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The Covid-19 nightmare for pregnant women


Tough call for pregnant women amid Covid-19

Fear of contracting disease in hospital and a curfew

When Vidia Nduku went into labour at 11pm on Monday, March 31, she knew she had to get to hospital fast.

Her husband Mati Nyamai knew what to do as he had been preparing for this moment for months. Together, they left home for the hospital. Nyamai remembered approaching a boda boda rider. He desperately begged the rider to help him get his wife to the hospital in vain.

With the Covid-19 outbreak, the government had declared a nationwide dusk-to-dawn curfew. Although this was a medical emergency, which is exempted in the curfew, the riders said they feared altercations with the police should they be found moving around at night and could not help the couple.

MIDWIFE'S HELP

Without any other means to get to the hospital, the couple decided to seek the help of a midwife, who lives nearby. Unfortunately, the midwife said she was unwell and could not help Nduku.

His wife was in so much pain that Nyamai decided to take her another midwife. For hours, the midwife tried to deliver the baby and sent them away at 2am when she realised she could not help them.

Nduku started bleeding at 3am. A helpless Nyamai waited until 5am, when he called two boda boda riders, who took them to Kibwezi Sub-county Hospital. “At the hospital, doctors said my wife had lost a lot of blood and she need a transfusion,” said a tearful Nyamai.

On that day at 2pm, the doctors broke the bad news. The mother of six had died on the operating table while waiting for blood transfusion. Nyamai says they buried her the following day.

As Kenya and the rest of the world reel from the devastating effects of the Covid-19 outbreak, the somewhat encouraging news has been that infections among children do not seem to be as alarming as those in adults. However, the new coronavirus disease is now indirectly causing the deaths of newborns or leaving them orphans. Pregnant women, afraid to contract Covid-19 in hospital or unable to access health facilities due to the nationwide curfew, have opted to deliver their babies at home. The result has been drastic.

Nduku is one of the three pregnant women in Makueni County who bled to death because of these challenges. The other two women died while giving birth in county hospitals in the same week. Doctors said the women delayed going to the hospital, opting to wait for morning.

CHEAP INJECTION

Speaking to HealthyNation, a midwife at Mama Lucy Hospital, who sought anonymity as she is not authorised to speak to the press, broke down when she talked about two women she was monitoring. The women from Mathare had difficult pregnancies that resulted in the death of the babies when their mothers could not get to the hospital and instead delivered at home.

All these women died from postpartum haemorrhage, one of the leading causes of maternal deaths. According to the Emergency Medicine Foundation, a cheap injection of a drug called tranexamic acid - given to the mother three hours after delivery - stops the bleeding and would have saved the women’s lives.

The postpartum period, the time after birth, is particularly important for women, since it is during this period they may develop serious, life-threatening complications. Evidence has shown that a large proportion of deaths occurs during the postpartum period, with postpartum haemorrhage being a major cause.

With the outbreak and the curfew in place, expectant mothers have expressed fears of either contracting Covid-19 in the hospitals where they give birth or failing to make it to the hospital in time. A question posted by an expectant woman on a Facebook group for pregnant mothers asking for advice, gives life to these fears. “Now that there’s a curfew, what should a mother do when you go into labour at night?” She posed.

Another mother asked for advice from “anyone who has given birth at Mbagathi Hospital during this coronavirus outbreak”.

While one woman said pregnant mothers worried they might catch the virus at the hospital.

Health Director-General Patrick Amoth has said the curfew should not interfere with patient rights to health. The fear to get out and seek medical help at night could have been triggered by the events of the first day of the curfew when police violently enforced it, sending a chilling message to Kenyans.

MISS VACCINES

Now, healthcare workers are raising concerns that expectant mothers are reverting to the use of traditional birth attendants who are ill-equipped should the delivery result in a complication. It is ironic that a measure meant to save lives - curfew - would cause children’s deaths.

Makueni County Reproductive Health Coordinator Christine Muindi told HealthyNation that apart from the danger that the mothers could die at home due to - among many other complications - excessive bleeding, they could miss out on vaccinations.

Thankfully, Muindi said at least six infants born at home last week were presented to hospitals for registration and immunisation.

Even before the Covid-19 outbreak, the country’s referral system for pregnant mothers was flawed and protracted. In the counties, the Department of Health requires patients seeking ambulance services at night to find their way to a chief’s office, hospital or police station near their homes. The patient is then picked by the ambulance she or the family has hailed. That is why boda boda riders have become a life-saver for expectant women, but now they cannot move about at night for fear of the police.

This explains the high maternal and neonatal mortalities in Kenya. The Kenya Demographic Health Surveys show that the maternal mortality has improved tremendously from 488 deaths per 100,000 live births to 342 deaths per 100,000 live births.

The neonatal period - children aged under one month - contributes nearly 45 per cent of the deaths of children under five. Kenya’s child mortality rate currently stands at 22 deaths per 1,000 live births, and the neonates number has experienced the least drop among children.

According to data from the health department, Makueni County lost 15 mothers to maternal deaths in the whole of 2019. “Now, we have lost four mothers in just one week,” said Health Executive Andrew Mulwa. One other mother died after giving birth at home, but HealthyNation could not establish if she had trouble getting to hospital.

The Covid-19 pandemic has impacted women’s reproductive health services negatively and this has caught the attention of global health agencies. In Kenya, the pandemic has interrupted the supply of contraceptives, contraceptive counselling, testing and treatment for sexually transmitted infections.

FAMILY PLANNING

Dr Natalia Kanem, the executive director of the UN Population Fund (UNFPA), warned that the Covid-19 outbreak had “severely disrupted” access to sexual and reproductive health services.

Dr Kanem identified pregnant women as at risk. “They need antenatal care, but are unsure whether to attend a clinic, and women in abusive relationships are trapped at home during the lockdown,” she said.

This is already evident in Kisumu County. Nailantei Kileku, the chairperson of the National Nurses Association of Kenya, said they had observed a reduction in the number of women visiting post-delivery family planning clinics in Kisumu and other counties.

Vaccination, a tested and tried public health intervention that has saved the lives of millions of children, has also been interrupted. Henrietta Fore, the executive director of Unicef, posted a statement on the organisation’s website saying: “As the pandemic progresses, critical life-saving services, including immunisation, will likely be disrupted, especially in Africa, Asia and the Middle East where they are sorely needed.”

Due to the pandemic, access to healthcare for women and children has become even more difficult because of external issues such as the curfew. Also, as the health system is strained, resources meant to serve women and children have been reallocated to Covid-19, interrupting services such as immunisation.

To make matters worse, the body that supports vaccination programmes in Kenya and the rest of the world –Global Polio Eradication Initiative (GPEI) — has suspended polio vaccination campaigns. It has diverted resources to “prioritise support for the response to Covid-19”.

The vaccination campaigns will stop until June 1, after which the decision would be reviewed.

A statement posted on its website after a March 24 board meeting read: “GPEI assets, which include technical expertise, surveillance and community networks, and logistics should be made available to support the global response to Covid-19 for the next four to six months.”

Poliomyelitis, a highly infectious disease caused by a virus which invades the nervous system and can cause total paralysis in a matter of hours, mainly affects children under the age of five. One in 200 infections leads to irreversible paralysis and among those paralysed, five to 10 per cent die when their breathing muscles become immobilised.

The World Health Organization (WHO) reports that cases caused by wild poliovirus have decreased by over 99 per cent in the last 30 years from an estimated 350,000 cases to 33 in 2018.

NON-COMMUNICABLE DISEASES

According to the WHO, children are considered to have received all basic vaccines when they have been vaccinated against the following: tuberculosis also known as BCG, three doses each of the DPT-HepB-Hib which is also called pentavalent, polio vaccines and measles.

Experts are also raising concerns that Kenya is at risk of additional outbreaks of vaccine-derived polio virus, which arises when the live virus used in the Oral polio vaccine mutates and regains its ability to paralyse and spread.
Fredros Okumu, a Kenyan public health expert, told HealthyNation decisions such as suspension of vaccinations will have an impact that will be felt long after the pandemic is over.

“We are diverting resources not only from polio, but the same is also likely to affect public health measures in other diseases such as malaria, HIV and non-communicable diseases like cancers. We will feel it (the effects) much later,” said Dr Okumu, who is also the director for health at Ifakara Health Institute in Tanzania.

Even without the interruptions, Kenya’s performance in vaccination was hardly stellar. The 2018 Economic Survey shows vaccination coverage in 2017 dropped by six percentage points from 69 per cent in 2016 and 76 per cent in 2013. The 63 per cent is the lowest coverage since 2005 when it stood at the same level before rising until 2012.

The survey shows half of the children below one year in eight counties did not receive the compulsory vaccination up from one - Mandera that has since 2014 had the worst immunisation record among the 47 regions. Tana River, Wajir, Mandera, Isiolo, Samburu, Narok, Trans Nzoia and West Pokot are the counties where more than half of one-year-olds were not vaccinated.

As services reduce in hospitals to create room and free up more healthcare workers for Covid-19 patients, the Ministry of Health has issued guidelines to ensure services are rendered to children.

Government and private hospitals will continue with routine immunisation services countrywide during the Covid-19 outbreak and will use the smaller, less crowded levels 2 and 3 facilities for this function. This is according to the guidelines released to hospitals to guide paediatric care.

The statement reads: “A fully vaccinated child is more likely to be protected from vaccine preventable diseases and possible complications of Covid-19.”

The guidelines also ban visitors from the newborn unit, where there are children under one month old. While routine paediatric outpatient clinics have been postponed, parents of children with chronic illnesses will get their refills for medication.

“Where possible, a designated caregiver should refill the prescription of the child without going with them to the health facility,” the guidelines instruct.

It also commands hospitals to communicate any emergency measures they have taken against Covid-19. In counties such as Kisumu, the health department has instructed the network of community health volunteers to know each expectant mother in the units they are assigned to.

Health associations have also stepped in to assist counties in improving their response to expectant mothers. Together with the counties, the nurses association has tasked chiefs to be on call to help women in labour to get to the hospital.

“In case of labour pains and you feel like the hour has come, inform your area CHW (community health worker) and the area chief or assistant chief through a call,” said Ms Kileku.

Security forces have also been incorporated into the plan. Josephine Ouko, the Kisumu East deputy county commissioner, has instructed chiefs to inform the authorities of expectant women in their areas who may need to seek care within the curfew hours.

Even before the Covid-19 outbreak, the country’s referral system for pregnant mothers was flawed and protracted.

In the counties, the Department of Health requires patients seeking ambulance services at night to find their way to a chief’s office, hospital or police station near their homes. The patient is then picked by the ambulance she or the family has hailed. That is why boda boda riders have become a life-saver for expectant women, but now they cannot move about at night for fear of the police.

JOINT EFFORTS

As services reduce in hospitals to create room and free up more healthcare workers for Covid-19 patients, the Ministry of Health has issued guidelines to ensure services are rendered to children.

Government and private hospitals will continue with routine immunisation services countrywide during the Covid-19 outbreak and will use the smaller, less crowded levels 2 and 3 facilities for this function. This is according to the guidelines released to hospitals to guide paediatric care.

The statement reads: “A fully vaccinated child is more likely to be protected from vaccine preventable diseases and possible complications of Covid-19.”

The guidelines also ban visitors from the newborn unit, where there are children under one month old. While routine paediatric outpatient clinics have been postponed, parents of children with chronic illnesses will get their refills for medication.

“Where possible, a designated caregiver should refill the prescription of the child without going with them to the health facility,” the guidelines instruct.

It also commands hospitals to communicate any emergency measures they have taken against Covid-19. In counties such as Kisumu, the health department has instructed the network of community health volunteers to know each expectant mother in the units they are assigned to.

Health associations have also stepped in to assist counties in improving their response to expectant mothers. Together with the counties, the nurses association has tasked chiefs to be on call to help women in labour to get to the hospital.

“In case of labour pains and you feel like the hour has come, inform your area CHW (community health worker) and the area chief or assistant chief through a call,” said Ms Kileku.

Security forces have also been incorporated into the plan. Josephine Ouko, the Kisumu East deputy county commissioner, has instructed chiefs to inform the authorities of expectant women in their areas who may need to seek care within the curfew hours.

Even before the Covid-19 outbreak, the country’s referral system for pregnant mothers was flawed and protracted.

In the counties, the Department of Health requires patients seeking ambulance services at night to find their way to a chief’s office, hospital or police station near their homes. The patient is then picked by the ambulance she or the family has hailed. That is why boda boda riders have become a life-saver for expectant women, but now they cannot move about at night for fear of the police.

Reported by Verah Okeyo, Nasibo Kabale, Pius Maundu and Rushdie Oudia