Losing a life to give life: The cost of maternal healthcare
Any woman, who has undergone pregnancy, knows too well that the longest period of waiting is the nine months. It is a time of trials and temptations. Things that you once loved to do or eat are no longer options for you. Life is on a roller coaster, changing from time to time like the chameleon. I still hold on to dear memories of childhood that feel almost sacred to me now. As I was growing up it was fascinating to me how pregnant women looked. In my childish mind I wondered how they felt; was baby Jesus heavy (that’s how adults described the unborn to me), did he cry for milk. And as the woman’s tummy grew, bigger and bigger! What a wonder!
Such great respect was placed on the womb that even in public places such as buses, I saw big, fat, short and tall women and men springing from their seat to allow a pregnant woman rest. ‘Mama Keti hapa”. (Have a sit mum).Now that am done with childish thoughts, it is clear to me how women have faced the successes and challenges of pregnancy since creation and wish the same treatment would transcend during labor.
There I was in the labor ward of a public hospital with a 200 bed capacity with all the adequate equipment to save mother and baby. But that night I did not save the only child of a young mother in labor. I was working into my second week of night duty as a nurse supervisor which entailed taking reports and doing periodic rounds to check that nurses, doctors and paramedics were attending to all patients as needed. It was already promising to be a busy night with calls every ten minutes. ‘’I need an anesthetist fast, sister!” As I put down the phone, another one would rrrring! “Matron there is a child in respiratory distress; we need an ambulance!” Being a public hospital the number of patients would sometimes surpass the capacity. Into my third hour of the duty on this busy night, I already started feeling the effects of a buildup of pressure! And the night was still young!
Towards 11pm my energy was draining. A mother had been referred to our maternity from the Level I Facility health center within the city She presented complications of reduced fetal activity with a breech presentation (baby presenting with the buttocks first in the birth canal), that would require an emergency caesarean section. I called the doctor on duty to immediately attend to the mother. There was need to move with speed.
Later, I went to check the mother who by this time was in acute labor pains, wailing, kicking her hands high up! Calling upon God! Oh Lord! Save me, save my baby! Other women looked from afar with fear in their eyes. Before long another scream came from the furthest corner of the room, Sister! Sister, oh! Oh! Aaagh! The nurse ran to attend. It was just becoming chaotic; we had about seven women in their early labor, three in active labor, one waiting in theater for the same doctor. There were only two midwives in the labor ward. As we were waiting for the doctor to arrive, the mother was getting tired and it was futile to just wait and watch. I summoned my courage to do a vaginal examination and found the infant’s foot, confirming the breech position. The position of the baby meant going skillfully around the foot to loosen it with an incoming uterine contraction.
According to Fraser’s Text Book of Midwives (2008) the causes of breech presentations vary from multiple pregnancies to other uterine abnormalities. A vaginal examination every four hours is necessary during labor to ascertain the progress of a normally descending head and ripening of the cervix. In this case a cervix needs to open as a result of hormonal effects that are active as soon as labor starts up to allow for the descending presenting part (head, breech) to be delivered spontaneously The fetal heart beat was present but weak. I was able to deliver the legs out of the vagina, and to free the forehead of the baby out of the birth canal. Finally the hardest part of delivering was over.
Sadly the baby never cried! I felt butterflies in my tummy and a thin streak of sweat on my forehead confirmed my worst fears. The mother raised her head and with a weak voice asked, ‘Is my baby dead’, with tears flowing in her eyes. I did not have an answer. Cutting the umbilical cord, the pediatric doctor started the resuscitation of the newborn. The dreaded incident happened and within an hour we lost the baby. All due to delay access to reach the facility.
A second death that night dealt a hard blow. A fellow nurse succumbed to unconsciousness after delivery through a caesarean section which was too much for her to handle. She was taken to the intensive care unit and never woke up from the deep sleep. It was the last time to see a colleague, a nurse and a diligent young mother who had much dreams for the new life ahead. The baby survived. The health care system provided life and death for a new born and a mother.
The Health Care System in Kenya
Looking at the trials of these two women brings closer to home the disparities of maternal health care services in Kenya. For the last 50 years the government has been trying its best to address the issue of maternal health policies. Positive changes as well as pitfalls have occurred in health care starting from the 1960s when the government introduced free health care for all. As the population grew in the 1980s there was need in primary health care to focus on family planning, health education and promotion. In the 1990s the rural facilities increased, to cater for the growing population. With the expansion came the introduction of a user fee (paid by individual clients when accessing services) in public hospitals. User fees paralyzed primary health care meaning poor people had to wait to die in the event they didn’t have money to access health care.
A brilliant idea was borne to address women’s’ health. The Minister for Health in 2003 declared that at the Level 1 and 2 deliveries would be as low as Ksh 30 (I $-Ksh 80). This was meant to encourage women seek labor care in hospitals rather than with traditional birth attendants. However a community health worker I met in a village cautioned women on the limitations of the system. “It is good to deliver in hospitals because there are experts, however sometimes the care is not good there. If you don’t have money, it is hard. Remember those women who were locked out after nonpayment? Personally I tell the mothers to go to the hospital’’.
Ideally the health structure within the Ministry of Health functions in a pyramidal sequence starting from the Community then Dispensary as a 1 and 2 Level headed by a nurse licensed to practice-there is no deployment of a doctor. Citizens have these levels as the first contact to health care services .It has limited equipment. At the Health Center, 3rd levels there are basic emergency obstetric care. Personnel include nurses, clinical officers (doctor’s assistant), and laboratory for simple diagnostic investigations. Moving towards level 4-6 the services range from the curative to preventive and the health personnel team is specialized.
However, these levels are largely urbanized and the majority of Kenyans and pregnant women have limited access to these services. The first mother had to endure long waiting hours to reach level 4 of care due to delayed decision making and access that led to the death of her baby. During a focused discussion one business lady, a mother of two, replied,
“Compared to the public hospitals, the NGOs that have been in our area allow that a mother’s visit to their clinic during pregnancy permits a woman to deliver at no cost”.
This disparity in delivery of healthcare poses challenges in meeting the needs of the newborns and mothers. Health professionals are attracted to move to the urban facilities. The government has employed other positive measures to provide more nurses and midwives, and clinical officers to non-urban areas through an economic stimulus package. However the task has been huge to maintain the migration of nurses/midwives to Europe, America and Australia.
A schoolmate of mine in the nursing school and now working in the USA, explained during a Skype chat that, “as long as there are greener pastures out there to explore I will go. After all it is about the dollars and good living, I don’t want to die in poverty”.
However in terms of the National Health Policy Framework 2011-2030 within the Ministry of Health Kenya has made greater efforts in remunerations and promotion of health workers as compared to other East African Countries. The restructuring of the salary and remunerations scheme has awarded the health workers a fair deal even though it is not exhaustive. This is in accordance to the current reforms in the New Constitution that requires equal health care and a fair remuneration for health workers.
The New Constitution and Maternal Health.
I am a member of a professional body for nurses and midwives which during the constitutional referendum were greatly involved in the civic education at the grassroots. We urged Kenyans to vote wisely and to remember the Bill of Rights that promised basic rights to clean water, quality environment and highest attainable standard of health care. Health care was paramount. Without a healthy nation no better agenda could be moved forward.
The reforms of the Constitution of Kenya were the height of achievement in democracy in the Horn of Africa. It was a courageous move and other African nations waited to see the outcome. The people of Kenya displayed to the world an understanding of growing our nation to a better world in which to live. Even though the major hurdle in the Constitution was the Bill of Rights, majority of them (citizens) felt it was a good document that gave checks and balances. It addressed all aspects of life. At its best the government has been a signatory and ratified many International treaties that address women’s health.
Two years later the Constitution remains a popular theme in the country. The health care system has accommodated the articles that touch on health. The woman’s womb has seen controversial talks like never before in this New Constitution.
A childhood friend and an astute lawyer caution that “the Constitution is a good document, when I was conducting civic education some politicians spread rumors. This is not true! But people believed that! We voted for YES or NO.I say that am passionate about the Article 43 that touches on socioeconomic and this where the citizens should take the government to account. Do we have enough schools, hospitals? Are the youth employed?’’
Light at the End of the Tunnel
There are currently major strides to address the gaps in maternal health care. Both the civil society and the government are providing significant inputs towards it. Currently a consortium of non –governmental organizations are reaching out to the women in the hard to reach areas by providing basic training to the community in assisting women to deliver safely in hospitals.
Walking across the slums, I meet amazing women who are part of a community strategy, using tools such as phones and simple charts to explain the danger signs in pregnancy and I find this a positive journey towards reduction of maternal mortality.
The life of a mother and the unborn lie on the mandate of the New Constitution. They can die or live if the social amenities and political will are favorable to support them.
When I was young I thought being pregnant was sacred. I saw people having humility to assist a pregnant woman live in a stress free environment. There was special attention accorded to these citizens because we believed they were bringing forth life and that was precious.
The governments the world over must treat maternal health with utmost diligence and conscience, as they do with defense force in readiness for war or a nuclear plant launch. No woman should die while giving life!
This article is part of a writing assignment for Voices of Our Future, a program of World Pulse that provides rigorous new media and citizen journalism training for grassroots women leaders. World Pulse lifts and unites the voices of women from some of the most unheard regions of the world.