On a cool Saturday afternoon, the day
before Kenya celebrates Madaraka Day (June 1, 1963 — the date the country
attained internal self-rule), several of my colleagues from Population Action International (PAI) and I are having
lunch at the home of Rosemarie Muganda-Onyando in Nairobi.
director of the Centre for the Study of Adolescence and a dear friend of
PAI’s, has been instrumental in arranging logistics and interviews as we
film our latest documentary. She has gathered over a dozen people, many of whom work in
reproductive health, in her
lovely living room for a traditional Kenyan meal. Our conversation topics range from our children to
USAID to Nairobi’s biblical traffic jams.
It is only after many of the guests
have left and there are just six women remaining that the conversation
turns to the presidential elections in the U.S. There is such passion as
the Kenyan women talk about Barack Obama.
"He is our son," one
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They speak with awe of his father’s birthplace in
Nyanza Province, more than five hours away from where we are sitting in
Nairobi. Barack’s father was "brilliant," a woman says.
talked about how smart he was. It is the fish they eat there. You eat the
head of the fish and all the wisdom goes straight to your own head."
The women nod in agreement, assuming the senior Obama ate a lot of fish
Those of us from the States are grilled
about Obama’s chances of winning the election; there is no doubt in their
minds that he will win the nomination.
I ask if they would be this excited
if another African-American were poised to win the Democratic nomination
for president: Is it about race or is it about ancestry?
One woman shakes
her head and says, "Barack [they almost always call him by his first
name] is special. When he was just a teenager, he made the long journey
to his father’s village. He had to ride on the back of a truck. How many
teenagers would do that?"
Earlier in the lunch, an earnest young
man sitting next to me tells me that his greatest wish is to visit the
U.S. He says that he and his friends call the U.S. "Heaven."
While I try to give him a more realistic view of my country, he remains
steadfast. His parting words are, "Soon I will find a way to see the
As these well-educated, politically aware women talk
about the positive changes an Obama presidency would bring to the world,
I am reminded once again how small our global
nation can seem sometimes.
And, the women say, on the day after their "son"
is elected president, we will be able to hear the cheering of Kenyans all
the way in America.
Ipas’s senior clinical advisor Mary Fjerstad interviews Kenya’s much-respected Dr. John Nyamu to discuss the long and difficult path he and so many other Kenyans have traveled to get where they are today on abortion.
Until 2011, abortion was illegal in Kenya except to save a woman’s life. For years the climate of fear and secrecy surrounding abortion hurt women, their families, and health-care providers. Unsafe abortion in Kenya still causes an estimated 30 percent of maternal deaths and countless other injuries.
Now, a newly ratified Kenyan constitution allows for legal abortion on much broader terms—and, when the new law is fully implemented, it stands to dramatically increase women’s ability to exercise their reproductive rights.
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Ipas’s senior clinical advisor Mary Fjerstad recently sat down with Kenya’s much-respected Dr. John Nyamu to discuss the long and difficult path he and so many other Kenyans have traveled to get where they are today.
Mary Fjerstad: Doctor Nyamu, would you tell me what the situation was like in Kenya when abortion was considered a criminal act? [Editor’s note: Before constitutional reform, abortion in Kenya was highly restricted with few legal indications for having the procedure.]
Dr. John Nyamu:Most health-care workers were afraid of talking about it openly. Abortion was never performed in government hospitals unless the life of the woman was in real danger. Even then it was very bureaucratic as one doctor could only do the procedure with permission in writing from two other doctors; one doctor had to be a psychiatrist and the other doctor had to be a senior doctor in the hospital. Abortions were performed by D&C or induction. In reality, these legal abortions were provided almost exclusively at Kenyatta National Hospital, provincial hospitals and very rarely in district hospitals. (Kenyatta National Hospital is the major teaching hospital in Nairobi).
There were wards in hospitals where women who had unsafe abortions were treated for uterine and bowel damage due to perforations and developed sepsis, brain damage and many women died.
There was tremendous secrecy about abortion, women were aborting late. The penalty for a doctor who performed an [illegal] abortion was 14 years [in prison]; pharmacists could be imprisoned for three years for giving abortifacient medicines and women themselves could be imprisoned for seven years for having an abortion.
Some private clinics were providing safe abortion. They were harassed regularly by local police, usually by extortion. They were used virtually as the personal ATMs of the police [ATM =Automatic Teller Machine, a banking machine from which you can withdraw cash using a bank card]. A policeman would say, “I’m short of cash, give me your cash or I’ll arrest you.” The entire staff, including nurses, doctors and women seeking abortion could be arrested. Due to the fear, the providers kept servicing [the police] to buy their freedom.
In 2004, [data were shared] which showed worrying trends and consequences of unsafe abortion in Kenya. This was followed by a major crackdown on clinics, hunts for women who had abortions, some clinics were closed and I was targeted. There were 15 fetuses found along a major road with some documents from a hospital I had worked at previously but had since closed. My clinic was raided and two nurses and I were arrested. This appeared to have been very well organized with all the media including print, radio and TV present to report on the matter. When we were asked to pay bribes, we refused—because we knew the fetuses were not from our clinic and the documents were planted on the road—and we were locked up. [Editor’s note: subsequent pathology examinations found that the fetuses were still-born fetuses, not aborted fetuses.]
The three of us were ultimately charged with two counts of murder, rather than an abortion-specific offense. Since murder is a non-bailable offense in Kenya, we had to stay in remand prison pending our trial. We all spent a year in prison. One of the nurses was six months pregnant and delivered while she was in prison. One of the nurses still works for me and the other got her green card and has since immigrated to the United States.
A senior doctor, a gynecologist, was instructed by the Director of Medical Services of the Ministry of Health to accompany the police and inspect the two clinics operated by Reproductive Health Services. The purpose of the inspection was to verify if there was any abortifacient equipment. He gave witness in court that the two facilities had legal equipment normally found in a gynecologist’s clinic and he would be surprised if he did not find it as he uses the same equipment for his work. The police forensic department was asked to look for DNA on the equipment from the clinic. DNA was taken from any instruments or equipment with blood on them—even the couches and lab coats were confiscated. The results from the government chemist found that there was no DNA linkage between the fetuses found on the road and any blood specimens from the clinic. The doctor also found that the clinic was duly registered and all staff had proper and up-to-date licenses.
The case was eventually ruled as improper [Editor’s note: Theywere acquitted of all charges]. With that ruling, the attorney general decided not to pursue prosecution due to lack of evidence.
Was it horrible being in prison for a year?
Yes, it was horrible, but it was worth the sacrifice. I was held at the Kamiti Maximum Prison, which is where the hard-core criminals are remanded. I was confined in a small cell for a whole year. I really felt persecuted, but as I said, it was worth the sacrifice.
Why do you say it was worth the sacrifice?
My arrest and imprisonment was in the media virtually every day. The publicity was an opening for people to realize the magnitude and consequences of unsafe abortion in Kenya; women were dying in great numbers. Before that, abortion was never spoken of in public. There are only about 250 OB/GYNs in Kenya; some districts have none. The media sensation from this case galvanized the Kenya Obstetrical and Gynaecological Society (KOGS), the National Nurses Association of Kenya, the Federation of Women Lawyers, human rights advocates, women’s rights organizations and many others to form an alliance of reproductive health rights advocates.
This alliance exists to date and is known as the Reproductive Health and Rights Alliance (RHRA). The RHRA is an advocacy platform to agitate for the reduction of maternal mortality and morbidity due to unsafe abortion. This alliance also offers technical support to abortion service providers through Reproductive Health Network (RHN). The public became aware of abortion and the toll of unsafe abortion. The window was open to the public to realize the terrible toll of unsafe abortion in Kenya.
This debate extended to the drafting of a new Constitution in 2010. The Constitution says that “every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care.”
My arrest, imprisonment and [the resulting] publicity generated a public awareness that led to a transformation in the understanding that safe abortion is essential to preventing maternal morbidity and mortality.
Is there any further action in your own case?
Yes, I have since sued the government for malicious prosecution and subsequent confinement for one year in remand prison. The case has been in court for the last six years without yet being assigned a hearing.
What does the expansive definition of health in the new constitution mean in terms of when an abortion is considered legal?
Abortion is legal if the pregnancy endangers the life of the woman; as an emergency treatment; or when it endangers health, with health defined broadly: physical, social and mental. If in the opinion of a trained health professional an abortion is provided in good faith (in other words, where the pregnancy jeopardizes the woman’s physical, social or mental health), it is legal. [Editor’s note: Under the new law, a woman can make her abortion decision with one health-care provider; others are not required to be involved or sign off on the decision.]
What categories of health-care providers can perform legal abortion?
Physicians, nurses, midwives and clinical officers [who have completed training to perform abortion services] can now perform legal abortions.
What are the next steps in transforming the policies to establish safe, legal abortion in Kenya?
Ipas and other organizations took the lead in writing a document called, “Standards and guidelines for reducing morbidity and mortality from unsafe abortion.” The title is taken from a similar document from Zimbabwe and is brilliant. Kenya, like other countries, wants to achieve the Millennium Development Goal of 75-percent reduction in maternal mortality; this can’t be achieved if safe abortion isn’t available.
The other milestone on transformation is the revision of codes of ethics and scope of practice for all the professional associations in Kenya. These have been done and are waiting to be launched.
This transformation to legal abortion access in Kenya is a testament to very brave, inspired people dedicated to the common good who have sacrificed a lot. How have all the changes we’ve discussed affected providers of safe abortion and women?
Providers are now aware of the enhanced protections that have been offered by the constitution. This in turn has increased access to safe abortion services and thereby enabled women to realize their reproductive health rights. In addition, incidences of provider harassment are now on the decrease.
This Fall, viewers have been treated to two very, very different new shows about women’s healthcare providers, rife with yowling birth scenes and women being examined in stirrups. As different as they are, I thought it might be fun to look at them both at once.
“The Mindy Project” is a smartalecky sitcom by and starring Mindy Kaling centered around a group of young, single, verbal barb-slinging Ob-Gyns at a shared practice; “Call the Midwife” depicts a group of nuns and midwives in the post World War II slums of London. In both shows, delivery scenes abound and births are occasionally the fodder for jokes, and while the first trades in wit that verges on being too sharp, the second trades on emotional melodrama that can verge on treacly.
“The Mindy Project” has its laugh out loud moments, and reasons to root for it: a trailblazing heroine who is neither tiny nor white, nor entirely likable, and has a classic comedic self-centeredness. It has, for the most part, a non-shamey attitude towards sex and relationships and its heroine’s body.
But for me, at least, it verges too often towards mean-spiritedness, particularly in its depiction of a central male-female friendship. Like many other reviewers, I can’t get over the line in the pilot when Danny, Mindy’s colleague, frenemy, foil, and presumably someday romantic-interest, tells her to lose weight and the line just sort of hangs there, nastily. I was appalled that we were then supposed to accept the banter between the two of them as a core part of the show’s brand. But Kelsey Wallace at Bitch thought this was simply the show being realistic. Women get hated on for their weight–this is life.
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I’m not ready to entirely give up on the show yet. When “Parks and Recreation” became a goofier and gentler show in its second season, it won my heart. And I admire Kaling tremendously. But I hope “The Mindy Project” resolves some of its own inconsistencies–and those include the way it portrays the characters’ workplace.
Alyssa Rosenberg at Think Progress argues that the show fails to capitalize on the premise of the Ob-Gyn office, rarely using the setting for humor or even for interrogating cultural taboos about women’s health. An early scene in which Mindy triumphantly delivers a baby belies a subsequent “total disinterest in actual women’s health,” she writes.
My discomfort with the show began in the pilot when Mindy flat-out missed a delivery, blew off another in the midst of a date, and faced absolutely no consequences for her flagrant disregard for her patients. Obstetrics and gynecology are delicate health care issues, and I’d initially hoped that The Mindy Project might break television’s normal awkward silence around them. As that hope faded, I hoped that the show might at least redeem Mindy’s immaturity in other areas by demonstrating her basic competence as a doctor, something that provided the emotional and M.I.A.-scored climax of the pilot. But we’ve never seen Mindy in an extended scene with a patient since.
“Call the Midwife,” the BBC drama just ended at PBS (you can still watch it here) about midwives and nuns in London in the 1950s, is made up almost entirely, it sometimes seems, of extended scenes at the bedsides of patients, or by those patients sides in fish shacks, gutters, and other places where babies show up, demanding to be born. Its cast of nurses and midwives deliver babies (sometimes baby animals) at a regular pace, changing discreetly-filmed bowls of bodily fluids, and regularly calling for more hot water, towels, and “just another push, dear.”
This is quintessential British TV: unabashedly sentimental and piercingly brutal, too. To illustrate this contrast, I’ll describe a shocking moment in another series “Call the Midwife” creator Heidi Thomas wrote recently: her adaptations of Elizabeth Gaskell’s “Cranford,” memorably full of venerable older british actresses chewing the scenery. After a long romantic plotline unfolds for the maid employed by Judi Dench’s character, the show’s creators suddenly kill off both mother and baby in childbirth. The time-period-accurate plotline concludes with the maid’s husband riding away from Cranford, having lost everything he loves in an instant. Dench’s Miss Matty, who was longing for a baby in her home, sits alone in an entirely empty house. It’s devastating. Then some young people whose parents objected to their match are finally allowed to marry and we all cry again. Then more people die.
The death in childbirth described above prefigures a similar sudden maternal death in an episode of “Call the Midwife,” and its tone encapsulates this new show’s approach to heartwarming drama too: it will warm your heart but only if it breaks it too. Consider the impossibility of lasting through an episode without laughing over the unexpected birth of triplets or the shenanigans of “Chummy” the blue-blooded, clumsy nurse with a heart of gold, then sniffling over the miraculous c-section birth of a baby to a disabled woman–thanks, NHS and medical technology–then weeping at the death of a noble old soldier, or at the authorities removing the child of a young mother coerced into prostitution, an adulterous woman who sobs as she gives birth to a baby of another race, or a brother and sister pair who live out the end of their lives traumatized (possibly into incest) by growing up in the workhouse.
This is the no holds-barred vibe that on the other side of the pond, beat “Downton Abbey” in the ratings. The show also presents a somewhat simplified, problematic approach to class, with its nice middle class girls “learning so much about love” from the destitute folks to whom they tend. But for the most part, the show’s format works. It has the production values of BBC television–painterly shots that both show and soften the gritty realities of life in London’s East End (although it never gets, say “The Wire” level gritty, there’s prostitution, violence, death, lots of fairly graphic childbirth scenes, and some really nasty urban insects). But it also has that other British quality that I love: blatantly pushing a social message. As Amanda Marcotte noted in her podcast when the show premiered:
I knew going in that the show was going to be a love letter to the NHS. The midwives portrayed were part of the national health insurance England installed after World War II, which basically made health care free to all and is now being attacked by those who wish to privatize it. The show really emphasizes the quality of care that was made to women by the NHS, both in terms of regular prenatal visits from midwives, but also post-natal check-ups to make sure the babies were doing okay, all at the home.
In 1967 the Abortion Act was passed, and abortion was no longer illegal. When I was a gynaecology ward sister at the Elizabeth Garrett Anderson hospital in London, I was sometimes asked whether or not I approved of it. My reply was that I did not regard it as a moral issue, but as a medical issue. A minority of women will always want an abortion. Therefore, it must be done properly.
I’d love to see “Midwife'”s Thomas take that on.
For both shows to live up to their promise, there’s always next season. My message to their creators: “just push, dear!”