Under-Five Mortality in Nigeria: Perception and Attitudes of the IKWERRES in Rivers State towards the Existence of “OGBA – NJE”

The paper examines the under-five mortality in Nigeria with regards to the perception and attitudes of the Ikwerres about the existence of „Ogba-nje‟ (children from the spirit world) and the mode of treatment given to such children. The study elicited information from 1695 women of reproductive age in Port Harcourt and Obio-Akpor LGAs of Rivers State South-South, Nigeria. The study shows that (i) more than half of the respondents believe in the existence of Ogba-nje children; (ii) that Ogba-nje children can be identified from the evidence of past death, frequent indisposition, non-responsiveness of their illness to moderate medical care as well as repeated death and verification from traditional healers; that causes of illness differ between Ogba-nje and non Ogba-nje children; (iv) close to 71 percent of the respondents have faith in traditional methods of treatment for Ogba-nje children. The study, therefore, reiterate the need to integrate the people;s beliefs, attitudes and behavioural practices into health promotion progammes.


Introduction
Infant and child mortality remains disturbingly high in developing countries despite the significant decline in most parts of the developed world. The state of the world"s children indicated that about 12.9 million children die every year in developing world (UNICEF, 2011). Also, the Nigeria Demographic and Health Survey (NDHS), 2010 reported that 87 of 1,000 infants born in Nigeria die before their first birthday while 115 of 1,000 children die before reaching age five (FOS, 2010). The 2010 NDHS reported an infant mortality rate of 75 deaths per 1,000 live births and under five mortality rates of 140 deaths per 1,000 live births for the 2006 to 2010 period. Also, review of trends in under five mortality rates between 2000 and 2010 by UNICEF (2011), based on an estimate of 187 deaths per 1,000 for 2010 indicates a 10 percent reduction in Nigeria.
According to the Nigeria Demographic and Health Survey (NDHS) (2010), infant mortality and under five mortality rates for the ten years period preceding the survey for the South-South part of Nigeria, the focus of this study, are 70 per 1,000 and 102 per 1,000 live birth respectively (NPC, 2010). Fir five years immediately preceding the 2004 -2008 survey, the infant mortality rate was 100 deaths per 1,000 live births, while the overall under-five mortality rate was 201 deaths per 1,000 live births (NPC, 2010). The level of improvement in infant and child mortality in Nigeria as a whole is significantly lower than the average of 34 percent for the sub-Saharan Africa.
Common causes of child mortality and morbidity include diarrhea, acute respiratory infections, measles, and malaria. Studies have shown that many children in Nigeria die mainly from malaria, diarrhea, neonatal titanus, tuberculosis, whooping cough and bronchopneumonia (Tomkins, 2010;Ayeni, 2005;and Animashaun, 2000). Mosley and Chen (2011) also viewed morbidity and mortality of the child as being influenced by underlying factors of both biological and socio-economic, operating through proximate determinants. Jinadu et al. (2001), in a study, found dirty feeding bottles and utensils, inadequate disposal of household refuse and poor storage of drinking water to be significantly related to the high incidence of diarrhea. Studies have also shown maternal education to be a significant factor influencing child survivial (Caldwell, 2009;Orubuloye & Caldwell, 2005;Meegama, 2000;and Feyisetan, 2008).
Knowledge of measles and diarrhea is quite pertinent in an understanding of the role of cultural beliefs in helath seeking among the Ikwerres. In the traditional Ikwerre setting, measles attack is usally attributed to a variety of causes which have no link with the cocept of virus (Odebiyi & Ekong, 2002). Measles attack is traditionally considered as a punishment for breaking family taboos or as an evil deed from witches or enemies. The belief that the measles attack is caused by enemies is common among polygamous family where co-wives are natural suspects. While measles is perceived as deadly disease amnf the Ikwerres, diarrhea is perceived merely as a means of getting rid of body impurities or as a sign of "teething", or "stretching". Also mothers believe that diarrhea is caused by consumption of sweet things (Jinadu et al. 2001). Mothers with this view will not likely introduce oral rehydration solution to their children since it contains sugar and salt. Despite the fact that the major childhood diseases have been identified and modern technology to combat them developed, yet, children from African countries (Nigeria inclusive) die in large number from the attacks of these diseases. The adduced reason is deeply rooted in people"s beliefs and attitudes concerning childcare and behavioural practices into health strategies (Parry, 2004;Uboma-Jasaw, 2008;Feyisetan, 2008;and Adeokun, 2009). The Nigerian Health Policy recognizes the need to reduce the current high childhood morbidity and mortality into the health intervention programmes.
The non-disease specific beliefs among the Ikwerres in Rivers State, is the existence of "Ogba-nje" (children from the spirit world who can die as will). The Ikwerres belief that some children are from the spirit world and they will eventually return to the spirit world after a short period of time on earth unless certain rituals are performed, Ogba-njes are described as spirit children whose mercurial treatment, even rejection, of their parents (mothers especially) leave the mothers in most pitiable state. Ogba-nje children inflict a lot of pain and agony on their mothers. The pain suffered by the mothers of Ogba-nje and the efforts made by Ogba-nje mothers to placate their obviously mischievous, pain-causing offspring were succinctly displayed in s (1981) and Achebe"s ()1986 works. The Ogba-nje child also emerges as a frequent traveler between the world of the living and the place of the friendly dead (Achebe, 1958& Quayson, 1997. The notion of Ogba-nje is a common phenomenon in west African countries. Recognizing the implication of this belief for child health and its survival and upon the recognition of the fact that children under-five constitute an important segment of the Nigerian population, this paper, therefore, attempts to examine the perception and attitudes of the Ikwerres about the phenomenon called "Ogba-nje". The existence and the mode of treatment of "Ogba-nje" as well as the non "Ogba-nje" children are discussed in the paper.

Objectives of the Study
The study seek to achieve the following objectives: (i) to identify people"s perceptions of the etiology of certain childhood diseases and determine the impact of such perception of health seeking behavior; (ii) to determine mother"s knowledge and use of health services; (iii) to identify maternal and childhood feeding practices; (iv) to determine the impact of health-seeking behavior and other child care practices on child morbidity and mortality in Port Harcourt and Obio-Akpor Local Government Areas (LGAs) of Rivers State South-South Nigeria. In order to achieve these objectives, a survey on the people"s perceptions, etiology and cultural beliefs in Port Harcourt and Obio-Akpor LGA of Rivers State was conducted.

Methodology
The study elicited information from 1695 eligible women of reproductive age (15 -49 years) from the selectd rural and urban areas in five selected communities of Port Harcourt and Obio-Akpor LGA. The data were collected from Oginigba community, Rumumasi community, Rumuokwuta community, Rumoudumaya community and Akpor community (two from Port Harcourt and three from Obio-Akpor). A multistage, stratified random sampling design was used to select respondents from the communities/town. In the rural communities, selection of respondents was by simple random sampling technique. However, the random selection was made in such a way that all the different parts of the community Journal of Sociological Research ISSN 1948-5468 2012 www.macrothink.org/jsr 590 were represented. From the data collected, indirect infant morbidity and child mortality estimates were obtained.
Brass is one of the proponents of indirect method of mortality estimation. He based his mortality estimate on retrospective date given by women of reproductive age on the number of children ever born and their status (either dead or living). Other contributors in this line include Sullivan (1972), Trussel (1975), and Preston and Palloni (1978). However, indirect infant and child mortality estimates result from poor, inadequate and incomplete data especially in developing countries. Most deaths outside hospital premises were not recorded and that many people do not record infant deaths because they regard such occurrence as misfortunes, and when recorded, the age at death were either understated or overstated.
The method adopted in this study is the Lotus Program for the calculation of mortality by Samoza (1980). The variables examined include age, religion, education, type of place of residence, perception of illness, health seeking behavior and the respondents occupation as well a fertility-related variables such as children ever born, own children five years and under, age at marriage etc. data analysis was carried out using both univariate and bivariate approaches. The invariate analysis deals with the frequency distributions that show how varied the respondents are in socio-economic, child care and health seeking behavior variables. At the biverate level, the simultaneous analysis of two variables and child health seeking behavior as well as between child health and health seeking variables were examined. For the biverate analysis, interval measured variables were changed through recording into ordinal variables with few categories.

Findings and Discussion
The socio-economic characteristics of the respondents are presented in Table 1. The table shows that majority of the respondents fell within age range 30 -39 (42.1 percent). Nearly equal number of respondents were interviewed from the rural and the urban locations (50.5 percent and 49.5 percent in urban and rural areas respectively). More than 90 percent of the women had received formal education. The highest being secondary or higher levels with 40.5 percent. Majority of the respondents (90.4 percent) professed to be Christians. The Muslims constitute only 7.4 percent of the total sample, while those who are traditionalists represent only 1.2 percent of the whole respondents. About 86 percent of the respondents claimed to own one or two children under-five years of age, while only 1.2 percent claimed to have 4 or more. Majority of the respondents engage in either sales or services (58.8 percent), while close to 33 percent are also found in agriculture. Belief in the existence of "Ogba-nje" Respondents were asked to indicate whether or not they belief in the phenomenon called "Ogba-nje". The distribution of mothers according to responses to the questions on "Ogba-nje"is presented in Table 2.
Panel 1 of the table indicates the persistence of this belief among the Ikwerres. About 57 percent of mothers believe that there are Ogba-nje children; 30.1 percent do not share this belief and 12.9 percent are unsure of their beliefs. When the women were asked if they have ever had Ogba-nje children, only 15.4 percent of the mothers who believe in its existence answered in the affirmative (Panel 2). This finding is not surprising since many mothers, especially the educated ones, may not likely admit that they already have children they suspected to be Ogba-nje and none of their infants had died.
One of the mothers who claimed to have had Ogba-nje children, 83.2 percent reported that the "Ogba-nje" children have died (Panel 3). Asking mothers to state "how an "Ogba-nje" child can be identified", panel 4 of Table 2 indicates such responses as: "evidence of deformity from past death (such as being too dark to completion or having incomplete or deformed parts of body as the outcome of wounds inflicted on the body of previous child that died by the offended mother)". (27.4 percent); "frequent indisposition" (11.6 percent); "non-responsiveness of their illness to modern medical care" (17.9 percent). And "repeated death and verification from traditional healers (39 percent). Information was also sought on (i) whether a suspected Ogba-nje child should be subjected to the same treatment as a non-ogba-nje child and (ii) where treatment should be sought for a suspected ogba-nje child when he/she is sick. Panel 5 of Table 2 shows that 61.7 percent of the respondents shared the believe that a suspected ogba-nje child should not be treated like an ordinary child when he/she is sick. About 3 percent are not sure of the type of treatment to recommend to a suspected ogba-nje child. When asked "where a suspected ogba-nje should be treat", about 70 percent of the respondents mentioned traditional or spiritual healer"s home (panel 6). This finding reflects the belief that illnesses of ogba-nje are not caused by natural but by supernatural forces. Thus, such illnesses are believed to be incurable by "mere administration of drugs or injections in the hospitals".  (163) The percentages of mothers of different socio-economic backgrounds who claimed to have believed in the existence of ogba-nje children are presented in Table 3. The table shows that older mothers are more likely than younger ones to hold the believe that ogba-nje children exist. Education is negatively correlated with mothers" believe in the existence of ogba-nje children. The table shows that higher proportion of Muslims hold this believes, however, significant proportion of Christians also believes in the existence of ogban-nje. This is an indication that religion has not influenced or changed the perception of the Ikwerres concerning certain norms. Also, higher percentages of mothers in urban areas believe in the existence of ogba-nje indicating that urban residency has not erase completely the perception of these women about certain socio-cultural norms. It should, however, be noted that significant proportion of people residing in urban areas in Nigeria are migrants from rural areas and modernization and westernization have not seriously influenced their cultural perspectives. Treatment of "Ogba-nje" children According to traditional belief among the Ikwerres, there are two categories of children namely ogba-nje and non ogba-nje. Since causes of illness are believed to differ between the groups, we asked mothers to "state whether the two groups of children should be treated the same way when they are sick". As indicated above, only 35.3 percent of mothers believe that an ogba-nje child should be treated like any other child when he/she is sick. The percentage distribution of mothers who believe in similar treatment for both ogba-nje and non ogba-nje children is presented in Table 4 according to their background characteristics. It is discernible from the table that (i) a clear pattern of association does not emerge between age of mother and their believe in similar treatment for ogba-nje and non ogba-nje children; (ii) education is positively correlated with the belief in similar treatment for the two groups of children; (iii) the fact that less than half of women with secondary (or higher) education hold this belief is, however, a source of concern; (iv) Catholic and Protestant Christian mothers are least likely to believe in similar treatment for the two groups of children; (v) rural dwellers are more to proffer similar treatment for the two groups of children. This pattern of differential by place of residence is unexpected because mothers in the urban areas, who are not more exposed to Western ideas but also, have higher concentration of modern health facilities, are expected to have more rational attitude than the rural dwellers. Finally, mothers who reside in the city before age 12 are most likely to proffer similar treatment for ogba-nje and non ogban-nje children.
As indicated above, close to 71 percent of the mothers suggested traditional health facilities as places to treat ogba-nje children. Such facilities mentioned by these mothers include: traditional healer"s home (59.8 percent), church/mosque (9.2 percent) and other traditional health facilities (1.6 percent). The percentage distribution of mothers who suggested these placed by background characteristics is presented in Table 4 below. The table shows that: (i) the probability of suggesting a non-modern health facility does not vary among mothers who are under 40 years (ii) mothers with secondary or higher education are less likely to suggest traditional health facilities than mothers with primary or no education; (iii) the probability of suggesting traditional health facilities does not vary much among different groups of Christian mothers (iv) urban residence is positively associated with the probability of suggesting a traditional health facility; and (v) mothers who reside in the city before 12 are least likely to suggest traditional health facilities.
As mentioned above, majority of the mothers believed that spiritual healing should be sought for an ogba-nje child, though some of them still combined traditional healing with orthodox healing. They believed in the efficacy of traditional healing methods, thus corroborating earlier findings by Morrison (2008), Okri, (1995, Quayson (1997) and Achebe (1985) concerning the treatment of Ogba-nje. Panel 7 of Table 4 shows that majority of ogba-nje children that died were treated in traditional healer"s home (47.3 percent). The trust mothers in the area placed in faith-healing home was brought out in the study as 21.4 percent of the dead children. Significant proportion of the mothers (27.9 percent) claimed to have used the combination of both orthodox and traditional healing methods in the treatment of dead ogba-nje children.  ISSN 1948-5468 2012 It was found out from the study that quite a lot of people do not have clear perception of illness and treatment while some attached the death of under-five children to Ogba-nje spirit. This has serious implication on under-five morbidity and mortality in Nigeria.
The ultimate goal of governments all over the world is to postpone the inevitable "life ends" by reducing mortality to low levels and ensure the good health of all citizens. But in spite of a general decline in infant and child mortality in developing world, the rates are still high by world standard. The persistently high infant and child mortality level in Nigeria continues to be disturbing to both planners and policy makers. Despite the fact that the Nigerian Health Policy recognizes the need to reduce the current high childhood mortality, the people"s belief and behavioural practices have not been adequately integrated into health intervention programmes. It is disturbing to find out that people are still holding on to their wrong perceptions and attitude towards the etiology of certain childhood diseases and deaths despite the positive effect that modernization and education are having on people"s behavior. As Morrison (2008) noted, a mother who sees her child gradually wasting away without apparent cause, concludes that an Ogba-nje has entered it, or, as the natives frequently express it, that she has given birth to an Ogba-nje, and that it is being starved because the Ogba-nje is stealing all its nourishment. Many people have not realized that infant morbidity and child mortality result from the combined effects of nutritional deficiencies, infections, parasitic and respiratory diesaeses. Mothers do not have clear perception of illness and treatment while some attached the death of under-five to "ogba-nje" spirit. Therefore, there is need to integrate the people"s beliefs, attitudes and behavioural practices into health promotion programmes to achieve a maximum reduction in child and infant morbidity and mortality. Unless this is done, there might not b too much progress a regards curtailment of infant and childhood morbidity and mortality in Nigeria.