Updating of a clinical protocol for the prevention and management of postpartum haemorrhage at Kenyatta National Hospital, Nairobi, Kenya

Background: Postpartum haemorrhage (PPH) affects 6% of births and accounts for almost 30% of maternal deaths. The use of clinical protocols for preventing and treating PPH is recommended by WHO. Protocols should be evidence-based, regularly updated, widely available and routinely adhered to.Broad Objective: To update the Kenyatta National Hospital (KNH) PPH prevention and management protocol based on latest recommendations, and ensure its dissemination and use by providers.Materials and Methods: A literature search identified selected PPH-related guidelines which were assessed using the AGREE-II tool for guideline quality. A matrix was created to compare recommendations across  guidelines. Recommendations included in the KNH protocol were based on agreement across guidelines, guideline quality, publication year, and  contextual factors in our setting. To aid implementation, an updated KNH protocol document, a clinical algorithm and a PPH management checklist were developed. These were reviewed and accepted as best practice by KNH and University of Nairobi.Results: Six PPH-related guidelines were used (WHO, FIGO, RCOG, ACOG, FOGSI, and the Kenya National Guidelines for Quality Obstetrics and  Perinatal care). The KNH protocol covers PPH prevention, including: active management of third stage, oxytocin after vaginal or caesarean delivery, other drugs for prevention (when oxytocin is not available), controlled cord traction and delayed cord clamping. It also covers PPH management (supportive and definitive measures).Conclusion: An updated PPH prevention and management protocol for KNH was developed. Implementation and adherence will help standardize PPH-related care and improve health outcomes for women

Burden and outcome of neonatal diseases and conditions at a rural district hospital setting in Kenya

Although the common causes of neonatal morbidity and mortality are known, there is paucity of information on many aspects that are required for effective management of neonates presenting for care in health facilities in low-income settings. In this thesis, I set to bridge this knowledge gap by looking at the neonatal admissions burden, assessing the ability of clinical signs to identify very ill neonates likely to die, examining the causes of infections among neonates, and describing the long-term post admission outcomes. I found that neonates may comprise close to 20% of all under five years old children admitted to rural health facilities in low income settings and contribute nearly 60% of inpatient childhood deaths. Importantly, simple clinical signs are useful in identifying neonates at risk of death during admissions and could help target care in many conditions including invasive bacterial infections and hypoxemia. Crucially, up to 40% of all neonates admitted with severe illness (injuries during birth, bacterial infections & prematurity) suffer long-term neurological deficits post admission. However, data on long-term outcome is very poor in low-income countries. Urgent interagency approaches to improving data are therefore needed. In summary, in this thesis I demonstrate that it may be necessary to remodel our approach on how best to prevent neonatal morbidity and mortality in low-income countries. I suggest a more robust five-prong model that build upon the existing three-delay model

Emergency triage assessment for hypoxaemia in neonates and young children in a Kenyan hospital: an observational study

Objective To describe the prevalence of hypoxaemia in children admitted to a hospital in Kenya for the purpose of identifying clinical signs of hypoxaemia for emergency triage assessment, and to test the hypothesis that such signs lead to correct identification of hypoxaemia in children, irrespective of their diagnosis. Methods From 2002 to 2005 we prospectively collected clinical data and pulse oximetry measurements for all paediatric admissions to Kilifi District Hospital, Kenya, irrespective of diagnosis, and assessed the prevalence of hypoxaemia in relation to the WHO clinical syndromes of “pneumonia” on admission and the final diagnoses made at discharge. We used the data collected over the first three years to derive signs predictive of hypoxaemia, and data from the fourth year to validate those signs. Findings Hypoxemia was found in 977 of 15 289 (6.4%) of all admissions (5% to 19% depending on age group) and was strongly associated with inpatient mortality (age-adjusted risk ratio: 4.5; 95% confidence interval, CI: 3.8–5.3). Although most hypoxaemic children aged ≥ 60 days met the WHO criteria for a syndrome of “pneumonia” on admission, only 215 of the 693 (31%) such children had a final diagnosis of lower respiratory tract infection (LRTI). The most predictive signs for hypoxaemia included shock, a heart rate 60 breaths per minute and impaired consciousness. However, 5–15% of the children who had hypoxaemia on admission were missed, and 18% of the children were incorrectly identified as hypoxaemic. Conclusion The syndromes of pneumonia make it possible to identify most hypoxaemic children, including those without LRTI. Shock, bradycardia and irregular breathing are important predictive signs, and severe malaria with respiratory distress is a common cause of hypoxaemia. Overall, however, clinical signs are poor predictors of hypoxaemia, and using pulse oximetry in resource-poor health facilities to target oxygen therapy is likely to save costs

Cardiorespiratory fitness and physical activity in Luo, Kamba, and Maasai of rural Kenya

BACKGROUND: Although habitual physical activity energy expenditure (PAEE) and cardio-respiratory fitness (CRF) are now well-established determinants of metabolic disease, there is scarcity of such data from Africa. The aim of this study was to describe objectively measured PAEE and CRF in different ethnic populations of rural Kenya. METHODS: A cross-sectional study was done among 1,099 rural Luo, Kamba, and Maasai of Kenya. Participants were 17–68 years old and 60.9% were women. Individual heart rate (HR) response to a submaximal steptest was used to assess CRF (estimated VO(2)max). Habitual PAEE was measured with combined accelerometry and HR monitoring, with individual calibration of HR using information from the step test. RESULTS: Men had higher PAEE than women (∼78 vs. ∼67 kJ day(−1) kg(−1), respectively). CRF was similar in all three populations (∼38 and ∼43 mlO(2)·kg(−1) min(−1) in women and men, respectively), while habitual PAEE measures were generally highest in the Maasai and Kamba. About 59% of time was spent sedentary (<1.5 METs), with Maasai women spending significantly less (55%). Both CRF and PAEE were lower in older compared to younger rural Kenyans, a difference which was most pronounced for PAEE in Maasai (−6.0 and −11.9 kJ day(−1) kg(−1) per 10-year age difference in women and men, respectively) and for CRF in Maasai men (−4.4 mlO(2)·min(−1) kg(−1) per 10 years). Adjustment for hemoglobin did not materially change these associations. CONCLUSION: Physical activity levels among rural Kenyan adults are high, with highest levels observed in the Maasai and Kamba. The Kamba may be most resilient to age-related declines in physical activity. Am. J. Hum. Biol. 2012. © 2012 Wiley Periodicals, Inc