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Feminization and Stigmatization of Infertility in Malawi

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Boetumelo Julianne Nyasulu

5. Perceived Causes and Treatments

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1This chapter demonstrates that in Mngwangwa the interplay of culture, witchcraft, Christianity and biomedicine creates unique perceptions of causes of infertility and experiences of treatment. In a community where infertility diagnoses are limited to gynaecological exams for STDs, sperm analyses or a review of the individual’s reproductive history, when biomedical explanations for infertility remain incomplete or unknown, the unknown is best mediated through personalistic explanations (Gerrits, 1997, p. 44). However, in the interviews for this study it was quite uncommon for an interlocutor to provide only a single categorical explanation, as often both traditional and biomedical factors were considered.

5.1 Perceived Causes

5.1.1 Contraceptives

2Many of the women interviewed mentioned their use of contraceptives as a reason for their infertility. The majority of them had frequented family planning clinics around the Mngwangwa area in efforts to either prevent unplanned pregnancy or to space out future children. The contraceptive most commonly cited was Depo Provera, the brand name for medroxyprogesterone, an injectable contraceptive that is effective for three months. This comes as no surprise, considering that Depo is the highest-funded and most commonly supplied contraceptive for various clinics and health centres around Mngwangwa. One doctor at Mtema Health Centre – one of the two most frequented health hubs near Mngwangwa – mentioned that his own clinic was only stocked with 5 IUDs annually, without sterilization equipment, making it near-impossible for this solution to be offered, leaving Depo as the most feasible offer.

3In addition to this, similarly to other Southern African countries, Depo seemed to be the most preferred contraceptive owing to its low cost in comparison to other methods, a decreased need for vigilance and the “invisibility” of the method, as its application and consumption was less likely to be noticed by husbands or extended family members (Kaler, 1998, p. 369). This oppositional experience of the method’s benefit cast against its future cost was evidenced in Yamiko’s story, who had secretly taken Depo only to struggle with conceiving at a later stage:

What was your husband’s reaction?

“He was very disappointed that I took a contraceptive without his knowledge and kept him from having children, so he did not eat or bathe for two days, but later he just accepted it.”

What year was this?

“It was in 2015.”

What happened then?

“When the time frame of the injection I got was over, I still didn’t get pregnant even after accepting the need of my husband to have another child – because my mother advised me that what I was doing will give my husband thoughts of getting another woman. Since 2016 I was never able to conceive, then we were advised we should try seeking help as maybe the injection I took was still working in my body.”

4Consequently, despite Depo’s family planning benefits, various interlocutors felt that the hormones from the injection delayed or even permanently prevented the ability to have a child. Especially for the few interlocutors who mentioned having received the dosage twice or three times, in the belief that this would allow the birth control to work for longer. Adding to their frustrations, the women’s visits to the hospital only seem to have been met with instructions to continue to wait, as my interview with a nurse demonstrated in her response to my question on the correlation between Depo and failure to conceive:

“Yes, there are some people who have problems conceiving after using some contraceptive methods, not only Depo Provera, so they feel they are failing to get pregnant because of the method they used, but in due time they get pregnant.”

5.1.2 Sexually Transmitted Infections and Reproductive Issues

5Barden-O’Fallon’s findings on causes of infertility in Malawi was very much in line with Dr. Kalanda’s list of infertility causes in his interview:

“There of course is a male factor, which is hardly talked about. About 40-60 per cent of the cause for infertility falls upon the male, with a low sperm count as a contributing factor. But in most cases men don’t want to get tested. In other cases, sexually transmitted diseases as an obstruction can be a cause. The most common for women is tubal blockage due to sexually transmitted diseases or pelvic inflammatory diseases; other causes are hormonal issues and others have an unknown cause, where we’re not able to find out what is causing the infertility.”

6Another doctor from Mtema Clinic mentioned STIs being the largest cause, with syphilis as the primary affecter. In line with this, several women mentioned visits to the hospital where they were given medication for msungu (candidiasis), chibelekolo changa anachitembenuza (blocked fallopian tubes) or would directly mention an STI, although many were unable to identify exactly which STI they had been diagnosed with, or what medication they had been given. Visits to the hospital would be prompted either by no sign of conception or by symptoms of an STI that would vary from itching, vaginal discharge or sores on the individual or her partner, pain during sex and other symptoms.

7Kumbukani’s visit to the hospital not only marked the discovery of her infertility, but also the surprising cause of it:

Did you try seeking help from anywhere?

“We tried going to the hospital.”

What did the hospital say?

“They said I had syphilis but that my uterus was okay; so, they gave us some drugs, but nothing happened.”

Who did the doctor say had syphilis?

“The both of us, but we found out because I was the one sick.”

What did you feel?

“I felt itching, but I think my husband also had the disease and just did not tell me.”

Did the doctor tell you how you got the syphilis?

“No.”

How do you think you got it?

“I think my husband gave it to me.”

8There were of course those affected by complications from other infections, iatrogenic infections, reproductive abnormalities and unsafe abortions (Parrott, 2014, p. 175). While only three interlocutors mentioned having an abortion, none mentioned going to the clinic to have it done. The socioeconomic status of the majority of women in the Mngwangwa area forces many of the women to resort to unsafe abortions either performed by traditional healers, non-medical personnel or the purchase of an oxytocin-drug. One nurse expanded on the use of the drug

Are those drugs over the counter?

“No, they are not over-the-counter, it is an illegal drug… not really illegal but it’s not supposed to be sold, but some pharmacies sell them, so people access them. So, if people come here because of an abortion it means that someone is providing them.”

Does the pill cause complications for the uterus?

“That drug is the same one available here at the hospital. Let’s say someone has had an abortion but it’s incomplete, so we use it to get the rest out. Or if someone is in labour and the baby is struggling to come out, we use it to induce labour. But regular people don’t know the correct doses and timing.”

9Both this health centre and the Mtema Health Centre had large numbers of women coming in having had abortion complications or incomplete abortions that later affected their fertility status. One pastor in the Religious Leaders Community Discussion Group told the story of a woman he knew who went to South Africa to find out why she was having problems having a child. At the hospital was when they revealed the woman had gotten pregnant and had an abortion eight times. The constant abortions are what eventually led to her infertility. And this is the same for many cases. Unsafe abortions.”

5.1.3 God’s Will

10In several African communities, children are seen as a gift from God or the gods, and the inability to have children is thus explained as ‘God’s will’ for the individual – either as a result of their sin or unworthiness (Dyer, 2007, p. 74). As mentioned previously, Christianity is the most predominant religion in the Mngwangwa region, with 70 per cent of the population listed as practicing Christianity.

11Every interlocutor mentioned God in their interview, either when speaking of reasons for their infertility or the possibility of having a child in future. When mentioning God as the cause, however, it was more with an attitude of acceptance than of anger, as seen in the responses below:

What do you think are the reasons you are infertile?

“I think it’s just the way I was created and that in God’s time things will get back to normal.”

12And Mphatso, when asked for her sources of support added: The person who knows everything is God, so sometimes, I just pray. He is the one who decided that I am to be this way.” A religious leader speaking about supporting people with infertility mirrored this view, stating that Sometimes we church leaders misdirect people in our church. We try to tell our people that all things are possible with faith. But some situations cannot be changed even with faith. Barrenness is something that has happened because God has willed it.”

13Of the interlocutors who did mention ‘God’s will’ as a cause for their infertility, only one perceived it as a punishment for past transgressions, while others rested on the idea that God’s will can often be undecipherable and without need for explanation.

5.1.4 Witchcraft

14Studies in other African countries have revealed the prevalence of perceptions of witchcraft as a cause for infertility. Evans-Pritchard’s ground-breaking work on witchcraft among the Azande explains that beliefs in witchcraft are used to explain unfortunate events and regulate the responses to those events (Evans-Pritchard and Gillies, 1976, p. 18). While misfortune is often explained with a plurality of causes, more serious cases are often attributed to the action of witchcraft (Evans-Pritchard and Gillies, 1976, p. 18). Witchcraft is often instigated by feelings of greed, jealousy or envy (Richards, 2002, p. 88); consequently, interlocutors cited a diverse range of examples of witchcraft or curses that took on different forms. Madalitso explained that her infertility was a result of the ill conduct of her mother-in-law:

15“After the birth of my first child, my mother-in-law took the after-birth and told me that she was going to dispose of it. Because the place we stayed in was temporary, just for us to settle down for a bit, it had no toilets. So, my mother-in-law told me that she would dispose of them in the bedroom, burying them under the ground. After some years, when I realized I wasn’t able to conceive again I went to seek help from the sing’anga (traditional healer). The sing’anga told me that if I go and find my after-birth and remove it from the house then I would be okay. But when I went back to the house, I found that it was gone – that my mother-in-law had not in fact buried it in the bedroom that day. When I went back to the sing’anga, that is when I was told that my mother-in-law used my after-birth for her own rituals and benefits, and that is why I was infertile.”

16Two other interlocutors described a similar situation as the cause of their infertility, except that the after-birth was substituted with an umbilical cord for the one, and a cloth used during a menstrual cycle for the other.

17Those most exposed to your riches or successes are those closest to you in a community, and thus have a higher propensity for feelings of jealousy or envy. Several interlocutors felt their own family members had bewitched them, out of jealousy for their wealth or fertility:

“I think my cousins are responsible.”

Why do you think that?

“They sometimes come to my house and enter my bathroom, kitchen and toilet but do nothing. Then they just leave. So, I think they are witches and have brought this misfortune on my family. Other people know they are witches too.”

What exactly do they do?

“They might pass by a house and touch it for no reason or go into a house and not do anything then leave. And once a neighbour’s young girl died and they told the parents that they could kill another child in the neighbourhood as revenge.”

Why do you think you are infertile?

“I think someone is responsible for my infertility and bewitched me out of jealousy.”

Who do you think that person is?

“I think my aunt is responsible.”

Do you know why?

“I think she is just jealous. She was also jealous of my mother, which is why she struggled to have more children.”

Why doesn’t she want you to have children?

“She never wants to see my mother happy – because my mother didn’t have many children it would have been possible to make her happy if I did. But because my aunt was jealous and bewitched me that was never possible.”

18Another interesting form of witchcraft occurred in the dreams of two interlocutors. Chipi described her dreams of seeing herself crossing a river or seeing a house burning. She had the dreams several times after becoming pregnant, and right after the dream she would wake up with heavy bleeding and eventually miscarry. She believed that because she saw her in-laws in the dream helping her cross the river, they were responsible for her losing her baby and essentially ‘crossing’ into an infertile phase.

19Intriguingly, even if the interlocutors had suspected someone of bewitching them, they rarely, if ever, confronted their assailant. Evans-Pritchard offers a hypothesis that this could be due to the risk that an accusation of witchcraft against a family member might implicate other members of the family as witches (Evans-Pritchard and Gillies, 1976, p. 7). The inferior social position of an individual – in this study’s case as a woman, and further as an infertile woman – might also affect the gravity of their accusation, and in particular be framed as an insult if their potential accusee is of a higher social status (Evans-Pritchard and Gillies, 1976, p. 10).

5.2 Perceived Treatments

5.2.1 Traditional Healers or Hospitals

20Visits to either the sing’anga or hospital were cited in all of the interlocutors’ treatment seeking. Most interlocutors averaged between 2-3 hospital visits and 5-6 visits to a sing’anga, often in efforts to seek out different opinions or treatment options.

21One of the thirty infertile women interviewed only visited the hospital, explaining that I did not see any benefits of going there (to a sing’anga) as sometimes sing’angas also lie and can’t really be trusted.” Contrastingly, 2 out of 30 only visited the sing’anga and not the hospital, with the former explaining that this was due to a lack of finances, and the latter saying she had not gone to the hospital because my husband believes the help will be found in a sing’anga. The remaining 27 women visited both the sing’anga and the hospital, often multiple times, and saw the traditional and biomedical systems as complementary and re-affirming rather than mutually exclusive. This was apparent in several interviews, where the sing’anga would often give a diagnosis that was repeated in hospital, or vice versa.

“I was given some tablets from the hospital which I was to insert in the vagina, which they said would help wash me in the inside. The sing’anga gave me some herbs and roots to soak in water and to drink that would cleanse me inside and allow for things to be released through urine.”

22In fact, in a few instances interlocutors were advised by a hospital attendant to visit a sing’anga, as the hospital had no way to help them:

“The sing’anga gave me some herbs that would help me conceive and told me to wait as I had no fertility problems. I went to the hospital in 2013, where after screenings they found that I had no problem and advised me to seek help from a sing’anga. I explained that I had gone to a sing’anga once and nothing happened, and they just told me to go again.”

23Research indicates that traditional healers see 70 per cent of African patients, as they are often the first line of contact (Chipfakacha, 1997, p. 418). Traditional healers are well-suited to forms of diagnosis and treatment that acknowledge this diversity of perceived causes of infertility, ranging from the biomedical to the supernatural (Van Balen and Gerrits, 2001, p. 217). Consequently, in instances where a hospital gives a confusing or incomplete explanation of the cause of infertility, interlocutors were often able to gain clarity through a visit to the sing’anga, as demonstrated by Tadala’s visit:

Did they (the hospital) explain?

“They said this happened after the birth of my first child, but this was explained by a sing’anga who said someone had bewitched me and moved my womb to the wrong place.”

24Contrastingly, if the cause of infertility was not identified as witchcraft, the sing’angas visited by the interlocutors did not seem to offer any other explanation, nor was any information given on treatment methods, or medication provided, and it was this lack of information that would often prompt the interlocutors to seek help from the hospital.

25The methods of diagnosis of sing’anga cited in the interviews ranged from “seeing into other realms”, to bodily examinations with their hands, to conversations with the patient. In some cases, the sing’anga were even able to provide information on the person who was infertile:

“We tried to have a baby for four years and then we decided to get help. We went to a sing’anga who gave us some herbs. He said that the person who would sneeze was the one who was infertile but when we took it, we both sneezed so we went back to the sing’anga and he gave us some herbs to take together.”

26This same ritual was described by different interlocutors substituting sneezing with coughing or vomiting, or even an action that would occur later in the day (for example, an individual removing a stick from the interlocutor’s gate).

27Treatments from the sing’anga would include herbs to drink for one or both members of the couple, or herbs to insert in the vagina. When an explanation was given, these herbs were said to clean out the insides of the womb, heal sores or pains in the vagina or womb, or simply to “help them get pregnant”. Similarly, at the hospital interlocutors were often given medication in the form of tablets instead of herbs. The majority of interlocutors stated they did not know the function of the medication, unless they were antibiotics for STI treatment. Other services the hospital offered that the sing’anga did not were X-rays, STI diagnosis, semen analysis or contraceptives to correct or initiate the menstrual cycle.

5.2.2 God

28While ‘God’s will’ was cited as a cause for infertility, interlocutors would also touch on their turning to faith when efforts by the hospital or sing’anga were in vain. Interlocutors would mention praying for the gift of a child from God or visiting a religious leader or church in search of help. In one instance, an interlocutor even mentioned imploring her husband for them to stop seeking help from hospitals and sing’angas and instead “just wait upon the Lord because we were just spending money over things that did not bring results.” The most commonly cited answer given by the religious leaders or church members to “wait on God”. As one religious leader explained:

“God answers in three ways, which is YES, NO and WAIT, so when they see their answers being delayed it is either a NO or WAIT. There are times when God tells you directly that the person cannot be helped, but if you tell the person that God has told them NO they will not have children ever, he/she might just stop worshiping God and might seek help from elsewhere, like the sing’angas.”

29The church has a disregard for sing’angas that stems from the belief described by one religious leader: “[sing’angas] have a certain power, but not a power that is good. It taps into something that is evil – that Satan can take advantage of.” He added that a visit to a sing’anga when one is Christian confuses what source is truly responsible when a child is successfully conceived:

“In the story of Abraham and Sara [in the Bible], Sara was told to wait. In the time that she waited imagine if she had gone to the sing’anga? Then she would have birthed a child and assumed that the birth of the child was the result of the visit to the sing’anga and not the promise from God.”

30Prayer was the most common, if not only form of treatment offered and encouraged by the church. One religious leader mentioned praying for three infertile women and declared that all three presently had a child. Along with prayer, two elements were emphasized – that of faith and of wisdom.

“Faith comes by hearing and hearing by the Word of God. With a certain level of faith, anything is possible – you can move a mountain. Anything is possible. But faith goes with reasoning. If God wants to do something, of course he can do it. But he created us with a brain to reason about certain things. So, it’s not just about believing that certain things will come to pass.”

31This religious leader and half of the discussion group believed that while faith is necessary, a certain level of wisdom needs to accompany it. He went further to provide an example:

How do you see infertility issues in terms of faith?

“It needs both prayer, faith and wisdom. I remember from the story that my mother narrated to me that they had problems with my birth, it took them years for my mother to get pregnant. She heard from friends that, from what she was explaining, she could get help, and when she went to the hospital she got help and got pregnant after some months. Faith and wisdom go together. God will work in your circumstance if you also apply wisdom to it. He has the ability to give a child if he wills it, but you must be wise. When your faith is low also, go to the hospital and get help there. As religious leaders we should be able to discern those cases that need either wisdom or need faith.”

32While half the group of religious leaders stood behind this argument, the other half believed that faith did not always require an element of reason. One religious leader summed up their thoughts by responding that “In many instances that is true but at other times God can tell you something, some solution that you should do, where your reasoning would not make sense of it. Human reasoning is not applicable to all that God tells us.”

33All in all, however, the religious leaders were careful to emphasize that not all prayers for infertile people would result in conception. Whether one had unshakeable faith, or one applied an element of wisdom to pursue other forms of treatment along with their faith – in the end, God’s will still prevailed.

5.2.3 Remarriage or Polygamy

34Western literature has examined experiences of marital stress when couples are faced with infertility, but very few cover cases of male-initiated divorce as a result of female infertility (Greil et al., 2011; Greil, McQuillan and Slauson-Blevins, 2011; Van Balen and Gerrits, 2001; Van Balen et al., 1997). However, this outcome is present in several non-Western societies around the world, and has been cited in studies in countries like India and Egypt (Inhorn and Bharadwaj, 2007, p. 14). Similarly to the findings from the study of infertility in India mentioned previously, in Mngwangwa infertility is viewed as a valid reason for divorce or abandonment. All of the interlocutors had been divorced and remarried between two or seven times, and many of them were or had been part of a polygamous union. Often times, the added vulnerability and stigma of being not only an infertile woman, but an abandoned or divorced infertile woman would be enough motivation for the woman to accept a transition into a polygamous marriage. Other interlocutors accepted the union owing to their feelings that they were the ones to blame for, because of their inability to have a child, as expressed by Chifuniro:

What was your husband’s reaction?

“He told me that he would get another wife but that I did not need to leave and could continue staying with him as his wife.”

How did you feel when he said that?

“I just accepted it, as I knew I was the one who had the problem and could not bring us children. After a month, he went and got another wife who got pregnant after five months. She gave birth.”

35If these women have to deal with the discovery of their infertile status, they also have to manage it in the context of another fertile woman married to their husband, and the latter often takes a higher social status in the household upon bearing a child.

36Interlocutors spoke of their divorces as an almost obvious result of a husband discovering his wife’s inability to conceive; similarly, in a community group discussion one man stated, matter-of-factly, that “If she is infertile you either leave her or get another wife.”

5.2.4 Fostering

37The last response or ‘solution’ to infertility cited in the interviews was to foster, although the interlocutors never labelled it as such. Many of the interlocutors who had not had any children and were divorced and living alone had taken on the care of their siblings or extended relatives’ children. This could include those relatives who did not have the economic or spatial capacity to care for all their children, relatives who had passed away, or relatives who sympathized with the interlocutor’s feelings of loneliness. In most cases, the children would move to stay permanently in the same house as the interlocutor.

38There were also instances where the interlocutors in a polygamous union would care for the other wife’s children. One husband even moved his other wife’s child into the house so that Fatsani could care for them:

Does your first husband not want more children now that you’re back with him?

“No because he already has three children and I was taking care of the other wife’s youngest in our house, although she died a few years ago.”

Why were you taking care of the other woman’s youngest child?

“I took her because I loved her character and behaviour.”

Was the other woman okay with you taking care of her child?

“We had conflicts over the child but because my husband was on my side, she accepted it.”

Why did your husband agree that the child should stay with you?

“He saw the child would grow well under my care.”

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