Elective in the area of Kisumu, Western Kenya

Le Quesne Clinic, Ombeyi
Marie Stopes Clinic, Kisumu

Linden Stocker, Fifth Year Medical Student, Nottingham University

Equipped with a limited knowledge of obstetrics, little understanding of the local Luo tribal traditions and a non-existent Ki-Swahili vocabulary, I embarked on my 7 week elective in Western Kenya. My aim: to set up a maternity unit in a rural clinic.

Constrained by a culture which advocates polygamous marriage and wife inheritance, Kenyan women are second-class citizens. At no time is this more obvious than during their (numerous) pregnancies and deliveries. With their social status dependent on Grand multiparity women traditionally give birth at home, assisted by a village elder. Luo women are often poorly educated and the threat posed by HIV/AIDS infection, and the stigma attached, is greater here than in most of Africa.

The Kenyan obstetrician is faced with late presentation of fetal and maternal illness, women dying in obstructed labour and the after-effects of illegal terminations. In an area consumed with death I was fortunate enough to witness and assist some relatively safe and healthy deliveries.

I spent 3 days a week at the charity-funded clinic ‘Le Quesne', in Ombeyi. This is a 26km journey from Kisumu but, as I discovered to my peril, not always a passable route during the rainy season (i.e. my elective period!). Here there were fantastic opportunities to see many different conditions and plenty of scope for antenatal care. There was the facility for 35 in-patient beds (not yet fully open) and whilst I was there a laboratory was assembled and I set about ordering equipment for my maternity unit/delivery room. The staff consisted of a clinical officer (3yrs training), a laboratory worker and a partly trained nurse (who all lived on site). It was here I ‘constructed' a delivery room by buying a delivery bed from Nairobi, having a sink built with running water (there is no other source at the clinic) and I took a hand-held fetal Doppler with me which I had bought before I went. The clinical officer and I set up antenatal appointments and I was able to give him information about contraception which he did not have.

Whilst I was in Kenya I managed to organise spending 2 days a week at the Marie Stopes clinic in Kisumu. Marie Stopes is an international charity which provides sexual and reproductive health information and services across the globe. In Kenya, Marie Stopes is one of the leading providers of family planning and obstetric care and runs 20 centres with five outreach teams. It provides free and low cost family planning methods and has the mantra, ‘children should be born by choice, not chance'. Surplus income generated by its high-volume, low-cost reproductive health and obstetric centres in central Nairobi subsidises services for low-income clients.

Working with the resident doctor (who is on call 24 hours a day, every day of the year), I took part in ward rounds, outpatient clinics (general and obstetric/gynaecology patients), deliveries and ‘Caesars' as well as learning basic laboratory skills. The staff never tired of the novelty of having a Muzungo (white person) working with them!

It was pleasing to be able to see some better medical practice than is exemplified by the government-run institutions. The standard of care here is the best I have witnessed in Kenya. They perform safe, completely illegal abortions for a cost equivalent of about £30 (only therefore available to the wealthy) as well as standard obstetric and gynaecological medicine. They try to obtain legitimate drugs and have an operating theatre. They ‘borrow' the local anaesthetist from the government hospital (not a doctor, a clinical officer with anaesthetic training). However, whilst I was assisting in one section the doctor didn't realise the clinic had run out of stitches until the incision had been made and the baby delivered.

I also spent some time at the government clinic in Ahero (about 8km from Ombeyi). The Government-run clinics are abysmal with a constant stream of impoverished patients. Whilst the medical staff are doing their utmost to help, they are faced with horrific cases every day and work under difficult conditions with poor resources. From an outsider's perspective they appear to lack empathy but I think this is probably because, unlike me, they are used to seeing such cases. The cultural differences also mean the doctor-patient relationship is more dictatorial than I am used to.

We did outreach clinics from Ombeyi to the surrounding areas and I also opted to visit a couple of orphanages. I also visited another clinic in Osani. This community is primarily a fishing community, with sky-high HIV rates and long distances to travel to get medical help. The outreach clinics were good experience but quite disheartening as I could diagnose and prescribe, but the patients often could not afford the tests or drugs needed, so it sometimes felt a bit fruitless. The outreach antenatal care was also difficult as I realised I was likely to be the closest contact they made with a health professional for their antenatal care and deliveries; they couldn't afford otherwise.

The rich-poor divide in Kenya is frighteningly obvious, especially when considering medical provision. The governmental corruption is crippling the most vulnerable people and the health-care provision is often shocking. Some of the things I saw were truly abhorrent and difficult for me to understand. Female circumcision, multiple childhood deaths and AIDS are all normality for Kenyans.

I planned and undertook my elective alone. Some of my friends thought I was brave, some thought I was mentally unstable, some a little of both! However, I am extremely glad I went alone as the experience would not have been the same if I hadn't done so. The locals are incredibly welcoming and willing to share what little they have which was truly humbling. No electricity and boiling murky water to drink were easier to adjust to than anticipated. Whilst I was on my elective my high points were amazingly high, my low points correspondingly low! In 2 short months I had to learn to practise medicine like a Kenyan, barter for medical equipment and adjust to being accelerated to the most qualified member of a medical team.

Linden Stocker
Medical Student
University of Nottingham

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