In Kenya, maternal deaths represent approximately 15% of all deaths for women aged 15-49. In 2003 the maternal mortality ratio (MMR) in Kenya was estimated to be 414 maternal deaths per 100,000 live births, which rose to 488 in 2008. Given this increase there is an urgent need for innovative strategies to reduce maternal deaths if Kenya is to meet the targets set by Millennium Development Goal 5. Moi Teaching and Referral Hospital is the second largest referral Hospital in Kenya and serves as the referral centre for all of western Kenya. The Riley Mother and Baby Hospital (RMBH) functions as the Maternity and Newborn Unit for the hospital. It houses a 23 bed labor unit, conducts approximately 9,000 deliveries a year, and can accommodate up to 50 infants in the neonatal intensive care unit. Unfortunately, the medication procurement system is plagued with inefficiencies and the hospital experiences frequent stock outs of essential medications and equipment, posing a challenge in the provision of quality and timely emergency obstetrical care. For example, misoprostol, an essential medicine in emergency obstetrical care, was not being procured by the hospital due to misuse and misappropriation.Because of these issues, patients and caretakers were required to privately procure misoprostol from outside pharmacies and bring it to the hospital if it was required for care. Oxytocin, normal saline, and magnesium sulfate were also often out of stock. These delays in obtaining medications lead to numerous sub-optimally treated hemorrhages and high puerperal mortality rates. These inadequacies created a need to devise a system that would ensure immediate availability of emergency obstetrical medications in the context of a dysfunctional supply chain, an inefficient procurement system, and a busy maternity unit.
The three most common obstetrical emergencies encountered at the Riley Mother Baby Hospital are postpartum hemorrhage, hypertensive emergencies including pre-eclampsia and eclampsia, and cardiopulmonary emergencies. Based on our hospital records, it was estimated that approximately 50 postpartum hemorrhages are managed at RMBH on a monthly basis. To ensure uninterrupted access, we created 50 sealed single use Obstetrical Emergency Medication Kits (E-kits). We designed each E-kit to have medicines for the three most common emergencies at RMBH. The E-kit is made from a plastic fishing tacklebox with 4 shelves; medicines for hemorrhage on the top shelf, medicines for preeclampsia and eclampsia on the second shelf, medicines for cardiopulmonary arrest on the third shelf and other supplies such as gloves, syringes, needles, infusion sets and foley catheters on the bottom shelf. A sealed E-kit is kept in each delivery room for ease of access. Once the seal is broken and/or medication is used, a drug consumption form, contained in the E-kit is completed and the E-kit is returned to the pharmacy to be refilled and re-sealed for a new patient. A stock of at least 50 complete E-kits is maintained at all times to ensure a one month buffer supply is always available. At the beginning of each nursing shift it is the responsibility of each nurse to ensure there is a sealed E-kit in every delivery room.
We conducted a retrospective study using data extracted from the E-kit drug consumption forms and associated patient charts to describe the outcomes of E kit use. We included all women admitted at Riley Mother and Baby Hospital between October 2009 and October 2010 who used an obstetrical E-kit during their admission. Any patient admitted to the hospital who did not use an E-kit was excluded from the review. From October 2009 until October 2010 there were 8,269 deliveries and 8,120 live births at RMBH. Overall, 19 women died during delivery in the same period (0.2% of all deliveries or MMR of 234 per 100 000 live births). In the year preceding E-kit implementation, There were 7,080 deliveries, 6,935 live births and 27 women who died during admission (0.38% of all deliveries or MMR 389 per 100 000 live births). Therefore, there was a reduction in MMR by 155 per 100 000 live births in the first year after E-kit implementation.
Single use Obstetrical Emergency Medication Kits have been well accepted in our institution and have provided a system for immediate access to emergency medications. Introduction of the E-kits has resulted in high levels of usage and translated into a reduction in peripartum maternal mortality at Riley Mother and Baby Hospital in Eldoret, Kenya. To increase the effectiveness of the E-kits, nurses working at the facility received a 5 days training on emergency obstetric care and we also developed evidence-based clinical protocols for the common obstetrical emergencies encountered at the hospital. This is a simple intervention that can address poor medication procurement systems and poor organization in maternity units in resource poor settings. This low cost intervention can ensure immediate availability to essential emergency medications and could be implemented at other maternal care sites in resource constrained settings.
