Socio-Cultural Context and Civil Registration of Under-Five Children in Akwa Ibom State of Nigeria

Socio-Cultural Context and Civil Registration of Under-Five Children in Akwa Ibom State of Nigeria

Idongesit Eshiet and Grace Udoyen

Department of Sociology, University of Lagos, Nigeria

DOI: https://dx.doi.org/10.47772/IJRISS.2023.701066

Received: 09 September 2023; Revised: 01 October 2023; Accepted: 02 October 2023; Published: 03 November 2023

ABSTRACT

Vital statistics play a crucial role in development planning and effective utilization of resources in any nation, hence the need for the effective participation of citizens in civil registration. However, in Nigeria, effective civil registration has been marred by the socio-cultural environment and other contextual factors. This study investigated the influence of socio-cultural environment on the registration of births and deaths of under-5 children in Akwa Ibom State, Nigeria. The study examined the influence of cultural beliefs about maternal and child health, health seeking behaviour, poverty and administration of civil registration on under-5 children births and deaths. Primary data was gathered through 30in-depth and 3 key informant interviews conducted on child bearing women (18-49 years) and civil registrars respectively, as well as 6 focus group discussions with community members. Data were transcribed verbatim and transcripts analysed using NVivo version 12, based on pre-determined themes derived from study objectives. Findings reveal the negative influence of cultural beliefs about maternal and child health, health seeking behaviour, poverty, and civil registration administration on the registration of under-5 children births and deaths. To improve the civil registration of under-5 children, the study recommends intensification of awareness campaigns on the importance, usefulness and procedure of registering under-5 children; deconstructing the cultural myth surrounding maternal and child health; encouraging the use of formal health facilities for maternal and childcare; in centivizing delivery in formal health facilities and siting of registration points across communities, in order to facilitate ease of access.

Key words: cultural beliefs, child healthcare, vital statistics, civil registration, under-5 children.

INTRODUCTION

Registering the birth of a child is a fundamental right of the child. The United Nations Convention on the Rights of the Child (1989) provides in Article 7 that ‘The child shall be registered immediately after birth and shall have the right from birth to a name, the right to acquire a nationality and, as far as possible, the right to know and be cared for by his other parents’ (UNICEF, 2013^a). Similarly, regional treaties such as the African Charter on the Rights and Welfare of the Child (1990) highlight the importance and responsibility of the state towards birth registration (African Union, 1990).

Birth registration confirms a child’s nationality, place of birth, parentage and age. In many countries birth certificate serves as a key identity document. Without a birth certificate, a child may not be eligible to receive free healthcare and education services. Similarly, as a child grows into an adult, he/she needs a proof of identity when applying for a passport, driving licence or national identity card or to claim rights to inheritance or legal protection in courts of law. Similarly, proof of identity is essential to gaining access to basic services and to exercising fundamental human rights. Also, an adult without a birth certificate may not have the right to marry, vote, be employed in the formal sector, access credit and loans from banks, acquire a passport to travel outside their country of birth, or even to register their own children’s births. In addition, governments miss out on essential taxation revenue when young people are forced to work illegally or in the informal sector (Cody, 2009).Despite these substantial benefits of birth registration, about 230 million children under the age of five is still not registered worldwide(UNICEF, 2019^a), and by 2030, a 100 million children will not be registered, unless progress is accelerated (UNICEF, 2019^b).

On the other hand, Omran (2005) observes that an improved death registration enhances a state’s capacity to efficiently manage its healthcare system, track diseases and its changing patterns and their intersections with other demographic, social and economic variables. United Nations Inter-Agency Group for Child Mortality Estimation reveals that only sixty countries globally, have Civil Registration and Vital Statistics (CRVS) systems whose vital statistics on under-5 children death are reliable and only a few of these countries are located in the Global South (cited in UNICEF, 2019). Due to the inefficient CRVS systems in the Global South, only ten per cent of deaths are registered(Adair and Lopez, 2018).

Factors Influencing Civil Registration of Under-Five Children

Civil registration is the compulsory, continuous, permanent and universal recording of the occurrence and characteristics of vital events in a country, in accordance with the legal requirements of the country (United Nations, 2021). The need for a comprehensive and effective Civil Registration and Vital Statistics (CRVS) systems in all countries has long been recognized. Thus, various countries have taken steps to establish CRVS systems through enabling legislations. While countries in the Global North have effective CRVS systems, most countries in the Global South do not have efficient CRVS systems. This has resulted in lack of completeness of birth registration, untimely and unreliable statistics (United Nations, 2022).

In terms of continental spread, Africa remains one of the continents with an inefficient CRVS system.  An evaluation of countries in the region by the United Nations for a scaling up investment plan (2015-2024), revealed the absence of reliable statistics on vital events in 42 out of the 46 countries evaluated (World Health Organization, 2014).  Reasons adduced for the inefficient CRVS systems in some countries, include low awareness among parents, high costs of obtaining a birth certificate, inadequate infrastructure, discrimination based on gender and ethnicity, etc. (UNICEF, 2007).

Various studies have been conducted to unravel the factors that influence civil registration, especially birth registration. Socioeconomic, demographic and institutional factors have been identified as variables influencing birth registration at the household, local, regional and national levels (Ebbers and Smits, 2022; UNICEF, 2013^b; Li, Zhang and Feldman, 2010).Household wealth has been established as an important determinant of birth registration (Ebbers and Smits, 2022; UNICEF, 2005; Pais, 2002), while, education is equally a critical factor in influencing a parent/guardian’s knowledge of the importance and procedures of birth registration and thus the motivation to register a birth (Makinde et al, 2016; Kiprotich, 2013; UNICEF, 2005). Similarly, studies show that family structure influences birth registration. The absence of one or both parents may hinder birth registration, especially the absence of a mother who is the primary caregiver. And in countries where legislation requires the father to register the birth, the absence of a father may also pose a problem (Rodríguez, 2016; Pais, 2002; UNICEF, 2005;1998).

Bennouna et al (2016) study of birth registration in Indonesia also reveals other contextual factors that hinder registration. Their study found a low prevalence of birth registration in Indonesia, with barriers to registration being cultural beliefs and practices, distance, financial issues, and perceived poor quality of services. Similarly, Ebbers and Smits (2022) studied the determinants of birth registration in Sub-Saharan Africa (SSA),using multilevel logistic regression analyses. The study reveals a 48% prevalence of birth registration in SSA, but with huge differentials across countries. While Morocco, Egypt, South Africa, Botswana and Kenya have relatively high registration rates, Chad, Democratic Republic of the Congo, Ethiopia and Zimbabwe have very low rates. Similarly, there are subnational variations, within countries. Nigeria, Sudan, Angola and Madagascar manifest clear subnational variations. The study equally reveals household factors, such as a higher age, more years of schooling as a parent and having more wealth to significantly increase the odds of registering a birth in SSA. Similarly, children living in urban areas and in areas in which the average number of prenatal care visits is higher have higher registration rates. While countries with a centralized CRVS system, as well as countries where a fee is paid for registration have low registration rates. Birth registration rates are also higher in countries with higher fertility rates and in countries that experienced less conflicts. The authors conclude that issues surrounding birth registration in SSA are complex and highly context specific.

The low civil registration of under-five in Africa has been concerning to the African Union, hence in 2016, the Union declared 2017-2026, ‘A Decade for Repositioning CRVS in Africa’s Continental, Regional and National Development Agenda’. Subsequently, the Union, instituted some programmes that would assist states to improve their CRVS systems. A notable one is the Africa Program on Accelerated Improvement of CRVS (APAI-CRVS), which aims at harmonizing different CRVS programmes into a unified framework (United Nations Economic Commission for Africa, 2017).

Has the Nigerian State responded to this call and what influence does the socio-cultural context have on the civil registration of under-5 children? These are the issues this study intends to unravel with a focus on Akwa Ibom State.

Civil Registration of Under-Five Children in Nigeria

The civil registration Act No. 69 of 1992 is the law regulating civil registration in Nigeria. The Act prescribes a universal, compulsory, permanent and continuous registration of vital events. The law stipulates that registration of every birth should be done within 60 days and every death within 48 hours. A penalty (though not defined) is prescribed for late registration. The Act prescribes the National Population Commission (NPC), as the authority to register vital events(Federal Government of Nigeria, 1992). NPC operates a centralized CRVS system with a hierarchical structure. At the apex of the Commission is the Chairman, who is the Registrar General and oversees the operation of the CRVS system throughout the country. At the States and the Federal Capital Territory (FCT) are the Chief Registrars, who co-ordinate and supervise the system in their respective states, and report to the Registrar-General. At the Local Government Areas (LGAs), are the Deputy Chief Registrars, who co-ordinate and supervise the system in the LGAs and report to the state Chief Registrar. And finally, the Registrars who operate at the Community registration centers. A Registrar’s catchment area could be made up of a number of villages and health facilities. There are 4011 registration centres spread across the 774 LGAs in Nigeria (Bello, 2021). The Act also prescribes that Registrars be supported in the notification and registration processes by local prominent persons such as health care providers, traditional rulers, religious leaders, ward heads, village elders, traditional birth attendants, etc.

Despite the existence of a compulsory civil registration Act, statistics reveal that there has been only 30 per cent completeness of birth registration in Nigeria. NPC estimates a 70 per cent backlog of unregistered births (National Population Commission & ICF, 2019).Similarly, only 10 per cent of deaths including the death of infants have been registered in Nigeria (National Population Commission & ICF, 2019; National Bureau of Statistics & UNICEF, 2017).

Various reasons have been adduced for the poor civil registration of under-five children in Nigeria. Some of the supply side factors include – the inadequate financing of the central institutional framework charged with the statutory responsibility of registration of vital events; conflicting statutes and institutional arrangements for the registration of live-births, deaths and stillbirths; intra-organizational conflicts in resource allocation;  inadequate physical and technological infrastructure to aid institutional job performance and systemic corruption (Maduekwe, Banjo and Sangodap, 2017).

UNICEF (2019)impact evaluation survey on birth registration of Under-5 children in Nigeria in some selected states between 2012 and 2016 also reveals that most parents were ignorant about the importance and procedural requirements of birth registration, while long distances to registration centres and high service fee were barriers to registration. Other contextual factors that have been identified include unfriendly sociocultural norms, poverty and undeveloped civic culture (Maduekwe, Banjo and Sangodap, 2017).

However, an earlier study by Akande and Sekoni (2005) in Oke-Oyi town in Kwara State had revealed a high awareness of birth registration, while that of death was low. The study found government agencies as the major source of the awareness, while the mass media played an insignificant role. Similarly, Tobin, Obi, & Isah (2013) study in Egor Local Government Area of Edo State revealed a high awareness of birth registration and low awareness of death registration, although higher than what was observed in Akande & Sekoni (2005) study. They found reasons adduced for non-registration of births to include, lack of funds to pay registration fee; delivery at home or in remote villages where there are no registration centres; and not knowing the venue for registration. For the deaths, non-registration was attributed to factors such as when death involves a newborn; ignorance and not knowing the usefulness of death registration. Abbas (2014) study in Gombe State found spatial location and problem of accessibility as issues that affected civil registration.

Maduekwe, Banjo and Sangodap (2018) observe that Nigeria’s CRVS system is weak and lacks the capacity to produce the much-needed data to monitor the progress of Sustainable Development Goals (SDGs) in the country. This calls for more context specific studies that would inform policy and interventions.

Akwa Ibom State has a Total Fertility Rate (TFR) of 3.6 children per woman and an under-five mortality rate of 98 deaths per 1,000 live births (National Population Commission and ICF International, 2019). The National Population Commission and CIRCLE, Social Solutions International, Inc. (2020) observe that the high under-5 mortality rate in the state could be partly attributed to the preference to seek maternal and child care from informal facilities by mothers. Proprietary Patent Medicine Vendors (chemists), TBAs, traditional healers, churches, and private consultation with health workers in their homes are the preferred ways of seeking maternal and childcare. Formal facilities are only visited as the last resort. This reliance on informal care providers for maternal and child care may have implications for the civil registration of under-five children in the state, a matter this study investigated.

METHODS

Data Source: The study utilized primary data for its analysis. Mixed methods were used to gather qualitative data from different categories of people. In-depth interviews were used to obtain information from women of child bearing age (18 -49 years), who had given birth within the five years prior to the time of study. Key informant interviews were used to gather information from Deputy Chief Registrars, in charge of civil registration systems in local government offices, while focus group discussions were used to gather information from community members. An on-the-sport observations of registration centres were also carried out using a checklist derived from the NPC’s Five-Year Strategic Action Plan (2019-2022). Items assessed included office infrastructures, digitalization and automation of the CRVS system through adoption of Rapid SMS; scanners; Personal Digital Assistant (PDA)software; and availability of skilled staff.

Study Location: Akwa Ibom State is in the South-East corner of Nigeria, lying between latitudes 4⁰ 32 and 5⁰ 53 North and longitudes 7⁰ 25 and 8⁰ 25 East. It covers a land area of 8,412 sq. km. It is bounded on the north by Abia and Cross River States and on the South by the Atlantic Ocean. The base of its triangular shape rests on the Bight of Bonny (Akwa Ibom State, 2009). Based on the 2006 census, Akwa Ibom State had a population of 3,920,208 (1,875,698 females and 2,044,510 males) with an average population density of 350 inhabitants per square kilometer (FGN, 2007). However, the state estimated population in 2019 was 4.8 million people (NPC, 2020). Akwa Ibom State is a multi-ethnic state, comprising of thirty-one LGAs with three dominant ethnic groups, namely – Annang, Ibibio and Oron. The people are predominantly of the Christian faith, although a tiny minority practice African religion. Akwa Ibom State is the largest oil producing state in Nigeria, producing 31.4% of the total daily oil output (Yahaya, 2022).

Sample and Sampling Technique: A sample size of 30child bearing women (18 – 49 years) from the three LGAs was purposely drawn using convenience sampling. The three dominant ethnic groups were represented as follows – Ikot Ekpene LGA represented Annang; Uran LGA represented Ibibio and Okobo LGA represented Oron. Six communities, two from each LGA, representing rural and urban settlements respectively, were also purposely chosen.10 participants were randomly drawn from each of the LGA in the proportion of 5 urban and 5 rural respectively. The Deputy Chief Registrars, at the three selected LGAs constituted the key Informants. Six focus group discussions (FGDs) were conducted for males and females, respectively. Each group comprised of 6 discussants. Two FGDs (male and female) were conducted in each of the LGAs.  In-depth and key informant interviews and FGD guides, reflecting questions on socio-cultural milieu and issues of civil registration of under-five children, were used to collect the data. Informed consent was obtained from all participants, while ethical considerations of confidentiality and anonymity were observed.

Data Analysis

Responses were recorded and transcribed verbatim. Transcripts were coded using NVivo version 12, based on pre-determined themes derived from the study objectives. The themes include prevalence of civil registration of under-five children, socio-cultural factors influencing civil registration of under-five children and administration of civil registration.

RESULTS

Socio-demographic Characteristics of In-depth Interview Participants

The mean age of mothers was 23 years, while the maximum and minimum were 41 and16 years respectively. All participants were educated with the majority having secondary level education and two having primary and tertiary level education respectively. The number of children of participants ranged from one to six, however, the majority had between two and four children. All participants were income earners from economic activities outside the home, except for three who were full time housewives. Economic activities of participants included trading, farming, artisanal activities(tailoring and hairdressing) as well as public and private sectors’ employment. All participants were married and their husbands were all educated possessing secondary and tertiary level qualifications in almost equal proportion, although secondary certificate holders were slightly more. Most of the husbands were self-employed with few being public and private sectors’ workers respectively.

Prevalence of Civil Registration of Under-5 Children

The study reveals a low prevalence ofunder-5 births and deaths registration. Participants attributed the failure to register their births to ignorance about its importance, usefulness and procedure, as illustrated by these responses from mothers and a community leader.

Well, for child birth registration, I don’t really know much about it but where I deliver (TBA), she advised us to go to the health centre and register our babies, that the government wants it, so that is all I know about it.(IDI 1, Female, Uruan, Urban).

Some (mothers) like I said don’t know the procedure and so they believe it is not important, some think it may involve money, while some don’t believe in the registration at all. (FGD 3, Female, Okobo, Rural).

I don’t know anything about birth registration but the midwife said  we must register children. (IDI 3, Female, Uruan, Rural).

The study reveals an association between the place of delivery and birth registration. The civil registration Act prescribes that health personnel in facilities where birth takes place should notify the registrar of such births. Finding of the study reveals that only health personnel in public facilities abide by this prescription. Personnel in private facilities as well as TBAs do not do so, although they advise their clients to register their births. Thus, all participants who delivered in public health facilities had their births registered, while none who delivered at TBAs (constituting the majority) did so. A key informant blames the TBAs as the cause of the low birth registration in his LGA. In his words –

…..those that give birth at the TBAs, even though we tell them (TBAs) to always inform them (their clients) to come for registration of their births and deaths, TBAs do not do so in their own space. (KII 2, Okobo LGA).

However, the finding of the study negates the above assertion. Study reveals that TBAs do advise their clients to register their births as illustrated by this response “where I deliver (TBA), she advised us to go to the health centre and register our babies, that the government wants it”(IDI 1, Female, Uruan Urban).The response of the key informant however, reveals the failure of the Deputy Chief Registrars to carry out appropriate enlightenment with health personnel. The Act requires that health personnel notify the registrar of births in their facilities and not to merely inform their clients to go and register the births. Finding shows that contrary to the provision of the Act, Deputy Chief Registrars only emphasize on the need for health personnel to inform their clients to personally register their births, as illustrated by the response of this key informant,

We have created awareness. First by training the TBAs to always encourage women to register their child birth/death. Secondly for those who give birth at the health centres or in the hospitals, the staff encourage them to register their children. We have also had orientation at the health centres to sensitize women on the need to register their birth/death.

(KII 1, Male, Uruan LGA).

Assessment of birth registration in the three LGAs, shows Ikot Ekpeneas the LGA with the highest birth registration. All the participants from the LGA, except one had their delivery in public health facilities and so had their births registered.

With regards to the registration of under-five children deaths, the study reveals the lack of awareness about the compulsory requirement to register such deaths. Their common response was as illustrated by this mother who had lost a baby.

I did not register her death. I don’t know I should register children death o-o-o! (IDI 8, Female, Okobo, Rural).

A key informant also corroborates her response –

Registration of a dead child? Hahahaha! People don’t come for death children registration o oo! (KII 2, Male, Okobo LGA).

Socio-Cultural Factors Influencing Civil Registration of Under-5 Children

Finding of the study reveals the negative impact of the socio-cultural milieu on the civil registration of under-five children. Contextual factors such as cultural beliefs; health seeking behaviour; poverty and civil registration administration, negatively affect registration.

Cultural Beliefs and Health Seeking Behaviour

The study reveals that the prevailing cultural belief is to associate negative events in anyone’s life, including negative pregnancy outcome with spiritual forces. There is a common belief that ‘wicked village people’ (a commonly used phrase during the interviews and FGDs) can cause harm to pregnant women and the unborn child, especially during delivery. Because of this belief, the preferred place of delivery is not a formal health facility but spiritual churches and TBAs. It is widely believed that such facilities can shield mother and child from spiritual attacks, as illustrated by the response of this female community leader.

There are people who have a lot of ‘problems’ following them [spiritual attacks], so that when they are pregnant they cannot go to the hospital. Many of them though they go to hospital for ante-natal, but when it is time to deliver, they go to TBA. (FGD 3, Female, Okobo, Rural).

Her response is also supported by this response from a mother –

Hmmmm! I will not lieooo! In this community, people go to TBAs to deliver, very few go to health facilities. Because it is safe there from wicked village people(IDI 6, Female, Okobo, Urban).

Similarly, child’s illness is associated with the evil works of wicked people who ‘çharm’ [spiritually inflict] such children with illnesses to kill them, as illustrated by these responses –

This is villageo!, we have wicked people who use satanic powers to ‘charm’ children [inflict children with sicknesses] using another spirit. The children become sick and die.  (FGD 4, Male, Okobo, Rural).

Sudden death of under-five children is caused by attack from the spirit world. It is abnormal for a child to die just like that. Some believe it is ‘ndem’ [water spirit], ‘mkpon tokeyen’ [children spirit]. We consider all these before we talk of malaria and typhoid or even Covid-19 now.

(IDI 6, Female, Okobo, Urban).

Due to these beliefs, mothers are of ten reluctant to expose their babies to the general public (such as taking them out for birth registration), for fear of the baby being harmed as depicted by this response –

I delivered at TBA. For me, I will not take a child that I just delivered for birth registration because you don’t know who will come with a bad hand and touch the baby (harm the baby spiritually) and he may die.

(IDI 1, Female, Uruan, Urban).

As the finding of the study has revealed, births delivered at TBAs are not registered either by the TBAs or other informants, including the mothers.

With regards to health seeking behaviour, the study found that the cultural beliefs influenced the health seeking behaviour of mothers. The association of child’s illness with spiritual forces, cause mothers and other caregivers to seek treatment in informal facilities such as spiritual churches, healing homes and TBAs. Often time, such mode of treatment is not very potent to curtail the illness, thus resulting in the child’s death as reflected by the responses of these mothers.

He fell sick … we resorted to treating him with herbs and eventually, he died. But my mother in-law came up to say that the child died because we did not perform what they call ‘okpoho’ [ritual to appease the person the child was named after]. According to her (mother in-law), this is a belief in Ibibio land that when a child is named after somebody, a ritual must be performed in respect to that, else the child will die.

(IDI 2, Female, Uruan, Urban).

He was hot. I treated him with herbs but he died. Well, here we believe that evil forces and witch can cause sickness to a child. Also, jealousy from your co-wives and even relatives from your husband’s home.

(IDI 9, Female, Ok obo, Rural).

Deaths in informal health facilities are of ten not registered due to ignorance about the compulsory requirement to register such deaths (as earlier revealed by the study). Secondly, even if aware, the context of such deaths is devoid of meeting the procedural requirement for registering death as prescribed by the Act,which stipulates that a qualified medical practitioner who has attended to the child during his/her last illness in the medical centre or at home, shall provide an informant a medical certificate or notification for registering the event at the registrar’s office(Federal Government of Nigeria, 1992).

Poverty

The study reveals that poverty negatively impacts on the civil registration of under-five children. Akwa Ibom state, although rich in oil still has a high prevalence of poverty, as depicted by the experiences of some of the study participants. Although the state has a policy on free maternal and under-five children healthcare, poverty has hindered some mothers from accessing this care. There are certain basic fees and requirements (laboratory tests, delivery materials, etc.) that must be met by beneficiaries. Pregnant women and nursing mothers who cannot afford these, resort to informal care as illustrated by these responses from a mother and a male community member.

I delivered at the TBA. You can always pay her when you have money but, in the hospital, they expect you to buy everything at the same time for them and there is no money.(IDI 1, Female, Uruan, Urban).

As it concerns pregnancy and child birth, there are women who are pregnant ………feeding is a problem, talk more of registering in the hospital, this also is a problem. People like that will rather go to the TBAs and take herbs until it is time to deliver …… they will enter the TBA to give birth or go to the church. (FGD 2 Male, Uruan, Rural).

Births delivered at TBAs and spiritual churches as our finding has shown are not registered.

Civil Registration Administration

The civil registration Act prescribes the National Population Commission (NPC) as the authority to register vital events in Nigeria. NPC operates a centralized CRVS system but has 4011 registration centres spread across the 774 LGAs in Nigeria. The study reveals that there are no community registration centres in the three LGAs. Two of the LGAs (Uran and Okobo) have a single registration centre located in the LGA headquarters’ office complex. However, Ikot Ekpene LGA has two registration centres which are located in close proximity within the urban space, as illustrated by the response of this key informant. “We have two, one here at the Council Headquarters and the other one at the general hospital, not far from here”(KII 3, Male, Ikot Ekpene LGA).The lack of community registration centres, creates financial and distance difficulties for mothers and other informants, as illustrated by the response of this mother – “ the Council is a bit far from here. We pay maybe to and fro, five hundred naira”. (IDI 5, Female, Uruan, Rural).

The on-the-spot observations of registration centres revealed office settings that were devoid of the required infrastructure for effective functioning. There was no power (electricity), computers, adequate furniture, trained staff, etc. None of the processes of digitalizing and automating the CRVS system such as the use of Rapid SMS, ICR Scanners, and Personal Digital Assistant (PDA)software, were in operation. This response from a key informant depicts the situation –

One of the major challenges I have here as a registrar is poor facilities in terms of computer, furniture, electricity and other working tools which could make the work environment interesting. For instance, we compute the vital registration manually, this would have been done using computer. Secondly, we have staff who are not computer literate, so each time we need a document, we struggle to get it done. (KII 1, Male, Uruan, LGA).

DISCUSSION

The civic culture of reporting vital events involving under-five children is undeveloped in Akwa Ibom state. There is a general apathy towards registering births by mothers. Although all study participants were informed and aware of the compulsory requirement to register births, they were however still not sufficiently knowledgeable about its importance, significance and procedure, to do soon their discretion, without the assistance of a health personnel. With regards to death registration, awareness was almost non-existent, as participants had no idea about the compulsory requirement to register under-five deaths. These findings align with that of UNICEF (2019) survey of birth registration of Under-five children in some selected states in Nigeria.

The socio-cultural milieu of maternal and childcare is a major contributor to this undeveloped civic culture. Cultural beliefs and health seeking behaviour on maternal and child care are enmeshed in the supernatural, thus discouraging the use of formal health facilities for care. Similarly, poverty was found to hinder access of mothers to formal care as they could not afford the user fees. This reliant of mothers on informal care hinders their compliance with the requirement to register their under-five children births and deaths. This finding corroborates that of Maduekwe, Banjo and Sangodap, (2017).

The Commission estimates the nearest registration centre to cover a maximum distance of five kilometres (Bello, 2021). The findings did not align with this. There was scarcity of registration centres and this has created a problem of distance for rural dwellers, thus hindering their access to registration centres. This finding supports Abbas (2014) study of Gombe state where spatial location of registration centres created problems of accessibility to informants. It similarly supports Ebbers and Smits (2022) finding that children living in urban areas have higher birth registration rates due to proximity to registration facilities.

In response to the Africa Programme on Accelerated Improvements of Civil Registration and Vital Statistics (APAI-CRVS), NPC has developed a Five-Year Strategic Action Plan (2019-2022) to revitalise and upgrade the CRVS system in Nigeria. The Plan’s strategy includes, the digitalization and automation of the CRVS system. The on-the-spot assessment of the registration centres revealed office operations that were not digitalized and automated. Births and deaths’ registration are still paper-based and processed manually. This finding supports the Commission’s estimation of a seventy per cent backlog of unregistered births (National Population Commission and ICF International, 2019; International Development Research Centre, 2019), as well as affirms Maduekwe, Banjo and Sangodap (2017) assertion that inadequate physical and technological infrastructure to aid institutional job performance constitutes  a hindrance to an effective CRVS system in Nigeria.

CONCLUSION

Based on the Nigeria Demographic and Health Survey (NDHS) (2018), Akwa Ibom state has a high prevalence of under-5 mortality, which stands at 98 deaths per 1,000 live births. The state similarly has a fertility rate of 3.6 children per woman. The finding of this study shows a number of unregistered births and deaths in Akwa Ibom state with the socio-cultural milieu having an influence on this outcome. Cultural beliefs, health seeking behaviour and poverty have negatively impacted on the utilization of formal healthcare services by pregnant women and nursing mothers, thus limiting their compliance with the mandatory birth and death registration law and access to registration services. The mortality and fertility rates as reflected in NDHS (2018) may have probably been different if there was a developed civic culture of registering under-five births and deaths in Akwa Ibom state.

Mothers and community members in general had limited knowledge about the importance, usefulness and procedure of under-5 children registration. Although the key informant investigation reveals periodic engagements of the registrars with mothers, TBAs, religious leaders and community heads, such efforts should be intensified with a more efficient mode of information dissemination. Therefore, to aid massive awareness, posters in English and local dialects on the importance, usefulness and procedures of birth and death registration of under-5 children should be displayed in strategic public spaces, such as health facilities, TBA homes, churches, town halls, etc.

To discourage mother’s preference to seek care in informal facilities, government agents should actively engage in deconstructing the cultural myths surrounding maternal and child health. This should be done first, with the custodians of tradition, who will in turn influence their subjects for behavioural change. At the same time, active campaigns to encourage the use of formal health facilities for delivery and childcare should be intensified, while poor women who deliver in formal facilities should be incentivized by token gifts to mother and baby, to serve as boosters to attract others to use such facilities. Similarly, more registration points should be sited across communities, in order to give rural in for mantsease of access.

Having a functional registration system that adequately captures births and deaths of children under-5 years in Akwa Ibom state will contribute to producing reliable vital statistics on birth and death of under-5 children in Nigeria. It will also aid government at local, state and national levels to formulate appropriate policies and interventions to address the high maternal and under-5 children mortality in the state.

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