Overcoming low birth registration coverage and improving death registration in Nigeria

bySharon Oladiji

Outline1. Description of the Challenge

– The Country– Background information and problem description

2.Critical Evaluation – Underlying Causes– The methodological and conceptual framework

3. Changes in Practices– Role of legal Moral and social norms– What did not work– Plan of action to promote institutional shift

4. Conclusion

The country•Land area of 923,768 square kilometres. •Population of about 162 Million (2006 Census). •Operates a 3-tier federal system of government

comprising the Federal, State and Local Governments.•There are 36 states, 774 local government areas and a

Federal Capital Territory, Abuja. •Six geo-political zones.• Children (0-17 years)constitute about 50.•Children < five populations constitute 17%.

Map of Nigeria

Rivers

Ekiti Osun

Lagos Ogun

Oyo

Delta

Bayelsa

Ondo Edo

Kogi

Sokoto

Niger

Kwara

Kebbi

Kaduna

Zamfara

Adamawa

Abia Imo Anambra Enugu

Cross River

Akwa Ibom

Ebonyi

Benue Taraba

Jigawa

FCT, Abuja Nassarawa

Katsina Kano

Gombe

Plateau

Bauchi

Yobe Borno

Background information and problem description -1

•Efficient civil registration systems.•Importance of birth and death registration.•Birth registration is a frontline tool in combatting of early

marriage. •Parents and care-givers cannot inflate age to disguise child

marriage if evidenced by birth registration.•Real protection is elusive in the absence of certainty about

age, be it 12, 16, 18 or anywhere in between. •Death registration helps monitoring the impact of public health

programs and child hood deaths. •All these can be linked to other harmful practices discussed

during the UPenn course

Background information and problem description -2•Major disparity exists between the South and the

Northern part of Nigeria.•58% of about five million children born annually in Nigeria

are not registered at birth:– They have no birth certificates, – In legal terms they do not exist,

•Northern zones have 2 times lower registration levels compared to southern zones.

• All health indicators are poorer and worse off in the North compared with the South.

Southern and Northern States DisparityIndicators South North

Birth registration 31.4% 16.2%

Adolescent birth rate 89 births for 1,000 women

170 births for 1000 women

Fertility rate 5.7 births per woman

7.2 births per woman

Infant mortality rates 55 and 83 per 1000 live births

123 and 208 per 1000 live births

Women literacy rate 81% 37%

Underlying causes of low birth registration in the North•The cultural values of the people of Northern Nigeria are

practically shaped by religion/Islam.•Practice of a serious gender bias/norm that excludes most

women from the entire decision making process in the home.

•There is a continuous disadvantage in educational access for girls and high rates of female illiteracy.

•Huge ignorance and lack of awareness of the importance of births and deaths registration. Limited knowledge base.

•Most women give birth at home and do not register the births of their children and do not access health services or attend health centres.

Scripts and Schemata

The ‘script’ for a lot of very rural women in Northern Nigeria whether in Purdah or not features:•“limited knowledge base” •“delivering of babies in their homes”, •“not knowing the importance of accessing health care services”•“disadvantaged educationally and with poor socio economic status” •“exposed to cultural/religious practice based on deep rooted religious beliefs”impacting negatively on the registering of births and deaths of their children and other health indicators.

Conceptual Framework

Normative Expectation

Empirical Expectation

I believe other women

believe I must be

subjected to my husband

I should be subjected

to my husband

Social Expectation

Deep rooted core beliefs

Pattern of behavior

with sanctions

Schemata/stereotypesScripts

Critical Evaluation of the work• Strategies that worked:• Core group formed: NPOPC and NPHCDA and INGOs.• Changed the script through - Coordinated Actions:

Opportunities such as MNCHW, IPDs and RI targeting newborns and under-five population.

• Social Network Analysis by Health Social Mobilization teams: Communication strategies developed and implemented.

• Worked within high degree and nodes: Religious and traditional leaders persuaded to shift grounds.

• Incentives introduced: Level of ignorance and practices fueling the problems dealt with.

• Organized diffusion took place: Over a million births registered during 2 rounds of MNCHW- 8 days

What worked• Engaged second core group to implement the MNCHW.•Value deliberation: Preparatory and participatory consultation

and deliberations between the NPHCDA and NPopC held in Kano state- Northern part of Nigeria; to

• Trigger: integration activities •Clarified key issues •Mapped out the diffusion strategy, logistics, roles and

responsibilities of different teams involving:– birth registrars, – health social mobilization teams, – sub-registrars and health facility personnel

Diffusion of the innovation

• Diffusions enabled out-reach to thousands of women/mothers/care givers of millions of <5 under-five in communities including remote, excluded and hard to reach areas.

• House to House (H H) ‐ ‐ ‐engagements, established Fixed Posts (FP) and use of Special Teams

Source: Everett M. Rogers, 2004.

Change in practices•Positive sanctions/Incentives introduced: ”obtain birth certificate free to

obtain passport for your child, to be able to go to Mecca”• Change in social expectations:• Women were made/allowed by their husbands to access health care

services and register the births of their children. – Women changed their factual beliefs and registered the birth of their

children, because other women in their reference networks (within the same communities) conformed to registering (empirical expectations).

– Women did register their children because most women in their relevant networks believe that they ought to conform/ought to leave their homes and enclaves and come out to register their children (normative expectations).

•

Key results•334,027 births from 33 states and FCT registered

in May/June rounds. •694, 922 children in 34 states and the FCT

registered during the November/December rounds.

•Within the two rounds (4 days each) of MNCHW, about 1,028,549 births were registered.

MNCHW State Results, 2010May-June 2010 Nov-Dec 2010

Rivers

Ekiti Osun

Lagos

Ogun

Oyo

Delta Bayelsa

Ondo Edo

Kogi

Sokoto

Niger

Kwara

Kebbi

Kaduna

Zamfara

Adamawa

Abia Imo Anambra

Enugu

Cross River

Akwa Ibom

Ebonyi

Benue Taraba

Jigawa

FCT, Abuja

Nassarawa

Katsina Kano

Gombe

Plateau

Bauchi

Yobe Borno

20,000-39,000

5,000-19000

missing

40,000 and above

Rivers

Ekiti Osun

Lagos

Ogun

Oyo

Delta Bayelsa

Ondo Edo

Kogi

Sokoto

Niger

Kwara

Kebbi

Kaduna

Zamfara

Adamawa

Abia Imo Anambra

Enugu

Cross River

Akwa Ibom

Ebonyi

Benue Taraba

Jigawa

FCT, Abuja

Nassarawa

Katsina Kano

Gombe

Plateau

Bauchi

Yobe Borno

Mockus theory of Legal, moral and social norms•Despite the ‘Births and Deaths (Compulsory

Registration)’ Act No.39 of 1979’ and Act 69 of 1992 in place - but low coverage persists (Legal norm).

•Social mobilization of men and women, raising awareness on the importance of birth registration, changing of social expectations, (Social norm) use of incentives and high degree nodes (Moral norm) all contribute to achieving higher birth registration coverage.

What did not work•Issue of death registration was not raised/affected.

•Core beliefs of keeping women in the background- to be seen and not heard, to have poor education status and deep rooted belief of Purdah was not affected.

Plan of action for institutional shift

•Post triggering actions:•Diagnostic study: by Ulamas and muslim clerics to

create messages for diffusion.•Public declaration.•Working with women groups and town criers•Strengthening fathers/male dominated core

groups/value deliberations.•Social marketing.•Sustainability strategies.

M&E Indicators• QUANTitative: Help to answer questions

about things inherently expressed in #• How many? How often? How much?

• QUALitative: Help to demonstrate, describe, or measure that something has happened

• How? When? Who? Where? Which? What? Why?

Qualitative!Qualitative!Quantitative!Quantitative!

ConclusionThe approach:

– to raise awareness on the importance of birth registration;

– to dealing with socio cultural barriers; – unequal power relations;– patriarchal beliefs– that persistently limits mothers and care givers to

register their children

will be further accelerated by successful models learnt at Upenn.

Thank you