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 Table of Contents  
REVIEW ARTICLE
Year : 2013  |  Volume : 12  |  Issue : 2  |  Page : 103-113

Sexual and reproductive health: Concepts and current status among Nigerians


Department of Obstetrics and Gynecology, College of Health Sciences, Faculty of Clinical Medicine, Delta State University, Abraka, Nigeria

Date of Web Publication20-Jun-2014

Correspondence Address:
Lawrence Omo-Aghoja
Associate Professor of Obstetrics and Gynecology, College of Health Sciences, Faculty of Clinical Medicine, Delta State University, Abraka
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2384-5589.134906

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  Abstract 

Background: Sexual and reproductive health (SRH) came to the fore against a background of increasing rates of liberal sexual behavior and activity, with its attendant reproductive health implications and sequelae globally. The Millennium Development Goals, particularly eradication of poverty and hunger, cannot be achieved if population and reproductive health issues are not addressed. Materials and Methods: This review involved an extensive search of databases that included Medline, Elsevier, Medscape, Medicine and PubMed. Literature on the subject was also researched using manual library searches of cited textbooks and articles in journals. The search covered a period of 1960 to 2013, but the literature included was from 1985 till date. Results: The status of SRH of Nigerians remains abysmally poor and available data tend to suggest worsening indices. Conclusion: The right of every citizen, particularly women, to lead the highest standard of health must be secured as good health, in particular SRH, is a sine qua non for productive and fulfilling life. The right of all citizens, especially women, to control all aspects of their heath, in particular their own fertility, is basic to their empowerment. Therefore, a society where individuals have knowledge, skills and resources to enjoy their sexuality is one we must all aspire to be part of and bequeath to future generations.

Keywords: Concepts, current status, Nigerians, sexual and reproductive health


How to cite this article:
Omo-Aghoja L. Sexual and reproductive health: Concepts and current status among Nigerians. Afr J Med Health Sci 2013;12:103-13

How to cite this URL:
Omo-Aghoja L. Sexual and reproductive health: Concepts and current status among Nigerians. Afr J Med Health Sci [serial online] 2013 [cited 2019 Mar 26];12:103-13. Available from: http://www.ajmhs.org/text.asp?2013/12/2/103/134906


  Introduction Top


Sexual and reproductive health (SRH) is a relatively new concept in the context of the dynamics of contemporary global issues. [1] It came to the fore against the background of the worldwide increasing trend in the rates of liberal sexual behavior and activity, with its attendant reproductive health implications and sequelae. [1] SRH is closely intertwined with the trio of Health, Population and environment, the three foremost challenging issues currently requiring global attention. It is greatly and significantly influenced by sociocultural, political and religious considerations. [1],[2] "It 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 to its functions and processes. 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 right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning, as well as other methods of their choice for regulation of fertility which are not against the law, and 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. In line with the above definition, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and wellbeing by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases." [3] The Practitioners of SRH are usually drawn from across disciplines, which may include Obstetricians and Gynecologists as head of the team, Sociologist and Social workers, Counselors and trained nurse/midwives. Other practitioners are Teachers, Community stakeholders and heads of family, Religious leaders and, indeed, just anybody.

Awareness about women's health issues that lead to the crystallization of this subject matter was raised by the passionate works of earlier leading advocates and champions of maternal wellness. [2],[4] The first major attention was following the seminal publication in the mid -80s of Rosenfield and Maine, [4] who were working in Colombia University. They raised a very critical question in their Lancet publication captioned: Maternal mortality - a neglected tragedy: Where is the M in MCH? About the same time, Harrison, [5] working at Zaria in northern Nigeria, in his publication in the famous British Journal of Obstetrics and Gynecology titled: Childbearing, health and social priorities: A survey of 22,774 consecutive hospital births in Northern Nigeria noted social, cultural and educational factors as crucial underlying factors in maternal morbidity and mortality and the association of early marriages (6% of mothers under 15 years accounting for 30% of maternal deaths). Before then, the overall global attention was on child survival without recourse to the "goose that lays the golden egg." However, following these triggers, the scope was broadened to include maternal health issues in the context of reproduction and family planning. Before these, some earlier international conferences such as the World Population Congress (WPC) that was held in Bucharest (1974), Convention on the elimination of discrimination against women (CEDAW, 1979) and International conference on population in Mexico in 1984 had attempted to look at issues and modifiable factors that could be addressed to optimize WOMEN and maternal health.

These efforts were hardly translated into concrete and palpable realities as a number of largely sociocultural gender impediments and religious considerations militating against the [6] women folk acted as obstacles. Advocates of women's health issues matched these obstacles with sustained advocacy activities that led to successive global initiatives and international conferences relevant to women's SRH, including the 1987 Safe Motherhood Conference in Nairobi and the 1986 through 1987 Carnegie Corporation Prevention of Maternal Mortality Network in West Africa. [7],[8] Others were the World Conference on Human Rights (WCHR, 1993), International Conference on Population and Development (ICPD, 1994), World Conference on Women (WCOW, 1995), ICPD+5 (1999) and the WCOW+5 (2000). These initiatives argued strongly that issues that border on reproduction and maternal health are of fundamental human rights and that indeed they should be justiciable.

The hallmark and turning point was the 1994 ICPD in Cairo that resulted in a radical departure in the scope of SRH to include adolescent SRH, and the issues of sexual and reproductive rights was adopted. [1],[9] It was also observed that men needed SRH and that their involvement was pivotal if the obstacles to SRH were to be dismantled. [1] At the ICPD, the consensus of evidence was that ensuring access to SRH services for all and protecting reproductive rights were essential strategies for improving the lives of all people. Participating countries in this conference adopted "sexual and reproductive rights as human rights, and affirmed them as an inalienable integral and indivisible part of universal human rights." [3 ] To further buttress this, Kofi Annan - the immediate past Secretary General of UN, aptly summed it up this way: "The Millennium Development Goals, (MDGs) particularly the eradication of poverty and hunger, cannot be achieved if questions of population and reproductive health are not squarely addressed." And that means stronger efforts to promote women's rights and the greater investment in education and health, including reproductive health and family planning.

Interestingly, Nigeria continues to take the lead in the sub -region with regard to signing on to global initiatives as enunciated above, while at the same time adopting, adapting and/or making policy pronouncements as to the readiness of the government to implement the tenets of the respective initiatives. Despite these, there are hardly palpable indices to suggest that the government pronouncements translate to a better state of health for its citizenry. The Nigerian Demographic and Health Survey (NDHS, 2008) [10] and indeed other reports [11] clearly attest to this fact that there is continuing high rates of maternal and perinatal morbidity and mortality, poor contraceptive prevalence rate, high incidences of unsafe abortions and its sequelae, high rates of vesicovaginal fistula and female genital tract malignancies among other reproductive health challenges. Therefore, like was rightly echoed by Kofi Annan, it is doubtful whether the MGDs and indeed the set targets of other initiatives will be realizable in Nigeria, particularly in the face of ravaging poverty and hunger across the country. Also, considering the fact that SRH and associated issues are greatly and significantly influenced by sociocultural, political and religious considerations and colorations, the true concepts may not be correctly presented to a larger proportion of the populace. It is against the foregoing background that this review article was conceptualized to X -ray the concepts of SRH and its current status in Nigeria. We believe that the findings would be revealing and capable of identifying relevant interventions that will help improve on the SRH status of Nigerians and help in realizing the MDGs and tenets of other similar initiatives in the country.


  Materials and Methods Top


The articles used for this review covered a period of 1985 -2013, and in all 136 articles were retrieved following extensive literature searches; of these, 74 were adapted for this article. Others were excluded either because they were extremely old publications, the full texts of the articles were not retrievable or unavailable or the articles were case reports. Most of the papers adapted for this review article were well -conducted qualitative surveys and epidemiological studies, cohort studies, case control studies, clinical studies, case studies and cross -sectional studies. The articles were retrieved following extensive literature searches using the following search engines or databases: Medline, Elsevier, Medscape, eMedicine, Google and PubMed. The literature search was performed using the following keywords as a guide: Sexual and reproductive health, concepts, current status and Nigerians. Literature on the subject was also researched using manual library searches from relevant cited textbooks and articles in journals.


  Discussion Top


Sexual and reproductive rights

As a sequel to the ICPD 1994 in Cairo, the concept of sexual and reproductive rights emerged and the participating countries in this and indeed other mentioned conferences adopted "sexual and reproductive rights as human rights, and affirmed them as an inalienable, integral and indivisible part of universal human rights." The right to safe pregnancy and childbirth is a basic human right, as is the freedom of choice about parenthood and sexuality. [1],[3],[12]

Therefore, reproductive rights imply the recognition of the rights of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have information and means to do so. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents. Similarly, sexual right means that everyone should have a right to engage in sex that is enjoyable and safe, and to decide for themselves whether to do so, when, how and with whom, in circumstances that are free of discrimination, coercion or needless risk of sexually transmitted infections (STIs).

Young people, women and men are all entitled to receive clear and accurate information about sexuality as well as access to safe and affordable contraceptives of their own choosing and safe abortions. Women should have access to all the services they need to guarantee safe pregnancies and deliveries.

In some developing countries including Nigeria, however, people cannot be sure of these rights as they are not yet domesticated in the country and not contained in the Nigerian legal system. This creates major problems, such as a high level of unwanted pregnancies, maternal mortality and human immunodeficiency virus (HIV) infection. [1],[3],[10],[12]

Accumulated evidence since the ICPD shows that when people can exercise their sexual and reproductive rights, they experience far -reaching benefits throughout their lives, as do their families, communities and countries. [1],[9]

Scope and components of sexual and reproductive health

The scope of SRH was defined in the ICPD program of action to include the following components [1],[13] : Safe motherhood and child survival, family planning information and services, prevention and management of infertility and sexual dysfunction in both men and women and prevention and management of the complications of abortion. Other components are provision of safe abortion services where the law permits, prevention and management of reproductive tract infections, especially STIs including HIV/acquired immunodeficiency syndrome (AIDS), adolescent reproductive health, responsible and safe sex throughout life and gender equality. In addition, elimination of harmful practices, such as female circumcision, childhood marriage and domestic violence against women as well as management of non -infectious conditions of the reproductive tract/system (genital tract fistula, malignancies, complications of female genital mutilation [FGM] and menopause) and men's SRH, in particular andropause, were included. It was rightly observed by the Women's Health [1],[14] Organizations in Nigeria that women are the ones frequently targeted by government family planning programmes; yet, it is men who usually make the decisions about family size. Therefore, changing women's attitude and behavior will not reduce the number of children a woman has until men's attitudes and behaviors are changed too. Their inclusion in SRH was therefore very apt.

Lack of sexual and reproductive health and rights (SRHR): Reasons and implications

Many developing countries lack adequate sexual health and rights mainly for reasons of widespread stigmatization. [15] The stigmatization of people living with HIV in Nigeria is real and discrimination against certain other groups such as homosexuals and lesbians is very well known. [16],[17],[18] There have been reports of people living with HIV who have been dismissed from their jobs or refused employment as well as children who have been sent from schools either because they are retroviral positive or their parents are living with HIV/AIDS. [19] Same sex marriage is still illegal in Nigeria and homosexuality and lesbianism according to the Laws of the Federation of Nigeria 1990, Chapter 77 of the Criminal Code Act, committing carnal knowledge "against the order of nature" is punishable with 14 years in prison. [13] In addition, states in the Northern region have gone beyond this to enshrine the Sharia law on homosexuality therefore legitimizing the stoning of gays to death. [8] Furthermore, a parliamentary "same sex marriage prohibition" bill has reached an advanced stage in the National Assembly toward being promulgated into a law. Under the proposed law, a 10 -year jail term awaits those who advocate gay rights or participate in gay marriages. Secondly, there is gender inequality arising from discriminatory culture, norms and practices, which prevent women from becoming self -reliant. [2] In many settings in Nigeria, for example, women are denied inheritance rights, which makes it difficult for them to set up their own businesses. [19 ] There is also the denial of access for young people to sex education or contraceptives, or the point of access to such services is not made user friendly to them. [20],[21],[22] And, for many women, childbirth is without midwives or other skilled personnel in attendance or lack of other forms of medical assistance, leading to many avoidable maternal and infant deaths. Very importantly too, there is the Governments' failure to allocate sufficient funding to education and services promoting SRHR. [9]

The most significant of the many grave consequences of the lack of adequate sexual health and rights in Nigeria is the denial of the sexual health and rights of women, sexual minorities and people with HIV. A huge number of women and girls wanting to practice birth control cannot gain access to contraceptives. The contraceptive prevalence rate in Nigeria is just about 15%. [10] Also, each year, a significant number of girls aged between 15 and 19 years have unwanted pregnancies, often through poor sex education, early marriage or lack of access to contraceptives. This can lead to unsafe abortions. There are approximately 40,000 avoidable deaths each year during pregnancy or childbirth in Nigeria. [23] By the end of 2007, there were an estimated 2,600,000 people infected with HIV in Nigeria, and approximately 170,000 people died from AIDS in 2007 alone (UNAIDS, 2008). [10] In recent years, life expectancy in Nigeria has declined partially as a result of the effects of HIV and AIDS. [10]

Current status of sexual and reproductive health in Nigerians

Following the global trend of strong advocacy for the domestication of the tenets of SRH in respective countries and societies of the world, Nigeria was one of the first nations in Sub -Saharan Africa to make adoptive policy statements. [3],[10] The series of pronouncements and policy initiatives include the fact that in 1998 Nigeria adopted the Regional Reproductive Health Strategy and endorsed all the components of SRH as entrenched in the ICPD platform for action except "the provision of safe abortion services," which is against the law in Nigeria. [11] Nigeria has equally signed onto the MDGs with its array of implications for reproductive health. [10] Some states of the country, particularly in northern Nigeria, have commenced domestication of the concept of SRH through their HIV/AIDS and Family Life Education programs. [10]

Despite these pronouncements and seeming efforts, the status of SRH of Nigerians remains abysmally poor and available data tend to suggest worsening indices. [10] Some of the core critical indices to highlight this include increasing rates of liberal sexual behavior, high incidence of STIs including HIV/AIDS, widespread unintended and unwanted pregnancy, high rates of unsafe abortion, poor contraceptive prevalence rate (about 15%) and horrifying rates of maternal and neonatal mortality and morbidity. In addition, there is an increasing number of disadvantaged children in the community and declining quality of life, [3],[10] child abandonment is frequently seen, [24] there is an increasing prevalence of gender -based violence and harmful traditional practices, [10],[12] prostitution is commonplace, there is absence of SRH programs for adolescents, [12] menopausal symptoms are widespread and our women come with late stages of cervical cancer and other genital tract cancers. [25],[26] There is a high rate of infertility among Nigerian couples, vesico -vaginal fistula (VVF) is extremely high in Nigeria (>800,000) [27],[28],[29],[30] and there are no programs targeted at men.

It is globally acknowledged that there is an increasing rate of liberal sexual behavior and a high proportion of young people who are engaged in unprotected sexual activities. Studies [20],[24],[31],[32],[33],[34] from most parts of Nigeria provide evidence in support of the same. Unprotected sexual exposure is usually the prime event in the cascade of series of other reproductive health failures like unplanned/unwanted pregnancy, which may ultimately result in unsafe abortion and its sequelae, STIs including HIV/AIDS, consequent tubal blockade, ensuing infertility and predisposition to development of cervical malignancy among others.

There is a high incidence of STIs, including HIV/AIDS. [12],[35] These entities are most common in the 15 -24 years age group, and young women face the highest risk of HIV infection through heterosexual contact. The risk of infection is increased by the low social status of young women, who may be forced into sex or have little power to negotiate condom use with sexual partners. STIs can lead to infertility and have a devastating impact on the life of an adolescent. [36] In a survey by Oye -Adeniran et al., [35] they demonstrated a high (3 -5%) prevalence of STI or STI symptoms, which was highest among women who were never married, dwelling in Urban areas, in south -east Nigeria and those with higher educational status; in men, a higher incidence was noted in those who were single and those who lived in rural areas. The low level of knowledge of reproductive health among adolescents and limited access of young people to youth -friendly health services have been identified as underlying factors contributing to the rising trend of HIV/AIDS in Nigeria. [35]

There is also widespread unintended and unwanted pregnancy. [10],[12] Evidence abounds that not all young Nigerian women who become mothers had planned to do so. [10],[12],[20],[36],[37],[38] In 1990, 10% of births to all women aged 15 -24 years in the previous 3 years was unplanned. By 2003, this proportion had increased to 16%. In the South West and South South regions, the increase was much steeper than the average, rising from 12 -14% to 32 -43% during the 13 -year period. In stark contrast, in 2003, only 5% of women this age in the North West reported an unplanned birth in the past 3 years. Unintended and unwanted pregnancy is a result of an unmet contraceptive need, and the response to this in most instances is to seek an abortion; because of its illegal status in Nigeria, it is often unsafe with its hazards.

Available data show that Nigeria continues to have high rates of unsafe abortion. With an illegal abortion law, Nigeria still has one of the highest sets of abortion ratios globally, with a reported average of 25 per 1000 women of the reproductive age, and over 610,000 abortions estimated to occur in the country annually. [36],[37],[39],[40],[41] Abortion rates are higher in the southern regions of Nigeria than in the north; specifically, the abortion rate is highest in the Southwest (46 abortions per 1000 women), somewhat lower in the Southeast (32 abortions per 1000) and much lower in the two northern regions (10 -13 per 1000). [42] This difference is to be expected in view of the higher levels of urbanization, education and economic development in the south. These factors generally lead to a desire for smaller families to delays in the age at marriage and to higher levels of premarital sexual activity, all resulting in unintended pregnancies. Unsafe abortion is one of the leading causes of maternal mortality in Nigeria and is estimated to account for 30 -40% of maternal deaths. [20],[37],[38],[39],[40],[41],[43] Other leading complications of unsafe abortions with reproductive health implications are hemorrhage, septicemia, spread of HIV/AIDS, Asherman's syndrome, chronic pelvic pain and infertility. [36] Some young women, especially unmarried ones, who experience an unwanted pregnancy seek induced abortions to resolve the situation. However, because abortion in Nigeria is highly restricted by law, the procedure is often performed clandestinely and under unsafe conditions. Such procedures pose serious health and social risks for all women, particularly for young and disadvantaged women who may not have the means to obtain a safe abortion. [42]

The contraceptive prevalence rate in Nigeria is poor even among married couples. Overall, this is about 15%. [10],[12],[21] A report by Sedgh et al. [12] indicates that married adolescents use contraceptives less than single adolescents of comparative age (4% versus 39%). The use of modern contraception by sexually active adolescents is highest in the southern parts compared with the northern parts of Nigeria. In Nigeria, existing data further suggest that unmet contraceptive need is high among married young women and never married sexually active young women alike. The overall proportion with an unmet need for modern contraceptive is very high - 60% as of 2003. The South Eastern part of the country has the highest level of unmet contraceptive need, with three -quarter of these category of women having unmet need for modern contraception. They conjectured that the low levels of contraceptive use are probably due to their poor knowledge of where family planning services can be obtained.

Maternal and neonatal mortality and morbidity rates remain high. [10],[12] Nigeria's health and development indicators are among the worst in the world, especially in the Northern states. Even though Nigeria contributes only 2.4% to the world's population of 7 billion, it contributes over 10% to the global maternal mortality burden of about 360,000 maternal deaths per annum. [23] In absolute numbers annually, Nigeria records approximately 40,000 deaths, [23] second only to India in its contribution to the global burden of maternal deaths. According to the 2008 Nigeria Demographic and Health Surveys (NDHS), the national maternal mortality ratio (MMR) is estimated at 545 per 100,000 live births, [10] but the data did not provide regional distribution of MMR. Other hospital data have shown MMRs ranging from 270 [44] to 2420 [45] per 100,000 live births. Furthermore, for every woman or girl who dies, another 20 -30 women and girls suffer short - or long -term disabilities such as obstetric fistula, ruptured uterus, chronic pelvic pain resulting from pelvic inflammatory disease and secondary infertility.

In addition, there is an increasing number of disadvantaged children in the community and declining quality of life. In fast -growing cities of Africa, Asia and Latin America, there are millions of street children most of whom are likely to encounter sexual exploitation and, with it, the risk of infection with STI and HIV, unwanted pregnancy and child abandonment. [10],[12],[22],[46] There is an increasing prevalence of gender -based violence and harmful traditional practices such as female genital cutting. [47] It is estimated that 2 million girls are at risk of genital cutting or mutilation. The procedure is typically carried out with primitive, unsterilized instruments while the young girl is forcibly held down. The immediate complications that are very common include violent pain, shock and hemorrhage. Others are injury to adjacent organs, infection and death. Later problems include scarring, painful and prolonged menses, recurrent urinary tract infection, sexual complications, psychological trauma and difficult childbirth (prolonged labor, lacerations and vesicovaginal and rectovaginal fistulas). [22] Complications are most serious for girls who are also subjected to infibulation where, due to scarred vaginal tissues, subsequent intercourse is difficult and usually forced, leading to some tearing and bleeding, and infections. Some husbands may turn to anal sex or other partners contributing to the spread of the same. [22]

Other areas of challenging reproductive health status of Nigerians are early and childhood marriage, which is still commonplace in the northern zones of the country, prostitution as a means of subsistence and sustenance is still widely practiced and there is absence of SRH programs for adolescent. [12] A huge number of Nigerian women suffer menopausal symptoms without being able to access appropriate care, and there is paucity or absence of centers for such services in our healthcare facilities. Nigerian women come with late stages of cervical cancer and other genital tract cancers. [25] There is a high rate of infertility among Nigerian couples, and VVF is extremely high in Nigeria (>800,000 cases); it is a major public health challenge. Prolonged obstructed labor remains the most common cause of VVF in Nigeria as in other parts of the developing world, [27],[28],[29],[30] and there are no programs targeted at men.

Determinants of sexual and reproductive health

The literature is replete with evidence [1] that supports the fact that SRH is greatly and significantly influenced by sociocultural, political and religious determinants. These determinants include:

Social change: Striking in this regard is the progressively decreasing age at sexual debut with increasing rates of liberal sexual activities. Reports by different workers [12],[13] show that the age at sexual debut in Nigeria has progressively decreased particularly over the last two decades. Seven out of every 10 males and five out of every 10 females attending secondary school in Nigeria are sexually active or have had sexual relations at least once. Isiugo -Abanihe et al. [48] in their study on the age of sexual debut and patterns of sexual behavior in two local government areas in Southern Nigeria reported that the median age of first sex among never -married males and females was 17 years and 18 years, respectively; that more than one in five adolescents have had sex before the age of 16 years; that never -married males and females initiated sex earlier than ever -married, older respondents; that 14% of married men keep other sexual partners besides their wives, which is indicative of substantial extramarital relationship. It was also seen that 12% of never -married male respondents with regular sex partners have other sexual partners. [39] In a recent study, it was shown that just less than half of the respondents had their age at sexual debut between 5 and 24 years. [49] There is also a high rate of unprotected sexual intercourse, multiplicity of sexual partners and widespread casual sexual activities. [50],[51],[52],[53],[54] This is undoubtedly so against the background of poor contraceptive uptake and practice, and this certainly predisposes to the occurrence of unwanted pregnancy and the act of unsafe abortions with its attendant morbidity and mortality. Also sequel to this is the associated increased incidence of STIs including HIV/AIDS and its role in the development of cervical cancer, as well as tubal blockade and infertility in both males and females. All these have tremendous implications on the overall SRH outcomes of Nigerian women. [12]

Economic status of the citizenry also plays a significant role in determining the status of the SRH of a nation. [55],[56] Ravaging poverty occasioned by the high levels of unemployment and poor business outlay predisposes the female folks to prostitution as a means of sustenance and subsistence. This is quite prevalent across the nation, and the exploitation is usually perpetrated by the economically viable political class, business men and military operatives in crisis -ridden/ -prone zones were they are on special missions.

Inadequate infrastructure such as the lack of educational facilities or lack of access to one, and lack of basic health services or lack of access to one, plays contributory roles. [57] These are two ambits of the social services sector that significantly impact on the status of our SRH. Evidence abounds [58],[59],[60],[61] that education is one tool that greatly influences the status of SRH, the higher the educational status the more the likelihood that the SRH indices would be better. [62] The link between education and reproductive health is two -directional. Education of girls is closely related to improvements in family health and to falling fertility rates. In turn, girls born into smaller families are more likely to be sent to school and to complete more years of schooling. Educating women benefits the whole of society. It has a more significant impact on poverty and development than men's education. It is also the most influential factor in improving child health and reducing infant mortality. The ICPD and FWCW affirmed everyone's right to education and gave special attention to women and girls, recognizing that education is a cornerstone of women's empowerment because it enables them to respond to opportunities, to challenge their traditional roles and to change their lives. Paragraph 4.2 of the ICPD Programme of Action states, "Education is one of the most important means of empowering women with the knowledge, skills and self -confidence necessary to participate fully in the development process." The two conferences also emphasized eradication of illiteracy as a prerequisite for human development.

One of the strongest statistical correlations in developing countries is between mothers' education and infant mortality: The children of women with more years of schooling are much more likely to survive infancy. Better -educated women are also likely to have a greater say in decisions such as when and whom they marry and to use family planning to bear only the children they can provide for. Obviously, education affords them better knowledge and understanding of SRH issues and, therefore, they usually have better health -seeking behavior and more likely to have the means to do so as they have better job positions and earning power. [63] Globally, nearly 600 million women remain illiterate today, compared with about 320 million men in Nigeria; the literacy level remains low and this is particularly so among the female population who take the major brunt of adverse SRH. This situation is further compounded by the widespread paucity of health care facilities in several communities in Nigeria and, where available, affordability may pose further impediment to prompt and adequate treatment. Additionally, there is paucity of youth -friendly reproductive health facilities and services, which usually acts as barriers to adolescents seeking help when in need, as commonly seen with unmet needs for contraception and adolescents seeking unsafe options to resolving an unwanted pregnancy.

The age at marriage also plays a significant role in determining the SRH indices of Nigerians. The earlier young women marry, the sooner they are likely to start childbearing, and the greater their maternal health risks. [12] Moreover, early marriage compromises young women's education, perpetuating a vicious cycle in which their economic prospects are diminished and they will likely have fewer resources to invest in their own children's well -being and education.

Rural-urban migration in search of white collar jobs or more lucrative means of subsistence is another major determinant of the SRH of the nation's citizenry. [64],[65] Interestingly, a lot of these persons migrate to these urban centers without specific job positions and relatives or even close friends to hook up with. While the males will readily take to crime and criminality as well as high -risk behavior with serious adverse implications for the SRH outcomes, the females readily settle down to prostitution, often with multiplicity of sexual consorts. This predisposes them to a number of adverse reproductive health outcomes, including diseases.

Increasing biosocial gap is another factor that influences SRH in Nigeria. Biosocial gap implies the time interval between menarche or first sexual intercourse and marriage. [66] It is one much -discussed example of how biology and society interact by various pathways across the "biosocial gap" between menarche and socially sanctioned childbearing. The wider this gap, the more space for different pathways and the greater the risks of social disapproval and deleterious effects on health and life opportunities. [66] This is increasing by the day in Nigeria because of the fact that most of our women and young men now pursue academic careers to higher levels, contrary to what was obtainable in the past when some girls were actually married out before attainment of menarche. [12],[67],[68] This scenario is further compounded by late marriages due to ravaging poverty, as several young persons usually take time searching for means of subsistence and sustenance before thinking of marriage. Within this period, the young persons would have had serial sexual relations, which increases the risk of development of adverse SRH outcomes.

Religion is yet another strong influence on the SRH indices of Nigerians. [69] Religion is a prominent force in all societies as it is estimated that more than 5 billion people follow one of the world's religions. [69] In many societies, religious people and institutions promote human rights. However, some use religion to justify violations of human rights or to oppose certain rights, including SRHR. While the fundamental values of all religions promote the integrity and well -being of all human beings, differences in interpretations and the ways the values are translated into practice can create barriers to SRHR. This is especially so for young people seeking to make choices about their sexual and reproductive lives that in any way deviate from common practice. Young people often face contradictions between their religious beliefs, as passed on by religious leaders and institutions, and their life circumstances. Further to this, religion may operate through a number of other processes that include establishment of health facilities that are devoid of adequately trained health personnel. They may also teach their followers not to access medical help but rather seek healing through faith, and limitation of their followers' choice of contraception, all of which adversely impinge on their SRH. [2]

Culture is yet another strong determinant of the SRH indices of Nigerians, particularly as it permits the practice of gender inequality in societies across the country. [2],[70] The impact of culture commences the day the girl child is born, when the news of her birth is greeted with less enthusiasm. As the child grows, she is subjected to less -favorable conditions such as nutritional deprivation, unlike the male counterpart that is offered the best portion including meat, eggs and other proteinous nutriments needed for proper and adequate growth. This may result in inadequate or contracted pelvis later on in life, with its potential attendant complications at child birth. Another aspect where culture comes to play is in the areas of female circumcision, childhood marriages, wife hospitality, widowhood rites and wife inheritance. [71] Additionally, the male child is preferentially offered educational opportunities, thereby creating a scenario for economic dependence and deprivation as well gender disempowerment from the cradle for the women. [20] They are therefore not able to appreciate clearly the issues of SRH, unable to take independent decisions on issues of their health, where and when to seek care as well as being able to afford the means to do so. Cultural taboos on sexuality have made it very difficult to create adequate policies and programs to deal with youth SRHR. Sexuality itself is a difficult topic to broach in the public arena, and the idea of young people and sexuality introduces another level of difficulty. Even when laws and policies exist to protect youth's SRHR, cultural and religious climates may hinder their implementation. Cultural norms may also place girls and young women at an increased risk of HIV infection. About 7.3 million young women are living with HIV or AIDS compared with 4.5 million young men. Early marriage can lead to an increased chance of infection, as young women tend to marry older men, who are at increased risk of being already infected. In these circumstances, most young married women cannot safely request their husbands to use condoms. [71]

Reduced funding by government/relevant stakeholders and ideological resistance to the SRH and rights paradigm in an increasingly conservative environment is another major determinant. These two closely intertwined factors have contributed to the persistence of these unmet needs in Nigeria and, indeed, many developing countries. [9],[72] As Anna Glasier and colleagues describe in their paper, [3 ] SRH, apart from HIV/AIDS, has failed to attract the financial resources that were expected from the donor community, especially in the fields of family planning, unsafe abortion and STIs. Insufficient international support from donors is often attributed to the incapacity of the SRH community to sell such a complex concept and to show in a clear and compelling way that improvement is achievable. Indeed, the ICPD definition is too comprehensive to measure, explain or communicate easily. The use of this broad model could have diverted attention to the different components of SRHR. Moreover, the misperception that the population crisis is over has further reduced resources for family planning, one of the pillars of reproductive health and women's empowerment. Donor fatigue and the financial downturn in the US economy in the early years of this decade have also limited the financial support to SRH. Resources from developing countries have fallen short. Many of the promised changes have remained at the stage of policy pronouncements and have not reached implementation because of a lack of political will (especially on sensitive issues such as adolescent sexuality and abortion), an absence of financial commitment, little technical expertise and competing priorities. There has been increased conservatism in Nigeria as well as in some donor countries, and these has taken a heavy toll on the efforts to advance the international agenda on SRH and rights in Nigeria. Indeed, contrary to scientific evidence, conservative forces interpret the ICPD Programme of Action's call for information and services for young people as promoting promiscuity and irresponsible behavior, [9] and hauls constant attacks by conservative forces on all issues that relate to sexuality and abortion limit, thereby limiting access to several services and technologies that should be used to improve SRHR.


  Conclusion Top


It is apparent from the foregoing discourse that the SRH indices of Nigerians remain poor and unimpressive. It therefore calls for urgent policies and actions to address them otherwise the future is best captured in the seminal words of the immediate past Secretary General of the United Nations - Kofi Annan - aptly summed up this way: "The Millennium Development Goals, particularly the eradication of poverty and hunger, cannot be achieved if questions of population and reproductive health are not squarely addressed." We therefore recommend the following as urgent steps that must be taken to address the challenging national malaise.

The government and all relevant stakeholders must ensure universal access to SRH services for all through the primary health care system to the highest levels of care. SRH should also be made an integral part of national development planning and included within the national monitoring and progress reporting. Additionally, the government should build and strengthen the capacity of primary health care systems, from communities to hospitals, to facilitate the delivery of quality, user -friendly SRH services.

There is also the need to strengthen linkages between SRH and HIV/AIDS in legislation, policies and programs. This will give some impetus and make commitment on the part of government agencies and relevant stakeholders mandatory. There is also the need to ensure the supply of SRH commodities, including a full range of safe, effective contraceptives and particularly male and female condoms, with secure and increased funding to cover all existing shortfalls in this regard. Priority should also be given to meet the SRH needs of poor and marginalized groups, including adolescents and people living with HIV/AIDS, and health care providers should be sensitized to their peculiar needs.

The government should make sexuality and reproductive health education a mandatory part of school curricula and accessible to out -of -school youths. Some states in Northern Nigeria have domesticated this as Family Life and HIV/AIDS Education programme with impressive outcomes. There is the need to prevail on government and all relevant stakeholders to implement fully and effectively all international treaties on SRH. Girl child education, which is the bed rock of female empowerment, and the right to choice by women is also recommended for urgent and priority attention by the government at all levels.

Finally, the government at all levels must increase budgetary allocations and donor contributions for SRH services, information and education to meet - at a minimum - the ICPD commitments of our quota of US $21.7 billion in 2015.

The right of every citizen, particularly women, to lead the highest standard of health must be secured as good health, in particular SRH, is a sine qua non for productive and fulfilling life. The right of all citizens, especially women, to control all aspects of their heath, in particular their own fertility, is basic to their empowerment.

Therefore, a society where individuals have knowledge, skills and resources to enjoy their sexuality is one we must all aspire to be part of and bequeath to future generations.

 
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