By Marta Bornstein
The experience of infertility is often over-looked within public health literature, despite being a common experience for individuals and couples worldwide.1,2 Infertility comes with a range of consequences associated with poor health outcomes, including social stigma, relationship instability/divorce, depression, and intimate partner violence.3,4,5,6,7
In societies where gender roles and social status are intrinsically tied to parenthood, such consequences are intensified.
In 2018, Dr. Jessica Gipson and I developed a qualitative study to better understand infertility in a rural area of Central Malawi as part of the Umoyo Wa Thanzi research program. We wanted to understand how infertility, and the fear or anticipation of potential infertility, impacted women’s and couples’ decisions around family planning. In a recently published article we explore how both the experience and anticipation of infertility is shaped by gendered expectations of parenthood and the social consequences of infertility broadly.8
Infertility-related stigma affects both women and men, but differently
In rural Malawi, childbearing is an important marker of adult status and is expected shortly after marriage. For women, motherhood is essential to securing status within one’s family and community. Several women talked about the pressure they felt from themselves, their partner, family, and community to become pregnant quickly. The visibility of pregnancy contributed to this pressure by clearly marking those who had and had not “achieved” pregnancy when expected. In the absence of diagnostics, women were frequently blamed for not becoming pregnant. In an interview, a woman shared that her partner suspected that she was using contraception behind his back when she did not become pregnant after they first married. Another discussed the exclusion and fear she experienced when her friends who married around the same time as her started to become pregnant, while she did not.
For men, the ability to father children denotes masculinity and strength. In focus groups with both women and men, participants expressed that a man who cannot impregnate his partner was considered fundamentally broken (he was likened to “a bicycle without a chain,” or “someone who fell from a papaya tree”). While spared of blame for infertility related to a first pregnancy, men often were suspected as the cause of secondary infertility, due to the need for men to demonstrate paternity through subsequent pregnancies. Like women, men who were suspected to be infertile were often subjected to ridicule within their families and communities. In a focus group, one participant suggested that a man would need to “run away” from his community to escape a reputation as infertile.
Participants stressed that couples who could not become pregnant were often encouraged to divorce, as they were considered incompatible—either biologically or interpersonally. Through divorce and remarriage, individuals may be given additional chances to demonstrate fertility, although their marital prospects diminish over time. Women are uniquely vulnerable in a divorce, as they often face heavy economic, social, and physical consequences.
Infertility-related stigma factors into decisions around family planning
Individuals and couples make decisions about family planning with their future fertility in mind. This is influenced by a desire to avoid stigma due to infertility. Women are discouraged from using contraception before they have two children with their partner for fear that they may not be able to have children in the future. The majority of women we interviewed did not use contraception until after their second child was born because of the need to demonstrate fertility of both partners. Although many women shared that they wanted to have 3-5 years of space between their children, this spacing did not apply to the time between the first and second child. There is extensive literature on the adverse health consequences of short birth intervals on women and children. 9
Women and men associated certain behaviors with increased risk of infertility, including early or prolonged contraceptive use and abortion. In fact, the stigma associated with both infertility and abortion reinforced each other. If a woman was infertile, she may be suspected of having had an abortion; and, if a woman had an abortion, she could face rumors of infertility in the future.
The consequences of infertility-related stigma are relevant to public health
Studies have shown that infertility is associated with poor health outcomes, but the mechanisms between infertility and poor health outcomes are not well understood. Our findings contribute to a body of literature that explores stigma as a possible mechanism. We found evidence that suggests proving fertility in order to avoid infertility-related stigma may be a key factor in how couples plan their families.
Public health has not adequately addressed infertility.10 However, as the field increasingly aims to use a reproductive-justice approach, we must expand our view of reproductive health to include infertility. There is a need for public health programs to prevent and treat infertility, as well as reduce the intense and harmful social stigma around infertility.
Thank you to the Umoyo Wa Thanzi Research Program, especially our research team in Malawi.
Thank you to our participants, who generously shared their perspectives and experiences with us.
Marta Bornstein is a PhD candidate at the Fielding School of Public Health in Community Health Sciences. CSW awarded Bornstein with the Jean Stone Dissertation Research Fellowship in 2020. Her dissertation explores the interrelatedness and health impacts of a spectrum of reproductive experiences, including both unintended pregnancy and infertility, in Malawi.
- Polis, C. B., C. M. Cox, O. Tuncalp, A. C. McLain, and M. E. Thoma, “Estimating infertility prevalence in low-to-middle-income countries: an application of a current duration approach to Demographic and Health Survey data,” Human Reproduction 32 (2017), 1064-74.
- Boivin, J., L. Bunting, J. A. Collins, and K. G. Nygren, “International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care,” Human Reproduction 22 (2007), 1506-12.
- Hansanpoor-Azghady, S. B., M. Simbar, and A. Vedadhir, “The Social Consequences of Infertility among Iranian Women: A Qualitative Study,” International Journal of Fertility and Sterility 8 (2015), 409-20.
- Ameh N., T. S. Kene, S. O. Onuh, J. E. Okohue, O. U. Umeora, and O. B. Anozie, “Burden of Domestic Violence Amongst Infertile Women Attending Infertility Clinics in Nigeria,” Nigerian Journal of Medicine 16, no. 6 (2007).
- Rao N., A. Esber, A. N. Turner, G. Mopiwa, J. Banda, and A. Norris, “Infertility and self-rated health among Malawian women,” Women & Health 58 (2018), 1081-93.
- Stellar C., C. Garcia‐Moreno, M. Temmerman, and S. Van Der Poel, “A systematic review and narrative report of the relationship between infertility, subfertility, and intimate partner violence,” International Journal of Gynecology & Obstetrics 133 (2015), 3-8.
- de Kok B. C., “‘Automatically you become a polygamist’: ‘culture’ and ‘norms’ as resources for normalization and managing accountability in talk about responses to infertility,” Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 13 (2009), 197-217.
- Bornstein M., J. D. Gipson, G. Failing, V. Banda, and A. Norris, “Individual and community-level impact of infertility-related stigma in Malawi,” Social Science & Medicine 251 (2020), 112910.
- Conde-Agudelo A, A Rosas-Bermudez, F Castano, MH Norton, “Effects of Birth Spacing on Maternal, Perinatal, Infant, and Child Health: A Systematic Review of Causal Mechanisms,” Studies in Family Planning 43 (2012).
- Gipson JD, M Bornstein, and MJ Hindin, “Infertility: A Continually Neglected Component of Sexual and Reproductive Health and Rights,” Bulletin of the World Health Organization 98, no. 7 (2020).