NIAMEY, 14 December 2007 (IRIN) - Every two hours in Niger a woman will die during her pregnancy or while delivering a baby - a symptom of under-resourced health services, neglected transport and education infrastructure, and a lack of awareness among women of their rights, health officials and experts say.

Niger's 13.5 million people (Nigeriens), spread across a barren territory roughly the size of Western Europe, have missed out on much of the development that has happened in other countries on the African continent.

There are just a hanful of paved main tarmac highways, and most people live in remote villages miles from a road, school, health centre or local government office.

Fatima Trapsida, director of the Gazouby maternal health hospital in the capital, Niamey, says this is the first obstacle to getting women to the help they need: "Getting to a doctor can mean taking a horse and cart, waiting for public transport, or paying for the petrol for one of the country's ambulances."

The health system

The distances involved can be vast, and getting to a health centre does not guarantee treatment.

There are just 17 doctors trained to perform Caesarean operations in the entire country - seven based in Niamey and 10 in the regions.

Some regional capitals like Diffa and Tillaberi do not have anyone available to perform birth-related surgery.

"The system is still very insufficient," said Soumana Hama, one of the emergency doctors based at the Gazouby maternal health centre in Niamey.

"It's a problem of getting the means - maternal mortality was not a priority until very recently," he said.

According to the UN annual Human Development Index, a trained midwife tends to only 16 percent of the 600,000 Nigeriens born every year.

Education

Another powerful factor driving up the country's maternal mortality rate is the impoverished state of girl's education in Niger, experts say.

Just 15 percent of girls overall, or less than 10 percent in some areas, can read or write. Many thousands of the girls that do make it to school drop out early to marry, often before the age of 15.

"There is still not enough awareness of the importance of modern healthcare for pregnant women both during pregnancy and during labour," Amoul Kinni Ghaichatou, a medical officer at the UN Fund for Population Affairs (UNFPA) in Niamey, said. "If women and girls and their families knew what the consequences of not going to modern health centres would be, they would go to hospital to have their children."

Instead, she said, many families - which are usually run by the man - will turn to local charlatans, religious officials and traditional healers for help with complicated births, before finally seeking out a doctor.

"The big need is to get people's children to school, especially girls, because if she goes a lot of things will improve. That's the big challenge - getting all girls to school. Then all health indicators will improve," Trapsida said.

Costs

Poverty is another problem. Nigeriens are among the poorest people in the world, with 85 percent still relying on primitive rain-fed subsistence agriculture to scrape by.

Although Niger's government has elaborated national strategies for free healthcare for under-fives, free Caesarean births, and pre-natal consultations - in reality many people have had to keep paying for these services as the central fund to subsidise health centres has not been fully operational. http://www.irinnews.org/Report.aspx?ReportId=60749

Once they have paid for the transport and other costs to get themselves to a health centre, there's often nothing left to pay for treatment at the clinic or hospital, experts say.

"Women are dying five metres from health centres because they can't afford to go inside," Ghaichatou said.

Change

Despite the scale of Niger's problems, officials insist change is possible.

While getting a functioning education system off the ground and changing stereotypes about educating girls could take a generation or more to filter down, targeted information campaigns aimed at women and girls do help, according to Issa Sadou, a programme officer also at UNFPA.

Sadou points to a campaign against female genital mutilation/cutting, incidences of which decreased by 2 percent in Niger between 1998 and 2006. The turning point in that campaign, Sadou said, was 2001 when a law was passed banning the practice.

"Making change takes time. It means working to change laws and sometimes traditions," he said.

UNFPA's Ghaichatou sees a link between increasing people's awareness of what should be available to them and the rate of improvements in the system.

"People have the right to access the health service. When they understand that, they will claim it and demand better treatment," she said.

"As things are, we could have the best healthcare facilities in the world here, but if people don't understand why it matters, they won't go."

This is the first story in a three part series looking at maternal mortality and child marriage in Niger.

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[BOXOUT] Health system woes

Niger's health problems are not restricted to the maternal health sector.

Malaria, tuberculosis and diarrhoea are all big killers of adults and especially children, with problems compounded by widespread malnutrition, from which 50 percent of the population suffers each year.

Diseases such as measles, cholera and sleeping sickness that have nearly been stamped out in many other sub-Saharan countries remain endemic in parts of Niger.

Yet Niger is one of the biggest spenders on public health in the West Africa region. In 2006 it allocated 12 percent of gross domestic product (GDP) to healthcare, according to the World Health Organization (WHO).

The country's paltry national income means that investment only added up to around US$5 per Nigerien - far short of the WHO's suggested US$35.

Source: Niger: Cash shortfall derails child health goals http://www.irinnews.org/Report.aspx?ReportId=60749

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