Reproductive health

INFERTILITY IN AFRICA SOUTH OF THE SAHARA

R.J.I. Leke
C.U.S.S., University of Yaounde, Cameroon

Infertility is the inability to achieve a pregnancy after at least one year of adequate sexual exposure without contraception. Infertility can affect both the man and the woman. Despite the increase in world population, 10-20% of couples in the world suffer from infertility. In Africa this rate may be as high as 20-30% in some areas, and vary from region to region even within the same country.

In the African context where having children constitutes the raison d’être of all marriages, infertility is considered a curse and a real tragedy for the couple, the entire family and the community. The magnitude of the whole problem of infertility of Africa is not well known and this lack of accurate knowledge of the problem may explain why we lack strategies to prevent it. The lack of accurate knowledge of this public health issue is aggravated by the difficulty to harmonize the different definitions of infertility, thus rendering interpretation of the results of different studies very difficult. It is in this light that clinicians consider infertility as the inability to achieve a pregnancy after one year of adequate exposure without contraception while demographer consider infertility as the inability to have a child after one year of exposure and without contraception. The geography of infertility shows different zones of low fertility in Africa with a large zone of hypofecundity extending through most of West Africa from Senegal, Mali, Burkina Fasso, and Niger, through Cameroon, to Sudan, Zaire, Uganda, Kenya and Tanzania.

Factors that affect the prevalence of infertility include:

  1. Socio-cultural factors like taboos.
  2. Ethnic and regional variations as in West Africa.
  3. Sexually transmitted diseases, e.g. gonorrhoea.
  4. Postpartum and postabortal infections.
  5. Age of the partners.

Diagnosis of infertility

The diagnosis of infertility is only possible after a clinical and paraclinical investigation of the couple. Simple paraclinical tests like basal body temperature charts and semen analyses may be done at the periphery, and at the level of the district hospital. Other tests like the postcoital test, hormonal assays, evaluations of follicular development and ovulation, ultrasound and laparoscopy are usually done at the reference level—University Hospital or Provincial Hospital.

Prevention of infertility

Prevention of infertility should be the primary goal of any strategy that seeks to reduce the impact of infertility in Africa. The preventive approach is justified because of the inaccessibility of curative treatment which benefits only a few couples. One of the major causes of the inaccessibility of curative treatment is its very high cost and its low success rate. Prevention will permit better access and better utilization of services at different levels of health care. This preventive strategy must involve the effective control of sexually transmitted diseases.

The two main objectives of preventing sexually transmitted disease are to interrupt the transmission of the infection and to prevent development of its complications. For these objectives to be achieved, exposure to infections in Africa must be reduced through education, liberal use of condoms, screening for frequent sexually transmitted diseases, adequate treatment of cases of sexually transmitted diseases, and use of family planning and safe abortion techniques.

One can see from Table 1 that activities like information, education and communication as well as integration of sexually transmitted diseases control into primary health care (PHC) programmes can best be done at peripheral levels.

Table 2 shows the possibility of making available different diagnostic tests of sexually transmitted diseases at the level of health care, as adapted from WHO.

Table 2 reveals that all diagnostic tests of sexually transmitted diseases do not need to be done at the central level. Some of the screening tests could and should be performed at peripheral and district levels.

Constraints in prevention and treatment of infertility in Africa

Some of the difficulties that can hinder prevention and treatment of infertility in Africa are:

  1. Lack of knowledge of the importance, impact and distribution of infertility.
  2. Poor planning and organization due to lack of specific objectives and strategies.
  3. Lack of political commitment.
  4. Lack of knowledge of the attitudes, practices and beliefs of the population with respect to infertility.
  5. Lack of standards and protocols to integrate infertility service into other existing services such as family planning.

Bibliography

  1. African - Latin American Workshop on Research in Reproductive Health. Final Report - Campainas - Brazil - WHO, Nov. 1988.
  2. Greenhall, E., and Vessey, M. (1990): Fertil. Steril., 54:978-983.
  3. Leke, R.J.I. (1991): Infertility and the African Environment. Paper presented at International Meeting on Environment and Infertility. Copenhagen.
  4. Lesthaegh, R. (1984): Fertility and its proximate determinants in Sub-Sahara Africa: The record of the 1960s and 1970s.
  5. Mati, J.K.G. (1985): Sexually transmitted Diseases (STD) in Adolescents. Presented at WHO Workshop on Adolescent Reproductive Health.
  6. Nasah, B.T., and Drouin, P. (1982): Care of the mother in the Tropics, pp. 215-233.
  7. Over, M., and Piot, P. (1990): HIV Infection and Other STD, World Bank Health Sector Priorities Review.
  8. Simplified Approaches for Sexually Transmitted Disease (STD), Control at Primary Health Care Level (1984): Report of WHO working Group, Geneva.
  9. WHO (1987): Fertil. Steril., 47:765-772.

 

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Edited by Aldo Campana,