53 International Peer Reviewed Journal Beliefs, Health-Seeking Practices, and Effects of Childlessness: The Experiences of Married Women LUZVIMINDA P. RELON https://orcid.org/0000-0003-1334-4227 College of Teacher Education University of Northern Philippines Vigan City, Ilocos Sur Originality: 99 • Grammar Check: 97 • Plagiarism: 1 ABSTRACT In a society which recognizes the significance of children, giving birth to a child completes womanhood and the family. Thus, being a mother is synonymous with being a woman. The failure, then to become a mother, constitutes not fully achieving the status of a woman. Relatively, the desire for motherhood is inevitable and almost universal. This qualitative study analyzed the beliefs, and experiences of married women focused on their childlessness, health-seeking practices, and effects. Data were gathered through in-depth interview. Results showed that childlessness typified an unanticipated condition among the childless women. Regardless of the current age, age at marriage, marital duration, educational attainment and income, the respondents disclosed that childlessness is a condition which can be treated, provided the woman is still young. Childless women with higher income would likely seek medical help. Length of marriage disclosed to have affected the childless women’s recognition of their incapability to sire. Open communication coupled with trust, love, and understanding between couples Vol. 32 · March 2018 DOI: https://doi.org/10.7719/jpair.v32i1.575 Print ISSN 2012-3981 Online ISSN 2244-0445 This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. https://creativecommons.org/licenses/by-nc/4.0/ https://creativecommons.org/licenses/by-nc/4.0/ 54 JPAIR Multidisciplinary Research would keep the marriage intact. Findings revealed that their self-esteem, marital relationship, relationship with relatives and friends were affected by the absence of children. Almost all of the respondents expressed that the communities they are into neither, in any way, bothered with their condition nor rejected them due to their childlessness. Keywords — Social Science, childlessness, qualitative research design, Philippines INTRODUCTION In a study conducted by the World Health Organization, Programme of Maternal and Child Health and Family Planning Unit (1991), it estimated that globally there are about 60 to 80 million couples with unwanted infertility. Boivin, Bunting, Collins, and Nygren (2007) affirmed in his study that approximately 70-80 million couples worldwide are currently infertile, thus, estimated that tens of millions of couples are primary sterile or childless. For most people, having children is immensely vital; not being able to have children is a primary life problem. Globally, between 8 to 12 % of couples experience some form of infertility during their reproductive lives. It is important to note that the incident levels in some of the African countries are even higher to the level of 20 to 30 %. The underlying causes and contributing factors of infertility vary from one state to another and even from one locality to another. To the main part (55 % and above), infertility is the consequence of sexually transmitted diseases or complications suffered during postpartum or post-abortion period (particularly illegal induced abortion), all of this infertility to a great extent is preventable. Jejeebhoy (1998) mentioned that about 5 % of couples’ infertility rate is attributed to anatomical, genetic, or immunological factors among others. Moreover, Livingston and Cohn (2010) disclosed that the prevalence of childlessness varies by race and ethnicity as well. Hispanic women are far less likely to remain childless throughout their childbearing years than non-Hispanic whites or blacks. Just 10% of Hispanic women ages 40 to 44 now report of having no biological children. At the other end of the spectrum, fully 17% of white women in this age range account the same. Some 15% of black women are childless, as are 13% of Asian women. In Indonesia, an analysis of the East Javanese data shows that childlessness is a composite category.  Demographic childlessness occurs where a combination of proximate determinants (nuptiality, 55 International Peer Reviewed Journal mortality, primary and pathological sterility) leads to no childbearing and child survival. De facto childlessness arises where there is a lack of support from any children. Actual childlessness aggregates demographic and de facto childlessness, net of adoption or remarriage where these provide alternative access to children. (Butterfill & Kreager, 2005). Although the proportion of women who remained childless was higher ear- ly in the 20th century, estimated levels of childlessness at the start of the 21st cen- tury is a social issue for at least two reasons. First, the inability to sire a child con- tributes to fertility decline, with ramifications for the future size and age structure of the population (Australian Social Trends, 2002). Second, the increasing level of childlessness mean that in the future there will be older people with no chil- dren. The family members, in particular, the children, contribute to the support and well-being of older people. For some, the cost of raising children, regarding both time and money, is a barrier, while for others, health concerns such as fear of passing on a genetic defect to a child are contributing factors. Infertility, as far as gender is concerned, appears to affect more men than among women. Moreover, from 10,000 infertile couples, the rate was 33% among male partners and 25% among female partners (WHO, 1991). While this is the figure, women worldwide appear to be a countless burden of reproductive setbacks of all kinds, regarding blame for the reproductive failing, personal grief and frustration, social stigma and ostracism, and in some cases, life-threatening iatrogenic interventions. The acceptance of the society differs though. According to a study conducted by Huijts, Kraaykamp, and Subramanian (2013), the disadvantage in psychological well-being of childless people is smaller in countries with tolerant norms towards childlessness and high levels of social contacts. The results suggest that the extent to which childlessness is associated with lower psychological well-being appears to be dependent on the societal context. Moreover, there are studies which affirmed that childless women had affected their social life. Wirtberg, Möller, Hogström, Tronstad, and Lalos (2007) disclosed that childlessness had had a strong impact on all the women’s lives and was for all a major life theme. The effects were experienced both on a personal level and on interpersonal and social levels. Half of the women were separated, and in all but one, sexual life was affected in negative and long-lasting ways. The effects of childlessness were especially increased at the time the study was conducted, as the women’s peer group was entering the ‘grandparent phase’. Many coped with their childlessness by caring for others, such as the children of friends or relatives, elderly parents or animals. http://www.abs.gov.au/AUSSTATS/abs@.nsf/2f762f95845417aeca25706c00834efa/8d6ff77e09c179b5ca2570ec000a24ff%21OpenDocument 56 JPAIR Multidisciplinary Research Among developing countries, childlessness is still a common dilemma among couples. Findings of the study of Ibisomi and Mudege, (2014) show that not having children, whether voluntarily or not, contributes to a kind of invisibility and poverty in Nigeria. Regardless of the reason, voluntary childlessness evoked strong negative feelings. The study also shows the broad definition given to voluntary childlessness in Nigeria as including individuals that are childless because they chose to stay with an infertile partner and also those who could not have biological children and chose not to adopt. Likewise, in a study in Northern Ghana on Childlessness, couples without children are denied membership in the ancestral world thereby losing the opportunity to live again (Tabong & Adongo, 2013). All the studies on childlessness presented were conducted in other countries. Jimenez and Serrano (1998) disclosed that in the Philippines, limited funds allocated discouraged the conduct of research related to infertility. Hence, this study on childlessness hopes to provide a more comprehensive understanding on the beliefs, treatment practices, and psychosocial consequences effects of childlessness. Thus, the data obtained in this study can be utilized as inputs in the discussion, advocacy, and other related activities and improving current programs or initiatives related to childlessness. The results of the study may also help in raising consciousness about the plight of women in facing their dilemmas. Hence, these may eventually lead to better understanding them especially in a pronatalist country like the Philippines. CONCEPTUAL FRAMEWORK Figure 1. The Research Paradigm 57 International Peer Reviewed Journal OBJECTIVES OF THE STUDY This study analyzed the views and experiences about the beliefs on the causes, health-seeking practices and the psychosocial effects of childlessness among selected childless married women. METHODOLOGY Research Design This study explored the views and experiences of the childless couples on the beliefs of causes, health-seeking practices, and psychosocial effects of childlessness. It was exploratory due to the limited studies conducted. Qualitative and quantitative methods were employed in the study. An in-depth interview was conducted among the fifteen childless women. There was a limited number of childless women in the locality being studied who qualified the criteria set. Consequently, these married women were purposively chosen based on the set of criteria established by the researcher. The criteria are: 1) should belong to the reproductive ages from 20 to 49 years old; 2) have been childless for five years and above; 3) have openly expressed the desire of wanting to conceive and produce children; and 4) have never been separated from her spouse. Data Gathering Instrument An interview guide was utilized in this study. Open-ended questions were used to allow probing to gather significant information that was important in the analysis of data. The instrument was pre-tested with two childless couples. Likewise, the instrument was translated to Iloco with the help of some people who are knowledgeable on the language. The research instrument was divided into four categories, namely, the profile of the respondent, causes of childlessness, health-seeking practices, and psychosocial effects of childlessness. Data Gathering Procedures The first step done by the researcher was to search for potential respondents. The researcher experienced difficulty in looking for childless women who were willing to answer the questions. Some childless women who met the criteria refused to be interviewed for personal or psychological reasons. As a result, only 15 childless women participated in the study. Some respondents allowed 58 JPAIR Multidisciplinary Research the researcher to record the interviews. Informed consent was also secured. The respondents were assured of their anonymity and confidentiality of their responses. The answers of the respondents on the open-ended questions were transcribed, categorized and content-analyzed. This enabled the researcher to improve and probe deeper the areas that were not given considerable focused in the interviews. Likewise, content analysis was done to cull out the similarities and differences of the respondents’ views and experiences regarding the causes, health-seeking practices and psychosocial effects. The findings of this study could not be generalized to all childless women. These would only apply to the respondents being studied. RESULTS AND DISCUSSION Sociodemographic Characteristics of the Respondents More than half of the childless women (10 out 15) married at their 20s, three in their 30s. Only one associated her late marriage with her childlessness. More than half, too, of the respondents have been living together for only less than ten years (8 out of 15), two have been married now for 11 years, one for 12 years, two for 17 years and one for 18 years. One woman had been living with her husband for 26 years now. All childless women underwent schooling. Majority of the childless women (9 out of 15) are college degree holder, four are high school while the other two are elementary graduates. Eleven out 15 women are gainfully employed, either as teachers, vendors/store owners or employees in the private or public sector. Four of them are plain housewives. Majority of the respondents (14 out of 15) are Roman Catholics. One is a Born Again Christian. The income of the respondents ranged from P1000 to P20, 500. The estimation of the average monthly income included the income of the husbands based from the personal account of the women. Regardless of the category, more than half (8 out of 15) were earning below P5,000 (20 USD) or exactly P5,000 (100 USD) each month, majority (13 out of 15) married at the peak of their reproductive period and all of them have high expectations of conceiving after a month or longer of unprotected sexual intercourse. In the case of those who married in their 30s, two associated their childlessness with old age. Hence, it was difficult for them and their husbands to produce a child. An important consideration is that, husbands of these childless women have a problem on low sperm count. 59 International Peer Reviewed Journal Based on the findings of the study, regardless of age, marital duration, educational attainment, and occupation, religion as well as income, childlessness is regarded as a problem of the couples, particularly, the women being studied. Causes of Childlessness. The respondents narrated their experiences on the causes of their childlessness. Their answers were categorized into biomedical and sociocultural causes. More than half (11 out of 15) attributed childlessness to prolapsed uterus. Other frequently cited reasons were irregular menstruation, low sperm count, hereditary factors retroverted uterus and absence of a soft bone in-between the ribs of either wife or husband. One woman shared her story: “Maybe one of the reasons why a woman could not get pregnant easily is due to irregular menstruation. Just like me for example, I only menstruate four or five times a year. Because of this, there is a difficulty in identifying the fertile period of a woman, which some say that conception would easily take place during these periods. Aside from this, when we went to the hilot she said that I don’t have the soft bone just between my ribs. Also when she did the same thing to my husband, she found out that he has it but a very small one. According to her, we might have difficulty producing a baby because of this.” This result affirms the study of Jejeebhoy (1998) on infertility that only in about 5 % of couples stated that the causes of infertility are attributed to anatomical, genetic, endocrinological or immunological factors among others. Other causes of their childlessness included habitual drinking of husband, blood incompatibilities of couples, mumps, exposure of underwear at night and electric shock and excessive weight. According to the gainfully employed individuals, they associate childlessness to the psychological effect of their work (3 out of 15), especially stress and problems. One related: “Oftentimes when we arrive at home, I am so stressed out resulting in a loss of sexual urge or loss of concentration in our sexual intercourse.” The interplay of hot and cold element within the body was also mentioned by a childless woman. Thus, the presence of such would somehow affect the fertility of a woman. However, despite seeking this provider’s help and undergone such treatment she firmly believed that the interplay of hot and cold element in 60 JPAIR Multidisciplinary Research the body was not the reason of their childlessness. The childless woman recalled: “There was a time when I went to a hilot who was known in the community because of her capability to help childless women bear their own child. I was massaged by her and was treated 7 to 9 days successively. She told me that my body was full of cold element. When she massaged me, I felt that hot element came out from my head and cold in my feet. However, I still firmly believed with the doctor. The reason of childlessness is not me but my husband due to his operation on appendicitis and his diabetic, which we found out just recently.” Most of the reported own causes of childlessness were attributed to the wives. One of the most frequent answers was prolapsed uterus (7 out of 15), three attributed it to irregular menstruation and two on the inverted uterus. Two childless women mentioned profuse bleeding during their monthly period. However, the other one still considered the cause unexplainable because the doctor assured her of her normal condition to produce a child. For those who attributed childlessness to their husbands, the causes were low sperm count, and lack or no sperm cell is released during intercourse. Another childless woman openly expressed her belief that her husband was the main cause of their childlessness. His job as an electrician could have affected his capability to produce a child especially he was electrocuted before. Other causes mentioned were overweight, appendectomy, diabetes and hereditary factors. Same findings were revealed by the study of Yebei (2000) about what causes of infertility. On the case of heredity, according to them, the inability of couples to sire rooted from their ancestors, as to why they could not bear a child, it is unexplainable. Likewise, low sperm count was perceived by the childless women as a cause of their incapability to sire. Psychological factors include blockages of the fallopian tubes and an acidic uterine environment while Psychopathological causes factors include psychoses, alcoholism, drug abuse, cigarette smoking and psychic stress. Health-seeking Practices The respondents indicated they had consulted their concerns to the health provider. More than half of them (8 out of 15) sought the help of a hilot and a doctor simultaneously. They mentioned that they went to hilot to find out if their uterus is low or in the proper position. One mentioned that she, together with her husband, 61 International Peer Reviewed Journal is apprehensive of consulting a doctor. This would result only in blaming each other. Others who consulted a quack doctor were given root extract to drink and went to sacred places and prayed to the “Miraculous Lady of Manaoag” to plea to sire. For those who visited medical doctors, five consulted once while the other five did it regularly on a monthly basis. One expressly mentioned that in spite of financial constraints, due to high costs of medicines and limited income, she was motivated to undergo such medication due to the willingness of her husband to undergo the same treatment. However, when their condition did not improve, they stopped the consultation and medication. They opted for relying on faith and destiny. It can be noted that the respondents disclosed that nothing happened after consultations with the hilot, medical doctor, quack doctor or faith healer. The other four childless women affirmed that they experienced regulated menstruation, positioned uterus, relief from menstrual cramps, and discovered who is infertile. Majority (12 out of 15) also remarked that they never underwent any counseling formally or informally. Experienced Psychosocial Effects of Childlessness. Some of the respondents admitted that they were being questioned for their incapability to bear a child. One even lamented that what society wants is for women to bear children, which further aggravated her thought of being a childless one. One childless woman, who was still in the first five years of her marriage shared her experience every time people noticed and commented on her being childless. This affirms the findings of the study of Ibisomi and Mudege, (2014) that not having children, whether voluntarily or not, contributes to a kind of invisibility and poverty. Regardless of the reason, voluntary childlessness evoked strong negative feelings. Another childless woman shared how her being childless affected her sense of worth as a woman. She added that her work was even affected and which results to the feeling of loss interest in work. However, everything had changed when she and her husband agreed to adopt a child. On the other hand, other childless women viewed differently on their being childless. According to them, their womanhood was never and should not be questioned because of the presence of many women who also have similar faith as theirs and further added that their acceptance of their fate, together with their husbands, has helped them a lot. One of these childless women, who has accepted her fate due to her menstrual problem, boldly expressed the following: 62 JPAIR Multidisciplinary Research “Why should women put themselves down? For me, it’s not most especially I am not the only one who has this problem and maybe it’s my fate. One thing more, those who don’t have any menstrual problem are not being questioned, how much more to me. For me, I have a valid reason why I couldn’t bear a child.” Six childless women, the same person who that their mentioned womanhood has not been questioned by people, those who stated that childlessness has affected their self-image/ self- esteem most especially those who have expressed that they, together with their husbands, have already accepted the situation. Besides, their being childless has never become a source of their misunderstanding. The respondent women after knowing that their husbands were the cause of their difficulty in bearing a child, regained their morale as a woman. Five admitted that they were envious of women especially of their friends who have their own children. Other effects given by the respondents were: two, indicated depression, two, have lost their sense of drive in working while the other two regarded themselves as incomplete and admitted that at times they lost their self- confidence. One considered herself as worthless while the other was desperate already to have a child. One gainfully employed respondent openly admitted that her womanhood was being challenged and felt guilty, most especially when her husband was so desperate and unhappy due to the absence of a child in their family. Table 2. Effects on Self-Esteem Effects on Self-Esteem Frequency Feeling of worthlessness Depressed Desperate Normal Envious of other women Absence of drive in working Feeling of incompleteness Lacks self- esteem Lacks self- confidence Guilty 1 2 1 6 5 2 2 1 1 1 *22 The interview disclosed the effects of sterility to their marital relationship. Majority of them (12 out of 15), young and old alike, revealed that their relationship was normal just like any couple who has a child. It can be noted 63 International Peer Reviewed Journal that the younger category, where bearing a child is still very high, appeared to have some problems. The older women expressed that acceptance of their fate or leaving everything to God kept their relationship run smoothly. Talking about the problem with the husband made the acceptance easier and their marriage became stronger, and others mentioned that the presence of hope helped to normalize everything. Besides, childlessness according to them, did not become a source of conflict. Only in every few instances had childlessness became a problem to the respondents. One of the childless women openly discussed that there was a time that she discovered that her husband is seeing another woman. However, she did not admit that the womanizing of her husband was due to the absence of a child in the family. She further added when she came to know everything and peacefully confronted her husband, that if only the other woman did not abort the baby, she would be very willing to adopt and accept the child as her own. How she came to know and accepted all these things, she told this story: “There was a time it’s already 4 years ago when I learned that he was courting one of our neighbors. But I came to know about it when the woman became pregnant and the baby was aborted. I learned all about these things through a mailed letter that was sent to me through the post office. The sender’s name was not written, it was anonymous; I talked with my husband upon reading it, but he didn’t admit the affair. I asked him calmly why he did not tell the woman to continue her pregnancy so that after delivering, we would get and adopt the baby. But it was gone already. I was happy when I learned it, I did not feel angry because at least I would have a baby that I could consider as my own even though it came from the other woman, at least the father is my husband. I didn’t get angry with my husband since I have already accepted the fact that I could not bear a child of our own.” On the other hand, two childless women accepted irritability to their husband and blamed them at the same time, which resulted in cold treatment for each other. One of them decided to adopt a child which changed everything. The baby brought happiness to their family. When one of these childless women, who eventually adopted a child from their relative was asked why she said that her husband treated her coldly or vice versa, she honestly admitted: “When the baby was not yet with us, I felt we were not sweet to one another. He treated me coldly, and so did I, but I just ignored it especially 64 JPAIR Multidisciplinary Research to avoid conflict. It started when we consulted a doctor, he even blamed me but I just answered him. What can I do? Maybe it’s my fate. Sometimes I got easily irritated before, but my husband just tried to understand me to avoid conflict.” This study also found out that the 14 childless women remarked that their friends, relatives, and neighbors were always teasing them due to their childlessness. However, all of them added that it was done in a jokingly manner, and it did not become a reason on their part to stop befriending them, although at times they were also slighted. They just kept the feeling to themselves. Anyway, they were being treated well by these people despite their being childless. Oftentimes they advised or suggested them to consult or seek the help of a Traditional Birth Attendant (TBA) or a doctor. They considered their relationship normal, similar to those who have children. Most of them mentioned that they were able to maintain good and harmonious relationship. Only one respondent mentioned that that she was being jeered and ridiculed. This prompted her to become aloof with them and preferred to stay at home. CONCLUSIONS Childless women with higher income would likely seek medical help continuously than the women with low income. Length of marriage would tend to affect the childless women’s recognition of their infertility. The childless women tend to attribute their childlessness both on sociocultural and medical causes. The childless women tend to seek the help of both medical and traditional practitioners. Self-esteem, marital relationship, and dealings with relatives, friends and neighbors tend to affect the childless women. Childlessness is socially accepted. TRANSLATIONAL RESEARCH The findings of the study may be best translated to different media of communication for information dissemination and further awareness campaign that will eventually lead to the strengthening of the existing programs of the local government units along the protection and promotion of women’s reproductive, emotional, and mental health. The local television channel and radio stations 65 International Peer Reviewed Journal situated within the locality shall be utilized for the information dissemination. Relative to this, an infomercial may be designed using the Iloco language. This may focus on the biomedical/gynecological causes of childlessness and the existing services offered by the different Rural Health Units (RHUs). LITERATURE CITED Australian Social Trends (2002). Canberra Time. Family Formation: Trends in childlessness. Retrieved from http://www.abs.gov.au/AUSSTATS/abs@.nsf/ bb8db737e2af84b8ca2571780015701e/1e8c8e4887c33955ca2570ec000a 9fe5!OpenDocument. 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