PPPH! PPH!” Alice Juma, a nurse at the Rachuonyo Level Four Hospital shouted at the top of her voice from the hospital’s delivery room, where she was massaging and squeezing a patient’s abdomen to expel clots from her uterus and stop the torrential bleeding after birth, known as post-partum haemorrhage (PPH).
The patient, 27-year-old mother of six Rebecca Adhiambo, had just pushed out twin girls, with seven kilogrammes between them, and her overstretched uterus had failed to contract. When the placenta was expelled, the floodgates opened.
As recommended, Ms Juma administered oxytocin and misoprostol, but the bleeding didn’t stop. Meanwhile, Rebecca’s blood pressure was dropping and she was going into shock. She had lost 1,500ml of blood.
Her limbs had gone cold and her pulse had weakened. A deathlike pallor was taking over her face. She was exhausted and slipping into unconsciousness, moving steadily towards becoming a maternal mortality statistic.
Postpartum haemorrhage is the number-one killer of women in maternity wards, killing about 130,000 women every year, mostly in sub-Saharan Africa. More than half of these deaths occur within 24 hours after childbirth.
The bleeding is caused by either a placenta that is not expelled after birth or when the uterus fails to contract after delivery.
Postpartum haemorrhage is defined as blood loss of 500ml or more within 24 hours after giving birth. Blood loss above 1,000ml within the same timeframe is considered to be more severe. Each pregnancy magnifies a mother’s risk especially if she does not have access to healthcare.
The Confidential Enquiry into Maternal Deaths released earlier this month, showed that postpartum haemorrhage accounts for 34 per cent of maternal mortality in Kenya, followed by pre-eclampsia/eclampsia (19 per cent) and unsafe abortion (nine per cent).
The enquiry into maternal deaths done between June 2015 and June 2016, found that nine out of 10 women who died of obstetric bleeding had received substandard care, and that different management of the condition would have saved their lives.
Delays in starting treatment, incorrect diagnosis, and lack of adherence to treatment protocols, are some of the factors that lead to death of mothers from excessive bleeding after birth.
When Ms Juma’s colleague heard the dreaded distress call, she rushed in with a uterine balloon tamponade (UBT), a water-filled condom balloon, which was inserted into Rebecca’s uterus and water pumped inside. Ten minutes later, the bleeding had been arrested. The balloon was left in the uterus for an hour as the nurses monitored the bleeding. Two days later, Rebecca went home with her twin girls.
Had it not worked, Rebecca would have been taken to theatre where her uterus would have been tied or removed (hysterectomy) to stop the blood loss.
She could have died. Rebecca is one of five women that have been saved by the uterine balloon tamponade, which comes in handy in saving lives of mothers giving birth in rural health centres that are resource-constrained.
The UBT is made of two condoms, two cotton strings, one Foley catheter and a 60ml syringe. The condom attached to a catheter is inserted into the uterus and filled with water slowly to inflate it. As it swells and takes the shape of the womb, it applies pressure on the uterine wall to stop excessive bleeding. If it works, bleeding stops within 15 minutes. The low-cost catheter is disposed after use.
SAVES 97 PER CENT OF USERS
The condom balloon can remain in the uterus for two days, and when used properly by trained health workers, it saves 97 per cent of the women who use it.
A 2017 study in four countries including Kenya titled Every Second Matters found that 306 women with uncontrolled after-birth bleeding, their survival rate was 97 per cent when UBT was used.
Statistics from the Kenya Health Information System (KHIS) show that the number of maternal deaths associated with PPH has been on the rise.
In 2015, Kenya reported 11,770 maternal deaths, 2,246 more than the 9,524 recorded in 2014. By October 2016, 9,854 mothers had lost their lives due to PPH across the country.
According to Dr Monica Ogutu, the executive director of the Kisumu Medical and Educational Trust, while pregnancy and childbirth-related conditions account for 14 per cent of deaths among women of reproductive age (15 to 49 years), more than 75 per cent of those deaths are preventable.
“We can arrest these deaths by the use of the device. This is why it is important for all the facilities in the country to have the kit on standby to arrest emergency cases,” said Dr Ogutu.
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.
STUFFING UTERUS WITH TOWELS
In many cases when nurses can’t stop the bleeding, they stuff the uterus with towels to absorb the blood, while waiting for the doctor to come and perform surgery.
When the doctor arrives, he may remove the uterus (hysterectomy) to stop the bleeding, in addition to transfusing the mother to replace lost blood.
Often, it is too late to save the mother’s life. Many women bleed to death, yet they could be saved by the rudimentary but effective remedial measure especially in health centres with acute staff shortage.
The device prevents death and removal of the uterus (hysterectomy), which happens when medics cannot stop the bleeding. Families are also saved the hassle of looking for blood donors. All that is needed is a nurse and assistant, while in surgeries, up to nine specialists would be needed.
In cases where interventions including oxytocin and the kits are not available, Dr Paul Mitei, an obstetrician/gynaecologist in western Kenya, says that breastfeeding immediately after birth may arrest the situation.
“When the baby suckles, the brain is stimulated to produce oxytocin, which helps the uterus contract and stop bleeding,” he says.
In cases where bleeding does not stop, Oxytocin is administered, but it is occasionally out of stock. In better-equipped facilities, surgery to stop the bleeding or remove the uterus takes place, but can be too expensive.
Now the Ministry of Health and the counties have committed to purchase the UBT. In a communique signed in early March, the national and county governments committed to reduce maternal deaths by implementing and scaling up its use, an innovation that is cheap, safe, easy-to-use and effective.
The governments pledged to review National Post-partum Haemorrhage Protocol to include UBT kits on the list of essential commodities. The Kisumu Medical and Education Trust, the sole assembler and distributor of the kits in Kenya, will supply the hospitals at Sh1,000 apiece.
“Ending preventable maternal mortality is our mandate in line with Goal 3 of the UN Sustainable Development Goals, which seeks to reduce maternal mortality to less than 70 per 100,000 live births. There is also the 2014 commitment made by governors in 15 counties with the highest burden of maternal and newborn mortality in Kenya,” said Dr Jackson Kioko, Acting Director of Medical Services.
Dr Kioko said that plans are underway to incorporate UBT into pre-service training for nurses and other health workers.
Among other priorities is ensuring sustainable supply and distribution of the UBT kits in all counties while strengthening resource allocation towards quality improvement.
The kits have been approved for use by the Kenya Pharmacy and Poisons Board and the Kenya Obstetrics and Gynaecological Society. However, it is underutilised by hospitals because many healthcare providers do not know how to use it. Another challenge has been that health workers do not see its benefit.
The Confidential Enquiry into Maternal Death revealed that women who die of obstetric bleeding are usually referrals from Level 3 and 4 hospitals, pointing to the need to have Level 4 hospitals functioning as comprehensive emergency obstetric care units.
The enquiry recommends that such facilities should have midwives, medical doctors with the ability to perform Caesarean sections and availability of anaesthesia and safe blood transfusion.
“With commitment from everyone, supply and uptake challenges will be addressed and we will ensure that we give each person’s right to the highest attainable standard of health, including reproductive health,” Dr Kioko said.