for National Geographic News
In coastal West Africa, a woman's ticket to a secure future is to have children. Lots of them. On average, women living in rural Gambia get married at age 15 and have at least six children over the course of their lifetimes.
The physical toll is huge. More than 70 percent of women living in the Farafenni region of Gambia have at least one reproductive tract disorder, according to a recent study. In fact, reproductive disorders are so common that very few of the women in these villages had looked to health care services for a remedy.
"They think the condition is normal, can't be fixed, or that anything that could be done is too expensive to bother about," says Gijs Walraven, lead author of the study, which was published in the medical journal The Lancet.
The study is the first of its kind in sub-Saharan Africa, and has wide-ranging implications for the design of health care delivery programs and the allocation of spending for health services.
Culture of Silence
Gambia is a predominantly Muslim country with a population of just over 1 million people, 85 percent of whom live in rural areas. Villages in the Farafenni region range in size from 32 people to more than 1,200. None of the villages have electricity; most have a public well. The overwhelming majority of the villagers are farmers, and 45 percent of the families have a yearly income below U.S. $150. Education levels are exceedingly low; only three percent of the women who participated in this study had received any formal education.
It is a polygamous society, and men may have several wives living in the family compound, all bearing children. A husband can divorce a woman who produces no children during the first seven years of marriage. Women who want to abstain from sex, space their pregnancies further apart, or practice safe sex to avoid sexually transmitted disease face many obstacles.
"To the husband, extra children and extra wives mean extra work force, out in the fields or in the family compound," says Walraven. "It doesn't really cost him that much to have children. He can feed them from the land, there are no educational expenses, clothing expenses are minimal.
"To the woman," he added, "children take care of you when you are older, whether by emigrating and sending money back home or providing a home."
Infertility is therefore a major threat to a woman in Gambia.
According to a study by the World Health Organization, only 20 percent of the cases of infertility in developed countries are related to infectious diseases, whereas in sub-Saharan Africa infectious disease accounts for 80 percent of all infertility cases.
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