In 2013, the president of Kenya abolished hospital fees for giving birth, in an effort to reduce maternal and child mortality rates. Almost a decade later, both rates remain stubbornly high. Does a pattern of abuse explain why?
Tabitha Gateti, aged 43, is a mother of two. Within the last nine years, she has lost four babies during delivery in two different hospitals. She alleges that the deaths are due to human error and lack of care on the part of the healthcare providers at her local clinics in Nairobi.
Visibly shaken up, she recalls that three of the pregnancies resulted in stillbirths and she said it was “due to violence by doctors”. Her fourth child was a live birth, but the baby later succumbed to what the doctors called perinatal asphyxia, two days after his delivery.
For the 43-year-old Gateti, “It has been a living hell”, dealing with the loss of her children. Coping with the grief and the multiple losses is worsened by the fact that “the doctors who metted the violence against me are still working”, she says.
On one occasion, during labor she alleges that the doctors and nurses beat her up while forcing her to push for the baby during delivery. “As I was pushing, they would beat me continuously without empathy. I lost my baby.”
Her fourth pregnancy “resulted in a live birth, but my baby boy died two days later due to perinatal asphyxia,” she explained – “after an overdue labor that took fourteen hours with physical and verbal assaults metted on me by the health workers. The baby cried very little while he was born”, she narrated.
According to the Winchester Hospital definition, Perinatal asphyxia (also known as neonatal asphyxia or birth asphyxia) is a diagnosis caused by a number of conditions that stop or slow the normal blood and oxygen flow to a baby’s brain before, during labor and after delivery.
Some factors that may cause these problems include pressure on the umbilical cord, but there is controversy regarding the medico-legal definitions and impacts of birth asphyxia. Experts argue that birth asphyxia is preventable, and is often due to substandard care and human error.
But Gateti is not alone. Hundreds of other women are said to undergo the same process during childbirth in most maternity wards across Nairobi, Kenya and other rural communities. According to the World Health Organization, birth asphyxia accounts for an estimated 900,000 deaths each year and is one of the primary causes of early neonatal mortality.
Not only infants, but also mothers are at risk during birth. A 2018 study by Jackling Oluoch-Aridi et al published in the journal Reproductive Health, found that “indirectly caused maternal deaths form a significant portion of all maternal deaths within the health system.” Many of these deaths may be avoidable and occur during delivery and labor.
The study, citing experiences similar to those Gateti had shared, revealed that Kenyan women are subject to mistreatment at health facilities, including physical abuse such as slapping and pinching, verbal abuse such as yelling, as well as other acts of abuse, discrimination and negligence during childbirth in Nairobi.
Interviewing nurses and doctors, the authors of the study found that violent and abusive behavior was normalized among the medical staff, who described many women as “rude” “difficult” or “uncooperative”. Nurses noted that they had been trained to be firm with the women, and justified their behavior as necessary to force women to comply with their instructions.
Among the mothers interviewed, there was also a perception of discrimination against patients based on their ethnicity, age, marital status, as well as whether or not they had attended birth-preparation courses.
Gateti’s uterus was eventually declared “weak” by the doctors, forcing her to then opt for a cesarean section. She said many women go through similar procedures, and most suffer in silence and are afraid of reporting their plight to relevant authorities and in rural communities the situation is much worse, “The doctors often called me names apart from the physical abuse, they punched me in the womb,” Gateti says.
Mr. Daniel Yumbya, the chief legal officer of the Medical Practitioners and Dentist Board, a government agency saddled with the responsibility of licensing doctors and nurses countrywide, alludes that, “a lot of the women have experienced preterm labor, hemorrhaging, placental abruption, and uterine rupture”. He continues, “Other cases have involved fetal injuries, stillbirths and death of mother”.
The agency, “usually conducts comprehensive investigations before presenting the cases in court but the victims fear to report due to stigma and threats to their life,” Yumbya explained.
He insisted that there has been a series of convictions and sentences but “depending on the nature and degree of the crime”. “We have permanently withdrawn the medical licenses of at least 19 doctors in the last nine months alone”.
This represents a small number of the complaints. “On average, we receive at least ten cases per month forwarded to us for investigations.”
Yumbya adds that most of the cases involve doctors, nurses and other birth attendants neglecting pregnant women. “They leave them unattended and some end up dying, especially those in need of elective or emergency caesarean section”.
For the legal officer, most of the cases of violence are treated as negligence and medical licenses are withdrawn and a six-month prison sentence is usually handed to them (the offenders) by the courts. He however advocated for a legislation to be put in place as “most cases only attract a six-month prison sentence”.
Yumbya confirms that the board is investigating several hospitals across the country for violence against pregnant women. And what is more, some facilities are also being investigated for rape of women in labor.
One such facility is the government-owned and largest referral hospital in East and Central Africa, Kenyatta National Hospital. The board is investigating the facility on rape allegations dating back to 2018.
Police records show that over 30 alleged incidences of rape took place in late January 2018 on different dates. The crimes were committed late at night on the desolate corridors of the expansive Nairobi hospital.
Lactating mothers were raped as they were visiting toilets outside their wards, according to the medical reports from the police made available to the board. Other hospitals that are being investigated include Pumwani Maternity Hospital, Nairobi Women’s Hospital and 42 other facilities.
A Kenyan human rights group says that the government needs to do more to address the concerns of new mothers. Kagwiria Mbogori, Chairperson of the Kenya National Commission on Human Rights (KNCHR) said the group is currently assisting 150 women.
"These cases are rarely reported in the media. That is partly why many of the cases go unsolved, leaving the victims highly traumatized and in despair.”
“As lawyers and human rights defenders, we hope to get convictions in the courts as we believe we have adequate evidence against the perpetrators.”
She expressed hope that justice will be served, as some of the cases and crimes date as far back as ten years ago. “We are getting good leads to jumpstart criminal charges and we are working closely with the police,” says Mbogori.
She said because the maternity services in government hospitals are free, the women continue to patronise them as they cannot afford good quality healthcare services in the large and expensive private hospitals.
She however stated that they also are unable to afford legal services and “that is why we work closely with them and give them free legal aid”. She confirmed that a few cases handled by the agency have led to convictions.
Tabitha Gateti isn’t the only one speaking out, Salome Wanjiru aged 80, says she lost her pregnant granddaughter “in the hands of gynecologists and nurses eight years ago”.
“I lost my youngest grandchild as well as my premature great grand-child when she was in labor”. She explained, alleging her granddaughter died at the then Kakamega General Hospital (Now the Kakamega County Hospital) “after a long beating by doctors and nurses”. Wanjiru says that she is still awaiting justice, many years later.
Veteran Lawyer Judy Thongori said, “Women who are assaulted and possibly murdered in maternity hospitals are part of the growing number of gender based violence”.
She said the government needs to pay closer attention to these cases and reports. Thongori confirmed that cases of pregnant women being physically assaulted are on the rise and many are yet to be concluded.
According to figures from the Gender Based Violence Recovery Center (GBVRC) in Nairobi, over 5,404 cases were recorded in 2020 alone. Most of the incidents involved women and children but much larger numbers went unreported. The number of cases continues to grow during the pandemic.
There are increasing concerns by health workers in the country who allude that health workers are overworked and underpaid, difficult working conditions and understaffed workforce. Organisations like the doctors union continue to advocate for better working conditions for doctors and nurses.
Globally, the maternal mortality rate declined 38% between 2000 and 2017, to an average rate of 211 deaths per 100,000 live births. Many countries are well below this rate, with Japan for example, at 5, and Italy at 2 deaths per 100,000, according to the World Health Organization.
By comparison, Kenya’s rate remains very high, at 342 death per 100,000 as of 2017 estimates. This, despite the change that Kenyan women were 1,3 times more likely to deliver in a hospital setting after the removal of delivery fees in 2013.
Maternal mortality remains a global health challenge but maltreatment remains a growing concern not only in the East African country, but across Sub-Saharan African countries, such as Nigeria, Ghana, Guinea, and Tanzania. A factor contributing to the high maternal mortality ratio and mistreatments, experts argue, is the low rate of skilled birth attendants and adequate funding that allows for recruitment of personnel.
But the elephant in the room remains corruption and lack of accountability – health workers are underpaid and doctors are owed salaries, sometimes up to three months.
A recent collaborative investigation by Organized Crime and Corruption Project, Africa Uncensored and others exposed loopholes in Kenya’s procurement process, enabling “budgeted corruption.” Particularly in the healthcare sector.
The investigation explicitly identified companies belonging to a niece of a powerful Member of Parliament, Rachael Nyamai, who had oversight of the health ministry’s spending at the time suspect contracts were awarded.
It says, “The companies, which had no history of delivering medical supplies, appear to have been paid $240,000 to do just that. One of the companies, Tira Southshore, was also awarded a mysterious $43 million agreement to supply hand sanitizer, according to the government’s procurement system.”
Dr. Abidan Muchuma, the New Chairperson of the Kenya Medical Practitioners Pharmacists and Dentists Union (KMPDU) told Unbias the News, "doctors are overworked, very many hours and sometimes as long as 18-20 hours a day. This makes them very tired to deliver to their expectations.”
Muchuma owned up to some of the accusations leveled against the medical practitioners. “We can’t deny there are cases of negligence, but that is very minimal,” he said, maintaining that “doctors are professionals and we adhere to the highest professional standards”.
He said, if a member of the union is accused of malpractice, the organization expels them and forward their names to the relevant authorities for legal action. He added that many doctors employed by the government are also underpaid and their motivation to work is sometimes challenging.
Many colleagues even go several months without receiving their salaries in their bank accounts in addition to the low pay.
The average salary for a doctor in Kenya is between 30,000 shillings ($300) to about 60,000 ($600) shillings a month, depending on level of experience. The union will in the next few months be pushing for higher wages from the government.
“The allegations against doctors need to be looked into carefully, as the good outweighs the bad”, Dr. Muchuma said.
Dr. Muchuma says there is also a need to train and hire more medics. He says it is important for better service delivery.
Figures from the Medical Practitioners and Dentists Board show that there are only 2.089 specialized doctors and a total of 5,660 medical doctors. Out of this total, only about 397 gynecologists are licensed to practice in the East African country.
Shortly after free maternal care was implemented in 2013, Josephine Majani went into labor at the Bungoma Country Hospital in Western Kenya.
Beaten, chastised and left to deliver on the floor, her abuse at the hands of medical personnel was captured on camera and in 2018 she won financial damages for her ordeal, in a landmark case against the government. The court found that Majani’s constitutional and international rights had been violated by the local and national government.
Justice Ali Aroni added that the national and county government of Bungoma failed to ensure that healthcare facilities provide quality maternal healthcare services by neglecting to allocate the necessary resources and put in place minimum standards for provision of these services.
Almost a decade after Majani’s ordeal, women continue to experience harsh and sometimes deadly treatment when they seek free medical assistance during labor. In an era of increased attention to the forms of abuse endured by women globally, it is time to realize that not just the price but the quality of care received during childbirth can make all the difference.
Read editor Mercy Abang’s look behind the scenes of this story.
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“The people who face the most barriers are often those who need our care the most – and yet their voices are not the ones we hear in maternity care.”
