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Marriage & Family Review
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wmfr20
Sociocultural Implications of Infertility and
Challenges in Accessing Assisted Reproductive
Technology: Experiences of Couples from Two
Health Facilities in Southern Ghana
Gideon Nii Okai Okantey, Emmanuel Brenyah Adomako, Frank Darkwa
Baffour & David Lim
To cite this article: Gideon Nii Okai Okantey, Emmanuel Brenyah Adomako, Frank Darkwa
Baffour & David Lim (2021): Sociocultural Implications of Infertility and Challenges in Accessing
Assisted Reproductive Technology: Experiences of Couples from Two Health Facilities in Southern
Ghana, Marriage & Family Review, DOI: 10.1080/01494929.2021.1880529
To link to this article: https://doi.org/10.1080/01494929.2021.1880529
Published online: 24 Feb 2021.
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Sociocultural Implications of Infertility and Challenges
in Accessing Assisted Reproductive Technology:
Experiences of Couples from Two Health Facilities in
Southern Ghana
Gideon Nii Okai Okantey
a
, Emmanuel Brenyah Adomako
a
,
Frank Darkwa Baffour
b
, and David Lim
c
a
Department of Social Work, University of Ghana, Legon, Ghana;
b
James Cook University,
Townsville, Australia;
c
University of Western Sydney, Sydney, Australia
ABSTRACT
Introduction: In most traditional societies in Ghana, infertility
is unacceptable and every couple is expected to conceive chil-
dren by any means. This study explores the sociocultural
implications of infertility in Ghana and the challenges couples
encounter in accessing assisted reproductive technology.
Methods: The study used a qualitative descriptive design in
two health facilities in an urban community in Southern
Ghana. The study recruited 20 participants: 16 individuals who
had accessed assisted reproductive technology, two nurses
and two gynecologists. Participants were purposely selected
and data were analyzed thematically.
Results: Culturally, couples who are unable to give birth are
considered witches, discriminated against in decision making
and are believed to be rejected by the ancestral world when
they die. It was found that these sociocultural implications of
infertility compelled couples to access assisted reproductive tech-
nologies and were faced with social challenges, psychological
implications, economic constraints, and medical complications.
Conclusions: Children born through assisted reproductive
technologies are not accepted by some sections of the society
despite the challenges couples encounter in accessing these
technologies. Public sensitization should be intensified in
Ghana to accept the use of assisted reproductive technologies
to limit stigmatization of couples with fertility problems and
children born through assisted reproductive technology.
Abbreviations: ART: assisted reproduction technology
KEYWORDS
assisted reproductive
technology; infertility;
couples; childbirth
1. Introduction
In Ghana, the prevalence rate of infertility is relatively high (Tabong &
Adongo, 2013). It is estimated that 15% of persons of child-bearing age in
Ghana are faced with infertility (Donkor & Sandall, 2007). Further, it has
CONTACT Emmanuel Brenyah Adomako e.ad42@yahoo.com Department of Social Work, University of
Ghana, Legon, Ghana.
ß2021 Taylor & Francis Group, LLC
MARRIAGE & FAMILY REVIEW
https://doi.org/10.1080/01494929.2021.1880529
been estimated that infertility affects one in four couples in low and mid-
dle-income countries (Rutstein & Shah, 2004). These statistics suggest that
many people in low and middle-income countries in their reproductive age
face difficulties having children. It is therefore essential for persons with
fertility problems to have access to treatment and/or to be able to resort to
alternative means to have children. The challenges to conceive and the
desire to get treatment tend to negatively affect individuals with fertility
problems. Most often, these individuals are traumatized both psychologic-
ally and emotionally (Peloquin & Lafontaine, 2010; Ying et al., 2015), and
may experience anger, regret, loss of self-esteem, and maybe ostracized by
the community, particularly in low and middle-income countries
(Behboodi-Moghadam et al., 2013). In most low and middle-income coun-
tries, individuals feel a personal responsibility to conceive and married cou-
ples are also expected by society to have children of their own (Ombelet,
2014). This expectation burdens couples especially, to conceive immediately
after marriage, making infertility a socially constructed process whereby
individuals define their inability to give birth as a problem (Greil
et al., 2010).
Infertility is a serious social problem because childbearing is expected of
married couples especially in low and middle-income countries (Gyekye,
1996). Given that in most cases, as suggested by Caldwell’s intergenera-
tional wealth flows theory, a child is supposed to care for his or her parents
in their old age especially in low and middle-income countries (Kaplan &
Bock, 2001), and being unable to conceive has an impact on the individual
as well as the community (Gyekye, 1996). In low and middle-income coun-
tries, traditional stories or folklores modeled around the significance of
children tend to disempower couples facing challenges in having a child
(Inhorn & Birenbaum-Carmeli, 2008).
Most often, the decision by individuals to conceive or not, is likely to be
affected by stigma and prejudices, depending on the nature of the commu-
nity in which these persons reside (Inhorn & Birenbaum-Carmeli, 2008). In
developed countries, an individuals’decision not to have children is more
acceptable when compared to some low and middle-income countries
where individuals are expected to have children at all costs. For example,
in low and middle-income countries such as Ghana, childbearing is consid-
ered important in determining the power and economic wellbeing of both
women and men (Riessman, 2000). In Madagascar, not having a child is
attributed to a woman’s marriage to a spirit, the inability of husband’s and
wife’s blood to “mix”or being the captive of a witch (Gerrits, 1997). In
Egypt, the inability to conceive children is attributed to the husband’s
“worms”being weak (Inhorn, 2003). The meanings associated with infertil-
ity as explained above can affect individuals negatively.
2 G. N. O. OKANTEY ET AL.
In Ghana, persons with fertility problems experience stigmatization and
discrimination, coupled with psychological distress from the sociocultural
beliefs of the community (Hasanpoor-Azghdy et al., 2015; Karaca & Unsal,
2015; Osei, 2014). This stigmatization most often leads to couples with fer-
tility problems in countries like Ghana to be excluded from leadership roles
in their respective communities and in some instances denied membership
in the ancestral world (Tabong & Adongo, 2013). The pressure associated
with infertility and its treatment could lead to negative sociocultural experi-
ences, which could result in psychological problems, mental disorders and
marital problems (Alhassan et al., 2014). Accordingly, women with fertility
problems become desperate to have their own children so as to complete
their womanhood and fulfill societal expectations (Ulrich & Weatherall,
2000). In most African countries, persons seek infertility treatment from
traditional healers and sometimes pastors due to the belief that their condi-
tion is a result of witchcraft (Dyer et al., 2002). Others perceive infertility
as a phenomenon that requires medical intervention with specific attention
to psychosocial consequences (Greil et al., 2010).
Generally, due to the frustrations and stigma associated with infertility in
Ghana, persons with fertility problems often resort to alternative means of
having children such as assisted reproductive technology (ART). Over the
past three decades, many ART, including in vitro fertilization, intracyto-
plasmic sperm injection, intrauterine insemination or artificial insemin-
ation, and surrogacy have been introduced to assist reproduction among
persons with fertility problems (Inhorn & Birenbaum-Carmeli, 2008). ART
was introduced primarily to help persons with fertility problems to have
their own children and to ease sociocultural pressure and psychological dis-
tress that are often associated with infertility.
According to the theory of planned behavior, an individual’s intention to
do something is influenced by personal attitudes, subjective norms, and
perceived behavioral control (Ajzen, 2011). Individuals are motivated to
perform a particular behavior when they have strong intentions for such
behavior (Ajzen, 1991). Accordingly, attitudes are determined by an indi-
vidual’s personal evaluation of issues (Ajzen, 2011). In this regard, individ-
uals are likely to access ART if they are certain it would help them
conceive and avoid the negative consequences associated with not conceiv-
ing. In addition, the subjective norms are the perceptions that would be
developed by individuals about the importance community members place
on the intended decision (Cameron et al., 2012). Also, the subjective norm
defines the perceived approval or disapproval of other members in the
community if the behavior is manifested. In this regard, persons who have
fertility problems are likely to evaluate if the decision to seek other means
of having children is accepted or frowned upon by community members.
MARRIAGE & FAMILY REVIEW 3
People that seek alternative means of conceiving are stigmatized and
encounter sociocultural, psychological and health barriers (Amato & Jacob,
2004). In view of that, conceiving through ART has come under serious
scrutiny since its inception, especially in low and middle-income countries.
As reported by some scholars, ART is perceived as against the norms and
the traditions of giving birth (Inhorn & Birenbaum-Carmeli, 2008;
Bradbury & Sutcliffe, 2014; Gourounti, 2016). This is because some soci-
eties hold the belief that ART creates problems as to who are the biological
parents of a child as the dichotomy between the biological and social basis
of kingship has become unclear (Taylor, 2005). In addition, studies have
revealed that some communities do not perceive ART as an acceptable
solution for treating infertility due to the stigma (Savage, 1992).
Furthermore, parents of children conceive by ART face a dilemma with
regard to disclosing information about conception to their children and
other members of the community (Bradbury & Sutcliffe, 2014; Gross et al.,
2004). Scholars have therefore argued that ART challenges the traditional
and sociocultural norms of giving birth and parenthood especially in low
and middle-income countries (Bradbury & Sutcliffe, 2014; Inhorn, 2003).
Psychologically, women who conceive by ART are perceived to experi-
ence greater emotional stress as compared to women who conceive natur-
ally (Gourounti, 2016; Morreale et al., 2011), especially during the first
three months of pregnancy (Lin et al., 2013). ART is also perceived to
result in multiple births, which may affect the health of the resulting chil-
dren with complications such as stillbirths, cerebral palsy, growth malfunc-
tions, neurodevelopmental issues, neurological consequences, cancer-related
risk, psychological development malfunctions, physical risks, and low birth
weight as well as long term effects like poor physical health, developmental
malfunctioning and cardiovascular diseases in adulthood (Belva et al., 2006;
Bradbury & Sutcliffe, 2014; Lu et al., 2013; Reynolds et al., 2003).
Moreover, ART is stigmatized as a source of poor maternal health, preterm
delivery, and unhealthy infants coupled with low birth weight and infant
mortality (Kiely, 1998). Additionally, ART may put pregnant women at a
higher risk of pregnancy-related complications, such as pregnancy-induced
hypertension, gestational diabetes mellitus, placenta abruption, antepartum
hemorrhage, postpartum hemorrhage and perinatal mortality (Qin et al.,
2016). The use of ART has been perceived as a source of prenatal compli-
cations during and after conception as well as complications that come
with the health of the baby when it is born (Kiely, 1998).
To date, studies on fertility and ART in Ghana have focused on depres-
sion among women who are facing fertility problems (Alhassan et al.,
2014), coping strategies of women seeking infertility treatment (Donkor &
Sandall, 2007), and the implication of infertility in Ghana (Fledderjohann,
4 G. N. O. OKANTEY ET AL.
2012). The focus of research on infertility in Ghana has left other issues
related to fertility treatment only partially addressed. This study explored
the experiences associated with the use of ART as a means of conceiving,
focusing on the sociocultural implications of infertility and the challenges
faced by those accessing ART. It is hoped that the findings of the study
will contribute to existing knowledge.
2. Methods
2.1. Study setting and design
The study was conducted in two health facilities in an urban community in
Southern Ghana. The selected health facilities specialized in the provision
of ART. The study area was considered appropriate because most hospital
facilities that provide ART services are situated in Southern Ghana. The
study employed a qualitative descriptive research design. Qualitative
research design helped the researchers to understand socially constructed
realities and interpreted cultural meanings (Erikson & Kovalainen, 2008),
allowed the researchers to engage directly with participants to tell their sto-
ries as they experienced it (Creswell, 2013). The study employed a purpos-
ive sampling technique to select participants who had the needed
information to help address the study objectives (Creswell, 2013).
2.2. Participants and method of data collection
The target population for the study consisted of persons who had accessed
ART, nurses and gynecologists who had specialized in ART. The study
sampled 20 participants, 16 of whom were persons who had accessed ART
as an alternative means to conceive at the time of data collection. The
study also included two gynecologists and two nurses. Initially, the
researcher intended to interview 30 participants but reached data saturation
with 20 participants due to the intensive and detailed nature of the inter-
views (Ritchie & Lewis 2003). The criteria for inclusion in this study were:
(a) persons must have accessed ART at the time of data collection, and (b)
gynecologists and nurses were included only if they had specialized in the
area of ART and engaged with persons who had accessed ART to conceive.
Individual in-depth interviews were conducted in English and Twi (local
Ghanaian language). A total of 20 interviews were conducted and each
interview lasted between 40 and 60 min. Interviews were recorded using an
audio recorder with permission.
MARRIAGE & FAMILY REVIEW 5
2.3. Data analysis
The interviews were transcribed verbatim on Microsoft word. Six phases of
thematic data analysis were used to analyze data (Braun & Clarke, 2006).
The first phase ensured that researchers familiarized themselves with the
transcribed data. By this we mean, we separately read through the initial
data, generated codes and made categorizations from the codes. Following
this, the research team came together to compare the generated codes and
these were collated into potential themes in the third phase. Further, in the
fourth phase, we generated a thematic map and ensured that themes were
related to the entire data set. In the fifth phase, names were assigned to the
generated themes based on the objectives of the study. Finally, we pre-
sented the report in the sixth phase. The authors made sure their prior
knowledge on participants had no effects on the data collected through the
use of bracketing. To eliminate biases and to ensure the trustworthiness of
the data, we did coding separately and came together afterward to agree on
the themes that were presented.
2.4. Ethical consideration
Codes of ethics such as informed consent, privacy and confidentiality were
ensured. The study participants were informed about the nature and poten-
tial consequences of the study in which they were involved. Participants
were informed that they could withdraw from the study at any point in
time. Privacy and confidentiality of the participants’information were
ensured in the study. Participants’identities were not disclosed to any third
party and the privacy of their information was assured.
3. Findings
3.1. Demographic characteristics of participants
Couples who had accessed ART were between the ages of 36 and 51 years
and the gynecologists and nurses were aged 35–73 years. The gynecologists
and nurses had worked in the field between 13 and 40 years. The two gyne-
cologists were males and the nurses were females. Almost all persons who
had accessed ART had completed tertiary education with the exception of
two who completed the “Ordinary Level.”With regard to occupations, the
persons who had accessed ART were revenue officers, traders, businessmen
and women, bankers, auditors, accountants, and secretaries. Ten of them
were married and six had married but divorced. In addition, 10 of the par-
ticipants who had accessed ART had conceived before. The remaining six
had never conceived, even though they were in intimate relationships. Also,
with regard to the number of years the participants had been trying to
6 G. N. O. OKANTEY ET AL.
have children, findings of the study indicated that the minimum number of
years was 6 and the maximum was 20. This is shown in Table 1.
3.2. Sociocultural implications of infertility
In Ghana, the expectation of every marriage, according to the study partici-
pants, was to have children. Therefore, after years of marriage without any sign
of pregnancy and children, it attracted concerns from the community. At this
point, the decision of whether to conceive or not, was influenced heavily by the
community rather than the couples. In many cultures, marriage ceremonies are
marked by prayers to God and the ancestors to bless the marriage with chil-
dren; this explains the value society places on children. This section is
explained under the theme societal pressure and cultural meanings of
infertility.
3.2.1. Societal pressure
To society, children are the priority in marriage, to them, the primary motive of every
marriage is to have children, if you do not have children after two years of marriage
then you are inviting pressure upon yourself, it happened to us and we had to go
through difficult times to cope with the pressure which was coming from all angles
Male, #4, ART).
Ghanaian society has very negative perceptions about infertility and they
associate infertility with promiscuity on the part of couples and individuals,
especially women, before marriage.
Participants revealed that society viewed infertility as a condition caused
by excessive abortions during one’s youthful age:
Some people are of the view that your inability to give birth is because you abused
your reproductive system through numerous abortions and excessive sex, it is very
disgraceful to some of us when people can have such thoughts because you have not
been able to have a child (Female, #8, ART).
Table 1. Demographic characteristics of participants.
Number of participants
N¼20
Individuals who accessed ART 16
Marital status
Married 10
Divorced 6
Years of accessing ART 6–7 years 16
Status of childbirth
Given birth 10
Not given birth 6
Age range 36–51 16
Level of education Tertiary 16
Gynecologist 2
Nurses 2
MARRIAGE & FAMILY REVIEW 7
This participant narrated how she was insulted without any provocation by
her in-laws:
Sometimes your in-laws without any provocation can tell you in your face that, you
have removed all your children into the gutter and you are coming to waste their son
or brother’s time …can you say this to a person you only knew after she- married
your son? This is what l had to endure, all in the name of bad marriage (Female,
#14, ART).
In the Ghanaian context, not having a child is frowned upon; therefore,
voluntarily deciding not to have a child is unacceptable. The culture
demands children from any marriage relationship:
In Ghana, you cannot say that I am married and I do not want to have children, you
will be ridiculed by your friends and neighbors. It is a must to have children- …I
think it’s better you do not marry than to marry and tell your family and friends you
do not want to have children (Male, #1, ART).
This is what another participant had to say, concerning marriage and the
need to have children:
Our society has been structured in such a way that once you marry you must bear
children, unlike Europe where married couples can decide they would not want to have
children, is it very difficult for such a decision to be accepted here …so, any marriage
that lacks a child or children becomes problematic (Nurse, #2).
This participant revealed how married couples are expected to have chil-
dren at all cost:
In many African countries, which includes Ghana, people think that, once you get
married the next thing is for you to have children, they forget about other functions of
marriage, they forget about everything, whether you have a problem or you do not
have a problem, they think that, oh, once you are married by hook or crook give birth
(Female, #7, ART).
Society’s strong desire for children in every marriage compels couples to
“go the extra mile”to get children of their own. In this regard, resorting to
all possible means to get a child was considered the only coping strategy to
contain the pressure from society:
I think all these negative factors should encourage every couple to go the extra mile to
have children of their own because these are challenges that arise when you are not
having kids …but how to overcome these challenges is paramount, we all need to be
encouraged to go the extra mile to at least get a child to glorify the name of God
(Female, #11, ART).
Some participants revealed that society does not treat persons who are
yet to have children fairly. They believed there are times in everyone’s life
to have children and that society should support their relatives instead of
labeling them and taking them through all sorts of negative treatments:
8 G. N. O. OKANTEY ET AL.
I was treated unfairly just because l am yet to have a child but society fails to understand
that, people have children at a particular time in their lives, it could be earlier or it could be
later, l do not think it is the wish of any woman to be in any marriage relationship without
children …all we need from our parents, relatives and friends are words of encouragement
instead of the meanings they attach to one’s inability to have children (Female, #5, ART).
3.2.2. Cultural meanings of infertility
In most parts of Ghana, children are supposed to be heirs to their parents
and carry on the lineage of their parents. Failure to have children means
that a person will die without leaving a legacy whatsoever. Participants
revealed that, after death, persons without children are not recognized any-
more. They do not qualify to be ancestors, making their names fade off
just after their demise:
In Ghana, children are inheritance, when you are dead and gone, it is the generation
you have left on this earth that will inherit you, whatever achievement you made on
the earth is carried on by your children …so, if you came to this earth and no
matter your achievement and you die without children your name will be forgotten
(Female, #16, ART).
This participant narrated how the inability to have a child can prevent
one from becoming an ancestor:
In my hometown, we grew up to believe that ancestors are very important in our
tradition but death does not make one become an ancestor, you need to bear children
and die a respectable death, that will make you an ancestor (Male, #4, ART).
Moreover, in Ghana children are considered as a source of social security
for the aged. In view of this, adults in their reproductive age are required
by tradition to have children, take good care of them in a way that they
will be equipped enough to take good care of their parents in their old age.
Ghana practices a reciprocity type of social security where parents give to
their children in their tender ages and children are expected to give back to
their parents when they are old. Also, in Ghana there are no daycare cen-
ters for the aged, parents are cared for by their children. Therefore, the
consequence of not having a child is felt more during old age. This tends
to put pressure on couples and even individuals in their reproductive ages
to do everything humanly possible to have children:
Our way of life in Ghana places value on children thus making them very important, I
am saying this because I have seen patients who were much concerned when they were
growing old. They were much concerned about who would care for them when they
become weak and weary …situations like this puts pressure on every- Ghanaian to
have a child …at least one child who would be there for his or her parents in their
old age (Gynecologist, #1).
MARRIAGE & FAMILY REVIEW 9
For this participant, she believes pension benefits are not enough and
there is the need to have children who would support you in your
old age:
Talking about pension benefits in this country is not enough and older people will
always need support, where will this support come from? It will effectively come from
your children, even when someone in the family would have to assist, it would not be
like your own child …so, I think all these exert pressure on Ghanaians to have
children (Nurse, #2).
In addition, participants indicated that they were sometimes viewed as
victims of a curse.
Some community members believed that infertility is a result of a curse due to the
disobedience of the elderly or a bad spirit. Also, it is believed the curse could have been
placed on a person’s forefathers and they are bearing the consequences for their
forefathers: Sometimes the inability to have a child is seen as a curse, some people
believed that you or your wife had done something to someone and the consequences is
your inability to have children, in my case, my mother always inquired if I have
wronged somebody …. l remember a pastor told my mother that my husband and l
had done something very sinful to someone and we need to make a sacrifice to God,
even though we know we have not offended anyone, we made the sacrifice but nothing
happened (Female, #3, ART).
For this participant, her inability to have a child was attributed to the
sins of her grandparents:
Some people may trace your infertility to sins your great-grandparents committed and
will cast a lot of insinuations about your family just because you are not having a
child, meanwhile, these same people forget that, it is not everybody that came to this
earth to bear children (Male, #1, ART).
Among the Akans and other tribes in Ghana, couples with ten or more
children are often rewarded with a sheep. This is done to encourage other
family members to have more children which is vital for the survival of
the lineage:
The Akans and some tribes in Ghana, reward women who had given birth to ten
children or more and they claim this is to encourage others to also have more children,
my brother, l can tell you that, in this day and age, having more children would affect
your finances and well-being …. even though l know the importance and value society
places on children, l think ten children is too much (Female, #15, ART).
Most often adults without children were not recognized in some
Ghanaian communities and they experienced countless social hardships.
Participants’were sometimes left out of decision making and sometimes
seen as useless and burdensome to the family and the communities in
which they live:
I believe this is something that happens in every region in Ghana. Adults without
children are not recognized, they are not respected, and tend to go through all kinds of
10 G. N. O. OKANTEY ET AL.
negative treatment wherever they live. l know it would be difficult to change this
practice but not having a child should not affect your contributions when it comes to
decision making (Male, #1, ART).
This participant revealed how persons without children were
disrespected:
To live without a child can be very difficult in some Ghanaian communities. One sad
thing is, no matter your age you are not recognized, you are not respected and some
members of the family see you as useless and not fit for anything (Female, #10, ART).
3.3. Challenges encountered in accessing assisted reproductive technology
Having realized that infertility is a medical condition which affects both
men and women and prevents them from having children, it has become
imperative for patients to find treatment for infertility. ART has been con-
sidered among other medical treatments and interventions as among the
most effective ways of treating infertility. However, ART as an alternative
means of having children has not been completely accepted socially in
most low and middle-income countries, including Ghana. ART is said to
contradict the social ethics of having children and as such has attracted lots
of challenges from various cultures. In addition, ART as a medical treat-
ment comes with its own side effects, which can lead to serious health
complications. Also, it has been revealed by persons who accessed it, and
practitioners, as very costly and tend to drain the resources of couples and
individuals who access this technology:
I think ART has helped my husband and l a lot, that needs to be acknowledged, but I
must admit that it is very costly. You need to have substantial amount of money
before you would be able to access this technology, if you are not well prepared in
terms of finances, you might get stuck halfway during the procedure (Female,
#13, ART).
Based on the responses from study participants, the researchers have
grouped the challenges in accessing ART under broad themes which
include social challenges, psychological implications, economic constraints,
and medical complications.
3.3.1. Social challenges
There are challenges faced by couples and individuals in their various com-
munities as they resort to ART as an alternative means to have children. In
addition, it encompasses how people felt about the act and how people
treat them due to their involvement in ART. Participants contended that
the Ghanaian society frowns upon any untraditional methods of having
children. As a result, persons who had conceived or had children through
MARRIAGE & FAMILY REVIEW 11
ART keep their situation confidential and would not like to disclose it
to anybody:
The truth must be told that most Ghanaians are ignorant about ART, I mean, not many
people know about it and if they get to know that a child was born through this procedure
they would see this child differently from other children who were conceived naturally
(Female, #9, ART).
Another participant revealed how she and the spouse had been discreet
after engaging the services of a surrogate mother to have their children:
My husband and l haven’t told anyone we sought the services of surrogate mothers to
have our children, during all these two periods I had to behave as if I was pregnant, I
had a costume that l worn and it made me look like I was pregnant …hmm, despite
what l had to go through, l thank God for giving us these adorable children (Female,
#3, ART).
Prior to accessing ART, participants are often left in a dilemma due to
comments from spouses or partners and most importantly the larger fam-
ily. These comments tend to discourage people from accessing ART:
The first and foremost challenge is the acceptance by your spouse and parents, if only
they think it’s necessary for you to access it, they come up with lots of excuses like;
these children are not healthy, they are not children from God, some may even be
physically challenged, they say these things in order to deter you from accessing the
technology (Female, #12, ART).
This participant supports the revelation by other participants who had
accessed ART:
The problem we have about ART is that, to the layman IVF simply means producing
test-tube babies, they feel the babies are reared in test tubes as we know in the normal
lab test tube and they are kept in there and when you come, we remove one- for you. I
think, it is about time a lot of public education comes up, for people to really
understand what ART entails (Nurse, #2).
Participants indicated that if they had disclosed the process they went
through before having their children, they and their children would be stig-
matized and discriminated against:
Society is not ready to know this, that is how I see it, if you are not careful and you
let anybody know your children were born through ART they will discriminate against
you and the child for reasons best known to them (Female, #7, ART).
This participant revealed what a patient who had a child through ART
told her:
One day this patient who was also a friend came to me and she looked so depressed
and sad, I asked her what the problem was and she told me she had some
misunderstanding with a neighbor and this neighbor said to her in the presence of the
child that “you are bringing yourself, that toy you went to the hospital to bring, you
think you have brought a human being”(Nurse, #1).
12 G. N. O. OKANTEY ET AL.
Also, some participants identified religious and ethical challenges that
tend to prevent people from accessing ART. Professionals consider these
beliefs to be misconception, which put unnecessary pressure on persons
with fertility problems:
Even though many of my church members are aware l am a medical doctor, they
consider my assistance to would-be parents who had accessed ART to have children as
ungodly just because they think ART is not something God approves of
(Gynecologist, #1).
This gynecologist had this to say with regard to people’s view on ART:
Some people believe it is ungodly to manipulate sperms and eggs, then after
fertilization, the embryo is transferred into the uterus. For them, it is unethical way of
conception and giving birth, as a medical practitioner, I do not see it that way
(Gynecologists, #2).
Here, a brief history on ART by a gynecologist and some personal expe-
riences he had encountered over the years:
I would like to give you some history about ART, a lot of issues came up when Louise
Brown, the first IVF baby was conceived and born, it raised a lot of moral, religious
and ethical concerns. A lot of newspaper articles came up that, monsters would be
created. Now it is quite funny when clients walk into my office and ask me, are the
kids normal? Are they intelligent? How do they look like? and so on and so forth
(Gynecologist, #2).
Yet another pondered on the public perceptions about ART as an alter-
native means to have a child:
Initially, when ART was discovered, a lot of countries disallowed it, they thought
doctors were going to create monsters. There are still some religious groups who are
still opposed to ART because they do not think it’s natural. However, we are—not
creating eggs, we do not create sperm, we only manipulate the sperm that God has
given to the man and the eggs that God has given to the woman, so we are not doing
anything unnatural (Gynecologist, #1).
Another had to say this about perceptions people have about ART:
In Ghana, some people think IVF is fake, not natural, it is not of God and so lots of
people frown against it, and they do everything possible to discourage persons with
fertility problems from accessing it, they think people who cannot have children
naturally are less fortunate and have to live with this condition, (Female, #14, ART).
3.3.2. Psychological implications
Pregnancy through ART can be psychologically arduous. Assisted repro-
ductive technologies are new in the African context and its experiences of
medical processes and procedures usually put people into thinking. Some
participants shared their psychological challenges in this regard:
MARRIAGE & FAMILY REVIEW 13
Earlier, I felt very bad that I could not carry my own baby due to certain health
issues, it was a bitter pill for me to swallow, come to think of it, psychologically, this
weighed me down for almost a year, by his grace l was able to overcome the problem
and l am happy to say l have a child (Female, #10, ART).
This is what another participant said in regard to the stress and psycho-
logical trauma she had to go through:
I was affected psychologically because I had tried the procedure about three times but
wasn’t successful, l waited for a year after the last one and tried again, l became
pregnant at the fourth attempt …my brother, l went through stress and psychological
trauma till l delivered (Female, #8, ART).
Sometimes, accessing ART for a number of times without getting results
can be psychologically challenging as is indicated by this participant:
At a point, l felt it was a waste of time and money, psychologically it wears you down
and can make you very bitter because you psyche yourself towards having a baby and
it does not work out, having gone through the procedure twice or three times without
any positive results is heart-breaking and very frustrating (Female, #5, ART).
A nurse gave her assertion about the psychological issues associated with
the use of ART:
What I have observed over the years is that, sometimes, some couples come to you
with high hopes and when things do not go as they had anticipated, it affects every
aspect of their lives, their mood and ability to work, all these are affected, but you see
them very excited when the result is positive, especially when they see their baby or
babies after delivery (Nurse, #2).
A gynecologist supported the assertion above by narrating how emo-
tional the use of ART can be:
The whole procedure you are doing is emotional, there is an emotion attached to it,
you do not know the end from the beginning, right from start you are a bit down, if
you should finish and you are successful, let me say, you are happy, extremely happy
to tell yourself that l have also joined the league of women in quotes, as l would say
(Gynecologist, #1).
Acceptance of the baby by family members and the larger community
becomes a vital psychological concern to individuals who accessed ART:
Another challenge is, after the delivery of the baby, how are they (society) going to
accept the baby. Will they accept the baby as one of the normal babies or one who was
just pushed into you? You know they have a whole lot of perceptions about these
children and their attitude towards them is different from the children they call normal
babies (Female, #12, ART).
3.3.3. Economic constraints
Economically, participants stated they were cash strapped after accessing
ART, with some indicating they would like to have another child through
14 G. N. O. OKANTEY ET AL.
ART but considering the financial demands, they feel reluctant accessing
it again:
I guess it is a good idea to access ART to have a child or children when there is
no light at the end of the tunnel that you can have a child naturally, at a point, I
had to take a loan from my bankers to support the process …we wish we can
have another child through the same process but the money involved is scaring us
(Male, #1, ART).
This participant revealed that ART is good but expensive and persons
who have intentions to access it who do not have the finances should
investigate getting loan:
I must admit that ART is good, as much as you have resources to access it, financially,
it is expensive no doubt about that, because there are a lot of people who want to
access it but cannot finance it. Thank God we can, but for others who want to access
it and think they do not have the money, my advice to them is to go in for a loan,
after all, people go for loans to buy cars and houses (Male, #2, ART).
For this participant, recognizing it is very costly to access ART, there is
still no guarantee:
I can tell for a fact, ART is not cheap and ART is not absolute, success rate is still low,
compared to what happens in nature where the success rate of pregnancy is higher,
with natural conception when you give one hundred women one chance to have a
baby, a few of them may fail but with ART, when you give them one chance the
success rate is about forty or fifty percent and it’s very expensive and not everybody
can access it because of the cost (Gynecologist, #2).
3.3.4. Medical complications
Despite the assistive nature of ART, it has been proven as an effective alter-
native means of conceiving even though sometimes it affects the health
conditions of persons who access it. Miscarriage was identified as one
major health complication of participants accessing ART. Some participants
that were interviewed revealed that they encountered miscarriage at some
point after conceiving as the result of accessing ART:
I experienced two miscarriages but was very fortunate when I attempted the third time
and it worked because at a point I had told myself I would not go in for the fourth
IVF if it fails …luckily enough it worked out, I would like to say that, sometimes it
pays to persevere (Female, #8, ART).
This gynecologist revealed some of the side effects associated with ART:
I would say the side effects of ART are minimal and sometimes it can even happen in
normal pregnancies. The issue of congenital anomalies and all those things can happen
in natural pregnancies. Miscarriage can happen in IVF and the same can- happen in
natural pregnancies just that the rate of miscarriages in IVF is very high than the
normal pregnancies (Gynecologist, #2).
MARRIAGE & FAMILY REVIEW 15
Participants revealed some common side effects associated with the use of
ART. Side effects such as ovarian hyperstimulation, headaches, dizziness and
drowsiness were stated as the most reported side effects by persons who
accessed ART:
Yes, like l said earlier on, l mentioned ovarian hyperstimulation syndrome, that is one
possible side effect, the risk in stimulating the oocytes or stimulating the ovaries to
produce multiple eggs. A lesser side effect normally could be bruises at the injection site
which can be attributed to the numerous injections that these patients had to take
(Gynecologist, #1).
The use of fertility medications may affect or may not affect every
patient as is indicated below:
Sometimes fertility treatment medications may have some side effects like slight
headache, dizziness and drowsiness which may or may not affect every patient, it is
patient-specific, every patient reacts to these medications differently (Nurse, #2).
This participant shared her experience on what she had to go through
after she became pregnant having accessed ART:
I suffered a lot when l became pregnant, at a point, I thought I would die, just two
months into the pregnancy I started having complications which led to my admission
to hospital for almost nine months, after which, l had to deliver my twins through
caesarian section and since then, I am still recovering (Female, #16, ART).
Despite the numerous challenges associated with accessing ART as an
alternative means of conceiving, persons who accessed ART labeled the
children they had as lucky children. To them, the end justifies the means
and once you have a child after years of endurance, it is worth access-
ing ART:
Prior to accessing ART, l thought the most important thing was for me to have a baby,
a baby I can call my own, so whatever method you go through to have the baby, so far
as it is affordable and would be successful, l would not hesitate to access it …I think
these children are lucky because parents go the extra mile to get them in and so when
they come, I think they are even luckier and should be treasured more than the
normal babies who just popped into your womb and was delivered (Female,
#12, ART).
For this participant, her only conviction was to be called a mum
one day:
When l started the procedure, I was not too concerned about the challenges that are
associated with ART, my only conviction was to be called a mom one day, so that,
those who think I am barren to be ashamed …I am happy now, that l have two kids
and trust me, l really do not remember the challenges l went through (Female,
#13, ART)
16 G. N. O. OKANTEY ET AL.
4. Discussions
Within Ghanaian societies, once couples get married, childbearing becomes
the means by which the success of the marriage is measured. The
Ghanaian society puts so much priority on children because they are per-
ceived as the basic form of security. Culturally, this study has affirmed that
society considers children as the source of financial security and carers for
parents during old age. Ghanaian society expects every couple to have chil-
dren, take good care of them so the children will in return take care of
their parents when they are old and unable to provide for themselves. In
addition, the current analysis suggest that society puts pressure on couples
to have children because pension benefits are not enough so children
become the basic sources of care during old age. These findings affirm
Caldwell’s theory of intergenerational wealth flows which states that each
additional child adds positively to a parent’s wealth, security in old age and
social and political wellbeing (Kaplan & Bock, 2001).
In some cases, society perceives couples who are unable to have children
as cursed due to sins committed by great grandparents of either the woman
and/or the man. In addition, participants reported that couples who are
infertile are left out of decision making and disrespected in Ghanaian soci-
eties. Also, it was found that no matter the number of properties a person
acquires in life, if one dies without a child, society considers him or her as
dying without leaving a legacy. Persons who die without children are not
accepted in the ancestral world according to Ghanaian culture. Our study
concurred with previous studies that reported negative perception about
infertility in Ghana (Alhassan et al., 2014; Gyekye, 1996; Riessman, 2000;
Tabong & Adongo, 2013).
Marrying without children in many low and middle-income countries is
unacceptable and couples are supposed to go the extra mile to have their
own children. As a result, couples and individuals without children experi-
ence stigmatization and prejudices in their various communities, which
affects them negatively. In this study, it has been revealed that couples with
fertility problems experience social exclusion and are often disregarded by
families, friends, and neighbors. This study has confirmed that sociocultural
implications of infertility metamorphosed into stigmatization of couples
who are unable to conceive naturally as found in previous studies (Gerrits,
1997; Hasanpoor-Azghdy et al., 2015; Inhorn, 2003; Karaca & Unsal, 2015).
In some instances, immediate family members are those who perpetuate
these forms of stigmatization. Even though Ghanaian society expects cou-
ples to have their own children, prestige is given to children born naturally.
Children conceived and delivered through ART are most often disregarded
and discriminated against when community members are informed. As a
MARRIAGE & FAMILY REVIEW 17
result, couples in desperate situations for children do hide their identity
when accessing ART in Ghana.
This study has shown that children are the priority of any marriage or
relationship in Ghana. Marriage without children is frowned upon by soci-
ety and attracts intense pressure from the families of the couples. A few
years after marriage without children raises concerns about infertility and
most couples try to find remedy for it. The most available and reliable rem-
edy for persons to find solution to their fertility problem is the use of ART
(Inhorn & Birenbaum-Carmeli, 2008). However, ART as an alternative
means of having children is not acceptable in most African communities
(Savage, 1992). As a result, individuals who have children by accessing
ART tend to face intense stigma and prejudices.
Despite these intense pressures from the community, individuals without
children ignore these pressure and stigma to proceed with their pursuit of
having a child by accessing ART. In this study, persons who accessed ART
as an alternative means of having children shared their experiences about
society’s negative perceptions about ART. However, they believed that life
without a child is more unbearable than being stigmatized for having a
child through ART. This affirms the theory of planned behavior regarding
why participants access ART despite the challenges associated with it.
Participants’personal evaluation of accessing ART made them understand
that all society wants is for one to have a child. Therefore, there is a greater
possibility that they would get a child after accessing ART, which shaped
their intentions to access ART. Thereafter, participants came to the realiza-
tion that the means by which they want to have a child is not acceptable
and frowned upon by the community.
Accessing ART is challenged in low and middle-income countries due to
the cost implications, medical complications and psychological trauma as
confirmed by the findings of the study and research findings of other stud-
ies (Belva et al., 2006; Gourounti, 2016; Kiely, 1998; Lin et al., 2013;Lu
et al., 2013; Morreale et al., 2011; Reynolds et al., 2003). Despite these chal-
lenges, couples find all other means to access the processes of ART in
Ghana and other parts of the world in order to skip stigmatizations por-
trayed by society and enjoy their marriage.
4.1. Limitations
The study focused on two hospital facilities in Southern Ghana hence the
findings may not reflect on other countries with different cultural settings.
It is recommended that future studies should extend investigations to other
parts of the world to explore the experiences of persons who have accessed
ART as an alternative means of childbirth.
18 G. N. O. OKANTEY ET AL.
5. Conclusions
The findings of the study and the literature reviewed indicated that infertil-
ity is a sociocultural concern in Ghana due to the value placed on children.
Therefore, not having a child can be a serious personal and social problem.
Children are important as they are supposed to continue the lineage of
parents upon their demise. Also, in a country where daycare centers for the
aged are limited and not encouraged to a larger extent, adults in their
reproductive ages are required to have children who will take care of them
in their old age. Not having children, therefore, becomes a problem, which
may attract negative responses from the wider community.
Being married for years without a child in Ghana attracts stigmatization
and prejudices. As found in this study, couples without children were per-
ceived differently. They faced verbal and emotional abuse in their respective
communities. This led to discrimination in their extended families when it
comes to decision making. These and other challenges associated with
infertility compel persons without children to adopt other alternative means
such as ART in order to conceive. It has been revealed in this and other
studies that, accessing ART contradicts the traditional means of having
children in Ghana and some other low and middle-income countries. As a
result, persons who resort to ART to have children are stigmatized and dis-
criminated against; these discriminations do not exclude the children that
are born. Furthermore, parents go through a myriad of psychosocial prob-
lems after ART to conceive. They are faced with the problem of disclosing
information to members of the community and resulting children, regard-
ing their decision to conceive and have children through ART.
Aside from the sociocultural challenges of accessing ART as an alterna-
tive means to conceive, its accessibility is also very costly and not all per-
sons can afford it. In addition, the use of ART to conceive may result in
health complications, and persons who access it may experience headaches,
dizziness and other medical side effects. Also, accessing ART has resulted
in some miscarriages among persons who have accessed it (even though
participants acknowledge miscarriage occurs in natural pregnancy, the rate
of miscarriages among persons who have accessed ART was high). The
study has shown the negative perceptions of people in low and middle-
income countries like Ghana have about infertility and the challenges in
trying to access ART as a means to conceive. The findings will educate the
public about the need to accommodate people who are unable to conceive
naturally and inform people about the general preparedness needed before
accessing ART.
Based on the findings, practitioners of ART and social workers are rec-
ommended to offer counseling services for couples and persons with fertil-
ity problems to maximize clients’social functioning and wellbeing. This
MARRIAGE & FAMILY REVIEW 19
will help build their coping skills and functioning capacities. Due to the
values the society places on children, it is important that clients with fertil-
ity problems are empowered in order to deal with everyday challenges asso-
ciated with infertility. In addition, it is recommended that governments in
low and middle-income countries should offer public education and sensi-
tization to create awareness of ART to limit the negative perceptions about
infertility.
Acknowledgements
We take this opportunity to thank all gynecologists, nurses and individuals who willingly
offered their time to share their experiences. We also thank the authorities of the health
facilities where the study was conducted.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The dataset used and/or analyzed during the current study are available from the corre-
sponding author.
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