The Covid-19 pandemic came with several restrictions, especially on movements and gatherings of people. While Kenya introduced a night curfew and closed some of its borders in the early stages of the pandemic, pregnant women in informal settlements in the country suffered a huge blow as they struggled to access health facilities for lack of transport or failure to get birth companions when labour struck. Lilian Kaivilu spoke to some women who share their experiences.
Linet Wambu is a 28-year-old mother of one. Wambu, a resident of Soweto area in Kayole gave birth on July 2, 2020 at the Kenyatta National Hospital.
At this time, the government had put travel restrictions across counties. The night curfew was effective between 10pm and 4am.
While giving birth is an ordinary event to some mothers, it was a painful nightmare to Wambu. A casual labourer, Wambu did menial jobs, particularly laundry in people’s homes to eke a living. On the day labour pains started, Wambu had returned from work, about two hours away from her home. “I would walk from 6am to 8am to reach the area where I did laundry. On this particular day, I walked as usual to and from work,” she remembers.
The first-time mother’s labour would start at about 8pm. With only two hours to the start of night curfew, Wambu struggled to find transport to the nearest health facility.
With the restriction of movements and fear of the coronavirus disease, maternal health was adversely affected in many parts of the world. The World Health Organization (WHO), however, recognizes that pregnancy does not have to stop due to the pandemic and emphasizes the need to prioritize the needs of mothers. “Pregnancy is not put on pause in a pandemic, and neither are fundamental human rights. A woman’s experience of childbirth is as important as her clinical care,” said Dr Ӧzge Tunçalp, a scientist at WHO.
Dr Ӧzge added: “In the ‘new normal’ of Covid-19, WHO strongly recommends that the emotional, practical and health benefits of having a chosen labour companion are respected and accommodated. The pandemic must not disrupt every woman’s right to high-quality, respectful maternity care.”
But for Wambu, the introduction of curfew presented a challenge of not only a birth companion, but also the means of transport for her to get to a health facility. After frantic efforts to get some means of transport, Wambu’s neighbour offered to use his motorbike to transport her to the nearest health facility: Mama Lucy Kibaki Hospital. She was expected to pay Sh1,500 ($14). “When we got to Mama Lucy Kibaki Hospital, the doctors said my baby was in bad shape and that the hospital beds were full,” she narrates.
Difficult journey to hospital
Still in labour pains but clutching on to the motorbike, Wambu tried to get a car but drivers were hesitant as the curfew time was fast approaching. She eventually got to Kenyatta National Hospital at midnight aboard the motorbike.
Despite the difficult journey to the hospital, Wambu would later give birth at Kenyatta National Hospital through a caesarean section. “But my baby stayed in the nursery for a week before we were discharged,” she says. Wambu believes the complications occasioned by the curfew could have been averted had there been clear referral mechanisms in the country.
Bonface Musyoka is the nurse in charge at Provide International, a health facility that serves Kayole areas and other places in Nairobi’s Eastlands area. While the facility could have served as an answer for Wambu who resides in Kayole, Musyoka says the pandemic caused the hospital to limit the number of patients seeking services therein. “Before the Covid-19 pandemic, we would admit up to 20 mothers per day for delivery. Today, we can admit a maximum of 15 mothers,” explains Musyoka.
According to him, cases of mothers giving birth on their way to the hospital are not new as many face the challenge of transport, especially due to the existing night travel restrictions imposed by the government. In March and April alone, Musyoka says they had cases of three mothers giving birth on their way to hospital. This, he opines, could have been prevented with the establishment of a clear referral system. “Some mothers risked their lives by coming to the hospital at night as their husbands would be arrested by police while escorting their wives to the facility,” Musyoka added.
With attention shifting the Covid-19 response, Musyoka decries the financial challenges that have befallen the facility. “We cannot chase away a mother who is in labour. And for those without money, the hospital bears the cost as it has to pay for the medical equipment used and the human resource.” Musyoka disclosed that by January 2021, the facility had lost Sh300,000 [add US$ equivalent] in delivery costs, doctors fees, drugs and other costs. This, he adds, is compounded with non-payment by the National Hospital Insurance Fund (NHIF) that he says owes the hospital Sh8 million ($74,000).
Maternal health challenges, one year later
Benard Okoth , a Community Health Worker (CHW) in Nairobi’s Mukuru Kayaba informal settlements says the challenge for pregnant women continues even today. With the curfew and movement restrictions, Okoth says it is difficult for women to opt for hospital delivery. Consequently, many of them opt for home delivery which may result in maternal health complications.
Community Health Workers (CHWs) are Kenya’s health volunteers at the community level, usually heading a community unit comprising between ten and over a hundred households. Ordinarily, community health workers/volunteers are the first point of contact for members of the community. Although they undergo basic training on health, including referral, these health workers are not licensed to operate as qualified medical personnel.
According to Okoth, the government should provide protective equipment to CHWs and provide them with passes to enable them to safely and conveniently handle such cases as Wambu’s. “Unlike doctors who have work permits and licenses, we don’t have government identification to show that one is a CHW. We ask the government to get us identification to facilitate our smooth movement especially when we have to accompany patients to the hospital past curfew hours,” he says.
Okoth says CHWs have had a hard time since the start of the Covid-19 pandemic. “People are seemingly more stressed hence there are many cases brought to us to solve. Cases of domestic violence are particularly on the rise,” says Okoth.
To Rhoda Munini Luka, resident of Sisal in Mukuru Kwa Njenga informal settlements, her now seven-month-old baby did not come easily. She vividly remembers the traumatic events of June 3, 2020 that led to the delivery of her baby girl. For her, labour started at 11pm on that night. With no means of transport, Rhoda’s husband sought the help of three neighbours who carried his wife to the nearest health facility.
“The first hospital we knocked failed to open their doors. Unaware of our Covid-19 status, the guard at the gate was hesitant to serve us. We proceeded to the next facility. At this time, my waters had broken, and I could feel my baby making movements,” she recounts.
Fortunately, Rhoda was admitted in the next health facility, about 30 minutes away where she delivered. All this time she was being carried by the four men on foot. Sadly, this continues to be the experience of many women, especially in informal settlements and areas with poor road networks where ambulances cannot access. With the introduction of curfew and movement restrictions to avert the spread of Covid-19, many pregnant women continue to suffer due to poor referral systems. “In my opinion, women living in informal settlements suffered the most at the peak of covid-19. This was because of inaccessibility of our houses by any means of transport,” Rhoda concludes.
Lessons learnt and the need for evidence-based response
According to Stephen Yambi, County Advisor at Options Consultancy Services Ltd – Evidence for Action Mama Ye, some fear to visit health facilities as mothers viewed them as places where they could contract the virus. “Also, lack of protective gear for healthcare workers would make healthcare workers shy away from offering the services. At some point we had healthcare providers contracting Covid-19 hence they were not very confident to handle maternal cases. Somehow, this affected service utilization,” he says.
The fear to visit health facilities, especially for antenatal care (ANC) has seen many mothers miss the four ANC visits recommended by the WHO. However, there is no data showing the number of women who missed the required ANC visits during the past year of coronavirus disease in Kenya.
Yambi adds that there was no comprehensive framework to address the effects of the curfew on maternal health. For example, with ambulances situated or parked at health facilities instead of being parked within reach for community members, this affects referral, especially when the night curfew is in effect. As the country marks one year since reporting the first Covid-19 case in March 2020, Yambi says there is need for swift action by stakeholders in the health sector. This, he opines, includes reviewing the country’s level and quality of response, interrogating the data and having an evidence-based way of addressing maternal health amid the pandemic.