Measuring the effectiveness of maternal delivery services: A cross-sectional and qualitative study of perinatal mortality in six primary referral hospitals, Kenya

Introduction

The hospital sector represents approximately 45–69% of government health expenditure in sub-Saharan Africa and the effective performance of the sub-sector is therefore critical to overall health system goal achievement¹. Globally considerable efforts have been made to develop health system performance (HSP) assessment frameworks that take into consideration the peculiarities of health systems and the multiplicity of stakeholders in health with different perspectives². But HSP benchmarking is often done between countries as part of a global health comparison, rather than being used at a subnational level, where policymakers in low income countries with high disease burden seek to understand how well the delivery of healthcare meets the needs of citizens³.

In Kenya, overall health status is measured by indicators including life expectancy, and under-five and maternal mortality⁴. However, health system performance is measured mainly through process input indicators such as health per capita spend and human resource availability⁵. This disconnect leads to poor performance accountability defined as “demonstrating and accounting for performance in the light of agreed-upon performance targets focusing on services, outputs and results”⁶. An ideal health system performance indicator would link hospital process and outcomes to overall health system effectiveness, allow for hospital comparisons, be sensitive to outcomes under the control of the health system and ensure provider accountability^6,7.

Maternal delivery service (MDS) indicators and outcomes, such as skilled delivery levels, coverage of caesarean sections and neonatal mortality, are sensitive indicators of the effectiveness of the whole health system⁸. The core impact indicators are also well defined; however the Every Newborn Action Plan (ENAP), launched in 2014, recognised that efforts are needed to improve data quantity and quality, with only 17 countries that have a policy for reporting and reviewing stillbirths and neonatal deaths^9,10.

Roughly one third of 363 interventions in the Kenya Essential Package for Health focus on reproductive health¹¹. Despite the focus, Kenya did not meet the Millennium Development Goal (MDG) target for maternal deaths of 147 per 100,000 live births by 2015, and little advancement has been made in reducing mortality among newborns, which now accounts for 45% of all child deaths^4,12. Facility-based delivery has gained traction as a key strategy for reducing perinatal mortality in developing countries¹³. In Kenya, healthcare provision is devolved to the 47 counties, which provide care to geographical defined populations¹⁴. In the delivery of MDS, primary referral hospitals are expected to provide comprehensive emergency obstetric care, which includes all basic emergency obstetric care interventions and caesarean sections^15,16.

Efforts to reduce maternal mortality and morbidity in low-resource settings often depend on global standards and indicators to assess obstetric care. However these standards often do not take into account the local context especially in terms of skill and resource availability¹⁷. Moreover, using a national average does not provide timely and accurate measurements of levels and trends at local levels, which are crucial to assess progress, allow benchmarking and provide policymakers with the data to prioritize the areas of greatest need¹⁸.

Methods

Results

The six hospitals ranged in maternity bed capacity from 13 – 70 with a median of 55 beds. Total deliveries in the calendar year ranged from 381 at the 13 maternity bed private hospital to 8,279 at a 70 bed public hospital. The bed turnover ratio ranged from 29 – 163 with a median of 80. The lowest number of perinatal deaths was 1, while the highest was 208. The average length of stay varied from 0.7 to 5.1 days and was associated with perinatal mortality P<0.001, 95%CI: 0.6472–0.7542) (Table 1).

The average caesarean section rate for the all the hospitals was 25.9%. When the public hospitals (P) were grouped together and compared to the private [for profit (PFP) and faith based organisation hospital (FBO)], public hospitals had caesarean section rates of 18.4%, 23% and 27.1%, (P2-Kiambu, P3-Nairobi and P1-Kaimbu, respectively), while the private hospital caesarean sections rates were 31.6%, 42.5% and 43.4% (FBO1-Kiambu, PFP-Nairobi, FBO2-Kiambu, respectively). The odds of a caesarean section were 1.67 higher in a private hospital compared to a public hospital (P<0.001 95% CI: 1.5833-1.7763). The number of perinatal deaths per 1,000 live births in private hospitals were 2.62, 9.91, 13.15 (PFP-Nairobi, FBO2-Kiambu, FBO1-Kiambu, respectively), while in the public hospitals they were 25.12, 29.74, 39.17 (P2-Kiambu, P3-Nairobi, P1-Kiambu, respectively) (Table 2).

The perinatal death rate was 2.6 times higher in public hospitals (29.76 per 1,000 births) compared to private hospitals (11.39 per 1,000 births). The number of skilled delivery staff available per 1,000 patients were as follows: P1-Kiambu, 4; P2-Kiambu, 7; FBO1-Kiambu, 15; P3-Nairobi, 22; FBO2-Kiambu, 34; PFP-Nairobi,235. Despite the wide range of skilled delivery staff availability, there was an association between the skilled staff availability and the perinatal mortality (R squared 0.260, P<0.001). The bed turnover ratio and perinatal mortality were associated (R squared 0.064, P<0.001).

Discussion

County referral hospitals play an increasingly significant role in maternal delivery services. Kenya recorded an increase in the proportion of facility based deliveries from 44% in 2008 to 61% in 2014²⁰. A total of 186,688 deliveries in 2014 occurred in such facilities, roughly 15% of all deliveries in Kenya²¹. In this study the total number of deliveries were 24,534 in 2014. The average length of stay for patients admitted for maternal delivery services was just under 2.7 days (median 2 days). This is in line with global practice; in a 92 country review of hospital the mean length of stay after child birth ranged from 1.3 to 6.6 days with the majority of women staying too short a time to receive adequate postnatal care²². However, the average masked considerable differences between the different hospitals, with the public hospitals discharging patients in less than 24 hours compared to two days for private hospitals. Developing countries have reported neonatal infection rates 3–20 times that of developed countries due to poor intra-partum and postnatal infection-control practices²³. Neonatal infection in the first week of life account for 26% of neonatal deaths in sub-Saharan Africa²⁴. The short time available to monitor the mother and newborn could explain the association between the high bed turnover ratio in the public hospitals and high perinatal mortality.

This study reported the average perinatal mortality rate for all the hospitals at 24.63 per 1,000 live births. This is a little higher than the national average of 22.5 per 1,000 live births in 2015²⁵. Yet it is reported that in sub-Saharan Africa the risk of perinatal mortality is 21% higher for home compared to facility-based deliveries¹³. In agreement with our study results, a Bangladesh study looking at whether facility delivery modified the risk of intra-partum related perinatal deaths found that the risks were higher for facility deliveries compared to home deliveries²⁶. The reported perinatal mortality in the present study compared poorly with an assessment of facility quality and association with neonatal mortality in Malawi; it found an average of 17 per 1,000 live births with the newborn mortality rate of 28 per 1,000 births at low-quality facilities and of 5 per 1,000 births at the top 25% of facilities²⁷. However, perinatal mortality in South Africa was reported at 33.4 deaths per 1,000 births in 2013²⁸; while a cross sectional descriptive study of eight major hospitals in Dar es Salaam in January 2009 established a perinatal mortality rate was 44/1000 births (range: 17 – 147)²⁹.

Public hospitals had a perinatal mortality rate 2.6 times higher than private hospital (29.8 and 11.4 per 1,000 live births respectively) in the present study. In Bangladesh, the risk of perinatal mortality in a public health facility was twice that of a private facility, with the difference being attributed to quality of care²⁶. Emergency obstetric care including caesarean section has been recommended as the first priority intervention in reducing stillbirths³⁰. One of the key differences observed in our study was that mothers in private hospitals were almost twice as likely to undergo a caesarean section compared to those in a public hospital. The reported difference here is consistent with studies that show that regardless of a woman’s risk and contextual factors, for profit hospitals are more likely to perform caesarean sections compared to not for profit hospitals because of financial incentives³¹. As expected, the hospitals with higher caesarean section rates also reported lower perinatal mortality³².

Previous studies have shown strong associations between patient mortality and low staffing levels^33,34. However, there was weak association between the ratio of skilled birth attendant and patients, indicating that perhaps primary referral hospitals had met the threshold of minimum number of staff required. This finding contrasts with a study that found that the presence of a doctor at birth reduced maternal and infant mortality³⁵. Since staffing numbers weakly predicted mortality rates, it can be hypothesised that the quality of clinical decision making in not identifying mothers requiring caesarean sections was poorer in those hospitals with relatively low caesarean section rates.

All the hospitals in this study reported having at least two, with a median of three, methods of monitoring standards of care, including SOPs in managing maternal delivery services. Public hospitals in particular had more methods compared to private, though none reported having Ministry of Health oversight. This finding may appear to contradict an assessment of the quality of maternity care in an Indian metropolitan city that concluded that public hospitals practices fell short of evidence-based guidelines, while there was relative overuse of interventions in private hospitals³⁶. However, it is known that reporting having certain quality improvement methodologies is not enough to lead to an outcome of high standards of care without an imbedded culture of quality improvement³⁷. It is possible that a weakness in the health system building blocks of leadership and health information are the weak links in not enabling health workers to champion the process of improvement and use of best practice guidelines to monitor performance¹⁰.

In this study, none of the hospitals reported having been inspected by the national Ministry of Health, but county health teams had visited the three public hospitals. Despite these visits and the reporting of available protocols to ensure quality of care, the public hospitals reported worse perinatal outcomes. Quality-of-care audits have been promoted as useful in identifying and changing suboptimal care, and therefore reducing perinatal mortality; however a study in South Africa, did not demonstrate that quality-of-care audits improved perinatal mortality²⁸. However, in the monitoring of external non medical regulations only the non-government hospitals were subjected to inspection by a non ministry of health regulator such as the National Environmental Agency, symptomatic of many policies in developing countries where there are often conflicting existing laws and legislations and overlapping bureaucratic mandates leading to policy implementation failure³⁸. This uneven treatment of hospitals does not augur well for policymakers and hospital boards efforts to relate hospital performance to overall health system effectiveness.

Conclusions and recommendations

The study demonstrates that the average perinatal mortality in primary referral hospitals was high with considerable variation between public and private hospitals. This is despite all the hospitals reporting having various methods of maintaining standards of care. While there was considerable variance in size and patient numbers among the hospitals, staffing levels were not associated with perinatal mortality, suggesting that the quality of clinical decision making as measured by the caesarean section rate was a factor in improving outcomes. Given the heterogeneity of primary referral hospitals, the use of perinatal mortality as a performance indicator to measure the effectiveness of maternal delivery services and hold hospitals to account in relation to the entire health system is recommended.

Data availability

Dataset 1: Effectiveness of maternal delivery services and perinatal mortality in six primary referral hospitals. DOI, 10.5256/f1000research.14862.d206064⁴²

The datasets generated and/or analysed during this study, other than those provided herein, are not publicly available as ethical restrictions apply to publicly sharing the qualitative interviews transcripts due to potentially identifiable information detailed in the transcripts. Excerpts of the data are however available from the corresponding author on reasonable request and approval by the Kenyatta National Hospital/University of Nairobi- Ethics Review Committee (KNH/UoN-ERC) by contacting ayah@uonbi.ac.ke or uonknh_erc@uonbi.ac.ke.