When antenatal is a luxury: the IDP story

Pulwa Achaba, 23, is five months pregnant with her fourth child. She fled Kuda, Adamawa State in 2016 after it was sacked by Boko Haram. She now lives in Gongola, a camp where internally displaced persons reside in Abuja. For her previous pregnancies, Achaba said she diligently went for antenatal sessions at the Cottage Hospital […]

Pulwa Achaba, 23, is five months pregnant with her fourth child. She fled Kuda, Adamawa State in 2016 after it was sacked by Boko Haram. She now lives in Gongola, a camp where internally displaced persons reside in Abuja.

For her previous pregnancies, Achaba said she diligently went for antenatal sessions at the Cottage Hospital Gulak, Adamawa State, where it cost a maximum of N200 to register and transportation was N50 at the most.

Although she was registered to receive free treatment at the Asokoro General Hospital, Abuja by the FCT Emergency Management Agency, paying N700 once a week for her antenatal session, she said, “is way too much for me. I cannot afford it; N700 is luxury where I come from. It is big money.”

This is the reason she has not attended a single session since she got pregnant – a fact her mother, Cecilia Joseph, who was a Junior Community Health Institution worker in Gulak, only discovered during our reporter’s conversation with her daughter.

Saratu Adamu, 26, was displaced from Gulak. She is five months pregnant and has since 2015, lived in Kuchigoro one of the host communities in Abuja where IDPs live. She was diagnosed with jaundice at the early stage of her pregnancy and given medication for it. But lack of funds has prevented her from attending antenatal sessions and restocking on her medication comprising blood tonic, and Folic Acid which she ought to take for the duration of her pregnancy.

The mother of three said she had to pay N3,000 registration fees at the AMAC Hospital Kuchigoro but went there, only because she took ill with malaria.

She said, “That was when the doctor told me I had jaundice and put me on medication. I cannot afford to pay the N300 for every antenatal session and cover the transportation cost to and fro every time I have to go.

“In my village I paid N200 to register for antenatal card and only N50 for a return trip to the hospital. The sessions were free,” she said.

The story isn’t different for displaced persons in Orozo, a suburb where IDPs have settled and New Kuchigoro another camp in the FCT.

A mother of two, Liyatu Ayuba, 24, in her third pregnancy, had her first antenatal session at eight months. This was thanks to a medical outreach in Orozo by an NGO. She said she was not registered in any hospital because she couldn’t afford to pay N3,500 at the closest hospital to her as against the N150 it cost her in Gwoza, Borno State before Boko Haram chased her out of her home.

In 2015 floods chased Ummita Sule, 27 and her family from their home in Darazo, Bauchi State. It destroyed their farmland and house, forcing them to relocate to New Kuchigoro.

The shy mother of two toddlers and a three month-old considers herself lucky to be in this camp because, “We get a lot of help from NGOs who also give us medical care. It was because they came here I was able to go for antenatal. Otherwise, I would never have been able to afford it.

“One of the NGOs also helped pay my medical bill when I went to give birth.”

A report by an international humanitarian organisation, Internal Displacement states that there are 3.3 million Internally Displaced Persons (IDPs). This is the largest in Sub-Saharan Africa and the third largest globally.

If IDPs were to make up a state in Nigeria, their population would make them the 20th largest state in the country, surpassing the numbers of the FCT, Kogi, Enugu, Kebbi and Zamfara states. According to the National Population Commission 80 out of 100 displaced persons in Nigeria are women, while 92.4 percent of this number live with host families and 7.6 percent live in camps.

The difference in the cost of registration in Abuja and their hometowns, is not the only challenge the women have to deal with. They also complain that the cost of giving birth is high.

Saratu said, “In Gulak, I only paid N1,000 which came with a set of baby cloths. But in Abuja, in a government hospital we are asked to pay N6, 500 which is non-refundable. They have never explained to us the reason for this sum, even when we ask.”

Mr. Daniel Bishara, chased out of his Gulak home by the insurgency, said, it cost him about N90, 000 to pay for his wife’s medical care when she had their now ten-month-old son. He said he thought taking her to a hospital in Kaduna would be significantly cheaper than if she gave birth in Abuja, but the difference wasn’t as much as he expected.

Bishara who was unemployed at the time, said he was excited about the coming of his first child, and added that he wanted him born with the best care he could afford. But even at that, he didn’t expect it would cost him that much.

He said, “Back home, I know it doesn’t cost as much as N15, 000 to give birth. But here the list of items to buy is at least this amount. What is also painful is that, there things on the list of items to buy given from the hospital here, which were not used like the catheter and the two jumbo packs of sanitary pads which were stolen at the hospital.”

Looking on the bright side, he said he won’t have to buy them again for the delivery of their second baby due in about seven months.

For Pulwa, Saratu and the other pregnant IDPs, giving birth in a hospital is out of the question. According to Achaba, this is because, “first of all, we need to budget at least N20, 000 to buy the items on the list of things we need for the delivery. Whereas at home in Adamawa we didn’t need more than N3, 000 for this list.”

A nurse, Sa’a Inuwa who was a former staff of the Cottage Hospital Gulak but now works at the Specialist Hospital Yola, shed more light on what the women said.

She said, “Antenatal card costs N200 and the once a week sessions are free. The only things they pay for are the compulsory tests for urine, blood group and genotype and PVC. These cost about N550. The HIV test is free.”

Inuwa enumerated some of the items on the delivery list as two surgical hand gloves, two packs of sanitary pads, one oxytocin injection, Jik bleach, cut clam, olive oil, one syringe and needle and two nightingales with extra wrappers.

The women are confident in the delivery skills of fellow IDPs in Gongola camp whom they consider veterans in the business of giving birth. They rely on the like of Mary Ayuba, who trained as a nurse at the Mubi School of Health and Cecilia.

Mary said, “As much as I can, I encourage them to go to the hospital for antenatal sessions and their deliveries. But where they can’t afford to, they come to me and I help them deliver at home. I use hand gloves when I do this, especially to pack the blood or if I have to turn the baby. Where I have difficulty, I call on Madam Cecilia to help.”

Maryam Abbas, a traditional birth attendant ten minutes’ motorbike ride away in Tudun Munstsira, is another option the women explore. They acknowledge that there is risk involved in patronizing her because they have heard of the death of a new born at her place due to complications she could not handle.

A visit to her abode, a two roomed accommodation, fenced off with corrugated roofing sheets with a strip of curtain as its gate, further revealed how dire the situation is.

Maryam, who learnt the trade from her mother in their village, Yankara in Katsina State and has practiced for 20 years, took our reporter on a tour of her facility where she helps the women give birth. It comprised of a space barely two arms wide and two arms and a quarter long, carved out after making space in the room to accommodate her chaotically organised queen size bed.

The delivery suite

On the unpainted wall just above the ‘delivery suite’ where children seemed to have had some fun drawing with chalk, hung what seemed like half used packs of saline solution (drip) and their connection tubes. The delivery bed, is the floor on which she and our reporter were standing, cushioned with linoleum. But when the women come to give birth, the TBA – who spoke in Hausa as Mary translated – said she “spreads cellophane on the floor to avoid blood from the births from flowing under the bed.

“As soon as the woman puts to bed, I use Dettol and methylated spirit to disinfect the items before taking them outside. I buy all these items from my pocket so that the expectant mothers don’t need to bring them along. They only come with their wrappers and cloths to dress the baby in.”

Responding to questions about what she does with the saline solution, she said, “If I see that a woman is too weak to push, I administer drip. This pushes the baby out.”

When asked where she gets her supplies, she said, “I don’t buy. When I need, I send for a doctor who brings and administers them on the patient and then allows me to do my job. I take care of the rest after he administers the drip.”

On how she ascertained he is a trained medical doctor, she said, “He is a Katsina indigene who worked in a hospital until he retired and then came here. He now runs a chemist. He is qualified, given the fact that we have not had any hitches.”

For cases where there have been neonatal deaths – which according to a UNICEF 2016 report is 19 per 1,000 births globally –  she said, “I sometimes experience stillbirths especially when the babies drink some amniotic fluid in the womb. By the time the mother gets here, it is unfortunately too late. When the case is very challenging, especially if the baby comes out with its hands, I resort to prayers. However, it is easier to deliver stillbirths.”

Maryam who at the time of our reporter’s visit had in less than 24 hours delivered two women of their babies – one in her facility and the other in the patient’s home – said her main worry is lack of funds to put up a proper structure to cater to such deliveries.

Regardless, the displaced women don’t see these as good enough deterrents. They consider it a better deal to pay her the N7,000 she requests than what the hospitals demand of them.

Asmau Yusuf, 28, who was sacked from Gulak and was delivered of her third child by Maryam in her facility, especially considers her a saviour. She said the TBA saved her from purchasing the long list of several unnecessary items she had been given in one of the hospitals and from undergoing surgery as had been prescribed by doctors in hospitals where she would have had to pay at least N150, 000 for the procedure.

A consultant Obstetrician and Gynaecologist, at the Ahmadu Bello University Teaching Hospital, Zaria, Dr. Zulaiha Pawa who spoke on the risk of their patronising the TBA, said, the thing is that TBAs are not answerable to anybody. The main trouble with administering drip is that it comes with complications which the TBA may not be able to identify since she has no scientific backing. Sometimes, TBAs also hide such complications and only the successes of their deliveries are celebrated.

On the possibility of babies drinking the amniotic fluid, Pawa said lay people refer to it as drinking but it is like perspiration. Instead of air going in, the fluid goes in and disrupts breathing.

She emphasised that it is risky to use saline solution that has already been punctured and left exposed, adding that, “it is an easy way to transmit infection from patient to patient.”

Speaking on the way forward, she said the only way is to provide adequate healthcare and in reasonable proximity to the displaced.

Pawa said, “They should also have trained personnel amongst them to give adequate care. These along with the TBAs can be used as agents to refer patients to hospitals with the TBAs also receiving trainings and assisting nurses to take deliveries as Ondo State is doing with its Abiye programme.”

Of the total number of displaced people, according to a global independent advocacy organization, Refugee International only approximately eight in 100 displaced persons are in government-run IDP camps or settlements. “Livelihood opportunities are grossly limited for those living both inside and outside of camps,” RI said.

While the women bragged about being successful farmers making no less than N20, 000 per bag of beans or soya beans they said it is impossible to even grow a vegetable farm for subsistence use because there is no space to plant anything.

They said before Boko Haram forced them to migrate, eating right in pregnancy was not a problem as they grew a lot of the foods they needed or daily got them fresh from the village market.

Juliana Yahaya, 26, one of the displaced persons said, “Keeping up with good diet in Abuja is like a big man’s affair [sic]. Goza market along Airport Road [in Abuja] is where we shop because it is where we get things cheapest. But we don’t have money of our own to buy them as often as we need them and when people bring donations, they don’t necessarily bring us such food items. So we make do with what we have.”

She added that, “We were never full time housewives in our villages. We had our farms and worked there daily. We had a trade that brought in money. Those who didn’t farm, had petty businesses they ran and earned a living.”

“It is frustrating to depend on charity,” she sighed.

Mr. Bitrus Samuel a FEMA staff who spoke on the matter said, “IDPs in the FCT are not restricted only to Asokoro General Hospital and can access free medical care but they must first go to the FCT office to get a note which they then take to the general hospital of their choice.”

Our reporter during a visiting to the FEMA office with one of the displaced women, Jummai Francis, was told by a staff that, “FEMA only works with Asokoro and Wuse general hospitals. They only have to come here once to get documented. After they have been captured, they can go to either of the two hospitals to be documented and go there any time they have need to.”

This news brought short-lived smiles to the IDPs who were already beginning to fish out their ID cards in readiness for registration.

Although Jummai got her referral note which she took to Wuse General Hospital, she was refused registration when she got there because, the officer she met, told her, “There is no space. Go to Maitama or Asokoro hospital.”

This is regardless of the fact that her case isn’t one warranting hospitilisation.

Efforts to speak with the Wuse General Hospital management on the issue as at the time of filing this report were still ongoing and had not yielded any result.

There is also the problem of transportation to and fro the hospital in the event that they are finally registered.

They query  why they cannot be registered in Life Camp only about 15 minutes’ drive away as against Wuse which is about 30 minutes from their camp and could be longer if the timing is wrong or Asokoro which can take up to an hour.

In this regard, one of the doctors at the Gwarimpa General Hospital, Life Camp who preferred to be unnamed at this stage, is exploring avenues through which IDPs in Gongola camp can use the hospital since it is the closest one to them.

Suggestions have also come up about the possibility of getting a rickshaw driver who could ferry them to and fro Life Camp, at a discounted price if the doctor’s plans work out. Otherwise, a taxi driver who can convey them to Wuse at a discount. Since the trips would be regular, they are optimistic their plans will materialise.

Still, there is also the problem of healthy diet among the pregnant women, as Achaba queried, “If we don’t eat well, how will the medicines work in our body.”

This is a difficult question to answer especially in terms of sustainability as they depend on charity which is what has largely kept them going, with most of their livelihoods lost.

To alleviate their plight, several individuals, groups and organisations have helped with the provision of food, healthcare and other facilities. One of such is the Pro Health International with Dr. Iko Ibanga and his team of volunteers who have gone round various IDP camps in the FCT and north east.

Ibanga, a Public Health specialist and executive director of the faith-based organisation said, there are daily stories of the challenges bedevilling IDPs across the country and those who have become refugees in neighbouring countries like Cameroun, Chad and Niger.

“Maternal health is a delicate issue and needs prompt and adequate attention,” Ibanga said.

He added that, “Every pregnant woman needs to have medical care as often as she needs it. For those who cannot afford it on the camps, we give it to them when we visit and do follow ups afterwards. All these come at no cost to them.”

50 percent decline in maternal mortality between 1990 and 2015 which has also fallen by around two-thirds in Eastern and Southern Asia and North Africa, it also revealed that in developing countries, the ratio in the proportion of mothers who do not survive childbirth as against those who do is still 14 times higher than in developed regions.

The organisation said, “Only half of women in developing regions receive the recommended amount of healthcare they need.”

This raises questions about what hope there is for the likes of Achaba, Saratu, Liyatu and Juliana who said, “We have done without it thus far. God has been helping us and what He wills, will happen in the end.”

While maternal health is a most visible problem among the IDPs, there are other challenges like open defecation and indiscriminate dumping of refuse. The women complain of persistent toilet infection which various courses of medication have not cured.

As one enters into the Kuchigoro camp, polythene bags and other waste and the stench from feaces make it impossible to take a leisure stroll under the shades of the tree into the community. People briskly walk through them to avoid enduring the eyesore and nauseating smell.

Against the backdrop of the debilitating drop in the quality of life for Nigerians across the board, the fate of the next generation hangs rather precariously.

The country is witnessing the rise in a generation of young Nigerian children who are faced with the IDP camps becoming their homes. So far, government policies on resettlement do not as yet pay much attention to the most vulnerable such as the likes of Achaba, Saratu and Liyatu who are merely a metaphor of the larger problems of maternal and infant mortalities that are the fate of women.

There is an urgent need for a more co-ordinated medical programme across the board, linking government, faith-based communities, private and NGO groups to secure our future by developing a robust response to this lingering crisis. There is need for government to develop a timeline for IDPs so as to ensure they do not descend deeper into a more precarious existence that exposes the next generation to violence and early death.

Photos: Adie Vanessa Offiong

This story was done with support from Code For Africa.