Access to Reproductive Health Care for Internally Displaced Women in Northern Nigeria: A Critical Ethnography By Oluwakemi Amodu A thesis submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Faculty of Nursing University of Alberta © Oluwakemi Amodu, 2020 Abstract In Nigeria, Boko Haram terrorists and Herdsmen have forcibly displaced over one million women from their homes. These women are living in precarious circumstances with limited access to essential services. Grey literature shows that displaced women are predisposed to rape and unintended pregnancies. Little is known about how these women access reproductive healthcare. My doctoral research addresses this gap in knowledge. Using a critical ethnography research design founded on feminist intersectionality theory, my doctoral dissertation examines access to reproductive healthcare for internally displaced women living in a relief settlement in Northern Nigeria. Thirty-nine participants including women, health service providers and policy makers were recruited for the study. Imperative reproductive health concerns identified among women include widespread urogenital infection symptoms and noticeable high rate of childbearing associated with a need to replace children lost to terrorist attacks. There were limited health care resources and services at the available health centers reflecting broader structural challenges in the health sector. Women navigated this limitation by seeking care with local midwives and a patent medicine vendor. The Nigerian government is overly reliant on aid agencies to support displaced women’s health needs. As funding to humanitarian agencies is scaled back, displaced women are left to depend on grossly inefficient primary health care facilities. The findings of this research are invaluable to Ministries and institutions on the need to develop appropriate policies and guidelines to address the reproductive health needs of internally displaced women. My work is aligned with the United Nations Sustainability Development’s broad goal “to leave no one behind” by prioritizing issues affecting the health and wellbeing of the most marginalized persons around the world. ii Preface This thesis is an original work of Oluwakemi Amodu. The research project, of which this thesis is a part, received research ethics approval from the University of Alberta Research Ethics Board, Project Name “Reproductive Healthcare Access for Internally Displaced Women in Nigeria: A Critical Ethnography Study”, No. Pro00089091, May 6, 2019. Furthermore, approval was obtained from the National Social Investment office, Nigeria. The three manuscripts contained herein were prepared by Oluwakemi Amodu and at this time, the first paper is published (Chapter 2), Chapter 3 is under peer review for publication and Chapter 4 has been accepted for publication, with my supervisory committee members as co-authors. iii Dedication This dissertation is dedicated to all women who have been displaced from their homes because of terrorist attacks particularly those who shared their stories with me. iv Acknowledgments I have had the privilege of being supported by many great persons, erudite scholars and dedicated family and friends as I went through academic life at the University of Alberta. Accomplishing this PhD will not have been possible without your support therefore; I would like to recognize your immense contributions to my success. To begin, I want to thank God for giving me sufficient grace to complete my studies. I would like to express my unreserved appreciation to my wonderful supervisors, Dr. Bukola Salami and Dr. Solina Richter for their selfless support and mentorship that aided my academic growth. I cannot count all the ways you helped in this journey. I am grateful that you believed in me and were patient. I am grateful for your compassionate supervision, for listening to my questions and providing me with opportunities to work with you and with other members in your research network. Thank you specifically for teaching me the value of hard work and dedication. Thank you for your attention to my personal and professional development at all my milestones which helped me to thrive in my career progression. I am very grateful to you. I would like to express a special appreciation to Prof. Philomina Okeke-Ihejirika, who is a member of my PhD committee. I am humbled and grateful to have had the opportunity to learn from you and to gain a broader perspective on women’s research. Your critical feedback has enriched my thinking and allowed me to reason outside the immediate scientific horizons of my work. Thank you for stirring my passion to complete this dissertation. Your valuable contributions have enhanced my scholarly development in every way. I want to especially thank the 29 women who participated in my study, and trusted me with their stories and gave me the consent to write about their experiences. Your stories bring to life the experiences of many other women who may not have survived the terrorist crisis or may v not have the opportunity to share their stories. Thanks to the camp leaders and women leaders who gave me access to their community and homes to experience significant parts of their daily realities with them. I consider this an unusual privilege. I appreciate the valuable support of stakeholders in Nigeria including Prof. Oladosu Ojengbede and Dr. Kayode Afolabi and others who connected me with needed resource persons in Nigeria and helped me navigate the terrain. I appreciate your insights, and support throughout my field research in Nigeria. I want to acknowledge mom, Modupe Henrietta Amodu, who has been an inspiration to me in my nursing career, my forever-supportive dad, my older siblings Jumoke, Toyin, and Rotimi, for their love and prayers throughout my graduate program. I cannot neglect to mention my younger sister Ife, my cheerleader, and personal financial advisor, helping me negotiate prices of things in Nigeria when I was completing my fieldwork. Thank you to my very good friends, who encouraged me to keep going. There are many amazing individuals whose contributions have helped me forge ahead in this journey but who I do not have space to mention. Thank you so much for being there. Finally, I want to acknowledge the funding support of the Women and Children’s Health Research Institute, through the Royal Alexandra Hospital, Canada, and the International Development Research Center, Canada and other internal awards received from the Faculty of Nursing, the University of Alberta that enabled me to complete my research and thesis writing. vi Table of Contents Chapter 1: Introduction ............................................................................................................... 1 Significance ................................................................................................................................ 5 Background ................................................................................................................................. 6 Internal Displacement ...................................................................................................... 8 Gender and Internal Displacement ................................................................................. 10 Conflict-Induced Displacement...................................................................................... 13 Conflict and Displacement in Africa .............................................................................. 14 Displacement in Nigeria ................................................................................................ 15 Nigeria .......................................................................................................................... 15 Displacement in Nigeria and Reproductive Health ......................................................... 18 Purpose of the Study ................................................................................................................. 21 Research Questions ................................................................................................................... 21 Research Objectives .................................................................................................................. 21 Methodology: Critical Ethnography .......................................................................................... 22 Philosophical Underpinning ........................................................................................... 23 Intersectionality ........................................................................................................................ 26 Self-Awareness.............................................................................................................. 28 Voice and agency .......................................................................................................... 29 Methods .................................................................................................................................... 31 Study Site ...................................................................................................................... 31 Shelter type ................................................................................................................... 32 Access to Basic Services ................................................................................................ 33 Safety Measures ...........................................................................................................