Conversation about Obs-Gyn at Kijabe Hospital including particularly high-risk patient populations: uninsured with cancer diagnosis and teenage pregnancy.
David - What is your name and what do you do at Kijabe
Lilian - I’m Lilian and I’m an Ob-Gyn in Kijabe, for the last four years, but been here a lot longer.
David - When did you start?
Lilian - 2007, internship for two months, elective term, 2009 internship for one year. I left for 8 months and came back in October 2010. Then residency, and I came back fully in 2015.
David - Who is your husband and when did you meet?
Lilian - He’s George (Otieno) – we met in undergraduate in our third year of medicine and surgery. When we came to Kijabe from the first time we were already dating.
David - Lilian is head of Ob-Gyn at Kijabe, here you say obs/gyn, is that right? George was head of internal medicine, but now he’s promoted right? He’s inpatient subdivision head. Both do so much for the hospital, they’re amazing.
What we’ve been talking about lately, and working on, are some of your needs for the OB department. Some we’ve gotten sorted and some are in process. Two years ago, we were having a big problem with the delivery room. And now that’s done.
Lilian – Thank God. Now we can walk in and smile and not be embarrassed. That used to be my nightmare. For example, patients come, they don’t know where the delivery room is, and they walk into this ugly room. That used to be a very big problem for me, it was nothing for a woman delivering her first child. I’m happy.
David – And now it’s really nice.
Lilian – Thank you for spearheading that process for renovation.
David – It’s night and day different. I think there is a process we are going through, not just in Kijabe, but in Kenya, where the bare minimum is not acceptable anymore.
Lilian – No it’s not. We have to give the best to our women. . .and to any patient who walks into any hospital. I think we have gotten used to the poverty mentality to the point that we are not willing to go the extra mile to make things better, as opposed to just living today.
David – We were just talking with a doctor who wanted to come visit a clinic doing more open surgeries than laparoscopy. Which is reality for a lot of places. But here in Kijabe, I feel like we have the option to do things with excellence. That’s why you’re here!
Lilian – That’s why we are here. To make a difference, and to live our purpose too, which is to do everything with excellence.
David – What we’ve been talking about is how as Friends of Kijabe, we can help with the Obs/gyn department – what is feasible to do, and in some ways, what is the Christian thing to do.
Why don’t you tell me about the patients or populations/demographics that have been the most stressful, and that we agree these might be able to most easily address their needs?
Lilian – Among the patient populations we’ve been concerned or have special interest about have been cancer patients who come and need urgent care, yet they’re not able to pay for the services offered. These are patients who are coming and don’t have National Insurance Cover. National cover requires three months to mature, even if someone was to apply as soon as the diagnosis is made, but that is too long to wait.
David – Because with cancer, usually they’ve waited too long anyway right?
Lilian – Yeah, so by the time they are coming, we need to make radical decisions at that point. As much as it may be a small population, we feel like the care they deserve should be accorded to them, regardless of their financial status. That’s why we feel they need support.
David – So for gynecology-oncology patients, do they require surgery and chemotherapy or sometimes just surgery?
Lilian – It depends on the type of cancer and the stage or the spread. Early cervical cancer patients might require only surgery and that is it, unless they have evidence of spread, like in the lymph nodes in which case they need chemo-radiation. In case of radiation-therapy they have to be referred out of Kijabe.
David – Chemo, you can usually do here now?
Lilian – Ovarian cancer, most of those cases will go through surgery, then eventually will require chemotherapy after, which can be given to them in Kijabe.
Some cases are strict referrals, for example, advanced cases, which are not operable. We will refer for the combined chemotherapy/radiation therapy. The few we are able to handle here require chemotherapy and surgery.
David – This is becoming a big issue in Kenya, it’s all over the news.
Lilian – It’s all over the news. I think, partly because of improved diagnostics. There is more advocacy for screening and early detection. There are over 3,000 deaths from cervical cancer every year.
Our joy has been able to sort patients at an affordable cost compared to what they would have to pay in Nairobi.
In 2016, we had 11 cancer surgeries for gyne. In 2017, we rose to 31, in 2018, we had 41. We hope this year we can have an even higher number that are detected early to get surgical management. There is more awareness and people are coming through referrals and we are doing aggressive screening for cervical cancer.
David – I don’t know if it would directly relate to your patient population in Kijabe, but life expectancy in Kenya has grown 1 year every year for the last 15 years. Fifteen years ago, life expectancy was 48 and now its 63.
Lilian – Yes, it’s 63 now. It’s an improvement. As much as we know many are still dying, I really think there is something positive happening as far as improving primary health care and advocacy for many things, with health being a big agenda for the president. We are seeing a lot happening even in the country places. We appreciate that they are doing something.
David – That’s gynecology/oncology, what’s your other patient demographic that you personally stress over? This isn’t something out there, it’s something very close to your heart.
Lilian – For gyne-onc, I’ve also lost family through cancer and I think there is so much we can do in terms of primary prevention and early detection, which is not really emphasized so much. I think for Kijabe that’s one area we could do well in.
A second type of population we see are young pregnant women who need emergency care and they can’t access to the point of saying “don’t admit me.” We know that whatever happens on the other side, the care they will get is substandard.
For example, a patient who comes with preeclampsia in the 7th month of pregnancy, the baby requires newborn ICU admission and the mom require HDU or ICU care, clearly you can’t refer those patients because of finances.
There are teenage girls with unplanned pregnancies coming with no insurance cover, who require emergency, comprehensive obstetric care. That population is at very high risk for mortality and morbidity for both mothers and babies. They may be few, but those few deserve to live.
David – you’re concerned specifically about abortion or if the baby does come, what happens to the baby afterwards.
Lilian – We’ve had different encounters with primary school, high school girls coming and wanting a termination, and we’ve said no. But even if we say no, we are supposed to be giving them solutions, alternatives. Who is going to help with the clinics? They are already high-risk by virtue of age, by virtue of them wanting to terminate. Who takes care of the clinic bills, who takes care of the delivery, who takes care of the child afterward in postpartum clinic reviews? If baby requires specialized care, what happens? These are young girls who are prone to depression, psychosis, suicide, and I feel like they deserve better because that’s a point of ministering to them. I think those few hours we spend with them are enough to actually change their lives, not just because of their condition, but even in terms of eternity.
These high-risk patients that come to us and they don’t have better options, I think they deserve more. Especially those who come with unplanned or what you call crisis pregnancy.
David – There is precious-few resources for things like that.
Lilian – One, young people are condemned by society for making wrong choices. Two, there are no options given to them. If they are given, they are poor options, like terminations, which means going to the backstreets to terminate. It is cheaper of course and it won’t be known. That has resulted in high mortality for girls.
Among the top 5 [maternal] killers in our country, we still have abortion. Beyond hemorrhage and hypertension, have abortion topping because of girls going to the back streets for termination of pregnancies.
As we take care of them and do abstinence and user protection, when all those steps have been bypassed, we need solutions for these girls.
David – I’ve seen Kijabe babies be placed in homes.
Lilian – There are many options, it’s just I think we don’t take that time that has to be spent walking with such, there is the financial aspect that must be considered from way before, during pregnancy, delivery and thereafter. We have a few rescue homes that do a job for these girls, but not all go to the rescue homes. So, can we be a sort of rescue home in terms of the medical care that we’re giving.
David – And we can make sure that they are not making bad decision for lack of finance. A delivery in Kijabe is $250 or $300.
Lilian – That could be all it takes for them to actually see there is hope.
David – Who is the one you were telling me about that came with the grandmother.
Lilian – At least a happy one. This was a sixteen year-old, who got pregnant while in form 2. For you guys, that would be 10th grade. Every time she would come for a clinic, she would be accompanied by the grandmom who would pay the bills for the clinic. And the grandmother would make sure she was okay.
This was a grandmother who lost her daughter, and her daughter left her with a grandchild who became pregnant. She was taking care of the great grand-child after the delivery.
I think what really made my heart feel warm was the love, and the fact that she was there to support her and tell her, I’m here, I will pay your bills, and I’ll take care of my great grandchild, and you’ll go back to school after the first few months.
That love shown to this young girl who may have opted for termination if there was no other option.
The grandmother was able to afford some coins to walk through the journey. No fancy clothes for the babies, but maybe, some coins to buy a packet of chips, to say, “I’m here for you.”
David – One other one that was very special for several of us and for me personally, the first time I walked through this process, was a teenager who came in with a pregnancy, I think it was twins and they lost the first twin. I think it was 30 or 32 weeks. I heard about it from Dr. Mary Adam, “Hey, there’s this little baby and the mom has gone, she has abandoned.” All the nurses and the doctors at the hospital, said, “this is our baby.” That was the first person we ever crowdfunded for individually. The way it happened was amazing. I walked through the NICU one day with a camera. She raised her hands up to me. "
You want this picture don’t you? You want people to take care of you!"
In that picture she was wearing a diaper that came up to her neck, and now when you see her, she is two years old, she is round and chubby.
For what it takes to do the right thing, in my mind, it’s such a tiny amount of money, to take care of the mother and the baby.
We do have some general funding coming in toward this. We hope that can increase over time, as some of our obgyn’s become involved. Also, any of you guys who might be listening to this, anyone who gives to the Friends Fund, a portion of that goes to vulnerable patients. Basically we want to say yes when someone needs something. That’s the goal.
Anything you would like to add?
Lilian – Just requesting humbly for support wherever it comes from. Of course we are very grateful for those who have had Kijabe in their minds, and for whichever way they support, whether by been human resource, whether it’s financial, whether it’s prayers, whether it’s encouragement.
David - Absolutely
The Estimated Incidence of Induced Abortion in Kenya: A cross-sectional study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4546129/