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SOCIO-ECONOMIC AND CULTURAL
ROOTS OF REPRODUCTIVE
HEALTH CARE PROBLEMS IN NORTH –
WESTERN NIGERIA.
by
Sulaiman khalid, ph.d
department of sociology,
Usmanu danfodiyo university,
SOKOTO – NIGERIa.
e-mail: sulkhalid@yahoo.co.uk
EXECUTIVE SUMMARY
This study is undertaken on the premise that
consultation on the views, perception, constraints and attitude of people
towards reproductive health issues is very important. The research seeks
to provide supplementary information that may support the findings
generated by the quantitative data.
The study, using participatory and qualitative tools (FGD/IDI),
was carried out in eight communities, reflecting the three Senatorial
geo-political division, age, gender and rural/urban dichotomy of Kebbi
State. Birnin-Kebbi, Argungu, Jega and Zuru Local Government Areas (LGAs)
were selected in a way to reflect as much as possible the geographical,
ethnic, linguistic and religious variety of the state. Two sites each were
purposively selected in each of the four LGAS making sure that there is
one rural and one urban site. In all there were eight sites. In each site,
FGDS were held separately for male and female, taking into cognizance the
age group categorization i.e. 12-24 or 25 and above. In depth interviews
were conducted with two community/opinion leaders and two health
personnels.
The study has revealed that people were generally
dissatisfied with the availability and quality of health care facilities.
Maternal mortality and morbidity, arising from pregnancy and childbirth
were found to be very prevalent in all the communities studied. The
immediate underlying factor is the non-availability or poor access to and
utilization of modern maternal health care services. Economic and cultural
factors also play very crucial role in deepening the reproductive health
crisis in the state. Incidence of unwanted pregnancies by both teenage
girls and married women were widely reported. Women have lower social
status in relation to men. Age at marriage in Kebbi State is one of the
lowest in the country: 12-16 for girls and 17-20 for boys in rural areas.
In urban areas girls got married at the age of 14-18 while marriage age
for boy was given as 20-26.
There is a high awareness of the prevalence of HIV/AIDS
and it seems to be on the increase. People living with the virus receive
little sympathy, little support from the community.
The civil society organizations were found
to be remarkably proactive in filling the resource gap created by the
failure of the State to provide health care services for their respective
communities. There is need to harness their energy and resourcefulness in
RH/FP programming.
There is also the urgent need for increased public and
private sector investment in the provision of health care services in
rural areas.
Concerted efforts should be made to fight
poverty with the view to increasing people’s financial capacity to access
the RH/FP services.
In view of the cultural and religious
sensitivity of the RH/FP program in the area, there is no alternative to
engaging the community leaders, ulema and faith-based organizations
in planning and implementation of reproductive health programs in the
State.
1.0
INTRODUCTION
The past two decades have witnessed a considerable improvement in
reproductive health in the world. However, this progress has been uneven
in different regions, countries and even within countries. Nigeria, for
example, with a maternal mortality ratio (MMR) of 704 per 100,000 live
births, still has an extremely high maternal mortality ratio, one of the
main indicators of the state of the reproductive health. The MMR in
Nigeria is about 100 times worse than in the industrialized countries.
Reproductive health situation in Nigeria however, varies with regions.
The MMR in the North East Zone of 1,599/100,000 live birth is almost 10
times higher than the rate of 165/100,000 found in the South West Zone,
more than twice the national average. With a rate of 1,025/100,000 live
birth, the North West Zone MMR is almost four times the rate in the South
East Zone. Of the estimated, 200,000 – 400,000 VVF cases in the country,
it is estimated that 70% are from the North (NDHS, 1999).
Non utilization of antenatal care services was found to be 65% in the
North West Zone, 13 times higher than the figure of 4% documented in the
South West Zone. Trained birth attendants in North West supervised only
8% of deliveries. Even lower figures were found in local studies in
villages around Sokoto where only 2.3% of the deliveries were attended to
in the home by unskilled Traditional Birth Attendants (TBA) or friends and
relative. Women of childbearing age in the Sokoto state have a 1 in 17
lifetime risk of dying during pregnancy or childbirth, and 60% of the
maternal deaths occur at home, 7% on the way to the health facility (Shehu,
1999).
The mean age of first marriage from the NDHS is 14.6 years compared to
19.1 years in South West. A local survey indicated that 33.5% of the
female population in Sokoto state have been married before 15 years with
some 12.8% having had a least one pregnancy before that age (Shehu,
1999). Against this background, the contraceptive prevalence rate in the
North of 3.2% is 8½ time lower than the rate of 25.2% seen in the South
West zone (NDHS, 2001).
While generally, the sero prevalence rate of HIV/AIDS infection in Nigeria
appears to be lowest among the Muslim North, cross-border informal
economic activities, underground and cross-border sex work in shari’ah
implementing states, the high risk activities of long distance commercial
drivers, within a context of fatalism and ignorance, polygamy, in a
context of frequent divorces and re-marriage, thus creating a large circle
of sexual partners, can lead to an explosion of infection rates in the
Muslim area.
THE PROBLEMATIQUE
This research was carried out on the assumption that several
factors are accountable for the distressing reproductive health indices in
the study area. They include:
(a)
Health care system factors like poor distribution of facilities,
lack of essential equipment and supplies, inadequate skilled personnel,
etc.
(b)
Social and cultural factors such as religious beliefs and
practices, gender relations in terms of decision-making and economic
dependence of women within family.
CONTEXT OF THE STUDY
Created in 1991 Kebbi State is located between
latitude100 8’N and 130 15’N and latitude 30
30’E and 60 02’E. It is bounded by Sokoto State to the north
and east, Niger state to the south, and Republics of Niger and Benin to
the west. It has a total land area of 36,129 square klms. According to the
1991 population census it has 2.06 million people and growing at 3.0% per
annum. The rural population, which accounts for 78% of the states total,
live in small and highly dispersed settlements. Their main occupation is
in primary production-subsistence farming, animal pasturing, some trading
and public service. Despite continued efforts, the educational standards
of the state are well below the national average. The percentage of female
in school is one of the lowest in the country, reflecting limited
educational opportunities for girls until very recently.
Traditional and cultural values place a high premium on
early marriage, and wife seclusion (kulle) or purdah is widely
practiced. Numerically, the Hausa speaking people dominate the state.
However, far greater linguistic and ethnic groups are to be found in the
state. They include the Fulani, Zabarmawa, Kambari, Dakarkari etc. Hausa
is however the language spoken by every person in the state. Islam is the
dominant religion in the study area particularly among the Hausa, Fulani,
Zabarmawa. Christianity is practiced mostly among the smaller ethnic
groups like Dakarkari and Kambari. There are also pockets of practitioners
of traditional religion in the southeastern part of the state.
The states characteristics and problems very much
typify the major problems and challenges in the Northwest geo-political
zone. The condition of roads, the status of health services and manpower,
the strongly held traditional beliefs and customs and other variables
impact negatively on the reproductive health situation in the state.
Traditional authority is still very prominent in all the communities
covered by the research. The existing authority structure is centralized
with a hierarchical ordering. The talakawa are the people in
general who live in the communities, which may be divided into wards (unguwanni).
The latter are headed by masu-unguwa who reports to the village
head or dagaci. The uban kasa or District Head has a number
of villages under him and the hakimai report to him. He, in turn,
reports to the Emir, the final traditional authority.
This centralized political form is powerful in the
communities and dynamic force for change. As such any innovation or change
of custom and accepted ways of handling such life forms involving
reproductive health must necessarily go through the traditional leaders.
Along with religious leaders, they cannot be bypassed. What is even more
critical in the context of Kebbi State is that there are no traditional
authority structure or public officers for women equivalent to those of
the men. Issues concerning women are therefore handled by men and using
the traditional authority structure, as the initial contact is the most
appropriate if not the only option.
RESEARCH QUESTIONS
This research was guided by the following key
questions:-
i. What obstetric problems if any, exist in
various communities in the state?
ii How have the people been coping with the
problem?
iii. What health facilities are available in
these communities?
iv. How do members of these communities perceive
the quality of care provided at available service delivery points?
v. Are they satisfied with service rendered in
these health facilities?
vi. How do people in these communities perceived
the position of women in the society?
vii. Are female and male children treated
equally?
viii. How do women and men of these communities
space their births?
ix. What is the attitude of the people towards
early marriage?
x. Are they aware of the negative implications
of early marriage?
xi. What is the attitude of the people towards
unwanted pregnancies?
xii. What is the attitude of the members of these
communities towards sexually transmitted infections?
xiii. What is the attitude of these communities
towards HIV/AIDS?
xiv.
What suggestions do the members of these communities have towards
developing strategies to help ameliorate identified reproductive health
problems?
METHODOLOGY AND PROCESS
The study relied heavily on the open-ended tradition of
participatory and qualitative research tools, using specifically focus
group discussion (FGDs), in-depth interviews (IDI) and case studies. A
one-day training orientation workshop facilitated by the Principal
Investigator and FGD/IDI consultant was organized on February 9, 2004, for
the four -member team of research assistants on the research methodology
and tools as well as key principles of participatory research using FGD
and IDI. A study guide to explore themes of the research, especially the
cultural sensitivity of reproductive health issues, was also discussed at
the orientation with the view to conceptualizing it to the socio-economic
and cultural realities of Kebbi State. A short trial was undertaken as
part of the workshop. The fieldwork was conducted between 10th
and 28th February 2004. The research assistants consisted of
two males and two females.
Sampling Design and Selection
The fieldwork was undertaken by dividing the state into
3 zones, reflecting three senatorial districts of the State. One Local
Government Area each was selected in the north and south senatorial
districts. In central senatorial district, which is the largest in terms
of population and landmass, two LGAs were selected. This gave us four
sites from the three senatorial districts. The four sites, namely
Birnin-Kebbi, Argungu, Jega and Zuru LGA’s were selected in a way to
reflect as much as possible the geographical, ethnic, linguistic and
religious variety of Kebbi State. Two sites each were purposively selected
in each of the four sites making sure that there are one rural and one
urban sites. In all there were eight sites as follows: Urban sites consist
of Birnin Kebbi; Jega; Argungu and Zuru; rural sites consist of Dumbegu,
Zauro, Gulma and Senchi. In each site two FGDs were held separately for
males and females, taking into cognizance the age group categorization,
i.e. 12-24 or 25 and above.
The participatory nature of the research explicitly
encouraged study teams to explore key issues that emerged by culture,
religion, social group, gender, age and other dimensions of difference of
local importance such as rural/urban divide. The study focused on the men,
women, male and female youth. Different case studies (in-depth
discussions/interviews) were conducted with two health personnel (one male
and one female) community/opinion leaders (one male and one female) in the
four study sites.
Quality Assurance Method
FGD sessions took place simultaneously for both male
and female participants. The male session typically took place under the
tree or in the door entrance of village head or community leader’s house.
All female sessions were conducted inside the house and were conducted by
two female members of the research team. One of them served as the
moderator while the other performed the task of note-taker, observer and
back stopper. The male members of the team attended to the male sessions.
They divided their role into (1) Moderator (2) Note-taker and (3) observer
or manager. All the four in-depth interviews (IDI) were conducted by the
consultant.
Before the commencement of each FGD session, the
objective of the researchers’ visit was explained to the participants,
i.e. to generate information on the health needs of the people in the
community especially reproductive health and HIV/AIDS issues. Permission
was sought from the participants for the use of tape-recorders and each
participant was encouraged to speak frankly and confidently.
All the FGD sessions were conducted in Hausa
language. At the end of each day’s activities, tapes were replayed and the
important points were transcribed, reproduced verbatim and translated into
English. Three of the IDI respondents spoke in English, while one
preferred to speak in Hausa language.
A total of 16 Focus Group Discussion sessions were
conducted in the four LGAs. This is made up of 74 males and 70 females.
URBAN SITES
All the 4 urban sites have a population of not less
than 50,000 and above (Kebbi 1999). They also seem to have access to vital
social infrastructure such as electricity, pipe born water supply,
educational institutions, tertiary health care facility (public and
private), access to postal services and township roads. The supply of
water and electricity as well as other services are generally irregular
and epileptic, though.
The most prominent occupation among men across the
urban sites is agriculture, involving animal husbandry and farming in most
communities, fishing in Argungu and hunting in Zuru. Artisanship,
government employment and labour supply on farms featured as the prominent
occupation of men. Most women are full time housewives. They engage in
food processing, petty trading through intermediary children and few civil
servants.
Each urban site has a mixture of many social groups
co-inhabiting on them. For example the same urban community may have
Hausa, Ibos and Yoruba’s but only one ethnic group the Hausa’s/Fulani/Dakarkari,
is aboriginal while others are migrants. Islam is the dominant religion in
three of LGAs, while it shares equal numerical strength in the fourth LGA,
i.e. Zuru.
RURAL SITES
The rural sites are typical rustic villages or towns
with a population of about 5,000 or less. In all the rural areas basic
infrastructures are of the ordinary type. Health care facilities, mainly
dispensaries may be understaffed, non-functional, functioning
inefficiently or reach only a very small proportion of the local people.
All the rural sites are supplied with electricity, which is not regular.
None of the rural sites have pipe-borne water.
The major occupation is agriculture, involving farming,
animal husbandry, hunting and fishing. Other minor occupations are
hunting, artisanship, petty trading, civil service, working as hired
labourers, hair dressing, crafts, tree felling and selling of firewood and
food processing. The level of unemployment seems to be very high among the
male youth.
The rural areas appear to be homogenous in their
ethnic/linguistic, cultural and religious composition. They are mainly
Hausa-Fulani and Muslims.
PROBLEMS ENCOUNTERED
In any large-scale research of this nature problems are
bound to occur especially during field work. The initial problems
encountered have to do with the composition of the FGD/IDI team, which did
not take the cultural peculiarities of Kebbi State and indeed the Muslims
North into consideration. It was centrally decided that a three-person
team should conduct the FGD/IDI under the supervision of the consultant.
However, in view of the socio-cultural realities of the study area, which
requires gender segregation, it becomes necessary to form two separate
teams to conduct the research according the gender divide. Thus we found
it necessary to recruit four assistants made up of two males and two
females. This was because, according to the cultural and religious
setting, women cannot lead an all -male group discussion, nor can men
appear in an exclusively female discussion forum. Research fatigue was
another problem clearly brought out by most groups, especially the male,
who appeared to have spent time and effort in the past answering questions
and filling, questionnaires without any tangible benefit accruing to them.
People complained that many groups came before but there was poor follow
up and no feedback. This has however not affected the conduct of the FGDs
since the complaints are made only offer the discussions are over.
FINDINGS
OBSTETRIC CARE
Maternal mortality and
morbidity arising from pregnancy and childbirth are very common in Kebbi
state. Some of the direct causes of maternal death identified by different
FGD, groups include: hemorrhage, sepsis, pre-eclemsia and anaemia. Causes
of the pregnancy-related problems were given as lack of physical or
financial access to the health care facility, girl-child marriage, and
high cost of drugs and so on. Long and obstructed labour the communities
realized has been responsible for both maternal death and maternal
morbidity such as vesico-vaginal fistulae. Some of the responses are given
below:-
“The common saying in this
area is that when a woman is pregnant, she has her one leg in heaven and
the other in this world. Anything could happen. Many have died, and they
are still dying from pregnancy related complications. This problem is
complicated by general ignorance of the local communities, early marriage
for girls and lack of visits to hospital by pregnant women”.
(IDI, female Health
personnel, Birnin-Kebbi, urban)
Availability and Quality
of RH Care
Availability of reproductive
health care facilities varies according to rural/urban divide of the
society. The urban communities in the FGDs reported that they have
adequate facilities, public and private, which provide reproductive health
services. There were however complaints about the cost of the services.
There are enough
health care facilities where pregnant
women receive care.
There are also private clinics where
women could deliver.
Most of these hospitals are
within the trekking
distance from our homes. But some
women in other parts
of the town have to take public
transport to reach the
facilities. Federal Medical Centre
(Birnin Kebbi) for
example, is located at the outskirt of the
town. So you need some
means of transportation to go there’’
(FGD male,12-24,Birnin
Kebbi,urban)
We have both public and
private hospitals in this town. The
distance is not far
away from our residences. The cost
of the services is
however high these days, particularly
at the private
clinics. One has to pay for everything, from
hospital record
cards to drugs, bed-space if admitted
and so on.
(FGD,male 12-24,Zuru urban)
The
rural communities on the other hand reported virtual absence of
reproductive health services in their immediate surrounding environment.
Their women have to travel to the nearest major towns for antenatal,
delivery, and post-natal services.
“We have only one health
personnel (community health assistant) manning our dispensary. He is very
hard working. He goes round the surrounding villages to attend to
patients. Our pregnant women have to take commercial vehicles to Jega
General Hospital. Many husbands cannot afford the combined cost of the
transport services
(FGD, male 12-24, Dumbegu,
rural).
“We are taken to the
hospital only after we spent a long period, sometime 2 to 3 days. Many
died on their way to hospital. The problem of obstructed labour is more
common among under-age married girls in labour. Others suffer from
Yankan-gishiri (VVF) and they get divorced by their husbands”
(FGD, Female 25+, Gulma,
Rural)
Senchi is the only rural
community that stands out in terms of both availability and quality of
services provided by their facility.
“We have a community
clinic. We have abandoned the public dispensary. The clinic is headed by a
respected consultant physician. He is assisted by an NYSC Doctor, nurses
and other medical personals. Our clinic has adequate equipments:
diagnostic laboratory, ultra-sound, x-ray machines and so on. Patients
from Zuru, other parts of Kebbi, Niger and even Kano state visit this
clinic due to the reputation of our Doctor. The services are generally
affordable. Our women received their ANC services and they deliver in the
facility”.
(FGD, Male 25+ Senchi,
Rural)
Attitude of Health
Personnel
Dissatisfaction with the
attitude of health care providers towards their patients was widely
reported.
“The attitude of health
workers in our hospitals is generally hostile, unsympathetic, uncaring.
Patients and their relatives are often humiliated by the health workers”
(FGD male 25+, Argungu
urban)
The private clinic workers
are friendlier, more humane, but many of their staff is less qualified
than their counter parts in the public hospitals.
(FGD Male 12-24, Zuru, Urban)
Drugs
Drugs have literally
disappeared from the existing hospitals, and where they are available, the
cost is hardly affordable to the average person in the society.
Communities recalled, with nostalgia, the 1970’s and PTF days (in 1990s)
when health cares services were readily available in both quality and
quantity.
During the days of PTF
drugs used to be available in our hospitals. They disappeared with the
winding up of the organization.
(FGD male 25+ Jega urban)
The distance between people’s
perception of their health care problems and their solutions vis-à-vis
government programs was brought also to light by the participants. They
could not understand why government should spend so much resources and
energy fighting polio, while deadly diseases such as malaria, measles and
cerebral meningitis which kill their children instalmentally, are not
given the desired attention.
Drugs are available in the
hospitals for those who have money….some times it is supplied free for
children, not for pregnant women.
(FGD male 12-24 Zuru urban)
Government should go back
to its role of supporting the sick persons in the society. If the
government can provide free polio vaccine to children, I see no reason why
it cannot provide free malaria drugs to them
(FGD male 25+ Jega urban)
Gender Power Relation
The disadvantaged position of
female gender in the study area was brought to light. It is the men, not
women, who make decision and manipulate the public sphere. Female members
of the society are relegated to a subordinate position. That partly
explains the general preference for male children over female.
“Male children are
generally preferred to female children largely because of the fact that
the male child perpetuates the name of the family and takes care of the
entire household in future. The girls on the other hand, marry as soon as
they reach the age of puberty and move to another family afterwards. It is
not that people don’t like girl child. They are loved and properly catered
for. In fact people tend to spend more or girls than both if you consider
the expenses incurred during their wedding festivities”
(FGD Male 25+ Zauro, Rural)
“Children are gift from
God. Which ever is given to me male or female, I will thank God. I do not
know which of them will be more beneficial to me in future”
(FGD female, 12-24 Senchi,
rural).
“In matters of
decision-making at the level of family, the father generally consults his
male children. The female children and their mother’s are only notified of
the decisions. This is true even in matters relating to choice of spouse
for girls…Of course, girls are allowed to bring their future husband of
their choice, but it is the male relatives who approves or disapprove”
(FGD male, 12-24, Birnin
Kebbi, urban).
“In a certain family a
child took ill. The mother wanted to take the child to the hospital but
the father, apparently too poor to pay the medication bill, refused. He
said that if she should leave the house with his child, it will be the end
of her marriage. After the husband left the child’s sickness worsen and it
begins to convulse. The wife defied her husband and rushed the child to
the hospital. On reaching the hospital the child was confirmed dead. When
the mother returned home, her husband divorced her. She lost both the
husband and the child.
(FGD Female 25+, Gulma
rural)
Early Marriage
The medical implication of
girl-child marriage was widely recognized.
For those girls who have
not been to (western type) school, the age at marriage is twelve. By
thirteen they become pregnant, without breast, they cannot deliver. They
have to be brought to the hospital for assisted delivery.
(IDI, Female Health
personnel, Argungu urban)
The most important role of
the women in the society was seen to be at home, caring for the children
and cooking for the family. Anything else she achieves is secondary. For
this reason, her education is relegated to the background.
Most parents enrol their
daughter into secondary school on a “temporary” basis. She is withdrawn
and married up as soon as she gets a suitor.
(FGD, male 12-24, Dumbegu
rural)
“Ideally, a girl should
experience her first menstruation in her matrimonial house and should be
married before her sexual potential is fully developed”.
(FGD female 12-24 Jega urban)
Unwanted Pregnancies
The participants in both the
FGD and IDI sessions made a conceptual distinction between two types of
unwanted pregnancies: (a) unwanted pregnancy within the marital union and
(b) unwanted pregnancy outside wedlock. When a married woman conceive
within the period (2 years) she is breast-feeding another child, it is
referred to as rurrutsa.This type of pregnancy, the people believe,
pose direct heath hazard to the breast feeding child, and would not allow
the women to rest: people also point to financial cost on the part of the
husband who has to constantly pick the medical bill of the breast-feeding
child. On the other hand, pregnancy outside wedlock is referred to as
cikin shege (lit. bastard pregnancy) and the child, if delivered, is
labelled shege (bastard). Cikin shege is widely disapproved,
and the product (shege) remained stigmatized for life. Cikin
shege brings shame and dishonor to the family.
Unwanted pregnancy (rurrutsa) among married young women
is very common and a source of concern to may young women. Many attempt to
physically abort it, using both traditional and orthodox medical
facilities. It is a major reason why women visit clinics to received
contraceptive devices so that they could space their children.
(FGD female, 12-24 Zauro
rural)
Unwanted pregnancy outside
wedlock (cikin shege) brings shame and disgrace to the entire family. The
affected women usually take step to terminate it in the private clinics.
Public hospitals are not permitted by law, to abort pregnancies.
(IDI male Health Personnel,
Jega urban)
As far as I am concerned,
if any daughter should conceive outside wedlock I will do everything I
could to terminate the pregnancy. It is a big shame for me and my
off-spring. It will damage my name and family reputation. I will never
allow her to deliver the child alive. I have a duty to save my name and
the reputation of the family.
(FGD female 25+, Zuru urban)
Family Planning
Inspite of the cultural
resistance to family planning programs in the state, it is generally
tolerated if practiced within the marital life. The society seems to look
the other way when a woman adopts contraceptive methods with the views to
spacing her children. It is however widely disapproved when practiced
outside family life.
A certain mother met me
with some drugs her teenage daughter has been taking. They were pills. I
advised her not to stop her from taking it, otherwise she will become
pregnant……….
(FGD female 12-24, Argungu
urban)
If you visit a patent
medicine store you’ll be taken aback when you see the number of teenage
girls buying condoms………
(FGD female 12-24 Argungu
urban)
Family planning issues in
our community are shrouded in secrecy. Nobody wants to discuss it openly.
But I believe women in our community receive the services and their
husbands do not seem to oppose it. Some husbands actually accompany their
wives to secure it at the clinics.
(IDI male Community leader
Zuru urban)
“There is a lot of
hypocrisy on the part of our men with regard to child spacing and family
planning. They openly condemn it, but they send their wives to us for
family planning services. They allow their wives to take pills. They even
buy it for them. Some even recommend IUD for their wives. However, very
few of them accompany their wives to us”.
(IDI, female health
personnel, Birnin-Kebbi, urban)
“Men generally do not like
their spouses to conceive within the first two years after child-birth.
They often insist on abortion, but we discourage them. We will rather ask
them to have the child and after wards the wife could start taking pills,
injectables, IUD and so on”
(IDI female health personnel, Argungu, urban).
STIS/HIV/AIDS.
People are sufficiently informed about the prevalence
and ravaging impact of the dreaded disease. This was the impression given
in both the rural and urban sites of the study area. However, even though
people are slightly aware of other sources of HIV viral infection such as
blood transfusion, use of unsterilized syringes, barbing clippers and so
on, it is still widely associated with indiscriminate, illicit sexual
behaviour. This largely explains people’s negative attitude towards PLWAS.
Yes, we heard about it
(HIV/AIDS). It is no longer a here say. Every one here knows about it. The
disease is real and some people in this community are living with it and
some deaths were attributed to it.
(FGD male 12-24, Zuru urban
)
“Yes, it is true that the
HIV virus could be transmitted through the use of unsterilised syringes,
barbing clippers, infected blood and so on. But most victims we saw are
persons known to have engaged in circle”
(FGD, male 25+ Jega urban)
No matter the source of
infection people assume that HIV/AIDS is as a result of illicit sexual
bahaviour. The victims suffer serious discrimination even by health and
medical workers. Nobody wants to come close to him. Friends and even
relations desert him. He gets no sympathy, no support. His wife(ves) and
even children are avoided
(FGD,male
12-24 Birnin Kebbi urban).
If one is afflicted with the disease
he receives no symphathy.
Infact, if one should die from the
disease,it may become
difficult to get people to
participate in his burial ritual.Only
very close persons (i.e.relatives)
attend to his burial.
(FGD,female,Gulma rural)
Prevention Measures
Virtually every community has
evolved some measures to check the spread of the HIV/AIDS in their
environment.
We heard that, enlightened
men who intend to marry take their would-be spouses to hospitals for
(HIV/AIDS) screening’.
(FGD,female,Gulma,rural)
Nowadays, intending
couples voluntarily and secretly submit themselves for blood screening in
the hospitals in order to know their HIV status. Some seek for information
about their would-be spouses from the hospitals records.
(FGD
male 12-24 Zuru urban)
ANALYSIS OF RESULTS
OBSTETRIC CARE
The focus group discussions and in-depth interviews
have indicated that maternal deaths, arising from pregnancy and child
birth, are very common in Kebbi State. For each maternal death, 10 to 15
other women develop various morbidities (Shehu, 1999). Medical causes of
maternal deaths and other pregnancy-related complications are similar to
the ones in other parts of the country. The most common direct obstetric
causes of death in the study area include hemorrhage, sepsis, pre-eclamsia
and anaemia. Prolonged and obstructed labour was however found to be the
main identified complication of pregnancy which leads to mortality and
morbidity. Vesico-vaginal fistulae (VVF) was one of the most common cases
of morbidities easily identified by people. Victims of VVF are usually
young, poor, illiterate girls having their first babies, who develop
obstructed labour because their pelvises are not biologically matured to
allow for the passage of the babies head. In the absence of appropriate
obstetric interventions they develop this complication. However, while VVF
can be found in all parts of the state, rural areas of the state reported
the highest prevalence, with a large backlog of cases (Khalid and Zango
1996). Interestingly, people realized that ‘child-mothers’ aged 12-16
constituted the high-risk group of maternal mortality and morbidity.
Several factors have been found to account for the high
morbidity in women. These include social, cultural, economic,
accessibility and health facility associated problems. The immediate
underlying factor is the non-availability or poor access to and
utilization of modern maternal health services. Availability and
accessibility to both public and private health care service are surely
limited especially for women in the rural, areas. In addition to
availability of health personnel is also a problem. For example, in
Dumbegu, Jega Local Government and Zauro, Birnin Kebbi Local Government,
there are male nurse and a male community health assistant manning their
respective dispensaries, which do not provide antenatal and delivery
services.
Most of the deliveries are conducted at home under the
supervision of untrained traditional birth attendants or friends and
relatives. Women in labour are taken to hospital only when it is late and
when condition is hopeless.
Another underlying cause of high maternal mortality in
Kebbi State is risky reproductive health practices: pregnancies too early,
too many and too late. Socio-cultural factors play a determining role in
the promotion of these practices. Women in these areas are valued in terms
of their reproductive functions. Because of the low values placed on
female education and the fear of initiation of sexual activity before
marriage with its attendant risk of pregnancy, girls are married off soon
after the onset of puberty.
GENDER POWER RELATIONS
Today, gender consideration has become important in any
move towards development. Referring to the differences between sexes in
social terms gender is essentially a consideration of what society expects
from men and women. In our study area, such expectations are very clear.
Men are the leaders, the bread winners and authority structure within the
family, community and society is vested in them and hence more attention
is given to them making them better equipped for their future roles. Both
the male and female groups in our FGDs admitted that women occupy a rather
low status in the society, hence the preference for male child in the
family. The rather low status of women serves to reduce their decision
making capabilities in matters affecting their health. In the absence of
husband and other male relatives, she can hardly decide to seek care
outside the community especially from health facility in case of
complication.
The impression one gets from the FGD/IDI was that it is
the men, not women, who monopolize decision-making both at the community
and family levels. The ideal women and wife is viewed as submissive,
obedient and contented to enjoy reflected status from her husband. The
sole role of the women is perceived generally to be in the home caring for
the young and cooking for the family. Marriage and childbearing remain,
therefore, the central most important role of women.
In particular, the low status of women and their
limited education hinder their ability to make decisions about
reproductive health matters. For most women in Kebbi State, the problems
begin from the fact that they are not involved in the choice of marriage
partners as they are married off in their early and mid teens. Once
married, the girl-wife is confined within the four walls of the harem.
Consequently, due largely to the restriction imposed by male household
heads via the institution purdah or kulle (wife seclusion), few
pregnant women attend ante-natal clinic, while child birth taken place in
the home and some 97% of these deliveries were attended to by unskilled
traditional birth attendants (TBAs) or friends and relatives. Only 2.3% of
the deliveries were conducted at health facility (Shehu, 1999). Using the
sisterhood method of estimating maternal deaths from six villages, the PMM
research team found that women in the childbearing age group in the area
have a 1 in 17 lifetime risk of dying during pregnancy or childbirth.
Thus, 60% of the maternal deaths occur at home 7% on the way to the health
institution (Shehu, 1999).
Even in case of complications women cannot decide to
seek care from health facility in the absence of her husband and other
male relatives. As such women with prolonged and obstructed labour are
conveyed to the hospital only when the situation is hopeless and when it
is too late. Such restrictions on women’s access to formal health services
tend to prevent problems being detected in time, contributing to the high
rates of maternal mortality and morbidity.
EARLY MARRIAGE
The research revealed that age at marriage differs in
terms of gender and rural/urban divide of the society. For girls in the
rural areas, marriage age was given as 12-16 years, while that of boys was
between 17 and 20 years. In the urban areas girls got married at the age
of 14-18 years, while marriage age for boys was given as 20 to 25 years.
The general explanation given for variations in the age
at marriage for boys and girls was that girls mature into puberty much
early and it is “not safe” to keep her unmarried if she has a suitor.
Underlying this attitude is the fear of possible conception outside
wedlock. Unwanted pregnancies are considered to be the result of parental
irresponsibility. Thus, the implication for a family of such development
can be adverse. It will certainly loss its honour and respect in the eyes
of the community, for a family is accorded honour on the basis of its
ability to control, manage and bring up its members according to the norms
and standards of the community. There are many reasons why girls are
married early. One reason occurs when a society define girls and women
solely as wives and mothers. In this social setting it may be that getting
married and having children is the only means for young girls to secure
identity and status in families as adults in society. Also, in many
cultures around the world a woman’s sexuality is out of her control and is
in the hands of male relatives. Because of this, the decision to marry and
to initiate sexual activity is often not a young woman’s but that f the
family members, whose honour is defined by whether or not she is chaste
before she marries. Again, poverty plays a role in early marriage. In
families that are very poor a daughter may be seen as an economic burden
that must be shed through marriage as early as possible.
There are many consequences of early marriage: early
marriage contributes to a series of negative consequences both for young
girls and the societies in which they live. Young married girls are at
greater risk of reproductive morbidity and mortality. The timing of early
marriage almost always disrupts girls education, reducing their
opportunities for future financial independence through work. Young women
are often married to men who are much older, and find themselves in new
homes with greater responsibilities, without much autonomy and
decision-making power, and unable to negotiate sexual experience within
marriage. Conditions are thus set for girls-child marriage with all its
attendant negative social consequences and health hazards.
Unwanted Pregnancy
Participants are also conversant with the health
implications of early marriage which include maternal death and other
forms of morbidity especially the dreaded vesico-vaginal fistulae (VVF).
An earlier survey conducted by Prevention of Maternal Mortality (PMM) in
Kebbi State has also revealed that 33.5% of the female population in the
state have been married before 15 years, with some 12.8% having had at
least one pregnancy before that age. (Khalid and Zango, 1996).
Early marriage presents its own peculiar problems as of
invariably leads to early sexual contact and subsequent pregnancy at a
time when the pelvic bone of the under-aged girls is not adequately
developed to permit the passage of a baby with relative ease. At birth,
this leads to prolonged and obstructed labour and, where medical attention
is not immediately sought, results in maternal death. In all the
communities visited, participants in the FGD pointed out that many young
women who survive the childbirth without necessary dying suffer physical
impairment that may lead to long-term medical problem such as VVF.
Incidences of unwanted pregnancies were widely
reported. It occurs both within and outside marital circle. Within the
marital circle, it is common among young, inexperienced female and always
a source of anxiety for both the wife and her husband. It occurs mainly
after the birth of the first child. In many cases, the initial response of
the couple is to terminate the pregnancy. When they turn up at the public
hospital, they are usually encouraged to have the child and then adopt
family planning methods afterward. Many women, in both urban and rural
areas, have their first experience of family planning out of fear of
unwanted pregnancies and the desire to space childbirths. In spite of the
cultural resistance arising from religious beliefs and the perception that
family planning is synonymous with population control, contraceptive use
is reluctantly accepted and generally tolerated by the society if it is
practiced within marital life with the view to spacing child birth.
Unwanted pregnancies outside wedlock were as also
widely reported. It generally occurs among the non-married adolescent
girls who do not know how to avoid pregnancy. Conception and childbirth
outside wedlock brings shame and disgrace to the family. It is considered
to be the result of parental irresponsibility. Thus, the implication for a
family of such development can be adverse. It will certainly lose its
honour and respect in the eyes of the community, for a family is accorded
honour on the basis of its ability to control, manage and bring up its
members according to the norms and standards of the community. The
negative attitude of the communities towards unwanted pregnancies is based
on the fact that Islam does not permit extramarital sexual activity
(adultery) for married Muslims or pre-marital sexual relationships
(fornication) for unmarried Muslims. Adultery and fornication are not only
serious sins but also - in Islamic law - serious crimes with severe
punishments. The punishment for fornication is one hundred lashes. Married
men and women found guilty of adultery are to be stone to death. In most
cases the initial response is to secretly abort the pregnancy as soon as
it is discovered by the family. This type of abortion takes place at the
private clinics since the public hospitals are not allowed, by law, to
terminate pregnancies. If however the family did not succeed in
terminating it, the baby is suffocated and thrown into dustbin or nearby
bush in order to save the name of the family. In very rare cases, the
child is saved and raised within the family but it’s true identity
concealed from members of the community. As for girl-child marriage, this
serves as a pointer to near total neglect of female education in the study
area. Participants at the FGD sessions maintained that boy-child education
is accorded higher priority because he will ultimately inherit the father
and perpetuate the name of the family, while the girl, no matter her level
of education, relocate to another family after her marriage thus rendering
investment in her education not worth while. Today, there are three times
more boys in primary school than boys in Kebbi State (Iliya and Kwabe,
2000). This gap get wider and wider as children move along the educational
ladder as fewer girls than boys reach secondary and tertiary institutions
of learning where they acquire meaningful skills for participation in
public life and at the same time serve to delay their marriage so as to be
biologically matured enough for pregnancy and child birth.
STD/HIV/AIDS
There is a general sense of awareness of the
prevalence, causes and consequences of HIV/AIDS and other sexually
transmitted diseases in both the urban and rural areas of our study sites.
Virtually every participant in the FGD/IDI sessions have seen or heard of
someone who is either living with full blown AIDS or has died of it.
The overwhelming awareness notwithstanding, there is a
general feeling of false safety especially among the rural communities.
This is dangerously demonstrated by the attitude of many people in the
state who see HIV/AIDS as “other” people’s problem. With one of the
highest rates of illiteracy in the country, Kebbi State harbours as much
potential as any part of the country for the epidemics. Socio-culturally,
certain practices in the area serve as good breeding grounds for the
epidemic infection. Polygamy, within the context of frequent divorces and
re-marriage among the Muslims, thus creating a large circle of sexual
partners, activities of long distance travellers, especially professional
drivers, seasonal labour migrants within a context of fatalism and
ignorance, can lead to an explosion of the disease.
People living with HIV/AIDS face discrimination and
stigma that are associated with the disease. The stigma surrounding
HIV/AIDS stems not only from the sero status of an individual, but also
from social responses to behaviours and lifestyles that are associated
with the disease. Stigma affects all aspects of life for people living
with HIV/AIDS including public and private relationship. Once an
individual is clinically diagnosed as HIV positive, literally everyone,
including family members, keep a safe distance from him. His wife (ves)
and even children are stigmatized and discriminated in the community.
Thus, despite public education efforts, the people’s
attitudes towards the disease reveal that there is a great deal of
misconceptions surrounding HIV transmission. The initial response to AIDS
as a sexually transmitted disease spread through illicit hetro-sexual and
bi-sexual behaviour has made people living with HIV/AIDS to face perpetual
biases and tend to receive less sympathy regardless of the method of its
transmission.
This, the stigma surrounding HIV/AIDS stems not only
from the sero status of an individual but also from social responses to
bahaviours and lifestyles that are associated with the disease. No wonder,
most participants emphasized that the best way to tackle the problem was
for people to abide by the teachings of Islam, which prohibited
fornication, adultery, sodomy and many other vices that aid the spread of
the disease.
Strategies Emerging From the
Communities
Civil society organizations in Zauro and Senchi have
been remarkably proactive in filling the resource gap created by the
failure of the state to provide efficient and reliable health care
services for their respective communities. The Senchi community has built
a clinic, which is, relative to the standard of public health care
facilities in the state, fully equipped in terms of personnels and
diagnostic equipments. The clinic, headed by a consultant physician
supported by an NYSC Doctor, Nurses, Midwives and other paramedical
personnels, is equipped with diagnostic equipments ranging from
ultra-sound, X-ray to HIV/AIDS screening machines. The clinic is the only
rural facility in Kebbi State that provides antenatal and delivery
services, the management of reproductive tract infections, in addition to
health promotion and disease prevention. The clinic is visited by
patients from all over Kebbi and neighbouring Niger States.
In Zauro, the village community built their clinic and
abandoned the dilapidated and ill-equipped public dispensary, which was
later converted into a POLICE POST.
The women had to travel to Birnin Kebbi for antenatal,
maternal and post-natal care. The community has also evolved a transport
alert mechanism in which the local road transport workers union (NURTW)
provide prompt ambulatory services to women in labour.
Faith-based civil society organizations in Zuru area
were found to be at the forefront of war against the scourge of HIV/AIDS.
In Senchi, a predominantly Christian community, Churches demand for
pregnancy and HIV/AIDS-free certificate, duly signed by the respected
physician in their community clinic before solemnizing marriages.
The Rikoto community in Zuru have also reported that,
nowadays, would-be couples subject themselves to HIV/AIDS screening before
formalizing their union as husbands and wives.
This innovation has served both the purpose of control
as well as awareness of the dreaded disease in their communities. The
Muslim segment of the community, as in the rest of the state, are yet to
institutionalize blood screening for intending couples with the view to
curbing the spread of HIV/AIDS and other sexually transmitted,
blood-related diseases among their community. This is surely one big way
of combating the menace of the marauding disease.
Cultural and Religious
Sensitivity
In our study area, individuals and organizations with
community links are particularly advantaged to address gender and
reproductive health issues in a culturally sensitive and integrated
manner. The problem is that most development agencies, international NGOs
and their local implementation partners failed to take time to understand
Muslim North and in many cases held false assumption about what would work
or not work. Nowhere in the UNFPA baseline research project were the
Muslim scholarly class and Islamic organizations targeted as object of
study with the view to engaging them in the course of project
implementation.
Debatably, the most powerful section of the society,
the ulema (Islamic scholars) and Islamic civil society
organizations maintain an intellectual vigilance and discipline at
grassroots and wield unlimited influence on the individuals, the
communities and the state. The in-built, male-held perception of gender
within our study area is legitimated and reinforced by the Muslim
scholarly class. Cultural resistance to reproductive health and child
survival programs in the area often take religious colour. Any program
not duly endorsed and sanctioned by them is doomed to failure. A case in
point is the on-going controversy over polio eradication program in the
Muslim areas of the North. The general line of argument could be summed
up as follows: Islam has pervaded every sphere of life that it remained
the decisive reference on all issues, gender and RH/FP issues inclusive.
Allah, the Creator, has given guidance in the Qur’an on matters of life,
procreation, child birth, marital and gender relationships. Prophet
Muhammad (SAW) gave elaborate guidelines on human sexuality. RH/FP
programs represents attempt by Zionists and Western imperialists to
promote promiscuity and curtail Muslim population.
Thus, social context operates directly to affect gender
and reproductive attitudes and decisions. This is to say, programming for
the study area must take into account the, complex cultural and religious
fabric of the society if it is to succeed.
Pathfinder International’s engagement with FOMWAN in
training of 144 Muslim Health Workers on integrated RH, PAC, STI and
HIV/AIDS prevention and syndromic management in Kaduna, Kano, Plateau and
Sokoto states is a good example of how respect for cultural and religious
sensitivity is to programs acceptance and success. Programmers, policy
makers, donor agencies, NGOs and International Development Organizations
should take note of this.
Conclusions and Recommendations
Conclusions
The outcome of the
qualitative study indicated a general awareness and even concern over
pregnancy related problems resulting in wide-spread maternal mortality and
morbidity. These problems were attributed to several factors. The
immediate and underlying factors were the non-availability or poor access
to and utilization of modern maternal health care services. Others were
identified as early marriage, poverty, religious and cultural practices.
Health care facilities and
reproductive health services are reasonably available in the three
senatorial districts of Kebbi state. However, access is limited by
location of facilities away from the majority of users, poor staffing and
deficient skills, inadequate equipment and consumables, unaffordable costs
and weak linkages. Availability and accessibility to both public and
private health care services is much less in the rural areas. In addition,
physical distance to the facility, long waiting period and negative, often
hostile, attitude of health care providers have combined to keep the
patients away from the facility.
Women occupy lower position
in the society and are denied the opportunity to influence decision-making
even on life and death issues of health. Women are valued in terms of
their reproductive functions and, because of fear of initiation of sexual
activity before marriage with its attendant risk of unwanted pregnancy;
girls are married off soon after the onset of puberty. Hence, the age at
marriage was found to be as low as 12-16 in rural areas.
There is a high awareness of
the prevalence and ravaging impact of HIV/AIDS in the communities.
However, the overwhelming perception of AIDS as a sexually transmitted
diseases spread through illicit hetro-sexual and bi-sexual behaviour has
made people living with HIV/AIDS to face incessant stigma and
discrimination.
Incidences of unwanted
pregnancies occur both within and outside marital life. Within the family
setting, unwanted pregnancies has been responsible for adoption of family
planning practices by couples who desire to space child births in spite of
the cultural resistance to it. However, whenever it occurred outside
wedlock, pregnancy becomes a source of anxiety and dishonour to the family
concerned. The usual family response is to terminate it as soon as is
discovered. There appears to be a direct relationship between fear of
unwanted pregnancy and girl child marriage with its attendant health
hazard.
Recommendations
1.
There is urgent need for increased public and private sector
investment in the provision of health care and reproductive health
services in the rural areas.
2.
Health care service workers need to be retrained and re-oriented to
improve both their skills and attitude towards their clients.
3.
Special attention should be given to girl-child education with
particular focus on access to, enrolment, and completion of primary and
secondary education and vocational training.
4.
Since Islam has its views positions and fatwas (legal
opinions) on RH/FP, the issues should be more widely discussed
and debated among the Ulama. They should
be made to appreciate the gravity of RH/FP problems in their communities
and make it an issue in their sermons, open air preaching media
discussions and so on.
5.
The service provider must be culturally sensitive and restrain
himself/herself from going beyond those areas agreeable by Islam and the
general sentiment of the communities, less he jeopardize the successful
interventions in other areas of reproductive health.
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