Insights

In Kenya there has been a consistent challenge of high facility Maternal Mortality Ratio (MMR) that stands at 355/100,000 live births according to the 2019 Kenya National Bureau of Statistics (KNBS) national census. Narok county has some of the highest rates of maternal death in Kenya at 522/100,000 live births (KNBS, 2019), an increase from the Kenya Demographic Health Survey (KDHS) 2014 where it had been recorded at 434/100,000.

With such a high rate of maternal mortality, Narok County remains a focus area to improve the quality of maternal health services and increase uptake of services. Various contributing factors to the high MMR, include low uptake of antenatal (ANC) services, lack of skilled birth attendance, lack of adequate equipment, and lack of healthcare worker skills in handling maternal emergencies especially in the marginalized areas. In the initiation of the project, NPI EXPAND Kenya aimed to establish interventions that would target the gap in skilled health workers.

Using the adapted World Health Organization (WHO) Service Availability and Readiness Assessment (SARA) tool the project conducted capacity assessment of health care workers in 101 facilities that were supported by the project. Health care workers (HCW) in Narok County reported inadequate training on emergency obstetric and neonatal care (EmONC), which informed NPI EXPAND to prioritize training in this area.

Background of the Facility

The Emurua Dikirr Level 4 Hospital, is one of the facilities that NPI EXPAND identified as a high need facility for training due to the high number of maternal referrals and emergencies. This facility is situated in Emurua Dikirr Center, a serene town in Transmara East, which is a region in Narok County, Kenya. USAID’s NPI EXPAND project, through the Anglican Development Service South Rift (ADS SR), supported emergency obstetric and newborn care (EMONC) mentorship of staff at this hospital. The facility is capable of handling at most 120 to 170 deliveries each month.

In any given month, the facility receives about 50 obstetric emergencies of which up to 60% of the emergencies a referred to the Narok Level 5 hospital. Most of the referrals were due to lack of HCW capacity to handle and unpreparedness for obstetric emergencies.

The facility has a medical officer who also doubles up as the sub-county medical officer of health (SCMOH) and is actively involved at the maternity ward and helps to manage obstetricemergencies.

EmONC Mentorship Leads to Enhanced Knowledge, Skills, and Motivation Among Skilled Workers

As identified by the SARA baseline assessment, EmONC was a key gap in providing quality maternal health services with 84% of healthcare workers working in the 101 facilities supported by the project reporting to have never been trained in EmONC. The project trained 87 HCW on EmONC, who in-turn mentored 100 additional HCW. In addition, 90 HCW were trained in postpartum family planning (PPFP).

The mentorship activity was structured over a period of six to eight weeks using national guidelines. The mentees had logbooks where they documented their progress on various competencies. The mentorship targeted HCWs in both government institutions and private facilities in areas where there were no government facilities to offer services EmONC. All the mentored HCW were assessed by the national government officials from the Division of Maternal, Reproductive and Neonatal Health (DRMNH) and certified to have acquired the required level of competence for EmONC, PPFP and LARC.

In Emurua Dikirr level 4 hospital, two key staff, Mercy and Florida, were trained on EMONC and as mentors. Mercy Langat joined the staff in November 2022 and is a passionate maternity nurse, EMONC mentor, Continuing Medical Education (CME) officer, drill coordinator, and student clinical mentor.

On her time at the hospital, Mercy reflects: “I have been able to conduct several CMEs, a number of drills, that is, at least 1 drill and 2 CMEs per month.” She continues to confirm that the mentorships have equipped the facility staff with enhanced skills and a better attitude when handling obstetric cases. Mercy continues to say, “I personally have a very specific interest in EMONC mentorship, and I actually enjoy it!” She adds that she enjoys teaching and learns more while she does so. The team was also able to watch Florida and Mercy conduct a successful delivery and newborn resuscitation, resulting in a healthy newborn baby.

“I am very grateful to partners who have made this possible for me especially USAID NPI Project through ADS SR., I was one of the participants during the EMONC mentorship training.” said Florida Sena.

Florida highlighted some of the impacts that she has observed. “Previously there was an increased number of referrals since the staff had minimal knowledge, skills, attitude and right equipment to tackle obstetric emergencies,”

Florida reflected. “Currently the referral cases have reduced by half since the staff have been equipped with the right skills, knowledge, and attitude to handle obstetric emergencies, the community has since developed trust in the facility staff and the facility in general…evidenced by 100 percent facility deliveries indicating reduced home deliveries, early detection of complications and proper management, and lastly knowledge and skills gained by the mentees. All these are gains achieved through the USAID NPI project implemented by the Anglican Development Services South Rift.”

When asked if there were any recommendations she would give as the Reproductive Health Coordinator, Florida said the following: “I wish to request if more mentorship trainings can be supported. The facility would appreciate it if the project procured for them equipment mainly the KIWI,” which is a type of vacuum extractor that is safer and more effective than forceps delivery.

Still at the Emurua Dikirr facility, staff unpreparedness for obstetric emergencies was a problem for quite a long period of time. From the inadequate supply of medical supplies and equipment to significantly deficient knowledge amongst the staff of the requisites for anticipating obstetric emergencies, there were several causes for the unpreparedness.

Paul Sang, a registered nurse who worked at the facility recounts that before mentorship provided through the NPI EXPAND project, “I didn’t really have the skills or the confidence to handle most of the obstetric emergencies, you know, like neonatal resuscitation (NNR).”

Through the NPI EXPAND project, ADS partnered with obstetric mentors, and the relevant county officials to train Paul and other mentees through presentations and drills. Paul narrates that: “The practical approach allowed me to experience an almost real-life scenario while handling neonatal resuscitation.” He continues to recount how during one of the skills lab drills on neonatal resuscitation, he was able to identify the mistakes he had been making and he successfully demonstrated the standard neonatal resuscitation procedure on a simulator.  

Paul recounts his experience by citing, “There has been drastic reductions of both neonatal deaths and unnecessary referrals in my practice since the mentorship.”

Knowledge gaps have been bridged, and now Paul undertakes his services and deliveries with more confidence. The mentorship and training provided by NPI EXPAND trickled down, and the hospital’s reputation amongst the community has never been better.