The Kenya Obstetrical and Gynecological Society (KOGS) recently held a sensitization forum to discuss the Every Second Matters (ESM)- Uterine Balloon Tamponade (UBT) and ESM-Ketamine innovation in Kisumu, Kenya. The African Institute for Health Transformation (AIHT) team in collaboration with the head of Reproductive and Maternal Health service Unite (RMHSU) Dr. Joel Gondi brought together 16 members of KOGS drawn from Kisumu, Bungoma, Kakamega, Garissa, Turkana, Homa Bay, Vihiga, Busia and Migori Counties. One main objective of the forum was to to discuss the best strategies to accelerate rollout, data collection, reporting, uptake, and scale-up of both the Uterine Balloon Tamponade and Ketamine innovations. The forum also focused on sensitizing KOGS members on maternal health lifesaving innovations.
The forum began with introductions and welcoming remarks from Dr. Onyango, the Chairperson of KOGs Western Chapter, and followed with the first presentation by Dr. Joel Gondi. Dr. Gondi commended Obstetrician and Gynecologists for their efforts in making a difference in maternal and reproductive health service provision. He emphasized how to implement locally generated evidence based innovative techniques that offer local solutions to maternal and adolescent reproductive health challenges. He also emphasized the need for quality of care to be improved, and he acknowledged it is at the heart of all the best practices they are expected to implement. Dr. Gondi highlighted critical observation is where quality of care is compromised not as a result of scientific, but rather administrative systems failure especially where there is staff shortage or delay in offering services.
Dr Gondi also wanted to know how far KOGS has been articulating and propagating some of the best practices such as UBT and Ketamine innovations in their practice. He emphasized the need for KOGS to shape direction of Maternal Health policies in Kenya. He invited KOGS to participate in the review of the Reproductive Health Policy that is ongoing, and he mentioned that this review would attempt to interpret and meet the constitutional requirement that Kenyan Citizens have a right to the highest standard of Reproductive Health in a devolved system of governance.
Dr. Gondi concluded by highlighting resources and partnerships KOGS could use, provided by the Ministry of Health (MOH), in rolling out and scaling up the two Maternal Health Innovations. Dr. Gondi stated, “So long as the two innovations are recognized by the National Steering Committees and the Technical Working Groups (TWGS), and Science supports the innovation, the MOH will support the scale up”. He mentioned this could have been achieved earlier in the year, but unfortunately the industrial actions and the political climate have not been conducive enough. This however, he said was in the pipeline for execution in the next quarter where the MOH will make and implement supportive legislation, policy, and guidelines on Maternal Health Best Practices in Kenya.
Dr. Kereki, KOGS President Representative, also made a keynote address at the forum, and during his keynote address, Dr. Kereki gave the audience some startling statistics on maternal health.
Some of the startling statistics Dr. Kereki shared;
- Every month more than 20 women die at childbirth.
- According to confidential reports, 857 mothers died in the 1st half of 2017 as compared to 142 mothers during the same period in 2016.
- Only 10% of maternal deaths are reported. What happens to the 90% unreported cases? For instance DHIS reported 962 deaths in 2016.
- Over 50% of Public Health Facilities remained closed over the strike period. Doctors went on strike for 100 days and nurses 150 days; this he observed set stage for a perfect “relay” where Kenyans were exposed to 250 days without medical services in the public facilities.
Dr Kereki continued to highlight some of the challenges reproductive health care face. He highlighted:
- Lack of prioritization of resources where Maternal Health Care is not prioritized
- Leakage of maternal health resources due to corruption and nepotism.
- Ineffectiveness of Free Maternity Care due to lack of resources to support the same and misappropriation of the meager resource allocation for the same.
- Inadequate, inappropriate, and erratic supplies.
- Lack of maternal services in communities where they are needed the most (adolescents and youth; nomadic and pastoralists; people with disability; street population; and populations in informal settlements in all our cities).
- Inadequate trained professionals to handle some very unique and specialized but necessary Reproductive and Maternal Health services.
Dr. Kereki proposed solutions to some of the challenges. He urged Active involvement of KOGS members in policy making using a phrase that, “You are either on the table or you are in the menu…where do you want to be?” Dr. Kereki also stated that most of the local problems have local solutions such as the UBT and Ketamine, an old drug that has been tried and tested locally, and the only question is on roll out, uptake, and scale up. Dr. Kereki emphasized so long as there is no missed opportunity and there is a call for agitation by KOGS that every life matters, then the local innovations can and will make a big impact on the negative maternal health indicators currently reported in Kenya.
Another keynote speaker at the forum was Professor Khama Rogo. Professor Rogo acknowledged that maternal and reproductive health problems are similar in Africa, but solutions can be developed and adopted locally to make a difference. “As professionals we are not any less guilty. In health the consequences of omission are not the same as the consequences of commission”, stated Prof Rogo.
Professor Rogo discussed the delays and inefficiencies at facility level giving a case scenario in Siaya County where a 14 year old succumbed to postpartum hemorrhage (PPH) due to provider delays at facility level, referral delay, and blood scarcity. He emphasized medicine is an apprenticeship, and young doctors need role models to mentor them. He noted that internship is the final stage of molding after which it would be difficult to churn out quality medical doctors into the health care industry. Prof Rogo mentioned that the role of Obstetrician Gynecologists is only second to the work of God. He stated, “When God leaves you, you are done, when the Obstetrician Gynecologist leaves you, you die”.
He continued to also discuss near misses. Near misses, he mentioned are “deaths” in the eyes of an African woman because the loss of a uterus would basically “kill” her womanhood and status in the society. He challenged Obstetrician Gynecologists to embrace their roles with courage and to know that they are dispatched to counties not because of perfections, but rather imperfections that they are expected to correct. “You must therefore leave that place better than how you found it!” he concluded.
According to Professor Rogo a lot of emphasis needs to be put on governance, health financing, equipment, infrastructure, pharmaceuticals, and essential drugs and human resource strengthening. All these he said can be achieved even at county levels as counties are now allowed to legislate at the County Assembly level with regards to what works for them best.
Professor Rogo also encouraged the KOGS team members to participate in evidence-based research and do as many publications as possible as it is the only way that local innovations can be acknowledged internationally.
He closed his remarks with a quote to the Obstetrician Gynecologists. “You don’t light a lump and hide it under the table. You guys are light; are you under the table or above the table? It is not the numbers that count, but the commitment to get it done. Do it now…you are the best, you are qualified and gifted!” he stated.
Monica Oguttu, KMET Executive Director and chairperson Kisumu Health Task Force Committee, and Dr. Solomon Orero presented the ESM-UBT and ESM-Ketamine innovation at the forum. During her ESM-UBT presentation, Monica Oguttu addressed the KOGS team in her capacity as KMET Executive Director and chairperson for Kisumu Health Task Force Committee. She mentioned that despite the gains made by many government interventions such as “Linda mama” and “beyond zero” initiatives by the first lady, maternal health indicators still remain negative. Kisumu alone has many OBS/GYNs but teamwork seems to be the missing link.
Her presentation captured the PPH situation in Kenya, recommended procedure for PPH management in AMSTL, provided statistics on PPH in Kenya, and highlighted the percentage contributions to PPH by each of the four T’s (trauma, tissue, tone, and thrombosis). The UBT innovation was then introduced, from sharing information to proof of concept stage, trainings conducted, endorsements obtained (including from KOGS), and finally lives saved to date. A video documentary was also shared showing the UBT technique and how it has impacted lives of many women in Garissa County.
During the ESM-Ketamine presentation Dr. Solomon Orero gave a history of ketamine use in Kenya, the rationale for use, dosage, and side effects. During the plenary discussion a number of OBS/GYNS testified to having successfully used ketamine to save lives in instances where there was no anesthetist or where patient referrals would cause delays in saving the patient’s life. A few other participants raised concerns about their job security, especially in the event that ketamine failed and a patient died. Dr. Orero reassured them that as long as proper documentation and procedures are adhered to as per the expected SOP’s they would not be victimized. “You have two options, you either do nothing and watch the patient dies, or you use ketamine and you get a chance to save the patient’s life” he stated.
With prior emphasis from Professor Rogo, Dr. Orero further emphasized that Ketamine is not being used as a replacement to general anesthesia, but rather recommended when conventional management levels have failed. Basic eligibility criteria such as a functional theatre in place, an MO, where there’s no anesthetist, and basic checklist requirements such as availability of oxygen in the theatre before ketamine use. An Obstetrician from Kisumu testified having used ketamine for all the surgeries they had in Kaplong for a couple of years with no adverse out comes. It was similarly observed by other obstetricians present that the safety level of Ketamine was better than spinal depending on the experience of the anaesthetist or anesthetist assistant.
The meeting concluded with action plans and next steps highlighted below:
Way forward/Next Steps:
- KOGS Western region to share a write up on maternal health gaps and the proposed solutions to be adopted.
- Kakamega OBS/GYN will hold a stakeholders’ forum where he will address the issue of ketamine use where there is no anaesthetist.
- KOGS have an important role to play during MPDRS and in county MNH TWGs.
- Vihiga County OBS/GYN promised to lobby his county to purchase ESM-UBT as an essential maternal health commodity.
- Turkana County OBS/GYN plan to hold a reconnaissance meeting with the Turkana CHMT to discuss gaps in ESM-UBT utilization and UBT commodity security.
- KOGS to document county specific maternal health situation during the Industrial strike period by health providers (Doctors and nurses)
- In the next quarter (January 2018-March 2018) MOH will make and implement supportive legislation, policy and guidelines on Maternal Health Best Practices in Kenya where the ESM-UBT will be discussed by the MNH TWG and MNH steering committee.
- Joint planning with obstetrician/gynecologists as team leaders to accelerate rollout of Ketamine and UBT in their respective counties
We would like to thank all our partners that made this forum possible. We would like to appreciate our partners AIHT, KOGS, MGH, RMHSU, and KMET for their continued mission to saving maternal health with lifesaving innovations.