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Feminization and Stigmatization of Infertility in Malawi

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Boetumelo Julianne Nyasulu

2. Literature Review

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1Chapter Two reviews the relevant literature on infertility, both globally and that which specifically looks at countries of the Global South, as well as infertility studies for Malawi. The chapter situates the discussion of infertility within an analysis of the value of children, in order to better understand the social and personal effects of the absence of children. The studies included will provide insight into both differences and similarities in experiences, perceptions and treatment of infertility.

2.1 The Value of Children in Society

2Globally, motherhood is valorised as a milestone of adulthood for women (Riessman, 2002, p. 166). In certain societies, an environment of pronatalism prevails, even with changing ideas around marriage, family forms and the economy. In these societies, the expectation for women is that they marry and reproduce, and any postponement in this phase of life is tolerated as a temporary delay rather than accepted as a permanent choice (Riessman, 2002, p. 166). In Agadjanian’s study, he demonstrates that social interaction influences the regulation of fertility, and as such argues that reproductive matters ought to be analysed in the context of the broader societal structure in which they occur (Agadjanian, 2001, p. 292). He conducted interviews with 84 women and 60 men in Maputo, Mozambique, interviews that centred around issues tied to their reproductive histories and experiences. Through these conversations, he found that Maputo’s socio-cultural context, similarly to other Sub-Saharan African nations, lies at the intersection between indigenous Bantu cultures, colonial cultural heritage, and post-colonial indigenous interpretations (Agadjanian, 2001, p. 294). Bantu tradition, which can be found at the origins of a number of traditions in Southern African countries, roots a woman’s status in her fertility. This, merged with colonial heritage, which has a history of exalting women as reproducers of the nation, this has resulted in these societies equating the value of women with their ability to reproduce (Agadjanian, 2001, p. 295).

3For decades, large families and a high fertility rate have been economic and social mechanisms for survival in Sub-Saharan Africa (Caldwell and Caldwell, 1987, p. 409). Feldman-Savelsberg similarly examined Bangangte women’s perceptions of infertility vulnerability through discourse and metaphors. Her findings demonstrated that children are constructed as socio-economic symbols of value for the family, and as symbols of “group continuity, strength, pride and honor” (Feldman-Savelsberg, 1994, p. 471) for the kin group and for the community as a whole. She explores the Bangangte women’s understanding of infertility as vulnerability through cooking metaphors. Through culinary imagery, the Bangangte women relate their experiences or perceptions of infertility to plundered kitchens, and use metaphors of cooking to cast an abundance of food – or children, as a source of wealth – in opposition to fears of poverty and empty wombs. The conclusion finds that Bangangte women link infertility to feelings of vulnerability in a broader social context of increased migration, high poverty levels or economic dependency, that in turn place a high social value on children (Feldman-Savelsberg, 1994, p. 471). This high social value implies that producing a higher number of children equates to higher income returns for the family, increased labour for subsistence farming and increased social status in the community (Caldwell and Caldwell, 1987, p. 422).

4Throughout Africa, marriages occur often and at a young age, and often with the purpose of producing children, rather than for love (Dyer, 2007, p. 70). In fact, the presence of children often acts as a confirmation of conjugal ties for the couple (Dyer, 2007, p. 75). As such, the inability to have children can often lead to marital instability, whether that be divorce, polygamy or extra-marital affairs. Additionally, in African rural communities where land is owned by men, the only economic return women can gain from the land is through their children, who either inherit it, submit land claims or carry out subsistence work on the land (Dyer, 2007, p. 70). In Hollos and Larsen’s study analysing 2,019 women and their partners through a Tanzanian household survey (Hollos and Larsen, 2008), they expand on this assessment by highlighting six economic advantages children bring to their families, which are identified as: the labour children provide in producing goods, the services they provide when young, the contributions they make to family or community activities, the care they provide for the elderly, and the education they provide for their younger siblings. Children thus participate in generating an instant form of wealth for the family, but also contribute towards the accumulation of a continual intergenerational wealth, thus furthering their value for the family.

5The value of children, however, lies not only in an assurance of economic security, but also in emotional and religious security. In Dyer’s broad literature review on the value of children in African countries, he aligns with many of the previous findings while adding insight from the various studies he reviews. Dyer maps out informants from studies carried out in Nigeria, Mozambique and South Africa, who all relate their infertile status to feelings of unhappiness or unfulfilment (Dyer, 2007, p. 75). In a sense, children are portrayed as bringing a type of emotional security to the home that the husband cannot. For religious societies, children are represented as gifts from God that introduce a moral imperative, whereas couples without children are deemed unworthy or sinful. The consequences that women without children are faced with thus convolutedly bring together emotional, religious and economic imperatives.

6The intimate ties between human reproduction and socialization within communities creates a relationship between the achievement of the status of womanhood and the achievement of a high social status through bearing and rearing a child (Hollos et al., 2009, p. 2068). Significantly, in the case studies examined in several articles (Upton, 2001; Riessman, 2002; Inhorn and Van Balen, 2002) both primary and secondary infertility, the inability to become pregnant or carry a child to term after previously giving birth to a baby (Mayo Clinic, 2017), resulted in equal, if not similar, social consequences. In fact, in Upton’s article on a community in Botswana, many of the women interviewed were actually referring to secondary infertility when talking about infertility (Upton, 2001, p. 357). In Dyer’s analysis of several studies, women with either primary or secondary infertility were shown to be excluded from participating in or conversing about traditions that concerned fertility, childbirth or motherhood. The symbolism of social security, social power and social permanence represented by children thus come together to perpetuate complex experiences of maltreatment, stigma and their consequences for women who are infertile or childless (Dyer, 2007).

2.2 Experiences and Perceptions of Infertility

7In 2009, 72 million women globally had self-reported as infertile, with a majority living in the Global South (Naab, Brown and Heidrich, 2013, p. 135). In Africa, the prevalence ranges from 20 to 46 per cent in the West, and is at 30 per cent in the Sub-Saharan Region (Naab, Brown and Heidrich, 2013, p. 135). Ericksen and Brunette’s comparative study of 27 African nations found that the most common cause of infertility in Africa was STDs, resulting in Pelvic Inflammatory Disease (PID) (Ericksen and Brunette, 1996, p. 214). Studies in Gambia also indicated that malaria and malnutrition are other possible causes (Meera Guntupalli and Chenchelgudem, 2004, p. 250). The STDs most implicated include gonorrhoea, chlamydia and syphilis, which can cause damage through the scarring of fallopian tubes, and then lead to foetal loss through spontaneous abortion or stillborns (Ericksen and Brunette, 1996, p. 214). In fact, the findings demonstrate that in Africa 70 per cent of PID cases are attributable to STDs, with abortion and unsafe delivery practices accounting for the remainder (Ericksen and Brunette, 1996, p. 214). Higher rates of infection are concentrated among young girls whose low immunological resistance can often result in permanent sterility (Richards, 2002, p. 87).

8Several articles have approached the theme of causes and consequences of infertility under an anthropological demography approach (Upton, 2001; Hollos et al., 2009). Upton’s article, for example, explores the question “What makes a woman infertile and why are such labels so significant socially?” and Hollos et al. ask “What are the meanings and consequences of infertility?” Both authors utilized ethnographic methods for their studies; Upton’s article focused on qualitative data – formal interviews, informal discussions, participant observation – while Hollos et al. applied a combination of quantitative and qualitative methods through in-depth interviews and surveys. The authors criticize the tendency of demographic explanations to assume that women are hyper-fertile individuals “in need of reproductive regulation” (Upton, 2001, p. 354), which consequently silences any discourse on infertility and renders invisible those individuals who are infertile. Upton demonstrates that despite a demographic discourse on numbers that indicate an overall decline in the total fertility rate (TFR) in Botswana, there is still an increasing extramarital fertility rate that has a direct correlation with the cultural construction of infertility and the significance placed on children (Upton, 2001, p. 350). In Botswana, childbearing has been constructed as a key aspect of the female identity – so much so that bearing a child prior to marriage does not seem to create problems for the woman’s social status, because of the value of reproduction (Upton, 2001, p. 352).

9In Gerrits’ qualitative study on the social and cultural aspects of infertility in Mozambique, she conducted interviews with 34 infertile women, six cured women, ten fertile women, and traditional healers, to compile data on infertile women’s treatment seeking behaviour. Prior to divulging the study’s findings Gerrits introduces two categories of discourse, originally coined by Foster and Anderson, used by the interviewees to explain their infertility: personalistic and naturalistic. Personalistic explanations include “acts of people, spirits or witches” that cause infertility, while naturalistic explanations include biological causes of infertility, such as STIs or a low sperm count (Gerrits, 1997, p. 44). In many African societies similar to the Mozambican one studied by Gerrits, it is not uncommon for personalistic and naturalistic explanations of infertility to be used in tandem, as mixing culture, traditions and biomedicine are not considered to be mutually exclusive. However, it is important to note that biomedical explanations and information about infertility is often largely inaccessible to poor and rural areas, particularly in developing countries (Meera Guntupalli and Chenchelgudem, 2004, p. 256).

10The causes of infertility and experiences of it should not only be understood from a medical standpoint, but are also influenced by socio-cultural contexts, just as health and illness are socially constructed categories (Greil, McQuillan and Slauson-Blevins, 2011, p. 737). Neff’s study on the matrilineal Nayars of South India examines how constructions of fertility and gender shape the construction of infertility. Among the Nayars, fertility satisfies social interests to extend lineage and insure inheritance through the female line (Neff, 1994, p. 475). Several rituals conducted by the Nayars venerate and emphasize the importance of fertility, such as a puberty ceremony, a pre-puberty marriage ceremony and a formal marriage ceremony (Neff, 1994, p. 475). The Nayar women are described as having a feminine power known as ‘sakti’, a procreative force that is understood to proliferate in other areas of society (Neff, 1994, p. 475). Sakti is released for the benefit of the group when a woman is finally able to marry and bear children – without this step, her sakti is contained and accumulated and can bring on misfortune and disharmony for her kin group and society (Neff, 1994, p. 478). When a woman is infertile among the Nayars, it is believed that it is a result of the wrath of the gods on the kin group and signifies curses that have befallen its members. Such beliefs mean that the infertile individual faces extreme vulnerability; she faces a stigmatized position as a barren woman, the loss of support from her kin group and social exclusion from her community (Neff, 1994, p. 477).

11Just as the Nayars explain infertility as being caused by an external force, Inhorn’s study on threatened fertility in Egypt revealed a similar concept, where infertility is understood to be caused by ‘kabsa’ – when a polluted individual enters the room of a reproductively vulnerable woman (Inhorn, 1994b, p. 487). This “reproductively vulnerable woman” can be a woman who was recently circumcised or devirginized, or who has just delivered a child (Inhorn, 1994b, p. 487). During this vulnerable state, a woman is isolated in a room for 40 days and is meant to be separated from contact with “polluting substances”, which can include blood (vegetable blood, menstrual blood), unwashed substances (semen, breastmilk, urine), death or wealth (Inhorn, 1994b, p. 489). Fertility is deified in two ways – through its capacity to ensure the continuation of a lineage, and to satisfy a man’s greatest creation in Egyptian society – a child. As such, the consequences of infertility far outweigh the burden, embarrassment or fear of de-polluting healing rituals that infertile women go through to subscribe to Egyptian rituals, and to distance themselves from accusations of infertility.

12Many African societies have spiritual and social explanations for infertility. Richards’ ethnographic study on definitions and responses to infertility in Cameroon records interviews that attribute it to “God’s will”, contraceptive use, lack of tradition and witchcraft (Richards, 2002, p. 88). These causes are commonly cited throughout developing countries; for instance, Meera’s qualitative study on the Chenchu tribe of India revealed that infertility was attributed to supernatural powers, God, black magic, body heat and nutrition (Meera Guntupalli and Chenchelgudem, 2004, p. 253). While witchcraft and spirit possession are referenced as the most commonly perceived causes of infertility in several African countries, the next most common causes include women’s sexual promiscuity, blood incompatibility, abortion and STDs (Hollos and Larsen, 2008, p. 161).

13The intersection between the value placed on children, and perceived causes of infertility has several implications for experiences of infertility in African societies. Fledderjohann conducted 107 semi-structured interviews in gynaecological and obstetric clinics in Accra, Ghana, to analyse the social and gendered experiences of infertile women. Upon discovery of a woman’s infertile status, a marriage often either suffers from high conflict and instability, is riddled with extramarital affairs, transforms into a polygynous marriage or ends in divorce (Fledderjohann, 2012, p. 1384). The findings from the Gambia study showed that while 99 per cent of the sample of infertile women were now presently married, 26 per cent had been previously divorced or abandoned, 35 per cent had been married before, and in this latter group 16 per cent had also been married once before that (Sundby, 1997, p. 33). Additional sexual partners for either member of the couple causes an increased risk of exposure to STDs or reproductive tract infections, which can thus compound the infertility problem in future relationships (Fledderjohann, 2012, p. 1384).

14In most cultures in Sub-Saharan Africa, there has been a tendency for infertility talk to fall into a discourse of blame, where women are attributed sole responsibility (Hollos et al., 2009, p. 2062). Dyer et al.’s study on men’s infertility treatment seeking behaviour in South Africa conducted 27 interviews with men in Cape Town and found that infertile men suffered from stigma and abuse, and that generally while awareness of male infertility existed it was rarely admitted. One interlocutor expanded on this by saying that “In society today man cannot be the problem” (Dyer, 2002 p. 962). Infertility in several societies across Africa does not exist as a health problem alone because of its social and interpersonal dimensions. It bears the social consequences of exclusion, discrimination, and marital instability, as well as economic insecurity, and affects mental health and stress levels (Sundby, 1997, p. 30).

2.3 Distress and Stigma

15Several studies have shown the direct impact of infertility on psychological wellbeing. Dyer et al. conducted 30 in-depth interviews with involuntarily childless women seeking treatment in urban South Africa and noted experiences of stigmatization that in turn caused psychological suffering for the women. The women described experiences and feelings of loneliness, desperation, deep sadness and bitterness; they also described experiences of abuse in their families or communities where they were shouted at, cursed at or outcast (Dyer et al., 2002, p. 1664; Fernandes et al., 2006, p. 871; Edelmann and Connolly, 2000, p. 366).

16While Hollos et al. also explore infertility through a demographic approach, they examine the differing rates of two communities in Nigeria and demonstrate how the meanings and psycho-social experiences attached to infertility are shaped locally through lineage structure and community mechanisms. Women in Lopon had less serious consequences for infertility than their counterparts in Amikiri, owing to the matrilineal structure of their community and the presence of community structures that economically or socially involved and supported infertile women (Hollos et al., 2009, p. 2061). Hollos et al.’s findings demonstrate that community mechanisms and family structures are crucial for mitigating the effects of stigma, and the negative experiences of infertile individuals.

17Fernandes et al.’s in-depth interviews with two infertile women revealed the complexity of the experience of infertility, in its intersection between the physical, the social and the emotional. Physical pain and suffering of the body inherently affect the emotional state, which then impacts social interactions – the links between the three are indubitable (Fernandes et al., 2006, p. 871). Fernandes et al. thus frame suffering as a struggle in which an individual fights to maintain control over their physical, emotional and social domains and at times may become so overwhelmed with suffering that returning to their previous, normal state is unthinkable (Fernandes et al., 2006, p. 872). The results of the study emphasize that suffering can be a deeply personal experience, and as such is affected by different layers of identity – personality, past and present experiences and the environment (Fernandes et al., 2006, p. 851). The authors highlight that the experience of suffering can be diverse – existential for some and meaningless for others; perceived as punishment by some and a mystery to others – but always in pursuit of answers for the question ‘why me?’ (Fernandes et al., 2006, p. 852).

18The visibility of motherhood or pregnancy can make it hard to avoid the probing and interactions of community members. For many of the women who stay in virilocal residence, the pressure they feel from the family is direct and every-day, as they live with their in-laws and attempt to assert their status in the household – often only elevated through the status of motherhood. As Fernandes et al. state, “[motherhood is constructed as] a woman’s crowning glory, the pinnacle of achievement: what we are all destined for and ultimately the only means of true fulfilment” (Fernandes et al., 2006, p. 861). The conflation of womanhood and motherhood, as well as the female body and female identity, creates a sense of failed purpose or body that translates to a failed identity for those women who can’t bear children. Inhorn argues that this infertile identity creates a complex experience of stigma, particularly in poorer communities where the woman faces disempowerment or stigmatization because of her “barrenness, femaleness [and] poorness” (Nahar and Richters, 2011, p. 335). For many women in African societies, barrenness further complicates their position, as the husband’s family can claim back the bride price previously paid for the wife with the expectation that she would bear children (Dierickx et al., 2018, p. 8). Reclaiming the bride price not only brings on feelings of shame for the woman and her family, but also places her family in a precarious economic position if they have already spent it. Having failed to bear a child, the woman often encounters social stigma from her family or wider community, where she is denied a higher social status or ostracized to levels that may even reach divorce, banishment, economic isolation or accusations of witchcraft (Hollos et al., 2009, p. 2068).

19A significant challenge for women in several countries in Africa is what Dyer et al. call a “culture of silence” around the issue of infertility, which renders talk about infertility a taboo subject, and often isolates infertile women, thus placing a triple burden of secrecy, fear and stigma upon them (Dyer et al., 2002, p. 1667; Dierickx et al., 2018, p. 9). Dierickx et al. report that within these communities, infertility talk often circulates around gossip, jokes, rumours or even claims that infertile women are witches or “eating their own children” (Dierickx et al., 2018, p. 7). The blame for barrenness is attributed to women either through accusations of witchcraft, of immoral extra-marital sexual behaviour, of abortions or use of contraceptives (Dierickx et al., 2018, p. 8).

20The combination of these feelings and experiences of stigma were found to result in a state of emotional distress in Donkor and Sandall’s survey, conducted with 615 women in South Ghana. The authors developed a stigma measurement tool originally used for stroke patients and conducted regression analyses to map those women who experienced either no stigma (36 per cent), moderate stigma (23 per cent) or severe stigma (41 per cent) (Donkor and Sandall, 2007, p. 1688). The study concluded that the presence of a polygamous union, the lower the education and the higher the number of years spent seeking treatment, the higher the infertility-related stress level (Donkor and Sandall, 2007, p. 1688). Expanding on this, a compelling finding from a longitudinal study analysing fertility-specific distress among a sample of 266 infertile American women found that feelings of low self-esteem, sadness or isolation often continued for as long as twenty years after suspending treatment (Greil et al., 2011, p. 87).

21A shortcoming of many of the articles looking at distress is their focus on individuals seeking treatment, which largely excludes those for whom treatment is inaccessible or unaffordable. As such, people from marginalized economic backgrounds, ethnicities or classes are often excluded from these studies. In terms of psychological correlates of infertility, there is an over-abundant focus on Western societies, which is quite disappointing considering Dyer et al.’s findings that participants in developing country studies on infertility exhibited “a significant” and “arguably greater” level of distress, than those in countries in the developed world (Dyer et al., 2005, p. 1942). Added to this, there have been calls to consider the socio-cultural context and how it affects the experience of infertility, and this approach can also shine a spotlight on a demographic and context that has traditionally been ignored by the medical research agenda.

2.4 Treatment and Coping

22In a study on the choices and motivations of infertile couples in the Netherlands, Van Balen et al. present statistics from a 1992 national survey they conducted with 3,295 women. In it, they identify five treatment seeking options that couples may explore when facing infertility: (1) medical help, (2) adoption, (3) fostering, (4) alternative medicine and (5) other life pursuits (Van Balen et al., 1997, p. 19). Davis and Dearmen’s study conducted in the US found similar coping strategies, with the addition of avoidance, sharing the burden or searching for explanations (Donkor and Sandall, 2009, p. 82). Van Balen et al.’s research found that medical help was often sought within the first year, after attempts to conceive, while the other options followed after failed medical help (Van Balen et al., 1997, p. 22). Alternative medicine was mapped as a more infrequent option – a last resort when no other medical options existed (Van Balen et al., 1997, p. 24). Interestingly, those women who coped through avoidance strategies or acceptance were shown to experience higher levels of distress than those women who relied on support networks, highlighting the importance of social support in the experience of infertility (Richards, 2002, p. 82). Several studies emphasize the importance of the spousal relationship in providing support for coping with feelings associated with infertility (Richards, 2002; Donkor and Sandall, 2009).

23While various treatment options and assisted reproductive technologies (ART) have emerged in the Global North, many of these options remain unavailable or undesirable for infertile women in the Global South. Treatment seeking behaviour and coping strategies among women in African societies can vary from doctor’s visits, religious support or practices, to visits to a traditional healer – in many instances, women may try a combination of strategies as they do not stand as mutually exclusive (Richards, 2002, p. 90). Of course, the option of modern medicine also exists in African countries – infertility cases are often treated with contraceptives or antibiotics for the STDs causing the infertility (Gerrits, 1997, p. 44). This is due to a lack of resources, medical personnel, drugs, equipment and infrastructure in the health care services of many of these countries (Van Balen and Gerrits, 2001, p. 215).

24In contrast with van Balen et al.’s study on the Netherlands, in most African rural societies, alternative medicine is often sought out as a primary option rather than a last resort. Most women seek out a traditional healer for health problems, as they provide not only health support but also therapeutic and social support (Mariano, 2004, p. 267). Considering that about 60 to 80 per cent of the population of developing countries live and/or work around the borders or rural areas, it comes as no surprise that traditional healers are more accessible both economically and geographically (Chipfakacha, 1997, p. 418). In her study on the socio-cultural aspects of infertility in Mozambique, Gerrits found that if some of the 34 infertile women had visited between twenty to thirty traditional healers each, and others had gone only once or twice, all of them had turned to a traditional healer prior to seeking out other treatment options (Gerrits, 1997, p. 43). In these rural areas, healers are generally well distributed geographically, and are regarded with respect in their communities (Chipfakacha, 1997, p. 418). Their lived experience in the community, identification with the culture, and fluency in the local language gives them good knowledge of the socio-cultural contexts in which they work (Chipfakacha, 1997, p. 418; Van Balen and Gerrits, 2001, p. 217). Treatment methods can include herbal teas, balms, baths, exorcisms or prayers to the spirits (Gerrits, 1997, p. 44).

25In many developing countries’ culture of silence surrounding infertility, some women may adopt a strategy of secrecy in an attempt to deny or avoid the label of infertility. Papreen et al. showed that, in order to appear fertile to their community, women in Bangladesh adopt this strategy by faking miscarriages (Dyer et al., 2002, p. 1666). Avoidance strategies for women in close communities in developing countries can often be near-impossible, as their lack of children is seen and noted at community gatherings, hang-outs or daily activities (Nahar and Richters, 2011, p. 333). In some African societies, the practice of giving a child from one family member to an infertile family member can be common practice – especially for those families struggling to provide for their existing children (Sundby, 1997, p. 34). While this may not necessarily be explicitly labelled as adoption or fostering, it is often a solution for resolving infertility issues or childlessness, or a form of coping for the infertile individual.

26For many men in several African societies, a solution to their wife’s infertility is often found in extramarital affairs, the taking of a second wife, or divorce (Gerrits, 1997, p. 45). The patriarchal nature of most of these societies places women in a vulnerable position when faced with these situations, and often supports men in their efforts to keep their infertile status a secret. However, there are some societies in which women also seek out extramarital options – such as the Macau in Mozambique, as noted in Gerrits’ study (Gerrits, 1997). Riessman has specifically examined how married women manage or resist definitions of family, and how the strategies they use can be interpreted as forms of resistance. Riessman takes a different approach to the other studies, in that she focuses on poor women who are voluntarily childless, where the decision is made owing to the lack of material or social resources. She unpacks the idea that, for lower-income women, motherhood often represents an improvement in status within their husband’s family and within the village, and that “being a mother is a master status for village women [that] overrides other identities” (Riessman, 2002, p. 114). Riessman’s discussion of resistance strategies is unique in that she contextualizes and localizes forms of resistance by these women – speaking out, refusing deviant labels, strategically avoiding people or rejecting motherhood. Her study and analysis add nuance to the literature on stigma by providing a localized Global South perspective of resistance strategies, within a rich contextualization and from a unique perspective.

2.5 Infertility Studies in Malawi

27There is far less research and literature on infertility in Malawi, in comparison to the literature on other African countries. Earlier articles on infertility or the health sector in Malawi focus on a more quantitative approach. The pioneer article discussing infertility in Malawi is Ericksen and Brunette’s 1996 country-wide survey of infertility across 27 nations. The study sought to provide a comparative study of infertility across nations utilizing a multivariate analysis of 27 of the most recent World Fertility Surveys (WFS) and national Demographic Health Surveys (DHS) (Ericksen and Brunette, 1996, p. 210). Similarly, Larsen’s 2000 study utilized Malawi’s and other countries’ DHS to examine primary and secondary infertility in Sub-Saharan Africa. Both studies took on a quantitative approach and focused on data from the birth histories of women between the ages of 20 and 41 who had been exposed to conception for at least five years. The studies were limited by the data collected in the WFS and DHS, which focus on a narrow age group, do not differentiate between contraceptive and non-contraceptive users, and whose definition of infertility is insufficient. This last criteria, defined as an absence of birth in the five-year period of exposure to conception, disregards women who were intentionally preventing childbirth in that time period (Ericksen and Brunette, 1996, p. 210; Larsen, 2000, p. 286). Nonetheless, the availability of the data from these two surveys allowed the researchers to take up a different approach from those taken in the past, which focused on regional low total fertility rates (TFRs) to measure infertility (Ericksen and Brunette, 1996, p. 209).

28Ericksen and Brunette’s study found that in 1992, Malawi’s primary infertility rate levelled at 1.1 per cent, and that 15.8 per cent percent of fertile women had had previous periods of infertility (Ericksen and Brunette, 1996, p. 212). One of their major findings was the role of STDs in causing infertility, specifically gonorrhoea, chlamydia and syphilis through the scarring of fallopian tubes or foetal loss (Ericksen and Brunette, 1996, p. 214). Their second major finding concerned the negative implications of sociocultural factors on infertility, such as culture, marital status, history of multiple unions, sexual initiation at puberty, and urban residency (Ericksen and Brunette, 1996, p. 214). While there is no direct causation between these factors, the analysis stressed that such factors could increase the chances of disease acquisition. For example, an individual’s place of residency can affect availability of health services, or increase the likelihood of encounters with infected men (Ericksen and Brunette, 1996, p. 216). Cultural beliefs could also affect the acceptance of multiple marriage unions or of polygyny, and thus through multiple partners, the increased risk of an infected sexual partner (Ericksen and Brunette, 1996, p. 216). These findings tie into the article’s conclusion that the transmission of diseases most linked to infertility causes are also affected by sexual histories, place of residence and a country’s sociocultural context. Ericksen and Brunette surmise that this explains the diverse infertility rates across Sub-Saharan Africa, and emphasize the need for culturally and socially appropriate health services that contribute to the diagnosis of STDs and Pelvic Inflammatory Disease (PID) – the major causes of infertility.

29Barden-O’Fallon expounds on this in his study on infertility treatment seeking in a rural district in Malawi. Similar to Ericksen and Brunette’s findings, he notes that various factors contribute to fertility impairment, which he separates into three different categories. The first of these is demographic, and includes age, marital status, residence area, religion and education level (Barden-O’Fallon, 2005, p. 2229). The second is health, focused on and including sexually transmitted infections – and specifically chlamydia, trichomoniasis, syphilis and HIV, considering that correlations between these conditions and infertility had been noted in the region (Barden-O’Fallon, 2005, p. 2229). His final category is sexual behaviour; taking account of multiple partners and the age that the interviewee had their first sexual experience, as these behaviours can increase the risk of infection acquisition (Barden-O’Fallon, 2005, p. 2229). O’Fallon uses these categories to distinguish between how men and women self-report fertility problems. He found that men typically associated fertility impairment with sexual behaviour, while women associated fertility impairment with a ‘child deficit’: the difference between their actual and ideal number of children (Barden-O’Fallon, 2005, p. 2234). Thus the process of self-reported infertility in women was more of a subjective and emotional experience. Barden-O’Fallon notes that, while one in five women reported having difficulty becoming pregnant, fewer reported being infertile (Barden-O’Fallon, 2005, p. 2224). He concludes that participants may make a distinction between perceived fertility difficulties and actual infertility; either owing to an unwillingness to self-label as infertile, or the desire to have additional children (Barden-O’Fallon, 2005, p. 2229). Owing to this, Barden-O’Fallon finds that it may be more comprehensive to measure fertility problems in African populations through analysis of those having self-reported difficulties getting pregnant, rather than self-reported infertility. Were he to follow this approach, his results would actually record 60 per cent of individuals with self-reported difficulties getting pregnant and seeking treatment (Barden-O’Fallon, 2005, p. 2234).

30Eriksen and Brunette’s study, and that of Larsen used Malawi’s 1992 Demographic Health Survey. However, while Ericksen and Brunette provided an analysis of primary infertility rates, Larsen went a step further by providing deeper insight into secondary infertility in Sub-Saharan Africa. The study found that while primary infertility prevalence rates were quite low, at an average of about 3 per cent across the region, high secondary infertility rates predominated throughout the region (Larsen, 2000, p. 289). With respect to Malawi, the study demonstrates that the secondary infertility rate of couples aged 20 to 44 sits at a high of 17 per cent (Larsen, 2000, p. 290).

31The last available study from the late 90s and early 2000s with an insight into infertility is a 1998 cost-comparison of sexually transmitted disease (STD) treatment in Malawi. The study used a nationwide survey to collect data on drug prescription practices for STD patients in 39 healthcare facilities across the country (Costello Daly et al., 1998, p. 88). Notable findings that impact the understanding of infertility in Malawi are the high HIV and STD rates of Malawi in the late 90s, with a 23-32 per cent prevalence in urban antenatal women, and 42 per cent of urban antenatal clinic patients having been diagnosed with at least one STD in 1989 alone (Costello Daly et al., 1998, p. 87). Costello Daly et al. sought to compare the cost of Malawi’s clinical diagnosis of STDs – that is, when treatment is conditional on confirmation from laboratory testing, which can be costly and cause delays – shown to be largely ineffective in comparison with a syndromic approach to STD treatment – that is, when two antibiotics or more are provided to a patient, based solely on a patient’s symptoms. A shortcoming of the study was that its analysis included an overrepresentation of commercial clinics and hospitals, to the detriment of the health centres found in most rural areas, as well as its strong focus on two STDs: genital ulcers and urethral discharge, which are shown to represent only 50 per cent of new STD patients (Costello Daly et al., 1998, p. 92). Nonetheless, the study not only found that the syndromic approach would add no additional cost and cut laboratory and personnel costs, but also that at the time patients with more than one STD were highly undertreated, with more than 31 per cent of patients surveyed receiving inadequate treatment (Costello Daly et al., 1998, p. 92). Not only does this point to the grim reality of STD treatment and management in Malawi, but it also provides a clearer picture of the environment in which infertility rates prevailed at the time.

32Of the few articles found on infertility-related studies in Malawi, the most recent one by Fiona Parrott differed in its qualitative approach. Parrott analysed male infertility in rural northern Malawi to examine how infertility diagnoses through semen analysis contributes to the visibility of male infertility and shapes gendered relationships. She conducted 55 interviews with men of different ages and marital statuses from the Karonga District (Parrott, 2014, p. 177). Parrott establishes that infertility diagnosis for men can initiate feelings of shame or secrecy, while threatening their sense of self-worth, owing to discourses of weakness and emasculation that situate infertility as “a lack of sexual strength (nkhongono)” and “conflate virility with fertility” (Parrott, 2014, p. 177). Causes of infertility are variably attributed to biomedical problems – the obstruction of tubes, menstrual irregularities, abortion – or the realm of the spiritual and witchcraft (Parrott, 2014, p. 178). Causation thus ties into treatment, as individuals often turn to traditional healers (sing’anga) or religion to offer solace or deliverance from spirit possessions or bewitchment; problems that are perceived to lie outside of biomedicine’s knowledge and expertise (Parrott, 2014, p. 179).

2.6 Thesis Rationale

33In demographic discourse, declining fertility is often celebrated, as the country is said to be moving towards a more industrialized economic system. The rhetoric of the demographic transition invisibilises the social and psychological consequences of infertility experienced in varying contexts. Malawi’s primary infertility rate lies at 2 per cent, and it has a secondary infertility rate of 17 per cent (the inability to become pregnant or carry a child to term after previously giving birth to a baby), which puts the country in the upper-middle range of infertility rates in Sub-Saharan Africa (Barden-O’Fallon, 2005, p. 2229). This study seeks to add to the literature that has so far focused on childlessness, by including a sample of secondary infertile women. The prevalence of social, emotional and psychological consequences, even with secondary infertility, provides an indication of the high premium placed on children. In rural areas especially, children are a symbol of economic and social value for the family, and a promise of continuity for the kin group and community. In the village’s social context the child is seen as the link that ties the woman to her extended family and larger community. In an economic context with minimal social welfare mechanisms, the child also acts as an economic security for the elderly, while for wealthy families the child ensures the transfer of inheritance or property (Riessman, 2002, p. 112). As such, motherhood offers several benefits to the women of the community, and a lack of children often leads to a woman suffering from confusion or harassment from the community. The intimate environment of the village often makes it difficult for women to avoid interactions with their own communities, where there is high likelihood to encounter acquaintances in public transport, on journeys to the shop, or while collecting water at the pump (Riessman, 2002, p. 118). This proximity makes it difficult to hide the fact that you have no children, and gives the space for village gossip over those who don’t (Riessman, 2002, p. 166). The Malawian rural context thus provides insight into women’s experiences, perceptions and interactions around infertility, in a community where individuals encounter challenges concealing or managing their infertile identities.

34Despite its significance, infertility is a severely under-addressed problem in many Sub-Saharan countries, Malawi included. The demographic discourse that celebrates a decline in fertility in less developed countries invisibilises the negative experiences of infertile individuals, and silences their voices on the research and policy level. While literature in the developing world often focuses on declining fertility rates as an outcome of empowerment or autonomy at the individual level, and economic improvement at the national level, this study will offer a different perspective to that of the demographic field, in highlighting the negative social consequences of declining fertility rates.

35The findings of the study will provide information on how stigma is experienced or perceived and in what physical or relational context it occurs, opening the discussion for the proposal and development of different preventive or mitigating measures. It contributes to a literature that currently stands at a minority, by focusing on the contextual consequences of infertility, rather than infertility as an isolated event. By engaging with the infertility conversation, these findings could be used to measure the quality or lack of infertility health care in Malawi, and contribute to improvements in the quality management of infertility, and the broader service areas of health, education and social security. The study will also give insight into a bottom-up approach that can be taken into account when building social and medical support systems for women, an approach that emphasizes the need to prioritize the impact of infertility and its consequences on women’s wellbeing.

36The descriptive study of experiences of infertility and stigma in the Global South has been a growing field in the past years. However, when it comes to the region of Southern Africa, many studies tend to focus on a narrower and more specific range of countries, such as Botswana and South Africa; leaving a research lacuna in many other countries, including Malawi. Inhorn’s groundbreaking work, Quest for Conception, was one of the first few trailblazers in the literature that focused on descriptive experiences of infertility in the Global South. My own thesis will add to this field by focusing on the question of how stigma is understood and managed in the context of the local ecology of Malawi, the socio-cultural perceptions of infertility, and its consequences on lived experiences and gender identities. A literature search revealed that no study has discussed coping strategies specific to Malawian individuals dealing with infertility. The qualitative data drawn from the interviews in my own research will offer a rich account through the different groups interviewed: infertile individuals, religious leaders, community workers, health workers, traditional healers, and doctors. This approach also acts as a form of empowerment, allowing the voices of those included in my study to be heard, and highlighting their needs rather than silencing them – as tends to happen when broader national population policies are drawn up. It will focus on the perceptions of causes, the social meanings and the consequences of infertility, to contribute to the limited knowledge that exists in this area in the context of Malawi. This contribution will also respond to the growing call for a social approach to the field of health psychology, one that prioritizes the emotional and interpersonal influences on people’s behaviour.

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