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'I don't experience any insults, but my wife does': The concerns of men with infertility in Ghana.

Although infertility affects both men and women, the experience of infertility among men and women in Africa appears to differ immensely. Globally, the evidence that women suffer more consequences from infertility than men is overwhelming. [1-5] Similarly, many research reports suggest that women in Africa suffer more negative consequences, such as depression and stress, compared with men. [2,4,6] Nevertheless, research evidence suggests that men equally suffer many psychosocial problems associated with infertility, especially when the infertility is known to be male-factor related. [7,8] In an intervention study in South Africa (SA), men with infertility in the treatment group were reported to have high levels of distress when compared with men in the control group. [8] In Ghana, men with infertility reported issues of depression, social isolation and stigma in a qualitative study. [9] These studies in Africa suggest that infertility is a distressing experience for men with infertility. It is therefore important to note that the experience of infertility among men in Africa may be under-reported. In fact, because of the cultural connotations of infertility as being a female problem in Africa, male infertility appears to be a problem of secrecy. As a result, many women in Africa are blamed when a couple is infertile. [10,11] Women are under intense pressure to conceive, and those with difficulties conceiving may end up divorced as a consequence, and may be ridiculed in society. [5,11]

Blame may be described as a process of considering someone or something responsible for a misdeed, failure or undesirable outcome. Some psychologists describe three main categories of blame. [12] First, blame is described as being both cognitive and social, because the outcome of the two processes is a judgement made by people in society. Second, blame is sometimes used for a social regulation of human behaviour, in which cultural morality is the driver of this social regulation. Third, blame is believed to rely on social recognition for its function, such that it is a judgement directed at a person who has violated a norm. Malle et al. [12] define blame as arising from a negative event, where the person blamed is seen as the cause of the negative event.

Viewing infertility within the lens of these descriptions, it may be described as an undesirable outcome for couples, and the blame is obliviously socially directed at the woman as the agent of causality. In the experience of infertility in Ghana, blaming the woman seems unavoidable, because of the culture of the Ghanaian people. Even though scientific evidence suggests that ~40-50% of infertility is attributable to men, women are largely blamed by spouses, families and society for the couple's infertility. [10,11,14] The purpose of this study was to explore the concerns of men with infertility, and particularly to address possible concerns about their wives being blamed for the couple's infertility.

Methods

Study design

A descriptive exploratory qualitative design was used to explore the concerns of men who were receiving treatment for infertility about the blame for male infertility falling on their wives.

Participants

Married men aged [greater than or equal to] 25 years who were receiving infertility treatment from a public hospital in Ghana were recruited via their wives.

Recruitment and data collection procedure

The Institutional Review Board of Noguchi Memorial Institute for Medical Research at the University of Ghana provided ethical approval for the study. The management of the hospital granted permission for data collection. A semi-structured interview guide was designed, based on the study objectives, which was divided into two sections. Section A consisted of questions on demographic characteristics, while section B had open-ended questions on the psychosocial experiences of infertility among the participants. Participants were purposefully sampled to include only married men aged [greater than or equal to] 25 and receiving treatment for infertility. The sample size was based on data saturation at the 12th participant. In-depth interviews were conducted. Each participant was interviewed twice. The first interview lasted ~20-30 minutes, while the second interview lasted 10 minutes. The second interview was used for member checking, that is, for validation of the findings by each participant. Each interview was transcribed verbatim for conventional content analysis.

Data analysis

Conventional content analysis was conducted. [15] This is used when the researcher has no clear preconceived ideas of what categories will be present in the data to be analysed. As a result, soft copies of all twelve transcripts were retrieved and re-read for familiarity by both authors, and from this, codes were derived.

First, the exact words and phrases in each transcript that appeared to be describing an idea were highlighted for discussion. Next, each author made notes on the first impression about the highlighted words and phrases. Many codes were derived from the highlighted phrases, which were later organised into six categories. Later, similar categories were collapsed, and finally three main themes emerged from the six categories. In the final step, the three categories were defined and named, based on the content of each category.

Results

The three themes that emerged from the data were traditional influences, emotional disturbances and pressure on wives. The findings are presented as verbatim quotations from the participants.

Demographic characteristics of participants

Twelve married men who were receiving treatment for infertility in a public hospital, were interviewed. These included men with either primary or secondary infertility, who were aged between 29 and 41 years, with various occupations, ranging from low to moderate income. The majority of the participants had lived with infertility for at least 2 years.

Traditional influences

Traditional influence was identified as a primary factor in the blame game of male infertility. In Africa, infertility is shrouded in many beliefs and perceptions. The magnitude of the experience of infertility in Africa is different for men and women. In Ghana, it is traditionally believed that infertility is a woman's problem. This belief was widely reported in the interviews, as narrated by the participants:

'You know people have this in mind that it is always the women who don't produce, they consider the women as barren and this is what they believe.'

Some participants wondered why male infertility appears to be acceptable in the western world, while this is not the case in Ghana:
   'It is society that makes things this way because in the western
   part of the world, I think some people marry and they go to court
   to sign that they are not going to have children. What about that?


Traditional influence was also reported from the perspective of the patriarchal nature of Ghanaian society, in which men are described as the 'heads of families', and this notion was described as a result of the traditional influence as follows:

'We men feel that because we are the heads, we don't need to be bothered in issues such as infertility'.

A participant believed that this notion is an African problem more generally, rather than only Ghanaian:

'They believe that in Africa, men dominate and control society and other things, so even if they have problems and they know very well that they have problems, they still wouldn't like to come out and would rather attribute such problems to their wives'.

Another aspect of traditional influence described by these men was the concept of what makes a man in traditional Ghanaian society. A participant reported:

'In our traditional concepts, you are really considered a man when you father a child and if you can't, you are not respected in your family.'

'Men in general we have some ego of superiority and we've heard that we should be able to control everything'.

Furthermore, the traditional influence on the experience of male infertility was linked to the purpose of marriage:

The public believe that if you marry, within a year or two, you must have a child, and if it does not happen then they will start asking questions how and why.'

In terms of using children as social security in old age, a participant reported that:

'You have to look after somebody to grow, so that the person will also look after you in old age.'

A similar opinion was reported by another participant in this manner:

'I will definitely get old and in times of old age you might need some help and you cannot go and call somebody's child to come and assist you.'

These findings suggest that the experience of male infertility is influenced by traditional beliefs and practices.

Emotional disturbances of men with infertility

Another factor that fuels the blame is emotional disturbances of men with infertility. Four categories of emotional disturbance of men with infertility were reported. These were worries/sadness/fear, concerns for wives, pressure from family and friends, and mental consequences. All the men were worried about their infertility status, as expressed by many:

'Only the infertility is my worry. At times I feel bad but I just want to block that side of my sadness.'

'I am worried because women have their time to give birth and if it passes that time, I would have placed my wife in a serious kind of trouble'.

Another participant similarly reported that:

'If I am unable to find a solution to it and my wife gets beyond the age of giving birth, that is where it is going to affect me plenty.'

For some of these men, their sadness emanated from the fact that their wives tried to shield them from humiliation:

'I feel very bad when my wife tries to shield me from such humiliation and stuff like that'

Peer comparison was another source of sadness for these men:

'I worry because all my colleagues have children, some even have four children and I am the only one who does not have children. It really makes me feel bad'

In addition to their personal emotional disturbances, these men had many concerns about their wives. They narrated their wishes to relieve their wives from familial and societal ridicule:

'I wish that I could satisfy my wife to have a child so that the family problems will all be solved and nobody will be insulted'

'My concern is about the disturbance that the public is giving to my wife, because I see it that if not because of me she wouldn't be going through that trauma. That is my only concern but left to me myself, I am okay'

A participant passionately and sadly attested that his wife deserves better:

'I just tell myself that she does not deserve this kind of treatment'

Another area of emotional disturbance described was the pressure from friends and family; participants attested to this pressure as the most common source of their emotional disturbance. One of the men had this to share about his family:

'Some family members ask me, they go like, my son what are you doing up to now? You have been married for almost 2 years and there is no child'

On the side of friends, participants shared similar experiences, as stated:

'When we meet as guys, they discuss about their wives and children. For instance, some of them will say their wives are pregnant, others will say their wives have given birth and so on'

Also, these men reported indirect pressure from their wives, in the form of attitudinal change when they have visiting friends and families with children:

'I see it more often when friends of hers or sisters come around with their children'

According to these men, on days when these indirect pressure from their wives are experienced, there is usually disunity and unhappiness in their homes, as evidenced by these quotes:

'My family is troubled with anger and quarrels in the house, sometimes, something that is not supposed to bring about anger, generates a fight'

'Sometimes she is overwhelmed with going to church for prayers and the rest. In fact, the least mistake I make brings about problems in the house'

Other areas of emotional disturbance reported were varied issues of functional status involving mental instabilities and sexual dysfunction:

'I felt like killing myself, but one of my friends told me this is not the end of the world'

'When I first got the information, it disturbed my performance when it comes to sex for some time before I came back to normal'

The majority reported these emotional disturbances as central problems in their lives. As a result, some of these men actually contemplated having their wives engage in extra-marital affairs to mitigate these emotional disturbances:

'Sometimes some crazy things come to my mind that why not allow her to go outside and bear her own child, and if she is willing to bring it home, I will father it'

Pressure on wives

Ironically, infertility in men is primarily identified via the female partner. Women are usually the first to go to hospitals, and do not hesitate to undergo numerous invasive diagnostic procedures. It is only when the woman is deemed to be fertile according to conventional assessment that the man may be assessed for infertility. It appears that male infertility has always been a secondary, clandestine health problem in Ghana, shielded by society, as reported by many participants:

'Everything is centred on the woman'

'Society associates it with the woman'

Hence, women are blamed and they suffer the social consequences of male infertility, as reported by many of these men as follows:

'They are not putting pressure on me, they are putting pressure on my wife'

A participant narrated his wife's ordeal as follows:

'In less than 6 months after we married, they took her without my consent, and later they called and informed me that because of so and so we are taking your wife to a herbalist, and I was very angry'

Another participant simply put it this way:

'I don't experience any insults, but my wife does'

Yet another participant was of the opinion that society and the wife's parents were the main offenders in the blame game. Consequently, some of the participants believed that negotiating with their wives might salvage the situation:

'I love my wife, so when I was told, I had to compromise with her'

Another participant said passionately about his wife:

'It is hell, but she is managing. I will say she is a strong person and sometimes when she comes [to me], I just have to console her'

On the other hand, some participants reported that:

'Some men try their luck outside [the marriage], so that if he succeeds he puts the blame on the woman'

In summary, these findings suggest that the blame game of male infertility is centred on traditional influences, emotional disturbances among men and pressure put on their wives to conceive.

Discussion

The findings of this study suggest that it is traditional influences that lead to emotional disturbances among men with infertility. Although these men suffered many emotional problems, the patriarchal nature of Ghanaian culture appears to be a major contributor to some of their emotions. For instance, all the men in this study were informed about their medical infertility, yet it was common for their families to blame it on their wives. As has been found in other African countries, the man is culturally considered to be faultless. [11] Meanwhile, men suffer emotional problems as a result of infertility. Emotional problems such as worry, sadness and fear have been reported among men in South Africa [8] and Zimbabwe. [13] The emotional problems among men in the present study were caused by pressure from family and society on their wives to conceive. It appears that the blame game of male infertility would be mitigated if Ghanaian society were to accept infertility as a problem for the couple, rather than a problem only for the woman.

The men reported being protected by their wives in society, with wives accepting the blame when questions about their inability to conceive were asked by family and friends. Some of these men contemplated infidelity as a strategy to prove their cultural faultlessness. Infidelity might be a desperate coping strategy for couples who agree to try for conception outside their marriage.

The blame game of male infertility is also obvious in the medical system in Ghana. For instance, when a couple experiences difficulties in conceiving, the woman is more likely to be the first to be investigated medically, suggesting that the cause of the couple's infertility is perceived as likely to be female related. Nevertheless, it is worth noting that men with infertility in Ghana are very concerned about their inability to conceive being blamed on their wives by their families and society. This may be a sign that Ghanaian men are beginning to appreciate infertility as a couple's problem.

Conclusion

The men in this study reported the negative consequences of infertility on their lives. The most common cause of concern for these men is blame being put on their wives, with pressure coming from family, neighbours and society. These findings indicate that although male infertility exists in Ghana, its experience is shrouded in secrecy. There is therefore a need for public education on male infertility in Ghana.

Acknowledgements. We thank the participants for sharing their experiences of infertility as men.

Author contributions. FN conceived the idea for the secondary analysis, designed and conducted the secondary analysis, drafted and revised all versions of the article and gave the approval for the final submitted version. AAK co-analysed, reviewed, and provided feedback on all versions of the article. Funding. Author-funded.

Conflicts of interest. None.

Accepted 4 August 2018.

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F Naab, (1) PhD, MPhil, BA, RM, SRN; A A Kwashie, (2) PhD candidate, MPhil, BSc, SRN

(1) Department of Maternal and Child Health, School of Nursing and Midwifery, College of Health Sciences, University of Ghana, Accra

(2) Department of Research, Education, and Administration, School of Nursing and Midwifery, College of Health Sciences, University of Ghana, Accra

Corresponding author: F Naab (florencenaab@yahoo.com)
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Title Annotation:RESEARCH
Author:Naab, F.; Kwashie, A.A.
Publication:South African Journal of Obstetrics and Gynaecology
Article Type:Report
Geographic Code:6GHAN
Date:Sep 1, 2018
Words:3447
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