Paper for the conference "Expanding Access: Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective Abortion Care"
South Africa 2 - 6 December 2001.
MIDLEVEL PROVIDERS’ ROLE IN ABORTION CARE Kenya Country Report
The paper in pdf-format
Ms. Monica Oguttu
Table of contents
1. Country profile on abortion services1.2 Abortion Laws and Policies
1.3 Provider Profile
1.4 Organization of Abortion services
1.5 Knowledge and Perceptions of Abortion Services
2. Midlevel Providers’ Role in Abortion Services
2.2 History of Postabortion Services in Kenya: the Increasing Role for MLPs
2.3 Scope of Post Abortion Care Practice of Midlevel Providers
3. Professional Organizations of Mid-level Providers
4. Advocating Abortion Service Provision by Midlevel Providers
5. Lessons Learned Related to Access to Safe Abortion Services
1. Country Profile on Abortion Services
1.1 Country Overview and Magnitude of the Problem
General Information on Kenya
Kenya covers an area of 582,000 sq. km. and is bordered by Ethiopia in the north, Sudan in the northwest, Uganda in the west, Tanzania in the south, Somalia in the northeast and the Indian Ocean along the eastern edge. The major religions are Christianity (66%) and Islam (6%). A total of 26% of the population adhere to traditional beliefs (CRLP, 1997).
Literacy in Kenya is 78%, with male literacy at 86% and female literacy at 70%. Agriculture remains the mainstay of Kenya’s economy, accounting for 26 percent of the gross domestic product. Tea, tourism, coffee and horticulture are the main foreign exchange earners.
Preliminary results from the 1999 census estimate Kenya’s population at 30,339,770 people, up from 23.2 million in 1989. Although there is a significant increase in rural-urban migration, Kenya’s population remains primarily rural (72%) while only an estimated 18% of the population lives in urban areas. Most of the urban population (89%) is concentrated in towns with populations of 10,000 or more. Kenya has a very youthful population with at least half being below the age of 15 years.
Reproductive Health for Women
Even while Kenya’s total fertility rate has declined to 4.7 (Kenya DHS, 1998), and modern contraceptive use has risen to 33% among currently married women (PRB, 2000), unplanned and/or unwanted pregnancies are still common. As a result, complications from incomplete abortion are still one of the leading causes of maternal mortality and morbidity.
Women in Kenya face many pressing health issues. The average life expectancy for women is 63 years, compared to 59 years for men. Violence against women is thought to be a serious problem though accurate statistics are lacking. Thirty-eight percent of Kenyan women age 15 – 49 have been circumcised. The proportion of women circumcised increased with age nearing 50% for women age 35 and above (KDHS, 1998).
The 1998 Kenya Demographic and Health Survey (DHS) reported that almost a quarter of Kenyan women have unmet need for family planning services – 13.4% for spacing and 25.6% for limiting births. Although one third of Kenyan married women are currently using a modern contraceptive method and 7% are using a traditional method of contraception, 48.3% of recent births were still unwanted or mistimed.
Kenya’s maternal mortality ratio is 590/100,000. (UNICEF and WHO, 1996). Unrecorded deaths in the rural communities make it likely that this is unreliable and underestimated statistic. One of the major causes of maternal mortality and morbidity in Kenya is unsafe abortion, which contributes to between 30% and 50% of the maternal mortality and morbidity. (USAID/REDSO, ESA, 1997).
Additionally, at least half of admissions in the gynecology wards are due to abortion complications. (Lema, et al., 1989; Rogo, 1993). Over her life time, a Kenya woman will bear 4.7 children and has 1:36 chance of dying from a maternal cause (Kenya Demographic and Health Survey, 1998).
Population Action International's (PAI) " Poor, Powerless and Pregnant" Index, which rates the status of women in different countries, rates Kenya at 45 "very poor" out of a possible score of 100. On PAI’s broader "human suffering index " Kenya is ranked as relatively poor with a score of 75 out of possible 100.
TABLE 1
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Selected country statistics
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Source: 2001 World Population Data Sheet, Population Reference Bureau Inc.(except as indicated below)
* Preliminary results from Kenya’s 1999 census increase this number to 30,339,770.
* * WHO and UNICEF, Revised 1990 Estimates of Maternal Mortality: A New Approach by WHO and UNICEF (Geneva: WHO, 1996).
Reproductive Health and the Kenyan Government
Since independence, the Government has put in place numerous policies and strategies to improve the delivery of health care to the Kenyan people. Kenya was the first country in Sub-Saharan Africa to adopt an explicit population policy when the Family Planning Program was launched in 1967. In 1972, the program was integrated into maternal and child health services.
In order to further address demographic targets, Sessional Paper No. 4 of 1984 was issued to guide the implementation of a population policy that adopted a multi-sectoral approach to population education and service delivery. Following ICPD in 1994, the population policy guidelines were revised and updated to address emerging issues in reproductive health and to address the health needs of various target groups.
The 1994 Health Policy Framework outlines the Ministry of Health’s vision, policies and guidelines on population growth, equitable allocation of resources, creating an enabling environment for private sector and NGOs, increased community involvement and resource mobilization (Kenya’s Health Policy Framework, Ministry of Health, November 1994).
The Kenya National Reproductive Health Strategy was developed in 1996 to guide program implementation between 1997 and 2010. The strategy addresses the following key components:
- Safe Motherhood and Child Survival
- Management of STDs/HIV/AIDS
- Meeting the unmet needs of family planning
- Promotion of Adolescent and Youth Health
- Management of infertility and cancer of reproductive tract
- Gender issues and Reproductive Rights
The strategy is being implemented in the context of ongoing health sector reform efforts. The Revised Reproductive Guideline of 1997 has also included postabortion care (PAC) as one of the priority areas of reproductive health.
Sessional Paper No. 1 of 2000, The National Population Policy for Sustainable Development was recently passed. This paper expands on previous policy guidelines to incorporate other reproductive health needs, with an emphasis on the reduction of maternal mortality.
Additionally, there are goals for a further reduction of the total fertility rate to 2.5, as well as an increase in contraceptive prevalence rate to 62% by 2010 (Sessional Paper No. 1 of 2000: The National Population Policy on Sustainable Development, NCPD, Ministry of Planning and National Development, 2000).
1.2 Abortion Laws and PoliciesThe constitution of Kenya spells out the right to life of all people within its borders. The law therefore permits abortion only for "the preservation of the women’s life" as follows:
A person is not criminally responsible for performing in good faith and with reasonable care and skill a surgical operation upon any person for his benefit, or upon unborn child for the preservation of the mother’s life, if the performance of the operation is reasonable, having regard to the patient’s state at the time and to all the circumstances of the case. (SECTION 240 OF THE PENAL CODE)
Relevant sections of the Kenyan legal code which bear upon abortion include provisions regarding the procurement of abortion (Section 158 of the Penal Code), supplying implements of abortion (Section 160 of the Penal Code), and advertising drugs or appliances related to abortion (section 38 of the Pharmacy and Poison Act, Chapter 244), and are described in more detail below.
Procuring Abortion
Any person who, with intent to procure miscarriage of a woman, whether she is or not with a child, unlawfully administers to her or causes her to take any poison or other noxious thing, or uses force of any kind, or uses any other means whatever, is guilty of felony and is liable to imprisonment for fourteen years. (Section 158 of the Kenyan penal code)
Any woman who, being with child, with intent to procure her own miscarriage, unlawfully administers to her self any poison or any noxious things, or uses any force of any kind or uses any other means whatever, or permits any such a thing or means to be administered or used on her is guilty of felony and is liable to imprisonment for seven years. (Section 159 of Kenya penal code).
The two sections, while inflicting punishment on both the person performing the abortion and the woman in question, are slightly different. The former will be convicted whether the woman is or is not pregnant. In the latter case, the woman must be pregnant for the conviction to occur. Secondly the sentences are different for the two, although the offences are essentially the same.
Supplying implement of abortion
The penal code goes to state that:
Any person who unlawfully supplies to, or procures for any person any thing whatever, knowing that it is intended to be unlawfully used to procure the miscarriage of a woman whether she is or not with a child, is guilty of a felony and is liable to imprisonment for three years. (Section 160 of the penal code of Kenya).
Advertising drugs or appliances for abortion
Subject to the provision of this Act, no person shall take part in the publication of an advertisement referring to a drug appliances or article of any description in terms which are calculated to lead to the use of drug, appliance or article for procuring the miscarriage of women. (Section 38 of Pharmacy and Poisons Act of the Law of Kenya, Chapter 244, as revised in 1983). One convicted of conflicting with this section of the law, faces, on the first conviction of a fine of not more than one thousand shillings or not more than three months imprisonment or both the fine and the prison term. (Section 40 Of the Pharmacy and Poisons Act).
Although the law is fairly explicit and restrictive regarding abortion, there are few examples of enforcement. Clandestine, illegal abortions are being done in Kenya by the thousands and court cases under this section are very few indeed. Unfortunately, these unsafe abortions are the procedures that lead to high rates of abortion-related mortality in Kenya.
Abortions are also done in the private, formal health sector, recognizing the indication that "the woman’s life is in danger." It is difficult to define what this means in different situations. Another area of perceived flexibility relates to the provision of implements for abortion. The offence is said to occur when a person willing and knowingly supplies poison, drugs or instruments to be used for the purposes of abortion. However, it is possible to argue that the person supplying the implements did so without knowing that they were intended for use in an abortion, since many of the instruments used for abortion procedures may also be used for other "acceptable procedures."
1.3 Provider Profile
In Kenya, according to recent MOH data, there are an estimated 27,000 midlevel providers (2,300 clinical officers, and 24,600 nurses and nurse/midwives) and approximately 3,300 physicians. The midlevel providers (MLPs) are found at all levels of the health system, in both rural and urban settings, while the doctors are concentrated in the larger towns and cities.
As part of the government's overall plan to decentralize health care management, the Kenyan MOH has in the past decade allowed the licensing of MLPs for private practice. As a result, the number of private health facilities has increased dramatically.
Traditionally, midwives have conducted deliveries and only called upon a doctor in case of emergency. This practice continues today with midwives attending at 29.4% of rural births and 58% of urban births. Relatives and traditional birth attendants (TBAs) also assist at many deliveries. Physician attended births in only 10.6 % of rural births and 23.7 % of urban births (KDHS, 1998).
Midwives working in primary health care and maternity/nursing homes are responsible for a wide range of reproductive health services, including antenatal, family planning, counseling, and all deliveries. Between 1996 and 1999, several pilot projects to train midlevel providers to offer PAC were conducted by Ipas, the Population Council, the Ministry of Health, and the USAID funded PRIME program. The evaluation of these programs demonstrated that midlevel providers could offer PAC services efficiently, competently, and save women’s lives. These results are reflected in the MOH’s 1997-2010 Reproductive Health strategy, which calls for an expansion of the role of MLPs, notably in PAC.
Towards this end, the Ministry of Health is also finalizing a national curriculum on PAC, and discussions are underway to include PAC in pre-service training of midlevel providers. Simultaneously, several local, national and international organizations are involved in ongoing training of midlevel providers in PAC. These include KIMET, PRIME, AMKENI, Engender Health, and Ipas.
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