A frail figure emerges from the maternity ward, dressed in an over-sized gown, the expression on her face shows her pain and despair. Behind her are two women carrying a bucket and a polythene bag with clothes haphazardly stuffed inside. Another woman is carrying her baby wrapped in a baby shawl. Her facial expression shows something is amiss. She is carrying the lifeless body of her newborn baby.
The woman walking with difficulty is Phoebe Achieng, 27, who has just given birth at the Homabay District Hospital. She is not happy however because her baby is dead, and she blames the poor facilities at the hospital for the loss of her son. The story of Achieng is just one of the many challenges pregnant women face in public hospitals. In 2005, the government started a health insurance scheme to enable poor women access maternal care in a bid to reduce the high mortality rates then skyrocketing.
Seven years down the line, little seems to have been achieved. The programme dubbed 'output-based approach' had the objective of reducing the unskilled birth attendants by lowering maternal fees to mothers but the current situation paints a bleak future for the otherwise noble project. Traditional birth attendants are on the rise and the number of women delivering in hospital is a pale shadow and a sharp contrast to the high number who attend maternal care.
Meet Jennifer Auma, a 27-year-old woman, who ran away from high fees in hospitals to seek solace in a tiny ramshackle house at Sofia Estate where many other women have come to deliver.
She is among the over 60 per cent of women in Homa bay district who shy off from hospital because of the high delivery charges. Auma is not alone in this tin house. With her are seven other women who have come to seek the services of a traditional birth attendant, Petty Akoth, popularly known as Mama Jossy.
The 61-year-old Mama Jossy is an experienced traditional birth attendant. She claims she has 50 years experience in this business. At Mama Jossy's house, many photos of newborn babies are loosely attached to a cardboard from one corner to the other, a testimony to the uncountable number of children she has helped bring to this world. As if reading my mind, Mama Jossy proceeds to bring two big albums with more photos of the children she has delivered. Impressive as it is, the pictures are a stark reminder of the failure by our public health institutions to take care of the needs of poor women.
Mama Jossy says she delivers 15 women in a day. Auma and her colleagues who have come to Mama Jossy say they have run away from poor service, high costs and bad attitude from nurses at the Homabay District Hospital where they have been attending ante-natal clinic. They said the hospital charges them Sh1,000 for delivery besides a requirement that they carry their own consumable medical supplies. “We are forced to buy things like gloves, syringes, needles, cotton wool, detergent and sutures and we must buy them in the hospital pharmacy,” says Auma. They say those who fail to bring the consumables are left unattended for long. Sometimes they are attended to when it's too late.
Nancy Atieno, who lost her child in 2011 when she went to deliver at the facility, says she has lost faith in hospital delivery and the only attachment she has with the hospital, albeit grudgingly, is attending the ante-natal clinic. “Nurses at the facilities are arrogant and they don't seem to value life. They leave crucial activities to trainees and only come late when even the mother has lost her baby or died out of bleeding,” Atieno says. "In order to give birth in public hospitals, the women should come with their birthing kits - gloves, blood bags, scissors, cotton wool etc, which cost about Sh2,000.
If women come without the kit, the midwives don't take care of them very well, and not at all if they are HIV-positive," she says. Atieno confides that for the four days she was admitted at the Homabay District Hospital, she witnessed at least three mothers lose their babies because of the negligence of the nurses. “Women can buy the same drug more than twice; after one nurse has used it, she can either leave the needle on it or leave it open but when another one comes, she ignores it, saying it might have been contaminated or the needle left by a jealous relative thereby forcing the patient to buy a new one,” she says.
Bribes, poorly trained medical staff, lack of medical care for pregnant women and health facilities' directive to women to buy consumables needed before delivery has conspired to send women away from the hospital, away from safe delivery and subsequently negating government plans to reduce maternal deaths. The agony that women undergo in the hands of the nurses at the hospital has forced many women to only attend ante-natal clinics and choose to deliver at the traditional birth attendants 'clinics'.
During a recent survey on the situation of ante natal care, the province health stakeholders led by the public health and sanitation officials revealed that out of 465,078 ante natal cases, only 72,000 end up delivering in health facilities upon the fourth visit. Nyanza provincial Aids, STI co-ordinator, Dr Charles Okal, says a number of factors explain this worrying trend. “Monetary constraints, poor infrastructure and old beliefs that TBAs are more supportive than midwives is keeping many women from hospitals,” Okal says.
However, Joshua Olang, a programme officer at a community integrated health service K-met, an NGO headquartered in Kisumu, that deals with maternal and reproductive health says the threat on women at the hospitals is real. He says while the government announced subsidies in maternal health as a policy to enhance safe delivery, it has not gone beyond words into action. He says the continued existence of TBAs as an alternative to midwives is an issue that can only be tackled by serious change of attitudes and making the policy actionable by providing equipment. “If only there were enough midwives, TBAs could have been phased out with ease but their existence is hurting health provision, as some of them follow mothers up to maternity wards and take advantage of the health manpower shortage to continue delivering mothers,” he says.
“A hospital may have only three midwives who alternate between leave, workshop and the hospital. This makes it difficult for the personnel to take care of the surging numbers leading to neglect,” Olang says. His sentiments are echoed by his director, Monica Ogutu, who says the challenge of maternal services access is still far-fetched in most of the facilities in Nyanza province. "The government decided to set up health centres all around the country but the staff numbers hasn’t increased. In some facilities there are only three health workers in the maternity service who are supposed to cover more than 20 births a day. So stress is high among the staff," says Ogutu.
The stress coupled with low pay sometimes lead to the bad attitude and corruption in public hospitals. "It is not unusual for doctors to ask for money from expectant mothers for special care," she says. “The main challenge in Nyanza is affordability and availability of skilled midwives and consumables in the facilities,” Ogutu says. Homabay district medical superintendent Ojwang Ayoma, however, says it is not bad attitude among midwives that drives women out of the facilities but economic factors. He says infrastructure and proximity are some of the reasons why women prefer to deliver with unskilled attendants.
"The Ministry of Health recognises that there is a big unmet need for skilled attendants especially in hard-to-reach areas, a fact that often drives women to seek services from TBAs,” Ayoma says. “Given the biting poverty, low literacy levels, shortage of manpower, it would be unrealistic for government to think that it would improve the maternal mortality rates by terminating the services of TBAs,” Ayoma says. He however notes that mortality rates have reduced and live birth stand at 85 per cent compared to 46 per cent earlier in the district.
He says the mortality rates currently experienced in the district has been occasioned by TBAs and late arrival at the facilities after the TBAs have failed. He however defends the buying of consumables by pregnant women, saying it is part of the cost-sharing policy. About 80 per cent of all maternal deaths in Nyanza are due to haemorrhage, infection, unsafe abortion, hypertensive disorders, and obstructed labour, along with HIV/Aids and malaria, according to the statistics at the provincial public health office.