I sit in the waiting room outside of the office of the director of the Maternité Issaka Gazoby – one of the largest centers for women’s gynecological and obstetrical problems in the country. I’m here because so many women with fistula from the Tillabery, Ouallam, Tera, and Dosso regions of Niger found themselves at this center – the terminus of a catastrophic delivery gone awry. Often they awoke in an unfamiliar room, the only clue as to what they’d been through the fresh smell of blood seeping through the bandages covering their sore abdomens. Most were unconscious when they came through Issaka Goazoby’s doors, referred up through a long chain of mid and low level health centers – a process that often takes days. Many of these women could rightly count themselves as “near misses”, women who barely made it off the delivery table with their lives, waking up permanently marred – the war wounds of a morbid battle with their own body, their own child.
I came to the Maternité Issaka Gazoby to ask permission to observe the maternity ward for a couple of weeks, just to see how it operates. To see how midwives speak to patients. To see what kind of patients end up here. Which ones are carted out without breath. Which hobble out, arms empty, leaking urine. And which leave surrounded by their family with an infant nestled in their arms. I am looking to understand the dynamics between practitioners and rural women. I am interested in how these women are welcomed, where the onus of blame is placed – if at all. I want to see if women understand their conditions, if practitioners take the time to explain what’s happened to their bodies. I am looking to understand the context – to get a fuller picture of maternal health here in the country dubbed -perhaps dubiously-the “worst place to be a mother””, the country which shares the unflattering claim as the “least developed country in the world” .
I’ve spent countless hours in similar health centers in West Africa over the past decade. In Togo, Mali, Senegal, Ghana, and Burkina Faso I’ve watched women give birth in rural mud huts, and in empty (but far from sterile) concrete cubes which act as local health centers. I’ve seen women birth – or often fail to birth- in regional hospitals and reference centers, women’s last stop – their last chance.
I walked around the grounds of this maternity yesterday, I watched as women cradled sick children in the arms, spread out on plastic mats in the sandy outdoor passages. As older women sat patiently with their own adult daughters, whose hijabs tumbled over their pregnant bellies but failed to hide the worry and flickers of pain that was etched across their faces. I walked through the halls of the hospital rooms, where laborers threw buckets of soapy water, chasing the blood and the smell of rotting flesh out into the sand outside. Doctors and nurses donning the emblematic white and pink coats walked languidly though the halls, chatting to one another about their home lives, about the upcoming war between the west and Syria.
I closed my eyes and images of women from similar centers, in similar places, months and years before flashed across my mind. The woman who arrived to Maradi’s regional hospital – only the whites of her eyes visible, a bluish, swollen head and neck protruding from between her legs – he was stuck, dead for two days, she came 13 hours by mule cart.
I saw the image of a baby, torn from her mother without much reverence, placed dead without much ritual, perhaps forgotten, in a plastic tub in the corner of the room.
I saw a teenage girl, suffering from obstructed labor, left to a party of her aunts and neighbors while the midwife prepared herself dinner at home, exhausted from another day too much like those before it and those which inevitably will follow. I saw the women, holding down the girl on the floor of the clinic, one clenching her fingers around the girl’s mouth, suppressing screams of pain while another forcefully pushed on the girl’s belly — knowing that something has to give. I held my breath in the corner, hoping (praying even?) that the child gave before the girl’s uterus ruptured. It didn’t.
Every time that I sign on to Facebook, my news feed is populated by the grainy photos of someone’s early ultrasound: “Baby’s first photo!”, friends posing in bikinis, showing off their pregnant bellies, blooming. I read about birth-plans, and midwives, and follow impassioned exchanges– “Should I go natural or take the epidural?”, photos of baby showers and nurseries, elaborately decorated shows of certainty: this baby is coming home healthy. Once pregnant, the future feels predetermined – few seem concerned about obstetric complications, about risk (making miscarriage in the west a taboo, confusing, and often secret subject).
I’m reminded how different the experience of pregnancy is in sub-Saharan Africa where each pregnancy is a gamble. Where women go to great lengths to hide a pregnancy until she’s home with that baby. “She ate beans”, one might euphemistically say of a pregnant woman here, afraid of attracting the attention of evil spirits, superstitious that saying the words out loud might somehow jinx her.
And she won’t need any bad luck on her side – 240 out of 100,000 women in developing countries die from preventable causes related to pregnancy and childbirth a year. In Niger, that number rises to 590 out of 100,000. Indeed, 1 out of every 23 15-year-old girl will eventually die because of pregnancy or childbirth. In the United States, the maternal mortality rate is 21 (out of 100,000) quite high compared to Greece (with 3 out of 100,000), but still more than 2,800 % lower than Niger’s.
(explore the numbers for yourself on the World Bank’s website)
Still, despite the critical mass of emergent cases which populate the halls of Issaka Gazoby, centers like this one feel tranquil. No one runs. You don’t hear the screaming of women, nor children, nor the sirens of ambulance bringing another woman toeing the line between life and death.
The same impassive feeling, the same stale air surrounds me as I sit in the waiting room, staring mindlessly at the large upholstered door which stands between me and productivity. I had an appointment with the hospital’s director three hours ago. But, as setting appointments here is often an exercise in futility, a ritual of whimsy, he went out. I was told to wait. So I wait.
A mixture of low expectations, patience, and hope – a necessity for quotidian existence in Niger.
Sai hankuri, indeed.