Aisha Aliyu is eight months pregnant and splayed out on a mat in front of her house, surrounded by four of her children. Hauwa, two, and Abba, five, are weeping and tugging at their mother’s coffee-colored headscarf. She responds by rolling her eyes and flicking her tongue at them. She seems exhausted.

Aliyu is pregnant with her eighth kid. The final four were delivered at the Durumi Camp, which she and an estimated 3,000 other internally displaced persons call home in Nigeria’s capital city of Abuja.

Aliyu escaped her home in the village of Wala in Nigeria’s northeastern Borno State to the state capital, Maiduguri, in 2013. Boko Haram, an armed Islamist gang, she claims, assaulted and burned down her village. After the terrorist group struck Maiduguri two years later, Aliyuwas forced to flee once more, this time going over 856 km south to Abuja with her husband and five children.

The now 39-year-old regarded having numerous children as a means to replace family slain by militants, but she admits she was done after her final pregnancy in 2021 and started using contraception. She did, however, become pregnant again this year.

Aliyu, who had previously given birth to children at the Durumi camp (one of 264 settlements for internally displaced persons (IDPs) known to exist in Nigeria as of September 2021), was concerned about the limited resources she would have access to. The farmer’s wife couldn’t afford the food and medication she needed to be well, and prenatal care was scarce.

The facility first put up at the camp as a birthing center was primitive and hardly sanitary, according to LiyatuAyuba, who was chosenas the camp’s Women’s Leader by the site’s Chairman when she arrived in 2014. She has subsequently dealt with health, food, and children concerns on behalf of the IDPs.

“It was a tent that we swept, and I would put a mat or wrapper on the floor for the women to lie down on to give birth,” explains Ayuba, who has been the camp’s only birth attendant for much of its history. Many of the displaced women call her Mama.According to Ayuba, the tent was a shanty constructed with corrugated roofing sheets and a sandy bottom. If gloves were available, the birth attendant used them; if not, she wrapped her hands with polythene bags and cut the umbilical cords with a razor blade.

“I gave birth to three of [my children] on a mat under the shelter with Mama’s help on a mat under the shelter,” Aliyu says of the birthing tent. “The mother severed the umbilical cord and washed the newborn.”

A non-governmental organization established the camp’s health post in 2019, where Aliyu’s ninth child, Hauwa, was born in 2021. The post is a small clinic housed inside a repurposed 20-foot shipping container, with wooden boards dividing the space to create a delivery suite that looks more like a storage space and just about, holds a bed, a baby cot, a drip stand, a broken chair, a trolley and empty water containers. The second half is a consultation room with a table, two seats, a bed, and a closet with medications and instruments.

Though modest, the clinic gives women a consultation space that they previously did not have, and Ayuba is happy to note that the camp has not recorded any deaths among mothers or newborns under her supervision.The shipping container employed as the camp’s health post’s temporary birth room.

‘There is no ‘ special arrangement’ for pregnant women in Nigeria’s camps.

Aliyu is one of many internally displaced women with children in Nigeria’s camps, with some grounds without either a health post or a birthing facility, forcing women to give birth in their own homes or the homes of their birth attendants.

According to Fatima Mahmood Jibirilla’s 2021 Ph.D. thesis at Walden University, women living in IDP camps in Nigeria “have a higher risk of maternal death than women living in their homes. The author identified several factors that contribute to the high rate of mother and infant mortality in these settings, including limited access to family planning options and inadequate prenatal care services.

“In Nigeria, there are no particular programs for pregnant women in IDP and refugee camps.” “There are insufficient antenatal services to identify and address likely complications associated with pregnancy and other signs of poor pregnancy outcomes,” the writer says. Despite the lack of maternal or child fatalities at Durumi under her supervision, CNN was informed by multiple physicians who were involved with the camps in Abuja that the concerns mentioned in the article were indeed actual.

A doctor spoke with CNN about the severe problem of inadequate maternal healthcare in these camps, noting that the country in question has one of the world’s highest maternal mortality rates and, according to the Internal Displacement Monitoring Centre (IDMC), the third-highest number of internally displaced people (IDPs) as of the end of 2022.

According to the IDMC data for 2022, 4.5 million Nigerians were classified as “internally displaced people” due to natural catastrophes and conflicts; nonetheless, floods were the leading cause of displacement, surpassing prolonged warfare.

There is no data available on the gender or age distribution of internally displaced persons (IDPs) on a national level. However, according to a report from the Camp Coordination and Camp Management (CCCM) Sector in 2023, out of 2,124,053 IDPs in Borno, Adamawa, and Yobe, 1,575,741 are women and children.

Nigeria’s total IDP population relies mainly on the graces of charitable organizations for its health care, Ayuba and the camp’s nurse, Isa Umar, told CNN.

‘If it happens, I am dead.’ The prohibitive costs of care

Wednesdays are antenatal day in Durumi. Camp nurse Isa Umar, who was herself compelled to leave his home as a result of the insurgency, is in the consultation room when CNN arrives. She is using a handheld ultrasound scanner to monitor a baby’s growth and a fetascope to monitor the heartbeat of the pregnant woman coming in.

Before taking a weight, Umar checks the pregnant woman’s belly button. Seated on the clinic’s porch, the women compare notes after their appointments with Umar and discuss how they would pay for any medications he prescribes.

Nothing about the configuration is suitable. Umar mentioned to CNN that they are out of folic acid and anti-malarial medication. If I want them to buy, I’ll have to write them.There is a high risk of early labor and miscarriage among pregnant women in Nigeria due to the prevalence of malaria. Folic acid is recommended for those who are pregnant or planning to become pregnant to reduce the risk of specificcongenital disabilities.

Butthese costs are prohibitive for most of the 64 women recorded in the camp’s birth register this year. Folic acid, for example, costs ₦3,000 ($3.74) for 100 tablets, and Aliyu tells CNN she could not possibly have afforded that cost for the duration of her pregnancy. Unless non-governmental organizations (NGOs) have given her free supplies, she says she hasn’t been able to take this essential vitamin. She could access free folic acid and other resources during her pregnancy thanks to her N100 ($0.11) hospital card back in Wala.

Getting clean water at the camp is also a challenge, Aliyu shares, explaining that it’s a time-consuming, strenuous task requiring her to make several trips daily and is one she can no longer do in the final weeks of her pregnancy. She now pays to have it delivered instead. At its cheapest, enough water to make the family’s breakfast of pap (porridge made from ground corn) and other domestic chores for a month costs ₦24,000 ($28.43). Costs can rise by 25% on days when there is no electricity and a generator is needed to work the pumps or when water sellers must go farther to fetch it.

There are additional fees involved with giving birth in Abuja that Aliyu did not experience in her own country.To immunize her babies inside the camp, the mother of nine must transport them to the nearest government hospital, where staff has specific expectations that she must meet, she tells CNN.

These include ensuring the child is wearing diapers and giving additional supplies, which Aliyu claims she lacks, such as cotton wool and baby lotion.

Medical professionals are just looking out for the baby’s best interests, according to Dr. Charles Nzelu of Nigeria’s Federal Ministry of Health, who spoke with CNN about how a lack of knowledge, understanding, and communication regarding the women residing in IDP camps is affecting their care. “I am going to offer you medical advice regarding how it’s supposed to be,” stated the doctor. “When you become more experienced, you are flexible (with) how you relate with patients.” He goes on to add that the newly elected government will make an effort to fix problems like these.

Meanwhile, Aliyu says she is trying to satisfy her and her children’s requirements. Aliyu creates and sells wigs and traditional hats worn by males to afford what she can, earning an average of $10,000 ($12.49) per month.

Her primary concern is not money. Aliyu is concerned about contracting malaria and not being able to enough breastfeeding due to the low quality of her food. Her family relies on essentials like pasta and corn in various ways.

“I can’t afford the malaria treatment,” Aliyu says. “If it happens, I am dead.”

Promises are challenging to keep.

The National Commission for Refugees, Migrants, and Internally Displaced Persons (NCFRMI) is responsible for Nigeria’s expanding number of displaced persons. Its commissioner tells CNN that the organization, which was founded in 1989 and has a health budget of N250 million for 2024, has paid for midwives to visit IDP camps to help in the births of babies as regularly as funds allow and has even paid off people’s hospital costs in some instances. CNN could not verify the Commission’s budget amount, which it stated is not yet public.

However, some IDPs who have been in Durumi since the informal settlement was formed in 2014 say that no midwives sent by the Commission have visited the camp during their time here and that it has been difficult in the past to get the Commission to fulfill promises made to the camp, such as furnishing the health post with an additional bed, scanning machine, gloves, and other health equipment.

CNN spoke with the NCFRMI about the services it offers to residents in Durumi but did not receive a comment before publication.

The Federal Capital Territory (FCT), in which Abuja is situated, is responsible for all health problems, including services supplied to persons in IDP camps, such as reproductive care and sexual health services, such as birth control. Dr. DolapoFasawe, Mandate Secretary of the FCT Health and Environmental Services, tells CNN that IDP camps in the area have functional clinics supported by area council staff and outside partners. However, permanent structures cannot be built because the camps are temporary. She adds, “The issue with maternal care in such places is child spacing, not maternal mortality.” Because getting pregnant too soon after giving birth raises the chance of difficulties, birth spacing helps to enhance the mother’s health outcomes. Doctors interviewed by CNN expressed concern about this in the camps and throughout Nigeria.

However, several camp residents told CNN that they had never heard of the FCT Health Services or seen them at the camp and that birth control is provided by non-profits working in the camps. When CNN notified Fasawe of this, she said it was a wake-up call for her agency to act quickly. This “has opened our eyes to the need to focus on them,” says Fasawe. “We need to (conduct some) outreach ASAP.”

Nigeria’s Federal Ministry of Health oversees the country’s health (including the Commission’s recommendations). In response to the concerns, Nzelu from the Ministry of Health tells CNN that maternal and child health is a top priority for the government but explains that the Ministry primarily provides policies and guidelines for states, local governments, and government agencies to follow rather than intervening directly. He continued by stating: “As a government, we are still working to make sure that both governments and every one of these departments of government that are charged with implementing the legislation directly accomplishes everything they can to make sure that the inhabitants of IDP camps are well taken care of.”

For over 12 years, the African NGO Pro-Health International has sent volunteer medical experts to provide free healthcare services to IDPs across Nigeria. They last visited Durumi in June and described it as one of the poorest IDP camps in the Federal Capital Territory (FCT), which includes Abuja.

Dr. IkoIbanga, Founder and Executive Director of Pro-Health International, stated that his team highlighted the issue of health difficulties within IDP camps with the Minister of Health at the time, Dr. OsagieEhanire, two years ago. “We were told it would be looked into,” he says.

Ehanire did not directly respond to CNN’s question about whether Pro-Health International raised the issue of health challenges among internally displaced people with him. Still, the former health minister highlighted the NGO’s work as a helpful implementer of maternal health services in recent years and shared emergency response plans for IDPs that date back to 2016 in the northeast of the country (where Boko Haram is most active). “Women’s Health services were given top priority and highlighted prominently in the programs aimed at internally displaced women’s needs,” he reported to CNN. This zone, however, excludes Abuja, the location of the Durumi camp..

Women relaxing on the porch of the temporary health post at the Durumi IDP camp.
The health budget for 2023 is $1.17 trillion ($2.2 billion), a 42.6% increase over 2022 and the most significant percentage of the entire budget devoted to health. However, in Africa’s largest economy, this amounts to just 5.7% of the yearly budget of 20.5 trillion, far less than the 15% of annual budgets agreed by all African Union member states, including Nigeria, in 2001 to “improve the health sector.”

A health post, the most basic health care institution, should be able to cater to a population of 500 and have 34 things always accessible to service that population, according to the National Primary Health Care Development Agency. According to Ayuba and Umar, who both administer the facility without pay, Durumi’s health post serves around 3000 people. It has just ten items: a waste bin, scissors, fetoscope, weighing scale, chair, tables, two beds, kidney dishes, and a cabinet, all given by NGOs.

According to Nzelu, the Ministry of Health is now doing a health needs assessment in most IDP camps to determine what is and is not lacking to provide proper health care services. With the budget cycle on, he tells CNN, “It can inform some of the things we can get into the budget and hope that the National Assembly gets permission so that we can execute.

Ibanga of Pro-Health International is outspoken about the hazards that displaced people experience during pregnancy and beyond. He says, “When [a woman] is unwell, it affects everything related to her, and her children are the most essential things tied to her. “A woman who falls between the gaps is not alone in her descent.” “She is experiencing the same decline as her children.”