Lessons about Maternal Health in Kenya’s Largest Informal Settlement; Kibera

Originally from Delaware, Grace Firestone began engaging in nonprofit work in high school to provide disadvantaged youth with athletic equipment and improved living conditions. This led to a fundraising venture to Kenya in 2013, during which she climbed Mt. Kilimanjaro and stayed at an orphanage (now primary school) called Flying Kites. Pursuing her dream to return to Kenya with more substantial skills, she earned an MD followed by residency training in Primary Care. By way of connection with U.S. Senator Chris Coons during her final year of residency, she traveled to CFK Africa in January 2023 to work at the Tabitha Medical Clinic and Tabitha Maternity Home.

“Rotate.. rotate.. down.. now up!” Florence, one of CFK Africa’s OB nurses, dictated my movements as I guided baby out and onto his mom’s abdomen. A strong cry seconds later brought great relief and a deep exhale from my tightened chest. Healthy baby and healthy mom. Gotas “fist bumps” all around. This was the first laboring mom I had managed with the team, and it felt great to have a successful outcome. Interestingly, the baby had a small extra digit on each hand that we would later ligate with sutures. Otherwise, everything was “normal”.

What I feared, however – complication – was only a matter of time. Although there would be challenges to overcome, I was continually impressed with the clinical acumen and resourcefulness demonstrated by our nurses from Day One.

As Mary became more exhausted, it was clear this baby was not coming down. Either the baby was too big, or positioned in a way that was not amenable to vaginal delivery – Mary needed a C-section. To initiate the referral process outside of the Maternity Home, Florence started calling local hospitals for acceptance. Finally, after what seemed like an hour, we were good to go. We – Florence, Kenny (another OB nurse), and myself – loaded into the ambulance with Mary. The ambulance ride was rough enough to bounce us off our seats – my white-knuckled grip on the overhead bar was barely enough to keep me in place. Mary was groaning. When we pulled into the hospital parking lot, we walked Mary into the waiting room. Fortunately, a doctor quickly accepted her. After we saw Mary was safe in a hospital bed, we returned to clinic.

It was the start of Week Three. I walked into the Maternity Home and sat down in one of the chairs in two rows facing each other. The day team was getting a report from overnight staff. They greeted me with smiles and a cup of the uniquely delicious white tea. After the report, I was headed to see a postpartum patient with Kenny when he turned to tell me what happened the day before, while I had been away on a home visit. His face became somber. A pregnant woman around 32 weeks gestation had presented to Tabitha Medical Clinic (our primary care site) and was found ready to give birth. She was appropriately sent to the Maternity Home, where she had a preterm delivery almost immediately after arrival. For reference, “full term” is 37-40 weeks gestation. Unfortunately, the baby boy was in distress and needed an emergency referral. Respiratory distress is common in premature babies because their lungs are not fully developed. He was then taken by ambulance and accepted at the referral hospital. Sadly, the baby could not recover at this point; he died within hours.

The first elephant in the room – a tragic issue that is much more comfortable to avoid – is that clinics in informal settlements need more support. Computers. Printers. Basic labor supplies. Resuscitative training. A neonatologist and a surgeon. The nurses and medical assistants are clinically skilled, passionate, and hardworking, but they need more resources. The second, related elephant is that lives will be lost while waiting – which gives me chills and tearful eyes to write. The dedicated care at the Maternity Home provides significant harm reduction for mothers who would otherwise give birth at home. But my heart aches wondering about the mothers who have complications and need to be transferred to hospitals… and wondering about the ways this came to be, that mothers in informal settlements give birth with disproportionate risk to their health.

The resiliency of the Kenyan people – the CFK Africa staff, their patients, community organizers – seeped into my soul through conversations that often centered on creating opportunities for the next generation… And the environment – extreme heat, dryness, and clouded combination of dust, burning trash, and car exhaust – is something my skin and lungs will remember for quite some time.