Most maternal deaths occur out of office hours, says study


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 care 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 not 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 an 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 today 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.

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.

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 aimed to reduce the rate to 147 deaths per 100,000 live births.

On Wednesday, February 28, 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.

“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).