The socio-cultural burden of infertility in sub-Sahara Africa

A pregnant African woman holding her stomach.

Infertility or childlessness defines a couple’s inability to bear a child within 1 year of actively trying to achieve pregnancy. WHO reports that approximately 1 in 6 persons are affected by infertility worldwide [1] ranking this as one of the major reproductive health issues affecting the world. Infertility may present as either primary or secondary infertility. In a couple, the causes are multiple and involve a wide range of abnormalities that may affect both the males and or the females. Primary infertility refers to when there has never been ability to conceive despite actively trying while in secondary infertility, the ability to conceive comes after previous conception. Worldwide, approximately 15% of couples are affected.[2] Additionally, it was concluded that males were responsible for 20-30% of these cases of infertility.[2] The prevalence of infertility in women around the Central African region (Cameroon and Central Africa Republic) reported 20 and 25% between the age 20–44.[3] Due to inadequate maternity case, abortion and postpartum infections are preventable causes of secondary infertility found in Africa and low and middle income countries (LMIC’s).[4,5] Even though Sub-Saharan Africa (SSA) is estimated to have a fertility rate of five children per women with generally higher rates in rural populations [6], infertility issues are evident within certain regions and vary in prevalence. In some parts of Sub-Saharan Africa, infertility rates among couples may be as high as 30% [3,7] in countries like Cameroon and Central Africa and low as <10% in countries like Rwanda and Togo.[8] This difference may be attributed to environmental and dietary factors. Infertility in SSA is more than a health problem, not only does it have economic and psychological consequence, its severely affects the social and cultural life of the victims which will be explored in this article. [8]

Importance of children

In many cultures in Africa, (Zimbabwe, Ghana, South Africa, Nigeria, Uganda etc..) children are regarded as a means of social security, domestic support, social status and a source of continuity of family lineage. [9] Childbearing and parenthood are viewed as a form of social honour, by a majority of SSA, as couples are usually pressured to reproduce for the sake of continuity in the family tree. [9,10] Being of reproductive age, married and unable to conceive a child to full term pregnancy and childbirth in an African context is considered a taboo.[10] Unfortunately, women in many African societies suffer the most when it concerns infertility, largely due to its social construct, even if it has been medically confirmed the cause of infertility lies with the male partner [11,12,13] For example, in the Ijo tribe in Nigeria, childless women are commonly ostracized from attending certain meetings [14] as they have not attained adult status. At times, they were buried outside of town, alongside individuals suffering from mental illness. [14,15] Additionally, these women are not allowed to interact with other children nor babysit as they are said to be bewitched and may infect other people’s children.[16] Men on the other hand are called derogatory names attacked at their genitalia16 [16] and in order to avoid shame and disgrace, they revert to isolation. It is evident that social challenges experienced by infertile couples and individuals negatively affects the quality of life of the victims.

Increased extramarital affairs/polygyny

The high value placed on children and childbearing has led to individuals and couples going through any length to have children in order to avoid psychological and social issues linked to childlessness, hoping to be accepted by society. Moreover, childless couples are generally not given the same respect as those with numerous children and thus proving to society that they are qualified for parenthood, some individuals may engage in sexual activities with several partners in the hope that pregnancy will occur. [16] Men may often turn to polygyny, marrying numerous women, as a means of dealing with infertility in numerous African societies,[17] resulting from societal and family pressure. [18] In Malawi, such practices and extramarital affairs are considered ‘normal’ or culturally appropriate to manage infertility [18,19], often putting women at risk of contracting sexually transmitted infections (STIs) and further contributing to infertility. [20].

Divorce/ Separation

The inability to conceive can create a sense of disappointment, a feelings of failure and frustration causing couples to question their future together. [21] Ultimately, the overwhelming challenges of infertility can lead to a breakdown in the marriage, resulting in divorce as couples struggle to navigate this complex and painful experience. A study conducted in Zamfara State in Nigeria revealed that women suffering from either primary and secondary infertility reported divorce as one of the marital problems they experience, frequently caused by pressure from the husbands relatives.[22] Similarly, childlessness could be the leading course of divorce in Ghana.[23] Infertility hence makes married women vulnerable to being abandoned by their partners. As children in some African communities are considered a source of wealth as they may be entitled to inheritance of possessions [16,24] they also serve the purpose of prolonging family lineage. Women who are commonly blamed for infertility, in countries like, Mozambique, Gambia, Nigeria and Rwanda are divorced [18] or denied access to domicile, inheritance, economic security, and domestic support. [25] Consequently, infertility in men results in psychological distress, feelings of inadequacy [26] but it is more damaging to their social experience. In some societies in South Africa, they are commonly mocked and not respected as ‘a man’ due to childlessness.[26]

Increased domestic/gender-based violence

Infertility is a stressful condition affecting all aspects of life that may generate or escalate aggression within couples. Domestic violence affects everyone, however, violence against women is more widespread in the male-dominated social structure due to the cultural notion that infertility is primarily a female problem. Because of this, women who are labelled as infertile are twice as prone to violence compared to fertile women.[27] and among married women in Zimbabwe, 42.7% have expressed experiencing one form of domestic violence. [28] Violence directed at infertile women vary from psychological to sexual violence. However, some studies have shown that, psychological violence [29,30] is the most prevalent form of violence in LMIC’s and is commonly perpetrated by the men. Physical violence has also been found to be evident within infertile couples. [14,30] The various effects of violence have a negative impact on individuals self-esteem, social life and may drive its victims further into depression. [24,31]

Conclusion

It is evident that childlessness is more than a health issue in a majority of African societies. The inability of couples or individuals to achieve motherhood or ‘parent’ status is often accompanied by unfavourable social and cultural implications that ultimately affect their quality of life. In order to reduce the burden of infertility experienced by couples, various measures can be taken.

Recommendations

1.Create awareness in communities to decrease gender discrimination in couple infertility.
2.Reinforce healthcare systems to diagnose and manage treatable causes of infertility.
3.State policy to support victims of social discrimination because of infertility.
4.The governments should collaborate with mobile network providers and healthcare provider, to develop free health messages targeted at educating and sensitizing community members on the dangers of unsafe sex.

Regina Sinsai
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Regina Sinsai holds a Bachelor of Arts Degree in Psychology from the United States International University – Africa, in Nairobi and an HND in General Nursing from the Humanity Health Professional Training Center (HHPTC) in Yaoundé.

Constantine Asahngwa, Ph.D
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Dr. Asahngwa Constantine holds a PhD in Medical Anthropology from the University of Yaounde 1, Yaounde, Cameroon. He has served as Director for the Cameroon Center for Evidence Based Health Care for 10 years as an evidence synthesis, translation and utilization expert.He has also served as a Senior Adjunct Lecturer at the School of Public Health, Faculty of Health Sciences, University of Adelaide, South Australia for 10 years,

Dr. Bruna Djeunang Dongho
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Ghyslaine Bruna Djeunang Dongho, Ph. D., is the Senior Researcher in Global Health and Public Health at the Nkafu Policy Institute.

Solange Dabou
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Solange DABOU holds a Master of science in Clinical Biochemistry from the University of Dschang and have followed a distance learning training in epidemiology and health statistics from Aix Marseille University.

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Dr Ronald Gobina is a Nephrologist, working with the Regional Hospital in Buea. He is a Health Fellow and the Director of the COVID-19 taskforce for the DLF foundation. He is member of the International Society of Nephrology (ISN) and the Initiative to Strengthen Health Research Capacity in Africa (ISHReCA).

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