Effect Of Free Maternity Services On Maternal Nearmiss Morbidity Among Women Delivering At Embu County Referral Hospital – A Quasi Experimental Study.

Abstract

Background: Healthcare cost is a major barrier to access of essential maternal services in the developing world. On 1st June 2013, Kenya introduced Free Maternity Services (FMS) in an effort to promote access and improve maternal outcomes. Subsequently, service utilization increased resulting in pressure on existing resources- a potential compromise to the quality of care offered. The World Health Organization (WHO) maternal near miss (MNM) tool was used to evaluate maternal outcomes under FMS in a county referral hospital in Kenya. Objective: The broad objective was to evaluate the effect of free maternity services on maternal near miss morbidity at Embu County Referral Hospital. The specific objectives were to; determine the incidence of maternal near miss, compare the causes of Potentially-Life Threatening conditions and Near Misses and lastly to compare the MNM indicators before and after FMS. Methods: Study design: Retrospective quasi experimental (pre-post type). Treatment group: Records of 186 women with near miss morbidity after introduction of FMS. Post-period was June 2014 to May 2016. Comparison group: Records of 185 women with near miss morbidity before introduction of FMS. Pre-period was October 2010 to May 2013. Setting: Embu county referral hospital in Eastern Kenya. Study population: Women offered maternity services at Embu county referral hospital between Oct 2010 to May 2016. Data collection and analysis: Data abstraction form was adopted from the WHO Maternal Near-Miss tool. Analysis used SPSS version 24. Pierson Chi-square test of statistical significance was applied (p value <0.05). Results: The incidence of MNM was 2.2% and 2.5% in the pre and post periods respectively. The commonest cause of maternal near miss in both study periods was severe postpartum hemorrhage (PPH) and severe preeclampsia. Severe PPH increased (91.0% vs 80.0% p-value 0.005), while that of severe preeclampsia reduced in the post-period (6.5% vs 13.0% p-value 0.029). Anemia was the biggest contributory cause of near misses but reduced in the post-period (30.1% vs 43.8% p-value 0.020). Use of blood products increased in the post-period (68.2% vs 78.5% p-value 0.000). Maternal near miss ratio, which is a measure of the amount of resources needed in a facility, increased in the in the post-period (from 22.7/1000 to 26.3 /1000 live births). The proportion of severe maternal outcomes within 12 hours of admission(SMO12) increased from 66% to 69% after FMS. Conclusion: Introduction of free maternity services had mixed effect on maternal near miss morbidity at Embu county referral hospital in Kenya. MNM cases due to severe preeclampsia and anemia reduced significantly while those due to severe PPH increased.The need for blood transfusion also increased, and this mirrored the increase seen in severe PPH. xii The MNM indicators in this study suggest that the first and second delays in access did not improve as expected after removal of the cost barrier. In addition, these indicators showed that the resources required to manage severe complications of childbirth were suboptimal in the facility. Recommendations: To optimize obstetric care under the free maternity services program in Kenya, there is need to develop strategies for prevention and management of severe PPH. Secondly, national blood transfusion services need to be strengthened in order to match the increased demand for blood.Audit of the existing resources is also essential in order to identify specific areas that need to be enhanced. Also, other barriers of hospital access should be evaluated in order to reduce first and second delays.