When we speak to Noni A, she is preparing is to deliver her second child.
She is scheduled for a Caesarean section in two days. She says the need to buy items incessantly hasn’t been as urgent as during the first pregnancy, “I am checking into hospital tomorrow, and I just remembered I don’t have a nursing pillow. I want it, but I know that nobody will die if I don’t get it.”
Her biggest financial concern is the hospital. “I delivered at a high-cost private hospital the first time.
This time I chose a medium-cost one. But I also chose to go with a private (family) doctor. Not that I don’t trust the hospital, but I’d rather the person who has been giving me primary care finishes the process.
Also every care provider promises you the world. But I don’t think I have come across any hospital that doesn't have a negative review. You make a decision that minimises your risk — for me that decision is choosing a private doctor,” she says.
Asking her whether she feels that the pregnancy and birth has been overly commercialised, Noni says: “I think we are feeding wants, not needs. But I don’t blame the industry because we have done the same thing with weddings. People are trying to make a living. It is up to the consumer to do their due diligence.”
On a personal level, Anne, a nurse, agrees with Noni that birth is being commercialised to feed our wants.
“In Kibera, the only information they are given is to go to hospital so as to keep the baby safe.
But for the middle and upper class, the discussion revolves around private rooms.”
For her own delivery, Anne says she chose her caregiver based on the fact that they were cheaper than the top private hospitals.
She adds that their quality of medical and customer care was also better than public hospitals.
Asking her if she implies that one has to be prepared to spend a little (or a lot) more for a positive birth experience, she says, “there is obviously a big gap between the public and the private sector. It doesn't mean the woman in Kibera will not have a good experience. She will have an experience based on her expectations.
DEFENDING HER TRADE
If I am broke, I will lower my expectations and allow myself to be in hospital with no bell to summon the nurse.
When I have the money, my expectations rise — not necessarily for the birth experience, but for the extras.”
Both Noni and Anne say they didn’t see the need to get a doula (a person who assists a woman before, during and after birth by providing emotional and physical support) as they were attending their antenatal clinics regularly and both had their mothers and husbands for the extra support.
But Wambui Wanguhu, a doula, is quick to defend her trade, “My mother and aunties always tell me how lucky we are.
One of my mum’s friends, who is a midwife, says that even as a midwife, she didn’t have time to look after mothers. It was more like, are you in labour? Okay, do your thing. But for the mum, the question is, how am I labouring? What signs am I looking for? My mum always wishes that she should have had support because she laboured by herself for 19 hours.”
Wambui also argues that the birth scene has changed because we are a new generation, “We are not our parents.
Our body/pelvis is different because of our lifestyles. We are giving birth later in life. Our mothers are no longer as available as they used to be (for long-term support). The birth process is no longer what it used to be.”
The ‘new generation’ argument perhaps underscores that this is a new discussion and by extension, a middle-class issue.
In more marginalised populations, the problem is lack of adequate medical/maternity services, an occurrence that triggered projects such as the First Lady’s Beyond Zero campaign, which was designed to improve access to healthcare for mothers and children and reducing child mortality.
THE CLASH OF THE CARERS
“I start working with pregnant mums at about 29 weeks, and walk them through the whole journey,” says Wambui.
“I take them through (Lamaze) classes. We do the last visit to the doctor together. We labour at home, and then head to the hospital when the contractions are closer together. I am present during birth.”
Doulas, who are non-medical birth practitioners, say their job is to help a mother have an easier pregnancy and birth, labour as naturally as possible and as such have as little medical intervention as possible.
But late last year, one of the private hospitals in Nairobi banned doulas, who have specialised (medical) training, from being present during delivery. Wambui is also a trained nurse and was therefore affected by the ban.
“The hospital felt that sometimes doulas overstep boundaries,” she explains, “If a doctor says the baby is in distress and the mother needs C-section, but the doula thinks the mother can labour for another hour, the hospital can start feeling as if they are not in control,” she says.
Reflecting on the recent clash between medical and alternate labour support, Nurse Anne says, “The medical field, and the handling of a specific case relies on consultation between departments. There can emerge a measure of debate even inter-departmentally, so when an outsider is introduced, things can become chaotic.”
'IF ANYTHING HAPPENS...'
So what happens in case of disagreement between the hospital and the ‘outside’ support? “That’s where the hospital policy comes in.” Anne says, “Do they make you sign to show that you are acting against doctor’s advice? This way, if anything happens, you can’t come back and sue the hospital for your choice.”
While Wambui admits that the hospital raises valid concerns, she still points out the importance of the kind of care she offers, adding that the solution is not to deny mothers this support, “Studies have shown that people who have doulas have a 25 per cent chance of shorter labour, 60 per cent reduced chance of having an epidural and a 50 per cent less chance of having a C-section,” she notes.
A NATURAL PROCESS, A MEDICAL NEED
A 2015 report released by the World Health Organisation (WHO) expressed concern about the global rise of C-section births; even in developing countries. Katherine Graves is a popular birthing expert known for the book ‘The Hypnobirthing Book: An inspirational Guide for a calm, confident, Natural birth’.
She is an ardent proponent for natural birth. Listening to her speak in a pod-cast, Graves says, “Birth is natural. Medical support is wonderful when it is needed. For example, in clinics that have lower than 5 per cent caesarean rates, each one of those Caesareans saved a life.” But as the WHO report confirms, a more than 15 per cent occurrence of Caesareans does not necessarily increase the safety of the mother and/or child.
Nurse Anne says, “Yes, I agree, birth is natural. If it’s a normal pregnancy, you can even choose to give birth at home, but only if you have been attending your ante-natal visits.”
The WHO places a standard minimum of four check-ups before delivery for every pregnant woman.
But Wambui says: “I don’t do home births because I can’t do vaginal checks, or check the baby’s heartbeat. I also don’t think we are well structured for home births. When I practised in Australia, home births were an option because in case of an emergency you know an ambulance will be there in a few minutes. When you are well trained as a doula, you know your parameters.”
THE FEAR FACTOR
The running thread among birth specialists is that fear is the culprit — that if you take an environment where there is an alleged conspiracy to generate profit and mix it with a conscious fear on the part of the family, things are likely to get out of hand.
When Anne was pregnant, she says four stories about women who died in hospital after childbirth were making headlines.
The charge was negligence. “There was a lot of fear spreading around. When you hear of such things happening in fancy private hospitals, you can panic because people choose to pay good money to avoid such things.”
Noni says when you are newly pregnant, you get a lot of transferable anxiety. "But after you have had your experience, you see how different it was from everything you had heard. It doesn’t nullify the anxiety completely, but it also doesn’t make you overly irrational as before.”
Is there a kind of female machismo attached to, and therefore perpetuating the fear of birth? Is the ‘birth is hard’ a feminist card to prove the strength of the gender?
“That’s so wrong,” Noni exclaims, “It’s the same thing we do with emotional pain — we equate how much you love someone with how much crap you are willing to take. Modern medicine has advanced to a point where you can have a painless delivery. Pain is not a mark of strength and neither is it a right of a passage.”
But on the other hand, does the idea that ‘natural is better’ make it possible to shame women who have had a more difficult birth, emergency C-section or even those who have made the choice to have elective CS?
Noni says the fact that she is undergoing a CS is not a conversation she is usually willing to have with strangers. “When people ask me about it, I ask them what their favourite sex position is because that’s how intimate that conversation has got. I don’t even have to explain why or listen to your opinion because I have a very capable oby-gyn. We need to stop victimising each other. Your concern should be whether the baby is healthy — not ‘me I did it better than you’. It’s the same conversation around breastfeeding — there are some people who can and others who can’t, and we need to stop shaming those who can’t.”
A WOMAN’S CHOICE
“Women can do whatever they like,” Graves says, “If they are sensible, they will listen carefully to medical advice. They will also ask questions. They will learn how to work with systems in which they find themselves so they know their choices, they know the alternatives and they know the implication of their choices.”
Nurse Anne lays the onus on the mother; “At the end of the day, do your research so that you can make an informed choice. It goes back to our culture — we are not encouraged to ask questions and we act as if doctors and nurses are gods; whatever they say goes.
I have a friend who left hospital without learning how to breastfeed. She was complaining about the hospital and I asked, ‘were there classes?’ She said yes.
‘Did you attend them?’ She said no. ‘Did you ask the nurse who came to your bedside if they could show you how to do it?’ She said no. So the training was provided. She didn’t attend. She didn’t ask questions and after leaving the hospital, and she later had pay a lactation specialist to teach her.”