Maternal Mortality in East Africa

This partnership brings together researchers from the Arts and Humanities - history, historical and medical anthropology, linguistics and theatre studies - with medical and public health specialists, to address a key global health development challenge: extremely high Maternal Mortality Ratios (MMRs). It will focus on western Kenya, but seek to influence policy and practice across East Africa. While Kenya's crude death rate is now on a par with Europe, its MMR was 510/100,000 livebirths in 2015, 43 times higher than high-income regions. On current trajectories, Kenya, like most African countries, will not come close to the Sustainable Development Goal (SDG) MMR target of 70/100,000 by 2030. Our partnership seeks to develop new approaches to maternal health through interdisciplinary research and networking. Drawing on and further developing established relationships between East African and European arts and humanities and medical researchers, this medical humanities partnership will be based on the principles of international collaboration and co-production, motivated by the goal of reducing excessive maternal mortality. Our broader aim is to establish a regional consensus that socio-cultural research can effectively address major health problems.

That high MMRs are a particularly important, intractable health problem has been acknowledged both within the UK government, which has made working 'to end preventable child and maternal deaths' one its seven aid priorities, and in Kenya's national plan (Kenya Vision 2030), which identified MMRs as one of two key areas 'where Kenya is lagging'. Kenyan partners in government, medical institutions and key NGOs recognise high MMRs as a national priority, acknowledge that risk factors remain poorly understood, have informed the definition of problems which this partnership seeks to addressed, and are prepared to engage in research, policy development, and implementation. This partnership's approach has developed from medical researchers' recognition that high MMRs result not only from physiological problems and infrastructural deficit, but also relate to patients' experience of biomedical maternity services, domestic decision-making, social norms and collective understandings of motherhood, health and illness. Arts and Humanities researchers will work with medical practitioners, policymakers and teaching staff to consider in particular how, in both domestic and clinical settings, risk is evaluated, information is communicated, and resources are allocated.

Research will focus on the western Kenyan region around Kisumu, investigating why recent interventions, such as free maternity services and building referral hospitals, have had less impact in Kenya than anticipated. The partnership will consider why some interventions, effective in other countries, have proven problematic within the Kenyan context, and also compare Kenya's past successes in maternal healthcare with the relative stagnation of recent decades. Researchers will utilize a range of methodologies, including archival research, interviews, linguistic analysis and participatory theatre. They aim to better understand the tensions and miscommunication which often characterise clinicians' relationships with pregnant women, and the unintended consequences of policy changes. They will also investigate the gender and generational factors which shape health-related decisionmaking within the household, peer-groups, and extended family.

Throughout, our partnership will be shaped by co-production with African academics, practitioners and institutions, building capacity in north the Global North and South. This will assist communication of findings to government, hospital administrations, citizens and NGOs such as INDEPTH, WHO, and Unicef. Outcomes will be shared with policymakers across the East African region, and a range of tools, music, radio and theatre will be used to communicate key messages across the Kisumu region.

This project evolves out of longstanding relationships between UK-based researchers and East African hospitals, NGOs, policy-making organisations and universities. Impact will be facilitated by the partnership's established relationships with key figures in Kenya's referral hospitals, its leading medical school, the Ministry of Health's Maternal and Newborn Health Program Manager, the Kenya Obstetrics and Gynaecological Society, the INDEPTH Network's Maternal, Newborn & Child Health Working Group, and the WHO's Department of Maternal, Newborn, Child and Adolescent Health. Our partnership is shaped by their priorities, and findings will be influenced by ongoing discussions with these agencies as well as NGOs such as the African Center for Global Health and Social Transformation and local community groups.

The partnership aims to achieve three major impact goals.

1. It will influence policy and practice relating to maternal health in Kenya, and will share its findings among policymakers across the East African region. The partnership will build on its already strong relationships with Kenyan medical and government institutions, and key NGOs, sharing information and working alongside planned initiatives. We shall work with clinical partners in Kisumu's referral hospital to develop new methodologies of interdisciplinary co-production between arts and humanities scholars and medical practitioners, ensuring the immediate relevance of project findings within medical settings. Briefing papers and a series of workshops will enable partnership findings to be discussed with an array of supporting organisations actively involved in influencing or making policy, or delivering maternal health interventions in Kenya. The partnership will also seek to influence policy beyond Kenya, by involving maternal health specialists from neighbouring countries such as Dr Annettee Nakimuli, Head of Obstetrics and Gynaecology at Uganda's national referral hospital, in our Advisory Board and partnership opening and dissemination workshops.

2. It will seek to affect socio-cultural norms and behaviours relating to pregnancy and childbirth. Analyses of practitioners' engagement with pregnant women will be discussed with project partners in medical education in order to address identifiable problems through student training and professional development. Pregnant women's perspectives and experiences will be communicated to healthworkers around Kisumu through participatory theatre. The partnership will also respond to issues affecting pregnant women, their families and their peers such as antagonistic relationships between patients and medical personnel; inaccurate perceptions of risk; and lack of knowledge of medical procedures and health-related rights. To ensure we access the rural poor and urban adolescents, findings will be disseminated at varying scales through vernacular language popular music, radio miniseries, and short videos to be displayed in antenatal and maternity clinics and via community healthworkers' mobile devices. Follow-up interviews will be used to evaluate impact.

3. Capacity building and enduring impact. The partnership aims to develop an enduring network of medical humanities scholars, located in the Global North and South, focused on expanding research collaboration between arts and humanities and medical scholars in East Africa. Our goal is to establish a regional consensus that socio-cultural research can effectively address major health problems.