Midwife Sade Obidokun provides care to patients at the Redeemed Christian Church of God Maternity Centre in Ibadan, Nigeria.
IBADAN, NIGERIA – Mayowa Olumide is pregnant with her first child. She says she has struggled to obtain efficient maternal care at large public hospitals. But she is reluctant to take her chances with alternative health care providers.
On the days of her prenatal appointments, she wakes up before 6 a.m. to beat the traffic between her home in Ibadan, the capital of Oyo state in southern Nigeria, and Adeoyo Maternity Teaching Hospital. To ensure the staff attends to her quickly at the state-run hospital, she must be among the first patients to arrive.
“It’s not that easy, but it’s a sacrifice one has to make,” she says.
It is a long trip – on a good day. Olumide says she once had to walk part of the distance to the hospital when she had no small bills to take a motorbike taxi.
“On getting there around 7 a.m., my name was 52 on the list,” she says. “There were all these pregnant women already sitting, waiting."
They waited in rows for two hours before the nurses began to attend to them. But she says that is normal at large public hospitals such as Adeoyo.
"We will have to wait till 9,” Olumide says. “Some people will bring their food to eat. Some will look for food to eat. Then the nurses will start calling the names on the list. As soon as your name is called, you are attended to."
On some mornings, overwhelmed nurses are still struggling to complete the previous day’s list, she says.
“They will call those ones first, before they start attending to new people on the fresh list,” Olumide says. “Usually they attend to 60 people."
The nurses are busy from morning until evening as crowds of pregnant women come for routine appointments and obstetric emergencies. As such, the nurses are often stressed and impatient, Olumide says.
The long waits and harried staff at large hospitals have led some women to seek maternal care at alternative providers, including local government clinics, privately owned hospitals, and religiously affiliated maternity homes. But some women in Nigeria question the competence of these alternative practitioners.
Pregnant women in Nigeria say they prefer to visit large public hospitals because they believe that they provide more affordable and expert care than private hospitals. But overwhelmed staff at public hospitals snap at patients, urging them to seek care at smaller clinics. Religious mission centers are one alternative, but they lack the capacity and resources to handle emergencies. Government officials implore pregnant mothers to seek public health care at the local level to ease the burden on large public hospitals, where they are also conducting trainings to improve care.
Nigeria ranks nears the bottom – 169 out of 176 countries – in the Mothers' Index compiled in a May 2013 report by Save the Children, an international organization that works to defend children's rights. The index assesses the well-being of mothers in each country, and rankings reflect a composite score based on five indicators, including maternal health.
The estimated maternal mortality ratio in Nigeria is 630 deaths for every 100,000 births, according to 2010 data provided by the World Health Organization. The country is off track to meet indicators to improve maternal health by 2015 as part of the Millennium Development Goals set by the United Nations Development Programme.
Nigeria has one of the highest maternal mortality rates in the world, according to a 2008 report published jointly by advocacy groups the Center for Reproductive Rights and the Women Advocates Resource and Documentation Centre. The government of Nigeria distributes public health care at three levels: federal, state and local. The local government runs small clinics to provide primary care, while the state and federal governments provide health care in larger public hospitals.
In the face of such alarming statistics, women such as Olumide are willing to make long journeys to receive care at the larger public hospitals.
Olumide says she makes the journey because her life is important to her. Large public hospitals handle more cases, so the nurses have more experience than those at many private hospitals, she says.
"I just have to think about my own safety first,” she says. “Because when we are talking about private hospitals, at times we must think about their experience, the way they handle you.”
Oluwabunmi Adeleke, a businesswoman in Ibadan, says she also prefers public hospitals instead of private institutions. After the birth of her last child in January 2012, she does not trust staff at private hospitals.
She had registered to deliver at the Adeoyo Maternity Teaching Hospital but went into labor during a fuel shortage crisis in Nigeria. Because of the crisis, the Oyo state government closed the general hospital.
Desperate, Adeleke hurried to a private hospital to deliver her baby. A doctor immediately told her that he would need 60,000 naira ($380) to perform a cesarean section. But Adeleke was skeptical.
"He had not taken me to the labor room or examined me at all,” she says.
Suspicious of extortion, Adeleke went to another private hospital, where staff informed her that there was no need for a C-section.
But staff at the second hospital did not test her for HIV. She says this should have been standard procedure because they did not know her status.
"If they do such tests, they did not do one for me,” she says. “Though there are some private hospitals with good quality, but you will have to spend a lot of money for the services."
High costs also deter women from private hospitals. While fees for maternal health care services can range from 15,000 ($95) to 20,000 naira ($125) at public hospitals, fees at private hospitals can be as high as 50,000 naira ($315), according to the report published by the Center for Reproductive Rights and the Women Advocates Resource and Documentation Centre.
If she became pregnant again, Adeleke says she would return to a large public hospital.
"I will go to Adeoyo,” she says. “I believe that they are competent. They will look at your general health before they register you. However, this does not happen in all private hospitals. Whether the person has HIV, they do not know."
Although Adeleke prefers to visit state-run public hospitals, she also says that the staff does not always treat patients with respect. Because nurses at these hospitals must deal with emergency referrals as well as crowds of waiting women, they have a reputation for being short-tempered.
During her two pregnancies, Adeleke saw harried nurses snap at waiting patients, she says. Nurses tell women to seek treatment elsewhere rather than crowding the waiting rooms of large hospitals.
“Some nurses are good, and some are bad,” she says. “Some abuse patients. They say things like: ‘Is this the only hospital around? Why do you all come here? Is there no health center around your area?’"
Women commonly say that they receive negative treatment in public hospitals, according to the report by the Center for Reproductive Rights and the Women Advocates Resource and Documentation Centre.
“There is evidence that women do not seek maternal health care at hospitals and clinics due to prior embarrassing experiences or fear of being humiliated by the health-care staff,” the report states.
Rather than suffer abuse at public hospitals, some women turn to religious maternity centers and small private clinics for health care.
Folasade Onifade Akinsanya is a midwife in charge of the Redeemed Christian Church of God Maternity Centre in Ibadan. As at a government-run hospital, there is no cost for child delivery, although women must pay a registration fee, she says.
The center, which opened one year ago, accepts women regardless of their religious backgrounds and offers spiritual and medical services to them.
"The women gather in the church for prayers and counseling, during which we check their blood pressure, do the necessary checkups and also give health talks,” Onifade Akinsanya says. “Every second Wednesday of each month, we have deliverance sessions. For anyone with spiritual problems, we also go on fasting and prayers to solve the problem."
But the center has only three beds. It employs three midwives who attend to patients around-the-clock, Onifade Akinsanya says.
Because of the clinic’s small size, complicated cases pose a challenge, she says. Complications include the positioning of the baby in the womb, weakness or poor health of a mother during delivery, a slow fetal heart rate, or fits and seizures during a delivery. In these cases, midwives must refer patients to larger hospitals such as Adeoyo.
Adigun Ismail Adekunle, a community health officer at Al-Lateef Hospital and Maternity Centre, a private Muslim clinic in Ibadan, says there are some medical cases that the small hospital cannot handle.
“We cannot compare our work with the general hospital’s level,” he says. “When a patient comes, you will ask, ‘Is the management of this sickness under our power?’ If the case is beyond us, we refer.”
To ease the burden on large public hospitals, pregnant women should remember that local governments distribute care through primary health care centers, says Dr. Oluwatoyin Oyelakin, deputy director of reproductive health for the Ministry of Health in Oyo state.
“Those primary health facilities are there for them to patronize, and there is no reason to be afraid,” she says. “At the PHCs, they have fewer to attend to, and those who patronize them cannot tell us that they wait for over an hour.”
Ideally, centers run by the local government should handle between 80 percent and 90 percent of all pregnancies, she says. Women may also choose to visit private hospitals or religious centers.
Staff at large public hospitals will not turn away pregnant women, Oyelakin says. But these women must be prepared to wait.
“If you go to a place like Adeoyo, you will take your turn,” she says, “and you are going to prevent those doctors from attending to the emergency cases that they are supposed to be attending to.”
But the existence of primary health care facilities is news to some women. Olumide says she was unaware that the local government operated clinics in her neighborhood.
"I did not know there was a health center there,” she says. “There is no signboard or anything there.”
Had she known earlier that there was a primary health care center in her neighborhood, she would have registered to give birth there, she says.
Meanwhile, the Ministry of Health is aware that workers in public hospitals have a reputation for insensitivity, Oyelakin says. The government is addressing the problem.
“Measures are in place to counter this,” she says. “A lot of sensitization workshops and meetings have been held in all cadres of health workers to improve the interpersonal communication between our clients and ourselves.”
Whenever representatives from the ministry meet with nurses in hospitals, they train the staff to treat patients with concern, she says.
“We should care for them with all that we have,” she says. “With time, we will have that 100-percent perfection from everybody.”
