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.