Article pp.64-71 du Vol.27 n°1-2 (2015)

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NOTE /NOTE

Perceptions and attitudes towards reproductive ageing among rural women in the Marrakech region (Morocco)

Étude du vieillissement reproducteur des femmes en milieu rural de la région de Marrakech (Maroc) : perceptions et attitudes

R. Lotfi · M. Loukid · M. Kamal Hilali

Received: 31 May 2013; Accepted: 6 February 2014

AbstractThe purpose of this study was to estimate the prevalence of climacteric symptoms and provide an assessment of perceptions and attitudes towards the menopause among rural women.

The sample consisted of 643 women attending health care centres and living in rural areas around Marrakech. The women were interviewed using a structured questionnaire addressing the women’s socio-demographic and reproductive characteristics and their perceptions and attitudes towards the menopause and climacteric symptoms.

Our results show that about 62.7% of the post-menopausal women felt that the menopause was a bad experience and perceived it as the start of aging and illness, as against 34.5% who considered the menopause as a natural stage in life or as making their lives easier. Their perceptions differed according to age.

Among the menopausal symptoms reported, hot flushes and fatigue accounted for 96.5% and 94.9% respectively.

Next in frequency were night sweats and joint pains, reported respectively by 88.9% and 87.3% of the women. The association between symptoms reported and perceptions of the menopause was statistically significant.

Perceptions of the menopause were affected by many factors, making evaluation difficult.

KeywordsMenopause · Perception · Symptoms · Climacteric · Rural · Marrakech

RésuméCe travail a pour objectif d’estimer la prévalence des symptômes du climatère et de présenter une évaluation de la perception et des attitudes des femmes rurales envers la ménopause.

L’échantillon est constitué de 643 femmes résidentes en milieu rural de la wilaya de Marrakech.

Les résultats de notre enquête montrent que plus de 62,7 % des femmes déclarent vivre mal la post ménopause et considèrent cette période comme le début de la vieillesse et de la maladie, contre 34,5 % de femmes qui considèrent la ménopause comme étant une étape de vie naturelle ou comme une phase de gain et de satisfaction. Cette perception diffère selon l’âge.

L’analyse des symptômes du climatère montre que les bouffées de chaleur et la fatigue représentent 96,5 % et 94,9 % respectivement. Elles sont suivies de sueurs noc- turnes et des douleurs d’articulation pour respectivement 88,9 % et 87,3 % des femmes. L’association entre l’appari- tion des symptômes et la perception de la ménopause montre une association statistiquement significative.

Mots clésMénopause · Perception · Symptômes · Climatère · Milieu rural · Marrakech

Introduction

Menopause is defined as the permanent cessation of men- struation, resulting from the loss of ovarian follicular activity for 12 consecutive months with no obvious intervening cause [1]. In general, the menopause occurs around the age of 51 years and is accompanied by numerous symptoms [2], including a core syndrome of vasomotor symptoms, hot flushes, night sweats, non-specific symptoms including joint pains and fatigue, and psychological and psychoso- matic disorders [3-6].

Perceptions of the menopause and how it is experienced open up a broad field of investigation and raise important scientific questions that could lead to a better understanding of the gradual biological changes observed during the pre- menopausal and post-menopausal stages.

R. Lotfi (*) · M. Loukid · M. Kamal Hilali

Laboratory of Human Ecology, Faculty of Sciences Semlalia, University of Cadi Ayyad, Marrakech, Morocco

e-mail : [email protected] DOI 10.1007/s13219-014-0107-4

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Perceptions, attitudes and knowledge regarding the menopause are like to differ from one female population to another. Depending on points of view about this “change of life,”it may be viewed as either negative or positive. Bio- medical literature tends to describe the menopause as a“defi- ciency disorder,”resulting in a failure to produce constant amounts of oestrogen. From this angle, therefore, the menopause is a medical disorder and a negative event, for which oestrogen replacement therapy is needed [7]. Elsewhere, it may be viewed as a positive or neutral experience. Feminist scholars in general have pointed to a need to address women’s interests by focusing on their particular social con- texts. Applying this idea to studies of the menopause, feminist literature suggests that it can be a positive event that marks a period of transition for women. In other sources, the menopausal transition seems to be a neutral experience of minimal significance [7].

Anthropological and cross-cultural studies have chal- lenged the concept of the menopause as a universal phenom- enon with widely varying perceptions of its symptoms [8].

The menopause is not only a biological fact described in terms of an aging process of the reproductive system, but also a social and cultural fact [9]. Health phenomena are ultimately affected by different meanings derived from a host of factors, including life circumstances, fears, expecta- tions and the social reactions of friends and/or family mem- bers [10]. Cultural meaning systems are cognitive structures that influence the way individuals in society perceive or view social phenomena [11].

A study by Uncu et al. [12] involving a systematic ran- dom sample of 1,007 Turkish women showed that the majority of the women considered the menopause as a natural change in life. In France, Delanoë’s study showed a wide diversity of experience within a single society, in which perceptions are 16% negative, 23% ambivalent, 44% neutral and 17% positive. Negative representations are most frequent among housewives [13].

A great deal of information is available on menopausal women in western society. In Morocco, however, menopausal women have generally been neglected in scientific research as elsewhere; the menopause is surrounded by a degree of ambivalence.

The symptoms experienced by women during and after the menopausal transition are influenced by preconceived attitudes towards the menopause, by personality types and by greater or lesser exposure to life stressors [14]. Meno- pausal symptoms produce perceptions and attitudes towards the menopause as observed elsewhere among African women [15]. Epidemiological surveys on representative samples of menopausal women have shown that most of the problems they experience are also due to age [16], as well as to gender issues and hormonal status [17].

In Morocco, according to 2008 health statistics [18], women of 40 and over accounted for 27.75% of all females.

With a current life expectancy for women of nearly 75.6 years [19], women can now expect to live one-third of their lives beyond the menopause. This will have a tremen- dous impact on health care delivery in the future [20].

To our knowledge, studies in Morocco specifically inves- tigating rural women’s attitudes towards the menopause are non-existent. This study aims to contribute to an understanding of attitudes and perceptions towards the menopause among rural women from the Marrakech region, and to describe the prevalence of menopausal symptoms experienced by women in relation to their perceptions of the menopause.

Methods

Study design and sample

The field investigation was carried out between March 2010 and April 2011 in the health centres of Tahannaout, Ait Ourir and Amizmiz in the province of Al Haouz (District of Mar- rakech), in mid-southwestern Morocco.

The data for the questionnaire were collected by direct interviews in private, by the first author. We specifically tar- geted healthy women visiting the health care centres for general health check-ups or to accompany patients. Women suf- fering from a serious illness that could affect their hormonal status (e.g. diabetes, high blood pressure or liver disease) were excluded from the study.

Prior informed consent from the women was asine qua non condition of their participation in this investigation.

They were informed about the type of data to be collected and that it would be used in a scientific study. The study protocol was approved by the Ministry of Health.

The sample size was determined by taking the same proportion of eligible women in the three study areas. The study was conducted among a sample of 643 women of 40 to 74 years of age, with a mean age of 52.49 ± 7.47 years.

We adopted the menopause definition given by the World Health Organization [1]. Women who had not menstruated for 12 months or more, without surgery, were defined as naturally menopausal. Women who had undergone surgical menopause were excluded from the study, which thus cov- ered naturally postmenopausal women only.

Sampling method

The women were interviewed using a structured questionnaire adapted to Moroccan Arabic terminology and to local circumstances. The average interview lasted approximately 20 min.

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Information was collected on the following topics:

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1. Demographic and socio-economic information on the respondent, including age, level of education and marital and employment status.

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2. Health, including self-assessment and the presence of chronic conditions.

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3. The respondent’s reproductive history and reproductive health.

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4. Symptom checklist consisting of 16 items covering a variety of manifestations obtained from the literature: the women were asked whether they had experienced one or more of the following menopausal symptoms: hot flushes, night sweats, joint pains, headaches, waking up at night, insomnia, fatigue, stress, concentration disorder, loss of libido, depressive tendency, asthenia, vaginal dryness, urinary problems, mood swings, anxiety and irritability.

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5. Perceptions and attitudes towards the menopause: in this section, the question put to all the naturally menopausal women was: “How do you feel after the menopause?” This open-ended question aimed to find out what the women thought about the menopause in general.

On the basis of their responses, their perception of the menopause was classified as positive or negative.

Statistical analysis

Data management and statistical analyses were performed using SPSS V10 software. Results are given as numbers and percentages (%) with a 95% Confidence Interval (CI).

Theχ2-test was used to compare data categories. Tests pro- ducing P-values <0.05 were considered statistically significant.

Results

Socio-demographic characteristics of the participants

The main bio-demographic and socio-economic characteristics of the study sample are shown in Table 1.

The participants (n = 643) were divided into five age groups: 40–45; 45–50; 50–55; 55–60 and≥60 years. More than 62% of the women were between 45 and 60 years of age.

The sample was mainly composed of illiterate women (98.4%), housewives (95%) and currently married women (81.2%); 95.8% of the interviewees had given birth at least once. 60 women had only 1 or 2 children, 179 had 2 or 3 children and 377 had 4 children or more. The average number of children was equal to 4.78± 2.13 child per woman.

At the time of the survey, 67% of the women were menopausal. The mean age at menopause in our survey was 49.8±

3.27 years.

About 65% of the women considered that they were in poor health, against only 2.2% who said that they were in good shape. 42.3% of the women interviewed had used the contraceptive pill.

Perceptions and experience of the menopause

Figure 1 shows the distribution of the menopausal women according to how they felt about the menopause. It appears that almost 23% of the menopausal women are indifferent Table 1 Biodemographic and socioeconomic characteristics of the women interviewed (N=643) /Caractéristiques biodé- mographiques et socioéconomiques des femmes enquêtées (N=643).

Characteristics n %

Age in years 40-45 45-50 50-55 55-60

>60

127 133 134 134 115

19.8 20.7 20.8 20.8 17.9 Marital status

Currently married Non married

522 121

81.2 18.8 Occupation

Housewife Labourer, artisan Other

611 25 7

95 3.9 1.1 Level of education

Illiterate Literate

633 10

98.4 1.6 Number of children

0 1 to 2 2 to 3

>=4

27 60 179 377

4.2 9.3 27.8 58.6 Menopause

Yes No

432 211

67.2 32.8 Self-rated health

Good Average Poor

14 212 417

2.2 33 64.8 Use of Contraceptives

Hormonal (oral) Others

272 374

42.3 57.7

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towards this critical stage in life; these women perceived the menopause as a natural process.

Almost 21.3% of the women associated their menopause with a sense of aging (feeling older), or of illness (13.9%);

5.2% of the women equated the menopause with the begin- ning of ill-health and said they did not feel at all well. Anxi- ety was reported by 4.6% of the women and a sense of despair by 4.9%; 12.7% of the women said they suffered from stress.

Two different feelings expressed positive attitudes to the menopause: a sense of relief and greater well-being were reported by 4.4% and 7.4%, respectively, of the menopausal women interviewed, while 2.8% did not have an answer.

Of all the women, 62.7% reported a bad post-menopausal experience, as against 22.7% who experienced it as a normal and natural stage or life; 11.8% of the women said that life became easier with the onset of menopause, and 2.8% did not answer this question.

Age and perceptions of the menopause

In order to study the effect of age on the perceptions of menopausal women, we analysed (see Table 2) the relationship between the respondents’age groups and their feelings after the onset of the menopause.

A significant relationship emerged between the women’s ages and their attitudes towards the menopause.

A large proportion of the women reporting anxiety (35%) and despair (47.62%) were in the 45-50 and 50-55 age groups. These proportions decreased in the older age groups, while some age groups reported little change .

Most of those reporting either negative feelings (illness, feeling ill, feeling older and stressed), positive feelings (feeling better, relieved) or indifference towards the menopause were 55 to 60 years old and over.

Younger women seem to have a more negative perception of the menopause than older women, although their perceptions vary from a sense of relief and well-being to a feeling that the menopause signals the start of illness, stress and aging.

Menopausal symptoms

In order to study the prevalence of different menopausal symptoms, we considered those most frequently cited in the scientific literature (Table 3).

The main symptoms mentioned by the women in our sample, as shown in Table 3, were hot flushes (96.5%) and fatigue (94.9%), followed by night sweats (88.9%) and joint

Table 2 Relationship between interviewee age groups and their feelings towards the menopause /Association entre les classes d’âge des femmes et leurs sensations envers la ménopause.

Age groups (years) 40-45 (%) 45-50 (%) 50-55 (%) 55-60 (%) >60 (%) x²

anxious 6.00 35.00 30.00 10.00 19.00 69.94*

desperate 4.76 19.05 47.62 19.05 9.52

sick - 9.09 18.18 31.82 40.91

feeling sick 6.67 26.67 25.00 35.00 6.67

feeling better 2.08 15.63 25.00 25.00 32.30

feeling older 4.35 8.70 21.74 41.30 23.91

releived 7.27 18.18 16.36 30.91 27.27

stressed 4.05 16.20 25.86 31.46 22.43

indifferent 3.8 14.5 26.4 29.5 25.7

*p < 0.005

Fig. 1 Distribution of menopausal women according to the different feelings reported after menopause /Répartition des femmes ménopausées selon les différentes sensations éprouvées suite à la ménopause.

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pains (87.3%). Depression and irritability were reported by 47% and 44% of the women respectively. Sexual problems linked to loss of libido were reported by 70.2% of the interviewees and vaginal dryness by 64.6%.

Symptoms and perceptions of the menopause

Anxiety, despair, illness and feeling unwell, old or stressed are considered as negative perceptions of the menopause, while feeling better, relieved or indifferent are considered as positive perceptions.

The relationships between the most important menopausal symptoms and both positive and negative aspects as measured by the chi-square (χ²) test are given in Table 4 (excluding those women who did not give an answer).

A negative perception of the menopause seems to be sig- nificantly associated with the presence of headaches, insomnia and depression and loss of libido.

Our results show that the presence of these symptoms leads to a negative perception of the menopause, although this may vary depending on the symptoms recognized by the interviewees and how they affect their daily lives.

Discussion

Two-thirds of the women in our sample said that the menopause had been a bad experience for them. This is a higher proportion than the result we found among women from the urban area, where just over 58% expressed negative percep-

tions of the post-menopausal stage [21]. Interestingly, the same observation described in another study [22] suggests that the more negative attitude of rural women towards the menopause is largely a reflection of the higher priority they give to fertility and reproduction than their urban counterparts.

According to Loukid’s study [21], the most common feelings among women in the Marrakech urban area are asthenia and suffocation (60% of the women interviewed). 20% of menopausal women associated their menopause with various pathologies and health problems affecting them. A significant proportion of the women (15%) said they felt mel- ancholy, but only 4% of these women reported a sense of becoming old after the menopause.

Our findings confirm that the menopause is experienced differently by women in different places. However, other studies have shown that many other factors affect the way women experience and perceive the menopause [23,24].

The social, cultural and economic factors that are specific to the rural population we studied may explain some of the disparity. According to our survey, rural women do not link everything that changes in their lives to the menopause, but also to other social or economic changes. The relatively short but intense reproductive history of rural women - combined with daily household chores and illiter- acy - greatly influences their perceptions and experience of the menopause [21]. Some studies suggest that rural woman with a lower socio-economic status [25,26] and a larger number of children [27] have a more difficult time with the menopause.

Our results in Table 2, compared to those of Ayranci et al.

[28], confirm that women’s attitudes and perceptions towards the menopause differ according to their age, and that opinions are more negative in younger age groups.

The prevalence of menopausal symptoms was high in our sample (Table 3), and the data showed similarities as well as differences with other studies carried out in Morocco.

According to Loukid et al. [29], joint pains, headaches and fatigue are the symptoms most frequently reported by women in the city of Marrakech (over 80% of the women surveyed), followed by hot flushes (73%) and libido problems (72%). Similar results from the rural areas around Casablanca [30] partly concur with our results, mainly in the percentages of women reporting severe hot flushes, fatigue and irritability, although loss of libido was mentioned much less frequently (29%).

According to Guessous [31], anxiety was reported by 98% of the menopausal Moroccan women interviewed, followed by fatigue (85%), insomnia (85%), depression (71%), pain in the joints (70%), excessive perspiration (46%) and headaches (30%). The same author found that rural women in Morocco reported many more symptoms than urban women.

Table 3 Percentages of menopausal symptoms reported by participants / Pourcentages de la présence des différents symp- tômes du climatère.

Symptoms %

Hot flashes (N=417) 96.5

Night sweats (N=369) 88.9

Joint’s pain (N=378) 87.3

Headache (N=132) 30.6

Nocturnal awakenings (N=88) 20.4

Insomnia (N=219) 50.7

Fatigue (N=410) 94.9

Poor concentration (N=100) 23.1

Depression (N=203) 47

Asthenia (N=21) 4.9

Mood variability (N=270) 62.5

Irritability (N=190) 44

Anxiety (N=26) 6

Loss of libido (N=313) 70.2

vaginal dryness (N=220) 64.6

urinary problems (N=112) 26

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According to Metintas et al. [32], the vasomotor symptoms that are considered typical of the onset of menopause are more frequent among women in rural areas. This is a finding that can be accounted for by the rural lifestyle, which is generally characterized by multiple pregnancies and intensive use of contraceptives.

Psychological symptoms were less frequently expressed by the women in our sample when compared with those reported by Guessous for the Moroccan population as a whole [31]. Our results show that 62.5% of women suffer from mood swings, 44% from irritability and 47% from depressive tendencies, but only 6% seem to experience anxiety. Mood swings and depression are the main psychopath- ological reactions associated with the menopause [33].

Loss of sexual desire is reported by a higher percentage in urban than in rural populations in Morocco. This reflects the influence of personal and social values on women’s sex lives before and after the menopause [34]. The rural women in our region are generally conservative people who still consider that sexuality as a social culture is taboo. For these women, the menopause is a stage where they become distanced from conjugal life.

All these manifestations are linked to hormonal changes, but also to the impact of different social, economic, environmental and cultural conditions [35-39].

Table 4 shows that the women who suffer most from insomnia and anxiety have a negative attitude towards the menopause (77.6% and 73.1% respectively). This finding is supported by similar findings from other research [40].

According to these authors, psychological symptoms are perceived more negatively than vasomotor symptoms such as hot flushes or night sweats.

According to De Koninck [41], the majority of women experience the menopause as the inescapable onset of an established pathology, a perception that arises from the medical approach in which the menopause is defined as a hormonal disruption.

However, in other studies [40,42,43], women perceive the menopause as related to the aging process.

Conclusion

Attitudes to the menopause are complex, ranging as they do from optimism to resignation. In the population we studied, Table 4 Relationships between menopausal symptoms and women’s perceptions of the menopause /L’association entre les symp- tômes du climatère et la perception des femmes de la ménopause.

Perception

Symptoms Positive (%) Negative (%) X2

Hot flushes (N= 420) Night sweats (N= 420) Fatigue (N= 420) Joint pain (N= 420) Headache (N= 420) Insomnia (N= 432) Depression (N= 420) Anxiety (N= 420) Irritability (N= 420) Mood swings (N= 420) Loss of libido (N= 344)

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

35.3 60 32.8 49.2 34.9 45.5 33.9 46.3 28 38.6 22.4 49 29.7 40.4 26.9 36 31.2 38.9 33.2 39.1 31.1 66.7

64.7 40 67.2 50.8 65.1 54.5 66.1 53.7 72 61.4 77.6 51 70.3 59.6 73.1 64 68.8 61.1 66.8 60.9 68.9 33.3

0.139 ns 8.18 ns 1.01 ns 3.16 ns 4.34 * 32.91 * 5.22 * 0.886 ns 2.688 ns 1.523 ns 19.13 *

ns : not significant ; *p<0.05

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perceptions are rather negative. About 62.7% of the women interviewed said that the post-menopausal stage was a bad time of life for them, in contrast to the 34.5% who said that their life had not been negatively affected by the onset of menopause, and that it had, on the contrary, brought a sense of well-being and relief from the constraints of men- struation. However, this proportion of positive perceptions is lower than in the urban population of Marrakech.

This finding tends to confirm that the menopause is perceived differently by women in rural and urban areas.

The association between menopause and the onset of various pathologies is substantially present in the minds of the rural Moroccan women. It has been observed in the majority of the Moroccan population surveyed, and may account for the wide disparities found between menopausal“complaints” represented by various symptoms.

This image of multiple disorders is widespread among women and directly influences their positive or negative perceptions towards the menopause.

Socio-economic and environmental effects could be an important explanatory factor. However, this also raises questions about the different beliefs and myths among the rural Moroccan population that shape women’s attitudes towards the menopause.

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