Kenyan critical care doctor and UK-Med member Serah Kaara tells us of her experiences setting up a life-saving Intensive Care Unit for pregnant mums in Malawi, as part of the UK Emergency Medical Team’s (UK EMT) response to COVID-19.
In September 2021, the Malawian Ministry of Health sent a request for help to support the country’s COVID-19 response as the population battled a new surge caused by the Delta variant.
As part of the UK EMT, UK-Med sent a team of ten international doctors and nurses to Lilongwe, the country’s capital, in mid-October 2021, where they quickly began supporting and training health staff to deal with the virus and care for severely and critically ill COVID-19 patients.
“One of the saddest things was losing a 15-year-old mum in the main intensive care unit,” Serah tells us. “She was the seventh mother to die at Kamuzu hospital in the first few weeks we were here.”
Despite evidence of a growing trend in improved maternal health indicators, Malawi still has one of the highest maternal mortality rates in Africa and a high rate of neonatal mortality. Malawian women face a 1-in-60 risk of death related to a pregnancy or birth, according to the WHO[1].
“Poverty and a lack of access to education mean girls don’t get off to a good start.”
Given the challenges faced by staff to manage pregnant mums who were contracting the virus, the Ministry of Health had also asked our team to include pregnant women with COVID-19 in their support. While working in the main ICU, it became clear that there was still a tragically high number of mothers dying, even when they did not have COVID-19.
“Mothers were dying with abdominal sepsis and severe anaemia,” Serah explained. “Poor nutrition is a big issue here in Malawi. Poverty and a lack of access to education mean girls don’t get off to a good start.”
Whereas the median age for new mothers in Kenya is 28, where Serah lives and works as a critical care doctor, the median age in Malawi is much lower – at just 19. Giving birth at ages 14 or 15 have their own unique challenges and risks, such as eclampsia or babies with low birth weight.[2]
Following an urgent assessment, Serah and the team identified the opportunity for an additional two-bed intensive care unit that could provide specialist, life-saving support for pregnant women. Photo credit: Serah Kaara/UK-Med (left), Iain Lennon/UK-Med (right)
A life-saving training programme
Spurred on by the situation, Serah re-focused her work carrying out a rapid needs assessment to identify how the team could best help. Although Kamuzu hospital already had a four-bed HDU (High Dependency Unit), she discovered that very sick women weren’t always being transferred to the main ICU in time.
“The main issue we observed was that doctors and nurses needed support identifying the difference between serious and critically ill patients, so they could escalate a pregnant women’s care in time to prevent a condition worsening,” continued Serah. “A limited number of beds in the main ICU also meant women were having to wait for critical care.”
“A limited number of beds in the main ICU also meant women were having to wait for critical care.”
Serah and the team started running a training programme between 7.00 and 9.00 in the morning, followed by ward rounds to the ante-natal, post-natal, theatre, HDU and labour wards, where they provided hands-on critical care coaching and mentoring.
Working with the Heads of Anaesthesiology and Obstetrics and Gynaecology, Serah identified equipment in the stores they could use to set up an additional two-bed intensive care unit specifically for pregnant women.
“They realised there was a need, and they actually had the equipment in the store. They just needed the technical support from us to set up the equipment and feel comfortable using it,” Serah explained.
After just three weeks, the hospital staff had treated six mothers in the new unit.
“The big success story is that right now we don’t have any mothers being admitted to the main ICU and we’ve been able to save two mothers’ lives here in the maternity ICU.
“We’ve been encouraging staff to stop nursing mothers with conditions like hypertension, which can complicate in the general ward and bring them into the HDU so they can monitor them closely and give better care.
“The women have been able to deliver their babies safely and be in a position to continue with their life. That’s a good outcome.”
Getting mums and babies safely back home
One mum was admitted for shortness of breath but tested negative for COVID-19. While in the maternity ICU, the staff performed an ultrasound where they discovered she had rheumatic heart disease – meaning that the heart’s valves have been permanently damaged.
During pregnancy, there is an increased flow of blood which puts additional pressure on the heart’s valves. Rheumatic heart disease adds risk to both the mother and unborn child’s life. With this knowledge, the obstetricians were able to plan the safe delivery of the baby. We’re delighted to say that mum and baby are now safe and were able to go home.
Another young mum was admitted with pre-eclampsia. She was suffering from hypertension and developed shortness of breath, respiratory failure and pulmonary oedema – a condition that causes excess fluid on the lungs.
The team were able to give her antibiotics to clear the fluid on the lungs, intubate her and deliver her baby boy of 2.9 kgs by a Caesarean section. After being on a ventilator for 24 hours, she was able to recover in the post-natal ward and go home with her baby.
Serah tells us that the ICU has meant the obstetricians can manage their own critically ill patients without having to wait for a bed to become available in the main five-bed ICU. “The staff have been able to recognise the critically ill and the severely ill mothers and we have been able to save more lives.”
[1] https://data.worldbank.org/indicator/SH.MMR.RISK
[2] https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy
Feature photo credit: Lindsay Mgbor/Department for International Development
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