POLITICAL MATTER •

“From 2012 to 2015, Nigeria’s health budget consistently remained at around a paltry 6 per cent of the national budget; with a decrease to 4.64 per cent in 2016. This is despite pledging to commit 15 per cent of the national budget to the health sector at the Abuja declaration in 2001. One of the consequences is that an estimated 900,000 Nigerian women and children die annually from mostly preventable causes.”

In 2015, over 300,000 girls and women died from complications relating to pregnancy and childbirth. While the global maternal mortality rate has declined by a remarkable 44 per cent since 1990, 99 per cent of all maternal deaths occur in economically developing countries, with Sub-Saharan Africa and South Asia accounting for 88 per cent of maternal deaths globally. Sub-Saharan Africa on its own still witnesses the highest maternal mortality rate at 201,000 maternal deaths per year. Nigeria alone accounts for 14 per cent of global maternal mortality. In the country’s northern part, the problem of unnecessary female deaths as a result of languishing health resources is especially acute.

 the North-East region of Nigeria has the highest maternal mortality rates in the country. Out of 100,000 live births, 1,549 mothers die in the North East compared to 165 in the South West; a nearly 10 fold difference.

Geographically, northern Nigeria takes up 79 per cent of Nigeria’s total landmass. The region is home to just under 85 million of Nigeria’s 182 million-strong population; and the nineteen territories that make up the North are further divided between Christian and Muslim majorities.

Compared to a national female literacy rate of 51 per cent, literacy rates for women are as low as 5 per cent in some northern states. Literacy rates among women in the states of the North-East and the North-West range between 7.2 per cent and 55.7 per cent compared with a range of between 90.1 per cent to 96.4 per cent in the states that comprise Nigeria’s South-East, South-West, and South-South regions. The impact of such low levels of literacy and education among northern women on health outcomes for females in the region is enormous; and negative.

As a result of below modest investment, Nigeria’s health system is less effective compared to other African countries. From 2012 to 2015, Nigeria’s health budget consistently remained at around a paltry 6 per cent of the national budget; with a decrease to 4.64 per cent in 2016. This is despite pledging to commit 15 per cent of the national budget to the health sector at the Abuja declaration in 2001. On the other hand, significant health and economic improvements have been achieved with modest investments by countries such as Rwanda, Malawi, and Botswana, which allocated 18 per cent, 17.1 per cent, and 17.8 per cent of their respective budgets to healthcare.

an estimated 900,000 Nigerian women and children die annually from mostly preventable causes

One of the consequences of such poor investments in Nigeria’s public healthcare system is that, according to a 2016 World Bank report, an estimated 900,000 Nigerian women and children die annually from mostly preventable causes. A recent study into maternal and child care in the North concluded that such dire health outcomes are further compounded by the fact that access to health care in many parts of the North is a challenge.

There is a chronic lack of adequate health services, coupled with poorly equipped facilities that lack basic essential medicines. Additionally, the dearth of skilled health workers in the North and inaccessibility of health facilities due to distance and poor road networks results in poor health status for the population, particularly for women and children.

The low availability, accessibility, and affordability, of health services are not the only factors responsible for the poor health status of women and children in northern Nigeria. Many normative practices persist in the North that do not benefit the general well-being of women. For instance, many women will require the permission of their husbands, as well as being dependent for financial assistance, before they may be allowed to visit health clinics and facilities.

A recent study in the northern Nigerian state of Kano reported over 800 women seeking medical help presented with Vesico Vaginal Fistula within a year

The prevalence of home deliveries and female genital mutilation, and the low education of women about their own health all serve to contribute to many poor health outcomes for northern Nigerian women.

High maternal mortality and low education levels further serve to entrench women in low social and economic status, and in turn limits their already limited access to quality healthcare services. As a result, the North-East region of Nigeria has the highest maternal mortality rates in the country. Out of 100,000 live births, 1,549 mothers die in the North-East compared to 165 in the South-West; a nearly 10 fold difference.

The highest neonatal mortality within Nigeria – that is, the death rate of infants within the first 28 days of life –  is in the North East and North West regions. The highest death rate of under five children is also in the North-East and North-West regions.

Coupled with the escalating maternal and child mortality problem, northern Nigeria also boasts the highest fertility rates and teenage pregnancies in Nigeria. In the North-East and North-West regions respectively, approximately 32 per cent and 35 per cent of girls aged between 15 and 19 have started childbearing. These figures are to be compared with 8.2 per cent recorded in the South-West and South-East parts of the country.

One of the key reasons for this state of affairs is the lack of care available to girls before pregnancy, as well as the wide prevalence of low levels of education in some Northern states.

Compared to a national female literacy rate of 51 per cent, literacy rates for women are as low as 5 per cent in some northern states

Although effective family planning is a well-established approach to reducing maternal and child deaths, in states such as Katsina, Kano, Sokoto, and Jigawa, less than 1 per cent of married women use contraceptives. In stark comparison, at least 26 per cent of married women in Lagos state – in the southern part of Nigeria – use contraceptives. Other studies have this figure as high as 48 per cent for Lagos.

Additionally, access to prenatal and antenatal services are remarkably low in many parts of northern Nigeria. In fact, less than 50 per cent of women receive any antenatal care at all. Reported antenatal care coverage was as low as 41 per cent in North-Western Nigeria, 49 per cent in the North-East. Again, these figures are compared to 90 per cent and 91 per cent coverage in the South-West and South-East regions, respectively.

Overlooking Gynaecological Conditions

The poor state of healthcare for women in northern Nigeria is not confined to general demographic issues of fertility and maternal mortality. The prevalence of specified gynaecological conditions like breast and cervical cancer, and Vesico Vaginal Fistula (VVF), is on the rise among women in northern Nigeria.

In Nigeria, cervical cancer is the leading cause of cancer-related deaths in women. It is second only to breast cancer as the most common cancer in Nigerian women. The increasing number of deaths from cancer is the result of a general lack of public awareness about the disease, as well as poverty. Coupled with the limited number of screening programmes that exist in Nigeria, the outcome is often late diagnosis of the disease after it has already spread to other organs and become untreatable.

Vesico Vaginal Fistula or VVF – a complication arising from prolonged or obstructed labour that results in a hole between the bladder and vagina and leads to continuous involuntary discharge of urine into the vagina – is also an increasing problem in the North. Globally, over 20 million women are living with VVF, with 50,000 to 100,000 new cases annually. A recent study in the northern Nigerian state of Kano reported over 800 women seeking medical help presented with Vesico Vaginal Fistula within a year (between October 2011 and September 2012).

In North-East and North-West regions respectively, approximately 32 per cent and 35 per cent of girls aged 15-19 have started childbearing

While incidents of VVF and cervical cancer are increasing, partially as a result of early marriage in girls between the ages of 12 and 18 years, most cases are due to poverty, illiteracy, and poor obstetric services. In an ideal scenario, finding a cure to these diseases is the ultimate goal both in the global and the Nigerian medical communities. Presently, however, the focus must be on prevention.

Overlooking Female Genital Mutilation (FGM)

Recent figures reveal that 27 per cent of women in Nigeria aged between 15 and 49 have undergone some form of FGM, also know as ‘cutting’. Despite the fact that Nigeria is subject to the 2015 Violence against Persons Prohibition Act, FGM is still widely practised.

Unknown to many, however, is the fact that although northern Nigeria is very much affected by FGM, this dangerous and harmful practice is heavily prevalent in some southern parts of the country. According to a 2013 survey conducted by Nigeria’s National Population Commission, 77 per cent of women in Osun state, 74 per cent of women in Ebonyi, and 72 per cent of women in Ekiti had undergone FGM. This is compared to 40.9 per cent in Kano, 25.1 per cent in Kaduna, and 0.1 per cent in Katsina.

The Population Commission’s study found that the practice of FGM varies with levels of education and socio-economic status. Unsurprisingly, those with higher levels of education and higher socio-economic status are also those least likely to believe that FGM is required by their religion.

It is clear that outreach programmes are needed to provide basic education on the problem of FGM; particularly where rural populations that still practice female genital mutilation are concerned.

But besides the fact that urgent attention is now needed to address the issues of poor and under-utilised healthcare facilities, issues such as poor access to minimally existing medical services are further compounded by social, normative, and economic factors that include – but are not limited to – gender inequality in many areas of the North.

In terms of employment, generally older women are more likely to be employed than younger ones.  Also, more than 85 per cent of married women in northern Nigeria reported having less income than their husbands; with only 7 per cent reporting earning more in the North-East region.

A holistic approach to solving the problems of female-orientated healthcare in northern Nigeria cannot, and should not, ignore these facts.

Moving Forward

Improvement to the health quality and well-being of women in northern Nigeria is urgent and achievable. Swift infrastructural development including the building of passable roads, as well as safe and accessible water sources, is absolutely essential.

The highest neonatal mortality within Nigeria – that is, the death rate of infants within the first 28 days of life –  is in the North East and North West regions. The highest death rate of under five children is also in the North East and North West regions.

Interventions by both public sector policy makers and development workers should be designed and implemented with due consideration to the socio-cultural norms and beliefs that are prevalent in northern parts of Nigeria. These will be successfully implemented when done in collaboration with the relevant religious and community stakeholders. The education of males, and those in authority, in northern communities about the importance and impact on the whole society of female health is also vital. The wide-ranging problem of low education levels must also be urgently addressed.

Aisha Mukhtar Dodo is a Nigerian from Katsina State. She is currently a Ph.D. candidate in Public Health at Cardiff Metropolitan University where her research is focused on bridging the cultural gaps in cancer management in northern Nigeria.