Many teens die in pregnancy or during childbirth: study - Daily Nation

Many teens die in pregnancy or during childbirth: study

Many teens die in pregnancy or during childbirth: study

Only a third of the under-20s attended an antenatal clinic atleast once

One in 11 expectant and new mothers who die in hospital are teenagers, reveals a new study.

Figures from the First Confidential Enquiry into Maternal Deaths in Kenya show that two-thirds of the teenagers who died were having their first child and a fifth were having their second pregnancy. Only a third of them had attended at least one antenatal clinic.

The study also found that most women who die in pregnancy or childbirth in hospital are in the most secure age for child birth. The median age of pregnant women and new mothers who die in hospital is 27 years.

The oldest woman assessed was 47 and the youngest 14 in the assessment that involved more than half of the deaths that were reported in the District Health Information System (DHIS) for the year 2014.

The study also found that most women who die in pregnancy or childbirth in hospital are in the most secure age for child birth. The median age of pregnant women and new mothers who die in hospital is 27 years.

The best age to have a baby is from 20-35 years, shows information from the Royal College of Obstetrics and Gynaecology.

“There is a major problem with teen pregnancies that needs to be addressed,” says the Head of the Division of Family Health, Dr Mohamed Sheikh. His concern is supported by figures from the latest Kenya Demographic and Health Survey that show that one in five teens aged between 15-19 are pregnant or mothers.

Four in five of the deaths in teenagers are due to direct causes and 12 per cent are due to indirect causes. The leading direct cause is obstetrical bleeding (haemorrhage).

The condition is the leading cause of maternal deaths for all women and it was a factor in the death of two in five women assessed. It is followed by hypertensive disorders associated with pregnancy (15 per cent) and pregnancy related infection (10 per cent).

Water broke

Among the 484 files (51 per cent) of 945 dead women who were assessed in the study was the record of a 20-year-old with nine-hour history of lower abdominal pains. Labour progressed on well and two and a half hours later, she broke her water and delivered a live baby boy in the normal manner. Having been diagnosed with excessive bleeding after birth (post-partum haemorrhage) she was given several doses of the relevant drugs but the bleeding persisted.

The medical doctor was called to review the patient and he found a severely pale patient with low blood pressure. She was bleeding from puncture sites and her blood was not clotting. Her blood group was O positive but there was none available at the hospital and other neighbouring health facilities.

The patient was prepared for transfer to a higher-level facility for urgent transfusion and Intensive Care Unit care. One hour later, the patient died while en-route to the referral facility.

The assessors concluded that the quality of care provided could have been better and this may have made a difference in the outcome. Although the correct treatment protocol for excessive bleeding was followed initially, no grouping and cross matching of blood was done to determine her blood type. When it was eventually grouped, there was no blood for transfusion. A diagnosis of massive obstetrical bleeding in a facility without active blood transfusion services should have triggered a referral.

Saved lives

The assessment that was done from June 2015-June 2016 reveals that nine out of 10 women who died of obstetrical bleeding had received substandard care and that a different management may have saved their lives. Delays in starting treatment, incorrect diagnosis, lack of adherence to treatment protocols are some of the associated factors with maternal deaths from obstetrical bleeding.

Women who die of obstetrical bleeding are generally referrals from level 4 and level 3 facilities. This points to the need of having level 4 hospitals fully functioning as comprehensive emergency obstetric care units, 24 hours a day seven days a week.

The enquiry recommends that such facilities should have midwives, medical doctors with the ability to perform caesarean section, anaesthesia and safe blood transfusion available.

Massive bleeding can lead to death within two hours, so swift care is important. Almost half of the deaths happened at the place of first admission, so early recognition of complication by women and their families, prompt visit to healthcare facilities and good quality care at healthcare facilities is likely to reduce the risk of death.

In another case, a 36-year-old woman who was past her due date and was a known hypertensive had a vaginal delivery to a macerated stillbirth (dead foetus that has undergone loss of skin, and distortion of the features during retention in the uterus). She was diagnosed with placenta praevia, which is a condition where the placenta partially or wholly blocks the neck of the uterus interfering with normal delivery of a baby, during her pregnancy. She developed excessive bleeding immediately after delivery. She was started on intravenous fluids, a uterine massage was done and she was promptly referred to a county referral hospital.

However, the ambulance took three hours to get to the health centre and another one hour to the destination. At the referral hospital it was noted that she had bled for five hours. Examination on admission showed a weak pulse, low blood pressure and she was bleeding from her vagina. Two large IV lines were fixed, blood transfusion commenced, she was given drugs to stop bleeding and induce labour. A uterine massage was also done but she was still bleeding. The doctor advised that a vagina and cervical examination be done and he be informed promptly of the results. The patient condition deteriorated while being transfused. Resuscitation attempts were unsuccessful.

The assessors found gaps in the care provided at the primary facility (lack of adherence to treatment protocol), delay in the availability of ambulance for referral was a key associated factor. At the referral hospital there was incorrect diagnosis (clots had formed throughout the body blocking small blood vessels), lack of review by senior clinician and lack of adherence to treatment protocol for blood clotting condition.

The assessors concluded that promptly addressing these gaps in the quality of care probably may have resulted in a different outcome.

More than a third (37 per cent) of maternal deaths happened within six weeks after birth (postpartum period). This is usually the period of least vigilance as the baby has been delivered and seemingly no apparent danger is possible. A fifth of the women died during the period from onset of labour to the third stage of labour or (intrapartum) while the period of death was not specified for 21 per cent of cases.

More than two-thirds of intrapartum deaths were delivered by caesarean sections and the same proportion of post-partum deaths delivered vaginally.

Three out of 10 mothers who died had stillbirths and one in 10 died undelivered.

Even though Kenya has made significant progress in reducing HIV infections one in five  maternal deaths were due to non obstetric complications mainly HIV/AIDS and anaemia.

Half of all maternal deaths were among women who had been referred from another facility, mostly from level 4 to level 5 or 6 health facilities.