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Postpartum Haemorrhage (PPH) and Maternal Deaths in Resource Poor Settings.

Tackling the problem of unnecessary maternal deaths from postpartum haemorrhage (PPH) due to lack of appropriate and easily accessible healthcare in remote situations is both momentous and of great urgency. This is a narrative drawing from a personal (family) experience and, subsequently, from coordinating and conducting an introductory trial of a Bakri Balloon tamponade in referral hospitals in Western Kenya. As mother fate would have it, in March 2013, I joined a relatively small and young private university in the port city of Kisumu in Western Kenya as an Associate Professor of Clinical Biology whereupon two events occurred in the 'wrong' order - the first was my kid brother losing his newly wedded wife during childbirth (you guessed it - from PPH!!); the second being my being appointed soon afterwards as the Dean, Faculty of Health Sciences. The latter entailed running/coordinating faculty-based project and included reviving a moribund project, the Bakri Balloon Project involving three major referral hospitals within the region, the largest of which was where my sister-in-law died while giving birth - thank God the baby survived and is alive and well (just turned three on the 1st of June 2016!).

The scant information I got was that she simply bled out as the nursing team had been left without direction by the doctor responsible. The import of this is that the said nurses could have probably been able to save her life through the use of the Bakri Balloon tamponade since its insertion could've been done by the nursing team even without the specialist, of course after the relevant training. The institution's authorities promised a thorough investigation into the case but we are yet to hear what was unearthed from the investigations

The importance of the prevention of maternal deaths from PPH cannot be overstated, what with the well known but alarming statistics ascribed to it as the highest cause of maternal mortality worldwide with a prevalence rate estimated at 6%, but with Africa reported to have the highest at about 10.5%. In Africa and Asia, where most maternal deaths occur, PPH accounts for more than 30% (can be as high as 60% in resource poor settings)of all maternal deaths. 

The Bakri Balloon used in the trial, funded by an American university, is one of the several sterile packaged tamponade devices being made available for the preventative measures being undertaken in various places. For our project, we hypothesized that the Bakri Postpartum Balloon can be successfully employed to treat postpartum hemorrhage refractory to the usual conservative and medical interventions and will also help avoid operative and expensive interventions including hysterectomies. This is more so because it utilizes minimal additional equipment for placement during postpartum haemorrhage and would be optimal for use in low resource settings. That brings in that very pertinent question of affordability in some of the poorest settings in Africa and Asia. The project recommends further involvement by both the governments and the donor society for sustainability and setting up respectively. But first, the need for further trials in such settings is needed to create awareness further afield as was evidenced by the pleas from one of the facilities which had the highest uptake for further engagement (mentioned in the project report).

By Prof. Gonzo K. D. Manyasi.

http://aphrc.org/managing-research-grants-and-partnerships-in-african-universities-and-research-organization-impediments-of-success-and-what-needs-to-be-done/

Managing Research Grants and Partnerships in African Universities and Research Organizations – Impediments of Success and What Needs to be done

September 25, 2015

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By Loise Ochanda (IDRC), Prof. Gonzo Manyasi (Great Lakes University, Kenya) and Mr. Hamilton Mbokureeba (Uganda Christian University)
During a training on  Research Governance and Management organized by the African Population and Health Research Center (APHRC), Dr. Moses Ngware, reminded the research leaders present that a grant is a ‘conditional gift’ from a funder who has identified a problem and wishes to be part of the solution to the problem. The funder who can also be termed as the granter may have the resources but lack the expertise or the time to put in the work that could lead to the desired solution and this is where the grantee or researcher comes in. The process of grant management starts with the generation of a research or project idea through a proposal writing. This can be in response to open proposal calls or by knocking on doors of potential funders. The grantee would therefore be expected to come up with a solution, whereas exercising good stewardship for the funds. The grant agreement must be consistent with project plans and should be read carefully before agreeing to it.
Financial Accountability Challenges
Grantees often get into avoidable difficulties with budgets which can affect their relationship with the funder or even challenge the working relationships between them and other collaborators and consultants working on the project. In some organizations, there is a tendency of grants mismanagement, situations that have caused funders to recall their funding. The underlying reason being the financial accountability challenges faced perennially by the grantees.
These funds are sometimes misappropriated and are channeled to “wrong-users” of the grant. Sometimes, the investigators do not receive payment due to them as per the approved budgets; some organizations may transfer payroll responsibilities on to the grant budget lines, certain divert and / or reduce these budget lines to service other organizational activities. For example funds may have been provided to pay data entry clerks at an agreed amount over the period of the project, then mid-course into the project you may find that the agreed amount was drastically reduced or in some extreme cases the data entry clerks may not receive the payment due to them.
Managing project funds from a common pot, also pose problems. Personnel costs are often provided for in the budget – this covers for the extra staff time by the investigating team, but some organizations turn this stipend into the team’s regular salary. This system of not duly paying an investigator is demoralizing, leads to delays and failure to meet deadlines. Such behavior breaches contractual obligations between the granter and the grantee and erodes donor confidence in the medium and long run. Overall, organizations must understand and abide by the terms and conditions stipulated in the contracts they sign.
The bureaucratic nature of organizations, their inconsistencies and misappropriations of budget lines cause some investigators to hold dear some of the grants they win. Therefore, the earlier our organizations adhered to the terms of contract, the better for the smooth running of the projects under their custody.
Way forward
Organizations therefore need to maintain donor confidence through total honesty in the management of their funds in order to continue attracting more funds. For instance, it would be better to have separate accounts and budget lines for grants/funded projects from the mainstream organizational budget lines. This would mean that you would have bureaucracy to go through with few signatories and probably with the electronic funds transfers being put to use. Delayed project progress reports, project completions and accountabilities would be avoided.
Communication between the granter and grantee is the clear pathway that should be utilized to make sure both parties are well informed about any changes on budgetary reallocations, need for time extensions, problem solving and any change that occur out of the schedule and plan of the research project agenda.
This blog is part of a series that were written by participants during a Research Governance and Management Training conducted by APHRC in August 2015

RESEARCH GOVERNANCE AND MANAGEMENT - A SYNOPSIS

RESEARCH GOVERNANCE AND MANAGEMENT WORKSHOP – AUGUST 31^st - SEPTEMBER 2^nd 2015 - HELD AT THE SOUTHERN SUN MAYFAIR HOTEL NAIROBI. 

HOSTED BY THE AFRICA POPULATION AND HEALTH RESEARCH CENTER (APHRC).

SCOPE: It was a very comprehensive programme covering the various aspects of the subject matter namely, research governance and management. This ranged from an overview of the status of research leadership in Africa by the Executive Director APHRC, Dr. Alex Ezeh, through research governance overview, ethics and quality assurance, institutional research policies, research performance management, grants and partnerships management, transparency methods and data systems and data sharing (in APHRC).

DEPTH:  While some topics had the luxury of being subdivided, others didn’t get enough time allocation. In the former category were the transparency methods which had subtopics on registration and pre-analysis, programs and workflow and data replication. All in all, they were all treated to in-depth presentations that also involved group work and institutional research case studies.

TAKE AWAYS: Almost everything in the workshop content was of interest in terms of knowledge transfer for implementation at the participants’ various institutions. This was especially so in GLUK’s case, for instance, the need for a paradigm shift in institutional research policies in order to up our game, including the introduction of incentives for researchers (extra emoluments). Secondly, there’s an urgent need for setting up a management structure to direct research activities as opposed to loose groups – we can borrow a leaf on this from Egerton University’s well established structure and adapt it to GLUK’s situation.

 Prof. Gonzo Manyasi.