Hospital outcomes of newborns admitted after introduction of free maternity services at Moi Teaching and Referral Hospital, Eldoret, Kenya

Abstract

Background: Kenya has had dynamic changes in health care since independence. In the quest to attain the then Millennium Development Goal 4 by 2015 to reduce under 5 mortality by two thirds, a fee exemption on maternity and neonatal services in public health facilities was unveiled in June 2013 by the Government of Kenya. The Neonatal Mortality Rate (NMR) in Uasin Gishu county was 52/1000 live births in 2012 and patient staff ratio was 270:1 which points to the need for more clinical staff. Sustainable Development Goals stipulate that we need to reduce NMR to less than 12/1,000 live births by 2030.The study aims to identify the gaps in the implementation of this new free maternity policy so as to improve on it for the future. Objective: To evaluate hospital outcomes of neonates 1 year pre-and postimplementation of free maternity services at Moi Teaching and Referral Hospital newborn unit and their relationship to clinical staff in the newborn unit and maternity ward. Methods: Mixed methods cross sectional study whose site was the Newborn unit at MTRH Eldoret, Kenya. A data form for patient admission, morbidity and mortality was abstracted from archived records for 1year pre-and post-implementation. Monthly clinical staff return records were used for patient staff ratio. Self-administered questionnaires with open and closed ended questions were issued to staff while key informant interviews were done to assess their perception of free maternity services and challenges faced. Quantitative data analysis was done by STATA version 13 while qualitative data was coded and analysed by thematic content analysis. Data were presented in graphs and frequency tables. Outcomes assessed were: number of patients discharged, referred, neonatal mortality and length of stay. Results: A total of 3953 babies were admitted (1700 pre-and 2253 post implementation of free maternity services). There was a 5% reduction in number of babies discharged home alive; 5% higher mortality rate while no neonates were referred. Average length of stay post implementation ranged from 4-7 days. Post implementation, case fatality rate of gastroschisis decreased by 10.3%, while there was an increase in the following: extremely low birth weight 17.5%, neonatal sepsis 0.5%, birth asphyxia 2.7% and respiratory distress syndrome 3.8%. There was a positive correlation between the patient staff ratio and death rate whereby, the higher the patient staff ratio, the higher the death rate (r=0.6, p=0.002). Staff cited the following advantages after the change: equity; more patients were treated post implementation especially surgical cases and they had better outcomes, while the challenges cited were that staff were overworked due to overcrowding; lack of adequate resources and inadequate emergency equipment. The key informants also cited delayed reimbursements; inadequate funds to improve infrastructure and fewer clinical staff as factors affecting successful implementation. Conclusion: Post implementation, there was a higher mortality rate that was correlated with a higher patient to clinical staff ratio while inadequate infrastructure and inconsistent supplies were cited as a major challenge. Recommendation: We recommend employment of more clinical staff to be able to contribute to better outcomes.