Giving Infertility a Human Face Amidst Culturally Induced Stigma
It's time to move beyond outdated cultural beliefs and embrace a future where all individuals, regardless of their fertility status, are treated with dignity, respect, and compassion.
MZIMBA, Malawi—Debora Manda, 40, doesn't cry every time she nurses her 5-month-old baby girl, Desire. Debora Manda, 40, can't help but cry as she nurses her five-month-old baby girl, Desire, born out of wedlock. She's certain that if Desire had arrived during her marriage, she would have escaped the insults, ridicule, and ostracism she endured—a painful memory still etched in her mind, writes Ed-Grant Ndoza, MANA.
"Desire, where were you, mamie? Why did you come late?" Debora asks her baby, her gaze filled with a mixture of affection and resentment.
Desire's late arrival is blamed for the humiliation she endured at the hands of her husband, Bob Makomo, and his family.
Debora struggles to understand how the passionate love Bob once showered upon her during their courtship had so abruptly and acrimoniously vanished.
Their love, an exemplary romance that never wavered from moral righteousness, was the envy of the community, a model for aspiring couples.
Debora cannot believe she was divorced from a marriage that fulfilled all Christian vows and cultural values, culminating in a wedding blessed by a local church.
Looking at their wedding pictures, she remembers Bob tenderly feeding her a piece of cake, their faces flushed with love, their smiles bright. Her mind struggles to reconcile that joyous past with the harsh reality of her present.
As a devout Christian, Debora wonders why God allowed the dissolution of the marriage He had created.
During their wedding, the officiating clergy had emphasized the sanctity of marriage, citing two passages from the Bible, declaring it a union ordained for life, unbreakable by any circumstance.
Reverend Halifax Nyathi, quoting Proverbs 18:22, said, "He who finds a wife, finds a good thing and obtains favor from the Lord."
He then turned to Genesis 2:24: "Therefore, a man shall leave his father and his mother and hold fast to his wife, and they shall become one flesh."
The crime Debora committed was simply her inability to conceive and give birth to a child, preferably a girl, within her two years of marriage. In a community where a woman's value is often measured by the number of children she bears,
Debora became a target for verbal abuse, accused of infertility.
Bob's mother, desperate for grandchildren, spread rumors, questioning the wisdom of investing resources in caring for Debora.
"We are all men here. You have to pack and go," Debora remembers Bob commanding, after his ultimatum for her to conceive had long passed.
Debora had married in Makomo Village, a remote part of Mzimba South District, a region where a village's strength and respect are often judged by the number of children. In her childlessness, Debora found no solace or support from others.
Left with no options, Debora was forced to gather her belongings and leave. She succumbed to Bob's threats to marry another woman, threats openly endorsed by his mother and other family members.
Countless women have endured similar demeaning treatment. They are victims of infertility stigma and discrimination, deeply entrenched in the traditions of some communities.
In Sub-Saharan Africa, children are seen as a source of wealth, making infertility a serious issue, especially in societies where womanhood is defined by childbearing.
Beatrice Mateyo, Executive Director of the Coalition for the Empowerment of Women and Girls (CEWAG), explains that in most African societies, women, whether married or not, are expected to have children after a certain age. Children are considered a mark of adulthood and dignity.
Women unable to have children are often ostracized, stereotyped, and stigmatized, Mateyo adds.
This socially constructed role of childbearing is at the root of infertility stigma and discrimination against women, according to Mateyo.
"Women suffer from infertility stigma and discrimination because childbearing has wrongly been a socio-culturally agreed role of motherhood in our societies," she says.
In these societies, regardless of age, status, or social class, if a person has not fathered or given birth to a child, they are considered 'underage' and excluded from adult matters.
Until recently, patriarchal communities in northern Malawi districts like Mzimba, Rumphi, Karonga, and Chitipa, which practice the lobola (dowry) tradition, primarily in the form of cattle, valued families with daughters as wealthy.
It is therefore a significant transgression for a married woman to be barren after her husband's family has paid a hefty dowry in cattle to her parents.
In remote communities, livestock remains a key measure of wealth. The strong cultural belief that livestock symbolizes wealth and prosperity is evident in the ubiquitous presence of cattle and goat kraals in every village.
While lobola is not a practice in tribes that don't recognize it, girls are still often viewed as a form of wealth.
Emma Kaliya, Executive Director of the Malawi Human Rights Resource Center and a gender rights activist, has taken a nuanced stance on the lobola issue, acknowledging its historical role while recognizing its potential for harm.
Kaliya explains that in patriarchal communities, the groom's family traditionally gives something valuable to the bride's family as a token of appreciation for raising the bride.
Cattle was historically the most valuable asset at the local level, thus becoming the preferred form of lobola.
"Dowry was initiated as a gesture of appreciation for the good job the girl's parents performed to care for, grow, and mold her into an envious girl that catches the eagle eye of the bridegroom," Kaliya said.
Beyond serving as a token of gratitude, lobola creates a strong marriage bond, deeply rooted in cultural values.
The exchange of lobola from the groom's family to the bride's family signifies a traditional ceremony that formalizes the union.
Lobola, therefore, serves as a strong foundation for marriage, making it difficult to dissolve except in cases of serious violations of core cultural values.
However, the tradition becomes problematic when it prevents wives from leaving a marriage if they choose.
This practice faces condemnation from rights groups. If a wife experiences marital difficulties, or if her husband passes away, the lobola can effectively trap her in the village.
The widow may be inherited by another man without her consent, a practice that amounts to forced marriage.
It is dangerous for a wife to seek divorce or leave the village after her husband's death, as it can result in severe repercussions from her family. Her father may be forced to return the cattle received as lobola.
This tradition further stigmatizes infertile wives, as the cattle paid for them do not result in children, leading to accusations of wasted resources and widespread social stigma.
The practice of lobola also perpetuates significant inequalities between boys and girls. While girls are valued for bringing cattle to the village, this tradition often disadvantages them.
Cattle received as lobola is often used to fund boys' education, leading to a disparity in opportunities.
Boys who achieve academically often enjoy a better life due to the financial support provided by the lobola, while their sisters, particularly those with husbands who have limited income, struggle with basic needs and schooling for their own children.
Well-off brothers often disregard their sisters' needs when they seek assistance.
Despite claims that lobola strengthens marriage bonds, proponents of the tradition are confronted with accusations of primitive barter trade—effectively exchanging girls for material goods.
Group Village Headman Amon Mtampha Moyo, a conduit of Ngoni cultural values, strongly defends the tradition.
"Lobola was there, is here and will be there. It came to stay. It is not a medium of exchange at all. It is practiced for a purpose best known and appreciated by us. They must leave us alone," he said.
Moyo, deeply rooted in his culture, has received lobola for the marriages of his three daughters, ceremonies that adhered to both Christian and Ngoni traditions.
Lobola, which was once typically 10 to 8 cattle, has become more affordable due to factors like livestock disease outbreaks, economic challenges leading to cattle sales, and rampant theft.
The current price has dropped to around 5, 3, or even just one cow, according to Moyo.
Cattle holds significant importance in Ngoni villages, extending beyond lobola. It is a source of food, income, and barter for farm produce. Cattle are also used as fines in informal village courts, consumed by the court officials and village leaders.
Wealthy villagers use oxen to pull oxcarts and plow fields, and cattle dung has various uses, from fertilizing crops to building materials and even fuel. The skin is used for making items like dancing shields, spear handle sheaths, and burial shrouds for chiefs.
In the past, cattle served as a form of recreation for herd boys, who engaged in bullfights and bull riding.
The Ngoni people have a unique approach to infertility. While they value lobola, a woman's inability to bear children is not a cause for alarm or stigma.
Instead, when a wife cannot have children, the Jere Ngoni practice a custom called "Mbiligha" or "bonus wife."
The parents of the barren wife identify a well-behaved younger sister and encourage her to marry her sister's husband.
It's common for barren women to raise their younger sister's children, as they are deeply respected by both the husband and their "Mbiligha" sister.
The barren woman treats the children as her own, and the children view her as their biological mother.
This system is highly cohesive and often kept secret, with some children not realizing their true parentage until adulthood.
"Children born to the younger sister call the barren woman their mother. The elder sister enjoys all the respect and dignity from the younger sister because they are from the same blood," explains Ndawazake Thole, secretary of Esangweni, a powerful forum among Jere Ngoni elders known for their wisdom and leadership.
Other tribes often resort to polygamy for women who resist organized divorce.
The husband's relatives, often those with limited education, actively search for a woman who can provide children for the childless husband.
In polygamous families, the barren wife is often treated as second-class, particularly if she and the new wife are not related.
She must be patient and tolerant to stay in the marriage and is often subjected to the new wife's authority, who, often with more resources, may exert control over the household.
The barren woman can become invisible, especially if the second wife becomes pregnant.
The elder wife faces discrimination, leaving her stigmatized, stressed, and the target of negative comments from family members.
In many African settings, childlessness is often blamed solely on the wife, ignoring the fact that 50% of infertility cases affect husbands. In patriarchal societies, husbands, whose fertility has not been medically examined, often boast about their virility and place blame entirely on their wives.
These wives often face threats of divorce and being replaced by fertile women.
Communities that criminalize childlessness and hold women solely responsible often lack knowledge about fertility and sexual and reproductive health (SRH).
Infertility is a complex condition, defined as the inability to conceive or carry a pregnancy within a specific timeframe.
The World Health Organization (WHO) defines infertility as the inability to conceive after one to two years of trying.
There are two types of infertility: primary and secondary. Primary infertility refers to the inability to conceive the first pregnancy, while secondary infertility involves the inability to achieve a second or subsequent pregnancy.
However, infertility can be more complex than just a woman's inability to conceive. Miscarriages and stillbirths are also indicators of infertility.
Infertility is a global health problem, affecting over 180 million people worldwide.
Approximately one in six people of reproductive age will experience infertility at some point in their lives, leading to negative impacts on their well-being, families, and communities.
Sub-Saharan Africa has the highest rates of both primary and secondary infertility, largely attributed to the prevalence of sexually transmitted infections (STIs), postpartum infections, and unsafe abortion complications.
Beyond biological factors, non-medical conditions can also contribute to infertility.
Malnourishment, for example, can significantly affect a couple's ability to conceive.
Dorothy Ngoma, a Special Presidential Advisor on Sexual and Reproductive Health and Safe Motherhood, explains that a woman and man of childbearing age need a balanced diet.
"The couple will need food rich in proteins to produce healthy ovules (eggs) and sperms, for steady fertilization, implantation of an embryo in the womb, and onward development of a healthy baby to be born," she emphasizes.
Medically healthy couples struggling with infertility can benefit from diversifying their diet, focusing on fertility-boosting foods like whole grains, raw nuts, legumes, vegetables, fruits, non-animal protein sources, low-fat dairy products, and omega-3 fatty acids found in seafood.
Dr. Robert Shmerling, a practicing rheumatologist and editor for the Harvard Health Publishing Journal at Harvard Medical School, wrote in a 2020 article that women can naturally boost their fertility by consistently consuming foods rich in folic acid, omega-3 fatty acids, and vitamin B12, often referred to as the Mediterranean diet.
Poor lifestyle choices like excessive alcohol and drug use, smoking, obesity, inactivity, and certain medications for chronic illnesses can also contribute to infertility.
Environmental factors can also impact fertility, affecting the quantity and quality of eggs and sperm due to exposure to pollutants and toxins.
Erectile dysfunction (ED), a common problem in men with diabetes, is another serious cause of infertility. Diabetes can disrupt blood flow to the penile muscle, hindering erections.
Like many men who suffer in silence, Debora's husband, Bob, may have been a victim of ED, a debilitating sexual and reproductive health issue that often affects men with type 2 diabetes mellitus.
Diabetes is a metabolic condition caused by the pancreas's inability to produce enough insulin or by insulin resistance, resulting in the body's inability to regulate glucose levels.
Uncontrolled glucose levels lead to the buildup and hardening of blood in the arteries, a condition known as atherosclerosis, which disrupts blood flow.
This disrupted blood flow can suppress or entirely eliminate sexual desire due to reduced blood flow to the penile muscle chamber, essential for achieving an erection.
Fortunately, ED is often reversible. Victims can regain their sexual function through lifestyle changes like incorporating fiber-rich meals containing nitric acid, which dilates blood vessels, boosting blood flow to sexual organs and activating the libido-boosting hormone, testosterone.
Rapid and continuous fluctuations in glucose levels can also damage the peripheral nervous system (PNS), causing a condition called neuropathy.
Neuropathy disrupts the two-way communication system between the PNS and the central nervous system (CNS), meaning sexual arousal signals cannot be transmitted and decoded by the sensory nerves, preventing a physical response in the sexual organs.
This condition is severe. Even with intense stimulation, the victim cannot achieve an erection.
STIs and complications from abortions contribute to infertility stigma, disproportionately affecting women.
Victims of these conditions are often wrongly accused of engaging in promiscuous behavior during their adolescence, leading to assumptions that they engaged in unprotected sex with multiple partners, contracted STIs, and experienced unplanned pregnancies that were terminated unsafely to avoid embarrassment.
Men responsible for these pregnancies often disavow them, leaving women to manage the consequences alone.
Women perceived as infertile face a range of negative outcomes, varying depending on their tribe, cultural values, and social environment.
In many African settings, they are often ostracized, isolated, stigmatized, discriminated against, subjected to intimate partner violence, experience marital instability and disintegration, and face widespread stereotyping.
Beyond STIs and lobola, the issue of infertility stigma becomes even more complex when intertwined with religious beliefs.
Some perceive infertility as a punishment from God, pointing to biblical verses that describe the harsh treatment of barren women, including corporal punishment, isolation, and other injustices.
Biblically, infertility was seen as a serious issue, threatening family lineages and, ultimately, the survival of the tribe. Scripture often glorifies childbearing as a fulfillment of a woman's physiological role as a mother.
Rabbi Rachel Adelman wrote in an article for the Jewish Women's Archive (JWA), "In agrarian societies, during the biblical period (1200-600 BCE), bearing children was highly valued and women's primary role was that of the mother."
Many biblical passages emphasize God's intention for marriage, highlighting its purpose for intimacy, love, and procreation to ensure the continuity of generations.
Genesis 1:28 states that God blessed couples to produce offspring, saying, "Be fruitful, multiply, fill the earth, and subdue it."
Infertility stigma, therefore, appears to have its roots in both biblical teachings and modern societal values that equate children with wealth.
Kaliya views infertility from a different perspective, focusing on the legacy that individuals leave behind after death, particularly in an African context.
In many African cultures, those who do not have children are seen as lacking dignity, a perception that persists until their death.
In some societies with deeply rooted beliefs about infertility, the deceased bodies of barren individuals undergo cleansing rituals to prevent their spirits from haunting the village and tormenting the children of fertile residents.
In several African countries, marriage is seen as a primary means of procreation, not merely a union for companionship. Marriage is central to the continuity of the family lineage.
A barren woman is seen as defiant, blocking the expansion of the family name.
A high number of infertile women in a village poses a threat to the continuation of the family name. It is no wonder that a lactating woman is showered with gifts, especially if she was part of a lobola marriage and her child is her first.
The good news is that infertility is often treatable.
Ngoma explains that STIs can block reproductive system tubes, requiring surgical intervention by a qualified physician. Women with hormonal imbalances can be treated with injectable hormones. Many infertility issues are successfully treated with medications.
However, a significant challenge in Sub-Saharan Africa is that infertility is not often addressed through medical means.
Public health institutions often lack the capacity to conduct thorough fertility diagnoses and treatment.
This leaves those suspected of infertility with few options besides seeking help outside the formal healthcare system.
The lack of trained personnel, high-tech equipment, adequate infrastructure, and the high costs of treatment are major barriers to addressing infertility.
The World Health Organization (WHO) highlighted these challenges in a report on May 22, 2024.
In developed countries, where infertility is treated like any other disease, specialized facilities like assisted reproductive technologies (ARTs) and in vitro fertilization (IVF) clinics are equipped with advanced technology and highly trained personnel to provide comprehensive fertility services.
In Malawi, all public health facilities provide fertility services at various levels. Adrian Chikumbe, Public Relations Officer (PRO) for the Ministry of Health and Population, confirmed that reproductive health services, including fertility management, are available at all healthcare institutions.
He mentioned testing, counseling, treatment, and access to contraceptives as examples of services offered.
Chikumbe added that more serious cases requiring intensive diagnosis and specialized treatment are handled by district and central hospitals.
However, he acknowledged that misconceptions about fertility issues persist in rural communities, often blaming women exclusively, leading to underutilization of reproductive health services.
"The impact of the services is limited because of myths rooted in many rural communities that believe fertility and other reproductive health matters are the domain of women only," Chikumbe lamented.
Ngoma acknowledged the Ministry of Health's efforts in providing fertility services but stressed that limited resources hinder the delivery of high-quality care.
A significant portion of couples in remote and hard-to-reach areas do not benefit from public fertility services due to limited awareness of available services and a lack of understanding of the importance of seeking healthcare.
Cultural beliefs surrounding sexual and reproductive health and motherhood are also major obstacles, often leading to silence and a reluctance to discuss these topics openly.
Underutilization of reproductive healthcare services is also exacerbated by misconceptions about family planning contraceptives, which some believe can induce infertility.
Even in communities with access to education, some recognize the profound impact of cultural beliefs on reproductive health issues, particularly for women.
They acknowledge that discussions about sexual and reproductive health, puberty, fertility, pregnancy, and childbirth are often taboo, particularly for men.
This cultural taboo, unfortunately, overshadows the understanding that men play a significant role in a woman's fertility.
Men are often excluded from conversations about girls' puberty and are not expected to participate in managing menstrual hygiene.
This exclusion disadvantages girls whose well-being receives limited attention from men, particularly in a gender-insensitive environment.
Girls' hygiene and sanitary needs are often marginalized in male-dominated school management, leading to insufficient resources being allocated to school projects that benefit girls.
This results in inadequate or non-existent sanitary facilities, ultimately contributing to girls dropping out of school.
Ironically, educated women who seek medical examinations to address health concerns face undue criticism from some husbands.
Except for a few couples with access to education, many opt for traditional medicine, such as pregnancy-inducing herbs, administered by traditional birth attendants (TBAs) and self-proclaimed herbalists. The efficacy of these remedies remains questionable and often based on metaphysical beliefs.
Powerful concoctions, often made from roots, bark, and leaves, are administered to barren women under the watchful eye of a TBA and the mother-in-law, who ensure compliance.
These concoctions are sometimes so potent that they cause severe nausea, dizziness, and vomiting, leading to health complications.
Switiwe Jere from Luhomero area in northern Mzimba District described the challenges of consuming traditional medicine.
"The concoction is just too tough to take. It generates a strange nausea. Weaker women vomit and fall sick. Some feel serious dizziness after taking it," she explained.
Ngoma dismissed the effectiveness of these pregnancy-inducing herbs. She emphasized that no herb can force fertilization or interfere with the natural process of conception. She uses the analogy of faith and prayer, suggesting that sometimes, outcomes are achieved based on belief and conviction.
"By coincidence, yes, a woman may conceive a pregnancy after consuming herbs, which at times happens out of one's strong belief and conviction over what one wants to achieve," she said.
Ngoma advises childless couples to avoid non-clinical services offered by TBAs or herbalists.
If a woman does not conceive after a year of unprotected sexual activity, she urges them to seek medical advice. A doctor can conduct a thorough examination to assess their fertility status and provide counseling or treatment if necessary.
Ngoma cautions women against relying solely on herbalists and self-proclaimed prophets, who may exploit their desperation and engage in sexual abuse. Some herbalists use sex with a client as part of their "charms," claiming it's a divine intervention following prayers.
It is also important to be aware of those who exploit religious beliefs, performing fake miracles and engaging in sexual misconduct. Some "men of the cloth" have been jailed for exploiting desperate women.
Besides the health risks of contracting sexually transmitted infections, including HIV/AIDS, through sexual abuse, desperate women also risk their lives when consuming potentially poisonous concoctions.
It is also important to remember that women who are treated for infertility may be fertile, while the problem lies with their husbands.
Gender activist Kaliya is recognized for her work on the EU-funded Gender Equality and Women Empowerment (GEWE) project in the Northern Region of Malawi, promoting a more humane approach to women's rights and dignity.
She has launched an advocacy campaign, urging chiefs in Mzimba to dismantle oppressive and outdated cultural beliefs within the Ngoni community.
Kaliya strongly condemns the practice of forcing childless women to engage in sexual relationships with other men to conceive, often orchestrated by barren husbands.
"It is a big violation of women's rights for some husbands believed to be barren to strike a deal with men said to be potent, to sleep with their wives as surrogate husbands, to conceive a pregnancy," Kaliya said.
She warns that this practice puts women at risk for STIs and HIV/AIDS.
"It is a big mistake and carelessness of the highest order for women to sleep around with different men in a desperate hunt for babies, which must come at their own opportune time, as a gift and a blessing," she added.
The lack of screening to determine which partner is infertile often leads to situations like Debora's.
Her husband and relatives reacted with disbelief upon seeing her with her own baby, assuming that she had conceived with another man.
This only served to highlight Bob's own infertility, as he has never fathered a child despite engaging in multiple relationships since their divorce.
"When I met my divorced husband Bob, he almost ran mad on a glance at my baby. All he asked was if I swore the baby behind my back was biologically mine," Debora said about her first encounter with Bob after their divorce.
Bob could have been infertile from birth, but it's also possible that he suffered from ED or poor lifestyle choices that negatively impacted his sexual and reproductive health.
It's critical for men to overcome their chauvinism and be open about their own health status by undergoing medical examinations and screening for diabetes and fertility issues.
They should avoid blaming their wives for any fertility challenges, as this could lead to unnecessary shame and embarrassment.
Debora's case serves as a stark reminder of the misconceptions that prevail in some communities, where a woman's infertility is assumed after only a few months of trying to conceive.
Debora was not infertile. She became pregnant casually after sleeping with a former classmate, an act that was not intended to lead to a pregnancy.
Despite her initial disbelief, Debora was thrilled when a prenatal exam revealed she was three months pregnant.
Her joy was heightened by the disbelief of those who had mocked her for her supposed infertility.
The challenge for Debora was not her infertility but the societal inequalities that prevented her from speaking out about her situation.
Women are often silenced by oppressive societal structures and norms imposed by undemocratic local leaders, hindering their ability to challenge injustices.
Debora silently endured the abuse from her husband and his family, lacking the courage to question their assumptions or suggest that her husband might be the infertile one.
Deep-rooted inequalities and gender imbalances in many rural communities create fertile ground for gender-based violence (GBV), which hinders women's participation in public life and contradicts a key pillar of democracy: popular participation.
Their contributions to the socioeconomic development of their families, communities, and the nation as a whole are limited.
Despite the seriousness of infertility as a health and human rights issue, limited resources continue to hamper the provision of quality fertility care in public health facilities.
To address this, authorities must ensure that adequate resources are available in both public and private healthcare institutions.
These efforts will be instrumental in improving fertility management, including prevention, timely diagnosis, and treatment of infertility disorders, ultimately promoting women's rights and well-being.
The fight for a just and equitable society, free from the burden of infertility stigma, is a journey we must all embark on together.