Raliyo Kusow with her baby

NAIROBI, Kenya (WOMENSENEWS)–On hundreds of nights over the past 20 years, taps on the tin wall of her one-room house pulled Joyce Atieno from her bed and into the muddy streets of Nairobi’s slums to help another baby into the world.

In a city rife with predatory quacks and counterfeit pharmaceuticals Atieno, 38, was a trained birth attendant who gave her services for free. But not anymore.

"If somebody comes to me I just tell them no because there is no pay, nothing," she says. "I don’t want to continue with the work again because I don’t have the support from the hospitals."

She’s been worn down by the indifference and outright cruelty, not on the streets of the famously violent Mathare slum, but in Kenya’s health care facilities, where scandals and investigations of violence against women in labor have resulted in few improvements.

Her resolve broke in 2006, when one patient was turned away from a public hospital because she did not have the $45 deposit required for admission. Rushed to a private clinic, the mother was turned away again for lack of money. Kneeling in the mud outside, Atieno assisted the birth, tying the placenta with twine fished from the gutter. But it was too late. Both mother and child died.

Later that year, Atieno’s 25-year-old daughter died on the doorstep of the public health facility where her husband worked. Administrators told Atieno they were not equipped to handle the complications and their ambulance was out of gas.

A July 2007 report by the Center for Reproductive Rights in New York and Nairobi’s Federation of Women Lawyers document the extreme conditions in Kenya’s delivery wards as well as the indifference Atieno describes. Women who arrived at hospitals without their own supply of anesthesia were stitched up without medication. Each year, hundreds of new mothers unable to pay fees are detained in health care facilities.

In one case, a male clinician who was supposed to stitch up a tear a woman sustained during delivery used his scissors to genitally mutilate her instead. (Female genital mutilation was outlawed in Kenya in 2001 but the practice persists and an estimated 38 percent of Kenyan women have been cut.)

Though two independent doctors, including one from the police department, confirmed the crime, Kenya’s Medical Board found insufficient grounds for a hearing. So far, every complaint that the Federation of Women Lawyers has brought before the board has been dismissed as unworthy of further investigation.

International Focus

Health officials and advocates gathered at the Women Deliver conference last week in London to focus international attention on maternal health complications, which claim the lives of 536,000 women each year, according to the World Health Organization. Of those deaths, 533,000 occur in the developing world and half of those occur in sub-Saharan Africa.

Many African countries lack the funding and health facilities to provide care for pregnant women. But Kenya, one of the continent’s most prosperous, will receive over $500 million in health aid from the United States next year. Still, with 1 in 39 women dying in childbirth, it’s one of the most dangerous places on earth to be in labor.

From 1974 to 2002, Daniel Arap Moi’s government all but gutted health facilities. While politicians pilfered money earmarked for hospitals, unpaid staffers extorted patients and fenced stolen supplies and equipment to private outfits. By the time President Mwai Kibaki was elected on a platform of reform, most public hospitals were little more than shells sheltering demoralized and bitter employees.

Before she was dismissed last summer, Kenya’s progressive health minister, Charity Ngilu, one of 14 women in Kenya’s 224-seat parliament, managed to push through a bill waiving delivery fees for women unable to pay.

The new law doesn’t apply to Nairobi’s Kenyatta National Hospital and Pumwani Maternity Hospital, to which smaller facilities across the country send women with complications. Mothers who cannot afford $40 to $60 deposits must demonstrate they are too poor to pay, a lengthy process. Once inside the hospitals, it can be hard to get out again.

Wards Crowded With Detained Women

During a recent visit to Kenyatta’s maternity ward, 59 women shared 39 beds. Ten others rested on the scruffy linoleum floor with their newborns.

"Those ones will stay," said Anna Abwao, the maternity ward’s charge nurse, referring to the women who have claimed they cannot pay the delivery fees. "Of course we are trying ways of sorting them out. But some tell the truth; others are liars. So we try to evaluate them." Gesturing toward the floor, Abwao said, "We keep them down there."

Based on their own experience and that of mothers they’d attended, midwives told Women’s eNews of beatings, verbal abuse, filth and blood-soaked beds. They also recounted the infamous month two years ago when medical students performed Caesarian sections on most women who walked through the door, regardless of whether the operation was necessary.

Some women would rather risk giving birth at home, said traditional birth attendant Ann Mbuthia, even when they suffer heart conditions or are infected with HIV, making them more vulnerable to complications.

Faltering Political Will

The political will to reform the health sector is faltering.

Ngilu, whose ministry received just 9 percent of the national budget last year, was sacked this fall after abandoning the ruling party, partly over its inability to rein in corruption.

An official at Kenyatta said Ngilu had been the driving force behind recent improvements. Meanwhile, the reform agenda still has far to go. The 1,800-bed hospital routinely admits more than it can hold, sometimes up to 4,000 patients. In a room meant to accommodate six beds, there are sometimes 15, he said.

A younger generation of health workers, however, offers promise.

On a recent Monday in Kenyatta, a clinic offered free operations for women suffering from vaginal fistula, an incontinence-inducing injury caused by difficult deliveries or violent rapes.

Dr. Charlotte Kaliti, 31, cajoled thorough histories from a long line of women, many of them hunched after years of abdominal discomfort and enveloped in the humiliating odor of leaking urine. Kaliti said her contemporaries are struggling to make things better in spite of tiny salaries and a gargantuan workload.

"We are all aware that that type of abusive attitude exists so we talk about it," Kaliti said, referring to nurses and doctors who beat and verbally harass women during delivery. "If I go to the ward and I see somebody treating a patient badly, thereafter I can go and tell them, you know what, she’s having a hard time. Maybe if you talk to her more gently she might be more cooperative. We want to encourage them to come back. We want to encourage them to open up."

Zoe Alsop is a freelance journalist based in Kenya. Before moving to Africa she studied international affairs at Columbia University and was researcher for the book, "The Brotherhoods: The True Story of Two Cops Who Murdered for the Mafia." She expects to deliver her first child in Nairobi this February.

For more information:

Women Deliver

Center for Reproductive Rights, "Failure to Deliver: Violations of Women’s Human Rights in Kenya’s Health Care Facilities":

U.N. Population Fund, Safe Motherhood Initiative:

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