In Africa, Hope for the Stigmatized: Fertility Clinics

By Stephanie McCrummen
Washington Post Foreign Service
Thursday, August 14, 2008

KAMPALA, Uganda -- In a country with one of the highest birthrates on Earth, where bearing children is considered a woman's singular purpose, Betty Apio leads an unusual life.

She has no children, not by choice, but because of a string of medical mishaps. Though she cares for nieces and nephews, she essentially lives on her own in the Kampala suburbs, where her living room is adorned with photos of the smiling husband who left her for a woman who could, as people here say, "produce." Some neighbors believe she is cursed. They shoo their children away from the pretty lady next door, a teacher who dreams of building a day-care center. She has learned to ignore them.

"People will never give you respect," said Apio, 44. "You have no value. People insult you -- 'You barren woman! You are useless!' It's horrible. And if you are not strong, you will not survive."

But Apio and an increasing number of other middle-class African women are seeking their social salvation in a service unheard of here until recently: fertility treatments. In the past few years, two clinics have opened in Kampala, one in Nairobi and a handful of others in major cities across the continent.

The clinics offer an alternative to superstitious explanations of infertility and the dubious advice of traditional healers, whose cures include having women run naked in circles around a dead sparrow at night. Fertility doctors are also bringing to light an uncomfortable truth about a condition almost always blamed on women: that at least half the time, the problem is with the man.

"The number of clients is going up by the day," said Annie Akatabaazi, who helps run a clinic that treats some of the few thousand women here who seek help each year. "Some ask to come at night, so they'll not be seen. Some call whispering. Sometimes they don't want to give you their name. They come saying, 'My husband is going to leave me if I don't have children.' And the men, once they find out, they come every day. If they have an appointment at 9 a.m., they show up at 8."

In much of Africa, the stigma of infertility is so severe that it often drives women -- and men -- to suicide. In some rural areas, women who die without children are carried in their coffins through the back door of the church. Women are sometimes branded witches and in other ways forced into isolation in a society that has few places for them.

The deeply entrenched culture of large families in Africa has to do with economics. In societies with virtually no government safety net, children represent financial security: One way or another, they are expected to provide for their parents when they get old. And for women in particular, children are a kind of insurance, protecting mothers against a divorce system that tends to grant property to men.

"In the African sense, children are an investment," said Robinah Kaitiritimba, a health-care advocate in Kampala, a bustling, hilly city of contrasts, where extreme poverty exists alongside malls and middle-class neighborhoods.

Women in Uganda, where polygamy is legal, have seven children on average; a recent newspaper article described in celebratory tones the life and times of a man who had 120 children with seven wives.

Though ideas about family are slowly changing, even relatively educated, middle-class women such as Apio suffer in a culture that seems designed to shun them.

She and her husband, who is also a teacher, married in the 1980s to the joy of both their families and with the absolute expectation that children would soon follow. They bought a house in Kampala, which Apio furnished with brown velour couches, tables with white doilies and their wedding photos. But the children never came.

Apio, who agreed to discuss her situation in the hope that other women would feel less alone, attributes her condition to an abortion she had when she was young. Getting pregnant at her age was taboo in her village, she said, and so was discussing the matter with her mother. So Apio's sister arranged for her to have an abortion at a hospital.

Abortion is illegal in Uganda, and Apio's procedure was, she learned later, botched.

After she and her husband were unable to conceive, she went to a gynecologist who told her that one of her fallopian tubes was blocked. He recommended an operation to fix it. When Apio awoke, the doctor told her that he had removed the tube.

Distraught, she went to another doctor, who also recommended an operation. He removed the functioning tube, though she still does not know why.

Her husband's family taunted her and told him to find another woman, which he eventually did. They had two children. When Apio refused to pay school fees for them, his relatives complained she was jealous. "They say to my husband, 'Why are you keeping that woman?' " she said.

His new wife does not allow the children to visit Apio, saying she "has a dark heart," she said. Her husband comes around a couple of times a week, or sometimes just once a month. Though he mostly annoys her, Apio said she is worried that he will leave and take the house from her. So she tries to be kind.

"Sometimes I want a divorce and to stay on my own," she said. "Then I go to my mother, and she says to stay, that I'll shame the family. She says to stay in the marriage, even if it's painful. But sometimes I want to leave -- to do my own things. Sometimes I get annoyed with him and tell him not to come back. But then he comes back. I worry about the future."

Adoption is rare among Africans, though many care for the children of less-fortunate relatives.

Women unable to conceive often end up supporting the children of their sisters and brothers, aunts and uncles. Apio has put a nephew through college and is putting two nieces through private school, though she realizes she will not be able to depend on them later in life.

"When the time comes, they'll go," Apio said, noting that the nephew never comes around anymore.

She has found some comfort from her sister and two brothers and some relief at a counseling center in Kampala called Joyce. Its founder, Ritah Sembuyu, named the center for the child she never had. She runs support groups that comfort women by offering them scientific explanations of their situations, camaraderie and referrals to fertility clinics.

"Even if people tease me now, I don't care," said Apio, who is holding out hope that in vitro fertilization might work in her case.

Prakesh Patel, who runs one of the fertility clinics in Kampala, said women often pretend to be going to this shop or that, before rushing through his doors. Many come without their husband's knowledge. They offer to pay for late-night appointments. And they often wind up crying in his office. "I say to them, 'This is not a disease. There are many like you -- you don't have to be ashamed,' " Patel said.

Then he contends with the physical and psychological trauma done by traditional healers, who often prescribe herbs that do more damage than good. He gives basic anatomy lessons. He tells women they do not have to tolerate their obnoxious relatives and at times encourages women to consider their childlessness a blessing -- a way to escape the confines of a male-dominated society.

"I tell them that if people pressure you, don't let them," he said. "Women here are considered property -- as objects rather than human beings. Like a table with one leg gone wobbly is a useless table, if a woman cannot produce, she is a useless woman."

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