TAF Preventive Medicine Bulletin, 2010: 9(2)

Derleme/Rewiev Article

TAF Prev Med Bull 2010; 9(2): 139-144

Appraisal of Some Harmful Reproductive Health Practices in Nigeria [Nijerya’da Kullanılan Bazı Zararlı Üreme Sağlığı Uygulamalarının Değerlendirilmesi] SUMMARY Reproductive health indices in most developing countries are still deplorable, less than a decade to the Millennium Development Goals. In Nigeria, as is the case in most developing countries, many factors combine to nurture reproductive ill-health and developmental backwardness. Some of these factors are harmful reproductive health practices such as, early marriages, violence against women, widowhood practices, and female genital mutilation. These are highlighted and suggestions made on how to improve on them in line with the targets of the Millennium Development Goals. ÖZET Çoğu gelişmekte olan ülkede üreme sağlığı göstergeleri Binyıl Kalkınma Hedefleri için bir on yıl daha az zaman kalmasına rağmen hala, kötü durumdadır. Nijerya’da birçok faktör, çoğu gelişmekte olan ülkede olduğu gibi gelişimsel geriliği ve yetersiz üreme sağlığı uygulamalarını beslemek için birleşmiştir. Bu faktörlerden bazıları, erken evlilikler, kadına yönelik şiddet, dul kadınlara yapılan uygulamalar ve kadın sünneti gibi yanlış üreme sağlığı uygulamalarıdır. Bu yazıda Binyıl Kalkınma Hedeflerine ulaşılması doğrultusunda yapılması gereken iyileştirmeler yapılan vurgulanmaktadır.

Rosemary Ogonna Ibekwe1, Perpetus Chudi Ibekwe2 1

Federal Medical Centre, Department of Obstetrics & Gynaecology Ebonyi State University Teaching hospital, Abakaliki, Nigeria. 2

Key Words: Reproductive Health Problems, Teenage Marriage, Forced Marriage, Violence Against Women, Genital Mutilation, Nigeria. Anahtar Kelimeler: Üreme Sağlığı Sorunları, Adolesan Evliliği, Zorla Evlendirme, Kadınlara Karşı Şiddet, Kadın Sünneti, Nijerya. Sorumlu yazar/ Corresponding author: Perpetus Chudi Ibekwe PO Box 1019, Abakaliki (480001), Ebonyi State, Nigeria. [email protected]

INTRODUCTION The reproductive health indices of most developing countries are still typical of a subSaharan Africa, where poverty, illiteracy, low status of women, unrestricted sexual behaviour resulting in high population growth rate, harmful traditional practices and poor social amenities combine to nurture reproductive ill-health. In recent times, reproductive health has come into lime light not only as a yardstick for measuring national growth and development but also as an index for achieving the targets of the Millennium Development Goals (MDGs). Reproductive health is a state of complete physical, mental and social wellbeing; and not merely the absence of disease or infirmity in all things patterning to the reproductive system and to its functions and processes. Following the adoption of the components of the reproductive health by the www.korhek.org

international community, it was gradually observed that most of those components are wantonly neglected and abused by most developing nations (1). These abuses might be going on unknowingly as they are intricately interwoven in the culture and tradition of the people. With the emergence of International Conventions, Conferences, declarations, and Programme of action by International Agencies like the World Health Organization and UNICEF, some of these harmful reproductive health practices are daily becoming manifest. Such notable conferences, conventions and declarations are United Nations Declaration on the Elimination of Violence Against Women, Convention on the Elimination of all forms of Discrimination Against Women (CEDAW), International Conference on Population and Development (ICPD), 4 th World Conference on Women (4 th WCW). Notable among the reproductive ill health 139

TAF Preventive Medicine Bulletin, 20010: 9 (2) that have been the recurring decimal in these conferences are, early, under aged or forced marriage; violence against women; female genital mutilation; widowhood practices and wife inheritance. These harmful practices are still prevalent in the third world countries and sustained perhaps by culture and tradition. HARMFUL PRACTICES Early, under aged or forced marriage The African charter on the rights and welfare of the child (1990) (2), provides that child betrothal and marriage shall be prohibited and that effective action shall be taken to ensure that the minimum age of marriage is 18. Article 16 (2) of the Convention on the Elimination of all forms of Discrimination against Women, specifically addressed the age of marriage. It suggested that the age of marriage for both men and women should be 18. UNICEF and United Nations Population Fund have suggested that 18 should be considered the minimum age of marriage. This age has been adopted internationally by most countries, as is obtainable in South Africa, Ethiopia, Ghana, Nigeria and even in the United States of America (3). The incidence of early and underage marriage varies from place to place. A survey conducted by UNICEF showed that 5% and 14% of girls aged between 10-14years were married in Bangladesh and India respectively (3). In Kebbi State, Nigeria, the average age of marriage for girls is just over 11 years against a national average of 18 (3). In a separate study carried out in Northern Nigeria, it was revealed that 45% of girls marry by the age of 15 and 73% by the age of 18 (4). There are medical, socio-economic and psychological implications of early, under aged marriage. From the medical viewpoint, it is generally accepted that child bearing among women aged 15-19 doubles the risk of death from pregnancy related causes compared to women in their twenties (5). These deaths can be due to pregnancy induced hypertension, anaemia in pregnancy, prolonged obstructed labour, puerperal sepsis, which is very common among these groups of women. Those who do not die are 140

faced with life-long debilitating morbidity like bilateral tubal blockage and secondary infertility from puerperal sepsis, Vesico-Vaginal Fistula (VVF), rectovaginal fistula (RVF), social ostracization and economic impoverishment. The Ministry of Health in Nigeria estimates that between 200,000 and 400,000 women are living with fistulae with up to 10,000 new cases occurring annually (6). This condition leaves girls and women continually leaking urine or faeces and frequently leads to abandonment by partners, friends and family (7). These women also suffer increased incidence of low birth weight babies, preterm labour and premature delivery, birth trauma because of contracted pelvis, increased risk of operative interventions and puerperal psychosis (8). On the social aspect, due to their low income or lack thereof, most adolescents who give birth cannot afford medical care of their children. The resultant effect is high perinatal, neonatal and infant morbidity and mortality. Pregnancies impede on their opportunity to continue their education and they may never return to school or develop other work skills thereafter. Thus, a vicious cycle of child bearing, poverty and disease is set up. Domestic violence is also a widespread problem. Some studies reported that up to 81% of all young married girls admit experiencing some form of verbal or physical abuse by their husband; the lower the age at marriage, the higher the risk of domestic violence (9). Girls who marry early face social isolation and have no one with whom to discuss the unhappy experience. They have few social connections, restricted mobility, limited control over resources and low power in their new household. Psychologically, early marriage in most instances marks an abrupt transition into sexual relations with a husband who is considerably older and unchosen. Sexual debut is often unwanted, unprepared and traumatic for them with the attendant psychological sequelae. To worsen matters, in most cultures, children who refuse to marry or who choose a marriage partner against the wishes of their parents are often punished or even killed by their families.

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TAF Preventive Medicine Bulletin, 2010: 9(2) Violence against Women Violence against women (VAW) is another harmful reproductive health practice prevalent in most developing nations. It is also sporadic in some developed countries. Preventing violence against women is one area of reproductive health that has not really been given due consideration in most developing countries despite the fact that they are signatories to many international conventions on eliminating violence against women and promoting human rights (10,11). It is increasingly being recognized as a serious public health issue, resulting in significant physical, psychological and social impairment (12). World Health Organization (WHO), nongovernmental organization and other agencies had since recognized this and had called on countries to take appropriate measures to prevent violence against women (13, 14). Also, the ICPD programme of action and the 1995 Fourth World Conference on Women in Beijing specifically addressed the issue of eliminating violence against women (United Nations 1996). Several years after these conferences and conventions of which many developing countries ratified, violence against women still occurs everywhere and at anytime of the day. It affects the lives of millions of women worldwide and cuts across ethnic, cultural and religious barriers, impending on the rights of women to participate fully in the society (15). In Sierra Leone, Africa, 2 out of 3 women reported being beaten by a male partner while 50% had experienced forced intercourse (16). In Nigeria, there is gross underreporting of VAW but available data indicate that 24-79% of women had experienced physical assault by an intimate partner (11, 17, 18). Presently in some parts of Nigeria, wife beating is regarded as a sign of love, which some women have been socialized to accept, and sometimes encourage (19). The 2003 Nigerian National Demographic and Health survey revealed that more than 61% of women supported wife-beating (20). This confirms that VAW is accepted as cultural norm among Nigerians. Repelling of these obnoxious cultural laws will improve women’s health and status.

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The health and psychosocial consequences of VAW are enormous. It has been shown that children who witness violence between their parents are at increased risk of childhood behavioral problems and of violence in future relationships (21). Abused women are more likely to be exposed to psychological distress as well as engage in harmful practices such as substances and alcohol abuse (11). Also, the violent behaviour of rape, forced prostitution and refusal to use condoms interfere with women’s abilities to control their sexual and reproductive lives and puts them at risk of contracting HIV/AIDS and unwanted pregnancy. Women, for fear of violence, are unable to refuse sex or negotiate safer sexual practices.

Female genital mutilation Female Genital Mutilation (FGM) is one of the reproductive ill health of which has vehemently resisted change in many African countries. It is estimated that about 100 million women and girls in Africa have gone through some form of genital mutilation (22). Female genital mutilation is practiced in 28 African Countries; it is heavily concentrated in the horn of Africa, Egypt and parts of west and East Africa (23). The highest prevalence rates are found in Somalia and Djibouti; where it is virtually universal (24). Nigeria, due to its large population, has the highest absolute number of cases in the world, with an overall national prevalence rate of 50% (25). Various reasons have been advanced to justify female genital mutilation, they include, protection of virginity, prevention of promiscuity, increased sexual pleasure for the husband, ethnic identity, enhanced fertility and increased matrimonial opportunities (26). It has dangerous health implications, including haemorrhage, infectious such as tetanus, hepatitis, HIV/AIDS, chronic pelvic inflammatory disease, urinary tract infections and incontinence of urine or faeces (27). It has also serious psychological implications by symbolizing the subjugation of women and the control of female sexuality as was exemplified in a case reported by Ibekwe (28). 141

TAF Preventive Medicine Bulletin, 20010: 9 (2) Despite these complications, this harmful practice has continued unabated, sustained perhaps by traditional customs and beliefs. Serious advocacy is vital to stop the dangers of this practice. All proponents of reproductive health issues should look for strategies to curb this practice, including education of women, women empowerment and improvement in their socioeconomic status, as it has been shown that FGM is significantly associated with poverty, illiteracy and low status of women (29,30).

Widowhood Practices Widowhood practices are offensive traditional practices, which vary depending on culture and ethnic group within countries. It is a dehumanizing practice, which pose serious health problems. Some of those practices include, sleeping on bare floor, drinking of deceased bath water, eating from broken plates, staying indoors for one year, among others. Interwoven with the widowhood practices is wife inheritance in which a woman is given out to her deceased husband’s relation, often against her wish. When a woman looses her husband, she is automatically willed to a junior brother or another relation of the deceased husband with all the attendant risks of HIV/AIDS and other psychosocial problems.

The way forward In spite of the health consequences of these harmful reproductive health practices, no concrete attempt has been made to address these practices, despite the fact that most developing nations are signatories to many international conventions, conferences and programmes of action on sexual and reproductive health and rights. Preventing these harmful practices should therefore be revitalized and promoted as an important reproductive health intervention to address the debasement of women. There is need for public enlightenment on what constitutes harmful reproductive health practices. Education on the reproductive and sexual rights of woman should be intensified through the print and electronic 142

media and women organizations. There is also urgent need to review cultural and traditional laws that negate women’s rights: right to economic emancipation, right to autonomy, right to education and right to matters relating to their reproductive system and processes. Violence against women should be recognized as a criminal issue through the amendment of existing legal instrument and domestication of international laws and treaties on violence against women in which most developing countries are signatories. Also, the imposition of marriage particularly on children and adolescents who are in no way ready for married life deprives them of freedom, opportunity of personal development and other rights including rights to health and well-being, education and participation in civil life. Unless measures are taken to address the issue of early, under aged or forced marriage, it will continue to be a major stumbling block to the achievement of human rights. Formation of formidable women socio-cultural organization and religious groups as catalysts for positive change is advocated. Women can really play key and effective roles in eliminating gender-based harmful practices and in initiating and implementing programmes that guarantee their reproductive and human rights. Programmes to raise awareness, build strong advocacy and arouse interest on issues related to women should be organized regularly. There is also the need to train health professionals on gender-based issues. Apart from being instruments of positive change in the society, health care providers are expected to assist in alleviating the sufferings of women exposed to harmful reproductive health practices through physical support, medical treatment, counseling and prompt referral to other social agencies where assistance could be offered. Significant proportion of health workers lack adequate knowledge to suspect sexual and reproductive rights abuses when they present (31). Thus, efforts should be made to incorporate topics related to the components of reproductive health and also sexual and reproductive rights of women into the curriculum of doctors, nurses and students in higher institutions. In conclusion, elimination of harmful cultural practices, domestication of international www.korhek.org

TAF Preventive Medicine Bulletin, 2010: 9(2) instruments and legislation enforcing sexual and reproductive rights of women are areas that need urgent attention. Education, enlightenment and sensitization of the populace must be intensified. This will gradually lead to attitudinal changes. Finally, improvement in the reproductive health and rights of women will speed up progress towards achieving the targets of the Millennium Development Goals (MDGs).

15. De Bruyn M. Violence Related to Pregnancy and Abortion: a Violation of Human Rights. Sex Health Exch. 2002; 3: 14-15.

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