Obstetricians urge government to classify maternity care as emergency under SHA
After a sharp decline in deliveries at referral hospitals, maternal health experts are calling on the government to reclassify maternity care as an emergency under the national insurer (Social Health Authority), arguing that current financing rules are delaying treatment and putting mothers and babies at risk.
After noticing a drop in deliveries in Level 4 and Level 5 hospitals, maternal health experts are asking the government to recategorise maternal health as an emergency to allow women to access care in referral hospitals without the required upfront annual payment.
“We must treat pregnancy and delivery as a primary healthcare service, even in Level 4 and Level 5 facilities,” said Dr Mary Maina, an obstetrician-gynaecologist at Kiambu Level 5 Hospital.
“We should stop lumping pregnancy and childbirth with other medical conditions and instead agree that pregnancy and childbirth, whether in a Level 3, 4 or 5 facility, should be catered for under primary healthcare,” Dr Maina explained.
Defrontera previously reported that the number of deliveries in Level 4 and Level 5 hospitals—health facilities designed and equipped to handle maternal emergencies—has decreased by more than 87,000 since 2023. The data showed that deliveries in primary healthcare facilities (Level 2 and Level 3) increased during this period.
Dr Maina said she had handled multiple emergencies that resulted in maternal near misses, where mothers survive pregnancy but experience major complications requiring transfusions or permanent surgery, such as the removal of the uterus, due to complications that Level 2 and Level 3 facilities could not manage.
“When they go into labour, they start their journey in a Level 3 facility, and we know how our referral system is broken: by the time we get them to a Level 4 or Level 5 facility, they may have suffered a ruptured uterus or experienced a foetal demise,” Dr Maina explained.
Dr Kireki Omanwa, a consultant obstetrician-gynaecologist at Kenyatta National Hospital and president of the Kenya Obstetrical and Gynaecological Society (KOGS), said referral hospitals are increasingly receiving women whose complications should have been identified and managed earlier.
Dr Omanwa said lower-level facilities are designed to care for low-risk pregnancies. Women with severe anaemia, hypertension, diabetes, previous pregnancy losses and other complications should receive specialist care higher up the referral chain.
“We have seen patients who are referred to Kenyatta National Hospital with a haemoglobin level of two, when it should be around twelve, and these are very complicated cases which should be referred directly to a referral hospital,” Dr Kireki said.
Under the current Social Health Insurance Act, deliveries at Level 2 and Level 3 facilities are free and financed through one of the three funding pools within the insurance scheme, the Primary Healthcare Fund. Care at Level 4, Level 5 and Level 6 facilities is covered by the Social Health Insurance Fund (SHIF), which requires members to pay annual contributions.
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Dr Omanwa observed that a significant portion of the population finds the upfront requirement financially out of reach. This was the reality for Maryanne Wambui, a tout who was diagnosed with pre-eclampsia—a life-threatening complication in pregnancy—at Wangige Level 4 Hospital. To secure the necessary care, she was forced to text and call her friends and family to raise the Sh9,400 premium required by the facility.
While acknowledging the economic circumstances many families face and recognising that maternal health is an emergency, the Social Health Authority defended the annual upfront payments required for maternal health emergencies, stating that the funds are needed for the predictable pooling of contributions and to protect the sustainability of the fund.
“Since many informal-sector households do not have regular monthly income, annual cover helps prevent loss of access when income is interrupted by illness, job loss or other hardship,” the SHA secretariat wrote in its response.
SHA is still encouraging mothers to deliver in primary healthcare facilities because “free maternity services have been provided under Primary Health Care to remove cost as a reason for mothers delaying care, delivering at home, or avoiding health facilities”.
Referral facilities have resorted to delivering mothers and detaining them until they can settle the full bill before leaving the hospital. This is also costly for health facilities because the women require food and occupy beds that could otherwise be used by other patients.
Dr Josephine Kibara, a retired gynaecologist who is now a board member of Runyenjes Level 4 Hospital in Embu County, said SHA’s design makes it difficult to know which claims have been reimbursed.
“It is impossible to reconcile the funds because when they do reimburse the money, you cannot tell which period it covered—whether it was for January to March—or which procedures were reimbursed. It is all lumped together,” Dr Kibara said.
Delays, whether in seeking care or receiving it after reaching a health facility, have been cited as reasons why more than 5,000 women die during childbirth each year. Until the teething stages are fixed with SHA, experts worry more mothers are at risk of dying.
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