Margaret Wanjiru would rather forget the experience of having her first baby at one of the public hospitals in Nairobi, Kenya's capital.

"I remember going to the hospital in 2001. I was in pain, like most of the other women, but we were made to sit on a wooden bench and were not allowed to go into the labour ward without paying," Wanjiru recalled.

Once in the ward, there were a lot of insults: "You are asked to spread your legs ‘like you did for your husband’," she said.

According to a report, Failure to deliver, prepared by the Federation of Women Lawyers in Kenya and the Center for Reproductive Rights (CRR), there are numerous challenges facing women in Kenya's health facilities, including suffering abuse and neglect before and during delivery.

This includes being forbidden to enter hospitals without enough money for a deposit, and not being allowed to have family members on the premises or during delivery, according to the report.

According to Wanjiru, the female nurses are often very cruel, while the men are better.

"They [the nurses] are also old enough to be our mothers so we cannot answer back when they insult us," she said, "Sometimes they beat you up and say that you are pretending yet you are in pain."

According to the report, the women are also subjected to unreasonable delays waiting for suturing or to poor stitching. Due to insufficient beds, sharing is common, with those women who fail to pay ending up on the floor.

Free deliveries

The ministry of health has instituted a maternity health waiver allowing for free deliveries in health centres and dispensaries. This is intended to encourage more women to give birth in medical facilities while decongesting hospitals like Pumwani in Nairobi - the largest and busiest maternity hospital in East and Central Africa.

However, Wanjiru is not optimistic. "We were being mistreated even when we were paying, how about now that it is free?"

Elisa Slattery, legal adviser of the CRR’s Africa programme, says the violation of women's rights in Kenya is widespread, systematic and has been going on for decades.

Women are abused before and after receiving reproductive health services, Slattery said.

Poor record-keeping means increased patient waiting time, with only 23 percent of the facilities conducting reviews of maternal or newborn deaths or near-misses, she said.

Women also often lack access to contraceptives of their choice in some health facilities.

"Women are often abused verbally and physically," she said. "While motherhood is valued, there are many problems associated with it."

Private clinics

The situation is, however, different in most private health facilities, according to Ruth Otieno*, a nurse working at a private hospital in Nairobi.

"We do not keep the women waiting and our labour ward is always ready as our clients are aware of their rights and the kind of service to expect," Otieno said.

Moreover, at the end of their hospital stay, she said, the clients fill in a questionnaire assessing the quality of care provided.

The cost of a "normal" delivery, without including other charges, such as for the bed and consultation, at a private hospital is a prohibitive 30,000 shillings (US$448).

According to Otieno, the overwhelming burden of delivering many babies daily in public hospitals prevents the nurses from having a one-to-one relationship with the patients. Most public health facilities often lack trained personnel, medical equipment and bed space; in addition, staff are poorly paid.

Women in Kenya have a 1-in-25 lifetime risk of dying from a pregnancy-related cause, with at least 20 percent of all births being unwanted and another 25 mistimed, according to the Kenya Demographic and Health Survey for 2003.

Low morale

The chief clinical officer with the ministry of health, Alfred JBO Odhiambo, said: "The violation of patients’ rights occurs in isolated cases." He argued that the number of staff should be increased, along with the improvement of salaries and the provision of adequate medical equipment, to improve morale.

More health centres have been opened all over the country to decongest the main hospitals, thus allowing for improved care of patients, he added.

The hospitals now have a customer relations desk to improve service delivery. "We have made mistakes in the past which we are now correcting."

The health ministry has seconded some staff to work with the local government ministries responsible for some of the understaffed hospitals.

It is important that the medical personnel have a human touch, he said, adding that the cooperation of patients was also important. "Some of the clients already have negative attitudes towards nurses.

"We are changing how we handle clients and there is now a service charter spelling out what needs to be done across the board," he said.

According to Slattery, government guidelines on patients' rights should be disseminated widely so women are aware of their rights.

Recent government efforts to improve public health facilities seem to be paying off, albeit slowly, according to Wanjiru. The hospitals seem cleaner and the nurses help patients make their beds and there are also mosquito nets, she said.

"Since most women lack the funds to go to private health facilities there is a need for improvement of the public ones," she said.