Transforming Maternal Healthcare in Kenyan Slums

Jan 4, 2016

By Sybil Lewis

In 2011, Nick Pearson was working for Acumen Fund seeking to invest in businesses serving low-income populations in Kenya, when he felt compelled to start a social enterprise for improving maternal and infant health care.

Pearson’s decision was influenced by his wife, Megan Huchko, an obstetrician on the UCSF faculty who had worked extensively in Western Kenya. Together, they saw that even though the number of women delivering babies in health facilities had grown in Kenya, maternal mortality in peri-urban or slum communities remained high: 700 deaths per 100,000 live births, compared to the national average of 360.16, and a hundred times higher than some countries in Western Europe.

The aim of Jacaranda Health was to recognize that the main problem facing poor women was not a lack of access to health facilities, but a lack of quality facilities and skilled care.

“In the last 20 years there has been a strong focus on facility-based care across all income levels,” said Pearson, who holds a MBA from UC Berkeley. “The problem for the next generation is not that women aren’t going to the hospital, but that when they do go the quality is poor and they are often disrespected.”

Indeed, a 2006 study from the African Population and Health Research Center found 70 percent of births in Nairobi’s peri-urban areas take place in health facilities, but only 48 percent of women deliver in facilities meeting minimum standards. Women reported being physically and verbally abused by healthcare practitioners during their maternal visits, discouraging them from returning for postpartum check-ups.  Other reports found inadequate resources in public health facilities, resulting in understaffed facilities and overworked practitioners. Kenya falls below the international minimum threshold of 23 doctors, nurses, and midwives per 10,000 people to deliver essential maternal and child health services.

“Jacaranda Health emerged from a confluence of understanding health care through the eyes of women and identifying the gaps in the business landscape,” said Pearson. “This was a good opportunity to use business models to address clinical service gaps.”

In 2011, Jacaranda Health started operations as a mobile clinic providing antenatal care. By 2012, it had opened its first maternity clinic in Ruiru, a community east of Nairobi, after receiving feedback from women that they preferred a fixed clinic because it better met their expectations.

In September 2014, Jacaranda Health opened its second maternity hospital in Kahawa West, a community on the outskirts of Nairobi, with new facilities to perform cesarean sections and other emergency care. Since Jacaranda’s founding in 2011, the two clinics have served over 7,000 women and delivered over 900 babies with over a 99 percent survival rate. The nonprofit employs 80 people in Kenya.

A mother with her newborn child in front of the Ruiru maternity clinic.

A mother with her newborn child in front of the Ruiru maternity clinic.

Jacaranda Health’s model is built on the principal of patient-centered design and currently provide antenatal, obstetric, postnatal, and family planning services to its patients. In addition to providing medical services, the Kenya-based organization strives to be a “global innovation laboratory,” adapting and integrating the best clinical protocols, technologies, health information systems, and business approaches. Clinic staff focus on adapting internationally recognized medical protocols to the Kenyan context, to ensure that women receive quality care as well as care that is respectful and dignified.

“In the American health system, quality care is defined in seven pillars and one of them is respectful care, which is especially important when dealing with maternity care,” Pearson said. “From focus groups, I heard stories of women delivering their babies in public and private hospitals in Kenya, but being treated terribly by medical personnel who lacked empathy. This has an impact on women’s dignity, self-respect, and empowerment, preventing them from seeking further care.”

By adapting recommendations from international organizations, such as the World Health Organization and the Population Council, providers at Jacaranda Health ensure that women build a rapport with their providers while also receiving high quality of care. Some of the evidence-based protocols include checklists, evidence-based algorithms for clinic operations, and regular clinic case and chart reviews with staff. Jacaranda Health also incorporates a Japanese philosophy called Kaizen, commonly known as “Lean Methodologies,” which relies on small, continuous improvements to boost productivity and reduce waste.

Members of Jacaranda Health’s clinical team.

Members of Jacaranda Health’s clinical team.

Jacaranda has been able to succeed with its patient-centered approach by adapting human resources. Nurse aides conduct non-clinical care, and community health workers manage home visits and client education, granting Jacaranda’s nurses more time to tend to individual patients.

With the goal of being a health care think tank, as Pearson describes it, Jacaranda has incorporated various technological innovations to further improve its client experience. Because over 80 percent of clients have mobile phones, the clinics send SMS text messages to schedule appointments and send postpartum family planning information. Other simple uses of technology include a Whatsapp messaging group for groups of prenatal clients to ask questions and share their experiences.

Jacaranda supports itself through grants and client fees, with a goal of having its maternity facilities become self-sustaining from earned revenue. According to Pearson, normal delivery costs are about US$90, significantly less than other private clinics in Nairobi. Furthermore, in 2014 Jacaranda Health was certified to accept Kenya’s National Health Insurance Fund, reducing out of pocket costs for many clients.

While the majority of services provided are pregnancy-related, Jacaranda Health is expanding its family planning offerings. In 2012, Sirina Keesara, a UCSF medical student now doing her ob-gyn residency at the University of Chicago, won a $9,000 award from the Big Ideas@Berkeley competition in the Global Poverty Alleviation category to build Jacaranda Health’s family planning portfolio.

Keesara arrived in Kenya in August 2012, and implemented a human rights-based counseling process for nurses to better inform patients about contraceptive decisions. The process is based on the Population Council’s Balanced Counseling Strategy (BCS+), which allows mothers to lead the discussion as they consider their option. Keesara extended her stay in Kenya until August 2014 and increasingly focused on postpartum family planning, which is crucial to initiate six weeks after delivery. According to a study published in the International Journal of Obstetrics and Gynaecology, the ideal interval between pregnancies is 18 months and women with shorter birth spacing times were twice as likely to have a premature birth.

“In Kenya, almost all family planning resources are easily available, but what was missing was excellent counseling on the different options and the potential side effects to help women make the best decision for themselves,” Keesara said.

Training session of Jacaranda Health’s protocols.

Training session of Jacaranda Health’s protocols.

Jacaranda Health is also trying to involve male partners in family planning decisions by providing educational materials tailored to fathers’ needs and by encouraging open discussion.

To scale up its health impact, Jacaranda is working in partnership with public hospitals to adapt its tools for delivering high-quality care. In 2015, the organization launched its first partnership with two hospitals outside Nairobi and will expand its partnerships in 2016.

“To achieve scale and impact, we plan to have a few of our own maternity centers of excellence to act as drivers of innovation, and then to work with the government to adapt and replicate quality care in public hospitals,” Pearson said.

A mother and her child at Jacaranda Health.

A mother and her child at Jacaranda Health.

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