The problem of infertility in Africa

The problem of infertility in Africa

This article is from www.humanlifereview.com

Infertility causes great worry and sorrow for many couples in Africa, especially for the women. Medical evidence shows that men and women usually have the same rates of infertility.¹ Yet African tradition views infertility as always the woman’s fault.
In Africa it is taboo to discuss male infertility; that is something “to be concealed at all costs.” In Zimbabwe, for instance, “Covering up for men is usually done through a traditional practice called chiramu which involves the clandestine bringing-in of the husband’s close relative (usually a brother) to impregnate the wife.”² If that meeting is not successful, then it is concluded that the wife is to blame³ and should be sent back to her parents.
The assumption that the wife is at fault may also lead to polygamy. As one African woman wrote: “To appease a childless husband, and desperate to save their daughter’s marriage, the parents of the infertile woman sometimes purchase him a second wife. If they can’t afford to do so, they offer a younger sister or niece as a second wife. Some of my relatives have done that. But I shuddered at the thought of sharing a husband with any of my younger sisters.”⁴
The wife is obliged to protect the dignity of her husband. Yet nobody protects her, not even her own family. In my opinion, this is deceptive and destructive for all the parties involved.

Types and Causes of Infertility

Primary infertility is the state of couples who cannot have babies at all. This is usually measured by failure to achieve pregnancy after two years of trying. A 2008 study found a 2.7 percent primary infertility rate among women in an urban area of Tanzania. The authors said this “is in the range found throughout Sub-Saharan Africa.”⁵ Secondary infertility describes couples who have had one child but are unable to have more. This condition is very common in Africa, according to a 2011 report from the World Health Organization (WHO):

Women in the developing world, particularly Africa, suffer from high rates of secondary infertility. Countries in northern Africa, Southern Asia, and Latin America all report a high prevalence of secondary infertility ranging from 15% to greater than 25%, but in the so-called “infertility belt” of Sub-Saharan Africa, the percentage of couples with secondary infertility exceeds 30% in some countries, and in Zimbabwe, it has been reported that almost 2 out of 3 women over the age of 25 are infertile.⁶

Sexually transmitted infections (STIs) are the main cause of infertility in Sub-Saharan Africa. In Gabon, it is reported that 32 percent of women are infertile, almost entirely as a result of blocked fallopian tubes caused by STIs such as gonorrhea and chlamydia.⁷ Poverty and substandard medical care often aggravate this problem. As one report noted, “in Africa most of the sexually transmitted diseases which can cause infertility could be prevented or cured but are not because health services are not adequate, accessible, or affordable.”⁸ A study in Zimbabwe, for example, found that tubal blockages were the main cause of infertility in both men and women—“the result of delayed or inadequate treatment of reproductive tract infections (RTIs).”⁹ Another aggravating factor is early-age sexual intercourse. In some regions of Africa, girls often marry early, sometimes even before puberty. Elsewhere, because of poverty, many girls accept gifts—often financial—from older men to “play sex.” This places the girls at high risk for STIs and other reproductive problems.¹⁰ Also, the African practice of female circumcision may lead to infertility by causing infections, pelvic inflammation, and inelastic scar tissue.¹¹
Inadequate semen is another major cause of infertility.¹² Other causes include hormonal dysfunction, endometriosis, and polycystic ovarian disease.¹³ Sexual dysfunction is another factor; it is often caused by psycho-social pressure from those around an infertile couple.¹⁴ The aging process, of course, also affects fertility. As one expert noted, “Female fertility has a ‘best-before date’ of 35, and for men, it is probably before age 45-50.”¹⁵
A 2011 study in Nigeria found that infertile women were significantly more likely than other women to have had abortions.¹⁶ The abortion problem is acute in Africa, where abortions usually are done in poorly equipped health centers by unqualified personnel.¹⁷ A 2012 study, reporting an infertility decline during one period, noted: “Post-abortion complications are also an important factor contributing to infertility. The risk is higher for unsafe practices than for safe abortion procedures” (thus implying there is some risk even in “safe” abortions). “Decline in unsafe abortion rates in Sub-Saharan Africa between 1995 and 2003,” it said, “may have contributed to declines in infertility rates.”¹⁸

Consequences of Infertility for Women

A married African woman who has no child is living on borrowed time. The first threat in most cases is outright divorce, non-negotiable. She is someone because she is married, but she will be nobody outside marriage. A woman acquires an identity through marriage and, most importantly, when marriage is fertile. If not, she may be returned by the husband to her parents at any moment, in disgrace and shame. The husband considers himself wronged and deceived, as if the woman and her parents should have known beforehand that she could not bear children.¹⁹ To me, this is sheer insanity. Often, nobody takes the time to examine the couple in order to find the source of infertility.
There is also psychological distress and trauma for the woman, due to insults from spouse, relatives, and neighbors. If the husband takes a second wife, the first wife may then have trauma from living in a polygamous and abusive marriage. She may leave the situation if she has the courage to do so. A study in Rwanda found negative consequences for men as well. The authors wrote that, “although women carry the largest burden of suffering, the negative repercussions of infertility for men, especially at the level of the community, are considerable.”²⁰
A Harvard Mental Health Letter report noted that family and friends “may inadvertently cause pain by offering well-meaning but misguided opinions and advice.”²¹ This problem is even worse in Africa, where the extended family system is practiced and valued. Though this system may be beneficial in other ways, it often aggravates the infertility problem. Childlessness, which should be a private matter, becomes an issue for open inquiry from relatives, friends, and neighbors. Such pressure can place intense stress on the woman.²²
For women in mainstream Christian churches, infertility may lead to loss of their faith and resort to traditional healers or faith-based healers. Many turn to Pentecostal churches, which Africans often call “mushroom churches” because they spread so rapidly.²³ The theme of infertility is the number-one topic during sermons and rituals in these religious settings. They make couples believe that their infertility problem is spiritual, rather than medical. And in Zimbabwe, according to one study, “traditional beliefs linking infertility to witchcraft are rife.”²⁴

Media Influence

African media, especially the Nigerian film industry called Nollywood, emphasize the theme of infertility in films such as Blind Choice, Desperate Soul, Immoral Act, Soul After Soul, The Pastor’s Daughter, and The Power of Her Majesty.²⁵ I recall seeing a Ghanaian movie on this theme that really moved me to tears. It was about a young girl who, married to a wealthy man, was unable to have a child. Her parents, in order to save their daughter from the shame of childlessness—and, above all, in order not to lose their wealthy in-law—decided to give a younger daughter to the man. After that daughter had a baby, she and the man started working against the real wife—her big sister. The situation became so precarious that the older sister died out of frustration. She died practically in silence because she was unable to talk about her troubles with anybody, even her own parents. It was taken for granted that her younger sister was sent to save her marriage—so why should she complain? After her death, the younger sister took over the matrimonial home. Things went on well for a short time, but then the man started treating the younger woman the same way he had treated her sister. Eventually, she, too, died, leaving her small baby. The man remarried, and the new wife maltreated the child, who disappeared from his father’s house and was never seen again. So the grandparents lost their two daughters and a grandson in the name of covering up a daughter’s infertility. In their senseless act of covering up one problem, they created ones that were far worse.
As in the movies, so it is with African music, especially gospel music. Any music that does not say something about the solution to childlessness and ways to prosperity will hardly sell. The fertility dilemma is also a common theme in African novels and plays. According to Okonjo Ogunyemi, “childlessness is considered tragic, providing an irresistible attraction to writers.” She listed some classic Nigerian writings that feature infertility as their central theme: Song of a Goat, Behind the Cloud, The Dilemma of a Ghost, Anowa, Efuru, Idu, Many Things Begin for Change, The Joy of Motherhood, Chance or Destiny, and Garden House.²⁶

Actions To Be Taken

The first step is to end the “demonization”of infertile women in Africa and other parts of the world. This process should be for all. Let governments, churches, private groups, and others promote the dignity and rights of women. This can be done in workshops, seminars, and conferences. Some African women already have taken steps to improve the situation of women who face infertility. In Zimbabwe, for example, Betty Chishava and two other women started a support group for infertile women. Using words that mean “our own gift,” they called it the Chipo Chedu Society. Also in Zimbabwe, the Women’s Action Group (WAG), the country’s largest women’s organization, has run theater workshops and produced a booklet in the country’s two main languages to try and demystify the traditional beliefs that are associated with infertility and to urge that those who are infertile be accepted into society.”²⁷
The education of girls and women is very important. It helps increase an individual’s positive self-concept—the perception of one’s character, body image, abilities, emotions, qualities, and relationships with others.²⁸ In a culture where women are marginalized, their empowerment through education is crucial. And they should learn how to prevent infertility, or to cope with it, if they find themselves in that situation at any stage in their lives. Part of prevention is to revisit and rethink the tradition of female circumcision, which can lead to infertility and many other health problems. Another part is to discourage sexual activity at an early age—and promiscuous sexual activity at any age. Those practices encourage the spread of the STIs that often lead to infertility. Giving girls a sound moral upbringing helps prevent such practices. So does sending them to school and keeping them there until they complete their education.
When a couple is unable to conceive, it is important to find and treat the underlying cause(s), whether medical or psychosocial or both. Since popular media already pay much attention to infertility, perhaps they could be persuaded to include medical facts in their coverage. For example, they could make men more aware of male infertility and possible remedies for it. Good counseling can also help both men and women. Social and cultural expectations in Africa often limit the extent to which infertile couples talk about their sexual problems.²⁹ As two authorities noted, counseling “will help couples open up to each other and their doctor about their burden and obtain assistance, including information and education.”³⁰
There are now many remedies for infertility. In a case of low fertility, rather than none at all, timing intercourse for the fertile cycle may result in pregnancy. When a tubal blockage prevents conception, surgery may restore fertility. Some newer treatments for infertility, though, are extremely expensive and really beyond the reach of Africa’s many poor people. Some also pose serious ethical problems for both Christian and Muslim couples. Use of bought or donated eggs or sperm, for example, is sometimes called “high-tech adultery.”³¹ The in vitro fertilization and implantation of embryos often results in multiple pregnancies and the offer of “reduction” when a couple does not want twins or triplets. “Reduction” means killing one or more of the unborn children, usually by lethal injection to the heart.³²

The Adoption Alternative

Couples should seek medical solutions that are ethical. When those solutions fail, they should consider adoption. Many couples in Nigeria do seek adoption through my religious order, the Holy Family Sisters of the Needy. Our work was started as a response to great tragedy. After the Nigerian civil war (the Biafra War) of 1967-1970, there were many pregnant girls and women who had been raped and abandoned by soldiers on the streets. Their war-torn families could not take care of them, and many of the women died in attempts to abort their babies with local herbs. In order to save the lives of both women and babies, Rev. Father Denis Ononuju, CSSP, a Nigerian priest, started giving them shelter in his parish. With the help of his parishioners, he was able to take care of them, and the women were able to give birth to their babies. Father Denis was also involved in an adoption program that helped keep Catholic childless families together.
As the pro-life work grew, many lives were saved, and many childless families were able to adopt children. Father Denis thought of beginning a religious order of women who would dedicate their lives to this noble work. In 1983 he started the Holy Family Sisters of the Needy (HFSN). Today the Sisters run centers and homes for teenaged pregnant girls both in Nigeria and abroad. We encourage and help girls to put their babies up for adoption after birth if they wish. We also help childless couples to adopt the babies.
This is, however, one of the hardest options for infertile couples in Africa. Although attitudes are gradually changing, adoption is not generally an accepted practice there. One study in a Nigerian hospital found that 78 percent of infertile women would not consider adoption as a solution.³³ This is a problem not only in Africa, but also in the developed countries. For instance, the already-cited report in the Harvard Mental Health Letter said infertile patients in the United States find “great difficulty” in making “the transition from wanting biological children to accepting that they will have to pursue adoption or come to terms with being childless.”³⁴ This is why the work of the HFSN Sisters is very important in Nigeria and abroad.
When I was working in Nigeria, one couple came to me with a recommendation letter from their pastor (the first thing required for adoption) and their application. After going through the papers, I told them that I would open a file for them and contact them when we had a baby ready for adoption. They asked me how soon that might be, and I said that I couldn’t tell because there were other applications before theirs. The lady started crying and telling me what she and her husband had gone through at the hands of his relatives and friends. They were urging him to divorce her and marry another woman who could give him children. She begged that we sisters help stop that by giving her a baby as soon as possible. Noticing her big tummy, I said to her, “But you look pregnant.” She said no, although everybody thought that. She went on to tell me that she had a fibroid tumor and wanted to schedule surgery to remove it around the time that we would have a baby available for adoption. Receiving the baby and having the surgery the same day or thereabout, she reasoned, would make people think she had the baby naturally. Today, with a baby girl from our center, their relatives and friends are happy with them and they are delighted with their child. So our baby girl has a happy home.
Once a wealthy couple came to us for help, explaining that they wanted to adopt a baby boy and to keep the adoption secret. The man said he was a prince, the ruler of his village. He and his wife had a daughter, about ten years old, but his wife was unable to have more children. Without a son, he would cease to be a prince. But if he had a son and people knew that the boy was not his biological child, then the so-called “illegitimate” son could not be a prince and would never inherit his father’s kingdom. The husband said his only other option was to divorce his wife and marry another woman who could have a son who would inherit his palace and leadership role.
I explained that, for whatever reason, we seldom had boy babies and that others were ahead of them on the adoption list. The woman started crying and begging, and the man was fighting back tears. His wife, like the lady mentioned above, had a big tummy. When I asked her about that, she said that for months she had been wearing small pillows so that, when she received a baby through adoption, no one would know it was not her birth child. Speechless, I wondered how a woman could go through this for months. Later, though, they were able to adopt a baby boy from our center.
It is unfortunate that some couples feel they must hide an adoption because of social customs and pressures. I hope that attitudes toward adoption will change, so that people will be open about it. In this case, though, the couple is happy, and our poor baby boy is now a prince.





NOTES
1. J. Liebmann-Smith, In Pursuit of Pregnancy: How Couples Discover, Cope With, and Resolve their Fertility Problems (New York: New Market Press, 1987), 5; and A. Santona and G. C. Zavattini, “Partnering and Parenting Expectations in Adoptive Couples,” Sexual and Relationship Therapy 20 (2005), 309-22, 309.
2. Sue N. Matetakufa, “Our Own Gift,” New Internationalist, no. 303 (1998), http://www.newint.org/features/1998/07/05/infertility/
3. Dora R. Mbuwayesango, “Childlessness and Woman-to-Woman Relationships in Genesis and in African Patriarchal Society: Sara and Hagar from a Zimbabwean Woman’s Perspective (Gen 16:1-16; 21:8-21)” Semeia (1997), 29-37.
4. Quoted in Mark Mathabane, African Women: Three Generations (New York: HarperCollins Publishers, 1994), 13.
5. Marida Hollos and Ulla Larsen, “Motherhood in Sub-Saharan Africa: The Social Consequences of Infertility in an Urban Population in Northern Tanzania,” Culture, Health & Sexuality 10, no. 2 (2008), 159-73, 170.
6. World Health Organization, Incidence and Prevalence Data, “628.9 Infertility of Unspecified Origin (General Comments),” Capitola, First Quarter (2011), 1-22, 2.
7. Ibid.
8. Margaret Jean Hay and Sharon Stichter, ed., African Women South of the Sahara (New York: Longman Scientific & Technical, 1995), 247.
9. Matetakufa (online).
10. B. O. Ogunbanjo, “Sexually Transmitted Diseases in Nigeria: A Review of the Present Situation,” West African Journal of Medicine 8 (1989), 42-49, 42; E. O. Orji and S. O. Ogunniyi, “Sexual Behaviour of Infertile Nigerian Women,” Journal of Obstetrics and Gynaecology 21, no. 3 (2001), 303-05, 304; Chris Magnusson and Kari Trost, “Girls Experiencing Sexual Intercourse Early: Could It Play a Part in Reproductive Health in Middle Adulthood?” Journal of Psychosomatic Obstetrics & Gynecology 27, no. 4 (2006), 237-44, 240; Musie Ghebremichael et al. “Association of Age at First Sex with HIV-2, HSV-2, and Other Sexual Transmitted Infections among Women in Northern Tanzania,” Sexually Transmitted Diseases 36, no. 9 (2009), 570-76, 570; and Corben de Romero and Sare and Sunanda Ray, “Reproductive Health and New Technologies in Africa: Horizon Scanning for New Technologies,” African Journal of Reproductive Health 11, no. 1 (2007), 7-13, 9.
11. Janice Boddy, Civilizing Women: British Crusades in Colonial Sudan (Princeton, N.J.: Princeton University Press, 2007), 228.
12. World Health Organization (n. 6), 14.
13. Thomas Hilgers, “Infertility Treatments, in accord with Church Teaching” (2004), www.catholicculture.org/culture/library/view.cfm?recnum=6073.
14. On types of dysfunction, see B. M. Audu, “Sexual Dysfunction among Infertile Nigerian Women,” Journal of Obstetrics and Gynaecology 22, no. 6 (2002), 655-57, 655.
15. Juan Balasch, “Ageing and Infertility: An Overview,” Gynecological Endocrinology 26, no. 12 (2010), 855-60, 855.
16. Joyce O. Omoaregba et al., “Psychosocial Characteristics of Female Infertility in a Tertiary Health Institution in Nigeria,” Annuals of African Medicine 10 (2011), 19-24, 23.
17. H. A. Umdagas et al., “Prevalence of Uterine Synechiae among Infertile Females in a Nigerian Teaching Hospital,” Journal of Obstetrics and Gynecology 16, no. 4 (2006), 351-52, 351.
18. Maya N. Mascarenhas et al., “National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys,” PloS Medicine 9, no. 12 (2012), www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001356.
19. Mathabane, 12-13.
20. N. Dhont et al., “‘Mama and Papa Nothing’: Living with Infertility among an Urban Population in Kigali, Rwanda,” Human Reproduction 26, no. 3 (2011), 623-29, 624.
21. Harvard Medical School, “The Psychological Impact of Infertility and its Treatment,” Harvard Mental Health Letter 25, no. 11 (2009), 2.
22. Omoaregba et al., 23.
23. Ibid., 20.
24. Mathabane, 13.
25. “Nollywood Forever Movie Reviews,” nollywoodforever.com, accessed 9 Feb. 2013.
26. Chickwenye Okonjo Ogunyemi, African Wo/Man Palava: The Nigerian Novel by Women (Chicago: University of Chicago Press, 1996), 31-32.
27. Matetakufa (online).
28. Mary John Bosco Amakwe, Factors Influencing the Mobility of Women to Leadership and Management Positions in Media Industry in Nigeria (Rome: Gregorian University Press, 2006), 93-94.
29. Audu, 655.
30. A. C. Umezulike and E. R. Efetie, “The Psychological Trauma of Infertility in Nigeria,” International Journal of Gynecology and Obstetrics 84 (2004), 178-80.
31. James L. Fletcher, Jr., book review in Journal of Biblical Ethics in Medicine 2, no. 3 (1988), 23-28, 24.
32. Carol Turkington and Michael M. Alper, Understanding Fertility and Infertility (New York: Checkmark Books/Facts on File, 2003), 53-55.
33. Omoaregba, 21.
34. Harvard Medical School, 2 (see note 21).

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Paschal Ndaro