The Edge of Joy

Segment 1

TITLE: Hafliwa Maganin Mutuwa
TITLE: "Birth is the medicine for death" - Hausa Proverb
TITLE: Kano, Nigeria
KABIRU IBRAHIM: At about 5:30am, my wife Aisha gave birth at home. I rushed to borrow a car from my friend and took her and the baby to the local hospital.
AISHA AMIRU: Aisha was bleeding. I poured lots of water over her. But it didn't help, and the bleeding got worse. Honestly, when we brought her to the hospital, in her own words she kept saying she was going to die, she was going to die.
TITLE: Brown Doggy Pictures, in association with Woodlawn Avenue Productions, present: The Edge of Joy.
VOICEOVER: Nigeria is Africa's most populous country. Its 140 million citizens are divided almost equally between Muslims in the dry desert north and Christians in the lush south. Nigeria is a land of extremes. The West African country is blessed with some of the world's richest natural resources, and is best known as America's fifth largest oil supplier. But this isn't the story of oil. This is the untold story of more than 36,000 Nigerian women who die each year while trying to have babies. This is the second highest number of maternal deaths in the world. Battling this daily crisis are Nigerian families and healthcare professionals working on the front lines of maternal health.
TITLE: Kano, Northern Nigeria
SIGN: Murtala Mohammed Specialist Hospital
SIGN: Labor room
DR. BELLO DIKKO [Chief of Obstetrics & Gynecology, Murtala Mohammed Specialist Hospital]: So you are welcome to the labor room of Murtala Mohammed Specialist Hospital. It's one of the busiest maternity centers you can find in all of West Africa. There is at least an average of 30 deliveries in 24 hours, normal deliveries.
VOICEOER: Dr. Bello Dikko is head of obstetrics and gynecology at Murtala Mohammed Specialist Hospital in the northern Islamic state of Kano, one of the most difficult and dangerous regions in which to be a woman.
SIGN: Dawn shall not fall twice on a woman in labor
TITLE: Sakina Muhammed: mother of two, in labor with twins
AISHA BUKAR [Nurse Midwife]: I was trying to explain to her that she should bear down because she is carrying a multiple pregnancy.
VOICEOVER: Sakina delivered her first two children at home. More than half of Nigerian women give birth outside the hospital. During this pregnancy, Sakina heard radio messages about free maternity services for prenatal care and delivery, and told her husband Muhammed.
MUHAMMED MAKA [Sakina's Husband]: My name is Muhammed Maka. At home there is the possibility of encountering problems, so going to the hospital has its advantages.
AISHA BUKAR: We notice she's very weak, so we set up IV 5 percent dextrose for her.
MUHAMMED MAKA: I brought my wife Sakina to the hospital on a Saturday, and she gave birth to twins on Sunday. The first twin was a girl.
AISHA BUKAR: No contractions, nothing. So we add just a little pitocin for her in order to encourage her to start having the pains so that she can expel the [second] fetus.
DR. BELLO DIKKO: Because of the associated complications, the second delivery should not exceed five to ten minutes.
AISHA BUKAR: She was telling me that the presenting part of that patient, the second twin, is breach [feet first] presentation.
DR. BELLO DIKKO: Breach delivery, especially in a multiple pregnancy, is a very complicated delivery. There is a need for a qualified OB/GYN doctor.
AISHA BUKAR: We even called the doctor but he was not here. But if she is about to deliver we can take the delivery. We do it.
DR. BELLO DIKKO: The team on call -- we usually have four. Two of them must be on the ground, the doctor on duty and the first on call. So if these two are on the ground, they may likely be in the theater. So what will happen is they cannot unscrub. That is an emergency. This is an emergency.
SIGN: Post-partum hemorrhage
DR. BELLO DIKKO: Hemorrhage in obstetrics is one of the leading causes of maternal mortality.
MUHAMMED MAKA: Sakina labored in pain before the second baby was born. It was close to an hour before the boy was born. He came forth having problems.
AISHA BUKAR: He has very severe aesphesia. We need oxygen now and we don't have oxygen. I don't want the baby to die. I don't want her to miss that baby. That is why I try with all my effort to be able to help her or to help the baby too. We cannot leave him like this. He has to see a pediatric doctor. The [pediatric] unit is far.
SIGN: Emergency Pediatric Unit
MUHAMMED MAKA: My son needed medical attention, and we rushed into the emergency pediatric ward.

Segment 2

VOICEOVER: While the second twin was being stabilized, Sakina's condition worsened. She was diagnosed with post-partum hemorrhage.
FARIDA BABALLE [Head Nurse-Midwife, Murtala Mohammed Specialist Hospital]: She lost a lot of blood. She's a bit anemic. She has to receive a blood transfusion. They gave her this bio-plasma, about two liters, and then they gave her normal saline. I think with that, it can take her up to six hours. One of our main problems here is how to get blood. The husband has to go and donate. Before, we normally asked the Red Cross, they mobilized people to come and donate blood to the hospital. But now, due to HIV, we stopped. They have to go and check the blood group of the husband. Then they compare it to see if it's the same as hers. If it's not the same blood group --
MAN: "A" positive. Not the same.
FARIDA BABALLE: -- the husband must buy the blood. So all these things take time, and delay, and it causes the death of the woman. That is the largest cause of death of the women here.
VOICEOVER: Muhammed's search for Sakina's rare blood type took him to surrounding hospitals and private blood suppliers. One pint of blood costs 10,000 Naira, or USD$68. The average Nigerian makes about USD$94 a month.
TITLE: Three hours later
SIGN: Blood bag
DR. BELLO DIKKO: It is really disheartening to see a patient dying from a preventable cause. As far as I'm concerned, hemorrhage is a preventable cause.
SIGN: Murtala Mohammed Specialist Hospital
VOICEOVER: Sakina received a blood transfusion in time to save her life.
TITLE: Two days later
TITLE: Sakina and Muhammed's second twin
TITLE: Fatima, Sakina's mother
WOMAN: I don't think the baby is alive. I don't think.
MUHAMMED MAKA: We have a teaching in the religion of Islam that states, "What Allah gives, belongs to him. And what he takes also belongs to him." All of us are from Allah, and at some point, sooner or later, we shall all return to Allah. Even though we know it hurts, we can only accept its outcome.
WOMAN: Now on examination there is color, she is pink, not dehydrated. Then the BP is 100/70 so at least it's okay.
VOICEOVER: After eight days in the hospital, Sakina and her surviving twin daughter went home.
TITLE: Oyo, Southern Nigeria
SIGN: College of Medicine, University of Ibadan
VOICEOVER: Professor Oladosu Ojengbede is Director of the Center for Population and Reproductive Health. He is one of the continent's premier women's health physicians.
PROFESSOR OLADOSU A. OJENGBEDE [Center for Population and Reproductive Health]: One of the reasons I got into medicine was that obstetrics was a very practical subject. There's a problem, you see it, you solve it, you're happy, the family's happy, everybody's happy. I lost my mom when I was very young. I was only three years old. I saw there were very grave challenges you face when you don't have a mom.
TITLE: Professor Oladosu a. Ojengbede, Center for Population and Reproductive Health, University College Hospital, University of Ibadan
PROFESSOR OLADOSU A. OJENGBEDE: Most of our women live in rural areas. And so most of the births take place outside big cities. And if most births take place in rural areas, then that is where we must work. When I'm down in some villages and you think, "Could this be happening to human beings?" You become very emotional. And you feel like shedding tears.
SIGN: Akinyele Local Government, Maternity Center, Mele
PROFESSOR OLADOSU A. OJENGBEDE: But then you quickly remember that, look, this is something that needs to be resolved. And you are one of those who have made up their mind to resolve it.
VOICEOVER: Professor Ojengbede is pioneering low tech and affordable health solutions. He says these innovative tools are essential to keep women from dying of preventable causes.
WOMAN: So this is the garment we have brought that helps to save women's lives.
VOICEOVER: One of the most effective life-saving solutions is the anti-shock garment. This full-body suit, first conceived of by NASA, is being adapted for hemorrhaging women. The professor and an international team of colleagues have proven this suit can be used to treat shock by shunting blood from the extremities and back to vital organs. Bleeding to death is the number one killer of pregnant women, including those who live in this remote village of Mele.
PROFESSOR OLADOSU A. OJENGBEDE: In a remote area like Mele, to get immediate access to superior care may be a challenge. Mele actually in full means, "Mele-mu-cu," which means, "I will not choose death." I love the name of this village, because what we're here for is to prevent death and promote life.
PROFESSOR OLADOSU A. OJENGBEDE: Hello! How are you and the baby? Is the baby sleeping?
RACHEL OLATUNJI [Pregnant with fifth child]: Yes, the baby is sleeping.
PROFESSOR OLADOSU A. OJENGBEDE: We saw a couple. The wife is currently pregnant, and she had a two-year-old baby on her back, with scabies infections on the head and arm.
PROFESSOR OLADOSU A. OJENGBEDE: What is his name?
RACHEL OLATUNJI: Matthew.
PROFESSOR OLADOSU A. OJENGBEDE: Matthew! This is scabies.
PROFESSOR OLADOSU A. OJENGBEDE: This woman says she has five kids, and indeed the current pregnancy was really not planned for. And the question was, if it was not planned for, how come they couldn't prevent it?
TITLE: Olurim Olatunji, Rachel's Husband
PROFESSOR OLADOSU A. OJENGBEDE: According to the gentleman, he said, "Well, I'd rather stay with my wife than go out to find another wife for sexual responsibility." It is global knowledge that the higher the number of births beyond five, the risk increases, but even doubles from five or more. And the closer the pregnancies are, shorter than two years between birth and the beginning of another pregnancy, the higher the risk. Not just for the woman, but also for the born baby and the previous births, because they are all related.

Segment 3

RACHEL OLATUNJI: I have tried on my own to prevent pregnancy, but it is to no avail. Unfortunately, I wind up with unplanned pregnancies.
VOICEOVER: Rachel, like most Nigerian women, has five children. For Rachel, like most, at least one of those pregnancies is unplanned.
RACHEL OLATUNJI: I am very fertile. I tried to abort a pregnancy on my own with local herbs. I started having severe diarrhea, and I lost a lot of weight. I almost died. After a while, it became evident that I was still pregnant, so I started prenatal care and I accepted my fate.
TITLE: Sunday morning church service
ELIZABETH ADESINA [Community Birth Attendant]: When we speak of family planning, the husbands think this is a secret way of encouraging their wives to be unfaithful and start sleeping around. But if the emphasis is on preserving their wives' lives and the care of their children, they will understand.
PROFESSOR OLADOSU A. OJENGBEDE: The men in this village are eager to improve the reproductive life of their families.
PROFESSOR OLADOSU A. OJENGBEDE: What do we do -- what do we know so that we can make love to our wives but not have pregnancy occur? First, you can use tablets. If you use condoms all the time, they are very effective.
PROFESSOR OLADOSU A. OJENGBEDE: We are seeking a dialogue with the men today, to have an in-depth introduction in contraception, how it impacts on health, how it impacts on the family, on income, on development.
MAN: If a person can calculate the days very well, can there be a mistake between this time and this time for ovulation to take place?
PROFESSOR OLADOSU A. OJENGBEDE: Well, we didn't create this place where the egg comes from, and though there's a time range, it can vary. That is why it is better not to take the risk at all. So if you're waiting for that time, and you really want to make love to your wife, what are you going to do? There's nothing you can do to satisfy the need so that a man cannot wait! And if the wife says at that very moment, "Wait, you said we shouldn't get pregnant," the man can't think right! We should not guess. We should have a decisive method.
VOICEOVER: Every Thursday morning in Mele, preacher and community birth attendant Elizabeth Adesina opens her prenatal class with a prayer.
TITLE: Elizabeth Adesina, Community Birth Attendant
PROFESSOR OLADOSU A. OJENGBEDE: Faith-based practices probably see more patients in this country than the public sector facilities, simply because they provide the services within the context of understanding the values and the norms of the community they are serving.
ELIZABETH ADESINA: Glory be to your name that she will not suffer. We will always praise your name, Father, in Jesus' name, amen.
TITLE: Kano, Northern Nigeria
FARIDA BABALLE: I started practicing midwifery in 1986, almost twenty-something years as a midwife. I was posted here October 2007. I was on leave at that time. When I came down there, they said they are taking me to the labor room. I said, "I don't want labor room now. All my years of service, my experience, has finished in the labor room, so please can you change me now so that I can have another area." They said no. They wanted me to be here. "We need something from you to come out and implement it here for us." I said, "It's okay." That is how God willed for me to help my fellow women. So when I came back, I sat down and said, "Oh," I asked them, "What are your statistics?" So I took three years of the register. I picked three things. What is the problem there, in the ward? And I write what my observation is there. So from that, we'll do our own assessment. This will tell us if it's the problem of the midwife, the problem of the doctors, or the problem of the community.
FARIDA BABALLE: You see, January of last year we had eleven maternal deaths. So you know there is a problem here.
VOICEOVER: Women die in the north because their culture often forbids them from travelling without a male escort, even when they're bleeding to death. Aisha Ibrahim, who gave birth to her eighth child at home, is one of them. In fact, knowing this precept, her husband Kabiru stayed with her.
KABIRU IBRAHIM [Aisha's Husband]: My wife Aisha bled too much with her last two deliveries. So I made sure during this delivery I would stay close by to support her.
VOICEOVER: But in the midst of the crisis, his car broke down, and he left to repair it. Stranded and hemorrhaging blood, Aisha had to wait for her father-in-law's permission to take a taxi to Farida's hospital with another male relative.
AISHA AMIRU [Aisha Ibrahim's Sister-in-law]: I was there. They said she had lost so much blood. There was no more blood, that her blood was all gone. Honestly, when we brought her to the hospital, in her own words she kept saying she was going to die, she was going to die.
NURSE: We checked her BP [blood pressure]. The BP is 70/query [too low to measure]. Some patients even die with that.
FARIDA BABALLE: They just come at their dying minutes. They set a drip-normal saline and isoplasma for her. Then we applied the anti-shock garment. Then once you put it on, within a short time, when you check the vital signs, you find there is BP, there is pulse. The woman is coming back.
DR. BELLO DIKKO: The anti-shock garment is just a way of buying time before you can procure blood for the transfusion of this woman.
FARIDA BABALLE: The time that we didn't have this anti-shock garment, the woman will just go, will just die, because there is nothing we can do to help her. The only thing we can do is just to elevate the foot off the bed. Apart from that, there is nothing we can do.

Segment 4

VOICEOVER: Aisha's husband, Kabiru Ibrahim, is a taxi driver in Kano and a father of thirteen.
KABIRU IBRAHIM: When I arrived here at Murtala Mohammed Specialist Hospital, they told me about the garment they applied to control the bleeding. Then they told me she was in need of blood.
NURSE 1: The blood is her immediate need.
KABIRU IBRAHIM: My brother and I searched all around for her blood type. But there was none available. My calmness was rattled, of course. I was thinking, before I'm able to find the blood, I would return to find her dead. I was grateful to Allah that I had the means to purchase the blood, but it was nowhere to be found.
NURSE 1: The minute she came, we took her blood sample for relations to go look for her blood. But still yet you can see, how many hours ago? No blood yet.
VOICEOVER: After searching for five hours, Kabiru found two pints of Aisha's blood type.
NURSE 2: Blood pressure is 120/80 -- it's normal.
HALIMA BEN UMAR [PATHS2]: She was telling me how this was the worst, she suffered the most out of all the seven she had. Then I said, "Have you thought about family planning, I mean child spacing?" Then she said, "Yeah...ah, uh huh. Is it something you can do?" She said her husband would not allow her to stop giving birth. I said, "No, I'm not saying stop, I'm just saying space." Islamically, it is wrong for you to say you want to have two children, you want to have four, but Islamically you can space.
FARIDA BABALLE: The reason why most of our people don't believe in this family planning is because sometimes they misquote religion. They say God has said, "Deliver us many and they multiply the world."
HALIMA BEN UMAR: Sometimes I felt maybe should I talk about family planning? But I know I spaced my children. If I hadn't, I would probably have had fifteen. That would have been disastrous.
FARIDA BABALLE: I hope a lot of things that happen will change.
HALIMA BEN UMAR: The change is coming gradually. But I think we need to move a little faster than the rate we are moving. Islam moves with civilization.
FARIDA BABALLE: Yes, this is what I think.
VOICEOVER: Kano is one of the twelve northern states in Nigeria governed by Islamic law, or Sharia. Daily life in this ancient city revolves around Islamic culture. Improving reproductive health requires a delicate interplay between Islam and modern medicine.
SIGN: Allah is the greatest
HALIMA BEN UMAR: In this part of the country, you need to work with the religious leaders. If you want to achieve your objectives, your aims, then you need to look at, what does Islam say? How do you do it so that it becomes more acceptable? For me, I have always been an advocate of family planning. People see it as a western idea; people see it as the west trying to impose their ideas on us, so it becomes a little bit difficult.
SAKINA MAKA: Assalamu Alaykum
FARIDA BABALLE: Wa Alaykum Assalam. How is your day?
SAKINA MAKA: I'm well, and how is your day?
TITLE: Sakina and twin daughter, four months after delivery
FARIDA BABALLE: So, what we do here is family planning birth control. Do you know what that means?
SAKINA MAKA: It's like having control between deliveries. For example, two and a half years before having another baby.
FARIDA BABALLE: Within those two years, your husband will save up some money. You see? If you have a baby and then, in a year, another and another every year, he wouldn't save any money, and then you're not in good health and the baby will not be healthy. That's why we use family planning.
FARIDA BABALLE: Now there's a lot of awareness of family planning for our people. Our women are coming on their own. They don't wait for their husbands. They decide on their own health, instead of waiting for their husbands to decide on their health.
KABIRU IBRAHIM: Aisha stayed in the hospital for sixteen days until she regained her health. Then she was discharged and we went back home. That's what happened.
VOICEOVER: Kabiru's first wife died giving birth to their seventh child, and he has never used birth control until now. He attributes this behavior change to a deeper understanding of safe motherhood in the Islamic community.
KABIRU IBRAHIM: Before this delivery I didn't agree with the idea of a woman taking a break, because rest comes from Allah. If Allah does not grant a break, you will surely give birth. The Muslim religion allows that she take a break to save her life, because she might lose her life in the process. That is why I agreed.
AISHA IBRAHIM: Trial birth causes all sorts of mishaps and problems. It brings all kinds of thoughts to mind, like either you retain your life or you lose it.
PROFESSOR OLADOSU A. OJENGBEDE: You can say, women's rights should be well protected, but the truth is, for now, we have not put in place all the structures that protect women's rights completely in developing countries. And that's what we must put into context when we're fashioning out programs and projects that would serve women. We need to find the appropriate way and culturally acceptable way of circumventing the obstructions. That challenges are enormous, and sometimes they're depressing. The frustrations are everywhere, but the resolve is stronger than the frustrations.
TITLE: Murtala Mohammed Specialist Hospital
DR. BELLO DIKKO: Welcome to Habibu Sadouki Blood Transfusion Center, Murtala Mohammed Specialist Hospital. What you have is a blood bank fridge, which has the capacity of keeping about 300 units of blood. It will be tested, filtered, stored, and the ones that will be needed in the maternity will immediately go to maternity.
MAN: My message to you all is: please help keep our women alive.
VOICEOVER: Frustrated by the lack of blood supply for maternity patients, Dr. Dikko successfully lobbied health officials for a separate maternity blood bank. Since opening in February 2009, waiting times for maternity ward patients in need of blood has been reduced by 75 percent.
DR. BELLO DIKKO: If you go inside the blood bank now, the two fridges that you saw the other time are almost packed full.
FARIDA BABALLE: A lot has changed. It reduces the delay in having the blood. The midwives draw the blood, they send the blood, and then it quickly saves the lives of the patients. You can see the results in our reduction of maternal mortality. There are very few deaths now. It's very low.
VOICEOVER: The maternity blood bank began collecting blood donations one week after Sakina gave birth to her twins.
DR. BELLO DIKKO: Each and every one of us, whether a man or a woman, came out of a woman. As long as there is one maternal death, it's a family mortality. Not an ordinary mortality. If you can reduce maternal mortality in Kano State, then definitely the denominator in the issue of maternal mortality in the whole country will definitely reduce. And if it reduces, then it will be my greatest achievement, and I can even resign and go home.
TITLE: Dr. Bellow Dikko is part of a landmark effort to train religious leaders about reproductive health. He advocates for the right of pregnant women to travel without male escorts, and free maternity services. Farida Baballe's observational study showed maternal deaths have been nearly cut in half, from 196 in 2008 to 102 in 2009. Professor Ojengbede and international colleagues, led by Professor Suellen Miller at UC San Francisco, have tested the anti-shock garment on more than 3,000 women in Nigeria, Egypt, and Mexico. They found that women who received the anti-shock garment lost 50 percent less blood and have 64 percent fewer deaths. Pathfinder International, a non-profit organization, has trained more than 4,000 Nigerian health care providers to prevent, treat, and diagnose post-partum hemorrhage. Pathfinder has distributed 456 anti-shock garments and is collaborating with federal and state governments to scale up the project. While documenting these stories, the filmmakers worked in unison with families and healthcare workers to accurately portray pregnancy and childbirth. Several times we affected outcomes by contributing resources for transportation, cell phones, and pharmaceuticals. In the case of Sakina Maka, her husband Mohammed, an Arabic teacher, was unable to procure funding for blood after hours of searching. We gave Mohammed the 10,000 Naira needed to buy the blood.
VOICEOVER: What do you want to be when you grow up?
GIRL 1: I want to be a doctor.
GIRL 2: I want to be a doctor.
GIRL 3: A nurse.
TITLE: Brown Doggy Pictures, in association with Woodlawn Avenue Productions: The Edge of Joy. Director and Producer: Dawn Sinclair Shapiro. Narrator: Eliza Griswold. Executive Producer: Tod Lending. Editors: Michael S. O'Brien, Melissa Sterne. Director of Photography: Nicola B. Marsh.
TITLE: [End credits]

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