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July 20, 2011 / calebdresser

Who would choose to be a woman?

The midwife had nearly finished a difficult stillbirth delivery when she looked up from the bloody mess in the bucket and sadly asked, “Who would choose to be a woman?” Her question stuck in my head. For me, it has come to symbolize all the frustration and unfairness and inequality that are everyday facts of life for the women here. I’ve been planning to write about these issues almost since I arrived, but the more I learn the more difficult it is to convey my thoughts in a neat little essay on the internet.

It’s hard to know where to start. The issues are too far-reaching and pervasive to permit a simple explanation. I had hoped to write a piece that would explain the “how” and the “why” of the issues, but it’s simply too complex. So – here is the unvarnished “what” of these problems, in no particular order. Draw your own conclusions.

Women can’t make their own medical decisions. When a woman comes into the hospital here, she is treated the same way we would treat a child at home. If she needs induction, someone has to call the husband. If she needs a caesarean section, someone has to call the husband. If the husband isn’t available, the nearest male relative has to make the decision. Even in emergencies, the hospital isn’t legally permitted to perform procedures without a consent form signed by a man who has authority to make decisions for the woman. As might be expected, this policy sometimes kills women and often kills their babies. It also leads to some stunning contradictions – if the midwives here were to become pregnant and need a C-section, they would have to convince their husbands to sign the form, even though the midwives know far more about what the procedure is and why it is needed. Not to mention that, at the end of the day, it’s their body.

The C-section issue blends into the larger problem of family planning. Almost everyone here does family planning: they plan to have big, big family. We routinely see women who are coming in to have their tenth or even twelfth child; the highest number I have seen is fourteen. The desire for unlimited numbers of children leads to significant conflicts of interest when it comes to making medical decisions. A woman can only have a C-section three or at most four times, and typically once she’s had one C-section, the rest of her deliveries will also have to be C-sections. Clearly, having a C-section puts a severe limit on her ability to keep popping out kids, so husbands will often refuse consent and delay surgery as long as possible, sometimes until after the baby (or mother) is already dead.

It’s natural to wonder why everyone wants to have so many children. While the men’s motivation is somewhat ambiguous, ranging from ensuring some support in their old age to general concerns about masculinity to helping make Somaliland “a big country like America,” the women’s motivation is much simpler. If a woman doesn’t produce plenty of children, her husband will just go out and take a second wife (up to four are permitted under Islam) and she will be forgotten in a decaying house somewhere. If she keeps having children, she is more likely to remain in her husband’s favour and be better supported, along with her children – at least until menopause. Desperate middle-aged women sometimes show up saying they think they are pregnant, only to tell us that their last period was more than a year ago. Whether on not they can still have babies, the trip to the hospital for a maternity consult probably does good things for their status in the eyes of their husband.

Pregnancy (or lack thereof) is not the only reason for unnecessary trips to the hospital. At any given time, we usually have one or two women on the wards that are perfectly healthy, medically speaking. These usually get listed as something along the lines of “hysteria” or the more politically correct “conversion syndrome.” Their symptoms are usually mild, and change depending on who is asking them questions. Their history usually involves a fainting episode – the relatives bring them in if they don’t get back to normal fairly quickly – but a mysterious lack of any bruises, cuts or scrapes from the fall. Lab results, if any are taken, always come back normal.

Most of these women fall into two broad categories: teenagers who are psychosomaticizing the stresses of puberty and impending marriage, and older women who want some attention and a break from their families. Both of these groups of patients point to a larger problem: there is no psychological safety valve for most of the women in this society. The whole structure of their lives is dictated by others. There are no opportunities to go to the mall with friends, relax at the beach, take a vacation, or heaven forbid choose their own husband or get thoroughly drunk at the bar. The only thing they can do is adopt the sick role, bask in the attention of their family, snooze in a comfortable hospital bed for a few days, and try not to think about the future.

All of these problems are attributable to women’s lack of control over their own lives. Some of the other problems are even more aggressive. Essentially every single woman whose delivery I have been involved with has had some form of genital mutilation, including quite a few that obstructed the birth canal so much that the baby couldn’t get out until the midwife made some strategic snips with her scissors. While some people say that fewer young women have been having these procedures done to them in recent years, there are no solid statistics. We’ve had at least one teenager come in with abdominal pain resulting from an FGM that completely obstructed her opening to the point that her first periods couldn’t get out; the hospital’s OB/Gyv had to drain nearly a litre of stagnant blood. Brides-to-be, some as young as 15 or 16, sometimes come in to have their FGMs opened before their wedding night. It’s an ironic and extremely painful start to the marriage: the snipping procedures are done in the same room to which these women will return, year after year, for their deliveries. It’s hard to say whether they are marrying the husband or the hospital.

Even after her early years of marriage are over, women don’t have much of a chance. While husbands are supposed to support each of their wives equally, the majority of the men here are addicted to khat. Given the choice between feeding their families and feeding a khat addiction, many of them choose khat and head for a shady tree to chew away the afternoon. As a result, the women sometimes have to fend for themselves and their children or hide the money that families living in the UK or America send back as remittances.

As with most of the social issues here, it’s hard to see a clear path forward to a brighter future. Most women are caught in a viscous cycle, and unless they are willing to forgo the marriage that their family expects and try to make a career for themselves, they don’t have any easy way to break the cycle. Education, empowerment, employability training would help, but in an economy that staggers along from day to day through the charity of the Somali diaspora, these can only do so much. Even now, our educational efforts with women are hampered by their continual need to go off and tend to the needs of their families. Typically, if a son and a daughter go to school together, the son studies in the evening and sleeps in the morning while the daughter is helping with the supper, cleaning the house, and ironing his clothes. As a result, girls typically fall further and further behind in school.

Even if a woman wants to have fewer children, the system here says it isn’t really her decision. Marriage is considered to be as much the family and the clan’s business as it is the bride’s. Clandestine birth control clinics would incur the unbridled wrath of an armed populace if they were discovered, and it’s hard to picture any of the NGOs here adding another item to their long list of security concerns. Working on the men, trying to inculcate attitudes that favour family planning and that value a woman for herself rather than her baby-making potential, is equally difficult. This is a place that is ripe for new ideas.

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2 Comments

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  1. minstrelm3 / Jul 20 2011 4:19 pm

    Thank you for writing, Caleb. This sure is very sad. Much of it is like decades and centuries in the past around here and in Europe, when women were usually treated as property. The multiple wives and FGM make Somaliland look like there’s a far longer road to travel toward equality and happy lives. The overpopulation of our planet just can’t help. Education, health, goodness.

  2. Joe Maurer / Jul 31 2011 4:22 am

    Wow. This is quite an educational blog. If there’s anyone I believe in to effectively work to improve situations like this, it’s you. Thanks for writing, Caleb; I look forward to seeing you and hearing more about your summer soon!

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