Nigeria is a patriarchal society. Authority is vested in men, who tend to exert power and control over women in various spheres of life. This has an impact on women’s health and decisions about their healthcare.
Women’s health is affected not only by medical conditions and childbearing, but also by cultural behaviour and traditions. Social factors such as gendered access to healthcare or employment also affect people’s capacity to lead healthy lives.
The Nigerian feminist scholar Obioma Nnaemeka has described feminism in an African context as a matter of negotiation and compromise. She calls it “negofeminism”. It involves “give and take” instead of confrontational exchanges.
This concept helped me, as a global health researcher, to understand what rural Nigerian women said about seeking healthcare during and after pregnancy.
For our study, my colleagues and I interviewed women and their spouses in two rural communities in southern Nigeria.
Our findings describe ways in which women negotiate authority by ascribing the role of decision-maker to their men spouses while maintaining influence over their pregnancy healthcare decisions and actions. Negofeminism’s concepts of alliance, community and connectedness were highlighted through men’s constructive involvement in maternal health.
We found women were not passive victims. Instead, they navigated patriarchal environments to yield the best possible maternal health outcomes by gaining control of their healthcare decisions.
Recognising this form of agency can help in formulating policies and programmes that acknowledge how women’s wider social environments influence their health.
Maternal health in Nigeria
In Nigeria, limited access to quality healthcare contributes to 556 pregnancy-related deaths per 100,000 live births.. UNICEF reports that Nigeria contributes 10% of the global pregnancy-related death burden.
Some scholars have argued that women are only able to seek healthcare if they can make independent decisions. But this approach often ignores women’s realities, such as the fact that their social network (mothers, grandmothers, spouses and community members) influences their use of healthcare services.
Nevertheless, as our study shows, social dimensions don’t necessarily impede women’s autonomy.
Therefore, I believe that discussions of maternal health in an African context need to consider women’s experiences of being “African” and “women”.
The study
We studied two predominantly rural communities in Esan South-East and Etsako West, local government areas of Edo State in southern Nigeria. We conducted five women-only focus group discussions with a total of 39 women, and three men-only focus group discussions with 25 men. Participants were chosen from a database of women participating in maternal health interventions.
We asked them who women first consulted for pregnancy care, and who made the decisions about seeking maternal healthcare. We also asked about their experiences of men’s involvement in maternal and child health.
We categorised their responses as negotiation, collaboration and manoeuvring.
It appeared that men were considered the decision-makers at the household level. Participants said a woman’s spouse should be the first to know of her pregnancy. Both men and women said men should make all the decisions about healthcare during pregnancy, even though it was clear that women sometimes influenced decisions.
Describing her experience, one woman said:
In the aspect of care, I will tell my husband, so he will decide. After my husband knows, I will go to the hospital to tell the doctor so he can tell me what to do.
Similarly, men noted that women “cannot just go to healthcare facilities without the husband’s decision”.
But they also made comments like:
My wife will tell me, ‘take me to go and see the nurse’. When I am not around, she can go see the doctor on her own. It is a normal thing in our community.
Both men and women said it was important to get skilled care, especially for complications.
The act of the women telling the men can be thought of as a form of negotiation by women to influence decisions on access to maternal healthcare. First, she recognises the patriarchal environment and assigns the decision-making authority to men. But she is also using her agency in that environment.
Notions of men’s responsibility and collective action on maternal health were evident in the study. In these communities, men’s duties as expectant fathers were mainly of financial support to cover costs associated with pregnancy, including clinic visits, cost of delivery, essential medicines and feeding.
It can be argued that in ascribing decision-making authority to men, women benefit from men’s duty and responsibility to be providers. Women said they could not afford the high cost of maternal healthcare on their own. There was “give and take”.
Some women showed their resistance to men’s involvement in their pregnancy. They reported secretly seeking maternal healthcare without informing their partners. In this they were indicating control over their lives.
Why this matters
Our findings show that it’s important to involve women’s communities and spouses in maternal health programmes.
We show that patriarchy affords men power over decision-making or financial resources. Women are not passive in these situations, they actively find ways around it to ensure they have access to skilled healthcare during pregnancy.
This study shows that maternal health is not always an individual responsibility – it can be one for the woman’s community and the nation. Ignoring this can undermine programmes and policies aimed at improving women’s health.