UNIVERSITY OF GHANA COUPLES IN SEARCH OF CHILDREN: A STUDY OF STRATEGIES AND MANAGEMENT OF INFERTILITY IN CONTEMPORARY GHANA BY ROSEMOND AKPENE HIADZI (10090543) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF DOCTOR OF PHILOSOPHY (PhD) SOCIOLOGY DEGREE JULY, 2014 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh i DECLARATION I, Rosemond Akpene Hiadzi, hereby declare that, except for references to other people’s work, which have been duly acknowledged, this thesis is the result of my own research work carried out and submitted to the Department of Sociology, University of Ghana, Legon under the supervision of Dr. Dan-Bright Dzorgbo, Dr. Akosua K. Darkwah and Dr. Daniel K. Arhinful. Rosemond Akpene Hiadzi ………………………….. (Student) Date: ………………….. Dr. Dan-Bright Dzorgbo ………………………. (Supervisor) Date: …………………. Dr. Akosua K. Darkwah …………………………. (Supervisor) Date: …………………… Dr. Daniel K. Arhinful ……………………….. (Supervisor) Date: ………………….. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh ii DEDICATION This research work is dedicated to my dear mother, Mary Theresa Hiadzi, whose unflinching support and continuous encouragement have brought me thus far in my academic pursuits; and to my dearest Sel and our adorable children Selorm and Seyram for their understanding and sacrifice. They indeed challenged me with their presence to bring out the best in me. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENT To God be all the glory and honour and praise for all the great things he has done for me, for bringing me thus far in my academic pursuits and for bringing into my life all the people who helped in the successful completion of this academic endeavour. I cannot adequately express the enormous and invaluable debt of gratitude I feel towards all the well-wishers who supported me intellectually, financially, emotionally and spiritually throughout the course of this study. I owe a debt of gratitude to my supervisors, Dr. Dan-Bright Dzorgbo, Dr. Akosua Darkwah and Dr. Daniel Arhinful whose critical assessment of this thesis has helped in shaping it into the standard it has attained. These have served as mentors, fathers, friends, and inspired me throughout this arduous journey towards a PhD. Thank you for your patience as well as your encouragement. I am deeply grateful to you all for your support and direction. Financial assistance for this study was made possible through the kind contribution of the University of Ghana‘s Carnegie Next Generation of Academics in Africa Project (NGAA). I am grateful to the Project Director of the Carnegie NGAA project and her team of hardworking staff for their support. I am also grateful to the accounting team at the Office of Research Innovation and Development (ORID) of the University of Ghana for their help in facilitating the timely release of funds to enable me carry out this research. My deepest gratitude also goes to the staff of the hospital and clinics where I conducted my research. I am particularly grateful to them for the patience with which they tolerated my endless array of questions and for allowing me into their work settings to observe and experience their world of infertility treatment. Special thanks go to Mary, Michael and James. Their support has helped in enriching the data tremendously. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh iv The opportunity given to me by the Amsterdam Institute for Social Science Research of the University of Amsterdam was a tremendous boost to the writing of my thesis. I want to thank Prof. Sjaak van der Geest for connecting me with Dr. Trudie Gerrits, which began a very fruitful working relationship between the three of us. They were ever ready to suggest and provide me with all the relevant literature I needed to help in the writing of the thesis. Their advice and suggestions together with that of Dr. Rachel Spronk and a few others, during my writing retreat at the AISSR have been very valuable in shaping this thesis. Trudie again did not lose any opportunity to connect me to the world of infertility researchers. This, undoubtedly served as a boost to my research career beyond the PhD. I am also grateful to the administrative staff of the AISSR and the UvA, for their kind disposition towards me in the performance of their official duties. I also wish to thank my family sincerely for tolerating me and supporting me through the interesting as well as the frustrating and agonizing moments of this study. I want to say a big thank you to my dear husband and children for bearing with me especially during the times when I had to be away from home. I am also grateful to my mum for holding the fort whenever I needed to be away from home, and for her constant encouragement. Maa, your words always spurred me on. To my siblings too, I say ―akpe na mi‖ for your support and prayers. Finally, to all my friends and colleagues who constantly gave advice and direction whenever it was needed, encouraged me and urged me on, and in whom I found solace in the difficult moments, I am most grateful for all the assistance you offered me. To these and to all others who space will not allow me to acknowledge, I say, ―God richly bless you all‖. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh v ABSTRACT Marriages in Ghana are considered incomplete when there are no children. Changing social values have, however, placed more emphasis on biological parenthood while de-bunking the traditional ways of dealing with infertility. The pronatalist culture continues to persist in the light of these changes thereby making the burden of infertility even more pronounced and individualized. This creates an endless search for conception from various treatment options. This study describes the experiences of infertile married men and women and their responses to their infertile situation through the use of modern treatment options. It has the following objectives: to identify the categories of people utilizing low tech, medical herbalists and high tech fertility treatments, to understand the motivations behind their treatment seeking, to understand what determines their treatment choice as well as the contestations that exist between couples and other actors over treatment choices and how they are resolved. In addition, the study explored the processes that respondents follow in seeking treatment and reported on the social, religious and cultural context surrounding the use of ARTs as evidenced in respondents‘ ways of navigating around components of ART treatment. The respondents for the study were purposively selected from three sites namely a private herbal clinic, a government hospital and a private orthodox fertility clinic which utilises Assisted Reproductive Technologies (i.e. IVF, ICSI etc). These clinics are located in the capital, Accra. Based on qualitative in-depth interview data obtained through convenience sampling of 45 respondents and nine key informants, the study noted the following: infertile men and women continue to desire to become biological parents based on both societal considerations and personal desires. Specifically, factors such as marital security, University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh vi children as social security and for purposes of inheritance and social status were at play. In addition, although the health seeking behaviour of respondents was influenced by both kin and non-kin actors, some respondents showed a degree of autonomy in the final decision taken regarding treatment. Explanations provided for the cause of infertility by both respondents and their friends and relatives led them to seek treatment from either the biomedical or spiritual healer. However, where such treatment options were unfavourable and/or did not achieve the desired results, some respondents moved from herbal treatment to orthodox treatment and vice versa. In addition, they intensified their efforts at obtaining healing by complementing biomedical healing with spiritual healing. Finally, respondents accessing ART treatment were found to select aspects of the treatment procedure that created the least forms of dissonance for them based on socio-cultural, religious and personal considerations. The use of these technologies were not seen as conflicting with religious beliefs as in most cases, respondents drew on religion to explain treatment successes and failures. The study therefore recommends, amongst other things, that medical herbalism should be developed due to the continued reliance on herbal treatment. Some infertility treatments should also be considered for incorporation into the National Health Insurance scheme to improve access and reduce the burden of infertility. People also need to be well informed about treatment options while reducing the negative effects of media advertising. Future studies should also cover other major cities of the country and include an exploration of other modern treatment options such as surrogacy and the incidence of reproductive tourism as well as target those who may not be accessing any form of formal treatment. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh vii TABLE OF CONTENTS DECLARATION .................................................................................................................... i DEDICATION ........................................................................................................................ i ACKNOWLEDGEMENT .................................................................................................... iii ABSTRACT ........................................................................................................................... v TABLE OF CONTENTS ..................................................................................................... vii LIST OF TABLES .............................................................................................................. xiii LIST OF ABBREVIATIONS ............................................................................................. xiv CHAPTER ONE ................................................................................................................... 1 INTRODUCTION TO THE STUDY ................................................................................. 1 1.0 BACKGROUND .......................................................................................................... 1 1.1 THE PROBLEM ........................................................................................................... 5 1.2 OBJECTIVES OF THE STUDY ............................................................................... 10 1.3 SIGNIFICANCE OF THE STUDY ........................................................................... 11 1.4 DEFINITION OF TERMS ......................................................................................... 15 1.4.1 Infertility .............................................................................................................. 15 1.4.2 Marriage ...................................................................................................................... 15 1.4.3 Medical herbalism ................................................................................................ 16 1.4.4 Low-tech treatment .............................................................................................. 17 1.4.5 High-tech treatment/Assisted Reproductive Technologies (ARTs)..................... 17 1.4.6 In-vitro fertilization (IVF) .................................................................................... 17 1.4.7 Intra Cytoplasmic Sperm Injection (ICSI) ........................................................... 18 1.5 ORGANISATION OF THE THESIS ......................................................................... 18 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh viii CHAPTER TWO ................................................................................................................ 22 LITERATURE REVIEW .................................................................................................. 22 2.0 INTRODUCTION ...................................................................................................... 22 2.1 INFERTILITY: PREVALENCE, TYPES AND CAUSES ....................................... 22 2.2 THE GENDERED EXPERIENCES OF INFERTILITY ........................................... 25 2.3. BELIEFS AND PRACTICES ASSOCIATED WITH INFERTILITY AND ITS TREATMENT IN GHANA ............................................................................................. 29 2.4 TRADITIONAL APPROACHES TO MANAGING AND TREATING INFERTILITY .................................................................................................................. 33 2.5 MODERN APPROACHES TO TREATING INFERTILITY ................................... 37 2.5.1 Infertility treatment via Medical Herbalism......................................................... 39 2.5.2 Infertility treatment via Low technology ............................................................. 41 2.5.3 Infertility treatment via Assisted Reproductive Technologies ............................. 44 2.5.3.1 The development and spread of ARTs in the West ....................................... 44 2.5.3.2 Globalization of ARTs to the developing world ........................................... 47 2.5.3.3 Access to ARTs ............................................................................................. 48 2.5.3.4 ARTs as gendered technologies .................................................................... 51 2.5.3.5 Effects of the emergence of ARTs in the West ............................................. 53 2.5.3.6 Western technologies in non-Western worlds ............................................... 54 2.6 CONCLUSION .......................................................................................................... 58 CHAPTER THREE ........................................................................................................... 60 RESEARCH METHODOLOGY ...................................................................................... 60 3.0 INTRODUCTION ...................................................................................................... 60 3.1 RESEARCH METHODOLOGIES IN INFERTILITY STUDIES ............................ 60 3.2 PHILOSOPHICAL FOUNDATIONS OF THE STUDY .......................................... 62 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh ix 3.3 BRIEF PROFILE OF STUDY SITES ........................................................................ 63 3.3.1 Lister Hospital and Fertility Centre - The High Tech Treatment facility ............ 63 3.3.2 Champion Divine Herbal Clinic .......................................................................... 66 3.3.3 Korle-bu Teaching Hospital ................................................................................. 67 3.4 METHODOLOGICAL CHOICES ............................................................................. 69 3.4.1 Selecting and negotiating access to research sites ............................................... 69 3.4.2 Target population ................................................................................................. 72 3.4.3 Sampling size and procedure ............................................................................... 72 3.4.4 Data collection instruments .................................................................................. 73 3.4.5 Additional data sources ........................................................................................ 75 3.4.6 Negotiating access to potential respondents and initiating the data collection process ........................................................................................................................... 76 3.5 ETHICAL CONSIDERATIONS ............................................................................... 79 3.6 ANALYSIS OF DATA .............................................................................................. 80 3.7 REFLEXIVITY .......................................................................................................... 81 3.8 CHALLENGES ENCOUNTERED IN THE FIELD ................................................. 83 3.9 LIMITATIONS OF THE STUDY ............................................................................. 86 3.10 CONCLUSION ........................................................................................................ 87 CHAPTER FOUR .............................................................................................................. 88 THE RESPONDENTS AND THEIR REASONS FOR DESIRING BIOLOGICAL PARENTHOOD ................................................................................................................. 88 4.0 INTRODUCTION ...................................................................................................... 88 Ophelia‘s story .................................................................................................................. 88 Belinda‘s story .................................................................................................................. 89 4.1 THE CLIENTS‘ PROFILES ...................................................................................... 92 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh x 4.1.2 The Age factor ..................................................................................................... 97 4.1.3 Duration of marriage ............................................................................................ 99 4.1.4 Type of infertility ................................................................................................. 99 4.2 REASONS FOR WANTING CHILDREN .............................................................. 101 4.2.1 Marital security .................................................................................................. 101 4.2.2 Social Security and/or Inheritance ..................................................................... 105 4.2.3 Other factors fuelling the desire for biological parenthood ............................... 111 4.3 DISCUSSION AND CONCLUSION ...................................................................... 113 CHAPTER FIVE .............................................................................................................. 121 QUEST FOR CONCEPTION: EXPLORING THE TREATMENT SEEKING BEHAVIOUR OF THE ―INFERTILE‖ ......................................................................... 121 5.0 INTRODUCTION .................................................................................................... 121 5.1. WHERE TO GO AND WHAT TO DO: EXPERIENCES OF ―INFERTILE‖ MARRIED MEN AND WOMEN IN OBTAINING TREATMENT ............................ 121 5.1.1 Kin actors - Relatives: friends or foes ................................................................ 122 5.1.1.1 Mothers versus mothers-in-law ................................................................... 122 5.1.1.2 Spouses ........................................................................................................ 127 The dilemma of having an absentee husband .......................................................... 131 5.1.1.3 Siblings and siblings-in-law ........................................................................ 133 5.1.1.4 Extended family members ........................................................................... 135 5.1.2 Non-kin actors .................................................................................................... 137 5.1.2.1 The church - a place for finding rest or restlessness?.................................. 137 5.1.2.2 Friends, colleagues and neighbours ............................................................ 140 5.1.2.3 Media advertisements .................................................................................. 142 5.2. Patterns of treatment seeking ................................................................................... 144 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh xi 5.2.1 Simultaneous health seeking practice of respondents ........................................ 145 Case study One - Herbal and spiritual treatment ........................................................ 146 Case study Two - Orthodox and spiritual treatment ................................................... 146 5.2.2 Hierarchical health seeking practices ................................................................. 153 5.2.2.1 The preference for herbal treatment ............................................................ 155 5.2.2.2 The preference for orthodox treatment ........................................................ 158 5.2.2.3 The preference for spiritual treatment ......................................................... 159 5.3 Conclusion ................................................................................................................ 161 CHAPTER SIX ................................................................................................................. 166 ART USAGE IN GHANA: SOCIO-CULTURAL DIMENSIONS .............................. 166 6.0 INTRODUCTION .................................................................................................... 166 6.1 FEARS AND MISCONCEPTIONS ABOUT ARTs ............................................... 167 6.2. CHOOSING THE LESSER EVIL .......................................................................... 170 6.3 GENDERED DIMENSIONS TO ART USAGE ..................................................... 175 6.4 RELIGION AND ART TREATMENT ................................................................... 178 6.4.1 Explaining treatment successes - God is the ultimate healer ............................. 181 6.4.2 Explaining treatment failures ............................................................................. 183 6.5 CONCLUSION ........................................................................................................ 184 CHAPTER SEVEN .......................................................................................................... 186 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS .................................. 186 7.0 INTRODUCTION .................................................................................................... 186 7.1 OBJECTIVES OF THE RESEARCH ...................................................................... 186 7.2 RESEARCH METHODOLOGY ............................................................................. 188 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh xii 7.3 KEY FINDINGS FROM THE RESEARCH ........................................................... 189 7.4 POLICY IMPLICATIONS AND STUDY RECOMMENDATIONS ..................... 194 7.5 RECOMMENDATIONS FOR FUTURE RESEARCH .......................................... 196 REFERENCES ................................................................................................................... 199 APPENDICES .................................................................................................................... 221 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh xiii LIST OF TABLES Table 1 – Monthly embryo transfers and success rates for the year 2013…………. 65 Table 2 – Socio-demographic background data of study participants…………...… 93 Table 3 – Hierarchy of options….………………………………………………… 154 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh xiv LIST OF ABBREVIATIONS ARTs Assisted Reproductive Technologies CAM Complementary and Alternative Medicine GSS Ghana Statistical Service ICPD International Conference on Population and Development ICSI Intra Cytoplasmic Sperm Injection IVF In Vitro Fertilization TESE Testicular Sperm Extraction WHO World Health Organisation University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION TO THE STUDY There is no wealth where there are no children Gyekye, 1996 1.0 BACKGROUND Reproduction is the sure way of sustaining human life and societies have existed from generation to generation through this means. The ability to reproduce is often taken for granted due to the biological make-up of the human reproductive system which makes pregnancy a natural consequence of engaging in unprotected sexual activity. However, not everyone is able to reproduce during their lifetime. While some may voluntarily decide not to reproduce, others face circumstances that either prevent them or make it difficult for them to have their own children. Broadly speaking, the situation whereby a couple in their reproductive years are having sexual intercourse without the use of contraception but are unable to establish pregnancy within a year is medically referred to as infertility (Sciarra, 1994). It is a reproductive health problem that cuts across space and time. However, socio-culturally, different societies define infertility in different ways based on the differing values attached to childbearing. Infertility may not necessarily denote the inability to bear children. Variations in these definitions are evident in terms of the time frame within which one is expected to get pregnant after marriage, sex preference of children, number of children one is expected to have and so on. In India, China and Korea for example, male children are preferred over their female counterparts mainly due to their economic benefits (Das Gupta et al. 2003). As such, women in these societies experience social pressure to produce male children University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 2 and their inability to do so results in them being regarded as infertile. This preference for male children, the absence of which results in being branded as infertile is also found in some African countries such as Ghana and Nigeria (Okonofua et al., 1997; Tabong & Adongo, 2013). Tabong and Adongo (2013) in their research on infertility in the Upper West region of Ghana found that, the inability to have many children was defined as infertility. In that study, they discovered that, although a couple could decide on the appropriate number of children to have, members of the society considered it ideal and appropriate for a married couple to have five children; any number less than that was therefore an occasion to be branded as infertile. Evidence from Egypt and Nigeria also shows that the acceptable time frame for married individuals to bring forth their own offspring is usually less than a year after the marriage (Inhorn, 1994; Okonofua et al., 1997). When this time elapses, societal members begin to define one as being infertile. All these examples provide evidence of the different socio-cultural meanings attached to infertility. In order to gain a better understanding of the importance of infertility within the African social context, it is imperative to understand the importance of fertility in such contexts as well. The passion to conceive in Ghana as in many other African societies is anchored in the fact that children serve as social security for their parents in their old age (Caldwell, 1976; 1982). Children also bring prestige to parents, serve as free labour on their parents‘ farms, and help in perpetuating the lineage (Gaisie, 1972; Kamuzora, 1987; Nukunya, 2003). As a result of this, a lot of honour was attached to prolific childbearing in traditional Ghanaian societies. Amongst the Akans of Southern Ghana for instance, the birth of a tenth child heralded celebration. The woman who accomplished this feat was honoured with a public ceremony and she in turn offered her husband a ram (badudwan) as an appreciation to him for increasing the matriclan by ten University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 3 (Agyei-Mensah, 2005). Women and men alike in such societies therefore aspired to receive such honour from their spouses and the community at large. Beyond these expected familial and communal benefits, child bearing in African societies is culturally regimented to the extent that it is to be exercised only within wedlock and for a sizeable population, it remains the main purpose for marriage. As Mbiti (1990: 130) puts it ―….marriage and procreation in African communities are a unity: without procreation, marriage is incomplete.‖ In addition, whereas in Western societies, reproduction is largely a personal choice made by the individual or couple and as such infertility does not always come along with societal implications (Pennings, 2008), the same cannot be said of pronatal African countries such as Ghana. Having children in Ghana is a social obligation due the family and community at large. Unlike Western societies, childbearing in the Ghanaian society is an important component of marriage. The inability therefore to fulfil this obligation in marriage results in diverse social consequences in these societies targeted mostly at the women in such unions. Recent studies on infertility in the developing world have shown that it is mostly women in childless unions who suffer the shame and ridicule associated with childlessness. For instance, Nahar et al. (2000) report that infertile Bangladeshi women suffer marital insecurity, rejection and fear of abandonment from their spouses. In Cameroun, Feldman-Savelsburg (1994) reports that infertility is a ground for divorce and deprives the woman of access to land. In Ghana, Nukunya (2003) also points out how childless women face ridicule, humiliation and abuse from societal members. In Mozambique, Gerrits (2002) observes that infertility among the Macua ethnic group can result in the exclusion of infertile women from important social activities and ceremonies. In Nigeria, Okonofua et al. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 4 (1997) report that women in childless unions suffer much more than their male counterparts. These women suffer abandonment, economic deprivation, physical and mental abuse, neglect as well as social ostracism. In many traditional African societies which lacked sophisticated scientific knowledge and technology, there existed a number of practices which, intended or unintended, served as strategies to solving or coping with infertility. Anthropologists (e.g. Radcliffe-Brown, 1952) have documented various forms of polygamous or plural marriages which offered solutions to infertility. For example, polygyny, which was a common feature in traditional Ghana, allowed a man to marry more than one wife at the same time and this may solve an infertility problem in the first wife and consequently, childlessness in the home. This is because, social norms permit children born as a result of the sexual relationship between the man and his second wife to be regarded as children of the first (infertile) wife as well. This is by virtue of the fact that, these children are her husband‘s children. Sororate (―sister‖) marriages, common amongst such ethnic groups as the Dagaaba of Northern Ghana (Dery, 1987) also permit female siblings or cousins to marry their own sisters‘ husband and this could also serve the latent function of solving infertility problems in the first wife. There is also the practice of ―female husbands‖ or woman- to-woman marriages which is typical among the Igbo of Nigeria - a situation whereby an infertile wife finds a young bride for her husband with whom he can have children. Children borne out of this arrangement are, however, adopted by the first wife as her own children, thus allowing such infertile women to ―have‖ children (Amadiume, 1987). In parts of Kenya (Kershaw, 1973), Nigeria (Onah, 1992) and Sierra Leone (Harrel-Bond, 1975) amongst others, men gain rights of genetricem—that is, rights over the reproductive functions of wives. In this latter case, men have University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 5 exclusive rights over the offspring of their wives although they may have evolved out of extra- marital affairs. All these socially approved practices to a great extent provided respite for couples (both men and women) who were unable to have children of their own. In addition to these marriage practices, many traditional African societies relied on indigenous knowledge to solve their infertility. For example, there existed traditional notions of fertility - enhancing foods specific to either men or women. Men were encouraged to eat tiger nuts whereas women were encouraged to eat a lot of yams. Anecdotal evidence from Nigeria for instance has suggested that, the high rates of twin births in some parts of the country can be attributed to their ‗yam rich diet‘. Myths about the potential of certain foods such as ripe plantain and okro in reducing men‘s fertility also existed. Spiritualists and diviners also provided charms and amulets to people who were seeking to conceive (Pobee, 1976) while the traditional herbalist (odunsini) who had profound knowledge in herbs (Twumasi, 1975) prescribed those herbs that enhanced fertility. Fostering, a practice whereby people took care of the children of their relatives was also a common feature in the past (Caldwell & Caldwell, 1987). In such instances, a couple who was childless will take over the responsibility of raising a child (ren) of some other relative who had more children than they could adequately cater for. This helped reduce the burden of childlessness since they gained the experience of parenthood through this socially approved practice. 1.1 THE PROBLEM Over the years, the burden of infertility has become more and more of a personal one rather than a shared burden. In the wake of modernity and social change induced mainly by Christian ideals, University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 6 formal education and medicalization amongst others, there has been increasing nucleation of the family and preference for monogamous marriages thus undermining some, if not most of these traditional strategies of solving infertility within the family structure. There is also an increasing emphasis on biological parenthood as opposed to social parenthood. Infertility is thus, to a greater extent, no longer being dealt with using the traditional methods outlined in previous paragraghs. This has led to a situation that Illich (1974) describes as cultural iatrogenesis, the destruction of traditional ways of dealing with life‘s situations brought on by the medicalization process. Cultural harm is therefore created because people lose the societal coping mechanisms to infertility. Nonetheless, the Ghanaian society remains largely pronatalist in orientation with childbearing considered as an obligation in every marital union. Given this situation, it could be expected that people would be willing to undertake all kinds of strategies on a more individualized level to ensure childbirth within their union. Studies on the fertility seeking behaviour of people experiencing infertility problems in the developing world dating from the start of the twenty-first century have included such treatment - seeking options as biomedical treatments as well as traditional treatments employed by the infertile and rightly so. This is because, as some writers have observed, traditional healing methods fit into the traditional explanatory models about the causes of infertility (Gerrits, 2002; Mogobe, 2000; Nahar et al. 2000). This brings out the cultural relevance of these studies. However, few researchers have also studied the social and cultural aspects of biomedical infertility care as it applies to Sub-Saharan Africa. While only a few of these studies focus on low technology treatments (Hollos, 2003; Sundby & Larsen, 2006; Dhont et al., 2010 etc), even fewer focus on high technology treatments (Tangwa, 2002; Hadolt & Horbst, 2009; etc) despite University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 7 the increasing rates of provision of such services within the sub region (Giwa-Osagie,2002). Consistent with this literature, the existing studies in Ghana on the treatment seeking behaviour of the infertile focus mainly on the non-formalized modes of treatment employed by the infertile such as the use of traditional healers and spiritualists (Donkor, 2008; Tabong and Adongo, 2013). Other Ghanaian studies have also focused on biomedical treatments of infertility (Donkor and Sandall, 2007). Missing from these recent studies, however, is research that examines the use of Westernized herbal medicine (medical herbalism) as a pathway for the treatment of infertility. To be sure, the practice of medical herbalism has infiltrated various parts of the Sub Region. In Ghana, this form of treatment is gradually being incorporated into the public health care sector albeit not for the purposes of treating infertility. People are beginning to subscribe to this form of treatment since it offers them a chance at receiving a systematic diagnosis and evaluation of their condition through laboratory examinations (something which traditional herbal medicine does not offer to them). At the same time, they derive the benefits that herbal medicine has over orthodox medicine which involves the use of extracts from the whole plant in preparing the medication and not just the use of only the most active constituents. Anecdotal evidence shows that herbal clinics in Ghana that offer this Western style of herbal treatment and who have also incorporated infertility care as part of their services is gradually on the increase. Their role in infertility care can therefore not be overlooked since the demand for the service can be said to be what is contributing to its proliferation and subsequent gradual incorporation into the public healthcare sector. The omission of this form of infertility care in the University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 8 literature therefore does not do justice to the complete range of socio-cultural circumstances surrounding infertility and the responses to infertility within Sub-Saharan Africa in general and Ghana in particular. This study serves to fill this gap. Furthermore, as previously stated, in spite of the globalization of assisted reproductive technologies that facilitate conception and the important role they play in seemingly solving infertility for many couples, few studies exist in sub-Saharan Africa and little is thus known about the ways in which these technologies are used and experienced by Africans. This research is therefore timely and will present a good sociological inquiry into this phenomenon. The study also incorporates an analysis of the high level of religiosity exhibited by Ghanaians into their responses to infertility. The Global Index for Religiosity and Atheism (2012) placed Ghana first amongst the top ten most religious countries in the world with 96% of its population seeing themselves as religious people and only 2% stating otherwise. The Ghana Statistical Service (2013) also reveals that about 71.2% of Ghanaians are believers and practitioners of the Christian faith with 17.6% being Moslems and 5.2% being believers of traditional African religion. In tandem with these statistics, stories abound in both the print and electronic media in Ghana relating to spiritual healing of all types of ailments including infertility being offered by the charismatic and Pentecostal churches. ‗Men‘ and sometimes ‗women‘ of God as they are popularly called by their followers, often advertise prayer and healing sessions for people in search of the ―fruit of the womb‖. Moslem religious leaders popularly referred to as ‗mallams‘ 1 also feature in these stories. These are often spiritual healers who also utilize herbs in their treatment. The high level of religiosity in the country vis-à-vis the utilization of biomedical 1 A traditional Moslem healer who utilizes herbs for the treatment of diseases. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 9 treatments especially high tech treatments (where babies are created through the power of technology) presents a moot point- one worth exploring. Literature reviewed on treatment seeking for infertility in Sub-Saharan Africa showed that studies previously conducted had only focused on spiritual treatment relative to the African traditional religion to the neglect of the Western adopted religion of Christianity-another effect of Westernization. In addition, most of the studies have focused solely on women (Donkor and Sandall, 2007; Donkor, 2008; Donkor and Sandall, 2009; Dyer et al. 2002; Hollos, 2003; Kielman, 1998; Mogobe, 2005; Yebei, 2000 etc). This study therefore seeks to bridge this gap by making the target group as all-encompassing as possible. Studies have shown that, both men and women experiencing infertility in a marital union also go through feelings of sorrow, guilt and isolation amongst others (Phipps, 1993) although these feelings may be expressed differently. Infertility concerns both men and women. It is therefore constructive to include both men and women who are experiencing infertility when conducting research on infertility. Finally, a majority of the studies conducted in Sub-Saharan Africa (Bardon-O‘Fallon, 2005; Denga, 1982; Gerrits, 2002; Leonard, 2002; Mammo & Morgan, 1986; Sekadde-Kigondu, 2004 etc) including Ghana (Ebin, 1982; Geelhoed et al. 2002; Tabong & Adongo, 2013) have been community based studies conducted in homogeneous peri-urban or rural settings. This study seeks to highlight infertility and its treatment within urban Ghana. The research is situated in Accra, a heterogeneous urban settlement where one is sure to find characteristics of all groups of people residing. This makes it more holistic. Accra is also characterized by a proliferation of social amenities and services of which infertility treatment services cannot be left out. One can count as many as nine high tech treatment centres located in the Accra-Tema metropolis alone not to mention the biomedical herbal clinics and low tech treatment facilities all over the city. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 10 The surge in the provision of infertility treatment services (though mostly privately owned) within the nation‘s capital, Accra is perhaps a clear indication of the prevalence of infertility within the region and the country as a whole. However, the existence of these diverse treatment options for infertility brings to the fore the question of the extent to which these treatments are acceptable to the people it was meant for based on their socio-cultural circumstances. To sum up, by highlighting the socio-cultural factors fuelling the fertility behaviour of Ghanaians, this study sought to provide an understanding of the social and cultural context within which infertile Ghanaian married men and women find themselves. This study explored the various strategies adopted by the infertile, the cultural nuances that played out and the consequences thereof. Few studies in Ghana exist that explore the treatment seeking strategies of infertile married men and women with particular reference to the use of Assisted Reproductive Technologies (ARTs) as well as scientific herbal medicines and low tech orthodox treatment. Each of these treatment options have differing clientele and the extent to which they are able to assist infertile men and women achieve desired conception. For example, one may ask, what determines one‘s choice of treatment? Are these various strategies being used exclusively or simultaneously or sequentially with other strategies and why? Does their usage come along with contestations and if so, how are these resolved? These types of questions provided the motivation to carry out this exploratory study into the health-seeking behaviour of infertile married men and women in contemporary Ghana and the factors that fuel such behaviour. 1.2 OBJECTIVES OF THE STUDY The main objective of this study was to understand the present socio-cultural factors fuelling the desire for married men and women in contemporary Ghanaian society to address their infertility University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 11 as well as the experiences of these individuals as they seek treatment for their infertility. In addressing this objective, the following specific questions were developed for study: 1. What categories of people are utilizing fertility treatments such as low-tech treatments, medical herbalists and ARTs? 2. What are the motivations of the people who seek these treatments? 3. What determines their choice of treatment? 4. What processes do they follow in seeking treatment? 5. What contestations exist between couples and others over treatment choices and how are these resolved? 6. How does the social, religious and cultural context configure the meaning infertile couples make of ARTs? 1.3 SIGNIFICANCE OF THE STUDY Although infertility has been a part of our human existence since time immemorial, social and cultural studies on infertility in Sub-Saharan Africa arguably began to take root only in the latter part of the twentieth century. Studies conducted by Ebin (1982), Mammo & Morgan (1986), Sangree (1987), amongst others, provide good illustrations of cultural responses to infertility in the various societies of South-West Ghana, rural Ethiopia, Kenya and Nigeria respectively. Since the beginning of the twenty-first century, the amount of studies conducted on the social and cultural aspects of infertility on the sub-continent continue to increase. Notable amongst them are studies conducted by Barden-O‘Fallon (2005), Dhont, Luchters, Ombelet et al. (2010), Donkor & Sandall (2007), Feldman-Savelberg (2002), Gerrits (2002), Hollos & Larsen (2008), Horbst (2006), Leonard (2002), Mogobe (2000), Orji, Kuti & Fasubaa (2002), Sundby (2002) and University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 12 Sundby & Jacobus (2001). These studies were conducted within varying socio-cultural contexts in the respective countries of Malawi, Rwanda, Ghana, Cameroun, Mozambique, Tanzania, Mali, Chad, Botswana, Nigeria, Gambia and Zimbabwe. The authors shed light on the meanings and implications of infertility as experienced by the people in these various social settings. Some of these studies show that, the way in which the people in these various socio-cultural contexts have dealt with infertility has been largely shaped by their social and cultural circumstances as well as by the traditional health care systems available to them (Gerrits & Shaw, 2010). The medicalization of infertility is one product of development which has trickled down from the developed world to the developing world. Infertility has thus gradually moved from being a socially defined condition to a medical one. In response to this effect of globalization and the increasing Westernization of these non-Western societies, research on present day responses to infertility is imperative. The effects of this medicalization of infertility in comparatively less developed societies need to be explored relative to the different social contexts. Some of the studies outlined in the previous paragraph have sought to do that. However, the extent to which the medicalization of infertility has penetrated the societies of Sub-Saharan Africa is not commensurate with research on the socio-cultural effects of this medicalization process. This study sought to contribute to the literature on infertility and its medicalization by highlighting the ‗modern‘ ways in which people experience, explain and deal with infertility in an urban Ghanaian setting. The cultural ideals existing in contemporary Ghana regarding reproduction continue to emphasize childbearing as an integral part of married life. Married couples experiencing difficulties with childbearing thus continue to be compelled into resolving their infertility. In Ghana today, avenues available for resolving such a societally undesirable circumstance include biomedical health care services in the form of low tech treatments, medical University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 13 herbalism and the highly modernized use of assisted reproductive technologies such as in-vitro fertilization and intra-cytoplasmic sperm injection. Being a highly religious country with about seventy one percent (71%) of its populace being Christian, faith-based healing is also an integral part of the repertoire of infertility treatments. Knowledge gleaned from this research will contribute meaningfully to the medical anthropological and sociological discourse on infertility and infertility care. The research is all the more relevant as it targets an understanding of present day responses to infertility in this era of globalization and increasing Westernization of the Ghanaian society. On one hand, assisted reproductive technologies are a Western construct and may have implications when adapted in non-Western communities such as Ghana. Local considerations, be they cultural, religious, social etc may shape the ways in which these technologies are offered, used and experienced by these non-Western societies. An understanding of these local considerations therefore becomes significant in appreciating the acceptability and utilization patterns of Assisted Reproductive Technologies in Ghana. On the other hand, an exploration of the relatively less expensive treatment options available in contemporary Ghana with particular reference to the use of herbal treatment and low tech orthodox treatments offered in public hospitals in Ghana makes it more encompassing. It brings to the fore the indigenous ways in which ordinary Ghanaians seek solutions to their infertility. It also unravels any differences that may exist in terms of local understandings of reproductive biology, gender dynamics within marriage, class-based barriers to access as well as local versions/understandings of infertility. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 14 This knowledge is important in order to formulate a comprehensive reproductive health agenda in Ghana targeted at reducing the burden of infertility on those affected. Whatever knowledge and insights gained from the study may thus be useful to think-tanks both locally and internationally. Available literature also points to the fact that, it is the women in marital unions who often bear the brunt of infertility although they may not always be responsible for their condition. These women also become the objects of treatment and are often the ones who undergo the complex treatment procedures since their biological make-up makes them the carriers of the embryo- a product of the medicalization process. The research findings thus draw awareness to issues of the rights of women to safe and affordable reproductive health care with respect to prevention as well as treatment of infertility. The 1994 United Nations International Conference on Population and Development held in Cairo defined reproductive health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so (United Nations, 1994). At the conference, a reproductive rights agenda was developed and had as one of its issues for future action, ‗the prevention and appropriate treatment of infertility where feasible‘. However, almost two decades down the line, only a few developing countries (excluding Ghana), government agencies and clinics have made attempts at achieving this by starting to formulate policy and guidelines for the treatment of infertility, including regulations for institutionalizing and use of modern reproductive technology (Okonofua, 1996; Rowe, 1999). In addition, at a WHO meeting in Geneva in 2001, it was stated University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 15 that, infertility be recognized as a public health issue in all parts of the world including developing countries. Findings from the study may therefore contribute to policy in this regard. 1.4 DEFINITION OF TERMS The thesis makes use of certain terms which are defined in this section. The definitions as provided were employed throughout the entire research process and have been provided here as a guide to the reader. 1.4.1 Infertility Infertility is medically defined as the inability (for couples of reproductive age who are having sexual intercourse without contraception), to establish a pregnancy within a specified period of time usually one year (Sciarra, 1994). In addition to this medical definition, socio-cultural definitions of infertility also exist and differ from society to society. In this study, social definitions regarding the acceptable number of children to have as well as the sex of children that one desires to have are included in the study. Furthermore, infertility is of two types namely primary infertility and secondary infertility. Primary infertility denotes childlessness (or having no children) whereas secondary infertility refers to the inability to have an additional child after a successful live birth. 1.4.2 Marriage Marriage is universal to all human societies but its form and nature differs from society to society. Reporting on his cross-cultural survey of various societies in North America, Africa, Oceania, Eurasia and South America, the renowned family sociologist, Murdock (1949), defined marriage as a union in which both the economic as well as the sexual components of the University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 16 relationship between a man and a woman are united into one relationship. According to Murdock (1949:1), marriage defines the manner of establishing and terminating the relationship between a sexually associating pair of adults, the normative behaviour and reciprocal obligations within it, and the locally accepted restrictions upon its personnel. Nukunya (2003: 42) also defines marriage as ―any union in which the couple has gone through all the procedures recognized in the society for the purposes of sexual intercourse, raising a family or companionship‖. This definition was adapted in selecting the participants for this study. To further clarify, the union must be a heterosexual one (between a man and a woman) since that is the legally and socially acceptable relationship in Ghana today. In addition, the procedures that are recognized in contemporary Ghanaian society today are customary marriage, marriage under the ordinance and Islamic marriage. 1.4.3 Medical herbalism Medical herbalism is complementary or alternative medicine (CAM). It involves the combination of knowledge of traditional plant remedies with modern medical science. It is holistic medicine in the sense that it seeks to address the underlying causes of ill health in each patient as well as treating their symptoms. Medical herbalists use the healing power of plants to treat a wide range of medical conditions. They are health care providers trained in Western orthodox medical diagnosis who use plant based medicines to treat their patients. Whereas many conventional medicines are based on chemicals found in plants, herbalists use whole parts of the plant (such as leaves, berries or roots) as they believe this makes a more ‗balanced‘ natural remedy. Medical University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 17 herbalists specialize in Western herbal medicine, Chinese herbal medicine or Indian herbal traditions. 1.4.4 Low-tech treatment Low-tech treatment, according to Fidler and Berstein (1999), refers to infertility treatment that involves fertilization outside the body. They include such processes as the use of fertility drugs to stimulate superovulation (the development and release of more than one egg per ovulatory cycle) and intrauterine insemination (a process by which sperm are placed inside a woman‘s cervix to facilitate fertilization). In this study however, intrauterine inseminations are not included in the category of low tech treatment. This is because, these services rarely form a part of basic infertility treatment and are thus provided only by specialist (fertility) hospitals. 1.4.5 High-tech treatment/Assisted Reproductive Technologies (ARTs) High tech treatment refers to treatments that involve the handling of human eggs and sperms for the purpose of helping establish pregnancy. The common ARTs include In-Vitro Fertilization (IVF) and Intra Cytoplasmic Sperm Injection (ICSI). 1.4.6 In-vitro fertilization (IVF) In vitro fertilization is the most common type of assisted reproductive technology. When medical conditions prevent the sperm from reaching the egg, this procedure helps in the fertilization. It involves the fertilization of an egg by a sperm outside the human body. The term in vitro is Latin and means glass referring to glass containers such as test tubes, petri dishes or beakers. The procedure involves monitoring and stimulating a woman‘s ovulatory process, removing ova from her ovaries, inseminating them in the laboratory with a male‘s sperm and subsequently inserting back into the uterus as a fertilized embryo with the intention of establishing a successful University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 18 pregnancy. This is done after it has been cultured in a growth medium over a period of two to six days. In some cases, there is embryo cryopreservation. With embryo cryopreservation, excess embryos of good quality are frozen and stored for future transfer. A colloquial term used to refer to babies born through these means is the term test tube babies. 1.4.7 Intra Cytoplasmic Sperm Injection (ICSI) Intra Cytoplasmic Sperm Injection is an assisted reproductive technology commonly used to treat sperm related infertility problems. As the name implies, it involves the direct injection of a single sperm into a mature egg and is used to enhance the fertilization phase of IVF. The fertilized egg is then placed in the woman‘s uterus. Additionally, ICSI may be used to aid in the fertilization process when eggs cannot be easily penetrated by sperm. 1.5 ORGANISATION OF THE THESIS This thesis is organized in two parts. The first part provides the general introduction to the study, a review of literature underpinning the study as well as a report on how the fieldwork was undertaken. This constitutes the first three chapters of the thesis. The second part deals with the empirical findings of the research. It is also made up of three chapters and reports on the respondents and the social and cultural factors driving their desire for biological parenthood, their health seeking behaviour and the social and cultural dimensions of ART usage in Ghana. The overall summary and conclusions of the thesis are presented in chapter seven. In chapter one, the writer sets the scene for the study by presenting a historical overview of infertility and how it was experienced and managed in the past. The chapter also highlights the importance of children in marriage and provides a review of the plural marriage forms that served the latent function of relieving one partner from bearing the entire burden of infertility. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 19 Other traditional means of coping with infertility such as fostering, the role of the traditional herbalist and notions of fertility enhancing foods amongst others are also discussed. The chapter subsequently discusses the gap that this study seeks to fill by pointing out the changing nature of the Ghanaian society through the influences of urbanisation and Christianity and the need to explore present day experiences of, and responses to, infertility in the light of these changes. The objectives of the study are specified as well as the significance of such a study. The chapter concludes by defining certain key terms and concepts utilized in the thesis. Chapter two provides an extensive literature review on ethnographic studies conducted on infertility in various parts of the world starting from the developed countries of Europe and America to the developing countries of Asia and Africa with particular emphasis on Sub-Saharan Africa. It highlights the experiences of infertility in these various cultural contexts as well as the different ways in which the infertile have dealt with their infertility within the various contexts. Traditional ways, biomedical ways and the new assisted reproductive technologies are the various treatment seeking strategies that are reviewed in the chapter. Chapter three provides an extensive report on the fieldwork. This study was conducted in the urban heterogeneous capital city of Ghana, Accra. The rationale for this selection as well as the methodological choices employed in the study are discussed. The study was a multi-site study of three clinics/hospitals in Accra where infertility care services are provided. Two of the sites are privately owned and the third one is a government hospital. Clients and key informants in the form of health personnel were selected from these sites for the study. Additional data sources included key informant interviews with religious leaders, an interview with the chief executive officer of a non-governmental organisation targeted at childless couples, observation of a prayer session for people wanting to have babies of their own as well as media advertisements and University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 20 programs on infertility. The chapter concludes with a brief profile of the study sites and the core services being offered to clients of these facilities. Fieldwork and study limitations are also noted. In chapter four, the characteristics of clients utilizing infertility care services provided by a medical herbalist, government orthodox hospital as well as an IVF clinic are introduced to the reader. An analysis is made of such socio-demographic characteristics as the sex of respondents, ages of respondents, their duration of marriage as well as the type of infertility being experienced. The chapter further analyses the various motivations behind respondents‘ search for treatment highlighting any changes in motivations in comparison with the past. It concludes with a discussion of the sociological concepts of structure and agency which were seen as informing respondents‘ desire to become biological parents. Chapter five reports on the health seeking behaviour of the respondents. This is presented in two parts. The first part delved into the various contestations that exist between couples and significant others over treatment options and the role of the various actors in the decision making process towards treatment. It also includes in the discussions the effects of the contributions of these various actors especially the various ways in which these contributions serve either as an increased burden for the infertile or as a relief. This is based on the backdrop that, health seeking behaviours of the ‗sick‘ are influenced by various actors who form a part of their lives. The second part of the chapter reports on the patterns of health seeking behaviour employed by respondents. This is based on the plural medical systems in Ghana and highlights both the simultaneous and hierarchical treatment seeking patterns of respondents and the various reasons informing such treatment seeking behaviour. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 21 Chapter six discusses the ways in which the Ghanaian‘s social, cultural and religious context influence the acceptability and usage of Western biomedical treatment options with particular reference to Assisted Reproductive Technologies. It discusses the various ways in which respondents rationalize and navigate their use of Western technologies in areas where its usage conflicts with socio-cultural, religious and personal values. Chapter seven concludes the thesis by providing a summary of the findings of the research as well as recommendations for future research and policy. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 22 CHAPTER TWO LITERATURE REVIEW 2.0 INTRODUCTION This study explored the experiences of infertile couples who utilize herbal and orthodox treatments (including Assisted Reproductive Technologies) in their search for conception. To gain a better understanding of this study, the chapter examines the literature on the subject of infertility. Literature is reviewed on the worldwide prevalence of infertility, the types and the various causes highlighting its severity and preventable nature in the developing world, specifically, Sub-Saharan Africa. In addition, the different meanings attached to infertility in various contexts are captured with evidence from both the developed and the developing world. An overview of some anthropological research on the search for conception by infertile couples across space and time with reference to traditional as well as Western approaches including the adoption of Western technologies in non-Western societies concludes the segment on literature review. 2.1 INFERTILITY: PREVALENCE, TYPES AND CAUSES Infertility is a condition of our human existence. Current global estimates of infertility range between 8%-12% of couples in their reproductive years (Reproductive Health Outlook, 2002). This proportion translates into between 50-80 million of the world‘s population (Sciarra, 1994). There are, however, regional variations in the prevalence of infertility. Whereas the developed countries record infertility rates of between 5% and 10%, the problem is more severe in the developing world. Asia and Latin America record rates similar to the global rate of between 8 and 12%. In East Africa, infertility ranges between 8 and 13%, figures which are much lower than those recorded in Southern Africa (15-22%). Infertility rates among married couples range University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 23 from 15%-30% in Sub-Saharan Africa with some countries recording some of the highest rates of infertility in the world (Okonofua, 2003). Ghana is no exception when it comes to this. A study by Donkor and Sandall (2009) pegs the infertility rate of women in Ghana of childbearing age at 15%. Some community studies have also revealed high rates of infertility. For instance, a study conducted in the Berekum District in rural Ghana revealed an infertility rate of 11.8% among women and 15.8% among men (Geelhoed et al. 2002). These prevalence rates confirm the fact that Africa records the highest rates of infertility (WHO, 1991). Related to the rates of infertility across regions are the factors that cause infertility as well as the type of infertility being experienced. Generally speaking, according to Vayena et al. (2002), infertility occurs in every 15% of couples worldwide. Out of this number, 30% are attributable to male factors such as azoospermia (no sperm cells produced), oligospermia (few sperm cells being produced), malformation of sperm cells, genetic and / or chromosomal abnormalities amongst others. Another 30% is attributed to female factors such as ovulation disorders and blocked fallopian tubes as well as some congenital / birth defects involving uterine fibroids and/or the structure of uterus. In some situations, infertility is caused by a combination of male and female factors and this is said to account for another 30% of cases. The remaining 10%, however, falls into a category of unexplained factors. All these factors point to the complex nature of conception that depends on a variety of factors to be successful. Starting from the production of healthy sperm by the male and healthy eggs by the female, unblocked fallopian tubes that will allow the sperms to move towards the egg, the ability of the sperm to fertilize the egg when they meet, the ability of the fertilized egg (embryo) to be implanted in the woman‘s uterus and finally sufficient embryo quality all add up to making conception possible. Thereafter, the embryo must continue to remain healthy and the woman‘s hormonal environment must University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 24 remain adequate throughout the development of the embryo for the pregnancy to be able to continue to full term. When even one of these numerous factors is impaired, the resulting effect is infertility. In addition, infertility resulting from such natural causes as anatomical, genetic, hormonal and/or immunological problems affects about 5% of couples worldwide and is accountable for primary infertility. This figure does not vary much across regions and countries (Reproductive Health Outlook, 2002). Variations in prevalence rates of infertility across regions and countries, however, become more pronounced when preventable causes are examined which also accounts largely for secondary infertility (ibid). Most of the infertility that occurs in sub-Saharan Africa is as a result of untreated reproductive tract infections (namely postpartum infections, post abortion infections and sexually transmitted infections) and are thus preventable. Evidence from a WHO multi-national study attests to this. Eighty-five percent (85%) of infertility cases diagnosed were as a result of these infections (Cates et al., 1985). Anthropologists who study infertility in Africa have also documented the extent to which a large number of infertility cases on the continent are preventable. Their findings show that reproductive tract infections are the leading preventable causes of infertility in Africa (Bentley and Mascie-Taylor 2000; Brady 2003; Inhorn 1994, 2003a,b; Nachtigall 2006; van Balen & Gerrits, 2001). The ―infertility belt of Africa‖ which refers to the stretch across Central Africa from Tanzania in the East to Gabon in the West earned its name as a result of these high rates of infertility in the region attributed largely to these infections (Leonard, 2001). Furthermore, some studies both in the developed and in the developing world have shown that, men are the main causes of infertility or were a contributing cause to it (Cates et al. 1985; Vayena, Rowe & Griffin, 2002) University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 25 2.2 THE GENDERED EXPERIENCES OF INFERTILITY Although infertility can be biologically or medically determined, its meanings and effects vary from society to society. The experience of infertility is a shared reality of couples and/or individuals shaped by the specific social context within which they find themselves. It is associated with varying psychological and socio-cultural consequences for the one that is affected. In Western societies, studies on the effects of infertility on both men and women do not show any remarkable differences experienced by both sexes as a consequence of their infertility. Abbey, Andrews and Halman, (1991) for example in their survey in the United States of 185 infertile couples and 90 presumed fertile couples reported that the American society places emphasis on women‘s role as mothers. However, the consequences of infertility are experienced on a personal level rather than on a societal level with both infertile married men and women experiencing feelings of depression and helplessness. Similarly, in the Netherlands, Van Balen and Trimbos-Kemper (1993), in a study of 108 childless couples who were experiencing long – term infertility found out that these group of women experienced lower self-esteem and lower well-being than other women in general with no similar difference found between infertile men and men in general. The focus in the Western world on the psychological consequences of infertility could be attributed to the fact that, the prevailing cultural and economic circumstances of these countries make infertility a personal rather than a societal problem. As suggested by Pennings (2008), reproduction in Western societies is more of a self-chosen goal. This therefore makes studies on the psychological effects of infertility more relevant within these contexts. Beside the individual level, the effects of infertility on marriage have also been explored. These studies report that infertility has positive effects on marriages in the West (Baram et al., 1988; Schmidt et al., 2005; Van Keep, 1973). This is especially evident in couples who undergo University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 26 treatment together since the process brings them closer together. This effect of bringing couples closer together is also attributed to their shared experience of having to adapt to infertility. Greil (1997) in his review of the literature on the social and psychological effects of infertility with particular reference to the relationship between gender and infertility has, however, pointed out that writers who have conducted their studies on infertility in countries such as the United States, the United Kingdom and parts of Europe place little emphasis on the social construction of infertility. He is of the view that, although the various authors have portrayed these experiences as individual traits of the infertile, they are conditioned to a great extent by their social realities. This seems to be more obvious in the studies on the effects of infertility in the developing world where scholars working with a social constructionist perspective point out clearly the differences in gender experiences of infertility based on the meanings and interpretations that society gives to infertility. The societal value placed on prolific childbearing in many of these societies stems from the fact that, children are highly valued for their economic, religious and personal benefits. Reproduction is therefore largely a social obligation due the family and the community at large (Pennings, 2008). As such, the inability to fulfil this societal obligation comes along with varying societal consequences. In such societies, women in particular bear the brunt of infertility and undergo high levels of stigmatization from other societal members. The experience of an infertile woman in such a context is further buttressed by Mbiti (1990: 110) when he says: unhappy is the woman who fails to have children for, whatever other qualities she might possess, her failure to bear children is worse than committing genocide: she has become the dead end of human life, not only for the genealogical line but also for herself. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 27 Evidence from anthropological studies conducted in some developing countries have revealed the nature and extent to which women in childless and/or infertile unions are stigmatized by the society in which they find themselves. This stigmatization comes in various forms ranging from divorce, abuse, loss of social status, gossip, lack of participation in community activities amongst others. In Bangladesh for instance, Nahar et al. (2000) report that infertile women experience a lot of verbal abuse from family and community members. They also experience marital insecurity, rejection and a fear of abandonment by their husbands. In Cameroun, Feldman- Savelberg (1999), reports that infertility leads to stigmatization of women and can contribute to their impoverishment. Rural Bangate women, the subjects of her study, stand to lose their pride and full adult status if they are infertile. Among the Sara of Chad, Leonard (2002) reports that women who are unable to conceive are regarded as destined by nature to be sterile and are considered inferior in status to other women. In Egypt, Inhorn (1991) reports that infertile women otherwise referred to as ‗umm il-ghayyib‘ or ‗mother of the missing one‘ face such societal consequences as outright divorce or polygynous marriage from their husbands, stigmatization from extended family members and outright ostracism from the community of fertile women. Sundby (1997) also provides evidence from Gambia to the effect that many infertile women experience marital instability and psychological suffering as a result of scorn and gossip from family and community members. An example of such gossip is given as ―…..there are no women in that house, only two men-since she has no child‖ (Sundby, 1997: 34). Donkor (2008) in her study in Ghana also refers to the stigmatization of Ghanaian infertile women as a common social consequence of infertility within the country. This stigmatization is evidenced in the form of verbal abuse, gossip and quarrels coming from family and societal University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 28 members. Furthermore, according to Liamputtong-Rice (2000), amongst the Hmong of Laos, women who are unable to bear children for their husbands end up in polygynous marriages. They face a similar fate when they are unable to bear sons and/ or bear as many children as their mother or their mother-in-law. Gerrits (1997) also reports that in Mozambique, infertile women are excluded from societal events and ceremonies. In Nigeria, Okonofua et al. (1997) report that infertile women risk expulsion from their husband‘s house. They also stand the risk of being excluded from inheriting their husband‘s property, may not be included in decision making within the family and risk having any financial or social security amongst others. In South Africa, Dyer et al (2002) in their study of 30 women seeking treatment for infertility reported that these women experienced psychological suffering, marital instability, stigmatization and abuse from members of their family and the community as a whole. In Tanzania, Kielman (1998), reports that among the Pemba, infertile women risk losing their marriages. These various accounts of stigmatization suffered by women in African countries provide a worrying picture of the situation of infertile women in such societies and suggest the experience of even dire psychological effects as a consequence of the intensity of the societal effects being experienced. Despite all these reported effects of infertility on women, some studies conducted in the developing world, specifically in some parts of Sub Saharan Africa and the Indian subcontinent have also revealed the negative effects that infertility has on the lives of men. Among the matrilineal Macau of Mozambique for example, men are often blamed for infertility with their wives (and their family members) calling for a divorce in such childless unions (Gerrits, 1997). Male infertility is also sometimes conflated with impotence and as such is amongst the most stigmatized of male health conditions in Egypt (Inhorn, 2004). Infertile men in India also suffer University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 29 social disgrace and are regarded as ‗namard‘ or ‗lacking in masculinity‘ (Gujjarappa et al., 2002). Furthermore, research conducted by Nene et al. (2002) of middle-class families in India revealed that, some of the men in these infertile unions experienced arguments, humiliating comments and the use of sarcastic language amongst others from their wives. Bharadwaj (2000) in his study of infertile couples visiting fertility clinics in India also found out that infertile men and women equally suffered from the stigma associated with their condition. In sum, evidence provided by the various studies portrays a gendered dimension to the experiences of infertility in marriage in the developing world. Women in such societies suffer the most from the social consequences of infertility as compared to their male counterparts. Evidence from the developed world however points to the shared experience of psychological consequences of infertility by both men and women in such societies. 2.3. BELIEFS AND PRACTICES ASSOCIATED WITH INFERTILITY AND ITS TREATMENT IN GHANA In Ghanaian traditional religion, the hierarchy of authority which formed the basis of the religion consisted of different supernatural beings namely the Supreme Being, the ancestors and the other gods. Each of them had a role to play in the fertility of the individual. Although the Supreme Being was regarded as the omnipotent, he was believed to work through the other deities since he was too powerful to be approached directly. The ancestors are believed to give children to the living for the continuance of the lineage. Believers therefore pray to the ancestors for fertility. Among the Akans, this is referred to as ‗abawotum‘ (Pobee, 1976). In addition, there are fertility gods that are believed to endow people with fertility. Anyone desirous of children therefore prays to such gods and offers the necessary sacrifices for obtaining such blessings from the gods. Children born through these means could then be named after these gods. Some trees are also University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 30 believed to be inhabited by spirits which make people fertile (Eshun, 2011). Cutting down such trees therefore meant invoking the wrath of the spirit that was dwelling in the tree and punishment for this act came in the form of infertility (ibid). Furthermore, the ancestors and the gods are believed to bless those who are good with many offspring. However, one form of punishment for evil was seen in the inability to conceive. As Caldwell and Caldwell (1987) put it, traditional African religion affects fertility behaviour in the sense that, fertility is equated with virtue and spiritual approval whereas reproductive failure or cessation is regarded as a consequence of sin. Apart from the role of these deities in the fertility of the individual, witches also form an integral part of the traditional religious belief system and consequently, one‘s fertility potential. Witches are regarded as instruments of darkness that cause evil and misfortune to others. One of such misfortunes could be infertility. Sackey (2002), reports that the common belief in traditional Ghanaian society was that witchcraft was responsible for infertility. Meyer (1994) in her research in Ghana and Okonofua et al. (1997) in their research in Nigeria, also reported that witchcraft was often blamed for one‘s infertility. One way of combatting the effects of witches and to secure one‘s fertility was through the use of charms or amulets also referred to as suman (Pobee, 1976). These may be objects worn on or around different parts of the body and believed to be the repository of power derived from the gods or spirits. The traditional rites of passage form another aspect of Ghanaian traditional religion that has influence on fertility behaviour and connotes the importance of fertility. One of such rites of passage is the puberty rites, a ceremony that is performed to signify the transition from childhood University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 31 into adulthood. In some communities, the ceremony involves, among other things, the swallowing of an egg in its whole state by the girl who has reached the stage of puberty. This act is believed to bestow upon her the ability to be fertile when she gets married. The rites in itself are performed to usher the girl into marriage. As previously mentioned, the main purpose of marriage is procreation. As such, barrenness and sterility in marriage are not uncommon grounds for divorce (Pobee, 1976). With the advent of Christianity and Islam into the country, other beliefs associated with infertility and its treatment have emerged in Ghana in line with Christian and Islamic beliefs. According to Christian beliefs, man was admonished by his creator to ―be fruitful and multiply….‖ (Genesis 1:28). The primary value of a woman in biblical times lay in her chastity and after marriage, her reproductive ability. These may explain the desire to reproduce on one hand and the negative reactions that one suffers from members of the society if this God given obligation is not fulfilled. Evidence from the Bible, the guiding principle of Christians, suggests that God blesses his people with the capacity to reproduce when they do according to his will. ―Your wife will be like a fruitful vine within your house…‖ (Psalm 128:3) and ―…….none of your men or women will be childless….‖ (Deuteronomy 7: 14) are a few examples to that effect. However, there is evidence from the Bible pointing to the fact that childbirth was not necessarily an automatic consequence of the union between a man and a woman, nor was it always a consequence of doing God‘s will. Biblical accounts attest to the fact that, as far back as the period before Christ, women have had challenges with conceiving and have sought help from their God. Names of such women include Sarah (Genesis 21: 1-2), Rebekah (Genesis 25:21), Rachel (Genesis 30: 22-23), Hannah (1 Samuel 1), and Elizabeth (Luke 1) amongst others. Some University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 32 of these women suffered mockery and ridicule at the hands of their relatives and other members of society due to their childlessness. However, many of them were able to be healed of their infertility through their fervent prayers to God and subsequently gave names to their children that depicted the role of God in the making of the child. However, not all women in biblical literature were able to overcome their infertility. An example of a woman who remained childless in the Bible is Michal, King David‘s first wife (1 Samuel 19). Others are Anna (Luke 2:36-38), Esther (the book of Esther), Moses‘ Egyptian mother (Exodus 2: 1-10) etc. This brings out the important question as to whether biological parenthood is essentially an obligation as quoted in Christian literature. In Luke 23:28-29, it is recorded that during the crucifixion of Jesus, he addressed the women of Jerusalem saying: ―a time will come when you will say, Blessed are the barren women, the wombs that never bore and the breasts that never nursed!‖ This is a strong statement that could serve as a consolation to those who are having challenges in becoming biological parents. However, the extent to which this statement uttered by the person on whom Christianity is built is known and acceptable by its followers presents a moot point. Furthermore, Islamic beliefs and practices associated with infertility and its treatment are similar to that of traditional religious beliefs as well as Christian beliefs. In the holy book of the Moslems, the Quran, it is written ―….we cause whom we will to rest in the womb for an appointed term, then do we bring you out as babes……‖ (Quran 22:5). We, here refers to Allah or the Moslem God. This also brings to the fore the issue of conception being controlled by a supernatural being namely Allah. Likewise, barrenness is seen as a decree from Allah, ―...He leaves barren whom He wills… (Quran 42:50). However, this situation of infertility may not necessarily be a consequence of one‘s disobedience. Rather, Allah is seen as all knowing and competent and His actions can therefore not be questioned. Such occurrences may therefore be University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 33 seen as a test of faith. Accounts are given of couples who found it difficult to conceive. Ibrahim and his wife Sara (Quran 11: 71-73), and Zakariya and his wife Ishba (Quran 3: 38-40) provide typical illustrations. These accounts however depict the barrenness of the women in these relationships and the role of Allah in curing them of their barrenness (Quran 51: 28-30; 21: 89- 90). One woman who remained childless in Quranic accounts was Asya, Pharaoh‘s wife (Quran 66:11). According to Islamic beliefs, Pharoah was stricken with impotence by Allah thus accounting for their childlessness. Barrenness does not, however, make you less of a woman as Allah blessed Asya abundantly in other ways. In sum, the major beliefs associated with infertility and its treatment in Ghana point to the belief in fertility being orchestrated by a supernatural entity. For that matter, believers rely on these deities and their representatives in ensuring their fertility. In times when the potential for fertility is challenged, they again draw on religious beliefs and practices in the hope of obtaining a cure for their infertility. 2.4 TRADITIONAL APPROACHES TO MANAGING AND TREATING INFERTILITY Aside the existence of religious beliefs and practices in solving infertility, cultural practices also exist in Africa that serves as a means to managing infertility in a marital relationship. Bohanan (1949), in her article on the revaluation of marriage in Dahomey (present day Benin) analyses the rights and duties between husbands and wives with regard to their children. She introduces the concepts of rights in uxorem and rights in genetricem during her analysis. She refers to the rights in a woman as ‗wife‘ (uxor) and rights in a woman as ‗mother‘ (genetrix) to denote these two concepts respectively. Rights in uxorem therefore refer to the sexual, domestic and economic rights that a male partner has over a woman by virtue of her position as his wife. Rights in University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 34 genetricem, on the other hand, refers to a husband‘s rights to filiate his wife‘s child (ren) once they are born. This conceptualisation is further used to explain the way that some societies handle infertility. For example, according to Kershaw (1973), among the Kikuyu of central Kenya, if a woman in an infertile marital relationship subsequently conceives as a result of having extra marital relations, her husband assumes rights of genetricem over this child. Similarly, in Nigeria, cleansing rituals are performed to legalize any child born out of wedlock and thereby conferring rights of genetricem to the man (Onah, 1992). A study by Harrel-Bond (1975) in Sierra Leone also reported that although adultery committed by a woman is considered a very serious offense, it is often overlooked in a situation where it results in conception, thereby proving the infertility of the husband. A similar situation exists in Northern Ghana among the Lo Dagaa whereby a man had custody of children born to the woman based on the fact that he had paid the bride wealth (Goody, 1956). There are also other avenues that exist in some cultures that allow infertile couples to bring up children as their own though they may not be biologically related to them. Astuti (1988), reports that in Swaziland, a young and usually sexually immature girl is brought into the family of an infertile couple for the purposes of bearing children for the infertile woman. This girl is usually the infertile woman‘s sister or a member of the larger extended family. She is brought in by the family members of the woman and any child (ren) that she bears is considered as the infertile woman‘s child (ren). The Akamba of central Kenya also have a practice that allows an infertile couple to adopt a young girl for the purposes of assuming parenthood over any child she will bear through sexual relations with a third party male. This male therefore does not assume any role as either husband to the adopted girl or father to her child (ren). Children born out of such an arrangement belong solely to the infertile couple (Ueda, 1973). In Botswana also, Shapera (1955) University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 35 reports that, as part of traditional Tswana custom, another woman could be arranged for the husband of an infertile woman. Children born out of such a union were, however, considered to be the children of the infertile wife. Furthermore, in some parts of Sub-Saharan Africa, an infertile woman may marry another woman and subsequently lay claim to her children (Caldwell and Caldwell, 1990). This works in different forms in the various societies. Among the Abagusii of Western Kenya for instance, a woman with only female children marries another woman with the hope that she will bear a son for her (Oboler, 1980). The Lovedu of South Africa also had a practice whereby a married wealthy woman may marry one or more women in order that they may bear children for her (Sacks, 1982). Similarly, among the Igbo of Nigeria (Amaduime, 1987) and Benin (Eskeridge, 1993), this practice of female husbands exists. Other traditional approaches to solving infertility in the developing world include re-marriage (Nahar et al., 2000) and/or divorce (Okonofua et al., 1997; Kielman, 1998; Nahar et al., 2000; Leonard, 2002; etc). Macua women in Mozambique also engaged in extramarital relationships in an attempt to have children (Gerrrits, 1997). They did this in order to check if the blood of these other men were more compatible with theirs than their husband‘s. Adoption is another way of coping with infertility although it is less accepted in the developing world. Research by Bharadwaj (2003); Mogobe (2005); Inhorn (2006); Oladokun et al. (2009) amongst others have shown the low acceptability of adoption amongst infertile couples. Comparatively, fostering is more common and acceptable within the developing world (Gerrits, 1997; etc). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 36 In addition to these cultural practices, many of which may no longer be acceptable today within the various societies due to the influence of modernisation, Christianisation and Westernization, there exists groups of local people who are specialized in the provision of treatment for infertility. These people are believed to have the ability to diagnose and offer treatment for problems that cause infertility in both men and women. Inhorn (1994) refers to these local practitioners as ethno-gynecologists. Such traditional healers