Infertility is a major international health challenge, with sub-Saharan Africa having one of the highest prevalence rates1. The experience of infertility is shaped by the larger sociocultural milieu and social context within which it occurs, impacting on relationships. Infertile couples may face stigmatization, leading to depression, feelings of inadequacy, and low self-esteem in both partners2,3.
As a result of the social construction of gender, women experience infertility differently from men. In developing countries, such experiences have been attributed to the pronatalist and patriarchal nature of society4,5. In sub-Saharan Africa, the centrality of motherhood to the identity of women may also account for differential experiences of infertility6.
Medical assisted reproductive technologies (ART) are gradually increasing in Ghana, with more advanced options being based in private health facilities. At the same time, there is a proliferation of herbal clinics offering infertility treatments, especially in Accra, the capital city of Ghana. However, aside from these options, alternative practices have traditionally been sought to resolve infertility. For example, various forms of polygamous or plural marriages7 and sororate (sister) marriages have been reported to take place among ethnic groups, for example the Dagaaba of Northern Ghana8 whereby female siblings or cousins married their own sister’s husband. This then served the latent function of solving infertility problems in the first wife. Historically, men have also gained “rights of genetricem” that is rights over the reproductive functions of wives, as has been reported in parts of Kenya9, Nigeria10, and Sierra Leone11.
Religion also impacts on infertility. For example, Christianity encourages monogamy, and condemns plural marriages, hence polygamous marriages are unlikely to be sought by Christians to alleviate infertility. Furthermore, increasing urbanization and accessibility to ART has also led to the nucleation of the family and couples seeking medical intervention, rather than relying on traditional approaches. This is because urbanization, with its associated high cost of living, has led to more and more couples operating on their own and relying less on their extended family members.
The aim of this study was to explore contestations within infertile couples in a sub-Saharan society. The views of various familial actors involved in the negotiations that take place regarding infertility treatment were explored, including their arguments for or against different treatment options. The effects of the contributions of the various actors were analyzed.
Materials and methods
This study was conducted in 3 clinical settings in Accra: a private modern ART clinic; a private western-style herbal clinic that offered herbal medications and diagnostic tests; and a government hospital obstetrics and gynecology department offering orthodox medication, without surgical intervention, to treat basic infertility conditions such as anovulation, irregular menstrual cycles and fibroids. The 3 clinical settings also differed in terms of treatment costs and were selected due to the differences in their approach to solving infertility. The aim was to capture the behavior of Ghanaians seeking infertility treatment.
Participants were restricted to 45 patient journeys, with all participants from married heterosexual couples, and 15 patient journeys from each setting. Overall, interviews were conducted with 35 females, 5 males, and 5 couples (interviewed together so recorded as 1 patient journey).
Sampling was influenced by the need to understand the participants’ experiences from their own perspectives rather than achieving a representative sample. Participant age ranged from 20–59 years, with about half (23) between 30 and 39 years. Twenty-five participants had been married for between 5 and 14 years. Thirty participants had no children, 10 had a child from a previous relationship, and 5 had 1 child from their current relationship.
Semistructured in-depth interviews were the main mode of data collection. Respondents were asked questions relating to the decision-making process toward seeking treatment and the role and reactions of their partners and family members. One-to-one interviews were conducted by the author in one of 3 languages according to the interviewee (English and 2 local Ghanaian languages, Twi and Ewe), with all interviews transcribed directly into English.
During the interview process, interviews were digitally recorded. Any additional notes taken were read back to the respondents to confirm that they were consistent with their views, thus achieving respondent validation. Interviews were held in each facility, while the clients were either on admission or waiting to see the doctor. Of the 45 interviews, 40 were digitally recorded, while 5 participants agreed to note taking interviews only. Interviews lasted from 40 to 140 minutes (mean, 90 min).
Thematic analysis of data was employed12 to generate codes, review and define themes, and finally, write up the findings. Manual data coding began under appropriate potential themes, driven by theory and informed by the interview guide and research questions12. Where necessary, themes were modified to reflect the codes they contained and to reduce overlap. The analyses thus involved searching for repeated patterns of meanings.
Ethical approval was received from the Institutional Review Board of the Noguchi Memorial Institute for Medical Research, University of Ghana. Respondents who took part in the study signed and/or thumb printed a consent form to show that they willingly took part in the study. To ensure confidentiality, respondent names have been changed and identifying details removed.
Contestations tended to relate to 5 main themes: the cause of the infertility, male apathy, sperm production, an absentee husband, and finance (Table 1).
Contestations about the cause of the infertility arose over who was responsible for the infertility and consequently, whether the treatment should be for the male or female partner. Infertility was often automatically linked to the female either by the spouse or relatives.
Ethel, 29-year old, had been unable to conceive over a 5-year marriage, due to male factor infertility. However, her mother-in-law constantly pestered her with treatment suggestions which increased relationship tension, as the mother-in-law felt she is not heeding her advice. Some of the explanations that respondents found for this behavior of their mothers-in-law included the following narratives:
She thinks I am just spending her son’s money and have nothing to show for it
She just doesn’t like me and I don’t know why
She has never liked me, she actually wanted her son to marry someone from their hometown but her son defied her wishes.
Contestation also arose relating to male apathy. For example, according to 32-year-old Silvia:
It is almost impossible to get my husband to come with me to the hospital. He is always very busy with work and cannot find the time to do so. Besides, he is not very bothered about our childlessness because he keeps saying I am still young.
In another example, Cynthia’s husband did not want to rush for his wife to undergo intrauterine insemination as he had been put on medication to boost his sperm a month earlier. He preferred to wait a few months to finish his medication and try to conceive naturally, especially as they already had a 5-year-old child. Cynthia was eager to have more children, as she was aware her biological clock was ticking.
Some male partners used a distraction strategy to deal with the infertility. For example, Amanda said her husband had suggested:
Why don’t you take a vacation or start a Master’s programme so as to help take your mind off the desire for conception for some time.
Her situation was peculiar because her husband already had 2 sons from different relationships but had stated that he did not mind having a girl and so he had been supportive toward the treatment. Nonetheless she bore the financial costs single-handedly:
It was a headache for me to get him to come with me to the hospital so that they can prepare him for the procedure (IVF). I even told him that, if it is about money, I have got the money to do it. It was with a lot of prayers that he finally came. It was around that time that he told me another boy had been added to the family (referring to his child conceived out of wedlock). At that point I said to myself, why don’t I just find another person to do this.
Contestations relating to sperm production arose if men were uncomfortable with semen sample collection. This contestation even led to visit postponement. Some wives convinced health workers to allow sample production at home, although this option was not allowed by the herbal clinic.
Wisdom stated he was only able to produce a semen sample via intercourse. This led to arguments as his wife felt uncomfortable with having intercourse in the hospital environment. Since he had male infertility, Wisdom’s wife had become apathetic about the whole treatment. In such situations, clients relied on the medical herbalist/doctor to intervene since coming from a professional, their advice carried more weight than what their spouses requested of them.
Contestations also took place due to an absentee husband. In the instances, female participants stated that their husbands were often away from home due to work. For example, Aseye had a 9-year marriage but her husband came home only once per year for about a month. This situation drastically reduced her chances of natural conception. She was advised by family members and friends to:
walk away from the marriage, you’re growing old. All of us are waiting to see your baby.
However, according to Aseye:
It is not easy to walk away, especially when your husband is not a bad person. My husband…, he is the cool going type, he doesn’t worry you. He doesn’t want to sit on your happiness. These days, these crazy men out there … you’ll be living with him and you don’t know what you are getting yourself into.
She was therefore torn between staying in a relationship where conception was unlikely and her maternal desire. Her situation was exacerbated by the fact that she was advancing in age.
However, women of husbands who worked away stated that they were in relatively better economic positions to be able to afford fertility treatment. Hence, these women preferred to stay in the marriage and try conception through artificial means, especially if the husband was “a good man” and “supportive.”
In many instances contestation relating to finance took place, because husbands had to bear most, if not all, financial costs associated with fertility treatment. This led to tensions between spouses regarding whether or not to access the services of a particular clinic. Whereas husbands preferred cheaper options, wives were more concerned with obtaining higher chances of success which led to higher costs.
After his wife had undergone an unsuccessful IVF procedure that cost him an estimated amount of GHC 10,000 ($6450) Gameli stated:
… I gave up, I gave up, [referring to the possibility of becoming a father]. It was not easy to come by that kind of money and I was not sure whether I was ready or even able to make such an investment again but she kept pressing that we should try again. She would just not let it go.
Another male respondent said:
Aah!, there is so much money involved when me myself I can do “gbu gbu gbu” [sexual intercourse] and then I can get my thing [a baby].
That is to say, for this respondent, he believed he could get his wife pregnant through sexual intercourse if given some more time without relying on ART.
Another respondent who was scheduled to undergo IVF treatment had postponed it because her husband had called her saying:
… do you know what? I am not going to send the money right now. It will not be long, I’ll be back by six months’ time and we can try it again naturally.
Financial burden was also experienced with accessing treatment at the private herbal clinic. Grace could not continue with treatment there because the total cost was GHC 2,500 ($1600). At that point in our conversation she laughed saying:
… that amount of money can even be used to buy a plot of land.
According to her, there was no way she and her husband could have afforded it and so her brother-in-law, who was a doctor and working at the government hospital where she sought treatment, recommended a particular gynecologist whom she was consulting for diagnosis and subsequent treatment.
In Ghana, there has been an increase on the number of clinics offering various therapies for infertility, varying from medical ART or herbal remedies. There are also historic traditional options, such as polygamy. Given the increase in options, decision-making relating to infertility treatment can be complex and lead to contestations between couples. To date, there is a paucity of information of this topic, hence the interviews with these couples revealed interesting findings.
When it came to the cause of the infertility, it seemed there was a prevalence to blame the female for failure to conceive. Mustapha, 29-year old, had been married for about 8 years without a child. He and his wife have been taking herbal preparations for “boosting fertility” bought from itinerant herbal vendors for many years now conception. He was aware he had male factor infertility stating:
I do not want my wife to know of my condition. Everyone in the family blames her for our childlessness. Should she get to know of my condition, her attitude towards me may change to my detriment and she may even be forced to reveal my condition to anyone who blames her for our childlessness. I cannot deal with that. I would rather keep this diagnosis from her than risk letting my condition become public knowledge.
Partner blame by either partner has been linked to lower relationship satisfaction, whereas female self-blame predicted more depression and anxiety in their partner13.
It is well documented that men are less likely to seek help from health professionals especially in the absence of physical symptoms14. In Africa, despite the interference of social and physical barriers to women’s access to healthcare services, women continue to seek health care more often than men15. Regarding infertility issues, men may raise arguments such as previous conceptions with other women, in an attempt to absolve them from having male fertility problems.
For couples where the husbands worked away, this situation did not auger well for childbearing as it reduced the sexual intercourse frequency between partners. Where women decided to stay in these marriages, they accepted that they could then try ART, using the finances coming from the money earnt by the man. While this practice may be advantageous to the couple by increasing their economic well-being, it inadvertently creates a situation of artificial infertility due to the absence of regular sexual intercourse. It is documented that men are more likely to migrate in search of jobs16 and this kind of scenario draws attention to the changing nature of family life occasioned by globalization and job locations away from partners. Such women are placed in a dilemma as to whether to remain with a man who is able to provide for them economically by migrating for work, but due to his prolonged absence may be unable to meet their societal obligation of child-bearing.
Regarding finance, cost was observed to greatly determine the choice of treatment. Contestations confirmed the nature of ART as a form of stratified reproduction, spanning inequalities of race, class, gender, culture, and legal status experienced by women in their physical/biological and social reproduction. Many feminists have adopted this term to also examine issues relevant to the intersections of reproduction and stratification17. Stratified reproduction is therefore being used here to refer to the high cost involved in accessing ART treatment which makes it difficult for the low-income earner to access. The cost of fertility treatment is an issue for many countries, where access to state-sponsored fertility treatment is either absent or limited.
The desire of men to seek cheaper options affirmed the fact that the costs involved in accessing treatment could be a hindrance18,19, and a major source of husband-wife contestation.
In conclusion, this study has highlighted the contestations that arise between couple regarding their decision-making about alleviating their infertility. It is apparent that globalization and changing norms of family life have to a large extent, accounted for the changing ideas and practices surrounding infertility in urban Ghana.
Conflicts of interest
The authors declare that they have no financial conflict of interest with regard to the content of this report.
The authors are grateful to all the health workers and respondents from the various hospitals and the University of Ghana NGAA Carnegie Project for their support.