Consanguineous marriages: Implications for under-five mortality - - PDF document

Consanguineous marriages: Implications for under-five mortality clustering- A qualitative study from rural northern Nigeria.

Olatunji Alabi1, Clifford Obby Odimegwu2 and Olusola Omisakin1

1Department of Demography and Social Statistics, Federal University, Birnin-Kebi, Kebbi State, Nigeria. 2Department of Demography and Population Studies, University of the Witwatersrand, South Africa.

*Correspondence to: Olatunji Alabi, Federal University, Birnin Kebbi, Nigeria, Email: yomistorii@yahoo.com

Abstract Background: Under-five mortality remains high in Nigeria and northern Nigeria in

• particular. The concepts of under-five mortality clustering and the potential impact of socio-

cultural practices like consanguineous union on the clustering of death in certain family remains under researched. This paper explores the potential implication of consanguineous union on under-five mortality clustering in rural northern Nigeria. Methods: The study employed qualitative data collection method through the use of indepth interview with women with at least two under-five deaths from compounds with families who have lost 60% or more of their children from Nahuche Health and Demographic Surveillance System (Nahuche HDSS). A total of 56 IDI interviews were conducted between April-May, 2015 using a pre-tested structured interview guide to elicit information on the influence of consanguineous marriages on under-five mortality clustering. Result: Findings from the study showed that 68% of the participants were into consanguineous union. Most women in such marriages were not aware of the health implication of such union however such women had lost at least two of their children before their naming ceremony. Consanguineous union is seen mostly from traditional and religious perspective in the study area and mostly is without the consent of the couple Conclusion: The findings from the study underscore the need for awareness on the potential

• f socio-cultural practices like consanguineous marriage in supporting high regime of under-

five mortality clustering and thus calls for awareness on the health implication of such union

• n the child health outcomes.

Keywords: Under-five, mortality, clustering, northern Nigeria.

Introduction Undoubtedly, under-five mortality remains very high in most developing countries and sub- Saharan African countries in particular. There were almost 7 million of under-five deaths reported globally in the year 2013 (UNICEF, 2013) with wide variation between the developed and the developing countries. The highest rate of under-five mortality was from sub-Saharan Africa and Oceania (UNICEF, 2013). Nigeria is one of the countries with the most worrisome child health indicators and remains the second largest contributor of under- five mortality in the world after India. Within Nigeria, there is variation between regions and place of residency. Studies on determinants of under-five mortality have explored various levels of factors influencing under-five mortality from the individual (mother and child level factors), family and recently, neighbourhood factors. However, such studies are still limited as it neglects

• ther contextual factors at neighbourhood or community level that may influence the

clustering of child mortality in particular, socio-cultural factors (Adedini et al., 2013). There are limited studies focusing on the effect of socio-cultural practices on the under-five mortality in a culturally sensitive and oriented society like northern Nigeria. The lack of studies on the effect of socio-cultural factors on infant and child mortality in Nigeria was identified as one of the gaps in the literature on studies on determinant of under-five mortality in Nigeria (Adedini, 2014). Furthermore, one area which have suffered neglect in the study on under-five mortality in developing countries in general and Nigeria in particular is the aspect of under-five mortality

• clustering. There is dearth of literature on the concept of mortality clustering in Nigeria.

Klouda and Adamu (2013) and Rain (1997) are the two studies, to our knowledge, that have addressed the topic of mortality clustering in Nigeria. Under-five mortality clustering simply defined as the variability in the spread of under-five mortality in the population. It explores why under-five mortality clustered within certain individual, family or community. Vandezande, Moreels and Matthijs, 2010 opined that child deaths are unevenly distributed among women. In studying mortality clustering in a population, population genetics have suggested genetic problems in certain families as a factor in mortality clustering (kuate-Defo & Diallo, 2002). Certain genetic deformation may be present in children born to the same mother thus, some parental traits are sometimes found in their offspring. Underlying genetic variability between families, due to consanguinity or the high prevalence of the gene for sickle cell hemoglobin may also have played a major role in the concentration of child deaths in certain families within such communities (Ronsmans, 1995). Consanguineous marriage is allowed in the Northern part of Nigeria and it is not uncommon to see blood relations getting married to one another.

Consanguineous union is used as a proxy for the effect of “genetic fraility” on under-five mortality in the study area since the study does not involve laboratory test of collected specimens like blood sample to test for possible effect of genetic disorders and its impacts on under-five mortality among couples in such union. To this end, this paper explore the implications of the socio-cultural practice of engaging in consanguineous marriages as being commonly practiced in the Muslim dominated northern Nigeria on the high under-five mortality in the region in particular and Nigeria as a whole. Data and Research Methods Study Area: Nahuche Health and Demographic Surveillance System (Nahuche HDSS) site is located within six districts of Nahuche-Keku, Nahuche-Ubandawaki, Gada, Karrrakai, Bela and Rawayya in Bungudu Emirate of Zamfara State, northwest Nigeria. The population of the surveillance area stood at 142,127 as at December, 2013. Nahuche HDSS was established through funding from UKaid (Department for International Development) and the Norwegian Government in 2009 through the PRRINN-MNCH1 programme and Zamfara State Ministry

• f Health.

Infrastructures are generally substandard with poor road networks making some of the villages non-accessible especially during rainy season. Economic, maternal and child health indicators for most of the areas under the surveillance are among the worst in the country. For instance, there is high rate of home deliveries and very low health services utilization due to poverty and cultural factors such as lack of standing permission to access health services for maternal and child health (Alabi et al., 2016). Data and Methods: The study was carried out with purposively selected samples of women with at least two under-five deaths from compounds with more than two-third under-five deaths generated from the mortality dataset sampling frame from Nahuche HDSS. Nahuche HDSS quantitative data are collected once in every six months to update the database. Compound level clustering was assessed by adopting Kuate-Defo and Dialo (2002) methodology of classifying compounds according to the number of under-five deaths reported per compound: (i) ‘‘no concentration’’ comprises of the selected family in the sample whose children have all survived; (ii) ‘‘low concentration’’ includes families who have lost less than 20% of their children; (iii) ‘‘medium concentration’’ families have lost 20–59% of their children; and (iv) ‘‘high concentration’’ contains those families who have lost 60% or more of their children. The study employed Indepth interviews (IDI) to examine the effect of consanguineous marriages on under-five mortality clustering among selected women. A total of 56 IDI interviews were conducted between April-May, 2015 using a pre-tested structured interview

1 Partnership for Reviving Routine Immunization in Northern Nigeria; Maternal Newborn and Child Health

Programme.

guide to elicit information on the influence of consanguineous marriages on under-five mortality clustering. Zamfara State Health Research Ethics committee (ZSHREC), a sub-committee under the Operation Research Advisory Committee (ORAC), gave ethical clearance for the Nahuche HDSS survey instruments Verbal informed consent was obtained from respondents whereas community consent was obtained from district heads during the beginning of the HDSS

• activities. Informed Verbal consent (preferred and deemed more confidential by most

participants from previous studies in the study area, in addition to low literacy level) was

• btained from the participants of the IDI. Explanations were offered prior to interview date
• n the aims and objectives of the research, voluntary participation, right to withdraw at any

point in time without giving reason with no penalty, confidentiality and anonymity was

• ensured. Anonymity of participants was also ensured by using the assigned individual

number from the Nahuche HDSS database instead of names when selecting participants. Confidentiality of information was ensured throughout the interview by assigning numbers to participants during qualitative data collection and transcription of responses stored in a computer with restricted access. Data cleaning, processing, and analysis were done manually using a thematic framework

• approach. This process involves verbatim transcription of returned audios by the research

assistants after the data collection. The transcripts were screened, edited, and double-checked for internal consistency, accuracy, and elimination of possible spurious responses. Further, the data analysis involves coding, sorting, and theme identification. This process led to the development of a final list of themes and sub-themes that are relevant to the greater understanding of the topic of the research. After coding, sorting and theme identification, the generated qualitative data were analysed using content analysis method. Results: In terms of age distribution, table 1 shows that almost one-fifth of the participants were 30 years old. The mean age of the respondent was 29 years. Further, in line with the Nahuche HDSS data used, majority of the participants interviewed reported Quranic education while less than 10 percent had secondary education. Almost half of the participants had been married for 13 years or more while 11 percent had been married for 5 years or less. Considering the reported age and the duration of marriage, it is evident that majority of them had early marriage with some getting married as early as 11 years. There was also evidence

• f higher age at marriage for those who had either primary or secondary education compared

to those who had Quranic education when age, duration of marriage and educational level is

• considered. Those with secondary education were likely to marry in their early twenties

compared to those with Quranic education who mostly got married at 12 years. Mean age at marriage was 16 years. Mean duration of marriage was 13 years. Membership of a social group showed that 11 percent of the participants belong to one social group or the other. Social group membership may influence the knowledge of mothers on child care due to various child health improvement activities carried out by the groups.

Table 1: Socio-demographic characteristics of Participants (qualitative data)

Socio-Demographic Characteristics Frequency Percent AGE N=(56) 19 years and below 3 5.36 20-29 years 26 46.43 30 years and above 27 48.21 Mean Age = 28.8 years EDUCATION Primary 2 3.57 Secondary 5 8.93 Arabic 49 87.50 DURATION OF MARRIAGE 5 years and below 6 10.71 6-12 years 23 41.07 13 years and above 27 48.21 Mean duration of Marriage= 13.3 years Age at marriage less than 15 years 22 39.29 15-19 years 25 44.64 20 years and above 9 16.07 In consanguineous Union? Yes 38 67.86 No 18 32.14 Membership of a social group Not a member 12 100.00 Membership of a social group 0.00

Exploring the influence of consanguineous marriages on under-five mortality clustering in the study area was anchored on the potential role it may play in influencing child mortality clustering as suggested in the literature. For instance, consanguineous union may have effect

• n child survival from the genetic or biological built up of the child perspective. Literature

suggest that some families may have “weaker genes” and thus women who have difficulties in carrying pregnancy to term my give birth to children that will exhibit same traits when they start child bearing (Vandezande, Moreels and Matthijs, 2010). Findings from the study showed that most women in such marriages were not aware of the health implication of such union. Although, most of the women interviewed reported that such union is generally acceptable and they cited religious injunction as a reason for such

• union. One very common finding with women in such union was that they lost at least two of

their children before their naming ceremony but they however, did not think such were as a result of their marital union type. Some described the influence of consanguineous marriage

• n under-five mortality clustering as follows:

“ I have two kids who died before attaining the age of 5 but it has nothing to do with my husband being my uncle. If the relationship between the couple is cordial, then such marriage is the best to happen to someone and a lot of people practice such in this community”. IDI with a 30 year old woman of 16 years of marital life, Nahuche HDSS. “Even though I lost 3 children before naming ceremony, I don’t believe it was because I married my cousin. Allah gave and took them”. IDI with a 33 years old woman married for 20 years, Nahuche HDSS “Yes we are cousins (..laugh) but ‘malama’, does it have implication on my child’s death? I don’t think so, nothing wrong ‘malama’, no health implication at all. It fosters unity (…laugh) and love. Like me and my husband, we love ourselves. It has demerits especially when divorce sets in, it will bring disunity in the family and to both parent-in-laws”. IDI with a 19 years old woman in her 6th year of marriage, Nahuche HDSS. “I don’t have any child who attained the age of 5. All my children died at 6 months. No, we don’t go to hospital. Not even on labour. Malam will give us “Rubutu”. IDI with a woman who have been married for 12 years, Nahuche HDSS. “I don’t have any child up to age 5. My children, the highest age they can reach is 3 years. I don’t get any form of assistance from anybody except Allah”. IDI with a 30 years old woman, Nahuche HDSS. “The one I had died. I don’t get any form of assistance from any of the people you

• mentioned. No assistance at all”. IDI with a 25 years old woman, Nahuche HDSS.

Discussion The findings from the qualitative study showed that socio-cultural practice of engaging in consanguineous union in the study area have potentials of influencing under-five mortality

• clustering. From the above excerpts, it was clear that consanguineous marriages are well

practiced in the study area. However, the health implication especially as it affects child survival is however not known by most of the respondents. It is a scientific fact that having knowledge of intending couples blood group prior to their marriage prevents giving birth to sickle cell children. In a situation where there is genetic deformation in lineage, marrying within such families may have potential of influencing the health outcome of children from such union. Also, most of the couple in the study area does not undergo any medical checks before and after marriage to have basic understanding of issues like blood group and

• genotype. The only demerit mentioned by majority is in terms of disunity and hatred within

the two families involved in such relationship if there is a case of divorce. Furthermore, Vandezande et al. (2010), opined that information on parents might give us insight into the complex mixture of social and biological mechanism responsible for infant

and child mortality clustering. Family history of disease is an important piece of information in risk stratification and counseling (Øyen, Boyd, Poulsen, Wohlfahrt and Melbye, 2009). Consanguineous union is seen mostly from traditional and religious perspective in the study area and mostly is without the consent of the couple ab-initio. In the word of one of the women: “it is our parents wish and I fear my parent”. Further, it was also evident from their responses that children from such union barely celebrate their fifth birthday before dying and some even reported that the highest age attained by their children was six months. Conclusion Findings from the Indepth-interview showed that consanguineous marriage is commonly practiced within the surveillance area. However, one thing that was clear from the respondents’ responses was the fact that they were not aware of any adverse effect of such union on the health of their children. To make things more difficult, they don’t visit the health facility for any medical check before and after marriage to ascertain the genetic compatibility of such couples. The study thus, underscore the need for awareness on utilization of health services. Socio-cultural practices with potentials of supporting the high regime of under-five mortality clustering like consanguineous union should be discouraged

• r better still awareness on the health implication of such union on the child should be

increased. Limitations Findings shows that socio-cultural practices like consanguineous union might be a potential factor for the under-five mortality clustering observed among some of the compounds in the study area, this may not be conclusive yet due to inability of the present study to incorporate clinical test (e.g blood group test) in the protocol of the study to be able to drive home the

• suspicion. The hypothesis should be further research with a focus on a controlled clinical test
• f the couple to ascertain the genetic compatibility or otherwise and effects on under-five

mortality clustering in the study area. References: Adams, J., Hermalin, A., Smouse, P. (1990.), Convergent Issues in Genetics and

• Demography. Oxford University Press, New York, pp. 3–13.

Adedini, S.A, Odimegwu, C, Imasiku E.N.S, Ononokpono, D.N & Ibisomi, L (2013). Regional variations in infant and child mortality in Nigeria: A multilevel Analysis. J. Biosoc. Sci., doi:10.1017/S0021932013000734 Alabi, O., Baloye, D., Doctor, H.V., and Oyedokun,O.A.(2016). Spatial Analysis of Under-five Mortality Clustering in Northern Nigeria: Findings from Nahuche Health and Demographic

Surveillance System, Zamfara State. IJTDH, 15(1): 1-10, 2016. DOI: 10.9734/IJTDH/2016/24709 Kuate-Defo, B., and Diallo, K., (2002).Geography of Child Mortality Clustering within African

• Families. Health & Place (8) 93–117

Øyen, N., Boyd, H.A., Poulsen, G., Wohlfahrt. J.and Melbye, M. (2009). The Clustering of Premature Deaths in Families. Epidemiology, Vol. 20, No. 5, pp. 757-765. Retrieved from http://www.jstor.org/stable/25662750 Ronsmans C (1995) Patterns of Clustering of Child Mortality in a Rural Area of Senegal, Population Studies: A Journal of Demography, 49:3, 443-461, DOI:10.1080/0032472031000148766 UNICEF (2013). Levels and trends in child mortality. Retreived from www.data.unicef.org/child- mortality/under-five Vandezande M., Moreels, S., & Matthijs, K., (2010) Explaining death clustering: Intergenerational patterns in infant mortality Antwerp 1846-1905, Working paper of the Scientific Research Community Historical Demography, Centre for Sociological Research, Leuven www.iussp2005.princeton.edu/papers/51361