Mandera: Visiting the Kenyan region with the highest risk of dying in childbirth anywhere on earth

Kenya’s north-eastern region has an unenviable reputation

When Amina Mohammed, nine months pregnant with her fifth child, began to bleed, she knew that something was wrong. But it wasn’t easy to get help. First her relatives took her to the nearest clinic, but the doctor, lacking the facilities to deal with her, turned her away. When an ambulance arrived after an hour and a half to take her to hospital, her baby was dead and her life was in danger.

By the time the 25-year-old arrived at Mandera County Referral Hospital, she couldn’t walk, was badly dehydrated, and had lost three pints of blood. She had suffered a massive uterine rupture, a tearing of the womb, and was rapidly bleeding to death. 

She was in danger of becoming another statistic in a region where statistics really matter. The risk of dying in childbirth in Mandera, Kenya’s forgotten north-eastern region, is higher than anywhere else in the world. 

According to the United Nations Population Fund (UNFPA), 3,795 women die for every 100,000 live births in this county, nearly eight times the national average.  

“We found 15 of the 47 [Kenyan] counties account for 98.7 per cent of maternal deaths,” said Siddharth Chatterjee, head of the UNFPA in  Kenya, Mandera being “the most fragile of the fragile”. 

Few people think of Mandera when they think of Kenya, a vibrant East African economic powerhouse boasting some of the best private healthcare in the region. Stepping into Kenya’s north-east on the Somali border is like stepping back in time, a region where camel-herding nomads still live by the rains. 

The remote location and the widespread practise of child marriage and female genital mutilation (FGM) mean that the odds are stacked against women. 

“If you are pregnant in Mandera, you are sitting with one foot in the grave; so the question is whether you fall in or are able to come out,” said Dr Angela Muriuki, head of child survival at Save the Children in Kenya.

Luckily for Ms Mohammed, she reached help just in time. She was unable to speak, her tongue swollen by a tumour. She made no sound as the nurse explained how this pregnancy, coming so soon after the last one, weakened her uterus wall to the point of bursting. She survived only because her relatives accompanied her to the hospital, and donated the blood she needed to save her life. The hospital has no blood bank, and the nearest facility is hundreds of miles away in Garissa, too far to be of much use. 

Ms Mohammed was fortunate to live only a few miles from the county’s main town. But many women here live in the bush in far-flung parts of the county, and never see a single health worker throughout their pregnancy. When it comes to giving birth, they turn to unskilled helpers to guide them through it. 

When something goes wrong, they might be hours away from help, forced to walk to the nearest clinic, which itself may be ill-equipped. 

“By the time she gets here, the baby is 50-50, the mother is 50-50. She can live or she can die,” said Issack Aden, head nurse at Mandera’s hospital. Some of the worst complications come as a result of FGM. For a woman having her first child, it can extend labour by hours and cause tearing; sometimes women simply bleed to death. 

With child marriage so widespread here, the problem is made worse, not least because their bodies are too immature for birth, but also because they have no say over their care. “Their bodies are not developed, they are not mature enough,” Mr Aden said. “They don’t know what pregnancy is – physically or mentally.”

Flying by charter plane into Mandera, the makeshift airstrip at the heart of a military camp is a reminder of this county’s place in Kenya – an ignored frontier on the Somali and Ethiopian borders. No scheduled air-carrier flies here, and President Uhuru Kenyatta, nearly three years into his first term, has yet to visit. 

Savage attacks by al-Shabaab, the Somali terror group, in the past 18 months have contributed to the region’s isolation, with aid groups pulling back and hundreds of government employees, including medical staff, leaving their posts.

When in 1963 the British handed the entire north-east, closest to Somalia in terms of ethnicity, language and culture, to Kenya at independence, it plunged the region into a four-year secessionist conflict, triggering decades of marginalisation. When Kenya’s new constitution, approved in 2010, paved the way for devolution, it was, said Ahmed Sheikh, the county’s health chief, “a godsend”. 

The newly elected county leadership, taking office in 2013, inherited an almost defunct health system. “There was one doctor in the entire county,” Mr Sheikh recalled. Just three out of 57 health facilities were working and the main town was almost a no-go zone for government officials. 

“There were IEDs [improvised explosive devices] everywhere;  al-Shabaab controlled this town, ethnic conflict was raging,” he said. “We came in and said: ‘Where do we begin?’ .”

Over the next two years, the county put in simple, but effective, measures. They hired the Kenyan Red Cross’s nine ambulances, reopened clinics, upgraded roads, and hired new medical staff, bringing the number of doctors up to 16. 

In October last year, Kenya’s first lady, Margaret Kenyatta, donated a mobile clinic to the region as part of her Beyond Zero drive, aimed at curbing maternal and infant deaths. International aid, including World Bank funding, is also beginning to trickle in. 

While all this has undoubtedly helped – Mr Sheikh estimates the actual maternal death figure is now closer to 2,150, arguing that the higher figure is based on old data – the real challenge lies in changing attitudes, where a woman’s fate can rest in the hands of relatives acting against her own best interests.

In particular, suggested Dr Muriuku, religious leaders need to be brought on board and persuaded to use their influence to curb FGM and child marriage, and to encourage young girls to remain in school. Maternal education is the “deciding factor”, she said. “The more educated she is, the more likely she is to seek care for herself and her child.”

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