Jane Otai, a 2013 New Voices Fellow at the Aspen Institute, says that it is good that the Kenyan government will now provide free maternity health care for all its citizens, however it is also imperative to ensure that free care equals quality care.
The New York Times recently reported on the astonishingly high cost of giving birth in America, where the average pregnancy costs more than US$35,000. Meanwhile, in my country of Kenya, the newly appointed government has completely eliminated this cost. For Kenyan mothers, giving birth is now free.
As a public health worker and academic focusing on reproductive health in Kenya’s urban slums, I see this as a positive step. After all, Kenya currently has a Maternal Mortality Rate (MMR) of 488 per 100,000 live births per year, in large part because women do not give birth under a skilled health provider. Something has to change and free maternity care seems like a good place to start.
But as someone with over 15 years of experience talking with women and families in Kenya’s informal settlements, I also know that tradition and what many Kenyans perceive as poor-quality hospital care will stand in the way of this well-intentioned programme.
The Kenyan government’s efforts are admirable and intended to help us achieve the Millennium Development Goals of reducing our MMR and our infant mortality rates. But they will not work unless the free delivery services are combined with high quality of care – something many Kenyan women seem to doubt.
As it turns out, free health care is valued at the amount that women are expected to pay for it: nothing. One woman said to me, “A mother bled to death after delivery because the hospital did not have the facilities needed for intervention and the husband could not afford to pay for the ambulance that was meant to transfer her to another hospital.”
Women fear that if they accept free care they would be relinquishing their rights and would have to accept poor treatment. They would rather pay the traditional birth attendants with chickens or a piece of cloth and get the best service they can afford.
The first step to ensure women trust our health facilities is to make sure they are well equipped with appropriately-trained staff. Then, we need to spread the word and educate. Women need to be reassured that the provider has the skills to deliver their babies, the facility has the required equipment for delivery and that the government has certified these facilities.
But all these efforts will be for nothing if women continue to perceive skilled health providers as unfriendly and unconcerned with their well-being, a main reason why women continue turning to traditional birth attendants.
The women I spoke to prefer “Japolos” (traditional birth attendants), for good reason. “Japolos will assist you during delivery while a doctor will let you deliver on your own; the health provider leaves you to labour and finally deliver on your own and they only come once the baby is out,” said one mother.
Japolos are aunties and mothers. They rub labouring women’s backs and talk them through difficult moments. Why will our women travel up to 100 kilometers to be treated by skilled, but cold birth attendants, especially if they are afraid it might result in a poor birth outcome? They hear experiences of women being slapped by nurses, spoken to rudely, and not even attended by trained service providers. Mothers in labour want to be surrounded by caring personnel with kind words and genuine concern for their well-being.
We need to train skilled birth attendants to be more respectful to mothers who come in to deliver in the health facilities.
To be sure, when I last talked to a skilled health provider about this issue, she mentioned that overcrowding in clinics means individual care is not always possible. However, there is no point in offering free care if it is not utilised. There should be a deliberate effort to build more facilities so that women do not have to travel long distances to get to a health facility. There should be a facility within 5 to 10 kilometres from every woman’s home. This would reduce overcrowding and make it possible to provide the right kind of care.
So while the government celebrates free maternity care in our health facilities, there is still a need to convince women that they will get a high quality service from the health providers. The only way to do this is by providing medical services which come from skilled workers who respect these mothers’ need for kindness and attention during delivery. If the Kenyan government wants to prevent maternal and infant mortality, they must make delivery services not only available to anybody, but desirable to everybody.
Jane Otai is a Senior Program Advisor for Jhpiego, a non-profit global health affiliate of Johns Hopkins University. Currently she is working on the Tupange initiative, an urban reproductive health project focused on improving the health of women and families in the urban slums of Kenya. Otai is a 2013 New Voices Fellow at the Aspen Institute.