July 23, 2013
NAIROBI, KENYA – A narrow alley in the slums of Lunga Lunga, a settlement east of Kenya’s capital of Nairobi, leads to a dimly lit, one-room house. Old bedsheets form a modest partition between the room’s two wooden beds.
Esther Mwende, who is in the final weeks of her pregnancy, waits on a bed in the clinic of a traditional birth attendant, whom she knows only as Mama Mutisya. In pain, she sought out Mama Mutisya to learn whether her baby was due, she says.
Finally, the elderly birth attendant – whose real name is Peninah Musiawa – arrives and examines Mwende behind the curtains.
“The baby is not due yet,” she says. “Go home and come back in a week’s time.”
Mwende rises wearily from the bed and walks out of the room.
Mwende also gave birth to her two other children at Musiawa’s clinic, she says once outside. And she plans to continue to give birth here despite President Uhuru Kenyatta’s June 2013 announcement waiving delivery fees at all public health facilities.
“I avoid going to public hospitals because the services are poor and the nurses are very rude,” she says.
She argues that the new measure will not improve care. Public hospitals were crowded even before the president’s announcement, she says.
“I’m sure the services will get even worse now that they are free,” she says.
Further, she is confident in Musiawa’s skill, and she prefers the homey environment of her clinic, she says.
The government aims to reduce Kenya’s high maternal mortality rate by abolishing delivery fees in public hospitals and discouraging mothers from using traditional birth attendants. Although many mothers are taking advantage of the newly free delivery services in public hospitals, some mothers say they still prefer traditional birth attendants, citing poor services in public health facilities. Traditional birth attendants insist that they offer quality care but that their businesses are suffering because of the government’s interference. Officials say it is too soon to determine whether the new measure will affect maternal mortality rates.
Women in Kenya face a one in 55 chance of dying from pregnancy-related causes, according to 2010 UNICEF data.
Kenyatta declared on June 1, 2013, that public hospitals would begin performing deliveries free of charge.
More than 90 percent of mothers already attended prenatal clinics in hospitals, but only about 60 percent delivered there, says Dr. Robert Ayisi, the medical officer of health for the City Council of Nairobi and the officer in charge of Pumwani Maternity Hospital, the largest maternity hospital in Kenya.
Cost was one deterrent. Prenatal visits were free before Kenyatta’s announcement, but deliveries were not, he says. Pumwani Maternity Hospital previously charged 6,000 Kenyan shillings ($70) for a birth.
In addition, hospitals are difficult to access in rural areas, where traditional birth attendants typically work, he says. Other women have preferred to visit traditional birth attendants.
But the government is now encouraging women to forgo traditional birth attendants in favor of public hospitals by making deliveries free. Its goal is to reduce Kenya’s high maternal mortality rate.
“This is in line with the government plans to reduce maternal mortality rate from 520 per 100,000 live births to 147 by the year 2015,” Ayisi says. “The government wants to ensure that mothers access quality maternity care to reduce deaths.”
Reducing the maternal mortality ratio by 75 percent is one target of the U.N. Millennium Development Goals, which countries worldwide have pledged to achieve by 2015.
Traditional birth attendants should not assist women with childbirth in their homes because they often do not have formal training, Ayisi says.
“The skills are passed down from one generation to the next within members of a family,” Ayisi says.
The official stance on traditional birth attendants is that they should limit their involvement to monitoring pregnancies at the community level, says Dr. Samuel Ochola, director of health for Nairobi county.
“They are community resource persons who are supposed to take care of emergencies at the community level, especially in slums where ambulances cannot reach,” he says.
Traditional birth attendants should always refer women to the hospital if they detect danger during pregnancies, he says.
Many women are taking advantage of the newly free delivery services in public hospitals. Immediately after the president’s announcement, more women gave birth in public hospitals, Ayisi says.
On the day of the announcement, there were more than 100 births at Pumwani Maternity Hospital, he says. The hospital now registers 80 births to 100 births per day.
The hospital has hired an additional 10 nurses and four doctors to handle the increased demand, Ayisi says. It also now keeps its two operating rooms open for 24 hours a day.
Yet some mothers say they will continue to visit traditional birth attendants and pay for their care. They cite mistreatment at public hospitals as the reason they are forgoing the newly free services.
“I witnessed a friend lose her baby at Pumwani due to negligence by nurses,” says Mary Ngendo, a mother of two children. “She kept calling them to attend to her, but they ignored her.”
She decided that she would not return to a hospital to give birth. Instead, she delivered her second child at Musiawa’s clinic.
Ayisi says he is not aware of these allegations, as no one filed a complaint with the hospital regarding the incident.
“We try as much as possible to make the women comfortable at the hospital,” he says.
Esther Mueni, a mother of four children, attends prenatal clinics at a hospital during her pregnancies but gives birth at her home because the closest hospital is 25 kilometers (15 miles) from her village in Kenya’s Eastern province, she says. Motorbikes are the main means of transport from the village to the hospital, and they are not convenient in those circumstances.
“Even if the services are free, we cannot access them because the hospitals are too far away,” she says. “If the government built a hospital near my home, perhaps I would consider going there.”
At the same time, she also prefers the childbirth services of a traditional birth attendant in her own home, she says. Her attendant is always available and skilled at her work.
Traditional birth attendants say that their care is equal to or better than hospital care.
Musiawa, a mother of nine, was 18 and still in primary school when she first helped a woman to deliver her baby, she says.
“I had not undergone any kind of training,” she says. “I just found myself doing it. I even helped my father’s second wife to deliver.”
In this way, she launched her 42-year career. She moved to Nairobi from her village in eastern Kenya in 1991 and established her clinic in Lunga Lunga, where she charges 2,500 shillings ($30) per delivery.
Women prefer her style of care, she says.
“Women keep coming to me because they know, here, they give birth naturally, no matter the position of the baby,” she says. “If the baby is not in a good position, I massage the mother’s belly in a certain way, and the baby turns slowly.”
She refers a woman to the hospital only if the baby is too big or the cervix fails to open, she says.
“I also know how to prevent mother-to-child transmission of HIV during birth,” she says. “And in the 42 years that I have been a midwife, I have lost only one baby.”
Musiawa has never lost a mother under her care either, she says.
She attends to about five women every day when business is good, she says. Most of the mothers are from her neighborhood or other nearby slums.
But business is slowing because of campaigns to deliver in hospitals, she says. For example, community health workers have been discouraging women from giving birth at home.
Now, the abolition of childbirth fees in public hospitals has created additional pressure on her business. Musiawa says that it is not right for the government to deny her the opportunity to help women when she has more experience than most trained hospital staff.
Ayisi says it is too early to evaluate the overall impact of the president’s announcement on where women choose to deliver and how this will affect the maternal mortality rate.
“We are yet to know the impact of the free maternity services,” he says. “With time, we’ll be able to know whether the program has dissuaded women from giving birth at home.”
But he acknowledges that a woman’s choice on where to give birth is personal.
“Some women have a lot of trust in traditional birth attendants and will always go to them, no matter what we do,” he says.