Infertility and Women's Life Courses in Northern Malawi

BACKGROUND: Anthropological and epidemiological studies have identified infertility as a significant health and social problem, yet it remains largely overlooked in reproductive and sexual health policy and practice in developing countries. This study examined the effects of infertility across women’s lives in rural northern Malawi. METHODS: Qualitative data were collected during in-depth life history interviews with forty-nine fertile and infertile women. These data were supplemented by key informant interviews, group discussions, field notes and observations. Demographic survey data were analysed to contextualise findings and quantify selected outcomes related to infertility. The importance of infertility for current understandings of sexual and fertility related behaviour was evaluated. FINDINGS: Women experienced infertility within a complex social and metaphysical context, in which they had few alternative life course options apart from marriage and childbearing. Little help was available at hospitals, and most women took long courses of traditional medicine. Infertile women were more likely to be HIV positive, but only a minority of infertile women reported ‘risky’ sexual behaviour. Divorce was more common among infertile women, as children stabilised marriages in a variety of ways, but infertile women were no more likely to be polygynously married. Many infertile women had supportive marriages, often with polygynous men who had children with other wives. Infertile women negotiated marriages and living arrangements to make the most of their compromised situation, and were unwilling to tolerate secondary social status. Infertility was on a continuum of risks to successful childbearing: most fertile women had also experienced reproductive health problems and/or marital disruptions. IMPLICATIONS: Routine health services and information are inaccessible and inappropriate for infertile women. Current reproductive and sexual health programmes focus on fertility reduction, but there are feasible ways to improve infertility management in resource-poor settings, which could contribute to meeting other objectives such as tackling STIs and building trust around contraceptive use.