“Monday mornings are the worst,” the nurse tells me as we wade through pools of women at the chaotic Maternity Hospital. “Women wait at home all weekend, then come to the hospital after things have become urgent. You haven’t finished with one patient before three or four more urgent cases need your attention.” The nurse dresses me in an oversized white coat as we walk, the sartorial symbol that opens all doors here – a veritable carte blanche. She leaves me in the emergency triage room, where women from all over the region, and even throughout Niger, are referred for a host of issues including eclampsia, advanced gynecological cancers, and myriad obstetric catastrophes.
The room is small, about the size of a large bedroom. There are six black plastic examination tables, filling the room until only one thin aisle is left vacant. There is one light, a box of blue latex gloves, a pile of pink intake forms, and a few cracked, plastic lawn chairs for the clinicians.
In this small room, a single slice of the day, a single set of patients, one single hour, reflects the challenges practitioners face, the battles women fight, and the quotidian reality of maternal health in the Sahel.
Bed 1: Suffering in Silence
At 9am, a woman arrives with a half-delivered baby. She is torn and he is stuck. After some expert navigation by the midwife, the baby is delivered, and despite having 12 toes, miraculously, he is alive. Miraculously, he is perfect. She, however, is worse for the wear. I pass by as a midwife stiches up her deeply exposed flesh. The woman grimaces; she clenches her teeth. Silently, she feverishly massages her abdomen each time the needle dives back into her skin. She has not been given anything to dull the pain, nothing to dull the sensation. “If she needs it, we will give her Tylenol after,” the midwife assures me. “I hear in your country, women fear pain. I hear that women take medicine so they feel nothing. They can’t really consider themselves mothers….” The midwife shakes her head and the needle burrows deeper into the woman. Blood trickles down the woman’s legs and pools beneath her. Still, she does not make a sound.
Bed 2: Transgression and Trickery
At 9:10am, a woman with wide facial features and a somewhat haggard red and black weave shuffles in. She makes pained expressions, bordering on the theatrical. She groans. She screeches. “She’s not Nigerien,” the midwife assures me. “The way she’s crying, the way she’s making a scene. It’s shameful. Nigerien women aren’t like that. They are courageous.” Indeed, I learn that Grace is from Togo. She moved to Niger to marry, and it hasn’t gone well. When I probe about her pain, Grace tells me that she’s bleeding. She whips out a pair of underwear she was guarding beneath her head – pointing to the bloodstains on a soiled rag tucked inside. She tells me that her husband hit her last night, angry about her pregnancy. It sounds somehow rehearsed. I lower my voice. After a few minutes with Grace, I ask her if she took medicines to abort. Her eyes dart around the room before she nods yes. I ask her, “if they can save your pregnancy, do you want them to? Or do you prefer that they take it out?” “Out,” she says quickly, “I want them to take it out.”
Soon, the emergency room fills up – in a room no bigger than a bedroom, two dozen people squeeze inside – the smell of sweat and blood and vomit and amniotic liquids mix in the air, a vile potpourri. Grace quiets down, reanimating only when a nurse catches her eye. I reflect on the drug cocktail an old traditional healer provided her; I wonder if the grimaces painted across Grace’s face, these noises that fill the air around her, are born from pain – the physical consequences of a botched abortion in a place with no legal means for a woman to choose, or if they are performative, an attempt to conceal her transgression of the law.
She clutches my knee, shakes her head back and forward vigorously, asking me in a horse whisper, “they will take it out, won’t they?” She looks at me with pleading eyes, “I have two kids already, and there’s no money now for another. There is just no money. I need work. They must take it out.”
Eventually, Grace is moved to another room and given oxytocin. She waits calmly for the contractions to begin, knowing that soon it will be over, soon it will be out. However, twenty-four hours later she still lies in the same position, on the same bed, wearing her worry like a mask.
Bed 3: The Invisible Crisis
In the early morning, the third bed is occupied by a woman with a transverse fetus, then an older woman with a painful vaginal tumor. Both women are quiet and patient, disappearing behind a tattered screen. Around 9:15 am, the room is no longer so tranquil. A young Fulani woman is wheeled in, just referred from a rural health clinic. It isn’t clear if she is conscious. Her neck is limp and her head dangles off the back of the wheelchair. Suddenly, her head shoots up as she vomits repeatedly down her front. She jerks and begins to fall towards the tile below. My hand braces her shoulder, but I struggle to keep her up. The midwife instructs me to let her go, and the young woman tumbles to the floor, arms and legs akimbo in the middle of the small room. Workers, patients, and clinician step over her in their own race to heal or be healed.
Bed 4: Who You Know
At 9:30, a young woman in an expensive, embroidered dress with a plump face and a round belly seems to pull the attention of all the head nurses and the passing doctors. While other women are losing blood, losing consciousness, losing babies, I can’t quite pinpoint what this woman is on the verge of losing – her urgency isn’t visible. She gets up every thirty minutes or so and walks to one place or another, undergoing blood tests and ultrasounds. In her absence, women slip onto her bed, hoping to be seen: A 40-year-old woman dressed in all white whose enormous abdomen seems to be rapidly emptying its contents; A young woman brought in on an ambulance whose eyes flicker all white when they crack open. Both women are sent to plastic lawn chairs, sent to wait, when the young woman returns. The adolescent Fulani woman on the floor from Bed 3 begins to seize, and I step backwards, bumping into a well-dressed Hajiya (a rich woman who has made the pilgrimage to Mecca). After apologies and introductions, it turns out that she’s the former director of the hospital. The round-faced woman in bed four with the embroidered dress? Her daughter. Mystery solved.
Bed 5: The Malady Which Must Not Be Named
At 9:45, an older woman contorts her face in pain as she slowly, with careful attention, removes her blouse. While her left breast hangs low – a flat and flaccid marker of her reproductively fruitful years of yore – her other breast is hard and high, like an artificial and over-sized breast, except blooming with red and white sores, puss, and exposed tissue. The sores consume her nipple, which is no longer visible, and blossom underneath her arm, at her lymph nodes. This is breast cancer in the Global South. We tend to associate breast cancer, and pink ribbons, and lumpectomies, and silk headscarves, as markers of a sickness of affluence. And it is true, the incidence of breast cancer increases exponentially as does age – and in a place with a life expectancy of 54 years old, many women don’t make it to the prime years of cancer’s malice. Still, many do. And here, cancer is a scary, taboo, and undocumented illness, rarely written as the cause of death. This was the woman’s first visit to the hospital. She’s from a rural village, and probably thought, “it’s just an abscess, it will pass. It will pass…” until her arm was swollen in pain, immovable, and her breast swollen and hard, consumed by disease.
“It is a Neuro” the doctor tells her. She doesn’t know what that means, but that is the point. A neuroblastoma is a malignant cancerous tumor of the nerve tissue. “Sometimes,” he tells me, “I tell them it is a tumor. But we never use the word cancer here.” Cancer is thought of as a death sentence. Patients lose hope, they stop fighting, he explains, endorsing an unspoken policy of paternalistic beneficence. Just from a quick glance, the doctor knows that it has metastasized. He can see it in her lymph nodes; he can see its movement across her body. Nothing is explained to the woman at this stage. It isn’t clear if or when it will be. She is left alone on the plastic black table, struggling to dress herself.
Bed 6: The Lives That Count
At 10 am, a thin woman gazes into space as she curls up on a table. Next to her is a shadow of a baby. A skeletal thing that came in to the world months too soon. Among other problems of more immediate concern, her mom is severely anemic and can’t produce any milk. So, for four days, this 2-pound shadow of a human has not had a drop to drink or eat. She is quiet. There is no elasticity to her skin. Through her nearly transparent skin, each rib is visible. Her rapid heartbeat sends vibrations across her chest. Her mom tries to rock her, but as though she were a sculpture made of fine glass, the movement feels dangerous, violent even.
“Can’t we do anything for this baby?” I ask. “Is there no artificial formula for babies like this?” “Why?” the nurse asks me. “The mother isn’t well. What happens if the child lives and the mother dies? And even if she the mother lives, so you feed the baby today. Look at that woman; she can’t afford formula. What happens when you are gone? Who will feed the baby then?” the nurse says to me with an attitude creeping on indignation.
In the West the lives of babies are considered precious. Parents and hospitals and insurance companies hook up pre-term babies to machines in NICUs for months, babies once not even considered viable, monitoring them constantly, anticipating and responding to ruptured bowels and breathing problems. The lives of babies seem to be considered the lives most worth saving. The lives which most merit resources of money and time and technology and expertise. Here, most mothers (particularly- though not exclusively- from rural areas) expect about half of their children to make it past the age of five. Parents wait a week to give a baby a name, and when the baby dies, parents mumble: “God didn’t intend for this baby to continue on earth.” “It wasn’t its time.” “It wasn’t God’s destiny.” As this woman holds the fragile being, shaking her a little too hard, holding her a little too far, I wonder if this mother has already resigned this life to ‘destiny’.