The Kick Inside
A while ago I was in my local bakery – a tiny family business that continues to survive against all the odds at the heart of the urban village that is East Oxford. A man came in whom the baker recognized as someone whose wife had just been due to deliver her second child. Naturally she asked if it was a girl or boy and the name, the usual things. But his answers were clipped, dulled – utterly lacking in the expected joy. Small wonder – just four words spoken under his breath a few moments later told us that his wife had died in childbirth.
It was a terrible moment. It was like the ground had opened up beneath our feet to reveal a world of unimaginable pain and grief. It was all the more chilling because it was so unusual – though statistics show that some women still die due to complications during childbirth, in practice Western countries have reduced maternal mortality to a point where we no longer consider it as a serious possibility.
At the beginning of the last century, when that bakery was first established, this kind of tragedy would have been much more common in the terraced streets that surrounded it. And in countries like Burkina Faso, it is still an everyday occurrence.
The statistics put it this way: in Britain there are 13 maternal deaths for every 100,000 live births; in Burkina there are 1,000. Expressed another way by UNICEF: women in Burkina have a 1 in 12 risk of maternal death in their lifetime.
Personal testimonies, unfortunately, tell the same story as the statistics in a much more heartrending way. Within half an hour of arriving at Ouagadougou airport I hear from the acquaintance who has met me that his wife died in childbirth four years ago, leaving him to raise two children on his own – and because the baby died too, her death would not even be included in official maternal mortality figures.
The first thing Mariama tells me after we have said our hellos is similarly awful.
‘You remember Memnatu?’
‘Of course I do.’ Mariama’s first child, she was a chirpy nine-year-old when I first encountered her.
‘She died in 2000 having a baby. It was a terrible time. How can your own daughter die before you do? I wrote to tell you but the letter can’t have got through because I know you would have responded.’
As, of course, I would have done, though I am not sure my response now to this devastating news is anything like adequate. I touch her arm and say ‘_Je suis désolé_,’ (‘I’m so sorry’) but it doesn’t seem enough.
There is more bad news to come. When I stayed in the village 10 years ago I arranged for my evening meal to be prepared by a widow called Habibu (pictured right), who lived nearby and desperately needed the income. She had a perpetual air of sadness, as if she were ground down by the struggle to keep her family afloat. When I asked her about her hopes for the future she said: ‘Just for us all to be healthy.’ A year or so later it seems she married again, which could have been a passport to a more secure existence – only to die in childbirth before another year had passed.
Habibu died at home from complications that arose during the delivery. If she had given birth in the clinic there is every chance that she would have survived, since in the 10 years since I myself witnessed a baby being delivered by its midwives there has not been a single maternal death in the health centre.
So why on earth didn’t Habibu have her baby in the clinic? Yet again it comes down to money. To avail yourself of the services of the maternity staff, you need to pay a fee, and in a subsistence economy money is hard to find – it is all too tempting to go it alone, particularly if, like Habibu, you had your other babies at home without any problem.
As with school fees, the insanity of the situation makes you want to cry out in despair.
Thomas Sankara, 1985
My own babies were delivered without charge in British hospitals and, as they have grown, have benefited from free healthcare whenever necessary, courtesy of the welfare-state model that still (just about) prevails in Europe. Yet here, in one of the world’s poorest countries, where most families have no wages and cash is hard to come by, people have to pay a fee to use the services of a clinic. What kind of crazy world is this? [Poor Americans may ask themselves a similar question.]
The death of Habibu, along with the death in infancy from malaria of the baby Falilatu, whose birth I reported on 10 years ago, put names and faces to the everyday health tragedies that occur in any poor rural community. They underline how vital it is for the village to have a vibrant, active health centre at its heart – particularly in the sphere of mother-and-child health.
Fortunately Sabtenga has just such a thriving clinic. When I visited 20 years ago, a clinic had recently been built but it contained next to no medical supplies. Ten years later, the clinic had been transformed. It had a full-time nurse and a midwife, even if that was fewer staff than it needed; it was well stocked with medicines and seemed to be taking particularly impressive care of the mothers and babies who attended. Mariama herself had by then for seven years been working as a medical assistant to the nurse and midwife.
By the end of 2005 the clinic is in even better shape, with four full-time staff plus Mariama. It has a separate new maternity section that I witness in full swing one Thursday morning. Mothers queue to be first in line by nine o’clock and there is such a press of women and children over the next couple of hours that there isn’t even room for people to sit on the floor, let alone on chairs.
Each baby is weighed and the result noted in its own record book so as to monitor growth. As the women wait, assistant nurse René flicks through all the babies’ records, picking out those whose immunizations are not up to scratch. He then escorts a group over to the main building and promptly injects the babies with whatever they need to protect them against diphtheria, tetanus, rubella, yellow fever and so on.
Overseeing all this activity is the Nurse, a fresh-faced, fast-talking man in his late twenties who has the redoubtable name of Major Sankara, despite being neither a soldier nor related to the country’s Great Lost Leader. I meet him first in his living room watching TV. The first-ever television in Sabtenga, an astonishing sight to me, is apparently powered by the solar panels on the roof that keep the whole clinic going. He is actually on the point of moving on to the capital to embark on the next stage of his training, but his three-and-a-half years in the job have clearly been a success. A party is held in his honour to thank him for his contribution and village worthies take turns to sing his praises; I am appointed official photographer for the event.
The high regard in which Major is held is by no means a foregone conclusion. Ten years ago, the Nurse was the most irascible of men, who had rubbed people up the wrong way throughout the community. He didn’t speak the local language and had no interest in learning. ‘I’m not motivated to mend fences with the village and I’ll be seeking a transfer,’ he told me. ‘I wasn’t welcomed. Now I just do the minimum.’
Users fees? Duh!
User fees for health services were introduced in Africa during the 1980s. In many cases these were insisted upon as conditions for lending by the IMF and World Bank; in others they were adopted voluntarily by countries following the guidelines of the 1988 Bamako Initiative that saw user fees as a way of injecting more resources into the health system. It is now widely recognized in academic circles, however, that user fees have the effect of deterring the poor from using health services.*
Duh! Why have the poor had to endure a decade and a half of pain to reveal something that was evident to anyone with a grain of common sense from the outset?
*See, for example, on Burkina alone: Janet Edmond, Alison Comfort, Charlotte Leighton, _Maternal Health Financing Profile: Burkina Faso_, PHR Plus, Maryland, US; Ridde, ‘Fees for services, cost recovery and equity in a district of Burkina Faso operating the Bamako Initiative’, WHO Bulletin 81(7), 2003.
Having seen the destructive effect of his attitude, I felt no compunction about painting a negative portrait of him in the magazine. When he read the version specially translated into French, his reaction to it was predictably volcanic. The problem I hadn’t foreseen was that he blamed Mariama for the story, claiming she had poisoned me against him, and made life difficult for her until he left.
Given this background, my return to stick my nose into all areas of the clinic’s operation is probably about as welcome to Major as a bout of diarrhoea. But he copes with good humour and is able to back up his observations about the village’s health with carefully kept statistics. Between January and June 2005, for example, 244 pregnant women came to the clinic to be weighed. Of these, 147 (60 per cent) went through the whole programme and delivered their babies in the maternity ward.
In a catchment area with 410 infants under a year old in 2005, these are relatively high percentages – but of course not high enough. And for all Major’s accurate record keeping, the women like Habibu who fell by the wayside are entirely lost to view.