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The handle http://hdl.handle.net/1887/28942 holds various files of this Leiden University

dissertation

Author: Towns, Alexandra Maria

Title: Fertility and fontanels : women’s knowledge of medicinal plants for reproductive
health and childcare in western Africa
Issue Date: 2014-09-30
Chapter Six

Summary
 Summary and Conclusions
The four chapters presented in this thesis describe the medicinal plant knowledge, plant harvest
patterns, reproductive health perspectives, and infant treatment preferences of Beninese and Gabonese
women, as well as the value, volume, and diversity of Gabon’s medicinal plant trade. The major research
questions from each chapter are outlined below, with a detailed explanation of the results, hypotheses,
and conclusions. This summary concludes with methodological considerations, implications for public
health and education programs, and suggestions for future research.

Research Questions
Which vegetation types are major sources of herbal medicine for women and children in Bénin and Gabon?

The results in Chapter 2 support secondary vegetation as a crucial asset in both savanna-dominated
and forest-dominated landscapes. More than 80% of the 335 species cited in Bénin and 272 species
in Gabon came from disturbance vegetation and home gardens, supporting our first hypothesis
that women harvest predominantly from secondary forest and disturbance vegetation. Beninese
and Gabonese women from our study care for their children and their own well-being by growing
domesticated species, transplanting forest species to their gardens, and managing the vegetation in their
immediate surroundings. The women have overcome the vulnerability of having access to a limited
space and few resources to meet their families’ healthcare needs. Western African women’s medicinal
plant harvesting can be considered generally sustainable due to the heavy reliance on human-altered
habitats, but additional research is needed on the ecology and regeneration of medicinal plant species
in order to make specific conclusions on the sustainability of their harvest.

What are the differences in plant use patterns between herbal medicine vendors and urban and rural women
who harvest for personal use?

Like women in urban and rural areas, the majority of species cited by market vendors in Chapter 2
came from human-altered habitats. In Bénin, women who worked in large metropolitan markets, far
removed from the primary forest, were the most likely to cite vulnerable species due to their access to
primary forest products through trade. In a forested country like Gabon, primary forest products were
Chapter 6

still widely available, including for women who did not have access to trade networks, resulting in no
relationship between vulnerable plant use and informant type. Thus, we reject our second hypothesis
that rural women use more vulnerable and primary forest species than urban and market women.

Among all plants used for women’s health, how many are used to treat the statistical causes of maternal
morbidity and mortality?

As discussed in Chapter 3, women were knowledgeable on treating the major causes of maternal
mortality, but the majority of plants species in both countries were used for pregnancy-related
conditions, menstrual-related conditions, and vaginal cleanses. Thus, we rejected our hypothesis
that local perspectives, knowledge, and practices closely parallel African maternal mortality statistics.
Beninese informants cited 248 plant species in total for women’s reproductive health, in which 39
species (16%) were used to treat high blood pressure and 28 species (11%) were used in remedies for
postpartum hemorrhage. Out of the 46 informants in Bénin, 87% cited at least one herbal remedy for
high blood pressure, and 73% cited a remedy for postpartum hemorrhage. In Gabon, women cited a
total of 189 species, in which 35 species (18%) were used to treat high blood pressure, and 12 (6%)
were used to treat postpartum hemorrhage. 63% of the 41 women in Gabon were knowledgeable on
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 Summary

an herbal remedy for high blood pressure, and 41% knew treatments for postpartum hemorrhage.
One-half of the citations for postpartum hemorrhage, however, only involved the use of hot water and
thus were not plant-based in nature. Sepsis was not mentioned specifically by women in either country,
but the high number of plants reported to treat sexually transmitted infections and vaginal and uterine
cleanses may be reflective of local responses to treating infections.

What percentage of plants is used to treat locally-determined reproductive health concerns not addressed by
international health organizations?

Menstrual-related conditions and infertility were two of the most salient health concerns according
to the free-listing exercises, citation counts, and cited species presented in Chapter 3. These ailments
were not found to be prioritized in most international health programs. In Bénin, 83% of women
knew at least one treatment for a menstrual-related condition, and in Gabon, 76% of women knew an
herbal remedy. A total of 79 species (32%) were used for menstrual-related conditions in Bénin, with
28 species (15%) used in Gabon. 67% of the Beninese informants and 46% of Gabonese informants
knew herbal treatments for infertility. A total of 58 species (23%) were cited by Beninese women for
infertility, and 13 species (7%) were cited in Gabon.

How do local biomedical healthcare providers perceive the use of traditional plant-based medicines for
women’s health?

The biomedical staff interviewed in Chapter 3 recognized the role of plant-based medicine in women’s
reproductive health in both countries where we worked. They reported positive outcomes, such as
postpartum recovery through the use of a hot water massage and the successful delivery of difficult
births in private clinics through consultations with traditional healers, as well as negative outcomes
such as uterine rupture due to the use of herbal medicine to accelerate contractions. We did not find a
strong opinion among biomedical healthcare providers about plant-based medicines, yet both sets of
practitioners cited government policies did not authorize the use of traditional medicine in national
hospitals. These restrictions limited the amount of information practitioners were able to share with
their patients and discouraged patients to discuss plant use practices with their doctors.

Which children’s illnesses do Beninese and Gabonese mothers treat with medicinal plants?

Chapter 4 showed that mothers were most knowledge on plants to treat respiratory illnesses, malaria,

Chapter 6
and intestinal ailments, highlighting the similarity of mothers’ experiences of infant health and the
statistical causes of infant mortality. To a lesser extent, the women were also knowledgeable on plants
for folk illnesses. Our results conclude that plant-based medicine, and more specifically mothers’
knowledge of plants, is a major factor in the management of common childhood health ailments.

What are the major children’s folk illnesses in each country?

In Bénin, mothers frequently cited the skin rash illnesses atita (Fon) and ka (Fon). Gabonese mothers
commonly reported folk illnesses la rate (French) and les fesses rouges (French). Mothers from both
countries shared the cultural concepts of encouraging children to walk early, monitoring the closure of
the fontanels, and applying herbal enemas. As discussed in Chapter 4, these folk illnesses give insight
into local treatments and health perspectives and are of interest to biomedicine since they may reveal
important neglected diseases, such as the correlating symptoms of la rate and sickle cell disease.

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For which ailments do mothers seek treatment from biomedical doctors or traditional healers?

The mothers involved in the study described in Chapter 4 largely saw the three African systems of
healthcare as complementary. The women generally self-treated with plants first, sought biomedical
care for advanced stages of malaria, anemia, or fever or as a second source of healthcare and consulted
the spiritual realm to treat folk illnesses or those ailments with a superhuman cause. Biomedicine was
perceived to have the advantage of advanced technology and materials, especially for treatments related
to blood transfusions. Some mothers in Bénin reported a preference of using self-collected herbal
medicine over biomedical care due to the expensive of modern treatment.

What are the species, volume, and value of medicinal plant products sold domestically on major markets in
Gabon?

The market study described in Chapter 5 resulted in 263 medicinal plant products corresponding with
at least 217 species. We estimated that 27 tons of medicinal plant products with a value of US$ 1.5
million are sold annually on the major Gabonese markets. We encountered 13 species on one-third
of the surveyed stalls and found that 18 species made up almost 50% of the total volume of products
available daily, including the fruits of Tetrapleura tetraptera and seeds of Monodora myristica.

What are the most frequently sold species and plant parts and the most salient health concerns treated by
plants sold at the market?

Bark represented the majority of the Gabon market’s floristic diversity (22%) as well as the highest
percentage of daily stock (30%) in Chapter 5. The resin of IUCN red-listed rain forest tree species
Aucoumea klaineana represented 20% of the daily volume of the entire market. The most salient uses of
plants sold on the market were ritual purposes (32%), followed by women’s health (13%), and childcare
(10%). The strong presence of ritual plants on the marketplace highlights the role of spirituality and
local belief systems in present-day Gabon, particularly in its urban centers.

How does Gabon’s herbal medicine trade compare with markets in West Africa, Tanzania and South Africa?

Chapter 5 showed that the herbal market in Gabon was smaller in volume and value than markets in
the Eastern Cape Province of South Africa, Ghana, and Bénin, and larger than the market in Sierra
Leone. Gabon’s floristic diversity on the market was higher than in Cameroon, Sierra Leone, South
Chapter 6

Africa, and Ghana, and slightly lower than in Bénin and Tanzania. These results support the first part
of our hypothesis that Gabonese medicinal plant markets are smaller in volume than those in other
African countries, but reject the second part, that Gabon’s trade is smaller in floristic diversity. Herbal
medicine in Gabon was more expensive than in Ghana or Bénin resulting in a fairly high value for a low
volume of plant material for sale, and higher reported vendor salaries. In Gabon the most commonly
traded plant parts were sold in the form of bark and resin, where Ghana was dominated by fruits and
seeds, Bénin was mainly leaves and whole plants, and Sierra Leone was mainly barks and leaves. Bulbs,
tubers and roots were most commonly traded in South Africa, with barks and roots most prevalent
on Tanzania’s market. Markets in Ghana, Gabon and Bénin all sold the seeds and fruits that doubled
as food additives and medicine (Xylopia aethiopica, Monodora myristica, Aframomum melegueta) with
ritual and women’s health as top salient health concerns. The rank of women’s health plants among the
top two most salient health domains addressed by markets in Bénin, Gabon, and Ghana illustrate that
women’s health is a major concern treated by herbal medicine markets in Western Africa. The presence
of medicinal plants on markets throughout Gabon stresses the role of herbal medicine in relatively
wealthy African countries with heavily urbanized populations.

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 Summary

Methodological Considerations
Our methodology of utilizing ethnobotanical questionnaires with the corresponding collection of cited
plant species resulted in a large database of plant names and uses. Although we were able to match
98% of the Beninese database and 93% of the Gabonese database with scientific nomenclature, several
plants that were cited in questionnaires were unable to be matched with scientific literature, purchased
on the market, or collected in the field. While some of the plants simply were unavailable due to season,
location, or particular day on the market, many of the errors could be avoided in future studies. One
explanation to this shortcoming can be attributed to the challenge of working with an international team
of researchers with a variety of linguistic backgrounds (English, Spanish, Flemish, French, Dutch, Fon,
Yoruba, Fang). Some of the unmatched names may be a result of the multiple phonetic interpretations
of African plant names. Including special consideration for linguistics, including training in phonetic
spelling of African languages, in future ethnobotanical studies may help to avoid similar database
errors. Our data-collection methods could have been improved by follow-up focus group sessions with
women who participated in the questionnaires. These sessions could serve to reiterate the data gathered
in the questionnaires and confirm plant names with associated botanical collections. Future studies by
ethnobotanists should continue the methodology of combining questionnaires with plant collection
with these shortcomings in mind.

The largest critique of the methodology utilized in our study would be to spend more time in the
individual communities where we worked. Although the six months spent in each country was a
reasonable time frame for conducting doctoral fieldwork of this nature, field visits typically lasted
from a few hours to several days. Spending more time with each woman and her broader community
could result not only in more thorough understandings of local treatments from an anthropological
perspective, more complete collection of medicinal plant vouchers from a botanical perspective, but
also benefit sharing from an ethical perspective. In only one community from our study, a village
in Bénin, were we able to contribute to a community-driven project directly from the results of our
research. We sent the database of all herbal remedies cited by the community to the school director,
complete with scientific identifications. The director plans to work with the school children to create
and distribute booklets on medicinal plants for childcare directly from the knowledge generated in our
study. Theoretically, our work can be applied to stimulate health care and conservation decisions from
a policy viewpoint, but future research should seek to work closer with local people, health clinics, and
conservation organizations to strengthen the direct outcome of ethnobotanical research for African

Chapter 6
communities.

In addition to creating stronger links with the communities where we worked, spending additional
time with students at the universities and with research institutes could improve future research
cooperation. Local African students are incredibly well-versed in the local languages and cultures but
often have not had the same training as their peers outside of Africa. Foreign researchers have the
possibility to expand the skillset of local students through offering opportunities to work on research
studies and to build their anthropological, botanical, and logistical research skills.

Implications for public health and education programs

The local doctors, midwives, and gynecologists are uniquely positioned at the intersection of the
two medical systems, situated between cultural practices and the biomedical science promoted in
government hospitals and clinics. Although research on the effects of medicinal plants is sorely needed,
in the meantime, educators and healthcare providers should familiarize themselves with common
practices and herbal treatments in order to facilitate fruitful discussions with their patients and avoid

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the negative effects of combined healthcare systems. Biomedical research is still inconclusive on the role
of vaginal cleanses in either preventing or increasing vaginal infections (Myer et al. 2005; Low et al.
2011), yet anthropological research has shown that these practices are deeply embedded in a woman’s
agency over her own fertility and relationships (Martin Hilber et al. 2012). Dismissing local treatments
or discouraging their use will further distance women from the treatment options available through
biomedicine. Educational efforts can also focus on the link between sexually transmitted infections
(STIs) and infertility, as infertility is a frequent concern of the women involved in our study, and STIs
are considered one of its major causes (Collet et al. 1988).

Future research
In order to further the discussion on the sustainability of harvesting in secondary vegetation from
Chapter 2 and the commercialized species highlighted in Chapter 5, future studies should carry out
population assessments, impact studies and natural regeneration measurements of species indicated
as having conservation concerns such as Baillonella toxisperma, Garcinia kola and Pterocarpus soyauxii
in Gabon and Xylopia aethiopica, Khaya senegalensis, Monodora myristica, and Caesalpinia bonduc in
Bénin. Additionally, future research on male knowledge domains (e.g. ritual plants and aphrodisiacs)
and associated plant harvesting patterns can help illustrate the gendered differences of medicinal plant
use and its variable impacts on surrounding vegetation.

Echoing the biomedical healthcare providers interviewed in Chapter 3, additional information is

needed on the role of plants in women’s gynecological healthcare, including the specific benefits and
risks of plant-based medicines in the long and short-term. Research should go beyond the goal of
substantiating efficacy, instead focusing on improving biomedical healthcare providers’ abilities to
provide relevant information and practical advice to their patients.

Unlike the biomedical providers interviewed on women’s health, the mothers in Chapter 4 largely
saw the three African healthcare systems as complementary. This dissonance creates fertile ground for
politically-focused research on African governments’ provision of biomedical care services, policies on
herbal medicine, and local women’s practices of managing reproductive and pediatric health.

Finally, in Chapter 4, we concluded that mothers’ knowledge of herbal medicine is a major factor in
the provision of infant healthcare. However, we did not take into account differences in ethnicity or
Chapter 6

age. In our study, we defined “mother” as any woman who had at least one child, which resulted in
the participation of mothers and grandmothers. Future ethnobotanical research in Africa can assess the
human behavior theory surrounding “grandmothering” (Hawkes et al. 1997; Bezner Kerr et al. 2008),
focusing on the medicinal plant knowledge of women of the third age. This highly debated theory
suggests that the presence of women in the post-fertile period of life is an evolutionary advantage,
contributing to the wellbeing and survival of subsequent generations (O’Connell et al. 1999).

It is my hope that this study serves to give a voice to women from Bénin and Gabon on gynecological
and pediatric health issues. May it contribute to an honest discussion between all stakeholders, followed
with tangible action in improving the healthcare options and overall well-being of women and children
in Beninese and Gabonese communities.

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