Nerea Mlale Ojanga resigned from pregnancy and child birth after her fourth child. ‘This is my last baby,’ she told herself as she pushed one last time. And she did mean it.
Growing up Nerea witnessed her mother – and women her mother’s age – give birth in a trail that only stopped at menopause.
“I was born in a family of 12. My mother popped us like popcorn,” she says – on a light touch. “I am the sixth born; right at the middle’.
In those days children made the community blossom. Nerea grew up loving children as a result. If it were not for science Nerea says she would have had eight children.
You see, Nerea is not your average layman. She is a nurse by profession. As a matter of fact she is a midwife at Kenyatta National Hospital. You’d therefore say that birthing is her craft.
As a student of nursing – and thereafter as a practitioner – she has come close enough to grand multiparity. What is that, you may ask.
“A woman who carries five pregnancies to term has reached grand multiparity,” Nerea explains. “At such a point pregnancy becomes a risk to her health. Her womb is not as strong as it used to be. Her system is not as ready to carry a pregnancy as she did with her firstborns.”
Pregnancy alone is enough to end a woman’s life. In Kenya 362 women lose their lives in every 100,000. The World Health Organisation says that with each pregnancy a mother’s health risks increases.
“That is exactly what grand multiparity means: that a woman could easily die from subsequent pregnancies,” Nerea says.
And so, Nerea, in her wisdom, decided to apply the brakes at 4 children. She says: “I know the risks of grand multiparity. I was not willing to put my life at risk just because I would love to have more children.”
In spite of the risks, Dr Elly Odongo, an obstetrician and gynaecologist, says that there is no medically recommended number of children that a woman should have.
“Whether a woman should have more children is based on several factors: like her health and spacing between the last child and the next pregnancy,” Odongo points out.
It is a view that Nerea holds too. “If this woman will attend all her antenatal clinics and she is sure she will be able to take care of the children then it is her own prerogative to give birth as much as she wants,” she says.
But here is the conundrum: a woman loses nutrients from her body with each pregnancy. Eventually, her body grows nutrient deficient. Does she risk?
“We call it maternal depletion syndrome,” Odongo says. “It is dangerous when the woman’s nutrient levels go low.”
But there are other factors at play as well. As a woman ages the risks of hypertension and diabetes instigated by a pregnancy elevates, the doctor notes.
At grand multiparity, Odongo says, chances are that a woman will suffer from uterine rapture and hence suffer postpartum haemorrhage.
Haemorrhage (both anti and postpartum) account for 40 per cent of all maternal deaths in Kenya. This emerged in the confidential enquiry report presented at the Kenya obstetrician and gynaecologist’s conference that took place in February 2016 in Mombasa.
“Postpartum haemorrhage threatens a pregnant woman’s life more than anything else,” Odongo says. “And chances of it occurring increase with more subsequent pregnancies.”
But why is it that mothers in 60s, 70s and earlier years gave birth to as many children as their ovaries could produce?
“First, our mothers lived in a different era. Their environment, food, practices, and lifestyle is not similar to today’s women,” Nerea says.
Odongo has a somewhat different explanation: while the modern woman begins child birth around her early to mid-twenties, our mothers began child bearing some as early as 13.
“They began early and therefore by the time one is 40 some have as many as 10 children,” he explains.
Even so, there is no available data capturing maternal mortality in Kenya pre independence.
It is however thought to be way higher than today. The Kenya demographics health survey of 2014 (KDHS 2014) shows that maternal mortality decreased from 488 to 362 deaths per 100,000.
Konina Taraiya from Elang’ata Wuas in Kajiado is 60. She gave birth to 6 children. Her oldest, a son, is 45 now.
When we met Konina she was recuperating from fistula surgery at Kajiado level five hospital. Konina, like many 60 year old women, did not set forth to have a certain number of children.
She suffered from fistula during the birth of one of her children. She can’t remember which one exactly but she says she has lived with the fistula – leaking urine and faeces – for decades.
As a traditional Maa woman her job was to give birth as often as she could.
“I don’t know if it was upon me to decide the number of children or not. I just gave birth and raised my family,” she says.
There is a lot of contrast between Konina and Christine Khasina; the founder of Supamamas, a company that provides motherhood related services.
Khasina is a mother of two. She says: “Initially I wanted to have only one child. But then when my first born reached six I felt I needed a second baby.”
Christine believes that with the birth of her second child she has closed pregnancy chapter in her life.
Christine’s reasons to stop birth at two children are greatly informed by her vision for herself as a woman and a mother.
“When I was growing up, a third born among six siblings, I felt a bit left out. I did not want my children to feel the same. With my two boys I am sure I can give them maximum attention and still have time to run my business,” she says.
Christine cherishes her independence. She wants to feel fully in charge of her career. Yet, she also wants to be a mother and give her children the best that a mother has to offer.
“I want to have enough time for my children, my career, my personal life and my independence,” she says. “I don’t want to lose my independence in favour of childbirth.”
Even without asking, it is clear that Konina didn’t have as much choice as Christine.
Apart from health reasons, Nerea says, she wanted to make sure that her children had a good life: attended best schools and could be provided for.
“There is an economic aspect to it. Whether we like it or not we have to be cognisant to this fact. Are you having many children that you can take care of or you just hope they will lead a normal life?”
In today’s realm, Odongo argues, by the time the average woman has five children they have likely reached premenopausal stage.
“As a woman gets older the baby they conceive and give birth stands higher risks of developing chromosomal abnormalities and hence congenital conditions. Therefore the baby too may suffer unintended consequences,” he says.
This subject, the medic says, cannot be tackled from the health perspective alone. There is culture and religion that also play a role.
All these make it difficult to legislate fertility. It therefore squarely remains a personal choice.