'Barrenness among plenty'--Silke Dyer.
And this 'barrenness among plenty' provides the challenges in addressing from a reproductive health perspective, the levels of both the infertility and the fertility. 'Reproductive behaviour in Africa is fertility oriented and so this is difficult to address, and then because the fertility is high, infertility issues tend to get pushed to the background,' she says.
Dyer, who has pioneered research on the social consequences of infertility among local women in the Cape Town area, says that her findings appear to be mirrored across Africa: That children have a high value in African society and that people want many children, and that as a result infertility often has consequences such as marital instability, stigmatisation and abuse.
'Our findings revealed that infertility can have a serious effect on both the psychological well-being and the social status of women,' says Dyer. 'Verbal abuse and public ridicule are common and there can even be ostracism from society.'
And if one thinks the situation is bad in South Africa, it can be much worse in other countries in Africa, she says, adding that not only women but men also can be affected. As an example, a finding from Mozambique is that women who are infertile are not permitted to participate in any of the traditions in any way associated with children, even weddings. Another example is from Nigeria, where women who are infertile have been accused of witchcraft and adults advised not to associate with these women. And in Tanzania the prevalence of HIV/AIDS was found to be higher in infertile women, the consequence, it is conjectured, of these women seeking to overcome their infertility with multiple partners and thereby putting themselves at greater risk of exposure to the virus.
Dyer says that while the prevalence of infertility across Africa is difficult to quantify, in Africa, unlike the developed world where the leading cause of infertility is ovulation dysfunction, infertility is generally secondary in nature, and the consequence of one or more factors including early age of marriage and first intercourse, inadequately treated complications during pregnancy and inadequately treated STDs due to poor reproductive health services, poor hygiene and poverty, and high levels of rape and prostitution.
'As a result infertility issues have become the Cinderella of reproductive health. They are not perceived as a problem and the level of suffering that occurs is poorly appreciated.'
And given how difficult it is appearing to effect any reproductive health changes in the face of the deadly HIV pandemic, it is not surprising that it is also difficult to change attitudes to infertility. But infertility can also ride on the HIV wave, says Dyer, commenting that as tubal disease is its most common cause in Africa, the most cost-effective intervention, in her view, is in vitro fertilisation (IVF).
'IVF is seen as sophisticated but in reality it is not. All one needs is a gynaecologist and an embryologist, an ultrasound machine, an incubator, a microscope and a clean area.' And medication, which can be costly. 'It is a question of resources, and the appropriateness of IVF in countries in Africa needs to be investigated,' says Dyer, adding that she believes it is very appropriate in South Africa. In her unit at Groote Schuur, for example, the treatment is subsidised by the patients. This subsidisation has kept the service active, with the unit achieving between 120 and 150 cycles per year currently.
Looking forward, Dyer says that effective intervention will require social, economic and political changes. One of the keys, she says, is to 'keep slowly chiselling away' at the socio-economic issues, such as poverty and the way women are perceived. 'If people know that their children are going to survive then they will have only the children they want.'
People also need to know that they have a health service to turn to, she says. 'My blueprint would be start integrating infertility into the health services, as part of the family planning services, and thereby providing a comprehensive reproductive health service.'
But the ultimate question that needs to be asked is: 'Is infertility a reproductive health priority in Africa?' Says Dyer, 'I believe it is and that it deserves much more attention than it has been receiving.'
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|Publication:||South African Journal of Obstetrics and Gynaecology|
|Date:||Apr 1, 2007|
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