by Leyla Akwabi, Grace Kariuki and Macharia Waruingi
The Live Mothers Live Babies Campaign for Kakamega County is centered on implementing a psidium guajava value system to produce woman and child health by systems thinking.
We intend to implement in Kakamega County, Kenya, a comprehensive program for preventing avoidable death of mothers and children, guided by systems thinking. We define death of mothers or maternal death, as “death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes” (WHO, 2016, para. 2).
Although the rate of maternal death has declined by 45% since 1990, more than 800 women die daily from pregnancy or childbirth related causes. Approximately 99% of these deaths occur in Africa. According to the United Nations Population Fund (UNFPA) this is equivalent to “about one woman dying every two minutes. Much worse, for every woman who dies, 20 or 30 other women encounter serious complications with long-lasting consequences. Most of these deaths and injuries are entirely preventable.
We define infant mortality as death of a baby before his or her first birthday. The infant mortality rate is the number of infant deaths that occur for every 1,000 live births. According to the World Health Organization, 4.5 million babies died before their first birthday in 2015. This accounted for 75% of all under-five deaths. Granted, the overall infant mortality rate has decreased from an estimated 63 deaths per 1,000 live births in 1990 to 32 deaths per 1,000 live births in 2015, worldwide. This decreased incidence of death did not occur in Africa. In 2015, the risk of a child dying before completing the first year of life was highest in the African region (55 per 1000 live births), over five times higher than that in the European region (10 per 1000 live births).
Kakamega County is located in Western Kenya about 30km north of the equator. Kakamega has one of the highest maternal and infant mortality rates in the world. A joint study by the Kenya Medical Research Institute and the Centers for Disease Control and Prevention of United States (KEMRI/CDC) revealed a very high rate of maternal death in Kenya of 488/100,000. Almost twice as many women died in Kakamega (800 per 100,000 live births) compared to the national average.
Our program in Kakamega is a part of Ubrica Live Mothers Live Babies campaign, a national project focused on creating conditions for production of health in women and children. Traditional programs for saving mothers and children in Kakamega County have not been effective. Women continue to die in large numbers, just because they are pregnant. Even when babies are born alive, their chance of life beyond one month is limited. Newborn babies face the greatest risk of death.
Our research has shown that death of mothers and children is closely linked to a critical interplay of four fundamental system elements:
- Human element, as it relates to the biological strength of the body to fight disease.
- Animal element, as it relates to the contribution of animal diseases to humans, (otherwise known as zoonosis).
- Environmental element, as it relates to the physical condition in which people live, work, play and learn.
- Economic element, as it relates to the ease of access to money for paying for physiological, safety, love/belonging, esteem and self-actualization needs.
Of the four elements, economic development is by far the greatest cause of improvement in health. Indeed, improvement of economic condition of humans could eradicate 99% of problems responsible for death of women and children. The economic engine in our program in Kakamega County will be a food/fruit processing plant. Kakamega is well known for abundance of rainfall. This much rainfall comes with an exuberance of fruit and vegetable produce. Unfortunately, nearly all of the fruits and vegetables, naturally growing in Kakamega rot to waste.
People in Kakamega County do not eat the abundant fruits and vegetables, because they do not know their nutritious value. Many people cut down the ubiquitous and highly nutritious Psidium guajava (common guava) and similar fruit trees, to clear fields for cultivating corn, for making staple ugali.
The preferred staple has much lower nutritious value compared to fruits and legumes. Women and children on low nutritional diet have weaker immune system; they are susceptible and succumb easily to infectious diseases. Malnourished women face complicated pregnancy, difficult childbirth, and problems recovering from childbirth. Many such women die due to pregnancy complications, problems giving birth, or bleeding after giving birth. Children of unwell women are born too early to survive without life-support. Those who make it to term are too weak to survive, have a poor immune system, and are easily attacked by bacteria, viruses, and parasites.
P. guajava has many effects on health. Its leaves contain phenolic compounds, flavonoids, Gallic acid, catechin, epicatechin, rutin, naringenin, kaempferol. The pulp is rich in ascorbic acid, carotenoids (lycopene, β-carotene and β-kryptoxanthin). The seeds, skin and barks possess glycoside, carotenoids and phenolic compounds. All parts of P. guajava are useful for different purposes. Guava products have hepatoprotection, antioxidant, anti-inflammatory, antispasmodic, anti-cancer, antimicrobial, anti-hyperglycemic, analgesic, endothelial progenitor cells, anti-stomachache and anti-diarrhea properties (Barbalho et al. 2012). Investing in P. guajava use, processing and marketing is a system level solution to the high rate of death of women and children in Kakamega.
We will work in close partnership with county health officials, and a local faith based organizations to enroll women of child bearing age into the Co-operative Society of Ubricans (CSU). The CSU manages the Ubrica Retail Clinical Center (URCC). A URCC is one-health clinical center connected to a retail system for bringing local produce/products to national market.
Our one-health clinic provides primary and secondary health care services to humans and animals, while improving the environment in which people live. Our retail system is supported by a series of workshops for improving quality of products/produce by local people who are members of the CSU. Improved goods are then uploaded to an electronic platform on a mobile application, downloadable to a mobile device such as a telephone or a tablet. These goods are then available for purchase by customers in the whole country, and all over the world through our mobile application. A local URCC managed by a local CSU creates a sustainable one-health community (SOHC).
Enrolled women will receive regular education, from our trained community workers, to increase their knowledge about the nutritious foods to eat, how frequently to eat, and non-nutritious food to avoid. In addition, they will receive education about pregnancy, how to avoid or treat diseases that affect pregnant women and how to monitor the progress of pregnancy.
The general problem is that despite numerous effort to address health of women and children, women continue to die just because they become pregnant. Children, particularly new born babies face high incidence of disease, disability and death. Each day, 830 women die due to complications of pregnancy; 99% of these deaths occur in Africa. Three times as many women die in rural areas and among poorer communities of urban areas, than affluent communities of urban areas. Much worse, pregnancy and childbirth are the leading cause of death in teenage women. In Africa, of every 1,000 newborn babies, 50.17 die daily. Of every 1,000 children below age five, 73.87 per die daily. These deaths indicate a serious problem about our understanding of the real problem.
Many interventions to alleviate the problem have not been successful. Many of these interventions focus on small aspects of the problem, but not the whole picture. Such interventions that focus on snapshots of reality fail to gather important details of the system producing the problem. Interventions that lack important details about the system producing maternal and infant death are unproductive, and often result in negative and unwanted consequences. Systems thinking is a social technology that could help to create a generative system level solution.
Given that economic development is the greatest cause of improvement in health, a system level solution necessarily involves building an engine to drive the local economy in Kakamega. In the absence of economic development, medical and technological interventions are an exercise in vain. Such interventions are not sustainable, for it is impossible to improve the health of a poor person by giving her more medicine or more technologies. Poverty is the greatest cause of disease, disability and death. A system level solution to maternal and infant death has to improve the general economic condition of the family.
At the heart of economic development is building of a retail system that would help to put local produce in the market. People become poor when they are not able to send to market the things that they produce. People also slide into poverty when they are oblivious of the value of natural produce available in their vicinity. Kakamega is rich in natural produce, such as fruits and legume, much of which goes to waste. Local people are not aware of the economic value of the local produce. As such, they neglect the local produce to rot in the very fertile fields. A fresh food/fruit processing and marketing system could have a major household economic impact in Kakamega.
Ninety-nine percent of all women who die during pregnancy reside in developing countries. Three times as many women die in rural areas and among poorer communities of urban areas, than affluent communities of urban areas. Within the past several decades Kenya has suffered a substantially high maternal and infant mortality rate. Despite much effort by the Government of Kenya to improve maternal and infant health, many women, new born babies, children and adolescents continue to suffer or die from preventable or treatable conditions.
In 2014, a total of 6,632 died of pregnancy related causes, this number made up 21% of the total number of women of reproductive age who died. One death due to pregnancy is one death too many. We hold strongly that fact that no woman should have to lose her life because she is pregnant. Among the forty-seven counties, Kakamega County ranks number five with the highest burden of maternal and under-five mortality rates.
We peg poverty according to the standard of living in a society at a specific time. People live in poverty when they are denied an income sufficient for their material needs and when circumstances exclude them from taking part in activities which are an accepted part of daily life in that society. Poverty and deprivation are major contributors to the health disparities that exist between the richest and poorest people in the society. Evidence shows that by socio-economically advantaged people have a longer life expectancy and better health. Socio-economic deprivation works through anemia, poor nutrition, and excessive physical work to produce a large number of low-birthweight babies. Such babies suffer damage on a large scale, becoming stunted in adult life.
Babies who survive the assault of an unrelieved obstructed labor severe enough to cause obstetric fistula, are on average lighter at birth than those who die. In conditions where pelvic contraction is common and most births are unsupervised, the surviving babies may not be the best babies. Socio-economic deprivation produces damaged children, who as adults give birth to more damaged children. The result is a horrible cycle. To break it, merely saving mothers and babies from death is not enough. Instead, the answer is to produce a generation of well-developed fetuses and infants. Only system level economic and social development can achieve well-developed fetuses and infants. Such fetuses and infants cannot be achieved by snapshot actions at a health center.
Systems thinking is an approach to problems that asks how various elements in the ecosystem of health production influence one another. Rather than reacting to individual problems that arise, a systems thinker will ask about relationships to other activities within the system, look for patterns over time, and seek root causes.
At its core, systems thinking is an enterprise aimed at seeing how things are connected to each other within a whole entity. We often make connections when conducting and interpreting research, or in our professional practice. Anytime we talk about how some event will turn out, whether the event is an epidemic, a war, or other social, biological, or physical process, we are invoking a mental model about how things fit together. However, rather than relying on implicit models, with hidden assumptions and no clear link to data, systems thinking deploys explicit models, with assumptions laid out that can be calibrated to data and repeated by others. The word system derives from Greek word sunistánai—to cause to stand together. A system is a whole of parts that interact toward a common purpose. Systems thinking is intended to improve the quality of our perception of the whole, its parts, and the interactions within and between levels.
The iceberg is illustrative. We know that an iceberg has only 10% of its total mass above the water while 90 percent is underwater. But that 90% is what the ocean currents act on, and what creates the iceberg’s behavior at its tip. Global issues can be viewed in this same way.
- The Event Level
The event level is the level at which we typically perceive the world such as impacted labor, uterine rupture, postpartum hemorrhage, maternal death, infant death etc. While problems observed at the event level can often be addressed with a readjustment, the iceberg model pushes us not to assume that every issue cannot be solved by simply treating the symptom or adjusting at the event level.
- The Pattern Level
If we care to look just below the event level, we notice patterns. Similar events have been taking place over time. Women with short stature and small pelvis are experiencing impacted labor, uterine rupture, postpartum hemorrhage, maternal death, infant death compare to taller women. Short stature and small pelvis are associated with maternal malnutrition. Babies born of such women experience stress during birth. Observing such patterns allows us to forecast and forestall events.
- The Structure Level
Below the pattern lies the structure. When we ask, “What is causing the pattern we are observing?” the answer is usually some kind of structure. Economic deprivation leading to inadequate diet and improper maternal nutrition. Lack of money to travel to health facility for health education, medical check-up and treatment of incident problems.
- The Mental Model Level
Mental models are the attitudes, beliefs, morals, expectations, and values that allow structures to continue functioning as they are. These are the beliefs that we often learn subconsciously from our society or family and are likely unaware of. Mental models resulting in maternal disease and death in Kakamega County abound. Believes about food types. Believes about how to manage pregnancy and newborn, etc.
Traditionally, epidemiologic methods have focused on measurement of exposures, outcomes, and program impact through reductionist, yet complex statistical modeling. Systems approach offers us the opportunity to understand the operation of economic, social, medical, environmental, and behavioral factors affecting health of women and children. Systems thinking offers a framework to re-envision how women and children programs should be implemented, monitored, evaluated, and reported to the larger public health audience. By systems thinking we can begin to understand and measure the broader public health context, account for the dynamic interplay of the economic, and social environment, and ultimately, develop more effective women and children programs and policies (Kroelinger, 2014).
Money speaks to the economic aspects of health production. Women with little or no money are more likely to get sick, are more likely to develop complications of disease when they get sick, and are more likely to die when they get sick. To produce health in women, we must have the capacity to put money in their pockets. The act of putting money in women’s pockets involves buying goods and services that the women produce at a fair price. Women everywhere in the world produce goods and services that can be of value to other people. When women are unable to sell their goods and services to others, they regress into poverty. Women become poor when no one buys what they produce. By contrast, women become rich when others buy the goods and services that they produce.
Production of health among women in Kakamega must involve building capacity to purchase whatever the women living in the county produce. It must also involve putting those goods in the market so that people in distant locations can buy them. Helping Kakamega women to sell their goods and services is the work of market creation. A good market for local goods and services helps the local women to have money that they can use to buy other things to improve their lives. When Kakamega women have money, they can afford to buy or build a good house; buy enough food for the family, pay for education of their children, pay for health services, and so forth. Women who have a market for their goods and services are wealthy. They have better health.
This argument indicates that to produce maternal health we must help women sell their goods and services wherever they are in the world. The URCC comes with a retail component designed to help women in Kakamega sell their goods and services. The retail component has five subcomponents that help to create market for local goods and services. The first component comprises the local women engaged in subsistent activity such as growing crops, herding livestock, creating artisan goods, or providing services as tour guides to foreign tourists. Ubrica’s community economic development workers make door-to-door visits to learn what the local women are producing and to help bring their produce to the market or to Ubrica Co-operative Workshop for value addition.
The second component is the Ubrica Co-operative Workshop located at the URCC. Local women bring their produce to the workshop. Activities in co-op workshops depend on the type of goods and services that the local people produce. Various types of workshops in a URCC are shown on the table below.
The third component is the Ubrica Co-operative Retail Store. Depending on location, the Ubrica Co-operative Retail Store can be a small convenient store or a big super-market. The retails store serves as the marketplace for selling the goods produced and added value in the workshops depicted on Table 1.
Types of workshops in a Ubrica Retail Clinical Center
|Perishable food processing||Cleaning and packaging fruits, and vegetables|
|Dry food processing||Packaging grains, milling grains to produce and sell flour|
|Meat processing||Cutting and packaging meet|
|Woodshop||Processing wood for construction and furniture|
|Metal shop||Processing metal for various uses|
|Leather processing||Processing leather for making garments, ornaments and various other uses|
|Milk processing||Packaging milk, processing milk into products such as cheese, butter, yoghurt, ghee|
|Arts and crafts||Creating local art, jewelry, fabric, clothing, curios, etc.|
The fourth component is the Ubrica ecommerce platform that serves as an online market place for all the goods and services produced by the local people. With the help of the community economic development workers, people in the village take digital photos of the goods and post them to a mobile friendly web application. Goods and services thus posted online are accessible in the global market place through the World Wide Web. This component creates a global market for local goods and services.
It is against this backdrop that UBRICA launched with the Live Mothers Live Babies Campaign. This initiative is cognizant that giving birth should not be a death sentence. Live Mothers Live Babies comes into the maternal and infant mortality scene with the sole purpose of reducing or completely eradicating the high incidence of death of women and children Kenya. Live Mothers Live Babies complements the ongoing national and global maternal and infant mortality reduction efforts. In Kakamega County, it complements the current maternal and newborn health programs.
We propose to implement Ubrica Live Mothers Live Babies in Kakamega County. UBRICA is the lead applicant for this County Innovation Challenge fund. The funds will be essential in building a URCC in Kakamega County that shall be well equipped with a state-of-the-art maternity and neonatal wing. The Live Mothers Live Babies project shall not only raise awareness of the dire situation, it shall be the foundation of the mother and child unit within the URCC. The project shall be run by the CSU managing our URCC in Kakamega County. The URCC in Kakamega County shall have a primary care retail clinical center model. This model is a basic community health center with added space for collection of specimens. This model is customized to fit into the specific targeted location way down to the village level.
UBRICA intends to run the clinic sustainably through its CSU presently doing business as Inukeni SACCO. The women and the children will have access to subsidized quality antenatal and postnatal healthcare through the URCC as members of the cooperative society. The women members will be economically empowered by the URCC, through selling their produce at a profit to the CSU. Thereafter value shall be added to the produce.
The URCC comprises several value-addition workshops, customized to suit the produce found within the area. Kakamega County is a green fertile land that is rich in vegetation and crops fit both for human and animal consumption. A value-addition workshop is a fruit-processing unit that shall be established for processing fruits available within the area.
The URCC shall also be equipped with well-trained community health workers and clinicians who will be equipped with information and special prenatal skills. This specialized human resource shall empower the mothers with information that will contribute to their overall health as well as their babies.
The impact of the campaign shall be felt on the ground. It will go a long way in empowering underprivileged women of child-bearing age. Saving a mother’s life equates to saving a society, while saving a baby secures the survival of the next generation. The Live Mothers Live Babies campaign is a long term endeavor that shall promote life, health and wellness.
The purpose of this project is to create a P. guajava value system within our URCC in Kakamega. The food/fruit processing system is a system level generative solution to the maternal and child health problem in Kakamega County. This generative solution addresses the fundamental problem of generalized poverty in the county. Economic development is a required and sufficient condition for achieving health of women and children. The design is open and inclusive using open large group process for gaining access to mothers. The approach is participatory using indwelling community health workers.
Guava is mainly grown for its edible fruits that are eaten raw or made into purée, jam, jelly, paste, juice, syrup, chutney, etc. It is cultivated in orchards or in home gardens in many tropical countries. Guava grows widely in Kakamega, where it forms dense thickets with more than 100 trees per hectare.
Guava wood is useful for tool manufacturing, fences or firewood (it is a good source of charcoal. Handling of guava fruit is difficult and the rate of cull fruits is high (about 40% in Florida in the 1980s). Guava processing yields 25% by-products that can be used in animal feeding. For the production of guava purée the fruits are chopped and fed through a pulper, which removes seeds and fibrous tissues and forces the remainder through a finisher, which removes the stone cells. Guava waste from this process consists of a mixture of seeds, fibrous tissues and stone cells. Guava leaves can be used as fodder. Guava flowers are fragrant, and a good source of nectar for bees.
Guava fruit is highly perishable. It should be handled carefully during harvest and transportation. Fully ripe guava fruits should be processed quickly but can be held for a longer period if stored at a cool temperature. Guava fruits stored at 5°C and 75-85% relative humidity have a shelf-life up to 20 days. In India, plastic bags providing ventilation allow storage at room temperature for 10 days.