The Kenyan government abolished delivery fees in all public hospitals and health centers in 2013 to encourage more births to take place within them rather than at home in the hope of reducing the number of pregnancy-related deaths. Approximately 342 women die per 100,000 live births in the country — a stark contrast to countries such as Finland and Iceland, where the figure is as low as 3. In order to reach the Sustainable Development Goals — specifically SDG 3 on good health and well-being for all — the global maternal-mortality ratio should be reduced to fewer than 70 for every 100,000 by 2030, as per target 3.1.

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Maternal mortality rates in Kenya (per 100,000 live births)

Source: World Bank

Despite the fee waiver — which previously ranged between 5,000 and 36,000 Kenyan shillings ($56-$300) depending on the facility — not every woman is reaping the benefits of a free birthing experience.

The distance to public hospitals remains a barrier, said Peter Inoti, director of the Imara Health Care Center, a facility that charges low fees for its services. While government hospitals are indeed catering to mothers and their newborns at no cost, there isn’t always one situated near enough to be accessible. Despite there being three public hospitals and multiple health centers in Nairobi, traffic congestion is inevitable due to the city’s 3 million residents, and what should be hours in a ward can turn into hours in the back of a car.

Peter Inoti, director of the Imara health care center, at his desk.

Smaller, local, and private clinics like the Imara Health Care Center are filling the gap. Found amid the muddy roads, sewage trenches, and makeshift buildings of the Mukuru kwa Njenga slum, the center offers services — including maternal care — but its dependence on donations and small fees means money is scarce and facilities are limited. Red paint above a door at the end of a dusty corridor spells “operating theater,” and wash facilities maintain privacy with slats of wood held together by nails before giving way to a hole in the floor. The stench filters through to the maternity ward.

While the clinic meets a massive need in the low-resource community, its private status means it still has to charge fees: An outpatient consultation costs around 200 shillings, or $2, while admission for surgery can cost 3,000 shillings, or $30.

Imara health care center in Mukuru Kwa Njenga slum in Nairobi, Kenya.

If a government hospital with their free services can be reached instead, it’s likely there would still be a cost implication. Shortages in staff, a lack of functioning equipment, and limited drugs mean the service is rarely without its charges, said Faith Muigai, regional director of SafeCare, a program that supports health care providers in resource-restricted settings.

For women living in the likes of one of Nairobi’s 200 slums and unable to find the extra shillings to cover the cost of labor in a private facility or the cost of supplies and resources in a public hospital, they face a birth without pain relief and adequate care, making death during childbirth a very real possibility.

Edinah Kemunto Ombati, 26, faced such a reality three years ago. Living a few minutes away from the Imara Health Care Center in a house built of corrugated iron, Ombati described her first delivery, with her daughter Birha, as painful and scary. Sitting in front of the curtain that divides the one-room house into living and sleeping quarters, she explained that in the months and weeks prior to giving birth — anticipating the potentially precarious situation that lay at the nine-month mark — she and her partner did their best to find the 3,600 shillings ($36) it would cost to provide her with the essential care she’d need during labor. They begged from friends and family, but it was not enough.

Edinah

Kemunto

Ombati

Mother, 26