A Decade of Care at Riley Mother and Baby Hospital
This year marks the 10th anniversary of the Riley Mother and Baby Hospital (RMBH) at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya. When the mother and baby hospital was dedicated in August 2009, the expectation was that there would be approximately 20 babies delivered per day and up to 7,000 per year. The hospital now averages 40 deliveries per day and 14,000 per year.
Additionally, the neonatal intensive care unit (NICU) has a capacity of 50-60 infants and averages 120 patients each day. Forty percent of these babies are referred from other hospitals or birthing centers from throughout Kenya.
As the number of patients has increased, so have the services and specialties available at the public hospital. Faculty members specializing in obstetrics, pediatrics, surgery and neonatology are now on staff at RMBH. The cost for maternity services are now covered by the Kenyan government as well.
When Jim Lemons, MD, a neonatologist at Indiana University and Riley Hospital for Children in Indianapolis, and his wife Pam, a neonatal nurse practitioner, began working with AMPATH in 1994 the nursery consisted of three tiny rooms where nurses would care for up to 20 babies. Lemons recalls that 6-8 babies would share one small crib and death by infection and sepsis were common. One of the first upgrades was tearing down the walls and installing rows of wire baskets. “We could put one baby in each basket, so at least they were not touching each other physically,” recalls Lemons. “That was an awesome improvement.”
After several years working in the cramped and insufficient space, the idea for a new building began to take shape.
“We wanted to create a beautiful facility where patients and nurses could have hope and where faculty and students would be proud to work, do research and practice good care,” said Lemons. “We wanted to build this facility mostly to lift up women and children visibly so that the community would know that the women and children were the priority,” said Dr. Lemons. “We wanted to create something that was the promise of the future.”
Originally, the new RMBH was budgeted to cost $100,000 (US). Dr. and Mrs. Lemons began fundraising. As the needs grew, so did the budget. In the end, the hospital cost $2.3 million, all of which was contributed by private donors. “Many people said it was going to be impossible, but we made a lot of friends and we persisted because of those relationships,” said Lemons.
As the hospital neared completion after two years of construction, Lemons realized he had not given any thought to how to equip it. As luck would have it, the aunt of a Riley nurse in Indianapolis was a nun who operated a medical supply organization that repurposed equipment and supplies from the Franciscan Hospitals. Lemons was ultimately able to procure several million dollars in equipment for $30,000--the cost of shipping three 40-foot containers to Kenya with a matching donation to the organization.
“They unpacked those containers the night they arrived, and the next day they started delivering 20 babies a day,” said Lemons.
After the hospital first opened, the nurses told the Lemons family that many of the poor patients would get visibly angry when escorted to the new labor ward. The hospital facility was so nice that they thought they were being moved to a private wing and would incur enormous charges.
“The nurses said the greatest joy they had was being able to tell them, ‘No, everyone is treated the same here. Rich or poor, you will get the best of care.’ It was just so tangible of how important it was for poor people to be seen and valued as we should all be,” said Lemons. “That was a reminder for all of us how important it is to have a place, especially around birthing, that is beautiful, safe, and where all are treated equally,” he continued.
Audrey Chepkemoi, M.B.Ch.B/M.Med (Paediatric), recently joined the faculty at MTRH as the first board-certified neonatologist. Her interests are improving short-term and long-term newborn outcomes, mentorship, teaching and research. “The AMPATH partnership has benefited the clients at RMBH greatly through infrastructure development, capacity building, donating equipment and daily patient care through prevention of mother-to-child transmission of HIV,” she said. “I am one of the beneficiaries of the partnership. During my M.Med training at Moi University, I had an opportunity to do my external rotation in Riley Children’s Hospital in Indiana. This was an eye opener for me,” she continued.
Rachel Spitzer, MD, MPH, FRCSC, was among the first faculty members from AMPATH consortium member University of Toronto (UofT) to practice reproductive health with Kenyan colleagues in Eldoret. One of the key goals of UofT’s involvement with AMPATH was prevention of maternal morbidity and mortality. “The Riley Mother and Baby Hospital helps us address that key objective,” said Spitzer.
Spitzer, vice-chair of global women’s health and equity at UofT, began working at MTRH before the new mother and baby hospital was constructed and recalls how the opening of RMBH changed the labor and delivery experience overnight. “The entire labor and delivery area (at MTRH) was the size of half a ward. Women would labor in one area, a couple of women to a bed, and would then deliver in a room with just two delivery beds. Obviously sometimes you would have more than two women delivering at a time,” she recalls. “We went from two beds to 20 beds overnight.”
She cites the proximity to the neonatal unit and direct access to an operating theater as two key benefits to RMBH. Prior to the dedicated facilities, women would have to be moved to the main operating theater if they needed a cesarean surgery. “In a specialty where sometimes the minutes matter very, very much, this gives us the potential to make a huge difference,” Spitzer continued.
“It was indescribable to go from this cramped tiny, tiny space where some of the most critical circumstances play out to suddenly have three floors of space to divide up the different clinical needs,” Spitzer continued. “This has led to a lot of what we have been able to achieve and what follows.”
Sarah Esendi Kagoni, nurse manager of the obstetrics unit (labor ward, antenatal ward, reproductive health, well-baby clinic, postnatal ward and hostels), details the impact that the RMBH has had on patient outcomes. In addition to an increase in the number of deliveries, these include “reduction in the maternal mortality rate, an increase in patient satisfaction, increase in staff satisfaction in terms of working space, many success stories in terms of near misses, and an expansion of other reproductive health services such as family planning and management of different conditions.”
“There are a lot of patients who come in to our facility in a very bad condition and they require ICU care,” she continued. The most common conditions are acute kidney injury, HELLP syndrome, eclampsia, post-partum hemorrhage and puerperal sepsis. These patients receive aggressive management by a multidisciplinary team. She encourages more doctors to join the new maternal fetal medicine (MFM) fellowship.
The MFM fellowship launched in January 2019 at Moi University/MTRH in partnership with the Departments of Obstetrics & Gynaecology at University of Toronto and at Indiana University. Julie Thorne, MD, MPH, FRCSC, AMPATH reproductive health team leader, said this fellowship will improve management of high-risk pregnancies. This is just one of many educational opportunities that the RMBH has enabled. Thorne also cites the Mmed registrar program in obstetrics and gynecology, and multi-disciplinary emergency obstetrical training programs such as Comprehensive Emergency Obstetric & Newborn Care (CEmONC) and Advanced Labour and Risk Management (ALARM) as examples of ways of improving the standard of care through training.
“Our brand new ultrasound is being installed now at RMBH and the quality of obstetrical ultrasounds is only going to improve,” she continued. “Our Department of Reproductive Health has broader dreams of an Uzazi Centre—a centre of excellence in all women’s reproductive health care, including minimally invasive access surgery, comprehensive urogynecology, endocrinology and infertility, pediatric and adolescent gynecology, in addition to our general obstetrics and gynecology, maternal fetal medicine, and gynecology oncology programs,” she continued.
Han Sitters, a midwife from the Netherlands who provided both care and training for more than a decade at MTRH and RMBH, reflects the dedication that helped make RMBH a reality and which continues to drive improvements as the mother and baby hospital enters its second decade. “As a care giver you need to 'love' every patient a bit and go all the way to get her the best care, even if that means you need to make longer hours and spend more energy. This is not an office job, so dedication is what one needs,” she concluded.
Chepkemoi said the team in RMBH newborn unit plans to build capacity in the NICU so the newborn unit at RMBH becomes a center of excellence in Africa. They also hope to be able to use data to improve newborn care not only in RMBH, but Kenya at large. Their goals include an outreach program to empower the staff in lower level facilities with information on newborn conditions that can be managed within their facilities to effectively reduce the number of referrals for common neonatal conditions, which would alleviate the high numbers in the newborn unit at RMBH. They are currently working with Moi University in developing a curriculum for a neonatology fellowship program at MTRH which would improve newborn care in Kenya.
Dr. Lemons recently visited RMBH and returned to Indiana with renewed enthusiasm for the advances that the faculty and staff of RMBH continue to make. “They have implemented ventilator care in the NICU along with surfactant administration (to aid in lung development). These are huge new leaps in the level of care,” he praised.
“Seeing how far we have come over the past 30 years, it is clear that caring for each other, letting love lead the way, has been the guiding force,” Dr. Lemons concluded.