Lillian Wanjiru, 30, with daughter Rosemary. She begged not to have an expensive C-section.
NAIROBI, KENYA—Lillian Wanjiru is in labour, about to give birth to her third child, and she is worrying about contracting HIV or some other infection in the maternity ward.
She is lying on a rusted metal cot covered with a cream vinyl mat. It’s been given a quick wipe with disinfectant and water after the previous birth.
Quarter-sized drops of other women’s blood dot the floor of the labour ward, where nearly 30 women, many teenagers, are giving birth. Pieces of placenta lie on a bloodied mat a few beds over.
Meticulously, Wanjiru — round and petite with kind, saucer-shaped brown eyes — pulls a multicoloured wrap under her waist, down past her knees, trying to protect her naked body from the worn vinyl. She closes her eyes and scrunches her face, wincing through a contraction.
There are no painkillers. No family members are allowed, to wipe sweat from foreheads or rub sore lower backs. Some women whimper, soft moans. Others holler, rambling as if they are speaking in tongues, eyes rolling back in their head.
“You’re coming where your money is affording you,” Wanjiru says quietly. Rich people in Kenya go to private hospitals, with clean sheets, not here to Pumwani, one of the largest public maternity hospitals in Africa.
Poking out from her overnight bag, a new blanket and onesie for her baby. Wanjiru is praying for a girl. Her two-bedroom Nairobi apartment is already filled with school-age son Clinton, toddler Michael and husband Paul.
To build her strength, the 30-year-old housekeeper, who taught herself English by watching African soap operas, has been trying to eat porridge, greens and some fish. But there were many days when she went with little, eating just ugali (a mixture of maize flour and water) to save for the costs of delivering in Pumwani.
It’s a perverse trade off: to receive skilled medical assistance, she sacrifices her health.
Two nights in hospital costs about $12.50, a sizeable chunk of the $70 she and Paul, a contract construction worker, earn in a good month. A caesarean section costs double.
Despite the expense, Wanjiru says the hospital — where trained staff can deal with complications such as a breech baby — is safer than giving birth at home. In Kenya, there were 530 maternal deaths for every 100,000 live births in 2008. It’s a rate that has risen steadily since 1990, although it is down marginally from its peak of 580 in 2005.
In a 2010 interagency report, the World Health Organization and others said Kenya had made “no progress” in improving maternal health.
A recent Kenya Demographic Health survey found only two out of five births were attended by a skilled health-care worker. For the poorest fifth of the population, a trained attendant was present just 21 per cent of the time.
Rose Oranje, a policy and communications specialist with the African Institute for Development Policy, thinks a “persistent lack of political commitment,” helps explain why Kenya has made little progress — something that’s reflected in the limited amount of government resources allocated to maternal health. There are only 14 physicians and 118 midwives per 100,000, according to the World Bank.
Unsafe abortions account for a third of all maternal deaths in Kenya, she says, adding that other countries in sub-Saharan Africa, such as Ghana, Ethiopia and Rwanda, have prioritized maternal health care and reformed abortion laws, among other things. “But Kenya isn’t doing any of these,” she says.
And then there’s HIV. While its prevalence has declined, women are still almost two times more likely than men to contract the disease, which contributes to about 14 per cent of maternal deaths.
There is also a high rate of teenage pregnancy. Physiological and social factors can mean a greater risk of complications, such as obstructed labour, for young mothers and babies. In 2010, the country’s infant mortality rate was 52 per 1,000 births, an improvement from 77 in the 2003 health survey.
At least 100 babies are born each day in Pumwani’s tired cement building, which has seen few upgrades since it opened in 1926.
Run by Nairobi’s city council, costs are largely subsidized. Pills to help prevent the transmission of HIV from a positive mother to her baby are free. There are seminars on hygiene and breastfeeding. Abandoned children are sent to different orphanages, depending on their HIV status.
But the hospital has been criticized by human rights groups and the media.
A scandal during the early 2000s centred on the disappearance of newborns from Pumwani. A U.K.-based Kenyan evangelist had allegedly promised infertile women “miracle babies.” He is to be extradited to Kenya to stand trial for child abduction.
In September, a government task force found corruption, lack of critical supplies, mistreatment of mothers and absenteeism among doctors at Pumwani. More than 1,000 children died at the hospital in the past year. And while 13,000 women gave birth normally, 253 developed complications and 13 died.
Only a fraction of the necessary incubators are working. At-risk mothers waited 24 hours for an emergency caesarean section, the task force found.
Paint peels off walls, which look as if they haven’t had a good scrubbing in years. Curtains separating the beds are ripped and yellowed. Cockroaches jet out from corners. Staff is entirely hands-off and overworked. There are tales of women delivering on their own, babies almost falling off the cots.
Wanjiru came to the hospital the night before, having experienced stomach pains.
Her water broke at breakfast, although she doesn’t tell the nurses — she fears angering them if she bothers them. She calls her husband and tells him she’ll phone again after the baby is born.
By noon, a doctor makes his rounds. He does not speak to Wanjiru, but ruptures her membrane with scissors as she writhes from pain. It shouldn’t be much longer, a nurse says, especially since this is her third child.
But for nine hours, she struggles, dilated at five centimetres. Wanjiru keeps saying she can feel something is wrong, that she needs medicine to make the labour progess.
Women are supposed to be checked every 30 minutes, say nurses and doctors. A plastic cone is placed on their stomach to listen to the baby’s heart rate, starkly simplistic compared to electronic fetal monitors in Canada. Blood pressure, temperature, hydration status and contraction rates are all supposed to be monitored.
In reality, hours pass before anyone stops for more than a passing glance. No one, including Wanjiru, is counting the time between contractions. There are long periods where she may as well be at home. She’s on her own here.
At hour seven, head nurse Rosemary Mideva, a motherly woman who shepherds the ward but is stretched in too many directions, decides Wanjiru is progressing too slowly and her contractions are not strong enough to push out the baby.
A doctor needs to examine her and she may need a caesarean section. But another three hours will pass before that happens.
“I don’t want theatre,” says Wanjiru, referring to the operating room and pleading with a reporter to tell the nurses she can’t have surgery.
She worries that if she has an operation, the stitches will burst when she is at work, washing laundry in basins. But she doesn’t dare speak to the staff.
So Wanjiru waits, in pain, and worries.
Rice and beans are served from a metal bucket, but she eats a banana from home because it’s cleaner. She would never eat food here.
There are moments of serenity.
The women hold hands and hum. “We share the problem that now we are all going through,” says Wanjiru. They enter strangers and leave sisters. And there is something beautiful about that.
Around 10 p.m., a different doctor makes her rounds. She gives Wanjiru drugs to help with the labour.
For the first time in more than 10 hours, Wanjiru screams.
Finally, at 11:27 p.m. the baby’s head crowns. Two nurses rush over. The umbilical cord is wrapped around the baby’s neck. One nurse clamps both sides of the cord and cuts it. A faint whimpering, then a cry.
Wanjiru is lucky she’s come here — this sorry hospital saved her baby’s life, and probably her own.
Placed on a metal scale, the baby, a girl, weighs 5.5 pounds.
Her name, Rosemary. The name of Paul’s mother, who died from AIDS.
“I’m so very happy it’s a girl,” says Wanjiru, shivering and shaking after the birth. With the baby beside her on the vinyl mat, she closes her eyes, no blankets to warm her, exhausted.
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