what percentage of infertility cases are due to a cause involving only the male partner?

• Loading metrics

Open Access

Peer-reviewed

Research Article

Understanding the Social Meaning of Infertility and Childbearing: A Qualitative Study of the Perception of Childbearing and Childlessness in Northern Ghana

• Philip Baba Adongo

Understanding the Social Pregnant of Infertility and Childbearing: A Qualitative Written report of the Perception of Childbearing and Childlessness in Northern Republic of ghana

• Philip Teg-Nefaah Tabong,
• Philip Baba Adongo

x

• Published: January xvi, 2013
• https://doi.org/10.1371/journal.pone.0054429

Abstract

Background

Infertility is a major medical condition that affects many married couples in sub-Saharan African and as such associated with several social meanings. This study therefore explored community'south perception of childbearing and childlessness in Northern Ghana using the Upper West Region every bit a case study.

Methods

The study was exploratory and qualitative using in-depth and key informant interviews and focus group discussions. Fifteen matrimony unions with infertility (childless), forty-five couples with children, and eight key informants were purposively sampled and interviewed using a semi-structured interview guides. 3 focus group discussions were also carried out, one for childless women, one for women with children and one with men with children. The information collected were transcribed, coded, arranged, and analyzed for categories and themes and finally triangulated.

Results

The study revealed that infertility was caused by both social and biological factors. Socially couples could become infertile through supernatural causes such as bewitchment, and disobediences of social norms. Ballgame, masturbation and employ of contraceptives were as well identified as causes of infertility. Nigh childless couples seek treatment from spiritualist, traditional healers and hospital. These sources of treatment are used simultaneously.

Conclusion

Childbearing is highly valued in the community and Childlessness is highly engendered, and stigmatised in this community with manifold social consequences. In such a community therefore, the concept of reproductive choice must comprehend policies that brand it possible for couples to aspire to accept the number of children they wish.

Citation: Tabong PT-N, Adongo PB (2013) Understanding the Social Significant of Infertility and Childbearing: A Qualitative Study of the Perception of Childbearing and Childlessness in Northern Ghana. PLoS Ane 8(1): e54429. https://doi.org/10.1371/journal.pone.0054429

Editor: Mark Wainberg, McGill University AIDS Centre, Canada

Received: September 14, 2012; Accustomed: December 11, 2012; Published: January 16, 2013

Copyright: © 2013 Tabong, Adongo. This is an open-admission article distributed nether the terms of the Artistic Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The authors accept no support or funding to study.

Competing interests: The authors have alleged that no competing interest exist.

Introduction

Infertility or childlessness is a global reproductive event for both sexes yet ofttimes neglected and not discussed in public. Information technology is mostly believed that more than than seventy million couples endure from infertility worldwide [1]. In Sub-Saharan Africa, the prevalence differs widely from ix% in the Gambia [2], 21.2% in northwestern Ethiopia [3], between 20 and 30% in Nigeria [4], [v] and 11.8% amongst women and fifteen.8% amongst men in Ghana [vi]. There are varying opinions on the definition of infertility. The lack of consensus on the prevalence of infertility is a upshot of differing definitions of infertility, the varying periods of fourth dimension over which it is studied, and a failure to differentiate analytically between voluntarily childless and involuntarily childless [7]. Even so, the Ghana Demographic Health Survey reports that voluntary childlessness is not common in Republic of ghana, and currently married women with no live births are probable to exist those in relationships with fertility problems [eight]. Infertility has been divers as failure to conceive afterwards one year of regular unprotected sexual intercourse in the absence of known reproductive pathology [ix]. However, epidemiological studies take revealed that in a normal population of heterosexually agile women who are non using birth command methods, 25% will become pregnant in the first calendar month, 63% within half dozen months, and 80% within one year. By the end of a second year, 85% to 90% volition have conceived [ten]. Considering some couples, who are non infertile, may not be able to excogitate within the outset yr of unprotected sex, the Globe Health System therefore recommends the epidemiological definition of infertility, which is the inability to excogitate inside 2 years of exposure to pregnancy [9]. Infertility may be primary or secondary. Main infertility refers to infertility of women who have never conceived and secondary infertility refers to infertility of women who has conceived at least once earlier. The use of the ability of the female person to conceive as a measure to differentiate between master and secondary infertility is nonetheless problematic as it places couple infertility on the doorsteps of the female partners.

In the African culture, the true meaning of wedlock is just fulfilled if the couple conceives and bears children [11]. Africans consider their child to be a source of ability and pride, and children human action as insurance for their parents in one-time age. The almost of import aspect of bearing children is an assurance of family continuity. Anthropological and sociological studies conduct testimony to the considerable suffering associated with involuntary childlessness due to negative psychosocial consequences such as marital instability, corruption and stigmatization [11], [12]. A study among women seeking infertility handling in Southern Republic of ghana revealed that infertile women used their internal coping strategies by keeping their fertility problem to themselves as a result of the stigma associated with it whilst others coped by cartoon on their Christian religion [13].

There are varying findings on the contribution of the various sexes to couple infertility. An increasing body of social science and biomedical bear witness suggests that about 40–50% of infertility is owing to issues suffered by men. The underlying cause of infertility may be a male gene (40%), a female factor (40%) or a combination (xx%) of problems [14]. Some other written report states that about 50% of infertility is due to the female, 20–26% to the male and 26–thirty% is unexplained (couple cistron infertility was not reviewed), simply these findings are all from non-African populations [six]. Studies take revealed that the most common crusade of male person infertility is due to a problem in the sperm production process in the testes. Well-nigh 2 thirds of infertile men have sperm production problems. Low numbers of sperm are fabricated and/or the sperm that are made do non work properly [xv]. A number of factors can disrupt the production of sperm including undescended testis, infections such equally mumps, oestrus, sperm antibodies, torsion, varicocele, drugs or radiation damage. Blockages (obstructions) in the tubes leading sperm away from the testes to the penis can cause a complete lack of sperm in the ejaculated semen. This accordingly is the 2nd most common cause of male infertility and affects nigh three in every xx infertile men, including men with the common problem of having an earlier vasectomy [fifteen]. In some men, sperm antibodies can develop which can lessen sperm movement and block egg binding during fertilisation. About ane in every sixteen infertile men has sperm antibodies [sixteen] and this may crusade male person infertility.

In women, poor quality eggs may cause infertility, a blocked fallopian tube could forestall the egg and sperm from uniting, or the woman may not ovulate regularly – a problem that is sometimes results in irregular menstrual cycle [17]. There is a well-established link between a woman's historic period and infertility. Women over age 35 years have an estimated 50 percent chance of becoming pregnant naturally [16]. As women age, their fertility is afflicted by the quantity and quality of their eggs. In reality, the number of eggs bachelor in the ovary gradually declines. Every bit menopause approaches, an increasing number of cycles are not ovulatory, and therefore unable to event in formulation [17]. Moreover, an older woman's eggs are nigh susceptible to chromosomal changes that may produce abnormal embryos [18]. A study in Bawku in Northern Ghana identified tubal damage, male factor, anovulation, uterine factors and unexplained every bit the five chief causes of infertility. This study too states that almost 20% of infertility in Bawku in Northern Ghana was due to male factors [19].

In spite of these statistics, women all the same endure the worst of the blame for infertility problems. Leading male person Obstetricians and Gynaecologists are frequently quick to attribute couple infertility to female factors and can therefore exist blamed for the belief that is widely held [20]. Infertility is socially constructed in many cultures that is, men and women are meant to become parents and that women are especially socialized to become mothers [21]. Infertility is a problem both medically and socially in Ghana. Medically considering there are reports of high prevalence of infertility amidst couples with inaccessible fertility services. Infertility is as well a trouble socially because we live in a social club where womanhood and manhood are generally tied to maternity and fatherhood respectively. Despite these issues of infertility, not much has been done to understand customs's perception of infertility and childbearing in Republic of ghana. It is in the light of this that this written report examines community perception and understanding of childbearing and childlessness in Northern Ghana.

Materials and Methods

Ethics Statement

Upstanding approval for the report was received from the Ghana Health Service Ethics Commission. During the approving process for the study, the committee was explicit about the need to maintain confidentiality and anonymity whilst emphasising on the need to obtain verbal or written consents. In line with the approved procedure of obtaining consent for the study, exact or written consent were obtained from participants. Verbal consent was obtained from participants who had difficulty reading the consent class and those who opted to give verbal consent. To those who gave exact consent, the researchers read and translated the consent grade into the preferred language of the participant. They were further made to recommend a neutral member of the household to act as independent witness in the consent process. A comprehend canvas containing the demographic information except the names and locations that were coded and kept separately was used to document those who gave exact consent. This process for obtaining verbal consent was approved past the Ethics Committee of the Republic of ghana Health Service. To ensure confidentiality of participants that gave written consents, codes were used on the grade instead of their names. The specific locations of the participants were likewise non reported as this could lead to easy identification of the infertile couples that took office in the study. In improver, just codes were written on interview transcripts.

Written report Area

The Upper Due west Region is the smallest Region in Ghana with a population of 702,110 with 989 settlements. The region covers a total land area of xviii,476 km², with a population density of 32 persons per square kilometre [22]. The region is divided into xi authoritative districts and the people speak three master local languages namely: Wali, Dagaare or Sisali. The people of Upper West Region do patrilineal mode of inheritance and is a typical patriarchal society with male dominance in controlling. Polygamy is a common practice both by members of the Islamic community and those who profess African Traditional Religion. In all, at that place are 60-five sub-districts, five district hospitals located in four districts, a regional hospital in the regional capital. The region has a fertility rate that is the average number of children per couple of five, which is above the national average of four [22].

Data Drove

In-depth interviews (IDI), Focus Grouping Discussions (FGD) and Primal Informant Interviews (KII) were the main data collection methods used in the written report. Four (4) trained information collectors (Research Assistants) were used in the report. These research administration were put in groups of two, a male person and a female. Male interviewers were assigned for male respondents and female interviewers were assigned for female respondents with children. Feminist theorists argue that the positionality of the researcher: gender, form, and race bear upon all aspects of the research process, from the framing of the inquiry question to the belittling approach equally one'south own social location influences the full calibration of research choices [23]. In-depth interviews are social interactions [24] and hence race, class, and gender inequalities are inherent in these interactions and tin can therefore touch the results. Hence, interviewer/interviewee homogeneity was adopted to overcome this claiming of the effects of differences in gender between the interviewer and interviewee. Concerning couples with infertility (childless), the primary researcher who supervised the data collection carried out the interviews for both partners. This was washed because it was anticipated that some respondents might break down emotionally in an attempt to narrate unpleasant past experiences. The principal researcher'southward background in nursing and psychology therefore put him in a improve position to offer counseling for those who pause down in the course of the interviews. Interviews were either conducted in English or local linguistic communication depending on the language the respondent was comfortable with and the duration of the interviews was between 30–45 minutes.

The interviews were tape-recorded with the permission of the participants as well as note taking. In polygamous family, the male's partner and the private wives were interviewed starting from the most senior of the wives in line with community's norms. Younger wives in some instances were interviewed outset upon the request of the most senior wife in consultation with the husband. The same codes were written on the male and female interview guides and each recording was started by first mentioning the code on the interview guide to ensure data collected could be analysed as belonging to a couple for comparing to be made. The codes also differentiated betwixt the male person and female person partners that constituted a couple.

Field notes were written immediately later on each interview. The field notes covered the initial reactions to the interview, including the kickoff analytical reflections from the interview content, and whatever useful observations that would not be captured past digital recording. This covered the demeanor of the respondents, his or her body linguistic communication and mood, and any informal conversation that took place before or later on the interview.

Option of Study Participants

An informal discussion with the customs members and Community Health Volunteers (CHVs) was initially used to identify couples without children. After interviewing such couples, snowball techniques were then used to identify other couples with infertility in that customs. The study considered a married spousal relationship every bit a unit of measurement of analysis irrespective of the number of partners involved. Hence, 15 (xv) units of childless marriages were interviewed. Even so, three of the childless male person partners in the study were married to two wives. This therefore increased the number of childless individuals in the study to 30-iii (33) comprising of xv (fifteen) childless males and eighteen (18) childless females. The age for the males' partners ranged between 35–63 years as against a female age range of 28–52 years. The couples were married for between three–25 years and included couples with both primary and secondary infertility.

Couples with children were likewise purposely selected and interviewed. The couples were recruited from both urban and rural settlements where childless couples lived. In all, forty-five (45) married unions were recruited and interviewed within the neighbourhood (households) where couples without children lived. All the same, four of the males were married to two wives whilst one was married to three wives increasing the number of women with children interviewed to fifty-i (51) with ninety-six (96) participants with children. The daily analysis of the transcripts made the research saturated with Forty-5 married unions. Collecting enough information to the point of saturation adds to the credibility, dependability of the study and transferability of the study results to other studies on infertility and childbearing.

Focus Grouping Discussion

3 Focus Grouping Discussions (FGDs) were organized. I FGD for women without children as their male person counterpart refused to accept part in FGD. Their refusal to take part in the FGD was considering infertility was perceived to be the inability of women to acquit children and therefore non suitable for males to discuss. The researchers organized ii (2) FGDs for community members selected from where infertile couples were resident, one for males and one for females to elicit normative ideas on childbearing and childlessness in the communities. The discussants drawn from the communities were all married adults with children. The FGDs lasted for between lx–90 minutes and were conducted in the evenings as participants preferred to do that after the day's work. All Focus Group Discussions were conducted in Dagaare (local dialect) however; participants who wished to contribute in English at any indicate in the discussions were allowed to do that. Such contributions were translated immediately to Dagaare for participants who did not empathise English. This was done to ensure that such contributions conformed to the normal do in the community. All participants were allowed to give their view on any subject field raised earlier progressing to some other theme.

Key Informant Interviews (KII)

Eight (viii) Key Informants Interviews (KIIs) were conducted. 2 Gynaecologists who take care of infertile couples were interviewed equally Primal Informants. An Islamic scholar was too interviewed to provide expert view on infertility and childbearing in the Islamic Customs. A female Christian leader was likewise interviewed every bit she provided back up for infertile females. Two traditional medical practitioners who besides provided care for infertile couples were further interviewed. A director of the National Health Insurance Scheme and a managing director with Private Insurance Company were equally interviewed as Key Informants to provide data on the infertility related insurance policies in Ghana.

Data Analysis

The taped interviews were transcribed verbatim and the resulting texts analysed by using thematic analysis. An attempt was first made to extract wide themes from the transcripts and so progressed to identifying coded themes. In establishing themes, considerations were given to statements of meaning that were present in most of the relevant data. In an attempt to ensure, the credibility of the findings independent coders were used to verify or corroborate the themes extracted from the data. This allowed the researchers to progressively focus the interviews and observations, and to determine how to test the emerging conclusions. Individual and comparative assay of the response of couples was carried out. The transcripts were entered into QSR Nvivo 8© for assay. We developed a codebook based on the major themes of the written report. The major themes were transformed in tree nodes and complimentary nodes. The authors based on the codebook adult and verified independently coded texts from the transcriptions. The emerging themes and sub-themes were identified and written out in the results. Quotes from respondents were used to support the emerging patterns of concepts from the information.

Results

Reasons for Preference for Children

The acme of reasons for preference for children was to maintain the family lineage and inheritances. Children are often given the family name of the male parent as the communities practise patrilineal style of inheritance and they are supposed to marry in future and proper noun their children after the family unit name. This co-ordinate to respondents was washed to ensure the perpetual existence of the family unit lineage. Examples were given of great families whose lineage had wiped out because they were unable to give birth to more children and majority gave birth to female children who got married and named their children after their husbands. Life without children was perceived not to be worth living as at that place will exist nobody to inherit the properties of the deceased and not all efforts past such individuals are ever appreciated in the community.

"Children are supposed to maintain lineage and inherit your property…nosotros are suffering on earth because of our children" – (A 66-year onetime man with children in FGD).

A 2d reason for procreation was for assist at dwelling and in the farm. The number of children most especially male children is an indication of the worth of the couple equally it implies more easily in the farm. More easily in the farm ways more than revenue for the family as extra farm produce could be sold to generate income for the family unit. This further means more savings and security for time to come. This practice has become necessary specially equally discussants stated, the intermission in the extended family organization and increasing nucleation of families has made the quest for own children very significant as they provide security in old age.

"I use to plow just 5 acres of land but with my 5 children, I am now able to plow over xv acres improving on the family income"- (A 56-year old man in IDI).

The third reason for procreation, which was stated emphatically by the respondents, was to obey Gods words as the Bible and Koran enjoin Christians and Moslems to multiply and make full the earth. Respondents especially believed that failure to afford children was confronting the holy books (Bible and Koran) and such a family will never receive the blessings of God.

"The bible says in genesis that we should multiply and fill up the earth to ensure the continuous beingness of the earth"- (A 36-year sometime human being in FGD).

Children are also source of joy, companionship and respect for customs members. Children console their parents and are a symbol of achievement for couples. At old age, grandchildren human action every bit companions for grandparents and this was believed to brand them happy and prolong their life.

"Children make you happy, it is the greatest achievement on earth…nosotros respect people with children in this community specially male children"- (A FGD female participant).

Clearly from the respondents, one of the reasons for procreation is to take a befitting funeral, every bit there are significant deviation in the performance of funeral rituals for people with children and those without children. Adult without children are more likely to be interred earlier in traditional communities and their funeral not attracting the needed attending it deserves equally compared to adults with children. This is even more distinct for females than males without children. This is considering of women traditional role to afford children to the family of the in-law. This reproductive role becomes the exclusive right of the husband following the credence of the bride wealth and not having biological children implies that the woman has failed in a fundamental manner resulting in a loss to the family of the hubby. In addition, childbirth is the culmination of a woman's rites of passage to adult womanhood. Without a alive nascency, she remains in an infinitesimal state where she is neither a man nor fully a woman. The rituals performed for a deceased adult without children were comparable to that of a child.

"Adults without children do not take funerals in this customs every bit they are treated the same mode equally the death of a child"- (An FGD male participant).

Noesis on Causes of Infertility

Co-ordinate to respondents, infertility was caused by both biological and social factors. The biological causes were more pronounced amidst the urban and educated residents whilst the rural communities attributed infertility principally to social factors. The highest biological factor that has been blamed for infertility among females was previous utilize of contraceptives. This was also straight attributed to past promiscuous lifestyle of the woman equally the contraceptive were used to prevent unwanted pregnancies.

"Women who were prostitutes during their youthful ages, used contraceptives to prevent pregnancy…they are the people who by all ways get infertile in future and worry their partners. I know of a friend who used those family planning methods when we were growing up and is now hopping from hospital to hospital looking for a child"- (A 45-yr woman in FGD).

The believe in contraceptives every bit a cause of infertility was unanimous for both male and female participants and couples strongly believed the apply of contraceptive could issue in them becoming infertile. Some infertile women even attributed and strongly believed that they were currently having difficulty in condign pregnant considering they had used contraceptives in the past to preclude unwanted pregnancies since abortion was illegal in the land. Males in FGD alluded to this belief and indicated that contraceptives were a major enemy in the community because it (contraceptives) use encourages promiscuous lifestyles for the youth and give trouble to their male partners in future.

"My married woman made a mistake and took those drugs (contraceptive), and information technology took her several years to get significant over again. This almost resulted in a divorce but I accept since warned her never to take those drugs again"- (A 45-year former man in FGD).

Sexually transmitted infections (STIs), blocked fallopian tubes and uterine fibroid were as well mentioned as female person factors that can crusade infertility. Knowledge on the relationship between STIs and blocked tubes was high every bit it was unanimously agreed in FGD and cited in in-depth interviews. Participant mentioned gonorrhoea, syphilis and Chlamydia infections as common causes of infertility in the community.

"My wife was told that her tubes were blocked and that was why we could not get a child, when I heard this I immediately suspected she has had gonorrhoea before"- (A 42-year old infertile man in IDI).

Abortions in all forms (safe and unsafe) are too believed to cause infertility simply most especially those conducted by unqualified individuals. To customs members, all women are born with a fixed number of children to conceive and when these children are aborted, and then the consequential effect is infertility. However, males are believed not have such fixed number of children and are therefore capable of producing uncountable number of children. Safe abortion in this context refers to an abortion that has been carried out by a qualified person using appropriate equipment and in a place designed for such procedures. Unsafe abortion, which they believe, is what is performed past quacks in the community and the use of herbs.

"Some women throw all the children they were supposed to give birth into the gutters through abortions"- (An FGD female participant).

There was a paradox concerning Female person Genital Mutilation (FGM) and infertility. As FGM was mentioned as capable of causing female infertility, an "extra-germination" of the clitoris was also believed to crusade infertility. Equally to which size of the clitoris was considered normal, at that place was no consensus but it was generally believed that the gods give direction when consulted by the healers. Therefore, the gods volition often determine the "actress-formation" in which case it has to be excised by the traditional healer after which herbs are applied.

"Extra-formation of the clitoris can cause infertility and in such a case yous cutting off that actress germination"- (An FGD male participant).

"….My married woman bled highly when a part of her clitoris was excised by a traditional medical practitioner every bit treatment for infertility"- (A 46-year childless man in IDI).

Contrary to the female factors that were spontaneously mentioned in IDIs and FGDs, male factors were not mentioned until when prompted by the researcher. Males especially attributed infertility to lifestyles such as intake of excessive alcohol and smoking, though taking of booze was perceived to be socially acceptable, smoking was more often than not believed to exist alien to the culture and described as Western culture.

"Too much intake of alcohol and smoking can crusade infertility….It leads to weak penis and impotence"- (An FGD male participant).

In that location were varying views on which alcoholic beverages and what amounts could exist described every bit too much. As some participants stated that all alcoholic beverages could cause infertility when non taken in moderation, other believed that bottled drinks were more accountable whilst the local alcoholic beverage pito was even considered to increase both sperm production and authority and could be used to treat infertility.

"Pito can increment sperm product and that is why information technology is sometimes required that you add pito to the herbs in the management of infertility"-(A traditional medical practitioner in FGD).

Another school of thought was that bottled alcoholic beverages that are believed to enhance sex activity and increment appetite could cause infertility. Calls were even made to ban the production and advertizement of all such alcoholic beverages as they take go and so mutual and hands accessible even past minors, participant emphasised.

"This bottled drinks that can increase erection can cause low sperm product and cause infertility. Whatsoever human who relies on drinks to perform will not exist able to impregnate his wife or give birth to weak children"- (A 56-year old human being in FGD).

"You lot see, our ancestors did not have a trouble with childbearing, because they took things that were ethnic, merely what practice we run across today, different varieties of foreign foods in our markets that we are blindly eating….These are responsible for some of the funny weather condition we are seeing today"- (A 48-year man in FGD).

Female participants withal mentioned watery sperm and inability of a male to sustain an erection every bit common causes of male person infertility. References were likewise made to the employ of aphrodisiac preparations as they tin render a man impotent.

"Some males produce watery sperms and their penis is usually not potent enough during sexual practice to impregnate a woman that is why we describe such people as having a dead penis"- (Female infertile FGD participant).

The belief in supernatural (social) causes of infertility was widespread and consequent. The conventionalities that some women are witches, and that either curses can exist placed on them or their associates was consistent. Such women are believed to live for longer years because they are capable of exchanging their expiry with the expiry of children in the community. Such former women are abandoned by their relatives and hooted at when seen in public and are not allowed to come shut to children, as they are believed to be capable of bewitching them. Children are specially socialised to run away upon seeing such quondam women in the communities and some of them are beaten mercilessly sometimes when seen in public gatherings.

"A childless adult female later on killing all the children in her womb recently took the head of a child in my community and was beaten until she returned the head. She has later on been banished from the community"- (An FGD female participant).

Though participants also agreed that some men could be wizards and curses invoked on them, the penalties for such infractions with the gods appear non to include infertility for men. All the same, there was consensus on wizards also bewitching children but it was a common phenomenon with females.

"Men who are wizards at old age use their witchcraft to protect their family"-(An FGD female participant).

Ane of the main and common social causes was described as a pledge made to the gods by people to cede their manhood or womanhood for wealth referred to equally plumma or donpuli. This pledge can only be reversed by undergoing some rituals, which is often prescribed by the soothsayers or traditional medical practitioners. Still, the fear of losing one's properties and becoming impoverish discourages people from reversing such a pledge. To exist able to maintain the wealth and acquit children, the individual has to perform several rituals which are always very expensive and not within the ability of infertile couples. Such people are reported to exist exploited past healers.

"Some people commutation their children with wealth but afterward coming to world to meet people having children, they become interested in children"- (A 56-year former traditional medical practitioner in FGD).

"I accept sacrificed several animals in an attempt to reverse a pledge I was told I made to the gods to exist rich yet the traditional healer is yet demanding more because he has seen that am desperate to have a child"-(A 38-year quondam childless human in IDI).

Breaking the codes of marriage was also widely held belief every bit a cause of infertility. The gods and ancestors were believed to be "supernatural policemen" who are capable of rewarding couples with children and punishing those who pause the codes of spousal relationship or visiting them with infertility.

"The gods and ancestors who are the custodians of this land tin can show their disapproval of the conduct of the union couple past making them infertile"- (An FGD male person participant).

Male couples who are currently non seeking biomedical management tended to attribute their infertility to female person factors whilst their females' counterparts also blamed the males for their inability to make them pregnant. This was a basis for 1 to testify his or her fertility by engaging in multiple sex activity with other partners with the promise of either becoming pregnant or making another woman pregnant. In a response to a question on why information technology was hard for them (couple to have children). The female respondent in an individual interview stated:

"My husband is unable to brand me pregnant, for me am fertile; my mother gave nascence to eight of us and so how tin can I be infertile"- (A 36-year old childless woman in IDI).

The male partner of this childless female also stated in an IDI, "I think my wife is barren considering I have fabricated a girl pregnant before when we were growing upward".

Another supernatural crusade of infertility, which was widely reported and justified by Christians was masturbation, which was described as "male person abortion". Masturbation was perceived to be sexual immorality and a sin. Respondents generally believed that masturbation could attract a penalty of infertility as information technology is deemed an immoral act. Participants believed that masturbation was a form of ballgame (male abortion) equally sperms were believed to be pre-formed babies that are put in woman's womb to incubate until the woman brings it out during delivery. There was therefore no distinction betwixt a woman aborting a fertilized ovum and a man masturbating and discharging spermatozoa.

"Sperm are man beings and should not exist masturbated and discarded…in fact information technology is male abortion and God is against ballgame"- (A 45-year old Christian participant in FGD).

Infertility and Sexual activity Preference

Apropos the definition of infertility, iii main themes emerged in interviews and FGDs each without time limit. One related to the medical definition and the others related to the desire to have many children and sex preferences. To the participants, infertility is not only defined equally the inability of a couple to beget children. It also includes disability to beget male person children or inability to comply with social club's norm of having many children. The ideal numbers being a function of the want of the couples but in many cases about five is preferred.

"Infertility is the inability to give nascency to the number of children that you prefer and most especially male person children"- (A 56-year sometime FGD participant).

By and large, it is believed that it is the responsibility of the male person to maintain the lineage of the family. Hence, male person partners volition become to all extent to accept male children including marrying multiple wives or go along to give birth until such a time that a boy is built-in. The significance of male children is so intense that couples without male children are treated in the same way every bit those who do have children at all.

"I am married to three wives considering I thought my first two wives were unable to give me male person children. When my third married woman gave nascence recently, a friend came to congratulate me, after which he asked whether this time my wife had given birth to a human beingness. With my and then many female children, I will exist treated like someone who has not given birth at all when I dice"- (A 63-year-old man in IDI).

However, the three wives of the man believed that they were only incubators and therefore simply brought out what the man has put in in that location during delivery and could not be blamed for their inability to give nascency to male children.

"I told my husband that he cannot requite birth to male person children only he refused and went in for a second and 3rd wife, but see we are all giving birth to females" -(First wife of a man who is married to multiple wives in IDI).

This is because it is the responsibility of deceased's male kid to go to the bush to harvest a special stick known equally Kpiendaa, which is to be kept in a special room reserved for ancestor to symbolize the deceased acceptance in the ancestral globe.

Help-Seeking Behaviour of Infertile Couples

A consensus reached by the private interviews and focus grouping participants was that the treatment of infertility in the community is commonly directed specifically at women and that virtually people employ 3 handling outlets: churches (spiritualists), traditional healers and hospitals (biomedical). Withal, there was no agreement betwixt and within the groups on which of the three methods that people prefer well-nigh. Nonetheless, at that place was a strong sense that people often use the three treatment methods in combination and in sequence. The first method chosen is frequently determined by the perception of the couple regarding the causes of the infertility. As most people are deeply convinced of the supernatural causes of infertility, information technology is not surprising that infertile people often patronize traditional healers and religious leaders very early. Orthodox medical practitioners are ofttimes consulted later when religious and traditional methods take failed to provide a solution to the infertility.

"I am using both traditional and orthodox medicine, only I first went to the herbalist"- (A 38-yr old infertile woman in IDI).

The traditional remedies ranges from making sacrifices of animals to pacify the gods or ancestors for wrongdoing to taking of local concoctions prepared from herbs. They may also be requested to perform some rituals at a place where two, 3 or iv roads cross or at where ants alive and this was the pronounced ritual. Another ritual that is ofttimes practiced is the wearing of prescribed costume mostly by the female partner, which is removed at the entrance to their residents. Another treatment, which was mentioned both in private interviews and in focus grouping discussions was the excision of some part of the clitoris, which is believed to crusade infertility in women. It is belief that an 'actress-germination' of the clitoris was capable of causing infertility in women. The gods are believed to give direction when consulted by the healers.

"….My wife bled highly when a portion of her clitoris was excised by a traditional medical practitioner as treatment for infertility"- (A 46-year childless man in IDI).

Churches also prescribed number of days of fasting and prayers and making of some special offerings to the church building. References were too made of washing of women genitalia with holy h2o and anointing oil prepared and blessed by the religion healers.

"I was given some anointing oil to smear on my private part before having sex with my husband"- (A 36-year old infertile woman in IDI).

Another important consideration in the pick of a practitioner is the issue of privacy. As infertility is considered a very sensitive issue in the community, people oft seek out practitioners who will be able to keep their infertile status a hush-hush. Both individual interviews and Focus-grouping participants had different views almost which practitioners; orthodox, traditional or spiritual, would maintain the nearly confidentiality. Although it was generally agreed that traditional healers are capable of assuring the about confidentiality, nevertheless, the view was expressed that traditional practitioners ofttimes exploit women consequently, either financially or sexually. This did not yet reduce the ability of the treatment provided by the traditional healers, but was considered "a good price to pay" to get a child to brand you happy and save you from ridicule and your union. In general, the modus operandi of traditional medical practitioners was believed to maintain meliorate privacy than that of biomedical practitioners. Their facilities are ofttimes situated at the outskirt of the community where customs members hardly become except for those with issues who have gone to consult.

"Traditional medical practitioners get their powers from divine sources and are therefore compelled to maintain their practice in secret otherwise they loss the powers and this is unlike from the infirmary where nobody cares about privacy"- (An FGD female person participant).

Many participants also recognized the importance of going to the hospital for tests and firmly believed that the doctors tin often determine the exact cause of the infertility, and prescribe drugs to care for information technology. Withal, the medical approach is often not used immediately since biological factors are non acknowledged equally prominent causes of infertility in the community. Many people believe that Western medical treatment tin only help if in that location is a biological cause of infertility. If people believe that the infertility was caused by a curse or spell, or by gods and ancestors, they will seek an appropriate solution, which may not include the biomedical practitioners. They may seek help from traditional doctors or spiritualists commencement, and come to the medical doctor after. This will be done for additional aid or to treat a problem acquired by the herbal treatments. The social stigma fastened to infertility bug means that people are cautious of revealing their problems, and the hospital surroundings may be too open up to accommodate such secrecy, participant's claim. Participants also described assigning special days and clinics for infertility in hospitals as dissemination to the whole world about the infertility status of the clients and therefore not confidential plenty.

"You go to hospital, and they will announce that those with infertility should go this consulting room telling everybody of your problem. The side by side thing you see is that people are pointing fingers at you lot in boondocks"- (A female infertile woman in FGD).

Interestingly, either couples with infertility sought remedies individually or the women were the only people who reported to exist seeking handling especially in biomedical facilities. Males as well tended to seek for treatment alone at the traditional medical practitioners and only invited their wives when both are to perform some rituals. It was likewise very interesting to annotation that when it is even established that the aetiological factors had to do with male factors, traditional medical practitioners still focused on women and they are still compelled to atomic number 82 the rituals.

"It is nosotros, the female who are e'er concerned about childlessness, because of the pressures we become from our in-laws, so nosotros are the ones who look for treatment. Your hubby may even turn down when invited by the medical practitioners, even when the cause is from your husband y'all are withal supposed to practise something as a ritual"- (An infertile woman in FGD).

Prevention of Infertility

The prevention of infertility was also unanimous and pedagogy was seen as the core preventive strategy especially for the younger generation as many of the perceived causes are consequences of behaviours during youth. People commonly suggested that drugs used for abortion should be banned fifty-fifty though in that location were other herbs that were believed to be capable of inducing abortion, which are believed to be relatively safer than medical abortificients.

The drugs used to cause ballgame are sold around by individual in the customs only not in the drug stores- (An FGD female participant).

In several cases, the participants suggested that the use of unsafe drugs should exist stopped. It was suggested in some cases that the "doctors" themselves were selling these drugs. When prompted on the people described equally "doctors" it was discovered that the term was used to refer to people that sell drugs in the customs and diverse workers in biomedical health facilities. Many of the participants expressed the wish that all abortions should be eliminated. When the effect of prevention turned to the use of contraceptives, respondents were split on the value of contraceptives: while often, people believed that contraceptives could forbid pregnancy, and thus prevent illegal abortion and the infertility that might follow; others felt that contraceptives themselves caused infertility, and that their use should be stopped. Some of these aforementioned people felt that women should be encouraged to bear the children if they became pregnant because of the fixed number of children every woman is destined to conceive and give nativity.

"Those drugs that prevent pregnancy should exist stopped, they besides crusade infertility and in this customs, many women accept complained that they are unable to conceive over again later on using those drugs"-(An FGD female participant).

Another preventive strategy of hereafter childlessness was education of the youth to desist from unhealthy lifestyles similar excessive alcohol intake, utilize of sexual practice enhancing drugs and smoking. A telephone call was made on government to place a ban on the importation of such products.

Supernatural causes are regarded as not within the command of the individuals hence hard to forbid. All the same, respecting the norms of lodge and adhering to codes of deport for wedlock couples were primal in preventing the social causes of infertility.

"Respect for societal norms will forestall infraction with the gods and ancestors who are capable of visiting infertility on couples"- (A male person FGD participant).

Discussion

There was trivial variety in the participants' definition of infertility. Many defined it simply as a woman's inability to deport children or disability of couples to take children. Focus-group participants generally recognized the concepts of chief and secondary infertility in addition to another grade of infertility, which will be described as "third infertility". The surname is very important in the civilization of the people of Northern Ghana and since women who get married are, supposed to name their children after their husband, or utilise the husband's surname, male children symbolize the worth of the human [25], [26]. Couples without male person children can therefore exist described as suffering from "3rd infertility" as they are treated the same way as those without children. Primary infertility has been described every bit the inability of couples to excogitate after two years of unprotected regular sexual activity and secondary infertility equally the inability of couples who have conceived earlier to beget children [nine]. The desire to have male children poses a threat to family unit planning services too equally STI control programmes equally males generally experiment with other women in an attempt to have male children [25]. The use of children as farm helps likewise deny children of formal education and a challenge to achieving universal primary education to accomplish Millennium Development Goal 2.

Cognition on the biological causes of infertility was generally loftier and unanimous. The function of STI every bit a common cause of infertility for both males and females was undisputed. Nevertheless, couple infertility was more attributed to female factors. Previous use of contraceptive was the mostly mentioned biological causes of infertility for females. Northern Ghana is a poverty owned region in the state and therefore efforts are tailored towards reducing the fertility rate of couples. The perception that the use of contraceptives tin can cause infertility in females therefore poses a challenge to approach adopted by the Ghana Health Service in her reproductive wellness policy to prevent unwanted pregnancies and ensure proficient child and maternal health aimed at accelerating progress towards achieving the Millennium Development Goals, 4 and v respectively. Family planning providers must besides be concerned most sexually transmitted diseases, induced ballgame and infertility and they should be able to observe ways to incorporate such concerns into their programs. An integrated reproductive wellness policy that encompasses family planning, prevention of STIs and infertility will give a holistic approach to problem solving in Ghana. Vertical and disease specific approach may undermine and fail some as pregnant social problems in community context.

The conventionalities that Female Genital Mutilation (FGM) can cause infertility in females is of medical importance. FGM is a negative cultural practice that is commonly practiced among people from the northern part of Republic of ghana [25], [27]. The perception that FGM can crusade infertility therefore implies that parents will resist the excision of the clitoris of their female person children making the cultural practices outdated. At the opposite side of this is the belief that an extra-formation of the clitoris could cause infertility. Female genital mutilation may therefore be embedded in this belief and therefore a major challenge to the prevention of this unhealthy traditional practice. The worldview that violating of marriage code of conduct could result in infertility had some positive effects on marriage unions. Because of the supernatural supervision of wedlock by ancestors and sanctioning of couples who violate the codes, married couples alive within the societal prescription of the behave of union couples. This creates harmony and prevents extramarital activities especially for female person. This may therefore reduce incidence of STIs amid couples.

Cigarettes incorporate nicotine, which has received much attention for its interference with normal endocrine part, it has been shown to cause testicular atrophy, gonadal dysfunction, and male gene infertility past triggering testicular cytotoxicity [28] and this was cited as one of the causes of infertility in males. However, of medical interest is the role that masturbation places in infertility. Though information technology is unclear how masturbation tin can cause infertility, the community believed that masturbation was a form of abortion. The concept of male person ballgame (masturbation) to the best of the cognition of the authors has never been reported previously, and this serves as a social cistron that plays a very important role amongst communities in Northern Ghana.

The written report revealed that couples used three principal medical outlets: spiritual, traditional medical practitioners and biomedical. Couples used these facilities concurrently or in sequence. This finding agrees with similar studies in Nigeria and South Africa. Several women with infertility consulted herbalist, autonomously from a witch doctor. Others visit churches for handling because they perceive infertility as a misfortune, which God can redress [29]. Traditional health care was likewise identified every bit an important alternative source of understanding, coping and medication for health problems, including infertility in the The gambia [xxx]. The traditional medical practitioners were the most utilized outlet of care as infertility was given a more spiritual cause than medical and they were deemed to provide better privacy than biomedical facilities. Contrary to this finding, medical handling was the preferred choice for many couples in an earlier study [31]. Confidentiality and power to keep infertile status of couples as a secret adamant the help seeking behaviour. Since many respondents believed that the environment and way of operation of the biomedical health facilities was not private enough, it was generally not conceived as starting time line treatment. Traditional medical practitioners in this written report are very instrumental in the diagnosing and management of infertility in Northern Ghana. It is therefore very relevant to integrate traditional medical practitioners into the primary health care organization because of the multiple advantages it presents. A good collaboration among the traditional and orthodox medical practitioners will provide an opportunity for the grooming of traditional medical practitioners in current scientific cognition and heighten inter-practitioner referral system, which can cater for both biological and spiritual aetiologic factors.

Still, the use of specialized clinics or designation of some days within a general hospital for some disease atmospheric condition is widely used in Republic of ghana, the findings of this report point to the negative effects and perception among customs members especially for disease conditions with stigma. The general believe in the community is that such clinics literally broadcast the affliction conditions of clients and hence additional measures should be put in place to ensure privacy and confidentiality of clients. Both the use of donated egg and sperm were generally unacceptable among participants in this written report. Adoption was viewed as service to God but not a remedy for infertility. A study also institute negative feeling associated with adoption in a study of Hindu couples (in Bharat) because it was perceived as highly visible indicator of infertility [32]. Donated eggs seemed to be marginally more adequate than the use of donated sperm, which is seen as sexual in a way [thirty].

Some of the couples, who believed that their infertility was due to witchcraft, curse or whatsoever crusade other than physical are those who sought for spiritual help. Some of the couples had sought assist from spiritual churches and prayer camps. The study revealed that traditional medical practitioners prescribed rituals including wearing of some special costumes. In Nigeria, herbalists prescribe certain ritual or actions, such as the women bathing at night at a identify where roads meet, or making sacrifices of food to evil spirits that may be causing the problem and leaving the items at the crossroad [4]. The findings of this report are therefore similar to the report in Nigeria. Of medical interest is also excision of some portions of the clitoris by some traditional medical practitioners. Excessive bleeding, scarring and difficulty during labour could effect from such procedures. Since the equipment used for such procedures are not unremarkably sterile, this predisposes the victims to infections. Insertion of objects and concoctions into the vagina of women as treatment for infertility can also result in infections that may aggravate the situation.

In is clear from the written report that the concept of health have social undertones. Societal perception of a disease directly affects the behaviour of the community to people suffering from that disease and it intends impact the help-seeking behaviour of clients. In a typical pronatalist community like Northern Ghana, the concept of reproductive health can only be meaningful, when opportunities are bachelor for individuals to beget the number of children they prefer. This can just exist accomplished through an integrated approached to reproductive wellness. Infertility and childbearing should be given a priority and the possibility of fertility insurance should exist explored.

Acknowledgments

The authors wish to express their unconditional gratitude to all participants in this study for agreeing to share their experiences with the researchers. We are also grateful to the research assistants and bearding individuals who independently coded the interviews.

Writer Contributions

Conceived and designed the experiments: PTT PBA. Performed the experiments: PTT. Analyzed the data: PTT PBA. Contributed reagents/materials/analysis tools: PTT PBA. Wrote the paper: PBA PTT.

References

1. 1. Fathalla MF (1992) Reproductive health: a global overview. Early Human Development 29: 35–42.
   • View Article
   • Google Scholar
2. 2. Sundby J, Mboge R, Sonko Southward (1998) Infertility in the Gambia: frequency and health intendance seeking. Social Science Medicine 46: 891–899.
   • View Article
   • Google Scholar
3. 3. Haile A (1990) Fertility conditions in Gondar, Northwestern Ethiopia: an appraisement of current status. Study on Fam Plan 21: 110–118.
   • View Commodity
   • Google Scholar
4. 4. Okonofua Fe (1996) The case against new reproductive technologies in developing countries. Journal of Obstetrics and Gynaecology 103: 957–962.
   • View Article
   • Google Scholar
5. 5. Larsen U (2000) Primary and secondary infertility in Sub-Saharan Africa. International Periodical of Epidemiology 29: 285–291.
   • View Article
   • Google Scholar
6. 6. Geelhoed DW, Nayembil D, Asare K, Schagen Van Leeuwen JH, Roosmalin J (2002) Infertility in rural Ghana. International Journal of Gynaecology and Obstetrics 79: 137–142.
   • View Article
   • Google Scholar
7. 7. Miall C (1986) Perceptions of informal sanctioning and the stigma of involuntary childlessness. Deviant Behaviour 1 (6): 383–403.
   • View Commodity
   • Google Scholar
8. viii. Republic of ghana Statistical Service (GSS), Noguchi Memorial Institute for Medical Enquiry (NMIMR), and ORC Macro (2004) Ghana Demographic and Wellness Survey 2003. Calverton, Maryland: GSS, NMIMR, and ORC Macro.
9. 9. WHO (1987) Infections, pregnancies, and infertility: perspectives on prevention. Fertility and Sterility 47: 964–968.
   • View Article
   • Google Scholar
10. 10. National collaboration centre for women and children wellness (2012) Fertility: Assessment and treatment for people with fertility problems. London: RCOG. 20p.
11. 11. Dyer SJ, Abraham Northward, Hoffman 1000, Van der Spy ZM (2004) You are a man because you have children: experiences, reproductive health knowledge and handling-Seeking behaviour amongst men suffering from infertility in South Africa. Human Reproduction xix(iv): 960–967.
    • View Commodity
    • Google Scholar
12. 12. Gerrity DA (2001) The biopsychosocial theory of infertility. The Family unit Journal 9: 151.
    • View Commodity
    • Google Scholar
13. thirteen. Donkor ES, Sandall J (2009) Coping strategies of women seeking infertility treatment in Southern Ghana. African Journal of Reproductive Wellness 13(iv): 81–93.
    • View Article
    • Google Scholar
14. 14. Bernstein J (1999) Infertility: from a personal to a public wellness trouble. Public Health Reports 114 (half-dozen): 494–504.
    • View Article
    • Google Scholar
15. xv. McLachlan R (2007) Andrology in Autralia. Clayton: Monash Medical Centre. 1–2.
16. 16. WHO (1991) Infertility: a tabulation of available data on prevalence of primary and secondary infertility. Geneva: WHO/MCH/91.ix.
17. 17. Ford WC, North K, Taylor H, Farrow A, Hull MG, et al. (2000) Increasing paternal age is associated with delayed conception in a large population of fertile couples: evidence for declining fecundity in older men. The ALSPAC study team. Human Reproduction xv(8): 1703–1708.
    • View Article
    • Google Scholar
18. 18. Roupa Z, Polikandrioti Chiliad, Sotiropoulous P, Faros E, Koulouri A, et al. (2009) Causes of infertility in women at reproductive historic period. Health Science Journal 3(xx): 80–87.
    • View Article
    • Google Scholar
19. 19. Fiander A (1990) Infertility: an approach to management in a commune hospital in Ghana. Trop Medico 20(three): 98–100.
    • View Commodity
    • Google Scholar
20. 20. Horton R (1993) Fertility rights and wrongs. Lancet 342 (8862): 45–54.
    • View Article
    • Google Scholar
21. 21. Gibson DM, Meyers JE (2002) The effect of social coping resources and growth fostering relationships on infertility stress in women. Journal of Mental Wellness Counseling 24 (one): 68–81.
    • View Article
    • Google Scholar
22. 22. Ghana statistical Service (2011) Republic of ghana Population and Housing Demography Report 2010. Accra: Ghana Statistical Service.
23. 23. Naples NA. (2003). Feminism and method: Ethnography, discourse analysis, and activist inquiry. New York: Routledge. 123–140.
24. 24. Warren CA, Karner TX (2005) Discovering qualitative methods: field inquiry, interviews and assay. Los Angeles, CA: Roxbury Publishing. 158p.
25. 25. Adongo Pb, Phillips JF, Kajihara B, Fayorsey C, Debpuur C, et al. (1997) Cultural factors constraining the introduction of family unit planning amongst Kassena-Nankana of Northern Ghana. Soc Sci Med 45(12): 1789–1804.
    • View Article
    • Google Scholar
26. 26. Adongo Pb, Phillips JF, Binka FN (1998) The influence of traditional religion on fertility regulation among Kassena-Nankana of Northern Ghana. Studies in Family unit Planning 29(1): 23–twoscore.
    • View Article
    • Google Scholar
27. 27. Adongo Lead, Akweongo P, Binka F, Mbacke C (1998) Female person Genital Mutilation: Socio-cultural factors that influence the practice in Kassena-Nankana, Ghana. African Journal of Reproductive Health 2(two): 25–36.
    • View Article
    • Google Scholar
28. 28. Gocze PM, Freeman DA (2000) Cytotoxic effects of cigarette smoke alkaloids inhibit the progesterone product and cell growth of cultured MA-10 leyding tumor cells. European Periodical Obs. Gynecol Reprod Biol 93: 77–83.
    • View Commodity
    • Google Scholar
29. 29. Dyer SJ (2007) The value of children in African countries-Insight from studies on infertility. Journal of Psychosomatic Obstetrics & Gynaecology 28(2): 69–77.
    • View Commodity
    • Google Scholar
30. xxx. Wischmann T, Falter H, Scherg H, Gerhard I, Verres R (2001) Psychosocial characteristics of infertile couples: A written report by the Heidelberg fertility consultation service. Human Reproduction 16: 1753–1761.
    • View Article
    • Google Scholar
31. 31. Haimes M (2004) Psychological factors in the aetiology of infertility: a prospective cohort report. Human Reproduction viii: 1039–1046.
    • View Article
    • Google Scholar
32. 32. Bharadwaj A (2002) Culture, Infertility and Gender–Vignettes from South Asia and North Africa. Sexual Health Exchange (i2): 14.
    • View Article
    • Google Scholar

moffittcuble1997.blogspot.com

Source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0054429