Maternity, Medicine, and Power: Reproductive Decisions in Urban Benin [Reprint 2019 ed.] 9780520330894

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Maternity, Medicine, and Power

COMPARATIVE STUDIES OF HEALTH SYSTEMS AND MEDICAL CARE General Editor John M. Janzen • Founding

Editor

Charles Leslie • Editorial

Board

Don Bates, M.D., McGill University Frederick L. Dunn, M.D., University of California, San Francisco Kris Heggenhougen, University of London Brigitte Jordan, Michigan State University Patricia L. Rosenfield, World Health Organization Magdalena Sokolowska, Polish Academy of Sciences Paul U. Unschuld, University of Munich Francis Zimmermann, Ecole des Hautes Etudes en Sciences Sociales, Paris •

For a list of titles in this series, see back of book.

Maternity, Medicine, and Power Reproductive Decisions in Urban Benin

CAROLYN FISHEL SARGENT

UNIVERSITY OF CALIFORNIA PRESS Berkeley Los Angeles London

University of California Press Berkeley a n d Los Angeles, C a l i f o r n i a University of California Press, Ltd. London, England C o p y r i g h t © 1989 by T h e R e g e n t s of t h e University of California Library of Congress Cataloging-in-Publication

Data

S a r g e n t , C a r o l y n Fishel, 1947— Maternity, medicine, a n d p o w e r : r e p r o d u c t i v e decisions in u r b a n Benin / Carolyn S a r g e n t , p. c m . — ( C o m p a r a t i v e studies of health systems a n d medical care) Bibliography: p. I n c l u d e s index. ISBN 0 - 5 2 0 - 0 6 4 8 4 - 4 (alk. p a p e r ) 1. Maternal health services—Benin. 2. Medicine—Benin. 3. Medicine, Primitive—Benin. 4. Benin—Social conditions. I. Title. II. Series. [ D N L M : 1. M a t e r n a l H e a l t h Services—Benin. 2. Medicine. T r a d i t i o n a l — B e n i n . 3. Obstetrics—Benin. W O 100 S245m] RG966.B45S37 1989 362.1 ' 9 8 2 ' 0 0 9 6 6 8 3 — d e 19 DNLM/DLC f o r Library of C o n g r e s s 88-39254 P r i n t e d in t h e U n i t e d States of A m e r i c a 1

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Contents

Acknowledgments

ix

1. INTRODUCTION T h e Urban Context Methodology Theoretical Perspectives

1 7 13 17

2. MEDICAL BELIEFS AND PRACTICES AMONG URBAN BARIBA Medical Beliefs and Practices: Rural-Urban Contrasts Folk Illness Childcare Health Care Practices Mystical Concepts and Practices Childbirth Practices Agendas and Action

25 27 29 34 35 36 40

3. PATTERNS OF OBSTETRICAL CARE AMONG PARAKOU WOMEN T h e Parakou Hospital Hospital Costs The Private Clinic Home Delivery Patterns of Obstetrical Service Use in Parakou Family Influence and Delivery Assistance

48 48 56 60 63 67 83

4. OCCUPATION AND REPRODUCTIVE PRACTICE Data Collection Attributes of the Total Research Population Attributes of the SNAFOR Sample Childcare and Domestic Organization

87 90 90 92 97

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Factory Implications for Abortion Employment Histories Conclusions

101 105 110

5. COSMOLOGY AND MEDICAL CHOICE Infanticide in Parakou Age at Death Witches and Their Fate

115 119 121 125

6. STATUS IN PARAKOU Bureaucracy and Indigenous Authority in Town The Concept of the "Civilized" Person in Bariba Thought Domains of Power for Bariba Women

133 133

7. PAIN AND URBAN ETHNICITY Pain as a Cultural Construct Methods The Pain Response in Bariba Ideology The Actual and the Ideal Mechanisms Influencing the Pain Response Pain Response in the Urban Context

166 166 167 168 172 174 178

154 158

8. PROSPECTS FOR INDIGENOUS MEDICINE IN BENIN Midwifery and the State: T h e Case of Pehunko The Status of Indigenous Medicine in Benin The Implications of Professionalization for Bariba Midwives Formal Organization for Bariba Midwives Prospects for the Future

194 197 200

9. CONCLUSION

204

Appendix A B C D

215 219 221 223

181 181 185

Contents

vii

Notes

227

References

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Index

243

Acknowledgments In the course of conducting this research, I benefited from the cooperation and advice of numerous individuals in the People's Republic of Benin. I express particular appreciation to the Ministry of Health, which assisted in arranging permission for the research to proceed, and to Dr. Eusebe Alihonou, at that time Director of the Maternity Clinic of the National Hospital Center and Professor of Obstetrics at the National University of Benin. Dr. Alihonou, who also collaborated on my research project in Benin in 1976, provided a medical resident, Ibrahima Midou, in the process of preparing his thesis, to participate in the research by conducting a study of the health status of pregnant women attending the Parakou prenatal clinic. In addition to his research contributions, Ibrahima Midou assisted me in making contacts with government officials in order to obtain data on current health policy. During my sojourn in Parakou, the District Chief S. Aboudou introduced me to the mayors of the six Parakou neighborhoods that comprised the study's population. These mayors generously took the time to present me with information collected by the local administrations regarding neighborhood composition and residence patterns. I am grateful to them for their cooperation. T h e Land Chief of Parakou also offered me counsel on many issues pertinent to this research. Among the many Parakou administrative officials who assisted me, neighborhood delegates Juliette Adjamasshouhon and Jeanette Zancran deserve special mention. In addition to introducing me to residents in their neighborhoods, they engaged in thoughtful and provocative analyses of the changing roles of women in contemporary Benin; their insights have been instrumental in my interpretation of women's reproductive decisions. Dr. Boubakar Yaya also offered invaluable assistance in arranging data collection at the hospital maternity clinic and at the prenatal clinic, in addition to sharing personal experiences that helped to clarify the concerns of government medical personnel. Madame Da Costa and Madame Wollo kindly allowed me to IX

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Acknowledgments

visit their private clinics and interview their clients, while the indigenous midwives Yaayi Bake, Yaayi Ganigi, and Yaayi Yo were generous with their time and patient in their explanations. I am especially indebted to Yaayi Ganigi, who over the past decade has always welcomed me and taken a personal interest in my research. I am similarly grateful to Sarre Zachari, Sarre Buyon, and Kora Zaki Zaliatou, whose hospitality and affection have consistently made research in Benin a memorable experience. Throughout this research, Biaou Adama assisted with interpreting in Parakou for those of the sample who did not speak French, the national language, while Seidou Adisa, my research assistant in 1976, again provided translation advice during my visit to the village of Pehunko. Their competence in several of the languages of Benin prevented me from floundering on numerous occasions. This research was funded by the National Science Foundation, Grant No. BNS-8203842. I am pleased to acknowledge this generous support, as well as that of The Institute for the Study of Earth and Man, Southern Methodist University, which financed a preliminary planning trip to Africa in 1981. I also want to acknowledge the efforts of Josephine Caldwell, who participated in data collection in Parakou, and John Marcucci, who assisted with statistical analyses. Carole Browner, Arthur Rubel, and Charles Leslie encouraged me throughout the preparation of the manuscript, for which I am very grateful, while David, Barbara, Alayne, and Jennifer deserve particular credit for their tolerance and support during the period of research and writing. I dedicate the book especially to Jennifer, who considers that her prenatal presence in Africa entitles her to claim participation in the production of this work.

1 INTRODUCTION

Sero Imorou is a civil servant, a Bariba 1 by ethnic origin, employed by the government of the People's Republic of Benin to serve as Director of the Provincial Carpentry Cooperative located in the urban administrative center of Parakou. Imorou, educated in Germany, dressed in a fonctionnaire suit, the fashionable attire for a person of his status, explained the mentality of the urban Bariba: he illustrated the ideals of Bariba culture, as exemplified in the values, beliefs, and behavior of the rural Bariba. T o the true Bariba, honor, courage, and stoicism ranked high among idealized attributes. Accordingly, a much admired Bariba would be the h u n t e r who fell into a trap, lay for several days with a mangled leg, and, when rescued, never uttered a moan. A m o n g women, the mother who delivers her children alone, in silence, is much admired. But what of the urban Bariba? Do the men and women of Parakou retain such ideals as these, and to what extent does their behavior reflect elements of Bariba tradition? T o Imorou, the answer is clear. Urban Bariba, he claims, are neither African nor European; rather, the town Bariba are jugglers, choosing a bit of this, a bit of that, and able to rationalize why they did not do the right thing. T o a Bariba of Imorou's father's generation, to dishonor a commitment would be shameful. Imorou's age-mates, contrastingly, walk a delicate line between the rights and obligations, values and beliefs of the Bariba culture and those imported f r o m Europe and elsewhere. With this explanation, Imorou provides a m e t a p h o r for the translation of the behavior of the Bariba, a major ethnic g r o u p inhabiting the n o r t h e r n provinces of Benin. This book will focus on one particular dimension of that behavior—medical beliefs and practices of Bariba women in the town of Parakou— 1

2

Introduction

and will assess the influence of cultural factors on medical choice. Of special emphasis are the domain of obstetrical care and, more broadly, the implications of reproduction for Bariba women in their many roles as urban residents, mothers, wives, entrepreneurs, and healing specialists. This study contrasts obstetrical practices of rural Bariba with changing patterns of obstetrical care among urban women and examines the relationship between decisions regarding preferred modes of physical reproduction and women's broader social concerns. I discuss women's choices of obstetrical care within a general framework of the aspirations and opportunities for women in rural and urban environments, leading to an assessment of the implications of gender ideology and economic options for reproductive practices. Thus this book details both the political and economic constraints on Bariba women seeking obstetrical care and the beliefs and values that inform obstetrical choice. An incident from the life of Sero Imorou may further clarify the focus of this work. Imorou had a motorcycle accident in 1983 while braving the traffic of Parakou. He sought medical care for his broken foot at the government hospital, a provincial medical center. Hospital staff x-rayed his foot, placed it in a cast, and sent him home. Subsequently, he determined that the bone had been badly set and returned to the hospital where he was told that his foot had been improperly set and he would require surgery. Disgusted, he consulted a Bariba bonesetter, who informed him that he could have treated the case initially but could not remedy the botched hospital procedure. Imorou then attempted to break the bone to enable the bonesetter to reset it, but he was unable to do so. Eventually, he did undergo surgery at the Parakou hospital. This case illustrates a number of facets of medical treatment among urban Bariba, including the use of different modes of medical care; the characteristic first resort of the civil servant to allopathic medicine; the ideals of self-sufficiency, stoicism, and courage. One also glimpses the perspective of the bonesetter and the inefficiency of the hospital treatment. In general, Imorou's interpretation of his condition and his decisions regarding care reflect the central theme of this book:

Introduction

3

the relationship between cultural belief and behavior. This relationship—which Imorou has aptly termed "juggling"—is mediated by a complex set of individual goals and priorities, or agendas. T h e agendas of importance in this medical domain of decision-making include: 1. Proverbial Virtues, such as honor, courage, and stoicism: these concepts are exemplified in Bariba concern for appropriate behavior by both men and women when confronted with ordeals including warfare, hunting, initiation, or childbirth. Ideally, the true Bariba faces pain and danger with endurance and impassivity and would prefer death to shame. 2. Religious Factors, here primarily involving concern for witchcraft control: in this regard, Bariba perceive childbirth as an event with spiritual dimensions. Given that witchcraft is defined as a possible source of misfortune in h u m a n society, the detection of infants who may be witches requires vigilance on the part of kin and healers. T h e significance attributed to surveillance and control of potential witches is evident in the existence of villages that specialize in ritual procedures to identify witch babies and to protect the community f r o m the threat of witchcraft. 3. Status Aspirations, in particular the goal of attaining elite status by joining the higher echelons of the government civil service or achieving prominence in commerce: this objective often entails emulation of the lifestyle of the national elite, which in turn may involve adoption of European languages, dress, food habits, and other admired attributes. Thus, urban Bariba aspire to be categorized as "civilized," a composite of qualities associated with Europeans and with the elite of Benin. 4. Medical Concerns, or the search for competent care: this priority appears influenced historically by the marked successes of cosmopolitan medicine in eradicating epidemic diseases, in providing trauma care in urban centers, and in treatment for endemic diseases in both rural and urban Benin. Clients residing in urban settings such as Parakou may consult an array of indigenous and cosmopolitan practitioners; personal experience with a category of practitioner as well as reported efficacy influence perceptions of competence. Among

4

Introduction

the alternative health services in Parakou, the provincial hospital serves as a major medical center and is strongly recommended by the government for obstetrical assistance. These agendas are, in turn, informed by factors extrinsic to belief systems, such as political goals of the military socialist government and economic dynamics at the national level; accessibility of health services and, correspondingly, the efficiency of communications systems; and public policy in the realms of health, child welfare, and criminal justice. T h e four agendas described above represent beliefs, values, and expectations that comprise particular sets of goals regarding medical care. Extrinsic factors deriving from national political and economic realities set the parameters within which individuals make obstetrical and medical decisions. Agendas, then, refer to the cultural dimension of the decision-making process, in particular, to the culturally informed goals and priorities influencing medical decisions, while extrinsic factors refer to a set of structural parameters constraining such decisions. These concepts thus indicate dimensions of culture and structure. Accordingly, a primary effort of this book is to trace the interplay between cultural and structural factors influencing decisions in the realm of reproduction. The research reported in this book was conducted in Parakou between June 1982 and August 1983 and elaborates the contents of agendas influencing medical choice among urban Bariba women and the processes of accommodation to extrinsic political and economic pressures. Following chapters will enlarge upon these themes, to portray the use of health services by Bariba in the Parakou region. In earlier research on health care decision-making among Bariba, the significance of extrinsic factors and agendas operating at the individual level emerged. In that research, which was conducted among rural Bariba, I explained why peasant women rarely utilized government clinics for obstetrical care (Sargent 1982). The reasons were as follows: 1. Decisions regarding the use of alternative medical services derived largely from the possibility of witchcraft. Parturients and their families selected a specialist competent to confront this problem.

Introduction

5

Thus, a discrepancy existed in models of obstetrical care held by lay people and government personnel. Rural women preferred indigenous birth practices, particularly the "solitary delivery," where the parturient attempted to disguise signs of being in labor, delivered unassisted, and called for a female relative or neighbor to cut the umbilical cord and perhaps to assist with delivery of the placenta. T h e solitary delivery allowed the opportunity to diagnose a possible witch baby and to decide the fate of such a child. According to Bariba thought, the signs indicating a witch child were: Breech birth Child that slides on its stomach at birth Child born with teeth Child born with extreme birth defects Child born at eight months Child whose teeth came in first in the upper gums Customarily a witch child was killed shortly after birth, either by a specialist who administered poison or by starvation. The need to kill witch babies constrained women from using dispensaries or maternity clinics that would inhibit this option. Women said that non-Bariba clinic personnel did not inform the mother at the time of delivery of the position of the child, or realize the importance of the presentation. Thus, signs of a witch baby might be overlooked. Furthermore, a generalized fear of government authorities made rural clients reluctant to risk infanticide following a clinic delivery. 2. The domain of reproduction represents the primary arena in which women controlled decision-making and had the potential to enhance prestige. A necessary route to achieving any position of respect and influence was to be a "mother of children," especially sons. T h e goal of producing many children was largely the responsibility of women. They managed pregnancy and delivery, trading advice with other women and seeking the counsel of elderly female specialists. Moreover, professional specialization in reproductive disorders provided

6

Introduction

a rare avenue for women to transcend sex and to achieve fame. A woman who decided to deliver in a cosmopolitan health service surrendered control of a customary domain of female responsibility. A home delivery, whether assisted or solitary, generally remained the complete responsibility of the household women. They could request assistance from a specialist, but if a woman was contemplating a national health service delivery, she had to ask permission from the male head of household. T h e decision to select this type of assistance thus diminished responsibility and authority. Since she could not deliver alone, she relinquished her ability to decide the fate of the child. She also lost her authority to request and then to accept or reject treatment offered by an indigenous midwife, and her opportunity to gain prestige by the solitary delivery. 3. In discussing the cultural construction of clinical reality, Kleinman et al. wrote, "Through diagnostic activities and labeling, health care providers negotiate with patients medical 'realities' that become the object of medical attention and therapeutics" (1978:254). In Bariba obstetrics, the degree to which models of clinical reality were shared by patients and practitioners strongly influenced selection of practitioners. The absence of shared expectations among nurse-midwives and prospective clients regarding appropriate role behavior, and differing concepts of causation of obstetrical complications and of appropriate midwifery practices discouraged prospective patients from utilizing the clinic. Those women who used the national health maternity services in the rural area lived within a two-kilometer radius of the clinic and were wives of civil servants, wealthy traders, and men in "modern" occupations. Peasants represented the lowest percentage of clinic patrons in proportion to their representation in the population, yet they increasingly utilize the maternity clinics. This trend was one facet of the process of national integration, and it developed as Bariba women acquired new information from clinic patrons, originally "foreigners," who served as role models. 4. Monetary constraints and constraints related to transportation and support services for maternity patients influenced

Introduction

7

decision-making and in many cases prevented the utilization of the clinic from being a real option. In this earlier research, strong evidence suggested the importance of witchcraft beliefs for obstetrical care choices in Pehunko, but factors such as clinic accessibility and familiarity with bureaucracy also played a role in the selection of obstetrical assistance. For an elite minority, status aspirations appeared to influence medical choice. However, the relative weight of the various agendas and extrinsic factors remained unclear in this earlier analysis. T h e purpose of the current research was to clarify this relationship. Parakou, an urban conglomeration with obstetrical facilities accessible in principle to all urban residents, served as an ideal site to pursue this investigation. I posited that variation in clinic use in this setting would illustrate the dynamics of what I now term individual agendas. In particular, I expected to find that the perpetuation of witchcraft beliefs would explain patterns of clinic use. Thus, following the rural pattern, those women concerned with witchcraft control would not choose a hospital delivery, whereas hospital patrons would no longer adhere to such beliefs. Rather, I discovered that belief in witches represented merely one element in the set of agendas described above, and this belief itself was undergoing discernible transformation. THE URBAN CONTEXT

T h e town of Parakou, a provincial capital located in northern Benin, proved to be an appropriate site in which to investigate the issues sketched above. Later chapters will detail the characteristics of the health services available in Parakou. In this chapter, I note merely that a variety of options for obstetrical care exist in Parakou, including a government hospital, private clinics, and indigenous midwives; moreover, all forms of assistance are readily available to the bulk of the population residing within the urban conglomeration. Cost of care seemed largely comparable for the several alternatives, with certain exceptions (see chap. 3). Given the relative absence of extrinsic

8

Introduction

constraints (in contrast, for example, to the rural setting), it seemed illustrative to examine patterns of obstetrical service use by Bariba women in Parakou. Government data on health service utilization in Parakou indicate that government maternity services are heavily utilized in contrast to patterns of utilization in the surrounding rural areas. Nonetheless, public health officials estimated in 1981 that as many as fifty percent of urban women did not deliver at a hospital or clinic, but rather chose to deliver at home either alone or with the assistance of family or an indigenous midwife (Provincial Director of Health, personal communication). Parakou is situated approximately 400 miles from the coast and the capital city of Benin and is the railroad terminus for the country, the railroad having been completed in the mid-1930s (see figs. 1 and 2). According to the 1979 census, Parakou has an estimated population of 60,797 residents, of whom 31,292 are men and 29,704 women. Parakou, now the administrative capital of the Borgou Province, developed as a commercial center and "caravanserai" possibly dating to the 16th century. Cogui Nduro Issifou described the evolution of Parakou over the past 400 years as "from caravan stop to commercial center by means of long-distance trade with Niger" (Cogui 1978:125; my translation). Historically, Parakou has been divided into two distinct districts—that of the Bariba, in a neighborhood surrounding the house of the chief, and that of Muslim traders, or "strangers" (Lombard 1965: 109, 471). A multiplicity of cultural influences—Hausa, Yoruba, Djerma, Dendi, Malinke, Dioula among others—characterizes Parakou, thus its Bariba name kpara-kuru, "gathering of many peoples." Although Parakou does not present a pure "Bariba personality," like that of a small town such as Kouande with a population of 4,000 (Lombard 1965:110-112), it remains the urban area with the most numerous Bariba population in Benin. T h e results of an ethnicity census, which would provide more precise figures regarding ethnic distribution in Parakou, are not yet available; however, in 1959 Lombard estimated that Bariba represented a majority of the population of the town. Since that time, the population has increased (in the interval from 1971 to 1981 the official population rose from

Burkina Faso

BORGOU ^atitmqou#Kouandé p|f*\ "tehunko ; ; ; ATA KOR A Ndali C N,

Djougou

Parakou