Evolution of Modern Obstetrics and Gynaecology Practice in Kenya

In a previous post it was opined that although Kenya has the capacity to train the nurse workforce it needs, the prevailing challenge is ensuring all trained nurses and midwives are employed and efficiently deployed. The State of World’s Midwifery[i] 2011 observes that appropriate employment and deployment of skilled midwives is essential for Kenya to make meaningful progress towards achieving MDG 5. The current post seeks to highlight some of the milestones in the evolution of modern practice of midwifery and midwifery training in Kenya.

In colonial Kenya and before the mid-1960s, obstetrics and gynaecology were practiced as separate services located in different facilities. Whereas gynaecology services were availed as sub-specialty within the department of Surgery at the King George VI Hospital (later renamed Kenyatta National Hospital), midwifery services were considered a separate service altogether, provided in maternity homes that were usually sited some distance away from the main hospital. The tradition of building maternity wards some distance away from the main hospital arose as a long-practised measure to prevent cross infection especially from surgical patients. It also reflected the colonial policy that whereas the Government undertook to provide Africans with what was described as ‘complete medical care’, this service did not extend to obstetric care, which was regarded as a responsibility of the local authorities, the Municipal Councils or in the reserves, the African District Councils[ii].

The initiative to develop midwifery services in urban areas of Kenya is credited to the East African Women’s League (EAWL)[iii] which, “out of concern for the lack of a maternity ward for African women”, and with the encouragement of Lady Grigg (Governor‘s wife), founded the Lady Grigg Child Welfare and Maternity League in 1926. By 1928 the Lady Grigg Maternity Home at Pumwani (now the Pumwani Maternity Hospital) had been built. Other maternity hospitals followed, in Mombasa- Lady Grigg Maternity Hospital Mombasa (now part of the Coast Provincial General Hospital), and in Nairobi- the Social Service League Ngara Maternity Home (sadly, this has since ceased to be a hospital).

The EAWL also advocated for the training of African nurses and midwives, and all three maternity hospitals mentioned above undertook the training of the early midwives in Kenya (to enrolled midwife level). Later on, in pursuit of primary health care following the Alma Ata Declaration of 1978, midwifery training was incorporated into nursing training to produce the Enrolled Community Health Nurse. Training at registered midwife level had to wait until registered nurse training had started in Kenya. Training at para-medical level in Kenya can be traced back to 1927 when the first group of students was recruited for training as Medical Assistants at the Native Civil Hospital, (later re-named King George VI Hospital and Kenyatta National Hospital). This cadre was trained to provide both Nursing and Clinical services. These are the forerunner of the Clinical Officer of today. In 1952 the first batch of Kenya Registered Nurses commenced training at the King George VI Hospital and the Medical Training Centre (now Medical Training College)[iv]. Registered nurses could then undertake a further year’s training in midwifery to qualify for registration as Registered Midwife.

By 1954 of the 12 full time specialists at the King George VI Hospital, only one, Dr Peter L Candler specialised in gynaecology[v]. According to Peter Candler, the most common gynaecological condition he dealt with at that time was vaginal fistula resulting from lacerations during childbirth. This was followed by complications of generalised pelvic sepsis and infertility. However, he reported that ‘attempted’ abortion was unlikely among Africans because of the strong desire to bear children! Nearly two decades later when we came into the scene, the pattern of gynaecology had changed little, except in the case of abortion which had since become a prominent gynaecological problem.

The expansion of obstetrics and gynaecology services in Kenya is largely attributable to the University of Nairobi’s Department of Obstetrics and Gynaecology. The medical school in Nairobi was established through a presidential directive shortly after 1963, the year of Kenya’s independence. To implement the directive, the Ministry of Health with British Government financing, invited the University of Glasgow to assist in preparing the KNH as a teaching hospital ahead of the launch of the University of Nairobi Medical School in 1967. Thus, a team from Glasgow arrived, and in September 1965, oversaw the opening of the Obstetric Unit at the KNH. Initially, patients were ‘borrowed’ from the Pumwani Maternity Hospital through a process whereby one of the consultants would select a couple of women in early labour and transport them to the Obstetric Unit at KNH for their management. In addition, the Department ran, on behalf of the Nairobi City Council, four antenatal clinics at the health centres in Riruta, Waithaka, Woodley, and Langata. This way it was possible to have enough clinical material for the medical students and student midwives from the School of Nursing. It should also be mentioned that the first medical students taught at KNH were actually ‘borrowed’ from Makerere Medical School! Initially these were Kenyan students who chose to spend an elective term at the KNH, but later the hospital provided refuge to students who fled Idi Amin’s tyranny in Uganda, including some students from other countries.

Establishment of gynaecology (gynae) as a specialty at KNH, separate from Surgery, was not without resistance and intrigues. There were those surgeons that felt there was absolutely nothing new to be gained by creating a department of gynaecology- after all, hadn’t they treated gynae cases all those years? A thorny area concerned the allocation of operating theatre space for a regular gynaecology list. We needed a theatre for emergencies such as ruptured ectopic pregnancy and incomplete abortion; as well as another theatre for elective (‘cold’) cases. I remember one senior surgeon openly saying incomplete abortion never required an evacuation- after all many occurred in the ‘bush’ where there were no doctors! He had always sent them away without any evacuation.


[i] The State of World’s Midwifery 2011, was launched in June 2011 by the United Nations Population Fund (UNFPA)

[ii] Letter written on October 20, 1954 by Robert F Gray to Mr Walter Rogers of Institute of Current World Affairs, 522 Fifth Avenue, New York 36, New York. http://www.icwa.org

[iii] The East Africa Women’s League is an organisation for white women who were born in, lived or worked in East Africa. It was founded in Nairobi in 1917, its main concern being the welfare of women and children of all races in the country then known as ‘British East Africa’. http://www.eawl.org

[iv] http://www.kmtc.ac.ke/public_site/webroot/cache/article/file/Nursing_log1.pdf

[v] Note: Dr Peter Lawrence Candler was admitted to the Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) in 1962.

 

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