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Learning from tragedy in a ‘no blame’ environment

How maternal and perinatal death reviews are improving the quality of maternity care in Kisumu County, Kenya

Taking a pregnant woman‘s vital signs upon admission to maternity ward

More than 7000 women die every year in Kenya during pregnancy, delivery or shortly after giving birth. With German support, the county health department in Kisumu now conducts a detailed audit of every maternal and perinatal death to find out what went wrong and how to prevent it from happening again.

As a result of the devolution of powers in Kenya brought about by the adoption of the 2010 Constitution, the governments of the country’s 47 counties are responsible for realising the vision of equitable and affordable health care guaranteed to all Kenyans. In Kisumu County, in the west of the country, this has meant tackling the large burden of maternal deaths.

In 2014 Kisumu was identified by the Kenyan government and the United Nations Population Fund as one of 15 counties in Kenya with a maternal death rate above the national average. At that time well over 200 women per year were dying before, during or after delivery at health centers and hospitals across the county. Many of these deaths could have been prevented if the danger signs had been caught earlier, if critical cases had been referred in time, and if communication and collaboration between the different facilities, departments and staff members involved in managing the women’s cases had functioned more smoothly.

County authorities tackle problems head on

Over the past three years, leaders at the County Health Department have made saving mothers’ lives one of their top priorities. Following national guidelines from the Ministry of Health, and with technical support from the Health Sector Programme implemented by GIZ on behalf of the Federal Ministry for Economic Cooperation and Development (BMZ), the Department has begun systematically reviewing the details of each and every maternal death to understand what went wrong - and then introducing changes to address the underlying causes. With its strong commitment to carrying out these ‘maternal death reviews’ at the community, facility and county level, the County Health Department is leading the way to more accountable and better quality health services for the people of Kisumu.

Monthly meetings lay the basis for improved communication, teamwork and trust

Dr Rosemary Obara, Kisumu County Minister of Health

For Dr Rosemary Obara, Kisumu’s Minister of Health, the rationale behind maternal and perinatal death reviews is simple: to be able do something about maternal mortality, it’s necessary to understand the root causes. Where did systems fail? What was going wrong, where and why?
The key to figuring this out is regular communication and teamwork. Although the national guidelines suggest holding county-level maternal and perinatal death reviews on a quarterly basis, Kisumu County holds them monthly. Dr Obara and Dr Dickens Onyango, the County Director of Health, attend every meeting.

Each maternal or perinatal death which occurred in the previous month is briefly presented by a member of staff from the facility and jointly discussed. The death reviews are not about assigning blame: on the contrary, one of the core principles of the review process is to maintain a ‘no blame’ environment so that lessons can be learned from mistakes which may have been made. Each meeting ends with an action plan for follow-up.

‘The death review meetings are the place where we discuss the deaths of mothers and what we can do about them,’ Obara explains. ‘Everyone involved in these meetings is focused on one thing: coming up with a plan to improve the way we deliver maternal care.’


Important changes in the delivery of maternity services

Meetings to review maternal deaths aren’t only held at county level, but also within the health facilities where the deaths occur. Each time a mother dies during or soon after a delivery, staff convene a review meeting to go through all the details of the woman’s clinical history and her pathway through the health facility from the moment she arrived.

‘The review meetings have helped us recognise that tackling these deaths must be a team effort’ explains Dr. Juliana Otieno, CEO of Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH). ‘We have seen that the reasons can be related to medical oversights, but also to transport or to maintenance issues. So we make sure that all these departments attend the reviews so that we can learn and find solutions together.’

Many changes have been introduced at JOOTRH as a result of the review meetings. Now, pregnant women who come to the hospital to deliver are registered without delay and examined to determine whether a normal delivery can be expected. If a woman appears to require special medical attention, a clinician is notified immediately. Women are now monitored more frequently throughout their stay at the hospital. This approach is bearing fruit: The number of maternal deaths has gone down markedly over the past three years.

‘When we reported zero maternal deaths at the county review meetings, our colleagues rewarded us with standing ovations - and this is making us proud,’ says the midwife at JOOTRH who coordinates maternal death reviews.


Tackling challenges as a team

Nurses at Kisumu County Hospital

At Kisumu County Hospital (KCH), the staff is equally enthusiastic about the county government’s determination to reduce maternal deaths. ‘In the past staff were afraid to come forward and discuss mistakes because they feared that they would be punished‘, says the Nursing Director. ‘But with the no-blame approach, this has changed. We look at the problems together and we come up with improvements.”

One such improvement is a bell that has been installed in the maternity ward. When a patient is in a critical condition, it starts ringing and all the available staff come running to help out and avert a possible death. Doctors, clinical officers and nurse-midwives now work as a team when it comes to ensuring that mothers deliver safely. As a result, KCH has been able to considerably reduce the number of mothers who die during or after deliveries.

Engaging the community in the reduction of maternal deaths

The challenge of preventing maternal deaths does not end with the hospitals, because many of the underlying factors have their roots outside the walls of the facility. In the future, Dr Rosemary Obara, the Minister of Health, wants to involve community health workers more deeply in the prevention of maternal and neonatal deaths. This means ensuring that pregnant women attend regular antenatal check-ups, know the danger signs of pregnancy-related complications, and go to the facilities to deliver.

‘We have shown that the commitment of our leaders and our hospitals can make a real difference when it comes to making pregnancies and deliveries safer‘, says Dr. Obara. ‘Now it is time to take our efforts further, so that we can bring better services right down to the community level. In the end that is what devolution is all about.’


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