I've never given birth in a hospital and I don't plan to

When Halima Hassan was eight months pregnant with her first baby, she went into labour only to have a still birth.

“I started contractions at night, which lasted until the following day in the evening,” she recalls. The traditional birth attendant told her the baby was too big to be delivered and had drank amniotic fluid.

She remembers being in labour for very long as they waited for a motorbike to go to the nearest hospital. “After nine hours, the baby was out, but unfortunately dead,” says Halima, a resident of Dololo village in Garissa County.

Although she was in so much pain, she feared going to the hospital on foot as it would have taken her four hours on a bicycle, a move which could have put her in more danger. She decided to give birth at home.

“I buried my child and did not lose hope. I fell pregnant with my second born within one-and-a-half years,” she says. As if fate had conspired against her, she still could not get a vehicle or money to hire a motorbike to take her to the hospital. Considering the distance, she had no option but to give birth at home.

This time around she was lucky and gave birth safely. “Since then, I have given birth to all my eight children at home. I have never stepped in a hospital ward. I tried going to the hospital with my fifth pregnancy, but I did not make. I started the journey at 7am, but an hour into the walk, I was forced to stop and deliver the baby by the road,” says Halima.

Fortunately, the birth attendant had accompanied her. “I had not carried anything to cover the baby. I was very embarrassed. Well-wishers gave me lesos. I covered my child with one, cleaned myself up with the other and walked back home,” she adds, cringing at the memory.

The journey back home was a nightmare. She was in pain and could not walk properly. Halima reached home after three hours of dragging her feet under the scorching sun. “I would really love to give birth in a hospital, but after such an incident, I decided to be waiting for my babies at home,” says Halima.

No vaccines

She has a designated a corner in her bedroom that acts as her “maternity ward”. “I am still giving birth, but until a hospital is built near us, I will have my deliveries at home,” she tells HealthyNation.

Fatuma Ibrahim, a mother of seven, shares Halima’s sentiments. “Giving birth is like going for a long call. I will give birth anywhere,” she says. “I am not afraid because this is our way of life. I have given birth to all my children at home.”

The only time Fatuma went to the hospital was when she was expecting her fifth child. She started bleeding when she was seven months pregnant, and was taken to Garissa County Hospital. Then, she was staying in Garissa town. “I was induced and I gave birth to a bouncing baby boy, who stayed in an incubator for two months. I am glad he made it and I thank God. However, without complications, I would not walk for hours to the hospital just to give birth. I have my attendants just next door,” says the 35-year-old.

When the mothers give birth at home, the children are not taken for immunisation later and most of them are not vaccinated at birth, exposing them to diseases like polio, pneumonia, meningitis, measles, influenza and hepatitis.

These diseases, long identified as among the biggest health threats in the region, could ravage the nation in the coming years if these children are exposed to their vectors. Health experts say it is not easy to measure the gravity of the situation, but the ripple effect will be felt countrywide. “Vaccination is the safest way to protect children and pregnant women from a long list of serious and potentially life-threatening illnesses,” says Dr Walter Otieno, a paediatrician.

“Vaccines protect children by preparing their immune system to recognise and fight deadly infections. When a child misses a vaccine and there is an attack, for instance, the likelihood of that child going down with the virus is high.”

For Halima and Fatuma, almost all their children were not immunised. Halima only had her last born immunised at four months. “Last month when my child was four months old, the county government sent a mobile clinic for normal outreach, that is when my son was immunised,” says Halima.

This is the way of life for almost all women in Dololo village. Some of them have never stepped into a maternity ward. Some have been lucky not to develop complications that warrant the attention of specialists.

Unplanned out-of-hospital birth is generally assumed to occur for women who have a history of a short pushing phase of labour or are experiencing a precipitate birth. However, women in semi-arid and arid counties in Kenya, with prolonged labour, have no luxury of choosing where to give birth.

Why a woman can give birth at home in 2020 because of how far hospitals are, remains a puzzle.

Haemorrhage risk

Giving birth outside a hospital can be risky. Complications can arise and if not managed by a trained health worker, the expectant mother and her baby are put in danger, with injury or death as a probability.

Obstructed labour, infections, haemorrhage, high blood pressure and other complications can be addressed in a hospital or the mother quickly referred to another facility for specialised care.

While free maternity services introduced in 2013 have played a big role in reducing home births, increasing hospital delivery and taking away the financial burden that kept mothers from delivery rooms, mothers among Garissa’s rural communities still prefer to give birth at home, thanks to the long distances. Pregnant mothers have to walk for hours or hire a motorbike at Sh1,500, which is costly and risky. Even so, motorbikes are also not readily available in the area.

The women are faced with a tough choice: give birth at home or on the way to the hospital. The nearest hospital, which does not admit mothers before they go into labour, is five kilometres away.

Mubarak Hussein, the area chief, says the villagers live by the grace of God. “I appeal to the county government to make mobile clinics a monthly affair if it is not impossible to build a health facility near the village,” he says. “Getting an ambulance is another struggle.”

The cases are a reflection of some of the problems with the health system overall in that the poor often struggle to access care. Rural communities are often left out on routine primary care, maternity care or emergency care.

In cases where distance is not an issue, then basic medical supplies are often hard to find, there are no workers or equipment. Prenatal and maternity care are a priority, yet the mothers lack transportation to go for follow-ups.

The mothers are left in the care of traditional birth attendants. There is no doubt they are a much-needed resource in areas like Dololo. Unfortunately, not all of them are skilled enough to handle cases and complications.

The county’s maternal, newborn and reproductive health coordinator Fatuma Maalim says skilled delivery stands at 56 per cent. Which means out of 10 deliveries, four of the women give birth at home. “We are doing some good work, but it is not as required,” she says.

Prefer midwives

The county has a religious affair docket to address barriers to health seeking behaviour more so child spacing and encourage women to give birth in hospital.

Data from the Kenya National Bureau of Statistics released this year indicated that 80 per cent of rural women prefer traditional birth attendants to skilled ones. This is portrayed by the number of women that Fatuma Muhammed, a traditional attendant in Dololo village, has dealt with. Having practised for decades, she has lost count of the number of women she has helped. She assists about 20 mothers in a month or more.

“I learned this skill from my mother when I was very young. I have helped almost all women in this village. I do not charge them. When they develop complications, I refer them to the hospital, which is several kilometres away. I thank God we have not had many complicated cases,” Muhammed tells HealthyNation.

Dr Elizabeth Ogaja, a health analyst, says midwives are an integral part of the healthcare system. According to her, the reduction of maternal and newborn mortality in developing countries requires rigorous efforts that involve governments and non-governmental organisations in identifying traditional midwives who are known by the community to be experts.