Maternal care and child immunisation are managed by nurses

An accident that kills 20 passengers in the country hits the headlines instantly and  remains in the  news for days.

Yet nearly an equal number of women die in childbirth every day but do not receive as much attention, medical experts note.

Worse still, this happens when the healthcare system is working at optimum level.

A confidential Ministry of Health report derived from the District Health Information Systems (DHIS2) shows that 857 women died in childbirth in the first half of this year, up from 413 for the equivalent period last year.

Yet the ministry captures only 10 per cent of maternal deaths since many more go unrecorded. Last month the Business Daily reported that the ministry was able to capture only 10 per cent of maternal deaths because more than 50 per cent of the public health facilities remained closed during the nearly five-month nurses strike that ended early this month.

However, a senior official in the Ministry of Health who sought anonymity for fear of being victimised told DN2 that the 10 per cent applies not just to the period of the strike, but is what the government has been able to track all along.

A 2004 gazette notice by the health ministry made it mandatory for chiefs and local medical officers of health to report maternal deaths that occurred in the community and at medical facilities respectively within 24 hours.

But does this mean that even with the notice the health ministry still cannot track all maternal deaths?

“It can track them. The infrastructure is there. The problem is at the health facilities and at the community level. There are many taboos related to reporting a woman’s death. And  because of cultural beliefs, many people don’t report a maternal death. Yet as a health worker, if you report a maternal death, you get into trouble (they have in the past been accused of negligence by both the community and regulatory bodies such as the nursing council, which can lead to prosecution), so medical officers report such deaths as having been caused by something different,” says the source.

CLEARER PICTURE

To get a clearer picture, let us look at the 2016 figures captured by DHIS2, which  indicate that 964 women died in childbirth last year.

If, as the source indicated, this represents 10 per cent of maternal deaths, then extrapolating it to 100 per cent means the actual figure is 9,640, which translates to  about 26 maternal deaths daily. 

Soon after doctors resumed duty after a three-month strike, nurses and other health workers started a series of work boycotts, until nurses allied to the Kenya National Union of Nurses (KNUN) finally downed their tools on June 5, demanding a Sh25,000 monthly allowance, Sh15,400 risk compensation, and other allowances.

The result?

The number of mothers dying from complications during childbirth doubled. Besides, the country is staring at a coming disease crisis since children were not vaccinated, and diseases that had been brought under control are re-emerging, reversing the gains the country has made over the years.

To better understand the impact of the nurses’ strike on maternal and child health, it is important to look at the role they play in these areas.

“When it comes to maternal and child health, the nursing fraternity is indispensible,” says Dr Kimani Ngaruiya, a paediatrician and the director of clinical services at St Mary’s Mission Hospital in Langata. He lends credence to KNUN Secretary-General Seth Panyako’s assertion  that nurses manage 99 per cent of the childbearing process, from conception to post-delivery. 

Perhaps the biggest and most crucial role nurses play in any health facility is managing maternal healthcare.

“In all government facilities and even private, faith-based facilities like St Mary’s Hospital, it is the nurses who run the antenatal clinics, where women are followed up once they are pregnant,” says Dr Ngaruiya.

He adds that as part of their sub-speciality, nurses are trained as midwives: “This implies that they are the ones who handle normal deliveries, which are usually the majority because labour is a natural process.”

Notably, the 2014 Kenya Demographic Health Survey (KDHS), which sampled 31,079 women between the ages of 15 and 49,  showed the 96 per cent of those who had had a live birth in the previous five years had been given antenatal care by a skilled provider (doctor, nurse or midwife).

PUMWANI STATISTICS

Statistics from Pumwani Maternity Hospital indicate that on average, 500 women attend ante-natal clinics every month. When the nurses strike began in June, the number dropped to 178.

However, it gradually rose to 239 in July and to 296 in August respectively, reaching  360 in September, which is attributed to the arrival of a new group of nurses  at the facility that month.

“We have never closed this facility. Mothers just stayed away, probably thinking that we were also on strike. Most of our nurses are not members of the KNUN which called the strike,” says Dr Catherine Mutinda, head of clinical services at Pumwani Maternity Hospital.

The figures from Pumwani stand in sharp contrast to those recorded at St Mary’s Hospital. While on average 3,500 mothers have been attending ante-natal clinic at the hospital every month, these figures stood at 3,859 in June, 3,965 in July, fell to 3,571 in August and then rose again to 3,999 in September.

Another important role  nurses play is monitoring patients and implementing doctor’s orders.

Once a doctor has diagnosed a patient and decided on a course of  treatment, it is the nurses who monitor the patient and implement the doctor’s decisions and then report back to the doctor. So without nurses, doctors have a hard time coping. 

“I can tell you that it is almost impossible for a doctor to work in a ward where there are no nurses,” says Dr Ngaruiya. “When it comes to administering medication and timing of scheduled medication, that is the role nurses have been trained for and they are the experts in that field.”

He says that in the absence of nurses, a doctor’s decision cannot be  implemented, making it  useless.

With no nurses to attend to them in public health facilities, coupled with the fact that most women do not have the financial means to afford them private healthcare, Dr Ngaruiya says, it is most likely that most women opted to give birth under the care of traditional birth attendants (TBAs).

Despite the introduction of free maternity services in public hospitals in the country in 2013, the 2014 KDHS found that one-third of births still take place at home.

However, TBAs are not fully equipped to handle complications that might arise  during childbirth.

“The traditional birth attendants usually have just the minimal knowledge to assist the mother. If the birth is normal and nothing bad happens, well and good. But complications sometimes do arise, leaving the woman in labour for more than 18 hours. This puts the mother at risk of death or  developing a fistula. Meanwhile, prolonged labour denies the unborn baby oxygen supply to the brain, which can cause cerebral palsy,” offers Dr Ngaruiya. 

The KDHS report on hospital deliveries tells of a country that is heavily dependent on public healthcare. It  notes that six in 10 live births took place at health facilities, 46 per cent of which were public, and 15 per cent  private.

A facility like Pumwani that had been serving close to 2,000 women per month before the strike served only between 200 and 400 women during the nurses’ strike, with the highest number being 904 in September.

At St Mary’s Hospital, where an average of 450 women deliver every month, the numbers rose to 701 and 771 in August and September respectively.

While studies have shown that a baby derives a number of benefits from normal delivery such as lung maturity and function as well as bonding with the mother, Dr Ngaruiya is worried that in the absence of nurses, doctors might have been tempted to intervene before the recommended 18-hour labour period was over.

“There are few doctors and they can’t monitor mothers for 18 hours. So they might perform caesarean section to deliver more babies,” he says.

When epidemiologists look back a few years from now, Dr Ngaruiya says, the country will witness a reversal of the gains made in curbing maternal deaths as well as the strides made in immunisation, thanks to the frequent strikes in the health care sector.

Nearly eight in 10 children — 79 per cent — receive basic vaccination (BCG, measles, and three doses each of DPT and polio vaccine, excluding the polio vaccine given at birth), the 2014 KDHS reported.  Health experts say this figure might be reversed as a result of nurses’ strikes.

Further, the gains in maternal supplementation, that is vitamin A and iron supplements, which KDHS reported that 54 per cent of mothers were receiving by 2014, will have been reversed.

FORGOT TO INCREASE STAFF

“We never prioritised maternal health till Beyond Zero and the free maternity service programme came into being but even then,” the source at the health ministry says, “we took away only the financial burden from the woman but forgot to increase the number of staff to meet the demand. We also forgot to ensure that there is quality care; that is really what is biting us.”

According to the source, the country has the resources as well as the necessary manpower  to set up a reliable and efficient healthcare system that guarantees mothers survival and healthy babies; what is lacking is coordinated effort.

The Kenya Constitution might be silent on a number of issues, such as  what happens if a fresh presidential election or run-off is not held within 60 days, but it certainly guarantees Kenyans the right to reproductive health.

Article 43(1) (a) of the Constitution stipulates that every person has the right to the highest attainable standard of health, which includes the right to healthcare services, including reproductive health care.

***

The three life-threatening delays for women

Prof Mahmoud Fathalla, former President of the International Federation of Gynaecology and Obstetrics,  once famouly said “Women are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.” Notably, scientific studies have now come up with three predisposing factors that explain why women die in childbirth, popularly known as the three life threatening delays.

First is the delay in making a decision at home, where factors such as the inability to recognise a problem with a pregnancy, or complications arise during childbirth when a woman has been forced, or decided, to labour at home. In addition, some retrogressive cultures require a woman to seek permission from her husband or father-in-law to go to the hospital. There  is also the perception in some cultures that only a weak woman complains of pain or that she is sick when she is pregnant, which discourages some women from  going to deliver in hospitals, where they are assured of professional care. 

The second delay is accessing a health facility, which depends on a variety of factors, ranging from the distance from home to a health facility; the availability, and cost, of transportation; poor road networks; and an area’s topography.

But even if she overcomes the first two delays to get to the hospital in good time, a  pregnant women faces yet another hurdle: getting prompt, adequate, and appropriate care.  Poor infrastructure at health facilities, lack of medical supplies, inadequate referral systems such as a well-manned and equipped ambulance, inadequately trained and poorly motivated medical staff all threaten to send her to an early grave.