WOMEN'S REPRODUCTIVE HEALTH AND FOOD GROWING/PROCESSING: THE CASE OF NIGERIA
By TOMILAYO O. ADEKANYE
Paper prepared for the regional workshop on Women's Reproductive Health and Household Food Security In Rural Africa organised by the ECA Food Security and Sustainable Division (FSSDD), Addis Ababa, October, 1999.
Professor Adekanye is the immediate past Head of the Department of Agricultural Economics, University of Ibadan, Nigeria. She is chairperson of the Centre for Gender, Governance and Development (CEGGAD), an NGO which has its headquarters in Ibadan, and also president of the ten year old Association for Women Agriculturists and Home Economists (AWAHE) which is based at the Institute of Agricultural Research and Training (IAR&T) of the Obafemi Awolowo University.
Table of Content
Acronyms
Abstract
I. Introduction
1. 1 Literature Review
1.1.1 Biological Determinism
1.1.2 Reproduction and Production
1.1.3 Women's Studies
1.1.4 Reproductive Health
1.1.5 Food Growing/Processing
1. 2 Research Methodology
II. Women's Health, Work and Life
2.1 Maternal Mortality and Major Causes of Death
2.2 Health Care and Family Planning Facilities
2.3 Fertility
2.3 Agriculture and the Rural Economy
2.5 Consumption and Nutrition
2.6 Local Tradition
2.7 Other Socio - Cultural Factors
III. Conclusions and Strategies
3.1 Conclusions
3.1.1 Reproductive Health
3.1.2 Agro-Production3.2 Strategies
3.3 Alternative Development Paradigm
3.4 Orientation for Future Research
References
ACRONYMS
AIDS: Acquired Immune Deficiency Syndrome.
ECA: Economic Commission for Africa.
FOS: Federal Office of Statistics, Nigeria.
GHS: General Household Surveys, the Federal Office of Statistics, Nigeria.
LGA: Local Government Authority.
MICS: Multiple Indicator of Cluster Surveys, the Federal Office of Statistics, Nigeria.
MMR: Maternal Mortality Rate.
NGO: Non - Governmental Organisation.
NISH: National Integrated Surveys, the Federal Office of Statistics, Nigeria.
O & G: Obstetrics and Gynaecology.
SOG: Society of Obstetrics and Gynaecology.
SSRHN: Social Sciences and Reproductive Health Network, UCH.
STD: Sexually Transmitted Disease.
UAPS: Union for African Population Studies.
UCH: University College Hospital.
UNDP: United Nations Development Programme.
UNFPA: United Nations Fund for Population Activities.
ABSTRACT
A deliberate attempt is made in this paper to situate the Nigerian women's reproductive and food production/processing problems within the larger context of the socio-economic and sustainable development of the country. Women's reproductive problems include high maternal mortality, adolescent poor self perception, illegal abortions, non-accessibility and non-acceptability of family planning, etc. Women provide some 60 - 80 per cent of the labour input in food production, processing and trade. But factor inputs very often do not reach them in any significant amount. This is a major reason for food supply deficits. However, these reproductive health and production problems cannot be fruitfully addressed in isolation, as they impact on each other and (are impacted upon by) the socio-economic and cultural environment. An alternative paradigm is postulated for the women's development. This is participatory, holistic and action oriented, for regarding women not only as beneficiaries but also as partners in progress for health care, income increases and empowerment for them.
I INTRODUCTION
The objective of this paper is to analyse essential aspects of women's reproductive health and their involvement in food growing/processing, with particular reference to Nigeria. In this first section of the paper, an analysis of relevant concepts and studies are reviewed on women's reproductive health and food growing/processing in Nigeria. Methodological procedures used are then discussed. In section II, relevant aspects of women's health and life in Nigeria are discussed in considerable detail. These include reviews of maternal mortality, food consumption and nutrition, economic activities and the impact of socio-cultural beliefs and practices. In section III, policy strategies are discussed, for sustainable development for women in Nigeria.
On an overall basis, holistic view of development is taken in this paper. Thus, women's reproductive health and food growing/processing are situated within the wider context of their health and life in section II. Further, in deducing appropriate development strategies in section III, a broad view of women's welfare is adopted, involving not only their health but also their socio-economic well being at the household, community and national levels. Thus, an alternative view of development is adopted. In this, women are viewed not just as beneficiaries but also participants, in the development process.
1.1 LITERATURE REVIEW
Some relevant concepts are reviewed here as a background for the rest of this paper.
1.1.1 BIOLOGICAL DETERMINISM
A useful departure point here is the "babies" versus "brawn" argument. The kernel of this is the view that women are the weaker sex, delicately created for pregnancies and nurturing babies (Adekanye, 1997). As against this, men are strong and are to undertake the heavier tasks. This is the biological determinism of women's development and work. It is reinforced by socio-cultural beliefs and practices, including the views of the two dominant world regions of Christianity and Islam whose tenets have generally regarded women as subordinate to men. There is also patriarchy which is the basis for descent and inheritance through the male line. Yet women are not really weaker than men, inspite of anatomical and physiological differences. Except in a few countries of the world, women live longer than men, inspite of the socio-economic and cultural disadvantages they have. In Britain, for instance, there are four women to every one man over ninety six years of age (Lucas, 1998).
1.1.2 REPRODUCTION AND PRODUCTION
A critical issue often raised with considerable cynicism, is whether women are producing babies, goods or poverty. Large families are traditionally regarded as a "gift of God", providing a large pool of family labour for work in the agro-economy. As against this positive view is the negative Malthusian view of population growth. World population grows at a geometric, while food supply increases at an arithmetic, rate. Technology development has, however, proved the Malthusian theoretical framework to be empirically invalid. In its modern form, however, the Malthusian population thesis emphasises the dangers of over population due to continuing high growth rates. This is especially so in the less developed countries where population growth rates reach and even exceed 3 per cent per annum compared with less than 1 per cent in many developed countries. Food supply increases have tended to be lower in the former compared with the latter. It is often said that the solution to this problem lies in population control through lower birth rates. This is not that simple, however, as population issues are often deeply rooted in the socio-psychology of people.
Of greater relevance, perhaps, is the reproduction-production socio-economic interface, in terms of the impact of one on the other and on the larger environment. Africa is perhaps the region of highest economic activity and fertility for women, co-existing with very high maternal and child mortality. Related issues include coping strategies deviced by the women for their maternal, occupational and domestic responsibilities. There is also the impact of the local system of domestic organisation, marriage, parenthood and kinship which defines what is "African and Un-African" even in conjugal relationships, (Oppong, 1994). These issues are considered later, in the design of appropriate strategies in section III.
1.1.3 WOMEN'S STUDIES
A survey of literature indicates that at least three different strands can be identified in studies relating to women in Nigeria. These are: agro-socio-economic, nutritional, and, obstetric and gynaecological studies. These three different strands remained separate virtually until the end of the 1980's decade. Some convergence then emerged from the beginning of the 1990's decade especially through the primary health care programme and activities of the Federal and State governments of Nigeria, the activities of local non-governmental organisations (NGOs) and international funding agencies; and government supported women's mobilisation programmes.
Salient aspects of these studies and activities include the following:
(i) The earlier studies and works on women in Nigeria were essentially socio-economic, concentrating on the role and activities of women. (Sudarkasa's 1961 - 1963 work later published in 1973 was a trail blazer).
(ii) Other socio-economic and consumption studies emerged (see for instance Adamu, 1972 and Adekanye, 1974)
(iii) The studies of food consumption and nutrition especially in terms of dietary intakes were undertaken essentially in the Departments of Nutrition. The University of Ibadan was a leader in this.
(iv) Studies and work on the diseases of women were essentially an aspect of the work of the Department of Obstetrics and Gynaecology (O & G). The University College Hospital (UCH) led the way in this, followed by other teaching hospitals in the country.
(v) Family planning clinics started with the Department of O & G of the UCH in the early 1970's.
(vi) Women's reproductive health studies are really a late arrival, associated essentially with the 1990's decade.
(vii) Government's primary health and mobilisation activities involved in the "health for all by the year 2000" programme.
(viii) Some networks funded essentially by international agencies have emerged especially during the last five years or so, working on women's reproductive health. These include the United Nations Fund for Population Activities (UNFPA), the McArthur Foundation and the Ford Foundation funded projects.
(ix) Available indications are that the health of women continue to be on average poor and is in all probability, poorer than say, a decade ago, due to the effects of structural adjustment (reduced incomes, cut back in health funding, etc. ), (Government of Nigeria, 1999).
1.1.4 REPRODUCTIVE HEALTH
In a narrow sense, women's reproductive health deals with child bearing, labour, puerperium, the care of the new born and breast feeding. Work done on pregnancy related diseases include that of inococa meningitis which kills rapidly during childbirth and the high incidence of obstructed labour, constituting 6 - 13 per cent of pregnant women's admissions. The puerperium (the first 42 days after childbirth), when most maternal deaths occur appears to be the least studied of the pregnancy/lactation cycle, requiring considerable more work, particularly from the socio-behavioural viewpoint. The earliest work on breast-feeding in Nigeria was done in the 1960's in the UCH, ( Harrison, 1998).
A broader view of reproductive health for women encompasses much more, covering virtually the whole of the women's life cycle, including the health of the girl child, adolescent sexuality, contraception, menopause and sexually transmitted diseases (STD). Less than 10 per cent of African women who need contraception actually get it, because of inaccessibility and perhaps non-acceptability due to socio-cultural barriers. Bad nutrition for the girl child pre-disposes her to anaemia and other pregnancy related diseases later. Other relevant issues include the following:
(i) Male responsibility in reproductive health is a relatively new field of research (SSRHN, 1998).
(ii) Reproductive health problems of adolescents (sexual assault, homosexuality, induced abortion, prostitution, STD including the AIDS virus etc.) appear to be on the increase, in part because of the economic recession, little research and perhaps society's little understanding and rather authoritarian and patronizing posture, (Adeyefa, 1998).
(iii) Adolescent nutrition and reproductive health studies indicate that some 50 per cent of maternal deaths in Nigeria are during adolescent years; about 12 per cent of female adolescents are stunted etc.
(iv) There are significant differences between ethnic groups in Nigeria in attitude towards aging and menopause.
1.1.5 FOOD GROWING/PROCESSING
Of particular relevance to this paper is Boserup's (1970) assertion that Africa is the region of female farming "per excellence". Several other studies and reports have documented this involvement of women in agricultural (particularly food) production. For instance on the role of women in African economies, the ECA (1967, 1975, 1976, 1977) indicated that:
(i) In the pre-colonial era, African women were generally engaged mainly in food farming, while men were occupied in hunting, heavy clearing and "perhaps some farming".
(ii) However, the colonial governments generally held the view that men were better farmers and that women's place was in the home.
(iii) This has resulted in men being used as contacts or reference for development policies and projects so that women became a marginal group with regard to education, commercialisation of agriculture and general involvement in the modern economy.
Of relevance here is Sudarkasa's monograph based on her survey of Yoruba rural women in Nigeria in 1961-62. Her main research findings are:-
(i) Yoruba women of South Western Nigeria are overwhelmingly traders; they process such food and non-food commodities as soap, pottery, oils, clothes, beverages, cooked food; they sell the processed commodities as well as the unprocessed farm commodities, especially those of their husbands.
(ii) Women (and men) regard women's employment as an integral part of their roles as wives and mothers so that they are almost completely economically independent and they make considerable contribution to nuclear, affinal and natal family expenditure.
(iii) In the husband - wife relationship, the wife has a status inferior to that of the husband and she defers to the husband in decision making.
Adekanye (1981) surveyed 600 rural women in the Northern, Eastern and Western parts of Nigeria. The research findings include the following:-
(i) When all the women studies are considered together, trading is the most important activity, outside the home, followed by farming.
(ii) However while the Ibo women of Eastern Nigeria are mainly farmers, the Yoruba women of Western Nigeria are mainly traders but the socio-economic activities of the Hausa/Fulani women of Northern Nigeria in farming or in trade are more limited because of the practice of keeping women in purdah away from the sight of men strangers.
(iii) The women who are farmers grow mainly food crops, particularly maize and rice, for subsistence and for sale. They perform almost all farm operations themselves, even when such heavy work as land clearing or ridge making is involved. However, if necessary, they utilise supplementary family or hired labour.
(iv) The food crops processed include rice in the North, palm oil in the East and maize, cassava and rice in the West and the East. The women either process some of their own farm produce for sale and home consumption or they obtain supplies of fresh food crops from their husbands and other farmers for processing before sale.
(v) In general, the women's socio-economic status is lower than that of men. Average incomes are lower for women than men. Society demands that the women should defer to the men, particularly in the home and the community.
(vi) The problem encountered by the women include overwork in the home, drudgery of the present hoe-and cutlass farming system, the use of old equipment and laborious methods in food processing, inefficient pricing in marketing, low incomes in agriculture and general problems of underdevelopment.
1.2 RESEARCH METHODOLOGY
The methodology used for the research relating to women's reproductive health and food growing/processing in Nigeria over the last four decades or so includes the following:
(i) Survey methods - going round cities, towns and villages for studies of respondents through interview guides and structured questionnaire, (Adekanye, 1974, 1981 and 1983).
(ii) Focused studies - using groups of men and women for studies on particular issues including technology development (Adekanye, 1991).
(iii) Rapid rural appraisal - for short and quick surveys (see Adekanye, 1997).
(iv) Statistical and biometric studies - a major component are the National Consumer Surveys which are modules of the National Integrated Surveys Nigeria (NISH) of the Federal Office of Statistic (FOS) which started in 1953. The NISH surveys various aspects of household welfare, including housing, health, education income, expenditure, etc. Other relevant surveys by the FOS (1999) are the General Household Survey (GHS) which collects socio-economic data relevant for explaining the incidence of poverty, the Multiple Indicator of Cluster Surveys (MICS) of 1995 on health, nutrition, etc., as well as the Agricultural Survey. The FOS subjects its data to necessary statistical and mathematical analysis. For capacity building and strengthening purposes, the FOS has obtained training and other assistance from the World Bank.
(v) Consumer studies and econometric studies - these include focused surveys of household food consumption and nutrition, expenditure (see Adamu, 1972 and Adekanye, 1974).
(vi) Analysis of food samples, intakes, food equivalents, the construction of food balance sheets, etc. - aspects of these are the estimation of nutritional content of food and several nutrition studies by the Department of Nutrition in the different Universities.
(vii) Hospitals and health clinics - these are especially for obstetric and gynaecological studies and treatment of women, including family planning and counselling.
(viii) Market based studies - for counselling and distribution of family planning devices - this has proved to be a useful method for reaching large groups of women.
(ix) Counselling in Churches and Mosques - this is proving useful for counselling for breast feeding and child development. Family planning is likely to encounter resistance, however, because of the continuing prevailing negative attitude of the different religious groups.
(x) Scholarships, fellowships and grants for studies and thesis writing - these have been employed especially for focused studies of population issues, including those by the Union for Africa Population Studies (UAPS) and the McArthur Foundation. The research and methodological procedures indicated above have been kept separate for analytical purposes. They are not necessarily mutually exclusive and are often combined in different ways, depending on the research objectives (see for instance SSRHN, 1998).
II WOMEN'S HEALTH, WORK AND LIFE 1
2.1 MATERNAL MORTALITY AND MAJOR CAUSES OF DEATH
Nigeria has one of the highest maternal mortality rates (MMR) in the world. MMR for Nigeria is about 1050 compared with 170 for Pakistan, 305 for Sudan, 566 for Ethiopia, per 100,000 live births. Research and records at the UCH, Ibadan as well as discussion with Health officials indicate that the major causes of maternal death are anaemia, haemorrhage, obstructed labour, and infection of chest and alimentary tracts. Anaemia has a predisposing effect on women towards birth complications and possible death.
In assessing the birth-rate causes of death for women, Oyediran (1987) indicated, that three main birth-related complications which cause the majority of maternal deaths are haemorrhage, eclampsia and septicaemia. While haemorrhage is more common with the older multifarious women, eclampsia or toxaemia is more common with women having their first babies. Similarly, in an analysis of 116 maternal deaths in Calabar and Aba in South Eastern Nigeria, it was observed, that 32.5 per cent of the maternal deaths were caused by haemorrhage, 15 per cent by eclampsia and 14 per cent by ruptured uterus. Similar studies in Ibadan in 1986 indicated that the major causes are haemorrhage, eclampsia and ruptured uterus due to obstructed labour and septicaemia, (Adekanye, 1987).
In analysing the causes of high MMR for developing countries, the WHO (1986) indicated that "direct" obstetric deaths constitute 50 - 98 per cent of all maternal deaths, and haemorrhage, infection and toxaemia and obstructed labour were cited as the leading causes of maternal deaths. However, it has been said that "63 - 80 per cent of all maternal deaths could probably have been avoided with proper handling". Hence health care related facilities are an important factor in cases of maternal mortality. These include inefficient handling of complications, lack of essential equipment and trained personnel, limited access to maternity facilities and lack of pre-natal care. There are reproductive causes including maternal age below 20 or over 35, illegal abortions and parity. Several socio-economic factors are also associated with high MMR.
____________________________________________________________________________
1 Much of the discussion here is based on Adekanye, (1987) and Adekanye, (forthcoming)
2.2 HEALTH CARE AND FAMILY PLANNING FACILITIES
Statistics on medical institutions and information on family planning indicates that, for instance in Oyo State in 1985, there were 312 maternity and child welfare centres, 134 hospitals and nursing homes, 309 dispensaries and 11 dental centres. There was a gradual increase in the number of these institutions from 620 in 1981 to 766 in 1985. Out of these 60.7 per cent were Local Government Authority (LGA) owned, 6.9 per cent were State owned 1.2 per cent were owned by the Federal Government while 31.2 per cent were private establishments. Women's registration in family planning clinics is an indication of accessibility to health care. Only in four of the twenty-four LGAs did such clinics exist by 1984 - 85. Out of these 32 per cent were in Ibadan Municipality alone confirming better accessibility for the urban areas compared with the rural areas. A further distribution of the women by marital status, occupation, education and religion shows that:
i. Most of the women were married; many of them were farmers, indicating that a significant proportion of the women came from the informal sector.
ii. Approximately 60 per cent of the women were illiterate or had only primary education implying that family planning is not restricted to educated women alone.
iii. Approximately 50 per cent of the 17,363 women were Christians, 31 per cent were Moslems and 19 per cent belonged to other religions, indicating that family planning cuts across all religious groups.
Recent work on family planning reveals the following:
(i) MMR is still high in Nigeria, at about 15 per 1000 live births
(ii) Family planning is regarded as an important aspect of governments Primary Health Care and the "health for all by the year 2000" programme
(iii) The safe motherhood campaign was launched in Nigeria in 1990 by the Society of Obstetrics and Gynaecology (SOG), focusing attention on family planning by reducing unwanted pregnancies, child-births and mortalities.
(iv) Rural women are, in general aware of modern family planning devices but are unwilling to use them, essentially for socio-cultural reasons
(v) Azikiwe (1993/1999) found that 68.5 per cent of the rural women studied in South Eastern Nigeria did not accept the use of modern family planning; 28 per cent accepted while 3.5 per cent were ignorant of the methods.
The reasons for non-usage include the following responses:
(a) Children are a gift from God
(b) Culture forbids killing
(c) Family planning does not solve economic problems
(d) More children give higher social status
(e) Husbands do not approve
(f) Male children are preferred to the female, for preserving the lineage.
2.3 FERTILITY
Pure fertility indicates the number of children per woman and is mot affected by the mortality of children. Another concept of fertility measures the number of live children per woman taking into consideration childhood mortality. Using these two indices, estimates of fertility levels in Nigeria are close to 7. These include a fertility rate of 6.34 children per woman obtained the Nigerian Fertility Survey of 1981 - 1982. Oyediran (1987) obtained estimates of 4.69 and 4.05 for mean of children "ever born alive" and mean of living children, respectively, for their survey in Oyo State in South Western Nigeria. Iyun et al (1987) also estimated the number of live children per family at about 4 for markets in the city of Ibadan, the Oyo State capital. The sampled population were described as medium parity (as against low parity of two or fewer live births and high parity of five or more children). Urbanisation and modernisation were suggested as possible explanatory factors for the reduced fertility of the Ibadan market women sampled. The implication of this is that fertility is understandably higher in the rural areas. However, Oyediran study (1987) did not confirm this as virtually the same fertility rate (4) was obtained for their rural sample.
2.4 AGRICULTURE AND THE RURAL ECONOMY
More recent work has tended to confirm the findings discussed in section I, on women's work in agriculture and the rural economy. Farm level data have in general indicated that women's involvement in agro-related activities of production and processing have even increased in the 1990's, from the 1980's levels (Adekanye, 1993, 1996, 1997, 1998 and 1999). The reasons for this include the problems of structural adjustment and coping strategies employed for survival. Not only do the women farm more intensely even on marginal lands, they work for longer hours. Those in full seclusion reveal that with "understanding between husbands and wives", many of them are able to own farms, operate them and/or get their husbands to do this for them
2.5 CONSUMPTION AND NUTRITION
Consumption and nutrition surveys undertaken since 1950 in Nigeria indicate the following:-
(1) A general tendency for adult male calorie and protein intakes to exceed those of the adult female.
(2) For Northern Nigeria where the staple foods are grain based, there is a general tendency for protein intakes to exceed recommended requirement, compared with calorie intakes.
(3) For Southern Nigeria, both energy and protein intakes tend to be below recommended requirements, (Nicol, 1959).
Dema (1966) indicated that diet in Western Nigeria was deficient in calorie, protein, calcium, thiamine and niacin. Collis, et al. (1962) indicated similar differences for farmers in Ilesa, Western Nigeria. Other relevant findings of subsequent surveys include the following:
(1) Although dietary intakes in rural Southern Nigeria tends to be generally deficient both in terms of calorie and protein, the deficiency is relatively greater for protein essentially because the staple foods are mainly roots and tubers.
(2) According to Olusanya and Omololu (1972), except for East-Central and South-eastern Nigeria, all areas of Nigeria were generally deficient in both calorie and protein intakes.
(3) There are seasonal variations in average dietary intake. According to Oluwasanmi (1966), for instance, in Uboma area of Eastern Nigeria, dietary was greatest during the "hungry season" of March to June.
(4) Socio-economic determinants of food consumption and nutrition are primarily and most importantly income, and secondarily other related variables including urbanisation, education and employment, (Adekanye, 1974 and Aromolaran, 1987).
Quantitative estimates of the nutritional status of women per capital per day include:
(1) Adult females - 3006 calories and 105 crude protein (McFei 1967)
(2) Adult females (rural Ibadan - Osegere) - 1945 Kcal and 37.3gm protein.
(3) Lactating females (rural Ibadan - Osegere) 2144 Kcal and 22gm protein.
The quantitative estimates indicate in general that nutrient intakes for women are generally below those of men, although there are a few exceptions. The implication is that in the rural areas, for instance, where nutrient intakes are more deficient relative to recommended levels, women intakes are even more deficient.
In the comparative analysis of daily per capita nutrient intake undertaken by McFie, (1967) calorie and protein estimates for men in Lagos in 1967 were 1940 Kcal and 51gm, respectively, compared with 1464 Kcal and 42gm protein for adult women while those for lactating women were 1769 Kcal and 53gm protein. Similarly in the study by Oni (1987), adult male met 59.6 per cent of recommended calories and 35 per cent of protein compared with 57.2 per cent of recommended calories and 33.2 per cent of protein for adult females.
Several reasons can be given for this, including the following:
(1) The socio-cultural factors discussed below which amongst other things, allow for men take the choicest portions of food.
(2) Men's incomes are generally higher, hence they are in a better position to buy more and higher quality food.
2.6 LOCAL TRADITION
Several factors, relating to local tradition adversely affect women's health, life and well-being in Nigeria. Some of these are discussed below. However, no attempt is made to indicate that all women are affected by all these factors. Furthermore, with modernisation, many of the practices no longer take place, at least not in their traditional and pure forms.
(i) Birth of a Baby Girl: A baby girl may be rejected psychologically or even physically if the desire is for a male child. The mother of such a baby girl may be forced into several repeated pregnancies with the attendant health problems.
(ii) Tribal Markings and Circumcision: Babies are usually named on the seventh, eight or ninth day for a girl, boy or twins, respectively. Very often this is used as occasion for tribal markings, circumcision and related rituals, although tribal marks are dying out amongst the educated. Although female circumcision is not undertaken in hospitals, it is performed by traditional healers and surgeons. Very often this is limited to clitorectomy but may include the excision of the labia minora. There are risks of infection, haemorrhage and tetanus for the baby. Problems of excessive scarring, the formation of keloid, disturbed sexual functioning and difficulty during delivery may result later in life.
Unlike in the case of male circumcision, there are no health benefits of female circumcision. Several studies have documented its health hazards. For instance, Badejo (1983) reviewed the cases of twelve female and twenty five male children , aged from five days to eighteen months. Four (33 per cent) of the female had life threatening haemorrhage; another four (33 per cent) had developed epidermoid cysts while two others developed labia fusion and their urethra openings were displaced. They had to have vaginoplasty for viginal reconstruction. The complications of female circumcision identified by Egwuatu and Agugua (1981) among the Igbos included haemorrhage, epidermoid cysts, labia fusion, urinary retention, recto-viginal fistulae and tetanus. Other complications develop later in life and during delivery.
In a study of 181 patients at a family clinic (Oyediran, 1987) it was observed that there was an inverse relationship between support for female circumcision and education. About 54 per cent of the respondents who supported female circumcision had no formal education as against 18 per cent of them who had secondary education. It was also found that 78 per cent of the women had been circumcised at birth, 15 per cent at puberty and 6 per cent as adults. Furthermore, the proportion of those whose children had been circumcised decreased with increasing education, implying that education is a strategic component for an effective anti-circumcision campaign.
(iii) Female Upbringing: A girl's upbringing by and large affects her perceived future role of wife and mother. She receives training from her mother on cooking and processing, trading and even farming. It is of considerable concern for a mother to have a lazy daughter. To a considerable extent this lays the foundation for considerable over work for women.
(iv) Preparation for Marriage: Marriage is traditionally expected to occur when a girl is about 20. When it occurs especially later, the girl may be regarded as a freak with attendant tension and anxiety for the girl and mother, resulting even in several trips to the traditional healer with other attendant health hazards. Preparation for marriage includes several other traditional ceremonies including confinement and fattening up.
(v) Early Pregnancy: Several studies indicate problems of early marriage, unwanted teenage pregnancies and, delivery and other complications. A survey in Kano revealed that 43 per cent of the women studied had married before they were 14 and 87 per cent before they were 20 years old. Another study, in Sokoto in 1975, indicated that 94 per cent if the women surveyed who did not have any formal education had married before they were 16 compared with 49 per cent for those who had some secondary education (Oyediran, 1987). Effiong and Banjoko (1975) found that 31 - 40 per cent of the girls aged 16 and below whom they were studying were married. Also, the Nigeria Population Commission in 1981/82 revealed that 43.7 per cent of 15 - 19 years old were married.
The safest period for child bearing is between ages 20 and 35. There are several complications attendant to child bearing before the age of 20. These include obstructed labour due to cephalo-pelvic disproportion. It was found, for instance, that 27 patients out of 56 had caesarean delivery because of small pelvis relatively common with immature girls, (Adewumi, 1986). Another complication is toxaemia or pregnancy related hypertension which is more common with first pregnancy. Immature expectant mothers may not realise the full import of regular ante-natal care thereby causing avoidable distress or even death. Previous studies have indicated lower rate of maternal death for booked compared with unbooked deliveries. This includes a lower rate of 4.6 per cent per 1,000 births for the former compared with 107.1 per 1,000 births for the latter, for 1973. Corresponding estimated rates are 2.85 deaths per 1,000 live birth for booked compared with 27.06 per 1,000 for unbooked for 1980. It was estimated also, for Ibadan, that maternal death for unbooked patients was twelve times higher than the booked and was most common within the 15 to 19 years age group, (Adewumi, 1986).
Another problem resulting from early pregnancy is the incidence of abortion. On the basis of a five-year study (1974 - 79) at the University of Benin Teaching Hospital, it was indicated that 61 per cent of all induced abortions occurred in adolescent girls. Also, it was found that 55 per cent of a sample of women aged 14 - 20 years were sexually experienced; 45 per cent of these had been pregnant at least once and most of these had terminated the pregnancies. Such illegal abortions can be fatal or lead to such complications as cervical incompetence or secondary infertility, (Oyediran, 1987).
Vestico - viginal and recto - viginal fistulae often result from teenage pregnancies because of cephalo-pelvic disproportion where the baby's head is too big for the immature pelvis. In such cases obstructed labour results, leading to possible damage to the cervical tissues. Fistulae and incontinence result, with urine and / or faeces trickling down uncontrollably. Indications are that there is along waiting list for available surgical repair facilities. One hospital has reportedly performed 700 such repair operations per annum for the past ten years (Oyediran, 1987).
2.7 OTHER SOCIO-CULTURAL FACTORS
Several factors affect the health, nutrition and well - being of women. These include the following: arranged marriage, the dowry, polygamy, food taboos and similar beliefs, food sharing within the family, inability to have children in the right number and of the right sex, divorce related problems, menopause and widowhood. These are discussed below.
(i) Arranged Marriage: This takes place, particularly where a girl is regarded as precocious. In this case she is quickly married off to a man older than herself.
(ii) The Dowry: This custom still exists in many parts of the country. The dowry is received by the woman's parents as a token of the appreciation of the care taken in nurturing the girl. It is not supposed to be payment for the girl but the amount paid often increases with the educational attainment of the girl. Hence, when huge sums are paid as dowry, this gives the impression that the girl has been purchased, creating strains in the marriage.
(iii) Polygamy: Traditionally, the number of wives and children a man has is supposed to be an indicator of status, apart from providing him with a pool of family labour for production. Increasing cost of living, however, means that a man may not be able to provide adequately even for one wife and under-nutrition results when two, three or more wives are involved. A related issue is that of food sharing and existence of several "pots" or catering facilities in the household. Traditionally, a man has the choicest portions of food. Furthermore, in a polygamous setting, it very often happens that each wife has her own "pot" for herself and her children with the husband "circulating" between the different "pots". The wives compete for the husband's favour in catering for him (Adekanye, 1974)
(iv) Food Taboos: Pregnant and lactating mothers are often prevented from eating certain food items such as snails, pawpaw or even salt, palm oil and pepper before the baby's naming ceremony takes place. These food taboos and such other traditional beliefs probably served some useful purpose such as the prevention of allergies. However, over time they have probably become irrelevant but are nevertheless adhered to even among the educated.
(v) Infertility: A woman may not be able to have children in the number and of sex desired (usually male). Infertility is usually assumed to be the woman's fault, occasioning several trips to faith and traditional healers with all the attendant problems. A related issue is the birth of mal-formed child. Twin and other multiple births were regarded as abnormal in certain communities, and this was usually attributed to some fault in the woman. The times have changed and twins are no longer readily regarded as abnormal children, to be killed at birth. However, some women beg for aims for their twin children. The reason often given for this is that they had been told by traditional healers to do this to protect the health and lives of the twins.
(vi) Divorce: This remains uncommon in the traditional setting and takes place only after family counselling has failed. Usually, the woman does not even have her mother's consent for divorce and every barrier is put in her way. She is often advised to suffer it out as her mother did before her.
(vii) Menopause: It is traditionally assumed that, at the cessation of menstruation, a woman stops being a woman as her "productive life" has come to an end. She is relegated to the background, usually taking the back room, giving place to younger "more productive" woman. If the woman has no children, this becomes particularly painful for her.
(viii) Widowhood: In many parts of the country, there are many ceremonies attached to widowhood, some of which are supposed to indicate who is responsible for the man's death. Death is not assumed to be natural except in the case of the very old. The widow has to mourn for three, six, or even twelve months depending on the custom of the community. She may have to shave her head, wear black clothes and generally refrain from taking care of her person. At the end of the mourning period, she is inherited by a male relative of her dead husband, just like the rest of the man's property. However, unlike in the case of a woman, a man who has lost his wife is really not supposed to "sleep alone" for any length of time. Furthermore, allocations to wives from the dead man's property is usually in direct proportion to the number of children each woman has. This means a woman who has no child may have little or nothing allocated to her.
(ix) Extended Family System: There is also the in-law factor. For instance, a man's property on his death most often belongs not to his wife and children but to the extended family, even where she has many children and was legally married under the marriage ordinance. A considerable proportion of his income was probably spent on members of his extended family in his life time.
III CONCLUSIONS AND STRATEGIES
3.1 CONCLUSIONS
Three major conclusions have emerged from the Nigerian case study, viz.:
(i) Women's reproductive health problems are still of considerable concern with the continuing high MMR, adolescent sexuality problems, including the AIDS pandemic, the relative neglect of the girl child etc.
(ii) Women perform significant and sometimes conflicting maternal, conjugal/domestic occupational, reproductive and productive functions.
(iii) Gender aware and sensitive strategies need to be deviced to protect the women's health while simultaneously improving their social-economic welfare and status.
Specifications for reproductive health, agro-related tasks, appropriate strategies, alternative development paradigm and orientation for future research are indicated below.
3.1.1 REPRODUCTIVE HEALTH
(i) The MMR is unacceptably high and needs to be halted quickly and effectively.
(ii) The girl child needs to be better cared for and protected.
(iii) The adolescent girl is badly prepared for her maternal roles.
(iv) Male sexuality and behaviour are significant determinants of women's reproductive health, productive efficiency and overall welfare.
(v) Research has hardly had the desired positive effect on women's reproductive health.
(vi) The socio-economic and political environment is a major determinant of women's welfare.
3.1.2 AGRO-PRODUCTION
(i) The overwhelming importance of women in food production, processing and distribution indicates that women's involvement should constitute a strategic component of a food sufficiency strategy for Nigeria.
(ii) Women in full seclusion undertake considerable income-generating activities within the confines of the family compound implying that for development purposes, they are not to be treated just as women of leisure.
(iii) Nigerian society being mainly patrilinear, women's status is generally inferior to that of men, implying that except specific measures are taken to integrate women into development, the tendency may be to bye-pass them.
(iv) Women's home related activities (including fetching water, cooking and cleaning) as well as the agro-related and income generating ones are such that they appear over-worked. There is therefore, the need for selective mechanisation of difficult processes in agriculture, and in the home through the use of simple mechanised equipment for simple grating, grinding and processing food. The drudgery in the present system would thereby be reduced and productivity would be enhanced while the essentially labour intensive nature of the processes would still be retained.
(v) There is scope for home-based industrial development in form of cottage industries producing, processing and distributing agricultural commodities through the involvement of women, thereby promoting agro-industrial development.
(vi) Women's educational level, relative to that of men, is still generally low. If a developmental view of education is taken (i.e. as the process for transmitting economically useful knowledge) then efforts need to be made to undertake deliberate (as against non-deliberate) transmission of scientific and developmental knowledge for women to enhance their productive capacity.
(vii) Inadequate supply of agricultural requisites (e.g. credit, extension, improve seed etc.) is a problem which limits effective performance of women in agriculture.
3.2 STRATEGIES
In general, the notion of wives of leisure is foreign to Africa, as women have always worked, even within the confines of the family compound for the women in seclusion. The reproductive and socio-economic role and importance of the women exceeds their low status, relative to men's. This is often due to socio-cultural and religious factors, leading to male - female imbalance in food consumption rate, health care, work load, access to farm inputs, income, etc. The reproductive health problems of the women are particularly worrisome especially because of the continuing high maternity mortality and inadequate care for the girl child and female adolescent. With particular reference to agriculture, women occupy an important position in terms of the physical farm activities of production as well as in the off-farm processing and trade, particularly for food. But their inferior status often limits their access to resources. On an overall basis, therefore, empowering women for sustainable development, requires appropriate strategies aimed at grass root and mass mobilisation in action programmes. Women are to be involved in identifying their own problems and solutions to these problems, at the local level.
3.3 ALTERNATIVE DEVELOPMENT PARADIGM
An alternative development paradigm is postulated to promote women's health through out their life cycle while stimulating their socio-economic empowerment at the same time. The alternative paradigm is to be:-
(i) appropriate, to the needs of the women;
(ii) participatory, in that the women beneficiaries are to be involved in the design, execution and monitoring of projects;
(iii) holistic, and integrative, by focusing on women's reproductive and production related problems rather than on reproductive health in isolation;
(iv) action oriented, in being specifically aimed at the grass roots and for mobilisation for women in particular.
Previous development paradigms have tended to be, in general, top-down and separatist in approach. Instead, it is advocated here that the women be involved in devising solutions to their own problems.
3.4 ORIENTATION FOR FUTURE RESEARCH
The direction for future research emanates from the specifications for the conclusions, the strategies and the alternative development paradigm indicated above. The focus and topics for research are to include the following:
(i) The girl child, not only in terms of health care but also food consumption and nutrition and basic education.
(ii) Adolescent sexuality, especially the STD's including the AIDS pandemic, sexual violence, self perception of the female adolescent, etc.
(iii) Grass root mobilisation for women's empowerment and development, through improved and productivity enhancing projects.
(iv) Action programme, specifically for promoting food production and security.
(v) Family planning , child spacing and breast feeding.
(vi) Food consumption and nutritional improvement, aimed at correcting gender imbalance.
(vii) Education is to be given special attention, at all levels, both formal and non-formal, particularly at the local level.
(viii) Increased medical and bio-medical research on reproduction related diseases of women.
(ix) Appropriate technology development for agro-socio-economic development.
(x) Promoting responsible male sexuality for family development.
(xi) The process of aging, menopause and the socio-economic responsibilities of society.
In all this, education occupies a pivotal position. This is not just for reproductive health but also for overall and sustainable development. Education is a continuous process not only for skills transfer, employment and income generation but also for food consumption, proper nutrition, and health maintenance. The type of education required here is both formal and non-formal including mass mobilisation for men, women and children. This way, it will be possible to impact positively, amongst other things, on socio-cultural beliefs that tend to change only gradually through development.
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