Why Kenyan women and their babies are still dying at childbirth
Medical care for new mothers and their babies is in a sorry state, with doctors, nurses and clinical officers routinely ignoring clinical guidelines and lacking skills to treat and manage complications, reveals a NationNewsplex investigation.
Lack of essential drugs and limited access to life-saving services are also undermining the well-being of mothers and their babies.
While most health providers get the diagnosis of post-partum haemorrhage (severe bleeding after giving birth) and neonatal asphyxia (deprivation of oxygen to a baby before, during or just after birth) correct, only a small proportion offer the right treatment, according to the Kenya Health Service Delivery IndicatorSurvey (SDI) 2018 released recently. The two conditions are the leading causes of deaths in new mothers and their babies during birth.
Only 16 percent of doctors and clinical officers prescribed the right treatment for neonatal asphyxia even though 88 percent accurately diagnosed the condition, show figures from the survey that was done in 3,094 health facilities across Kenya. Likewise, less than half (43 percent) of health providers prescribed the correct treatment for post-partum haemorrhage while 90 percent gave an accurate diagnosis.
About 9,327 newborns died from neonatal asphyxia within the first 27 days of their birth in Kenya in 2017, according to the World Health Organization. Severe bleeding during birth is the leading cause of maternal deaths, accounting for a third of them in sub-Saharan Africa.
“If focus is not put on quality of care we might transfer deaths from communities to hospitals.”
Figures from the World Bank and the Ministry of Health study that was done from March-July last year show that the quality of treatment varied widely across the 47 counties. Less than five percent of health providers in 14 counties, including Nyandarua, Tana River, Mandera, Nyeri, Kiambu, Kirinyaga, Muranga, Bungoma, Nandi, Kakamega, Laikipia, Homa Bay, Mombasa and Vihiga, accurately got the treatment for neonatal asphyxia right, while about two-thirds of their counterparts in Garissa, Wajir and Makueni prescribed the accurate treatment.
Counties did marginally better in treating excessive bleeding during birth, with accuracy ranging from as low as less than a fifth in Mandera, Laikipia and Mombasa to about three-quarters in Isiolo, Baringo and Makueni.
Maternal and Perinatal Death Surveillance and Response (MPDSR) expert Peter Kaimenyi says perinatal healthcare is a much neglected area. “If focus is not put on quality of care we might transfer deaths from communities to hospitals,” he says.
Overall, health providers adhere to only a third of the clinical guidelines for managing pregnancy-related and newborn complications. Doctors adhere to a marginally larger share of guidelines (42 percent) compared to clinical officers (35 percent) and nurses (33 percent).
There is very little variation across facilities in managing maternal and neonatal complications. First-level hospitals have a higher adherence (40 percent) than health centres (35 percent) and dispensaries (32 percent).
Across counties, health workers in Wajir (70 percent), Garissa (60 percent) and Narok (56 percent) recorded the highest adherence to clinical guidelines for managing maternal and newborn complications while those in Vihiga (17 percent), Nyeri (20 percent), and Siaya and Nyandarua (21 percent each) had the lowest compliance.
Kaimenyi says that while a lot of effort has been put in promoting hospital delivery, more is needed to improve the quality of health services. Figures from the Kenya National Bureau of Statistics show that more than 70 percent of births across the country now occur in hospitals.
The survey also assessed the availability of Standard Treatment Guidelines in facilities. Less than half (43 percent) of the facilities had Integrated Management of Newborn and Childhood Illnesses guidelines. The guidelines were more likely to be available in hospitals than health centres or dispensaries.
Do no harm
The actions of health providers are under the spotlight against a backdrop of growing complaints over misconduct by health providers. There were at least 115 cases of major medical misconduct, mostly involving doctors (two-thirds), that resulted in the death or injury of patients published by the media in the last 20 months, according to Do No Harm, a Newsplex database on medical malpractice compiled from mainstream media stories. Patients died in four out of five of the incidents.
About three-quarters of complaints involved harm caused to children, accounting for 84 cases. Coming second were cases involving botched deliveries (11). Of these, five resulted in deaths, of which in three incidents mothers and their babies lost their lives.
The First Confidential Enquiry into Maternal Deaths in Kenya reveals that four in five expectant mothers who die in hospital receive poor care where a different health management could have saved their lives or that of their child. One or more health worker-related factor(s) were identified in three-quarters of the maternal deaths in hospitals, shows the enquiry that was published last year by the Ministry of Health. The most frequent health worker-related factors identified were delay in starting treatment, inadequate clinical skills, poor monitoring, and incomplete initial assessment.
During the confidential enquiry it was observed that monitoring the process of labour was not being adhered to in many facilities yet it is the means of determining whether labour is progressing well or if complications that require urgent and different interventions are required, says Dr James Gitonga, the head of MPDSR at the Health ministry. A response to the finding has been to offer training and mentoring to health workers in emergency obstetric and neonatal care.
Both the confidential enquiry and the SDI confirm that it is not just actions of health providers that undercut quality maternal and child healthcare but also inadequate access to life-saving services, drugs and equipment.
Priority drugs (on the Kenya Essential Medicines List) for pregnancy-related and newborn illnesses in health facilities are not readily available. Just a third of essential drugs for mothers and two-thirds for children are available in facilities across the country, according to the SDI. About a third of the necessary vaccines are missing.
Limited access to basic and obstetric care for women is leading to many complications during and after childbirth. Only one in nine health facilities provides basic emergency obstetric care, according to the survey, while just three percent of the facilities provide full comprehensive emergency obstetric and neonatal care.
Urban facilities (17 percent) provide basic emergency obstetric services at almost double the rate of rural ones (nine percent).
Health facilities are classified as offering basic emergency obstetric and neonatal care if they have performed seven signal tasks (except caesarean section deliveries and blood transfusions). Comprehensive coverage includes all functions.
Dr Gitonga says that lack of blood and blood products, which is easy to fix, was another issue raised by the confidential enquiry. The report recommends embracing and scaling up innovations that increase blood and blood products availability and safety.
In high fertility rate countries like Kenya, where women, on average, give birth to four children (KDHS) in their lifetime, quality obstetric care is critical for the health system.
With a maternal death rate of about 362 per 100,000 live births and an under-five death rate of 52 per 1,000 live births, Kenya’s progress in achieving key maternal, infant, and child health targets has been slow as set out in key national policy documents.
Overall, only a half of health facilities conduct deliveries. Almost all first-level hospitals (97 percent) offer birth services, whereas 88 percent of health centres and only 40 percent of dispensaries and clinics conduct deliveries.
There is a strong case to be made for improving the availability of assisted vaginal delivery to deal with the high maternal death rate. But only eight percent of dispensaries, 20 percent of health centres and a third of level 1 hospitals offer the service.
But more than 40 percent of level 1 hospitals do not have provisions for C-section and a third lack blood transfusion capacity.
It is important that the health facilities have the right equipment and training to support safe deliveries.
Some of the incidents of negligence highlighted in Do no harm are the deaths of 11 newborns in July this year at Kenyatta National Hospital after they were infected by a drug-resistant bacterium known as Klebsiella caused by the poor state of the newborn unit.