Children are highly valued in Rwandan culture and around the world, but the psychosocial challenges faced by families dealing with infertility are unfathomable.
Not being able to have a baby makes women and men feel inadequate, like they are failing. In many cases, however, the woman is thought to be at fault if a couple has problems trying to conceive.
The sad reality is that this is yet to change even in this 21st Century; couples with infertility problems still face stigma from society.
Solange (not real name), and her husband understand these challenges all too well.
In their four-year marriage, they have been trying to have a baby in vain, and this has since denied them peace of mind.
Although the couple has been patient with each other, Solange says societal negativity and pressure worsens the matter as it’s hard for them to comprehend everything around them.
"Although some people choose not to talk to us about it, their faces tell it all. Others, especially relatives, point it out saying without children, our marriage is doomed,” she says.
The 31-year-old notes that until one is in her shoes, they will never understand the pain she goes through every day, now that society seems to fault her more than the partner. After being referred to a well-established fertility centre in Kigali, Solange has been seeking treatment for her infertility condition for six months now with hope that she will bear her first child.
Understanding infertility
Infertility is recognised as a public health issue worldwide by the World Health Organization (WHO), which calculated that over 10 per cent of women are inflicted — women who have tried unsuccessfully, and have remained in a stable relationship for five years or more.
For Silvain Muzungu, a gynaecologist at University Teaching Hospital of Kigali (CHUK), infertility is a unique medical condition, not only because of its devastating social-economic consequences, but also because it is placed on the woman.
He adds that infertility is a challenge faced by a couple. As such, there is a need for mass education to eliminate the stigma that couples, especially women, face.
Dr Emmanuel Semwaga, a gynaecologist/obstetrician at Mediheal Diagnostic and Fertility Centre in Kigali, says infertility is one of the health issues that aren’t given enough attention and resources in developing countries. And that due to this, research in this domain is scanty.
The 2015 Rwanda Demographic and Health Survey (DHS), however, reported that 4.6 per cent of married women in Rwanda don’t have kids.
The level of secondary infertility in Rwanda is between 5 to 7 per cent among women aged 20 to 44 years.
Just like it is with other stigmatised conditions, experts say infertility stigma may contribute to people hiding information about their diagnosis from friends or family, and delaying or avoiding treatments.
Kenneth Ruzindana, a consultant at the University Teaching Hospital of Kigali, says this stigma may also strain relationships, and take a psychological toll on individuals.
"The inability to become pregnant can lead to a variety of emotions including anxiety, depression, anger, and even guilt,” he says.
He says that some studies have shown that over 40 per cent of couples that are not able to get pregnant suffered from some type of psychiatric condition. The most common diagnosis was anxiety disorder followed by depression disorder.
Ruzindana adds that both sexes can suffer from these problems which can further hinder a couple’s ability to have a child.
"Psychological distress is associated with infertility treatment failure and interventions to relieve the stress associated with increased pregnancy rates,” he says.
Although the best approach for the treatment of psychological distress related to infertility treatment has not yet been determined, some experts suggest relaxation techniques, stress management, coping skills training and group support.
When to see a doctor
Ruzindana says it’s recommended that a couple begins getting tests if they cannot get pregnant after having unprotected sex for at least one year, although these tests are done sooner, especially if the woman is over the age of 35.
"When a couple has problems getting pregnant medics usually carry out tests on both parties to figure out the cause. However, as doctors, it’s hard to figure out why a couple cannot get pregnant without tests,” he says.
To begin with, Dr Muzungu says infertility is a problem of the couple. The cause of infertility can come from the man, the woman, or both.
How to go about it
First, society ought to be educated to avoid shaming victims as infertility is not the end of everything, one can still be helped and get children of their own, according to Semwaga.
He notes that at their facility centre, they have treated such cases and the good news is that those helped have all been able to have kids of their own through the treatment available.
He goes on to add that although it might take time, eventually, there is still chance that any couple struggling with infertility can still have babies — given the right treatment and depending on the cause of infertility.
"There are several causes of infertility from either the man or the woman. The most common cause for women in sub-Saharan Africa is tubal occlusion, followed by ovulatory failure,” he says.
The treatment of male and female infertility, Semwaga adds, may include drug therapy, for causes like ovulatory failure for women, low level of sexual hormones for males, and ineffective sexual intercourse to name a few.
Dr Muzungu notes that the treatment can even be surgical procedures such as intrauterine insemination or in vitro fertilization. This is done for other tubal factors such as fallopian tubes damages.
Recently, Rwanda Military Hospital opened a fertility clinic which offers highly specialised services such as in vitro fertilization or uterine insemination.
In addition, private fertility clinics exist in Rwanda although these specialised fertility services remain pretty expensive and are not covered by community health insurance.