Women's Health and Action Research Centre (WHARC)
Tradition and Modernity in Cameroon: The Confrontation between Social Demand and
Biomedical Logics of Health Services
Author(s): Gervais Beninguisse and Vincent De Brouwere
Source: African Journal of Reproductive Health / La Revue Africaine de la Santé
Reproductive, Vol. 8, No. 3 (Dec., 2004), pp. 152-175
Published by: Women's Health and Action Research Centre (WHARC)
Stable URL: http://www.jstor.org/stable/3583401
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Tradition and Modernity in Cameroon:
Confrontation
between Social Demand
BiomedicalLogics of Health Services
The
and
Gervais
andVincent
DeBrouwere2
Beningzisse'
ABSTRACT
This paperexaminesthe culturalacceptabilityof biomedicalobstetricalservicesandcareacrossananthropological
literaturereview and a qualitativesurvey carriedout in North Cameroon.The results revealthat cultural
of biomedicalservicesis impairedbya seriesof requirements
suchasa too earlyfirstprenatalvisit;use
acceptability
in common of deliveryrooms,wardsand obstetricaltools; the absenceof traditionalhealinglike massageafter
delivery;refusalto handoverthe placentaand umbilicalcordto the family;and hinderingthe presenceof family
membersduringdelivery.Theseevidencessupporta transitionfromnormativemedicalsystemto an efficientand
flexiblemedicalsystemrelatedto the expectationsof the populationestablishedwith its participation.This is
2004; 8[3]:152-175)
commonlycalledpatient-centredcare.(AfJJReprodHealth
R1SUMW1
Traditionet moderniteau Cameroun:le conflit entrel'exigencesocialeet les logiquesbiomidicalesdes services
de la sant6. Cet articleetudie l'acceptabiliteculturelledes serviceset des obst&triques
biomedicaux" travers
litteraire
et
une
anthropologique
l'analyse
enqu&tequalitativemendesau nord du Cameroun.Les rdsultats
montrentque l'acceptabiliteculturelledes servicesbiomedicauxest entraveepar une s*ried'exigencestelle une
premibrevisiteprenataleprecoce,I'emploien commundes sallesd'accouchement,des sallesd'h6pitalet d'outils
comme le massageaprbsl'accouchement; le refusde rendrela
obstitriques,I'absencedu traitement
" traditionnel
le
et
ombilical
cordon
famille
et entravantla presence des membres de famille pendant
;
la
placenta
un systememedical
l'accouchement.Ces6videncesappuientune transitiondepuisun systimemedicalnormatifa"
efficaceet flexible,ayantun rapportavecl'attentede la populationetablieavecsa participation.On appellececi
communementle soin centresurlapatiente.(RevAfrSant/Reprod2004;
8 [3]:152-175)
KEYWORDS: Tradition,
obstetrical
care,Cameroon
services,
modernity,
deRecherche
enSanti(GRIS)andUnitideSantiInternationale,
SaintGroupe
University
of Montreal,
Interdiscplinaire
Edifice
5e /tage,Montreal,
Urbain,3875 rue Saint-Urbain
Quebec,H3W IVI, Canada.Fax: (1)514-4127108;E-mail
deBrouwere,
of TropicalMedicine,
ca'Vincent
PublicHealth,
Institute
.beninguisse@umontreal.
Professorof
Antwerp,
Belgium.
gervais
be
E-mailvdbrouvw@itg.
deRecherche
enSanti(GRIS)andUnitideSantgInternationale,
Correspondence:
of Montreal,
Groupe
University
Interdisciplinaire
3875 mreSaint-Urbain
5e itage,
Fax:(1)514-4127108;
Saint-Urbain,
Edifice
H3W I V1, Canada.
Quebec,
Montreal,
E-mail
ca
gervais.
beninguisse@umontreal.
Tradition
andModernity
in Cameroon 153
health centre,etc), with carefrom qualified
Introduction
health personnel (doctor, midwife, nurse,
AllAfricansocietiespossessedandmanyof etc).Nowadaysmost developingcountriesare
by a pluralityof traditionaland
themarefarfromhavinglost them specific characterised
modelsand practicesrelatingto pregnancy modernmedicalsystemsandsub-systems.An
andchildbirth.
Thesetraditional
modelsand understandingof the underlyinglogics will
of conception, make it possible to apprehendbetter the
practicesgivean explanation
the evolutionof pregnancyand childbirth, mechanismsthatareat the basisof a demand
which is consistent with the life forobstetricservicesandcare.
Startingfrom a confrontationbetween
of theethnicgroup.Theyalso
representations
traditionaland biomedicallogics, this article
define the way in which pregnancyand
seeksto identifysome of the implicationson
childbirth
areto beprotected.
Thepregnant the demandfor obstetricservicesand carein
womanobservedalimentary
andbehavioural theformof
hypotheses.
and prescriptions
prohibitions
gavebirthat
home, aloneor with the help of a matrone Methods
birthattendant)or a relative.A LiteratureReview
(traditional
networkof mutual aid and psychological
supportbetweenthewomenandtheirfamily The literatureis based on scatteredwritings
buriedin
works on particular
governed this pattern of maternity, ethnic monographic
groups in Cameroon dealing with
characterised
by simplicityof techniqueand
such as
social life
generalsubjects
sexuality,
and rudimentary
pharmacopoeia
working and organisation, procreation, etc. The
equipment.
With the scientific and technical
whichhasmarkedthe20thcentury
progress,
in the biomedicalfieldandhasfavouredthe
emergenceof what some have called the
or the "ideologyof
"biomedical
paradigm"
In addition
risk",thereareotheralternatives.
to thetraditional
formula,it is nowpossibleto
scientific study of representations and
customs relative to the expectation and
coming into the worldof childrenhas barely
begun. Between 1940 and 1996 therewere
only 23 publications on the subject.
Moreover,a number of observationsand
reservations
needto bemadeon theseworks.
Manyof theseworksrelateto a relatively
distantpast,but neverthelessthe descriptions
haverecourse
to thebiomedical
of
apparatus of customsand traditionsarestill up-to-date,
obstetricservices(hospital,clinic,dispensary, even if in contact with western cultural
mustbeunderstood
thecompkxof techniques,
Bymodelsandpractices
toa
bekefsandknowldgeof thetraditionalhealth
systempeculiar
andchildbirth.
whichlooksafterpregnany
givencommuniyw,
Thatis tosay,a complexof discourses
basedonthenotionof riskwhichclaimtoconstruct
in order
to deduce
objective
of danger
conditions
to themedicalmodeL3N
fromthemtypesof intervention
according
154
Healtb
Africanjournalof Reproductive
models (school attendance, Christianity,
modernity,etc.), some practicesaregradually
falling into disuse. We shall speak of these
models and practicesin the present tense,
without necessarilyimplyingthat they areto
be foundat thepresenttime.
Most of the authorsof these worksare
foreign ecclesiasticsor missionaries.Since
they are strangersto the culture they are
investigatingit is not alwayseasyfor them to
interpret, understand and faithfully
reproducewithout error or aberrationthe
lexicaland anecdotalnuancesof the idioms,
whichareso numerousin the languageof the
people they are dealing with, particularly
when they are concernedwith subjectsas
emotional as those relatingto sexualityand
reproduction.It maythus be fearedthattheir
writings have left free rein to arbitrary
prejudices, as Laburthe-Tolra' notes,
followingTessmann2:theirfrequentinability
effectivelyto judgefreelyandpresentthe facts
in a purely scientific manner, without
tendentiousnuances,prejudicesthe valueof
theirstudies.
Moreover,since these works were not
specifically undertaken for the study of
culturalaspects relativeto pregnancy,they
frequentlyremainsuperficial.The difficulty
of describing symbolic ' representations,
customs and practicesrelativeto pregnancy
and childbirthis not entirelyattributableto
the observers:it is also due to their complex
andsometimesesotericnature.
In spite of theirlimitations,theseworks
Far North
=
Mada,
Fufuld.,
Kirdi.
Mbororo,Mouyeng,Fali
* Centre/South/East= Bafia,Banen
Bassa (Nyong-Ekele),Beti,Kaka,
MakaPahoin,Yambassa,Baya,
Pygm6es
* Coast/West
= Babouantou,
Uangoua,akoko ,Bandjoun,
Bassa (Sanaga Maritime),Duala
.ii:
ii
Extreme
North
South-West/
NorthWest
=
Wuli
.Adamaoua
Coast
--
Figure1 GeographicalDistributionof the
EthnicGroups
TheQualitative
Survey
The qualitativesurvey was carriedout in
1997 in the form of group discussions.The
objective was to examine women's
perceptions of traditional and biomedical
systems of obstetric servicesand care in a
particularly unfavourable epidemiological
context. The region of North Cameroonis
the worstfromthe point of view of neonatal
mortality,availabilityof health servicesand
the use biomedical obstetric services.3The
methodologyof the surveywas simple.The
actually are the only basic material currently
way was prepared for it through the
available for any study of pregnancy traditionalauthorities
(village and district
representationsin Cameroon.
means
chiefs) by
of meetings for giving
informationand explanationsto traditional
Tradition
andModernity
in Cameroon
birth attendants, their patients and their
partners. Introduction of the survey to
traditionalauthoritieswas facilitatedthrough
accompanimentof a well-knownmemberof
staffof the local obstetricservices(a midwife
or a nurse)and a guide who also acted as a
translatorand interpreter.The discussions
were carried on with two categories of
informants:(i) traditionalbirth attendants;
and (ii) the clients,i.e. womenwho hadgiven
birthat leastonce with the help of traditional
birth attendantsand some who had given
birthatleastonce in hospital.
In orderto take partin these discussion
groups the only requirementwas to be a
traditionalbirth attendantin activepractice
or a clientandto be readyto answerquestions.
We recordedno refusals.A programmeof
discussions was prepared in advance. It
coveredthreemain themes:(1) the roleof the
traditionalbirth attendantand his/hersocial
representation; (2) opinions on the
motivationsfor the preferentialchoicesin the
care of pregnancy and delivery; and (3)
opinions on the conditions of work and
qualityof careby thevariousprovidersof care.
The applicationof the programmeof
discussions varied from group to group
accordingto the interestof membersof the
group in the themes under discussion. In
general,the atmosphereof the groups was
relaxed,makingit possibleto go thoroughly
into the subjects.The averagelength of the
discussionswastwo hours.Writtennoteswere
takenand the discussionswere also recorded
on audio tapes. Altogether four group
discussionswerecarriedout in the villagesof
Wak, Karnanga,Garoua and Ngaoundred,
with 24 members:eight female traditional
birthattendantsfromthe villagesof Wakand
155
Karnanga;two male birth attendantsfrom
Wak and Karnanga; eight female birth
attendantsfromNgaoundard;threeclientsof
traditionalbirthattendants;and threeclients
of theGarouahospitalcentre.
Results
TheSocialConstruction
in Cameroon:
of Pregnancy
Traditional
and Biological
Knowledge,
Physiology
Mechanisms
of Conception
Preventivebehaviourof a gestatingwoman
depends in part on her knowledge of the
physiologyof her organsof reproductionand
the biological mechanisms of conception.
This determinesher ability to identify and
detect her pregnancyat an earlieror later
stage.Beliefspertainingto the physiologyof
conceptionare usefulhere to the extent that
theymakeit possibleto betterunderstandthe
logicon whichpreventivebehaviouris based.
Conception is seen in most Cameroon
ethnic groups as the result of a mingling,
within the vaginalorifice,followinga sexual
relationship,betweenthe fertilisingmaleseed
(sperm)andfemalemenstrualblood. Forthis
minglingto producefertilisationit musttake
place at an ideal moment, which varies
betweenethnicgroups.Amongthe Beti4'it is
believedthat fertilisationcannot take place
while the woman's menstrualblood is still
fresh(thatis, when it is flowing),for thatis a
clear sign of the transgressionof the sexual
prohibition during menstruation. It is
preferable to wait until the end of
menstruation,when the menstrual blood
remainingin the vaginal conduit is partly
dried, so that the mingling of sperm and
156
Health
AfricanJournalof Reproductive
femaleblood mayleadto the formationof the
embryo.Moreover,the child will be all the
morevigorousif the spermand femaleblood
meet at a better time, that is, after
menstruation.Among the Yambassa(Begunu
tribe)'the chancesof conceivingarebelieved
to occurjust beforemenstruationorjustafter
aboveallnot duringmenstruation,forthereis
then a riskof violentheadaches,whichwould
hinderanylaterfertilisation.It is thoughtthat
just before menstruationthe vaginalorifice
combines all the conditions necessaryfor
fertilisation.Similarly,aftermenstruationthe
vaginalorifice, having been emptied of bad
blood,is readyto receivea pregnancy.Among
the Bassa',for fertilisationto take place it
mustoccurin the middleof the cycleandafter
menstruation (about two weeks), but
compatibilityof blood betweenthe parentsis
indispensable. This compatibility is
determinedaposteriori
when therehas been a
failureto fertiliseaftera sexualact performed
in themiddleof the cycle.
Menstruationis the necessaryoutflowof
blood that has become impure and even
harmful;it has been unableto contributeto
the formationof the embryo as a result of
being deprivedof its fertilisingforce.Among
the Bassa,6
awitch-doctorcoulduseit to bring
on evilspellssuchasbarrennessin thewoman.
It is necessary,therefore,to be prudentduring
the menstrual period particularlythrough
carefulanddiscreetintimatehygiene.
Sperm, also known as "sign of life",
"virile fertilisation force", "white blood",
caused by sexual excitement. Sperm is in
principlealwaysfertilising.In the event of a
failureto fertilise,the faultis mostlikelyto be
foundin thewoman.Shewill be invitedin the
first place to confess any transgressionof
prohibitionsor to admit her involvementin
sorcery and then subjected to therapeutic
treatmentby drugsand/orritualat the hands
of a soothsayer/healer.
'4'5' Since sperm is
destinedto give life, it is made sacredto the
point that it is not permittedto spoil it by
diverting it from the vaginal orifice, its
ultimatedestination,by masturbationor any
othercontraceptiveprocedure(suchasthe use
of condom). In additionto this efficiencyin
the biologicalprocess,spermis recognisedas
having the virtue of nourishing,supporting
and promotingthe developmentof the fetus.
Accordingly, sexual relations will be
continuedduringgestationandinterruptedat
a certainlevel of developmentof the fetus,
varyingbetweenseven and eight months of
pregnancy,in ordernot to "soil"the infant
with deposits of sperm that would make it
viscousorleaveit with a coldatbirth.
It is the "children'scords"(the ovaries)
thatpermitthe secretionof femalemenstrual
blood and ensure its transmissioninto the
vaginalorificeto leaveroomfortheencounter
with seminalliquid."4'8
From this encounter
areformedthe fetus(whichis stillonlya paste
or a concentrationof blood),the "bellywater"
(amnioticfluid) and viscousmatters.Forthis
purposea certaintime duringwhich thereis
an absenceof periods(amenorrhoea),
varying
accordingto ethnicgroup,must be observed.
Amongthe Bamilekk(Babouantoutribe),it is
at least two lunations(two months).'At the
end of a monthofamenorrhoeasomewomen,
"man's blood", etc, is a liquid derived from for example,the Bassa,6mayfeel the gurgling
male blood, produced in the lumbar areaand of the fetusin formationabovethepubisor in
stored in the testicles. It is evacuated from the
testicles following the warming up of the body
the right iliac fossa.
Tradition
andModerni-y
in Cameroon
The mingling of the sperm and female
bloodduringthe idealperiodfor conception,
even in a physiologicallyfertilewoman,does
not necessarilylead to fertilisation.This
minglingmust firsthavebeen blessedby the
transcendentand divine powers: this is the
spiritualor mysticdimensionof physiological
paternity. For from the moment the
physiologicalmechanismsof conceptionare
initiatedthe influenceof God, ancestorsand
earthspiritsis recognised.Conception then
appearsas the resultof copulatoryactionby
the parents, favoured by the providential
actionof transcendental
forces.1,4',,"'
Intrauterine
Life
Mostpopulartraditionsestimatethe duration
of a normalgestation at between eight and
nine lunations.When it is more than nine
lunations it is thought that the child is
sleeping, either because it thinks that the
conditions requiredare not yet in place, or
because God or the transcendentalpowers
havewilled it thus, or becausethe woman is
the victim of sorceryor mischance.Among
the Boubouantou,'however,the length of
gestationdependson the sex of the fetusand
on whetheror not it is twins. It is undernine
months for girls, nine months for boys and
over nine months for twins. The best
documentedillustrationof the stagesin the
developmentof the fetus is given by Daniel6,
Ombolo4and Onana Badang5for the Bassa,
Beti and Yambassa.The fetus passesthrough
thefollowingstages:
During the first two moons without
periods the embryo is still in the mollusc
phase, in the form of a small lizard. It is
described as "a quarterofa moon rounded at
157
one end with a kind of tail at the otherend".
Duringthe periodthe seminalliquidand the
femalebloodaremingling,the womansuffers
malaisessuch as fatigue,nauseaandvomiting
mainlyin the morning,frequentcravingsfor
sleep, a change in the pigmentationof the
breasts,etc, which are signs of a possible
intrauterinelife. Nevertheless,it is necessary
to be surethatthereis in factintrauterinelife.
Towardsthe third moon the limbs become
more distinct and resemblesmall buds; the
arms,then the legs. Betweenthe fourthand
fifth monthsall the limbsappearand develop
further,and the child'ssex can be recognised
particularlyfrom its position, its movements
and certainphysicalsigns.At this periodthe
woman regularlyfeels capriciouscravings.In
the sixth month the eyes, some hairand just
the roots of the nails can be seen. In the
seventh month, with the appearanceof the
nails, the child is completelyformed.Sexual
relations may now become less frequent,
finallyceasingat aboutthe eighthmonth,and
the time has now come to preparefor the
birth.
Throughoutthesestagesthe childleadsa
full intrauterinelife. It usually occupies a
stretchedout position along the pelvis and
makes movements, which are felt by the
woman. These movements are frequently
interpretedeither as "journeys"or as "fitsof
angeror signsof a misfortune,which is latent
in the family" (when they are particularly
violent).Throughthe mother'sbackthe child
"sees"what is happeningto the mother'srear
and could even resemblewhat it sees.Among
the Sawa(Duala)'2the pregnantwomanwill
benefitfromallowingto passor sleepbehind
her any personnoted for the delicacyof their
features or the elegance of their gestures.
Health
AfricanJournalqf Reproductive
Similarly,shewill be well advisedto avoidany
person whose physical features or moral
areconsideredundesirable.
characteristics
The fetus sleeps and wakes at regular
intervalsby day and by night. It feeds,either
by mouthor by the cord,on the food eatenby
themother,whichis in the amnioticfluid.It is
thoughtthatat six monthssexualrelationsare
sufficientto nourishit. It may be satisfiedor
not by its mother'sfood. If it refusesthis food
the mother will feel nausea (frequently
followedby vomiting) and sufferdiarrhoea,
crampor flatulence.The fetusmaywantmore
food and the mother will then feel hungry.
Finally, the fetus often feels the need to
urinate.In that event the motherwill suffer
from pollakiuria (the need to urinate
frequently).
This brief survey of beliefs and
knowledgeon the physiologyof the genital
organs and the biological mechanisms of
conception revealsa richnessof symbolism
foundedon the spiritualand natural(thatis,
On thesebeliefs
the "properly
physiological").
and knowledge will depend the social
experienceof pregnancyin its psychological,
physicalandbehaviouraldimensions.
158
TheSocialExperience
of Pregnancy
A woman's realisationof her pregnancyis
basedon the classic"presumptive"
signssuch
as the absenceof periods;a frequentfeelingof
fatigueafterperiodscease;engorgementof the
breasts (felt in the form of contractions);
nausea,mainly in the morning;pain in the
lower abdomen,etc. Once the pregnancyis
identifiedor presumedits social experience
will depend essentially on a preventive
therapeuticprogrammeconsistingon the one
hand of divinatory consultations whose
objectis to ensurethe properdevelopmentof
the pregnancyto determinethe sex of the
childandwhetherthey aretwins andon the
other of alimentary and behavioural
prohibitionsandprescriptions.
Divinatory Consultation, Purificationand
Exhortation
The divinatory consultation occupies an
important place in the process of
childbearing.It is a techniqueof investigation
usedto probeand interrogatethe invisibleon
the physiological state of the pregnant
woman, and to identify the dangers and
meansof counteringthem. It is partof a logic
of purificationand preventionof threatsand
anomaliesto which the woman may become
subject during this process. Among the
Banen,'3pregnancyis inauguratedwith a rite
knownas "purification
of the seed",eitherby
a bathin purewater(drawnfroma springat
dawn in a new vessel by a virgin) or by the
sacrificeof a braceof birds. In additionthe
one who hasan
pregnantwoman,particularly
excessof blood (assimilatedto polyglobulia),
will undergoa rite known as discharge,the
object of which is to prevent congenital
malformations.Among the Yambassa5
the
of
the
with
consultation
a
divinatory
object
of
means
the
soothsayer/healer
(by
trap-door
spider)is to determinethe sex of the infant
andwhetherit is twinsaswell as to ensurethe
good healthof the fetus and motherand the
normal developmentof he pregnancy.The
divinatory consultation may lead to a
therapeuticprogrammeof drugs or ritual
Thisritewill bean opportunity
for thepregnantwomantoget ridof herexcessblood(infusionsof
libations,scarifications
TraditionandModernityin Cameroon
according to the revelations by the trap-door
spider. Among the Babouantou,' as among
the Wuli," the divinatory consultation is
justified only by the occurrence of a health
problem or a complication (for example, the
threat of abortion) during the gestation and
only for therapeutic purposes. It is also an
occasion for forecasting the course of the
delivery.
and BehaviouralProhibitionsand
Alimentary
Prescriptions
In order to ensure a fortunate term to the
pregnancy and preserve the baby from any
physical or congenital flaw (malformation or
defect), the pregnant woman and her partner
are required,separatelyand in their common
life, to observe a number of alimentary and
behavioural prohibitions and prescriptions.
These become severer as the pregnancy
progresses. Some of the prohibitions and
prescriptionsare of a general nature and fixed
a priori,while others, more individualised, are
imposed later as the result of divination by the
soothsayer/healer.As in many other African
societies," pregnancy in the ethnic groups of
Cameroon passes through three major stages
corresponding to the three trimesters,each of
them with specific prohibitions and
prescriptions.
The first stage corresponds to the first
trimester of pregnancy (one to three lunar
cycles with no periods). The woman believes
that she is probably pregnant on the basis of
the classic signs described above. At this stage
it is believed that the product of conception is
merely a mass of blood, a mollusc, which is
not yet a true pregnancy. The woman has
every interest in keeping the news secret, far
from jealous and malevolent spirits', and in
159
ordernot to anticipatethe divinewill of the
powersof the beyond(geniuses,ancestors)on
a pregnancy that is still uncertain. This
discretion in the early stages allows the
woman to avoid the ridicule,which a false
alarm of pregnancycould bring. She will
speakof it only to close relativesin case of
necessity.In certainethnicgroupssuchas the
womenmaynot evenspeakof it to
Yambassa,5
theirhusband,becauseit is the husbandswho
betraythe secretof their new physiological
state in their conversations with other
members of the group. The husband, of
course,will noticethe pregnancyforhimself.
This permanentconcernfor discretionmay
constitutean obstacleto the woman'suse of
antenatal services, particularly an early
enoughfirstconsultation,whichaccordingto
current norms ought to take place latest
duringthe firsttrimesterof pregnancy.It may
be perceived as a potential occasion for
breakingthe secret and thus as a sourceof
danger.
The second stage correspondsto the
second trimesterof pregnancy(threeto six
lunar cycles with no periods). During this
period the woman gains the status of
pregnant woman". This is the time to
observe the alimentary and behavioural
prohibitions and prescriptions.'4Although
she is now certain of her pregnancy,the
woman will still pretend not to know this
even thoughshe can no longerdeceivethose
aroundher, the older women (experienced
multiparas)and traditionalbirth attendants
who are able to detect the pregnancyin its
early stages by physical signs. First they
observea change in the woman's features,
with the occurrenceof a palecomplexion,the
appearance(orthe increase)of pimpleson the
face and a reddishdown extendingfromthe
160
Health
AfricanJournalof Reproductive
templesto the cheeks."'This changeis well
known in medicine as chloasma or
mask".When theybathetogether
"pregnancy
in the riverthe "womenwho know"notice
that the pregnantwoman has a black line
running from the navel to the pubis. In
addition "the breasts have acquired a
handsome chestnut colour, with the tips
completelyblackand surroundedby aureoles
of smallspotsinsteadof beinguniform".'The
womanwill frequentlybe the subjectof jokes
fromherfriends:"sheissuffering
fromagood
illnesswhichis only a matterof time,"saythe
Yambassa.5
Finallythe thirdstagecorrespondsto the
last trimesterof the pregnancy(six to nine
lunarcycleswith no periods).This is a crucial
stagewhen the prohibitionsandprescriptions
are even stricter in preparation for the
delivery.The pregnancyhas developed,the
abdomenhasgrownin sizeand the womanis
beginningto feel the fetus moving. It is no
longer possible to conceal the fact of
pregnancy.To any who enquiresabout the
physiologicalstateof hiswife thehusbandwill
almostalwaysreplyby periphrasessuch as "I
chasedthe animalandkilledit".5
Prohibitions
Alimentary
andPrescrptions
are
Alimentaryprohibitionsandprescriptions
the
taken
to
ensure
the
among
precautions
birth of a healthyand normalchild, that is,
one free from any physiological,physicalor
psychologicaldefect.Generallyspeaking,the
pregnantwoman must avoid any food that
can give rise to a physical or psychic
indisposition. Since the fetus feeds on
whatever its mother eats, any malaise
following the eating of a particularfood is
perceivedasa refusalof thatfood by the child.
The alimentary prohibitions
and
are
of
such
that
it is
diversity
prescriptions
difficultto give an exhaustivelist.As Table1
shows, they concern all categoriesof food
(meatand fish, fruits,vegetablesand starchy
foods, tobacco and alcohol), frequently
deprivingthe womanof nutritionalelements
necessaryfor the properdevelopmentof her
pregnancy.
Althoughsome foods areproscribed,
othersarestronglyrecommended.These are
generallyfoodsthataresymbolsof fertility(or
of fertilisation) or which have virtues
facilitating delivery. Eating these foods
amountsto repeatingthe actof fertilisationby
the oralroutein orderto neutraliseanymove
for the destructionof the fetus by negative
forces.In orderto ensurepropernourishment
of herbodyandthe intrauterineenvironment
and avoid giving birth to an underweight
baby,a pregnantBassawoman'will eat large
quantitiesof beef (exceptthe feet) and palm
(whiteworms),whicharereputed
caterpillars
to be particularlyrichin proteins.In orderto
avoid anaemiaand facilitatelabourand the
expulsionof the child a pregnantYambassa
woman' will eat a great quantity of gourd
leaves, okra and cassava.She will seek to
protectthe skinof the fetusandstrengthenits
bones by eatingkaolin (whiteclay).In order
to overcomefatigue and ensure a sufficient
supplyof milk, a pregnantBafiawoman"will
eatvegetablesoups.
In some casesthe fatheris alsosubjectto
certain alimentary prohibitions and
prescriptions.Among the Bassa6he must
preservethe purityof his blood by avoiding
drunkennessandabstainingfromeatingviper
and certain fishes; palm rat (which lives
Tradition
andModernity
in Cameroon
161
Table1 AlimentaryProhibitionsand Prescriptionsaccordingto EthnicGroupsin Cameroon
Description
Category
Meatandfish Birds
in caseof transgression
Ethnicgroups
Consequences
of
breasts
in
1. Prevents
development
pregnant Bassa,Beti
women
Fish(silurid,
carp,
machoiron*)
2. Haemorrhage
andriskof abortion
inwoman Bakoko,
Bassa,Beti,
3. Childwouldbebornwithout
Yambassa
physical
careless
andindolent,
with
consistency,
ordermatoses
bronchitis,
epilepsy
1. Childwouldbebornwithanelongated
Beti
Reptiles
body Bakoko,
2.
andriskof abortion
inwoman; Banen,Bassa,Beti
Antelope/wart-hog
Haemorrhage
childwouldbebornwitha chronic
stateof
with
convulsions
or
dermatoses
somnolence,
(ofleprosy)
Wildrat/crow
3. Riskof abundant
Bafia,Bassa,Beti,
haemorrhage
during
Yambassa
delivery
4. Riskof infant's
deathfromchronic
diarrhoea
I. Causesoraggravates
inwoman
Maka
oedemas
Porcupine
Snails
2. childwouldslaverallitslifeorwouldbeborn Bassa,Beti
withhepatitis
baboon 3. Childwouldbebornwithchronic
Dog-faced
whooping Beti
cough
Elephant/buffalo 4. Childwouldbebornwitha largehead,coarse Bassa,Beti
skinorfan-shaped
ears
5. Childwouldbebomwithconvulsions
Monkey
Beti,Yambassa
6. Riskof chronic
orbeingbomwith Bassa,Beti
Pangolin/weaver-bird
impotence
epilepsy
Guineafowl
7. Riskof retention
of childorplacenta
atdeliveryFoulb6s
8.
Child
would
be
bom
toobig
Pig
Bafia,Bassa
Bassa
Chimpanzee/gorilla9. Childwouldhavetheirfaceandtheirwalk
of
child
a
murderer
Bassa
10.Risk
Leopard/lion
being
I1.Child
wouldbebornwithchronic
rickets
Duckorbat
Bafia,Beti
12.Child
wouldbebomwithout
hair
Egg
Beti,Yambassa
and Pineapple/banana 13.Child
wouldbeborncovered
withscabs,sores, Beti,Bassa
Vegetables
fruits
scratches
oroedemas
Taro
14.Child
wouldbeborncovered
withdirt;preventsBeti
closingof fontanelle
Kolanuts
15.Child
wouldbebornwithharelip
Yambassa
Beans
16.Problems
withspleeninchild
Banen
Yams
17.Leadstostammering
inchild
Beti
Macabo
18.Riskforchildof diarrhoea
anditchesinthroat Bassa,Yambassa
(red)
19.Reduces
ofmother's
milkbyexcessive Bassa,Yambassa
Sugarcane
quality
dilution
Cassava
leaf
20.Reduces
of mother's
milkbyexcessive Bassa
quality
dilution
Alcohol
Palmwine/beer
wouldbebornunder-size
andweakly Yambassa,
21.Child
Duala
22.Child
Tobacco
wouldbebornunder-size
andweakly Yambassa
*
Themachoironis a fish with sharp spines
Health
AfricanJournalof Reproductive
undergroundand is supposed to touch the
dead);snails,at the riskof makingthe childto
be born slaver;antelope(whichwould make
the childtremble);tortoise(forthen the child
wouldsufferfromdiarrhoea);or monkey(the
childwouldbe bornwithoutfingers).
162
Tobacco
andAlcohol
Generally speaking, the consumption of
tobacco and alcohol by women is regarded
negatively.It is seenasa signof badeducation,
social debaucheryor negativeemancipation.
A girldoeswell to avoidsmokingor drinking
at the riskof being rejectedand ill-thoughtof
by men. Only menopausal women can
ventureto do so. Smokingand drinkingare,
in principle,bannedforpregnantwomen;the
child would be born small and lacking in
vigourand would developinto a smokerand
alcoholic. In some cases the daily
consumption of a moderate quantity of
alcohol after birth palm wine among the
Yambassa,beer among the Duala promotes
thesupplyof milk.
nsandPresriptions
BehaviouralProhibitio
During gestation the woman is requiredto
redoublehervigilancein the matterof social
morality.Thus, she will avoid any conflicts
with those around her, touching other
people's property, offending a child, or
harming a domestic animal at the risk of
or a difficultdelivery.''""
havinga miscarriage
Gestures
andConduct
tobeAvoided
orObserved
womanwill take carenot to go neara grave,
enter the house of a dead or dying personor
takepartin a ritualassociatedwith death(for
examplea funeral).Among the Mouyengof
the North"' a pregnant woman will avoid
speakingof or referringto a miscarriage,a
deathin uteroor a difficultdelivery;lest that
shouldhavean evil influenceon the progress
of the pregnancy and the course of the
delivery.
For the risk of having the child
reluctant to emerge during delivery, a
pregnantBetiwoman4will not speakfromthe
thresholdof a house, but only when she has
passedthrough it into the interior.For the
samereasona Bassawoman6will neverremain
on the thresholdor lean out of a window.To
ensurea good presentationfor the fetus the
Bassawoman'will nevercrossher legs when
she is sitting down, or carrya hoe roundher
neck,or plaitotherwomen'shair.Forthe risk
of havinga difficultlabouror restrictingthe
passagefor expulsionof the fetus,shewill not
close the door with both hands, will never
embracestrangers(breastagainstbreast),and
will not touch the morning dew or spiders'
webs obstructingthe passage.She will avoid
splittingwood for the riskof havingherchild
born with a big head and wide fontanel.So
that her child may havea happyfaceshe will
avoid any attitude suggesting sadness. To
ensurethat her childwill havefine eyesand a
or Bassa
pleasant look, a pregnant Beti4"'7
woman6will never look with one eye into a
bottle or the hollow of a tree,will not drink
froma gourdwhile raisingherhead(thechild
would have a squint) and will not touch
incense(the childwould be bornwith pus on
its eyes). A Beti woman4 will avoid
approachinga chameleonlest her childsuffer
Dead body,or anythingconnectedwith it, is
to be avoidedasmuch as possible,forthatcan
be banefulforthe childto be born.A pregnant from a state of chronic emaciation.
Sincehewillstillbenourishing
thefetuswithhisbloodthrough
sexualrelations
TraditionandModernityin Cameroon
For the hygieneof the fetus, a pregnant
Bakokowoman8will takea purgeeverytwo to
four days.A Babouantouwoman' will avoid
takingoff the fireor puttingon to it a pot with
a lid. She will take careto removethe lid for
the riskof giving birth to a dumb child. To
preserveher child from any characterof
violence,a pregnantBassawoman6will weara
palmleaf fibreroundher neck and her loins.
She will alwayslook at something beautiful
andwill be carefulaboutwhom she eatswith,
for this will make sure that her child will be
wise, good naturedand of pleasantmanners.
A pregnantBeti woman' will make herselfa
piece of "armour"to protect her pregnancy
againstevil influences,gettingher motheror
other trusted person to make her a "bellyband"of rattanfibres(threeknots to the left
andthreeto the right),wornaslow aspossible
so as to avoid restrictingthe growth of the
fetus,which she will takeoff only at the time
of delivery.To avoid an abortion,a pregnant
Bassawoman7will wearroundherloins,from
the firstweeksof her pregnancy,a ropemade
from some vegetable fibre (for example,
rattan),which is difficult to cut with hand,
with nineknots.Shewill keepthison untilthe
ninthmonthof pregnancy.
during
Pregnancy
PlysicalActivity
Physical activity usually continues during
gestation,thoughas a rulea pregnantwoman
gets help from membersof the family (her
husband, mother-in-law,children, etc). A
pregnantBakokowoman'carrieson herusual
occupationsuntil the end of her pregnancy,
which sometimesleadsto prematuredelivery
in the plantationsor while fishing.A Banen
woman will continueworkingas long as her
163
pains permit. Physicallabour is sometimes
prescribedwith the idea of makingthe fetus
moveandasa methodof relaxationforlabour.
Among the Bassa6a pregnantwoman will
avoidviolentand arduousphysicalworkuntil
the 6th or 7th month of gestation.Fromthe
7th or 8th month, however,this typeof work
is particularlyrecommendedfor her in order
to give her the drive,courageand endurance
required for the ordeal of delivery.
Nevertheless,while doing this work,she will
be carefulto rest from time to time and will
avoid working in a steady and continuous
fashion.Periodsof relaxationof the muscles
(stretchingof the limbsandbody)arestrongly
recommended.
At the oppositeextreme,a pregnantBeti
4 .
woman is progressivelyrelievedof her usual
occupations as her pregnancy follows its
course.She receivesa greatdeal of help from
herfamily.
Gestation
during
SexualActivity
In many ethnic groups sexual relations
between the partners continue until an
advancedstageof the pregnancy,thatis, until
the child is judged to be completelyformed
andviable.This is a prescriptionthatis based
almostentirelyon the nutritivevalue of the
seminalliquidforthefetus.Amongthe Bassa,6
if the fatherfalls ill or is obliged to go away
beforethe child is completelyformedin the
womb, his contribution is replaced by a
therapeuticprogrammeof drugsconsistingof
(i) a food based on gelatinous plants like
ndjango,okra and wild mangoes; and (ii)
enemas made from mucilaginous plants
alternatingeverytwo days,for example,once
with leaves of hibiscus and the pollen of
164
Health
AfricanJournalqofReproductive
flowers,anothertime with leavesof nvagmikobTheDelivery
(stickyedible leaves).Among the Yambassa,'
for example,it is believedthat the fetus can When a pregnantwoman has nine or ten
developonly as a resultof the sexualrelations, notcheson the stickthatshe usesto markand
which the parentswill continue to maintain count her "moons"her partnerand she will
during pregnancy.In their view a pregnant preparethemselvesfor the fatefuleventof the
woman benefitsfrom not being deprivedof delivery.Aftershe hassucceededin protecting
"man'sblood" (sperm);otherwiseshe might herpregnancyagainstevil spirits,herdelivery
give birth to a puny and sickly infant.This is the finalcrucialstage,whichis awaitedwith
beliefis alsofound amongthe Beti,"'4''7
where a mixture of hope and anguish. The final
it is thought that sperm contributesto the divinatoryconsultationswith a soothsayerare
better physical fashioning of the child. carriedout with the objectof forecastingthe
Among the Babouantou,'in addition to its result of the delivery and prescribing
directives.The womanwill eatby
nutritiveand fortifyingvirtue for the fetus, appropriate
sperm is recognisedas having a therapeutic preferencesticky foods, will have frequent
mechanicalpropertyfordelivery.It is believed enemas based on gelatinous liquid, will
to promote the mechanicalenlargementof engagein physicaleffortsin orderto promote
the passagefor the expulsionof the fetus.A the dilatationof the uterinepassageand will
womanwho deprivesherselfof it or suspends relaxher musclesin preparationfor the pains
sexual relations with her husband of givingbirth.
prematurelyrunsthe riskof a difficultlabour
and delivery,since her genital organswould Place of"Delivery:A CongenialAtmosphere
theMother's
Intimacy
have lost the habit of being dilated Preserving
Nevertheless
sexual
relations
mechanically.
are not generallyrecommendedright up to The place of deliveryis selectedto meet the
the end of the pregnancy.As a ruletheybegin, permanentconcern for discretion,security
forvariousreasons,to die down betweentwo (forexample,the fearof malevolentsorcerers)
andthreemonthsbeforethe birth.Amongthe and a congenialatmosphere.The parturient's
is very frequentlythe most
original
Beti4thesuspensionof sexualrelationsshortly suitable familyWhen
this is the choice, the
place.
before the birth is justified on hygienicand
maternalfamily,with the parturient'smother
sanitary grounds. It is necessaryto avoid
providingcare,takesa solemn commitment
incommoding the traditional birth to ensurethe
safetyof the delivery.Amongthe
attendantsby the deposits of sperm on the
infant'sbody createdby the non-observance Bassa7thereis an old adage:Muta topbeiyana
"No one hasthe rightto makea
of thisprescription.In additionby findingits sop(meaning
hole in anyoneelse's gourd.A mothermust
way into the mouth of the fetus the male
make a hole in her own gourd");that is, a
seminalliquidmight give the infanta cold in
mother must make herself responsible for the
the head.
safety of her daughter and must accept the risk
TraditionandModernityin Cameroon
of somethinggoingwrong.For,as amongthe
Beti4,the motheris the personwho can best
look afterher daughterwithout repugnance.
Deliveryin the paternalfamily,though not
totallyexcluded,is a secondbest.As much as
possiblethe father'sfamily will be avoided,
since they may havereasonsfor resentingthe
new infant (jealousy,competition between
childrenfor the family inheritance,etc). In
the mother'sfamily of origin on the other
hand, the safety of mother and child is
guaranteedand will be the objectof attentive
anddelicatecare.
In generalthe deliverytakesplace in a
discreetplace, far from envious and jealous
glances that might cause or prolong the
mother'ssufferings.A deliveryin public is
almostalwaysperceivedas a calamity.Among
the Beti' it is thought that an enemy might
collectthe parturient'sblood in orderto bring
about the deathof the newbornand prevent
all future births. It is for this fundamental
reasonthat a woman will choose as much as
possibleto givebirthwhereshewill feelsafest
(in her native village, in her mother'sor a
sister'shouse).
The deliverytakesplace in the kitchen,
behindthe familyhut, on the deliverystone,
on the ground,on a mat, on leavesor undera
bananastem, or on a bamboo bed made for
the purpose.The spaceis preparedfora single
parturient,for it is out of the question for
several women to give birth together. It
frequentlyhappens, as the result of some
imprudenceorpoorpreparationforthe birth,
thata pregnantwomanis overtakenby labour
or deliveryfarfromhome in the fields,at the
marketplaceor while travelling.When labour
begins and the pains become increasingly
pressinga Yambassawoman5tries to retain the
165
childin herwomb until she gets to the family
home. Shewill pickup a pebbleandholdit in
her teethwhen she feelsa labourpain.This is
an essentially psychological therapeutic
measure.When, in spiteof everything,a birth
farfromhome cannotbe avoidedthewoman
is leftto herown resourcesandwill bereadyto
acceptanysuitablehelp,evenfroma man.
Assistance
in Childbirth:
IntheFirstPlacea Matter
fbrWomen
Childbirthis in the first place a matterfor
women,anexaltationof femininity;andmen,
includingthe fatherof the child, must keep
awayfrom the place of delivery.Among the
Ewondo (Beti tribe)'9and the Fufuldd,men
are called on in the event of a mechanical
dystocia,theirrolebeing mainlyto shakethe
parturientvigorouslyin order to accelerate
the descent of the fetus. In other ethnic
groups, like the Wuli" and the Kirdi,20the
function of birth attendant (which is
generallyhereditary)mayfallto a manaswell
as a woman. Among the Wuli," the male
holder of this post will choose his successor
fromamonghis children,niecesor nephews.
He inheritsthe ritualpost andthesecretof the
plants accompanying the ritual, but
whicheverof his wives was born outsidethe
norms will be his assistant,will inherit the
necessaryknow-how and the secret of the
plantsassociatedwith it. In most of theethnic
groups of North Cameroon the traditional
birth attendantis preferablyfemale, a man
being tolerated only if he belongs to the
family,and particularlywhen a mechanical
dystociais involved.Among the Fali,22only
the woman'spartneror his brothersmay be
presentat the birth but may not intervene
directly.
166
Health
AfricanJournalof Reproductive
The breaking of the waters occurs
Relativeto the Delivery:
Gestures
andProcedures
and
automaticallyunderthe effect of the uterine
Flexibility Congeniality
contractionsor is broughtaboutmechanically
The firstshootingpainsin the loinsandlower by the matrone
aftervaginalpalpation.Among
abdomen mark the beginning of labour. the Fali22this liquidhasfertilisingvirtuesand
Amongthe Bassa'thesepainsgive the feeling beneficialqualitiesforhealth;accordinglythe
of"a firecloseto the pelviswhich givesriseto women presentat the birth rub themselves
A with it.
a heat that in the long run is unbearable".
Delivery is then achievedwith the
Yambassawoman' performsher toilet and
emergenceof the newborn, usually by the
preparesthe place where the birth will take head,andthe placenta,underthe influenceof
is then told: "Evenif you the uterine contractions.The
place.The matrone
spontaneous
aregoingsomewheretoday,do not go far,and criesof the infant
of lifeandvitality can
signs
aboveallcomebackquickly."
then be heard. When necessary, the
During labour the woman is given Babouantoumatrone9 will clear the child's
liquidsto drinkin orderto facilitatedelivery
passagesof any obstructionsby
especiallyif it is difficult.Among the Mada respiratory
If
and the Mouyeng'6it is a libation of millet suckingits nose and mouth. this fails,as a
last
the
matrone
chews
a pepperand
resort,
dilutedin a littlewater.In manyotherethnic
insertsit into the child'snostrils;a methodof
groups,like theYambassa'and the Ewondo,'" re-animation considered
very efficacious,
it is a macerationof herbs with oxytocic
which
the child's
stimulates
automatically
propertiesthat produceuterinecontractions.
If
cries.
it
is
this
fails
a
clear
of
a
sign stillbirth.
Among the Banen'3a little ash diluted in a
After
the
umbilical
cord is cut
delivery
glass of water is enough to acceleratethe
of
delivery.The woman gives birth in a semi- usinga variety materialssuch as a splintof
seated or crouchingposition, on her knees raffia, razor blade, a sliver of bamboo,
with her upper body leaning forward, sharpenedmillet stalkcoatedwith redkaolin
oil, a sherdof pottery,an
supportedon herhands,or lyingdownon the mixedwith cailcedrat
deliverystone on the ground or on banana oyster shell, a special knife used for
leaves(asymbolof fertility).The matrone
turns circumcisionand infants'navels.The cord is
the fetus towards the exit in the normal cut either directly or after being ligatured
position(thatis, head first)by massagingthe (with braidingcord or nylon) at a variable
parturient'sabdomen.Meanwhileprayersare distance from the navel; one centimetre
said,the spiritsareinvokedso thatall maygo amongthe Fali,22two centimetres
amongthe
well, and aboveall thereareoralincantations Yambassa,5ten centimetres
among the
of psychologicalvalue, the therapeutic(or
and the Beti,4and five to thirteen
instrumental)efficacyof which resides,in our Bakoko8
centimetresamong the Babouantou9.The
view,in the beliefof those concernedin their
and umbilical dressing are usually
powerof giving freedomfrom pain, painless ligature
childbirthbeing one of the principalvirtues made from a piece of the parturient'sloin
cloth or a stringwith a varietyof substances
sought.
A birthis outside
thenormswhenit is afflicted
withsevere
congenital
malformations
Tradition
andModernity
in Cameroon
such as clay, powdered pottery, palm oil,
ashes,sheabutter,etc. The naveldoes not get
any dressingin the propersense;it is usually
givena coatingof a mixtureof substancesthat
causesthe cordto dropoff afterthreeto seven
days.Dugast'8had a biologicalanalysismade
of the coatingused among the Banen,which
gavethe followingresult:water6.43%, ashes
28.10%, etherealextract20%, phenols40%
of the etherealextract or 8% of the soot.
According to the analyst, the phenols are
certainlyresponsiblefor the antisepticaction
of this soot. Carbon has an absorbentand
anti-coagulantpower.This is the reasonforits
use in Africafor the cicatrisationof the navel
in newborninfants.
Sterilisationof material used for the
ligatureand the umbilical dressingis done
with hot water and/or soap; but alcohol or
perfumeis now increasinglybeing used.The
placenta,the umbilicalcordandthe maternal
breast are physiologically and intimately
connected. Accordingly the placenta and
uterineblood will be preservedfrom all evil
influences,hiddenor buriedin some discreet
and secret place so that no spells may be
wrought on the mother or the newborn
throughthem.Among the Bangoua'oand the
Bakoko'the placentais carefullywrappedup
in leaves and buried deep underground
within the village under a banana tree (a
symbol of fertility) whose fruit is in the
processof ripening(themothercannoteatit).
By this means the infant is linked with its
father'slandandsymbolicallyinscribedin his
filiations.
The birth of the babyis an occasionfor
manifestationsof joy,which is moreintenseif
it is a boy.After deliverythe motheris given
ritual massages and her abdomen and genital
167
organsare washedwith very hot water.She
alsoreceivesinfusionsandsoup.The objectof
theseessentialtherapiesis to promotethe reestablishmentof her strengthand organsby
getting rid of the clots of coagulatedblood
remainingwithin her abdomen, which are
believedto causepain and flatulence.Among
the Yambassa5it is thought that this
coagulatedblood can cause sterility in the
woman.Among the Bakoko'the motherwill
also have hot purges of boiled water with
leavesof the bushbuttertreein orderto clean
and restorethe intestinalpassage.The ritesof
purificationand protectioncomplementthe
caregiven to the motherin orderto give her
everyprospectof futurebirths.
The Biomedical Logics of Obstetrical
Servicesand Care in Cameroon
TheFollow-Up
qf Pregnancy
The programme for the follow-up of
pregnancy (antenatal consultations) in
Cameroonis fundamentallybasedon the risk
approach.The monitoringof a pregnancyis
consideredsufficientif the pregnantwoman:
(i) is cared for (with antenatal
consultations) by a qualified health
professional(doctor,midwifeor nurse);
(ii) hasherfirstantenatalconsultationin the
firsttrimesterof herpregnancy;
at leastfour antenatalconsultations:
has
(iii)
the firstin the firsttrimester,the second
about the sixth month, the third in the
course of the eighth month and the
fourthin the ninthmonth;
(iv) has at least two anti-tetanusinjections.
However, if she has already had an
168
Health
AfricanJournalqf Reproductive
injection during a previous pregnancy
one dose will suffice for the later
pregnancy.This vaccination wards off
neonatal tetanus, one of the causes of
neonatalmortality.
doctors) capable of performingemergency
obstetricinterventions.Finallythe systemof
referral and evacuation is subject to
considerableconstraintsof accessibilityboth
geographical (poor condition of roads,
scarcityof meansof transport)andfinancial.23
Thus, theavailabilityof modernantenatal
Assuming that these recommendations
in Cameroonis both technicallypoor
services
in
arescientificallyvalid, their efficacy terms
and
little
in touchwith thewomentheyserve.
of healthbenefitdependson the abilityof the
healthservicesto coverthe whole population.
CareFacilities
But this coveragein turn depends on the TheDelivery
culturalacceptabilityand geographicaland
financialaccessibilityof the obstetricservices. In spite of the currentcontext of economic
These requirementsseem to be still farfrom austerity, the availability of health
infrastructuresoffering obstetric care is
being satisfied in Cameroon. The offer of
of Healthstatisticsshow
antenatalcare is still based on an approach increasing.Ministry
that the number of health infrastructures
whose technical efficacy is doubtful; the
increasedfrom 847 in 1974/75 to 1,819 in
quality of the relationshipbetween health 1992/93,
though with considerable
personnelandthepopulationis farfrombeing disparitiesto the detrimentof the FarNorth
satisfactoryand,so far,takesno accountof the and the North-West/South-West.23 This
demand;and the organisationof the systemis
improvementis partlydue to the
insufficientto permitthe evacuationin time quantitative
involvement
of non-governmental
and at an accessiblecost of women who
organisations and private non-profit
requirean obstetric intervention in health organisations, particularlyin rural areas,
services.
where the majority of the poor live. The
in
Cameroon
antenatal
Ultimately
geographical accessibility of services,
consultationshave not yet been rationalised however,is still deficient,
mainly becauseof
and the availabilityof careis most frequently the long distancesto be covered,the isolation
reducedto a ritualfor the detectionof risks. of particularregions and the
shortage of
Moreover,the qualityof relationshipbetween means of transport. More than 45% of
healthpersonneland the populationhas not women live more than 5km from the nearest
yet reached an acceptable standard. In obstetric service and have no access to
addition, the peripheral level (the health motorised transport for getting there. In
centre) and the first referral level (the additionto this poor accessibilityof services
maternitydepartment of the hospital) are the conditionsin which careis given arenot
cruelly short of qualified staff (midwives, alwayssatisfactory.2"
inrecent
toreduce
the velsof mortality
andmorbidity
oftheantenatalservices
has
Thatisnotthecase.Because
yearstheability
effjctively
beenagain(asithadbeeninthe1930s)~ brought
intoquestion
where
itseficacy
wasessentialy
with
the
detection
moreparticularly
linked
women."
Thepresent
is thatevenin a developing
consensus
of risksinpregnant
countyin which
theprevalence
of risksis highest
the
detection
because
lowspecicitiy
value,
of riskshaspoorpredictive
ofitslowsensitivity
mainly
(around
90%).,
(30%)andrelativey
TraditionandModernityin Cameroon
The maternity hospital is generally
divided into a series of departments
corresponding to each of its specialised
interventions.Fromthe receptiondesk,where
the consultationfeesarepaid,the pregnantor
parturient woman passes necessarily
frequently facing long queues, through a
multitude of work stations like the
registration department, waiting room,
examinationroom,operatingsuiteor delivery
ward,recoveryroom, day room or mortuary
(in a fatalcase).The patient(asshe is calledin
Cameroon),accordingto hercondition,must
submitherselfto the medicalroutineand the
standard treatments;seated or recumbent
position,bodyadjustedto medicalequipment
andinstruments,banon eatinganddrinking,
weighing,a batteryof examinations(urinary,
haematologicaland radiographic),induction
of labour,monitoring,etc. They emergefrom
all this, usually relieved,with medical and
behaviouralprescriptionswhererequired,the
dateandplaceof theirnextappointmentand,
for those who can affordultrasonography,
a
more or less clearidea of their physiological
state,sexof thechildandwhetherit is twins.
The lengthof stayin hospitaldepends,in
principle,on the gravityof the case, but it
seemsfrequentlyto be determinedby reasons
that are not alwaysexplainedto the woman.
Visits by her family and the bringing of
variousfoodstuffsare prohibitedor, at best,
169
tolerated.Moreover,the circumstancesof the
hospitalcan generatestressesand frustrations
overwhichthewomanhaslittlecontrol.Such
circumstancesinclude the constantviolation
of her intimacyand her living space by the
presenceof othermothers,the multiplicityof
caring personnel, sometimes involving
ambiguousor contradictoryinformation,and
the checkon the baby'slayette.And when the
layetteis insufficientthere may be mockery
and criticism.The economiccrisis,whichhas
accompaniedthe crisisin the healthsystem,
has created or aggravatedmalfunctioning
such as the bringingby patientsof theirown
medical (alcohol, fingerstalls, cotton,
dressings,etc) and otherrequirements(e.g., a
mattress), the poor arrangementsfor the
reception of patients, corruption in the
provisionof care,the fraudulentdiversionof
patients to privatehealth care centres,etc.
Various situational studies since the early
1980s have revealedclear examplesof such
malfunctioning.242"
In spite of the malfunctioningof the
Cameroonian health system, access to
obstetricalservicesand careis betterfor the
maternalandchildhealth.Neonatalmortality
rate(probabilityof dyingin the firstmonthof
life) is closely relatedto antenatalcare and
medical assistance at birth. The neonatal
mortalityrate is highest in the absenceof
antenatalcarefrom trainedhealthpersonnel
and medicalassistanceat birthand lowestin
thepresenceof maternalcare(Table2).
2 NeonatalMortalityRate(per1000 live births)by MedicalMaternityCarein Cameroon
Table
No antenatal/delivery
care
Eitherantenatal/delivery
care
Bothantenatal/delivery
care
1991
DIHS
57.1
37.7
DHS 1998
47.3
25.2
23.1
27.5
Source:CameroonDHSreports(1991 & 1998).
170
Health
AfricanJournalof Reproductive
theQualitative
Survey
Evidencefrom
thepossibilityof painlesschildbirth;and
morehumanityand responsibilityin the
behaviourof theprovidersof care.
The resultspresentedhere are based on an
analysisof the content of the discussions,
and Off-Putting
bringingout thegeneraltendencies.
Aipectsof the Two
Facilitating
Obstetric
Care
Systems
of
Expectations
Expressed
In relationto the expectationsexpressed,we
Fromthe group discussionsthereemergesa asked membersof the discussiongroupsto
definitionof idealarrangements
forcaringfor enumeratethe
advantagesand disadvantages
which are of
and
around
delivery,
pregnancy
birth
in hospitalor in accordance
giving
expresseda variety of expectations.These with tradition.The results (Table2) reveal
not onlyguaranteea favourable tensional elements as well as
arrangements
points of
outcome but also are carried out in
accordancewith traditionalcustoms and in convergence.
conditionsthat areculturally,geographically
of eachsystem
andeconomicallyacceptable.Thus, it appears Advantages
thatthewomenunsurprisingly
want:
The therapeuticefficacy of the biomedical
wasnot questioned.As regardsthecare
adequate care for obstetric infections system
of pregnancy there was particular
andcomplications;
care which is easily accessibleat the appreciationof its abilityto determinethesex
of the child and whether it was twins, to
lowestpossiblecost;
detect efficientlyat-riskpregnanciesand to
respectfordiscretionin consultations;
care for malaria, and the prevention of
of theirintimacy;and
preservation
that the minimum package of care neonataltetanusby vaccination.As regards
should includetraditionalformsof care the management of labour, there was
of whose efficacy they are sure (e.g., appreciationof the controlof pain,caesarean
birthsandthe handlingofstillbirths.
massages).
Positiveaspectsof the traditionalsystem
Inaddition,
of care were seen as its economic and
theywant:
geographicalaccessibility,its concern for
to know the sex of the child in the womb preservingthewoman'sintimacy,itsabilityto
andwhetherit is twins;
provide better treatment of anaemia and
to have complete responsibilityfor the women's "worms",the scope it offers for
use made of the products of birth traditional customs of protection and
(placenta,umbilicalcord)afterdelivery; purification,the massagesafter delivery,its
the comfortingpresenceof their family concernfora
comfortingfamilypresenceand
throughoutthe processof givingbirth;
thenon-insistenceon the infant'slayette.
to members
causedbya worm,whichmakesits wayabouttheinteriorof the
According
of thediscussion
groups,thisis an infection
woman'sbody.It bitestheJpleen,contracts
thedorsalmuscles
It is saidto beeradicated
andproduces
by
parafysisorabortion.'
treatment
in waterandscarfication.
withdrugsbasedonplants(leavesorbark)macerated
therapeutic
TraditionandModernityin Cameroon
171
Table3 Comparative
of the Biomedicaland TraditionalSystems
Advantagesand Disadvantages
for the Careof PregnancyandChildbirth(GroupDiscussionsin North Cameroon)
Careof
pregnancy
Careof
childbirth
Biomedical
Traditional
system
system
Advantages
Disadvantages
Disadvantages
Advantages
of 1. Highcostof
costalmost 1. Noeffective
1. Services
1. Possibility
sex
services
examinations
knowing
nothing
of childand 2. Longdistances
to 2. Healers
areavailable2. Complications
often
whether
twins
cover
atanytime
detected
toolate
2. Effective
3. Reproof
forfailure3. Intimacy
is
3. Poortreatment
of
of
treatment
tokeep
malaria
andoedemas
preserved
malaria
of
4. Toomanyalimentary
appointments 4. Customs
4. Toomany
and
protection
prohibitions
medicines
tobuy,
observed
purification
asina caseof
5. Better
treatment
of
illness
women's
"worms"
5. Meninvolved
in
andanaemia
vaginal
examination
6. Nodiscretion
7. No intimacy
8. Longqueues
9. Insistence
on
familyplanning
10. Noprotection
1. Possibility
of
painless
childbirth
2. Caesareans
efficiently
performed
sorcerers
against
1. Highcostof
1. Services
costalmost I. Hygiene
notalways
services
nothing
respected
2. Longdistances
to 2. Birthattendants
are 2. Nocaesareans
cover
available
atanytime 3. Complications
are
3. Presence
of male 3. Layette
notrequired frequently
fatal
birthattendant 4. Intimacy
preserved
4. Violation
of
5. Massage
and
rites
intimacy
customary
5. Useincommon
of 6. Comforting
presence
material
of family
6. Nomassage
orrites
of purification
7. Umbilical
cordis
nothanded
overto
parents
8. Promiscuity
9. Checkonlayette
10.Restrictions
on
offamily
presence
members
172
Health
AfricanJournalof Reproductive
Disadvantages
Discussion and Conclusion:
The Challenge of Complementary
In parallelwith the advantagesthatarehighly
appreciated in the two systems certain The obstetriccontext of Cameroon
brings
deficiencies are also deplored. The
at
least
two
health
systems
of the biomedicalsystemareas together
disadvantages
each
and
its
traditional),
(biomedical
having
follows:
constructed interpretative models of
1. Economic
and geographical
normalityand pathologyand its preventive,
diagnosticandtherapeuticmethodsrelatedto
inaccessibilityof its careandservices.
its
basic ideological approach; a holistic
2. Constantviolationof women'sintimacy
by thepresenceof malebirthattendants. approachfor the traditionalsystem,singular
3. Use in common of materialof obstetric (centredon the individualor the patient),
interventions.
rational and biological approachesfor the
4. Failure to maintain the timetable of biomedicalsystem.
consultations.
The empirical example of North
5. Shortagesoflayette.
Cameroon supports the hypothesis of an
6. Absence of massages with hot water
matchbetweenthe availabilityof
macerated with plants and bark inadequate
biomedical obstetric care and the
(intended to restore the woman's
expectationsof the population.The technical
strengthand drive out of her body the contentof modernantenatalcareis in needof
"soiled"blood which puts her life in
being brought up-to-date, but the overall
danger).
7. Failure to return to the parents the efficacyof the modernmedicalsystemis not
questioned.The main challengewill be to
placentaandumbilicalcord.
8. Lack of information
and improveits culturalacceptabilityby adapting
communicationfromhealthpersonnel. the servicesavailableto the expectationsof
the population.The group discussionshave
9. Longqueues.
10. Promiscuityin the hospitalwards.
shown that the culturalacceptabilityof the
11. Enthusiastic promotion of family biomedicalobstetricservicesandcareon offer
is prejudicedby the followingfeatures:
planning.
12. Restrictionson the presenceof members
of thefamily.
The earliness of the first antenatal
13. Inabilityto protectthe motherandchild
consultation,fixedon a standardbasisin
frommalevolentforces.
the first trimesterof pregnancy(in a
way incompatiblewith the concernfor
The deficienciesof traditionalmedicine
discretion).
areits inabilityto detectat an earlystageand
The presenceof men among the caring
providecare for complications(fetal death,
personnel.
caesareans,malaria,oedema), the numerous
The
use in common of deliveryrooms
and
the
failure
to
alimentaryprohibitions
anddayrooms.
maintainstricthygiene.
Traditionand Modernityin Cameroon
173
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ofhealthpersonnel.
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