Wednesday, 19 December 2018

Procréation médicale et mondialisation - Expériences africaines

August 2018Volume 6, Pages 57–59 Noémie Merleau-PontyEmail the author Noémie Merleau-Ponty Reproductive Sociology Research Group, University of Cambridge, UK Open Access PlumX Metrics DOI: showArticle Info Abstract Full Text Article Outline Summary Gender and reproductive health Biomedicine, traditional healers, witchcraft and God Reconfigurations of kinship There have been numerous studies across the world dedicated to assisted reproductive technology (ART), on both local and global scales. Yet, to date, not a single book had been written on sub-Saharan countries. For this reason, Procréation médicale et mondialisation. Expériences africaines is a welcome addition to the field. With 12 chapters written in French and English, the reader will learn about patients and biomedical professionals from South Africa, Ghana, Uganda, Mozambique, Senegal, Gabon, Burkina Faso, Cameroon, and their trajectories inside their countries or as migrants in Africa and France. Most of the contributors to this edited volume are anthropologists, with the exception of a few scholars of media and communication technologies. Their work is based on participant observation in clinics, interviews, analysis of websites and blogs and the personal experiences of medical professionals. ART was introduced to sub-Saharan Africa in the 1980s–90s but is not widely used for both economic reasons (on average, one treatment cycle of IVF costs around two million CFA francs, or around US$3460 or £2700) and political reasons. Indeed, reproductive healthcare in general is not efficiently organized and governments' arguments around overpopulation and disinterest in infertility accompany family planning policies. Hence, studies have been carried out primarily in the private health sector and study participants tend to be middle- to upper-class people from urban areas. Precise information on the number of centres and their activity is difficult to collect as clinics are reluctant to share their results due to commercial competition in the sector. The International Committee for Monitoring Assisted Reproductive Technologies (ICMART) estimates that six centres in five sub-Saharan countries (Cameroon, Côte d'Ivoire, Bénin, Togo, Mali) undertook 897 oocyte retrievals in 2011 and helped to bring about the births of 196 children. In South Africa, 15 centres (out of over 20 estimated) reported 4861 egg retrievals and 1368 births in 2011. Challenging a position of ‘afro-pessimism’ – an approach that focuses on the difficulties existing in these countries to situate the African continent at the margins of globalisation – this book is a very rich, nuanced and critical contribution to existing discussions of medical pluralism, gender and reproduction, kinship and family making, as well as globalisation. Summary In the first part on the plurality of contexts, Frédéric Le Marcis, professor of social anthropology at Ecole Normale Supérieure (Lyon), writes about South Africa and reproductive health from the perspective of the politics of population. Overall, reproductive health is absent from these politics, even though 15–20% of this country's population is categorized as infertile, very often following untreated sexually transmitted infections or removal (rather than reconstruction) of fallopian tubes after extra-uterine pregnancies. This situation can be linked to the racial politics of the 1980s that enacted discrimination against black women, and the narrative of ‘black overpopulation’ (p.31). These discriminations are still at play today through economic criteria. The influence of the South African New Reformed Church and its patriarchal take on reproduction is also to be noted. The second chapter by Luc Massou, lecturer in media and communication studies at the University of Lorraine, is a comparative analysis of the websites of 37 clinics, revealing convergent dynamics in Togo, Mali, Burkina Faso, Côte d'Ivoire, Cameroon and South Africa. The importance of the web is certain even if, the author suggests, some characteristics of the digital platforms could be improved. Three aspects of clinic websites are highlighted: top-down circulation from professionals to patients, a lack of sources and citations (hence unreliability of information) and limited interactivity as the pages have static contents and offer no possibilities for discussion. The third chapter is co-written in English by Viola Hörbst, anthropologist of infertility in Africa and Trudie Gerrits, lecturer in the sociology and anthropology department at the University of Amsterdam. It shows how the scarcity of embryologists in Ghana and Uganda is managed through transnational connections of professionals that can impact how medical procedures are planned, resulting, for example, in the control of hormonal stimulation to allow the co-ordinated retrieval of eggs from an entire group of women on the same day. The fourth chapter by Véronique Duchesne, lecturer of anthropology at the university Paris Descartes, explores how sub-Saharan African migrants experience egg donation in France. It shows three paradoxes stemming from the experience of the norms and regulations of egg donation in France: anonymity, free-of-charge treatment and solidarity within couples. Both anonymity and free-of-charge treatment, instead of protecting from the formation of too many relationships (e.g. with donors and half siblings) and commercialization respectively, produce debts that cannot be repaid by these women. Furthermore, the French legal framework requires that male partners accept egg donation, as couples should be united on this. This may not fit with some women's desire to maintain confidentiality if they do not necessarily consider their fertility to be their husband's business. The second part on care trajectories and globalised experiences begins with chapters by Emmanuelle Simon, anthropologist and lecturer in media and communication studies at the university of Lorraine and Brigitte Simonnot, professor in media and communication studies at the University of Lorraine. Their texts highlight blogging strategies – how women manage their fertility trajectories through the use of the internet and use this type of writing to promote the de-stigmatization of their own experiences and choices by sharing and reading each others' stories. Then, a chapter in English by Inês Faria, PhD candidate at the Amsterdam Institute for Social Science Research, gives an overview of infertility in Mozambique and how poor health infrastructures there produce a movement of cross-border medical care to South Africa. Heterosexual couples from various backgrounds were interviewed, though women predominantly participated in the research. With reproduction being framed as a crucial part of these informants' lives, infertility is considered a huge disruption, an affliction connected to a local cosmological context. A mix of traditional and biomedical treatments can be pursued, even if the economical investment required to make a reproductive journey towards foreign private clinics produces great inequalities. Finally, Sylvie Epelboin, a gynecologist at the Hôpital Bichat-Claude Bernard, gives a summary of her experience in a French public hospital caring for sub-Saharan migrants. She shows with subtlety the medical misunderstandings that can arise from French biomedicine's encounters with people from other backgrounds in terms of how they conceive of infertility and how it ought to be addressed. She shows how the cultural backgrounds of patients are very often not acknowledged in care practices. She advocates for more research on the topic as well as more sensitivity towards patients' particular understandings of reproduction as it could ameliorate therapeutic interactions greatly. The third part on conjugality and familial relationships starts with a piece by Marie Brochard, doctor of anthropology and consultant for Agence de Médecine Préventive, on infertile couples' stigmatization in Senegal through an analysis of lineage logic. Families intervene in couple's intimacy through pressure to conceive after the wedding and control over therapeutic treatments. ‘Through the couple's procreation, the family awaits its own regeneration’ (p.177 my translation). Then Arielle Ekand Mvé, doctor of anthropology and worker for a non-governmental organization, writes about ART and witchcraft. In Gabon, she writes, personhood is composed of elements that can be subjected to various magical treatments. Successful couples can provoke jealousy and curses on their fertility from neighbours. Then, we turn to Burkina Faso and experiences of infertility treatments are delineated (uncertainty, life's disruption, risks of stigmatization, strong involvement of the extended family) in a chapter written by Maryvonne Charmillot, lecturer in education sciences at the University of Geneva. She shows how difficult it can be to study these topics as very few people are willing to share their stories. This difficulty is also addressed in the final chapter by Doris Bonnet, professor emeritus of anthropology at the Institut de Recherche pour le Développement, on the resistance shown by various informants to elaborate on male infertility in Douala, Cameroon. Men have difficulty accepting their infertility and sharing the news with their wife or welcoming sperm donation, as it would imply a recognition of their own ‘failure’ and bring ‘shame’ on their household. Women often bear the burden of infertility in family and public networks, while the biomedical treatment of male infertility is ‘private knowledge’ that does not circulate outside of the consultation room. There are three cross-cutting topics that stand to be of particular interest to readers: gender and reproductive health; biomedical and traditional medicines in the contexts of witchcraft and God's intervention; and contemporary reconfiguration of kinship in African families. Gender and reproductive health If this book refuses to nurture an afro-pessimism, it nonetheless addresses the reproductive health challenges that people in these countries face because of a lack of care infrastructures and information, due to political reasons that go beyond economic access or education. Furthermore, poor handling of sexual and reproductive health issues produces a context where women suffer from secondary infertility due to sexually transmitted diseases or tubal blockages following extra uterine pregnancies that are poorly taken care of by the medical infrastructures available (introduction and chapter 1). When women are not infertile themselves, they bear the burden of their husband's infertility, as discussing male infertility is a public taboo (chapter 12). Male infertility is not a new phenomenon, and solutions such as relying on family members to provide semen, for example, were always found to overcome the dramatic effects that this condition can have on people who fear becoming social outcasts. Overall the book gives the impression that, in these contexts, fertility is highly gendered. It is considered women's business and men's success (see also chapter 9 and 4). Biomedicine, traditional healers, witchcraft and God Blogging analyses show clearly that many African women are able to draw on and mobilize biomedical knowledge. However, it is certainly not the dominant frame of reference for infertility, the meaning of which is located at the nexus of social stigmatization, witchcraft accusations and medical pluralism. As Epelboin writes (p. 153 my translation), ‘The organ by organ, function by function analysis of parameters involved in fertility does not echo anything found in most traditional systems’. This can lead to misunderstandings in care relationships especially because biomedical models do not answer recurrent questions in the case of infertility – ‘Why me, at this period of time and in my life context?’ – while reference to witchcraft, dijnns and curses can provide answers, as the chapter on Gabon clearly demonstrates. The interaction between biomedicine and non-secular understanding is particularly intense with anonymous donations, given a context where bodily substances can be heavily charged with magical power as well as the capacity to reproduce not only nuclear families but lineages through resemblances with ancestors (chapter 9). Reconfigurations of kinship Infertility is stigmatized and extended families can place considerable stress on infertile couples in their journey toward conception. In Senegal, several models of relationship can coexist, such as civil, religious and traditional marriages as well as polygamy. In any case, a child belongs more to his/her lineage than to the couple (chapter 8 and 11). Moreover, reconfigurations of kinship practices can occur through the use of ART. For example, some couples will choose to name their child after a medical professional as a tribute. These practices can introduce tensions within a family as, generally, children are named after an ancestor. These studies show that infertility treatments through ART in a plural medical world entail discreet transformations of African family building. Couples manage compromises between the logics of lineages and the wishes of individual family members. The extended family plays an important role even when it is less present than in rural areas. While refusing to draw a pessimistic portrait of Sub-Saharan Africa, the authors do not hesitate to underline multiple complexities and limitations. One suggestion they make to help overcome these problems is to work for the development of patients' associations. When closing the book, readers might want to know more. But, because this collaborative publication welcomes some young scholars studying towards a PhD, I have no doubt that reproductive studies will continue to be enriched by their contributions to the field. Acknowledgements I would like to thank The Wellcome Trust for funding (Grant 100606) and Drs Mwenza Blell and Katie Dow for their help.