still early to measure the full impact, we’ve already seen an increase in deliveries at peripheral facilities, which reduces the burden on major facilities in central Kisumu. We are also beginning to foster cooperation between the private and the public sectors.

Strengthening primary health care has led to early detection of health issues and early referrals, resulting in better outcomes. We’ve also seen an increase in the detection of conditions like hypertension and diabetes, which are being identified earlier and managed more effectively. This has also helped improve maternal health indicators, such as reducing the distance women have to travel to access care.

How has the digitization of primary health care programs in Kisumu improved their efficiency and effectiveness?

Dr. Ganda: Digitization has greatly decreased the amount of paperwork and improved efficiencies. We receive reports faster and they take less time to complete. Now we know in real time what has happened on the ground. We can, in real time, say how many women have visited health facilities, how many households have been visited, and what is happening on the ground. I think we've saved around 15 million Kenyan shillings (US$116,000), which is quite a big amount for us.

What other initiatives are you excited about?

Dr. Ganda: What I'm most excited about right now is a new program that we are starting where we are digitizing the primary health care networks for better maternal and child outcomes, dubbed Safe Mama Tech program. To solve the problem of maternal and child morbidity and mortality, we're bringing all our digital tools into one program that harnesses the strength of each of the applications. To enhance our community health information systems and facility health management information systems, we will be working with Mtiba to create an incentive program for community health workers, health facilities, and mothers. Wonder EMR will help us with early detection and referrals. Whereas Safecare will monitor quality interventions in the health facilities. This ecosystem, we hope, will help to improve the demand for health services, improve quality, and improve outcomes.