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When Does a Hospital Become a Jail? When You Can’t Afford the Bill

Portrait of a woman
Maimouna Awuor tells a reporter on December 14, 2012, that Pumwani Maternity Hospital in Nairobi wouldn’t let her leave after delivering her baby. © Sayyid Azim/AP

When Maimuna, an HIV-positive mother of six, couldn’t pay her $36 bill at Kenya’s Pumwani Maternity Hospital, she was detained there by the staff for 24 days. During that time she was forced to share a bed with other patients. To give her new baby more space, she slept on the floor next to a flooding toilet and contracted pneumonia as a result.

Margaret, a 35-year-old mother of five, had a similar experience at Pumwani—twice. The first time, she was 15 years old. She underwent a caesarian section, and remained unconscious for 10 days. She had no money to pay the bill, so the hospital detained her for a week, during which time she slept on the floor and often went hungry as the detainees were fed last, if at all. When she returned to the same hospital a few days later complaining of stomach pains, it was discovered that a pair of scissors had been left inside her during her operation.

The second time was in 2010. Margaret arrived at the hospital in critical condition with her baby in breech position, but was left unattended and bleeding on a bench for more than two hours. After finally undergoing another caesarian section, she was billed $123. Since she only had $60, the hospital detained her again, this time for six days.

Pumwani is one of the largest maternity hospitals in East Africa, handling 30,000 deliveries per year, and the abuse and humiliation Maimuna and Margaret suffered there are inexcusable. But their experiences are not unusual. Despite a mandate from President Uhuru Kenyatta in June 2013 calling for free and universal maternal health services, access to quality health care is still a challenge that the Ministry of Health has failed to address.

The Kenyan government introduced user fees at public health facilities in 1989 as part of a World Bank push for cost-sharing in public services. User fees tend to hit women harder than men as women must frequently finance their reproductive health care. Poor patients are detained against their will until they pay the fees or the facility is satisfied that they cannot pay, which may take months or years. Although Kenya has implemented a general waiver system in public hospitals for those who cannot pay their medical bills, the process of obtaining this waiver can be burdensome, demeaning, and dangerous for the health of the patients.

Now the High Court of Kenya has stepped in and sent a strong signal that such abysmal treatment can no longer be tolerated. In September, the court issued a groundbreaking decision that found the detentions of Maimuna and Margaret to have been arbitrary and unconstitutional. Furthermore, it ruled that the two women had been subjected to cruel, inhuman, and degrading treatment, which was compounded by the fact that they were forced to be away from their other children, for whom they are the sole providers.

The Center for Reproductive Rights filed the case in December 2012 to hold Kenya’s Ministry of Health accountable for allowing rampant detention and abuse of women in health care settings, practices that the Center had previously documented in a fact-finding report, Failure to Deliver: Violations of Women’s Human Rights in Kenyan Health Facilities.

The court found that the treatment of the women fell short of the acceptable standards of health care that guarantee the right to dignity and, further, that the victims were discriminated against on the basis of their gender and economic status. In the words of the judge, “The experience of the petitioners is a demonstration of the danger that poor women would be denied maternity services, and if the services were provided, they were done in a manner that demonstrated the disdain that those charged with the provisions of the services held towards the poor women.”

The court directed the government to take necessary administrative, legislative, and policy measures to eradicate the practice of detaining patients who cannot pay their medical bills. It also awarded compensation to Maimuna and Margaret.

As this case makes clear, access to maternal health care alone is not enough. Research has shown that violating women’s rights during childbirth leads women to distrust health care providers and facilities. This not only makes women less likely to seek out maternity care, but other health services as well, such as family planning and antiretroviral therapy. For a continent with such a high burden of disease and high rates of maternal mortality, this has serious implications.

Detentions in health facilities for inability to pay medical bills is a widespread practice in many African countries, and many governments’ responses to the practice have been indecisive and contradictory. The High Court of Kenya’s decision is a challenge to governments throughout Africa to create and fully implement laws and policies that uphold quality maternal health care. 

The Center for Reproductive Rights is a grantee of the Open Society Foundations.

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