When Mistra Hassan raises gender issues with community leaders in rural Sokoto, her approach is methodical, honed over 20 years as a community nurse and midwife in this northern Nigerian state. She cuts through the biases that restrict women’s freedoms and lays bare the need for access to healthcare.

“We don’t tell the men they are wrong,” she says. “We just let them see the importance of what we are doing.”

On one occasion, she met with a group of village elders and asked how many women experienced problems during home births. They counted four recent deaths. Mistra explained that husbands can help their wives stay healthy by supporting them to seek regular antenatal care. This means allowing women to decide when they need to go to a healthcare provider, allotting transportation fees, accompanying them to appointments, and supporting them to take iron and folic (IFA) supplements every day and access healthy foods. These are practical matters, but each step is also a challenge to prevailing gender norms and must be proposed with care.

“Invite the man to come with the woman to the hospital,” says Mistra. “Motivate him. Tell him that the blood that is flowing within this woman is for two people, so she needs extra food, extra everything in terms of being healthy.”

The training

On December 13, 2021, Mistra was one of 50 health workers from Sokoto to participate in a training on maternal nutrition. The workshop was part of a collaboration between Nutrition International and the United Nations Population Fund (UNFPA) to improve maternal nutrition and reduce the risk of anaemia in pregnancy — a condition that puts mothers at increased risk of death and increases the risk of poor pregnancy and birth outcomes.

According to the Nigeria Demographic and Health Survey 2018, Nigeria’s anaemia prevalence amongst women of reproductive age was approximately 58% (as high as 72% in some states) and only 56% of women of reproductive age were classified as having an adequately diverse diet. Additionally, only 34% of married women aged 15 to 49 participated in household decisions, including regarding their own health care.

Geared towards health professionals with experience in nutrition, community medicine, midwifery and maternal and child health, the training was an opportunity to engage this audience on the gender barriers that exist in accessing healthcare and adversely impact women’s health.

Some participants, like Mistra, were keenly aware of how gender relations affect their work. Others would explore the connection for the first time.

Part of Nutrition International’s mandate is working within government systems to build capacity of healthcare workers. Developing a specific module on gender equality within maternal nutrition trainings is part of our commitment to mainstreaming gender as outlined in our Program Gender Equality Strategy. Modules that reframe masculinity enable more equitable distribution of household nutrition, health decision-making, caregiving or professional health-related responsibilities. Such approaches have an impact on promoting gender equality, women’s empowerment and nutrition.

As Sarah Pentlow, Senior Program Officer for Gender Mainstreaming at Nutrition International, explains, “We need to look at women as more than beneficiaries and think about the underlying dynamics in the household that impact on women’s rights to access and use nutrition and health services.”

How personal beliefs shape professional practice

In 2020, Nutrition International began conducting gender analyses in the countries where we work to better understand the gender barriers affecting nutrition programs and design targeted interventions. In Nigeria, qualitative methods included focus groups and in-depth interviews with pregnant women, husbands, mothers-in-law, community leaders, traditional birth attendants, community health workers and pregnant adolescent girls. The analyses revealed women’s limited access to information, education and financial resources; restrictions on movement and decision-making power; acceptance of early marriage; stigma surrounding pregnancy out of wedlock; and a lack of respectful care towards women by health care providers.

Pentlow suggests that by equipping frontline workers with additional skills to better serve women and families, the gender module is a tangible way to respond to a complex set of problems. The module guided participants through key topics, including sociocultural norms and power relations as they impact women’s health outcomes, the importance of engaging men on gender equality and health, and challenging personal bias as health professionals. In addition, Nutrition International reviewed the workshop as a whole to ensure gender responsive messages throughout all modules.

When it comes to maternal health, the way that providers conduct themselves in the workforce can often be shaped by their personal beliefs and values. “This was an opportunity to sensitize healthcare workers on gender equality issues generally and get them thinking about some of their own biases and how they may be playing out in their practice,” Pentlow explains.

One module’s cascading impact

With 26 male and 24 female health workers in attendance, the gender training module sparked lively debate. Mistra was impressed by the high level of engagement among the men, though she notes that power imbalances influenced the discussion. She recommends what is often referred to as a “low-dose, high-frequency” approach that avoids overwhelming the audience but also offers opportunities to reinforce and further the learning.

Following the day-long maternal nutrition training on December 13^th, participants split into groups and travelled to rural areas across Sokoto state to share what they had learned. In this way, this cascading training reached 450 people who work in maternal health—including primary health care teams, antenatal care providers, community volunteers and traditional birth attendants—in seven Local Government Areas. From there, sensitization meetings were held with traditional and religious leaders, considered community gatekeepers, with the goal of building support for women’s access to antenatal care and services such as IFA supplementation.

Pentlow hopes that as healthcare workers are sensitized to the issues and equipped with basic knowledge, they will not only be able to offer better service to their communities, but also emerge as a force for change. “If we’re able to influence training curricula that are then shared with all health care workers in a country, that’s having an incredible reach,” she says. “It’s about identifying those important entry points in a system where you can have the maximum impact.”

Plans are underway to embed a gender module in maternal health and nutrition trainings in other regions where Nutrition International works, with country offices moving at their own pace and responding to local contexts, while also sharing resources.

Reinforcing gender equality and removing barriers

For Nutrition International, gender mainstreaming means ensuring that core program areas like maternal nutrition are gender responsive and grounded in the local context. “If it’s not contextualized to people’s work environment and their situation, it doesn’t resonate, and then it just becomes a tick-box exercise,” Pentlow says, adding that gender training is not a one-off, but must be continually reinforced.

“The inclusion of a gender module within maternal nutrition training is part of promoting gender equality in all of Nutrition International’s programs,” says Caroline Mukeku, Nutrition International’s Regional Gender and Equality Advisor for Africa. “When an organization includes gender in this way women and girls experience the agency for their own health and nutrition. Additionally, when we design and implement gender responsive and transformative programs, we are able to challenge social and gender norms, stereotypes and sociocultural practices that constrain women and girls from achieving their full potential.”

Nutrition International has been operating in Nigeria for over ten years with funding from the Government of Canada to improve maternal and neonatal nutrition and child survival programs by working with the Ministry of Health and other partners. Currently, Nutrition International is supporting maternal nutrition programming in six states: Sokoto, Yobe, Katsina, Jigawa, Kebbi and Cross River.

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