WOMEN'S REPRODUCTIVE HEALTH AND HOUSEHOLD FOOD SECURITIES IN AFRICA
BY OLUSOLA ODUJINRIN
NIGERIA.
Reproductive Health is defined as a state of complete physical, mental and social well being and not merely the absence of disease or infirmity-in all matters relating to the reproductive system and its functions and processes. This definition was ratified at the ICPD in 1994 and is so contained in the ICPD programme of Action. Reproductive Health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the rights of men and women to be informed; to have access to safe, effective, affordable, methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law. Also implied is the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. It addresses the reproductive processes, function and system at all stages of life. Reproductive health encompasses all aspects of human sexuality and reproductive health needs of women and men during the various stages of life. It is a means of achieving improved human welfare through a more sustainable balance of population and resources, a reduction of disparities in life opportunities, a re-alignment and control of the risks and benefits of reproduction.
SEXUALLY TRANSMITTED INFECTIONS (STIS)/HIV/AIDS
Many people are unable to attain optimal reproductive Health because of incomplete knowledge about health and human sexuality, gender bias, high-risk sexual behaviour and the in-availability or poor quality of reproductive health care services. Violence against women such as domestic abuse and rape often leads to STI s and unwanted pregnancies as well as to physical injury and mental illnesses. Although the burden of ill health associated with reproduction is shared between the two sexes, women bear the bulk of it, for instance, only women face the health hazards of pregnancy and child birth, and STI s have more serious sequelae on women than men. The growing incidence of STIs including HIV/AIDS also affects reproductive health negatively as does the continuation of harmful practices such as female genital mutilation. Adolescents who lack information and services are particularly at risk. In Africa, the majority of new HIV infections are in young people between the ages of 15 and 24 and sometimes younger(1). Similarly, older women and men have distinct reproductive and sexual health needs that are often inadequately addressed.
A number of factors increase women's risks of HIV infection. These include:
_ Women's customary, economic and social dependence on a male partner ;
_ Inability to negotiate use of condoms or refuse sexual intercourse with spouses
_ Practices such as genital mutilation, proof of fertility prior to marriage and anal intercourse as a way of preserving virginity;
_ Lack of /limited access to STI prevention programmes for women, leading to untreated illnesses which increase the risk of HIV transmission as much as 5 to 10 fold;
_ Women under 18 are more vulnerable to STI s;
_ Lack of educational and economic opportunities increasing economic dependence and the likelihood of turning into commercial sex; and
_ Women's physiology which puts them at greater risk during heterosexual intercourse. In Africa, infected women out-number men by 6 to 5. Studies show that by the year 2000 an estimated 13 million women world wide will have been infected by HIV and 4 million of them will have died of AIDS (1). As more women become infected, there is a consequent increase in infections among children resulting from mother-to-child transmission (vertical transmission).
MATERNAL MORBIDITY AND MORTALITY
An estimated 585,000 women die annually from pregnancy, childbirth and related causes (maternal mortality) and as many as 15 times more suffer injury or infection (maternal morbidity). Most of these deaths and disabilities occur to women in developing countries, where pregnancy and child birth are among the leading causes of death for women of child bearing age and where the risk of death is 50 to 100 times more. Maternal mortality rate (M.M.R) is an important indicator of poverty and a pointer to the degree of priority society accords to the lives of women. The paucity of reliable national data on maternal mortality creates a handicap in creating an authentic national profile. There are however many institution based studies that give estimates of MMR in different parts of Nigeria. One should however be mindful of the fact that many women deliver outside the hospitals and clinics in Nigeria, and many of such births and the maternal deaths experienced go unrecorded.
A ten year review (1986-95) of maternal mortality at the Lagos University Teaching Hospital (L.U.T.H.) gave a maternal mortality rate of 1930 per 100,000 live births. One should however bear in mind that L.U.T.H is a referral centre and so, many difficult and complicated cases end up there. The study also demonstrated a steady rise in MMR over the years. Furthermore, it identified abortion (22.5%), eclampsia (16.4%), puerperal sepsis(13.4%) obstetric haemorrhage (11.7%), obstructed labour/ruptured uterus(8.8%) and ectopic pregnancy (5.8%) as the major causes of death. It however stated that 86.5% of the patients studied were un-booked cases who presented late to the hospital.(2). Other studies (3,4,5,6,7) undertaken in Nigeria to estimate maternal mortality gave similarly high rates and reported similar causes.
Many studies from different parts of Nigeria identified the role of bio-socio-cultural factors on maternal morbidity and mortality. Delay in seeking orthodox obstetric care directly due to poor financial status even when confronted with grave situations as bleeding was the most prevalent of these factors. Others were age, marital status, parity, booking status, education and socio-economic status. All were found to statistically affect maternal mortality (8.9.10.&11). Abortion performed under unsafe conditions is a threat to Reproductive Health. The World Health Organisation estimates that about 70,000 (seventy thousand) women die each year as a result of unsafe abortion and almost all of them are in the developing countries. In Nigeria, abortion is responsible for about 20-25% of all maternal deaths and about half of these are adolescents.
FAMILY PLANNING
Family planning services are an essential part of Reproductive Health care. These have saved the lives and protected the health of millions of men, women and children. The odds of a woman dying from maternity - related causes range from 1 per 10,000 women in northern Europe to 1 in 35 in southern Asia to 1 in 23 in Africa. Up to a third of maternal mortality and morbidity cases could be avoided if all women had access to a range of modern, safe and effective family planning services which will enable them to avoid unwanted pregnancy. Over the past thirty years, the development of modern contraceptives have given people greater individual freedom and enhanced their ability to plan their families. In general, world-wide, contraceptive use has increased from less than 10% of couples thirty years ago to some 60% of couples today and family size has fallen from an average of six children in the 1960's to less than three now. Unfortunately, the pro-natalist stance of Nigeria and indeed many other African countries, encourage large family sizes. The total fertility rate (TFR) for Nigeria is currently about 5.5 (NPC 1996). The social value of having many children, male preference and competition among wives in polygamous unions, continue to force high-risk mothers into high fertility behaviour and thus increase maternal morbidity and mortality. The National Demographic and Health Survey (N.D.H.S.) of 1990 showed that more than 67.68% of all births in Nigeria (from 1985-1990) were high-risk births.
Today, at least 350 million couples do not have access to the full range of safe and effective modern methods of family planning or social support for its use. Surveys from more than 60 developing countries indicate that more than 100 million women who are not currently using a contraceptive method want to delay the birth of their next child or to stop child bearing altogether. The NDHS (1990) also revealed that a total of 21% of married women in Nigeria have an "unmet need" for family planning. The desire to space births is highest among younger women within the 20-29 age bracket while older women's need is to limit births. Apart from socio-cultural constraints, religious beliefs, user charges and the attitude of service providers, information gap (only 37% of women knew where and how to obtain modern family planning methods) is considered to be a key explanation for the wide gap between knowledge and practice of family planning. The implications of unmet needs are that quite a high proportion of young women will continue to produce at a shorter birth interval, while a large number of older women will continue to have high risk pregnancies. It is also worthy to note that the unmet needs of the youths, men and single women were not ascertained at the time of the survey, so the real figures for the unmet needs should have been much higher had those for these groups been captured by the NDHS (1990). More detailed documentation is needed as this would allow for the development of realistic programme strategies for meeting the identified target groups.
ADOLESCENT REPRODUCTIVE HEALTH
By the year 2000 A.D., there will be almost 1.2 billion teenagers in the world, 1 billion of them in the less developed countries, of whom more than half are likely to be either married or sexually active. In many African countries, nearly half of all women have their first child before age 20. By the age of 15, 13% of girls in Nigeria are already with children; 16% of all births are by teenage girls who are under the age of 18 and 5-8 times more likely to die in pregnancy and child-birth than women in the low risk age group of 20-24. The high incidence of vesico-vaginal fistula (VVF) and recto-vaginal fistula (RVF) in very young girls in the northern part of the country is the result of early marriage and child-birth through immature pelves. The birth rate of teen mothers (15-19 years) in Nigeria is about 152 per 1000 live births (NDHS,1990). The premature status of motherhood destroys to a large extent, a teenagers life chances of achieving a desirable quality of life and self-actualisation.
Currently, an estimated 1 in 20 teenagers world-wide acquire a sexually transmitted infection in each year. Transmission and development of complication due to poor/mismanagement are higher in the developing countries due to lack of information and poor access to user friendly services. Unsafe abortion is prevalent among teenagers in Nigeria as in other developing countries of Africa. Teenage girls account for almost 25% of maternal deaths in Nigeria. Many studies have revealed that many young Nigerian girls 12-14 years are sexually active, do not use contraceptives (12-14) have multiple sexual partners (14,15) and procure abortions (13,14,16).
HOUSEHOLD FOOD SECURITY
Food security has been broadly defined as _a state of affairs where all people at all times have access to safe and nutritious food to maintain a healthy and active life_(17). The definition of household food security adopted by the committee on World Food Security of the Food and Agriculture Organization of the United Nations (FAO) specifies both physical and economic access to adequate food without undue risk of losing such access. This definition assumes that food will be available to meet the nutritional needs of _all people_ especially the vulnerable groups, children, pregnant women and the elderly. The phrase _at all times_ indicates that period of temporary food shortage and longer periods resulting in chronic under-nutrition/malnutrition must be addressed while _nutritional needs_ refers to dietary requirements rather than needs subjected to demand or purchasing power. Food security is at risk when some people do not have enough food to eat, a situation that can arise from many causes notably poor/lack of access to food, poverty and or inadequate supply of food. Those at risk can be subdivided into four broad groups:
* small farmers, landless rural workers and urban non-professionals. Under this group are young children and lactating mothers. This group may benefit from economic development in general. This tends to result in increased productivity and increased availability of food.
* The unemployed constitute a second group. In many instances, economic development at the national level may not necessarily impact greatly on them as they tend to be caught in a cycle of poverty.
* People suffering from chronic illness or physical disabilities, the aged and orphaned children who are characteristically dependent on others for survival and this dependence makes their predicament acute especially in times of hardship.
* Those suffering from temporary food deficiencies due to periodic shortfalls in food supply e.g. poor agricultural yields due to bad weather, fluctuation in international markets, availability of foreign exchange and harsh trade terms for countries depending largely on importation of essential food stuff.
Food security rests on the balance between the supply of food which determines availability and the size of the population to be fed, that is the demand for food.
POPULATION GROWTH AND DEVELOPMENT
The advent of the era of modern economic development after the end of the Second World War, saw unprecedented increases in per capita income and a general increase in the level of well-being. Extrapolating from the European demographic transition, this phenomenon led many demographers and social scientists to conclude that economic growth would suffice to reduce mortality rates and to bring fertility under control in the developing world where mortality declines have indeed been broadly registered (18-23). The anticipated declines in TFR have also been observed in a good number of the developing countries although the neat statistical relationship predicted is yet to evolve. For many African countries, the decline in mortality was followed with a gap, followed by a slow and gradual decline in fertility rates which is still continuing. The consequent sharp decline in death rate and relatively small decline in birth rate produce high population growth rates.
In the bid to explain the slow onset of the anticipated demographic transition, some social scientists have shifted their sights away from socio-economic development and population growth as aggregate phenomenon to the micro-level. They are examining increases in household incomes as opposed to average incomes and relating these to fertility decisions at the family levels. This broadly implies that an improvement in family income and well-being has synergistic effect on decreasing fertility and limiting family size. This permutation is still less than optimistic for a developing country like Nigeria where increases in per capita incomes have become difficult to obtain and where incomes of the masses have recently declined in real terms. The UNDP points out that notwithstanding regional gains in gross domestic product (GDP) in South-East and East Asia, 70 developing countries have lower per capita incomes than in 1980 and 43 are poorer than they were in 1970. In fact the recently launched United Nations Human Development Index Report placed Nigeria as one of the poorest countries in the world.
Three factors impact greatly on population growth. These are -i. momentum of population growth; ii) demand for children; and iii) the supply of children.
The momentum of population growth is the tendency of population size to continue increasing for sometime despite fertility decline, and before a stable population is attained. This is due to the young age structure of the population which will take decades to adjust given the decline in fertility.
Demand for children is generally greater in Africa and greater still at low income levels. Children provide labour, the pivotal input for production in environments with little capital and scarce resources and are sources for old age insurance for parents. With child survival becoming a reality in many African countries, it takes fewer births to achieve desired family sizes. Furthermore, as education levels increase, the costs of educating children increase. These also have regulatory effect on the demand for children, especially among those who appreciate the value of education.
Supply of children can overshoot the demand given the desired family size, if women have unwanted pregnancies. Unwanted pregnancies are largely the result of unmet need for contraception.
FOOD SECURITY AND POPULATION GROWTH
Historically global food security was assessed by comparing rates of growth of the population with the rates of growth of food production. Three quarters of African countries witnessed a decline in per capita food production and nine African countries faced decreases of more than 20%. These declines in food availability are the first harbingers of food security risk.
Although growth rates are declining, world population is continuing to increase by the largest annual increments in human history. Ninety-seven percent (97%) of the 80 million people that will be added to global population each year from 1995-2015, will be in the developing countries and one third of these will occur in Africa (25). United Nations estimates suggest that urban population in Africa will increase by 106% between 1980 and 2000 while rural will increase by 24%.(26) This indicates a tremendous strain on national, regional and global food marketing system to feed urban centres. While other developing countries outside Africa South of the Sahara, will be recording appreciable increase in per capita food supplies and substantial reduction in number of people with chronic under-nutrition, those in the rest of Africa, will only witness slight increase in per capita food supplies and phenomenal increases in the number of people with chronic under-nutrition between 1990 and 2010(27) .
WOMEN AND FOOD SECURITY
Women in developing countries are poorer than men and as such are specially at risk. In much of Africa, men and women household budgets are somewhat separate. Both in Ghana and in Cameroon, women_s average incomes are found to be one quarter those of men(28-29). Similarly a study of western Kenyan households found that men benefitted from the contributions of women and children in both subsistence and market production while men only shared small percentage of the income made from market production with them(30). Although the availability of food supplies is gender neutral, its acquisition can be gender-biased. Although women have been documented to spend longer hours than do men in households, they gain less from pooled resources especially as decision making is the exclusive preserve of the men. So with limited resources their food purchasing power is less, and where they engage in subsistent farming, due to limited income, poor education, negative cultural norms (in some cultures, women cannot own land), no access to credits and other financial assistance, they can not improve on their farming performance. Despite the fact that they spend long hours farming, they still remain poor. So the vicious cycle of the three Ps (poor, powerless and pregnant) becomes entrenched.
REPRODUCTIVE HEALTH AND HOUSEHOLD FOOD SECURITY
The committee for world food security of the United Nations Food and Agriculture Organization reported that one sixth of the people in developing countries still go hungry everyday and one child under five years in every three suffer from serious malnutrition. Studies in many countries show that gender also has implications for nutritional level, with women consuming systematically below their minimum daily calorie requirement.(31-33) This phenomenon has also been documented in some countries (essentially India) to be responsible for higher mortality among female children than the males.(34-35) The widespread mismanagement of the Nigerian economy and the structural adjustment programme (SAP) have gravely affected the economic situation of most families and accentuated the feminization of poverty. Many families are finding it difficult to provide adequate quantity and quality of food with vital nutrients for themselves. This has resulted in the deficiencies of such micro-nutrients as iron, iodine, vitamin A as well as protein - energy malnutrition (PEM). It has also been shown that about 20% - 40% of pregnant women suffer from PEM and anaemia with complications. In a UNICEF Nigeria country office report (1993), under-nutrition among mothers averaged 14% in five states (Ondo, Oyo, Bauchi, Kwara and Cross River). It seems therefore that in Nigeria, as in most other African countries, the prevailing poor nutritional status tends to confine women and their daughters in a web of poverty, low esteem, low birth weight, and stunted growth. The stunted growth results in narrowed pelvis which in turn results in obstructed labour with attendant development of vesico-vaginal and recto vaginal fistulae in many cases as observed in Akwa Ibom State.
The low status of women is more pronounced in the rural areas where women_s life chances are even more limited, thus making women socially handicapped to alter their position. A World Bank report (1991) indicated that 22% of urban households, 17% of rural households and 18% of all households were food insecure in Nigeria. A 1993 report from Obafemi Awolowo University (OAU) Ile-Ife, Nigeria confirmed that 70% of total household expenditure was spent on food, an indication of high level of food insecurity and poverty in the country. Under this poverty ridden situation, women, children and the aged are the most vulnerable.
The World_s population grows by more than 90 million each year. Each of these people needs a portion of the earth_s resources for food, shelter, energy and water. The steadily increasing burden of growing population can eventually overload natural systems including agricultural yields causing their collapse. By diminishing nature_s productivity, we are stealing from our children because non-renewable resources such as oil will run out and some of the renewable ones like clean air, forests, soil and water are threatened by overuse and pollution.
CONCLUSION
In conclusion, food is one of the most basic human needs. It has been demonstrated that the world is close to its maximum food production potential. World food output in 1988 would have fed 5.5 billion people, which was the expected 1993 world population on a mainly vegetarian diet while it would have fed only 2.8 billion people on a full but healthy diet including meat. This food yield is heavily dependent on intensive cultivation, heavy fertilizer use, crop yields higher than the U.S average and little change in the area devoted to cropland. Certainly African countries cannot afford these although their population growth far outstrips those of countries that can comfortably afford this maximum sustainable crop yield technology.
The issue of population growth must be addressed in order to ensure and sustain household food security. A number of social programs including reproductive health programs are necessary for its reduction; some of such programs include making family planning available, affordable and easily accessible to all including adolescents, men and single women;
* encouraging later marriage and childbearing which benefit women_s health;
* providing opportunities for women_s involvement in development through access to education, paid employment, assets such as land and credit facilities;
* encouraging breast feeding practices which not only promotes infant health but also can lengthen the interval between pregnancies; and
* improving women_s status and opportunities vital to women_s welfare, social justice and economic development. These at the same time reduce fertility.
In addition to addressing the issue of excessive population growth, poverty alleviation or women inequality, consumption levels, production technologies are equally important issues needing attention. Also much remains to be done to improve both our understanding of population environment linkages and capacity to act positively to promote household food security. The current declines in population growth rates must be further encouraged. Policies to promote food security at all levels must link population issues closely with those of poverty alleviation, enhanced educational and health services especially Reproductive Health Services.
Issues for Further Research
· Unmet needs for family planning for program strategy development
· Emergency Reproductive Health
· Post-abortion care
· Reproductive Health for displaced persons- refugees, migrants etc
· People living with AIDS (PLWA) and their survivors- Orphans, widows etc
· Linkage between Population growth/ Reproductive Health, Environment and Food Security and
· Maximum Sustainable Crop yields for Africa.
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