The social organisation and interpretation of human reproduction varies enormously across space and time, and this review discusses anthropological insights pertinent to the study of infertility. The following section is arranged according to different approaches taken to infertility and reproduction. It ends by summarising several influential studies, characteristic of recent trends in anthropological demography, which have employed both qualitative and quantitative approaches to problems such as infertility.
The literature on social aspects of fertility in sub-Saharan Africa reflects broader fashions in academia and policy. Anthropologists and demographers have always been interested in reproduction. Early ethnographies typically mentioned infertility in the context of kinship studies, whilst demographers studied infertility as a proximate determinant of fertility, and an explanatory factor for high fertility rates in Africa. With the advent of feminist approaches in anthropology, pregnancy and motherhood became popular topics of enquiry (Maclean 1982; Bledsoe 2002; Roth Allen 2002), and several recent ethnographies have provided rich local data on infertility, situating it as an RSH issue (Udvardy 1990; Feldman-Savelsberg 1994; Inhorn 1996; Gerrits 1997; Cornwall 2001; Pool and Washija 2001; Runganga, Sundby et al. 2001; Leonard 2002; Dyer, Abrahams et al. 2004).
Structural functionalist approaches have looked at the role of children in social life and how they contribute towards the maintenance and reproduction of society. Such an approach is typified by the Caldwells’ hypothesis on sub-Saharan Africa’s ‘resistance’ to lower fertility. They argued (using a rather ambiguous definition of ‘culture’ as a ‘religious belief system’) that culture caused African societies to maintain high fertility rates, primarily through concern that without descendants, one could not become an ancestor oneself. This fear of childlessness was thought to contribute to high fertility rates:
The horror of barrenness goes far towards explaining the fear of limiting family size, the aversion to sterilisation, or to accepting that family size is now complete, and the apprehension of most methods of sterilisation. (Caldwell and Caldwell 1987; 418)
The anthropologist Brian Morris has also argued for the importance of having children within the context of the traditional religion of ancestor worship in Malawi (Morris 2000). Failure to have children meant that after death, one’s perpetuation through the commemorative acts of descendents was not assured.
In this framework, children are seen in terms of their structural and functional importance, which is determined by the local context. In much of rural sub-Saharan Africa, in economic terms, these benefits include labour contributions to the household economy, receiving inter-generational wealth transfers from grown children in old age (Oppong 1992), and having a ‘child to send’ on errands (Gijsels, Mgalla et al. 2001). Having children gives women their place in the domestic cycle. Having sons who bring daughters-in-law into the household confers status onto older women, who can delegate work to their daughter-in-law. Daughters might bring bride price payments to their family upon marriage. As often the most mobile members of households, children may be actors in adults’ political alliances (Bledsoe 1995). Having children may cement marriages and secure economic support from men for women (Feldman-Savelsberg 1999; Runganga, Sundby et al. 2001). In some areas of Africa, a marriage is not seen as finalised until a child has been born (Guyer 1994). Infertility may thus deny men and women these benefits.
the principal way of women improving their status in sub-Saharan Africa, as in much of the world (Inhorn 1996; Hellum 1999). The argument is that in Sub-Saharan Africa, women have lower status than men, and labour is divided according to gender. In this system, women’s principal role is producing and nurturing children, and having children helps them to acquire additional status as they get older (Caldwell and Caldwell 1987; Spring 1995). Infertile women might thus be denied opportunities for improving their social status. The Caldwells paint a bleak picture of infertile women’s lives in rural Nigeria in the early 1980s. Regarded as witches responsible for their own condition, they were sent home, lived beyond their villages or had their bodies despoiled at death. Other negative consequences reported for infertile women have been domestic violence, psychological distress and facing social stigma (Daar and Merali 2001). Yet in some studies, infertility was not found to have such dire effects. In West Africa, child fostering is widespread, affording infertile women some of the benefits of having children (Bledsoe 1990). In Mali, women with no or few children, and hence fewer domestic responsibilities, can be very successful in the commercial sphere, able to travel and trade at markets (Castle 1992).
Such approaches have been criticised for being too narrow, looking at women as passive daughters, wives, and mothers in patriarchal systems (Mohanty, Russo et al. 1991). Women in developing countries are often talked about as though they were a homogenous group sharing similar status and concerns in the face of male domination. A call has been made for women to be reconceptualised as active agents in social life, who can and do influence their reproductive careers (Bledsoe, Banja et al. 1998).
The following studies describe how anthropologists have moved away from the individualistic cost/benefit perspective of having children, and have situated infertility in the wider social realm. Fertility is often the concern of the social group (be it a family or village) rather than the individual or couple. Failure to produce sufficient children can be seen to threaten the very existence of a lineage, village, or even state (Inhorn and Buss 1994c; Feldman-Savelsberg 1999), and to ensure the continuation of the group, elders may intervene. This might take the form of facilitating treatment, or encouraging people to divorce an infertile partner, or take an additional partner (Maclean 1982; Peltzer 1987).
Infertility can have important symbolic aspects at the group level. In Feldman-Savage’s ethnography on infertility in Cameroon, she found a wealth of symbolism associated with infertility: if large numbers of children represented good fortune, health and social status, she argued, then infertility was the ‘quintessential indicator of bad fortune’ and bore little relation to medical concepts of infertility (Feldman-Savelsberg 1999; 101). Infertility was interpreted as a sign of the overall decline of the Bangangté kingdom, reflecting on the potency of the royal family in particular.
Bledsoe (2002) suggested another potential aspect to the experience of infertility when she argued that the process of childbirth is seen to cause ageing amongst Gambian women, who do not see the process of ageing as an accumulation of chronological age, but rather as the result of accumulated ‘wear and tear’ resulting from repeated childbearing. A childless woman has therefore never aged, which was undesirable in societies where elders had elevated social status:
Suspended in an eerie state of agelessness, she knows that insinuations of supernatural interference hang over her. (Bledsoe 2002; 228)
In her influential study of women and infertility in Egypt, Inhorn powerfully argues that childbearing largely defines women’s identity. Infertility was an unexpected, chronic life crisis. Unable to proceed according to life course norms, infertile women felt incomplete, inadequate, and painfully different from their neighbours. The strength of Inhorn’s argument lies in her use of a feminist and political economy approach: she contextualises reproduction in Egypt within the broad economic and social environment in which women are socially and physically isolated and disempowered. Children were a source of comfort and companionship and a way of improving women’s tenuous social status (Inhorn 1994a; Inhorn 1996).
She also outlined a ritual process of seeking therapy, in which infertile women may face health problems from iatrogenic (medically induced) symptoms, caused by invasive procedures or toxic preparations such as pharmacologically active herbs inserted into the vagina. Such ‘quests for conception’ have been detailed in other anthropological studies of infertility (Leonard 2002; Bharadwaj 2003). Women, and sometimes their husbands, often undergo long and arduous treatment-seeking, visiting both traditional healers and hospitals (though suitable services are rarely available). Inhorn argues that
the difficulties surrounding infertility are compounded by the poor status of women and health systems in many parts of the developing world.
In her ethnographic work with the Pemba in Tanzania, Kielmann (1998) expanded the study of infertility to look not just at affected individuals, but also at the local discourse around infertility. This placed the responsibility of infertility within the context of social relations such as jealousy and bewitchment: she also saw infertility as an embodiment of day to day concerns such as ‘compromised physical conditions and disturbed social relations’ (Kielmann 1998; 139). There was evidence for a more modern discourse in which infertility was seen a punishment from ancestors or God, provoked by immoral behaviour such as drinking alcohol, promiscuity, contraception, and un-Islamic activities. Infertility could therefore have a detrimental impact on women’s identities and moral credentials.
There have been several small scale qualitative studies of infertility carried out in southern Malawi (Barden-O’Fallon 2005), Botswana (Mogobe 2005) and South Africa (Dyer, Abrahams et al. 2002b). Whilst providing interesting local details, these studies are limited in their approach. They were typically carried out over a short time period and with little contextualisation of findings. They tend to report what people ‘say’ about infertility in focus groups or interviews, whilst not making deeper inferences or theorising from results. Whilst it is useful to examine normative responses to infertility, they are not a substitute for investigating the lived experience of women affected by infertility. Some studies have concentrated on the exotic and peculiar cases, without paying attention to more typical, everyday experiences.
Fear of infertility at the community or even national level has also been investigated as a social phenomenon. Fear of infertility or rumours concerning causes of infertility have affected the delivery of family planning and primary care services such as vaccination programmes, most recently in Nigeria, where polio vaccine coverage has dropped catastrophically due to local fears that it would sterilise female children (BBC 2004). Historically in Malawi, the roll out of free contraceptives was delayed by many years by the government’s fear that the population would react unfavourably, as there were widespread rumours that the family planning programme intended to sterilise women. Such fears persist in Malawi: any fertility-related activity such as promoting condom use is viewed with suspicion (Kaler 2004). It has also been proposed that Nigerian
women may resort to illegal and unsafe abortion rather than use hormonal contraceptives, which they fear will damage their fertility (Okonafua 1997). If levels of knowledge concerning the relationships between STIs, HIV and infertility are low, as they have been found to be in Uganda (Nuwaha, Faxelid et al. 1999), women’s perceptions of relative risks to their reproductive health and fertility might not accord with epidemiological estimates of risk. For instance, illegal abortions or having unprotected sex at a young age is quantifiably more harmful for fertility than using suitable contraceptives or condoms to prevent HIV, STIs and youthful pregnancy, yet the examples just mentioned suggest that some women do not view these risks in the same light.