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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 6, Num. 1, 2002, pp. 84-95
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African Journal of Reproductive
Health, Vol. 6, No. 1, April, 2002 pp. 84-95
Spoiling the
Womb: Definitions, Aetiologies and Responses to Infertility in North West
Province, Cameroon
Sarah C Richards1
1Assistant Professor,
Department of International Health, Boston University School of Public Health,
715 Albany Street, T4W Boston MA 02118-2526. E-mail: sarahcr@bu.edu.
Code Number: rh02012
ABSTRACT
Only one generation ago, the Cameroonian
national population policy was pro-natalist, with great attention paid to the
problem of sterility. Now, family planning is promoted nationwide to reduce
population growth, and infertility is not addressed by public health policy
or services. In contrast to the biomedical definition used by planners, at
the local level infertility is defined as the inability to have a child when
desired, and it has many causes including contraception, abortion and witchcraft.
The young, less educated women especially are unlikely to use contraception
as long as they feel susceptible to infertility, since their economic, social
and psychological status hinge on their ability to have children. Drawing from
epidemiological literature and qualitative data gathered in a market town in
North West Province, I argue that a more balanced approach to reproductive
health, one that recognises the importance of infertility, is critical for
women's health and well-being. (Afr J Reprod Health 2002; 6[1]: 8494)
RÉSUMÉ
L'Endommagement de l'Utérus:
Définitions, Etiologies et Réponse à la Stérilité dans la Province du Nord-Ouest,
Cameroun. Il y a seulement une génération de cela, la ploitique nationale
camerounaise de la population était pro-nataliste et mettait beaucoup d'accent
sur le problème de la stérilité. A l'heure actuelle, on promouvoit la planification
familiale partout dans le pays afin de réduire la croissance démographique
et la politique de la santé publique ainsi que les services publics ne s'occupent
pas de la stérilité. Contrairement à la définition biomédicale dont se servent
les planificateurs au niveau local, on définit la stérilité comme l'incapacité d'avoir
un enfant quand on le veut pour des raisons différentes y compris la contraception,
l'avortement et la sorcellerie. Les jeunes femmes, surtout celles qui ne
sont pas bien instruites ont moins la possibilité de se servir de la contraception
tant qu'elles se sentent susceptibles à la stérilité puisque leur statut économique,
social et psychologique dépend de leur capacité d'avoir des enfants. En
me basant sur la littérature épidémiologique et sur les données qualitatives
recueillies dans une ville commerciale dans la Province du Nord-Ouest, j'avance
l'argument qu'une approche plus équilibrée de la santé reproductive, celle
qui reconnaît l'importance de la stérilité, est cruciale pour la santé et
le bien-être de la femme. (Rev Afr Santé Reprod 2002; 6[1]: 8494)
KEY WORDS:Women's infertility,
family planning, population
policy, Cameroon
INTRODUCTION
One of the ironies of the demographic and epidemiological transitions in sub-Saharan
Africa is that as population growth has increased the rates of infertility
have also increased, due to higher rates of sexually transmitted infections
(STIs) and earlier age at initiation of sex. Thus, while the focus at the national
policy level has been population control through family planning programs,
a major concern at the individual and community levels is the fear of not being
able to have a baby when desired. The data for this article, gathered in Bali
Nyonga, North West Province, Cameroon 199495, offers an insight into this
paradox as it occurs at the local level, in conditions of social flux, economic
stagnation and political instability common to market towns in the region.
With education and entrepreneurial
opportunities now open to younger unmarried women, the need for contraception
has never been greater. On the other hand, having children to prove fertility,
to mark adult status, and to create ties of obligation with men are reasons
that remain critical for women regardless of age, marital status, educational
level or occupation. In this period of economic decline and social conservatism,
women's economic self-reliance is still an unrealistic dream, and delaying
marriage and motherhood for any reason leaves women vulnerable economically,
socially and morally. The fear and experience of infertility, I argue, is a
driving factor in women's decisions to use or reject contraception, and acknowledging
this factor is critical to protecting the reproductive health of young women.
In this paper, I contrast biomedical
definitions and determinants of infertility with local definitions and determinants
of infertility and outline the history of national population policy within
the context of community mores of marriage, sex and parenthood. I argue that
young women in Bali Nyonga, though having relatively more freedom to shape
their future than in past generations, are also increasingly vulnerable to
disease and poverty. Similarly, towns such as Bali Nyonga benefit from increased
growth and diversity in modern times but their residents see a future of increased
vulnerability to external economic and political forces. As everywhere, an
important determinant of the future development of Bali Nyonga is the health
(and particularly the reproductive health) of its youth, therefore, community
planning, and family planning must address the reproductive health concerns
of young women, specifically infertility. This paper echoes the argument established
by Inhorn1 and Feldman-Savelsberg2 that understanding
locally recognised causes and treatments for infertility can help improve national
reproductive health strategies.
BACKGROUND
Bali Nyonga lies 23km southwest of Bamenda, the provincial capital and had
a population of over 23,000 at the time of the research. It has the highland
topography, monarchical political structure and history of colonisation first
by the Germans, then British forces common to Grassfields cultures. Bali Nyonga
is, however, unique within the Grassfields historically (settled by a conquering
tribe and place of the earliest Basel mission school) and linguistically. It
remains one of the three major kingdoms and is second in importance only to
Bamenda as a regional market centre.
Throughout the region, the patrilineage
is the fundamental concept for individual identity, family structure, residence
patterns and community organisation. The patriline is built on polygynous marriage,
which remains common to those men within the traditional structure who can
afford it. Upon marriage, a woman goes to live in her husband's compound, which
may include the houses of his father and/or brothers and their wives. A wife
retains membership in her father's patriline, her children likewise belong
to her husband's lineage. The patriline includes the living, the dead and unborn
as members, and threats to its existence logically supersede individual concerns.
Infertility is thus a problem for all of the patriline's members, which adds
to pressures felt by a childless woman or couple. The family head is the embodiment
of the line of succession chosen for life to rule over all of the members of
the patrilineage. His role as decision-maker and progenitor of the successive
generations determines the fate of the whole family to some extent. All other
members of the patriline are subordinate to him, no matter their relative age
or accomplishments. The family head is responsible for the spiritual, physical
and economic well-being of the family. These conditions are intertwined in
the relationships between living and dead family members. As a family head
serves as intermediary in disputes among family members, he also calls upon
the ancestors to look favourably on his kin. The fon, as head of the
royal family, is father to all Balians, and the major rituals of Bali Nyonga
tradition centre around his physical and spiritual power as protector and insurer
of prosperity of the kingdom. The ramifications of royal fertility for the
entire community are complex and far-reaching, as Feldman-Savelsberg has discussed
in the context of another Grassfields kingdom.2 Voma, a men's
secret society, which annually rids the kingdom of harmful forces and ensures
the fertility of its soil and people, is the other major traditional politico-religious
institution.
The state is represented in Bali
Nyonga in the form of the sub-divisional officer, the sub-division hospital,
agricultural extension offices and a post office. More influential in the daily
lives of the majority of Balian people, however, are the churches, predominantly
Presbyterian, but also Baptist and Catholic (which runs a large clinic).* Women
make up the majority of the church-going population, and at the time of the
research the many women's church groups were the only active, public female-led
community organisations.
At the time of the research, Bali
Nyonga was in the same condition of economic crisis as the rest of the country,
and the attitude of the community seemed suffused with pessimism about economic
prospects. In January 1994 when the CFA franc was devalued by 50% local prices
of many imported food and dry goods suddenly doubled and other prices followed.
Although the coffee prices doubled with devaluation, only a few farmers had
retained coffee trees after the market crashed in the late 1980's. Meanwhile,
the slumping market for locally grown foodstuffs was a subject of daily concern.
The market continued to decline after weathering a five-month strike by civil
servants.
METHODOLOGY
The data for this paper are mainly drawn from a series of church, youth and
neighbourhood group interviews conducted at the latter part of a twelve-month
research project in Bali Nyonga on treatment choice for infertility. Twelve
of the fourteen groups interviewed were pre-existent, the other two were recruited
to ensure inclusion of adolescent girls and older men. All discussions were
in variants of Cameroon Pidgin English, the local lingua franca.
Prevalence of Infertility
Attention to rates of fertility in Cameroon by demographers is not new; however,
the relative importance of the issue to national politics, health policy and
medical technology has been quite varied over the last several decades. Like
many sub-Saharan African countries, Cameroon had a pro-natalist population
policy from independence (1960) until the 1980s. The National Fertility Survey
of 1978 served to heighten interest in the sterility phenomenon, with household
survey results showing the percentage of women never pregnant, those who never
achieved live birth, and those without any living child broken down into age,
education, province, urban/rural, and religion categories; and compared to
other African countries.3 An astonishing 13.9% rate of primary infertility
was reported. Primary infertility measured in the 1991 demographic and health
survey was the highest of the 27 countries studied by Ericksen and Brunette,
at 10.3%.4 There is a great deal of variation within Cameroon, however,
with highest rates in the northern Muslim provinces. The North West Province
rates of infertility were in fact among the lowest, but perception of the problem
was and is great for two reasons a relatively high ideal family size and
Anglophone nationalist views of minority status.
Cameroon as a whole is considered
to be part of the central African infertility belt stretching from southwestern
Sudan and northeastern Zaire across to Cameroon, Gabon, Equatorial Guinea and
Cabinda Province in Angola.4 The reasons for this lower fertility
are not completely clear due to paucity of data, problems with survey data
reliability (e.g., dependence on unverifiable respondent recall, falsification
of data and inadequate interviewer training) and basic assumptions of design
(e.g., that a woman's marital history adequately reflects her sexual history).2 Two
of the most likely explanations are elevated infection rates of diseases that
affect reproductive organs (particularly the STIs gonorrhoea, chlamydia,
and syphilis) and having intercourse at a young age when reproductive organs
can be damaged. The risk factors for STIs for African women have been attributed
to three sets of factors in epidemiological studies sexual histories, geographic
residence and socio-cultural context. In their article Patterns and predictors
among African women: a cross-national study of twenty-seven nations, Ericksen
and Brunette explained the assumptions involved in calculating risk. In the
absence of direct measures of women's sexual behaviour women's partnership
history is often used as a proxy, with divorced and separated women more at
risk than married ones, and those with a history of multiple partners more
at risk than monogamous ones.4
Given that the increase in shorter
term lateral marriage strategies are due in large part to economic instability
for women and children, as Guyer5 and Bledsoe6 have shown,
the rate of STIs and, therefore, infertility is likely to increase as well.
Interestingly while the risk for STIs is much greater in urban areas than rural,
Ericksen and Brunette found that the size and demographic heterogeneity of
the urban areas do not appear to affect this pattern, since the chances of
being infertile are the same in both large cities and small towns and always
less likely in rural villages.4 This lends credence to Balians'
impressions of higher rates of infertility in Bali Nyonga now than in the past
and on a par with the urban centres of Yaoundé and Douala.
Biomedically and Locally Defined
Causes of Infertility
According to demographic literature, the fertility of any population can be
attributed to nine proximate determinants, namely, proportion of women married
or in sexual unions, frequency of intercourse, postpartum abstinence, lactational
amenorrhea, contraception, induced abortion, spontaneous intrauterine mortality,
natural sterility (3% of women of reproductive age) and pathological sterility
(sterility caused by infections especially STIs). According to Bongaarts et
al, all variation in fertility is by definition attributable to variation in
one or more of these variables.7 For sub-Saharan Africa, the most
important determinants in limiting fertility are breastfeeding and postpartum
abstinence.*
Although duration of breastfeeding
and postpartum abstinence have been declining in Cameroon as elsewhere in Africa,
the high variability in regional fertility rates is attributed to pathological
sterility. The interaction of these three determinants results in higher fertility.
Taking Kenya as a model for other sub-Saharan countries that experienced recent
rapid fertility increase, one study notes that a rise in fertility in many
countries of sub-Saharan Africa may be inevitable. This statement is especially
true in countries where the durations of breastfeeding and postpartum abstinence
are still long or where the prevalence of pathological sterility is high. Moreover,
the mere presence of infertility in a society will impede the acceptance of
contraception because the risk of becoming sterile makes childbearing uncertain,
which in turn tends to weaken individuals' interest in controlling their fertility.7
This scenario can explain the Cameroon
experience while rising fertility rates have become targeted for reduction
at national and international levels, the focus of attention at the level of
individuals and families has been pathological sterility. Family planning campaigns
that promote contraception without addressing infertility miss the target
population and, therefore, overall fertility and pathological sterility remain
high.
What then are the causes of pathological
sterility? Intercourse and delivery at a young age contribute to infertility
in several ways. First, the period of initial infecundity is longer. In addition,
physical complications such as vesico-vaginal and vaginoanal fistulae may
result in permanent sterility because infections associated with fistulae can
spread to the fallopian tubes. Less immunological resistance to STIs among
very young women can also lead to permanent sterility.8 A brief
report of a survey of adolescent mothers in four administrative divisions throughout
Cameroon shows two findings relevant to infertility in this population. First,
while knowledge of AIDS and its transmission is high it did not correspond
to adoption of safe sex practices; only 12% reported using a condom. The situation
with other STIs that can cause infertility may be similar. Also, it is reported
that 1538% of adolescent girls give birth at home. This poses a health hazard
to the girls sometimes with fatal consequences or permanent disabilities in
the case of complications.9 Such disabilities include vaginal fistulae,
a leading cause of infertility. Another study based on a 1996 survey of 1,600
urban Cameroonian adolescents found that 55% of the females were sexually experienced
(only 8% were married) and 10% of sexually active females had had a STI during
the previous year.10
Bali Nyongan's explanations for
infertility (gleaned from my ethnographic research on treatment choice for
infertility) went far beyond the nine proximate determinants into the realm
of social and spiritual relationships. While the first response from older
people referred to the unknowable God's will,a the typical respondent
cited many possible causes. One middle-aged woman in a Christian women's fellowship
(Presbyterian) group was particularly articulate, listing, in addition to natural
sterility, early sex, multiple partners, use of crude drugs (to avoid pregnancy)
and untreated venereal diseases (gonorrhoea and syphilis and all the like).
She added that the latter diseases and diabetes also affect male fertility.
Too many abortions and the use of birth control pills were cited in all groups
interviewed; less common causes were having sex without removing tampons and
malnutrition from food taboos. Paradoxically, though use of contraception is
commonly thought to spoil the womb and cause infertility, epidemiological
surveys show that whenever past contraceptive use is associated with infertility
it is `never users' who are more likely to be infertile, presumably because
women who have difficulty conceiving have a stronger motivation to avoid contraception.4 This
is an instructive point for reproductive health service providers in places
like Bali Nyonga and elsewhere where fears of infertility are heightened due
to economic and social upheaval.b
Writing about pregnancy loss in
Cameroon, Savage (1996) describes a holistic view of health and illness applicable
to Bali Nyongans. Reproductive morbidity, or the inability of a woman to bring
forth an offspring, whether through failure to conceive, miscarriage, stillbirth
or infant or child mortality is therefore an indication of disharmony with
the living and/or between the living and the dead. Within the context of traditional
society, health is therefore perceived as a harmonious state where the social/religious
or supernatural realm clearly impinges on physical and psychosocial well being.
Pregnancy, par excellence, is one of these states.11
Many examples of this perception
of health and of the disharmony of infertility were given throughout my research.
In the women's discussion group cited above, one middle-aged woman said that
lack of tradition may cause infertility. If the marriage was done behind
the door (in secret) without tradition (family acceptance, ritual, etc.)
then children will not come of it. Even if the couple goes to a hospital no
physical explanation will be found (no sick for they skin). She attested
to seeing cases that finally resulted in pregnancy only after performing the
traditional marriage rites. Thus, when social rules of marriage process (which
maintain harmony between families and their ancestors) are not followed infertility
results until balance is restored. Similarly, if one breaks the prohibition
against seeing the powerful and dangerous Voma fertility cult fetish,
sterility, miscarriage, obstructed labour and other maladies will occur until
special treatment by Voma is given.
The state of health and fertility
may also be threatened by witchcraft. Witchcraft is different from the tradition causation
in its origins. Instead of omitting or breaking a social norm, witchcraft stems
from the more volatile and unpredictable human emotions of jealousy, envy,
spite and greed. Savage gives a hypothetical example of how feelings about
bride price payments made over time from the husband to the wife's family can
set off a crisis. He explains that feelings of resentment may develop and with
time be transformed into malevolent thoughts, finally giving way to curses,
evil spirits, sorcery and witchcraft. Often the young couple are oblivious
of these sentiments until they start experiencing problems especially the inability
of the bride to conceive or carry a pregnancy successfully to term.11 In
such a case action must be taken to deflect or placate the witch and repair
the relationship between affines in order to restore the woman to fertility.
Many examples from discussion groups,
interviews, and casual conversation confirmed witchcraft as a determinant of
infertility. Witches can obstruct or prevent pregnancy and cause miscarriages.
Jealous female relatives are most often responsible, namely, husband's sister,
co-wife, even the wife's own sister may chop pekin (eat the child/fetus).
A variation on this common scenario was given by a young woman youth group
member: Some people are jealous of others, then go about consulting traditional
doctors and they destroy the other's womb. They may contact traditional doctors
to [interjection by a male: poison somebody] destroy the womb. Thus, traditional
doctors can assist in causing infertility directly by performing abortions
and indirectly by placing a curse, or by supplying poison.
There is another form of witchcraft
that is more often responsible for the deaths of already born children but
can also cause miscarriages. A parent may trade a child's life for power and/or
wealth as a member (or aspirant) of a witchcraft society. In Traditions,
Tales and Proverbs of the Bali Nyonga, Samuel Fe Tita Mangwa explains how
witches do their evil and powerful work, even from a distance, and how people
who have no witchcraft yet can receive it in their hearts. Once the magic power
is bought by a person he may use it to destroy his children. These are generally
greedy people to whom God has given many children.12
Therefore, while suspicion may
only rarely fall on a parent for preventing or terminating pregnancy, parental
culpability for their own childlessness is possible. Agnes, one of my research
case studies, had suffered several miscarriages during her marriage, and she
said that her in-laws and co-wives blamed her for her own infertility. Though
she does not fit the profile of having many children, the fact that she was
the (youngest) wife responsible for collecting her husband's rents and other
revenues may have left her open to accusations of greediness and of an unwillingness
to share or spend money on children (being stingy to his patrilineage). From
this view, any woman without children is by definition self-centred, and this
threatens household and patrilineal cohesion. This self-centred aspect of childlessness
is compounded in the case of an educated woman who by virtue of her willingness
to chop family resources for her education may already be seen as an object
or originator of witchcraft. Being selfish is counter-intuitive in patrilineal
logic. Being stingy with children is one of the worst forms of selfishness.
Ba Feh Tita Mangwa imagined a nephew insulting a barren aunt: When they asked
you to get married and have your own children you said it was better to go
harloting around and living a free and carefree life, because a saku (prostitute)
will not have time to get children.13
The interpretation of who is to
blame for childlessness, the jealous relative or the greedy spouse, can simply
depend on whose version of the problem is accepted. An accusation of witchcraft
can thus either lighten or worsen the blame visited upon an infertile wife,
depending on who is accused. Savage argues that where a pregnant woman does
not build necessary social support systems with kin and neighbours her miscarriage
is viewed as her own fault. An inability to cultivate this social network is
indicative of negative attributes in character [bad fashion in Pidgin], malicious
behaviour and a lacunae in her personal relationships.11 Considering
the dynamics of patrilocal marriage, the lack of supportive social relationships
of a young wife in an unfamiliar compound is presumably not an uncommon problem.
Savage's point is instructive the value of incorporation of individuals in
strong social networks is reinforced by ignoring or even blaming the less incorporated
women who, by not having children, further isolate themselves. Women who are
more independent of the local social networks by virtue of their education
and/or wealth derived from outside the patrilineal agricultural system may
not be subject to this type of sanction. But they can still be blamed for their
infertility on the basis of assumed or real sexual behaviour.
One young woman described one of
the causes of infertility combining elements of God's will, another's malice,
and one's own greedy desires. In the case of someone going into marriage,
you must not boast and say you will give birth, even if you do have a child
you must not boast because you never know. Sometime when you give birth someone
will see it ... he/she will decide to destroy your womb without you knowing.
So if you go to get married, don't keep in your mind that you must have children.
Tell yourself, `if God gives me I'll take them and if God doesn't I'll bear
with what has happened in my marriage.c
There are three key features to
this and most other emic explanations for infertility. The first is that one
may not know the true reason for one's childlessness. Incomplete or incorrect
bride wealth payment, a jealous relative, seeing Voma, a witch, or one's
own malevolence could all be possible causes, but one may not be aware of their
existence. Secondly, infertility can be caused intentionally or not. It may
be unwittingly self-inflicted by boasting or being arrogant or proud. Witches
who eat their own or others' children are said to do so intentionally. Most
important to the reproductive health of women is the implied intentionality
of those who engage in risky behaviour such as premarital sex, taking birth
control pills and having an abortion. Thirdly, the interaction of two or more
of these causes may be responsible, as succinctly illustrated in the last quote.
Though I have discussed them separately, the interrelationship of various causes
in live experience makes their sequence and boundaries indefinable.
Responses to Infertility
What women do in response to the problem of infertility is greatly influenced
by the causal explanations of their predicament. The concern with diagnosis
explains the importance of divination to the process of health and child seeking.
Divination from the emic perspective includes all sources of explanation as
to cause including laboratory tests, ngambe (traditional diviner) cowries,
the Bible, and so on. The interpreters of these explanatory sources multiply
possible reasons and necessary actions. From Savage's point of view, because
women are vulnerable to heavy social pressures to reproduce, they engage in
health-seeking behaviour, which follows contradictory logic, powerless to disengage
from the search for children.
Women take risks to achieve successful
pregnancy, sacrificing their well being and dignity in conforming with the
requests of health practitioners, both modern and traditional. Doing nothing
to redress pregnancy loss or childlessness is tantamount to a personal admission
of failure and of irresponsibility. It is also perceived as an overt admission
of guilt of having sold or pledged her babies (even before conception) to supernatural
forces in return for personal gratification such as longevity, wealth and success.11
In this view, a woman's tenuous
social status hinges on her successful reproduction. The economic dimension
of reproduction is also pertinent to health-seeking behaviour. Bledsoe, studying
the Mende of Sierra Leone, found that number and status of children reflect
the political and economic relationship of their parents. The logic of polygyny,
which dictates that a woman can make demands on her husband by virtue of having
his children, means that a sub-fertile wife or co-wife must regain her fertility
in order to maintain her own economic security. Guyer's influential paper on
sub-Saharan nuptuality described a shift in marriage/fertility configuration
from lineal to lateral strategies, from long-term to shorter term logic on
the part of both men and women.5 Economic decline has led to less
security for women in their marriages, leading to tenuous or marginalised marriage
such that women seek support in temporary relationships. The variations of
the logic of polygyny remain where marriages weaken serial monogamy, informal
unions, polyandrous motherhood, deuxième bureau, all may be seen as
causing similar responses to infertility.
National Population Policy
The disparity between biomedical definitions and local definitions of infertility
has implications for both public health policy and education interventions.
In the recent past, the national population policy reflected local concerns
about rising infertility. The 1985 Conference on the Sterility Phenomenon in
Cameroon stated the following Advice to the Masses:
- Considering the practices of rather too early involvement in sexual activity
and the low age at first marriage in the zones experiencing high fertility.
- Considering the importance of sexually transmitted diseases as one of the
important causes of sterility and its adverse consequences on the health
of mothers and children yet unborn.
We wish to inform the masses, especially
the youth that:
- the most favourable age range for producing children in stable conditions
and in good health is between 18 and 35 years.
- precocious sexual relations and sexually transmitted diseases are among
the principle causes of sterility.14
Scholars from many disciplines
contributed to this conference publication, with articles ranging from The
role of genetic factors in the aetiology of sterility
, written by a geneticist,
to Ethical consideration of the sterility question, by a priest (excerpted
by a physician), and Psychosocial aspects of infertility in the North West
Province of Cameroon, by a sociologist/social worker. These substantive issues
articles are followed by a set of population policy issues. Taken together,
the conference publication gives a strong impression of academic and scientific
concern about the sterility phenomenon in Cameroon in the 1980s.
The one article that presages the
radical shift in focus to population control is Economic implications of sterility. The
author, Sally Vega, summarises the interaction of national population and economic
policies since independence. She concludes by stating that the population had
grown sufficiently to fuel economic growth. Given this development, national
economic needs then shifted to reduced population growth, and even individual
women's economic levels were stable enough to mitigate the cultural sting of
natural sterility. Thus, a condition that is considered as horrible in one
economic system could indeed constitute a positive factor in another. It is
our considered opinion that as more women accept modern contraception (voluntary
sterility) in Cameroon the phenomenon of sterility will pass into oblivion
as a national problem and will continue only at microscopic level among individuals
and their families.15
There are several points here that
need elaboration in the context of infertility in Bali Nyonga. First, Vega's
take on the future direction of national population policy was accurate. Whether
the emphasis on family planning was caused by economic development or decline,
the phenomenon of sterility has certainly passed into oblivion as a national
concern, even though the most recent national survey conducted in 1991 showed
a continued mix of high total fertility and problematic rates of infertility
and wasted pregnancy. Despite the strong fecundity observed, a significant
percentage of women (26%) had, in the course of their life, at least one pregnancy
that did not end in a live birth and an important proportion of women remained
sterile (7% of women aged 3549 years), even if this total sterility seems
to have decreased since 1978 (11% in the National Fertility Survey).16d
Yet the demographic trend in Cameroon
that receives most concern nationally and internationally is rapid population
growth. The population has grown from under 6 million at independence to 7.6
million in 1976, and 12 million in 1991. The average number of children per
woman was an estimated 5.8 in 1991.17 Even though this total fertility
rate (TFR) is down from 6.4 in the 1978 survey, with the current growth rate
of nearly 3% a year, Cameroon's population is now 15.5 million and will reach
21 million by 2010.18 Indeed, by 1995 the World Bank Report, Cameroon:
diversity, growth and poverty reduction, focused on economic policy from a
poverty perspective, noting the consequences of declining GDP, soaring unemployment
and infrastructural decay. It is now a rare exception to find public sector
facilities schools, hospitals, clinics with adequate supplies to fulfil
their tasks unless these are supplied by a foreign donor.17 This
is a far cry from the independence era characterisations of Cameroon's economic
potential. Therefore, national government and international donor population
policy and programs focus on reducing family size. (The greatest irony of all
may be that the increased fertility has been attributed largely to a reduction
in the historically high incidence of pathological sterility in Central Africa
resulting from widespread STIs).19
Vega's mention of natural sterility may
have been used intentionally, with the knowledge that most of the infertility
in Cameroon's population is not natural (i.e., caused by congenital reproductive
problems) but pathological, caused by STIs, abortions and the like. This distinction
between natural (God's will) and unnatural/pathological is perfectly recognised
by lay people. For Bali Nyongans, unnatural infertility is caused by someone,
the woman herself through dangerous sexual activity, use of birth control pills
or abortion, or by malicious family members and friends (living or dead). The
discovery of three recent abortions and dismissal of three pregnant students
in a Bali High School occasioned an assembly for the female students including
the warning: if you have repeated abortions there will be a time you want
a child but it won't come, or it will come with many complications and you'll
blame God for your own cause.
Pathological infertility is not mitigated
by individual or national economic growth. It remains a significant moral,
social, political and economic situation no matter what the external economic
context. Here, looking at unnatural infertility or pathological sterility, some
of the core concepts of fertility and reproduction are shared by demographers,
economists, health workers and lay people. The prevention of premarital/adolescent
sex is a common objective, since it results in the most risky pregnancies,
highest rates of infant mortality, and both higher population (since the lifetime
fertile period is extended earlier) and higher probability of infertility (through
exposure to disease, early pregnancy and unsafe abortions). Not coincidental
is the threat to gerontocratic social structure by uncontrolled premarital
sex (especially among girls).e Concerns for adolescent fertility
are at the forefront of epidemiological and popular attention, as the 1991
demographic and health survey showed a drop in median age at first birth in
all age categories compared to the 1978 national survey.16 One of
the principal characteristics of this heightened fecundity is the young age
at which it occurs. In effect, over half of the women give birth to their first
child before the age of nineteen.16f In the North West and South
West Provinces, where median age at first marriage is 17.4, 31.3% of the 1519-year-olds
were mothers at the time of the survey, with an additional 3.4% pregnant with
their first child. This rate is second only to the northern Muslim provinces
where female median age at first marriage is 14.8 (Yaoundé/Douala 19.0).16
Implications of Locally Defined
Causes and Responses to Infertility
for National Policy
A 1995 study using interviews and focus group discussions with adolescents
and adolescent mothers confirmed the negative consequences to women's health,
education and even economic status of early sexual activity. Of the 1,306 girls
in the study, almost 60% had become sexually active before the age of 16, 20%
had used an abortion method, and 14% had had at least one abortion.9 Sixty
nine per cent of respondents were students when they got pregnant, 86% of whom
had not completed their lower secondary school education. Sixty per cent of
these students had dropped out of school at the time of the interview and 1123%
of the live births by respondents had died by the time of the study. 9
The authors of such studies, and
many parents and grandparents of Bali Nyonga who were interviewed, viewed adolescent
premarital sex with dismay and offered recommendations and advice on how to
stop it. I contend that while these people are justified in their views, and
their proposals urgently needed, the question of why adolescent girls engage
in sex before marriage has yet to be seriously addressed. From my research
in Bali Nyonga, I have seen that having sex, having a child, being an adult,
and being a mother are all status-defining (and self-defining) actions at the
core of economic instability and social change. As a girl's options for adulthood
still hinge on the ability to have children, the condition of and responses
to infertility are, if anything, more crucial than in past generations. Though
my research is indeed at the micro level of individuals and their families,
I believe that since infertility and hyper-fertility (population growth) are
interlinked in people's lives, the sterility phenomenon will pass into oblivion
as a national problem15 at Cameroon's economic, political and social
peril. Factoring in the HIV/AIDS epidemic to this equation of fertility determinants
means the fear of and response to infertility will only increase. Greenhalgh's
critique of contemporary fertility theories holds true in the case of Cameroon:
the human drama of fertility decline is now reduced to a technological issue,
one of the adoption of a modern innovation contraception through diffusion.20 She
calls for a demographic approach to fertility that sees reproductive life as,
in S. Ortner's words, a relatively seamless whole. Not to decide which level/motivation
is primary, but how they fit together.19
CONCLUSION
The local concerns with and responses to infertility described here are not
currently addressed in the national population policy. The national policy
shift from pro-natalist to population control is in line with international
(western) goals, but it is out of sync with its own population. The simultaneous
demand for and fear of contraception makes sense in the local situation of
economic and social uncertainty people want control over their fertility
to the extent that they can have a child when desired. Family planning policy
and program designers, therefore, must listen to the women in rural towns like
Bali Nyonga, as their reproductive health is critical to their personal, family
and community security. Working with existent women's groups and developing
safe forums (not limited to school settings) for young women to discuss their
own future plans will be the most basic component of any strategy. Cross-generational
discussions may also be effective for information gathering and dissemination.
The information that women can provide concerning their knowledge and experiences
of infertility can guide family planning and reproductive health service provision
as well as education methods. Given that the Bali Nyongan descriptions of fertility's
causes, responses and meanings are interconnected in physical, metaphysical
and social realms of knowledge and action, they also demand such a holistic
approach to reproductive health.
ACKNOWLEDGEMENTS
I would like to thank all of the respondents interviewed in Bali Nyonga and
my research assistants, Richard Nwana Mbalang, Nicodemus Fogako, Relindis Yovsi,
Eric Tav Dzelamonyuy and Angeline Ndifon. Research was supported by the Fulbright-IIE
Grant Program and the Wenner Gren Foundation for Anthropological Research (Grant
no. 5844). I greatly appreciate the editorial advice of my colleagues, Lucy
Honig, Shona Schonning, Rob Fredricksen and Taryn Vian and the helpful comments
from the anonymous reviewers.
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