How lack of blood for transfusion is killing women as they give birth

Thirty-year-old Noah Wanjala Simiyu stares at a fresh grave adjacent to his house at Nakhayama Village in Bungoma County, which hosts the remains of his wife, Faith, who died in June.

The father of two is yet to come to terms with the loss. His wife died while giving birth to their second-born at the Bungoma County Referral Hospital.

“My wife had spent the whole day working until that night when she got labour pains. I rushed her to hospital, and was instructed to leave her and go back in the morning. I went home joyfully, hoping to see my wife and the newborn in the morning,” Noah recalls.

Early the next morning, Noah received good news from a friend who was taking care of his wife at the hospital – she had given birth to a baby girl. However, he could only see her during the visiting hour at 1pm.

“I found my baby at the maternity ward, but was not allowed to see my wife. When I asked if she was ready to be discharged, the nurses told me to go and look for her file, which I didn’t get. They then advised me to come back later, indicating that her condition was not that good.”

Noah kept himself busy shopping for his wife and newborn daughter, then he received a distress call that his wife’s condition had worsened.

“At the hospital, I was directed to the theatre and shown her body. I didn’t understand what had happened. The doctor explained that my wife gave birth at 6am, but was taken to the theatre to repair her cervix. She bled profusely and died,” narrates Noah.

According to Catherine Mulwale, senior nursing officer in charge of maternity at the Bungoma County Referral Hospital, Noah’s wife had a complicated cervical tear, which took time to repair and, in the process, she lost a lot of blood.

“In the ward, we had only found a single tear, but in theatre, multiple tears were discovered. We asked for blood from hospitals in neighbouring counties, but by the time we found some, she had lost a lot of blood,” said Ms Mulwale.

Noah took his wife’s body for burial and the baby to Nyang’oma Children’s Home, where he felt it could be cared for adequately. He visits her every month.

In June, when Noah’s wife died, 18 mothers who gave birth at the Bungoma County Referral Hospital needed blood transfusions, which was half the number of transfusions done in May.

The needs vary from month to month, but one thing is clear – inadequate blood supply is a challenge pregnant mothers have to contend with as their pregnancies near term.

Blood group O-positive is particularly in high demand, making up 40 per cent of bloodstocks needed to replenish blood lost to post-partum haemorrhage (excessive bleeding after birth).

Often, the hospital has to request blood from as far as Eldoret or Kisumu, and in the wait, the patient may not make it.

“A patient was referred to us from Kopsiro with a ruptured uterus and was taken to theatre in 30 minutes. We started looking for O-positive blood for transfusion, but by the time we got the blood, the patient was dead. Being a referral hospital, we never have enough blood in our bank,” says Ms Mulwale.

The hospital gets about 600 pints every month, yet they need 700 pints or more determined by the emergency cases that arise, not forgetting that they give an average of 500 units to other hospitals.

At least 80 per cent of this blood is collected from schools and colleges, and the donations drop to between 200 and 450 pints per month when they close.

The confidential inquiry into maternal deaths in 2017, noted that countrywide, 34 per cent of women die due to excessive bleeding after childbirth, which is losing 500 millilitres of blood or more in the 24 hours after giving birth.

More than a third (37 per cent) of women who suffer obstetric haemorrhage are referred from lower level hospitals to county referral hospitals such as the one in Bungoma, and the main reason for referral is the need for blood transfusion or specialised care such as dialysis or intensive care.

Excessive bleeding can lead to death within two hours, so it should be caught and addressed early and urgently, yet 91 per cent of women who die from obstetric haemorrhage receive sub-optimal care, where different management could have resulted in a different outcome.

In 2016, Bungoma County Department of Health analysed the cause of maternal deaths and found that half were due to bleeding before and after childbirth.

These deaths reduced by half when the Bungoma satellite blood bank was established in 2014. It supplies 14 transfusing health facilities in Bungoma, including faith-based and private hospitals. It also supplies hospitals in neighbouring Kakamega, Busia and Vihiga counties.

Before then, explains Kanduyi Sub-county Medical Officer Dr Johnstone Akatu, 10 women would die from childbirth every year.

“In the first half of this year, we’ve had at most three deaths. The deaths were higher when we depended on the Eldoret regional blood bank, which is 100 kilometres away. Even though Bungoma is not a fully-fledged blood donation centre, at least we can collect blood, take it for screening in Eldoret and then bring it back for use in our hospitals,” said Dr Akatu.

However, even after the setting up of the satellite blood bank, problems with blood supply persist because outside school and college donations, there are very few voluntary adult blood donors.

“We can set up a blood donation drive at a church with a congregation of 1,000 people and only two or three will donate. Worse still, rhesus negative blood is hard to come by, so when patients require it, we have to send a vehicle to Eldoret, where we might not get enough,” explains Gosech Okumu, who works at the Bungoma satellite as a blood donor recruiter.

Potential blood donors who could help bridge the gap say they fear donating blood because it might be sold. Others fear they might get to know their HIV status in the process.

“We don’t donate blood because when it gets to the hospital, they sell it. You’ll find someone who has donated blood for his relative admitted in hospital, then when the hospital bill comes, they have been charged for the blood they donated. One can’t be sure that donated blood will help patients in need,” said Kelly Simiyu. But Dr Akatu insists that hospitals don’t sell blood.

“We don’t charge patients for blood. It should be very clear that blood is given for free because we also get it free from donors.”

Stephen Wamalwa, who lives in Mateka, said he had never donated blood because he fears it would force him to find out his HIV status.

As residents shy away from donating blood, the maternity wing at the Bungoma County Referral Hospital, where at least 10 mothers give birth every day, suffers.

Half of those mothers suffer post-partum haemorrhage and three will require blood transfusion. Blood is not just for women giving birth. Road accident victims, patients going for surgery and patients with malaria, cancer or sickle cell anaemia might need transfusions.

For Diana Makari, a resident of Ngoli in Bungoma, who suffers from sickle anaemia, getting pregnant meant even more need for blood.

She started falling sick more often when she was five months pregnant and tests showed that she didn’t have enough blood. She needed transfusion, but screened blood was not available.

A second and third hospital visit later, there was still no blood, yet she was so weak and pale, she could hardly walk. When blood was finally found after two months, she got three pints.

Doctors considered inducing labour, because she needed blood too frequently and supply was low, but she delivered at term in May and luckily has not needed blood after delivery.

An initiative by Evidence for Action and Mama Ye, that aims to prevent deaths of mothers and boost child survival, hopes to solve the blood problem in Bungoma.

According to Bungoma County governor’s wife Caroline Wangamati, who is working with the two organisations to convince more residents to donate blood, the county used to collect 450 pints a month before the initiative started last November, and that has since risen to 600 pints a month.

“We have been urging residents to donate blood and help save lives. Expanding the Bungoma blood satellite centre into a regional blood bank that is able to screen blood would help the situation even further because that would ensure availability of blood at all times, even to supply neighbouring counties. The county needs to allocate money to upgrade the blood bank,” noted Bungoma County Coordinator for Evidence for Action Stephen Yambi, adding that when there is urgent need for blood, blood has to be rushed to Eldoret for screening causing delays and leading to death in some cases.

Away from mobilising more blood donors, which is important, one of the recommendations from the Ministry of Health report to reduce the number of women who bleed to death is to improve the capacity of Level 3 and 4 hospitals to prevent and treat obstetric haemorrhage and manage any complications arising from pregnancy or childbirth.

Hospitals need adequate blood transfusion services to make a difference and improve standards of care. Further, treatment delays also need to be significantly reduced because time is of essence.

Another recommendation to ensure the availability of safe blood and blood products is the use of innovations such as drones to deliver blood where it is needed, with the hope that this will bring down maternal deaths that stand at 362 deaths for every 100,000 live births.

In Rwanda where drones have been put to use for blood deliveries, a health worker just needs to place a request for blood or blood products using his or her phone, instead of dispatching a vehicle to the nearest blood bank, which could be kilometres away.
He or she receives an immediate response, and blood is dispatched in six minutes, with a drone, where before it might have taken hours.

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Dying to give birth: One in 10 mothers bleeds to death

Last year, the Ministry of Health undertook the task of finding out why mothers were dying before, during or after childbirth, or what is referred to as maternal death.

They talked to obstetrician gynaecologists, paediatricians, anaesthetists, surgeons, medical officers, clinical officers, midwives, health information officers and public health providers in public, private and faith-based health facilities.

From the outset, the Ministry said there would be no blame games, just trying to find out the numbers and truths behind the deaths: They looked at factors arising from health workers such as inadequate clinical skills and delay in referrals and lack of obstetric lifesaving skills, among others.

They also looked at administrative factors, in which lack of blood for transfusion featured.

The result was a report titled Saving Mothers’ Lives 2017: First Confidential Report into Maternal Deaths in Kenya.

The investigators found that loss of blood before, during or after childbirth or obstetric haemorrhage is the leading cause of death among mothers in Kenya, killing two out of five women.

Excessive bleeding after birth (post-partum haemorrhage) accounted for 34 per cent of maternal deaths.

Post-partum haemorrhage is defined as losing 500 millilitres of blood or more, which is just over one unit of blood, in the 24 hours after giving birth. If the blood loss hits 1,000 millilitres, it is considered severe.

According to the Kenya National Blood Transfusion Service (KNBTS), 60 per cent of all blood donated in Kenya is used up by mothers and children.

However, the country still does not meet its blood needs that are estimated at 400,000 units per year, against a collection of 149,642 units in 2017, for instance.

It is estimated that every 10 minutes, roughly the same amount of time it takes to donate a pint of blood, at least one patient will need blood transfusion, and about 1,100 will need transfusion every day.

Among them are mothers who need blood to resolve blood-related complications including excessive bleeding. Eleven per cent of maternal deaths in the country are attributed to lack of blood for transfusion. Fifteen per cent of women who die from obstetric haemorrhage, die due to lack of blood for transfusion and three per cent of mothers who die from non-obstetric complications, die due to lack of blood for transfusion.

To make matters worse, the confidential report noted that women with obstetric haemorrhage receive sub-standard care, and health workers do not act in time to reduce the risk of death.- Felista Wangari