|Adam and Eve and the Serpent: Breaking the Bonds to Free Africa's Women (Ghana Universities Press, 1995, 141 p.)|
The wrathful God of the Old Testament is supposed to have addressed Eve as follows "Unto the woman he said, I will greatly multiply thy sorrow and thy conception; in sorrow thou shalt bring forth children; and thy desire shall be to thy husband, and he shall rule over thee." This appears to mandate men to lord it over women and to care little for their fertility-related problems from time immemorial and in virtually all cultures. His anger, which has been abated in many parts of the world, is still very much present in the poorer countries of the world, most of them in the continent of Africa, and his curse against Eve still prevails there. Women's lives in these countries are largely governed by pregnancy and childbearing, and their deaths too are often dictated by it. And everywhere it is women, not men, who suffer from mutilation, disease and death in the pursuit of high fertility.
Pregnancy and unsafe abortions are the leading causes of death among women of reproductive age in many countries. A maternal death may result from direct pregnancy complications, from problems arising at the time of delivery, from abortion or its consequences, or from post-delivery complications. Death may also result indirectly from pre-existing conditions aggravated by pregnancy.
The maternal mortality rate, which measures the rate of deaths of women due to pregnancy and childbirth, is higher in Africa than on any other continent: 630 deaths per 100,000 live births for the continent as a whole in 1988, rising to an average of 760 for the countries of West Africa. In some regions it is more than 1,000. This amounts to 500 deaths every day in Sub-Saharan Africa. This high mortality rate masks an even higher morbidity rate - the same causes that kill hundreds of thousands of women maim and render sterile many millions more of their sisters. For every woman who dies, there are 50 to 100 others who are going to have to suffer short, medium or long-term consequences from their pregnancies and deliveries. Tragically, maternal mortality seems actually to have worsened in Africa since the launch of the Safe Motherhood Initiative seven years ago by WHO, the World Bank and UNFPA, which aimed to halve the number of maternal deaths by the year 2000.
We may ask why it took so long for the world and national governments to take notice of such a major health tragedy. Would it be too cynical to say it is because of the low value placed on women's lives, the fact that their social and economic contributions are not counted and their general powerlessness to negotiate? It must rank as one of the most shameful aspects of twentieth century technology and humanity that they have ignored the tragedy of pregnancy-related death and sickness for so long.
At the root of this high maternal mortality and morbidity is a multitude of health and socio-economic problems which especially affect girls and women. Many girls are born prematurely or at low birth weight because their own mothers were malnourished, ill or overworked. If she survives infancy, an African girl will most likely grow up on a diet that does not meet her minimum nutritional requirements, As a child, she will have a heavy burden of household chores and may receive little or no schooling: almost all African girls receive less education than their brothers, although the literacy gap is beginning to narrow in some countries like Botswana, Swaziland, Tanzania, Zambia and Zimbabwe.1 She is likely to be married off young, especially if a good bride price is available, and taught that her main role in life is to bear and rear as many children "as God brings". During pregnancy, her needs for adequate rest, good nutrition and health care are too often ignored. Poverty forces her to work through the final stages of pregnancy, and myths restricting food consumption may further deplete a pregnant woman's strength at a time when she urgently needs a balanced diet. Eggs or certain vegetables or fruits may be prohibited.
Most of these maternal deaths are avoidable. Of the estimated 500,000 maternal deaths occurring world-wide annually, 308,000 are in Asia, 150,000 in Africa, 34,000 in Latin America, and only 6,000 in the developed countries.2 The maternal mortality rates mentioned earlier are actually ratios which give no idea of lifetime risks from pregnancy-related causes of death. To get the lifetime risk the total number of pregnancies and deliveries are factored in to give the following:
1 in 23
1 in 71
1 in 126
1 in 122
1 in 4006
1 in 2288
Thus we see the African woman as almost 100 times more likely to die from childbirth-related conditions than her European sister.
Three-quarters of maternal deaths can be attributed to five direct or immediate causes: haemorrhage, sepsis, toxaemia, obstructed labour, and the complications of unsafe abortion. The remainder result from 'indirect' causes, including complications of existing illnesses such as hepatitis, malaria and heart ailments, which may become lethal because pregnancy tends to diminish, the resistance of the body or its ability to adjust. Morrow and Sai in a study in Accra found that hepatitis-A was most lethal for pregnant and postpartum women. Of the more chronic conditions the ones most likely to be aggravated or precipitated by pregnancy include diabetes and hypertension. It has recently been found that between two and three per cent of all pregnant women suffer from pyelonephritis which may not be recognized.
Of the five main causes, haemorrhage may result from retained placenta, poorly performed abortion, difficult labour, or harmful traditional practices leading to uterine rupture; sepsis can arise from unhygienic delivery practices, long labour, retained placenta or abortion; abortion, when properly performed, is one of the safest medical procedures, but the use of unsterilized instruments, failure to perform complete abortion, or punctures in the uterus or cervix may result in haemorrhage or infection; eclampsia is a serious form of various conditions caused by high blood pressure during pregnancy which could be identified and managed with proper antenatal care; and obstructed labour may be caused by the mother's narrow pelvis, many previous deliveries or when the fetus is not head down during labour: it is most effectively corrected by Caesarean section which is unlikely to be available outside city hospitals in Africa.
Unrelieved, prolonged or obstructed labour, especially in women under 18, often causes fistula - a rupture of the birth channel which results in urine or faecal matter entering the vagina. A study in central Northern Nigeria showed that there were 300 young women a month being treated for vesico-vaginal fistula in one unit alone, and this hospital had a waiting list of a thousand girls coming from other areas. This distressing condition, which often causes incontinence and leads to repudiation by their husbands, is brought about usually by a child trying to have a child, or a child being forced to have a child. Their physique is simply not fully developed enough for pregnancy and delivery of a baby. The condition may also result from delays in seeking competent health care during prolonged labour from whatever cause. In some cases this condition may be caused or made worse by female genital mutilation.
Female genital mutilation is a particularly damaging practice which affects women's physical, emotional and sexual health.4 These women and girls experience pain, trauma and, frequently, severe physical complications, such as bleeding, infections or even death. The operations are usually done unhygienically, and can lead to the transfer of blood-borne or other infections, including HIV. Long-term physical complications include chronic pain, difficulties with urination and menstruation, pain during intercourse, and pelvic infection leading to infertility, and there are often substantial psychological effects on women's self-image and sexuality. For those with the severest form of female genital mutilation - infibulation - prolonged and obstructed labour when giving birth is common, and the trauma of mutilation is repeated with each birth.
This mutilation is performed on children and young girls, with or without their consent. It is therefore an infringement of the rights of children. Why is it done? It is an extreme example of efforts common to societies around the world to suppress women's sexuality, ensure their subjugation and control their reproductive functions. Voices are being raised, both in Africa and abroad, by women and men who want to eradicate female genital mutilation. We shall return to this subject in greater detail in a later lecture.
SEXUALLY TRANSMISSIBLE DISEASES
Sexually transmissible diseases (STDs) are a major problem in the world today, yet they receive remarkably little attention. Perhaps this is because, with the conquest of syphilis, they do less damage to men than to women. Certainly women's health is more seriously affected than men's by STDs, which cause a tremendous amount of suffering. According to WHO, STDs have become the most common group of notifiable diseases in most countries worldwide, but prevalence rates are particularly high in developing countries. Every year there are 250 million new cases, which, in pregnancy and childbirth, can cause blinding eye infections or pneumonia in babies, chronic abdominal pain in women, ectopic pregnancies and infertility.
The most serious STDs (apart from HIV, which I deal with separately) are gonorrhoea, syphilis and chlamydia. Chlamydia, which can be a silent infection, is not generally recognized as a major cause of infertility. Other infections have less serious consequences, but nevertheless cause immense suffering: they include trichomoniasis, human papilloma virus, genital herpes, chancroid, genital warts and bacterial vaginosis (which may or may not be sexually transmitted). There are two million new cases of chancroid every year, four million new cases of syphilis, 20 million of genital herpes, 25 million of gonorrhoea, 30 million of papillomavirus, 50 million of chlamydia, and 120 million of trichomoniasis5.
Among women, syphilis prevalence rates are 10 to 100 times higher in developing countries, gonorrhoea rates 10 to 15 times higher. The annual rate of new gonorrhoea infections in large African cities is 3,000 to 10,000 per 100,000 population (men and women), or as many as 1 in 10 people.6 In Kenya, the prevalence of gonorrhoea has been estimated at between one and 10 per cent, with the highest prevalence among rural women; chlamydia affected between 6 and 21 per cent, and syphilis between one and nine per cent.7 Figures are scarce for Africa, but other researchers have found gonorrhoea infection rates as high as 60 per cent in some populations in Nigeria and 20 per cent among schoolgirls in Cameroon. I know of no figures for Ghana; this must be due partly to the low priority this area of medicine has received until recently. There are the beginnings of a centre for STDs in Accra, but it cannot be considered as sufficient for the needs. Research efforts must receive high priority.
Women are also more likely to catch STDs than men: transmission occurs more readily from male to female than the other way round. As one medical writer puts it: "Both the transmission and the serious consequences of STDs show a biological sexism. The risk of acquiring gonorrhoea from a single coital event in which one partner is infectious is approximately 25 per cent for men and 50 per cent for women... Moreover, women suffer more serious long-term consequences from all STDs except AIDS, including pelvic inflammatory disease, ectopic pregnancy, chronic pelvic pain, infertility and even cervical cancer."8 Nature is truly unfair to Eve.
Social mobility and migration means that men are more likely to resort to prostitutes, the main source of STDs. Some STDs, as well as causing pelvic inflammatory disease and infertility - a major tragedy for a young woman in Africa - are likely to make more likely transmission of the worst, and incurable, STD - HIV and AIDS. Many STDs can also be vertically transmitted (during pregnancy and/or delivery) to the woman's children, often with devastating results. The rate of vertical transmission of HIV infection is believed to be around 25-30 per cent.
The scourge of AIDS affects even more women than men. The male to female ratio of 1 to 1 at the beginning of the pandemic has now reached 1 to 1.4 in Africa, contrasting with ratios of 8.1 to 1 in the United States and 4.9 to 1 in Western Europe. The incubation period for HIV infection to develop into AIDS, which is up to 10 years in men, is believed to be shorter in women. Factors such as inferior health and social status, polygamy, other STDs, malnutrition, access to care, ear piercing, genital mutilation and menstruation, all lead to easier transmission of HIV. When women are sick with AIDS or die, their children suffer, even if they were not infected themselves at birth. The story of STDs in women is one illustration of their powerlessness in sexual relations. Awusabo-Asare, Anarfi and Agyeman9 have found that many women would still go to bed with a spouse or partner, even if they knew of his risky sexual behaviour.
Rape and violence at home are other health hazards for women. The beating of a wife into submission is supposed to be a man's right and the police in most African countries would not intervene. I wish I could say that this is a problem for illiterates. There is far too much of this even among graduates. The amazing thing is that men who do this do not see how far below other mammals this particular behaviour puts them. Sane male mammals do not wage war on their females as far as I know. Rape is such a despicable crime that no society should treat it with the levity with which some of our African countries and judiciaries appear to do.
Infant and child mortality, which again more directly affects women than men (the women have the burden of replacement pregnancies) is still high in most African countries. In many African countries it is still more than 100 per 1,000 live births, and one of the main reasons for this is the close spacing of pregnancies.
HOW CAN WE HELP THE WOMEN OF THE DEVELOPING WORLD?
What can be done to help the women of the less developed countries in general and of Africa in particular to cope with the huge burden placed upon them? Sai and Measham discussed priority actions in three tiers. The first tier is to manage those who are pregnant or likely to get pregnant soon. The actions include family planning antenatal and pregnancy management with adequate obstetric services. Antenatal care is only useful to the extent that it provides good education for both client and community and serves to make all understand where to go for help and when. The next tier should deal with tomorrow's mothers by giving them the necessary education for handling their sexuality and encouraging them to postpone childbearing till they are biologically and socially mature. The third tier relates to those longer-term socio-economic and legal aspects which we shall discuss in later lectures.
Antenatal care and health education are the first things that can and should be improved. Anaemia is very common and can aggravate many conditions of pregnancy. While about 50 to 60 per cent of all African women are anaemic at some stage, as many as 75 per cent of pregnant women suffer from anaemia. Anaemia can usually be easily detected, and easily corrected cheaply and effectively.
The detection and treatment of hypertensive diseases of pregnancy would also be extremely effective, as would the prevention and treatment of certain infections, especially STDs.
An extension of primary health care and family planning services to the remotest village would probably be the biggest help that they could get. For it to truly answer women's needs such primary health care should have access to first-level referral facilities and possibly half way houses in which women likely to have trouble could stay within easy reach of competent intervention.
Lack of access to effective health care is a critical problem for the African rural woman. Generally, African health-care facilities are too widely spaced (and so too far away for most rural people), have too few trained health care providers, are too poorly equipped to identify or handle complications, and are deficient in quality of care. The percentage of the total population living within an hour's walk or transport from an appropriate health facility is as low as 30 in some African countries. The coverage of deliveries by trained attendants is as low as 15 per cent in some countries, and is less than half in many African countries. In Ghana the coverage is now about 40 per cent.
The World Bank has suggested that the extension of prenatal, delivery and postpartum care to 80 per cent of the world's population would reduce by 40 per cent the burden of disease associated with unsafe childbirth. It would include three components: information and education designed to create demand for clinical services, alert women to danger signs during pregnancy, and mobilize communities for the transport of women with complications to district hospitals; community-based obstetrics to provide prenatal care, including tetanus toxoid immunization, treatment for syphilis, provision of micro-nutrients (iron, folate and iodine), and detection of complications, obstetric first aid, early referral of severe complications, and safe abortion; and district hospital facilities to provide essential obstetric services and neonatal resuscitation.10
As is now well known, there is a high risk associated with pregnancies which are unwanted, too numerous, too closely spaced, too early or too late in the woman's reproductive life. The increase in the risk of maternal death in multiparous and adolescent women is often also associated with low social, educational or financial status. In addition, malnourished adolescents may have an even poorer developed pelvis, resulting in a high incidence of caesarean deliveries and vesico-vaginal fistulae following a long and difficult labour.
The availability and use of effective and safe contraception can help reduce the number of women dying in childbirth from high-risk pregnancies and botched abortions. Evidence from around the world shows that the risk of maternal or infant illness and death is highest in four specific types of pregnancies:
· Pregnancies before the age of 18
· Pregnancies after the age of 35
· Pregnancies after four births, and
· Pregnancies spaced less than two years apart.
The extra risks in these four types of pregnancies are due to both biological and social factors. Age, number of births, and birth spacing, all affect the mother's ability to carry a pregnancy safely and to provide optimal biological conditions for the developing fetus. Once the baby is born, these same factors affect the family's ability to feed and care for the new child and also to care for the older children. It must be realized, though, that normally the total numbers falling within these risk groups will be small. If services concentrate solely on them, the chances of influencing seriously the total population who may need help will not be great. Therefore these risks should not be considered the main criterion for planning services and their delivery.
In developing countries it is estimated that about 5.6 million infant deaths and 200,000 maternal deaths could be avoided each year if women chose to have their children within the safest years, with adequate spacing between births and had completed families of moderate size.
Surveys carried out in Guinea, Senegal, Nigeria and Tanzania have shown that multiparity was the chief factor affecting the maternal death rate; in Tanzania, for example, the death rate among women who have had five to seven children was three times higher than that of women with one to four children. In Guinea, half of all maternal deaths relate to women who had given birth many times.
When a wide range of contraceptive methods arc made accessible and affordable to all couples, the number of maternal deaths is likely to be reduced in three ways:
· The total number of births is reduced, and, since every pregnancy is associated with a certain risk, there will be an equivalent fall in the number of maternal deaths. There is evidence to challenge this assertion since there will be more first births, and these carry much higher risks.
· The number of unwanted pregnancies is reduced. Unwanted pregnancy is always a threat to a woman's health, either because she may resort to poorly performed and dangerous abortion, or, if she decides to carry the pregnancy to term, because she is less likely to take care of herself than if the pregnancy was wanted.
· The proportion of births to some of the women at 'high risk' is likely to fall. The risk of maternal death among women over the age of 35, many of whom already have several children, is five times higher than women aged 20-24. Those aged 15- 19 are up to three times as likely to die as a result of pregnancy or childbirth than those aged 20-24.
A decline in breastfeeding has been noted in many countries, as more women move to cities, take modern jobs and rely more on substitutes for breastmilk. These changes reduce the amount of time between births - and increase the total number of births - unless women use modem contraceptives for birth spacing.
Women living in rural areas tend to suffer from higher maternal and neonatal mortality levels than do women in urban areas. This is partly to do with the fact that rural people tend to be poorer, less educated and have higher fertility levels than do urban dwellers. Their illiteracy and high fertility is connected to their poverty as well as to the fact that they have little or no access to services such as secondary education, health and family planning services. In terms of maternal and neonatal health, the problem of access to medical services is a highly critical one, since rural women are more likely to be at high risk of developing complications in pregnancy and childbirth. This is why primary health care services, with an efficient referral system, and family planning services, should be a priority for all rural areas in African countries.
FAMILY PLANNING SERVICES NEEDED EVERYWHERE
Some African health professionals argue that family planning services are unnecessary because there would be no demand outside the urban areas. But recent research suggests that this is no longer true - if it ever was. For instance, the Demographic and Health Survey (DHS) of Kenya (1989) found that more than half the births in the previous 12 months were unwanted, and a similar survey in Botswana in 1988 found that 48 per cent were not wanted at the time they occurred. And even these statistics are likely to be underestimates due to many women's reluctance to admit to an unwanted birth or pregnancy, and because the data relate only to married women. The latest (1993) DHS results for Ghana have yet to be published but the indications from a baseline survey performed by the Social Marketing Foundation of Ghana indicated that family planning is making some advance. The contraceptive prevalence rate had risen to 27 per cent of which 15 per cent is for modem methods. This cannot be considered good yet, but it is a great improvement on the 12 per cent found in 1988.
Another telling statistic pointing to the urgent need for contraception can be found in the DHS surveys of five other African countries: more than 80 per cent of all the women surveyed, whether wanting another child or not, in Burundi, Liberia, Mali, Senegal and Zimbabwe, were categorized as 'high-risk', either because of their age, previous birth interval or parity.
Of course family planning services need to be integrated into maternal and child health services, and hospital and maternity care services, as WHO recommends - although some African countries have shown reluctance even to go this far. But just as important is the need to make family planning widely available at the community level, especially in rural areas and the marginal districts of cities. Communities should be directly involved in the design and implementation of these services, including obtaining funds where necessary. Particular attention needs to be given to high-risk groups, including high-parity women, women under 18 and over 35, as well as women who want to avoid or postpone pregnancy.
In Africa generally, most women have already had a baby by their 19th birthday - 40 per cent of them before the age of 17. In Nigeria, nearly one million babies are born to adolescent mothers every year, and in one Nigerian secondary school, more than 30 per cent of girls had had abortions. Girls who get pregnant while still at school are normally not readmitted, so their education is ended prematurely. Babies born to these young mothers are disadvantaged, because their birthweight is likely to be lower and their mothers are less experienced. In fact many studies have shown that the infant mortality rate - the number of infants dying before their first birthday - is 20 per cent or more higher when the mother is aged under 18, than when the mother is in her 20s.
Too often, these girls resort to illegal abortion. Data from 13 African studies show that girls aged 11 to 19 represented between 39 and 72 per cent of all admissions to major hospitals for abortion-related complications."
Social attitudes towards adolescent sexuality are responsible for many of these unwanted pregnancies. Often, there is a complete lack of sex education, so the girls do not even know that they risk getting pregnant when they are initiated into sexual intercourse. Even if they know methods of preventing pregnancy, few can get hold of contraceptives because in most countries family planning clinics will not serve unmarried young women. In most African countries, fewer than 30 per cent of sexually active adolescent women have ever used a modern contraceptive method. Since the mean age of first sexual intercourse for girls is 14.5 years, it is only to be expected that many babies are born to 15- and 16-year olds. The hypocritical attitudes of our society and church leaders with regard to adolescent sexuality must change to permit the inclusion of sensitive and sensible education, counselling and services for adolescents.
Women in most African countries are still expected to marry young. This means that they get pregnant too young, and that they end up having more children than they would if they married later. The social justification for early marriage no longer exists: life expectancy at birth for African females has increased from 39 years in 1950 to about 55 today. Since the average woman now completes the reproductive years, the focus on early marriage and early childbearing has become archaic.
The figures for infant deaths for women who are aged more than 40 are even higher, and yet there is tremendous pressure on African women not just to marry early, but also to continue bearing children as long as possible.
The high value placed on large families is also archaic, since more children survive to adulthood than was the case in the old days, and women need to be given the chance to acquire status from attributes other than frequent childbearing - education, running a business, becoming a teacher, bringing up and educating her children.
Other unnecessary causes of women's suffering are the cultural beliefs and women's status and economic dependency which act as barriers to women using health care facilities during pregnancy and childbirth. In some rural areas of Nigeria, Ghana and Sierra Leone women suffering from birth complications are thought to be undergoing punishment for wrongdoing and are not allowed to seek treatment until they have performed the proper penance.
Other women may not be able to afford the time or money to visit distant health facilities, or there may be no transport. Often, lack of supplies and shortage of trained staff mean that treatment is not available anyway. And there are, unfortunately increasing complaints of staff attitude.
FAMILY PLANNING AVAILABILITY
Let us look more closely at what family planning methods are available, and what are the advantages and disadvantages of each method. The most commonly used method is the Pill (combined Pill or COP), but there are different kinds of Pill. Modern Pills contain very low doses of hormones, have few side-effects, but they must be taken daily; because they tend to reduce monthly bleeding, and because they can be formulated to contain iron, Pills provide a protective effect against anaemia. They also provide some protective effect against pelvic inflammatory disease, ovarian and endometrial cancer. Progestagen-only Pills (POP) are more suited to breastfeeding mothers. Injectables work in the same way as the Pill, but they have the advantage of being long-acting and so cannot be forgotten or lost like the Pill. The implant has similar advantages and can be removed if the woman wishes, but its insertion and removal require specialized clinical back-up. The IUD provides long-term protection, but it requires more clinical back-up and is associated with some increase in bleeding and pelvic inflammatory disease, and does not protect against ectopic pregnancy. It is unsuitable for women with multiple partners or whose partner has multiple partners. Sterilization is effective but must be considered permanent, since it cannot be easily reversed. The 'rhythm' method (periodic abstinence) has the advantage of being approved by the Roman Catholic Church, but in practise is usually unreliable because of the difficulty in calculating the safe period and the reluctance of couples always to abstain before and during that time. The condom has no side-effects and protects against the transmission of sexual infections and HIV, but it may be difficult to ensure that couples in rural areas are kept adequately supplied.
No contraceptive method devised so far is perfect - they all have their drawbacks - and, although there is promising research being carried out into contraceptive vaccines, the chances of a radically new method being available within the next 10 years or so are remote. Yet it is precisely during the next 10 years that it is essential to increase contraceptive prevalence! The fact is that contraceptive research is sadly underfunded because most suitable companies have withdrawn from the field because of the threat of unlimited litigation. An encouraging development has been the launch of the female condom, a non-systemic method under female control.
WHO has recently announced the launch of a campaign to work with the world's pharmaceutical industries to develop a safe antiviral agent, which is not a spermicide, for use by women to protect themselves from HIV infection and not necessarily from pregnancy. The same or other antiviral drugs may be combined with contraceptives to achieve both ends. With the prospect of at least one million women facing infection with HIV every year, it is urgent to provide women with such a method. If an existing compound turns out to work in clinical trials, it could be developed for AIDS prevention within some three or five years. More and better methods for men are also needed, but there is little prospect of these being developed in the near future. In the meantime, we must concentrate on persuading men to become more involved in reproductive health issues and in sharing the burden of family planning which their womenfolk largely bear.
Because condoms are the best means of protecting against sexually transmissible disease and HIV, more must be done to increase the use of condoms in Africa. This should be easy: they require no medical back-up, and there are many ways they can be distributed through subsidized outlets. If men are unwilling to use them, they must be persuaded by personal contact, advertising or the media that it is the best thing for them and their partners that they do use them.
New approaches to providing services - often widely used in other regions of the world - are starting to be introduced in Africa. The community-based distribution (CBD) of contraceptives is already established in Ghana, Nigeria, the Gambia, Rwanda, Zimbabwe, Kenya and Tanzania, and experience there has shown that when the users of the services themselves participate in their implementation, the level of use is greater, and they become more accessible and culturally acceptable to the community.
Another approach is the social marketing of contraceptives through shops, markets and other community channels, which is being tried out in Madagascar, Ghana, Nigeria, Rwanda, Burkina Faso, Togo, Mali and Côte d'Ivoire.
The success of all these approaches will be measured, in part, by the extent that they reduce the mortality and morbidity of African women and their small children, and liberate them for other productive and creative work.
Some traditional families and fundamentalist religious leaders discourage the education of girls and women and the employment of women outside the home, which tends to make them less likely to understand the benefits of family planning or to have easy access to it. The patriarchal systems that prevail in rural Bangladesh, Pakistan and in Hindu communities in India as well as in parts of the Middle East certainly make the delivery of family planning services more difficult. The system of purdah results in the effective seclusion of women, which requires intensive outreach programmes, using female health workers, to deliver services at or near the client's household. Low levels of female education restrict this type of delivery: in Bangladesh, outreach workers have to have at least 10 years of schooling, but only 16 per cent of women are literate and a much smaller percentage have been to school for 10 years. Other constraints are the potential harassment of outreach workers, perceived as violating norms of female behaviour, and transport difficulties in a society where women bicycling is considered immodest. Fortunately we now have rather few of these problems in most of Ghana so in theory we should be doing very much better.
There are still political obstacles to the wider use of family planning, but they have certainly diminished over the past two decades. The number of countries overtly opposed to the provision of family planning services has fallen sharply: by 1989 governments in 125 developing countries provided support for contraception for demographic, health and human rights reasons and as part of poverty alleviation efforts. Only 16 of the 131 countries that responded to a UN questionnaire still provide no support for family planning. In any case, policies alone are not enough: Ghana published a population policy in 1969, yet by 1988 the contraceptive prevalence rate was only 10-12 per cent - and half of this was accounted for by the not too effective traditional methods. More recent figures as mentioned above show that Ghanaians are on the move with the use of modern methods reaching 15 per cent.
For programmes to succeed, national policies must be ratified and supported. Elected national-level politicians should be prepared to be identified with their population and family planning programmes. The leaders themselves ought to understand what the programmes are and then to speak for them. Tunisia's family planning programme could never have been as successful as it has been without the commitment and interest of the late President Bourguiba, and, more recently, Zimbabwe's programmes have benefited strongly from the leadership shown by President Robert Mugabe. That country's contraceptive prevalence rate rose from 17 per cent when Mugabe came to power to 43 per cent in 1991.
But the leadership of the formal or official politicians is not enough. Their efforts can be thwarted by lower-level echelons in the political and social administrative systems. There is also the possible social backlash that can be created at the peripheral level if the political leaders feel that contraceptives are being used in a discriminatory manner. The reverse is also true. With good local-level support and national-level approval, much can be achieved, as is shown by the experience of Indonesia, which developed its own family planning programme managed by a separate organization, BKKBN. This organization has the support and leadership of the President himself and it operates through the politico-administrative structure which at the most peripheral level is headed by the local mayors. These mayors are active proponents in the communities. The programmes themselves too do combine some mother and child care and are therefore seen by the people as answering some of their politically expressed needs.
Good quality family health and family planning services, especially when combined with better water and sanitation, proper schooling for children, alleviation of poverty and agricultural aid, have a dramatic effect on women's lives. When it occurs, the reproductive revolution alters the rhythm of women's lives, raising their consumption aspirations and the value they set on their time, and transforming the institution of the family. Between 1975 and 1987, the number of months that the average woman in Thailand spent pregnant during her lifetime fell from 40 to 20, and by 1987 she could expect to spend only 10 years with a child under the age of six. In Ghana today, by contrast, the average woman can expect to spend more than 20 years with a child under the age of six.
However you look at it, the reproductive revolution is must be a liberating process for women, releasing them from excessive fatigue and enabling them to fulfil themselves in many other ways than only through bearing and raising children. What are the factors that lead to this changed situation?
COMPREHENSIVE DEVELOPMENT ALSO NEEDED
Obviously, family planning programmes cannot expect to be successful in the absence of a comprehensive development strategy: one that includes lowering infant mortality, raising female literacy, improving maternal and child health and nutrition, providing clean water and sanitation. The most important element is probably, as the World Bank has pointed out, ensuring that girls receive a good education, because from this will result later marriage, better child care, hygiene and nutrition, a better understanding of the benefits of smaller families, and an improvement in women's status. Even in situations where household income is low, family planning is accepted and better family health is found where women are educated and have better status: an example is the Indian states of Kerala and Tamil Nadu. Demographic and Health Surveys have confirmed the close association of education and desired family size: in Liberia, for example, those with no education wanted an average of 6.8 children, those with primary education 5.3 and those with secondary or higher 4.5. Later marriage normally means fewer children and an enhanced maturity and ability to look after the children.
Declines in breastfeeding actually increase fertility, which suggests the need for proper education and programmes to make breastfeeding more acceptable and convenient during the modernization process. The availability of contraception is of course central in fertility transition - in its absence there will be increasing recourse to abortion.
Also important is the realization by couples that the economic contributions of children are relatively limited, and that the personal and social costs of having them are high. It is particularly important for men to change their views on the value of children and support their womenfolk in limiting their fertility.
Most governments today have accepted that people have a right to sexual and reproductive health services, and that family planning makes a positive contribution to family health, Most, too, have accepted that population dynamics and especially population growth have an important impact on development planning, and they increasingly see population management as essential to development, because rapid population growth often clearly poses a threat to their development aspirations. But policies and programmes are still far from being equal to the task. Only where there is full government commitment to family planning and there are programmes which accord women their rightful place in the conceptualization, planning and implementation, and are able to obtain the necessary leadership, publicity and resources to provide essential services, can success be achieved.
Contraceptive services are largely distributed through health services. In countries where comprehensive maternal and child health services reach only 20 or 30 per cent of the population, family planning programmes, even if they were fully integrated, would still only reach the same percentage. Contraceptive services distributed in the absence of health services are unlikely to be accepted, because women want the security of seeing their existing children alive and healthy before they take the initiative of limiting their births. Bringing basic health services to the whole population, so that infant and maternal mortality in particular are reduced, is a vital contribution to fertility reduction.
More attention must be paid to the quality of the services delivered, to training staff to be receptive and sympathetic to those coming for services, and to the rights of the client. Demographic and Health Surveys in 12 countries suggested that more than half of all women were not successful or not satisfied with the contraceptive methods they had been using, which is a measure of just how far contraceptive technology and family planning delivery programmes are falling short of what developing country women want and need. If programmes are to be successful, they must be based on a comprehensive approach to reproductive health, and the whole community, and especially the women who will be the main clients, must be involved in their planning and implementation.
PROXIMATE DETERMINANTS OF FERTILITY
Let me in conclusion recapitulate on the immediate factors that determine the levels of fertility: they are called the proximate determinants of fertility. These are marriage, and within marriage, the frequency of sexual intercourse, breast-feeding, the use of contraceptives, abortion, and sterility. Each of these is itself controlled by legal, social and cultural systems and other environmental realities. For example, in Ghana, many frown on the provision of contraceptives to minors. I know that both the Christian Council and the Catholic group of churches maintain that information and education counselling - so-called family life education - can be provided for young unmarried people, but that these young people should not be given contraceptives. Yet we know that many of them are sexually active and that if they do get pregnant and find that that pregnancy interferes with their life goals, they are likely to have recourse to often unsafe abortion. The legal system has now been freed, and there is absolutely no reason why proper counselling should not be accompanied by proper services. Let's remind ourselves that it was as long ago as 1974 that the world, in a consensus, stated that "every individual and couple have the right to determine the number and spacing of their children". That right must extend to young, sexually active adults, and they must be educated about their right.
In my view when faith clashes with ethics, ethics must win. Those capable of making babies must be taught how not to make them, and to make them wisely when they are really ready. A life is too important to start as the result of an evening's indiscretion or a fling after the night club.
The proximate determinants are also influenced by the level of education of the individual and their immediate society, by the legal system that governs them, inter-family life and relations and the social and cultural systems within which these operate. In Ghana for example we still have a system which binds the wife as a chattel to her husband. Whether the bride price, small as it is tending to be today, can be considered as central or merely as a cultural relic that makes it possible for men to lord it so much over women, is a matter of conjecture. One thing I am certain of is that our family system, as it exists today in the majority of African societies, enables men to exercise undue and unnecessary power over their womenfolk - their sisters, cousins and so on when they are young, and their wives when they marry.
We shall look further at these and other influences on the proximate determinants of fertility in the following lectures.
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