In 2016, nearly half of maternal deaths (48%)1 and almost a third of perinatal deaths (31%)2 occurring in health facilities in Bungoma County were referred from another facility. The facility level maternal and perinatal death reviews in the County, supported by the Maternal and Newborn Initiative (MANI) project highlighted multiple problems with the referral system, including:
- Delays in the decision to refer clients
- Inappropriate treatment prior to referral or lack of efforts to try to stabilise clients before transit (e.g. Administering magnesium sulphate to clients experiencing pre-eclampsia)
- Referring facilities not calling ahead to enable referral facilities to prepare for receiving emergency cases
- Referring facilities not sending completed referral slips or client history
- Lack of (or delays in organising) ambulances, drivers, and/or fuel, especially at night
- Lack of a nurse or clinician to accompany clients in ambulance
- Emergency clients being dropped off alone at facility entrances.
Alongside problems with blood safety and supply, MPDSR review meetings identified the weak referral system as one of the major contributors to facility-based maternal deaths. More than one fifth of maternal death reviews in Bungoma County in 2016 recommended actions to tackle referral system challenges1. To address the challenges with the referral system, the county-level MPDSR committee took the following action:
- Four Ministry of Health officials, from the County Health Management Team and Sub-County Health Management Teams, undertook a benchmarking visit to neighbouring Kakamega County to observe their effective inter-facility referral system.
- A Bungoma County Referral Strategy and Investment Plan (2017)3 was drafted.
- A two-day training on the Referral Strategy and emergency preparedness took place, with 60 health care workers attending from 33 facilities, to raise awareness of the referral process and protocols and improve communications between the referring facilities, including private and faith-based facilities.
The County deputy nursing officer in-charge, who oversees the ambulance services in the county, identified the ambulance drivers and the hospital administrators (who control the resources and influence ambulance protocols) as key stakeholders in the referral process, and organised a one-day workshop for 37 ambulance drivers and 22 hospital administrators to orientate them on emergency preparedness and the need to prioritise funding for fuel for ambulances.
Sub-county MPDSR committees play a crucial role in enabling information to be passed from facilities to the county level, ensuring the sub-county and county officials have a better understanding of facility-level challenges and can take coordinated action. Linked committees also enable feedback to be given, lessons to be shared, and create stronger inter-facility communication and teamwork. The referral example illustrates the positive impact a linked MPDSR system, operating at all levels, can have on reducing mortality. The county is proud of the progress made to date in addressing the referral system challenges, but are aware that there are many referral challenges identified by the MPDSR process still to be addressed, including ambulance maintenance, functionality and coordination, and emergency preparedness.
Photo caption: Benchmarking visit to Kakamega, which included the County Chief Nurse and Deputy and two Sub-County Public Health Nurses (SCPHNs). Photo credit: Caroline Lavu
This update was written by Sarah Barnett, Technical Specialist at Options and Peter Ken Kaimenyi, Maternal and Newborn Health Technical Advisor at MANI Project funded by UK Aid.
To read more about MDSR in Kenya, click on the articles below from September 2017:
- Maternal Death Surveillance and Response: A Tall Order for Effectiveness in Resource-Poor Settings
- Implementing Maternal Death Surveillance and Response in Kenya: Incremental Progress and Lessons Learned
1 Barnett, S. & Kaimenyi, P. (2017). MDR dashboard, Bungoma County 2016. MANI project, Options Consultancy Services Ltd.
2 Barnett, S. & Kaimenyi, P. (2017). PDR dashboard, Bungoma County 2016. MANI project, Options Consultancy Services Ltd.
3 Ministry of Health [Kenya]. (2017). Bungoma county referral strategy and investment plan 2016/17-2020/21. Nairobi: MoH.