Dr Orji Ejike is the country director of IPAS Nigeria. In this interview with Judd Leonard Okafor he speaks on the reasons why Nigeria still has the highest maternal and infant deaths in the world, even as he advocated for favorable laws to support abortion as a major ingredient in reproductive health.
How can Nigeria reduce maternal and child mortality?
If we are able to implement properly what we have on ground, we will meet the millennium development goals. The midwifery scheme was conceptualized based on the gaps that were seen in the field. One of the major gaps is that only 35% of women--the national average--have skilled attendants when they are pregnant. The other 65%, nobody is attending to them, and that's why these deaths are occurring.
The other significant thing is that poverty is quite high. If you follow the trend of maternal deaths around the country in terms of zonal arrangement, you will see where you have more of the deaths are where poverty is very high.
In the North, poverty ranges about 70%, while in the South it ranges between 25%, in the Southeast to about 35% in the Southwest. If you look at the disparity, you see that poverty is a major issue. For a little analysis: between the Northeast and the Northwest, there is little disparity of about seven percentage points in terms of poverty reduction.
As of two, three years ago, the maternal mortality of the Northwest if 2,500; than that of the Northeast is also 2,500. The north central is about 1,800. The reason is the 7% drop in poverty. That's how sensitive poverty is to maternal mortality.
Already, there is some significant drop in the deaths. It is the midwifery scheme that is actually making that happen, but it is not being implemented fully. Reasons range from lack of proper motivation for nurses to stay where they have been posted. There was a recommendation of N75,000, salary but the Federal government is paying thirty. States were supposed to pay twenty-five and local governments twenty. Most of the states and local governments aren't paying that money.
If that is fully implemented, I can bet there is no way there would be a dent in terms of MDG 5. And once the maternal mortality reduces, it would have a salutary effect on infant mortality. The reason infant mortality is high is once a child loses a mother and is under the age of five, the chances that that child will die are high. We have a high maternal mortality in Nigeria; we have the highest infant mortality in the world.
It was 201 per 1,000 live births, but it has slightly come down right now. If the midwifery scheme is properly monitored and evaluated, and you inform and sensitize the women that the services are there and free, and do a huge attitudinal transformation skills training across board in the health system, I don't have any doubt that the millennium development goal will be met.
The best way to even fund it ad infinitum is for the president to sign the Health bill. If it is signed, two percent of our national consolidated income goes to the primary health care service.
Mind you, 70 to 80% of services are supposed to be at primary care level. The other 20% will be secondary and tertiary. But almost all local government primary healthcare centres are broken down.
We also need to put a cap on our population. Our growth rate is 3.2% right now. At independence, we were just 56 million. Britain also was 56 million. Fifty years later, we added more than 100 million but Britain has added only about 8 million. The per capita income of Britain is hovering around thirty-something thousand dollars a year while ours is about $240 a year--less than a dollar a day. Family planning is a major ingredient in our national planning development.
Where do you find the most opposition against safe abortion?
In religious beliefs. A particular Christian sect (catholics) will not want to hear about abortion. Meanwhile, there is something we call The Law of Double Effect, which is also a doctrine of the Catholic Church. It has been existing since 1861. Rome is the headquarters of the Catholic Church. In Rome, they have a comprehensive legal law on abortion--Termination of Pregnancy Act 1971. It is only in Nigeria that people would want to mix religion with something that is purely a public health crisis issue.
America, where some of the anti choice people come from, (Like Sharon Slaters and Don Fider; they came to Nigeria to talk about anti choice issues) a minor can go out and get a termination of a pregnancy she doesn't want. In their own backyard, if their women are raped, or have incestuous relationship or their health is in danger, they have a safe termination. They come to Nigeria and tell Nigerians, 'they are killing our babies, don't allow women to terminate pregnancies that they don't want.' Their maternal mortality rate is below 10 per 100,000 live births; meanwhile we are losing 545 women per 100,000 live births.
How then to step up contraceptive prevalence rate?
If you look at the MDHS, 60% of women know about contraceptives. But you ask yourself, what do they really know? Yes, they know there is a way to stop having so many children or to limit the number of children you have, that's all they know. They don't know what the contraceptives are and how there are different types. So how to step it up is by working with the women themselves, doing community outreaches and then making sure any time any woman steps into a health facility, that is a big opportunity that should not be missed for any reason.
In other words, integrating family planning services into all health services--cancer screening, antenatal care, post partum care, post abortion care, screening for HIV. Opportunities, when a woman steps into the hospital should be grabbed as an opportunity that should not be missed. Women have word of mouth campaign, so when they go back they talk to other women. Most importantly, there are lots of women groups. Take the information to the women's groups.
In the Southeast, the Igbos have August meeting, where you see nearly 2000 women coming for the meeting. What we have done is to piggyback on those meetings to pass reproductive health information for the past three, four years. Every august, we go to three or four states, seven communities, and it is already yielding results.
How do you intend to get the support of religious organisations backing women's freedom to choose or use contraceptives? If they don't endorse it, people feel it is not right?
The problem with religion is interpretation. The Christian religion says, 'Husbands love your wife as the Lord loves the church.' If that is so, you love your wife up to the point of making sure she gets everything she needs to be alive and healthy, isn't it? If you are a man and you have information that if you make your wife pregnant before she is 18, she will probably end up with complications that might kill her; if she has more than two children within less than two years, there is a possibility of getting into trouble; if she has more than four and going to the fifth pregnancy, that fifth pregnancy might be more dangerous than the other four put together; or if your wife is almost getting to 40 and you are still trying to make her pregnant.
If you have all that information, the onus now lies on you the man, if you are truly a Christian, to make sure you avoid such things happening to her, unless you want her to die. I won't say the problem is religion; the problem is individual interpretation of religion. For people who say they don't want modern methods of contraception and are deeply rooted in religion, so abstain [from sex].
The Billings Method, natural method, does not work. So if you don't want to use a scientifically tested method to keep the number of pregnancies to the way it should be and keep the woman alive and healthy for you, then once you make her pregnant and you want to space for two years, please leave her alone for the next two years.
Because if you touch her and say it is the Billings Method, and it is not done properly--it is often subjective and most often than not is not done properly; you have to check your mucus to know when it is thick and all that. I am not saying if it is done probably it will not work, but, you see, how many people will be able to do that anytime they want to have sex? Sex is something whence two people are involved, it can happen any time.