Categories
Carrying Capacity

Glimpse at Religion in Africa

            In Africa, as elsewhere in the world, religious beliefs have an influence on the number of children a woman will bear. There are many factors that go into family size choices, and religion is one that is rarely explored.

            In the USA, Utah is an example of how religion influences family size. It has had the highest fertility rate, probably in part because of its large number of Mormons (Latter Day Saints). This religion has traditionally encouraged large families, and many Utahans have complied. I know an example from my practice. An LDS patient from Utah requested reversal of her tubal ligation, which was done after her 5th child was born. She regretted the sterilization and wanted more children. I succeeded in putting her tubes back together, and she ended up with 12 kids!

            In many African countries—especially south of the Sahara—the predominant religions encourage high fertility. Many groups of both Christians and Muslims believe that children are gifts from God and feel that contraceptive use is prohibited. Part of the motivation for large families seems to be that there is strength in numbers—especially if a group feels threatened. In addition, agrarian people tend to look upon children as a resource for work, while urban societies may consider kids financial burdens. Furthermore, rural people have less access to contraception than those who live in cities. A third major group of religious believers, those who follow traditional faiths, tend to have many children, perhaps because they are more likely to be subsistence farmers. 

            What can be done to help women get effective birth control? IUDs and implants, the most effective temporary contraceptive methods, are expensive and require skilled providers. Fortunately, a promising new variation of an old method has won favor in several African countries. For over 50 years women have trusted DMPA (DepoProvera®) for contraception. It is very effective, but requires a shot every 3 months—which is especially difficult for rural women. Some women have sickle cell anemia, an inherited disease in Black Africans, which causes painful crises. DMPA can actually prevent these crises in addition to preventing pregnancy!

            Sayana Press® is the same medication in a more convenient form. In a trial, Ugandan women who chose Sayana Press® were taught how to give themselves the first shot in a clinic. They went home with 3 more shots to self-administer at 90-day intervals. This meant only one clinic visit a year—much better for someone who might need to walk miles or take an expensive bus to the nearest family planning clinic.

            Education is an important way to empower women and for them to gain control of their fertility. Perhaps this teaching could include mention of the advantages of smaller families. In Sub-Saharan Africa, as in other parts of the world, the more years of school a girl or woman attends, the smaller her family is likely to be. Joyce Asimit Simiyu of northwest Kenya is a good example. She is the oldest of seven kids. Although elementary school was free, her family didn’t have resources for her to go to secondary school. The Quaker Girlchild Education Fund provided scholarship aid for high school and eventually she finished college. She and her husband are the parents of only two.

            There are innovative ways that family planning services are delivered in Africa. Catholic dogma is against modern contraceptive methods, but people have found ways around that doctrine. I asked a Catholic nun who runs a health center in Tanzania if they provided contraception. “No,” she said, “we leave that to the Protestants down the road.” Rwanda is another example, where much of the health care is provided by the Catholic Church. After the 1994 genocide, the government recognized the importance of family planning and placed a family planning clinic close to each of the Catholic facilities.

            Many places in Africa already exceed the land’s ability to feed its people, yet the world’s fastest growing populations are there. What works to slow growth? In many cultures religious leaders are key to promoting successful family planning. Although they may not be interested in slowing the growth of their congregation, most leaders will want to improve the health of their mothers and children. One of the best ways of doing that is with contraception to lengthen the interval between pregnancies.

© Richard Grossman MD, 2022

Categories
Consumption Public Health Reproductive Health Women's Issues

Recognize Problems in Some African Cultures

Different types of Female Genital Mutilation

            I have often heard that the need to reduce population growth in African countries is less important than in rich countries because consumption is so much lower in Africa. It is true that the impact of a person in Africa is much less than someone in a rich country, however there are important but different reasons for Africans to reduce their fertility.

            Although the average footprint of a person in Africa is small, there are already more feet than the land can bear in some places. Slowing population growth there will help people be healthier, happier and more productive. Traditions exist that are harmful to women and also lead to high fertility. These injurious traditions may have had their function in the past, but they have no place in the 21st century.

            In the past I was a cultural relativist. I believed that the practices in other cultures shouldn’t be evaluated by our standards. When I learned about Female Genital Mutilation, I changed my mind. If one believes that girls and women deserve the same respect as boys and men, one cannot be a cultural relativist.

FMG is practiced by many cultures in Africa. It consists of removing part or most of the external genitalia of girls. It is usually done without anesthesia and often with a dirty blade.When the margins of the vulva are separated by the (brutal) slicing, acacia needles are used to hold them together. Think of the agony FMG survivors suffer! Some victims die from blood loss or infection. The pain returns during intercourse and childbirth if the vaginal opening has been sewn nearly shut. Fortunately, there are many organizations in Africa that are working to get rid of FMG. Often they substitute another, more benign, coming-of-age ritual for girls.

            Child marriage is another damaging custom of some African cultures. Typically, the girl’s arranged marriage is shortly after she starts to menstruate, and she is forced to wed a man many years older than she. A girlchild is considered a burden in many societies, so the best way to get unburdened is to marry her off. Worse, rape of a young girl is not uncommon. Since virginity is a requirement for marriage in many societies, the girl’s parents force their daughter to marry her rapist. The pitiable girl is thus dominated by her husband for the rest of her life.

            The psychological effects on a girl who is married as a young teen must be terrible, however the physical effects can be fatal. Her pelvis may be too small to give birth if she conceives before her bones have finished growing. Obstructed labor may kill the fetus—resulting in a stillbirth. Sometimes pressure of the fetal head against the girl’s pelvis blocks blood flow to the girl’s tissues. The dead flesh dissolves, forming a hole through which pee and/or poop can pour.

            You might think that child marriage and FGM don’t exist in the USA, but that is wrong. Some immigrants practice both. In addition, some non-immigrant groups have allowed early marriage, often in response to early teen pregnancies. Delaware was our first state to ban marriage before age 18, only 4 years ago. Women who marry young tend to have more children and seldom advance far in education.

            Both child marriage and FGM are means of subjugating women; so is cutting short their education. Another way power is taken away from women is the absence of something we take for granted—clean and safe toilet facilities at schools. Many girls quit school after their period starts because their school lacks adequate, private toilet facilities.

            Where girls and women are treated as inferior, they have little control over their lives. They don’t have power over what happens to the most personal parts of their bodies, nor when or whom they marry. They may not say when they have sex, nor limit the number of children they bear, nor use contraception if they want to.

            Many organizations work to empower African women by putting an end to child marriage and FGM. One favorite is the Population Media Center, which has made great advances in education about these evils.

            Although I am not an anthropologist and have spent only a little time in Africa, these seem to be some reasons that the population is growing so rapidly there. In the future I’ll write about religions which encourage large families, and about overpopulation causing famine—one of the Four Horsemen of the Apocalypse. 

© Richard Grossman MD, 2022