Worldwide, women and men are confronted by the fact that they cannot have any children or not the number of children they would like to have. Infertility and childlessness are huge problems for the people involved, but they receive little attention from policy-makers, health workers and researchers in third world countries.

While 95% of infertility can be prevented through good reproductive health services, lack of adequate access to these services constitutes a violation of women's and men's reproductive rights. Recent studies on social and cultural aspects of infertility in some African countries - Mozambique, Nigeria and Egypt among others - show that when pregnancy does not occur, it causes many problems at the personal, conjugal, family and community levels. Infertile women - and sometimes infertile men as well - describe their life without children as meaningless, fruitless, miserable, shameful or unhappy. They also speak about feelings of guilt and loss of self-esteem. Childless women and men fear lack of social security and support from their children when they themselves grow old. Moreover, they worry because they will not have a child to bury them when they die.

Childlessness strongly influences sexual and marital life. Women are generally blamed when conception does not occur and many childless women suffer from physical and mental abuse, disrespectful treatment or neglect from their husband and his relatives. Many women also fear separation or divorce from their husband, or to become a second wife in a polygamous marriage. Often, female relatives of the husband force him to divorce or take a second wife, because his children are needed to guarantee the continued existence of their family lineage. Some studies report that divorced infertile women become outcasts and are excluded from inheriting property and decision-making in the family.

A study among the matrilineal Macua in the north of Mozambique, however, shows a different picture: Macua men are quite often blamed for infertility, which can lead to divorce initiated by the women or their relatives. Infertile Macua women will also have sexual relations with other men in order to get pregnant. Women seemed unafraid of the consequences of their husband finding out the child was not his, even if this led to divorce. Their main aim was to have a child, not to remain with their husband. This is related to the matrilineal kinship system, where children are of great value for a woman's own family and not for the continuity of her husband's family. Therefore a woman's family will support her search for a medical solution. For the same reason her husband and in-laws will not mistreat her because of infertility, which is common practice in societies where a patrilineal kinship system prevails.

Problems due to infertility, however, do not only exist at the family level. Both infertile men and women may be seriously offended, stigmatised and excluded from social events by community members. Infertile women, more often than infertile men, are accused of being witches. Children are told not to seek their company because infertile women would not be capable of looking after children and might use children for their ceremonies or give them the evil eye.

Many cases of secondary infertility are due to preventable infection (see box) and thus do not require new programmes. Accessible reproductive health care services, however, are essential for prevention and treatment of STIs, insertion of IUDs, obstetrical care and safe abortions. The public must be made aware of factors affecting fertility, although care must be taken not to further stigmatise the infertile.

"Low-tech" diagnosis and treatment of infertility must be improved. Besides, a reproductive rights perspective calls for introduction of "high-tech" diagnosis and treatment with proven efficacy and safety, where feasible and affordable. Infertile people are entitled to realistic information on the success rates of various treatment options and possible adverse effects, in order not to raise false expectations and to prevent wastage of sources. A recently developed screening scheme in South Africa shows how men and women complaining of infertility can be diagnosed, counselled and referred for treatment. Training and awareness raising of health workers are essential for successful implementation of such a scheme.

Childlessness is a reproductive health problem that needs more than a medical approach. Non medical activities include counselling childless women and men to live their lives without children, strengthening existing support mechanisms and creating new ones (like self-help groups). Possible actions go beyond the affected individuals and include such activities as:      

• enhancing and promoting legal possibilities for adoption and fostering;
• disseminating correct information on infertility to the public in general;
• empowering women by education, vocational training, credit and income-generating activities to assume and choose social roles other than the role of mother.

Trudie Gerrits, Medical Anthropology Unit, University of Amsterdam, The Netherlands; Tel: +31-20-5252.670, Fax: +31-20-5253010; email: gerrits@pscw.uva.nl

Infertility rates vary enormously among countries. 8-12% of couples around the world have difficulty conceiving a child at some point in their lives. In several Sub-Saharan African countries infertility levels reach 20-30%, affecting an estimated 8-10 million women (i.e. couples). About 5% of infertility cases is due to anatomical, genetic, endocrinological or immunological factors. The remaining 95% is due to preventable conditions: STIs, particularly gonorrhoea and chlamydia, are the leading preventable causes of infertility in women and men. In women, infections can transcend spontaneously from the lower to the upper tract, where they can cause pelvic inflammatory disease (PID), but the risk of upper tract infections is often aggravated by unsafe abortions, poor obstetrical care and improper intrauterine device (IUD) insertion when instruments pass through the cervix.