Ann [not her real name] lives in Kampala, Uganda, with her husband and one child from her husband's previous relationship. When she was married in 1996, Ann happily accepted his then four-year-old boy in the hope that one day she would have a biological child of her own. Unfortunately, in the early years of her marriage, she suffered several miscarriages including one that caused "extreme pain" and bleeding and rendered her unconscious.
"When I woke up, I found myself in the hospital. The doctor told me that I had an ectopic pregnancy. They had to take away the baby that was dying inside me" she says. Later she was told that she would no longer be able to conceive.
"Ectopic pregnancy can lead to infertility but more common causes include tubal occlusion from reproductive tract infections, which are often sexually transmitted, postpartum complications or unsafe abortion practices" says Dr Sheryl Vanderpoel from the Reproductive Health and Research Department at the World Health Organization (WHO). In countries such as India that have high rates of tuberculosis, genital tuberculosis is also a major, often undetected, cause of infertility.
Infertility affects up to 15% of reproductive-aged couples worldwide. WHO demographic studies from 2004 have shown that in sub-Saharan Africa, more than 30% of women aged 25-49 suffer from secondary infertility, the failure to conceive after an initial first pregnancy.
Although male infertility has been found to be the cause of a couple's failure to conceive in about 50% of cases, the social burden "falls disproportionately on women; according to Dr Mahmoud Fathalla, previous director of the Special Programme of Research, Development and Research Training in Human Reproduction based at WHO. "When a couple is unable to reproduce, the man may divorce his wife or take another wife if they live in a culture that permits polygamy" he says.
In many cultures, childless women suffer discrimination, stigma and ostracism. For example, Ann was banned from attending her father-in-law's funeral. "The relatives, when getting together, talk a lot about their children or being pregnant and having children. Those are the moments when I feel extremely isolated. So often, people do not regard you as a human. There is no respect" she laments. "Women like me often have to bear the extra-marital relationships that our husbands tend to have. I have overheard other women talking about us as being cursed."
According to Vanderpoel, "the stigmatization can be extreme in some countries, where infertile people are viewed as a burden on the socioeconomic well-being of a community. Stigma extends to the wider family, including siblings, parents and in-laws, who are deeply disappointed for the loss of continuity of their family and contribution to their community. This amplifies the guilt and shame felt by the infertile individual" she says.
Rita Sembuya, founder of the Joyce Fertility Support Centre in Uganda, says that this frustration and agony is shared by all women who come to her centre. "Our culture demands that, for a woman to be socially acceptable, she should have at least one biological child" says Sembuya. "Almost all cultures across Africa put emphasis on women having children ... marriage without children is considered as a failure of the two individuals."
Uganda is one of the countries in the "African infertility belt" that stretches across central Africa from the United Republic of Tanzania in the east to Gabon in the west. In this region a phenomenon described as "barrenness amid plenty" refers to the fact that infertility is often most prevalent where fertility rates are also high.
"In a world that needs vigorous control of population growth, concerns about infertility may seem odd, but the adoption of a small family norm makes the issue of involuntary infertility more pressing" says Fathalla. …