County’s simple steps now save mothers and babies lives

Fewer mothers are dying during childbirth in hospital in Bungoma after the county took simple actions like expanding blood supply to more health facilities, strengthening the referral process and mentoring health workers to handle pregnancy-related complications.

Figures from the Kenya Health Information System show that maternal deaths in the county declined by about a quarter in 2018 compared to 2014, the year before the rollout of the interventions.
Sobetter Musumba, 23, is one of the beneficiaries of the improved services.

A year ago, after completing her antenatal visits and having had an uneventful pregnancy, Sobetter looked forward to giving birth to her first child. When she went into labour at home, her husband immediately called a boda-boda to take them to the nearby health centre.

The trip cost them nothing because the Maternal and Newborn Improvement (MANI) project runs a programme where women who use boda-bodas to go deliver in hospital are reimbursed. The initiative is part of the Maternal and Perinatal Death Surveillance and Response (MPDSR) process that aims to expand access to quality healthcare in Kenya.

But after waiting for six hours at the health centre without being attended to even as the labour pains became more intense, the couple gave up, opting to go to Webuye County Hospital.
On arrival, Sobetter was quickly attended to, and soon after, delivered a baby boy. But her joy was short-lived when she started bleeding profusely. She ended up undergoing two surgeries and a blood transfusion. She later learnt that she lost over 40 percent of her total blood volume.

Post-partum haemorrhage − excessive bleeding at birth − is the leading cause of maternal deaths.

Had Sobetter experienced the same complication at the hospital three years earlier, the outcome might have been quite different as the hospital suffered perennial shortages of blood.

Webuye County Hospital Nursing Officer in Charge Bramwel Musambaki recalls the challenges staff would face treating new mothers who developed severe bleeding during delivery. The hospital routinely did not have blood on standby and often had to call surrounding facilities, looking for units whenever the need arose. He remembers losing a patient who developed severe bleeding after childbirth because of inadequate blood supply just before the hospital started participating in the MANI project that also assisted the facility to set up a functioning blood bank and efficient record keeping.

Much of the blood is transfused to children who have developed anaemia from malaria and those with sickle cell anaemia.

Blood transfusion is part of the comprehensive emergency obstetric and neonatal care. Four years ago Bungoma had just eight facilities with blood banks but the number has now doubled.

At Bungoma County Hospital the biggest need for blood is in the children’s ward, a fact that Mr Gossage Okumu, an officer at the Bungoma Blood Satellite, only realised after his team started keeping proper records on blood donations, storage and use.

Much of the blood is transfused to children who have developed anaemia from malaria and those with sickle cell anaemia.

Mr Okumu says the insight gained from data collection now enables them to plan how many units of blood are allocated to different wards, what blood types are in most demand and when to conduct blood donation drives. “I had never come across an O-negative blood type donor until we deliberately started searching for them,” says Mr Okumu. An O-negative is a universal donor but someone with the type can only receive O-negative blood. It is the most common blood type used for transfusions when the blood type is unknown. This is why it is used most often in cases of trauma, emergency, surgery and any situation where blood type is unknown.

But this was not the case just four years ago. Then, a single room at Bungoma County Referral Hospital, with a chair and desk, served as the blood bank. There were no places for blood donors to even sit. Stock-outs were frequent and when a patient needed a blood transfusion, often the hospital would ask a blood relative to donate or they would contact different hospitals looking for supplies, which sometimes came too late.

The situation turned around when the hospital enlisted in MANI and the Evidence for Action Mama Ye (E4A Mama Ye) projects, which support the government-led MPDSR process. The project lobbied the hospital to provide three more rooms for the blood bank, which they equipped with refrigerators and furniture for blood donors, and provided a canvas tent to be used during donation drives into the community.

Now, donation drives routinely yield about 700 units of blood a month, double the volume it produced in the past.

Another weakness that often led to negative outcomes for mothers and their babies that was pinpointed by the project was lack of coordination between lower-level hospitals and county referral hospitals.

MPDSR expert Peter Kaimenyi says there were many non-medical referral issues that hindered the patient referral process, including lack of transport, long waits for an ambulance and referred patients not being accompanied by health workers. Other issues included patients being referred without notes outlining what was observed at the lower-level hospital or the attempts made to stabilise them.

Healthcare worker skills was also a challenge. “Many of the health workers from health centres and clinics would not even call to inform us that they were bringing over a patient who had developed complications and the nature of their condition. On showing up with the patient, they did not want to be questioned by our staff. They would take offence when we asked questions,” says Mr Musambaki.

Health workers in health centres and clinics also lacked confidence in dealing with complications because they did not handle them regularly. The response led to a mentorship process where nurses from those facilities are seconded to higher-level facilities for hands-on experience in managing patients with complications and proper chart keeping.

Before the start of the MPDSR process, half of deliveries occurred in four hospitals in Bungoma yet the county has 200 facilities. The rate, however, reduced to 30 percent after the mentorship, says MANI project lead Gladys Ng’eno.
“The reduction in referrals is because health workers in lower levels now address some of the complications instead of being quick to refer them upwards,” says Ms Ng’eno.