Several lapses in care contribute to deaths of over 80 per cent of expectant and new mothers
By DOROTHY OTIENO
6 hours ago
Four in five expectant and new mothers who die in hospital
receive poor care where a different management could have saved their
lives or that of their child, reveals a new study.
The First Confidential Enquiry into Maternal Deaths in Kenya shows
that of the 484 maternal deaths assessed, 447 (92 per cent) received
poor care. Of these, 394 (81 per cent) received substandard care where
different management could have resulted in a better outcome.
The
assessment constituted 51 per cent of the 945 deaths of women who died
in pregnancy or childbirth that were reported in the District Health
Information System (DHIS) for the year 2014.
Obstetricians/gynaecologists were involved in the emergency care of only one in nine women who died even though more than 80 per cent of them received care at county and national referral hospitals where the specialists are supposed to be present.
The Head of Reproductive and
Maternal Health Service Unit Dr Joel Gondi says that substandard care
was defined as delay in initiating treatment, incorrect treatment,
infrequent monitoring and skipping required laboratory tests.
About three-quarters (73 per cent) of the deaths occurred out of
office hours between 5pm and 8am on weekdays, weekends and public
holidays, shows figures from the study that was conducted from June
2015-June 2016.
Obstetricians/gynaecologists
were involved in the emergency care of only one in nine women who died
even though more than 80 per cent of them received care at county and
national referral hospitals where the specialists are supposed to be
present. The highest cadre of healthcare provider involved in the
management at the facility where an expectant woman or new mother
(within six weeks of giving birth) died were mostly medical officers (54
per cent). About 19 per cent were attended to by nurses, clinical
officers (two per cent) while more than six per cent of the women were
unattended or managed by unskilled healthcare providers.
“The
reason medical officers care for most of the women is because the
protocol in the emergency or casualty units is that they attend to
patients first then determine if specialised care is needed. But the
concern is whether they are well-skilled to determine if a referral to a
specialist is needed and to request for an obstetrician in good time,”
Dr Gondi Joel, the Head of Reproductive and Maternal Health Service
Unit, tells Nation Newsplex.
The study
identified one or more health worker-related factors in three-quarters
of the maternal deaths. The most frequent issues identified included:
Delaying starting treatment (a third), inadequate clinical skills (28
per cent), insufficient monitoring (27 per cent), prolonged abnormal
observation without action (24 per cent) and incomplete initial
assessment (23 per cent). Others included wrong diagnosis, wrong
treatment and no treatment.
Dr Gondi explains that
there are no enough obstetricians/gynaecologists to care for all women
who need their services and most of them are concentrated in urban
areas.
On the issue of most deaths happening out of
office hours, the Head of the Division of Family Health Dr Mohamed
Sheikh explains that most county referral hospitals often only have one
of each specialist e.g. one obstetrician and anaesthesiologist. After
working long hours for the entire week they may end up taking a break at
the weekend.
Currently, Kenya has 349
obstetrician/gynaecologists, one obstetrician-oncologist and 145
anaesthesiologists registered with the Kenya Medical Practitioners and
Dentists Board (KMPDB). According to data from the Statistical Abstract 2017, there were 948,351 births in 2017.
Both
Dr Gondi and Dr Sheikh say that out of the engagement with the
professional bodies the Health ministry hopes to come up with a better
line-up of the first and second line of staff on call, and the right mix
and quantity of staff available in referral hospitals at all times.
Dr
Gondi says the enquiry is part of the Ministry of Health’s response
which started with identifying the gaps. He says the report has been
shared with KMPDB and the Kenya Obstetrical and Gynaecological Society
so that they can work together to find solutions to the issues raised.
Absence of staff
The
administrative factors associated with the deaths included absence of
trained staff on duty, infrastructural problems, lack of equipment for
obstetric surgery, lack of blood for transfusion as well as transport
and communication problems between health facilities.
Dr
Sheikh says the ministry will engage with governors starting tomorrow
so that they can come up with a new referral strategy and ways to
address the shortage of supplies, equipment and personnel.
DHIS only records facility-based maternal deaths, and does not capture deaths that occur in the community, a situation that is made worse by the fact that many hospitals have poor documentation. Poor record-keeping/documentation was noted in most cases of maternal deaths assessed. For those reasons, the system only records between 12 per cent and 15 per cent of maternal deaths in Kenya. An estimated 6,000-8,000 pregnant women and new mothers die every year. Dr Gondi says there is great disparity within regions with a third of counties (15) being responsible for about more than half (58 per cent) of the deaths, which means that the response to the issue must also have a regional component.
Sheikh says maternal deaths could be greatly reduced if delays in accessing quality care were addressed at three levels.
DHIS only records facility-based maternal deaths, and does not capture deaths that occur in the community, a situation that is made worse by the fact that many hospitals have poor documentation. Poor record-keeping/documentation was noted in most cases of maternal deaths assessed. For those reasons, the system only records between 12 per cent and 15 per cent of maternal deaths in Kenya. An estimated 6,000-8,000 pregnant women and new mothers die every year. Dr Gondi says there is great disparity within regions with a third of counties (15) being responsible for about more than half (58 per cent) of the deaths, which means that the response to the issue must also have a regional component.
Sheikh says maternal deaths could be greatly reduced if delays in accessing quality care were addressed at three levels.
The
first level is the delay at home, an area where he says the government
has made great progress by doubling the number of women giving birth in
hospital since the introduction of free maternal healthcare. Data from
the Statistical Abstract 2017 indicates that births in hospital increased by more than a third (38 per cent) from 634,442 in 2012 to 875,101 in 2016.
“No woman should die in a health facility because of staff, equipment and supplies issues,” says Dr Mohamed Sheikh.
To
increase the numbers of women giving birth in hospital even faster,
there is a need to boost community health work and antenatal care (ANC).
According to the Kenya Demographic and Health Survey 2014,
about 58 per cent of pregnant women complete all four antenatal care
visits. Of the women assessed in the enquiry, less than 10 per cent were
recorded to have made at least four ANC visits. This suggests that some
of the complications that led to their deaths might have been diagnosed
much earlier had they attended all clinics. While the World Health
Organisation recommends a minimum of four visits it is now advocating
for up to eight visits. “We should take steps to make sure all ANC
clinics conduct all basic tests including ultrasounds. Currently many of
them do not have the equipment,” says Dr Sheikh.
The
second level of delay is getting to the hospital (transport challenges
in remote areas) while the third level is delays in hospital.
“We are getting more women to hospital but we must ensure that when they arrive they get the best care possible. We have made progress in maternal health in the last few years but not as much as we wanted,” says Dr Sheikh.
“We are getting more women to hospital but we must ensure that when they arrive they get the best care possible. We have made progress in maternal health in the last few years but not as much as we wanted,” says Dr Sheikh.
In the 16 years to 2014 the maternal
death rate per 100,000 live births dropped by 38 per cent from 590 to
362. Kenya’s Millennium Development Goal that expired in 2015 targeted
to reduce the rate to 147 deaths per 100,000 live births.
Tomorrow,
the Ministry of Health will launch the report and the policy documents
that will guide the response to the issues raised in the study.
Dr Sheikh says that the ministry is already training health workers like nurses in management of the implementation of the national emergency obstetric care protocols.
Dr Sheikh says that the ministry is already training health workers like nurses in management of the implementation of the national emergency obstetric care protocols.
“No woman should die in a health facility because of staff, equipment and supplies issues,” says Dr Sheikh.
About 93 percent (446) of the case notes reviewed were from public health facilities of which 62 per cent (301) were from county referral hospitals, national teaching and referral hospitals (20 per cent), sub-county hospitals (10 per cent), and private and faith-based hospitals (eight per cent).
About 93 percent (446) of the case notes reviewed were from public health facilities of which 62 per cent (301) were from county referral hospitals, national teaching and referral hospitals (20 per cent), sub-county hospitals (10 per cent), and private and faith-based hospitals (eight per cent).
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