Only a third of the under-20s attended an antenatal clinic atleast once
By DOROTHY OTIENO
6 hours ago
One in 11 expectant and new mothers who die in hospital are teenagers, reveals a new study.
Figures from the First Confidential Enquiry into Maternal Deaths in Kenya
show that two-thirds of the teenagers who died were having their first
child and a fifth were having their second pregnancy. Only a third of
them had attended at least one antenatal clinic.
The study also found that most women who die in pregnancy or childbirth in hospital are in the most secure age for child birth. The median age of pregnant women and new mothers who die in hospital is 27 years.
The
oldest woman assessed was 47 and the youngest 14 in the assessment that
involved more than half of the deaths that were reported in the
District Health Information System (DHIS) for the year 2014.
The
study also found that most women who die in pregnancy or childbirth in
hospital are in the most secure age for child birth. The median age of
pregnant women and new mothers who die in hospital is 27 years.
The best age to have a baby is from 20-35 years, shows information from the Royal College of Obstetrics and Gynaecology.
“There
is a major problem with teen pregnancies that needs to be addressed,”
says the Head of the Division of Family Health, Dr Mohamed Sheikh. His
concern is supported by figures from the latest Kenya Demographic and Health Survey that show that one in five teens aged between 15-19 are pregnant or mothers.
Four in five of the deaths in teenagers are due to direct causes
and 12 per cent are due to indirect causes. The leading direct cause is
obstetrical bleeding (haemorrhage).
The condition is
the leading cause of maternal deaths for all women and it was a factor
in the death of two in five women assessed. It is followed by
hypertensive disorders associated with pregnancy (15 per cent) and
pregnancy related infection (10 per cent).
Water broke
Among
the 484 files (51 per cent) of 945 dead women who were assessed in the
study was the record of a 20-year-old with nine-hour history of lower
abdominal pains. Labour progressed on well and two and a half hours
later, she broke her water and delivered a live baby boy in the normal
manner. Having been diagnosed with excessive bleeding after birth
(post-partum haemorrhage) she was given several doses of the relevant
drugs but the bleeding persisted.
The medical doctor
was called to review the patient and he found a severely pale patient
with low blood pressure. She was bleeding from puncture sites and her
blood was not clotting. Her blood group was O positive but there was
none available at the hospital and other neighbouring health facilities.
The patient was prepared for transfer to a
higher-level facility for urgent transfusion and Intensive Care Unit
care. One hour later, the patient died while en-route to the referral
facility.
The assessors concluded that the quality of
care provided could have been better and this may have made a difference
in the outcome. Although the correct treatment protocol for excessive
bleeding was followed initially, no grouping and cross matching of blood
was done to determine her blood type. When it was eventually grouped,
there was no blood for transfusion. A diagnosis of massive obstetrical
bleeding in a facility without active blood transfusion services should
have triggered a referral.
Saved lives
The
assessment that was done from June 2015-June 2016 reveals that nine out
of 10 women who died of obstetrical bleeding had received substandard
care and that a different management may have saved their lives. Delays
in starting treatment, incorrect diagnosis, lack of adherence to
treatment protocols are some of the associated factors with maternal
deaths from obstetrical bleeding.
Women
who die of obstetrical bleeding are generally referrals from level 4
and level 3 facilities. This points to the need of having level 4
hospital fully functioning as comprehensive emergency obstetric care
units, 24 hours a day seven days a week.
The
enquiry recommends that such facilities should have midwives, medical
doctors with the ability to perform caesarean section, anaesthesia and
safe blood transfusion available.
Massive
bleeding can lead to death within two hours, so swift care is
important. Almost half of the deaths happened at the place of first
admission, so early recognition of complication by women and their
families, prompt visit to healthcare facilities and good quality care at
healthcare facilities is likely to reduce the risk of death.
In
another case, a 36-year-old woman who was past her due date and was a
known hypertensive had a vaginal delivery to a macerated stillbirth
(dead foetus that has undergone loss of skin, and distortion of the
features during retention in the uterus). She was diagnosed with
placenta praevia, which is a condition where the placenta partially or
wholly blocks the neck of the uterus interfering with normal delivery of
a baby, during her pregnancy. She developed excessive bleeding
immediately after delivery. She was started on intravenous fluids, a
uterine massage was done and she was promptly referred to a county
referral hospital.
However, the
ambulance took three hours to get to the health centre and another one
hour to the destination. At the referral hospital it was noted that she
had bled for five hours. Examination on admission showed a weak pulse,
low blood pressure and she was bleeding from her vagina. Two large IV
lines were fixed, blood transfusion commenced, she was given drugs to
stop bleeding and induce labour. A uterine massage was also done but she
was still bleeding. The doctor advised that a vagina and cervical
examination be done and he be informed promptly of the results. The
patient condition deteriorated while being transfused. Resuscitation
attempts were unsuccessful.
The
assessors found gaps in the care provided at the primary facility (lack
of adherence to treatment protocol), delay in the availability of
ambulance for referral was a key associated factor. At the referral
hospital there was incorrect diagnosis (clots had formed throughout the
body blocking small blood vessels), lack of review by senior clinician
and lack of adherence to treatment protocol for blood clotting
condition.
The assessors concluded
that promptly addressing these gaps in the quality of care probably may
have resulted in a different outcome.
More
than a third (37 per cent) of maternal deaths happened within six weeks
after birth (postpartum period). This is usually the period of least
vigilance as the baby has been delivered and seemingly no apparent
danger is possible. A fifth of the women died during the period from
onset of labour to the third stage of labour or (intrapartum) while the
period of death was not specified for 21 per cent of cases.
More
than two-third of intrapartum deaths were delivered by caesarean
sections and the same proportion of post-partum deaths delivered
vaginally.
Three out of 10 mothers who died had stillbirths and one in 10 died undelivered.
Even
though Kenya has made significant progress in reducing HIV infections
one in five maternal deaths were due to non obstetric complications
mainly HIV/AIDS and anaemia.
Half of
all maternal deaths were among women who had been referred from another
facility, mostly from level 4 to level 5 or 6 health facilities.
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