It took a few days, but we made it to Nairobi. We are rested, and settled into our lodgings.
We were able to meet the two local women who did the work to arrange the training and our trip. One is a midwife, the other is a US citizen, 10 year resident of Nairobi. Both are currently working as doulas. We have already asked many questions about birth, midwifery and the rights of women in Kenya. Here are some things we have learned thus far.
Kenya (like most other countries of the world) is experiencing a shortage of nurses. To help meet nursing needs, the government has changed the nursing program so everyone who graduates as a nurse is also a midwife. This has added a year to the program of study, so this may have harmed the country in the short term (taking longer to prepare a nurse). I was told the idea is that the nurses are better trained to work anywhere in the country – however most prefer to stay in Nairobi rather than running a health clinic in a rural area.
The country is very divided in terms of birth. Kenya has both public hospitals (highly subsidized by the goverment) and private hosptials. But there are still populations so poor (even within Nairobi) that they have their babies at home with traditional birth attandants.
Private hospitals are much more expensive. The private physicians are much more expensive, but for the families who can afford it you can basically have the birth you want. You can pay for midwifery care or physician care. Epidural is available, and is usually requesested and paid for before labor to help ensure the woman receives it. These hospitals have a 25% cesarean rate, and the main feeling is that this is the prefered route for the women who can afford it and the physicians.
In the public hospitals the midwives run the show and only hand off patients to the physicians if there is a problem. Epidurals are rarely used because people cannot afford them. Cesarean rate is very low. Nursing staff can be a bit rude, but this is changing as new nurses are trained. It seems the public hospitals in Nairobi work with very limited staff – on nurse to 60 or 80 patients – and the nurses may go months without pay. These levels would not be acceptable in the US in a nursing home, let alone a hospital. But hiring more nurses would cost more money on an already overworked system. So nurses are burned out and quit nursing early to start their own clinics (which they are allowed to do), or move to another country to work.
It seems Kenya also prefers to train physicians as generalists. This saves money becuase a generalist can do the work of a specialist but does not earn the higher income. It also allows the physicians to work anywhere in the country – though most want to stay in Nairboi. So cesareans and hysterectomies can be and are done by generalist physicians. It was unclear what other surgeries were done by generalists, we stayed close to the topic of birth.
The government had attempted to resovle some of the birth issues by improving training of traditional birth attendants several years ago, but there was resistnace from a segment of the medical community. It seems there were some who felt the jobs should go to the retired midwives, not the traiditonal birth attendants. The TBAs have a difficult task, and can be blamed for circumstances outside their control. For example, there are communities in Kenya where a woman is not allowed to seek medical help without the permission of her husband. There are places were the women (culturally, not legally) cannot consent to care without the approval of the husband. There are places where a woman, even if the TBA recommends they transport to a hopsital, does not have the finances or authority to make these arrangments herself. Even if the TBAs are highly skilled, they cannot overcome these issues on their own.
We should begin to understand more about how these and other factors affect the health care of women over the next few days. Tomorrow we have the opportuntity to observe a Lamaze class for local families. Should be interesting.