Pregnancy is a period that any woman who has undergone it, knows too well the longest period of waiting is the nine months. It is a moment of trials and temptations things that you once loved to do or eat, has no meaning again. Life is on a roller coaster changes from time to time like the chameleon. I still hold on to dear memories of childhood with such sense of humility, almost sacred that requires no second thought as I was growing up it was fascinating to me how pregnant women looked like, 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 the woman's tummy grew, bigger and bigger! What a wonder!
Such great responsibility was placed on the womb that even in public places or in 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 now clear vanity to me how women have faced success and challenges since creation and wish the same treatment would transcend during labor.
There I was in the labor ward of a 200 bed capacity of public hospital with all adequate equipment to save mother and baby. But tonight I did not save the only child to a young mother. I was working into my second week of night duty as a nurse supervisor which entailed taking reports and doing periodic rounds to keep check that nurses, doctors and other paramedics were attending to all patients within the required time frame. It was already looking a busy night with calls in every ten minutes from ‘’I need an anaesthisitst fast, sister”! Putting down the phone, another one rrrring! “Matron there is a child in respiratory distress, we need an ambulance”! Being a public hospital the number would sometimes surpass the capacity leading to overcrowding, longer working hours. This night already looked busy because into my third hour of the duty, I already started feeling the effects of a buildup of pressure! The night was still young!
Towards 11pm in the night my energy was going down with so many calls to reply, a mother had been referred to our maternity from the (Level I Facility) a health centre within the city, with complication of a reduced fetal activity with a breech presentation (baby presenting with the buttocks first in the birth canal), that required the mother to undergo an emergency caesarean section. I called the doctor on duty to immediately attend to the mother, there was need to move with speed. I went to check out again the mother who at 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 a far with fear registered 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 awaiting in theatre for the same doctor .The midwives in labor ward had been two. As we were waiting for the doctor to arrive, the woman was getting tired and it was futile to just wait and watch. I gained courage to do a vaginal examination that confirmed and incoming foot. Because of the position of the baby it meant going skillfully around the foot and loosen it with an incoming uterine contraction.
A four hourly vaginal examination 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. But this time round it was a foot.
Fraser (2008), author of the Text book of Midwives explains the causes of breech presentations vary from multiple pregnancy to other uterine abnormalities like abnormal lying placenta among others. The fetal heart was present but weak. Reassuring the mother to breathe in and out with the help of another midwife who kept confirming the progress of the mother, I was able to deliver the legs out of the vagina, and with my right hand holding the mouth of the baby, the left hand holding supporting the back to easily free the forehead of the baby out of the birth canal. Finally the hardest part of delivering was over and the baby was out.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 fast, the pediatric doctor was within and started the resuscitation of the newborn. After an extensive effort baby was taken to the newborn unit in the incubator, there was feeble heart rate. It was very unfortunate for the access and delay of the mother to reach the maternity; we lost a new born after one hour!
The second death dealt a hard blow when I lost a colleague, a nurse after a caesarean section. She had been a lively nurse working throughout her pregnancy without much obstacle, however this 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. Such complexity has caused a lot of interventions and sometimes failure in maintaining health of citizens.
Maternal Health care system in Kenya
The World Health Organization defines “a health system as all the activities whose primary purpose is to promote, restore, or maintain health”. Thus health systems provide values and norms for its operation.
Looking at the two women who underwent the most difficult periods in their lives brings closer home the disparities of maternal health care services in Kenya. For the last 50years the government has been trying its best to address the issue of maternal health policies. Positive changes as well as pitfalls have occurred in the health care starting from the 1960s when the government introduced the free health for all, but as the population grew in the 1980s there was need to reinvent in primary health care to focus on family planning, health education and primary intervention. In the 1990s the rural facilities increased, to cater for the growing population. With it came the introduction of user fee (paid by individual clients when accessing services) in public hospitals. It dealt a blow to the interventions of 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 again borne to address the women health, the then Minister for Health in 2003 declared that at the Level 1 and 2 delivery would be as low as Ksh 30.This was meant to encourage women seek for labor care in hospitals other than the traditional birth attendants. A Community health worker I met in the village cautioned women on, “It is good to deliver in hospitals because there are experts, however sometimes the care is not good there and even when you don’t have money, it is hard, you remember those women who were locked after nonpayment? I know Amref has empowered those birth attendants but personally I tell the mothers to go to the hospital’’.
Ideally as described in the International Centre for HumanResources in Nursing (ICHRN 2010) the health structure within the Ministry of Health functions in a pyramidal sequence starting from the community health services as a 1st Level and is headed by a nurses and community health workers, there is no deployment of a doctor notably the citizens have this facility as the first contact to health care services, which has limited equipment to provide highest attainable standard of maternal care. At the Dispensary, 2nd level there are basic healthcare services for emergency obstetric care and the personnel comprises of nurses. Moving towards level 4-6 the services are broad, ranging from the curative to preventive and the health personnel is wider and highly skilled. Apparently these levels (5-6) are urbanized and majority of Kenyans and pregnant women access the services when the condition is advanced. The first mother had to endure long waiting hours to reach at the level 4 of care hence delayed decision making and emergency treatment.
This disparity in delivery of health care poses challenges in meeting the needs of the newborns and mothers.A mother of two confirmed,“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”. The attraction of health professionals to move to the urban facilities has made the government to employ other positive measures in employing more nurses and midwives, clinical officers through an economic stimulus package to address the citizens’ access to quality care.However the task has been huge to maintain the migration of nurses/midwives to Europe, America and Australia. The maternal health care is needed now more than ever with skilled health care professionals.
Midwives Migration, education and practice
The delivery of breech presentation is an art, as a skill that needs patience. Not every midwife is competent to deliver such complicated cases. Due to difficult conditions that some midwives work in, the slightest opportunity to migrate always poses a threat to delivery of care especially in Level 1 and 2, where services have been affected from time to time. The Midwifery education in Kenya is by an Act of Parliament that mandates the Nursing of Kenya to regulate the practice and licensure of Nurses and Midwives. To acquire competence in delivery of women a nurse-midwife student is required t undergo accredited hours of practice in a clinical area.
According to a report by the Public Service International the push and pull factor that drives the nurses to the West is the lack of political goodwill in African countries, poor remunerations and working conditions. A mother who delivered in a public hospital and is a community worker observed that “sometimes when I take the mothers to the big hospital for delivery, I find midwives who are eager to help out, I have not encountered mistreatment but the major problem is that there are so many patients to look after and they are few. I don’t blame them when they delay to attend to my patient. There work is too much……….’’.
The migration of midwives is not new globally, currently the world over is grappling with an acute shortage of skilled midwives to scale up the maternal health care. In Kenya the maternal mortality as reported by the Kenya Health Demographic Survey (2010) indicates a worrying trend that there has been slow progression to avert maternal mortality which shot up from 414 in 2003 to 488% in 2010, this implies that for every 100,000 live births within the country 488 women died at the time of delivery. It happened to me when I was delivering the mother and my two colleagues had to run to attend to all mothers because the staff shortage was a result of my colleagues going back to school, others migrated to Southern Africa and America including internal posting to other hospitals within the country for service need.
According to the UNFPA report (2011) the world needs a unified scope of practice for a midwife. In its report the country has made major strides in provision of emergency obstetric care but still requires a suitable number of midwives to cope with growing population. The estimated number of midwives is at 25,000 countrywide with a population of 40million.
A schoolmate of mine in the nursing school and now working in the USA, during a Skype chat explained 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 it 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.
As a member of a professional body for nurses and midwives during the referendum we were greatly involved in the civic education at the grassroots for the citizens as well as the health workers. And of importance we had urged Kenyans to vote wisely and to remember the Bill of Rights that touched on the basic rights to clean water, environment and highest attainable health care. That health was paramount, without a healthy nation no better agenda would be moved. Evident of this was the UN Person of the Year 2011, who was a midwife and had endured to work in very severe conditions to deliver women.
The reforms of the Constitution of Kenya were the height of achievement in democracy in the Horn of Africa. It was a courageous move that other African nations waited to see the outcome. The people of Kenya displayed to the world an understanding of growing its nation to a better living world. Even though the major hurdle in the Constitution was the Bill of Rights, majority of them 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 touch on women health such as the Universal Declaration of Human Rights, Convention on the Rights of a Child, The Abuja Declaration on Health, Maputo Plan of Action.
Two years later the Constitution is 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 child hood friend and an intelligent lawyer cautions observed that “the Constitution is a good document, when I was conducting civic education some politicians spread rumors that women will abort carelessly. This is not true! But people believed that! We voted for YES or NO. Ask many Kenyans what they know about the Constitution; they will mention a thing or two about it meaning they at least read more than the politicians. I say that am passionate about the Article 43 that touches on the socio –economical and this where the citizens should take the government to accountability.’’
Light across the tunnel
There are currently major strides to address the gap in maternal health; both the civil society and the government are providing significant inputs towards it. Currently the Amref and Aga Khan Development Network are reaching to the women in the hard to reach areas by providing basic training to the community as a link in assisting women to deliver safely in hospitals.
The life of mother and the unborn lies on the mandate of the New Constitution, they can die or live if the social amenities are favorable and if the political will is there to support. Midwives too have the power to save a life or succumb to death in the face of a complicated healthcare system that has hurdles in realizing its priorities.
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 this citizens because we believed she was bringing forth life and that was precious. The governments the world over must treat maternal health with utmost detail and conscience, as they do with defense force in readiness for war or a nuclear plant launch. No woman should die while giving birth unless it is inevitable!