This chapter introduces the concepts associated with involuntary childless. Various socio-cultural norms world over, global and Indian statistical prevalence of infertility, stratification of infertility, health care mechanisms available for addressal of infertility and reproductive health rights in the context of millennium development goals and sustainable development goals-2030 will be discussed in the chapter.
Yearning for children and the heartbreak of barrenness have been a part of life since the beginning of mankind, chronicled throughout history by religious accounts, myths, legends, art, and literature. Whether driven by biological drive, social necessity, or psychological longing, the pursuit of a child or children has compelled men and women to seek a variety of remedies, sometimes even extreme measures. In fact, in all cultures involuntary childlessness is recognized as a crisis that has the potential to threaten the stability of individuals, relationships, and communities. Every society has culturally approved solutions to infertility involving, either alone or together, alterations of social relationships (e.g., divorce or adoption), spiritual intercession (e.g., prayer or pilgrimage to spiritually powerful site), or medical interventions (e.g., taking of herbs or consultation with ‘medicine man’).While spiritual and medical remedies for involuntary childlessness are common and often used early on by involuntary childless couples, social solutions demanding the alteration of relationships have been shown to be the last alternative individuals or couples usually consider.
Reproductive health is a state of complete physical, mental and social well-being in all aspects relating to the reproductive system and to its functions and processes. This implies that individuals are able to have a satisfying and safe sex life, and the capacity to reproduce and the freedom to decide if, when and how often to do so. Access to such treatments that provide the provisions for the same, is implicit as a fundamental right to an individual, this is a basic component of reproductive health and its prevention and appropriate treatment, where feasible, are essential. It is in this context that, the state of an individual not being able to reproduce is seen. The term that has been coined to describe this state has been named as infertility. Infertility is a world-wide problem affecting people of all communities, though the cause and magnitude may vary with geographical location and socio-economic status.
Dramatic contrasts are apparent between industrialized and developing countries in terms of reproductive health services and status. These include access to contraception, antenatal care, safe facilities in which to give birth and trained staff to provide pregnancy, delivery and postpartum care; the diagnosis and treatment of sexually transmitted infections (STIs) including HIV, infertility treatment, and care for unsafe or unintended pregnancy. Around the world, reproductive health initiatives aim to address the complex of economic, socio-demographic, health status and health service factors associated with elevated risk of morbidity and mortality related to reproductive events during the life course. At present, the central contributing factors to disparities in reproductive health have been identified as: reproductive choice; nutritional and social status; co-incidental infectious diseases; information needs; access to health system and services and the training and skill of health workers. The most prominent risks to life are identified as those directly associated with pregnancy, childbirth and the puerperium, including haemorrhage, infection, unsafe abortion, pregnancy related illness and complications of childbirth. There is however, very limited consideration of mental health as a determinant of reproductive mortality and morbidity especially in the developing regions of the world.
Mental health problems may develop as a consequence of reproductive health problems or events. These include lack of choice in reproductive decisions, unintended pregnancy, unsafe abortion, sexually transmissible infections including HIV, infertility and pregnancy complications such as miscarriage, stillbirth, premature birth or fistula. Mental health is closely interwoven with physical health. It is generally worse when physical health including nutritional status is poor. Depression after childbirth is associated with maternal physical morbidity, including persistent unhealed abdominal or perineal wounds and incontinence.
Women’s sexuality and reproductive health needs to be considered comprehensively with due consideration to the critical contribution of social and contextual factors. There is tremendous under-recognition of these experiences and conditions by the health professionals as well as by society at large. This lack of awareness compounded by women’s low status has resulted in women considering their problems to be ‘normal’. The social stigma attached to the expression of emotional distress and mental health problems leads women to accept them as part of being female and to fear being labeled as abnormal if they are unable to function.
The World Health Report 2005: Make Every Mother and Child Count (WHO, 2005) recognizes the importance of mental health in maternal, newborn and child health, especially as it relates to maternal depression and suicide, and of providing support and training to health workers for recognition, assessment and treatment of mothers with metal health problems. The International Conference on Population and Development (ICPD) Programme of Action and the Beijing Platform for Action urged member states to take action on the mental health consequences of gender-based violence and unsafe abortion in particular so that such major threats to the health and lives of women could be understood and addressed better. In addition, the mental health aspects of reproductive health are critical to achieving Millennium Development Goal (MDG) 1 on poverty reduction, MDG 3 on gender equality, MDG 4 on child mortality reduction, MDG 5 on improving maternal health and MDG 6 on the fight against HIV and AIDS and other communicable diseases. Moreover, humans are emotional beings and reproductive health can only be achieved when mental health is fully addressed as informed by the WHO’s definition of health and the definition of right to health in the International Covenant of Economic, Social and Cultural Rights.
Infertility is a world-wide problem affecting people of all communities, though the cause and magnitude may vary with geographical location and socio-economic status. Approximately 8-10% of couples within the reproductive age group present for medical assessment, generally
following two years of failed efforts to reproduce1,2.ICMR 2000
It is estimated that globally between 60-80 million couples suffer from infertility every year3, of which probably between 15- 20 million are in India alone. The magnitude of the problem calls for urgent action.
Typically, infertile couples are reluctant to jeopardize or disturb close relationships (perhaps because social changes are usually permanent) because they hope or believe infertility will be a temporary problem. By the same token, reluctance to consider solutions may be due to the hope and promise often attributed to medical and/or spiritual interventions. Nonetheless, infertile couples use all three measures – social, spiritual, and medical – as remedies for their involuntary childlessness; numerous examples of these remedies exist throughout history and across all cultures.
Divorce, polygamy, and extramarital affairs remain, as they have long been, social solutions to infertility, as do various forms of adoption and fostering. Examples of other social solutions include the continuing practice in some cultures of multiple wives in response to infertility (or lack of a son) or the custom in some cultures requiring a sibling (usually an eldest son) to provide one of his children to a younger, childless sibling.
Women’s bodies, especially in developing countries, are frequently the locus through which social, economic, and political power is exercised. Where the role or status of women is defined by their reproductive capacity, as when womanhood is defined by motherhood, infertility can have significant social repercussions including unstable marriages, domestic violence, stigmatization and in severe cases, ostracism. Infertile women in developing countries may suffer life-threatening physical or psychological violence when having children is a woman’s only chance to improve her status in her society or family. Individuals who are thought to be infertile are generally relegated to an inferior status, and stigmatized with many labels. Hence, childlessness has varied consequences through its effects on societies and on the lifestyle of individuals. Parenthood is personal for some women, whereas by some as a duty.
Parenthood is one of the major transitions in adult life for both men and women. The stress of the non-fulfillment of a wish for a child has been associated with emotional related problems such as anger, depression, anxiety, marital problems, sexual dysfunction, and social isolation. Couples experience stigma, sense of loss, and diminished self-esteem in the setting of their infertility. Although infertility is primarily a medical condition, its diagnosis can greatly impact the emotional functioning of couples dealing with this problem. Infertility is often an unanticipated, stressful, and life changing event. Infertility and involuntary childlessness have been often referred to as a developmental crisis that can threaten a couple’s future goals, as the family does not progress from the married couple without children, as a developmental phase.
The World Health Organization (WHO) has defined infertility as a failure to conceive over 12 months of exposure (which is a good practical guide to management), and leaves a longer term residual incidence of infertility of 10–15%.1) However, the chance to conceive is reduced almost twofold after the age of 35 years. As per various epidemiological data suggestions, approximately 80 million people worldwide are infertile. WHO has identified that the highest incidence in some regions of Central Africa where the infertility rate may reach 50%, compared to 20% in the Eastern Mediterranean region, and 11% in the developed world.3
What is involuntary childlessness and infertility? The effects of involuntary childlessness varies by location. India being a largely pronatalist society the effects of being childless has more negative social, cultural, and emotional repercussions for women than perhaps any other condition which is not immediately life threatening and the consequences of which can be devastating . In most Indian cultures, it is equated with ill-luck, being cursed and being a bad omen. These factions of thought have a direct impact on the well being and mental health of the individual in the due course of time. The impacts are felt and affects in different spheres, the determinants of which are the gender and social role played by the person.
Defining infertility and involuntary childlessness It has been hard to quantify the definition of infertility as estimating the prevalence of fertility difficulties, infertility or involuntary childlessness is hampered by variations in the definitions of these conditions (Schmidt & Munster, 19953; Kols & Nguyen, 19974). Marchbanks et al’,19895 has opined that infertility is a condition that can be regarded as a heterogeneous group of health problems, influence-able by a range of risk factors.
The definition of infertility has a significant impact on clinical outcomes, including those reported in research studies. Definitions vary in terms of whether the condition is identified by self-report, or based on a life calendar of reproductive events, a physician consultation or a physician diagnosis. WHO 20026 explains infertility to be the difficulty in conceiving and reaching a successful pregnancy by an individual of having a consummated relationship if two years without the use of contraceptives. There is a lack of a fixed definition of infertility, other than the conceptual interpretation followed by the WHO.
Fertility Rates: What does it imply?
Malthus has mentioned in ‘Essay on the Principle of Population’, human fertility has been highly debated. In the current context, the Western countries have undergone fertility transitions with high fertility rates dropping to levels around the replacement rate1 and sometimes even below2. In recent years, a number of Asian countries have followed this example. However, many countries retain extremely high fertility rates, especially in Sub-Saharan Africa (Malthus, 1798; O’Neill et al., 2001:39-48).
Over the past quarter-century massive changes in fertility behavior have occurred in most world regions. Many developing countries have experienced large and rapid fertility declines, and a number of countries in Asia and Latin America are now approaching the end of their transitions with fertility around or in a few cases (e.g., China) even below 2 births per woman. In the “more developed” world (Europe, North America, Japan, Australia, and New Zealand) average period fertility was already low in the early 1950s and, after temporary baby booms of varying magnitude, has decreased further to 1.6 births per woman in the late 1990s (United Nations 2001).
These recent fertility declines have been more rapid and pervasive than was expected. For example, medium variant projections for the late 1990s prepared by the United Nations Population Division in the 1970s, 1980s, and early 1990s slightly overestimated the fertility levels observed in the 1990s for the world and many regions. These results are primarily attributable to the invalid assumption that all countries end their fertility transitions with fertility stabilizing at the replacement level of 2.1 births per woman. This assumption was widely accepted in the past, and it is fair to say that the UN incorporated the consensus of the demographic community on this issue. Starting with its 1998 revision the UN no longer takes 2.1 as the eventual end point of the transition, and countries with low fertility are now projected, in the most commonly cited so-called medium projections, to remain permanently below the replacement level (United Nations 1999, 2000a, 2001).
One reason for this uncertainty about future fertility trends is that conventional demographic theory has little to say about levels and trends in post-transitional societies (Caldwell 1982). In an attempt to remedy this shortcoming, demographers and social scientists are engaged in an active debate on the causes of low fertility and the prospects for further change (Chesnais 1996, 1998; Lesthaeghe 2001; Lesthaeghe and Willems 1999; McDonald 2000). The matter is of considerable importance because further declines in fertility or even a continuation of current low fertility levels will contribute to rapid aging of populations and will lead to a decline in the size of national populations. These demographic developments in turn are likely to have significant social and economic consequences (Coale 1986; OECD 1998; World Bank 1994).
Theoretical Framework For Examining Fertility Levels
Current state of fertility theory
Many theories attempt to explain why some countries have undergone fertility transitions while others have not (Cleland & Wilson, 1987). Each theory presents important insights, yet no-one has been able to explain all known fertility transitions. Inspiration for such a model is drawn from the framework presented by Mason in Figure 2.1. (Mason, 1997). She claims that a model of fertility transition needs to be both ideational and interactive: Ideational to recognize that people’s changing perceptions ultimately induce fertility reductions and that these can differ from the reality they mirror. Interactive to reflect that societal changes do not affect fertility in isolation, but in interaction with preexisting conditions and other changes simultaneously occurring.
According to this model, a country’s fertility level is determined by three proximate factors: The perceptions among reproducing people of children’s probabilities of surviving, their perceptions of the costs and benefits associated with having children, and their perceptions of the costs of postnatal versus prenatal controls on family size and composition, with costs incorporating both social, psychological, and financial aspects. 5
The three proximate determinants are effects of the direct and interactive influences of four preexisting conditions and changes in these, viz. the country’s mortality level, the acceptable number of surviving children, the acceptable sex composition of surviving children, and the costs of postnatal versus prenatal controls on family size and composition. The preexisting conditions and changes in them are, in turn, affected by exogenous influences. Lastly, processes of social interaction can influence the proximate determinants directly and indirectly by interacting with the preexisting conditions and changes.
Maybe most importantly, the model perceives the household as a single unit. It thereby neglects to acknowledge that men and women can have differing fertility interests and that power structures between the sexes determine who dominates fertility decisions – an assertion recognized by Mason herself in a later article (Mason, 2001).
The Case of South India
The South Indian Fertility Project (SIFP), establishing as it does a geographic database on the village scale throughout South India, is integrated in this context.
Implications for future fertility
As in the past, future trends in the quantum and tempo of fertility will be driven largely by socioeconomic, socio-psychological, and cultural developments. Most analysts attribute low and delayed fertility to the difficulties women in contemporary industrialized societies face in combining childrearing with their education and a career, and to a rise in individualism and consumerism (Frejka and Calot 2001; Lesthaeghe 2001; McDonald 2000; van de Kaa 1987). These recent trends in childbearing are part of a larger process of social and demographic change usually referred to as the second demographic transition. In addition to declines in fertility, these new transitions are typically accompanied by widespread changes in attitudes and behaviors regarding sexuality, contraception, cohabitation, marriage, divorce, and extramarital childbearing (van de Kaa 1987).
Lesthaeghe (2001) identifies the following set of factors affecting childbearing behavior in post transitional societies:
(i)increased female education and female economic autonomy;
(ii)rising and high consumption aspirations that created a need for a second income in households and equally fostered female labour force participation;
(iii) increased investments in career developments of both sexes, in tandem with increased competition in the workplace;
(iv)rising “post-materialist” traits such as self actualization, ethical autonomy,freedom of choice and tolerance for the non-conventional;
(v) a greater stress on the quality of life with a rising taste for leisure as well;
(vi) a retreat from irreversible commitments and a desire for maintaining an “open future”;
(vii) rising probabilities of separation and divorce, and hence a more cautious “investment in identity.”
What is the concept of Reproductive Health?
“Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases”. Programme of Action of the International Conference on Population and Development, (UNFPA, 1994)
Reproductive Rights (WHO)
Reproductive rights comprise a constellation of rights, established by international human rights documents, and related to people’s ability to make decisions that affect their sexual and reproductive health (Sundari Ravindran, 2001). Reproductive rights include the basic rights of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children, to have the information and means to do so, and to attain the highest possible standard of sexual and reproductive health. They also include their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents (UNFPA, 1994 (para 7.3)).
Adding a gender and rights perspective helps to move away from a stereotyped conceptualization of reproductive health problems as “women’s troubles”. A gender and rights perspective moves beyond biological explanations of women’s vulnerability to mental disorder to consider their vulnerability to a range of human rights violations. This vulnerability has little to do with biology and much to do with gender-based inequalities in power and resources. From a gender and rights perspective, improvements in women’s reproductive mental health are contingent on the promotion and protection of women’s human rights rather than the paternalistic protection of women as the “weaker sex”. This perspective does not deny the role of biology; rather it considers how biological vulnerability interacts with, and is affected by, other sources of vulnerability including gender power imbalances, and how these can be remedied (WHO, 2001).
Although human rights violations are recognized as having a negative impact on mental health (Tarantola, 2001), there have been surprisingly few investigations of women’s mental health, including reproductive mental health, in relation to their human rights (Astbury, 2001). Nevertheless, the higher risk of depression among women clearly underlines the importance of using a gender and rights perspective.
Gender, Rights and Reproductive Mental Health
There is evidence that depression is the most important mental health condition for women worldwide and makes a significant contribution to the global burden of disease. Women suffer more often than men from the common disorders of depression and anxiety, both singly and as co-morbidities.
Sundari Ravindran, 2001, has described in the work by the WHO on Women’s mental health about the various Reproductive rights of the female partner. The rights that are being described by her have its basis in the various reviews of literature and extensive reading that has gone into from her side, and the team from the WHO that has been working in the current area for a while now. She has been able to identify the various areas that can be classified or those that can be introduced as the first step towards identifying the Reproductive Rights of Women.
These are: –
(i)the right to life;
(ii)rights to bodily integrity and security of the person (against sexual violence, assault, compelled sterilization or abortion, denial of family planning services);
(iii)the right to privacy (in relation to sexuality);
(iv)the right to the benefits of scientific progress (e.g. control of reproduction);
(v)the right to seek, receive and impart information (informed choices);
(vi)the right to education (to allow full development of sexuality and the self);
(vii)the right to health (occupational, environmental);
(viii) the right to equality in marriage and divorce;
(ix) the right to non-discrimination (recognition of gender biases).
The Role of Mental Health in Reproduction and Women’s Mental Health
Mental health as a component of reproductive health has generally been – and still is – inconspicuous, peripheral and marginal. The lack of attention it has received is unfortunate, given the significant contributions of both mental health and reproductive health to the global burden of disease and disability.
Of the ten leading causes of disability worldwide, five are neuropsychiatric disorders. Of these, depression is the most common, accounting for more than one in ten disability-adjusted life-years (DALYs) lost (Murray ; Lopez, 1996). Depression occurs approximately twice as often in women as in men, and commonly presents with unexplained physical symptoms, such as tiredness, aches and pains, dizziness, palpitations and sleep problems (Katon ; Walker, 1998; Hotopf et al., 1998). It is the most frequently encountered women’s mental health problem and the leading women’s health problem overall. Rates of depression in women of reproductive age are expected to increase in developing countries, and it is predicted that, by 2020, unipolar major depression will be the leading cause of DALYs lost by women (Murray ; Lopez, 1996). More than 150 million people experience depression each year worldwide.
Reproductive health programmes need to acknowledge the importance of mental health problems for women, and incorporate activities to address them in their services. Reproductive health conditions also make a major contribution to the global burden of disability, particularly for women, accounting for 21.9% of DALYs lost for women annually compared with only 3.1% for men (Murray ; Lopez, 1998).
The evidence base everywhere – in both high- and low-income countries – has significant gaps. Thus, the true impact on women’s mental health of the multiple reproductive health conditions experienced over the course of their life cannot currently be ascertained.