It is our shared commitment to end all preventable maternal and newborn deaths as well as stillbirths by 2030, especially as we march into the last decade towards achieving the sustainable development goals. But the COVID-19 pandemic has led to major set-backs in the progress made in increasing access to quality health care for many women and their babies in sub-Sahara Africa.
The World Health Organization (WHO) estimates that 15% of pregnant women will develop life-threatening pregnancy related complications. If complications arising in pregnancy or the postnatal period are not identified and treated early enough, they can lead to severe morbidity or mortality. Strengthening midwives’ skills to identify, manage or refer these complications to the next level of care is vital in improving health outcomes.
Options works to promote the health and well-being of women, girls, children and newborns in Africa and Asia, and is establishing strong partnerships with governments at different levels. In Kenya, East Africa, we are supporting a mentorship scheme to strengthen nurses’ and midwives’ competence and confidence in Emergency Obstetric and Newborn Care (EmONC) as part of our Maternal and Newborn Improvement-Quality of Care (MANI-QC) project.
Strengthening health care workers' lifesaving skills
I had a conversation with 14 midwives about the contribution of the mentorship scheme on their daily work. These midwives have between six months and 26 years of experience and work in health facilities in Mombasa and Kwale counties in Kenya.
Each of them told me about incidences in which they had to make quick decisions to save the lives of mothers and their babies. However, in some circumstances, either the mothers or their babies, or both, died.
Rhoda, a midwife nurse at Coast General Referral Hospital in Mombasa county and mentor, with over 20 years of experience, has so far mentored 19 nurse-midwives: “EmONC services mostly deal with emergencies which may occur from the time women and girls conceive until they deliver their baby. Every stage is very crucial. We have to equip nurses at antenatal care with skills to offer quality EmONC services.”
The MANI-QC programme carries out regular assessments to measure the capacity of health facilities to provide EmONC care. These revealed that the quality of care provided greatly differs between facilities; some have a very skilled workforce with equipment available, while others are experiencing human resource challenges, skills gaps amongst the team and at times lack equipment. This was in sync with the EmONC capacity assessment findings where in October 2019, we found five and four facilities in Mombasa and Kwale counties respectively, reporting health care worker skills gap. However, by July 2020, no facilities reported to have skills gaps.
Many of the nurses taking part in the mentorship scheme admitted that they lacked confidence to perform most of the emergency obstetric procedures. “I didn’t know how to perform Assisted Vaginal Delivery (AVD,) but at least now if a mother comes with prolonged labour, I am able to offer that service to that mother”, says mentee Noleen, who has completed 15 mentorship sessions at Coast General Referral Hospital. She is a young nurse with three years’ experience and works at the maternity unit of a faith-based hospital, which serves more mothers in a day than the two private clinics she previously worked at in Mombasa county.
Through mentorship, Haji, a nurse at Kwale County Hospital, has gained lifesaving skills to manage a mother who was suffering from excessive bleeding after delivery through her mentorship at Msambweni County Referral Hospital. When the woman arrived at her facility, her patient records file indicated that she was also diabetic with high blood pressure. Haji was able to work with other nurses, sharing her knowledge and experience gained from her mentorship in managing mothers with bleeding and high blood pressure. She is very proud that the mother’s life was saved.
Previously, Haji and her team would refer such cases to other health facilities as they lacked the competence and confidence to manage the conditions. Kwale sub-county is vast with a limited number of ambulances to serve all health facilities where in case of a referral such a life would be lost as a delay to reaching the next hospital.
Increased capacity and skills reduced referrals
I also asked the mentors who provide expert clinical guidance on the scheme about the quality of referrals they used to receive, and if healthcare workers in lower-level facilities have the right skills to detect and treat complications without needing to refer them.
“I’ll start with a sad one” says Kahati from PortReitz hospital in Mombasa County, a hospital with one of the highest number of deliveries in the county, as he tells me the story of a mother who delivered normally at home but the placenta was retained. She had to seek care in one of the primary health facilities to remove it. “They attempted to remove the placenta and failed. Then they had to refer the mother to our facility. By the time this mother arrived here she was gasping for her life. We lost this mother.” an emotional Kahati explains.
He believes that if health workers at primary health facilities, where mothers first go, had enough knowledge and skills for how to remove a placenta manually, this mother would never have died. Portreitz has offered mentorship to over 15 nurses from facilities around its area. This time smiling Kahati explains: “Since the time we started this mentorship until now, the number of referrals to the facility has tremendously reduced. Before they referred 90% but now most of the mothers they refer here are automatically for caesarean section.”
Scaling up the mentorship programme at the sub-national level
“A facility like Mlaleo used to conduct 30 deliveries per month but right now they are conducting up to 70 to 100 deliveries”, says Emily, who is a County Nursing Officer in Mombasa County department of health services. She believes that the midwives at Mlaleo who went through the mentorship programme have been motivated and increased their own targets for each month.
Emily also notes that despite the short period the EmONC mentorship programme has been rolled out by MANI-QC project, it has impacted positively on health workers attitudes and fostered relationships between facilities especially during referrals.
Health workers who have participated in the mentorship scheme go back to their facilities with much more confidence and motivation to offer quality services. Leaders in the county health management teams have already committed that mentorship for health care workers is here to stay, and both the governments of Mombasa and Kwale have stated that they plan to learn from the EmONC mentorship approach and scale it up in future in other programme areas.
This blog was written by Meshack Ian Acholla, Kenya-based Communications Manager for Evidence for Action – MamaYe’s (E4A-MamaYE) and MANI-QC programmes.