Conversation about training in Kijabe, safe deliveries, the healthcare landscape in Kenya, and the benefits of the Kijabe resident housing project.
Joshua Muhondwa, Obs-Gyn
David: Thank you so much for coming. I'm David Shirk, director of Friends of Kijabe. Maybe you could say who you are and what you're doing in Kijabe right now.
Joshua: Thank you for having me. My name is Joshua Imeri Muhondwa. I'm a third year began resident in Kijabe. So were you the first class? I am with my colleague Dr. Lynette.
David: Excellent. How is it going? How is how is Obs/Gyn?
Joshua: Well, so far it's well. We thank God for the progress. It was a much-anticipated program. It's hard everywhere, especially with a new program. But we have a very good support team from our faculty.
David: And how did you come to Kijabe? Where did you where did you hear about what we were doing here?
Joshua: I interned here. Okay. Some medical officer back in the year 2021.
David: Okay. Maybe tell me about your background. What made you interested in medicine? Why are you doing what you're doing?
Joshua: Okay. My mom, she was a nurse - she retired - and I think that's the only thing I knew as a little boy. I grew up loving being a doctor taking care of people well thinking through what is happening processing trying to figure out and should I say fix them maybe. Yeah. That's what I knew.
David: And so, when you when you say that like are you like looking at old people in church or who are you who are you thinking about?
Joshua: No, I mean, well my mom would come and tell stories about the sick people she's attending to. She used to work in an HIV based research program and so she would tell us and so I think I was just intrigued by how well the doctors handle it and how people would get better and so I think I was intrigued as a young boy... I'm not sure if I should say I developed my passion but that's the only thing I knew. I just wanted to be a doctor from from when I was young. Yeah.
David: That's awesome. Your medical journey. I mean, what is training like - for somebody who's not as familiar with the Kenyan's medical system? What is training like and how long has it taken you to get to the point where you're at now?
Joshua: All right. So, it all starts with being a medical student after you graduate from your high school and that takes six years overall. And so, and you're tracked directly from high school to medical school. Yes. And so the program takes it's a six year course three years of it being preclinical and three years of clinical where now you're exposed to a hospital setting and then you attend through the major five rotation that is psychiatry obstetrics, pediatrics, general surgery, internal medicine.
And so after it you graduate with bachelor of medicine in surgery but to complete it you need to do a one year internship. So that's how I came to Kijabe. And then after accomplishing your internship then you get license for practicing as a general practitioner. After attending it that's now then you can further your studies depending on whether you want world college-based program or the related affiliated programs like no exac and the rest that are available.
David: Excellent. I love that. Why, what was it about Kijabe that made you want to come and want to stay?
Joshua: Okay. Kijabe is well endowed, rich in resources number one, but also, I think what I like it most is the fact that you allow to practice your faith and so it helps you grow rather than behind. I think that's actually number one point. The fact that it's faith based and well even here we do have support like faith wise you have people who encourage you in department. So, I think it shows that not only we're growing professionalized but even spiritual wise which is more.
David: I love that. Maybe give a couple practical examples of what that looks like like. Do you have mentors like in your department or do you meet for Bible studies or what does it look like?
Joshua: Yes we do. I mean I think after we join not even during residence but even starting internship you assigned a mentor. So, like in obstetrics, I used to have a mentor Dr. Mameti, who's current program director. And then later when we joined residency still as soon as year one we had we were assigned mentor so I know the word mentor most times it means socially but these are people who even they check on you on your wellbeing both spiritually how are you and they allow you to share freely so they are able to offer you the support you need from both background of professionalism to know the spiritual aspect we have bible studies as residents. I happen to be also part of the Bible study program that is involved in other residents programs such as anesthesiologist, general surg, peds surg. Yeah, we do have meet every Thursday.
David: Is delivering babies stressful?
Joshua: No. No. It's okay. At least to me, it has never been stressful, to be honest.
However, maybe now standing here, that's when you know it is somehow stressful because you really don't know the outcome. Growing as a medical student, all you want to see is people pushing. So, you're really not aware of how things can go wrong.
But again, advancing your studies, going to internship after seeing the worst that can comes from what was expected to be initially normal, eventful turn out to be uneventful. That's when you know that there's a lot of things that can go wrong. Now every time there's a development, you're somehow nervous because you really don't know the outcome of it.
David: What is the landscape in Kenya because you mentioned that Kijabe is, I think your word was well-endowed or well-resourced. What is it like for moms having babies like in in a normal situation versus Kijabe and then and then how do those connect? Like do people get referred here on time? Sometimes I assume they do, sometimes I assume they don't. But I don't know - What is what is Kenya like for a mom trying to have a baby?
Joshua: Okay. So referrals. Yeah, there are those which get here on time especially if the mothers have been well followed up. So that means if arriving into diagnosis is sooner and the facility would realize that they can't handle it. That's when they will fight it. However, most times we get referrals pretty late, like these are diseases which are already poorly managed. They're uncontrollable and so you just receive it because you are on the edge and in terms of the landscape really Kijabe is giving the best.
I trained in Thika Level Five, and they were trying giving their best honestly but you can tell. . .here we have machines for monitoring which you call CTG’s which is not very available at that time. I think we had only one in where I trained. And so, it's hard because you're using a fetal scope and as a student you're forced to auscultate but you're not really sure whether whatever you're hearing is a heart fetal heartbeat or not. That affects outcomes for that fetus, unlike here, where it's a very objective way of assessing how the fetal status is. And so that's a pretty big variant. Working from one facility which was a bit of resource limited to now where you think you can fully provide the best for your patient. So, it offers you and appreciate them major difference between the two.
David: When you say they had one CTG machine like how many people would be trying to share that?
Joshua: We were actually not even using it because no one knew how to use it. And even if they wanted to, you would realize that there are no strips for printing. So, all you could use to is to like to auscultate one for about could accommodate around more than 20 women. These are in active phase what we call above 6 cm. There are those who are in latent phase who will be waiting in another room. So, it was a burden and that was four five years ago. I don't know the situation now. Yeah. Hopefully it's better.
David: It's a challenge in in most places and then even in Kijabe. How many machines do we have right now? The reason why I'm asking this is because I just got an equipment wish list and there's more CTG machines on that. But I was curious what we have currently available.
Joshua: So currently in our labor ward it's about six bed capacity and we have five however out of this only four which are functioning. So sometimes we're forced to use the ones in the internet or others and bring it in. Yeah, you're right we need help. Yeah, and it would be nice to have.
David: We're going through a transition. I know some of them literally came in a suitcase that I carried from America I bought on eBay that we carried over and it's amazing they're still working. But we're in this transition in Kijabe, to try and find both locally and kind of higher quality equipment. You know, you start out somewhere. You have to start somewhere but then bit by bit it gets better.
Where are you from originally? Where's home?
Joshua: I'm originally Tanzania. Okay. The southern part of Tanzania. Yes.
David: Excellent. Is Kenya different from Tanzania?
Joshua: Slightly different. Honestly, slightly different. I don't think the difference is significant. Yeah.
David: It seems like to me, and I'm just an observer. You know, I've been here 11 years, so I'm becoming more Kenyan, but it seems like there's a lot of commonality for East Africa. Each place has like little differences, but you can tell East African culture, I think, pretty broadly. So you love chapo?
Joshua: Yeah, very much.
David: What would be your dreams or maybe your hopes either for yourself or for the teams you work with? What do you hope to accomplish as a obstetrician?
Joshua:
Okay. So, our team broadly desires to improve both maternal and fetal outcomes. As much as I include fetal, remember before they become babies or newborns, we’re the ones who are managing them. So that's why I'm linking both the two. If we do not manage these fetuses well, well the pediatrics team, maybe they won't have much to do because the babies or are already affected. And so, it is a point that has to be well-collaborated by both teams.
And so by adequately diagnosing them on time and instituting the right care, be it caesarian or delivery, can impact that fetus status both on delivery and later. And maternal-wise. . . well, we know. . .I think it's even worldwide, that maternal mortality is a concern everywhere. This can actually be reduced from awareness education and this starts both from patients to now health care professionals. By this I mean even at the point of acknowledging that this is something that you anticipate could be of concern in terms of morbidity and hence in institute early referral to a maybe a tertiary level that is a major way of preventing maternal morbidity and mortality.
As we know right now PPH - that is postpartum hemorrhage - accounts for majority of death. So, our goal is to improve all these things. In Kijabe I think we are doing well, like last year we had like only one maternal mortality which is a major stride
David: How many how many deliveries do we do?
Joshua: Again, if I may put on like broadly, maybe like around close 1,000, actually.
Because having much of caesarian delivery than again spontaneous vertex delivery for reasons that are obvious because of CTG and again because we tend to manage most of our high-risk mothers. So, because of this you expect your delivery risk to be high and being a point of referral. It's another reason of again of why you're having more high-risk mothers because our community trust us. The infrastructure is good, well equipped to manage anything. Our lab is good. So, if you need blood, it's there timely which what I think we are really doing best. There are those which have happened but even the ones that we lost them it's because even in the US the mortality is high. One of our women who died had amniotic fluid embolism.
The literature says even in the US there's nothing you can do. So that's why I say we really try giving a lot, and effort is made because there are always doctors in the facilities 24 hours. So, there's no time that a mom can come and fail to be attended. Nurses are there, doctors are there, residents are there, consultants are there full-time. It's one of the efforts that are being made.
David: That's awesome. I would say my only complaint is probably a common complaint - just the appearance. On my list, I have a very long to-do list, but coming soonish, not next, Next we want to build we want to build housing for our residents on campus.
And then beyond that is working on a new outpatient facility.
Actually, that would affect your team at least on doing prenatal care like maternal child health center could it functions well. It's actually a nice space but it could be significantly bigger and probably better equipped.
But then, beyond that we will start doing redoing the inpatient heart parts of the hospital. And so, I would love a really nice birth center.
We're overdue. I think we're already 20 years overdue for that. If I could do everything I want to accomplish, that would probably be my last project in Kijabe last, but that would be fun.
Joshua: The last? Why?
David: Oh, just because the timing and scope and how long it takes to do really big things. you know, because this would look like what they have on the master plan. It wouldn't be just like redoing the maternity is now. It would be we would build the new outpatient and then demolish what is current outpatient and then build a big inpatient tower there.
Joshua: Ah, okay.
David: So, it will take some work, but I think it's I think it's possible and will be really nice. It’s an evolution we're going through in Kijabe, to try to match up medical capability with - we have really good clinicians, we have good equipment - but trying to get the environment to match the skill.
Joshua: Yeah. Well, I pray that it comes into fulfillment.
David: I feel like this has been super helpful. It's really nice to meet you.
Joshua: Me, too. Thank you.
David: There's a there's a trait that, you know different doctors have different demeanors or different specialties, but I can tell immediately like you are very gentle, you're calm, which is a really important trait for your specialty.
I know that the mothers love your care. I can tell already because you you're a very soothing like gentle personality and that's really important because it is it's stressful. It's stressful having a baby.
Joshua: Yeah, it is. Well, I think we have the grace to deliver that.
David: Absolutely. So, anything that you would like to share to as we as we finish, you know, anything we didn't talk about or any questions or things like that?
Joshua: Maybe appreciation. I think the fact that you're even working on thinking about the resident’s welfare especially coming up with accommodation structure I think that's very commendable not only on maybe human eyes but also godly eyes.
David: That's awesome. Thank you so much Joshua. I appreciate this has been great to meet you and really grateful for your time. Thank you so much. Great.