Leparua, Isiolo County, Kenya – it takes three hours to snake downhill on a motorbike, skirting gingerly around mud puddles, but for Salome, it feels like days.
Riding side-saddle, she exhales sharply over each bump on the track and rubs her heavily pregnant belly protectively.
In the driver’s seat is traditional birth attendant, or TBA, Afro. He squints through the monsoon rainclouds, carefully inching the motorbike forward. His gaze remains fixed on the horizon until, at last, the hospital comes into view.
Deep in Kenya’s interior, health facilities are sparse, with some located up to 100 kilometres from the communities they service. For pregnant women like Salome, reaching it can be perilous, particularly during the rainy season, when dirt roads flood and bridges become submerged.
“I know many women who went into labour and started to walk to the hospital alone,” she says, slumping down on a plastic stool at the hospital entrance. “But it is too far to walk with labour pains, so they had to deliver the baby in a bush.”
Fortunately, Salome is in safe hands, thanks to birth attendant Afro and his motorbike, or piki-piki, as it is known locally.
As she goes in to register, Afro leans heavily on a curved crook outside, exhausted. He explains why traditional birth attendants continue to play a central role within the Masai’s tribal structure.
“It is a great honour for us to deliver the new members of our tribe. This role gives us status within our communities.”
But with the arrival of the motorbike, he says, the role of the traditional birth attendant may be changing.
“In the past, I had to deliver the baby at the woman’s home with no medical knowledge. When there were complications, there was nothing I could do. Now I can bring the mothers here on my piki-piki and take the tiny babies back home when they arrive. So, we still play a significant role.”
Unfortunately, many women in Kenya do not have access to the same level of medical care as Salome. According to the latest figures from the World Health Organisation, more than 6,300 women died in childbirth last year, one of the highest in East Africa. It is estimated that more than 800 of those deaths occurred in Isiolo County.
Traditional birth attendant Afro, Leparua, Isiolo County, Kenya, 2016 Photograph: Nicola Kelly
With long distances, poor infrastructure and no licenced medical professionals nearby, women in this part of the country have relied on TBAs for generations.
In 2005, Kenya’s Ministry of Health banned traditional midwifery practices, saying TBAs had adopted increasingly risky methods of delivery. They focused their investment instead on training and equipment.
Nurse Julia describes how the ban further entrenched high-risk practices in Masai culture. “Many TBAs felt abandoned at that time. They felt they had no choice, so they continue to use these natural remedies. For example, they take a part of a tree commonly found here, boil the root and give the liquid to the pregnant woman to encourage the uterus to contract.
“But many midwives give the mother too much of the liquid. Sometimes, the ladies overdose, start fainting during labour and even lose their babies. It is traditions like this that we must prevent.”
She points to a small plastic bag filled with blood on a tray nearby and explains that this had been extracted from a goat by another TBA to increase the haemoglobin levels of an 18-year-old mother.
“Clearly, she needed a blood transfusion, but the TBA saw no alternative,” she adds. “This is how tetanus, hepatitis B, HIV and many other infections are being spread.” Afro says that, while these traditions will endure, he encourages his fellow TBAs to integrate their practices with skilled medical care.
“We used to deliver the babies with no protective gloves, but a lot of birth attendants contracted HIV. Now we know that it is not safe to do this. We have agreed not to assist women at home anymore.”
International development agencies believe that providing funding for motorbikes as part of the Rural Transport Network scheme, rates of maternal mortality in Isiolo County will improve. “By giving motorbikes to rural communities, we can ensure emergencies are quickly referred for specialised obstetric care,” Samuel Nyutu, Health Programme Officer for Christian Aid in Kenya, says.
“They allow TBAs to reach areas it would be difficult for an ambulance to get to and they are easy and cheap to run.”
Alongside the health benefits for the mother, there are a number of other incentives for the traditional birth attendants. They receive a small stipend, protective clothing and some also undergo midwifery training, working alongside nurses like Julia.
Afro hopes that more vehicles will be supplied to TBAs in the surrounding villages to ensure women in rural areas make the arduous journey to their local health facility.
“I see that my motorbike has helped to save lives. It helps the mother and the baby – and it also helps me!” he says, patting the saddle of his piki-piki fondly.