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Dignity in Childbirth

My interest in women’s health began when, in high school, I became aware of the ongoing genocide in Darfur. Learning about that conflict’s impact on women in terms of sexual trauma and maternal mortality opened my eyes to the depths of inequality that women face in the Global South. This, combined with the fact that I’m a first-generation Nigerian-American, led me to pursue a career in obstetrics and gynecology, with a global-health focus.

As a second-year medical student, I received a research fellowship to study Nigerian women’s choices of childbirth settings and medical care. I traveled from Chicago to Benin City, the capital of Edo State, in southern Nigeria, and spent eight weeks volunteering in a local labor ward.

I had often wondered why any woman with access to modern healthcare facilities with skilled birth attendants (SBAs, in medicalese) would choose instead to deliver at home or under the care of traditional birth attendants (TBAs) lacking formal Western medical education. My experience on the labor wards dramatically changed my perspective on this.

I quickly discovered that in Nigeria, as in the US, women of lower socioeconomic status receive a significantly lower quality of obstetric care. This is reflected in everything from a lack of skilled birth attendants to abusive treatment by providers.

Like most urban regions, Benin City has a mixture of richer and poorer areas. People in the wealthier areas, near the University of Benin, had access to tertiary-care centers, whereas people in the poorer parts of the city had to travel upwards of an hour to reach the nearest clinic.

The labor ward where I volunteered, in central Benin, was small and under-resourced, with frequent power outages. It had ten beds, five against each wall, with a bucket by each bed in which the laboring women could relieve themselves. There were no dividers to provide privacy, and the women were left to labor alone. Five nurse midwives were on the labor ward, but only one was handling deliveries at any time, while the other nurses chatted. Occasionally one of two physicians would stop by to see if any of the women needed to go to the operating room.

I was struck by the nurses‘ and midwives’ interventionist approach with the laboring women—monitoring each patient’s labor and speeding it along with repeated doses of pitocin—and how this was coupled with what seemed an almost complete emotional detachment.

If a woman cried out in pain, the nurses never responded—except, at times, with mockery. I never saw any of them attempt to gauge a patient’s pain or try to make her more comfortable. The expectation, it seemed, was that a laboring woman should be able to “control” herself and “behave.” For instance, all of the women were required to lie on their backs throughout labor and delivery.

When one woman, Ede, was ready to push, I watched as she held her own ankles and did her best to push without any instruction.

“You said you want to push. Now push!” the nurse said, slapping Ede’s legs open. “Don’t waste my time!”

“Okay, I want to listen,” Ede answered, clearly scared and in pain. I stood frozen, as everyone around me continued working, completely unbothered. I felt helpless. As a visitor being welcomed into this space, I chose not to speak. Was this out of shock, fear of how I would be perceived, or cultural indoctrination regarding respect and power dynamics? I’m not sure.

I watched as another woman, Esosa, whose pain seemed to worsen with each contraction, shifted about in bed, trying to find relief.

“This is a labor ward,” the nurse said sternly. “If you want to behave this way, you can leave.”

“I’m sorry,” Esosa said, turning to lie on her back once more.

A while later, I held Esosa’s hand as a nurse forcibly examined her cervix while she was in mid-contraction, ignoring her obvious pain.

When the nurse left, Esosa said, “Please find my husband and have him come to support me.”

Due to the lack of privacy, family members were required to wait in the hallways or outside the hospital. Failing to locate Esosa’s husband in the hallways, I finally found her sister.

“Please go back and stay with her,” she begged. “It’s her first child, and she should not be left alone.”

I stayed at Esosa’s bedside for the next four hours, acting as her doula, rubbing her back and offering words of encouragement. The nurses’ reactions came through clearly in their rolled eyes, giggles and whispers.

The hour grew late, and with a heavy heart I told Esosa, “I have to leave.”

“If you leave, who is going to stay with me?” she asked, grabbing my shirt.

I could only promise to visit her and her newborn the next day.

A wave of helplessness and anger washed over me. How can people treat laboring women with such contempt?

As easy as I found it to mentally vilify the nurses and midwives, I also remembered conversations in which they’d revealed that they were understaffed, overworked and exhausted. During my time on the ward, I was impressed by their resilience and resourcefulness in handling power outages and other challenges. Although a lack of resources is no excuse for negligent or abusive patient care, seeing their difficult work environment provided me with some perspective.

In the end, the women in the labor ward had uncomplicated labors and delivered healthy babies. But I couldn’t help wondering, Is that all that should be expected?

If what I witnessed is typical of delivery in healthcare clinics in Nigeria, then the question is not why some women still deliver with traditional birth attendants but rather why any woman would ever choose to deliver in a healthcare facility. Granted, the ward I observed does not reflect the entirety of Nigeria’s maternal healthcare system; but the fact that only 43 percent of Nigerian women deliver in a healthcare setting points to a broader systemic problem.

Obstetric care should, at the very least, allow women to maintain their dignity throughout labor and delivery. Regardless of her educational, socioeconomic or marital status, a laboring woman should never have to beg to be attended to, or feel pressured to “behave.” If a clinic setting is not emotionally and medically supportive, women may well conclude that they are better off delivering with a traditional birth attendant.

As I continue my medical education in the US, I’m becoming increasingly aware of instances of mistreatment of women, particularly minority women, in the US healthcare system. A well-known statistic is that Black women in the US die from maternal causes at two to three times the rate of white women. I can only wonder how often some form of mistreatment may lead to a woman’s missing her prenatal visits. On the flip side, how much power might there be in making sure that every woman, regardless of who she is, has a high-quality, dignified labor and delivery?

Dignity during labor is a human right. A mother bringing a child into the world should be celebrated, honored and supported in that process. This should hold just as true in the remotest villages of Africa as it does in the wealthiest hospitals of North America.

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Debra Eluobaju is a fourth-year medical student at the University of Illinois College of Medicine in Chicago. “As a physician-in-training, I understand that my impact is often limited to the patients with whom I have direct personal contact, but through writing I can reach a broader audience. Because of this, I hope to make storytelling, through observational studies and qualitative research, a large part of my career.”

Comments

8 thoughts on “Dignity in Childbirth”

  1. Henry Schneiderman

    Superb, beautifully restrained and even-handed report on an appalling reality. I am struck by Ms Eluobaju’s taking the effort to explore contributing causes to the callousness of some midwives, and her drawing a modulated and morally compelling conclusion and summary about it.
    The commentator’s point about collaboration between midwives and MDs in the USA bears one other point: a parallel team approach is quickly evolving in hospitalist medicine between NPs and MDs. One additional means of acting on our compassion is to create systems that make wisest use of all resources, human and otherwise. For while we are far more richly provided than Benin City, those in direct patient care here are often overstretched and exhausted as well.
    Ms E, I echo others in praise and in urging you to keep writing. And never believe those who rationalize their own shortcomings by mislabeling your compassion and idealism as naivete or youthfulness. I recommend Robert Coles’s book The Call of Service: a Witness to Idealism to you. It will resonate with you

  2. Patricia Shahamiri

    I am a white middle class woman who delivered my first child over 35 years ago in a modern hospital here in the US. I was intimidated by nurses on the labor ward who gave very little support to me and who suggested that if my labor didn’t progress more quickly, they would send me home. I had no family in state and the thought of being sent home in active labor with my husband who knew absolutely nothing about childbirth was so scary to me. The labor did progress, a total of 9 hours for a first birth, doesn’t seem so bad. My whole experience there left me wanting to get out of there as soon as possible. My second child who was overdue came on so quickly that a fireman caught him after a 911 call. I was holding him back until someone arrived. The baby and I were healthy and happy. Born in my own bed, I can see why having some control over birthing is reassuring even though I never planned on it.

  3. Abbey Pachter, PhD

    Dear Ms. Debra,
    I appreciate your recognition and distress over health disparities, particularly in the differences in maternal mortality rates between whites and BIPOC women, even right here in the USA.
    I can’t speak about the “5 nurse midwives” at the clinic you visited in Nigeria. However, I can guarantee that if you spend time with Certified Nurse Midwives in the USA, your experience will be entirely different. You will see health care professionals deeply “with women” (the definition of “midwife”) during pregnancies, labors, deliveries, and while providing gynecological care.
    I’ve taken the liberty of contacting the midwives of Illinois (midwivesofillinois.org), suggesting they reach out to you via this article. I also suggest you reach out to them, and to the American College of Nurse-Midwives (ACNM) at acnm.org to learn more about the outstanding care Nurse-Midwives provide, particularly to those who are underserved.
    My hope is is that you make time to work with a midwifery practice, observing and learning. In the best situations, CNM’s and MDs work in collaborative, supportive practices (together or separately), benefitting from the expertise each provides.
    Perhaps you will contribute to reducing such health disparities in the USA as well as in Nigeria and elsewhere as your career unfolds.
    Keep writing, keep caring, keep practicing, keep learning.
    All the best, from a retired, formerly Certified Nurse-Midwife.

    1. As a certified midwife from India, I can attest to the stellar care provided both there and here. This should be a learning experience for all as to what to and not to do. Let’s change negatives to positives by making sure patients get the care they receive and we speak up for them.
      A beautiful article that pains the soul witnessing unwarranted suffering. Keep writing.
      All luck and blessings at school!

  4. This essay sheds light on humanity’s capacity for heartlessness and compassion. Debra Eluobaju’s astute observations are certain to help her become the kind of doctor I would be honored to have.

  5. As a nurse educator, I applaud your stand on every birthing woman’s right to support and responsive care before, during and after labor and delivery. Thank you.

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