Every day, more than 800 women die globally from preventable causes related to pregnancy and childbirth, according to the World Health Organization (WHO, 2019). The COVID-19 pandemic has aggravated many health challenges, including the delivery of respectful and safe maternal and child healthcare. Yet, it has also prompted a digital shift that brings considerable opportunities in transforming maternal healthcare.
Since the pandemic was declared, healthcare resources and frontline workers of most countries across the world have mainly been positioned to deal with COVID-19 patients, public testing, vaccination, counseling, and other activities involved in managing the spread of the virus. Countries like Kenya with a weak healthcare system had to grapple with the challenge of lack of resources for other health issues such as maternal health. Additionally, these countries adopted curfews, limitations of face-to-face consultations, containment measures, and lockdowns, which put additional strain on already crumbling healthcare systems.
According to WHO’s 2021 “Scoping review of interventions to maintain essential services for maternal, newborn, child and adolescent health and older people during disruptive events”, the measures taken to reduce the spread of COVID-19 and shortage of health workers lead to the prevalent disruption of many health services including maternal health. The study also found that under certain scenarios, reducing coverage of essential maternal and child health interventions could cause additional maternal and child death in low- and middle-income countries.
According to CountryMeters, Kenya had over 1.9 million live births in 2021. It predicts that the Kenyan population will increase by over 1.4 million at the beginning of 2023. The project, which provides data on population for most countries globally, attributes this natural increase to an increase in the number of births and low death rates.
Given this context and ongoing COVID-19 disruptions, Kenya needs to adopt immediate innovative solutions to address long-prevailing maternal health problems like pregnancy-related deaths, late pregnancy diagnosis, HIV burden, delay in reaching, seeking, and receiving maternal health care, and more.
Some telehealth solutions are already being used in some parts of the country to improve maternal health and ultimately prevent maternal morbidity and mortality in high-risk populations. David Rimui Kamau, a clinical officer at St. Mary’s Medical Center in Wangige - a growing satellite town about 16 kilometres from the capital Nairobi - says telehealth is being widely used as a guiding tool to diagnose, treat and control diseases among pregnant women and children in Kenya.
“Here at St. Mary’s, we used telehealth as a guiding tool during the height of the pandemic mainly to provide outpatient care in the area of observations, medication, and assessing any arising issues during pregnancy,” he said. “It was especially useful during the time that the Kenyan government adopted the 7pm to 4am curfew, because mothers could not access health centers during curfew hours,” he added.
He is part of thousands of healthcare workers in the country who have witnessed the swift adoption of telehealth during the pandemic. “Let us say that a pregnant woman has a complication after 7pm. In this case, we would observe them from afar, and if possible, we could offer transportation to enable them to reach the hospital. Such cases lead to an increase in uptake of telemedicine in maternal health,” he recalls. He notes that before COVID-19 maternal telehealth was mainly used to book and confirm appointments and refer people.
While telehealth is mainly linked to remote and distant services, Kamau says this digital solution has enabled him to help mothers deliver babies at home safely during the pandemic. This is especially useful given that research shows pregnant women in Africa take more than the WHO-recommended two hours before accessing a health facility.
Researchers from the Institute of Tropical Medicine (ITM) in Antwerp and their counterparts from the London School of Economics and the London School of Hygiene and Tropical Medicine in a 2021 study found that women in Africa may be traveling much longer to hospital than earlier models predicted reinforcing the use of telemedicine as a necessary solution to the repercussions of prolonged travel time.
“One of my biggest successes with using telehealth to promote safe maternal care during the pandemic, was the safe delivery of four babies at home,” he says with a big smile. With the curfew, there was less work at night, and health professionals like David Kamau could provide mobile health services, and mothers could take the babies for vaccination to the hospital the following day.
WHO defines telehealth as the provision of healthcare services by healthcare providers from a distance by using information and communication technologies to exchange sound and accurate information. Telehealth also includes interactions between healthcare professionals and patients via technology (e.g. through mobile apps) to provide training, counseling, or even team meetings.
For example, Laura Thuo, a resident of Kiambu County, Kenya has been using a WhatsApp group during her prenatal and antenatal period to access maternal health-related information from fellow mothers and health professionals. The 26-year old says the group has truly guided her in motherhood, as she now knows what to look out for if the baby gets fussy or develops something like eczema and knows better the type of over-the-counter medicine she should buy.
“I joined the WhatsApp group during my prenatal appointment at Coptic Hospital. And it has really helped me as a new mum because if I have any questions, I can post them on the group, and a fellow mother who has experienced the same issue can advise me. The best part is that if the question becomes too complex, a health professional comes in and provides the necessary help,” she explains as she puts her baby to sleep in a wooden cot.
Some of the topics addressed in the group include COVID-19 vaccination for new mothers, expectations during and after vaccination, choosing a maternity hospital, weaning, breastfeeding, over-the-counter medicine for infants and children, among others.
“Now I know what type of medicine to buy because health practitioners and women in the group have already talked about it. Some of them post photos of the product and recommend websites where you can order medicine online,” she adds.Thanks to the group, Thuo says she now knows how to build a breast milk stash and thus, she can handle going back to work after her maternity leave as she knows her daughter has a good supply of milk.
The WhatsApp group, which has 140 participants, was created by Coptic Hospital during the COVID-19 pandemic to enable mothers and health professionals interact and communicate on issues related to appointments and address the challenges the new mothers would be going through. It comprises pregnant women, mothers, and health professionals such as doctors, nurses, and clinical officers.
Laura is only one among thousands of women who have benefited from maternal health services delivered through telehealth during the pandemic. Mary Nyokabi* 35, a mother of three, narrates the ups and downs of her first experience with maternal telehealth services during the pandemic. "Telehealth is a new world to me. I have three children, but I delivered two of them way before COVID-19, when doctors advocated for face-to-face consultations when accessing maternal services," she says as she pats her two-month-old son during the interview.
At first, she was excited and impressed by the provision of maternal services digitally without face-to-face consultations because it meant she and the unborn child would not be exposed to the virus. She also noted that this meant she would save money on transport and time, enabling her to concentrate on her other two children. However, this eventually changed as she was worried about the prolonged lack of face-to-face consultations. "Initially, I was going to M.P. Shah Hospital for my pregnancy clinic visits. The hospital had quite a large intake of COVID-19 patients and this made me concerned about being exposed to the virus," she recalls. "So when the nurses told me they would call me before my next visit to determine if I needed to go to the hospital physically or not, I felt relieved."
Mary says what followed were virtual prenatal check-ups for three consecutive months. "The nurses or doctors would just call me and ask me if I was doing okay and how the baby was doing. If I said we were both okay, that meant I did not have to go to the hospital."
She recalls how worried she was because she believed there needed to be some physical examination to determine if the baby was truly fine. "While I enjoyed access to healthcare at the comfort of my house, I understood the importance of being seen by a doctor physically. I wanted to know my weight curve, do scanning to determine the gender of the baby, and have the doctors listen to my baby's heartbeat. These are services I didn't have access to for three months."
Oversight and a Hybrid Model
Mary resolved that it was time to shift to a hospital with fewer COVID-19 patients, and thus more focus on all patients, including pregnant women, when she almost missed her anti-D immunoglobulin injection. "So much time had passed without a health professional reviewing me physically that I even forgot I was supposed to get the anti-D injection. It's my husband who reminded me."
If a Rhesus-negative woman falls pregnant to a Rhesus-positive man, there is a probability that the baby will be rhesus-D positive. There is a risk that some of the baby's blood cells will get into the mother's bloodstream during the pregnancy and birthing process, and she will form antibodies against the baby's blood.
If a mother who has developed the antibodies gets another Rhesus-positive baby, her antibodies cross the placenta and could damage the baby's red blood cells. Untreated babies may risk brain damage, be anemic or even die before birth. Anti-D immunoglobulin is administered during the third trimester of pregnancy to reduce a woman's chance of forming antibodies.
Mary is Rhesus-negative while her husband John is Rhesus-positive. “After doing our research we settled on Karen Hospital because they had less COVID-19 patients and they used telehealth together with in-person services. Eventually I was able to find the peace of mind I was looking for.”
Clinical Officer David Rimui said one of the failures he experienced while using telehealth to promote safe maternal care during the pandemic was when he had to re-diagnose a patient. "The main challenge of telemedicine is limited, or the completed lack of face-to-face clinical visits as health professionals mostly rely on symptoms and not physical examinations for diagnosis or treatment. In cases where you have two diseases that share common symptoms such as COVID-19 and malaria, it is easy to misdiagnose a patient if you are not doing the physical examinations."
In such a case, the primary diagnosis would change once the patient visited the hospital. Rimui recommends that telehealth be used as a tool by health professionals to reach patients and not for diagnosis. He believes that public and private sectors should collaborate and invest in education and training for health professionals and people from diverse backgrounds in both healthcare and digital skills to maximise the gains of telemedicine.
"To continue driving progress in maternal health beyond the pandemic through telemedicine, it is vital that Kenya and other countries ensure they have a workforce that has the right skills to develop and adopt digital health interventions and also have an in-depth understanding of the health needs and challenges of various populations. In our African or Kenyan setup, telehealth has a big role to play, especially as a guiding tool for maternal services.”
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