The 5th of May 2017 is International Day of the Midwife. This blog illustrates how the maternal and perinatal death surveillance and response (MPDSR) process in Kenya helped to lift the morale of midwives working in extremely challenging conditions.
The Maternal and Newborn Health Improvement (MANI) project has trained eight midwives from Lugulu hospital since September 2015 in MPDSR. Since then the facility has regularly conducted maternal and perinatal death reviews (M/PDRs). The primary objective of MPDSR is to identify areas where quality and access to emergency obstetric and newborn health care services can be improved to help prevent future deaths. However, in Lugulu hospital, the midwives found that MPDSR equipped them with strategies to cope during an exceptionally difficult period.
Like many faith-based facilities across Kenya, health providers in Lugulu Hospital in Bungoma County felt unable to turn maternity clients away during the four-month strike by Government doctors. During the strike, from November 2016 to February 2017, Lugulu Hospital experienced:
- An increase in maternity in-referrals from an average of two per month to over 100, including many cases from facilities in neighbouring counties
- A sudden six-fold increase in the number of deliveries and a seven-fold increase in the number of caesarean sections
Ordinarily, these additional clients would have used the free government maternity services, and lacked the resources to pay Lugulu’s standard fees. With clients unable to pay, Lugulu struggled to cover the additional demands on staffing, drugs and supplies, leaving the facility in a compromising situation. Midwives experienced a huge increase in their workload, typically working over 12-hour days, often for seven-consecutive days, leaving them both “physically and mentally drained” (Matron in-charge). Postnatal wards were grossly overcrowded. Emergency clients had to queue for caesarean sections in the hospital’s only operating theatre, with staff having to make difficult decisions regarding which emergency case was most critical. For some emergency patients arriving from elsewhere, delays in the weak referral system proved to be fatal.
The increased caseload and detrimental impact on quality of care resulted in midwives witnessing over 20 perinatal deaths a month at its peak, compared to an average of one per month before the strike. No maternal deaths had occurred at the facility between January and November 2017, but five occurred during the strike, leaving staff to feel “upset and demotivated seeing so many lives lost just because of money” (Maternity-in-charge).
Despite the excessive strain already placed on their workload by the doctor’s strike, midwives and other health personnel at Lugulu continued to meet to review all of the maternal and perinatal deaths that occurred during the course of the strike, and found that this was “a positive experience at a time when morale was low” (Matron-in-charge). The Maternity-in-charge went on to explain:
“Midwives see MPDSR as a learning experience and an important process for identifying and addressing preventable factors contributing to deaths. The review process helps us to see our weakness. We identify gaps in the management of difficult cases. We then take action, such as internal continuous medical education and training in emergency obstetric and newborn care.”
What was especially important during this crisis was that midwives found the meetings were an opportunity to “sit together as a team” (Matron-in-charge). During the doctors’ strike they felt determined to continue the M/PDR process as it helped them at a truly difficult time emotionally. Akin to a peer-support counselling session “some midwives even came to attend review meetings after working a night shift,” (Health Record Information Officer).
The MPDSR process was thus a pivotal mechanism enabling the midwives to cope in this difficult context. It confirmed MPDSR as a valuable process that strengthened their team work, reinforcing the need and appreciation of their collaborative efforts.
Acknowledgements: This blog was written by Sarah Barnett, Technical Specialist at Options.
To learn more about the experiences of midwives conducting confidential enquiries in Ireland, including the importance of having a peer-support system within the process, read our expert opinion piece on the role of the multi-disciplinary team in MDSR or similar models.