Why Kenya has failed to reduce newborn deaths

“He is going to be the last baby,” Teresia Ngendo, says as she walks out of the newborn unit at the Kenyatta National Hospital.

She has been at the facility for five days. Every three hours, she dutifully walks to the ward to feed her son as advised by the nurses.

In the incubator, the little boy’s beating heart and clenched fist speaks volumes of his continuing battle through what medical experts who take care of him and other children in this age bracket— zero to 28 days — consider “the valley of death”. Rachel Musoke, a professor of neonatal health at the University of Nairobi’s paediatric department explains just a few of the reasons why Ndung’u, who was born two months early, cannot survive out of that little box.

CAN'T REGULATE THEIR OWN BODY TEMPERATURE

“At that stage they cannot regulate their own body temperature, so they lose all the water through the skin and die of dehydration; they cannot eat so food has to be give through a pipe; they pick diseases very fast,” she explains.

Babies like Ndung’u also “forget to breathe” because their brains are not fully developed to co-ordinate these functions. They turn blue, start foaming and a nurse has to be there at that very moment to “remind him to breathe.”

“They are stimulated by touching, and sometimes resuscitated if they do not remember to breathe,”explains Prof Musoke.

Next to Ndung’u, are others who were brought here after falling victim to a health system that does not respond to their vulnerability.

They swallowed meconium, their own poisonous poop that gets into their lungs, during prolonged labour or if their mothers got to hospital late. The process of removing that green substance is very painful.

Another already endured dialysis after being brought to the hospital severally dehydrated.

BRAIN DAMAGE

Some will come out of this room alive, but because of the manhandling their mothers faced, they will have brain damage and will depend on others to move and eat for the rest of their lives.

Therefore, this electric cot cannot malfunction even for a second. It keeps the temperature and humidity within survival range. The hospital cannot run out of the intravenous fluids that feeds Ndung’u or he will starve to death.

Teresia does not know these medical complexities around her son but she feels it, and in the middle of the conversation, she gets emotional.

“He is so tiny,” she sniffs. “Ako poa kabisa, lakini ni kadogo haki... kadooogo” (He is okay, but he is tiny…really tiny.”)

Ndung’u is responding well to treatment, at least that is what the nurses said. So what is wrong? As tears well up in her eyes, she talks about a woman with whom they shared meals in the ward GFA where they would wait as they visited their children in the newborn unit.

This friend lost her child the day before Teresia talked to HealthyNation. She wonders whether her boy will die as well.

Between January and July 2018, 1,758 children were wheeled into this very newborn unit at the Kenyatta National Hospital, but 594 did not get out alive; this is nearly 34 per cent of the babies brought in here.

Nairobi county leads in this period with 1,475 deaths, followed by Kiambu (663), Uasin Gishu (631), Nakuru (580) and Mombasa (556) in terms of absolute deaths.

The number of stillbirths in each county is almost the same range as infant deaths.

The newborn unit which houses children aged between one and 28 days— called neonates— occupies the largest portion of the paediatric department at KNH.

UP TO FOUR SHARE A COT

Despite the fragile medical condition of babies in the neonatal ward, up to four of them share a cot.

 According to data seen by HealthyNation, the ward had a bed occupancy of up to 210 per cent between January to July 2018. As the world celebrated the World Prematurity Day last month (November 17), the ward meant to house 60 babies had up to 180 children, increasing the risk of cross infection threefold. Now the facility is struggling to tame the deaths in the newborn unit.

The nurses working in the department said they would not be losing as many babies had the it been one baby per cot.

While the official statistics released by the hospital’s management indicate a 34 per cent death rate, more than 13 nurses in the paediatric department that HealthyNation talked to in anonymity as they are not authorised to speak to journalists, report up to 50 per cent death rate on some days.

In the conversations, in different places, a common story is narrated of a foreign doctor on an exchange programme, who was appalled by the number of deaths.

In 2016, HealthyNation’s in-depth analysis had attributed the mortality in this ward and the entire maternity wing to improper referral system from the neighbouring counties.

Being a referral facility, the hospital receives the most complex cases in the nine-month pregnancy continuum.

Patients “would be shipped like cargo, not taking medical precaution to preserve their lives before they got here”, then head of gynaecology Dr John Ong’ech had said.

To date, the referral system is still contributing to many deaths of mothers — Nairobi, Kiambu, Machakos and Kajiado lead in referrals to KNH — but now nurses are adding another reason for the death of children: hygiene in the hospital.

They say that there are moments they have run out of sanitisers, and are forced to purchase their own as they wait for the hospital to replenish stocks.

Infection control has become increasingly difficult with all the mothers trooping in the ward during feeding time with the many babies.

Between 1990 to 2009, 79 million neonates died globally, according to data from United Nations body dealing with children’s issues UNICEF. 98 per cent of these deaths occurred in low-income countries such as Kenya.

NEONATAL MORTALITY

Between November 2017 and October this year, according to data drawn from the country’s health information system, Kenya lost about 10,241 newborns in this period.

According to the 2014 Kenya Demographic Health Survey, neonatal mortality is at 22 deaths per every 1,000 live births.

This has exhibited the slowest rate of decline of 33 per cent, as compared to deaths in children under the age of one and five. Nairobi’s mortality is nearly double the national number at 39 neonates dying per 1,000 live births.

Scientists are not apathetic of the difficulties that baby Ndung’u and others face in trying to survive that first month of their life.

In 2016 a detailed report— Kenya Reproductive Maternal Newborn Child and Adolescent Health (RMNCAH) Investment Framework — analysed why neonatal mortality is high and contributes 10 per cent of the total number of children who die before their fifth birthday.

The World Health’s Organisation judges that any primary healthcare facility should offer some basic services: antibiotics, magnesium sulphate to manage high blood pressure during pregnancy and bleeding, placenta removal and be assistance during birth. Comprehensive care should include Caesarean sections.

Using this guideline, only a quarter of all the health facilities had the essential tools to deliver babies such as a stethoscope, sterilising equipment, medication like Oxytocin to stop bleeding and the required healthcare workers for neonates.

Teresia had been attending clinics in Kikuyu in Kiambu County, but when she experienced labour earlier, the hospital referred her to Kenyatta as they could not operate on her.

Hospitals often lack midwives, proper delivery rooms as well as the special bags for breathing oxygen into the child.

The report estimated that a Sh34 billion investment would be needed for hospitals in the 20 most affected counties to take care of mothers like Teresia, for infrastructure upgrade, hiring more nurses and for supplies between 2015 and 2020.

The monies would also be needed for healthcare workers’ salaries and training.

This investment would reduce neonatal mortality from 20 per 1,000 live births to 17.

The Ministry of Health had not responded to inquiries from HealthyNation about how much of this investment has been spent by the time we of going to press.

Irene Inwani, the head of KNH’s paediatric department decried the few nurses at the neonatal department.

Kenya is already operating below par in nursing care: The World Health Organisation recommends 25 nurses per 10,000 people.

The Kenya Workforce Health Report notes that there are 31,896 active nurses, which translates to 8.3 per 10,000 people.

ONE NURSE, 30 BABIES

For children in intensive care, there ought to be one nurse monitoring one child due to the labour required, while the other children who are not critically ill or who do not need assistance to breathe require a nurse for every four children.

At KNH, sometimes it is one nurse per 30 babies. The children in the ward suffer from birth asphyxia, a medical condition resulting from deprivation of oxygen to a newborn that lasts long enough during the birth process to cause physical harm, usually to the brain.

The nurses’ duty often reads like a constitution: check the babies’ vitals such as respiratory rate and temperature every few minutes; administer intravenous and intramuscular injections; ensure that the temperatures at all 12 incubators are at 31 degrees; feed the babies; document every little activity and nursing care given to each baby.

Also, when the mothers come after three hours, monitor how they are expressing breastmilk and feeding the baby through the nasogastric tube. This is very necessary and missing a step can be fatal.

The milk is sucked by a syringe, then injected into the tube in drops and waits on gravity to take it down the baby’s throat. Some mothers, especially the young ones, get tired and force the liquid down the tube to speed up feeding.

The baby chokes and if a nurse is not around, it dies.

A study by KEMRI Wellcome Trust indicated that in most hospitals in Kenya, nurses are not only overworked but they take up jobs belonging to other specialists and ones they are ill-equipped to handle such as the roles of nutritionists and clinicians.

This study also found out that in 20 per cent of the time, nurses overprescribed the antibiotic Gentamicin which is toxic to the baby’s kidneys.

The hospital has now embraced Kangaroo mother care, a skin-to-skin childcare method where the baby relies on the warmth from its mother’s chest as a measure to fill the gap of few incubators, in a bid to reduce newborn deaths.

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Report: Newborns dying for lack of specialised care

by Angela Oketch

[email protected]

Nearly 30 million sick and premature newborns are in dire need of treatment every year, and many die from not receiving specialised care, says a new report by the World Health Organisation and UNICEF.

In 2017, some 2.5 million new-borns died, mostly from preventable causes. Almost two-thirds of babies who died were born prematurely. In addition, even if they survive, these babies face chronic diseases or developmental delays. In addition, an estimated one million small and sick newborns survive with long-term disability.

“When it comes to babies and their mothers, the right care at the right time in the right place can make all the difference,” said Omar Abdi, UNICEF Deputy Executive Director.

The report found that newborns with complications from prematurity, brain injury during childbirth, severe bacterial infection or jaundice are most at risk.

The report revealed that the financial and psychological toll on families has had detrimental effects on their cognitive, linguistic and emotional development of the foetus in the womb.

“For every mother and baby, a healthy start from pregnancy through childbirth and the first months after birth is essential,” said Dr Soumya Swaminathan Deputy Director General for Programmes at WHO.

“Universal health coverage can ensure that everyone, including newborns, has access to the health services they need, without facing financial hardship. Progress on newborn healthcare is a win-win situation. It saves lives and is critical for early child development thus impacting on families, society, and future generations,” he added.

Last week, Kenya launched Universal Health Coverage, that will offer free pre-natal and post-natal care.

Most hospitals in the country have also developed and set aside rooms for Kangaroo Mother Care for the babies born prematurely.

Without specialised treatment, many at-risk newborns will not survive their first month of life, according to the report.

“With nurturing care, these babies can live without major complications,” said Dr Swaminathan.

To save newborns, the report recommends hospitals provide round the clock inpatient care for newborns seven days a week rather than discharging them two days after delivery. It also recommends training nurses to provide hands-on care in partnership with families while counting and tracking every small and sick newborn and monitoring their progress and improving results.

ALLOCATE RESOURCES

Countries have also been called upon to allocate the necessary resources, as an additional investment of Sh20 per person can save two of every three newborns in low- and middle-income countries by 2030.

“Harnessing the power of parents and families by teaching them how to become expert caregivers and care for their babies, can reduce stress, help babies gain weight and allow their brains to develop properly,” says the report.

The report shows that by 2030, in 81 countries, the lives of 2.9 million women, stillborn and newborns can be saved with smarter strategies. In addition, almost 68 per cent of newborn deaths could be averted.

The report revealed that simple fixes such as exclusive breastfeeding; skin-to-skin contact; medicines and essential equipment; and access to clean, well-equipped health facilities staffed by skilled health workers can reduce newborn deaths.

“Other measures like resuscitating a baby who cannot breathe properly, giving the mother an injection to prevent bleeding, or delaying the cutting of the umbilical cord could also save millions,” said Dr Abdi.

According to the report, the world will not achieve the global target of health for all unless it transforms care for every newborn. Without rapid progress, some countries will not meet this target for another 11 decades.

“Almost three decades ago, the Convention on the Rights of the Child guaranteed every newborn the right to the highest standard of health care, and it is time for countries around the world to make sure the legislative, medical, human and financial resources are in place to turn that right into a reality for every child, the report says.