Charlotte Ames and Adelle Boughen wanted the opportunity to be involved with women and families living in underprivileged communities in a different country to understand the effect of extreme poverty on health and wellbeing in a different geographical and cultural context. While clinical placements in the UK are varied and expose student midwives to a range of settings, this trip provided a unique opportunity for more diverse experiences for additional personal and professional growth. After undertaking extensive research, they chose to travel with Mission Direct, a not-for-profit organisation, where volunteers join a 2-week overseas mission trip to build homes, schools, classrooms, hospitals and rescue centres (Mission Direct, 2018).
Although the reason for the trip was to help with the building works at Nkapilili School in Narok, Kenya, Charlotte and Adelle visited the local maternity unit and projects such as The House of Hope; the Mission with a Vision and The Fountain of Life. They were unprepared for the profound, long-term effect that these visits would have on them, both personally and professionally.
Visits
Nkapilili School
Schooling in Kenya is self-funded and so the poorest children often miss out on the most basic of education as their parents are unable to afford the fees. Sister Clemencia founded Nkapilili School as she saw that a number of disabled children in her local community were not attending school. Their families felt that their disabilities were a curse, meaning that the children were unable to learn. Building a dormitory for the girls who attended the school, thereby providing warmth, shelter, safety and security, was the main aim of the trip. Charlotte and Adelle attended the site most days and were mentored by the local builders who welcomed them into their team and taught them many new skills. Since its founding in 2011, the school has grown and now has a mix of children with and without disabilities, showing the progress that Sister Clemencia has made in reducing the stigma around disability in her community.
Charlotte and Adelle were overwhelmed and humbled by this visit and enjoyed having the opportunity to spend time with the children, who sang a number of songs for them, many of which were based on their rights for education and hunger for success in their lives. Their optimism, courage and strength became the ‘theme’ of the visit.
Maternity-led unit
Adelle and Charlotte spent a day at a maternity unit in a rural community set high up in the hills with very poor access. The unit catered for approximately 4000 pregnant women living in the surrounding villages and was run by two qualified midwives working between 9 am and 5 pm. They learned that midwives in Kenya are initially nurse trained and consider themselves to be nurses who have taken an additional interest in midwifery. Their role also encompasses the duties of a health visitor as there is no multidisciplinary team to provide care, as in the UK.
Facilities at the unit were basic at best: there were 6 beds in a single room for antenatal and postnatal care and a single delivery room. There was no running water, no heating, no clinical equipment, and no medical supplies. The ‘bathroom’ (essentially a hole in the ground) was outside and there were no washing facilities. The only evidence of guidelines and policies was a single sheet of paper mounted on the wall in one of the rooms—a stark contrast to practice in the UK.
There was no schedule of antenatal appointments: women were advised to come to the unit as and when they felt the need, which usually entailed walking many hours over difficult terrain to attend clinic. The unit was like a one stop shop: children were vaccinated in the waiting area, and babies were weighed at the front desk as they came in. At one point, Adelle questioned the clinical value of weighing babies dressed in layers of clothing or wrapped in blankets. She suggested that without first removing clothing, the weight would be impossible to compare each time. However, the midwives were confused by this and felt clothing made no difference to weight gain or loss. This was yet another reminder of the differences in care with the UK model.
Next year's project, ‘Build Ann a House’, is to build accommodation for two members of staff next to the maternity unit. This will mean the maternity unit will be able to operate around the clock, which should have a positive impact.
The House of Hope and Mission with a Vision
These community-based projects were set up and are run by Bishop Patrick Ngigi and his wife Josephine to house 60 girls who have fled their homes to escape female genital mutilation (FGM), underage marriage and serious domestic abuse. The projects supported the girls, gave them an education and aimed to one day reunite them with their families and communities. In doing so, it was hoped that this would show the girls' communities that women can be successful and that it is of great benefit to the community for girls to be educated. The refuges relied on sponsors and donations in order to feed, educate, clothe and provide sanitary products for all the girls. The Mission with a Vision also had a farm where the girls tended to the animals and farmed the crops when not at school, with the ultimate aim of becoming self-sufficient. Since the trip, the girls have begun selling their cows' milk in the town to provide extra income towards school fees.
Most girls arrived in December before ‘cutting season’, which takes place before the start of secondary school. Once a girl has been ‘cut’ she is unlikely to attend school and is usually forced to marry a much older man. By choosing to leave, these girls sacrificed everything and showed great bravery, as they did not know if they would find somewhere safe to live or if they would be returned to their families by the authorities to be punished. The atmosphere was more like that of a family home, with Patrick and Josephine referring to the girls as their ‘children’ and the girls calling them ‘mum’ and ‘dad’. The refuges provided the girls with a place of safety, a sense of family, a place to console each other, and a chance to be free and, more importantly, to be themselves.
Adelle and Charlotte were told some of the harrowing stories of how young girls had come to the House of Hope. Mary* was 12 years old when she was forced to marry her father's elderly friend in exchange for a cow. She had had two children before she was 15 years old but when she could no longer bear the daily beatings and rape, she escaped. Her physical wellbeing came with high emotional cost, however, as she lost contact with her children.
Jane* ran away from home when she realised that her family were making holes in her bedroom walls to pull rope through for her to be strapped up to undergo FGM. She pleaded with her father but was ignored and so had no option but to flee. She told Adelle and Charlotte that she has had secret meetings with her mother who, despite regular beatings from her father as a punishment for allowing her daughter to escape, begged her not to return—she saw Jane's escape as hope for other girls.
Mary and Jane, now a human rights lawyer and teacher, respectively, are role models for other young girls experiencing similar abuse. They have since returned to their communities and have educated younger girls about having hope, reminding them that they have choices and opportunities. Mary and Jane broke the cycle in their respective villages and by showing elders in their village that it was possible for girls to become educated. Those villages no longer support or practise FGM.
On their visit, Adelle and Charlotte were welcomed in and called ‘sisters’: they danced, they sang and they played games all day. The girls taught them how to make regional food and proudly told them how they had started to take control of their lives and exercising choice. They were emancipated, and their passion and determination were inspiring. They swapped necklaces as a sign of unity and the girls made Charlotte and Adelle bracelets and kissed their hands as they put them in place.
Visiting the refuges had a profound impact on both Adelle and Charlotte, who were overwhelmed by the strength of character and determination demonstrated by such young girls. The girls are pioneers and role models for so many women in Kenya and, without realising it, they are changing history.
The Fountain of Life Centre
This was a community-based project run by Pastor Robert Okiro and his family. Kenyan law fines families who are unable to support their children, and as a result, many children from poorer families, some below school age, are forced out of the family home if their parents cannot financially support them or afford the fines. The Fountain of Life Centre has a programme that feeds the many street children who live in Narok town, providing one meal per day, three times per week. For many of the children, this is the only time they will eat. Pastor Robert also provides skills training, such as furniture making, for young homeless boys, in the hope that they will be able to create an income and escape the cycle of homelessness. The Fountain of Life's women's circle provides a support network for the women in the community and also allows them to use their skills in sewing and jewellery-making to create an income, thereby giving them independence.
Female genital mutilation
The association between FGM and the projects that Adelle and Charlotte visited is clear. The projects all aimed to support young women to be emancipated and make choices, particularly in relation to FGM. Ongoing education was important for young women, not only for the individual but also for the positive long-term effect that this will have on their communities.
Adelle and Charlotte had some challenging discussions about FGM with the midwives at the maternity unit, showing the cultural chasm in opinions. They were told that if a woman had not undergone FGM, she would be ‘cut’ during labour, as it was believed that any person helping to deliver a baby to a woman without FGM would be cursed. Adelle and Charlotte talked about the imprisonment of a mother who performed FGM on her 8-year-old daughter. The midwives believed that it was unethical to prosecute the woman as it was a cultural norm, whereby the mother performed the FGM ceremony with the best of intentions. In her eyes and according to her culture, it ensured her daughter's purity and gave her the chance to marry and be looked after by a husband. In this culture, FGM was considered sacred and part of becoming a woman. The midwives defended their opinion by explaining that this woman's incarceration led to eight other children being left on the streets to fend for themselves and the mother experiencing mental health deterioration that resulted in her suicide. This was a stark reminder of the complexity of the issue.
Clearly Adelle and Charlotte's trip was life-changing, with many lessons coming from discussions with young women and the founders of the projects that supported them after they fled their homes (Boxes 1 and 2). While many of the stories they heard were harrowing, their reflections on the trip were very positive, as everyone they met had such an optimistic outlook and was committed to making a difference to their own lives and their communities.