|Year : 2013 | Volume
| Issue : 1 | Page : 15-19
What drives grand multiparous women in rural Nigeria to seek treatment for infertility
Odidika Ugochukwu Joannes Umeora, Uchechi Noelene Nzerem, Justus Ndulue Eze
Department of Obstetrics & Gynaecology, Federal Teaching Hospital, Ebonyi State University, Abakaliki, Ebonyi State 480001, Nigeria
|Date of Web Publication||19-Apr-2014|
Uchechi Noelene Nzerem
P.O. Box 980, Abakaliki, Ebonyi State 480001
Source of Support: None, Conflict of Interest: None
Context: Infertility is rife in Nigeria. Grand multiparous women are also affected and do seek management for various reasons. Objective: The objective of this study is to evaluate the factors, which compel women with at least five living children and a history of secondary infertility to seek further conception in rural Nigeria. Materials and Methods: This was a qualitative study employing in depth interview to study consented participants in a rural mission hospital in Ebonyi state of Nigeria. Research assistants interviewed participants at their second clinic visit for infertility management using a pre tested interview guide. The study lasted for eight months. Principal themes were isolated from the recorded interview and analyzed. Results: Ten women were interviewed with three men who accompanied their wives to the clinic. The main themes evident from the interviews included acquiescence to the male partner's wishes , desirability for male children, desire for more off springs, replacement of demised children, fulfillment of reproductive potentials and not being "out done" by co-spouses in a polygamous setting. Conclusion: Grand multiparous women still consult for infertility in rural Nigeria. Desires for male children or replacement of lost ones are some of the main reasons for such consultations.
Keywords: Multiparity, poverty, rural Nigeria, secondary infertility, tradition
|How to cite this article:|
Umeora OJ, Nzerem UN, Eze JN. What drives grand multiparous women in rural Nigeria to seek treatment for infertility. Afr J Med Health Sci 2013;12:15-9
|How to cite this URL:|
Umeora OJ, Nzerem UN, Eze JN. What drives grand multiparous women in rural Nigeria to seek treatment for infertility. Afr J Med Health Sci [serial online] 2013 [cited 2019 Jan 19];12:15-9. Available from: http://www.ajmhs.org/text.asp?2013/12/1/15/129917
| Introduction|| |
Infertility is prevalent in Nigeria and a common gynaecological presentation. ,, It is of major concern to affected couples with emotional, social and cultural implications to the affected families.  In the traditional African society, much premium is placed on procreation as children are held as blessings from the creator and basic to maintaining family lineage. In patrilineal societies like Nigeria, emphasis is on bearing male children. For the women particularly, children in marriage are seen as cementing their place in their matrimonial homes and a source of pride and confirmation of womanhood and fertility. In some cultures, pregnancy before marriage is welcome and an evidence of fertility.  Erroneously the female is often held accountable for almost all cases of infertility  resulting in enormous pressure on them and the desire to seek management. Aetiologically secondary infertility is the most prevalent form in Nigeria, with utero-tubal factors the leading cause.  This makes events of prior pregnancies essential in causation in parous women. Meanwhile, studies on socio demographics of infertile couples reveal that such couples are mainly either childless or of low parity. ,,,, However, informal review of gynaeological consultations in a rural mission hospital reveals that couples who had children have not been exempt from seeking consultations for infertility. It is easy to appreciate that childlessness or having very few children drives couples of no or low parity to seek infertility management; same might not be said of couples with at least five living children. This generates the research question "what drives the grand multiparous couples with at least five living children to seek infertility management in rural Nigeria?" This study aims to answer this question. Lessons from the study might help in the formulation of protocol in clinical counseling of such couples.
| Materials and Methods|| |
Ebonyi State was created in 1996. It comprises the rural areas of the previously existing Abia and Enugu States. The State with a population of over two million people are inhabited by the natives of Igbo extraction and few other ethnic groupings who are mainly found within the State Capital of Abakaliki - the only urban administrative unit in the State. This study took place at a Catholic Mission hospital in Ndubia- Igbeagu, Izzi local government area of the state. It is a rural setting. The hospital well-staffed with a specialist Gynaecologist and medical officers serves the local communities and their environs. It provides primary, secondary and occasionally tertiary health-care services and receives referrals even from outside the state. Majority of its clientele however, remains the Izzi clan who populate the area. They are mainly peasant farmers and petty traders. Poverty level is high and illiteracy prevalent. Christianity, African traditional belief system and animism constitute their religious inclinations. Superstitions and myths are rife and often used to explain medical conditions. They seek both orthodox health-care from modern health facilities and unorthodox care from traditionalists, herbalists and spiritualists.
This was a qualitative study using an in-depth interview of participants who consented to participate in the study. Participants were women/couples who have five or more children and presented with infertility at the gynaecological unit of the hospital. Grand multiparous women with less than five living children were excluded from the study. After the initial consultation with the Gynaecologist, the patients were sent for basic laboratory investigations and given a follow-up visit day and encouraged to present with their spouses. The interview took place after consultation at the second visit. Participants were approached by trained research assistants: A nurse and a medical laboratory technician not involved in the patients management. The research assistants were trained on conducting in depth interviews by the principal investigator. The study, its aim and implications were explained to them and their consent sought having emphasized their absolute choice to decline participation, which will in no way affect their subsequent management. Those who consented signed an informed consent form and were enrolled into the study. The study took place in an office at the laboratory section, with enough seats, but sparsely furnished to mimic their natural environment.
The principal investigator developed the interview guide after extensive review of the literature on the topic. Each patient was provided with snacks and a soft drink to create a friendly and relaxed atmosphere different from the routine hospital environment. At the end of the interview, they were provided with a transport stipend to compensate for their time.
The study spanned eight months from the 1 st of February until the 31 st of September 2011. The study was approved by the St Vincent's hospital management and ethical approval granted by the Research and Ethics Committee of the Ebonyi State University Teaching Hospital.
Data collection and analysis
The interview was recorded by a voice recorder and later transcribed verbatim by an assistant. The interview questions were mainly to explore the reasons for consultation for infertility. Major themes arising from the interviews were isolated and analyzed. The socio-demographic and clinical parameters of the participants were also captured.
| Results|| |
Three of the participants were interviewed with their spouses as well as seven others who could not attend with their spouses. The sessions lasted an average of 37 minutes with a range of 29-45 mins. The women ranged in age from 29 to 37 years with a mean of 32.2 ± 5.3 years. The mean parity was six. All had at least five living children. One had five children, all females. Eight were Christians and two practiced African Traditional Religion. Only one of the participants completed Primary level education while the rest either attempted primary education (four) or had no formal education (five). They all belonged to the lowest strata of the socio-economic ladder. Four of the participants were married in polygamous setting; one was in her second marriage following the death of her former spouse. The rest were in a monogamous family setting. The husbands, but one who was a bicycle repairer were all farmers while the women were also farmers (six), hairdresser (one), petty trader (two) and full time house wife (one). They all lived in the rural areas of Ebonyi State.
The themes evidently discerned from the interviews included acquiescence to the male partner's wishes, desirability for male children, desire for more off springs, replacement of demised children, fulfillment of reproductive potentials and not being "out done" by co-spouses in a polygamous setting.
Although only three men turned up with their female partners, the perceived opinions of the male spouses were evident. Six of the women hinged their desire for more children on the wish of their husbands for more children. For Mrs. NI, the only participant who completed her primary education and married in a monogamous setting, she would have embarked upon a family planning method discussed during her last antenatal care visit but for the opposition of her husband. She spoke in her native dialect (translated here).
"Nurse, I would have commenced on a contraceptive method we learnt during the antenatal period here in my last pregnancy, but my husband would not allow it, he wants more children from me."
The husband's wish was also the driving force for Mrs. AN married in a monogamous setting and interviewed alongside her husband.
"My husband is an only Son and he has made it clear to me that he wants more and more sons, now I have five children but only one son, he does not want his son to be an only son like himself, so my sister I have to continue and I know God will answer his prayer."
The three men interviewed did not hide the male domineering influence in reproductive health decision. Mr. ON, a farmer and spouse of Mrs. AN emphasized the wife's view. According to him, he underwent a lot of hardship and oppression in the hands of family members because he was an only son. As such he can never allow his own son to suffer the same fate, to have more sons therefore is a sine qua non. Moreover, more sons have additional benefits as he puts it.
"When you have many sons, you will have many helping hands whether in the farms, market or in the home. You as the parent will feel more relaxed knowing you have many sons who will protect you even when your neighbours or enemies want to fight you."
However for Mr and Mrs. JO who had six female children, the need for a male child was even more fundamental. They believed that the family would not be complete without a son. For the man, a son guarantees survival of the family name in generations to come.
"Nurse, whatever you say, I need a son who will inherit my name and carry the family name into the generations to come. Without a son, it means my family line will terminate when I am gone."
More important to the wife, was the need to consolidate herself in the husband's family.
On my side I want the male child so that no one will push me out of the family especially (God forbid) if my husband is gone.
The need for a male child to propagate the family name and fortune was echoed by many of the participants as a core reason for seeking further children by couples. However for others, it is not just the need for male children but generally more children of whatever gender. The reasons for wanting more children were not very clear during any of the interviews; some believed that the size of any family confers dignity and respect within the community. For some, number of children in a family translates to strength and equals prosperity.
For Mrs. JN the need for more children transcends personal desires, but is an acceptance of god's will. For her, god has a particular number of children for each woman and as a necessity a woman must fulfill this.
"I know God has so many more children for me and I must bear all of them. If I do not they may form fibrous (fibroids) or other growths in my womb, some call it cancer and it may kill me. I do not want to die now."
It was not precisely stated by Mrs. EE married in a polygamous setting, but was perceptible that she did not want to be outdone by her co-spouse in terms of procreation. She had five children who included a male child but the co-spouse - the second wife in the setting was delivered of a baby just three months earlier and now had four children.
"My partner (co spouse) in the house just delivered, I am still young, so should I not have more babies. I already had six but one died, so I need to replace him. Even some of the children may still die, I do not pray for that. At the end I will want to have at least six children."
| Discussion|| |
For many, infertility connotes childlessness, but this was not so for our study population, a subset of grand multiparous women still desirous of procreation for several personal, family and social reasons. In this study, many women desired to beget more children to fulfill their male partners' wishes, have male children or replace a demised child. Nigerian fertility rate is 5.7. 
Pregnancy in a grand multiparous woman is considered high risk and is fraught with complications, which contribute significantly to maternal morbidity and mortality. Whereas, effort has been made to decrease this by improving access to health through increasing antenatal care coverage and extensive production of family planning services, uptake of these services is still poor. An index of this uptake is the contraceptive prevalence rate, which was 14.6% in Nigeria in 2010, as opposed to 78.6% in the USA.  The contraceptive prevalence rate in Ebonyi state at 5.7%, is much less than the national average, unlike states like Lagos with rates of 41.8%.  This abysmal uptake is attributable to the non-participatory role of the male decision makers. The male folk exert an overwhelming influence in reproductive health decisions. This is evident in our study where the decision to have more children was in acquiescence to the male partners wishes in 60% of the cases. These male decision makers however do not participate in care seeking. This is also the case in our study where only three out of 10 women had their husbands present during consultation. The women are usually left to proffer solution to "her" problem, exposing her to the dangers posed by unorthodox practitioners who are usually the first port of call for this segment of the population. These unorthodox practitioners prey on the women's desperation and her desire to escape/avoid the physical and emotional abuse meted out to women in similar situations causes her to delve further into the harmful world of traditional medicine. In contrast, a Swazi study showed that the men aware of their contribution to infertility took active part in care seeking. 
The effects of infertility on a couple, especially the women, have been extensively documented. This study calls to mind the little considered demographic paradox (fertility-infertility dialect) wherein the countries with the highest overall fertility rates also have the highest prevalence of secondary infertility.  Nigeria is one of such countries, with a fertility rate of 5.7 children per woman and high infertility prevalence. This paradox is exemplified in our study where the women with at least five children are seeking management for infertility.
The influence of cultural values is an integral factor in most of the themes discerned from this study. The enormous value placed on children, especially male, drives the quest for the all precious male child to perpetuate the family lineage. The case is similar to that in China and India according to a 1995 study, where women with only female children were ostracized, at risk of suicide and often faced beatings, divorce or fatal "accidents".  Other themes discerned from the study which stem from the prevalent cultural/traditional beliefs are child replacement phenomenon, competitive child bearing (to outdo co-spouses in polygamous settings), attainment of perceived reproductive potentials and misconception about the origin of pathologies of the female reproductive tract (fibroids).
Polygamy which is a deep-rooted practice in most traditional African societies also plays a major role. In the typical polygamous family in Nigeria, the number of children each woman has, especially male, serves to consolidate her place in the family. This puts further pressure on her to procreate as a means to achieve family stability, dignity and respect. Close extended family ties, which are a cherished part of the family life in Nigerian society contributes further to the pressure. This is in line with the Bantu ideology  of "Ubuntu," which means that I am what I am because of what we are. Thus, an individual's place is society is defined by the web of relations formed with the nuclear and extended families (including dead and unborn), the village and the nation. Without children, this web is cut short, leaving the woman a societal outcast. This is a stark contrast to western societies where the core values are individual freedom and happiness; and so, reproduction is a self-chosen goal and a largely personal choice made by an individual or a couple. 
The devastating consequences of poverty and ignorance cannot be overemphasized. However, in addition to making the effort to alleviate poverty and dispel ignorance, steps should be taken to redress the pronatalist and patrilineal cultural ideologies. The study has demonstrated an unlikely form of infertility, which is for the most part overlooked. It is the reproductive right of couples to choose the number of children they want. However, assisting them to achieve their reproductive goals may expose them to the complications of grandmultiparity, as well as further depreciate their socio-economic status. More attention therefore, should be directed towards the reasons behind their desire for more children and cultural myths that encourage this unbridled desire debunked. Greater emphasis should be laid upon having the number of children couples can adequately cater for, irrespective of sex. This would also help to truncate the cycle of poverty. In order to achieve this, there is an intense need to involve the male folk in the reproductive process past mere decision-making roles. Continuous community enlightenment should be embarked upon.
This study is limited by the fact that all participants belonged to the lower socio-economic class and hence generalization of the findings may not be possible. Furthermore, the views were mainly of the females, only few males who reportedly were the forces behind the quest for more children participated. It would have been more instructive to get in depth views of the menfolk.
| References|| |
|1.||Omoaregba JO, James BO, Lawani AO, Morakinyo O, Olotu OS. Psychosocial characteristics of female infertility in a tertiary health institution in Nigeria. Ann Afr Med 2011;10:19-24. |
|2.||Adetoro OO, Ebomoyi EW. The prevalence of infertility in a rural Nigerian community. Afr J Med Med Sci 1991;20:23-7. |
|3.||Okonofua FE. Infertility in Sub-Saharan Africa. In: Okonofua FE, Odunsi OA, editors. Contemporary Obstetrics and Gynaecology for Developing Countries. Benin City, Nigeria: Women's Health and Action Research Centre; 2003. |
|4.||Okonofua FE, Harris D, Odebiyi A, Kane T, Rachael CS. The social meaning of infertility in South-West Nigeria. Health Transit Rev 1997;7:205-20. |
|5.||Umeora OU, Mbazor JO, Okpere EE. Tubal factor infertility in Benin City, Nigeria - sociodemographics of patients and aetiopathogenic factors. Trop Doct 2007;37:92-4. |
|6.||The Population Institute. Population and failing states: Nigeria, 2000. Available from: http://www.populationinstitue.org/external/files/nigeria.pdf. [Last accessed on 2012 Oct 10]. |
|7.||World Health Organisation. Contraceptive prevalence rates. World Health Statistics 2012. Available from: http://www.globalhealthfacts.org/data/topic/map.aspx.? ind = 89. [Last accessed on 2012 Oct 18]. |
|8.||United Nations Population Fund. Nigeria Family Planning Analysis: Selected Demographic and Socioeconomic Variables. Abuja: UNFPA Nigeria Country Office; 2010. |
|9.||Ziyane IS. Factors which deter Swazi women from using family planning services. A Doctoral Dissertation Presented to the Department of Advanced Nursing Sciences at the University of South Africa, February, 2002. |
|10.||Nachtigall RD. International disparities in access to infertility services. Fertil Steril 2006;85:871-5. |
|11.||Holmes HB. Choosing children's sex: challenges to feminist ethics. In: Callahan JC, editor. Reproduction, Ethics and the Law: feminist Perspectives. Bloomington: Indiana University Press; 1995. p. 148-77. |
|12.||Dhont N. Clinical, epidemiological and socio-cultural aspects of infertility in resource poor settings. Evidence from Rwanda. Doctoral Thesis Submitted to the Faculty of Medicine and Health Sciences, Ghent University. |
|13.||Penning G. Ethical issues of infertility treatment in developing countries. ESHRE Monogr 2008;2008:15-20. |