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Maternal deaths increase on shortage of excessive bleeding preventive kits

A doctor attends to a  woman soon after delivery. Globally 130,000 women die every year due to excessive  post-delivery bleeding with most of them in sub-Saharan  Africa. PHOTO | FOTOSEARCH
A doctor attends to a woman soon after delivery. Globally 130,000 women die every year due to excessive post-delivery bleeding with most of them in sub-Saharan Africa. PHOTO | FOTOSEARCH 

While giving birth, women face deadly risks such as bleeding. Often though this can be controlled by devices which, however, are occasionally out of stock in many Kenyan hospitals.

When Lilian Achieng walked into Rachuonyo South sub-county Hospital on Sunday, November 20, 2016 to deliver, she hardly expected anything unexpected to happen.

In less than one hour, she had delivered a 3.9-kilogramme bouncing baby boy, but she did not live to see him. She died immediately after giving birth due to excessive bleeding, also termed as post-partum haemorrhage (PPH), according to Dr Peter Ogolla who attended to her.

PPH is the number one killer of women in maternity wards. It kills about 130,000 women every year, majority of them in sub-Saharan Africa.

More than half of all the deaths occur within 24 hours of delivery. The condition is mainly caused by a retained placenta or when the uterus fails to contract after delivery.

According to the World Health Organisation, PPH is loss of 500ml of blood or more within 24 hours after giving birth, while severe PPH is defined as a blood loss of 1000 ml or more within the same timeframe. Each pregnancy magnifies the mother’s health risks, especially when she doesn’t have access to healthcare.

Speaking to the Business Daily, Dr Ogolla, who is the Medical Officer of Health at Rachuonyo South, said Ms Achieng had lost a lot of blood.

“Immediately after she had her baby, we injected her with oxytocin drug to control bleeding, but it did not stop,” said Dr Ogolla.

He admits that the hospital has saved many lives with the same condition as Ms Achieng using Uterine Balloon Tamponade (UTB), but on that unfortunate day, the kits were out of stock.

The UBT is a device recognised by the Ministry of Health as a cost-effective treatment option. It is the most efficient device for controlling excessive bleeding in women.

The device has been approved by the ministry and the Pharmacy and Poisons Board and placed among the essential items.

It was endorsed by the Kenya Obstetrics and Gynaecological Society during a conference in Kisumu last August.
It is also in the WHO document and PPH protocol in Kenya, but is underutilised by hospitals because most of the care providers do not know how to use it.

Statistics from the Kenya Health Information System (KHIS) show that the number of maternal deaths associated with PPH has been on the increase.

In 2015, Kenya reported 11,770 maternal deaths, 2,246 more than the 9,524 recorded in 2014.

By October 2016, 9,854 mothers have lost their lives due to PPH across the country.

“If this trend continues unabated, the total number of women who will die as a result of PPH will increase. Deaths that can be arrested by the use UBT,” said Dr Ogolla.

In Nyamira County, there has been a slight increase in the number of women dying from PPH. In 2014, 29 mothers died and 28 passed on in 2015.

Between January and October 2016 the number had risen to 47.

Last year, Siaya County reported 246 cases of PPH, Kakamega 1,884, Kisumu (1,600), Bungoma (1,260), Vihiga (700), Migori (600), Busia (377), Nyamira (278), Homa Bay (84) with Kisii recording the least deaths at 40 according to the KHIS.

Dr Aggrey Akula, a leading obstetric gynaecologist in western Kenya confirmed that UBT was one of the most effective ways of stopping excessive bleeding in women.

When using UBT, the bleeding should stop within 10 minutes.

Other ways of controlling postpartum haemorrhage can be through injection of oxytocin on the thigh to stimulate contraction of the uterus.

Dr Akula said in rural settings, where the kits are inaccessible, women are advised to breastfeed their young ones immediately after birth.

“When the child suckles, the brain is stimulated and produces oxytocin, hence the contracting of the uterus and the bleeding stops,” said Dr Akula.

He added that it is important for all health centres to routinely stock the kit in labour and delivery suites. “Most of the times when hospitals run out of the kits, they stuff the uterus with towels to absorb blood and wait for the doctor to come and perform surgery.”

He said many women often bleed to death despite the rather rudimentary remedial measure, especially in rural health centres where staff shortage is often acute.

Alternatively, Dr Akula said PPH can be controlled through blood transfusion and removal of the uterus.

“UBT is one of the most affordable techniques that can be used in low-resource settings,” said Dr Monica Ogutu, chief executive director, Kisumu Medical Education Trust (KMET).

Through a partnership with Massachusetts General Hospital, Harvard Medical School and KMET, the device was brought into the county.

“More than 34 per cent of all maternal deaths worldwide are attributable to post-partum haemorrhage accounting for approximately 130,000 deaths and 2.6 million disabled women every year,” said Dr Ogutu during the launch of the device in Kisumu in November.

The device, made out of two condoms, two cotton strings, one foley catheter and a 60ml syringe is in 13 counties and will soon be launched in all 47 counties.

The 13 counties include Kakamega, Kisumu, Siaya, Migori, Homa Bay, Nyamira, Nakuru, Nairobi, Isiolo, Mandera, Marsabit, Turkana and Garrisa.

The device consists of a water-filled balloon inserted in the uterus to apply pressure on the uterine walls to stop excessive bleeding. The low-cost catheter is disposed of after use.

The condom is attached to the catheter, then inserted into the uterus. Water is then introduced through the catheter tube slowly to inflate the condom to the shape of the uterus and presses against the bleeding uterine wall.

As the balloon swells, it slowly applies pressure to the uterus walls until the bleeding stops.

If the pressurised condom works, bleeding stops after about five minutes.

“The method provides a simple, rapid and affordable, effective point of care method of managing blood loss,” the doctor said.

Dr Ogutu said the condom balloon can stay in the uterus for more than two days while preventing bleeding, adding that the device has more advantages than surgery.

“The device can arrest bleeding in 10 minutes and has been proven to be 98 per cent effective,” said Dr Ogutu.
She said there’s a 98 per cent survival rate when the UBT is used properly by trained providers.

According to modelling done for the Innovation Countdown 2030 report, the UBT could save the lives of 169,000 women over the next 15 years.

The uterine balloon kit costs less than Sh1,000 and its parts can be found locally and easily assembled.

The KMET is currently the sole assembler and distributor of the UBT kits in the country.

Through a partnership with county governments, they assemble the kit and supply it to all hospitals in the country at Sh1,000 each.