Who Lives, Who Dies: When Well-Meaning Policies Fall Short at the Last Mile

At 2:17 a.m., a woman arrives at a county hospital in obstructed labour.

The maternity wing is new. The lights are on. A banner near the entrance promises free maternity care. 

Kenya has invested in expanding facilities. More women are delivering in health centres than a decade ago. Policies have moved in the right direction.

But the anaesthetist is covering two facilities. The blood bank has one unit left. The ambulance that should have transferred her earlier is parked—there is no fuel allocation remaining this week.

If she dies, the file will list haemorrhage or eclampsia.

That will not be wrong. It will just be incomplete.

Because the deeper cause lies in how we planned, financed, and managed the system around her.

As the messages of International Women’s Day begins to fade and the banners come down, the harder question remains: are the systems behind those promises actually working?

Each year, we reaffirm that no woman should die giving life. The phrase is morally sound—and achievable. 

Kenya does not lack medical knowledge. It does not lack policy frameworks. Through reforms aligned with Every Woman Every Newborn Everywhere (EWENE) Initiative, the country has committed to equity, quality care, sustainable financing, and accountability. 

Maternal and perinatal death surveillance has improved. Universal health coverage reforms are underway.

These are not small achievements.

Yet women are still dying from causes we have known how to treat for decades: severe bleeding, infection, high blood pressure, obstructed labour. 

Oxytocin is not new. Magnesium sulfate is not experimental. Blood transfusion is standard care.

What makes the difference is whether those basics are available every single time they are needed.

Too often, the weakness is not clinical. It is financial.

Free maternity services—when functional—remove a real barrier for many families. That matters. 

Yet facilities frequently face delayed reimbursements and cash-flow uncertainty. When payments stall, suppliers wait. Stock-outs follow. Managers stretch thin budgets. “Free” becomes fragile.

Budget speeches announce allocations. The harder question is whether funds reach facilities on time and in full. 

When disbursements are delayed, ambulances sit idle. Maintenance is postponed. Staff go unpaid. 

On paper, maternal health is funded. On the ground, providers struggle to make do.

Infrastructure has expanded, and that progress deserves recognition. But a maternity ward without enough skilled staff is still unsafe. 

In some counties, a single midwife covers labour, postnatal care, and outpatient services in one shift. Exhaustion is not a line item in the budget, yet it shapes outcomes.

Kenya has strengthened maternal and perinatal death reviews. Each death is examined. Patterns are identified. That is real progress. 

The next step is harder: linking those findings directly to financing decisions. If reviews repeatedly show transport delays, referral systems should receive protected funding. 

If hemorrhage leads the statistics, blood supply chains must be stabilised. Data must influence budgets. Otherwise, we are documenting tragedy rather than preventing it.

The uncomfortable truth is that Kenya does not need a breakthrough discovery to sharply reduce maternal deaths. It needs disciplined execution of what it already knows. 

Variation between counties proves this. Some manage staffing and supplies better than others within the same national framework.

This is not an unsolvable crisis. It is uneven governance.

And it matters to everyone. When a mother dies, newborn survival drops. Household income collapses. Children leave school. Poverty deepens. 

Maternal mortality is not only a health indicator; it is an economic shock at the family and community level.

This year’s “Give to Gain” theme of International Women’s Day should not end with speeches. 

It should be visible in how we fund ambulances, stock blood banks, and staff maternity wards—because when those systems fail, it is not rhetoric that women need, but readiness.

If we are serious about ending preventable maternal deaths, the response must move beyond declarations. 

Emergency obstetric and newborn care funding should be ring-fenced and protected from mid-year cuts. 

Reimbursements must be predictable so facilities can plan. Ambulance fuel, blood supplies, and essential medicines should be treated as protected essentials, not flexible expenses. 

Staffing benchmarks must be clear and met. County-level maternal health performance should be publicly visible and tied to future allocations.

If “Give to Gain” is to mean anything, then what we give must be measured not in words, but in whether a woman arriving at 2:17 a.m. finds a system ready to save her life.

That would be the most meaningful gift we could offer—not just in March, but every day that follows.

The author, Dr. Richard Mogeni Mogaka is Chairman of the Kenya Obstetrical and Gynaecological Society (KOGS) – Northrift.