Maternal Fetal Medicine Fellowship Changes Care for Mothers and Babies
Kenya’s first Maternal Fetal Medicine (MFM) fellowship developed through the AMPATH partnership is changing the outcomes and expectations for pregnant women and babies facing serious medical challenges in western Kenya.
Dr. Kosgei performs an ultrasound on an expectant mother.
“I have become confident that I know when this is a baby I need to be worried about or this is a baby I don’t need to be worried about,” said Wycliffe Kosgei, MBChB, MMed Reproductive Health, MFM, director of reproductive health at Moi Teaching and Referral Hospital (MTRH). Dr. Kosgei is one of five Kenyan doctors to graduate from the fellowship thus far and cares for women with a variety of pregnancy complications at MTRH. He is now also part of the leadership team for the MFM fellowship.
Dr. Kosgei was drawn to the fellowship by the frustration from having poor outcomes for mothers and babies. “When you have a baby or mother that doesn’t make it or does poorly, you feel like you are missing something or you just don’t have enough knowledge. When I look at what I’ve gained from the program, I’m really, really happy,” he said. “I almost feel like all obstetricians should do maternal fetal medicine.”
Maternal fetal medicine is sub-specialty training for high-risk pregnancies including expectant mothers with acute or chronic medical conditions and fetuses with congenital or genetic differences, or with placental dysfunction leading to growth restriction. In Kenya, pre-eclampsia and rheumatic heart disease are the most common conditions for which an expectant mother would need specialty care.
Nan Okun, MD, FRSCS, MHSc, was inspired by the success of the gynecology oncology fellowship and initiated the process to establish the MFM fellowship with Kenyan colleagues in 2014. Dr. Okun is a professor and division head of Maternal Fetal Medicine at Sunnybrook Hospital, in the University of Toronto (U of T), a member of the AMPATH Consortium. She began traveling to Kenya in 2009 to teach and provide support on maternal fetal issues.
The process of writing and adapting the curriculum and getting it approved took five years. The fellowship launched in 2019 with a plan to transition the fellowship over the course of six years from leadership by Dr. Okun and U of T faculty to leadership by Moi University and faculty members who have completed the MFM fellowship.
Dr. Pallavi Mishra and Dr. Bett Kipchumba were the first doctors to become MFM fellows in 2019. Dr. Okun and her U of T colleagues planned to have a faculty trainer on site as much as possible with some online content to supplement the training.
A donor from U of T donated a top-quality ultrasound machine to MTRH where the fellows work and train and the Burwin Institute donated the online foundational ultrasound curriculum. “We were able to take patients that were admitted to the hospital who would otherwise have been delivered for severe growth restriction or pre-eclampsia, which is so common in Kenya, and do the same type of sophisticated doppler we do in high resource areas,” said Dr. Okun. “The fellows were able to acquire those skills and apply them to those inpatients so that we could prolong their pregnancy safely, which is huge in Kenya as premature babies may not have the same survival statistics at early gestational ages.”
Four days before Dr. Okun and others were scheduled to travel to Kenya for the first-year fellowship exams in the spring of 2020, COVID shut everything down. “So that was terrible and good at the same time,” said Dr. Okun, “because we flipped immediately to an on online curriculum and they were able to attend all of the fellowship rounds at the University of Toronto.” This included fetal rounds on Tuesdays, maternal rounds on Thursdays and weekly case review with Dr. Okun and others at U of T providing guidance on the complex patient cases that the fellows were caring for at MTRH.
The fellowship training proceeded and Dr. Kipchumba and Dr. Mishra completed a two-day comprehensive online exam and graduated virtually in 2021.
“We were able to develop a multi-disciplinary team program simultaneously with the training program, with critical input from cardiologists, intensive care physicians and pediatricians for these complex patients,” Dr. Okun added. There is now a combined cardiology MFM clinic where patients with rheumatic heart disease and other serious cardiac issues get care and planned deliveries to reduce stress on their heart. “If patients are going into heart failure or they're at risk for going into heart failure, we can manage them in a much more sophisticated way. We've even had patients that have given birth in the Cardiac Care Unit,” said Dr. Okun.
Dr. Kipchumba and Dr. Mishra were the first graduates of the MFM fellowship.
Fetal Rh Disease is another common condition that occurs when a mother’s blood is Rh negative and a fetus’s blood is Rh positive. The condition causes fetal anemia, heart failure and can lead to death of the fetus. Unlike high resource countries, pregnant women are not routinely tested for this condition in Kenya, so they often present for care very late in pregnancy. Dr. Kipchumba and Dr. Mishra recently led a team that included Dr. Okun and Dr. Kosgei to complete a life-saving fetal transfusion for a baby in utero. As blood products and other supports become more available this procedure will be able to save more babies’ lives.
Although they had to complete their final exams virtually, Dr. Kipchumba and Dr. Mishra still celebrated with cake.
Dr. Kosgei graduated from the fellowship in 2022. Earlier this year, two more fellows graduated and are now practicing in Kitale and Nairobi. One fellow is in the second year of the fellowship and two more have just started. Dr. Kosgei and Dr. Kipchumba are on faculty at Moi University and are now taking a leadership role in training the current fellows with assistance from Dr. Mishra who practices at a local hospital. As the program continues to evolve under Kenyan leadership, the exams are beginning to include more population-specific questions. Maternal fetal medicine is now recognized as a sub-specialty by the Kenya Medical Practitioners and Dentists Council with established training standards.
There is no shortage of need for the care provided by the current MFM specialists and fellows. According to Dr. Kosgei, the MFM team might round on up to 25 inpatients daily who are at high-risk with pre-eclampsia, diabetes, cardiac disease or who have a history of recurrent fetal deaths. This would include the need for up to 10 daily ultrasounds. Very ill patients are often referred to MTRH from lower-level healthcare facilities, but Dr. Kosgei said that up to half of the patients are self-referrals of women who have heard about the specialty care and have concerns about their own pregnancy or baby.
A crucial component of the MFM fellowship is also supporting parents of babies who have conditions that are incompatible with life and who are likely to die before or shortly after birth. This includes preparation ahead of time and having the team support them through the birth process and providing counseling for what the process will be like. “Sometimes all you can do is walk people through that process as compassionately as possible,” said Dr. Okun.
Dr. Kosgei hopes the expansion of maternal fetal medicine helps his Kenyan colleagues better understand which conditions can be managed locally and which should be referred. “We have the technology now and the skills to be able to save more babies than we thought we could ever save,” he said.
“For example, we’ve now had some mothers with kidney transplants deliver vaginally,” said Dr. Kosgei. “Before we would have told them ‘You cannot get pregnant. You will lose the baby and you will lose the kidney you had transplanted.’ But now to see the joy of them having babies and still being healthy is impressive. I really get personal satisfaction.”
Dr. Kosgei recalled a mother who recently returned for family planning sharing photos of the baby he delivered by cesarean section when he was a fellow because the baby was in distress. “She said ‘Look at your son. He is now walking and talking.’ I got touched. I was really impressed by that.”
