Abortion in the Moral World of the Cameroon Grassfields

Abstract

Despite high levels of unsafe abortion in Cameroon, remarkably limited attention has been paid to the moral dilemma for women who seek abortions. In-depth interviews were conducted with 65 Cameroonian Grasslands women within a hospital-based study, complemented by participant observation, use of hospital records and interviews with key informants. The paper demonstrates how a hidden moral code on abortion helps women to exercise individual agency despite prevailing moral values. At the same time, women's desire to keep abortion secret can impede adequate medical treatment, which in turn can increase the risk of complications and mortality. Abortion was more often condemned by the women because of the risk to their lives and of infertility rather than for religious reasons or because it is illegal. However, the economic and social realities of everyday life often overrode their fear of complications when they needed to end a pregnancy. The paper concludes that women have already broken through Cameroon's stringent restrictions on abortion through their practice. There is a large gap between what is permitted under the current law, which is colonial in origin, and women's need for legal abortion on broad socio-economic grounds. This calls for reflection on liberalisation of the present law.

Résumé

Malgré des niveaux élevés d'avortement non médicalisé au Cameroun, le dilemme moral des femmes qui veulent interrompre leur grossesse a fait l'objet de bien peu d'études. Des entretiens ont été menés avec 65 Camerounaises des plaines dans le cadre d'une étude hospitalière, complétés par des observations des participantes, l'utilisation des dossiers médicaux et des entretiens avec des informateurs clés. L'article montre qu'un code moral privé sur l'avortement aide les femmes à agir malgré les valeurs morales dominantes. En même temps, le désir des femmes de garder l'avortement secret peut contrarier un traitement médical adapté, ce qui risque à son tour d'accroître les complications et la mortalité. Les femmes condamnaient plus souvent l'avortement en raison des risques de décès et de stérilité que pour des motifs religieux ou parce qu'il est illégal. Néanmoins, quand elles ont besoin d'une interruption de grossesse, les réalités économiques et sociales de la vie quotidienne l'emportent souvent sur leur crainte des complications. L'article conclut que la pratique des femmes aggrave les restrictions sévères du Cameroun sur l'avortement. Il existe un net écart entre ce qui est permis par la loi, d'origine coloniale, et le besoin qu'ont les femmes d'un avortement légal pour de vastes motifs socio-économiques. Cela exige de réfléchir à la libéralisation de la législation actuelle.

Resumen

Pese al alto índice del aborto inseguro en Camerún, no se ha prestado mucha atención al dilema moral de las mujeres que buscan servicios de aborto. Se realizaron entrevistas a profundidad con 65 mujeres de Camerún, como parte de un estudio hospitalario, suplementado por la observación de los participantes, el uso de registros hospitalarios y entrevistas con informantes clave. Este trabajo demuestra como un código moral privado en torno al aborto ayuda a las mujeres a tomar sus propias decisiones a pesar de los valores morales predominantes. A la vez, el deseo de las mujeres de ocultar el aborto puede impedir que reciban tratamiento médico adecuado, lo cual puede aumentar el riesgo de complicaciones y mortalidad. Las mujeres condenaron al aborto por temor de poner su vida y fertilidad en riesgo, y no por motivos religiosos o de ilegalidad. Sin embargo, las realidades económicas y sociales del diario vivir a menudo anulan su temor de complicaciones cuando necesitaban interrumpir su embarazo. Se concluye que, mediante sus propias prácticas las mujeres empeoran las rigurosas restricciones sobre el aborto. Existe una gran brecha entre lo que permite la ley, la cual es de origen colonial, y la necesidad de las mujeres de recurrir a un aborto legal por una variedad de motivos socioeconómicos. Esto exige mayor reflexión sobre la liberalización de la ley actual.

Key Word:

• contraception and unwanted pregnancy
• clandestine and unsafe abortion
• beliefs/norms/values
• maternal mortality and morbidity
• post-abortion care
• Cameroon

In Cameroon, induced abortion is permitted when a woman's life is at risk, to preserve her physical and mental health and on grounds of rape or incest.¹ Although illegal abortions are punishable by a fine and imprisonment of up to five years for the abortionist, one year for the woman herself and two years for anyone supplying drugs or instruments to induce abortion, prosecutions are rare. On the other hand, private, well-equipped clinics perform abortions for women who can afford their services, while poorer women attempt abortion by self-medication or are forced to rely on providers using unsafe methods. Clandestine abortion services offered by lay abortionists, trained midwives or so-called native doctors, out of view of the public health service, are in fact common.²³⁴⁵

Induced abortion is highly controversial as well as illegal in Cameroon as the Roman Catholic Church, to which 37% of Cameroonians belong,⁶⁷ considers abortion immoral and condemns abortion along with “artificial” forms of birth control.^* Moreover, religious leaders are key players in discussions touching on changes in society's attitude to contraception and laws on abortion.³⁹

Illegality and the immorality of abortion, which are at the heart of public abortion polemic, are often taken for granted as the ethical standard with regard to abortion. Yet despite this, a large number of Cameroonian women terminate unwanted pregnancies, with a high risk of complications.

In a 1989-93 hospital-based study in the Cameroon Grassfields, the proportion of maternal deaths due to abortion complications was as high as 37.3% of the 67 women who had died.¹⁰ In 1995, the number of unsafe abortions performed in Cameroon as a whole was estimated at 25-29 per 1,000 women, which had declined by 2000 to 20-25 per 1,000 women aged 15 to 49 years.¹¹¹² In 2000, the estimated ratio of deaths due to unsafe abortion in Cameroon was still high, at 90 to 100,000 live births.¹²In addition to deaths from complications, long-term consequences of unsafe abortion may include chronic pelvic pain, pelvic inflammatory disease, tubal occlusion and subsequent infertility. Behind these statistics lie not only physical pain and trauma for women, but also moral anguish and emotional turmoil.¹³ Not only are women's lives endangered but also, in a society that highly values children, their future reproductive capacity. Yet, it has been shown that where legislation allows abortion on broad indications, the incidence of unsafe abortion and associated mortality is lower, as compared to legislation that greatly restricts abortion.¹⁴

Remarkably little attention has been paid to the moral dilemma involved in the decision to have an abortion and the practice of abortion in sub-Saharan Africa. Yet both bioethicists and social scientists recognise that moral and ethical judgements are contextual and depend on local, cultural frameworks of understanding.¹³ This paper demonstrates that women's moral ideas about having an abortion are due to the health consequences of unsafe abortion and to ensuring that an abortion does not become a matter of public knowledge and shame, rather than to the illegality of the procedure or religious morality. However, induced abortions do affect women's moral identities and the “local, moral worlds” within which women's daily lives unfold.¹⁵¹⁶ The paper shows how social conflict and cultural tensions inherent in public attitudes to abortion force women to inhabit a dual culture, in which private moral codes emerge “off-stage” , hidden from the public sphere.¹⁷ These consist of beliefs and practices that may confirm or contradict normative, public codes. Knowing this helps outsiders to understand the contradictions between women's verbally stated ideals and their actual behaviour.

Research setting and methods

The research was conducted in the Northwest Province of Cameroon over a period of 16 months between 1996 and 1997, in the Anglophone Grassfields region, which is characterised by volcanic soil, steep escarpments and open savannah, and by numerous chiefdoms which are culturally and linguistically distinct, but share many features of political, religious and social organisation. A qualitative study was carried out in an urban area of the Grassfields to gain deeper knowledge of why women have abortions, despite the possible legal and medical consequences, and to what extent cultural and social grounds prevent a greater acceptance of modern contraceptives, apart from lack of information and availability.

The stigma of abortion dictates the secrecy of the procedure, and studying unsafe abortion requires sensitivity to women's need for privacy and confidentiality.¹⁸¹⁹²⁰ As a physician, I chose to do the research in a hospital in order to make contact with women who had had an abortion. The respondents were 58 women who had come to the hospital for treatment of complications of unsafe abortion or who had an induced abortion in their history. Another seven women who had had an abortion and had not been hospitalised were also identified for interview through a snowball sample. In-depth interviews were conducted with 65 women in all, after informed, oral consent was obtained; privacy and anonymity were assured.

A semi-structured questionnaire was used to focus the interviews, leaving women room to respond in an open-ended way. It started with formal questions and then progressed to more intimate issues. It is difficult to know whether I was given authentic answers by the women, but my confidence in the information was improved through participant observation, use of hospital records and interviews with key informants, including medical personnel.

Limited practice of contraception

Socio-cultural and moral values regarding sexuality influence women's access to and choice of contraception, and help to explain why unwanted pregnancies occur. For example, adolescents' access to education and information on sexual matters, including contraception, is largely restricted because of fear of encouraging immoral or unrestrained sexual behaviour. While the dominant moral ideology still restricts sexual activity to the marital sphere, premarital sexual relationships seem to be frequent, fostered by improvements in education, a rise in the age at marriage and young women's wish for financial support or gifts from a male partner.^* In contrast, married women have easier access to family planning through their marital status, but their decisions are influenced by their spouses and submissive gender roles, which may result in a hidden use of contraception. In general, the women relied on so-called traditional or natural methods, in particular the rhythm method, more than on modern methods. Further, they used dubious methods such as drinking saltwater immediately after sexual intercourse. Even when they chose a reliable method of contraception, there was often still a high risk of unwanted pregnancy because of insufficient information about correct use.

Making the decision to have an abortion

When women became pregnant their decision to have an abortion depended heavily on social and economic factors. For young, unmarried women, girlfriends and mothers often played a key role in the decision-making process, and gave support for seeking an abortion. Women might exclude their male partner from their decision-making, because they feared he could insist on his rights as a father and husband. Against that, unmarried young interviewees often gave as a reason for their decision to have an abortion that their partner refused to take responsibility for the pregnancy. On the other hand, some men agreed with the woman having an abortion, in particular those in premarital relationships, and gave the woman money to pay for it.

The young, unmarried women overwhelmingly cited fear of losing their educational opportunities, of their partner denying responsibility for the pregnancy and insufficient financial means. Insufficient financial means in a period of economic crisis in Cameroon was also a main reason why the married women planned to have no more children, as they were often the main caretakers and providers of food.

However, although all the interviewed women had undergone an abortion, they unanimously condemned induced abortion at the same time.²²²³ In many cases, their feelings of moral condemnation were overruled by socio-economic factors and resulted in the decision to abort. One mother of five children who belonged to the Presbyterian Church reported that in a discussion with other women when she had three children, she had said that abortion was a crime, and the others had answered: “Wait until your time comes.” Now, she said, her time had come. If she continued having children, what opportunities would they have? Her husband contributed nothing; she had only her farm and the food from the farm to feed her children. She had had an abortion. This example shows how she was able to resolve the moral dilemma for herself, while still having conflicting feelings about the illegality of the procedure and local moral values.

If abortion becomes public knowledge

There have apparently been only a few instances in the Cameroon Grassfields in which the law has been invoked after an induced abortion^* and the interviewed women were aware of the rarity of legal sanctions. Moreover, they described how public shaming and social control employed by classmates, husbands, family and neighbours in the villages were far closer to the lives of the women and had a greater impact. The women were more anxious about the response if their abortions were to become a matter of public knowledge than about the police or the courts.

“Just the way they mock them and they talk about it, is even worse than to bring them to the police. They know it is criminal. They know it is a bad thing.” (Mother of two children)

Songs that include the name of the woman who has had an abortion are sung when women are dancing together or if the woman shows up in public. The aim is to mock and ridicule her, which is very shameful for the woman concerned. For instance, they sing:

“When you are old, who will take care of you? When you die, who will bury you? ”

Or people make remarks such as:

“She has removed all the babies from her stomach. She can never have a child again.”

Further, a woman who has had an abortion can be accused of promiscuity, especially if she is young and unmarried. Besides public shaming, a woman can be forced to leave her village, and schoolgirls are expelled from school or may leave on their own to avoid public shaming. These examples of the public response to abortion illustrate the stigma attached, as well as community ostracism. They both reflect and challenge prevailing social behaviour and moral values in Grassfield society.

Abortion method chosen to preserve secrecy

Opposition to abortion by the Church and local moral condemnation can only remain without consequences for the individual woman if her abortion is performed in secret and remains a secret. The wish for privacy and secrecy, along with financial reasons, were key motivations for choosing a provider and an abortion method, which in turn decisively influenced the risk of complications. The women often attempted abortion first by taking patent medicines like chloroquine or native drugs that are inconspicuously available and cheap, such as egussi, which when referring to abortion does not denote a meal of steamed pumpkin seeds but a white substance which women apply through the vagina to induce abortion. If self-medication did not succeed, they resorted to the services of unskilled abortionists, who would carry out dilatation and curettage (D&C). Women were aware that D&C performed by trained personnel was an effective abortion method with a low risk of complications, which helped to keep the abortion secret. But the charge for a professional D&C was 10,000-15,000 CFA,^* while chloroquine cost only 30 CFA per tablet. Some women were even afraid to go to a physician precisely because physicians are allowed by law to perform abortions under certain conditions. Hence, there was no need for the physician to keep the abortion a secret, in the same way as a backstreet abortionist would have to do. Consequently, the fear of complications was in direct conflict with the need for an inexpensive, discreet procedure.

“They always hope for discretion and no complications.” (Cameroonian gynaecologist)

Secrecy a barrier to adequate post-abortion care

When complications occurred from unsafe abortions, I observed that women often presented to the hospital very late, if at all. I also observed that women sought treatment mainly in the early evening, at night or at weekends, when fewer visitors and personnel were on the hospital grounds. Adequate treatment was further complicated by women's unwillingness to admit they had had an abortion; they would give misleading histories or would not reveal anything, even if it meant they would die. For example, an 18-year-old woman was admitted during the night to the Department of Internal Medicine with a diagnosis of malaria. The next day, she was transferred to the gynaecology ward with a diagnosis of acute abdomen, heavy vaginal discharge and a positive pregnancy test. Her file read:

“History not adequate, patient withholding infos.”

She died that afternoon before surgery could be performed. Thus, women's need for discretion could conflict with the ability of medical personnel to provide adequate treatment.

Conversations with hospital personnel confirmed that taking a history from women who had had an induced abortion was a significant problem. For instance, to take an accurate medical history from a woman thought to have had an induced abortion, a nurse would start by saying: “Feel free, I am not the police. I am here to treat you” , and I have observed a physician who would give the woman to understand that he knew her secret and there was no need to hide anything. Thus, to prevent women's efforts to keep an abortion secret from ending in their deaths, health care providers needed to assure women that their abortion would not become public knowledge.

Moral condemnation of abortion

The health aspects of unsafe abortion were a serious concern to the women, and their condemnation of abortion was mainly due to the considerable physical risks, in particular, to their lives and fertility. All of the women interviewed had known a woman who had died as result of an unsafe abortion, and some of them knew women who had become infertile after repeated abortions or abortions at a young age. Beyond that, women's unfulfilled desire for children was given as a reason to condemn abortion:

“There are such a lot of people who would like to carry a child.” (Mother of three children)

However, the women rarely condemned induced abortion as a crime or for religious reasons, even though most of them were Catholic (43%) or Presbyterian (41.5%). Moreover, although their disapproval of abortion was always expressed openly and without difficulty, but not the fact of their own abortions, their condemnation was in direct contrast to their actual behaviour. This discrepancy was summed up by a Cameroonian academic as: “Do what I say, not what I do.”

Women's co-operative community meeting, Cameroon

Ways of covering up abortion

A number of strategies for keeping the intention to terminate a pregnancy vague or glossing over it emerged during the interviews. For example, women who were hospitalised with abortion complications claimed, when giving a medical history, that they had used native drugs to induce menses. Medical personnel saw that as a form of cover-up of an induced abortion.^* Thus, it helped during the interviews to use euphemisms when talking about abortion. One physician suggested using the phrase “management of unwanted pregnancy” in the interview questions instead of “induced abortion” . In general, the local experts proposed formulations which were possible to understand independent of women's educational background but with concrete reference to women's daily lives. Furthermore, it helped to use terms such as egussi. This showed I was familiar with local abortion methods, which is normally kept secret, and in addition to my being a woman, this seemed to put women at ease and promoted openness.

On the other hand, if women succeeded in hiding that an abortion had taken place, it made the act invisible, as if it had never taken place.

“Many women have done it. But if… nobody has seen you, you can keep it secret… It will be as if you had never done it.” (Interviewed woman)

“What does not become public cannot be bad. To keep your honour is very important.” (Trained midwife)

Gynaecological admissions

Altogether, 489 women were hospitalised on the gynaecology ward where I was working between November 1996 and October 1997, of whom 107 (21.9%) were admitted for complications of an induced abortion. Two-thirds of the 107 women came with an incomplete or septic abortion and eight died as a result. Their average duration of hospitalisation was four days, ¹⁰ yet some women left the hospital too early against medical advice or even disappeared. This was partly due to the costs of medical treatment, which had to be covered completely by the patient herself. In case of a curettage this could be 10,000 CFA. The unmarried women in this group, especially those younger than 24 years (65.4%), half of whom were childless, suffered worst from complications and mortality after poorly performed abortions, and this same age group formed only 4.2% of the 940 patients registered with the hospital-based family planning service.

Discussion

At the time of this study, maternal death and infertility were not merely individual women's concerns but were and remain a continuing public health problem in Cameroon.^2627282930 This study has provided an impression of women's fears and emotional response to unsafe abortion, its risks to their own lives, and the social and economic consequences of infertility in communities that highly value children and childbearing. The fear of infertility reflects women's vulnerability to impoverishment arising from husbands' diminishing interest in and favours for infertile wives, who may face divorce.³¹ Divorce means women are denied access to land, the means of production in an agricultural community.³²³³

In addition, there is anecdotal evidence that when a woman has died from an unsafe abortion her funeral is not celebrated. Bleek reports that in Ghana, if a woman has died from an unsafe abortion, during her funeral the abortion is not mentioned. Even indirect allusions to it are carefully avoided, since that is the only way to give the deceased a decent funeral. Tradition forbid a family from burying a woman if the abortion was publicly recognised. Thus, people were prepared to practise collective secrecy in order to save the woman and her family the greatest public shame, that is, the refusal of burial.³⁴

Thus, what people say as regards their values is more likely to reflect their ideals and social norms, and may include rationalisations and defense mechanisms meant to hide rather than reveal what they really think. Whereas what people actually do in concrete situations may show their real attitudes.² As with the great majority of the women interviewed in this study, who identified as Christian, Renne found in southwest Nigeria that Christian women who had terminated a pregnancy also showed no particular feelings of guilt about it.⁹

In the Cameroon Grassfields, the wish for privacy and secrecy in relation to abortion was paramount. This motivation, along with financial means, determined which abortion provider and what method were used, which in turn affected the risk of complications. As long as public knowledge was avoided, however, it seems women were able to violate the public moral code by terminating a pregnancy in a hidden sphere. It appeared to matter little that such violations were widely known to occur among the population. What mattered was when an abortion became public and was condemned publicly. The woman could be stigmatised and ostracised by the community and subsequently suffer physically, psychologically and economically. Or, as Bleek remarks:

“If the abortion is successful and remains secret, an insider would say that the woman did the right thing. This may sound contradictory, but if ethical behaviour is seen as establishing honour and avoiding shame, this attitude proves to be logical and consistent. If abortion can prevent the shame of, for example, having to leave school prematurely, it is good, but if the abortion fails, it will itself become a matter of shame and be regarded as bad.” ²

As Johnson-Hanks also argues, abortion is common among educated women in southern Cameroon because it can avert mistimed motherhood, making it protective against, and not only a source of, dishonour.³⁵ In this context, strategies have emerged like the use of euphemistic, veiled terms or words with double meanings, which help to leave the behaviour of women vague, and minimising the intentionality of terminating a pregnancy.

However, the incidence of unsafe abortion and associated morbidity and mortality still remain high in Cameroon.³⁶³⁷ While abortion matters have increasingly entered into the public debate, the restrictive abortion law is still in force.³⁸

What is to be done?

Through their need for and practice of abortion, women express, albeit secretly, their disagreement with the current restrictive abortion law. In effect, women have extended the already stringent restrictions on abortion in Cameroon through their own practice. There is a large gap between what is permitted under the current law, which is colonial in origin,³⁸³⁹ and women's need for legal abortion on broad socio-economic grounds.⁴⁰ This calls for reflection on liberalisation of the present law, particularly since it was long ago abrogated in France itself.

Even though the law is not enforced, it has a negative influence on the availability of safe and affordable services, including medical abortion. Alongside the need for prevention of unwanted pregnancies and access to safe abortion, treatment for abortion-related complications should be improved in Cameroon. In addition, guidelines should be developed for taking a medical history of women with a suspected induced abortion, in which the experience and interview techniques of local medical personnel are taken into consideration. Information should be provided to raise the awareness of health care providers to women's need for privacy and confidentiality, and to improve women's utilisation of health services. In addition, widely disseminating information to the public about what kind of physical symptoms require urgent medical help could reduce the severity of complications, long-term health consequences and mortality rates after unsafe abortion.

To avoid controversy, the authorities often try to deny the existence of the problem, and adopt a policy of neglect, which results in poor abortion-related care.²⁰ To help to break the cycle of neglect, silence and denial, the dilemmas involved in women's decision-making and the hidden practice of abortion within the “local moral world” should become the subject of public discourse.

Acknowledgements

Part of the research reported in this paper formed the basis for my PhD dissertation, “Der Schwangerschaftsabbruch im Grasland Kameruns: Medizin, Kultur und Praxis” , Department of Tropical Hygiene and Public Health, University of Heidelberg, 2004. The research was funded by a dissertation grant from the German Academic Exchange, and generously scientifically supported by Hans-Jochen Diesfeld, former Chair, Department of Tropical Hygiene and Public Health, University of Heidelberg. I owe special thanks to Arthur Kleinman, Esther and Sidney Rabb Professor and Chair, Department of Anthropology, Harvard University, for his inspiration and guidance .

Notes

* The Pastoral Letter on Induced Abortion of the Cameroonian Bishops Conference in Yaoundé says that the Church has always considered abortion a serious moral crime, and that the advocates of abortion have a rich glossary of euphemisms, circumlocutions and metaphors which aim at brainwashing the human conscience to the point where it no longer perceives the malice of abortion.⁸

* Reportedly, semi-prostitution is widespread in urban areas of Cameroon and typically involves young, single women who are students, maids, professionals or working in bars or hotels.²¹

* For example, in the Cameroon Post (9 May 1997) it was reported that a woman had been charged for abortion and illicit burial and given a three-month jail term with hard labour. Three days before she was to face trial, she was robbed of her personal effects and 78.000 CFA by boys from the quarter, who were said to have been sent by the traditional council of the village to hound the woman into exile.

* Communauté Financière Africaine franc (CFA). In comparison, a month’s salary for a schoolteacher is approximately 20,000 CFA.²⁴

* Folk concepts of delayed or suspended menstruation and the need for menstrual regulation are also part of the hidden codes of poor and powerless women in places such as northeast Brazil, but not part of the perceived reality of biomedical practitioners.²⁵