Saving Mothers LivesMINISTRY OF HEALTH

REPUBLIC OF KENYA

Confidential Enquiry into Maternal Deaths in Kenya

Summary of Findings2017

First ReportSummary of Findings

2017

Confidential Enquiry into Maternal Deaths in Kenya

MINISTRY OF HEALTH

REPUBLIC OF KENYA

Table of contentsAcknowledgements .......................................................................................................... iiList of abbreviations......................................................................................................... iiiDefinition of terms.............................................................................................................vForeword ........................................................................................................................ vii

1. Key messages from the report ..............................................................................12. Summaryofkeyfindings .......................................................................................42.1. Demographicandobstetriccharacteristics ...........................................................42.2. Antenatalcare .......................................................................................................52.3. Labourandchildbirth ............................................................................................62.4. Underlyingcauseofmaternaldeath .....................................................................82.5. Womenwhohadstillbirthsordiedbeforechildbirth..............................................92.6. Maternaldeathamongadolescentmothers ........................................................102.7. Qualityofcare .....................................................................................................112.8. Contributoryandassociatedfactors ...................................................................113. Recommendations ..............................................................................................144. Lessonslearnt .....................................................................................................175. Further research .................................................................................................17

List of Tables

Table1:CharacteristicsofwomenwhoreceivedANC .....................................................5Table3:characteristicsofwomenwhohaddeliveredatthetimeofdeath(n=329) .........7

List of Figures

Figure1:Percentageagedistributionofwomenwhodiedin2014 ..................................4Figure2:ProportionofwomenwhereANCtestswereperformed(n=229) ......................6Figure4:Percentagedistributionofperiodofdeath ........................................................8Figure5:UnderlyingcauseofmaternalDeathbasedonICD10classification ...............9Figure6:Underlyingcauseofdeathamongadolescentmothers ..................................10Figure7:Healthworkforcerelatedfactors......................................................................12Figure8:Summaryofadministrativefactorsidentified...................................................13Figure9:Summaryofpatient/familyfactorsidentified....................................................13

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Citation:Ministry of Health Kenya 2017: Saving Mothers Lives 2017. First Confidential Report into Maternal Deaths in Kenya.

This report was compiled by the National Maternal and Perinatal Death Surveillance and Response committee through the Reproductive and Maternal Health Services Unit of the Ministry of Health, Kenya. The report was edited by Wangui Muthigani, Charles A Ameh, Pamela M Godia, Elizabeth Mgamb, Judith Maua, Dan Okoro, Helen Smith, Mathews Mathai and Nynke van den Broek.

Contact:Kenya National Maternal and Perinatal Death Surveillance and Response Secretariat, Division of Family Health, Ministry of Health, Nairobi Kenya.

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AcknowledgementsTheNationalMaternalandPerinatalDeathSurveillanceResponse (MPDSR)Committeeacknowledgesseveralindividuals and institutions, whose hard work made itpossible to produce this report. We commend eachmember the committee for their commitment to serve,review,andapprovethisreport.

The committee acknowledges all the health careprofessionalsandinstitutionsacrosspublic,privateandfaith based health facilities involved in the retrieval ofmaternaldeathcasenotesthatoccurredin2014.

Thereviewofthe2014maternaldeathcasenoteswasspearheaded by the Ministry of Health, ReproductiveandMaternalHealthServicesUnit(RMHSU)throughtheNationalMPDSRSecretariat.WethankDrMohamedA.Sheikh–Head,DivisionofFamilyHealth(DFH),DrJoelGondi–HeadofRMHSUandallstaffinvolved.SpecialthankstoDrPatrickAmoth-formerHeadofDFH,andDr.DrBartilolKigen-formerHeadofRHMSU.

Weappreciatethecollaborationwithmedicalregulatorybodies and professional associations - KenyaMedical Practitioners and Dentists Board (KMPDB),Nursing Council of Kenya (NCK), Kenya Obstetricand Gynaecological Society (KOGS), Kenya MedicalAssociation, Kenya Midwives Association, KenyaPaediatric Association and Kenya AnaesthetistsAssociation.

Special recognition to all maternal death assessorswho were part of multidisciplinary teams that sparedtheir valuable time to participate in regional assessorsworkshopswhereindividualreviewsofmaternaldeathswere carried out. This process ensured that everymaternaldeathcounts.Wecommendtheeditorialteam

whoarealsomaternaldeathassessorsforfindingtimetodraftthisreport.

We recognize Dr Johan Coetzee an Obstetrician andGynecologist fromtheRepublicofSouthAfrica,whoisamember of theSouthAfricanCEMDCommittee, forsupportingtheprocessofadoptingtheMaternalMortalityAuditSystem (MAMAS)database foruse inmanagingand analysing the data. Professor James Neilson acollaboratoroftheMBRRACE-UKgroupandlongservingassessorforbringingtheUKexperiencetotheprocess.Recognitionalsogoes to the teamfrom theCentre forMaternalandNewbornHealthfromLiverpoolSchoolofTropicalMedicine (LSTM) for their technicalsupport ininitiatingtheCEMDprocessinKenya,trainingofnationalmaternaldeathassessors,conductingassessorsreviewmeetings,anddraftingandeditingthisreport.

SpecialrecognitionalsogoestomembersoftheNationalMPDSRSecretariatand the teamofanonymizerswhomadethecasenotesunidentifiable.DrWanguiMuthigani,DrPamelaMiloyaGodia, JudithMauaOng’ayi,JoyceOnyango,VenerandaKamanuforprovidingcentrallevelcoordinationof theCEMDprocess includingsettingupthe Secretariat.

Finally, our appreciation goes to Maternal andNewborn Health (MNH) Technical Working Group fortheir support. This review has been funded byUKaid/Department for International Development through theCentreforMaternalandNewbornHealthatLSTM.Wealso acknowledge UNFPA for co-funding the reviewprocess through the H4+ Partners programme. Otherdevelopment partners who have provided technicalsupport includeWHO,USAID andUNICEF.Additionalcontributorsareannexedtothereport.

Dr.KiokoJacksonK.OGWDIRECTOROFMEDICALSERVICES,Chair,KenyaNationalMaternalandPerinatalDeathSurveillanceandResponseCommittee

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List of abbreviations

ANC AntenatalCareBP BloodPressureC/S CesareanSectionCEMD ConfidentialEnquiryintoMaternalDeathCEMONC ComprehensiveEmergencyObstetricandNewbornCareCPD ContinuousProfessionalDevelopmentCPR CardiopulmonaryResuscitationCRVS CivilRegistrationandVitalStatisticsDFID DepartmentforInternationalDevelopmentDHIS DistrictHealthInformationSystemDHS DemographicHealthSurveyDIC DisseminatedIntravascularCoagulationDPHK DevelopmentPartnersforHealthinKenyaFBO FaithBasedOrganisationsFSB FreshStillbirthGA GestationalAgeHAART HighlyActiveAnti-RetroviralTherapyHb HaemoglobinHELLP HaemolysisElevatedLiverEnzymesandLowPlateletlevelsHIS HealthInformationSystemHIV HumanImmunodeficiencyVirusICD InternationalStatisticalClassificationofDiseasesandRelatedHealthProblemsICD-10 ICD,10threvisionICD-MM The WHO application of ICD-10 to death during pregnancy, childbirth and the

puerperium:ICD-maternalmortality

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ICD-PM TheWHOapplicationofICD-10todeathduringtheperinatalperiod:ICDperinatalmortality

ICU IntensiveCareUnitIU InternationalUnitsIV IntravenousJKUAT JomoKenyattaUniversityCollegeofAgricultureandTechnologyKMPDB KenyaMedicalPractitionersandDentistsBoardKNCHR KenyaNationalCommissiononHumanRightsKOGS KenyaObstetricalandGynaecologicalSocietyLSTM LiverpoolSchoolofTropicalMedicineMAMAS MaternalMortalityAuditSystemMD MaternalDeathmmHg MillimetresofMercuryMPDSR MaternalPerinatalDeathSurveillanceandResponseMSB MaceratedStillbirthMVA ManualVacuumAspirationNCK NursingCouncilofKenyaRMHSU ReproductiveandMaternalHealthServicesUnitSPSS StatisticalPackageforSocialSciencesTBA TraditionalBirthAttendantUKaid UnitedKingdomAgencyforInternationalDevelopmentUNFPA UnitedNationsPopulationFundUNICEF UnitedNationsChildrenEducationFundUSAID UnitedStatesAgencyforInternationalDevelopmentVDRL VenerealDiseaseResearchLaboratoryVE VaginalExaminationWHO WorldHealthOrganization

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Definition of terms

Associated factors Thesearenon-medicalfactorsassociatedwithmaternaldeathsbasedonthe3-delaymodel.Theyalsoincludehealthsystemfactors.

Confidential Enquiry into Maternal Death (CEMD)

Aconfidentialenquiryintomaternaldeathcanbedefinedasasystematicmultidisciplinaryanonymousinvestigationofallorarepresentativesampleofmaternal deathoccurringat anarea, regional (state)or national levelwhichidentifiesthenumbers,causesandavoidableorremediablefactorsassociatedwiththem.Throughthelessonslearntfromeachwoman’sdeath,andthroughaggregatingthedata,confidentialenquiriesprovideevidenceofwhere themainproblems inovercomingmaternalmortality lieandananalysisofwhatcanbedoneinpracticalterms,andhighlightthekeyareasrequiringrecommendationsforhealthsectorandcommunityactionaswellasguidelinesforimprovingclinicaloutcomes.

Contributing conditions Conditions thatmayhave contributed to ormaybeassociatedwith, butshouldnottobereportedassoleconditiononthedeathcertificateorselectedas the underlying cause of death. Contributing causes may predisposewomentodeath,aseitherapre-existingconditionorariskfactor.

Direct maternal death Directobstetricdeathsarethosedeathsresultingfromobstetriccomplicationsof the pregnancy state (pregnancy, labour and the puerperium), frominterventions, omissions, incorrect treatment, or from a chain of eventsresultingfromanyoftheabove.

ICD-10 International statistical classification of diseases and related healthproblems, Tenth revision (ICD-10). It’s the standard tool to guide thecollection,coding,tabulationandreportingofmortalitystatisticsbasedoncivilregistration.

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ICD-MM TheWHOApplicationofICD-10todeathduringpregnancy,childbirth,andthepuerperium:ICD-MaternalMortality(ICD-MM)isbaseduponthe10threvisionoftheICD(ICD-10)anditscodingrules.Itisintendedtofacilitatethe consistent collection, analysis and interpretation of information onmaternaldeath.

Indirect maternal death Maternal death resulting from previous existing disease or disease thatdeveloped during pregnancy and which was not due to direct obstetriccauses,butwhichwasaggravatedbyphysiologiceffectsofpregnancy.

Maternal death Amaternaldeathisthedeathofawomanwhilepregnantorwithin42daysoftheterminationofpregnancy,irrespectiveofthedurationandthesiteofthepregnancy,fromanycauserelatedtooraggravatedbythepregnancyoritsmanagement,butnotfromaccidentalorincidentalcauses.

Maternal and Perinatal Death Surveillance and Response (MPDSR)

MPDSRisaformofcontinuoussurveillancethatlinksthehealthinformationsystemandquality improvementprocesses from local tonational levels,which includes the routine identification, notification, quantification anddetermination of causes and avoid ability of all maternal and perinataldeaths,aswellastheuseofthisinformationtorespondwithactionsthatwillpreventfuturedeath.

Maternal death assessors

Amulti-disciplinarygroupofhealthcareproviders(differentcadres)trainedtoassign thecauseofdeath foreachmaternaldeathusing the ICD-MMclassificationsystem.

Underlying cause of death

Thediseaseorconditionthatinitiatedthemorbidchainofeventsleadingto death. The single identified cause of death should be as specific aspossible.There canonly beoneunderlying causeof death towhich anICD-10codecanbeallocated.

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ForewordSavingMothers’ Lives 2017,Confidential ReportintoMaternalDeathsinKenyaisthepremierreportofitskindtowardssavingthelivesofmothers.Thereport focuses onmaternal deaths that occurredin major county and national referral hospitalsduring the year 2014. It recognizes the fact that“everymothercounts”andthatunderstandingwhya woman died during pregnancy and childbirth,and taking steps to address contributing factorsareimportant ‘first’steptowardspreventingotherwomendyinginthesameway.

The Maternal and Perinatal Death Surveillanceand Response (MPDSR) process responds totheGlobalStrategyforWomen’s,Children’s,andAdolescent’sHealth (2016-2030)which seeks toend preventable maternal, new-born, child andadolescent death and still births. The Ministryof Health has developed national guidelines forMPDSR to provide guidance on how to conductreviews of maternal and newborn death andstillbirths, and near misses at both facility andcommunity levels. The guidelines also look atthe reporting pathways and documentation ofavoidable factorswith a clear response to avoidfuturedeath.

The Confidential Enquiries into Maternal Death(CEMD) is as a systematic multidisciplinaryanonymousinvestigationofallorarepresentativesample of maternal death occurring at an area,

regional (state) or national level,which identifiesthenumbers,causesandavoidableorremediablefactorsassociatedwiththem.Theenquiryprocesshighlights key areas for improvement aswell asactionable recommendations to prevent futuredeath.

Learning from experiences of CEMD conductedin the United Kingdom (MBRRACE-UK; Knight2015) andRepublic ofSouthAfrica (RSA2015),the findings presented in this report have beendrawnafter intensereviewsanddiscussionswithmultidisciplinary teams of health providers whoweretrainedasnationalmaternaldeathassessors.Thematernaldeathassessorsarecomposedofamixofcadresincludingobstetriciangynaecologists,paediatricians, anaesthetists, surgeons, medicalofficers, clinical officers, midwives, healthinformation officers and public health providersdrawn from different organisations includinguniversities,MinistryofHealthandCountyHealthteamsandprofessionalorganisations.

ThisCEMDreporthighlights the leadingcausesof maternal death, identifies the contributingconditions, and the associated factors. It alsopoints out actionable recommendations at thedifferentlevelsofpolicy,county,healthfacilityandcommunity/individual tostimulateactiontowardsaddressing avoidable factors, and preventingfuturematernaldeaths.

DrMohamedA.Sheikh,Head.DivisionofFamilyHealth

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Fifty-onepercent (484) of the 945 maternal deaths reported in theDistrictHealth InformationSystem(DHIS)fortheyear2014wereassessedandincludedintheanalysisofthisfirstCEMDreport.

Themedianageofwomenwhodiedwas27years.Theyoungestwomanwhodiedwas14yearswhiletheoldestwas47years.

8.9% ofthewomenwhodiedwereyoungmothersagedbelow20years.

Mostwomen(42.4%) thatdiedwerehavingtheirfirstorsecondpregnancy.

Only5 in 10ofwomenwhodiedhadantenatalcare.

Only2 in 10whoattendedANChadatleast4ANCvisits.

5 out of 10deathsoccurredintheIntrapartumandpostpartumperiod.

1 out of 10womenwhodiedwereundeliveredatthetimeofdeath.

3 out of 10womenwhodiedhadstillbirths.

1. Key messages from the report

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The leading cause of maternal deaths for all women is obstetric haemorrhage.

Quality of Care

2 out of 5 womendiedduetoobstetrichaemorrhage.

Sub-standardcarewasidentifiedin9 out of 10maternaldeaths

Oneormoreassociatedfactorsrelatedtohealthworker,administration,patientandcommunityfactorswereidentifiedinmajority(89.3%)ofmaternaldeaths

1 out of 5maternaldeathswereduetonon-obstetriccomplicationsmainlyHIV/AIDSandanaemia.

Delayinstartingtreatment,inadequateclinicalskillsandinadequatemonitoringwerethemostfrequentlyidentifiedhealthworkforcerelatedfactors

Obstetricianswhereinvolvedintheemergencycareof1 in 10womenwhodied.

Over 7 out of 10 deathsoccurredoutofofficehours(between5pmand8amonweekdays,weekendsandpublicholidays).

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Themajority(91%)ofwomenwhodiedofobstetrichaemorrhagereceivedsub-optimal care, where differentmanagement would have resulted in a differentoutcome

Half (50%)of allmaternal deathswere amongwomenwhohadbeen referredfromanotherfacility,mostlyfromlevel4tolevel5or6healthfacilities

Poor record keeping/documentation was noted in most cases of maternal death

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ThefirstCEMDinKenyawasconductedbetweenJuly2015andJune2016.Itcoveredmaternaldeaths that occurred in 2014.Centre forMaternal andNewbornHealth, Liverpool School ofTropicalMedicine supported theKenyaMinistry ofHealthReproductiveandMaternalHealthServices Unit to establish support systems (National MPDSR Committee, National MDSRsecretariat,NationalmaternaldeathassessorsandCEMDreportwritingteamtoproducethisreport.ThereportwasapprovedbytheKenyaNationalMPDSRcommitteeonthe12thofOctober2016.A summaryof the key findings, recommendations, lessons learnt and further researcharepresentedbelow.Also,a tableofkey recommendations, responsibilitiesand timelines forimplementationisprovided.

Fifty-onepercent(484) of the 945maternaldeathsreported in theDistrictHealth InformationSystem(DHIS)fortheyear2014wereassessedandincludedintheanalysisoftheCEMDreport.

2.1. Demographic and obstetric characteristics

Themedianageofwomenwhodiedwas 27years.Theyoungestwomenwhodiedwas14yearswhiletheoldestwas47years(Figure 1).

0

5

10

15

20

25

30

Not recorded45+40-4435-3930-3425-2920-24<20

Figure 1: Percentage age distribution of women who died in 2014

Percentage age distribution of women who died in 2014. N=484

8.9

23.121.5

12.6

4.3

0.4 1.7

27.5

2.0 Summary of key findings

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• 54.5% (264)ofwomenwhodiedwerehavingtheirfirst,secondorthirdpregnancy.

• 50% (242) ofthewomenhadbeenreferredfromotherhealthfacilities;mostlyLevel4(sub-Countyhospitals)tolevel5and6healthfacilities

• Withintheregions,majorityofthedirectmaternaldeathswerefromRiftValley21.3% (80) whilemostoftheindirectmaternaldeathswerefromNyanzaregion24.7% (24)andNairobi23.7% (23).

2.2. Antenatal care

• 47.3% (229) of thewomenwhodied receivedAntenatalCare (ANC),11.4% (55) didnotreceiveANC while records of 41.3% (200) women did not have documentation ofANCattendance.

• Only15.7% (36)womenwhoreceivedANChad4ormoreANCvisits

Table 1: Characteristics of women who received ANC

Characteristic Categories n=229Frequency Percent

Booked<16w? No 17 7.4Yes 14 6.1Norecord 198 86.5

No.ofvisits One 16 7Two 23 10Three 22 9.6Four 23 10> Four 13 5.7Norecord 132 57.6

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Figure 2: Proportion of women where ANC tests were performed (n=229)

• Amongthe229womenwhohadANC,Rhesustestwasreportedtohavebeendonefor 76.9% (176) womenfollowedbyHemoglobinfor 72.1% (165)andVDRL62.5% (142).Urinalysiswasperformedforonly22.3% (51)ofthewomen(Figure 2).

• HIVstatuswasnotrecordedin45.2% (219)ofthecases.Ofthe265 deathsinwhichtheHIVstatuswasrecorded,73.6% (195)wereHIVnegative,26.4% (70)wereHIVpositive.

2.3. Labour and childbirth• 77% (374) of women who died had given birth, 8% (40) had a pregnancy with abortive

outcomewhile14% (70)diedbeforechildbirth(undelivered)

• Ofthe374womenwhohaddelivered,88.8% (332)deliveredinahospital,7.5% (28) deliveredathomeoronthewaytothehospitalandtheplaceofdeliverywasnotspecifiedfor3.7% (14) thematernaldeaths.

• Ofthe374womenwhodiedafterchildbirth,50.5% (189)hadalivebirth,33.2% (124)hadastillbirth,andthedeliveryoutcomewasunspecifiedfor16.3% (61).

Sugar

Stool

Malaria

Urinalysis

VDRL

Hemoglobin

Rhesus test 76.9

72.1

62

22.3

9.7

4.4

3.1

9.2

0 10 20 30 40 50 60 70 80

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Table 3: characteristics of women who had delivered at the time of death (n=329)

Characteristic Categories Frequency Per cent

Placeofdelivery HealthFacility 332 88.8Home 26 7.0Bornenroute 2 .05Notrecorded 14 3.7

ModeofDelivery VaginalDelivery 229 61.3Caesareansection 138 36.9Assistedvaginaldelivery 7 1.9

Pregnancyoutcome LiveBirths 189 50.5StillBirths 124 33.2Notrecorded 61 16.3

Mode of delivery by timing of death

• 37.4% (181)ofthematernaldeathoccurredinthepostpartumperiod.

• 18.4% (89)ofthedeathsoccurredduringtheintrapartumperiod

• 70.8% (63)ofintrapartumdeathsweredeliveredbyceasereansection

• For 70% (126)ofpostpartumdeaths,themodeofdeliverywasvaginal.

• Ofthematernaldeaths,mostoccurredduringthepost-partumperiod62.2% (301)

• Cumulatively most women died outside working hours (5pm-8am on week days,weekendsandpublicholidays)73.3% (355)(Figure4).

8

Weekend, 143

,

Figure 4: Percentage distribution of period of death

2.4. Underlying cause of maternal death

• 77.7% (376)weredirectMDswhile19.8% (96)wereindirectMDs.

• Obstetrichaemorrhage39.7% (192),non-obstetriccomplications/indirectMDs19.8% (96) andhypertensivedisordersassociatedwithpregnancy15.3% (74)werethemostcommoncausesofallmaternaldeaths(Figure 4).

• The3 leadingcausesofdirectmaternaldeaths(376)wereobstetrichaemorrhage51.1% (192),hypertensivedisordersassociatedwithpregnancy19.7% (74)andpregnancyrelatedinfection12.5% (47)

Week end 29.5% Weekday out of office hours (8AM-5PM)

43.4%

Weekdayworkinghours(8-5PM)

26.7%

Public Holidays - 0.4%

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05 10 15 20 25 30 35 40

Unknown/undetermined

Direct deaths without an obstetric code

Unanticipated complications of management

Other obstetric complications

Pregnancy-related infection

Pregbancies with abortive outcome

Hypertensive disorders

Non-obstetric complications

Obstetric haemorrhage 39.7

19.8

15.3

8.3

9.7

2.7

1.9

0.2

2.5

• The leading causes of indirect maternal deaths were HIV-related complications 22.9% (22),Anaemia 14.6% (14), Protozoal diseases e.g. Malaria 10.4% (10) and Diseases ofthe circulatory system10.4% (10).Mental disorders anddiseasesof thenervous systemconstituted3.1% (3).

Figure 5:UnderlyingcauseofmaternalDeathbasedonICD10classification

2.5. Women who had stillbirths and women who died before childbirth

• 25.6% (124) ofwomenwhodiedhadastillbirth.

• 14.5% (70) ofwomendiedbeforechildbirth(undelivered).

• For women who had stillbirth, 54% (67) of the maternal death were due to obstetrichaemorrhageand21% (26)wereduetohypertensivedisordersinpregnancy,childbirthandthepuerperiumperiod.

• 40% (28)ofwomenwhodiedbeforechildbirthdiedduetonon-obstetriccomplications21.4% (15)duetohypertensivedisordersand18.6% (13)duetoobstetrichaemorrhage.

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2.6. Maternal death among adolescent mothers

• 8.9% (43) of the women who died were young mothers aged below 20 years.

• 62.8% (27) of them were having their first and 20.9% (9) were having their second pregnancy. One adolescent mother was having their 4th pregnancy.

• 81.4% (35) of the deaths in adolescents, were due to direct causes and 11.6% (5) were due to indirect causes.

• Most adolescents died of obstetric haemorrhage 27.9% (12) (Figure 6).

05 10 15 20 25 30

Unknown/undetermined

Other obstetric complications

Unanticipated complications

Hypertensive disorders

Non-obstetric complications

Pregnancies with abortive outcome

Pregancy related infection

Obstetric haemorrhage 27.9

23.3

11.6

9.3

4.7

2.3

7

14

Figure 6: Underlying cause of death among adolescent mothers

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2.7. Quality of care

• Medicalofficerswereinvolvedinthemanagementof54.1% (262)ofwomenwhodiedandobstetricianswereinvolvedinthecareofonly11.4% (55) of cases.

• Mostofthematernaldeaththatoccurredintheantenatalperiodwereduetonon-obstetriccomplications(indirectcauses)46.6% (34)andhypertensivedisorders24.7% (18).

• Most 73.3% (355)maternal deaths occurred outsideworking hours (after 5pm to before8am),onweekendsandpublicholidays.26.7% (129)diedduringweekdaynormalworkinghours(8am-5pm).

• Ofthe484maternaldeathsassessed, 447 (92.4%) receivedsub-optimalcare,wheredifferentmanagementwould have definitively madeadifferencetotheoutcome.

• Themost frequent gaps in care ofwomenwho died at all levels of carewere, incorrectmanagement when a correct diagnosis wasmade, infrequent monitoring and prolongedabnormalobservationnotedbutnoaction.

2.8. Contributory and associated factors

• Of the484maternal deathsassessed, oneormoreassociated factorswere identified in89.3% (432)ofthematernaldeaths.

• Oneormorehealthworker related factorswere identified in75.4% (365)of thematernaldeaths.

• Oneormorepatient/familyandadministrative factorswere identified in41.9% (203) and34.9% (169)ofMDsrespectively.

• For 64.5% (312) ofthematernaldeathstherewasinsufficientinformationtoidentifycommunityassociatedfactors.

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Healthcare worker factors

Themostfrequenthealthworkerrelatedfactorsidentifiedwere:delayinstartingtreatment32.9% (159), inadequate clinical skills 28.1% (136), inadequatemonitoring 26.9% (130), prolongedabnormalobservationwithoutaction 23.6% (114) andincompleteinitialassessment22.7% (110).

05 10 15 20 25 30 35

No treatment

Unsafe Medical treatment

No information

Wrong treatment

Partograph incorrectly used/not used

Wrong diagnosis

Delay in deciding to refer

Inadequate antenatal care

Inadequate resuscitation

Lack of obstetric life saving skills

No avoidable factors

Initial assessment incomplete

Prolonged abnormal observation without action

Inadequate monitoring

Inadequate clinical skills

Delay in starting treatment 32.9

28.1

26.9

23.6

22.7

16.5

14.5

14.0

13.0

11.9

11.2

10.5

7.9

8.0

7.2

2.9

Administrative factors

• Among the 353 deaths in which information was available, 47.9% (169) had avoidableadministrativefactorsthatmayhaveaffectedthequalityofcareprovided.

• Themostfrequentadministrativefactorsidentifiedincludedabsenceoftrainedstaffonduty12.5% (44),infrastructuralproblems12.5% (44),lackofequipmentforobstetricsurgery11.6% (41),lackofavailabilityofbloodtransfusion 11.0% (39)andlackofqualifiedstaff9.1% (32).

Figure 7: Health workforce related factors

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Figure 8: Summary of administrative factors identified

Figure 9: Summary of patient/family factors identified

Lack of antibiotics

Lack of laboratory facilities

Communication problem between health facilities

Transport problems between health facilities

Lack of qualified staff

Lack of availability of blood transfusion

Lack of equipment for obstetric surgery

Infrastructural problems

Abscence of trained staff on duty 12.5

12.5

11.6

11

9.1

3.7

3.4

2.8

2.5

0 3 6 9 12 15

Lack of transport

Use of traditional medicine

Unsafe self - medication

Unsafe cultural practices

No antenatal care

Delay in decision making

Delay in reporting to health facility 42.4

32.8

11.9

7.5

5.7

3.9

0.6

0 10 20 30 40 50

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3. RecommendationsSeveral recommendations fordifferent levelsof health careadministrationandmanagement,andthecommunityareasfollows:

1. Leadership

WhiletremendousinvestmentshavebeenmadeinmaternalandnewbornhealthinKenya,relatedhealthindicatorsdonotmatchtheinvestments.ThisreportillustratesaneedforaccountabilityforresultsinmaternalandnewbornhealthbythehighestlevelofleadershipfromtheNationalandCountygovernments.

2. National Level

• Developrelevantpolicyand legislativebackup for theconfidentialenquiry intomaternaldeathprocessbyanchoringtheMPDSRprocessinlegislation-MNCHBill.

• Strengthenthematernaldeathsurveillancesystemtoimprovethenotificationofmaternaldeaths.

Patient/family factors

• Of the 335 deaths in which information was available, the most frequent patient/familyassociatedfactorsweredelayinreportingtohealthfacility42.4% (142)anddelayindecisionmaking 32.8% (110). Therewerenoavoidablepatient/familyfactorsidentifiedin132 (39.3%) ofthedeaths.

Community factors• Failuretorecognizedangersigns 12.2% (21) anddelayindecidingtorefer11.0% (19) were

themostfrequentlyidentifiedcommunityfactorsassociatedwithmaternaldeaths.

• Of the 172maternal deaths inwhich informationwas available; therewere no avoidablecommunityfactorsidentifiedin143 (83.1%).

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• Integrateaqualitativeenquiryintheconfidentialenquiryintomaternaldeathsurveillanceandresponseprocess.

• Standardize patient record documentation to improve quality of records at healthcarefacilitylevel.

• Exploreuseofelectronicmedicalrecordsinmaternalandnewbornhealth.

• Providers ofmaternity care should have regular andmandatory updates in emergencyobstetricandnewborncare.

• Expand on diagnostic capacity including laboratory services and point of care tests inMNCH.

• Embraceandscaleupinnovationsthatincreasebloodandbloodproductsavailabilityandsafetye.g.deliveringbloodusingdrones.

• Rationalisestaffingnormsandmodelsforremunerationofspecialiststhroughoutput-basedmodalitiessuchasfeeforservice,capitation,andmixedmethodpayment.

• Provide up-to-date treatment protocols in a user-friendly format including in electronicformatsandapplicationsforallmaternitycareproviders.

• Developpolicytoexpandaccesstopostabortioncare(PAC)services.

• Strengthenadolescentsexualandreproductivehealthpoliciesandimplementationmodelstoaddressteenagepregnancies.

• Embraceandscaleuptheuseoftechnologytoenhanceaccessandavailabilityofqualitycareinmaternalandneonatalhealth(MNH).

• Institute mechanisms for perinatal death reviews in all health facilities and produce anationalreportbiannually.

3. County level

CountygovernmentsthroughtheDepartmentofHealthshould:

• Withinayear,increaseperformanceoffacilitiestoabove70%withallsignalfunctionsinBEMONCandCEMONCfacilitiesineachcounty;and,securefinancialarrangementsforcountydepartmentofhealthespeciallyMNH.

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• Embraceandscaleupinnovationsthatincreasebloodandbloodproductsavailabilityandsafetye.g.deliveringbloodusingdrones.

• Ensurecapacitybuildingandmentorshipofhealthcareworkersatall levelsofcareandretentionwithintheappropriatedepartmentforatleast2years.

• Ensurespecialistsareavailable-rationaliseworkinghours,remunerationandincentives.

• Improvedataquality anduse - stock takingofmaternal andnewbornhealth indicatorsagainstsettargets.

• LinkMNHtocriticalcare-usingavailableresourcestoimprovecareforwomen.

4. Health Facility Level

• Enforceandsuperviseproperdocumentationofthecareprovidedtomothersinallhealthfacilities.

• Maternity care providers should have regular (2 years) and mandatory updates inemergencyobstetricandnewborncare(includingtriageandreferral),antenatalcare(ANC)andpostnatalcare(PNC).

• Embraceandscaleupinnovationsthatincreasebloodandbloodproductsavailabilityandsafety.

• Providetheminimumpackageofcare inANCandPNCtoallclientsatall levelsof thehealthsystem(publicandprivate).

• ImprovedmonitoringofwomeninANC,labourandinthepost-partumperiod.

• Regular audit and feedback of care should be conducted to continuously improve thequalityofcare.

• Reorganizationof care toensure that high riskpregnanciesaremanagedby specialistteamssupportedbyappropriateresources(testreagents/kits,drugs,equipment,intensivecareunitetc.).

• Trainingintheuseofspinalanaesthesiaandprovisionofresourcesneededisimportantespeciallyatlevels3and4hospitals.

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5. Further researchFurtherresearchintofactorsassociatedwithpost-partumdeaths,caesareansections,qualityofcareforANCandpost-partumcareisneeded.Also,furtherexplorationofthefactorsassociatedwithdeathsoutsidenormalworkinghoursisneededtodevelopmeasurestoreversethepatternobserved.

4. Lessons learntThefirstCEMDconductedinKenyacontainslimitedinformationonperinataldeaths.Consultationswillbemadewithrelevantstakeholderstomaptheresourcesrequiredtoincludeperinataldeathsinfuturereports.

Someimprovementstotheassessor’sformshavebeenidentified,theformandMAMAssoftwarehavebeenupdatedandwillbeusedinsubsequentCEMDsinKenya.

4. Community Level

• Expandcommunitylevelhealthservices(level1).

• Preventiveandpromotivehealthservices.

• Datagenerationanduseatcommunity.

• Strengthenlinkagesbetweenthecommunityandthehealthfacility.

• Referralofallwomentothehealthfacility.

• Strengthencommunityreportingofmaternaldeaths.

Kenya National MPDSR Secretariat, Reproductive and Maternal Health Services Unit,

Division of Family Health, Ministry of Health

Afya House, Cathedral Road, P.O. Box 30016-00100, Nairobi - Kenya.