Women in West Africa Face Heavy Toll From High Birthrate

Hillary Mayell
for National Geographic News

May 1, 2001

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.

The researchers found that in the Farafenni region, more than 50 percent of the women were anemic, nearly 50 percent had damage to their organs from child-bearing, nearly a third had genital herpes, and nearly half had reproductive tract infections—conditions that can impair fertility.

Yet cultural practices and attitudes tend to inhibit Gambian women from seeking out health care services.

Public Policy Implications

Initiatives begun by the United Nations in the mid-1990s have drawn worldwide attention to the importance of providing reproductive health care services for women.

"I've seen women bleed to death after childbirth because the husband couldn't be found to give permission for her to be transferred to a hospital," Walraven said. "We need to empower these women and make services more women friendly."

In many regions, the culture of silence surrounding disorders of the reproductive organs is more likely to be broken if the focus is on the risks of infertility rather than the threat of acquiring AIDS, Walraven and his co-authors concluded.

"We need to educate both the men and the women to change community attitudes," he said. "And more money needs to be spent. And realistically, it is not going to come from the governments of these countries."