Sm. Sci. Med.
Vol. 35. No. 7, pp. 907-913, 1992
0277-9536/92 $5.00 + 0.00 Copyright0 1992 PergamonPressLtd
Printedin Great Britain.All rightsreserved
ARTIFICIAL DONOR INSEMINATION IN YAOUNDE: SOME SOCIO-CULTURAL CONSIDERATIONS OLAYINKA MARGARET NJIKAM SAVAGE
B.P. 1935 Yaounde,
Cameroon,
Central
Africa
Abstract-Infertility affects about 14% of the population in Cameroon. The majority of those affected arc between 26-30 years old. Between 40-50% of all cases of infertility are associated with male failure, and azoospermia is implicated in 14.4% of the cases. There is thus an indication for assisted reproduction among this category of infertile couples particularly artificial insemination by donor (A.1.D). A
comparative study on fertile and infertile couples’ perception of A.I.D. revealed that knowledge of A.I.D. is low, 35.30% of infertile respondents were aware of the procedure vis g vis 30.6% of their fertile counterparts. Nonetheless 49% of infertile respondents accepted A.I.D. in principle compared to 37.75% of their fertile counterparts. Despite the high value respondents placed on having children and the strong desire by infertile couples to have their reproductive potentials fulfilled, only 19.6% of infertile respondents and 42.87% of their fertile counterparts respectively, would actually practice A.I.D. if the need arose. There are indications that respondents did not perceive A.I.D. as an acceptable solution to infertility. Evidently, the possible influence of socio-cultural barriers to A.I.D. as well as perceived socio-cultural alternatives which may be more acceptable to infertile couples than a technically assisted form of reproduction, have been overlooked. Key words-infertility, alternatives
male failure,
artificial
insemination
INTRODUCTION
35’7--F
cultural
barriers,
socio-cultural
2630, in other words those in the prime of their child bearing years. Infertility affects about 14% of the population of Cameroon, although there are regional and ethnic variations. For example, there is a 3- to 4-fold difference in the incidence of childlessness between the West and East Provinces, with 7% and 28%, respectively. The high level of infertility in the East Province is due to the fact that it is part of the infertility belt of the Central Africa region. It is an area with high sexual mobility, high levels of sexually transmitted diseases (STD) and low level of socio-economic development. Religious differences also appear to have more significance among the Moslems than the nonMoslems in North Cameroon. Infertility tends to be higher among Moslems than non-Moslems in North Cameroon. The common practice of polygamy does much to encourage the spread of STD. Indeed it is not uncommon for a man to select one of his spouses for medical care in the case of STD and infertility [l]. Similarly, there are sociocultural variations in the accepted modality of treatment. The socio-cultural observations on A.I.D. as a treatment modality would be discussed within this framework: firstly the traditional concept of infertility would be examined, followed by local perceptions on artificial insemination by donor. The various factors which constitute socio-cultural barriers to A.I.D. will then be considered and lastly the perceived socio-cultural alternatives to A.I.D.
With scientific innovations in human reproduction, artificial insemination by donor (A.1.D) has become an available alternative to natural reproduction, especially in the Western countries, in cases of azoospermia or oligospermia. The decreasing numbers of babies available for adoption due to legalisation of abortion, easy access to contraceptive services, and increase of single parents have popularized A.I.D. Variations of the procedure such as surrogate motherhood with its legal and moral implications have also become widespread especially in the U.S., U.K., Europe and parts of Asia. Although A.I.D. is practised world wide, there is usually no individual request for it in many countries, particularly in Africa. Nonetheless, artificial donor insemination has been successfully initiated at the Central Maternity and University Hospital Centre, Yaounde since 1984 especially in cases of couple infertility where the male factor is implicated. In Cameroon as in most African countries, a great deal of value is placed on children. In fact, so ubiquitous is the presence of the children in a marriage or family that most people find it difficult to define the value of children. Nonetheless, the value of children varies from proof of consummation of marriage, assurance of proper burial, security in old age, social prestige to guarantee of lineal continuity. Infertility in Cameroon affects the young and sexually active in the population, between the ages of La
by donor,
907
908
OLAYINKA MARGARET NJIKAM SAVAGE TRADITIONAL
CONCEPT
OF INFERTILITY
In many societies, especially in African societies, the value of the woman is intrinsically defined within the context of her bio-social role as the bearer and rearer of children. Her value is further enhanced by the number of children she bears especially the number of sons. Thus in traditional society, infertility is always alluded to as a female problem. Only within the last two decades has the male factor become increasingly implicated as cause of couple infertility. This has increasingly led to the current practice of couple evaluation in cases of infertility. Nonetheless traditional attitudes to infertility remain basically unchanged. In couple infertility in Yaounde, the male factor has been implicated in between 40-50% of cases. Azoospermia (complete absence of live sperms) or oligospermia (low sperm count) are often indicated as causal factors [2, 31. In Eastern Nigeria, Chukudebelu [4] in a study found out that males were responsible for couple infertility in 55% of cases. In Lagos, Giwa-Osagie [S] also found the male factor implicated in 34% of cases of couple infertility. Kenyan husbands were responsible for between 20-30% of reproductive failure [6]. Although studies conducted revealed that most cases of infertility are caused by protracted or poorly treated episodes of sexually transmitted diseases (STD), ongoing research activities indicate a disparity between popularly held beliefs and established medical facts about causes of infertility [7]. Thus respondents believed that early commencement of sexual activities especially by females predisposed them to infertility just like repeated resort to abortion especially septic abortion. The implication of STD as a cause of infertility was only referred to by those respondents with post secondary level of education. Vague references were also made by less educated respondents to sickness as a cause of infertility with special reference to the abdomen. Surprisingly, only few respondents attributed infertility to witchcraft given the general low-level of education in Cameroon and the predominance of the population living in the countryside. Although genetic factors were attributed to by some respondents, less than 5% grudgingly admitted the possibility of the male factor as cause of couple infertility. Over exposure to artificial methods of contraception especially the pill was also cited as a contributive factor to infertility even by the pill users. It was the unanimous opinion of respondents that the childless woman suffered considerable social discrimination especially in the rural areas. She is often the centre of hostility in addition to being considered a person to be feared and hated because childlessness is often seen as a retribution for some wicked deeds performed in the past or previous promiscuous life. In theory therefore, most women would accept any treatment to end the scourge of
childlessness trauma.
and its attendant
social and emotional
LOCAL PERCEPTIONS ON ARTIFICIAL INSEMINATION BY DONOR
A study of a comparative investigation on the determinants of the acceptability of A.I.D. among infertile and fertile couples was undertaken among clients consulting at the mother and child health centre at the University Hospital Centre (UHC), Yaounde [8]. When this study was conducted, the UCH was the tertiary level of health care in Cameroon. This Centre comprises an antenatal, a family planning and an infertility clinic. These clinics operate usually on specific days. The fertile respondents were recruited from the antenatal clinic and their infertile counterparts from the infertility clinic. Both fertile and infertile respondents were included in the study to investigate their knowledge of A.I.D. as a treatment modality in the clinic population especially since infertility in Cameroon is predominantly secondary in nature. A previous study conducted in Yaounde had indicated that 63% of women attending the infertile clinic had secondary infertility [2]. AVAILABILITY
OF A.I.D. PROCEDURE
The practice of A.I.D. was introduced in 1985 in the department of Obstetrics and Gynecology of the University Hospital Centre (UHC) and subsequently at the Central Maternity, both in Yaounde. Up to 1989 services were available in these places. Presently, services are only available at the Central Maternity. Very few of the respondents in the study were aware that the procedure was available in Cameroon. None of the respondents had come to enquire about A.I.D. In fact, since the practice of A.I.D. was initiated in Yaounde, there has been no overt demand or request for it. A.I.D. is only suggested as a treatment modality to couples who have no other locally available possibility of achieving a pregnancy. In the study, respondents were asked if they know about or had heard of A.I.D. As a means to verifying answers, those who responded in the affirmative were then asked to describe the procedure. The UCH because of its specialized nature and its corresponding fee structure generally caters for persons from the middle and high income level group. This perhaps explains the educational distribution of respondents. The majority of the population in Yaounde are Christians. Clients were recruited using the systematic sampling technique. These clients were then informed of study objectives and only those who consented to participate were included in the study. The data was collected by the interview technique using a semi-structured questionnaire. All interviews were conducted by a final year medical student. Spouses were interviewed separately from
Artificial
909
donor insemination in Yaounde
their partners to reduce interference. The refusal rate for the study is unknown. The study population comprised 102 infertile and 98 fertile respondents out of which there were 113 females and 87 males. The mean age of the respondents was 30.24yr, and the age range was between 1947 yr. The majority of the sample population were educated, 73% had at least secondary school education. However, more of the better educated clients were more likely to be infertile than fertile [8]. Also 8 1% were married, 15% were single and only 4% were involved in cohabiting unions. Most of the couples involved in the study were Christians with Presbyterians comprising 56% of the study population (Table 1). The degree of awareness about A.I.D. among respondents was low, among the fertile respondents 30 (30.6%) were aware of A.I.D. Infertile respondents on the other hand seemed more knowledgeable about the procedure and 36 (35.30%) of this category were aware of it. However, very few respondents were aware that the procedure was being performed in Cameroon as the majority had derived knowledge of A.I.D. from journals and mass media all within the context of foreign countries. Knowledge of A.I.D. was better displayed among persons with postsecondary school education and above. Fifty-five percent of whom had heard of A.I.D. compared with 23.8% of respondents with secondary school education and less. This general low level of knowledge may be due to the comparative low level of education in Cameroon as well as the existing poor medium Table I. So&-demographic Fertile (n = 98)
of information and communication especially with regard to reproductive health matters. Also, the Cameroonian society despite the fast pace of urbanization and growth in some of its cities, notably Douala and Yaounde is still predominantly rural based. Among other questions respondents were also asked: “if you were childless because your husband had a major infertility problem, would you accept A.I.D.?” Responses indicate what line of action respondents themselves would undertake. Generally, women were more likely to approve of A.I.D. than men. This was probably because they bore the socioeconomic and psychological brunt of infertility more than their male partners. A more positive attitude towards A.I.D. was also observed among infertile respondents than their fertile counterparts, 50 (49%) of the former accepted the procedure in principle compared to 37 (37.75%) of the latter. Age of respondents was important in their attitudes to A.I.D. In principle, the younger respondents approved more of A.I.D. than their older counterparts. Thus 35.7% of fertile respondents under 35 years approved of A.I.D, a figure comparable to 38.2% of favourable responses derived from infertile persons. However, among the older respondents from the infertile groups 10.78% were more receptive to A.I.D. than 2% of their fertile counterparts. Under normal circumstances, procreation takes place within the context of conjugal union. Among our study population, child bearing tended to be a premium for married persons rather than the unmarried. Young single women are generally not preoccupied with childbearing until marriage. Not characteristic Infertile
of respondents
(n = 102)
N
(%)
N
40 I3 22 I4 7 2
(40.81) (13.26) (22.44) (14.28) (7.14) (2.04)
20 38 26 10
(6.86) (19.60) (39.25) (25.49) (9.80) (0.98)
Primary Secondary Post-secondary University
7 30 40 I5 4
(3.5) (15) (20) (7.5) (2)
I6 54 29 4
(0.5) (8) (27) (14.5) (2)
Total
96
(48)
104
Single Married Cohabiting
30 62 6
(15) (31) (3)
Total
98
(49)
Catholic Presby. Moslems Baptist Born again None
28 58 6 3 I
(14) (29) (3) (1.5) (1.5)
Total
96
(48)
(%)
Total N
(%)
47 33 60 40 I7 3
(23.5) (16.5) (30) (20) (8.5) (1.5)
Age 19-25 26-30 31-35 3-o 4145 4&50 Education NotIe
Marital
status
8 46 94 44 8
(4) (23) (47) (22) (4)
(52)
200
(100)
100 2
(so) (I)
30 162 8
(15) (81) (4)
102
(51)
200
(100)
44
(22)
54 2 2
(27) (1) (1) K)
72 II2 8 5 I 2
104
(52)
200
-
Religion
(36) (56) (4) (2.5) (0.5) (1) (100)
910 Table
OLAYINKA MARGARET NJIKAM SAVAGE 2. Relationship between marital status and knowledge A.I.D. in infertile resoondents
of
Knowledge of A.I.D.
No knowledge of A.I.D.
Married Cohabitating
34 (33.33%) 2(1.96%)
66 (64.71%)
100 (98.04%) 2(1.96%)
Total
36 (35.29%)
66 (64.71%)
102 (100%)
Marital
status
Total
Single
surprising therefore it was the married couples, both fertile and infertile who exhibited more knowledge of A.I.D. than their single or cohabiting counterparts. Single women tended to be less knowledgeable about A.I.D. than their married counterparts in both the fertile and infertile groups. The difference was however more marked among infertile respondents among whom none of the single women knew about A.I.D. while 33.33% of the married and 1.96% in the cohabiting groups respectively, knew about the procedure (Table 2). Thus marital status of infertile respondents appeared to have significant difference in their knowledge of A.I.D. (P < 0.001). Not unexpectedly no single infertile respondent would accept A.I.D. while 24 (23.54%) of their married but fertile counterpart would. Among the fertile respondents, more than twice as many married respondents 24,44% would accept the procedure than those in the unmarried category (10.2%). There was little difference in level of acceptance of A.I.D. between infertile and fertile married women (Table 3). Nonetheless, the real opinions and beliefs of respondents towards assisted reproduction were revealed in their responses to questions on the possibilities of their ever practicing A.I.D. Specifically, respondents were also asked: “if it became necessary (i.e. you and your husband could not have a child by any other means) would you practice A.I.D.?” The question was posed to both fertile and infertile respondents in the hope of receiving an insight as to what they themselves would do in case of male failure. Contrary to expectations, while 42.8% of fertile respondents agreed to practice A.I.D. if the need arose, only 19.6% of their infertile counterparts would do so. This significant difference in responses of the fertile and infertile groups may be due to the fact that since the procreative ability of the first group was already confirmed, they did not really ponder seriously on the medical. moral, legal and sociocultural implications posed by artificial donor insemination unlike the fertile group and were thus more ready to accept the procedure. Thus it was not a Table 3. Relationship
between marital
real life issue for the fertile respondents. Despite the strong desire by infertile couples to have children, they did not perceive assisted reproduction as the panacea to their bio-social problem. The reasons given for the rejection of A.I.D. indicate that cultural factors constitute far more importance than is perceived in the acceptance or non-acceptance of A.I.D. SOCIO-CULTURAL
Thus while refusal for A.I.D. was often due to a variety of reasons, a large number of fertile and infertile respondents, almost 40% found the procedure unacceptable for reasons they could not verbalize, probably because it was counter to all social and cultural norms of acceptable patterns of child bearing. Some of the responses in Table 4, also reflect the prevailing socio-cultural attitude regarding male failure and male acceptance of infertility. During the interview it was made clear to all respondents that the crux of the question was what they would do as regards the practice of A.I.D. in the case of established male failure on their part or their partners. Yet 22% of both infertile and fertile respondents said they would rather practice polygamy than resort to A.I.D. Their responses did not so much indicate lack of comprehension of the question but rather reflects a typical male attitude to infertility. Since socioculturally, infertility is always a female fault, taking on of a second wife or a mistress is usually perceived as a remedy to a childless marriage. It is only when the second (or subsequent union) also fails to produce a child that fertility status of the male partner starts being questioned. About 15% of fertile and infertile respondents felt the procedure was morally questionable (Table 4). Also treatment seeking behaviour for a spectrum of disease or illness is not clearly divided between consulting a physician or a traditional healer. Sometimes the traditional healer may be consulted first and the patient only seek modern health care as a last resort, or vice versa. At other times both may be consulted simultaneously. Preference of traditional treatment to A.I.D, for example, was upheld by 49.8% of respondents. As stated [9] traditional treatment as a possible cure of infertility is still very popular among those affected, irrespective of their level of education. In the treatment of veneral infection which is often implicated in infertility, the study showed that while 62.5% of women with gonorrhea had been treated by a traditional healer, and 12.5% by paramedical personnel, none of those
status and approval
of A.I.D.
among Infertile and fertile respondents Fertile
InfertIle Marital
status
Accept A.I.D.
Reject A.I.D.
Single Married Cohabiting
24 (23.54%) 2(1.96%)
76 (74.50%)
Total
26 (25.5%)
76 (74.50%)
‘Accept’ of A.I.D. was estimated by the response to the question: would you accept A.I.D.?”
BARRIERS TO A.I.D.
Total
Accept A.I.D.
Reject A.I.D.
Total
100 (98.04%) 2(1.96%)
lO(lO.2%) 24 (24.49%) 3 (3.06%)
20 (20.41%) 38 (38.78%) 3 (3.06%)
30 (30.61%) 62 (63.27%) 6(6.12%)
I02 (100%)
37 (37.75%)
61 (62.25%)
98 (100%)
“if you were childless because your husband had a major infertility
problem,
Artificial
donor
insemination
Table 4. Reasons for refusal to practice A.I.D.
Reasons Procedure tantamount to adultery” Problems of anonymity of patemityb Morally incorrect Against religious doctrine Prefer adoption Prefer polygamy Prefer traditional treatment No reason
Fertile respondents (N = 98) N (%)
Infertile respondents (N = 102) N (%)
l(l.02)
2(1.96) 24 (23.53) 5 (4.40) IO (9.80) 22 (21.57) 30 (29.42) 9 (8.82)
lO(10.20) l(l.02) 14 (14.28) 22 (22.45) 20 (20.41) 30 (30.62)
“Mostly given as response by males. bMostly given as response by females. This table indicates distribution of responses to the question: “if it became necessay (i.e. you and your husband could not have a child by any other means) would you practice A.I.D.?”
infected had consulted a doctor. And 25% had never been treated [lo]. Recourse to traditional forms of treatment is important because of its often ineffectiveness in curtailing the spread and chronicity of sexually transmitted diseases as was well documented in another study of males in Yaounde [ll]. Rather than submit to A.I.D. 44% of fertile and infertile respondents considered polygamy as a more palatable solution to infertility. However, as this study was on male failure, this preference of polygamy may not only be an indication of chauvinism among male respondents but also an indication of traditional male refusal to accept responsibility for couple infertility, even in the face of medical evaluation. A.I.D. AND PROBLEM
OF ANONYMITY AND SECRECY
Secrecy is by rule advocated by most couples and physicians in the administration of artificial insemination by a donor. However in our own context, anonymity which is closely linked with this aspect of secrecy poses a real socio-cultural problem. This problem of anoymity of genitor in the administration of A.I.D. was not only raised by many respondents but constituted a basis for the outright rejection of the procedure by 23.5% of infertile respondents. It is worth noting that this factor was raised mostly by females. In most African societies, a person’s identity, his social, economic and political rights, and obligations are all bound up in his family name. Social identity in Cameroon is often based on patrilineal descent and more rarely as among the Kom of the North West Province, on matrilineal descent i.e. through females. It is therefore of paramount importance that the genitor is established from birth. Hence the question, ‘Who is your father?’ is one encountered from the informal social context as in bars, ‘chicken palours’ to higher level social and political meetings. ‘A chicken parlour’, is a social forum where friends, acquaintances gather to discuss or chat in the evenings, after work over a piece of chicken or fish grilled over charcoal fires. A variety of these exist
in Yaounde
911
catering for a diversity of socio-economic groups. Even though this question may be sometimes couched in light terms, the significance is far reaching. It is through the establishment of a genitor that ones e.g. social, economic, political and inheritance boundaries are defined. While artificial insemination by donor provides a scientific intervention for childless couples, the problem of anonymity looms large within the African context. Also associated with this is the fear of incestuous unions which in the African context is often not limited to siblings, but also to other more distant categories of kinsmen. Another common barrier to A.I.D. raised by respondents is the problem posed by the outcome of pregnancy in terms of the normality and possible unbecoming temperament of the baby as a result of unknown genitor. This factor has also been raised elsewhere as a worrying component in A.I.D. [12]. This is because traditionally, physical, temperamental and psychological make up of a person are often perceived as inherited family characteristics. However, adequate counselling of clients before and after the A.I.D. may help to mitigate such fears. The importance of counselling cannot be overstressed. A.I.D. is more than just a clinical procedure. Biological or physical maturity of the couples in itself is inadequate in the face of the potential emotional and psychological trauma couples contemplating A.I.D. are exposed to. A.I.D. as a biosocial procedure makes it imperative for the integration of a psychologist (in the team of clinicians and technicians) to offer adequate counselling services to couples before and after the procedure to minimize the possibilities of trauma to couples and in the long run their offspring. Still related to the issue of anonymity of genitor and the family secret which infertile couples who undergo A.I.D. have to bear, is the accompanying social and psychological burden. The majority of those fertile respondents who regarded A.I.D. as an acceptable alternative to natural reproduction and the outcome (child) as ‘normal’ did so on the presumption that the procedure would take place under the cloak of secrecy. Yet, studies undertaken elsewhere indicate that many couples now consider that very cloak of secrecy which is created to give them and their offspring a life of normality, as an indirect sanction of the denial of their problem of infertility. This family secret is also seen to interfere with the couple’s acknowledgment of their infertility problem, thus inhibititing their ability to come to terms with and discuss their inadequacies. This inability to have open discussions has been known to result in transient impotence and loss of self esteem in husbands. Among women such suppressed feelings have been known to give feelings of anger and guilt and sometimes a death wish on their husbands [13, 141.
912
OLAYINKA MARGARET NJIKAM SAVAGE SOCIO-CULTURAL
ALTERNATIVES
TO A.I.D.
Child fostering
Just as infanticide and child abandonment have been used in African societies to regulate family size especially in cases of multiple or deformed births SO also has child fostering among other practices been used to redistribute fertility. Child fostering is widely practiced and accepted. It entails the making of alternative arrangements for social, economic or political reasons for children’s upbringing which may span several years of childhood. Fostering serves to mitigate social and economic hardship among those with too many or, insufficient children and those with none at all through redistribution of children. Usually fostering takes place among close kins e.g. aunt, uncle, cousin and grand-parents. In Cameroon between 13-24% of children under the age of I5 are fostered. Similar proportions are also found in Ghana, Cote d’Ivoire and Lesotho. Generally, fostering is more prevalent among the less educated and rural-based families than their educated urban counterparts [ 15-171. Fostering is thus an important social structure for the maintenance and, reinforcement of familial ties especially among infertile couples or elderly single and childless persons. This bio-social pattern of redistribution provides such person(s) with ready made families, creates opportunities for them to participate in child rearing even as surrogate mothers. It also constitutes a crucial support system which makes for the maintenance of high fertility in African communities. In some cases, children grow up not only bearing names of foster parents but also being totally ignorant of their real genitor. Child fostering thus eliminates or at least reduces the social, psychological harassment, feelings of alienation as well as hostility, fear and hatred often directed at childless persons. Although barren women are often regarded as evil, by the larger community especially as they become old and all chances of procreation have disappeared, younger, childless women can and do foster children. Siblings or other close relatives who perhaps because they are more knowledgeable of the actual cause of their childlessness and because of their kinship ties tend to be more sympathetic and often foster their children on to them. Adoption
The practice of formal adoption is negligible in most of black Africa. However, in some countries, e.g. Nigeria scarcity in the number of babies available for adoption and the corresponding increase in waiting period and administrative red tape makes adoption an unpopular preference to natural procreation. Presently, there are no adoption homes in Cameroon, the closest existing organizations are orphanages like the mission based one in Banso North West Province and private philanthropic ones
like the Dan and Sarah Foundations in Yaounde, Centre Province. More commonly, informal arrangements without statutory bonds are undertaken between persons in lieu of formal adoption, not unlike some form of fostering. It is thus not surprising that 23% of fertile and infertile couples would sooner resort to adoption than undergo artificial insemination by a donor The children involved are usually reared as real offspring of the adoptive couple who become fully responsible for their present and future needs. Sometimes, even on realization of the identity of their natural parents, adopted children out of allegiance may still prefer to go by the names of their adopted parents. Fostering and adoption both refer to the transfer of parental rights from one person to another. Although similar in some respects, there are fundamental differences between the two. Fostering is informal and usually takes place between close kinsmen for a specified or unspecified length of time. Adoption on the other hand is a highly formalized arrangement consisting of a series of legal procedures between the state (as representative of the adoptee) on one hand and the new parent(s) on the other. In adoption, the legal exchange of parents is a permanent one and it usually occurs between unknown and unrelated persons with the true identity of the original parents secretly guarded or undisclosed. In fostering, like adoption, children may assume the family (surnames) of their fostered parents since in the African family structure words for uncle and cousins do not exist. In any case efforts are made to treat all the children in the household the same. Often children are unaware of having being fostered until adulthood. However the identity of their biological parents is never a secret. This eliminates problems of personality crisis and search for identity which adopted persons often experience on being told of their adopted status, and the subsequent frantic search efforts to trace biological parents. Natural
donor insemination
Also within the traditional context, another commonly used procedure in cases of infertility is natural insemination by donor rather than artificial insemination by donor in the case of male failure. In other words, in cognisance of his inability to father a child, a husband might give his unspoken consent for his wife to seek a male partner within the community to give her a child. A lot of tact and secrecy is often demanded by the parties concerned in such circumstances. In some cases the choice of the male donor is actually selected by the infertile spouse himself, e.g. a brother, close relative or friend. The resultant offspring would in the true sense be a member of the community. Thus the ancestry of his real genitor would be well known and accepted by his putative genitor and among those who share the family secret. This procedure eliminates completely the problem of anonymity and fear of normality and any possible
913
Artificial donor insemination in Yaounde potentially trait
embarrassing
which
developmental
the
offspring
physical might
and
behavioural
exhibit
along
its
stages.
Yet in a third variety, the wife in desperation of her inability to become pregnant may secretly seek solace elsewhere and rear the resultant offspring as her husband’s, the spouse being none the wiser. In the case of female failure, there is the popular choice of polygyny, whereby in accepted societies the male simply marries another wife. In some societies to avoid divorce, return of dowry or family shame of infertility, a female relative of the wife, often a sister, is given as co-wife or just bearer of children. In the latter case, the female as bearer of children, technically has no claim on the offspring who are regarded as belonging to the infertile couple. Although these alternatives are not without their own legal and social problems they are often culturally defined with acceptable social procedures of settling them within the community. Therefore in the African context where traditional norms still hold sway over acceptable patterns of reproductive behaviour (in addition with limited knowledge of modern medical interventions for infertile couples) these socio-cultural alternatives are more readily accepted as alternative methods of procreation for the infertile couple than artificial insemination by a donor. Not only are the traditional alternatives more familiar to the people, but in addition, have the advantage of often taking place within the local community. Thus, these socio-culturally prescribed alternatives are perceived as more natural and humane than the impersonal atmosphere of the hospital or clinic with the all too familiar problems of inadequate counselling, donor screening against infectious diseases especially now with the scourge of the acquired immune deficiency syndrome (AIDS). The traditional alternatives available to the infertility couple also provide the possibility of a ‘shared secrecy’ about the identification of the real genitor among a close circle of relatives, thus easing the psychological burden of absolute secrecy on the infertile couple. In addition this procedure solves the problem of anonymity of the genitor with its potentially dreaded consequences on physical and psychological make up of offspring and its putative family. Thus, until artificial donor insemination can match the traditional procreation and child rearing alternatives are available to the African infertile couple, its chances of acceptance among the population will remain low, even among the better educated segment of population.
Acknowledgemenfs-This research was undertaken under the collaboration of the WHO Research Centre for Human Reproduction, CUSS, University of Yaounde. I also wish to thank Professor B. T. Nasah for his constant encouragement and for reviewing the manuscript. REFERENCES 1. Nasah B. T. Infertility in Reproductive Health in Africa (Edited by Mati J. K. G. ef al.), 1984. of infertility in Cameroon. 2. Nasah B. T. Aetiology Nigeria Med. J. 8, 452456, 1978. 3. Nasah B. T. and Cox J. N. Vascular lessons in the tests associated with male infertility in Cameroon. Possible realationship to parasitic disease, Virchows. Arch. A. Path. Anat. Histol. 377, 225-236, 1978. W. 0. The male factor in infertility4. Chukudebelu Nigeria experience. Inf. J. Ferr. 23, 238-239, 1978. Ogunyemi D., Emuveyan E. and Akinla 5. Giwa-Osagie, O., Aetiologic classifications and socio-medical characteristics of infertility in 250 couples. Int. J. Fertility 29, 104, 1984. 6. Waghmarae D. Infertility. East Afr. Med. J., 698-702, 1972. I. Njikam Savage 0. M. Research on local perceptions on sexually transmitted diseases and causes of infertility in Cameroon, 1990. of the acceptability of 8. Nyambi D. The determinants artificial donor insemination (A.1.D) in Cameroon: A comparison of infertile and fertile couples. Med. Thesis, University of Yaounde, 1989. 9. Wankah C. Some aetiologic aspects and psychosocial consequences of infertility and sub-fertility. M.D. Thesis, CUSS, University of Yaounde, 1975. S. Contribution a l’itude de: Neisseria. 10. Omboto Gonorrhea trichomonas vaginalis candida albicans dans pathologie genitale feminine en milieu scolaire a Sangmelima. Medical Thesis, University Hospital Centre, Yaounde, 198 1. 11. Sede M. Trichomonas vaginalis and neisseria gonorrhea in male sexually transmitted un rethnitis. Medical thesis, Yaounde, 1980. 12. Thompson W. and Boyle D. D. Counselling patients for artificial insemination and subsequent pregnancy: Clin. Obstet. Gynaecol. 9, 21 l-225, 1982. 13. Berger D. M., Eisen A., Shuber J. and Doody K. F. Psychological patterns in donor insemination couples, Can. J. Psychiaf. 31, 818-823, 1986. 14. Rawland R. The social and psychological consequences of secrecy in artificial insemination by donor (AID) programmes. Sot. Sci. Med. 21, 391-396, 1985. 15. Caldwell P. and Caldwell J. C. Fertility control as innovation: “A report on in-depth interviews in Ibadan, Nigeria”. In The Cultural Roots of African Ferfility Regimes, Proceeding of the Ife Conference (Edited by Van Walle E.). Obafemi Awolowo University, Ile-Ife and the Universitv of Pennsylvania, Philadelohia. . 1987. U. C. Child fostering in West Africa. 16. Isiugo-Abanihe Pop. Dev. Rev. 1988. 17. Frank 0. The demand for fertility control in SubSaharan Africa. Stud. Fam. Planning 18, 195, 1987.
Vol. 35. No. 7, pp. 907-913, 1992
0277-9536/92 $5.00 + 0.00 Copyright0 1992 PergamonPressLtd
Printedin Great Britain.All rightsreserved
ARTIFICIAL DONOR INSEMINATION IN YAOUNDE: SOME SOCIO-CULTURAL CONSIDERATIONS OLAYINKA MARGARET NJIKAM SAVAGE
B.P. 1935 Yaounde,
Cameroon,
Central
Africa
Abstract-Infertility affects about 14% of the population in Cameroon. The majority of those affected arc between 26-30 years old. Between 40-50% of all cases of infertility are associated with male failure, and azoospermia is implicated in 14.4% of the cases. There is thus an indication for assisted reproduction among this category of infertile couples particularly artificial insemination by donor (A.1.D). A
comparative study on fertile and infertile couples’ perception of A.I.D. revealed that knowledge of A.I.D. is low, 35.30% of infertile respondents were aware of the procedure vis g vis 30.6% of their fertile counterparts. Nonetheless 49% of infertile respondents accepted A.I.D. in principle compared to 37.75% of their fertile counterparts. Despite the high value respondents placed on having children and the strong desire by infertile couples to have their reproductive potentials fulfilled, only 19.6% of infertile respondents and 42.87% of their fertile counterparts respectively, would actually practice A.I.D. if the need arose. There are indications that respondents did not perceive A.I.D. as an acceptable solution to infertility. Evidently, the possible influence of socio-cultural barriers to A.I.D. as well as perceived socio-cultural alternatives which may be more acceptable to infertile couples than a technically assisted form of reproduction, have been overlooked. Key words-infertility, alternatives
male failure,
artificial
insemination
INTRODUCTION
35’7--F
cultural
barriers,
socio-cultural
2630, in other words those in the prime of their child bearing years. Infertility affects about 14% of the population of Cameroon, although there are regional and ethnic variations. For example, there is a 3- to 4-fold difference in the incidence of childlessness between the West and East Provinces, with 7% and 28%, respectively. The high level of infertility in the East Province is due to the fact that it is part of the infertility belt of the Central Africa region. It is an area with high sexual mobility, high levels of sexually transmitted diseases (STD) and low level of socio-economic development. Religious differences also appear to have more significance among the Moslems than the nonMoslems in North Cameroon. Infertility tends to be higher among Moslems than non-Moslems in North Cameroon. The common practice of polygamy does much to encourage the spread of STD. Indeed it is not uncommon for a man to select one of his spouses for medical care in the case of STD and infertility [l]. Similarly, there are sociocultural variations in the accepted modality of treatment. The socio-cultural observations on A.I.D. as a treatment modality would be discussed within this framework: firstly the traditional concept of infertility would be examined, followed by local perceptions on artificial insemination by donor. The various factors which constitute socio-cultural barriers to A.I.D. will then be considered and lastly the perceived socio-cultural alternatives to A.I.D.
With scientific innovations in human reproduction, artificial insemination by donor (A.1.D) has become an available alternative to natural reproduction, especially in the Western countries, in cases of azoospermia or oligospermia. The decreasing numbers of babies available for adoption due to legalisation of abortion, easy access to contraceptive services, and increase of single parents have popularized A.I.D. Variations of the procedure such as surrogate motherhood with its legal and moral implications have also become widespread especially in the U.S., U.K., Europe and parts of Asia. Although A.I.D. is practised world wide, there is usually no individual request for it in many countries, particularly in Africa. Nonetheless, artificial donor insemination has been successfully initiated at the Central Maternity and University Hospital Centre, Yaounde since 1984 especially in cases of couple infertility where the male factor is implicated. In Cameroon as in most African countries, a great deal of value is placed on children. In fact, so ubiquitous is the presence of the children in a marriage or family that most people find it difficult to define the value of children. Nonetheless, the value of children varies from proof of consummation of marriage, assurance of proper burial, security in old age, social prestige to guarantee of lineal continuity. Infertility in Cameroon affects the young and sexually active in the population, between the ages of La
by donor,
907
908
OLAYINKA MARGARET NJIKAM SAVAGE TRADITIONAL
CONCEPT
OF INFERTILITY
In many societies, especially in African societies, the value of the woman is intrinsically defined within the context of her bio-social role as the bearer and rearer of children. Her value is further enhanced by the number of children she bears especially the number of sons. Thus in traditional society, infertility is always alluded to as a female problem. Only within the last two decades has the male factor become increasingly implicated as cause of couple infertility. This has increasingly led to the current practice of couple evaluation in cases of infertility. Nonetheless traditional attitudes to infertility remain basically unchanged. In couple infertility in Yaounde, the male factor has been implicated in between 40-50% of cases. Azoospermia (complete absence of live sperms) or oligospermia (low sperm count) are often indicated as causal factors [2, 31. In Eastern Nigeria, Chukudebelu [4] in a study found out that males were responsible for couple infertility in 55% of cases. In Lagos, Giwa-Osagie [S] also found the male factor implicated in 34% of cases of couple infertility. Kenyan husbands were responsible for between 20-30% of reproductive failure [6]. Although studies conducted revealed that most cases of infertility are caused by protracted or poorly treated episodes of sexually transmitted diseases (STD), ongoing research activities indicate a disparity between popularly held beliefs and established medical facts about causes of infertility [7]. Thus respondents believed that early commencement of sexual activities especially by females predisposed them to infertility just like repeated resort to abortion especially septic abortion. The implication of STD as a cause of infertility was only referred to by those respondents with post secondary level of education. Vague references were also made by less educated respondents to sickness as a cause of infertility with special reference to the abdomen. Surprisingly, only few respondents attributed infertility to witchcraft given the general low-level of education in Cameroon and the predominance of the population living in the countryside. Although genetic factors were attributed to by some respondents, less than 5% grudgingly admitted the possibility of the male factor as cause of couple infertility. Over exposure to artificial methods of contraception especially the pill was also cited as a contributive factor to infertility even by the pill users. It was the unanimous opinion of respondents that the childless woman suffered considerable social discrimination especially in the rural areas. She is often the centre of hostility in addition to being considered a person to be feared and hated because childlessness is often seen as a retribution for some wicked deeds performed in the past or previous promiscuous life. In theory therefore, most women would accept any treatment to end the scourge of
childlessness trauma.
and its attendant
social and emotional
LOCAL PERCEPTIONS ON ARTIFICIAL INSEMINATION BY DONOR
A study of a comparative investigation on the determinants of the acceptability of A.I.D. among infertile and fertile couples was undertaken among clients consulting at the mother and child health centre at the University Hospital Centre (UHC), Yaounde [8]. When this study was conducted, the UCH was the tertiary level of health care in Cameroon. This Centre comprises an antenatal, a family planning and an infertility clinic. These clinics operate usually on specific days. The fertile respondents were recruited from the antenatal clinic and their infertile counterparts from the infertility clinic. Both fertile and infertile respondents were included in the study to investigate their knowledge of A.I.D. as a treatment modality in the clinic population especially since infertility in Cameroon is predominantly secondary in nature. A previous study conducted in Yaounde had indicated that 63% of women attending the infertile clinic had secondary infertility [2]. AVAILABILITY
OF A.I.D. PROCEDURE
The practice of A.I.D. was introduced in 1985 in the department of Obstetrics and Gynecology of the University Hospital Centre (UHC) and subsequently at the Central Maternity, both in Yaounde. Up to 1989 services were available in these places. Presently, services are only available at the Central Maternity. Very few of the respondents in the study were aware that the procedure was available in Cameroon. None of the respondents had come to enquire about A.I.D. In fact, since the practice of A.I.D. was initiated in Yaounde, there has been no overt demand or request for it. A.I.D. is only suggested as a treatment modality to couples who have no other locally available possibility of achieving a pregnancy. In the study, respondents were asked if they know about or had heard of A.I.D. As a means to verifying answers, those who responded in the affirmative were then asked to describe the procedure. The UCH because of its specialized nature and its corresponding fee structure generally caters for persons from the middle and high income level group. This perhaps explains the educational distribution of respondents. The majority of the population in Yaounde are Christians. Clients were recruited using the systematic sampling technique. These clients were then informed of study objectives and only those who consented to participate were included in the study. The data was collected by the interview technique using a semi-structured questionnaire. All interviews were conducted by a final year medical student. Spouses were interviewed separately from
Artificial
909
donor insemination in Yaounde
their partners to reduce interference. The refusal rate for the study is unknown. The study population comprised 102 infertile and 98 fertile respondents out of which there were 113 females and 87 males. The mean age of the respondents was 30.24yr, and the age range was between 1947 yr. The majority of the sample population were educated, 73% had at least secondary school education. However, more of the better educated clients were more likely to be infertile than fertile [8]. Also 8 1% were married, 15% were single and only 4% were involved in cohabiting unions. Most of the couples involved in the study were Christians with Presbyterians comprising 56% of the study population (Table 1). The degree of awareness about A.I.D. among respondents was low, among the fertile respondents 30 (30.6%) were aware of A.I.D. Infertile respondents on the other hand seemed more knowledgeable about the procedure and 36 (35.30%) of this category were aware of it. However, very few respondents were aware that the procedure was being performed in Cameroon as the majority had derived knowledge of A.I.D. from journals and mass media all within the context of foreign countries. Knowledge of A.I.D. was better displayed among persons with postsecondary school education and above. Fifty-five percent of whom had heard of A.I.D. compared with 23.8% of respondents with secondary school education and less. This general low level of knowledge may be due to the comparative low level of education in Cameroon as well as the existing poor medium Table I. So&-demographic Fertile (n = 98)
of information and communication especially with regard to reproductive health matters. Also, the Cameroonian society despite the fast pace of urbanization and growth in some of its cities, notably Douala and Yaounde is still predominantly rural based. Among other questions respondents were also asked: “if you were childless because your husband had a major infertility problem, would you accept A.I.D.?” Responses indicate what line of action respondents themselves would undertake. Generally, women were more likely to approve of A.I.D. than men. This was probably because they bore the socioeconomic and psychological brunt of infertility more than their male partners. A more positive attitude towards A.I.D. was also observed among infertile respondents than their fertile counterparts, 50 (49%) of the former accepted the procedure in principle compared to 37 (37.75%) of the latter. Age of respondents was important in their attitudes to A.I.D. In principle, the younger respondents approved more of A.I.D. than their older counterparts. Thus 35.7% of fertile respondents under 35 years approved of A.I.D, a figure comparable to 38.2% of favourable responses derived from infertile persons. However, among the older respondents from the infertile groups 10.78% were more receptive to A.I.D. than 2% of their fertile counterparts. Under normal circumstances, procreation takes place within the context of conjugal union. Among our study population, child bearing tended to be a premium for married persons rather than the unmarried. Young single women are generally not preoccupied with childbearing until marriage. Not characteristic Infertile
of respondents
(n = 102)
N
(%)
N
40 I3 22 I4 7 2
(40.81) (13.26) (22.44) (14.28) (7.14) (2.04)
20 38 26 10
(6.86) (19.60) (39.25) (25.49) (9.80) (0.98)
Primary Secondary Post-secondary University
7 30 40 I5 4
(3.5) (15) (20) (7.5) (2)
I6 54 29 4
(0.5) (8) (27) (14.5) (2)
Total
96
(48)
104
Single Married Cohabiting
30 62 6
(15) (31) (3)
Total
98
(49)
Catholic Presby. Moslems Baptist Born again None
28 58 6 3 I
(14) (29) (3) (1.5) (1.5)
Total
96
(48)
(%)
Total N
(%)
47 33 60 40 I7 3
(23.5) (16.5) (30) (20) (8.5) (1.5)
Age 19-25 26-30 31-35 3-o 4145 4&50 Education NotIe
Marital
status
8 46 94 44 8
(4) (23) (47) (22) (4)
(52)
200
(100)
100 2
(so) (I)
30 162 8
(15) (81) (4)
102
(51)
200
(100)
44
(22)
54 2 2
(27) (1) (1) K)
72 II2 8 5 I 2
104
(52)
200
-
Religion
(36) (56) (4) (2.5) (0.5) (1) (100)
910 Table
OLAYINKA MARGARET NJIKAM SAVAGE 2. Relationship between marital status and knowledge A.I.D. in infertile resoondents
of
Knowledge of A.I.D.
No knowledge of A.I.D.
Married Cohabitating
34 (33.33%) 2(1.96%)
66 (64.71%)
100 (98.04%) 2(1.96%)
Total
36 (35.29%)
66 (64.71%)
102 (100%)
Marital
status
Total
Single
surprising therefore it was the married couples, both fertile and infertile who exhibited more knowledge of A.I.D. than their single or cohabiting counterparts. Single women tended to be less knowledgeable about A.I.D. than their married counterparts in both the fertile and infertile groups. The difference was however more marked among infertile respondents among whom none of the single women knew about A.I.D. while 33.33% of the married and 1.96% in the cohabiting groups respectively, knew about the procedure (Table 2). Thus marital status of infertile respondents appeared to have significant difference in their knowledge of A.I.D. (P < 0.001). Not unexpectedly no single infertile respondent would accept A.I.D. while 24 (23.54%) of their married but fertile counterpart would. Among the fertile respondents, more than twice as many married respondents 24,44% would accept the procedure than those in the unmarried category (10.2%). There was little difference in level of acceptance of A.I.D. between infertile and fertile married women (Table 3). Nonetheless, the real opinions and beliefs of respondents towards assisted reproduction were revealed in their responses to questions on the possibilities of their ever practicing A.I.D. Specifically, respondents were also asked: “if it became necessary (i.e. you and your husband could not have a child by any other means) would you practice A.I.D.?” The question was posed to both fertile and infertile respondents in the hope of receiving an insight as to what they themselves would do in case of male failure. Contrary to expectations, while 42.8% of fertile respondents agreed to practice A.I.D. if the need arose, only 19.6% of their infertile counterparts would do so. This significant difference in responses of the fertile and infertile groups may be due to the fact that since the procreative ability of the first group was already confirmed, they did not really ponder seriously on the medical. moral, legal and sociocultural implications posed by artificial donor insemination unlike the fertile group and were thus more ready to accept the procedure. Thus it was not a Table 3. Relationship
between marital
real life issue for the fertile respondents. Despite the strong desire by infertile couples to have children, they did not perceive assisted reproduction as the panacea to their bio-social problem. The reasons given for the rejection of A.I.D. indicate that cultural factors constitute far more importance than is perceived in the acceptance or non-acceptance of A.I.D. SOCIO-CULTURAL
Thus while refusal for A.I.D. was often due to a variety of reasons, a large number of fertile and infertile respondents, almost 40% found the procedure unacceptable for reasons they could not verbalize, probably because it was counter to all social and cultural norms of acceptable patterns of child bearing. Some of the responses in Table 4, also reflect the prevailing socio-cultural attitude regarding male failure and male acceptance of infertility. During the interview it was made clear to all respondents that the crux of the question was what they would do as regards the practice of A.I.D. in the case of established male failure on their part or their partners. Yet 22% of both infertile and fertile respondents said they would rather practice polygamy than resort to A.I.D. Their responses did not so much indicate lack of comprehension of the question but rather reflects a typical male attitude to infertility. Since socioculturally, infertility is always a female fault, taking on of a second wife or a mistress is usually perceived as a remedy to a childless marriage. It is only when the second (or subsequent union) also fails to produce a child that fertility status of the male partner starts being questioned. About 15% of fertile and infertile respondents felt the procedure was morally questionable (Table 4). Also treatment seeking behaviour for a spectrum of disease or illness is not clearly divided between consulting a physician or a traditional healer. Sometimes the traditional healer may be consulted first and the patient only seek modern health care as a last resort, or vice versa. At other times both may be consulted simultaneously. Preference of traditional treatment to A.I.D, for example, was upheld by 49.8% of respondents. As stated [9] traditional treatment as a possible cure of infertility is still very popular among those affected, irrespective of their level of education. In the treatment of veneral infection which is often implicated in infertility, the study showed that while 62.5% of women with gonorrhea had been treated by a traditional healer, and 12.5% by paramedical personnel, none of those
status and approval
of A.I.D.
among Infertile and fertile respondents Fertile
InfertIle Marital
status
Accept A.I.D.
Reject A.I.D.
Single Married Cohabiting
24 (23.54%) 2(1.96%)
76 (74.50%)
Total
26 (25.5%)
76 (74.50%)
‘Accept’ of A.I.D. was estimated by the response to the question: would you accept A.I.D.?”
BARRIERS TO A.I.D.
Total
Accept A.I.D.
Reject A.I.D.
Total
100 (98.04%) 2(1.96%)
lO(lO.2%) 24 (24.49%) 3 (3.06%)
20 (20.41%) 38 (38.78%) 3 (3.06%)
30 (30.61%) 62 (63.27%) 6(6.12%)
I02 (100%)
37 (37.75%)
61 (62.25%)
98 (100%)
“if you were childless because your husband had a major infertility
problem,
Artificial
donor
insemination
Table 4. Reasons for refusal to practice A.I.D.
Reasons Procedure tantamount to adultery” Problems of anonymity of patemityb Morally incorrect Against religious doctrine Prefer adoption Prefer polygamy Prefer traditional treatment No reason
Fertile respondents (N = 98) N (%)
Infertile respondents (N = 102) N (%)
l(l.02)
2(1.96) 24 (23.53) 5 (4.40) IO (9.80) 22 (21.57) 30 (29.42) 9 (8.82)
lO(10.20) l(l.02) 14 (14.28) 22 (22.45) 20 (20.41) 30 (30.62)
“Mostly given as response by males. bMostly given as response by females. This table indicates distribution of responses to the question: “if it became necessay (i.e. you and your husband could not have a child by any other means) would you practice A.I.D.?”
infected had consulted a doctor. And 25% had never been treated [lo]. Recourse to traditional forms of treatment is important because of its often ineffectiveness in curtailing the spread and chronicity of sexually transmitted diseases as was well documented in another study of males in Yaounde [ll]. Rather than submit to A.I.D. 44% of fertile and infertile respondents considered polygamy as a more palatable solution to infertility. However, as this study was on male failure, this preference of polygamy may not only be an indication of chauvinism among male respondents but also an indication of traditional male refusal to accept responsibility for couple infertility, even in the face of medical evaluation. A.I.D. AND PROBLEM
OF ANONYMITY AND SECRECY
Secrecy is by rule advocated by most couples and physicians in the administration of artificial insemination by a donor. However in our own context, anonymity which is closely linked with this aspect of secrecy poses a real socio-cultural problem. This problem of anoymity of genitor in the administration of A.I.D. was not only raised by many respondents but constituted a basis for the outright rejection of the procedure by 23.5% of infertile respondents. It is worth noting that this factor was raised mostly by females. In most African societies, a person’s identity, his social, economic and political rights, and obligations are all bound up in his family name. Social identity in Cameroon is often based on patrilineal descent and more rarely as among the Kom of the North West Province, on matrilineal descent i.e. through females. It is therefore of paramount importance that the genitor is established from birth. Hence the question, ‘Who is your father?’ is one encountered from the informal social context as in bars, ‘chicken palours’ to higher level social and political meetings. ‘A chicken parlour’, is a social forum where friends, acquaintances gather to discuss or chat in the evenings, after work over a piece of chicken or fish grilled over charcoal fires. A variety of these exist
in Yaounde
911
catering for a diversity of socio-economic groups. Even though this question may be sometimes couched in light terms, the significance is far reaching. It is through the establishment of a genitor that ones e.g. social, economic, political and inheritance boundaries are defined. While artificial insemination by donor provides a scientific intervention for childless couples, the problem of anonymity looms large within the African context. Also associated with this is the fear of incestuous unions which in the African context is often not limited to siblings, but also to other more distant categories of kinsmen. Another common barrier to A.I.D. raised by respondents is the problem posed by the outcome of pregnancy in terms of the normality and possible unbecoming temperament of the baby as a result of unknown genitor. This factor has also been raised elsewhere as a worrying component in A.I.D. [12]. This is because traditionally, physical, temperamental and psychological make up of a person are often perceived as inherited family characteristics. However, adequate counselling of clients before and after the A.I.D. may help to mitigate such fears. The importance of counselling cannot be overstressed. A.I.D. is more than just a clinical procedure. Biological or physical maturity of the couples in itself is inadequate in the face of the potential emotional and psychological trauma couples contemplating A.I.D. are exposed to. A.I.D. as a biosocial procedure makes it imperative for the integration of a psychologist (in the team of clinicians and technicians) to offer adequate counselling services to couples before and after the procedure to minimize the possibilities of trauma to couples and in the long run their offspring. Still related to the issue of anonymity of genitor and the family secret which infertile couples who undergo A.I.D. have to bear, is the accompanying social and psychological burden. The majority of those fertile respondents who regarded A.I.D. as an acceptable alternative to natural reproduction and the outcome (child) as ‘normal’ did so on the presumption that the procedure would take place under the cloak of secrecy. Yet, studies undertaken elsewhere indicate that many couples now consider that very cloak of secrecy which is created to give them and their offspring a life of normality, as an indirect sanction of the denial of their problem of infertility. This family secret is also seen to interfere with the couple’s acknowledgment of their infertility problem, thus inhibititing their ability to come to terms with and discuss their inadequacies. This inability to have open discussions has been known to result in transient impotence and loss of self esteem in husbands. Among women such suppressed feelings have been known to give feelings of anger and guilt and sometimes a death wish on their husbands [13, 141.
912
OLAYINKA MARGARET NJIKAM SAVAGE SOCIO-CULTURAL
ALTERNATIVES
TO A.I.D.
Child fostering
Just as infanticide and child abandonment have been used in African societies to regulate family size especially in cases of multiple or deformed births SO also has child fostering among other practices been used to redistribute fertility. Child fostering is widely practiced and accepted. It entails the making of alternative arrangements for social, economic or political reasons for children’s upbringing which may span several years of childhood. Fostering serves to mitigate social and economic hardship among those with too many or, insufficient children and those with none at all through redistribution of children. Usually fostering takes place among close kins e.g. aunt, uncle, cousin and grand-parents. In Cameroon between 13-24% of children under the age of I5 are fostered. Similar proportions are also found in Ghana, Cote d’Ivoire and Lesotho. Generally, fostering is more prevalent among the less educated and rural-based families than their educated urban counterparts [ 15-171. Fostering is thus an important social structure for the maintenance and, reinforcement of familial ties especially among infertile couples or elderly single and childless persons. This bio-social pattern of redistribution provides such person(s) with ready made families, creates opportunities for them to participate in child rearing even as surrogate mothers. It also constitutes a crucial support system which makes for the maintenance of high fertility in African communities. In some cases, children grow up not only bearing names of foster parents but also being totally ignorant of their real genitor. Child fostering thus eliminates or at least reduces the social, psychological harassment, feelings of alienation as well as hostility, fear and hatred often directed at childless persons. Although barren women are often regarded as evil, by the larger community especially as they become old and all chances of procreation have disappeared, younger, childless women can and do foster children. Siblings or other close relatives who perhaps because they are more knowledgeable of the actual cause of their childlessness and because of their kinship ties tend to be more sympathetic and often foster their children on to them. Adoption
The practice of formal adoption is negligible in most of black Africa. However, in some countries, e.g. Nigeria scarcity in the number of babies available for adoption and the corresponding increase in waiting period and administrative red tape makes adoption an unpopular preference to natural procreation. Presently, there are no adoption homes in Cameroon, the closest existing organizations are orphanages like the mission based one in Banso North West Province and private philanthropic ones
like the Dan and Sarah Foundations in Yaounde, Centre Province. More commonly, informal arrangements without statutory bonds are undertaken between persons in lieu of formal adoption, not unlike some form of fostering. It is thus not surprising that 23% of fertile and infertile couples would sooner resort to adoption than undergo artificial insemination by a donor The children involved are usually reared as real offspring of the adoptive couple who become fully responsible for their present and future needs. Sometimes, even on realization of the identity of their natural parents, adopted children out of allegiance may still prefer to go by the names of their adopted parents. Fostering and adoption both refer to the transfer of parental rights from one person to another. Although similar in some respects, there are fundamental differences between the two. Fostering is informal and usually takes place between close kinsmen for a specified or unspecified length of time. Adoption on the other hand is a highly formalized arrangement consisting of a series of legal procedures between the state (as representative of the adoptee) on one hand and the new parent(s) on the other. In adoption, the legal exchange of parents is a permanent one and it usually occurs between unknown and unrelated persons with the true identity of the original parents secretly guarded or undisclosed. In fostering, like adoption, children may assume the family (surnames) of their fostered parents since in the African family structure words for uncle and cousins do not exist. In any case efforts are made to treat all the children in the household the same. Often children are unaware of having being fostered until adulthood. However the identity of their biological parents is never a secret. This eliminates problems of personality crisis and search for identity which adopted persons often experience on being told of their adopted status, and the subsequent frantic search efforts to trace biological parents. Natural
donor insemination
Also within the traditional context, another commonly used procedure in cases of infertility is natural insemination by donor rather than artificial insemination by donor in the case of male failure. In other words, in cognisance of his inability to father a child, a husband might give his unspoken consent for his wife to seek a male partner within the community to give her a child. A lot of tact and secrecy is often demanded by the parties concerned in such circumstances. In some cases the choice of the male donor is actually selected by the infertile spouse himself, e.g. a brother, close relative or friend. The resultant offspring would in the true sense be a member of the community. Thus the ancestry of his real genitor would be well known and accepted by his putative genitor and among those who share the family secret. This procedure eliminates completely the problem of anonymity and fear of normality and any possible
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Artificial donor insemination in Yaounde potentially trait
embarrassing
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developmental
the
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physical might
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Yet in a third variety, the wife in desperation of her inability to become pregnant may secretly seek solace elsewhere and rear the resultant offspring as her husband’s, the spouse being none the wiser. In the case of female failure, there is the popular choice of polygyny, whereby in accepted societies the male simply marries another wife. In some societies to avoid divorce, return of dowry or family shame of infertility, a female relative of the wife, often a sister, is given as co-wife or just bearer of children. In the latter case, the female as bearer of children, technically has no claim on the offspring who are regarded as belonging to the infertile couple. Although these alternatives are not without their own legal and social problems they are often culturally defined with acceptable social procedures of settling them within the community. Therefore in the African context where traditional norms still hold sway over acceptable patterns of reproductive behaviour (in addition with limited knowledge of modern medical interventions for infertile couples) these socio-cultural alternatives are more readily accepted as alternative methods of procreation for the infertile couple than artificial insemination by a donor. Not only are the traditional alternatives more familiar to the people, but in addition, have the advantage of often taking place within the local community. Thus, these socio-culturally prescribed alternatives are perceived as more natural and humane than the impersonal atmosphere of the hospital or clinic with the all too familiar problems of inadequate counselling, donor screening against infectious diseases especially now with the scourge of the acquired immune deficiency syndrome (AIDS). The traditional alternatives available to the infertility couple also provide the possibility of a ‘shared secrecy’ about the identification of the real genitor among a close circle of relatives, thus easing the psychological burden of absolute secrecy on the infertile couple. In addition this procedure solves the problem of anonymity of the genitor with its potentially dreaded consequences on physical and psychological make up of offspring and its putative family. Thus, until artificial donor insemination can match the traditional procreation and child rearing alternatives are available to the African infertile couple, its chances of acceptance among the population will remain low, even among the better educated segment of population.
Acknowledgemenfs-This research was undertaken under the collaboration of the WHO Research Centre for Human Reproduction, CUSS, University of Yaounde. I also wish to thank Professor B. T. Nasah for his constant encouragement and for reviewing the manuscript. REFERENCES 1. Nasah B. T. Infertility in Reproductive Health in Africa (Edited by Mati J. K. G. ef al.), 1984. of infertility in Cameroon. 2. Nasah B. T. Aetiology Nigeria Med. J. 8, 452456, 1978. 3. Nasah B. T. and Cox J. N. Vascular lessons in the tests associated with male infertility in Cameroon. Possible realationship to parasitic disease, Virchows. Arch. A. Path. Anat. Histol. 377, 225-236, 1978. W. 0. The male factor in infertility4. Chukudebelu Nigeria experience. Inf. J. Ferr. 23, 238-239, 1978. Ogunyemi D., Emuveyan E. and Akinla 5. Giwa-Osagie, O., Aetiologic classifications and socio-medical characteristics of infertility in 250 couples. Int. J. Fertility 29, 104, 1984. 6. Waghmarae D. Infertility. East Afr. Med. J., 698-702, 1972. I. Njikam Savage 0. M. Research on local perceptions on sexually transmitted diseases and causes of infertility in Cameroon, 1990. of the acceptability of 8. Nyambi D. The determinants artificial donor insemination (A.1.D) in Cameroon: A comparison of infertile and fertile couples. Med. Thesis, University of Yaounde, 1989. 9. Wankah C. Some aetiologic aspects and psychosocial consequences of infertility and sub-fertility. M.D. Thesis, CUSS, University of Yaounde, 1975. S. Contribution a l’itude de: Neisseria. 10. Omboto Gonorrhea trichomonas vaginalis candida albicans dans pathologie genitale feminine en milieu scolaire a Sangmelima. Medical Thesis, University Hospital Centre, Yaounde, 198 1. 11. Sede M. Trichomonas vaginalis and neisseria gonorrhea in male sexually transmitted un rethnitis. Medical thesis, Yaounde, 1980. 12. Thompson W. and Boyle D. D. Counselling patients for artificial insemination and subsequent pregnancy: Clin. Obstet. Gynaecol. 9, 21 l-225, 1982. 13. Berger D. M., Eisen A., Shuber J. and Doody K. F. Psychological patterns in donor insemination couples, Can. J. Psychiaf. 31, 818-823, 1986. 14. Rawland R. The social and psychological consequences of secrecy in artificial insemination by donor (AID) programmes. Sot. Sci. Med. 21, 391-396, 1985. 15. Caldwell P. and Caldwell J. C. Fertility control as innovation: “A report on in-depth interviews in Ibadan, Nigeria”. In The Cultural Roots of African Ferfility Regimes, Proceeding of the Ife Conference (Edited by Van Walle E.). Obafemi Awolowo University, Ile-Ife and the Universitv of Pennsylvania, Philadelohia. . 1987. U. C. Child fostering in West Africa. 16. Isiugo-Abanihe Pop. Dev. Rev. 1988. 17. Frank 0. The demand for fertility control in SubSaharan Africa. Stud. Fam. Planning 18, 195, 1987.
