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IN HER LIFETIME: Female Morbidity and Mortality in Sub-Saharan Africa
TABLE 6-1 Mental Health Problems in Sub-Saharan Africa: Gender-Related Burden
Exclusive to Females
Greater for Females than for Males
Burdens for Females and Males Comparable, but of Particular Significance for Females
Psychological disorders associated with pregnancy and the puerperium
NOTE: Significance is defined here as having impact on health that, for any reason—biological, reproductive, sociocultural, or economic —is different in its implications for females than for males.
so that such effort is more likely to be made for men, who generally have a higher socioeconomic status. For all these reasons it was —and still is—true that more men than women are admitted to mental hospitals in Africa, as demonstrated by a number of epidemiological investigations providing data about the percentage of male and female users of psychiatric in- and outpatient services (Ihezue, 1982; Khandelwal and Workneh, 1988; Levin et al., 1981; Orley, 1972).
The preponderance of excited patients admitted to mental hospitals for social control purposes was also a factor that led to the erroneous conclusion that the depressive disorders were rare in Africa. Misdiagnosis of weakness and multiple somatic complaints as only somatic, rather than in any way psychological, was another factor, especially in the tumultuous context of busy outpatient departments that allow just a few minutes for each patient and only a limited number of treatment responses.
With better understanding of the nature of many mental disorders, and with the growing number of epidemiologic studies in community samples or among general health clinic clients, it became clear that most mental disorders are, in reality, frequent in Africa. A better understanding of changing rural lifestyles further helped to dispel the notion that African populations are free of stress and that their culture somehow protects them from the pressures that normally affect others.
Despite this wider awareness, until recently many European and American observers held on to the notion that stressful situations have different, generally milder, consequences among African women than among women elsewhere. Some have believed that African mothers are relatively immune to grief that comes with the death of a child; apparent helplessness in the face of such events has been mistaken for coolness, rather than anguish.
It is clear that the stresses on Sub-Saharan women as they go through life are intense, even in the most traditional societies. In the many parts of the region where disruption, famine, war, and forced migration prevail, the pressures are all the greater (Toole and Waldman, 1990). The customs and expectations of women's roles, although variable among African societies, can also lead to stress on women, even where there is no disaster or disruption of family and social ties. In some societies, a young woman will move to her husband's home after her marriage and break many of the ties with her natal family. A "bride price" is often paid to her family, which can mean that if she wishes to return, even for a good reason such as maltreatment, her family will be reluctant to take her back because they would be obliged to return the wealth they had been paid for her. If she bears no children, this too is reason to withhold installments on the price that may have been held back pending proof of fecundity; this puts her at a disadvantage with both her husband's family and her natal family.
The great value placed on a woman as a bearer of children should mean that the menopause might be a time of great stress. Yet this can also become a time of caring for grandchildren, although this may depend, at least in the virilocal marriage situation that is normative in much of Africa, on her having borne sons. Even for women who have not borne children, their childless state can be somewhat attenuated by living in a polygamous household and having access to other wives' grandchildren or to a husband's brother's grandchildren. At the same time, living in a polygamous household may be still another source of strain: the frequent jealousy of co-wives can lead them to deliberately harm one other. Although not conducted in Africa, a recent, well-designed epidemiologic study carried out in a sample of women in Dubai, one of the seven Arab Emirates, confirmed that polygamous marriages are psychologically stressful (Ghubash et al., 1992). In this study, the overall prevalence of any