Onyema Afulukwe of the Centre for Reproductive Rights in New York, writes on the high rate of maternal mortality in Nigeria
Hospitals demand compulsory blood donations, patients are given a mandatory list of medical supplies that they must bring with them, and women who can’t pay for their treatment are detained until they have begged the requisite sum from other patients, he tells Anna Bruce-Lockhart
One incident that stood out was my sister’s friend, an only child, who died when they delivered her first baby. She had a good doctor in a well-established hospital, and she had had an uncomplicated pregnancy, but somehow she died in labour.
It was some kind of emergency, something came up at the last minute and the hospital didn’t have the capacity or the equipment to manage it, so she died. I felt very disturbed by it – not just because she was an only child and I knew her parents would be heartbroken, but because there was no reason for her to have died.
As I grew up I became interested in campaigning for women’s rights – especially during Nigeria’s military dictatorship when human rights abuses were common. It became obvious to me that women were particularly disadvantaged; and that whatever happened to them usually had a horrible impact on their children and on other members of their families.
What is most disturbing about maternal mortality is that – it’s a cliche by now – pregnancy is not a disease. When women die it’s particularly unfair because they are not sick. And it’s rampant where I come from; Nigeria has the second-highest number of maternal deaths in the world. There is this lack of value around women’s lives and lack of understanding that their death is a violation of their human rights.
The health system in Nigeria is dysfunctional for many reasons. In the federal system there are three levels of government, and each level is responsible for a particular level of healthcare. But there is no law stating what each level of government should do. There is a policy, but no law. Government officials simply tell you they’re doing the best they can.
Local government receives the least funding from the national budget, so there’s also the question of whether it has the money to make a difference. In terms of health there are no fundamental rights; there is a chapter in the constitution that demands there be adequate medical and health facilities for all, but this is a social objective and does not impose a legal obligation.
There is also an absence of transparency about what money there is. You hear officials from government agencies and legislative bodies saying that they have put funds into the health sector, but nothing gets done and no one seems to ask questions. If and when resources are allocated, they are not necessarily used in an accountable manner.
The government has admitted that there is a problem, but whether consciously or unintentionally women are undervalued. There are so many policies on maternal health, on reproductive health and gender issues, and on mother-and-child health. If any of them had been implemented they would have made a huge difference, but they are just words on a piece of paper.
It is also a matter of mismanagement, and an absence of political will. The government has not yet made steps towards making a difference; ministers have not followed up their policies and do not appear to be investigating allegations of mismanagement and fraud.
The high “user” fees demanded by hospitals prevent many women from getting treatment. Interestingly, we found that some states and local governments have taken independent steps to waive user fees. But when we probed further we found that some of these fees were not comprehensive – they could cover visits to a doctor’s office but not prescriptions or follow-up visits. Some local governments would sustain a waiver for a few weeks or months and then run out of cash.
Some women who can’t afford to pay are detained in hospital until they can find the money. I spoke to a woman who had just given birth, and she told me it was common to see women going round the wards begging for money so that they could leave. I heard about another woman who ran away in the middle of the night after having a caesarean section, before her stitches had set properly.
But what I find most disturbing is the compulsory blood donation in some hospitals. If a woman comes as a patient she is asked to bring her partner to donate blood. One woman told me that she had been refused treatment because her husband wouldn’t agree. She had to go to another hospital that didn’t have the same quality of care and ended up losing her baby and almost her life.
The blood requirement is common. One of the health practitioners I spoke to said that hospitals do their best, but they do not have reliable blood supplies and are just making sure that the women don’t haemorrhage to death. But what about the women who don’t have spouses or are widowed?
Some hospitals will take fees instead. But this option is not always made clear to the patient. The woman who lost her baby had not been told that she could do this. Even if this information was made public, the system still discriminates against the poor and those on low incomes.
Many hospitals in Nigeria are poorly equipped. There are frequent power failures and cases of electricity going off during surgery. The son of a friend of mine was being operated on when the power failed and the doctors had to continue by flashlight.
What I’d really like to see in the short term is an end to the mandatory lists given to women when they are about to go into hospital. They are told to buy particular brands of syringes, antiseptics, cotton balls and so on. If they bring the wrong brand they won’t be admitted or given care.
In the long term more funding must go into the health sector. At the regional level, there was the 2001 Abuja pledge, where all the African governments pledged to donate a minimum of 15% of their national budgets to healthcare. So I hope the government will do that, and I hope there is more transparency around where resources go and what they are used for. And international donors that fund programmes in Nigeria, such as the Department for International Development in Britain, must push for change.