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This chapter introduces the concepts associated with involuntary childless. Various socio-cultural norms world over, global and Indian statistical, prevalence of infertility, stratification of infertility, health care mechanisms available for addressal of infertility and reproductive health rights in the context of millennium development goals and sustainable development goals-2030 will be discussed in the chapter.
1.1Incidence and Prevalence
Infertility is a world wide issue affecting spanning across all geographical locations, across all demographics and socioeconomic status. It has been said that about eight to ten percent of all couples within the reproductive age have sought medical treatment and testing at some point in their lives for a suspected infertility. Globally, about sixty to eighty million people are said to be suffering from infertility, of which between fifteen to twenty million are in India. The World Health Organization (WHO) defines infertility, as the failure to conceive and have a biological child over twelve months of cohabitation and active sexual life. This chance of conception reduces in an individual aged thirty five and above.
Epidemiological data from the WHO has identified that regions of Central Africa has the highest incidence of infertility and has been known to reach fifty percent as opposed to twenty percent in he Eastern Mediterranean region, and 11% in the developed economies.
There have been no specific studies conducted in India to know the incidence and prevalence of the condition. The limited available data is from the National Family Health surveys and Census, which measures the number of women without children, but dosen’t evaluate the causes of the same. Childlessness has been found to be 2.4% among all married women in the country.
In the other South Asian countries, statistics the same as India have been seen. (Bangladesh, four percent; Nepal, six percent; Pakistan, five percent; and Sri Lanka, four percent). Globally, also three to six percent of the population has been identified to have infertility. Middle East, three percent; Latin America: three percent; Europe: five percent; North America: six percent; Caribbean: six percent)
1.2Reproductive Health
UNFPA, 1994, in their charter on Programme of Action of the International Conference on Population and Development, has cited that “Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases”
1.3.1 Millennium Development Goals, Sustainable Development Goals (SDG-2030) and Reproductive Health
The World Health Report 2005: Make Every Mother and Child Count (WHO, 2005) has mentioned the importance of mental health for maternal, new born and child health. They have trained midwives and other based health workers for understanding and evaluating maternal depression, post partum psychosis, suicidal ideations and immediate first aid to manage such situations. The International Conference on Population and Development (ICPD) Programme of Action and the Beijing Platform for Action, has sought its member nations to take action for rectification of gender based violence and unsafe abortion, so that lives of young mothers can be helped better. In addition, the mental health aspects of reproductive health are critical to achieving Millennium Development Goal (MDG) 1 on poverty reduction, MDG 3 on gender equality, MDG 4 on child mortality reduction, MDG 5 on improving maternal health and MDG 6 on the fight against HIV and AIDS and other communicable diseases. Good reproductive health can be achieved when mental health and functionality can be achieved by an individual.
There is a difference between developed and underdeveloped nations in terms of access to care and reproductive health care services. World over, the aim of reproductive health has been to address economic, demographical variations, health status and health service factors that impact morbidity and mortality. Unsafe abortion, hemorrhage, childbirth and the period of pregnancy have been identified to be of highest risk. Even though such constraints exist, mental health is has not been taken as major determinant of health pregnancy.

1.3.1 Reproductive Health Rights
UNFPA, 1994 and Ravindran, 2001 have defined the concept of reproductive health rights. Reproductive rights comprise a constellation of rights, established by international human rights documents, and related to people’s ability to make decisions that affect their sexual and reproductive health (Ravindran, 2001). it considers conception and childbirth as basic rights of individuals just as a fundamental right. Power to decide freely, how many children they want, and to attain the highest standard and quality of sexual life they would like to have. It also ensures their right to make decisions in matters of reproductive health as free of discrimination, coercion and violence, as expressed in human rights documents (UNFPA, 1994).
Women have been portrayed as the weaker sex throughout and infertility has been seen as woman’s problem. A gender based perspective adds weight to this conceptualization. This does not rely on the biology of the individual, rather as a rights perspective. It expresses on how a woman’s biology can be a vulnerability.

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Psychological wellness issues may create as an outcome of reproductive health issues. These incorporate absence of decision in regenerative choices, unintended pregnancy, hazardous fetus removal, sexually transmissible diseases including HIV, childlessness and pregnancy difficulties, for example, unsuccessful labor, stillbirth, untimely birth or fistula. Psychological wellness has a proportionate relationship with physical wellbeing. It is for the most part more difficult when physical health including nutrition is poor. Depression after labor is related with maternal physical ill-health is associated with abdominal wounds or perineal injuries and incontinence.

Ravindran, 2001, has portrayed in the work by the WHO on Women’s emotional wellness and mental health about the different Reproductive privileges of the female partner. The rights that are being depicted by her have its premise in the different audits of writing and the group from the WHO that has been working in the domain. Based on the findings of the team, she has proposed nine points which need to considered as Reproductive Rights of Women.
These are: –
(i)the right to life;
(ii)rights to bodily integrity and security of the person (against sexual violence, assault, compelled sterilization or abortion, denial of family planning services);
(iii)the right to privacy (in relation to sexuality);
(iv)the right to the benefits of scientific progress (e.g. control of reproduction);
(v)the right to seek, receive and impart information (informed choices);
(vi)the right to education (to allow full development of sexuality and the self);
(vii)the right to health (occupational, environmental);
(viii) the right to equality in marriage and divorce;
(ix) the right to non-discrimination (recognition of gender biases)
1.3.3 The Role of Mental Health in Reproduction and Women’s Mental Health

Mental health is an important aspect of reproductive health., even though has limited space and the attention given to this is negligibly small. The absence of consideration like other medical illness has led to significant contributions in incereasing global burden of illness and and disability.
Psychological well-being issues may create as a result from conception related medical issues . These incorporate absence of decision in conception choices, unintended pregnancy, risky fetus removal through unsafe abortions, sexually transmissible diseases including HIV and pregnancy complications like unsuccessful labor, stillbirth, premature birth or fistula. Positive mental health is firmly joined with physical well being. It is for the most part more awful when physical well being including nutritious status is poor. Melancholy and sadness after labor is related with maternal physical morbidity, including tireless unhealed stomach or perineal injuries and incontinence.
Neuro-psychiatric disorders top the list of incapacity among persons world over among common ten such condition’s. Depression is the commonest among such conditions. Affective disorders are the leading cause of or over one in 10 disability-adjusted life-years (DALYs) lost (Murray ; Lopez, 1996).One DALY is calculated as a year lost from healthy life. Depression is seen more commonly in women as compared to men. It has been identified by various studies and also by Murray ; Lopez, 1996, that unipolar depression as one of the major illness creating more DALY’s than any other condition in the context of childlessness. It has been estimated that men loose upto three DALY’s against women with loss of nine DALY’s ,Murray & Lopez, 1998. current statistics state that more than one fifty million people world wide experience depression each year.
There is a lack of awareness among women about their own health problems. They have been used to the idea of “normal” to have health issues and to not seek treatment until the condition deteriorates further. There is a social stigma attached to feeling emotional and vulnerable. This culture of silence is even more when there are mental health issues involved. Mental health problems create a sense of feeling abnormal in women with involuntary childlessness. Hence, it is quite difficult to quantify the impact of mental health on reproductive capacities cannot be truly ascertained.
1.3.3.1 Determinants Of Mental Health
The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. This can also be interpreted as, the lack of mental health problems also do not assure good mental health.
Individuals with involuntary childlessness have been known to have mild to moderate depression,anxiety and difficulties in coping with stressful situations. The “capability approach” by Amrtya Sen says that “the range of things which people value doing or being may vary from “elementary ones (such) as being adequately nourished and being free from avoidable disease to very complex activities or personal states, such as being able to take part in the life of the community and having self-respect”. This condition also needs to be seen from a capability based approach since, all individuals seeking treatment by their choice are seeking resorts within their limitations to absolve their insecurities and live a life of self-fulfilment.
There are five broad determinants of mental health which can be applied to identify and apply strategies to seek interventions for reduction in mental disorders and promote well-being of mental health in an person. “The determinants are:
1.Life course : Prenatal, Pregnancy and perinatal periods, early childhood, adolescence, working and family building years, older ages all related also to gender;
2.Parents, families, and households: parenting behaviours/attitudes; material conditions (income, access to resources, food/nutrition, water, sanitation, housing, employment), employment conditions and unemployment, parental physical and mental health, pregnancy and maternal care, social support;
3.Community: neighbourhood trust and safety, community based participation, violence/crime, attributes of the natural and built environment, neighbourhood deprivation;
4.Local services: early years care and education provision, schools, youth/adolescent services, health care, social services, clean water and sanitation;
5.Country level factors: poverty reduction, inequality, discrimination, governance, human rights, armed conflict, national policies to promote access to education, employment, health care, housing and services proportionate to need, social protection policies that are universal and proportionate to need.”*

* adapted from the WHO and Royal College of Psychiatrists document on Social Determinants of Mental Health, 2014 series.
1.3Transition in Human Fertility
Fertility transitions, ie. the childbearing and fecundity among populations has been seen to follow highly unpredictable statistics. Countries with developed economies in the past years has seen a transition to such levels below replacement level of one. A few Asian countries have also seen similar results, with levels of two. Many developing countries have seen sudden decline in fertility rates. This was debated and discussed by Malthus in “Essay on the Principle of Population”, (Malthus,1798)
Cleland & Wilson, 1987, in their article has said that there are many theories which try to explain why some countries have undergone significant fertility transitions. But there has been no single comprehensive theoretical framework which explains this. In this context, Mason 1997, developed her own theoretical framework which conveys ideas and is also interactional with the public using it. Ideational so that people are able to recognize changing perceptions towards induced fertility reductions and interactive, so that existant conditions and co-existant changes are also considered.

According to this model, a country’s fertility level is determined by three proximate factors: The perceptions among reproducing people of children’s probabilities of surviving, their perceptions of the costs and benefits associated with having children, and their perceptions of the costs of postnatal versus prenatal controls on family size and composition, with costs incorporating both social, psychological, and financial aspects.This model views each household as a single unit. Hence it is also open to accepting that men and women in the house may have different points of view about fertility and reproductive health. Mason, 2001 has said that power structures within households is based on the sex who also is also the powerful partner in fertility decisions.

(Mason, 1997)*, model adapted from Mason, K. (1997). Explaining Fertility Transitions. Demography,34(4),443-454. Retrieved from http://www.jstor.org/stable/3038299. This model was developed to understand interactions between different factors that lead to lower fertility rates and replacement levels.
1.3.1 The Case of South India*
The South India Fertility study is a baseline of trends and transitions about demographic and fertility transitions in the southern states of India. It is a geographical study about village level changes in child bearing capacities. It has been anticipated that future fertility will be based socioeconomic, socio-psychological, and cultural developments in societies. Hence, this study has a predictive nature about human fertility transitions in the southern states in comparison to the northern states. Better standards and easier access to education for women, being career oriented- at least do work in small scale industries in the villages, becoming independent- economically and emotionally and also having buying capacities to suit their needs has contributed to such an autonomy, Frejka and Calot 2001; Lesthaeghe 2001; McDonald 2000. This trend has been known as the second demographic transition. van de Kaa 1987, says that with this sense of autonomy , such transitions are accompanied by changes in attitudes and behaviors which define sexuality, contraception, marriage, divorce and in certain cases having children outside of wedlock.
1.3Pathways of Help-Seeking
The methods of seeking treatment and medical help by affected men and women are known as pathways of help-seeking. Ravi, 2017 has identified four pathways of medical help seeking by affected women .

*Guilmoto, C. Z., & Rajan, S. I. (2001). Spatial patterns of fertility transition in Indian districts. Population and development review, 27(4), 713-738. a study specifically undertaken to understand transitions in population in South India compared to rest of India.

The common types of treatment seeking patterns were identified to be :
1.Allopathic-Ayurveda-Allopathic-Ayurveda-Homoeopathy systems of medicine pathway
2.Allopathic-Ayurveda-Allopathic systems of medicine pathway
3.Allopathic-Ayurveda systems of medicine pathway
4.Allopathic-Homoeopathy systems of medicine pathway
These women had approached different systems of treatment for seeking resolution for their involuntary childlessness related difficulties. The Government of Kerala had introduced a new system especially to cater to women in need, named AARDRAM. It is an initiative to make government hospitals more people friendly and to improve the basic infrastructure of government hospitals.
Ravi,2017 has also identified certain pathways of treatment seeking which were not popular but nonetheless were sought by affected women. These were;
5.Allopathic-Siddha-Homoeopathy systems of medicine pathway
6.Allopathic-Herbal systems of medicine Medicine pathway
7.Allopathic-Allopathic systems of medicine hospital in neighbouring state pathway
Couples seek different pathways for seeking adequate help for conception. These are based on accessibility, affordability and requirement of treatment needs.

The want for children and the heartbreak from an inability have children been a part of life since the beginning of mankind, chronicled throughout history by religious accounts, myths, legends, art, and literature. Whether driven by biological drive, social necessity, or psychological longing, the pursuit of a child or children has compelled men and women to seek a variety of remedies, sometimes even extreme measures. In fact, in all cultures involuntary childlessness is recognized as a crisis that has the potential to threaten the stability of individuals, relationships, and communities.
Every society has culturally approved solutions to infertility involving, either alone or together, alterations of social relationships (e.g., divorce or adoption), spiritual intercession (e.g., prayer or pilgrimage to spiritually powerful site), or medical interventions (e.g., taking of herbs or consultation with ‘medicine man’).While spiritual and medical remedies for involuntary childlessness are common and often used early on by involuntary childless couples, social solutions demanding the alteration of relationships have been shown to be the last alternative individuals or couples usually consider.

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