As Nursing Officer In-Charge at Lwala Community Hospital, Tonny Ochieng Otieno supports health workers every day to better care for the mothers and newborns in his community. But he remembers a time before he had the skills and confidence to do this work.
“Before I was trained on emergency obstetric and newborn care, I didn’t have all the knowledge or equipment I needed to help a baby born not breathing or a mother who was bleeding post-delivery,” says Tonny. “I had the basics, but I usually had to refer mothers elsewhere.”
All Tonny knew was that a future where no woman or newborn dies during delivery had to be possible. In Kenya, obstetric hemorrhage, or excessive bleeding during childbirth, is still the leading cause of maternal death. One of the leading causes of newborn death worldwide is birth asphyxia, or inability to breathe at birth. “These deaths could be prevented if health workers had the right tools and training available,” says Carren Siele, Program Coordinator for Clinical Training at Lwala.
Today, Lwala is working to make this a reality. At the national level, we are influencing the policies and systems that prepare health workers to respond to the leading causes of maternal and newborn death. We are also championing new approaches to train, equip, and mentor health workers–and over the next few years, we will expand this work to a total of 15 counties. The result is a health system better able to save the lives of mothers and newborns.
A bundled approach to emergency obstetric and newborn care
At the core of Lwala’s community-led health model is ensuring more women are accompanied by community health workers (CHWs) to deliver in facilities. When they get there, women must be met with high-quality care and skilled providers to safeguard their health and the health of their newborn. But facilities across Kenya often lack health worker training and lifesaving medicines and commodities, resulting in poor quality of care. To close this gap, Lwala has championed two clinical training initiatives focused on obstetric hemorrhage and neonatal resuscitation.
In 2018, we began to train health workers to use the non-pneumatic anti-shock garment (NASG), a low-cost, easy-to-use compression suit that stops bleeding and gives mothers an additional 72 hours to get advanced care. The NASG can reduce maternal mortality related to obstetric hemorrhage by up to 67%. With the Migori County government, Lwala led the first county-wide scale up of the NASG. But we knew health providers needed more tools to respond to obstetric emergencies. So Lwala launched the Obstetric Hemorrhage Initiative to train health workers on a bundle of protocols, which includes lifesaving supplies like the NASG, uterotonics, tranexamic acid, and the uterine balloon tamponade. This enables health workers to respond to a variety of maternal health emergencies related to hemorrhage during and after delivery.
At the same time, we recognized health workers also needed training to prevent newborn deaths. So in 2019, we worked with the Migori County government to introduce Helping Babies Breathe, a training program from the American Academy of Pediatrics aimed at improving neonatal resuscitation in low-resource settings. The program includes a set of basic equipment, including a penguin sucker to remove fluid from a baby’s airway and a bag and mask to pump air into a baby’s lungs. In settings like Tanzania, this training was associated with a 47% reduction in newborn deaths and a 24% decrease in fresh stillbirths.
Changing policies and systems to support mothers and newborns across Kenya
Lwala’s vision is that every mother in Kenya delivers in a facility equipped to save her life, as well as her newborn’s. So we are using what we’ve learned through these clinical training programs to make changes at the national level.
“To save every life,” says Wycliffe Omwanda, who oversees clinical training at Lwala, “we are influencing policies, training curricula, and supply chains to ensure that the right tools and commodities reach every facility.”
Central to this work is ensuring that priority commodities–including the NASG, uterotonics, and the uterine balloon tamponade–are included in government policies and that training curricula include modules to train health workers to use these tools. After successful advocacy from Lwala, the Ministry of Health added these technologies and protocols to the national training package on emergency newborn and obstetric care in 2022. Lwala also partnered with Kenyan Medical Training Colleges (KMTC) to update the nursing school curriculum–meaning that every nurse entering the workforce will have the skills needed to respond to obstetric emergencies and use tools like the NASG. Finally, the Kenya Medical Supplies Authority (KEMSA)–with input from Lwala–recently updated Kenya’s essential medicines lists to include commodities for emergency obstetric care, including the uterine balloon tamponade, the NASG, and uterotonics like carbetocin. This will make it easier for counties to procure the commodities they need.
Over the next year, we will train KMTC lecturers to roll out the new nursing school curricula, quantify the need for maternal and newborn health commodities within counties, work to get the NASG into the national supply chain through KEMSA, and continue to plan for the scale up of these lifesaving commodities with the national government.
Expanding to new counties, learning new lessons
In addition to national-level work, Lwala is on a mission to support 15 high-burden counties in strengthening emergency obstetric care. To date, we have trained 4,605 health workers across 413 health facilities in 6 counties, including Migori, Homa Bay, Baringo, Kilifi, Garissa, and Mombasa. In Migori County, where we began this work, we reached an important milestone: “Every facility conducting deliveries has been trained and equipped on both emergency obstetric care and Helping Babies Breathe,” says Meshack Wafula, Clinical Training Coordinator at Lwala. As we expand emergency obstetric care to reach a total of 15 counties, we are tailoring our approach to meet the unique opportunities and needs of each county. And we’ve already learned some key lessons:
Restructuring mentorship to fit county needs: In Migori, health workers traveled to a central facility for ongoing mentorship. In Baringo, however, health facilities are much more spread out. After holding initial training at a single, central venue, we realized that the county’s vast terrain makes consistent mentorship at a central location more difficult and places an added burden on health workers who travel long distances. So in Baringo, we plan to offer mentorship for health care providers in the comfort of their own facility. This will be more convenient for health workers, requiring them to be away from their duties for a shorter period of time, and we also expect it to be cost-effective.
Taking advantage of the policy environment: Because of devolution, Kenyan counties have more power than ever to adapt national policies to fit their unique contexts–this means that the policy environment in each county is different. Mombasa, for example, recently passed a Facility Improvement Financing Act, which improves the ability of facilities to direct funds toward community needs. Lwala advocated for some of these funds to purchase commodities for emergency obstetric care. As a result, facilities in Mombasa have purchased 20 NASG garments on their own, which was matched by another 20 from Lwala.
Leaning on existing partnerships: Understanding the unique partner landscape in each county is key to success. In Homa Bay, for example, government, RedCross, Zipline, and Momentum were collaborating to ensure the availability of blood products–this is essential for managing blood loss during cases of obstetric hemorrhage. Bringing these partners together, we now convene to discuss county-wide blood demand, mobilization, and action plans. Lwala offers transport for health workers during blood drives and distributes blood to nearby banks. We also advise blood bank teams on ensuring quality distribution and transfusion at facilities. As a result, blood access has improved across the county, and the health system is better able to save lives during obstetric emergencies.
In addition to lessons learned, we are continuing to build an evidence base to underscore the impact of well-equipped, well-trained health providers on maternal and infant mortality. We are currently conducting a study of the Obstetric Hemorrhage Initiative led by the University of California San Francisco. Preliminary results from Migori showed a 49% decrease in maternal case fatality rate after program implementation, and we are expanding this research to include evaluation of the intervention in new counties. For Helping Babies Breathe, we have partnered with Vanderbilt University to understand how the training model impacts the survival rate of newborns in Kenya.
A future where lives are saved is possible
Emergency obstetric and newborn care can transform health outcomes for mothers and infants. Now when health providers like Tonny face a mother or newborn in need, they can act. For Tonny, supporting health workers to gain these skills further inspires his work.
“Now I can offer all mothers and their babies the care needed to survive. Today, I am the one giving directions in trainings and in maternity rooms,” he says.
Stories like his paint a picture of the future Lwala envisions–one where every woman and newborn receives the care they need during and after childbirth.
