Written by Arushi Kothari and Parul Bansal
A child holds great value for individuals, couples, families and communities across the world. One only has to look at ancient art, literature, architecture to unpack the deep emotional and psychological significance that pregnancy, birth and parenthood has been imbued with across cultures. Thus childlessness, particularly due to infertility, has gained immense focus in the past 40 years, particularly with the arrival of advanced assistive reproductive technologies (ARTs). Within this complex interweb of medicine, desire and relationships, our work has focused on the experiences of low-income childless couples dealing with infertility in India. The narrative qualitative research involved in-depth interviews with 12 low-income couples seeking infertility treatment at a private IVF centre in New Delhi, India.
India, as a country is situated at a very unique location in this discourse on childlessness and infertility. As the world’s most populous country, the dominant narrative that exists nationally and internationally is one of an ‘overpopulation crisis’. Yet, as a country that is home to an estimated 10-15 million couples dealing with infertility, the experiences of couples wanting to have a child and being unable to have one cannot be ignored at any cost (Chander et al., 2000).
Infertility and its treatment is often conceptualised as an exclusively ‘couple experience’ in western white discourse. Right from the choice of treatment, to the different decision points in the journey of making sense and responding to infertility, popular imagination conceives rather ironically, a couple sitting together and choosing for themselves how they would like to move forward in trying to have a child. Yet this script is often rejected, flipped, and transformed in India and our research with Indian couples belonging to lower income couples has highlighted this experience in three significant ways.
The first significant finding of our work was that infertility is rarely an individual or a couple experience. Right from emphasising the importance of a child through family rituals, suggesting faith-based healing practices to encouraging and supporting medical interventions, families play an important role in couples’ lives. In-laws, particularly mothers-in-law play an important role in emphasising the importance of trying to have a child and suggest multiple ways in which couples and particularly women can seek a ‘cure’. Families are extremely involved in the choice of treatment sought and often end up funding the medical help that couples seek. Thus, family is a site of both immense pressure and (un)conditional support for many couples.
Samaira, a 32-year-old Muslim woman spoke of her experience with her sister who kept motivating her to continue with treatment and shared that her sister would often tell her “Don’t take tension of work or anything else. You just need to think I want to bring a baby into this world no matter how. For you, for your life. She makes me understand that this is the right thing.” A study with Chinese couples found that an important factor that influences infertility related stress in women particularly is family adaptability (i.e., the extent to which the family can adapt to changed circumstances and problem) (Lei et al., 2021). Thus, it becomes essential for healthcare providers to give due importance and primacy to the family context as it not only shapes lived experiences of couples but also impacts fertility related decision making and couples’ interface with the medical system.
Second, families offer parenting opportunities to childless couples. Many couples in our study shared the opportunity to ‘play and live out’ the parent role to nieces and nephews. A child is therefore never only owned by a couple or biological parents, children are considered to belong to the entire family unit. Poonam, a 42-year-old woman who had been undergoing treatment for 15 years shared how her sister-in law’s children are like her own and often spend time with her more than their own parents. She shares, “I treat my sister-in-law’s children and my brother’s sons just like my own. He used to stay with me till 12 am at night, I used to take him back at night around 11 pm, in the morning I would reach there to massage him, feed him milk. So, at that time I felt that he is my child only”. Additionally families also offer paths to informal adoption which serves as a healing opportunity as couples undergo gruelling rounds of IVF treatment. This is particularly valuable in India where formal routes of adoption are often complex and expensive, which makes adoption difficult to access for low-income couples.
Finally, and perhaps most significantly, families also determine the nature of couplehood and intimacy that couples experience. Families and social networks are intimacy ‘defining, regulating and negotiating forces’ in the Indian context. Elders in the family have specific and culturally sanctioned beliefs and practices on how couples should navigate their relationships. Right from time taken for courtship (or not at all) before marriage, to the frequency of sexual intimacy, alone time spent in marriage, expressions of care, leisure and division of labour, families have played an important role in determining how couples relate with one another. This influence works as a dual edged sword- sometimes offering guidance and support to young couples and at other times being restrictive and suffocating to individual choices. Beck and Beck-Gernsheim’ (2001) work in the context of individualism is relevant here and they argue that being oneself while being close to others requires a delicate balancing act, one which requires individuals to prioritise their needs for closeness and intimacy with family relationships characterised by rules and rituals that regulate intimacy.
Any psychotherapy practice in the Indian, and perhaps Asian context cannot underplay the role of families in a couple’s experiences with infertility. An exclusively dyadic intrapsychic focus may lead to incomplete or worse, culturally ignorant interventions. This need has been recognized by researchers in the health psychology domain, who argue that practitioners responses to individuals and couples seeking infertility services need to be shaped by the contexts, fertility histories, intentions, beliefs and values of each couple (Shreffler et al., 2017). It’s crucial that researchers and therapists working in collectivistic contexts integrate family systems as sources of stress and support in the understanding of childlessness due to infertility. The role of emotional and psychological factors in fertility outcomes cannot be underestimated, particularly with the shift from the medical model of infertility to the bio-psycho-social medical model (Zhu et al., 2022).
The role of families in infertility therefore is an important area of exploration in critical health psychology to enable voices from marginalised, low-income communities in developing countries who navigate infertility through a familial and community lens rather than a solely individualistic one. It is not enough to only recognize the psychosocial components of the infertility experience; it is important to conceptualise and implement family and community centric intervention models to enhance individual, couple and family well-being.
About the Authors
Arushi Kothari is a practicing psychotherapist and PhD Scholar in the Department of Psychology, University of Delhi. She has completed her undergraduation in Psychology from Lady Shri Ram College for Women and her Masters in Applied Psychology with a specialisation in Clinical Psychology from Tata Institute of Social Sciences. Her training and practice is informed by principles of social justice and strengths based orientations.
Parul Bansal is an Associate Professor of Psychology at Lady Shri Ram College for Women, University of Delhi, India. Her research interests are in the fields of Critical Psychology, Mental Health, Psychoanalysis and Psychology of Social and Cultural.
References
Beck, U., & Beck-Gernsheim, E. (2001). Individualization: Institutionalized individualism and its social and political consequences. Sage
Chander, P. P., Indira, H., & Kusum, Z. (2000). Need and feasibility of providing assisted technologies for infertility management in resource poor settings. ICMR bulletin, 30(6-7), 55-62.
Lei, A., You, H., Luo, B., & Ren, J. (2021). The associations between infertility-related stress, family adaptability and family cohesion in infertile couples. Scientific reports, 11(1), 24220.
Shreffler, K. M. (2017). Contextual understanding of lower fertility among US women in professional occupations. Journal of Family Issues, 38(2), 204-224.
Zhu, C., Yan, L., Wang, Y., Ji, S., Zhang, Y., & Zhang, J. (2022). Fertility intention and related factors for having a second or third child among childbearing couples in shanghai, China. Frontiers in public health, 10, 879672.