In most parts of Kenya, the majority of maternal deaths happen at high volume tertiary facilities that receive referrals of obstetric and newborn complications from lower level facilities. In Bungoma county, four out of the county’s 163 maternity facilities receive and manage 62% of all maternal emergency referrals. These four facilities conduct 26% of Bungoma’s total deliveries (DHIS2).
These high-volume facilities suffer from a lack of health workers to cope with the number of cases, and are therefore unable to provide the necessary standard of care for mothers. This problem has been aggravated by the county’s limited budget to hire more staff.
In addition to low staffing numbers, the available staff who work at smaller facilities manage relatively low caseloads and therefore have infrequent exposure to providing Emergency Obstetric and Newborn Care (EmONC). When staff lack the opportunity to practice and refine these clinical skills, they can struggle to manage emergencies correctly and with confidence when they do occur.
Throughout 2016, the reality of these challenges emerged clearly from data produced through maternal and perinatal death surveillance and response reviews. The Maternal and Newborn Improvement (MANI) project and the Bungoma Country Department of Health (DoH) agreed that something innovative needed to be done to address the dual challenges of staff shortages and EmONC skills gaps.
In March 2017, a mentorship programme was put in place at Bungoma County Referral Hospital and Webuye County Hospital, to augment the acute staff shortages in these facilities, and to develop the skills of nurses and midwives working throughout the county in lower level facilities.
How does the mentorship programme work?
Health workers at lower level facilities are invited to work maternity shifts in busy tertiary hospitals. Staff on duty at the higher-level facilities continue their usual work, while also providing hands-on mentorship and supervision to the visiting health workers. To take part in the mentorship programme, health care workers must be willing to volunteer, eager to gain skills and experience, and be on leave from their home facility at the time of participation.
This innovative approach gives staff from the lower level facilities the opportunity to improve their skills through hands-on experience, managing obstetric and newborn complications in an environment where back-up support and guidance are available. This boosts their confidence to manage complications on their own when back at their home facilities, reducing their need to refer complications. At the same time, the mentorship programme reduces the workload of staff at the high-volume hospitals, providing extra hands to assist in dealing with the steady stream of complex cases around the clock.
Nurse William, who works at the Mihuu Dispensary, took part in the mentorship programme; "Before the mentorship programme, I had a case of a pregnant woman with antepartum haemorrhage and unfortunately, I didn’t know how to manage it properly. I managed to reach some level, until I had to refer to Webuye Hospital, but unfortunately that lady passed away at Webuye."
During a routine review of maternal and perinatal mortalities at his facility, William acknowledged he had a skills gap on managing emergencies, as he was fresh from a nursing school, and was posted to a dispensary with minimal support. He volunteered to participate in the mentorship programme, where he learnt key skills and gained confidence in handling the full range of obstetric and newborn emergencies.
"In Webuye Hospital I performed two breech deliveries alone, even one I performed with a first time mother. They were waiting to take her to the theatre but she was already in second stage, so I decided to proceed and I delivered a live baby."
Since then, deliveries at Mihuu Dispensary have increased dramatically as William and his team have been able to improve the quality and availability of maternity services.
In the first eight months of the mentorship, over 200 health workers participated, conducting 3,395 deliveries. The quality of care has improved at participating facilities, with more complete care and improved documentation. With better monitoring of labour, complications are identified earlier and handled faster.
The programme has been embraced by the county leadership as an innovative and sustainable solution. Gertrude Wanyonyi, thee Chief Country Nurse for Bungoma County said, "At a time when resources are not able to cover additional staff recruitment, this has been a very economical, efficient and effective approach to supporting one of the key pillars of the health system."
The hospitals have also seen improvement in the protocols used for emergency referrals between health facilities. As one health worker from Webuye County Hospital said, "Mentorship becomes an eye-opener as to what it’s like on the receiving end. The mentees are recognising the need for quicker referral, and the need to try to stabilise clients before referring. Now they always inform us in advance, they stabilise their clients, they refer with a complete partograph and medical history, and some even prepare clients for surgery before referring to reduce delays. Just within the few months this has been operating we’ve seen a huge difference."
Recognition and integration
In June 2017, Bungoma county received a Beyond Zero award from Kenya’s First Lady, Margaret Kenyatta, in recognition of the achievements of the mentorship programme as being an innovative approach to tackling the human resource challenges.
As the mentorship programme matures, some mentees are already starting to become mentors. Participating health workers are taking their knowledge and skills back to their home facilities, mentoring their colleagues on the job, and encouraging them to participate in the mentorship programme.
In light of these successes, the county has included a budget to sustain the mentorship programme it its 2018/19 annual work plan, and intends to continue the approach as a routine activity to ensure that health worker training goes beyond the classroom.