Outside a zinc-roofed shack on the fringes of Nigeria’s capital, Abuja, Dada Nguru, a self-taught midwife, hangs a large sugar sack that has been ripped open out to dry. Earlier that day, she had laid a woman on it as she delivered her baby boy.
Hours later, a saline bag still hangs from the small open window, the only source of light in the cramped single room that is heady with the smell of sweat.
Nguru’s children sleep in this room, the same room that the women come to give birth in. For more than a year, this ramshackle building in the suburb of Kabusa has been their home – and the midwife’s delivery room.
Her one-year-old son, Muhammadu, nursing at her breast beneath the folds of her flowing red abaya, was still in her belly when she fled her home in the town of Gwoza, in the northeastern state of Borno, and arrived here.
“I came pregnant and gave birth to him here,” she says, adding: “We left because of Boko Haram.”
A midwife’s gift
Nguru sits on a low stool beneath a metal sheet awning in her small dirt yard, just hours after delivering the baby on the sugar sack. The story she begins to tell is one that many women share. As the insurgency in the northeast has escalated over the past few years, the number of Nigeria’s internally displaced persons (IDPs) has skyrocketed, with 2.15 million displaced as of last September, according to the UN high commissioner for refugees (UNHCR) and the International Organisation for Migration. These IDPs are either living in camps or are living scattered across neighbouring states.
Hundreds of thousands of those forced to flee their homes were women, and Nguru knows first-hand, as a mother and a midwife, the particular challenges they face.
“It’s a gift,” she says of her skill as a midwife.
The 37-year-old mother of nine, who has a long scar running across her right cheek, has been a traditional birth attendant for more than a decade, learning, she explains, from knowledge passed down by others and her own intuition. “I can tell if the child is positioned right,” she says, smoothing her hands over her stomach. “If a woman has a baby that is breach, I can turn it.”
Five other women from Gwoza gather around her as she speaks. Some of them are her patients. Her elderly mother, Aishatu Audu, whose lined face is marked with the same furrowed brow as her daughter, sits among them, playing with her three-year-old granddaughter, Umma.
Mamma Mary, as the women affectionately call a softly-spoken mother of six with a vibrant wrap of fabric around her head, is nine months pregnant. Nguru says she is ready to give birth any day now.
“Our life in Gwoza was good before Boko Haram,” Mary sighs. “We had our houses, the kids were in school, we had food.”
The day Boko Haram came
It was late afternoon on a Tuesday in October 2014. Nguru remembers how fighters in army uniforms drove into their village in armoured vehicles. They entered their homes, forcing the women and children out. At first, the women had assumed they were soldiers.
“Then we noticed a lot of them were wearing flip-flops,” says Nguru. “Some of them, the trousers wouldn’t be their size – they had to fold the bottoms. They were not looking smart.”
They ransacked houses and dragged men outside before slaughtering them in front of their wives. “They told us they were instructed not to kill the women,” she says. “Otherwise, they would have killed us, too.”
In the panic, families were separated. Nguru thought her husband was dead and kept scanning the ground for his body. When they began to set fire to the houses, she and the other women fled. Her mother hid with others in the mountains nearby for five days. Both are in Kabusa now.
‘They took our children’
Many of the women lost children along the way. One sitting among them now clutches a toddler to her chest and wipes tears from her cheeks.
“They took her kids,” says Nguru. “The one feeding her baby there, they took her boy.”
Two of Nguru’s own children, her 14-year-old daughter and nine-year-old son, were separated from her in the chaos of the attack. “We couldn’t find them,” she says simply. “I hope they are still alive.”
The journey for Nguru and the other women from Gwoza to Kabusa took a month. First they fled on foot, walking for nearly two days to reach the nearby town of Madagali, where they hoped to rest.
But after they arrived, Boko Haram attacked there also, so they had to push onwards. It took them five days to reach Mubi, the next major town. They spent a week or so there. But once again, Boko Haram followed, as if hunting down the women. They pressed on, getting lifts from passing trucks or cars whenever they could.
“The vehicles that picked us [up] would be the ones driven by traders, used for carrying beets,” says Nguru. “If it were a smaller car, one woman would go in the car and we would give her the children.”
Some women gave birth as they walked along the parched, barren roads, with nothing but miles of bush around them.
“We had to cut the umbilical cord with anything sharp we could find,” Nguru remembers. “We would pack the babies and keep on walking, and most of those babies survived.”
Miscarrying: ‘I sat on the road – there was blood’
Rakaya, a fresh-faced 22-year-old in a black T-shirt and white head wrap, sits quietly as Nguru speaks. She was five months pregnant when they fled. She miscarried on the road.
“We were scared, we were running, the stress of everything happening around us,” she explains. “I was walking on the road when I felt I was losing my pregnancy, so I just sat on the road and there was blood.”
She is pregnant again now and nearly at the same stage of her pregnancy as she was when she lost her last baby. She already has three children. Nguru worries that this pregnancy will be difficult since she did not get the medical attention needed to evacuate the womb after she miscarried on the road.
“Medicine and healthcare are our main challenges here,” says Nguru, adding: “Some of the women [from Gwoza] cannot afford food to eat.”
Helping the unreachable
Her own supplies are rudimentary – a bottle of Dettol and methylated spirits for sanitising, a knife for cutting the umbilical cord and washing detergent to clean the sheet and towels. But, often, even these run low. Plastic gloves are a luxury. Nguru says she needs everything from cotton wool to IVs and clamps for the umbilical cord.
Most of the women here, she explains, have no access to a hospital: The private clinics near by are unaffordable and the public ones are hard to reach.
The UN children’s fund, UNICEF, has been training outreach teams of health workers to support more than 100,000 displaced people living across 17 camps in Borno state, as well as others in nearby Adamawa and Yobe states. But it is the traditional birth attendants, like Nguru, who are often there for the women when no one else is.
“In some of the camps, we cannot say it’s 100 percent secure. At night, the health teams don’t stay there,” says Kennedy Ongwae, a health specialist with UNICEF in Nigeria. “Women who go into labour in the night, the traditional birth attendants have been trained in those camps to assist with those deliveries.”
Here in Kabusa, Nguru estimates that there are more than 1,000 internally displaced people from Gwoza. As of this month, she has helped more than 64 displaced women to give birth safely.
“We know there are pockets [of IDPs] here in Abuja and in other states,” says Ongwae. “The main issue coming up, both in the capital of Abuja and in restive Borno, is that the hospitals operate on a fee-for-services system.”
Those who are displaced are technically entitled through an emergency measure to receive free healthcare, with hospitals reimbursed for treating them by the government, but Ongwae says that without an effective system in place, the IDPs often have to pay out of their own pockets upfront before seeing a doctor. This, Ongwae believes, is one of the biggest challenges facing displaced women.
Those who have taken shelter among local communities, like the women from Gwoza, can be difficult to identify and reach, Ongwae explains, and traditional birth attendants such as Nguru have played an important role in providing support where health systems and even emergency aid have failed.
“Traditional birth attendants are part of the social support mechanism,” says Ongwae. “Not just for deliveries.”
An advocate for displaced women
Nguru has become an advocate for the women within the local community, with her talents as a midwife making them welcome. Local scavengers, known as baban bola, bring them scrap pieces of wood for their cooking fires. Night and day, her yard is abuzz with women coming and going.
On a busy day in Kabusa, Nguru says she can deliver as many as five babies, sometimes more. Her reputation has travelled by word of mouth in a country where maternal mortality rates remain stubbornly high. Despite efforts to improve maternal health over the past few decades, a woman’s chance of dying from pregnancy and childbirth in Nigeria is one in 13, according to UNICEF, making it the second-largest contributor to the world’s maternal mortality rate.
The fact that Nguru rarely loses a mother or a child has kept her services in demand. A week ago, one of the women from Gwoza had a stillborn, she says. But other than that, the women cannot remember the last time she had a bad outcome.
A consultant obstetrician and gynaecologist who volunteers with Foundation for Refugee Economic Empowerment, a grassroots NGO which has been assisting the displaced in Kabusa, visited Nguru last year. She came away impressed by Nguru’s skills and knowledge and promised to provide her with further training so that she can better help the women from Gwoza, as well as the local community. Another organisation, Mothers Alive, supplied her with a non-pneumatic, anti-shock garment (NASG), a special device to stop haemorrhaging during or after pregnancy.
The woman who had given birth earlier that morning on a sugar sack had experienced some difficulty with her labour. “She was shaking as if she had a fever, so I called the pharmacist, and we gave her an IV,” Nguru explains. “If I notice they have eclampsia, I have to send them to the hospital.” She makes a rolling sound with her tongue, describing the seizures some pregnant women can experience if they suffer from the condition.
Family planning: ‘Tell our husbands’
On Saturdays, pregnant women come to Nguru’s house for appointments so that she can assess them.
Babies that are breach will grow up to be wise, she says, her knotted brow loosened by a wide smile, amused by her own proverb. If the labour is long, she sometimes uses a gloved finger to break the woman’s water. If a woman becomes feverish or the pregnancy is too complicated, she will make sure she gets to the hospital.
While she tries to help as many displaced women in the area as she can free of charge, Nguru charges local customers 3,000 naira ($15) for her services, a meagre sum to cover the cost of materials and keep a roof over her family’s heads. Her trade also helps her to support the other women from Gwoza.
She has ambitions to expand her small business. By Christmas, with some help from a local NGO, she had converted the open space in her yard under the awning into a four-walled room for deliveries. Her dream is to get a bed for the women with a heavy metal frame, so that they can have something to grip on to when in pain.
Nguru is not only concerned for the women’s health during pregnancy, but their overall wellbeing. With their unstable living conditions, she has tried to counsel the women on options to avoid getting pregnant.
“I told Mama Mary she should stop,” Nguru says. Mama Mary nods. She does not want more children, but there are few family planning options available to her. Nguru tells the women to try to go to the pharmacy to get a morning-after tonic, but it is beyond the women’s budgets. “Tell our husbands,” the women laugh.
Celebrating a new baby, remembering a lost one
A week later, another of the women from Gwoza, Aisha Musa, gave birth. She lives along the roadside, next to the New Life Baptist Church, one of the countless single-room churches in the area where sermons and singing blast from open doors on the weekends.
Behind a patchwork of sewn-together cement bags that serve as a gate to the small compound, she stands, waiting for Nguru to come and conduct a check-up.
“I am happy she is here,” she says of Nguru.
When Nguru arrives, the sleeves of her dark blue abaya pushed up to her elbows, Musa untacks a tattered sheet hanging in front of the entrance to the shed-like building where she lives. Five other families from Gwoza live in the small compound. At night, more displaced families who have nowhere else to sleep also shelter here.
Musa emerges from the darkness with her newborn daughter in her arms. The baby’s eyebrows are smudged with black kohl, a tradition in Gwoza, her little mouth pursed as she sleeps. She would remain nameless for three days, a common practice, and a salve against the common loss of newborns.
This is Musa’s fifth child, Nguru explains, but only four are with her now. “I had a small boy, Mahmoud,” Musa says. “He was one year and nine months. I buried him in Mubi.” He had died on the road as they tried to find safety. Nguru stands beside her as Musa, flushed and smiling, cradles her new daughter, unwilling to let the past spoil her current joy.
From the women of Gwoza to the women of Kabusa
As dusk approaches, green husks of corn scatter the dirt roads and the smoke from cooking fires fills the air. Nguru accompanies a local woman, whose baby she has just delivered, home.
Within the small walled compound, 22-year-old Safara’u Haruna sat on a wooden bench, cradling her fourth child. Born only 20 minutes before, the infant still has a waxy, white residue on her hands and head. She is wrapped in a colourful piece of patterned fabric, just her chubby face poking out.
She had given birth to her previous children alone, in her own bedroom and without any help, even from a local birth attendant. The labours had been difficult. But, this time she had just walked the five or so minutes to Nguru’s small room to deliver.
Her husband, Abdullahi, a broad man in his early 40s, is pleased with the service Nguru provided and is happy that the women from Gwoza have come to Kabusa. “We’re feeling their impact positively,” he says. Compared with the nearby medical centres, Nguru’s skills come cheap. “It’s practically free,” he says.
Boko Haram ‘burned everything’
In the dusk, having checked up on the babies she delivered that day, Nguru begins to make her way back home to feed her own children and to prepare the room in case another woman arrives in the night.
When asked if she ever thinks of returning to Gwoza, she shudders, shaking her head slowly. More displaced people are still coming to Kabusa every week.
In December, President Muhammadu Buhari declared that Nigeria had “technically” defeated Boko Haram and assured Nigerians that the return of millions of displaced people would begin “in earnest” this year. But the attacks have continued, and many, like Nguru, fear returning home.
“They burned everything there,” she says, pausing for a moment before slapping her hands together and pushing up the slipping sleeves of her abaya. “My work is here now.”