Nigerian Hospitals Are Locking Up Women Unable to Pay Their Childbirth Bills
Fashion designer Folake Oduyoye died in custody in 2016 after her hospital refused to discharge her until she paid her outstanding bill. Her death is part of a global phenomenon known as hospital detention.
Illustration by Owain Anderson
Before her life changed irrevocably, Folake Oduyoye was an ordinary woman, working as a fashion designer in the bustling city of Lagos, Nigeria. She loved her job, her husband Adeyemi Oduyoye recalls. He would plead with her not to work too late, so that they could leave at the same time each day and head home together to take care of their three young children. “I used to tell her, do your best and leave the rest until tomorrow,” Adeyemi says, smiling a little.
But when Folake went to hospital to deliver their fourth child in late August of 2014, the familiar rhythm of their lives was suddenly upended. She developed an infection after her C-section and was referred to a government facility, the Lagos University Teaching Hospital (LUTH), for emergency care. Her lengthy time in ICU racked up a fee of almost 1.4 million Naira (approx. $4,000) that became impossible for her and her husband to pay. When it was time for her to be discharged, Adeyemi alleges that the hospital refused to let her go.
Instead, they moved Folake to a guarded ward, where she was imprisoned alongside other patients who couldn’t pay their medical bills, her husband claims.
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He says that Folake was forbidden from leaving this ward, or receiving any treatment within it. Adeyemi slept beside her each night. During the day he tried to convince hospital staff to let him pay the bill in monthly instalments and let her go; he was driven by his wife’s hope that she’d be home for Christmas. But according to him, the hospital refused. “We spent a month and 13 days there, without treatment, without anything, before my wife developed a cough,” Adeyemi says.
It was a fatal sign: A few days later, in the early hours of Saturday 13 December, Folake died with Adeyemi by her side from a combination of sepsis and pneumonia.
Today, Adeyemi, a slight, soft-spoken man, says he still weeps when he thinks of her. “These people, they caused me to have no wife, they made my children motherless,” he claims, referring to the hospital staff. Speaking on behalf of LUTH, the hospital’s lawyer Onmonya Oche Emmanuel said they denied these allegations at the time, and that this still stands. But Adeyemi doesn’t accept that. “I need justice. If I step aside, they will continue doing this.”
Four years on, a team of lawyers called the Women Advocates Research and Documentation Centre (WARDC), is still trying to get to the bottom of Folake’s case. This Lagos-based organization provides pro-bono legal services to women experiencing human rights abuses, including domestic violence and acid attacks. When Adeyemi contacted them four years ago with his wife’s story, it intensified WARDC’s activities to stop the illegal practice that caused Oduyoye’s death—a phenomenon known as hospital detention.
Imprisoning someone within a hospital is a clear contravention of the human right to liberty—and yet this practice is surprisingly widespread, occurring far beyond Nigeria. It is a global phenomenon, typically occurring in countries where emergency healthcare isn’t free or insured. For underfunded hospitals, it’s a means of extracting fees from people who can’t pay their medical bills upfront, usually by forcing them to call on relatives and friends to come to their aid. Women face a higher risk of being detained because birth often involves unforeseeable emergency care, such as C-sections, or the treatment of postpartum haemorrhage. It’s possible that thousands of people in Nigeria are detained in hospitals yearly—though without data, it’s difficult to confirm the precise number, says Onyema Afulukwe, senior legal counsel for Africa with the US-based Center for Reproductive Rights (CRR).
Inside WARDC’s offices, Emmanuela Azu, one of the lawyers on Folake’s case, wears an easy smile that belies the steely resolve required to do her job. “There’s a culture in Nigeria that when a woman dies [in childbirth], it’s an act of God. But it’s beyond an act of God; it’s due to the negligence of someone, somewhere,” she says.
This thinking is embodied by a 2008 report that WARDC produced with the CRR investigating the causes of Nigeria’s high maternal mortality rate—which ranks second-highest in the world. Annually, the country loses roughly 40,000 women during pregnancy and childbirth. “The idea behind [the report] was to identify hidden or ignored factors behind the high level of preventable maternal deaths,” says lead author Afulukwe.
During an undercover fact-finding mission that took her into Nigeria’s hospitals, Afulukwe and WARDC colleagues discovered multiple cases where women—often those who had given birth—were being illegally detained. “Typically the women would be kept in a separate ward. In some instances they couldn’t see sunlight, they would be forced to sleep on the floor, and they wouldn’t be given any food,” she says. “It was a condition of detention that amounted to torture, in many instances.”
Alongside other more direct causes of death, like negligence, WARDC and CRR argued that the practice of detaining women compounds the country’s already elevated maternal death rate, mainly by making pregnant women too afraid to seek medical care for fear of being imprisoned.
Against this backdrop, when Oduyoye’s story came to WARDC’s attention in 2014, it was potent fuel for their growing awareness campaign against maternal deaths in Nigeria. “It brought to reality most of the issues we have been agitating for over the years, such as high user fees, detention, and negligence,” says Azu.
It also represented a unique opportunity to hold the state directly accountable for the continuing deaths of women in healthcare facilities. WARDC founder Abiola Akiyode-Afolabi explains that the organization typically focuses on cases like Oduyoye’s that distil major gender equality issues in Nigeria—cases that “can become a class action, that can address issues on a larger scale,” she says. In 2015, they took the case to court, with Adeyemi as their key witness against the state.
WARDC’s premise was that it was the government’s failure to provide a working welfare department at the hospital that forced the institution to revert to illegal means of making people pay, Azu explains. “The state should have a mechanism of holding people accountable to repay—not detaining them and denying them their rights to freedom and healthcare,” she says.
But after more than two years of sluggish proceedings, Oduyoye’s case was overturned in May 2018 on a technicality by the Federal High Court in Nigeria. “I was really very depressed,” Azu says. “The judgement was very frivolous—the merit of the case wasn’t even looked into.”
Akiyode-Afolabi has her own beliefs about why it was struck off: “It was obvious that the state was just trying to find a way of dismissing the case, because if we’d gotten a judgement it would have affected other cases across Nigeria,” she says. “They really don’t want that precedent to be laid, and that’s why we’re going back to court.” WARDC plans to continue pursuing the Oduyoye case, motivated by the fates of so many other women that hinge on its outcome.
Most of WARDC’s work on maternal rights abuses revolves around more general cases of healthcare failure in government facilities—such as delayed care, understaffed hospitals, and underpaid staff—issues that ultimately fall under the government’s remit. “When you look at the web, it goes back to the failure of the state to do something at a particular time,” Azu says.
This tack has brought them successes in the past. In one case, their investigations prompted a public enquiry in a government hospital that delayed treatment of a woman who haemorrhaged to death after giving birth. In another, five women died in the space of a week after each receiving a blood transfusion: WARDC exposed a local blood bank as the source of contaminated blood, and the facility was subsequently shut down.
"We can stop detention—we can stop all this—if we push, and if people are ready to stand to the end. "
To help them tackle more cases like this, WARDC runs training courses that teach lawyers how to creatively navigate the Nigerian constitution to litigate cases revolving around maternal, sexual, and reproductive rights. In 2017, Azu says they trained 24 judges on these issues, from across the federal high courts of Nigeria. She adds that the organization also employs a team of 20 people to work on this problem at the frontline: inside hospitals.
These ‘maternal health monitors’ are “women who we train to become like spies, who go into hospitals to find out about their state,” explains Akiyode-Afolabi. Continuing in the tradition of 2008 fact-finding mission, the monitors—who rotate between about 30 hospitals mainly in Lagos and the northwestern state of Kaduna—report back on instances of hospital negligence, and also identify new cases of hospital detention.
Funmi Jolade Ajayi is one of these 20 monitors, and has been volunteering with WARDC since 2012. She explains that her presence works to deter the maltreatment of patients in the three government hospitals where she routinely works. “They know me as an activist, and that I have to monitor the wrongs of the government to correct them,” Ajayi says. “My presence there is a threat to them.” She also enlists the help of pregnant women in her community to report back on conditions within the hospital, and gathers photographic evidence to share directly with the police, she says.
In the aftermath of Oduyoye’s death, WARDC became acutely aware of how it important it is to formally identify cases of hospital detention using their network of monitors. Getting women to come forward with their stories would reveal the national scale of this phenomenon: “I think the fact that we don’t have this kind of data means people don’t really know that it’s happening,” Akiyode-Afolabi says.
WARDC’s next ambitious task is to gradually build up a class-action case against the government, made up of female detainees—though getting identified victims to share their grievances hasn’t been easy, Akiyode-Afolabi admits. Women who have been through detention or other forms of hospital maltreatment understandably want to distance themselves from the trauma. Many also aren’t aware that their rights should protect them from these scenarios, she says.
Their efforts to establish a class-action case are therefore just as much about versing women in their rights, as achieving justice—something that goes back to the organization’s founding principles, Akiyode-Afolabi explains. “The issues of pregnant women were issues only for researchers. We hadn’t seen them take actions on their own,” she says. “We decided to focus on working with pregnant women, so we could build their capacity, to help them to speak for themselves.”
The fruition of that goal would be seeing women testify in court against a system that has infringed on their rights. The lawyers are now gathering evidence to make this class-action a reality. A long road lies ahead. But Akiyode-Afolabi remains adamant: “We need to fight more for accountability. We can stop detention—we can stop all this—if we push, and if people are ready to stand to the end.”
Meanwhile, in early March WARDC received news that Folake’s case has been approved for appeal. It will be considered again in court on the 2nd of May, marking a new phase for this landmark case. Adeyemi insists he will be there beside WARDC, fighting on his wife’s behalf. “We are,” he explains, “supposed to value a human being more than money.”
The reporting for this article was made possible with funding from the European Journalism Centre’s Innovation in Development Reporting program.