- Email: [email protected]
Women and infertility in Sub-Saharan Africa
Reviews
by J Ties Bocrnma and Zaida Mqalla (eds), KITPress, Amsferdam,
J Ties Boerma, ~ EPRODUCTIVE
19.W
Zaida Mgalla health
is now high on the and national health programmes and spans a range of health and population programme areas, including family planning, safe motherhood, infertility, and control of sexually transmitted diseases (STDs) and HIV. The potential benefit of combining these population and health issues under the umbrella of reproductive health lies in the interrelationships among the interventions and their ultimate effect on health. For instance, family planning programmes that prevent unwanted pregnancy are also likely to improve maternal and child health. Promoting condom use prevents both unwanted pregnancy and STD or HIV infection. Programmes that are successful in addressing underlying gender issues are likely to benefit many facets of reproductive health. A broad intervention package to improve reproductive health as a whole may thus have a much greater effect than the sum of the effects of the individual packages. This book examines an element of reproductive health in sub-Saharan Africa that is often neglected: while infertility is common in subSaharan Africa, it has received only piecemeal attention in research and health programmes. The main reason is the lack of feasible, affordable and effective treatment interventions. In addition, population and health programmes in Africa have primarily been oriented towards high fertility and high rates of population growth. Why address infertility? This book argues that infertility is a major public health problem and a human rights issue with far-reaching consequences for the individual, the couple and, to a lesser extent, the health system. Furthermore, infertility is intertwined with many other elements of reproductive health. We contend that it is a logical part of any reproductive health programme. The chapters discuss infertility from the standpoint of different disciplines, including demography, clinical medicine, epidemiology, anthropology
I3 agenda of international
and public health. They illustrate the linkages of infertility to sexual behaviour and marital behaviour, to STDs and HIV, to maternal health and to family planning, from these different disciplinary perspectives. In bringing this material together, our hope is to provide information and increase awareness about infertility within reproductive health and other women’s health programmes. Infertility is an all-pervasive issue for those who experience it; realising its importance to women, men and families can facilitate treatment, mitigate the consequences of infertility and help the achievement of other reproductive health goals.
Measurement
of infertility
A range of terms and definitions are used to describe and measure impaired fertility in women, men and couples by clinicians, epidemiologists, demographers and anthropologists. In this volume the following terms are used: l Sterility: inability to conceive or to impregnate. This term often implies complete and permanent inability to conceive. l Infertility: inability to produce a live birth. This term captures inability to conceive, impregnate or carry a pregnancy to term and live birth. Women who conceive but have subsequent abortions (pregnancy wastage) are considered infertile, just as women who are unable to conceive. Distinction is made between primary infertility (has never given birth) and secondary infertility (cannot give birth following at least one live birth). l Childlessness: not having a living child. A woman may have given birth to at least one live child but all have died. In populations with high levels of child mortality, the difference between the prevalence of childlessness and primary infertility is not trivial. For instance, in 27 national Demographic and Health Surveys (DHS) in sub-Saharan Africa, the median -^ 18S
proportion of women 35-49 years who never had a live birth was 3.0 per cent, while 4.5 per cent had no living child. Demographers often use the term childlessness to refer to primary infertile women. Measuring the prevalence of infertility is difficult because it focuses on women who are still in their reproductive age span (women may still deliver a child before their menopause) and because it requires a delineation of a period of exposure to the risk of pregnancy. For clinicalepidemiological purposes the W H O Scientific Working Group on the Epidemiology of Infertility defined infertility as the inability of a woman, man or couple to have a conception after a period of two years of exposure without conception (WHO, 1975). Most clinicians, however, use a 12month period of unprotected intercourse (Rowe et al, 1993). A distinction between inability to conceive and inability to carry a pregnancy through to term and have a live child is also made. Most estimates of the prevalence of infertility rely on data collected in cross-sectional surveys. In such surveys birth histories are collected from female respondents aged 15-49 (only in a few cases from male respondents). Methods have been developed to estimate the prevalence of primary and secondary infertility from such incomplete birth histories, that is, from women who may still bear additional children (Larsen and Menken, 1989). The duration of the period of exposure to the risk of pregnancy since marriage or the last birth is set at five to seven years, depending on the measure being used. If no detailed birth history is available, the proportion of women with an open birth interval of five years or longer is often used as an indicator of secondary infertility (Larsen, 1996). Extrapolations from survey data need to take contraceptive use into account. While some women who use contraceptives are infertile, contraceptive users are, on the whole, more likely to be fertile than non-contracepting women. In any case, as contraceptive use increases it will become increasingly difficult to estimate infertility from survey data. In most sub-Saharan African countries, this problem is still not insurmountable, as shown in the analysis by Ulla Larsen and Hans Raggers in the chapter ‘Levels and trends in infertility in sub-Saharan Africa’. 184
All of these factors increase the difficulty of estimating the magnitude of the problem of infertility in sub-Saharan Africa. Using Larsen and Raggers’ estimates of primary infertility, we estimate that about three to four million women in sub-Saharan Africa are currently affected. As voluntary childlessness is rare in most of subSaharan Africa, it is likely that an equal number of women (and couples) consider this as a health and social problem. A larger number of women can be considered to have secondary infertility, probably more than 13 million, The number of women (and couples) who perceive this as a health and social problem is smaller than 13 million, because some of these women may have already achieved (all or part ofl their desired fertility. The data from infertility clinics show that about 40 per cent of the infertility cases are primary infertility and 60 per cent secondary infertility (Favot et al, 1997; Cates et al, 1985; Giwa-Osagie et al, 1984; Moutsinga, 1973). This would correspond with about five to six million women for whom the problem of not being able to bear another child is sufficiently serious to justify a visit to an infertility clinic. Based on these calculations, we estimate that eight to ten million women in sub-Saharan Africa are currently suffering from infertility. The definition of infertility has considerable impact on the estimate of the prevalence of infertility and thus on evaluations of the success rate of infertility treatment. Marchbanks et al (1989) analysed five different definitions of infertility in the USA. Three measures were based on a questionnaire and two on a life-event calendar (which includes pregnancy, births, sexual exposure, contraceptive use, etc). The prevalence of infertility was 12.5 per cent based on couples reporting no conception after two years of trying to conceive. When based on those who had consulted a physician (and no conception after two years of trying to conceive) it was 9.6 per cent, and when based on physician’s diagnosis (with no conception after two years of trying to conceive) prevalence was 6.1 per cent. Much higher levels of infertility were found using measures based on the life-event calendar (which is more comparable to demographic methods of estimation): 20.6 per cent if no conception occurred after 24 months of unprotected inter course and 32.6 per cent if no conception occurred after 12 months of unprotected intercourse. The
study also showed significant differences in subsequent conception rates, depending upon the definition used. The Marchbanks et al study suggests that belter measurfmenl of infertility may bc achieved by asking more direct questions about the couple’s desire to get pregnant. For instance. surveys might ask directly if a \voman is currently trying to have a child (or another child). In the World Fertilit) Survey (WFS) a question was asked to married womcn about their ability to have anothel child with their husband if they wanted one. not results were The considered a good indicator of actual inability to bear children (Vaessen, 1984). It is worthwhile adding a question to surveys about efforts to conceive, to obtain better estimates of infertility from such surveys. In Rakai, Uganda, results from this question appeared to be useful (Ron Gray, personal communication).
Who pays the price: women or men? Infertility may be due to the woman, the man or both. However, the indicator of infertility of the couple is the woman, whether infertility is the result of female or male factors. In sub-Saharan Africa male infertility is likely to be a significant factor, although data are limited, as discussed in the chapter by Philippe Mayaud, ‘Infertility in Africa: the role of reproductive tract infections’. Even so, anthropological and demographic studies indicate that the majority of infertility is likely to be associated with female I’actors. Women who do not bear children are often divorced and have multiple, life-time partners, and are (herefore apt to have sexual interc-ourse with fertile partners at some point in their lives. Three chapters discuss these issues: Marjolein Gijsels, Zaida Mgalla and Lilian Wambura, “No child to send”: context and consequences 01’ I’c:male infertility in North West Tanzania’; Zaida Mgalla and Ties Roerma, ‘The discourse of infer[ilit\ in ‘l’anc.ania’; and Ties Boerma and Mark
Urassa, ‘The association between female infertility, HIV and sexual behaviour in a rural area of Tanzania’. Anthropological studies also describe the coping mechanisms in place to circumvent male infertility without breaking up the marriage, by assuring that the woman becomes pregnant from another man without the knowledge of the husband. This is discussed in the same chapters as above by Gijsels et al and by Mgalla and Boerma, and also in the chapter by Denise Roth ‘Mchango, menses and the quality of eggs: women’s perceptions of risks to fertility in a rural Tanzanian community’. There is ample evidence in the papers about Tanzania that infertile women are paying a heavy price for not being able to fulfil the reproductive expectations of their husband, family, clan and community at large. For example, the anthropological study by Gijsels et al employs life histories to document the miserable treatment of ‘barren’ women in north-west Tanzania. This includes public derogation, beatings and divorce. The low social status of women with infertility is also illustrated by the group discussions with men and women in Tanzania by Mgalla and Boerma, the interviews with women in a rural community in western Tanzania by Roth, and the interviccvs with infertile women and men in the Gambia and Zimbabwe by Johanne Sundby and Ailccn Jacobus in the chapter ‘Health and tradi185
tional care in infertility: Gambia and Zimbabwe’.
experiences
from
the
Relationships with other elements of reproductive health Sexual behaviour
and marriage
Anthropological studies have described the changes in marriage and sexual behaviour among infertile couples and infertile men. A man or a woman may be more likely to have extramarital partners if no children are born. Studies in Sierra Leone (Harrell-Bond, 1975) and Uganda (Southwold, 1973) suggest that husbands of infertile wives often had extra-marital partners, although it is not immediately clear to what extent their sexual behaviour can be attributed to the infertility per se. As mentioned earlier, several authors in this book describe the secret arrangements made to assure a woman becomes pregnant in the event of suspected male infertility, and in most societies infertility is also an important reason for divorce (see also Nabaitu et al, 1994; Solivetti, 1994; Reyna, 19751, while in other societies men may add another wife to their infertile union (David and Voas, 1981; Pool, 1972). A few epidemiological and demographic studies lend further evidence to the anthropological studies. In population-based surveys infertility was associated with greater marital instability in Cameroon and Nigeria and with polygyny in Cameroon (Larsen, 1995). In rural Tanzania, infertile women also had more sexual partners and more marriages than fertile women, and HIV prevalence among infertile women was three times higher than among fertile women (see Boerma and Urassa in this book and also Favot et al, 1997). The association between HIV and infertility is largely due to the fertility-reducing effect of HIV, but may also partly be a consequence of behaviours associated with infertility. Primary infertility was very common in the 1950s and earlier. The chapter by Richard White, Basia Zaba, Ties Boerma and John Blacker, ‘Modelling the dramatic decline of primary infertility in sub-Saharan Africa’, shows that the high prevalence of primary infertility is likely to have been associated with a very early onset of sexual intercourse, often prior to menarche. An increase in age at first sex and sexual mixing patterns may have contributed to the pro186
nounced decline in primary infertility that can be observed from about the middle of the 20th century. The chapter by Ulla Larsen shows that in the heart of the infertility belt in the Central African Republic, primary and secondary infertility have also declined considerably, allhough levels are still considerably higher than in most other parts of Africa.
STD/HIV Reproductive tract infections, including STDs, are common in many parts of sub-Saharan Africa. Initially, ecological studies (e.g. Romaniuk, 1968, Arya et al, 1980) and later clinical research (Gates et al, 1985) demonstrated the prominent role of STDs in the aetiology of female infertility, which Mayaud’s chapter discusses. Both gonorrhoea and chlamydia infection may lead to pelvic inflammatory disease (PID), which may lead to scarring of the tubes of the female reproductive system and subsequent infertility. The review of data for the first half of the 20th century in the chapter by White et al shows that a high prevalence of STDs, notably gonorrhoea, is the most likely cause of the very high levels of primary infertility several decades ago. Microsimulations and evidence from in-depth studies suggests that the dramatic decline in primary infertility has largely been due to the introduction of antibiotics. Current efforts to improve STD case management practices in health facilities are likely to reduce the risk of infertility following an STD, among those who make use of health facilities, as Mayaud shows. A significant proportion of patients, however, do not make use of modern health facilities, but they do practice self-treatment, buy drugs in shops or pharmacies and use traditional healers (see the chapter by Roth). Among traditional healers, many may have specialised in STD care, as was found in rural Tanzania (see the chapter by Robert Pool and Ndatulu Robert Washija, ‘Traditional healers, STDs and infertility in north-west Tanzania’). The healers may also have some biomedical knowledge and appeared to be keen on better collaboration with the modern health sector.
Maternal
health
Secondary infertility is common according to the estimates in the chapter by Larsen and Raggers.
In part, this is due to increased biological infertility l’rom aging of the woman. The number of infertility is, however, \Lomen with secondary well in excess of what could be expected on the basis 01‘‘natural infertility’ levels observed in historical populations in Europe and the USA IBongaarts, 1982). The main culprit appears to be post-partum infections, and to a lesser extent post-abortal infections. Reproductive tract infections, mostly STDs, may easily lead to PID during the puerperal period, according to Mayaud, but there is a dearth of studies. Caesarean section may also lead to posl-partum infection and subsequent infertility, as is shown in a study by Xavier De Muylder, Pierre Buekcns and Bruno Dujardin and colleagues in the chapter ‘Caesarean section and infertility: a case-control study from Zimbabwe’.
Family planning From as early as the 1950s Anne Retel-Laurentin (1974) tried to draw attention to the link between the problem of infertility and the acceptability and success of family planning programmes. She argued that attention to the problem of infertility would enhance the acceptability of family planning programmes to African populations, especially those with high levels of infertility. At present, even with the success of family planning programmes, adolescent girls arc still concerned with infertility: the consequences of not being able to bear children are devastating. In interviews with women (chapter by Roth) and in focus group discussions in Tanzania, where use of modern contraceptives is still low, these concerns became very clear (chapter by Mgalla and Boerma).
Interventions According to Sundby and .Jacobus, infertile women report high levels of health services utilisation. For instance, women attending a hospital infertility clinic in Tanzania reported that they had visited on average 2.7 different kinds of modern health facilities and 5.9 traditional healers in association with their infertility (Favot et al, 1997). In a rural community in ‘fanxania, more than half of the traditional healers reported that they specialised in dealing with infertility problems (chapter by Pool and Washi,jal As Sundby and Jacobus report from --
their Zimbabwe and Gambia studies, women with infertility problems often present with several other complaints and leave without the health worker diagnosing the underlying cause for the visit. Repeated visits to modern and traditional health facilities represent a cost to women, couples or families as well as to the health system. Not infrequently, inappropriate interventions such as dilatation and curettage are performed. Addressing infertility should be part of reproductive health programmes. This comprises prevention of infertility through prevention of STDs and timely and adequate treatment of STDs. Treatment of infertility is feasible in some cases with limited resources, while health workers need to be better equipped in dealing with infertility, if only to avoid inappropriate interventions and to improve their counselling skills. At the societal level, there is a need to address the social dimension and enhance discussion about infertility as a reproductive health and social problem. In some settings the establishment of local organisations of women with infertility may help the women themselves, such as the ‘Kanyaleng’ in the Gambia (chapter by Sundby and Jacobus). Infertility is a substantial public health problem in sub-Saharan Africa, with an estimated 810 million women (i.e. couples) affected. The significant social stigma attached to infertility strongly affects the lives of both women and their partners. However, a great deal can be done. We can help to prevent reproductive tract infections, particularly STDs, by sexual health education and promotion of condoms. We can reduce the consequences and spread of such infections through accessible, timely and effective treatment. We can provide low-cost treatment for infertile women and couples, even though success rates may be low. Finally, we can mitigate the consequences of infertility for those who cannot be treated, by improving counselling and by addressing the issue of infertility in society at large. If we neglect female infertility, then we fail to address the full potential of reproductive health for women.
Note This text is excerpted firom the draA /ntroduction to this book, rrprinted with kind permission ofthe Royal Tropica/ institute KIT Press, 0 7999.
References -
Larsen U, Menken J, 1989. Measuring sterility from incomplete birth histories. Demography. 26:185-201.
Arya OP. Taber SR, Nsanze I, 1980. Gonorrhea and female infertility in rural Uganda. American JournaJ of Obstetrics and Gynecology. 138:929-32.
Marchbanks PA, Peterson FIB et al, 1989. Research on infertility: definition makes a difference. AmericanJournaJ of Eprdcmiology. 130:259-67.
Bongaarts J, Potter RG, 1983. Fertility, Biology and Bchawour: An Analysis ofthe Proximate Determinants. Academic Press, New York. -
Moutsinga I-I, 1973. La sterilite feminine au Gabon en consultation gynecologique journali&re. MCdicin d’Afrique Noire 20: 103-09.
Cates W, Farley TMM, Rowe PJ 1985. Worldwide patterns of infertility: is Africa different? L.ancet ii: 596-99. David N, Voas D, 1981. Societal causes of infertility and population decline among the settled Fulani ofNorth Cameroon. MAN. 16:644-64.
Nabaitu J, Bachengana C, Selle) J. 1994. Marital instability in a rural population in South-west Uganda: implications for the spread of HIV-1 infection. Afiric-a 64: 243-51.
Favot I, Ngalula J, Mgalla % et al 1997. HIV infection and sexual behaviour among women with infertility in Tanzania: a hospital-based study. International.lournal of Epidemiology. 26: 414-19. -
Pool JE, 1972. A crosscomparative study of aspects of conjugal behavior among women of 3 West African countries. CanadianJournaJ of African Studies 6:233-59. Reyna SP, 1975. Age differential, marital instability, and venereal disease: factors affecting fertility among the Northwest Barma. In: Nag M (ed), Popuiatlon and Social Organkation. Mouton, The Hague.
Giwa-Osagie OF, Ogunyemi D, Emuveyan E E et al, 1984. Etiologic classification of infertility in 250 couples. InternationalJournal of Jnfcrtility. 29:104-08. Harrell-Bond BE, 1975. Modern Marriage in Sierra Leone: A Study ofthe Professional Group. Mouton and Co, The Hague
-
Romaniuk A, 1968. Infertility in tropical Africa. In: JC Caldwell and C Okonjo (eds). Jhe Population ofTropical Africa. Longmans, London.
Hughes EC (cd), 1972. Obstc,trics/C;vnec-ology ‘J’crminology. FA Davis Co, Philadelphia.
Rowe PJ, Comhaire FH, Hargreave TB et al, 1993. L$‘/lO Manual for the Standardized fnvcstigation and Diagnosis of the Infertile Couple. Cambridge University Press, Cambridge.
Larsen U, 1995. Differentials in infertility in Cameroon and Nigeria. Population Stud&. 48: 459-74.
Solvetti LM, 1994. Family, marriage and divorce in a Hausa community: a sociological model. Africa 64:252-71
-- Larsen U, 1996. Childlessness. subfertility and infertility in ‘l’anzania. Studies in Famil)~ Planning. 27:18-28.
-188
Southwold M, 1973. The Raganda of Central Africa. In: A Molnos (edI, Cultural Source Material forPopulation Plannmg in East Africa. Volume 111,Beliefs and Practices. East African Publishing House, Nairobi, Kenya. Vaessen M, 1984. Childlessness and Infecundity. W F S Scientific Studies No. 31, lnternational Statistical Institute, Voorburg, Netherlands. The Eppidcmro1og.yof Jnfcrtilil~. Report of a Scientific Working Group, W H O Technical Report Series No. 582, Geneva, 1975.
Available in September 1999 from: Royal Tropical Institute KIT Press P. 0. Box 95001 1090 HA Amsterdam, Netherlands Fax: 3 l-20-568 286 Email: [email protected] Website: www.kit.nl Price: JXJ. 49 ISBN 90 6832 126 1
by J Ties Bocrnma and Zaida Mqalla (eds), KITPress, Amsferdam,
J Ties Boerma, ~ EPRODUCTIVE
19.W
Zaida Mgalla health
is now high on the and national health programmes and spans a range of health and population programme areas, including family planning, safe motherhood, infertility, and control of sexually transmitted diseases (STDs) and HIV. The potential benefit of combining these population and health issues under the umbrella of reproductive health lies in the interrelationships among the interventions and their ultimate effect on health. For instance, family planning programmes that prevent unwanted pregnancy are also likely to improve maternal and child health. Promoting condom use prevents both unwanted pregnancy and STD or HIV infection. Programmes that are successful in addressing underlying gender issues are likely to benefit many facets of reproductive health. A broad intervention package to improve reproductive health as a whole may thus have a much greater effect than the sum of the effects of the individual packages. This book examines an element of reproductive health in sub-Saharan Africa that is often neglected: while infertility is common in subSaharan Africa, it has received only piecemeal attention in research and health programmes. The main reason is the lack of feasible, affordable and effective treatment interventions. In addition, population and health programmes in Africa have primarily been oriented towards high fertility and high rates of population growth. Why address infertility? This book argues that infertility is a major public health problem and a human rights issue with far-reaching consequences for the individual, the couple and, to a lesser extent, the health system. Furthermore, infertility is intertwined with many other elements of reproductive health. We contend that it is a logical part of any reproductive health programme. The chapters discuss infertility from the standpoint of different disciplines, including demography, clinical medicine, epidemiology, anthropology
I3 agenda of international
and public health. They illustrate the linkages of infertility to sexual behaviour and marital behaviour, to STDs and HIV, to maternal health and to family planning, from these different disciplinary perspectives. In bringing this material together, our hope is to provide information and increase awareness about infertility within reproductive health and other women’s health programmes. Infertility is an all-pervasive issue for those who experience it; realising its importance to women, men and families can facilitate treatment, mitigate the consequences of infertility and help the achievement of other reproductive health goals.
Measurement
of infertility
A range of terms and definitions are used to describe and measure impaired fertility in women, men and couples by clinicians, epidemiologists, demographers and anthropologists. In this volume the following terms are used: l Sterility: inability to conceive or to impregnate. This term often implies complete and permanent inability to conceive. l Infertility: inability to produce a live birth. This term captures inability to conceive, impregnate or carry a pregnancy to term and live birth. Women who conceive but have subsequent abortions (pregnancy wastage) are considered infertile, just as women who are unable to conceive. Distinction is made between primary infertility (has never given birth) and secondary infertility (cannot give birth following at least one live birth). l Childlessness: not having a living child. A woman may have given birth to at least one live child but all have died. In populations with high levels of child mortality, the difference between the prevalence of childlessness and primary infertility is not trivial. For instance, in 27 national Demographic and Health Surveys (DHS) in sub-Saharan Africa, the median -^ 18S
proportion of women 35-49 years who never had a live birth was 3.0 per cent, while 4.5 per cent had no living child. Demographers often use the term childlessness to refer to primary infertile women. Measuring the prevalence of infertility is difficult because it focuses on women who are still in their reproductive age span (women may still deliver a child before their menopause) and because it requires a delineation of a period of exposure to the risk of pregnancy. For clinicalepidemiological purposes the W H O Scientific Working Group on the Epidemiology of Infertility defined infertility as the inability of a woman, man or couple to have a conception after a period of two years of exposure without conception (WHO, 1975). Most clinicians, however, use a 12month period of unprotected intercourse (Rowe et al, 1993). A distinction between inability to conceive and inability to carry a pregnancy through to term and have a live child is also made. Most estimates of the prevalence of infertility rely on data collected in cross-sectional surveys. In such surveys birth histories are collected from female respondents aged 15-49 (only in a few cases from male respondents). Methods have been developed to estimate the prevalence of primary and secondary infertility from such incomplete birth histories, that is, from women who may still bear additional children (Larsen and Menken, 1989). The duration of the period of exposure to the risk of pregnancy since marriage or the last birth is set at five to seven years, depending on the measure being used. If no detailed birth history is available, the proportion of women with an open birth interval of five years or longer is often used as an indicator of secondary infertility (Larsen, 1996). Extrapolations from survey data need to take contraceptive use into account. While some women who use contraceptives are infertile, contraceptive users are, on the whole, more likely to be fertile than non-contracepting women. In any case, as contraceptive use increases it will become increasingly difficult to estimate infertility from survey data. In most sub-Saharan African countries, this problem is still not insurmountable, as shown in the analysis by Ulla Larsen and Hans Raggers in the chapter ‘Levels and trends in infertility in sub-Saharan Africa’. 184
All of these factors increase the difficulty of estimating the magnitude of the problem of infertility in sub-Saharan Africa. Using Larsen and Raggers’ estimates of primary infertility, we estimate that about three to four million women in sub-Saharan Africa are currently affected. As voluntary childlessness is rare in most of subSaharan Africa, it is likely that an equal number of women (and couples) consider this as a health and social problem. A larger number of women can be considered to have secondary infertility, probably more than 13 million, The number of women (and couples) who perceive this as a health and social problem is smaller than 13 million, because some of these women may have already achieved (all or part ofl their desired fertility. The data from infertility clinics show that about 40 per cent of the infertility cases are primary infertility and 60 per cent secondary infertility (Favot et al, 1997; Cates et al, 1985; Giwa-Osagie et al, 1984; Moutsinga, 1973). This would correspond with about five to six million women for whom the problem of not being able to bear another child is sufficiently serious to justify a visit to an infertility clinic. Based on these calculations, we estimate that eight to ten million women in sub-Saharan Africa are currently suffering from infertility. The definition of infertility has considerable impact on the estimate of the prevalence of infertility and thus on evaluations of the success rate of infertility treatment. Marchbanks et al (1989) analysed five different definitions of infertility in the USA. Three measures were based on a questionnaire and two on a life-event calendar (which includes pregnancy, births, sexual exposure, contraceptive use, etc). The prevalence of infertility was 12.5 per cent based on couples reporting no conception after two years of trying to conceive. When based on those who had consulted a physician (and no conception after two years of trying to conceive) it was 9.6 per cent, and when based on physician’s diagnosis (with no conception after two years of trying to conceive) prevalence was 6.1 per cent. Much higher levels of infertility were found using measures based on the life-event calendar (which is more comparable to demographic methods of estimation): 20.6 per cent if no conception occurred after 24 months of unprotected inter course and 32.6 per cent if no conception occurred after 12 months of unprotected intercourse. The
study also showed significant differences in subsequent conception rates, depending upon the definition used. The Marchbanks et al study suggests that belter measurfmenl of infertility may bc achieved by asking more direct questions about the couple’s desire to get pregnant. For instance. surveys might ask directly if a \voman is currently trying to have a child (or another child). In the World Fertilit) Survey (WFS) a question was asked to married womcn about their ability to have anothel child with their husband if they wanted one. not results were The considered a good indicator of actual inability to bear children (Vaessen, 1984). It is worthwhile adding a question to surveys about efforts to conceive, to obtain better estimates of infertility from such surveys. In Rakai, Uganda, results from this question appeared to be useful (Ron Gray, personal communication).
Who pays the price: women or men? Infertility may be due to the woman, the man or both. However, the indicator of infertility of the couple is the woman, whether infertility is the result of female or male factors. In sub-Saharan Africa male infertility is likely to be a significant factor, although data are limited, as discussed in the chapter by Philippe Mayaud, ‘Infertility in Africa: the role of reproductive tract infections’. Even so, anthropological and demographic studies indicate that the majority of infertility is likely to be associated with female I’actors. Women who do not bear children are often divorced and have multiple, life-time partners, and are (herefore apt to have sexual interc-ourse with fertile partners at some point in their lives. Three chapters discuss these issues: Marjolein Gijsels, Zaida Mgalla and Lilian Wambura, “No child to send”: context and consequences 01’ I’c:male infertility in North West Tanzania’; Zaida Mgalla and Ties Roerma, ‘The discourse of infer[ilit\ in ‘l’anc.ania’; and Ties Boerma and Mark
Urassa, ‘The association between female infertility, HIV and sexual behaviour in a rural area of Tanzania’. Anthropological studies also describe the coping mechanisms in place to circumvent male infertility without breaking up the marriage, by assuring that the woman becomes pregnant from another man without the knowledge of the husband. This is discussed in the same chapters as above by Gijsels et al and by Mgalla and Boerma, and also in the chapter by Denise Roth ‘Mchango, menses and the quality of eggs: women’s perceptions of risks to fertility in a rural Tanzanian community’. There is ample evidence in the papers about Tanzania that infertile women are paying a heavy price for not being able to fulfil the reproductive expectations of their husband, family, clan and community at large. For example, the anthropological study by Gijsels et al employs life histories to document the miserable treatment of ‘barren’ women in north-west Tanzania. This includes public derogation, beatings and divorce. The low social status of women with infertility is also illustrated by the group discussions with men and women in Tanzania by Mgalla and Boerma, the interviews with women in a rural community in western Tanzania by Roth, and the interviccvs with infertile women and men in the Gambia and Zimbabwe by Johanne Sundby and Ailccn Jacobus in the chapter ‘Health and tradi185
tional care in infertility: Gambia and Zimbabwe’.
experiences
from
the
Relationships with other elements of reproductive health Sexual behaviour
and marriage
Anthropological studies have described the changes in marriage and sexual behaviour among infertile couples and infertile men. A man or a woman may be more likely to have extramarital partners if no children are born. Studies in Sierra Leone (Harrell-Bond, 1975) and Uganda (Southwold, 1973) suggest that husbands of infertile wives often had extra-marital partners, although it is not immediately clear to what extent their sexual behaviour can be attributed to the infertility per se. As mentioned earlier, several authors in this book describe the secret arrangements made to assure a woman becomes pregnant in the event of suspected male infertility, and in most societies infertility is also an important reason for divorce (see also Nabaitu et al, 1994; Solivetti, 1994; Reyna, 19751, while in other societies men may add another wife to their infertile union (David and Voas, 1981; Pool, 1972). A few epidemiological and demographic studies lend further evidence to the anthropological studies. In population-based surveys infertility was associated with greater marital instability in Cameroon and Nigeria and with polygyny in Cameroon (Larsen, 1995). In rural Tanzania, infertile women also had more sexual partners and more marriages than fertile women, and HIV prevalence among infertile women was three times higher than among fertile women (see Boerma and Urassa in this book and also Favot et al, 1997). The association between HIV and infertility is largely due to the fertility-reducing effect of HIV, but may also partly be a consequence of behaviours associated with infertility. Primary infertility was very common in the 1950s and earlier. The chapter by Richard White, Basia Zaba, Ties Boerma and John Blacker, ‘Modelling the dramatic decline of primary infertility in sub-Saharan Africa’, shows that the high prevalence of primary infertility is likely to have been associated with a very early onset of sexual intercourse, often prior to menarche. An increase in age at first sex and sexual mixing patterns may have contributed to the pro186
nounced decline in primary infertility that can be observed from about the middle of the 20th century. The chapter by Ulla Larsen shows that in the heart of the infertility belt in the Central African Republic, primary and secondary infertility have also declined considerably, allhough levels are still considerably higher than in most other parts of Africa.
STD/HIV Reproductive tract infections, including STDs, are common in many parts of sub-Saharan Africa. Initially, ecological studies (e.g. Romaniuk, 1968, Arya et al, 1980) and later clinical research (Gates et al, 1985) demonstrated the prominent role of STDs in the aetiology of female infertility, which Mayaud’s chapter discusses. Both gonorrhoea and chlamydia infection may lead to pelvic inflammatory disease (PID), which may lead to scarring of the tubes of the female reproductive system and subsequent infertility. The review of data for the first half of the 20th century in the chapter by White et al shows that a high prevalence of STDs, notably gonorrhoea, is the most likely cause of the very high levels of primary infertility several decades ago. Microsimulations and evidence from in-depth studies suggests that the dramatic decline in primary infertility has largely been due to the introduction of antibiotics. Current efforts to improve STD case management practices in health facilities are likely to reduce the risk of infertility following an STD, among those who make use of health facilities, as Mayaud shows. A significant proportion of patients, however, do not make use of modern health facilities, but they do practice self-treatment, buy drugs in shops or pharmacies and use traditional healers (see the chapter by Roth). Among traditional healers, many may have specialised in STD care, as was found in rural Tanzania (see the chapter by Robert Pool and Ndatulu Robert Washija, ‘Traditional healers, STDs and infertility in north-west Tanzania’). The healers may also have some biomedical knowledge and appeared to be keen on better collaboration with the modern health sector.
Maternal
health
Secondary infertility is common according to the estimates in the chapter by Larsen and Raggers.
In part, this is due to increased biological infertility l’rom aging of the woman. The number of infertility is, however, \Lomen with secondary well in excess of what could be expected on the basis 01‘‘natural infertility’ levels observed in historical populations in Europe and the USA IBongaarts, 1982). The main culprit appears to be post-partum infections, and to a lesser extent post-abortal infections. Reproductive tract infections, mostly STDs, may easily lead to PID during the puerperal period, according to Mayaud, but there is a dearth of studies. Caesarean section may also lead to posl-partum infection and subsequent infertility, as is shown in a study by Xavier De Muylder, Pierre Buekcns and Bruno Dujardin and colleagues in the chapter ‘Caesarean section and infertility: a case-control study from Zimbabwe’.
Family planning From as early as the 1950s Anne Retel-Laurentin (1974) tried to draw attention to the link between the problem of infertility and the acceptability and success of family planning programmes. She argued that attention to the problem of infertility would enhance the acceptability of family planning programmes to African populations, especially those with high levels of infertility. At present, even with the success of family planning programmes, adolescent girls arc still concerned with infertility: the consequences of not being able to bear children are devastating. In interviews with women (chapter by Roth) and in focus group discussions in Tanzania, where use of modern contraceptives is still low, these concerns became very clear (chapter by Mgalla and Boerma).
Interventions According to Sundby and .Jacobus, infertile women report high levels of health services utilisation. For instance, women attending a hospital infertility clinic in Tanzania reported that they had visited on average 2.7 different kinds of modern health facilities and 5.9 traditional healers in association with their infertility (Favot et al, 1997). In a rural community in ‘fanxania, more than half of the traditional healers reported that they specialised in dealing with infertility problems (chapter by Pool and Washi,jal As Sundby and Jacobus report from --
their Zimbabwe and Gambia studies, women with infertility problems often present with several other complaints and leave without the health worker diagnosing the underlying cause for the visit. Repeated visits to modern and traditional health facilities represent a cost to women, couples or families as well as to the health system. Not infrequently, inappropriate interventions such as dilatation and curettage are performed. Addressing infertility should be part of reproductive health programmes. This comprises prevention of infertility through prevention of STDs and timely and adequate treatment of STDs. Treatment of infertility is feasible in some cases with limited resources, while health workers need to be better equipped in dealing with infertility, if only to avoid inappropriate interventions and to improve their counselling skills. At the societal level, there is a need to address the social dimension and enhance discussion about infertility as a reproductive health and social problem. In some settings the establishment of local organisations of women with infertility may help the women themselves, such as the ‘Kanyaleng’ in the Gambia (chapter by Sundby and Jacobus). Infertility is a substantial public health problem in sub-Saharan Africa, with an estimated 810 million women (i.e. couples) affected. The significant social stigma attached to infertility strongly affects the lives of both women and their partners. However, a great deal can be done. We can help to prevent reproductive tract infections, particularly STDs, by sexual health education and promotion of condoms. We can reduce the consequences and spread of such infections through accessible, timely and effective treatment. We can provide low-cost treatment for infertile women and couples, even though success rates may be low. Finally, we can mitigate the consequences of infertility for those who cannot be treated, by improving counselling and by addressing the issue of infertility in society at large. If we neglect female infertility, then we fail to address the full potential of reproductive health for women.
Note This text is excerpted firom the draA /ntroduction to this book, rrprinted with kind permission ofthe Royal Tropica/ institute KIT Press, 0 7999.
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