MOI UNIVERSITY – MAIN CAMPUS SCHOOL OF ARTS AND SOCIAL SCIENCES DEPARTMENT OF SOCIOLOGY MANAGING INFERTILITY AMONG WOMEN IN RURAL PARTS OF KISUMU BY JAJ ALVINE OTIENO A RESEARCH PROPOSAL SUBMITTED IN PARTIAL FULFILMENT FOR DEGREE IN SOCIAL STUDIES (SOCIOLOGY) Table of Content List of Figures Figure 1Kisumu District 2006-2008 infertility record Figure 2Prevalence of infertility Glossary InfertilityInability to procreate within a year SterilityInability to produce a child FecundityIs the capacity/ability/potentiality to produce a live child Primary infertilitydenotes infertility of women who have never conceived

Secondary infertilitydenotes infertility of women who have conceived at least once Ectopic PregnancyIs a pregnancy in which the implantation of the embryo occurs outside the uterine cavity HypofertilitySignifies the biological inability to bear children Child DeficitOccurs when the ideal numbers of births outnumbers the actual number of births for the individual who have been exposed to sexual intercourse for years (5 years) Abbreviations “norro” The local term for gonorrhea STIs Sexually Transmitted Infections

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HIV/AIDSHumino Deficiency Syndrome/Arquired Immune Deficiency Syndrome WHO World Health Organization PID Pelvic Inflammatory Disease IVF In vitro fertilization ICSIIntracytoplasmic sperm injection SPSSStatistical Package for the Social Sciences 1. 0CHAPTER ONE 1. 1Background to the study This chapter presents an overview of global trends of infertility and also reveals the community views on the causes, effects and treatment of infertility. The chapter covers statement of the problems, objectives, and hypothesis as well as research questions.

Anthropological studies categorize causes of infertility into two broad groupings: traditional and naturalistic (Gerrits, 1997). The former may be classified into personalistic (human) or mystic causes (Janzen, 1981; Gerrits, 1997). Personalistic causes include the inability to procreate as a result of witchcraft and other spiritual problems. Naturalistic infertility involves close association between modern or biomedical causes and traditional causes. Other naturalistic causes include infection of uterus, ovary and “norro”, the local term for gonorrhea (Gerrits, 1997).

Lukse and Vacc (1999) posit that the term “barren” conveys the trying, potent emotional toll that failure to produce children exerts on a couple. Worldwide, between 8 and 12 percent of couples suffer from infertility or inability to conceive a child at some point during their reproductive lives (Reproductive Health Outlook, 1999). Despite that, in some non-Western societies, especially those in the “infertility belt” of Central and Southern Africa, rates of infection-induced infertility may be quite high, affecting as many as one third of all couples attempting to conceive (Collet et al, 1988; Larsen 1994; Ericksen and Brunette, 1996).

However, the new reproductive health facilities found in the West are unavailable in Africa (Inhorn, 1994a). Sundby (2001) observes that where reproductive health facilities are available, modern health care services may be of poor quality in many developing countries. Hence, it is not surprising that the ‘infertile’ often turn to traditional remedies and healers (Inhorn, 1994b). Many studies on reproduction reveal that women worldwide bear the major burden of infertility (Abbey, Andrews, and Halman, 1991; Greil, Leitko, and Poter, 1988; Inhorn and Van Balen 2001; Stanton et al. 991; Van Balen and Trimbos-Kemper 1993). Inhorn and Van Balen (2001) add that infertility has gendered social consequences, which are more grave in non-Western settings than in the Western World. Despite this, policy makers in developing countries are often obsessed with curbing population growth rates, ignoring the subpopulations suffering because of “barreness amidst plenty” (Inhorn 1994a). Infertility has impacted negatively at individual and community level. Many communities believe that infertility is caused by medical and socio-cultural factors.

To a greater extent, infertility makes women to suffer from personal grief and stigma as well as economic deprivation. Majorly women are blamed for reproductive mishaps and are sometimes divorced. Among the Ewe and the Ashanti of Nigeria, a man or woman who has no child is not considered fully adult and after death they are not buried with the full adult funeral rights. (Forter, 1978). Among the Ekit and Yoruba of Nigeria and the Aowin of Ghana), interfile women are treated as outcasts and their bodies are buried on the outskirts of town (Ademola, 1982; Ebin, 1982).

The Tswana of Botswana ensures that an infertile woman is not accorded full adult womanhood hence does not progress through the stages of the lifecycle which only comes after giving birth ( Suggs, 1993). Boddy (1989) reveals that in Sudan, children are a source of pride for a woman hence infertility threatens this power. In addition to that children connect society to ancestors besides playing vital role in subsistence production. Daniluk (1979) says that a woman who is infertile suffers form the loss of not being able to conceive a child and also the loss of meaningful relationship with close friends.

Infertility in a woman leads to dissatisfaction in a woman. This is true because such woman tend to lack experiences of pregnancy, childbirth and motherhood. As one woman struggling with infertility explains: Infertility challenges everything … your beliefs about yourself, about what’s important, about marriage, about what is fair and just, about good. Being infertile makes you question the purpose of marriage and life….. nothing is left unaffected by this expedience…Being infertile changes everything (as cited in Daniluk, 1997, p 103)

The problem of infertility is compounded by the fact that health sector in developing countries is undeveloped and mainly targets primary health care. As a result of this, a lot of attention is given to the reduction of maternal mortality and promotion of family planning. The disparity in rural and urban health provision is yet another factor that hinders infertility treatment. While urban areas enjoy relatively better reproductive health services, rural areas lack basic health facilities and funding. The situation is made worse by the fact that many health practitioners do not prefer to work in such remote areas. Bergstrom (1992) adds that in many rural areas of developing countries women see the problem of excessive fertility indicating that infertility is indeed a major social and healthcare problem in developing countries. This study aims at establishing the community’s views on the causes of infertility, effects and management means used by inhabitants of rural parts of Kisumu district, Nyanza province. Rural areas offer different characteristics as far reproductive health and sexuality issues are concerned. The differences are mainly geographical, historical, religious as well as cultural.

Although health information and services have been made available to the rural areas of Kenya, tradition and cultural beliefs are still more prevalent in these areas than in the urban populations. People still prefer consulting with traditional healers than with bio-medical health officers. In addition to that, human reproduction is viewed in most of rural Kenya as a natural process that should not be interfered with artificially. This view is reinforced by lack of culturally-appropriate information and education.

Hence the study focuses on rural areas of Kisumu district. 1. 2Statement of Problem There is widespread concern about a possible decline in female fertility in many of Kenya. This situation is mainly linked to Sexually Transmitted Infections (STIs), ovulatory disorder and unsafe abortion. All these have connections with infertility. Ovulatory dysfunction is yet another cause of infertility and is experienced when a female has a history of irregular menses. Such women miss their menses frequently and sometimes experience a lot of pain.

A history of very irregular cycles suggests an ovulation which needs further evaluation for its various causes, including premature ovarian failure and hypothalamic dysfunction like eating disorder and excessive exercise (Boivin et al, 2007) Mburugu (2004) asserts that infertility, whether primary or secondary, is unexpected by couples who decide to marry in Kenya. This is because the major reason for marriage in African society is to have children. He adds that a woman who cannot or decides not to have children is an object of pity.

Mburugu and Adams (2001) study of four societies in Kenya quote some of the rural women thus: “We divorced after two years because I was incapable of giving birth”. Another woman said, “Since I can’t give birth and people in my village know it, no man wants to be associated with me” (Mburugu and Adams, 2001). The male response is either divorce, or to seek a second wife. One person in the rural area had this to say: “My relatives keep telling me to get a second wife, since mine is barren. ” Another man stated: “I might marry another wife because we cannot have children and they are the ones that make life a success.

Without them life is useless” (Mburugu and Adams, 2001). It must be noted that such comments are made in a rural set up and that such comments may be very rare in urban centres where people are educated and exposed to better medical services. In Kisumu, a young lady called Atieno suffers from infertility. She is married and sells fish along the beaches of Lake Victoria while her husband is a rice farmer in Kadibo division. Atieno has been suffering from infertility for the last five years. Her desire to have children has not been fruitful.

Her mother in law has tried to advice her to consult with traditional healers but she has not accepted this. The mother in law believes that traditional healers can end Atieno’s infertility. Atieno had this to say: When I learnt of my inability to conceive, I talked to my husband about it but he said nothing. Instead he looked at me ferociously. Immediately, I experienced a sense of loss. I quickly concluded that something was wrong with me and that is why I am not able to conceive just like other women in the village.

I asked myself: how could this happen to me? My attempts to get family support have not been received well. Some family members have been telling me that I have brought curse to their home. And that my inability to conceive has got to do with some of the rituals that my parents did not do (primary source). Atieno has never lived a normal life since then. Her husband has opted to test his fertility by being involved in extra marital affairs. Her friends and relatives whisper behind her back. "She is barren,” Someone announces. "She may have the money but... magine a woman over 40 and still childless, her father must have been a witchdoctor hence she has been cursed" (primary source). Other whisper that her barrenness is as a result of an earlier sexually transmitted infection. Atieno was advised to undergo procedures to clean her womb. Van Balen and Gerrits (2001) sum up some of those practices as exploitative and potentially damaging. This study is in agreement with (Kimani et al, 1996) who report that that in Kenya, up to 60 per cent of the women who visit gynecologists report fertility-related problems.

The figure is high yet there are many unreported cases in remote parts of the country. Kisumu district gynecological record reveals that between 2006 and 2008 there are 484 women that have been confirmed to be suffering to be suffering from infertility (KDH, 2008). Among these women, 290 were from Kisumu district (60 percent), 77 from Siaya (16 percent), 48 from Bondo (10 percent), 34 from Nyando ((7 percent) and 15 from outside Nyanza (3 percent) (KDH, 2008). Refer to diagram 1. [pic] Source: Kisumu District 2006-2008 infertility record

Management of infertility may require changes in lifestyle, diet and the use of nutritional supplements. The use of herbal drugs can restore hormonal imbalances, encourage ovulation besides maintaining a pregnancy incase it occurs. For a better understanding of herbal medicine, traditional healers should not be overlooked in the process of treatment. This is because traditional healers are highly respected by members of the community. In addition to that, they speak the local language besides living in the same culture as their patients (van Balen and Gerrits, 2001).

As a result of this, their cooperation may be important in the development of new health strategies. This study has been necessitated by the desire to get insight into the explanations given by the community on the causes and effects of infertility among the residents of rural parts of Kisumu district; and second, to identify effects and the use of herbal drugs as healing options put in place by the community. The study acknowledges the fact that whereas several studies have been done on fertility issues, little has been done on infertility issues within Western Kenya. . 3Research Objectives To find out whether STIs leads to infertility To explore how ovulatory disorders lead to infertility To describe how unsafe abortion contributes to infertility among women To establish whether infertility leads to poverty To find out whether infertility leads to divorce To assess the use of herbal drugs in managing infertility among women 1. 4Research Questions Does STIs lead to infertility? Do ovulatory disorders lead to infertility? Does unsafe abortion contribute to infertility among women? Does infertility lead to poverty?

Does infertility lead to divorce? Can herbal drugs manage infertility among women? 1. 5Research Hypothesis 1There is a positive correlation between STIs (a dependent variable) and infertility and infertility (independent variable) (Sciarra, 1997; Gerrits, 1997; Zaba and Gregson, 1998; Bambra, 1999; Mayaud, 2000; Boerma and Urassa, 2001; Ikechebelu et al. , 2002) 2There is a positive correlation between ovulatory disorders (a dependent variable) and infertility (independent variable) (Cates et al. , 1998; Wiswedel and Allan, 1998; Fiander, 1990; Chigumadzi et al. 1998; Ikechubelu et al. , 2003; Larsen et al. , 2005) 3There is a positive correlation between unsafe abortion (a dependent variable) and infertility (independent variable) (Geelhoed et al. , 2002; Nachtigall, 2006) 4There is a positive correlation between poverty (a dependent variable) and infertility (independent variable) (Braverman, 1997; Alemaji and Thomas, 1997; Mulgaonkar, 2000) 5There is a positive correlation between divorce (a dependent variable) and infertility (independent variable) (Langley, 1979; Mbururu and Adams, 2001) 6Herbal drugs can manage infertility.

Correlation between herbal drugs (a dependent variable) and infertility (independent variable) (Ebomoyi and Adetoro, 1990; Gerrits, 1997; Koster-Oyekan, 1999; Seybold, 2002) 1. 6Purpose of the Study The outcome of the study will contribute to the theoretical knowledge on causes, effects and management of infertility in women. The findings will contribute to available knowledge in this subject area. Further, the study is expected to motivate other scholars to undertake more research on infertility and treatment.

It is hoped that the knowledge created from the study will contribute information that can drive the formulation of policy for the more effective implementation of infertility services in rural areas. It will also be helpful to further studies on the role of religion and herbal drug in managing infertility. 1. 7Scope and Limitations of the Study The study covers rural parts of Kisumu and will target infertility in women. Several challenges will be encountered in compiling secondary data on infertility.

These include making long journeys to different places to collect valid data besides and getting most recent information on infertility in Kenya. The study will also not cover the male factors that cause infertility. 2. 0CHAPTER TWO 2. 1LITERATURE REVIEW Chapter two covers the global prevalence of infertility among women besides illuminating the two types of infertility. It also explains the various causes, effects and management means of the same. The two types of theoretical framework are discussed in details.

Although there is little information in developing countries on infertility according to the definition of non-conception after one year of unprotected intercourse, World Health Organization (WHO) reports that infertility is a public health issue worldwide. It poses a major challenge to those involved in its treatment and assisted reproduction (Vayena, Rowe and Griffin, 2001). It is estimated that over one billion women aged between 15 and 49 years are currently in marriage or consensual unions as per the year 2006.

This includes 122 million women in less developed countries ((Boivin et al 2007). Within the same category are 72 million women aged 20-44 years living in marriage or consensual relationships. These women suffer from infertility defined as currently experiencing 12 month delay in conception while not using contraception. Of these women, 40 million are likely to seek healthcare and 32 million will not seek health care for the management of infertility due to stigma attached to it.

Out of the estimated 40 million women suffering from infertility, only 12 million would seek treatment (Boivin et al, 2007). In China, lowest estimated rate of childlessness in the first 5-7 years of marriage was one percent, whereas the highest estimated rate was 17 percent using the weighted average for sub-Saharan African countries (the range was 8-28 percent for the 28 countries that are in the original report (Larsen, 2000). Larsen (Ibid) observes that in Africa, prevalence of primary infertility is low, while secondary infertility affects 14-16 percent of women age 20-44 years.

He adds that tubal disease is the leading cause infertility and that ovulatory disorders have been diagnosed in 18-29 percent of cases. In the 1970s it was well documented that infertility was relatively low in Central Africa, although the extent of infertility throughout sub-Saharan Africa was unknown (Page and Coale 1972; Adadevoh 1974). It is estimated that about three percent of all couples cannot have children due to immunological incompatibility, genetic abnormality, anatomic abnormalities or other conditions that prevent conception or reduce viability (Bongaarts and Potter 1983).

The risk of infertility varies significantly by demographic and socioeconomic characteristics throughout sub-Saharan Africa. For instance, in Cameroon, Nigeria, Central African Republic, Kenya and Tanzania, women who initiated sexual relations in their early teens, women married more than once, and women in polygamous unions had higher odds of being infertile compared to women that became sexually active at age 20 or older, women in first union and women in monogamous unions (Larsen 1989, 1995, 2001, 2003a, 2003b).

This pattern suggests that sexual practices and STIs, such as gonorrhea and chlamydia, are important factors for pathological infertility. Extrapolated statistics on female infertility in East Africa stands at 242,515 in Kenya, Tanzania (265, 226) and Uganda (194,046) (www. wrongdiagnosis. com). Larsen (2000) reveals that 3% percent of Kenyan women suffer from infertility. He adds that secondary infertility is also prevalent in Lesotho (25 percent), Mozambique (21 percent) and Mauritania (21 percent) in women aged 24 to 44 years.

Farot and colleagues (1997) reveal that public health effects of fertility include exposure to sexually transmitted infections (STIs) including HIV, as infertile men and women in Sub-Saharan Africa often seek extra-marital relationships. Mayand (2001) emphasized the importance of STIs resulting in infertility of both the male and the female. Syphilis does not damage fallopian tubes but leads to foetal wastage and still birth, a condition that is also enhanced by HIV virus. Many developing countries are struggling to overcome infertility.

The situation is even worse in rural areas due to dilapidated medical infrastructure and poverty. The rural women are poor and cannot afford the high cost and the challenges that go with modern interventions in developing countries (Inhorn, 2003). In Nigeria, one cycle of IVF is estimated to cost between US $2,000 and U. S. $ 2,700, but the minimum wage in Nigeria is typically no more than U. S. $720 a year (Giwa-Osagie, 2002). Two cases of successful ICSI have recently been reported from a private IVF clinic in Lagos, Nigeria (Ajayi, Parsons and Bolton, 2003).

Table 2 is based on the findings of the four studies aimed at examining infertility prevalence for a period between 5 and 7 years after marriage. In general, the prevalence of lifetime infertility ranged from 5. 0 percent to 25 percent. The lowest estimated rate of childlessness in the first 5-8 years of marriage was 1. 3 percent in China, whereas the highest estimated rate was 16. 4 percent, using the weighted average, for sub-Saharan African countries (Larsen, 2000). In 28 countries, infertility ranged from 8 to 28 percent (Larsen, 2000).

According to Table 2, the prevalence of current infertility rate shows a range from 6. 9 percent for a 24- month delay in northern Tanzania to 9. 2 percent and 9. 3 percent for 12- month delay in Gambia and Shanghai, respectively. For more information refer to Table 2. Table 2: Potential need for medical care (prevalence of infertility) Authors Country or Year of Women Age of survey Reproductive Time to state Period covered population Percent Region Survey Sampled sample state defined (months) by survey sample size infertile

More developed countries Current Philippov et al. (1998) Russia 1998 married 18-45 Infertility 12 Current 2000 16. 7 Royal Commission 1993 Canada 1991 married 18-44 Infertility 12 Current 1412 8. 5 >1 yr

Royal Commission 1993 Canada 1991 married 18-44 Infertility 24 Current 1412 7 >1 yr Stephen and Chandra USA 2002 married 15-44 Infertility 12 Current 15 303 7. 4 (2006) Van Balen et al. (1997) Netherlands 1992 All 5-49 Infertility 12 Current 3295 10. 7 Webb and Holman Australia 1988 married 16-44 Infertility 12 Current 1495 3. 5 (1992) Lifetime Buckett and Bentick UK 1995 All 45-54 Infertility 12 Lifetime 728 17. 3 (1997) Dick et al. 2003) Australia 1991-1993 All 15-50 Infertility 12 Lifetime 1638 18. 4 Ducot et al. (1991) France 1998 All 18-49 Infertility 12 Lifetime 3181 12. 2 Greil and McQuillan USA 2002 All 25-50 Infertility 12 Lifetime 580 21. 2 (2004)

Gunnell and Ewings UK 1993 All 36-50 Infertility 12 Lifetime 2377 26. 4 (1994) Olsen et al. (1998)a Europe 1991-1993 All 25-44 Infertility 12 Lifetime 6630 11. 3 Rostad et al. (2006) Norway 1985-1995 All 50-69 Infertility 12 Lifetime 9983 6. Schimidt et al. (1995) Denamrk 1995 All 15 -44 Infertility 12 Lifetime 2865 15. 7 Templeton et al. (1990) U. K 1988 All 46 – 50 Infertility 24 Lifetime 766 14. 1 Webb & Holman Australia 1988 Married 16 – 44 Infertility 12 Lifetime 1495 19. (1992) 52253b Less Develop countries Current Che & Cleland (2002) China 1988 -1995 Newly 25 – 45 Infertility 12 Current 7872 9. 3 Married Larsen (2005) Northern 2003 All 20 -44 Infertility 24 Current 2019 6. Tanzania Sunby et al. (1998) Gambia 1994 Married 15 – 49 Infertility 12 Current 2918 4. 2 Lifetime Bar4den O- Falon (2005) Rural 2000-2002 All 15 – 34 Infertility 12 Lifetime 678 19. Malawi Fuentes & Devote Santiago 1993 Married 15 – 45 Infertility 12 Lifetime 474 25. 7 (1994) Chile Geelhoed et al. (2002) Rural Ghana 1999 All 15 – 44 Infertility 12 Lifetime 1073 11. Unisa (1999) India 1998 Married 20 – 49 Childlessness 36 Lifetime 6640 5 (Prasdesh) ? 3 Years Zarger et al. (1997) India 1997 Married 15 – 44 Infertilityd 12 Lifetime 10063 15. Kashmir ? 1 Year Che & Cleland (2002) Shanghai 1988-1995 Newly 25 – 45 Infertility 24 First 5 years 7872 3 China Married Ericksen & Brunnette Sub – Sahara n 1977-1992 Newly 20 – 41 Childlessness 60 first 5 Years WFS & DHS 14. (1996)C Africa Married Larsen (2000) Sub – Saharan 1977 – 1997 New 2 0- 44 Childlessness 60 First 7 Years 66453 16. 4 Africa Married Liu et al. (2005) China 2005 New 15 -57 Childlessness 84 First 7 Years 21970 1. (National) Married 120160 actually planned to conceive. Information from the European Study of Infertility and subfecundity. Data also used by Olsen et al. (1996) and Karmaus and Juul (1999). b Total does not include duplicate current and lifetime. c. DHS, Demographic and Health Surveys; WFS, World Fertility Survey; Lifetime: in pre- menopausal women this means lifetime to date of interview. d.

Primary Infertility only. Boivin et al. 2007 Primary and Secondary Infertility Sciarra (1994) describes infertility as a situation where couples of reproductive age who have sexual intercourse without contraception are unable to have children. He adds that infertility means inability to establish a pregnancy within a specified period of time, usually one year. Primary infertility denotes infertility of women who have never conceived while secondary infertility denotes infertility of women who have conceived at least once.

The World Health Organisation (WHO) (as cited in Rowe, Comhaire, Hargreave and Mellows, 1993) recommends modifying the clinical infertility definition for use in epidemiological research as follows: “The absence of conception in 24 months of regular unprotected intercourse. ” WHO proposed to extend the period of trying to get pregnant from 12 to 24 months because it had been found that many couples who did not get pregnant in a period of 12 months did eventually get pregnant without treatment.

The clinical and epidemiological infertility definitions capture cases of couples that cannot conceive, while the demographic definition includes both those that cannot conceive and those that are unable to carry a pregnancy to term and deliver a live birth, for instance pregnancy wastage (Wilkson, 1999). Causes of infertility A study conducted in Chad revealed that women are born with unknown number of children in their bodies, except for a few women who are born infertile (without children in them) and cannot be cured (Leonard, 2002).

Female infertility is most commonly caused by lack of ovulation, which is the development and release of eggs from the ovary. Ovulation problems can be caused by hormonal deficiencies or lifestyle factors, such as obesity, alcohol intake, or being severely underweight (Office for National Statistics, 1987). Fallopian tube blockage is another common cause of infertility. This blockage is commonly caused by scarring from a previous untreated sexually transmitted disease. Uterine tissue that grows outside the uterus can also contribute to infertility.

In addition, anatomical abnormalities, such as fibroids can contribute to the inability of sperm to meet the egg or cause the egg to fail to implant in the uterine wall (Hull & Abuzeid, 1997). Some women are believed to be incompatible with their husbands and hence cannot conceive. Unsafe obstetric practices during abortion can introduce new infections that can lead to Pelvic Inflammatory Disease (PID) or other problems that may hinder conception. Several cases of infertility after delivery or abortion may however still be due to Chlamydia and other Sexually Transmitted Infections (STIs).

STIs are recognized as the most commonly preventable cause of tubal infection. Medically, pelvic infection which is linked to tubal damage is one of the leading courses of tubal sub fertility. Such damages can be caused by sexually transmitted diseases, miscarriages, termination of pregnancy or insertion of an intrauterine contraceptive device. Chlamydia tracchomatis accounts for around half the cases of acute pelvic inflammatory disease. It is the commonest sexually transmitted agent in many countries.

Chlamydial infections are often not diagnosed because they have few symptoms of infection. Chlamydia infections can damage the reproductive tract hence leading to infertility. Presence of gonorrhea in both rural and urban areas as a result of multiple sexual partners among the young may lead to infection of the female genital organs. Gonorrhea presents itself as a localized infection of the lower genital tract and as an invasive infection of the upper genital tract hence leading to infertility.

In addition to that Genital tuberculosis can cause tubal damage leading infection of ovaries and frozen pelvis hence leading to infertility. Post-pregnancy sepsis or abortion may lead to damages in the uterine walls leading to difficulties in conception. There are other harmful traditional practices which hinder conception. For instance narrowing of vagina using foreign substances can hinder conception. These include inserting some herbs and washing detergents into the vagina. This practice can make sexual intercourse uncomfortable.

Some communities believe that eating certain parts of chicken leads to infertility in a woman. Others believe that having sexual intercourse with older people can lead to infertility. There is a myth surrounding the use of condoms postulating that it contributes to infertility among married couples. For adults, age is a factor that can lead to infertility in a woman. This view is supported by Boivin and associates (2007) who assert that the age of the mother is one of the determinants of infertility.

They acknowledge that for women below 26 years of age, cumulative conception rates is 60 percent at six months and 85 percent at a year of regular sex, but conception rates are more than halved by age 35. After 35 years there is a decrease in the number of eggs which ovulate as well as a decrease in the quality of eggs (Boivin et al, 2007). Since women are born with all of the eggs that they will ever have, the longer a woman lives, the more likely it is that cell division and exposure to toxins can cause genetic problems within her remaining eggs (Cahill et al, 1994).

In addition to male and female-factor infertility, there is also a medical entity called "Unexplained Infertility" which occurs when doctors cannot pinpoint a specific cause for infertility. Infertility can lead to stress onto an already frustrating and confusing condition of the woman. Infertility in a couple can be caused by factors that are attributed to the male’s condition. Conditions leading to their infertility are often referred to as the male’s factors. Such factors play a bigger role in household infertility.

In at least one third of couples, infertility cases are attributable to a male factor. The male’s condition or factors that lead to infertility include testicular injury, abnormal sperms, history of STIs, urinary or hernia surgery and infection (Maheshwari, Fowler and Bhattachanya, 2006). Management of Infertility In some Africa countries, the reproductive technologies are feasible and successful in low resource settings with trained human resources and equipment. In Mombasa, Kenya, an IVF center was created in 1995, and nearly 50 patients had attended by early 2003, according to Dr Abdallah Kibwana, an bstetrician/gynecologist from Mombasa’s Coast General Hospital. At a regional obstetrical conference, he reported that 19 of the patients seen at the IVF center have conceived with the help of simple ovarian stimulation, and two babies have been born using IVF (Kibwana, 2003) Koster-Oyekan (1999) acknowledges that infertility can be managed by a number of different traditional healers, herbalists and spiritual healers. He adds that treatment involves sacrifices offered to deities or ancestors, various ceremonies to lift evil curses as well as powders and medicinal soaps.

Linked to these interventions are preventative strategies which include charms, herbs and the adherence to cultural taboos. A further preventative strategy is the avoidance of contraceptives and vaginal speculum examination as these are believed to be possible causes of infertility (Koster-Oyekan, 1999). In southern Chad, infertility-related health-seeking behaviour is referred to as 'looking for children' and 'doing research (Leonard, 2002). At the outset of this 'research' the cause of infertility has to be identified-often from a multitude of possibilities.

Intervention can also involve reconciliation ceremonies, food offerings and ritual cleansing. In contrast, help is sought from the biomedical sector for most of the somatically expressed causes of infertility (such as infections, worm infestation and a 'dirty' womb) (Leonard, 2002) Marabouts, who are healers connected with the Muslim faith, play an important role in providing infertility-related health care in the Gambia (Sundby, 1997). Interventions are usually based on medicinal drinks and amulets containing writings from the Koran.

Other aspects of traditional health care involve spiritual healers, herbalists, fortune tellers and visits to sacred places. Several other studies describe the important role that herbs, medicinal drinks, amulets, cleansing rituals, spiritual and religious healers play in the management of infertility in Africa. (Ebomoyi and Adetoro, 1990; Gerrits, 1997; Seybold, 2002), Collectively, these studies indicate that, although traditional health systems may differ in their individual contexts and in the beliefs upon which they are built, their overall role and structure is remarkably similar throughout the continent (Sundby, 1997).

Available evidence on infertility related health-seeking behaviour in Africa indicates that women (and at, times men) access both traditional and modern health services, and in both health sectors infertility is a leading cause for consultation (Inhom and Buss, 1994; Shai-Mahoko, 1996; Genits, 1997; Sundby, 1997; Koster-Oyekan, 1999: Leonard, 2002; Richards, 2002; Stekelenburg et al. , 2005). Attempts to improve fertility may require “a pre -conception care” and this can involve the use of folic acids, zinc, vitamin E and C. A healthy diet is recommended for conception to occur and ensuring a healthy baby.

It may also call for individuals to avoid certain foods and drinks that lower fertility. For instance one may have to avoid drinking alcohol and taking caffeine or being exposed to pesticides. Fatty acids are likely to improve quality of sperms and increase sperm count. In 1994, the United Nations International Conference on Population and Development emphasized the need to ensure prevention and appropriate treatment of infertility. In spite of this, no progress has been made in education and service in Sub-Saharan Africa due to a lack of guidelines or concrete actions and programs (Fathalla, 2007).

In Kenya, the ICPD program was integrated into National Population Policy for Sustainable Development. This policy document outlines the population and development goals, objectives and targets to guide its implementation up to the year 2010 in Kenya. Broad goals and objectives included reproductive health and reproductive rights, adolescents’ reproductive health, gender perspectives, and HIV/AIDS. Kenya has faced numerous challenges in re-orienting its programs to be in line with the recommendations.

Some of the challenges include underdeveloped infrastructure and health care delivery, weak adolescent reproductive health services, infertility, and safe motherhood as well as child survival. On a more specific note, infertility services are mainly offered at Kenyatta National Hospitals as well as Nairobi Hospital. These hospitals are located in the city centre out of reach of the rural poor. The Kenya Vision 2030 that envisages high quality life by 2030 may not be attained if the country does not invest heavily in the reproductive health services.

Men and women may employ strategies, which are not related to the health sector. These include feigning pregnancies and miscarriages to avoid the worst of the stigma. The same state of affairs is witnessed in Kenya and more so in Nyanza Province. Those who reside in the rural parts of Kisumu district, Nyanza province are known for herbal drugs which are used to manage infertility, a view supported by Gerrits and Sundby (1997). This study intends to find out more on causes, effects and management of infertility within the rural parts of Kisumu 2. 2THEORETICAL FRAMEWORK . 2. 1Life Crisis Theory Menning (1977) proposed the life crisis theory of infertility similar to the grief model used with dying patients and their families. Donnis and Menning (1984) reveal that the life-crisis model views infertility as a major negative social setback. Proponents of this theory believe that infertility can increase anxiety and stress and negatively affect coping skills of a woman (O’Moore, O’ Moore, Harrison Murphy and Carruthers, 1983). The term “life crisis” refers to the occurrence of something unexpected that negatively affects the recipient.

A crisis may also be because of the lack of an expected transition to childlessness, otherwise known as "nonevent" (Schlossberg, Waters, & Goodman, 1995). Many persons who are infertile have made a decision to have children, only to find that they are unable to do so. The inability to achieve parenthood and fulfill personal and societal goals can cause a life crisis (Menning, 1977). The effect that infertility has on an individual depends on his or her type of personality, coping style, and motivations for children (Battrerman, 1985; Blenner, 1990; Rosenthal, 1998).

Menning (1977) urged helping professionals to use crisis intervention techniques and grief or loss interventions when working with couples who are infertile. Other authors have suggested that the initial crisis often turns in to a chronic condition and requires additional long –term interventions (Wilson, 1991; Forest & Gilbert, 1992). This theory suits this study because it views infertility as an expected social setback which affects a women’s coping mechanism. The effects of infertility are felt at individual, family and community level. 2. 2. 2Biopsychosocial theory of infertility

Infertility may lead to stress, a view supported by Pasch and Dunkel Schetter (1997) who asserts that infertility alters a couple’s expectations. Gove and Carpenter (1982) say that biological, psychological and social factors interact in complex ways. Biosocial theory attempts to explain human behavior in a way that addresses the interaction of biological, psychological and social factors. It views infertility as an acute life crisis which has long-term complications for the individual, his or her partner, their relationship, and family and friends.

This notion is reinforced by the very important role played by children in connecting the community with the ancestors. Meyers and others (1995) assert that children provide existential meaning, identity, and status; they grant parents the traditional means of participating in the continuity of family, a culture, and the human race. The ability to have a child is linked to cultural and social belief about identity. Inability to conceive or carry a child to term may affect an individual’s views of feminity, (Carmeli and Birenbaum-Carmeli, 1994; Woollett, 1985).

Individual diagnosed with infertility frequently feel defective, unattractive, and unacceptable to others (Battreman, 1985; Valentine, 1996). Greil et al, (1988) add that failure to conceive creates doubts for the individual about competencies in other roles such as parenting and marital relationship. Ferber, (1995) and Valentine (1986) are of the opinion that infertility revives insecurity and inferiority feelings. It also strains relationships and communication within families.

The use of modern reproductive services is often expensive and rejected by the community members who fail to understand or accept a child who is biologically different. This is likely to lead to isolation of the couples by the community. Such lack of understanding leads to encroachment on privacy and rejection of alternative solutions (Meyer et al, 1999). The two theories compliment each other and so it is important to use two of them in this study. The life crisis theory explains the negative effects of infertility in a person.

Infertility leads to crisis that is mental and hence leads to stress which in turn affects other body parts. The biosocial theory puts more emphasis on social issues. In other words, infertility affects one’s relation with relatives, friends and community in general. 3. 0CHAPTER THREE RESEARCH DESIGN AND METHODOLOGY Chapter three touches on the study site, research design, sampling and subjects. It also covers the various types of methods of data collection like in-depth interviews, focus group discussions and secondary data.

Methods of analyzing qualitative and quantitative data are discussed as well as recruitment procedures and population. 3. 1The study Site The study site is rural areas of Kisumu district, Nyanza Province, Kenya. Kisumu comprises four divisions namely Kadibo, Kombewa, Maseno and Winam. This district is host to Kenya’s second City, and a harbor on Lake Victoria. In addition, it is an important regional center linking Kenya to the East African countries of Uganda and Tanzania. This is basically an agricultural and fishing region inhabited by either poor or middle income earners.

The district mainly experiences the following diseases: Malaria, respiratory tract infections, diarrhoea diseases, skin diseases, and urinary tract infections, and HIV/AIDS. 3. 2Research Design Leedy & Ormrod (1985) view research design as a blue-print or a detailed plan of how the study is going to be conducted. In this case, the study will rely on interviews, secondary data and focus group discussions. 3. 4Sampling and subjects The term infertility refers to inability to procreate or inability by a couple to conceive within a given year.

It can also be used to mean inability by a couple to produce a live birth (Healy, Trounson and Andren, 1994). Infertility can be measured at the level where a woman cannot have a child totally or for a period of one or two years. The study targets 60 women experiencing children deficits as a result of infertility. In this case a child deficit will be considered as a situation where the society’s ideal number of births outnumbers the actual births for those individuals who have been exposed to sexual intercourse. The other 20 respondents will be those who have tested HIV positive and suffer from infertility.

In this case the study will aim at establishing correlation between HIV and infertility. In other words the study will find out whether infertility leads to or can be a consequence of HIV. 1 3. 5Data Collection Techniques 3. 5. 1In-depth Interviews Qualitative method will be used in this study because it is well suited to an exploratory study of a population about which "little” is know for two main reasons. First, open ended interviews provide an opportunity to gain insights into the dynamics of behavior and experience of the group.

Second, the researcher is able to assess subtle interaction between an individual woman's behavior and the larger and the larger social context. The data will be guided by the participants experiences (Berg, 1998). It will assume that 1) women suffering from infertility can provide the most relevant accounts of their own account of their personal experiences and feelings, 2) a small sample (N=45) will yield sufficient data as each participant will have potential to provide information on all the various aspects of the phenomenon being explored, and 3) the study would inform future, larger scale research.

Seeking the participants' voices and personal experiences as told by the participants' will elucidate experiences as told by the experiences of success and frustrations as defined by the individual participants themselves (Denzen,1989). The expression of an individual's voice is a positive step toward emancipation (Gillinland, 1995; Noel, 1994). Reinharz (1992) rightly puts it "interviewing offers researchers access to people's ideas, thoughts, and memories in their own words rather than in the words of the researcher” (as cited in Guno, 2001, p. 50). 3. 5. 2Focus Group Discussions and Interviews

Focus groups have been used extensively within the health and nursing arena to explore a range of issues with minority ethnic communities (Dignan et al. , 1990; Fallon and Brown, 2002). Focus group discussions and interviews have a number of advantages and few disadvantages. For instance, they do not discriminate against people who cannot read or write and are often excluded from more formal channels of communication. They also encourage participation from people often reluctant to be interviewed on their own. and might give the opportunity for participants to speak more freely about negative experiences (Kitzinger, 1995).

In the general literature, focus groups have also been advocated for their value in helping researchers gain access to “community” responses to an issue thus allowing them to understand group norms and values that would be more difficult to discern via individual interviews (Waterton and Wynne, 1999). In health studies, focus groups are used to get views, beliefs, or attitudes of a target population (Barbour and Kitzinger, 1999). Merton and Kendall (1946) reveal that the use of focus groups can be traced to the focused interviews and focus group discussion.

Through discussion, participant questioning and disagreement, focus groups have particular potential for exploring the processes through which meaning is jointly constructed (Wilkinson, 1999). However, some disadvantages have been noted, for instance, focus groups can be difficult to organize; recordings are time –consuming to transcribe, and data are more difficult to analyze than those of individual interviews. The possibility of group effects cannot be ignored (Asch, 1951; Carey and Smith, 1994). There are also important concerns in relation to reliability and validity. . 5. 3Secondary Data The data for this study will be obtained from ministry of health offices, National Archive, Kenyatta National Hospital, University libraries and from the NGOs like Aphia Nyanza and Engendered Health. In addition to that, the researcher will collect a lot of material from the internet. Examples of secondary materials that will be used include articles, dissertations other publications. The information will be filtered, interpreted and focused to meet the priority of the study and to identify gaps in the area of infertility. 3. 60Data analysis

The data will be evaluated using SPSS with the chi square (? 2) test and percentage (%) ratios where possible. Independent variables, which can affect the dependent variable, will be determined using a logistic regression model, which is used as a multivariate analysis method. Abortion, witchcraft, STIs and others will be chosen as independent variables. The Qualitative data will help describe and explain social phenomena. These categories will be derived inductively, that is, obtaining information gradually from the data or using information deductively, either at the beginning or the end.

Discourse analysis will be used to ensure that discourse or themes are identifies by reading and re-reading transcripts of each interview. It will also focus on how words, description and metaphors are assembled to form discourse that socially constructs a concept such as STIs, as Chlamydia infections or gonorrhea. 3. 70Recruitment procedures and population Both the male and the female participants will be recruited from the rural parts of the four divisions in Kisumu districts. The selection of the participants will be done randomly.

Information on how to reach the women suffering from infertility will be obtained from the herbalist who offers treatment for them on different days of the week. The first category of females to be interviewed will be those that suffer from infertility. For the purpose of in-depth interviews, 45 women participant will be recruited randomly from the four divisions of Kisumu District. The sample of women for the qualitative interviews will be selected based on their status as infertile. The selected women will be of different education, religions, backgrounds and ages.

Some of the questions to be asked include, how long have you tried to get pregnant? Women will be interviewed without the presence of their partners and in their preferred language, Dholuo since this is the most widely spoken language in the area. All interviews will be conducted by professional research assistants trained in qualitative and quantitative data research. A three part questionnaire with a first part that will target community’s views on what causes infertility will be administered. The second part will target effects of infertility in women while the third part will target community’s treatment options using herbal drugs.

The second category will be 5 female herbalists who will be interviewed on the treatment seeking behaviors of their clients. The third category will be 20 females out of which 10 are married and other 10 are not married. The group will be interviewed on issues touching on their feelings women suffering from infertility. There will be 8 focus groups out of which 4 groups with a total of 30 females suffering infertility drawn from these communities will participate in the discussions. The other 4 focus groups will be made up of 20 married males.

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