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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 9, Num. 2, 2005, pp. 26-37
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Untitled Document
African Journal of Reproductive Health, Vol. 9, No. 2, August, 2005, pp.
26-37
Denying and Preserving Self: Batswana Women's Experiences
of Infertility
Dintle K Mogobe
Department of Nursing Education, University of Botswana,
Private Bag 00702, Gaborone, Botswana. Tel: 00 267- 3552362; E-mail: Mogobekd@mopipi.ub.bw
Code Number: rh05023
Abstract
This qualitative study was conducted to understand and theoretically
explain infertility from the perspective of 40 infertile women and four members
of the traditional health care system. Symbolic interaction and feminism were
combined to under-gird the study. Through ongoing data collection and analysis,
a theoretical framework of denying and preserving self was constructed. Preserving
self or self-preservation means developing personal measures aimed at preventing
or reducing harm inflicted by others as a result of one's infertility. Contributory
factors to denying of self include denial of status as a woman; denial of immortality;
denial of experiences of pregnancy, labour and delivery; denial of economic
and social security; and the belief that they are being chastised by God and
the forefathers. In addition, the women develop strategies to deal with such
denials by looking for deeper meaning, working it out, giving in to feelings,
getting more involved, getting away, and doing adoption. Implications of the
study are discussed. (Afr J Reprod Health 2005; 9[2]: 26-37)
Résumé
Nous avons mené cette étude qualitative afin
de comprendre et d'expliquer, de façon théorique, la stérilité à travers
la perspective de 40 femmes stériles et quatre membres du système
de service de santé traditionnelle. Nous avons combiné l'interaction
symbolique et le féminism dans l'étude. A travers la collection
des données suivie et l'analyse, nous avons construit un cadre théorique
de l'abnégation et de l'instinct de conservation. La préservation
de soi ou l'instinct de conservation veut dire le développement des
mesures personnelles qui visent la prévention ou la réduction
du mal infligé par les autres à cause de la stérilité de
soi. Les facteurs qui contribuent à l'abnégation comprennent
la négation de sa situation de femme, la négation de l'immoralité,
la négation des expériences de grossesse, du travail et de l'accouchement,
la négation de la sécurité économique et sociale,
et la croyance que c'est le bon Dieu et les ancêtres qui les punissent.
De plus, les femmes conçoivent des stratégies pour contenir de
telles abnégations tout en recherchant un sens plus profond, en recherchant
la solution, en s'abandonnant aux sentiments, en s'impliquant davantage, en
quittant et en adoptant un enfant. Les implications de l'étude ont été discutées.(Rev
Afr Santé Reprod 2005; 9[2]: 26-37)
Key Words: Infertility, women, gender, Botswana
Introduction
Infertility is medically defined as the inability to conceive
after a year or more of regular unprotected sexual intercourse. It affects
both men and women of reproductive age in all parts of the world. Estimates
on the prevalence of infertility are extremely variable in literature, and
its occurrence varies from continent to continent as well as from country to
country. Worldwide, it is estimated that 8-12% of couples (50-80 million people)
experience some form of infertility during their reproductive years.1 In
the US, it is estimated that nearly 12 million people are infertile.2. In
the British population, at least as many as 16% of couples are believed to
be affected by infertility.3 Infertility is believed to account
for over 50% of cases seen in gynaecology clinics in the developing countries.
In Africa, no reliable information is available about the prevalence of infertility,
however, WHO estimates that as much as one third of all gynaecological and
family planning resources are devoted to infertility and related problems.1 Several
reports claim that gynaecologists spend two thirds of their consultation time
on patients complaining of infertility.4,5
In a study conducted by Mwalali, Tharakan and Tharakan, infertility
was reported to be the second most frequent cause of admissions to the gynaecology
ward in Botswana.6 According to the health statistics report of
Botswana, outpatient attendance of patients having fertility problems between
the ages of 15 and 45 years were 4400, 45+ years were 551 with a total of 4495
(0.2% of all outpatients).7 These numbers do not include individuals
and couples who were seen by private doctors, traditional healers and spiritual
healers. Yet how this population of Batswana perceives and copes with their
infertility is a topic that has been relatively neglected.
A review of literature on infertility in Africa has revealed
that most studies such as those of Chatfield, Belsey and Frank focused on the
incidence and causes of infertility.4,8,9 An insignificant number
of studies found that infertility "hurts", that it can be both traumatic
and debilitating for women who, for personal and cultural reasons, view womanhood
and motherhood as synonymous. While research investigating the causes and incidence
of infertility abound, there was less literature about the experience of infertility
and its psychosocial effects on the lives of the African women affected. Women
researchers, women organisations, nurses and midwives had and still have done
little, if anything, to give voice to the experiences of women with infertility.
The reasons for their lack of interest are unclear. One of such is the fact
that developing countries (Botswana included) have high fertility rates, hence,
emphasis has been on the control of fertility while the problem of infertility
is
seldom discussed.
African women appear to bear the major burden of reproductive
setbacks, including blame for reproductive failure, personal grief and frustration,
marital duress, social stigma and, in some cases, life-threatening interventions.10,11 Infertility
is also related to many other important domains of social life, including kinship,
inheritance, marriage divorce patterns, economic production, gender relations
and notion of the body.10-12 Examining infertility also leads to
the discovery of constructed meanings of motherhood, fatherhood and the children
themselves, which is a critical area for further research particularly in Botswana
where it has been relatively neglected. It is on the basis of this that the
study was conducted.
Purpose of the Study
The study was conducted to understand and theoretically explain
the phenomenon of infertility from the perspective of those who were experi-encing
it. The specific objectives were: to (1) describe the meaning of infertility
from the perspective of women who were experiencing it; (2) identify and describe
how women felt that their spouses, friends and other significant family members
influence their meaning of infertility
and; (3) delineate the processes and strategies
used by women in dealing with infertility.
Methods
Study Setting
The study was conducted in Gaborone, capital city of the Republic
of Botswana. It has a total population of 186,007 people, of which 94,184 are
females.13
Conceptual Framework
The theoretical framework for the study was an integration
of symbolic interactionism and the principles of feminism. Symbolic interactionism
guided the theory, data collection and analysis, while principles of feminist
research directed the ways in which the research was conducted, which informed
the purpose of the research as well as the analysis.
Symbolic interactionism states that the unique characteristic
of the human mind is the use of symbols to designate objects in the environment.
With symbols one can rehearse possible actions, develop common meanings among
parties in the interaction and put oneself in another's position. These purposes
can facilitate adjustment and survival. Through interactions with others, one
can crystallize self images into a stable though dynamic conception of oneself.
Through accumulated interactions, one develops a self image as seen from the
generalised other.14,15 Meanings are acquired during an individual's
experience in the group, and these meanings lead to the development of self
or an identity. Therefore, the underlying assumption in this study, derived
from symbolic interactionism, is that identity of self is constructed and maintained
with the social interaction that occurs between the individual and the environment.
These ideas were clearly applicable to the situation of infertility in Botswana.
Women who were experiencing infertility made meaning out of it, as they interacted
with other persons in the environment. Women's experiences
may be understood in terms of the
meaning they attach to infertility. Women experiencing
infertility interact with multiple people such as
the mother, partner, friends, health care
providers and many others. Therefore, the meaning of
infertility arises during the process of
interaction. They labelled themselves in a variety of ways as
a result of what some members of the society made them believe.
Feminism is a broad term for a variety of conceptions of
the relations between men and women in the society.16 It refers
to a family of philosophies and strategies that are centred on women's experiences
and interests.17 According to feminist theories, the researcher
and participants should be equal partners in the research process, and women's
experience is a legitimate source of knowledge.18,19 This framework
led me to be aware of both the common experience and the differences in women's
experiences. In order to allow for multiplicity and fostering of differences
among participants, open-ended questions were used during the interview.
Recruitment of Participants
Recruitment of participants started after the research proposal
was approved by the Office of the President, the Ministry of Health and relevant
hospitals and clinics in Botswana. Recruitment of participants was done through
the gynaecological clinic at Princess Marina Hospital (referral hospital) verbally
and through the use of fliers. Most of the participants (87.5%) were receiving
outpatient treatment at the infertility clinic. A small percentage (12.5%)
of women participants were recruited verbally.
Sample Size and Demographics
Data from interviews with 40 women aged 21-44 years are presented
in this paper. These include domestic workers, receptionists, general duty
assistants, small business (running Kiosk) owners and secondary school teachers.
Type of
infertility was not considered before
recruitment into the study, but if the woman perceived
she had a problem, she was included in the sample.
Participants' educational level ranged from zero to 24 years
of schooling with a mean of 8.2 years. Only thirteen (32.5%) of the forty participants
were married. The rest (67.5%) were single (62.5%), separated (2.5%) or engaged
(2.5%). Twenty five women (62.5%) had no children at all (primary infertility),
whilst fifteen (37.5%) had one to three children each (secondary infertility).
Data Collection
Data were collected through the use of qualitative interviews.
The interviews were conducted for about six months (April to September 1997)
and ranged in duration from about forty five minutes to one hour.
Study Findings
Discussion of the findings revolves around a theoretical framework
of denying and preserving self. Preserving self means developing strategies
to prevent or minimise harm inflicted by others as a result of infertility.
The analysis sought to identify women's feelings about themselves as well as
their constructed meaning of infertility that informed their self-care responses
to the condition.
Denying of Self
The study findings revealed that women perceive infertility
as denying of self to varying degrees within the larger social context of patriarchy.
The contributory factors include denial of status as a woman; denial of economic
and social security in old age; being chastised by God and the forefathers;
denial of the experiences of pregnancy, labour and delivery; and denial of
immortality. These denials are discussed.
a. Denial of status as a woman
Several women made reference to phrases such as "ga
ona seriti" (one lacks dignity), "ga o mosadi wa sepe or "go
nyenyafatsa bosadi jwa motho" (you are less of a woman), "ga
o motho" (you are nobody). These were labelled as "denial of
status as a woman". Participants believed infertility means that one
is denied appropriate status in the society. A Motswana woman usually gains
adult status as she gets to be called by the first child's name, Mma Semangmang,
meaning "mother of So and So". This practice, according to the
women, shows respect as opposed to a woman with no children who continues
to be called her first name. Therefore, failure to achieve motherhood brings
with it lack of status and low self-esteem.
b. Denial of economic and social security
Batswana women perceive infertility as denial of social and
economic security, specifically in old age. Within Botswana cultural contexts,
children owe their parents a debt for bringing them into the world and rearing
them. In order to pay this debt, children ought to pay respect to their parents
partly through taking care of them in old age. Having children, therefore,
is considered the best way of securing a reasonable socio-economic status in
old age, and this security is definitely threatened by infertility. Two participants
stated:
The problem is when you are a grown up and have nobody to take care (emotionally,
socially
and economically) of you.
I am still young. I must have children, otherwise who will
take care of me in old age?
c. Being chastised by God and great grandfathers
Many women believed infertility means that one is being chastised
for her omissions and commissions. This belief was evidenced by the constant
use of the statement "petso ya Modimo"
(God's chastisement). Some women felt that
they had sinned against God by not going to church earlier in their lives, or
by becoming pregnant at an early age, having an abortion and not
getting proper Setswana treatment for the abortion.
This belief is driven by culture and religion that
strongly emphasise that if a woman does any wrong,
the ancestors or God will become angry with her, and as a result take away her
fertility. Some women were uncertain of what wrong they might have done against
either God or their forefathers.
One woman stated:
Ga ke itse gore ke diretse Modimo eng (I do not know in
what ways I have wronged God).
Still another woman stated that several times she asked herself
what she has done to her forefathers:
Tota badimo bame ke ba diretse eng se setona (what have I done to my forefathers
that is
so gross?)
d. Denial of infertility through being named after
In this study, two women stated that infertility simply means
taking after somebody. One woman was named after her aunt who had no children
at all. She believed that it was because of this identification with someone
who had no children that she was experiencing infertility. Another woman was
given the name of a relative who had experienced infertility and she made reference
to problems that included infertility on her part.
e. Denial of immortality
Childbearing gives an assurance of immortality, as one's name
will be perpetuated through one's children, especially the sons. Consequently,
the women believed that infertility means denial of immortality because there
are no offspring. One woman said that everything about one would be forgotten
if one dies childless.
There will be no remnants of her (children) on earth to show
that she ever existed.
f. Denial of the experiences of pregnancy, labour and delivery
Women who were experiencing primary infertility felt that
infertility denied them of the experiences of pregnancy, labour, delivery,
breastfeeding and parenting. The women stated that they would like to experience
pregnancy and labour pains so that they could also have something to talk about
in the presence of other women. This denial is emotionally painful, according
to them. The women reported that their emotional pain increases at social gatherings
where they meet other women with children, especially as such gatherings always
end up with discussions of experiences of either pregnancy or labour and delivery.
g. Being emotionally stressed
In response to the question "What does infertility mean
to you?", several women made reference to terms such as emotional pain,
problems, worries and other similar words or phrases to convey the fact that
they perceived infertility as emotionally painful. These responses were grouped
together and termed emotional pain or stress. Reasons for the emotional pain
included insults from in-laws and the presumably fertile population, not being
called "So and So's mother, having noticed that women of the same age
or even younger ones have children, and lack of dignity.
Other women have to endure significant emotional abuse by
partners especially around their menstrual periods. Women reported how, because
of disappointments, partners use abusive language on them, beat them and accuse
them of secretly taking contraceptive tablets or sleeping with many men. Other
men become so angry that they leave the home and stay away for days. Others
just sit at home without talking to their spouses.
Strategies for Preserving Self
Women developed various strategies to overcome or deal with
the problem of these denials. Those strategies were discovered by asking the
question: "Since you realised that you had an infertility problem what
have you done in order to cope?" Participants reported the use of a variety
of coping strategies to manage their denial of self. These strategies were
for self-preservation. Self-preservation means developing strategies aimed
at either protecting oneself from getting emotionally hurt or harmed by others
or reducing the harm inflicted by others. The strategies include looking for
deeper meaning, giving in to feelings, working it out, compromising, getting
more involved, getting away, or doing adoption.
a. Looking for deeper meaning
The first strategy used for preserving self was looking for
deeper meaning. Sub-categories as trust in God through prayer, spiritual re-awakening,
questioning and looking for hidden meaning were put together to form the category
looking for deeper meaning. The women sought existential meaning. Many of them
found comfort by looking for hidden reasons for their infertility. Many believed
that it was God's will. One woman stated:
Ke kgona go ipolelela gore ke kabelo ya Modimo, fa Modimo
o sa mpha bana ga go na sepe se ke ka se dirang (meaning that it was God's
will that she had no children, so let it be, as there was nothing that she
could do).
The women in this study reported that they commonly ask themselves
the questions: "why me", "why at this point" and "why
in this way". This was initially coded as questioning. Usually the answer
that they got from the traditional healers had something to do with ancestral
beliefs. Other women got their answer through their Bible readings.
During the process of infertility treatments and failures
many women felt helpless without
God and this led to the insight that allows for
a new understanding of self. The women realised their grounding in God's powers,
that without God's will they would not have children.
This process of a woman's direct experience of her grounding in God's powers
was labelled
"spiritual re-awakening." The women believed more strongly in God,
hence, they attended church more frequently than when they had not realised that
they were infertile.
b. Giving in to feelings
The second strategy for preserving self was "giving in
to feelings". This is defined as crying, neglecting tasks, and having
suicidal ideas. Many of the women gave in to their intense feelings of sadness,
frustration and depression at not being able to conceive. The women stated
that they cry many times because of their infertility. Crying served as a form
of relief to some women, because after they gave in to their emotions and cried,
they felt better equipped to deal with their unfulfilled goal. For others, "giving
in" involved neglecting tasks such as having to close their small businesses
or even neglecting their personal hygiene. Other women reported that they became
so depressed that they entertained ideas of committing suicide. Some women
reported attempted suicide. Many women tended to cry more or have suicidal
ideas during menses because of disappointment that conception had definitely
not occurred. Some women said they cried because of anger on the part of their
partner. One woman said:
At that time (menses time) I was so hurt and scared of
my partner that I took tablets and a glass of water with the intention of
swallowing them all. I sat there, stared at the tablets, but then ran out
of courage and just started crying.
c. Working it out
Another commonly used strategy was "working it out".
Working it out means engaging in
discussions with husband, traditional healers,
relatives and other women with experience of infertility in order to find solutions
to the problem. It also included subcategories of negotiating and mutual sharing.
Negotiating was done
with husband and members of the traditional health care system. Women negotiated
with their partners/spouses, relatives and friends for
more and more money as they moved from one doctor to the other to seek help.
Money was needed for transport, accommodation and treatments. In
the case of traditional healers, where the fees
were higher, women had to negotiate to pay in instalments. Unfortunately, medical
insurance does not cover the use of traditional healers, so
the women had to pay the bills in full. In the
event that all interventions failed they still had
to negotiate with partners/spouses and family members for adoption. Legal adoption
of a child from a non-relative was almost always unacceptable to the husband
and family
members, and in some cases created family conflict.
The women were also "working it out" through sharing
their problems with their husband, friends or other women who were experiencing
the same problem. They were able to share their problem under the conditions
of a supportive environment. Some of the women admitted sharing the burden
with their husband. One woman stated:
I have a partner, I share this problem, I feel very much
supported, and since I have his support, I come to feel much better, because
like I was saying earlier, when he is here, I sleep comfortably.
"Sharing the burden" with other infertile women
was rarely mentioned by the women. Only two out of forty women mentioned that
they shared the problem and information with other women who were experiencing
the same problem. The two women said they shared their problems and searched
for more information from other women experiencing infertility when
they met at infertility clinics. None of the women,
however, mentioned looking for more information
from literature.
Although some women felt that sharing
strengthened their relationships, unfortunately a
larger percentage ended up with marital discordor broken relationships. One woman stated:
Several men left me because I can’t havechildren and it is a painful thing to go through.
d. Compromising/accommodating
Women utilised this strategy by allowing or even
encouraging their husbands to have children with
other women. These other women could be
relatives or any other woman. Compromise also
included accepting and taking care of their
husband’s children from other women. This was
the ultimate coping strategy used by some women.
I term it “ultimate” because it seemed to be used
by women out of desperation. They use this
strategy when they feel that they can no longer
have children or when their husband is threatening
to leave for another woman.
e. Getting more involved
“Getting more involved” was another strategy
used by women. This is defined as seeking active
treatment from providers in the health care system
and getting involved in infertility treatments. All
women reported the use of this strategy to a
large extent. This strategy consisted of actual
involvement in infertility treatments. Therapeutic
modalities involved the use of drugs, herbs,
fumes, purgatives, sea water, epsom salts, body
massage, etc. These therapeutic modalities were
provided by self-proclaimed physiotherapists,
traditional healers, faith healers and members of
the modern health care system.
f. Getting away
This is defined as emotionally distancing oneself
from the struggle of denying and preserving self.The strategy involves combining the subcategories
of the women said that they kept themselves
busy with their career-related activities or got
involved in community service, which kept them
busy to the extent that at times they momentarily
forgot about their infertility problem. This kind
of distraction was termed shifting focus.
Some women got to a point that they felt
they had exhausted almost all interventions without
success. In such a situation they felt that theyneeded a break from infertility treatments.
g. Doing adoption
The seventh strategy used by women was "doing adoption".
This was a rare strategy and women thought of doing adoption only after all
attempts at conceiving a biological child failed. When asked about adoption,
few women were aware of the legal adoption option. The few women who understood
the process of legal adoption were faced with resistance from their husbands/partners
and/or family members. Resorting to such option was considered a mistake.
All women were aware of the traditional form of adoption
(go abelwa/tsalelwa ngwana) though they were still against it. Women
experiencing infertility did not favour the customary form of adoption for
several reasons. First, they stated that the identity of the biological parents
is never kept secret. As a result, as the child grows, people are likely to
tell the child that mosadi yo ga se mmago (this woman is not your real
mother). As the women explained, the child may then eventually return to his/her
biological parents. Second, there is a problem of parental intervention, especially
if the biological parents believe that their child is not treated well by the
adoptive parents. The biological parents may eventually seek custody of their
child.
As a result of the problems associated with adoption, only
three women in the study had considered adoption. The first woman was in the
process of legally adopting a child. The second one failed because of lack
of support from her
husband and family members and the third
woman was thinking of in vitro fertilization in the future.
Discussion
The constructed meaning of denial of status as a woman in
the society is derived from the way girls are socialised in the Tswana culture.
In the Tswana culture, a girl has her earliest relationships with her grandmother,
mother, sister, aunt and other older women. Throughout childhood, women are
socialised that on reaching adulthood they should get married and start a family.20 As
she grows up, the woman takes up the images of the women around her and consciously
and unconsciously internalises what it means to be a woman in Botswana.
In Botswana, womanhood is generally considered to be synonymous
with motherhood. Motherhood is rather a mandate and not an option. As Schapera
noted, children symbolise several things in Tswana society; among them it makes
the father a man and the mother a woman.21 Schapera stated that
with the birth of the first child, couples acquire a new dignity. The man has
proved his manhood as he has a child who would perpetuate his family name and
memory. The woman has fulfilled her supreme destiny.21 According
to Schapera, the birth of the first child also enhances the status of couples,
as reflected in the change of names. They (couples) now become generally known
by the child's name mother of So and So, or father of So and So. Therefore,
the significant purpose of sexual act remains a reproductive one.
Batswana women perceive infertility as denial of the experience
of pregnancy, labour and delivery. In their day-to-day lives, women socialise
with other women, friends and relatives. It is during these periods that issues
such as labour pains and raising of children arise. Unfortunately, those women
who have never experienced labour pains then feel out of place, as they have
nothing to talk about in relation to such issues.
Batswana women perceive infertility as a denial of social
and economic security especially
in old age. Throughout their childbearing
years women bear children and take care of them at
a young age. In old age, women depend on children for both economic and social
security, particularly in a developing country like Botswana
where government has few social welfare
programmes. As clearly stated by Matebesi, children
are expected to take care of their parents in old
age, since there are no nursing homes in
Botswana.11 Thus, in Botswana it is mainly the children and not the
government who provide social and economic security to their aged parents. The
government is less burdened when children assume responsibility for the aged.
Therefore, having children is considered the best way of securing a reasonable
socio-economic status in old age, and this security is certainly threatened by
infertility.
Women made reference to denial of immor-tality. Botswana
is a patriarchal society and most women take their husband's name when they
get married. Consequently, it is the husband's name that is then passed to
the children. Children, especially sons (girls get married and change name),
ensure one's immortality because one's name will be perpetuated by future generations.
Infertility, or specifically the lack of a son, threatens immortality.
As a result of the numerous denials that they experienced,
women felt emotionally stressed, they felt like their personhood was disintegrating
or falling apart. Consequently, they developed strategies to reduce such stress.
Such strategies sought self-preservation. As mentioned earlier, preserving
self means developing strategies to prevent or minimise emotional harm inflicted
by other people in the woman's environment. Strategies could be described as
what is commonly known in infertility literature as coping strategies. Coping
strategies refer to the specific efforts, both behavioural and psychological,
that women employ to reduce or minimise harm resulting from the stressful infertility.
Women reported the use of both emotion-focused and problem-solving
strategies in order
to cope with infertility.
Emotion-focused strategies (such as looking for deeper
meaning, giving in to feelings and getting away)
included efforts to regulate the emotional
consequences of infertility. Problem-solving strategies, such
as working it out or getting more involved, aimed at finding solutions to the
cause of infertility. Folkman and Lazarus indicated that people
use both types of strategies to combat stressful
events.22
Some of the strategies reported by women have roots in the
old/traditional Tswana custom. For instance, compromising/accommodating as
a strategy has roots in the old/traditional Tswana custom. Schapera explained
that the husband of an infertile woman has a right to ask his wife's family
or she herself would request them to provide him with another woman with whom
to bear children.20,21 Any children she (surrogate mother) bears
him are then regarded as the children of the first wife. Although through such
a process, the first wife suffers some form of misery and humiliation, she
does not complain since this is considered better than being sent away (divorced).
Accommodation or compromising, as a strategy, was perhaps
useful in the olden days, before the era of HIV/AIDS. Nowadays, because of
the risk of being infected with sexually transmitted diseases including HIV/AIDS,
the strategy should be discouraged. As explained earlier, accommodating/compromising
involves allowing a spouse to have a child with another woman. The practice
of multiple partnerships and unsafe sex exposes couples to the risk of contacting
sexually transmitted diseases including HIV/AIDS. This is particularly scary
in a country like Botswana with an HIV rate of 37.4%.23
It is worth noting that "doing adoption" was only
thought of after all attempts at conceiving a biological child had failed.
Attempt at using this strategy was only employed by three women. Adoption is
not common because of certain beliefs and practices. Some Batswana believe
that moral character is hereditary, and that an adopted child can be assumed
to have the biological
parents' character. For instance, if the parents
of an adopted child are thieves, the child would
also be a thief. The Batswana believe that even if
such a child is put in a different environment,
she/he will eventually become like his/her
biological parents. Although children who are known
(by adoptive parents) are considered to be better adoptive candidates, the practice
was viewed as problematic by the women experiencing
infertility because of periodic interference from
the biological parents. Interference from
biological parents is common in situations where they
feel that the child is not properly cared for.
Eventually, according to the women, such a child may
return to his/her biological parents.
The other reason for the lack of use of such strategy was
that very few women were aware of the process of legally adopting a child.
Reasons for the lack of information regarding legal adoption are unclear to
the researcher. Perhaps not much effort has been put into educating couples
about legal adoption. As a result of the existence of such beliefs, practices,
lack of information on legal adoption and resistance from the family, neither
traditional nor legal adoption is acceptable to women experiencing infertility.
Strategies used to preserve self (reduce or prevent harm
from others as a result of infertility) do not include two obvious strategies.
First, women did not attempt to deflect any insults or name calling by blaming
or naming their spouses as the reproductive "failure". Tswana culture
does not allow women to publicly fault their husbands. Consequently, women
become the target of any name-calling and other forms of abuse for infertility.
Second, there is no mention of the use of a support group.
Use of a support group is not mentioned because such a group does not exist
for infertility. Although there are longstanding women's groups in the country
aimed at advancing women's issues, none of the groups ever attempted to encourage
a support group for couples experiencing infertility. The struggle of women
with infertility remains a private issue.
Implications of the Study
First and foremost the study has implications for the usual
definition of infertility, nursing education, practice and research, as well
as wider implications on policies in Botswana. The results of this study revealed
that infertility is not restricted only to biology, but it also affects a total
sphere of a person's life. For instance, the study revealed that infertility
affects marriage, social and economic security, and women's identity. The results
could mean that as observed at different periods by other authors, the usual
definition is restrictive25 and should vary from culture to culture.26
The study findings have implications for nursing and midwifery
curricula. More needs to be done to integrate infertility into the Botswana
nursing and midwifery curricula. The study has revealed many of the psychosocial
and cultural issues related to infertility. These cultural and psychosocial
issues should be integrated into all aspects of nursing or midwifery curricula.
Since women experiencing infertility need counselling, nurses and midwives
need to acquire more skills in counselling. Counselling skills are useful to
enhance and improve communication, learn to listen effectively, and to facilitate
a conducive environment for movement towards acceptance of infertility.
The study revealed that women have various cultural and religious
beliefs about the causes of infertility. It should lead to the development
and implementation of appropriate therapeutics and comprehensive programmes
for couples experiencing infertility. Infertility research in Botswana has
not addressed who should be targeted (among all members of the institutions
experiencing infertility) and how intervention should be approached. While
different approaches to infertility are possible, I recommend a comprehensive
programme. Important components of a comprehensive programme include prevention
of infertility through health education and improvement of the environment,
awareness raising of the whole society, more research studies
in the area, and modification of health
policies. This type of comprehensive programme is
based on an ecological model for health promotion
and aims at modification of the individual beliefs
and practices as well as the environments within
which infertility is experienced.
The study revealed that infertility is an individual as well
as a family matter. A larger study that includes men/husbands and some members
of the extended families of women experiencing infertility is necessary. A
comparative study of the meaning of infertility among presumably fertile and
infertile women would be useful.
Policymakers could use the results of this study as they
develop policies related to sexual and reproductive health.
Conclusions
Infertility, as a worldwide problem, needs more attention
especially in pronatalist countries like Botswana where it is a burden for
a woman. The study has revealed that infertility is an important phenomenon
that affects all of a person's life. It is my hope that the medical and nursing
community and the public at large will become aware of its implication on the
definition that is usually restricted to biological functioning. Attempt to
define infertility in the developed world may not be appropriate because of
the way it is viewed in Botswana.
As the study has revealed that infertility is a serious matter
in Botswana, members of the health team and the government at large should
address it seriously based on some of the study findings. Provision of care
should reinforce the need to involve couples rather than women alone. At least
the initial assessment of infertility should include husband and wife/spouse.
As women did not mention the use of support groups, they should be encouraged
with the assistance of a midwife or any relevant health worker to form such
support groups within the country. The positive aspect of support groups is
that members share common concerns. Women with infertility
would help each other understand the
experience and get help from others who have gone through similar experiences.
Infertility support groups would provide an accepting
environment where there is empathy. It is within such
groups that women could express their feelings and
know that they are understood. As most women in
this study were not fully informed about legal adoption available in the country,
it is important that the adoption system be examined in order
to make it more accessible to couples experiencing
infertility.
Acknowledgements
Support for this study was provided by the University of Botswana
with funds from Kellogg Foundation, although the views expressed in this article
do not reflect those of the University or Kellogg Foundation.
References
- World Health Organization. Infertility: A Tabulation
of Available Data on Prevalence of Primary and Secondary Infertility. Geneva:
WHO Program on Maternal and Child Health, 1991.
- Krishnan V. Attitude toward surrogate motherhood in Canada. Health
Care for Women International 1994; 15: 333-357.
- Raval et al. The impact of infertility on emotions and
the marital and sexual relationship. J Reprod Infant Psychol 1987;
5(4): 221-234.
- Chatfield WR, et al. The investigation and management of
infertility in East Africa: a prospective study of 200 cases. E Afr Med
J 1970; 212-216.
- Mati JKG. Infertility in Africa: magnitude, major causes
and approaches to management. J Obstet Gyneacol E Cent Afr 1986;
5(65): 65-69.
- Mwalali, Tharakan and Tharakan. Fertility differentials
for antenatal clients and infertility clients in Princess Marina Hospital.
Unpublished research study. Gaborone, Botswana, 1990.
- Central Statistics Office. Health Statistics. Gaborone
Printing and Publishing, 1995.
- Belsey MA. The epidemiology of infertility: a
review with particular reference to sub-Saharan Africa. Bull World Health Org 1976;
54: 319-340.
- Frank O. Infertility in sub-Saharan Africa: estimates and
implications. Pop Dev Rev 1983; 9(1): 137-144.
- Inhorn MC and Buss KA. Ethnography, epidemiology and infertility
in Egypt. Soc Sci Med 1994; 39(5): 671-686.
- Matebesi L. What are the cultural issues associated with
infertility of women in Botswana? Unpublished B. Ed. Nursing dissertation,
Gaborone, Botswana, 1994.
- Hirsch AM and Hirsch SM. The effect of infertility on
marriage and self-concept. J Obstet Gynecol Neonatal Nurs 1998;
18(1): 13-20.
- Central Statistics. Botswana Housing and Population
Census. Gaborone Government Printer, 2001.
- Turner JH. The Structure of Sociological Theory. 5th
edition. Belmont: Wadsworth, 1991.
- Blumer H. Symbolic Interactionism: Perspective and
Method. Berkely: University of California Press, 1969.
- Mannathoko C. Feminist theories and the study of gender
issues in Southern Africa. In: Gender in Southern Africa: Conceptual and
Theoretical Issues. Harare: Sapes Trust, 1992.
- Leslie M. Stiwanism: feminism in an African context. In: Recreating
Ourselves: African Women and
Critical Transformation. Trenton: Africa
World Press, Inc, 1994.
- Campbell J and Bunting S. Voices and paradigms: perspectives
on critical and feminist theory in nursing. Adv Nurs Sci 1991; 13(3):
3-15.
- Wuest J. Feminist grounded theory: an exploration of the
congruency and tensions between two traditions in knowledge discovery. Qualitat
Health Res 1995; 5(1): 125-137.
- Schapera I. Some Kgatla theories of procreation. In: Suggs
D and Miracle AW. Culture and Human Sexuality: A Reader. California:
Brooks/ole Publishing Company, 1929-1939.
- Schapera I. A Handbook of Tswana Law and Custom. London:
Oxford University Press, 1955.
- Folkman S and Lazurus RS. Stress, Appraisal and Coping. New
York: Springer Publishing Company, 1984.
- Ministry of State President, The National AIDS Coordinating
Agency. Botswana Second Generation HIV/AIDS Surveillance. Gaborone:
Government Printer, 2003.
- Agunloye K. Infertility: a socio-cultural definition. Nig
Nurse 1978; 10(3): 27-29.
- Louw DJ. Pastoral care to the infertile couple. Paper
presented at the Annual Conference for Marriage and Family Therapy, Washington
DC, 1990.
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