Since 2000, when the UN adopted its Millennium Development Goals (renamed Sustainable Development Goals in 2015), statistical benchmarks have allowed public authorities to gauge the success of their health and social policies. In the Sahel region, progress has been far from satisfactory: inequality between men and women persists, extreme poverty still affects 30-40% of its populations, and total fertility rates (1) remain between 4.1 and 7.6.
Governments and their partners have had to revisit the conditions for demographic transition and measures needed to achieve a real reduction in fertility. They are now focused on improving adolescent health, especially through family planning programmes. This implies promoting the autonomy of adolescent girls, a principle that is part of many national development programmes. It’s a collective effort, with local authorities supported by international organisations such as Unicef (UN Children’s Fund), the UNPF (UN Population Fund) and the WHO (World Health Organisation); cooperation agencies such as the French Development Agency, the Swiss Agency for Development and Cooperation, and Belgian Technical Cooperation; and NGOs such as Médecins du Monde or Pathfinder International.
The term used to refer to promoting women’s autonomy is ‘empowerment’. The UN Commission on the Status of Women (CSW) made this the focus ofits 63rd session this March, in New York, and the international advocacy organisation Women Deliver did the same at its annual conference in June, in Vancouver. The empowerment principle aims to make adolescents full participants in the implementation of projects intended to benefit them, not just targets. However, getting adolescents themselves to take charge of such projects,and to take advantage of sexual and reproductive health services, presents many challenges, especially in Africa. Things that are taken for granted in the West, which has been strongly influenced by the feminist struggle and the fight for human rights and women’s rights, cannot be taken for granted in other parts of the world, where social customs, religion and patriarchal ideology are dominant, and impose other values.
In Muslim countries, religious norms increasingly influenced by Salafist and other fundamentalist ideologies (2) define family and relationships between men and women in patriarchal terms. This view of society legitimises a fundamental inequality between men and women, especially at family and sexual level, manifested in polygamy, child marriage,the obligation of sexual relations within marriage, repudiation and discrimination in inheritance. It promotes procreation: the more children a woman has,the greater the respect society accords her. And the precarious living conditions and lack of social security facing most of the region’s populations make procreation the equivalent of a pension plan: having many children ensures parents will have someone to support and care for them in their old age. Socio-cultural and economic norms place children at the centre of a number of issues: wealth, inheritance, social status, the struggle against poverty through the work they do, competition among wives in polygamous households. In Christian-majority countries, the most conservative and patriarchal forms of Christianity (promoted especially by evangelical and Pentecostal churches) dominate family, sexual and reproductive life.
Macron disregards local feelings
The birthrate control policies promoted so insistently by the West are clearly at odds with local social, religious and economic norms. At the G20 meeting in Hamburg in July 2017, France’s president Emmanuel Macron expressed the view that uncontrolled demographic progression was a major obstacle to development; he spoke without regard for how his statement would be received by populations that see high fertility as a good thing, which contributes to development. In the eyes of Muslim civil society, it is not for governments and their international partners to decide policy on the regulation of fertility (3).
We often fail to agree on desirable spacing of births, especially with our partners. We've had presidents who vetoed the creation of a family planning directorate Former official, Niger
In Sahel countries, female contraceptive behaviour is still controlled by men, in both family life and the religious sphere. Womenare seldom allowed totake advantage of modern healthcare,especially birth control.They are often forced to resort secretly to traditional services (from practitioners of traditional medicine, door-to-door salesmen, marabouts) and to local folk practices.
There are only five periods in a woman’s life when society allows her not to bear children: before marriage, during breastfeeding (generally two years), after numerous pregnancies in close succession (‘grand multiparity’ in medical language or when they are ‘tired’ in popular parlance), when their husbandgone away to look for work, and before remarriage. Women are not free to make decisions on reproduction and sexual relations; they are governed by socio-cultural norms that stigmatise those who do not conform.
But local socio-cultural and religious norms also influence healthcare professionals. The most widely dispensed contraceptives are the pill and intrauterine devices and implants, but the rate of contraceptive use remains very low, at 15.2% among women aged 15-49 (4). Many nurses and midwives refuse to prescribe contraceptives to adolescents. A Nigerien health worker said, ‘It’s our job. But we don’t have to do it. We didn’t take an oath to do that kind of thing. If we do, we know we’ll have to answer to God.’ There is a conflict between religious beliefs and professional ethics that would be interesting to study in the context of the very high fertility rates in the Sahel countries.
The attitude of institutional actors (government ministries, health agencies, elected representatives) can also be ambivalent. Some advocate controlling population growth through family planning, sending girls to school, and fighting maternal and child mortality. In this, they are following western recommendations. But research in Niger (5) shows that, in private, the same people may take the opposite position and that, in practice, they can be reluctant to promote contraception. Population programmes sometimes make slow progress because their soundness is questioned: ‘We often fail to agree on the desirable spacing of births, especially with our partners,onwhat’s best for the couple, and so on,’ said a retired official of a Nigerien institution, who wanted to remain anonymous. ‘We’ve even had presidents who vetoed the creation of a family planning directorate.’
‘Don’t bite the hand that feeds’
Public authorities in Sahel countries fail to act on their convictions: the negotiations between states with reduced financial resources and wealthy but prescriptive international and bilateral institutions are too unequal.A representative ofNigerien civil society said in response to a study on perceptions of humanitarian aid, ‘You don’t bite the hand that feeds’ (6).
Demographic policies are complex, involving social, cultural and economic factors, especially those relating to adolescent girls, whose status is very different from the usual western vision. This is especially true in Africa, for both socio-cultural reasons (family structure, marital practices, gender and age relationships, polygamy) and socio-religious reasons (the prevalence of Islam, increasing influence of Wahhabist ideology, Christian fundamentalism). In the Sahel, especially in rural communities, adolescent girls seldom have material or moral autonomy — which does not mean they are unable to devise effective solutions themselves.
In Africa, high fertility is essentially a phenomenon of the working class, who are the most influenced by religion and local social norms. Only the higher urban classes have begun a demographic transition, and it is in these classes that women have the greatest autonomy. Teenage girls and the poorest women have the least access to contraception and are most likely to succumb to child marriage or marital rape, or be repudiated or abandoned without financial support. Child marriage is known to be a major factor in girls dropping out of school (7).
Empowering teenage girls and women — as promoted by development and contraception awareness programmes — conflicts with local social and religious norms, which make it appear unsuited to working-class circumstances. It is often seen as a western plot to undermine fertility in Africa — poor people’s only asset. The strength of the resistance should not be underestimated.