Impact of free maternity health services on quality of care offered to women presenting with late obstetric haemorrhage at Kenyatta National Hospital

Abstract

Study title: Impact of free maternity health services on quality of care to women presenting with late obstetric haemorrhage at Kenyatta National Hospital. Background: Obstetric hemorrhage is the leading cause of pregnancy – related mortality worldwide and is considered to be the most preventable cause of maternal mortality. Skilled care averts majority of maternal/fetal morbidities and mortalities that may occur due to unskilled care. Free maternity services in Kenya was a step to increasing SBA utilization. With the free maternal care policy in play, it is cited that the burden on facility resources and health professionals increases without adequate increases in compensation and/or staffing which threatens quality of medical services and outcomes. Increased staff load and problems in handling patient load clearly indicate that emergency obstetric care will be suboptimal. For patients with obstetric haemorrhage, delayed care or poor monitoring arising from the overburdened resources is catastrophic. Improved quality of medical care is the most important factor for the prevention of mortality due to obstetric hemorrhage and therefore there is need to improve the capacity of the facilities to provide quality services to mothers especially in the Sub-Saharan Africa where majority of maternal mortality occurs. Objective: To compare the quality of care offered to women presenting with late obstetric hemorrhage at Kenyatta National Hospital one year after and one year before the free maternity care policy in Kenya. Methodology: Study design: This was a quasi-experimental study of the pre-post design in which treatment group of women (174 women presenting with late obstetric haemorrhage one year after introduction of free maternity care policy) were compared with control group (174 women presenting with late obstetric haemorrhage one year before introduction of free maternity care policy) for quality of care at Kenyatta National Hospital. Setting: Kenyatta National Hospital labour ward unit. Study population :Women presenting with late obstetric hemorrhage seeking care at the Kenyatta National Hospital labour ward unit for the periods(June 1st 2011 to May 31st 2012) and (June 1st 2014 to May 31st 2015). Sample size :174 for each group. Data Collection Instruments: Structured mainly pre-coded questionnaires. Data analysis : The data was analyzed using SPSS version 18. Basic frequencies were run and data scrutinized for cleaning and identification of outliers. Grouped data analysis was done in accordance to the pre- and post- intervention measures for structure, process and outcomes. Comparisons were based on differences btw structure, process and outcome indicators for the periods before and after. Appropriate tests of significance were applied (Chi-square), and a p value of <0.05 was considered statistically significant. Logistical regression analysis was used to determine the relative significance of the factors identified. Results: A percentage availability score showed no major changes in resource availability and staffing during the two periods. There was a significant change in the xiv admission status of maternity clients (p = 0.006), referred patients increased from 42 (24.1%) to 81 (46.6%) while there was reductions in clinical attendants at the facility (19.5 to 9.8%) and attendees with an unrecorded admission status (41.1 to 30%).There were significant improvements in documenting patient severity classification (p = 0.019), expected date of delivery (p = 0.038) and ANC decision on mode of delivery (p < 0.001). Blood pressure measurement improved from 69 versus 90.8% (p < 0.001), pulse rate (60.9-88.5%, p < 0.001), respiratory rate (44.7 to 81%, p < 0.001), temperature (5.7 to 27%, p < 0.001). Decline in performance following the intervention were fundal height reporting that declined by 49% (OR 0.51, 95% CI 0.30-0.87), recording of admission character of FHR (OR 0.39, 0.25-0.60), speculum/ VE findings (OR 0.61, 0.39-0.97), and results of PMTCT or PITC HIV testing (OR 0.50, 0.32-0.79). The prevalence of uterine rupture OR 1.72(1.07-2.77) and PPH OR 11.93(1.49-95.88) as causes of obstetrical hemorrhage increased significantly .To achieve hemostasis, uterotonic use as the primary mechanism increased (8 to 38.5%, p < 0.001), as did uterine repair (4 to 10.3%, p = 0.027). The CS rate increased from 43.1% to 48.3% OR 1.23(0.81-1.88), p = 0.333. Use of general anesthesia declined (30.5 to 21.3%) while use of spinal anesthesia increased (14.9 to 28.7%). The median duration between decision to conduct CS and delivery was 70 minutes in 2011/12 and this duration increased to 110 minutes in the post intervention period (p = 0.05). The complication rates following CS increased significantly from 3 (1.7%) to 15 (8.6%), p = 0.009. Documentation of outcome of care improved in the following areas: delivery data (60.3 to 73%, p = 0.013), delivery time (60.9 to 71.8, p = 0.032), reporting of duration of 2nd stage (58 to 74.1%, p = 0.009), newborn outcome reporting (58 to 74.1%, p < 0.001), mode of delivery (60.3 to 79.9%, p = 0.002), APGAR and weight documentation. Declines were noted in documenting NBU outcomes (10.3 to 6.3%, p = 0.03). Conclusion: Quality of care declined with the introduction of free maternity services in Kenya. It is noted that the structure measures remained constant with increased patient loads. The processes of care were affected directly resulting in increases in PPH , uterine rupture and post caesarian section complications. While free maternity services was a strategy by the government to improve both fetal and maternal outcomes, absence of significant changes on patient outcomes following the intervention is a setback to the initiative. If free maternity care is to be effective in improving health, quality issues must be addressed.. Recommendations: There is need to increase the staffing numbers and essential resources in proportion to patient numbers. KNH should be set aside as a referral facility to handle patients needing tertiary care while patients requiring primary care to be managed in primary care facilities. Quality assurance programmes to be put in place to constantly monitor performance. A standard admission care continuity form to be derived for late obstetric haemorrhage. Late obstetric haemorrhage champions could be identified amongst HCW to advocate for good practice in management. Continuous medical education to keep all staff up to date with current management protocols for emergency obstetric care. Protocols for shock and APH should be displayed in KNH labour ward unit to constantly serve as a reminder for good practice