Maternal & Child Health

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FT.COM/BIRTH CHAD FERTILITY ‘God gave me this bigfamily’

Centuries-old social traditions andpoverty have trapped Chad in acycle of high birth ratesand highmortality

By Andrew Jack in Lake Chad Photographs by Kate Holt

alngaye Adam grimaces as he squats on amat in ahot,dusty compound in Tagal, avillageofone-storeymud and wooden houses on the shore of Lake Chad. “Life has become verydifficult,”he says, flanked by his wife and 10 children. MIn the country’ssouthwestern Lacregion, flooding, raids by radical Islamic Boko Haram militants —and government-forced displacement in response —have squeezed the amount of land he has to cultivate. Drought has reduced his crop of maize to afraction of previous levels. Arecent influx of refugees from neighbouring Nigeria —and the accompanying aid workers —has pushed up food prices. He glances round at his nine boys and single girl, unable to recall their precise ages, and says he cannot poorestcountries with the fourth highestfertilityrate. Amatterofpride Instead, rising overall numbers of young dependents camels and long-horned cattle than cars, traditional afford to paythe fees to send anyofthem to school. With an averageofnearly seven children per mother Malngaye Adam, right, in Chad are exacerbating health and nutrition problems, practices prevail. Thelocal chief, Ali Koura, preaches “It’samatter of pride to have abig family,” he says. —and rising —the countrydefies the typical global with his wifeKattouma triggering conflicts and forcing communities to spread the merits of “family limitation”and says thatfive or six and their 10 children in “Lots of children help you. It was not my choice. pattern of so-called “demographic transition”. Normally, the village of Tagal in anygains verythinly at the expense of improved services. children are sufficient, although he has 13 by five wives. Godgavethem to me.” improved health and development reduces early deaths the Lake Chad basin “I tell heads of statethatthe bestassettheyhaveis In anearby walled compound of huts, Ashta He married his wife, Kattouma, when she was 15 and and afall in birth rates follows, resulting in abalanced their people,”saysBabatunde Osotimehin, aformer Mohammed, now aged 22, says she was forced by her he was 22. He is now 52. “If she had given me only two population for each agegroup. health minister of Nigeria and now executive director parents to marryat14and had the firstofher four children, Iwould have taken asecond wife —ifI’d had Thepopulation of Chad, however,isaround 13m and of the UN Population Fund, which is active across the children within ayear.“Isuffered alot,”she recalls of the the money,”hesayswith asmirk. But, as she breastfeeds growing at 3.5 per cent ayear,with two-thirds of its region in promoting improved family planning. “Young birth, saying she would now liketopausefor three years. her nine-month-old youngest, Kattouma says firmly people aged under 25. Without greater efforts to limit people can transform societies, but if you have so many But she sees herselfeventually having afamily of at least thatshe has had enough children and would have used this expansion, expertswarn thatChad risks missing it’s not sustainable.” eight. “[Having] lots of kids will help me.” contraception had she known about it earlier. out on the “demographic dividend”—asurgeofpeople In Tagal, atwo-hour drive from the Lacregion’s capital In Africa’sfifth-largestcountry, which sits on Their situation is typical in Chad —one of the world’s entering the workforce to boosteconomic growth. of Bol along ruggeddeserttracks more often used by significant oil reserves, some pronatalists argue there

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‘Thisisaninsular population living precariously,in ignorance, with no education or health infrastructure’

is no need for birth control, with plentyofland to go round. Thedifferent tribes and faiths vie for influence and are concerned about security, withhostileneighbours across the largely uninhabited northern and eastern sub- Saharan desertregions, including Libya and Sudan. Most of Chad’s population is concentrated in pockets of the westand themore verdant south, where rising fertilityrates are driving malnutrition and unnecessary deaths of mothers and infants as well as creating environmental pressures such as over-fishing and farming and desertification of agricultural land. As 2. resources are squeezed, periodic conflicts break out. “Things have become difficult,”saysMohammed Kale, one of Tagal’s manyfishermen. “There is less water and too manypeople are fishing. Tenyears agothere were 1. space is the same. There are tensions between farmers and plentyoffish. NowIcatch asixth as much and mostof Youssef Mbodou cattle herders. Everyone wants land,”hesays. them are smaller.I’m only 40 years old, but Ihavegrey Mbami, the traditional Hisfamily has provided leaders in the region for six chief of the Bolregion hair from the stress of looking after myeight children.” 2. and3. generations. He himself has 15 children, and he stresses Fishermen at work underlying causes in the isolated, landlocked country nBol, YoussefMbodouMbami, Chad’s former on the lakebythe thathelp account for unrestand high fertility.“This is an ambassador to Niger and Nigeria who has returned to village of Tagal, where insular population living precariously,inignorance and resourcesare under his roots as the traditional leader for the region, points to with no education or health infrastructure,”hesays. I increasing pressure long-standing but intensifying feuds linked to nomadism Theneglectofthe population’s social needs reflects and transhumance (the moving of cattle in search of both the legacyof60years of colonial rule by the French pasture). “The number of people has increased but the and half acenturyofinstabilityand conflictsince independence in 1960. Long before the displacements triggered by the rise of BokoHaram in the pastthree 3. years, militaryand securityactivities dominated government. Foreign powers, with an eyeoncontaining Islamic extremism, have also focused on Chad’s strategic importance, ignoring the need for domestic reform. There is alargeFrench militarybasenear the airportin the capital N’Djamena and anew multistorey, fortress- likeUSembassy is being constructed on the outskirts. Health accounts for less than 7per cent of the state budget and, with mostpeople required to payout of their own pocket even for nominally free public services, total spending on health was just3.6 per cent of gross domestic productin2014, according to the World Bank, compared with 17.1 per cent in the US and 8.8 per cent in South Africa. This lack of investment helps explain both the high rates of infection and death and the scant use of family planning. Supply and demand for modern forms of contraceptives are among the lowestinthe world, with

1. surveys suggesting theyare used by less than 5per cent of women in Chad.

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sees such cases frequently.One reason is the extremely ‘The cultureremains lowuse of exclusive breastfeeding by mothers, partly because of abeliefthatifeither mother or child is ill, impenetrable. People think breastmilk will be harmful. “Theygive herbs, ashes, buy powdered milk and mix it with water,” he says. of girlsaswomen as soonas “Gastroenteritis is verycommon.” While mostofthe 100 children currently being they reachreproductiveage’ treated at the feeding centre need at leastseven days’ care, Dr Dickosaysmothers sometimes takethem home sooner while theyare still ill, or even abandon them. “Husbands want their wives at home, and there is family pressure to look after the other children. They think theycan always have more.” At afamilyplanning clinic in N’Djamena’smain market,where women can slip in discreetly while selling or shopping, Josephine Nangtan, acounsellor, ore indirectwaystolower fertilityare also absent. gestures towards abox on her desk containing dozens Literacyfor girls is at 20 per cent and just12per of registration cards. “Theyask me to keep them here, Mcent even startsecondaryschool. Instead, nearly because if their husband sees them, it could be areason 68 per cent are married before the ageof 18and 29 per for violence or divorce,”she says. cent before theyreach 15, according to Unicef. Girls begin giving birth while theyare still physically immature, ttitudes are beginning to change. Protestant Church leading to complications such as obstetric fistula (internal leaders supportcontraception —not to limit tearing during childbirth thatleads to incontinence). Afamily size but to stress the need for a“responsible” They then face along reproductive cycle, often marked by number of healthychildren, starting later and spacing inadequate spacing between births, and the inabilityto births. TheCatholic Church takes asimilar line, while produce sufficient breastmilk to feed their children. stressing it only encourages natural methods. Thesame “Here, the woman has no power,” says BakarySogoba, is true of Muslim leaders. Sheikh Abdaddayim Ousman, head of child protection for Unicef inChad, drawing a secretary-general of the Higher Council on Islamic contrastwith neighbouring countries thathavelower Affairs, says: “The prophettoldustomarry and have a fertilityrates. “InMali, there is along tradition of travel. family of quality, not quantity. Islam also distinguishes Chad is less open to the exterior.The cultureremains between marriageand the consummation of marriage.” impenetrable. People think of girls as women as soon as On paper,atleast, legislation passed in 2002 theyreach reproductive age—theyare sometimes even guarantees access to reproductive health in Chad, promised to aboy at birth. And where there is polygamy, overturning colonial-eralawsthatbanned birth control you can have competitive reproduction between multiple and widespread practices that, until far more recently, wives vying to have more children than their rivals.” required husbands or parents to authorise anyfamily “There is progress, but it’s not enough,”saysMoussa planning. An official plan has setfour children per Khadam, Chad’s minister of public health, whose woman as an objective for the countryby2030.

grandfather had 63 children but who has limited himself 1. More radically,lastyear President Idriss Déby Itno to two. “Chad has veryhigh illiteracyand is already pushed through alaw banning marriagebefore the age overpopulated in the centre and the south. We need of 18 —afirstinwestAfrica and amove possibly linked better tools for family planning and greater awareness to to his current international profile as the chair of the tackle traditions thatare centuries old.” Mortality rates Such practices explain whyChad ranks among the African Union. Khadam, the health minister,says some When public moneyisprovided, however,itisnot in Chad world’s worstperforming countries in terms of health. ‘Inrural areas, practically violations have already been prosecuted. always used effectively.Behind Khadam’s ministry With maternal deaths of 856 per 100,000 live births in Yetfor now,asAbbot Gabriel Dobade from the building in N’Djamena are more than 100 unused 2015, and infant deaths of 85 per 1,000 live births, life nothingisbeing done. Catholic Church’s Episcopal Conference, puts it, there ambulances neatly parked among growing weeds; expectancyatbirth is just53.1 years. In part, the country are fewsigns of broader public investment in Chad’s none of them even has anumber plate. Even if theyare has not experienced the demographic transition because We aregoing backwards’ development. “Inrural areas, practically nothing is eventually deployed as intended, and do not quickly manyof the pre-determinants are not yetinplace. being done,”hesays. “Weare going backwards in break down on the country’sfew passable roads, many Having more children remains away to replace those areas where we should be advancing. There is injustice see them as awasted investment. 856 who do not survive. 2. and poor governance.” Rolland Kaya, countrymanager for the Médecins maternal deaths per After years of rising government revenues, the drop Sans Frontières humanitarian aid mission in Chad, 100,000 livebirths tatherapeutic feeding centre in N’Djamena, in the oil price in recent months has imposed fresh argues thatmuch more public funding should go into Nelkam Dadimra, who is barely 15, cuddles her austerity. Theconference centre where the African Union supporting basic prevention methods and local health Amalnourished 10-month-old daughter,Salut. She was supposed to hold its meeting in N’Djamena lastyear clinics. “Often there are no supplies, no vaccines, no came to the capital three years agotofind work as a sits unfunded and unfinished. Public sector workers bed-nets againstmalaria, no hygiene training to stop cleaner and gave birth at home, leading to complications 1. and students on grants have not been paid in weeks, Girls use the waters infection, and workers are not paid,”hesays. and stomach pains from which she still suffers. Unable of Lake Chad to do triggering marches, strikes —including in health centres Theresult is thatpeople turn instead to traditional 139 to breastfeed, she fed her child amilletporridgemade the washing —and stone-throwing by young people. healers, whose interventions often makematters deaths of children with water which she is too young to digest. This has 2. Just as the state’sability to investinhealth, family worse. He cites strangeherbal concoctions, incisions under fiveper caused diarrhoea and fever.“Godgives us children,” Nelkam Dadimra, 15, planning and other public services has been reduced, 1,000 livebirths with her 10-month- made into the skin as supposed treatments and, in one she says. “Maybe Iwill have 10.” old daughterata the mostrecent swelling cohortofyoung people is case, aremedy for diarrhoea thatinvolvedburning the With malnutrition affecting 40 per cent of Chad’s therapeutic feeding moving towards adulthood and is beginning to make affected young child’s anus. children, Dr Ibrahim Dicko, who runs the centre, says he centreinN’Djamena its frustration felt.

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