Over the course of this semester, I have learned a great deal about how gender intersects with, and affects, the human body, medicine, sickness and health in many different cultures of the world. It is evident to me that all cultures have different gender roles creating different social norms. All cultures also have very different models of the human body, medicine, sickness, and health. Through the five different anthropological perspectives, anthropologists are able to study these differences in order to get a better understanding of the culture and its people, as well as ways to target some of the health problems prevalent in a given society. For the purpose of this final blog post, I have chosen to focus my attention on the African country of Chad, also known as The Republic of Chad. Chad is located in the northern central region of Africa and is home to many different cultural and ethnic groups. While there are a multitude of different languages and religions, the two official languages of the country are French and Arabic, and the two most prominent religions are Islam and Christianity (more specifically Catholicism). (BBC, 2016) Chad has a very young population. Out of its total population of 12,448,200 people, 6,904,600 are under the age of 18, and 2,406,400 are under the age of 5. (UNICEF, 2013) Two big factors that play a part in the age distribution of Chad’s population are the very high fertility rate of 6.4 and the fairly low life expectancy of 50.7 years (both according to UNICEF data from 2012). While there are many health problems that contribute to the low life expectancy, the health problem that I found the most heartbreaking, and the one I plan to focus on for the rest of this blog post, is Chad’s horrendously high Maternal Mortality Rate. Maternal Mortality is defined as “The death of a woman during pregnancy, childbirth, or during the 42 days after childbirth.” (Hogan, 2010) Chad is ranked as the second highest country in the world for maternal mortality according to UNICEF statistics. For every 100,000 live births in Chad, 1,100 mothers will die. (UNICEF, 2013) This startling statistic turns out to mean that the lifetime risk of maternal mortality is that one in every fifteen mothers will die due to pregnancy/childbirth related complications. To further examine the problem of Maternal Mortality in Chad, I have decided to examine the culture using the Feminist Theory, because I believe that a majority of maternal deaths come from gender inequalities prevalent in Chadian Culture. I believe that, because of the different gender roles in Chadian culture, girls are often married at such a young age that their bodies are not able to handle pregnancy and child birth. I will also look at social, economic, and cultural determinants of health in Chad, and the influences that I believe they have on maternal health. While inequalities in gender roles create social norms that influence child marriages, I also believe that high rates of poverty play a large part in child marriages and the huge disparity in health care for pregnant women between the richest 20% of Chad and the poorest 20%, as well as those who live in urban areas versus those in rural areas.
To begin examining the issue of the extremely high maternal mortality rate in Chad, I first had to choose which Anthropological perspective I thought would give me the most insight into the causes, and possible solutions, of this health problem. Because there are many cultural influences that create different expectations for men and women in Chad, I decided that Feminist Theory would give me a good look into the different social determinants of health and health disparities between men and women that may lead to such a high maternal mortality rate. Feminist Theory emerged in the study of Anthropology around 1850. Up until this point, medical and ethnographical research had been performed on men, by men, with no real regard to women’s perspectives, or how their gender role in society influenced their experience. (Bratton, 1989) Feminist theory emerged as a way to study the roles women played in society, and to gain insight into female’s experiences and events. While Feminist Theory began primarily to examine the roles of women as subordinates to men, the theory has evolved and today looks at all kinds, causes, and effects of gender inequalities. Intersectionality also plays a large role in the present day Feminist Theory. Intersectionality looks at not only the experiences produced because of gender inequalities, but also how all of the other social categories, such as race, class, and education level impact a person’s experiences and opportunities. In regards to the maternal mortality rate in Chad, intersectionality is crucial for examining the health disparities in women of the upper class versus the lower class, as well as those who live in urban areas versus those in rural areas. Feminist Theory is a great asset for anthropologists studying cultures that are different from their own. This is because a major cause of disparities between men and women are the culturally defined ideas on gender. Different cultures view women differently; what it means to be a woman and how women are valued and treated can vary greatly depending on where you live. Feminist Theory aims to determine how cultural definitions of gender, such as gender roles, level of education, age of marriage, etc. influence social norms in that society. The two main questions that Feminist Theorists try to answer when looking at different situations are: How does gender impact the situation? and; Is there an inequality present due specifically to gender? (Gabriel, 2016) It is important to remember when using feminist theory that inequalities may not be consistent throughout a society, and may be present at different levels such as national, state, or individual/household levels. “Feminist Anthropology is more than the study of women. It is the study of gender, of the interrelations between women and men, and the role of gender in structuring human societies, their histories, ideologies, economic systems, and political structures.” (Moore, 1988) In my opinion, using the Feminist Theory is the best way to examine the gender inequalities as well as other cultural, social, and economic determinants of health that contribute to the extremely high maternal mortality rate in Chad. I believe that because many of their cultural ideas on gender influence the prominence of extremely young brides and, in turn, very young girls giving birth, which is one of the biggest causes of Maternal Mortality, especially in a country lacking the public health infrastructure to care for these high risk pregnancies. I think that understanding cultural reasons for girls to be married so young will be a key aspect of how maternal mortality in Chad must be targeted if the situation is to be improved. To understand these cultural concepts, it will be crucial to examine the disparities between the men and women of Chad in regards to gender roles/expectations, treatment in society, and education.
I believe that culturally defined gender roles are one of the largest factors in Chad’s extremely high maternal mortality rate. Girls younger than 15 years old are, on average, about five times more likely to die due to complications in childbirth when compared to women in their twenties. (Walker, 2012) For girls ages 15-19, pregnancy is one of the leading causes of death. Young mothers are at a very high risk for eclampsia, postpartum hemorrhage, increased risk of malaria, obstructed labor (due to their pelvis not being large enough), and fistulas. Child marriage is a very common practice in Chadian society, and it is deeply rooted in their cultural traditions and ideas about the female gender. Chad is ranked second in the world for the occurrence of child marriage. According to UNICEF statistics, 72% of Chadian girls are married before they reach the age of 18. (UNICEF,2013) In Chadian culture, women often are expected to submit to the men in their lives, whether that be their father or their husband. So, often times they do not have complete control over their own destiny, such as their education, marriage, contraception, or child bearing. Often times, parents seek to protect their family honor, by marrying their daughters off at such a young age, in the hopes of preventing them from engaging in “taboo” pre-marital sexual activity. (Nour, 2006) Because of the gender expectations in Chad, girls are expected to remain virgins until they are married, or else they bring shame onto their family. Men, on the other hand, are expected to have more sexual experience before they are married and so do not feel the pressure to marry at an extremely young age as many girls do. Parents also choose to marry their daughters off at a young age to avoid pre-marital sexual relations in the hopes that they will protect them from STD’s such as HIV/AIDS and HPV/Cervical Cancer that are very prevalent in Chad. While these parents believe that marrying their daughters off so young will protect them from these dangerous STD’s, the sad truth is that, according to the the International Center for Research on Women’s Health, child brides often have a much higher risk for contracting HIV from the man they marry because he is generally older, with much more sexual experience. In Sub-Saharan Africa as a whole, girls 15-19 are about 2 to 8 times more likely to get HIV than boys their age because of the practice of child marriage. (Nour, 2006) Men also seek young, virginal brides because they know they would face a high risk of contracting HIV themselves from girls who are older and may not be virgins. Because girls are expected to be married, this search for virginal brides is another contributing factor to the prominence of child marriage. Another cultural expectation placed on the women of Chad is to prove their fertility soon after being married. Often times, no contraception is used and child brides become pregnant very quickly and in rapid succession, soon after being married. The contraception prevalence in the Chad in 2012 was only 4.8%. Brides are often completely financially dependent on their husbands and have no way to make any demands of them, such as using contraception, or expressing their wishes to wait to have children until their bodies are more mature and ready to handle it. Often times, because the girls are so much younger than their husbands, they have little in common with them, so there is not much to discuss besides the wife’s household responsibilities and child rearing. (Nour, 2006) The final major culturally defined gender inequality that I believe has an impact on the maternal health of the women of Chad, is the practice of Female Genital Mutilation/Cutting (FGM/C). According to tradition, women who are circumcised have a higher chance to get married than their uncircumcised peers. (Foumsou et. al, 2015) In Chad, 44.3% of women ages 15-49 between the years of 2002 and 2012 were victims of FGM/C, and 18.2% of those women had at least one daughter who was also a victim of FGM/C. (UNICEF, 2013) At this time, 37.7% of the population had positive attitudes showing support for the practice of Female Genital Mutilation/Cutting. It has been suggested that the practice of FGM/C stems from another culturally defined gender identity, “The stereotypical perception that women are the principal guardians of a community’s sexual morality.” (Cook, 1992) FGM/C is traditionally viewed as a way to curtail a woman’s sexual desire and reduce the likelihood that she will seek premarital sex, or cheat on her husband. It is also supposed to prepare the girl for the pain of childbirth. Both of these ideas add to the symbolic ritual of FGM/C as a rite of passage and preparation for a girl to become a good wife. Not only is FGM/C traumatic, painful, and dangerous to a girl, but it also has negative consequences on her ability to carry and deliver children. Some common maternal complications that arise from FGM/C are: Perinea tear, excessive bleeding due to a perinea tear, and an episiotomy to help prevent a perinea tear. (Foumsou et. al, 2015)
Another cultural determinant of health in Chad that has an effect on the maternal mortality ratio is religion. Both religious and cultural traditions in Chad play a large role in the age at which girls are married and begin to have children. Islam and Catholicism are the two most prevalent religions in the area. Both religions value abstaining from premarital sexual activity, which bolsters the cultural ideologies and push towards child marriages with virginal brides. In the Islamic faith it is common, especially for women, to get married at a young age, and Catholicism discourages couples from using contraceptives. The lack of contraception could contribute to many unplanned pregnancies in girls whose bodies are not yet ready to handle them. When girls are getting married at such young ages, it is no wonder they begin to have children before they are physically ready when there are no precautions or use of contraceptives.
Economic determinants of health are also an important factor when looking at targeting the maternal mortality rate in Chad. One major problem in Chad is that many of its population live in poverty. The percentages of the population living under the International Poverty line of the U.S., $1.25/day in 2011, was 61.9%. (UNICEF, 2013) This country wide economic crisis is extremely troublesome in their public health and education spending. The public spending as a percentage of the GDP in 2011 allocated to health was 1.2% and the percentage allocated to education was 2.9%. The average amount of healthcare dollars spent on a citizen in Chad comes out to be around $4.20 per person. (Wyss, 2003) Due to a lack of public health physicians and caregivers, many women do not receive the proper prenatal delivery and care. According to a statistic gathered in 2006, Chad had one of the lowest ratios of physicians to individuals of any country; just 0.04 physicians per 1,000 individuals. (CIA, n.d.) Because access to the proper healthcare is scarce, only 53.2% of women receive at least one prenatal care visit and only 23.1% of women receive at least four prenatal care visits. (UNICEF, 2013) It is even less common for women to have a skilled attendant at birth and/or to have their delivery take place in a medical institution. Only 22.7% of women have a skilled attendant present at the time of birth and only 15.8% of deliveries took place in a medical institution. It is important when using the Feminist Theory, even while examining economic determinants, to remember to use intersectionality. It is critical to examine the differences in the inequalities between women of different socio-economic status (even though they are all relatively low compared to a developed nation like America), as well as the area in which they live. The percentage of skilled attendants at birth in 2012 were 61.3% for women of the richest 20% of the country and only 8.1% for the women of the poorest 20% of the country. The percentage of skilled attendants at birth in 2012 were also highest for the women living in urban areas (59.6%) when compared to women living in rural areas (8.1%). It is obvious that, even in a country with a very low GDP and little public healthcare, disparities in socio-economic status still play a role in determining the access to health care. The lack of public healthcare is not the only economic determinant of health at play in the maternal mortality crisis in Chad. Socioeconomic status also plays a large role in the practice of child marriage. Poor households are about twice as likely to marry their girls off before they turn 18 than families with stable economic situations. (ICRW, n.d.) The families receive a dowry for every daughter who marries, and no longer have the economic burden of feeding them, clothing them, and sometimes, educating them. It is often prudent to marry their daughters off a younger age because, in some areas, the dowry decreases as a girl gets older.
Yet another very important social determinant of health in the world is education. Because girls from poor families are more likely to become child brides and be pulled out of school at a young age, they do not have the educational tools to break the cycle of poverty, which often leads to the continuation of the child bride cycle in their children. Through education, people are able to improve their socio-economic status, employment opportunities, health, and overall well being. One major problem in Chadian society is a lack of overall education. According to UNICEF statistics, the overall adult literacy rate (percentage of the population, 15 years and older, who can read and write) in the country was 35.4% from 2008-2012. (UNICEF, 2013) A lack of proper education is an even larger problem for the women of Chad. In 2012, the net attendance ratio for secondary school participation for males was 22%, while the net attendance ratio for females was only slightly over half that of the males at 11.6%. If girls were allowed to stay in school and receive a proper education, they would open up many more opportunities for themselves and give them a greater chance to be independent. This would give them a greater say over how they and their bodies are treated, and not force them to be completely dependent on their husbands. Not only does receiving a proper education benefit women by providing more opportunities for them, but staying in school also reduces their chances of having children before their body is ready. If girls were able to stay in primary school and continue on to receive their full secondary education before they married and began having children, then their bodies would have the time they need to mature and develop in order to safely, and effectively, carry and deliver children. Also, allowing women to stay in school longer before getting married may also give them the time to receive education about their bodies, pregnancy, childbirth, and contraception that they would not get outside of school. Because sex is a “taboo” topic in Chadian society, there is almost no information given to young girls about these “forbidden” topics. Premarital sex/pregnancy bring much shame upon a girl’s family, so there is little discussion of the options they have available to them. Because it is tradition to marry girls off at such a young age to prevent them from shaming their families, most parents consider it unnecessary to give them information about safe sex. This lack of sex education is evidenced by the very high fertility rate (6.4) and low prevalence of contraceptive use (4.8%) in the country. It is no wonder that girls begin having children as soon as they are married with a contraceptive rate that low. If women, as well as the entire community/country, were educated on different contraceptive methods available, and the dangers of bearing children at such young ages, they may begin to change their culture and practice safe sex, or strive to remain unwed or abstinent longer. Another benefit of women staying in school to receive further education would be the opportunity for some of them to be trained to become midwives or obstetricians. The prevalence of trained medical professionals in Chad is very low, and contributes to the extremely low percentage of women who receive antenatal care and deliver in the presence of a trained professional, both of which would help combat the high maternal mortality rate. “The availability of skilled delivery personnel, life expectancy, national economic wealth, and health expenditure per capita predict the maternal mortality rate of a country.” (Buor et. al, 2004) Because the country is in an economic crisis, education, in my opinion, is the best bet to improve maternal mortality ratios. If more women were trained to assist with births, the process would become safer for many. Further education for both men and women in the country of Chad may also help to change ideas on the cultural practice of FGM/C, which is still a fairly common practice in the country, and can cause complications with pregnancy and delivery. Because FGM/C is a cultural norm, both men and women fail to see any problems with continuing the practice. If, through education, they could see that FGM/C can have adverse effects on women’s ability to carry and deliver children, the prevalence of this traditional practice may decline, as long as the cultural ideology is targeted in the right way.
So, what can be done to begin to improve health and reduce the devastatingly high maternal mortality rate in chad? Because of the different gender norms and expectations in the country of Chad, girls are often married at very young ages. Whether it is to ensure the bride is a virgin to uphold the family honor, secure a higher dowry, or protect her from the risk of contracting an STD, this practice is often detrimental to her physical and emotional health. Chad has the second highest maternal mortality rate in the world, largely in part due to this prevalence of child marriage. Chad also has one of the lowest contraceptive use percentages at only 4.8%. With very little funding for public health and an extreme shortage of physicians and trained midwives, there is almost no support for these young girls when they become pregnant. In Chad, 47.8 girls out of every 1,000 give birth under the age of 15. (Neal, 2012) For girls ages 15-19, pregnancy is one of the leading causes of death in the world, and girls under 15 are about five times as likely to die due to complications in childbirth than a woman in their twenties. It is no surprise that maternal mortality is so high in a country where so many girls are put in the position to be at risk for one of the leading causes of death in the world. Because of the young age at which many women give birth and the inadequate medical attention most will receive during their high risk pregnancies, one in fifteen women will die from a pregnancy or childbirth complication in Chad. While the country is in desperate need of economic aid to increase funding for both public health and education, I believe that targeting education is the major stepping stone needed to combat maternal mortality and the cultural ideologies that fuel it. Increasing education in Chad could potentially help boost the economy to provide the better public healthcare that it needs by lowering the number of dependent people and possibly increasing jobs. Education for both men and women would raise awareness for the dangers of women becoming pregnant and giving birth to children at such young ages, which may help to shift cultural ideologies and gender norms allowing girls to grow and mature into women who are both ready for and desire to become mothers. With sexual education in school, both males and females would learn about the value in contraception for preventing both pregnancy and sexually transmitted diseases. Education for both men and women may also help to shift perceptions of FGM/C, and expose the dangers not only in performing the practice, but also the detrimental effects it can have on women’s ability to carry and deliver children safely. Finally, completing their education before being married would allow women many more opportunities to be able to support themselves and not be completely reliant on their husband. It would also open the doors for women to become trained midwives, obstetricians, or physicians to help create a safer environment for the women of Chad to navigate their pregnancies and deliveries. Ultimately, the country of Chad needs a cultural ideology revolution and I believe that education is the key. Education for community leaders/chiefs/elders/religious leaders will be an important step in changing the aspects of Chadian culture/tradition that put women into these dangerous situations. Child marriage is a violation of basic human rights; a practice deserving of much attention and many strong efforts to eradicate it, not only in Chad, but all over the world. Maternal mortality is a health crisis that can be solved through economic stimulation and education that work together to shift cultural ideologies and practices.
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