Nairobi, Kenya — To the casual visitor, the dusty, dimly lit room may not look much like a birthing center. But many women consider their babies lucky to enter the world in this mud-walled space in Kibera, one of Africa's biggest slums, because of Emily Mteeshe.
Mteeshe, 60, nicknamed "Grandmother" by local residents, stands about five feet tall and is bowed by a slight stoop. Patches of grey hair poke out from the hood she is wearing. Reaching into a box hidden away in one corner of the room, she pulls on a pair of white latex gloves and falls into a crouch. In a measured voice that sometimes peaks with excitement, she describes how she soothes women in labour.
"I ask them whether they would prefer giving birth while kneeling or lying on their back," Mteeshe says, her normally wrinkled brow softening. "After the baby is born, I wrap it in a warm blanket and place it on the bed as I wait for the mother to recover from the strain."
As a child, Mteeshe watched her mother perform the same services, and sometimes helped her, cleaning items that were used during the procedure, and ferrying messages for mothers and families. She started practicing as a traditional birth attendant (TBA) herself in 1990.
Kenya faces a dilemma when it comes to birth attendants like Mteeshe: sideline them or provide training to improve their skills. The choice may have a serious impact on improving Kenya's maternal health.
A Question of Cost
As part of a series of poverty-reduction goals the international community adopted at the United Uations in 2000, Kenya aims to reduce the rate of maternal mortality 75 percent 2015. With three years to go, the number of deaths from pregnancy-related causes remain high - about 500 deaths per 100,000 live births - and tens of thousands more mothers suffer serious health consequences as a result of pregnancy every year.
Some one million babies are born in the country every year, and 46 percent of them are born in homes that cannot afford food, healthcare and education, according to official statistics. The 2008-2009 Kenya Demographic and Health Survey said TBA-assisted deliveries accounted for 28 percent of all births in the country. They are far cheaper than those in hospitals.
For instance, a Nairobi-based mother who has been visiting Avenue Hospital, a private facility in the city, says her normal monthly check-ups cost 600 Kenyan shillings (about U.S. $7.50). The price for a delivery can run into tens of thousands of shillings.
Nairobi's Pumwani Maternity Hospital is among the least expensive. It is also the only specialized public maternity hospital in East and Central Africa. A monthly check up costs as little as 50 shillings (less than $1), and an uncomplicated delivery 4,000 shillings (about $48).
Grace Njinju, a volunteer health worker with the Area Chief's office in Kibera, values the skills of TBAs but sees the need for training. She recently visited Mteeshe to find out if she would be willing to learn about topics such as effective hygiene and the need to consult health experts during emergencies.
As part of the visit, Mteeshe will receive a delivery kit, including sanitized razor blades, suture thread, a needle, and clean swaddling cloth.
Traditional attendants provide only basic services, and are incapable of carrying out vital checks such as a heartbeat rate, general weight and blood pressure - services that only hospitals provide. Expectant mothers also miss out on having an ultrasound, which can monitor the development of the foetus and determine whether the baby is well positioned for safe delivery.
Personal Touch
Many expectant mothers say they prefer visiting traditional birth attendants, even if their medical skills are inferior, not only because it's more economical, but because it's more personal.
Mary Atieno Fumira, 52, from the slum of Korogocho, said she found the TBAs to be more comforting than nurses at the local health centers when she gave birth. In addition, she said, women in labour are reluctant to go out at night in Korogocho for fear of fear of crime and other assaults, making visits by birth attendants more appealing.
In one incident, Fumira recalls, a neighbour was taking his expectant wife to the health center at night, when they were attacked. The husband was beaten, and the wife raped while she was in labour.
Fumira, who has given birth to nine children, says she started using the services of birth attendants in 1983, after losing her first baby.
"They mishandled me [at the health center] when I was delivering, and so my son was born with a lot of problems," says Fumira. "The baby would often fall sick and showed signs of slow growth. He died eight months later. I decided henceforth I would be seeing a traditional midwife."
Many birth attendants thrive on this type of confidence and trust; indeed, as with Mteeshe, it is almost a part of the service. They believe public health officials should acknowledge their informal yet essential role in impoverished communities. But this is not likely to happen.
Local Initiatives
Dr. Fridah Govedi, a senior official at Pumwani Maternity Hospital, says the Kenyan government is in the process of phasing out TBAs, in line with its Vision 2030, Kenya's development master plan. But these intentions are undermined by a meager budget and the absence of reproductive health legislation. Until these issues are resolved, maternal and child health for the poor are unlikely to improve, health workers say.
In the 2010/11 fiscal year, the government allocated a billion shillings ($1.2 million) to support reproductive health. But the Centre for the Study of Adolescence (CSA) estimates that about five billion shillings is needed every year if poor Kenyans are to gain a tangible improvement in reproductive health care.
"We need to keep pushing the government to commit 15 percent of the budget to health if Kenya is to make progress towards achieving maternal and child health services," says Rosemary Muganda, CSA executive director.
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Some organizations, such as the African Medical and Research Foundation, have tried to assist by teaching maternal and newborn health skills to birth attendants. They team them up with retired nurses and try to persuade them to work as community health workers.
Other TBAs, like Josephine Ameyo Okot, have started community-based initiatives to support poor mothers. Okot, 53, who honed her skills in the 1980s as a hired midwife in Pumwani Hospital, says she founded the Provide Maternity Facility in 1996. But it closed in 2002 due to a lack of funds.
However, Okot currently runs a school in Korogocho for children who have been delivered by traditional birth attendants, with support from the Feed the Children organization.
"The school has a baby class and operates up to class eight," Okot says. "But our donors say they could stop supporting us because it is becoming difficult for them to visit due to insecurity in the slum."
For now, women like Mteeshe believe it is their duty to serve the struggling poor, despite threats that traditional birth attendants will be phased out.
"I am not worried about the government interfering with our work because mothers like our services," says Mteeshe. "They usually come to us and leave satisfied and grateful."
