How Vihiga is combating post-childbirth bleeding deaths with low cost solution

It was a sharp pain, so sharp that 30-year-old Salome Achieng stopped, dropped the broom in her hand and touched her belly, to ensure her baby was still in it. That was in the evening.

At 10pm, the pain intensified and when she stepped down from her bed, she noticed the first clot of blood.

Alarmed, her husband rushed her to Vihiga County Referral Hospital.  She was writhing in pain as she was being driven from their home in Hamisi subcounty.

After examination at the health facility, the clinician advised that they induce labour and deliver her baby.

“I remember them telling me something about my placenta and that I needed to have the baby delivered immediately,” Achieng said.

Have the baby she did, but the pain returned and she was bleeding profusely. She started feeling lightheaded.

She may not have known it, but she was experiencing postpartum haemorrhage (PPH), the deadliest maternal complication in Kenya.

The World Health Organization defines PPH as a blood loss of 500ml or more within 24 hours after birth. 

In the 'Saving Mothers’ Lives 2017, Confidential Report into Maternal Deaths in Kenya', the Ministry of Health said PPH is responsible for two of five of all maternal deaths in Kenya.

Vihiga county’s reproductive health coordinator Veronica Musiga said PPH occurs because of many reasons on the part of the community and patient and some causes are in the health system.

“The mother may come late to the hospital when the bleeding starts or when they are in the hospital, there is a misdiagnosis of the PPH,” she said.

Musiga, who is also a nurse, said they used to lose up to 11 mothers a year at Vihiga County Referral Hospital.

Many more suffer from maternal near-miss, where a mother experiences complications that nearly take her life and even when they survive, result in long hospitalisation.

This year, Musiga said, the health facility has recorded only two mortalities. She attributed the improvement to a low-cost intervention called Emotive, which helped save Achieng’s life.

Emotive is a package meant to detect and manage postpartum haemorrhage, giving all the interventions at once as opposed to one after the other as was previously done.

Developed by the University of Birmingham, the bundle has a calibrated blood-collection drape that provides objective, accurate and early diagnosis of how much blood the mother has lost.

Kenya included the package as part of their response to PPH after the World Health Organization published a study that found the bundle led to a 60 per cent reduction in heavy bleeding for women experiencing PPH.

Musiga said before the diagnosis of PPH, they relied on clinicians experience in Vihiga.

“Sometimes the nurse would estimate that the blood lost is 300ml, when in reality it was more than 800ml because the mother started bleeding before coming to us, but with Emotive, we have not been missing the PPH,” she told the Star.

As she cradled her daughter, Achieng said the team in Vihiga hospital were supportive and "made sure that I knew that I was in good hands".

Isabella Atieno, a midwife and PPH expert at John Hopkins Affiliate, Jhpiego, said the drape placed under the bed offers accurate diagnosis.

She said Emotive provides the mother the WHO-recommended treatment, massaging the uterus, providing medicine that prevents excessive bleeding and intravenous fluids.

Atieno said, “Offering the treatment as a whole, rather than one after the other, results in dramatic improvements in outcomes for women and had been shown to reduce severe bleeding by as much as 60 per cent and they are less likely to die.”

As the hospital uses the Emotive package, the county has recorded reduced need for blood transfusions for pregnant women.

As of 2022, Vihiga’s maternal mortality rate was 393 deaths per 100,000 live births.

While there are other causes of death, the county has termed PPH as a public health challenge.

When women attend antenatal care, clinicians can detect the risks to PPH such as being anaemic.

Midwife-nurse Cynthia Muhambe said when a woman is anaemic, even the smallest blood loss can cause complications because she does not have sufficient blood anyway.

Cash-strapped and with few technical experts in the changes in maternal health, Vihiga has been courting partners to build the capacity of doctors, nurses and clinical officers looking after mothers.

USAID has supported the county to look after mothers such as Achieng.

The county has trained more than 70 healthcare providers on emergency care for mothers, through a project called Momentum Country and Global Leadership (MCGL).

The programme is also funding the county’s efforts to increase antenatal care.

Cynthia Muhambe, who is MCGL’s Vihiga technical specialist, stressed the importance of antenatal care:

“Antenatal care is robust in Kenya and healthcare providers can check haemoglobin levels early in pregnancy and provide treatment, potentially saving more lives,” she said.

Another project, the Emotive Trial from the University of Birmingham and Jhpiego, trained nurses like Susan Obilo on the use Emotive Package.

"Before Emotive, we relied on visual estimates or containers to gauge blood loss but after the training, we closely monitor the mother's condition, even when blood loss is not visibly apparent."

The nurse said together with others in the facility, they participated in a yearlong study and mentoring programme on the new technology.

To continue with the learning, the county built a skills lab, where other healthcare providers can train.

"The skills lab has dummies for practice, so we can continually remind ourselves of what we have learned," Obilo said.

 The county plans to scale up the Emotive intervention to more level 4 hospitals.

“We are equipping ourselves so we don’t have a mother with PPH,” Musiga said.

Vihiga’s main referral hospital handles approximately 350 deliveries each month, making the successful implementation of Emotive a critical factor in safeguarding the lives of mothers.