Most health providers have a story about obstetric hemorrhage that stays with them. For Carren Siele, the Head Nurse at Lwala Community Hospital, it was in 2017, when a woman came to deliver late at night. She began to bleed, and the facility didn’t have the right tools or enough blood for a transfusion. Carren wanted to refer the patient to a higher-level hospital, but violence had broken out following a contested presidential election, and travel was risky.
So instead, Carren stayed with the woman all night and did everything she could, checking her vital signs and adding fluids to her IV. Luckily, the bleeding stopped, and the mother survived.
“We have seen too many near misses and deaths,
so we are working to make a change.”
- Carren Siele, Head Nurse, Lwala Community Hospital
In Kenya, obstetric hemorrhage, or excessive bleeding after childbirth, is the leading cause of maternal death. This life-threatening condition is treatable–but only if a woman delivers at a health facility that has the right tools and medicines. Lwala’s vision is that every mother in Kenya gives birth in a facility that is well-equipped to save her life.
The Obstetric Hemorrhage Initiative (OHI) is helping us achieve that vision. OHI is a bundle of protocols and tools that can treat obstetric hemorrhage, and it relies on lifesaving supplies—like uterotonics, tranexamic acid, the uterine balloon tamponade, and the non-pneumatic anti- shock garment (NASG)—to stop bleeding. But it also requires trained health care providers to know which tools to deploy and when.
In partnership with government, Lwala is expanding access to OHI across Migori County. Since the start of the program, we have provided training and mentorship to thousands of staff at 167 facilities. We will reach 56 additional facilities in 2022–meaning that all 223 facilities in Migori conducting deliveries will be equipped with OHI knowledge and tools. We are also laying the groundwork for OHI expansion to 40 facilities in new counties this year, focusing on geographies in Western Kenya with the highest burden of maternal mortality.
Meshack Wafula, who coordinates OHI training at Lwala, has seen “so much motivation and enthusiasm from health workers, because they all have a story like Carren’s.”
Preliminary data from a study of Lwala’s program led by the University of California San Francisco found a 70% decrease in maternal mortality. This amounts to a 0.9 case fatality rate when the Obstetric Hemorrhage Initiative was operational, compared to a rate of 3.16 prior to the program–a statistically significant reduction in deaths.
The study also revealed critical lessons for OHI scale-up. First, of all obstetric hemorrhage cases eligible for the NASG, 61% received it. Second, tranexamic acid (another OHI commodity that reduces bleeding) was out of stock in many facilities. If we are able to further increase NASG use and address supply chain issues for tranexamic acid, we could see further reductions in maternal death. Final data analysis and journal submissions are underway, but in the meantime, we are sharing these findings with the Ministry of Health to inform the scale-up of OHI to mothers far beyond Migori County.
At the national level, Lwala is working to ensure that OHI is adopted across the country. After a year of advocacy and technical input, the revised Emergency Obstetric Care Training and Mentorship Guide now includes OHI–meaning that every health provider should learn about OHI protocols and interventions during routine in-service training. The guide was officially adopted in April 2022, and the national Ministry of Health already asked Lwala to support training on OHI components. Lwala is also partnering with the Kenya Medical Training Colleges to include OHI in the nursing school curriculum.
Yet training is only effective if health providers have the right supplies–so Lwala is advocating for OHI commodities to be added to essential medicines lists that unlock procurement. In March, Lwala and partners wrote a memo to the Ministry of Health on this issue, and we will also generate demand for action from the Council of Governors. Ultimately, we want to make it easier for counties to order OHI commodities so that every facility is fully equipped.
Underneath this data are the stories of women whose lives have been changed.
Lillian Akello safely delivered her third baby at a nearby health facility last year. But soon after birth, she began bleeding and collapsed in the bathroom. Trained staff lept into action. They used the NASG and uterine balloon tamponade, giving Lillian critical time to reach a higher-level facility, where she received a blood transfusion.
Lillian’s community health worker, Pamela, was by her side in the ambulance. It was because of Pamela’s encouragement that Lillian chose skilled delivery in the first place. “If she didn’t go to the facility,” Pamela says, “she may not have made it.” Today, Lillian and her 1-year-old son are both healthy, and Pamala continues to check up on their family.
“Saving a woman from obstetric hemorrhage means so many things coming together. Motivating women to deliver at a facility, increasing the knowledge and skills of health workers, changing policies and guidelines to make training systemic.”
- Wycliffe Omwanda, Manager for Clinical Excellence
When we put these pieces together, we can make sure that every woman has the safe, dignified childbirth she deserves.
