Boats for Maternal Health: What Lamu County Teaches Us About the Real Meaning of Access
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When global health leaders talk about maternal health, the conversation often begins with numbers. Maternal mortality ratios. Skilled birth attendance. Facility delivery rates. Insurance coverage. Universal Health Coverage targets. Sustainable Development Goal indicators. But in Lamu County, on Kenya’s northern coast, maternal health begins somewhere else.
It begins with the tide.
It begins with whether a woman can afford a boat.
It begins with whether the health worker is present when labour starts at night.
It begins with whether a dispensary has medicine, whether a maternity wing has staff, and whether an ambulance boat can actually reach an island village when the water is too low or too high.
It also begins much earlier than labour.
It begins with whether a girl grows up knowing her rights. Whether a woman has income of her own. Whether she is safe from violence in her home. Whether climate change has destroyed her family’s livelihood. Whether insecurity has cut her community off from services. Whether she can speak in public forums. Whether anyone in power is listening.
This is the reality that Lynette Aloo, Executive Director of the Lamu Women Empowerment Network (LAWEN) , shared on My Community, My Voice, a podcast by Impact in Health that asks one urgent question: what do health policies look like on the ground, in the communities they are meant to serve? Her answer was both beautiful and painful. Lamu is known across the world for its beaches, old town, culture, history, donkeys, dhow boats, and white sand dunes. To visitors, it is paradise. But beyond the postcard image are communities living at the edge of health systems — geographically, politically, economically, and socially. Lamu is not one place. It is a collection of islands and mainland communities. Some areas have no roads. Some villages can only be reached by boat. Movement depends on the tide. When the tide is wrong, access stops.
For a pregnant woman, this means the journey to care is not simply a matter of choosing to attend a facility. It is a negotiation with geography, poverty, gender norms, insecurity, infrastructure, climate, and time. And in childbirth, time is often the difference between life and death.
When childbirth becomes uncertain.
Lynette spoke not only as a community leader, but as a mother. She is raising daughters in Lamu. When asked what future she wants for them, she spoke about freedom, leadership, financial independence, and the ability to make their own choices. But she also named something more basic: the right to access quality healthcare when they need it, without delays, unnecessary referrals, or having to leave their community just to receive basic care.
That aspiration should not be radical. Yet in parts of Lamu, it remains uncertain. If a woman has an uncomplicated birth, her chances may be good. But if a complication arises, even a minor one, the situation can change quickly. Survival may depend on where she lives, whether she is on a remote island, whether the tide allows movement, whether a boat is available, whether she has money for transport, and whether a trained health professional is present at the receiving facility. This is what “access” means at community level. It is not only whether a policy says care is free. It is whether the woman can physically reach care. It is whether the care is functional when she arrives. It is whether she had the power, money, information, and support to seek care in the first place. In Lamu, too often, the system has not been designed around her reality.
Maternal health does not begin at the maternity ward
One of the most important lessons from Lamu is that maternal health cannot be separated from the conditions in which women live. A woman’s risk in pregnancy is shaped long before she reaches a health facility. It is shaped by poverty (including menstrual period poverty). If a household survives day to day, paying for transport to a clinic may be delayed until the situation becomes severe. If medicine is unavailable at a public facility and must be bought from a private pharmacy, “free care” becomes meaningless for the poorest women.
It is shaped by geography. In remote island communities, distance is not measured only in kilometres. It is measured in tides, boat fuel, darkness, insecurity, and the availability of someone who can move quickly in an emergency.
It is shaped by gender-based violence. A woman who is unsafe in her own home may not be able to make decisions freely about contraception, antenatal care, facility delivery, or when to seek emergency help. Violence weakens women’s health, autonomy, confidence, and ability to plan for safe motherhood. It is shaped by climate stress. In coastal and island communities, livelihoods are closely connected to land, water, fishing, trade, and natural resources. When climate shocks affect income and food security, women carry the burden. Poor nutrition, household stress, displacement, and reduced income all affect maternal and newborn health.
It is shaped by insecurity. Lamu is a border county to Somalia, by land and by water. Insecurity affects movement, service delivery, livelihoods, and the sense of safety women need to seek care. For communities already living far from major facilities, insecurity adds another layer of exclusion. It is shaped by women’s leadership. When women are absent from decision-making spaces, the systems built for them often ignore the details that determine whether they live or die.
This is why the work of LAWEN matters. LAWEN does not treat maternal health as a narrow clinical issue. It works across the realities that shape women’s lives: reproductive health, gender-based violence, climate resilience, economic empowerment, leadership, and governance. This is not a scattered agenda. It is an integrated response to the truth that women’s health is determined by the systems around them. A woman cannot be healthy if she is poor, unsafe, unheard, unable to move, unable to pay, and unable to influence decisions. Maternal health begins there.
The gap between policy and reality
Kenya, like many countries, has committed to Universal Health Coverage. The promise is powerful: that every person should receive the health services they need without suffering financial hardship. On paper, maternal health is covered. In policy language, maternity services, prenatal care, and postnatal care are prioritized. Primary healthcare facilities are supposed to be the entry point for care.
But Lynette’s experience from Lamu reveals a different story. The Social Health Insurance system, as experienced by many women in her community, does not meet them at their point of need. In practice, she explained, coverage is often associated with inpatient care. If a woman needs outpatient services, a consultation, a specialist review, medicine, or support before a condition becomes an emergency, she may still have to pay out of pocket. And even where services are officially “free,” the facility may not have the medicine. A prescription may be written, but the woman may be sent to a private pharmacy. For poor and vulnerable households, this is not a small inconvenience. It is a barrier.The result is a cruel contradiction: maternal healthcare may be free in policy, but unaffordable in practice.
For women in remote island communities, the cost of transport adds another layer. A boat is not a luxury in Lamu. It can be the only route to emergency care. Yet boat transport is not systematically integrated into maternal health financing. The county may have an ambulance boat stationed at King Fahad Hospital, but if a woman is in a village such as Faza and the tide is low, the boat may not be able to reach her when she needs it. This is where national policy language collapses against local geography.
Beautiful buildings are not enough
One of the strongest messages from Lynette’s testimony was this: communities do not need buildings that only look good in reports. They need facilities that function. Lamu County has made visible investments in health infrastructure, including maternity wings in some areas. These investments matter. Communities do need facilities closer to them. But infrastructure alone does not save women.
Lynette described facilities with new buildings, beds, and equipment, but without enough personnel, medicine, or reliable services. A maternity wing may be attractive from the outside, but if a woman goes into labour at night and there is no one available to attend to her, the building does not provide care. In Kiangui, she described a facility that looks good externally but lacks basic services inside. Even simple medicines may not be available. In Siyu, a new maternity wing may have equipment and beds, but still face shortages of staff and supplies.
This is a lesson global health leaders must take seriously. A health facility is not a building.
A maternity wing is not maternal healthcare. A policy launch is not implementation.
For women, functionality is what matters. Can they receive care at night? Is there a skilled provider? Are medicines available? Are referrals timely? Is transport guaranteed? Are vaccines available when mothers bring their children for postnatal services? Are students and trainees properly supervised? Is quality protected? These are the questions communities ask because these are the questions that determine survival.
What LAWEN is really building
LAWEN’s work is powerful because it starts where women are. It does not wait for women to become visible to the health system only when they are in crisis. It works with women before the emergency, before the referral, before the complication, before the statistic.
Through reproductive health work, LAWEN helps women understand their bodies, their rights, and the services they should be able to access. In communities where information may be limited and services distant, knowledge itself becomes a form of protection.
Through its work on gender-based violence, LAWEN addresses one of the silent drivers of poor maternal health. Violence affects whether women can seek care, use contraception, attend clinics, disclose symptoms, or make decisions during pregnancy. A maternal health system that ignores violence is only treating part of the problem.
Through climate resilience, LAWEN recognizes that women’s health is tied to the environment around them. Climate shocks affect livelihoods, food security, household income, and displacement. For women already living in fragile coastal and island settings, climate resilience is also health resilience.
Through economic empowerment via bee-keeping, LAWEN tackles one of the most practical barriers to care: money. A woman with some financial independence has more ability to pay for transport, buy medicine, seek care early, and make decisions for herself and her children. Economic empowerment is not separate from maternal health. It is one of its foundations.
Through leadership and governance, LAWEN pushes for women to participate in the decisions that shape their communities. This is essential because many maternal health failures are not only clinical failures. They are planning failures. Budgeting failures. Governance failures. Listening failures.
LAWEN’s work shows that the solution to maternal mortality is not only more facilities or more policies. It is stronger women, stronger communities, and systems that are accountable to the people they serve. This is community-led health systems strengthening. It may not always look like the global health interventions that receive the most attention. It may look like a woman learning her rights. A survivor of violence finding support. A community leader speaking in a county forum. A mother joining other women to demand medicines at a facility. A local organization documenting the gap between what policy promises and what women experience. But these actions are health interventions.They change whether women are seen. Whether they are heard. Whether they are safe. Whether they survive.
Devolution without localization leaves women behind
Kenya’s health system is devolved, meaning counties carry major responsibility for delivering health services. But Lynette’s reflections show the tension between national policy design and county-level implementation. Universal Health Coverage frameworks may be developed nationally, but counties are the ones expected to make them work. When national decisions do not reflect local realities, counties like Lamu are left trying to implement policies that were not designed for island communities, indigenous women, mobile populations, or remote villages cut off by tides.This is not only a technical problem. It is a governance problem.
If maternal health policies are created without the voices of women from places like Lamu, they will continue to miss the details that matter most. For example, a national planner may see an ambulance as a vehicle. In Lamu, an ambulance may need to be a boat. A referral pathway may look straightforward on paper, but in reality it may depend on weather, water levels, insecurity, fuel, and household cash. A primary healthcare model may assume dispensaries are functional, but women know which facilities have no medicine, no staff, or no night services. Localization is not an optional add-on to global health policy. It is the difference between a promise and a service.
The funding crisis is felt first by women
The discussion also highlighted the fragility of donor-supported health systems. Lynette noted that many services, especially in maternal and postnatal care, had depended heavily on external support. When funding is reduced or withdrawn, the effects are immediate at community level. Health workers may be laid off. Facilities may struggle to provide services. Programs that once supported vulnerable women may disappear. Counties are then expected to fill the gap, often without the resources to do so.
For global health leaders, this should raise difficult questions. What happens when donor-funded programs end without a transition plan? Who carries the burden when services collapse? Too often, the answer is women. Women pay through out-of-pocket costs. Women delay care. Women travel further. Women rely on family members to raise transport money. Women take risks during pregnancy and childbirth because the system has become too thin to hold them. A sustainable maternal health agenda cannot depend on short-term funding cycles that leave counties and communities exposed. Financing must be predictable, locally responsive, and designed to protect essential services even during political or donor transitions.
What Lamu community asks of global health leaders
LAWEN is not asking for charity. It is asking for health systems that listen. The experience of women in Lamu offers several lessons for global health leaders.
Access must be defined from the woman’s starting point, not from the facility’s location. A service is not accessible simply because it exists somewhere in the county. It is accessible only if the woman can reach it in time, afford the journey, and receive quality care when she arrives.
Maternal health financing must include the hidden costs of care. Transport, referrals, medicines, and emergency logistics are not peripheral issues. They are central to maternal survival.
Infrastructure investments must be matched with staffing, supplies, supervision, and service readiness. Buildings do not deliver babies. Health workers do.
National policies must be localized. Universal Health Coverage must be flexible enough to serve island communities, pastoralist communities, informal settlements, border counties, and other settings where standard models do not fit.
Maternal health strategies must address the wider realities of women’s lives. Poverty, gender-based violence, climate vulnerability, insecurity, and lack of decision-making power are not “social issues” outside the health sector. They are maternal health issues.
Community-led organizations must be treated as essential partners, not afterthoughts. Organizations like LAWEN understand where women are falling through the cracks. They know which services are missing, which facilities are not functional, which policies are not reaching people, and which solutions communities trust.
Finally, women must shape the systems meant to serve them. Not as symbolic participants, but as decision-makers, budget influencers, watchdogs, advocates, and leaders.
Listening as a form of accountability
The most powerful part of Lynette’s testimony was not only what she said, but where she spoke from. She spoke as a woman in Lamu. As a mother of daughters. As a community leader. As someone who knows the beauty of her home and the inequalities hidden behind that beauty. As someone who understands that policies can sound promising while still remaining out of reach. For global health leaders, listening to such voices is not a communications exercise. It is accountability.
Maternal health will not improve through global commitments alone. It will improve when policies are tested against the realities of women’s lives. It will improve when a woman in labour at night does not have to wonder whether the tide will allow her to survive. It will improve when a maternity wing is not just opened, but staffed. It will improve when insurance covers what women actually need, not only what is administratively convenient. It will improve when women are safe from violence, able to earn, able to speak, and able to influence decisions.
Lamu reminds us that the last mile is not an abstract phrase.
Sometimes, the last mile is water.
Sometimes, it is a boat.
Sometimes, it is a mother waiting in pain while the tide decides whether help can reach her.
And sometimes, the solution begins with women organizing in their own communities, telling their own stories, and refusing to let policy continue without them.
That is what LAWEN is doing. And if global health is serious about equity, then maternal health systems must be built not only for women like those in Lamu, but with them.
Listen to full podcast at My Community My Voice
Co-authored by Lynette Aloo and Mary Moehlmann
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