Last month, I wrote about the five countries I enjoyed visiting in Africa, including citing their incredibly low GDP per capita. Although most of the population growth over the next few decades is expected to occur on this continent, I see some glimmers of hope.
There are two places in the world where studies have been conducted on ways to increase voluntary family planning, along with other important medical research. One is Matlab, Bangladesh, and the other is Navrongo, northern Ghana. I had never heard of Navrongo’s studies until shortly before going there.
Both Matlab and Navrongo have shown that community health workers can significantly improve health. In addition to family planning, Ghanaian studies have investigated several successful interventions, including vitamin supplementation and mosquito nets treated with insect repellent. Their research on family planning has shown that it is possible to increase contraceptive use and slow population growth even in a poor and poorly educated population. This is particularly important research because Navrongo is close to the Sahel, and the people there resemble Sahelians in their preference for large families.
In 1995, when the Navrongo studies began, the average woman had about five children. Fifteen years later, in 2010, that number had dropped to just over four, both in the Navrongo control group and in the country as a whole. One of the interventions further reduced fertility to 3.7; a significant reduction. Today, a decade later, the fertility rate for the whole country is 3.7 children per woman. This group was 10 years ahead of the rest of the country! This group combined specially trained community health nurses (instead of assigning them to a clinic or hospital) and ‘zurugelu’.
Zurugelu means “together for the common good” and was once centered on men. For a better explanation, I asked one of the investigators who had worked at Navrongo what zurugelu meant. Here is Dr. James Phillips’ response:
“The zurugelu approach is a social engagement strategy that involves merging the organizational system of primary health care delivery with the traditional system of social organization and governance. Where gender issues were evident, we attempted to end patriarchy by working with women’s social groups in traditionally male-dominated ways. Social events, called “durbars”, were traditionally male events led by traditional male social leaders. (A durbar is a meeting of men with their leaders.) To strengthen women’s autonomy and roles, we worked with leaders to eventually have durbars convened and led by women. We also had gender sensitization activities to meet the needs of women. As such, the zurugelu approach was a gender development strategy.
Interestingly, neither community health nurses nor zurugelu alone had much effect on fertility. Even though nurses educated women about family planning and provided necessary materials, fertility did not decline significantly in areas where they were introduced but did not have zurugelu. Zurugelu alone also didn’t have much effect on its own. It took the two working together for the fertility to decline.
The need for both nurses and zurugelu is a very important observation. It has often been said that worldwide more than 200 million women wish to limit their fertility but do not have access to modern contraception. Since the nurses provided this access, we know that access alone is not enough – at least in this group of people. Apparently, tradition and paternalism were significant barriers to contraceptive use. It took zurugelu to change mindsets before people made the most of what was available in family planning.
What difference did the zurugelu make? This traditionally masculine role has opened men’s eyes to women’s needs. In addition, Navrongo programs strengthen the role of women.
Now back to my visit to Ghana. It was dark as we drove from Navrongo to Nalerigu. We passed a straw hut whose roof gave off smoke.
“Is it on fire?” I asked.
“No,” replied my host. “She’s just cooking dinner.”
Although there is a lot of beauty in Northern Ghana and everyone I met was warm and friendly, I feel like life is hard. Now that infant mortality is a quarter of what it was 50 years ago, people will benefit from smaller families as well as more education.
Richard Grossman, MD, is a retired obstetrics and gynecology physician who lives in the Bayfield area. He wrote this column for The Durango Herald for 26 years.