Maternal & Child Health

Maternal & Child Health

Maternal & Child Health

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Opening Scenario

Esther is 22 years old and seven months pregnant with her first child. She lives in a rural area of Siaya County. She has attended one antenatal care visit — the first one, at 16 weeks, when she confirmed the pregnancy. She has not gone back. Her mother delivered all six of her children at home and survived. Her husband thinks the clinic is far and expensive. Esther herself is not sure what else there is to check — she feels the baby moving, which seems like a good sign.

Ester does not know that her blood pressure has been elevated since her last visit — a warning sign for pre-eclampsia that, without monitoring, could become a life-threatening emergency for her and her baby. She does not know because no one has been to see her.

This module is about what needs to be known — and communicated — to prevent stories like Esther's from ending badly.

Antenatal Care: The Minimum Standard of Evidence

Antenatal care (ANC) is the healthcare provided to a pregnant woman and her developing baby during pregnancy. Its purpose is not only to monitor the pregnancy but to identify complications before they become emergencies, provide preventive treatments, and prepare the woman for safe delivery.

The WHO recommends a minimum of 8 ANC contacts during a normal pregnancy — Kenya's Ministry of Health recommends at least 4, with the first visit ideally before 12 weeks of pregnancy. What happens at these visits matters:

First visit (before 12 weeks): Confirmation of pregnancy, blood tests (haemoglobin, blood type, HIV, syphilis, glucose), blood pressure baseline, weight, urine test, tetanus vaccination if needed, Iron and Folic Acid supplementation, malaria prevention (intermittent preventive treatment in malaria-endemic zones)

Subsequent visits: Blood pressure monitoring (critical for pre-eclampsia detection), foetal growth assessment, repeated HIV testing, birth planning discussion, emergency signs education

Final visits (36+ weeks): Presentation check (is baby head-down?), birth plan confirmation, discussion of facility delivery, warning signs review

A CHW's role in ANC is not to conduct these assessments — that is the clinical officer's job. The CHW's role is to ensure women attend: tracking pregnant women in the community, reminding families of appointments, addressing barriers (transport, cost, male partner resistance), and identifying and referring women who show danger signs between visits.

Kenya's maternal mortality ratio is approximately 355 deaths per 100,000 live births — more than 20 times higher than in high-income countries. The majority of these deaths are from preventable causes: haemorrhage, hypertension, sepsis, and unsafe abortion.

Source: Kenya Demographic and Health Survey (KDHS) 2022; WHO Maternal Mortality Report 2023

Danger Signs During Pregnancy: The CHW's Critical Knowledge

These are the warning signs that require immediate referral to a facility. A community health worker who recognizes these signs and acts on them can save a life. This is not a list to memorize passively — it is a list to internalize and act on:

Severe headache that does not go away — may indicate dangerously high blood pressure (pre-eclampsia)

Blurred vision or seeing 'spots' — another sign of pre-eclampsia

Severe swelling of the face, hands, and feet — normal ankle swelling late in pregnancy is common; severe sudden swelling is not

Vaginal bleeding at any stage of pregnancy — always an emergency

Absence of fetal movement for more than 12 hours after 28 weeks

Severe abdominal pain not associated with labour contractions

High fever (above 38°C) — can indicate infection including malaria, which is especially dangerous in pregnancy

Difficulty breathing

When any of these signs are present: refer immediately. Do not wait to 'see if it improves.' Do not allow the family to delay because of cost. Transport costs can be recovered. A maternal death cannot be undone.

Child Nutrition: Growth, Milestones, and Warning Signs

Kenya uses the Road to Health booklet — distributed at birth — to track a child's growth and vaccination status. This is one of the most important health tools a family can have, and a CHW should know how to read it.

Child growth is measured using three indicators:

Weight-for-age: Is the child gaining weight appropriately for their age? Tracked using growth charts in the Road to Health booklet. A child consistently below the lower reference line requires nutritional assessment.

Height/length-for-age (stunting indicator): Chronic undernutrition causes reduced height relative to age. Stunting is associated with long-term cognitive and physical development delays — it cannot be fully reversed after the critical first 2 years.

Weight-for-height (wasting indicator): Acute undernutrition causes low weight relative to height. Severe acute malnutrition (SAM) is a medical emergency — children with visible wasting, oedema (swelling) of both feet, or MUAC (mid-upper arm circumference) below 11.5cm require immediate facility referral.

MUAC measurement is a simple, accurate tool any CHW can learn to use. A strip of colored measuring tape placed around the middle upper arm indicates: green (adequate nutrition), yellow (at risk — monitor closely), red (severely malnourished — refer immediately).

Breastfeeding and Complementary Feeding

The evidence on breastfeeding is unambiguous: exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding alongside appropriate complementary foods until age 2 or beyond, represents the single most cost-effective child survival intervention available.

Key messages for community health promotion:

Breastfeeding should begin within one hour of birth — the first milk (colostrum) is rich in antibodies and protects against infection

Exclusive breastfeeding means breast milk only for the first 6 months — no water, no porridge, no other fluids or foods

Breast milk provides all the water a baby needs, even in hot climates

At 6 months, introduce soft, diverse complementary foods while continuing to breastfeed — frequency: 2-3 times daily at 6-8 months, 3-4 times daily from 9-23 months

Mothers living with HIV should discuss feeding choices with a healthcare provider — Kenya's guidelines support breastfeeding with antiretroviral therapy

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Skilled Birth Attendants — Impact in Kakamega County | Kakamega, Western Kenya

In 2012, fewer than 50% of deliveries in Kakamega County were attended by a skilled birth attendant. By 2022, that figure had risen to over 70% — driven by a combination of Linda Mama free maternity care, community health volunteer mobilization, and facility improvements.

Community health volunteers in Kakamega were specifically trained to conduct birth preparedness counseling during home visits to pregnant women. The counseling covered four elements: identifying a skilled facility for delivery, saving money for transport, identifying a birth companion, and knowing the danger signs requiring emergency referral.

Analysis of the intervention showed that women who received birth preparedness counseling from a CHV were 2.3 times more likely to deliver at a health facility than those who did not. The CHV's relationship with the family — not the facility's services alone — was the decisive factor.

This is the evidence base for community health worker programs: trusted people, with the right knowledge, in the right relationships, change outcomes.

A child who is stunted by age 2 will on average earn 20% less as an adult than a well-nourished peer. Undernutrition is not only a health crisis — it is an economic one, passed from one generation to the next.

Source: World Bank — The Cost of Stunting; The Lancet Nutrition Series (2013, updated 2021)

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