EMERGENCY RAPID RESPONSE WHATSAPP GROUP AS AN INNOVATION TO REDUCE MATERNAL MORTALITY

CAUSES OF MATERNAL MORTALITY
Maternal mortality is the death of a woman during pregnancy or within 42 days after giving birth due to pregnancy-related cause. The main causes of maternal mortality are:
– Severe bleeding is the leading cause of maternal mortality worldwide. Postpartum hemorrhage (PPH) is severe bleeding after childbirth. Adoption of the EMOTIVE Bundle is helping reduce its impact. Antepartum Hemorrhage (APH) is bleeding before or during childbirth. It can be suddent and catastrophic. It has two main causes – Abruptio Placenta, separation of a placenta before the baby is born, and Placenta Previa, a low lying placenta going before the baby at the cervical os.
– Infections especially after childbirth, are another major cause of maternal mortality. The potential areas that can get infection after childbirth are the breasts because of breastfeeding, the uterus, the urinary system, wounds such as perineal tears or cesarean section wounds.
– High blood pressure: Pre-eclampsia and eclampsia are types of high blood pressure associated with pregnancy that can cause maternal mortality. Unmanaged High Blood Pressure associated mortalities are some of the reasons that the maternal mortality may never be zero.
– Complications from delivery: These include obstructed labor with ruptured uterus and other complications.
– Unsafe abortion: This includes induced abortion, miscarriage, and ectopic pregnancy.
– Preexisting medical conditions such as untreated HIV infection could lead to maternal mortality.

MEASURING MATERNAL MORTALITY
How is maternal mortality measured and reported?
Maternal mortality ratio is he number of maternal deaths per 100,000 live births during a given time period.
Maternal mortality rate is the number of maternal deaths per 1,000 women of reproductive age.

MMR
Maternal mortality is a big problem in Kenya. The various counties are also at various stages of battlimng with the problem. The Maternal Mortality Ratio of Kenya was described as 355 / 100,000 live births. The Sustainable Development Goal (SDG) target for maternal mortality ratio (MMR) is to reduce it to less than 70 per 100,000 live births by 2030. Even where the care of mothers is highly advanced, some maternal mortality occur as a result of some conditions that may be difficult to control like a eclampsia or emboli of various types like pulmonary emboli or amniotic fluid emboli that can quickly deteriorate to maternal death. Nevertheless, we continue to strive to prevent the death of every mother complicates.

THE THREE DELAYS MODEL
The three delays model is a framework for understanding the factors that contribute to maternal mortality. It identifies three stages where delays can occur that increase the risk of death:
First delay: The delay in deciding to seek medical care
Second delay: The delay in reaching a health facility
Third delay: The delay in receiving adequate care at a health facility

MPDSR
One way of reducing maternal mortality rate is by learning from mortalities. The concept of preventable maternal mortality is used to help improve care so as to prevent future modalities. The 3 delays thus are the target of Maternal and Perinatal Death Surveillance and Response (MPDSR). MPDSR is a quality improvement intervention that aims to reduce maternal and neonatal deaths. It was launched by the World Health Organization (WHO) in 2013.

The principles of Response (MPDSR) include:
• No blame, focusing on health systems, not individuals.
• Zero reporting,regular reporting, even when there are no deaths.
• Participatory, involving health managers and providers.
• Evidence-based, that examining medical and social factors.
• Multi-sectorial approach to response.
• Educational, with MPDSR meetings primarily being educational experiences.
• Anonymised data where death audit data are anonymized and cannot be used for disciplinary purposes.
• Documentation with patient case notes being the main source of information for MPDSR.
• Verbal autopsy, interviewing relatives as the main source of verbal autopsy information.
• Response, where mechanisms are put in place to prevent avoidable factors in the future.

With MPDSR and adequate response there is light at the end of the tunnel because the majority of maternal mortalities are PREVENTABLE.

MURANG’A COUNTY MPDSR

Following a call through the Council of Governors (COG,) Murang’a County operationalized MPDSR in the county. A County MPDSR team was constituted. County MPDSR Online meetings are carried out every Tuesday between 0730hrs and 0900 hrs. Where necessary the County MPDSR team visits affected facilities for support supervision. Responses are monitored and reported in the online MPDSR meetings. Participants in the MPDSR meetings also include the Ministry of Health and COG.

EMERGENCY REAPID RESPONSE WHATSAPP GROUP

The problem – Broken Communication, slow turnaround
One problem that kept recurring in MPDSR meetings was the broken nature of communication between personnel and health facilities during maternal and paediatric emergencies, that affected the turnaround speed of actions that should be taken to save a mother’s life.

Formation of the ERR WhatsApp Group
Following several MPDSR discussions, the Murang’a team decided to form a EMERGENCY RAPID RESPONSE WHATSAPP GROUP whose sole purpose is coordination of a distress to avert maternal mortality. The group does not entertain comedy or any other messages that are not related directly to a patient care. That way, any message put in the WhatsApp group is considered a call for help and thus is taken with the seriousness that it deserves, resulting in swift action that would enhance saving our mother‘s life.

Who is in the ERR WhatsApp Group?

The group contains all the personnel who can help should an emergency response be required in any part of Muranga county. The group is led by the county gynaecologist. It has contacts of the heads of the health facilities in the county, relevant health personnel and county government officials including the chief officer in charge of health.

Improved response time
Since the creation of the emergency rapid response WhatsApp Group the response time to a maternal emergency has improved dramatically. If blood is needed, the lab people in the group immediately indicate where this can be gotten. Should an ambulance be needed the coordinator is there. Should a doctor be needed, they are right there. The WhatsApp group has also helped in the interfacility transfers that previously were a thorny issue. If a facility needs to refer a patient, then they are assisted as to which facility is nearest to them. If a referral is coming to a particular hospital, then the receiving facility is already aware of what preparations they need. It was common previously for a receiving facility to complain that they were not informed of a critical patient being brought in. The referring personnel were also stressed when accompanying such a patient as they would not know how they would be received, if they would be received at all.

The improved response time has proved life saving. Previously, it may have been difficult to have concerns raised acted upon in a timely way because of the need to make phone calls, the need to know who has what, or where the ambulances are, or even who to talk to on the other side. The emergency response WhatsApp group has that solved the problem of the delay that occur when a particular communication needs to be done. It also ensures those charged with any form of response respond quickly enough so as to save the life of a mother.

All health facilities involved – Public, Private, Faith-Based
One of the first responses was for a 23-year old mother who had been in labor at a health centre and had developed features of some form of obstruction of labor. The midwife in the health centre at night did not have an ambulance and did not know where to send the patient. A call in the group immediately elicited a response from the nearby faith-based hospital that saved the day for the young mother. It is important to note that emergency response is not limited to the public health facilities in Murang’a. Faith-based and private facilities are included in the response because you never know where the emergency will get you.

EWENE
Kudos to the Murang’a MPDSR teams. In the spirit of #EWENE (Every Woman Every Newborn Everywhere) other counties are encouraged to open EMERGENCY RAPID RESPONSE WHATSAPP GROUPS to save mothers’ lives.

#WhatsAppGroupSavingLives
#EmergecyRapidResponseWhatsAppGroup

Dr Simon Kigondu is a consultant gynaecologist
simonkigondu@gmail.com