Comparing labour induction outcomes using misoprostol and dinoprostone in term pregnancies: A retrospective study at Kiambu Level 5 Hospital between 2018 and 2020.

BACKGROUND: The Maternal and Perinatal Death Surveillance and Response (MPDSR) was introduced in Kenya in 2016 and implemented at Kiambu Level 5 Hospital (KL5H) three years later in 2019. During a routine MPDSR meeting at KL5H, committee members identified a possible link between the off-label use of 200mcg misoprostol tablets divided eight times to achieve the necessary dose for labour induction (25mcg) and maternal deaths. Following this, an administrative decision was made to switch from misoprostol to dinoprostone for the induction of labour in June of 2019. This study aimed to assess the overall impact of MPDSR as well as the effect of replacing misoprostol with dinoprostone on uterine rupture, maternal and neonatal deaths at KL5H. METHODS: We conducted a retrospective cohort study of women who gave birth at KL5H between January 2018 and December 2020. We defined the pre-intervention period as January 2018-June 2019, and the intervention period as July 2019-December 2020. We randomly selected the records of 411 mothers, 167 from the pre-intervention period and 208 from the intervention period, all of whom were induced. We used Bayes-Poisson Generalised Linear Models to fit the risk of uterine rupture, maternal and perinatal death. 12 semi-structured key person questionnaires was used to describe staff perspectives regarding the switch from misoprostol to dinoprostone. Inductive and deductive data analysis was done to capture the salient emerging themes. RESULTS: We reviewed 411 patient records and carried out 12 key informant interviews. Mothers induced with misoprostol (IRR = 3.89; CI = 0.21-71.6) had an increased risk of death while mothers were less likely to die if they were induced with dinoprostone (IRR = 0.23; CI = 0.01-7.12) or had uterine rupture (IRR = 0.56; CI = 0.02-18.2). The risk of dying during childbearing increased during Jul 2019-Dec 2020 (IRR = 5.43, CI = 0.68-43.2) when the MPDSR activities were strengthened. Induction of labour (IRR = 1.01; CI = 0.06-17.1) had no effect on the risk of dying from childbirth in our setting. The qualitative results exposed that maternity unit staff preferred dinoprostone to misoprostol as it was thought to be more effective (fewer failed inductions) and safer, regardless of being more expensive compared to misoprostol. CONCLUSION: While the period immediately following the implementation of MPDSR at KL5H was associated with an increased risk of death, the switch to dinoprostone for labour induction was associated with a lower risk of maternal and perinatal death. The use of dinoprostone, however, was linked to an increased risk of uterine rupture, possibly attributed to reduced labour monitoring given that staff held the belief that it is inherently safer than misoprostol. Consequently, even though the changeover was warranted, further investigation is needed to determine the reasons behind the rise in maternal mortalities, even though the MPDSR framework appeared to have been put in place to quell such an increase.

Adapting clinical practice guidelines for diabetic retinopathy in Kenya: process and outputs.

BACKGROUND: The use of clinical practice guidelines envisages augmenting quality and best practice in clinical outcomes. Generic guidelines that are not adapted for local use often fail to produce these outcomes. Adaptation is a systematic and rigorous process that should maintain the quality and validity of the guideline, while making it more usable by the targeted users. Diverse skills are required for the task of adaptation. Although adapting a guideline is not a guarantee that it will be implemented, adaptation may improve acceptance and adherence to its recommendations. METHODS: We describe the process used to adapt clinical guidelines for diabetic retinopathy in Kenya, using validated tools and manuals. A technical working group consisting of volunteers provided leadership. RESULTS: The process was intensive and required more time than anticipated. Flexibility in the process and concurrent health system activities contributed to the success of the adaptation. The outputs from the adaptation include the guidelines in different formats, point of care instruments, as well as tools for training, monitoring, quality assurance and patient education. CONCLUSION: Guideline adaptation is applicable and feasible at the national level in Kenya. However, it is labor- and time -intensive. It presents a valuable opportunity to develop several additional outputs that are useful at the point of care.

11 Years of experience in vitreoretinal surgery training in Nairobi, Kenya, from 2000 to 2010.

OBJECTIVE: We aim to demonstrate that vitreoretinal surgery can be established in Nairobi, Kenya, by intermittent short visits of experienced surgeons combined with clinical/surgical observerships over a longer period of cooperation. This strategy might be a model for other developing countries. DESIGN: Time series over 11 years. PARTICIPANTS: 685 operations were performed over 11 years. METHODS: After the 1998 al-Qaeda bomb assault on the U.S. embassy in Nairobi, Kenya, the Ludwig-Maximilians-University München (Germany) provided materials for surgery of 42 victims with eye injuries. From the year 2000 onward, this equipment has been used to establish a training unit at the Kenyatta Hospital in Nairobi. In 1 annual "project week," 1 author (C-L.S.) performed vitreoretinal surgery at the University of Nairobi in cooperation with the Kenyatta National Hospital and supervised resident eye surgeons. After 7 years of training in Nairobi, clinical/surgical observerships of vitreoretinal surgeons and operating theatre staff were commenced in Munich by 4- to 12-week visits. The project week in Nairobi was carried on. Number, indications, operating surgeons, kind, difficulty, duration of operations, and preparation were recorded and evaluated. RESULTS: The percentage of operations by resident surgeons increased from 29% (in 2000) via 80% (in 2009) to 73% (in 2010) with a partial failure of the laser device. The learning curve of local surgeons is also reflected by an increase of the operations' difficulty with only a moderate increase in operation time and marked decrease of preparation time. CONCLUSIONS: A vitreoretinal unit has been established in Nairobi using our training model. This unit has the potential to train colleagues from other sub-Saharan countries. This strategy has advantages over long-term aid deployment of foreign physicians such as avoiding financial burden for the surgeons to be trained and improving the home facility, but it requires commitment for long-term cooperation.