Birth in Central Africa

We were up early to check in at the airport and had enough time left over for a cup of coffee before we needed to board. But the representative from Kenya air couldn’t give us boarding passes for the Amsterdam leg of our journey, and the Java House was out of coffee. We sat quietly wondering how we would negotiate less than an hour lay-over having to get new boarding passes.

The flight from Nairobi was uneventful, thankfully.  This time we were seated near a window and marveled as we slowly crossed the Sahara desert. Huge does not even begin to describe it. Hours of nothing but sand as far as the eye could see. I knew we were reaching something important when I could see a road and a few houses. Then suddenly the desert stopped right at the Mediterranean Sea.  I wondered about the view from the other side of the plane–were they able to see the Nile river delta?  Soon we began passing beautiful islands and finally we arrived at the European continent as we flew over Greece –a country that is as green and hilly as the Sahara is flat and sandy.

We arrived to thunderstorms in Amsterdam, which meant the guidance system was shut down and we sat about 100 yards from the gate waiting for the lightening to pass. By the time we stepped off the plane we knew about 40 others were transferring to the Atlanta flight, but we would need to hurry. Through security and up to the counter only to find out that we had never actually been checked in for this leg of the flight and our seats (which we had selected a week ago) were reassigned. I was dumbfounded. We produced our tickets from Nairobi as proof that we had checked in for the entire flight, our bags were checked through to Atlanta, this had not been our error. The efficient and sympathetic KLM representatives got us the only seats left on the plane.  We could not sit together, but we would be in first class. The flight was fantastic.

Aside from being very annoyed that TSA agents made us throw out unopened water bottles given to us on the plane by KLM to go through a carry on security check to LEAVE the airport, the rest of the trip home was great. Tammy is flying back to Iowa this morning. I will see my children as soon as they wake up –in about two hours.  It seems my body will take a day or two to readjust this time

We are counting the hours until a taxi comes to collect us.  Our bags are packed, and Tammy’s looks to be OK even as it bulges at the seams. I’m sure all my clothing will smell like the coffee beans packed under my dirty clothes when I return home Good thing I like that smell.

At the end of the training, each doula made a wish for the women of Nairobi while placing a glass heart on a tray.  As we left, we each took one of the wish hearts to keep safe until next year.  I shared my wish, that no woman in Nairobi will have to give birth alone, with a tear in my eye.  And as Kenyan tradition requires, the women gave us gifts and sent us off “showered with flowers.”

Life will continue for the doulas of Nairobi. We are hoping that the easier access to communication will allow us to have more frequent updates from this group, and are looking forward to sharing their successes, and challenges, with you.  Tammy is already planning a return trip to train even more doulas to ensure no woman in Nairobi gives birth alone.

We were reminded today that to say most international residents of Nairobi have epidurals is unfair. Which made us realize how little we really shared about the hospital system of Nairobi. This gets confusing, but I’ll do my best.

First – there really is no set price for hospitals. Public hospitals are subsidized so much more standard in price (I think, that is the impression I got), but private hospitals set a fee based on the level of service. So to be in a private room in a hospital (for example Aga Kahn where we visited) is significantly more expensive than to be in a semi-private room. Additionally, Aga Kahn has a different cost for a maternity stay than Nairobi hospital (another private hospital) even when they are offering the exact same service.

Second – there really is no set price for physicians. The range of fee for a private physician is wide, one midwife guessed the costs could be anywhere from $30,000 Ksh to $100,000 Ksh (roughly US $300 – $1,000).  I get the impression you are paying for prestige, which is not necessarily the same as skill or quality.

Third – there really is no set price for cesarean surgery.  As one midwife estimated, the hospital fees alone can range from $20,000 Ksh at the “cheap” hospital to $120,000 Ksh at the top hospital.

Fourth – Nairobi is huge, with very busy roads and many hospitals. We are guessing the “nicer” hospitals are in the “nicer” regions of Nairobi. Some women have the funds to travel to differing districts for care. But other women are limited to what is in their region, not only in hospital but also in physician. It looks like the antenatal clinics are associated with a specific hospital, rather than one physician having admitting privileges at several hospitals as is done in the US.

So you put this all together and what you see in midwifery practice is that what is “normal” of the patients at one hospital is not the “normal” at another hospital. This made for a very interesting training as we tried to gauge what maternity care in Nairobi was like. Apparently, there is no consistency. So, while a midwife at one hospital may see all her international patients receiving epidurals, that may have more to do with the opinions of the referring physician at that hospital than the choices of the women.

We began our last morning by visiting a local baby fair to see what is available for Nairobi families. We met one of the women from our training at the fair, she had already booked the booth and was advertising herself as a doula (and childbirth educator from her Lamaze training last year).

We then stopped at a local book store to see what pregnancy and childbirth books were available to the women of Nairobi. Nearly everything we found was out of the UK. We took note of a few titles and will offer suggestions for suitable substitutes for the DONA reading list if necessary.  I am happy to say I found a cookbook put together by a Kenyan woman with a local cooking show.  I now have the recipe for Mandazi!

We toured the walking safari at the national park, which was similar to a zoo with fewer animals and larger habitats. At the edge of the safari is a stream that separates the walking safari from the rest of the park. One of the workers was explaining that all the animals of the park are free to roam there, and sometimes guests are able to see lions stopping by for a drink. But on our visit we were only able to watch a crocodile sunbathe. It does turn out that crocodiles are native to Nairobi, although I would never have imagined they were this far south.

After lunch we visited another tourist sight to view the various dances and national costumes of the people of Kenya.  Some were more lively than others, and if you get a chance ask Tammy to do what we now refer to as the “Mine is Bigger than Yours” Dance.

We ended our day with a short walk to purchase some kangas because we were unlucky at finding them at any of the tourist shops. I am leaving Nairobi without soccer jerseys for the boys. What a strange world we live in that it is easier for me to order a Kenyan national team jersey from the United States than it is to actually find one in Nairobi.

We learned about Nairobi epidurals today. We laid one of the women on the floor and taped long strings of toilet paper to her to represent all the different things the mother must negotiate during labor. The epidural is still very new and so is met with skepticism from locals. Women are afraid to use one because they do not know about the side effects. They think it may make them go blind, or worse. So women avoid them. But at only about US$25, women are starting to take notice. Almost every international resident uses one at birth.

Families share the fear of epidural, and families can be just as destructive to a mother’s trust in herself as they are in the US. So families complain the woman is weak if she uses an epidural. In some cases, the women will use an epidural but not let her family know she did.

I’m not sure how I feel about epidurals that must be planned in advance. On the one hand this means the woman must meet with the anesthesiologist before labor begins to learn about the process and consent to the procedure. She is better able to ask her questions and be properly informed before agreeing. But on the flip side, this means that a woman must choose to use an epidural before she even tries labor, and the epidural is often placed at 3 cm so the woman gets complete pain control for the entire labor. Nothing is ever easy.

Today’s doula training focused on the problem of difficult births.  In the United States, doulas in training often think they have little to do if the mother has an epidural or if she is planning a cesarean surgery. The women in the Nairobi training began with the same belief. We took them through a few exercises to recognize the needs of the mother in those situations and watched as they changed their personal definition of a doula.

We asked each of them to share a story of a difficult birth. An hour later the women were amazed at how their most difficult experiences were not the discomforts of labor, but the families who needed such strong emotional support. What do you do when a baby dies? What do you do when a mother feels she has no say? What do you do when a doctor gives no options? How do you help those mothers remain empowered?

We then moved on to the difficult birth of Kenya’s first professional doula association. We learned about some of the unique issues that will face the doulas of Nairobi.  For example, unlike the United States, you cannot just walk into a hospital and be a doula. The women needed letters of introduction to present with their certificate of training to prove they could be there. The doulas will also need to work with the hospitals to ensure policies are in place that protect the right of the family to have a doula with them during labor and birth.

One issue we identified was the lack of culturally appropriate education materials for families. Most materials that are brought into Nairobi are from South Africa and have images of Caucasian families and babies. Physicians have started refusing education materials from Johnson & Johnson if they do not have dark skinned models. This should not be too hard to fix. There are many health departments that provide downloadable brochures and information sheets with multi-cultural photos.  We just need to help the women find them.

So now we pack up the training and prepare a list of recommendations to DONA on how to best serve the doulas of Kenya. For example, getting books from overseas is not easy.  Tomorrow while we are out we plan to pick up some childbirth and breastfeeding books that have been written and published here in Nairobi with the hope these books will be accepted for the reading list. I have my own biases, and they would be to empower the doulas of Kenya to have their own certifying body. But I am not even a member of DONA anymore, and it is up to their board to make the best decisions for the organization.

For those who want to see the photos of our Nairobi Training, follow these links:

For day one: Day One Photos

For day two: Day Two Photos

For day three: Day Three Photos

They are hosted at Google’s Picasa, so you need a gmail account to log in and then you can see them all.  Enjoy!

When we were training in Nayngezi, we were very isolated from the rest of the world. No phone, no internet and very few people who even spoke our language. But Nayngezi was a rural area, Nairobi is a major metropolitan melting pot with residents and visitors from around the world.

In our retreat center we have met:

A Sudanese woman who came for vacation and relaxation.

An Indian man living in the USA who had just spent a month in Sudan to be at the birth of a new nation.

A South African pastor in Nairobi to preach.

A family from Belgium helping to train counselors in Nairobi.

A group of teenagers just returning from a year of student exchange in the USA.

A group of teenagers preparing to spend a year of student exchange in the USA.

A recent college graduate from the USA planning to spend a year completing an internship in microfinance.

A dutch couple whose host for their week long visit was suddenly called away.

An eastern European couple who did not speak enough English for us to communicate.

Busy place, and very fun.

Kenyan women and American women approach meal times quite differently. To the point the cook at the retreat center has asked me why I don’t like the food. Don’t like the food!  But I eat everything, including the ongali.  For those who listened to our stories from DRC, you may remember our first tastes of fufu. Fufu is a paste made from cassava flour and boiled water. We tried, we couldn’t eat it. Ongali is the Kenyan version made with cornmeal.  As an American, I will say it is much more palatable. It is similar to polenta or grits.  The problem is that American women eat only a little, while Kenyan women heap their plates and enjoy every bite.

I’ve actually started approaching tea time like a Kenyan. Mangazi, or beigent if you prefer the French term, are fabulous little fried sweet dough. I confess, I ate six of them yesterday, and pouted when today’s tea was served with rolls instead of mangzi. Perhaps tomorrow the cooks will prepare them again.

Tammy and I have just had the most fun with rebozos since we introduced comfort measures to the women in the DRC. The Kenyan doulas breathed a collective sigh of amazement when they saw the first rebozo technique performed. I have to agree. Rebozos are amazing.  A simple and versatile tool to help meet many needs in labor.

We were not sure how much experience they would have with comfort measures. Most of the women are midwives by training, and we were concerned most of what we taught would be repeat information for them. But in reality it is not repeat information. They know how the information determines their role as midwives, but the role of the doula is different.  We did not need to teach them about birth, but we did need to teach them what a doula does at birth.

You can see the photos of our day here. The photos were not posed; we really were having that much fun. If you didn’t get a chance to see the women learning during day one, check those photos out here.

Tammy’s big surprise for the day was the induction process and cascade of effects on labor. It was almost identical to the induction process in the United States. But unlike the American women, Kenyan women do need to undergo induction unless they are post-dates, which is defined as 10 days beyond the estimated due date. The women were shocked that Americans will induce a woman at 39 weeks, and even more shocked the doctors needed to be told to stop inducing at 37 and 38. Honestly, from what we have seen and heard about the hospitals, there is no room to bring a woman in for a potentially two long induction.

A disturbing similarity we are experiencing is a collective warning to stay out of the public hospitals. The ministry of health tries to encourage women to give birth in hospitals, but the poor women know how they will be treated in labor at a public hospital and choose to avoid that treatment. This was exactly what we were told by the women in DRC. We find this very similar to the current movement in the USA to give birth at home to avoid unwanted interventions – though on a much smaller scale in America.

We spent the afternoon working through some scenarios to represent problems a doula may face. We were so encouraged by how quickly the women adjusted to the doula role, and we were greatly entertained by how wonderful many of them were at pretending to be in labor. In return we entertained them with our Swahili.

The writer from the parent magazine arrived today and watched part of the training. He was very impressed and shared his belief that this type of work would be very beneficial for the women of Nairobi, but he also challenged us and recommended the training would be helpful for rural women as well. We don’t disagree, we just know how difficult that was to arrange in the DRC.  But we have such an amazing group here in Nairobi, we could eventually expand.

We have already begun making plans for returning next year. I know the trip will be in the middle of my final semester, but I also know I cannot miss it. How wonderful that my global health teachers will encourage me to miss class for the trip, and my nurse-midwifery teachers will be equally excited for the opportunity.