African Journal of Reproductive Health Women's Health and Action Research Centre ISSN: 1118-4841 Vol. 13, Num. 1, 2009, pp. 79-91

African Journal of Reproductive Health, Vol. 13, No. 1, March, 2009, pp. 79-91

Original Research Article

Adesina Oladokun¹, Oyedunni Arulogun², Regina Oladokun³, Imran O. Morhason Bello¹, Elijah A. Bamgboye⁴, Isaac F. Adewole¹ and Oladosu A. Ojengbede¹

¹ Departments of Obstetrics & Gynaecology, College of Medicine/University College Hospital, Ibadan,
² Nigeria; Department of Health Promotion and Education, College of Medicine, University of Ibadan, Nigeria; ³ Department of Paediatrics, College of Medicine, University of Ibadan, Nigeria; ⁴ Department of Epidemiology, Medical Statistics and Environmental Health, College of Medicine, University of Ibadan, Nigeria
For correspondence: Dr. A. Oladokun, Department of Obstetrics & Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria. Tel: 234803 3285279 E-mail: oladokun@comui.edu.ng; sinaoladokun@yahoo.com.

Code Number: rh09008

ABSTRACT

Infertility remains a global health challenge with devastating psycho-social consequences in many African communities. Adoption that may serve as an alternative strategy for the affected couples is not widely practiced. This study was conceptualized to assess the acceptability of child adoption as a management option by Nigerians. Twelve focus group discussions were held involving three communities stratified into inner core, transitory and peripheral, within Ibadan metropolis, South-Western Nigeria from May to July 2008. The participants were purposively selected based on gender and age group. The barriers mentioned were cultural practices, stigmatization, financial implications, and procedural bottle-necks. Measures suggested to curb these negative attitudes were advocacy, community mobilization and enactment of supportive law that will protect all parties involved (Afr J Reprod Health 2009; 13[1]:79-91).

RĖSUMĖ

La stérilité demeure un défi de la santé partout dans le monde, ayant des conséquences psycho-sociales désastreuses dans plusieurs communautés africaines. L’adoption qui devrait servir de stratégie alternative pour les couples affectés n’est pas très répandue. Nous avons conçu cette étude pour évaluer l’acceptabilité de l’adoption des enfants comme option à tenir par les Nigérians devant la stérilité. Il y a eu douze discussions à groupe cible qui concernaient trois communautés qui ont été stratifiées ainsi : parties intérieure, transitoire et périphérique, a l’intérieur de la métropole d’Ibadan au sud-ouest du Nigéria du mois de mai jusqu’ au mois de juillet 2008. Les participants ont été deliberamment sélectionnés selon le sexe et le groupe d’âge. Les obstacles mentionnés étaient les pratiques culturelles, la stigmatisation, les implications financières et les difficultés liées au procès de l’adoption. Pour mettre un frein à ces attitudes négatives, nous avons suggéré la plaidoirie en faveur de l’adoption, la mobilisation de la communauté et la promulgation d’une loi favorable qui protégera toutes les parties concernées (Afr J Reprod Health 2009; 13[1]:79-91).

KEYWORDS: Child Adoption, Infertility, Community survey, Nigeria

Introduction

Infertility is a common health problem with devastating psychosocial consequences on the affected couples especially in Africa¹ . Worldwide, 5 to 15 percent of couples suffered from infertility¹ . In Africa, the prevalence is up to 45 percent^{1, 2}. The childless couples suffered from the conflux of personal, interpersonal, social, and religious expectations thus bringing a sense of failure to them³ . In some cultural settings in Africa, infertile couples are even not allowed to take lead role in important family functions and events. In addition, these couples are often socially ostracized by their immediate families. These challenges are not only restricted to the developing world³ .

Although, there are many management options for infertile couples, the outcome of the treatment depends on the aetiological factors, available diagnostic tools, skills of the attending physician and above all the financial status of the couple^{1, 4}. The technological breakthrough that led to the birth of baby Louise in 1978 further raised the hope of many childless couples all over the world and many have benefited from it⁵ . In Africa, there are limited assisted reproduction centres because they are mostly private sector driven^{6, 7}. Even, where they exist, the cost of accessing them and the low success rate despite the huge financial resources constitute a major hindrance for most desiring couples⁷ . They are therefore left to suffer from the agony of childbearing failure and this is manifested in form of emotional disturbances, depressive illness and marital disharmony^{8, 9}. In addition, these couples are often socially annihilated by both immediate families and their community at large^{9, 10} .

Adoption is an alternative strategy in the management of infertility aimed at bringing succour to the affected couples. This management option had gained wider acceptance in developed countries even before the era of reproductive technologies¹¹ . Then, infertility usually meant one of two things: permanent childlessness or adoption. However, with the advent of assisted conception, adoption rates in developed countries has reduced and it is only practiced by couples with intractable infertility^{12, 13} .

The process of adoption differs between countries depending on the socio-cultural settings and the constitution. For example, the adoption process in United Kingdom is backed up by the 1980 Children Act. This law stipulates that the process of adopting should be open and it is aimed at ensuring honesty with the child and the biological parents¹³ . Aside this, many governmental and non-governmental agencies as well as other organizations provide counselling to willing couples before embarking on adoption in developed countries as a mandatory prerequisite¹⁴ .

These agencies offer necessary emotional guide and support that will assist them to appreciate the realities of adoption.

Studies have shown that the couples that adopt grieve less about their childless challenge and also have better emotional support compared with their peers ^{14, 15} . The concerns of many adoptive parents that usually constitute a barrier to this infertility management option include fear of disloyalty by the child and future claim by the biological parents, lack of genetic linkage with the child and religious reasons^{11, 12}. Inhorn et al showed that these concerns should be carefully handled as it could potentially cause marital disharmony among the prospective adoptive couples¹⁶ .

Nigeria – a country of over 140 million citizens located in Sub-Saharan region accounts for about a quarter of African population. Although, the country is heterogeneous in terms of ethnic diversity, multi-religious affiliations and cultural systems, however, childbearing is a unanimous measure of matrimonial bliss in all communities. At most wedding ceremonies, special intercessional prayers are usually offered for the new couples against infertility. Despite this, a significant proportion of Nigerian couples have intractable infertility that may need child adoption as an alternative^2. The country presently does not have a uniform national guideline/protocol for the child adoption process including a law but, what is available now, is the individual states and some private organizations guidelines. Furthermore, there is no national data on the acceptability or otherwise of child adoption by Nigerians for appropriate policy formulation and implementation. A study by Ezugwu et al in South-Eastern region of Nigeria, revealed that majority of infertile women have heard about adoption but only few (27.3%) knew the correct meaning, its legality and the process it entails¹⁷ .

The study was therefore conceptualized to assess the knowledge and attitude of Nigerians to child adoption as well as assessing its acceptability as a management option for the infertile couples.

Methods

Study Design

The study was a descriptive qualitative study that utilized focus group discussion (FGD). Qualitative study method was chosen because of its usefulness in exploration of people's knowledge, views and experiences. The other advantage of qualitative methods is that they can be participatory, democratic and empowering. This may result in development of new perspectives and attitudes that are health promoting. Use of open-ended questions in in-depth interviews allowed the participants to express themselves in their own vocabulary that would be difficult in close-ended questions characteristic of quantitative methods.

Study setting

The study was conducted in Oke Seni, Apata and Elere communities in Ibadan. Ibadan is located in the South-Western part of Nigeria and it is the capital of Oyo state. It has 11 Local Governments Areas (LGA) with 5 within the metropolis and the remaining 6 on the outskirt rural areas. The metropolis has a population of about 1.3 million according to the 2006 National Population Census figure. The University College Hospital – the foremost public tertiary health institution is located within Ibadan metropolis. This hospital serves as referral for all other health care facilities within the city and other states of the Federation for the management of infertility. Furthermore, there are both State and Private-own establishments that offer Child Adoption services. This is usually coordinated by the State Ministry of Women and Welfare in conjunction with the High Court and Ministry of Justice.

The three study sites were selected from the 5 LGAs within the metropolis using the Nigerian National Population Commission enumeration map as a sampling frame. Initially, all the communities within the 5 LGAs were identified and stratified into 3 sub-sets namely, inner core, transitory and peripheral. Thereafter, one community was then randomly selected from each category as a study site.

Data collection methods

The research team held series of meetings involving all investigators to fine tuned the research protocol and also agreed on ways to ensure quality assurance throughout the study duration. Training on qualitative research was conducted for the eight research assistants (4 males and 4 females). A focus group discussion guide was designed in English and translated to the local language – Yoruba, which was pretested among persons of similar characteristics in Mokola area of Ibadan.

The FGD were conducted for both male and female community members stratified into married men between 20 – 30 years, married men above 30 years, married women between 20 – 30 years, and married women above 30 years. The participants at each community were selected with the assistance of a field organizer. At each FGD, the participants were between 6 and 10 members. The four sessions were held at the 3 study sites totaling twelve in all.

Issues in the guide included types of health facilities in the community; types of sexual and reproductive health diseases people in the community experience; Adoption (what it is, awareness, meaning, components, requirements, prevalence, where the service is provided); Community members’ perception, beliefs, attitudes, acceptability; Factors hindering and /or facilitating child adoption process in the community; Benefits or usefulness of adoption; Problems being faced by infertile couples as far as adoption is concerned and what ways could community members support adoption? Generally the discussions were carried out in a harmonious, friendly and open atmosphere. Each discussion lasted about one hour. During the discussion, data was recorded using hand written notes and tape recorder.

Data analysis

After the field study, both written and recorded materials were immediately transcribed to English. The actual analysis began with reading through the transcribed responses and listening to the audio records in order to have a good grasp of all the data. The key idea and emerging themes were identified from all the groups. These themes were then pooled together and integrated into a common one. Thereafter, there was generation of concepts for ease of organizing the presentation of the study findings.

Results

Demographic characteristics

The participants were married men and women within 20 – 45 years age range.

Types of health Facilities in the communities

In order to get an insight into the general health indices of the communities, the participants were asked to describe the types of health facilities in their communities. Across sites, the participants mentioned names of different private health facilities, University College Hospital (UCH), Primary Health Care Centre and traditional healing homes. For the inner core participants who mentioned UCH, they were asked to explain their response and they said the centre was established for them by the UCH administration and it is acting as an annex to the big hospital. However, in the Apata community, the male respondents said there was none in their community and that they had to leave their community to neighbouring communities for health care access. Their female counterparts were more specific by saying that there is no government hospital in their community but all that are available are privately owned. Types of services provided by these health facilities ranged from treatment of common ailments like malaria to child delivery, eye care, and dental problems. The female participants in Oke Seni mentioned referral services to ‘big UCH’ whenever a case could not be treated at the annex. Participants’ satisfactory level of the services being provided varied. Most of the participants mentioned nonavailability of doctors in the hospitals, high cost of treatment, inadequate staff. This perception cut across all the study sites. On the distance of the health facility from the community, all groups except the male group in the transitory sector said the facilities were near to them. The male participants in the transitory sector said they have to pay as much as between N100 to N200 on transportation to the health facility.

Types of Sexual and Reproductive Health Diseases in the Community

Participants were asked to mention the sexual and reproductive health diseases that are common in their communities. Gender differences were seen in the responses. The male groups were more open and explicit than the female groups. The male groups across sectors mentioned ‘atosi’ (gonorrhea); ‘jerijeri’ (syphilis); ‘swelling of private parts of men’; miscarriage, ‘oyun anibu’ (seeing menstruation while pregnant), early morning sickness and back pain. For the women groups, those in the inner core said there are no sexual and reproductive health problems in their community. Participants from the transitory sector mentioned that ‘many women find it difficult delivering babies and either would die in the process’; prolonged labor; infertility, premature delivery, carrying pregnancy for 11 months, still birth, miscarriage as a result of stress because their husband leaves them to do all the house work, they would fetch water from the well which puts pressure on the womb’. The women in the peripheral sector in addition to mentioning miscarriage said ‘we don’t know since people will not expose themselves if they have such problems’.

When asked the ones they perceived as the most common sexual and reproductive health problem, the female groups could not identify any but their male counterparts mentioned gonorrhea, and seeing menstruation during pregnancy. One of the participants said ‘gonorrhea is very common. If we gather 20 men, am sure 15 of them will have the disease’. The most serious of the diseases as perceived by the male participants were gonorrhea, infertility, menstruation in pregnancy, and miscarriage. The female groups on the other hand mentioned infertility, miscarriage, still birth, depression resulting from infertility and hypertension.

Awareness and Knowledge of Adoption

All the FGD participants had heard of adoption. Knowledge of adoption was measured by asking participants to define adoption, say what the components are, the requirements, prevalence and where the services are rendered. Various definitions were given by the participants that cut across gender and site. The female groups define adoption as ‘a situation where a childless person decide to take possession of another person’s child so that such a child can be bearing the persons’ name; ‘a situation where barren person tried to comfort him/herself by taking control of a child given birth to by another person’; ‘getting children from the government under defined law and regulation to make these children yours, so now they are legally yours and nobody can collect them from you’; ‘it is a means by which infertile couples decide to take child or get a child from orphanage home to become their own’. The definition of adoption by the male groups is not different from their female counterparts but they added that a child must be up to 7 years before he or she can be adopted.

The participants were not conversant with the components of adoption process. However, they were able to elicit some requirements of adoption. Requirements as listed by the male groups were ‘those who need it have to go to government and demand for the type of child needed either male or female; obtain a form and go through motherless babies home and doctors and nurses to know the type of child to be adopted; the court should be aware because whatever happened to the child will be transferred to court; lawyer will be involved to help them in taking that child; such a person should be able to sponsor the child to school; the person must have time for the child and must have a house where the child will be living with them’. For the women groups, additional requirement mentioned in addition to the above was that ‘couple must agree on adoption’.

Prevalence and places where Child Adoption is offered

All the participants both male and female said that adoption was not common in their community. The inner core group said ‘we don’t have such in our community’ while the peripheral group said ‘there is no adoption in our community except our relative children that are with us’. Participants listed some areas within the city like Aleshinloye, Sango, Catholic Church, Welfare Iyaganku, motherless babies’ homes and University College Hospital as places where they perceived adoption services are rendered.

Community Perception of Adoption

Gender differences were exhibited in the perception of adoption. The female group from the inner core considered adoption as bad, as the last hope for the childless and that adoption does not remove the stigma of being barren or childless. The female groups in the other two sectors said that adoption ‘is not a big deal as one can adopt if there is capacity for doing so’; ‘we see it as a good alternative for infertile couple because it will serve as comfort for them’; through adoption, God can remember them’.

The inner core male group said that people in their community have some thought about adoption. A participant said that sometimes a person who wants to adopt a child would want to do that because there is an ulterior motive to use the child for something else. Also, it was said that people living beside the person who adopts a child may not have a good attitude towards them. The group at the transitory sector said that adoption is ‘taking such a child from frying pan to fire because the environment is not conducive as our community is a local area’ and that ‘it is hard to take such a child as if the child is one’s biological child’. The peripheral male group said they disliked adoption because ‘we have not taken care of our own children not to talk of another person’s child’. Also participants said that ‘some people belief that an adopted child is a bastard and that such children would destroy their homes’

Beliefs, Attitudes and Acceptability of Adoption

The Yoruba cultural belief that ‘ori omo lo npe omo wa’ye’ meaning a child usually attract yet to be borne children to come to the physical realm, this was widely expressed by all the FGD participants. Attitudinal disposition vary across sites. The participants in the inner core said ‘we do not know how the community members would feel if it happens because it has never happened in our community’

while their counterparts in the peripheral site said that ‘adoption is not bad because nobody wants to release their children to go and live with one brother/sister but when one adopts one knows the child is one’s own for life’.

On acceptability, the participants at the inner core and peripheral said that adoption was not acceptable in their community as according to them they ‘belief in having our own biological children’ and because ‘it has not happened before’. Other reason was that Yorubas believe that such a child is ‘a bastard and that with time the child will ask for his biological parents’.

Factors hindering and /or facilitating adoption process in the community

A myriad of factors hindering/militating against the adoption process were enumerated. Topping the list was Yoruba cultural belief, followed by attitude of health workers, poverty, non-acceptance by the family of husband or wife who would prefer their son or daughter marrying another person rather than adopt a child as well as disagreement between couples.

Benefits of adoption

Several benefits of adoption were mentioned. These included temporary consolation for childless couple so that they will not feel lonely or feel the impact of being childless; it prevents thuggery or prostitution and can bring good luck to the family because child can become someone great in future.

Problems faced by infertile couples as far as adoption is concerned

Several problems were envisaged in the process of adoption. These are opposition to adoption by one of the couples or disagreement; people in the environment would start telling the child history of the child belonging to government, extended family problem because the child can never be accepted and can make the couple to divorce each other, long procedure in the adoption process, stress from government as couple may have to travel out of their station, fear of what people will say and finally no enlightenment on child adoption.

Ways members of the community support the adoption process

On ways that community members can support adoption process, male participants from transitory sector said that if they are enlightened about it they can support adoption because there are people in this situation but who do not know anything about child adoption. The male group from inner core said ‘if God blesses us we can adopt children and help them but before doing that we must inform our family’ while the male group in the peripheral sector said ‘we can’t support child adoption because every one of us has his own children, no one can adopt. If motherless babies’ home is built here, we can support financially and dash them things’. On the other hand, the female groups in both the inner core and transitory said ‘nothing because it is not accepted in our community’; we cannot support because common NEPA(National Electricity Generating Board) people are not cooperating. Health centre would have been built here but the landlords did not agree which may be due to high cost of land’. The female group at the peripheral on the other hand said they would support ‘through financial assistance and materially by taking things to them at the motherless home’.

Awareness of Adoption Law

Almost all the FGD participants were aware of the adoption law. On things known about the law, participants listed child must not be subjected to suffering and must not be denied of what he/she wants; if the child dies, the case is between government and the couple. For the ones who said they were not aware, they said there were no awareness programmes on it otherwise they would have heard about it on the television or radio once in a while.

Discussion

Infertility has remained a public health challenge with most of the burden in developing countries . In Nigeria, there is abundant evidence that despite infertility being one of the commonest gynaecological presentations, outcome of treatment is usually marred by poor facility, expertise and poverty. The option of child adoption is yet to be fully explored in those that have intractable infertility following unsuccessful conventional and artificial management.

The knowledge of the study participants at the three sites on common sexual and reproductive health rights further confirms the high prevalence of sexually transmitted infections (STIs) in Nigeria. Most times, these STIs are usually poorly treated resulting in myriads of complications including tubal infertility in both genders with adverse clinical outcomes^{20, 21} . In addition, it is also possible that the level of miscarriages mentioned may not be unconnected with the aftermath sequelae of STIs and indiscriminate unprotected sexual intercourse resulting into complications of unsafe abortion following unwanted pregnancy ^{19, 22} . Another issue mentioned in this study is the common occurrence of maternal death during pregnancy and childbirth as well as stillbirth. This observation is a reflection of the poor maternal and perinatal morbidity and mortality indices in Nigeria over the years ^{23, 24} . The openness demonstrated by the male group compared to females on sexual and reproductive health issues has remained a peculiar problem in most developing countries. The timid attitude by females to openly discuss their own reproductive health challenges negatively affects the quality of their advocacy and subsequent intervention²⁵ .

Although, the meaning and implications of child adoption is known but, there are some misconceptions. For example, the opinion by the male study participants that adopted child should attain a particular age is not part of the requirement. The guideline and other requirements for adoption is not well known by all participants. Most believed that only the child that is either abandoned or at motherless babies home could be adopted. Despite the fair level of knowledge, none of the participants have had a practical experience but, many engage in fostering. This finding is in tandem with the Araoye’s study that child adoption is not a popular alternative to infertility among Nigerians¹⁸ .

The general perceptions about adoption varied based on gender, location and socio-economic status. The female group mostly have an aversion because of their belief that adopted child cannot fully replace the position of their own biological child. Previous studies have reported similar finding among womenfolk with higher aversion among the infertile group⁹ . This position may be due to general cultural stance of the majority of the ethnic groups that marriage without procreation cannot be regarded as being blissful²⁶ . Therefore, accepting adoption by any woman may be tantamount to childbearing failure and this may be a leeway for her partner to engage in polygamy^{18, 27} . Consequently, such women may sometimes be excluded from the benefit of the family’s inheritance. Another factor mentioned was the financial demands of fending for extra child at their own family’s expense. This is a reflection of the poverty level in Nigeria as most children suffered from this by dropping-out of school and this may catalyzed into other anti-social behaviour. The burden of childupbringing is enormous and it may generate an internal conflict that might be difficult to resolve because of the notion that an adopted child could be claimed back by his/her biological parents. Other fears expressed were the possibility of labeling the child ‘bastards’ and likelihood of anti-social behaviours.

The community acceptance of adoption practice is influenced by the Yoruba beliefs, poor attitude of health workers, poverty and disposition of different families. The reported belief by Yorubas that adopted child is a ‘bastard’ could discourage any willing couples for fear of tarnishing their family’s good name. Although, child fostering is culturally entrenched with the Yoruba cultural system, however, the practice is not solely for infertile couples. In recent years, information on the subject has become more plentiful, with substantial contributions from demographers and scholars in related disciplines^{28, 29}. It has social and economic benefit. In the past, many children are reared by foster parents which is a confirmation of a local proverbial statement that “eni kan lo n bimo, opo eniyan lo n ba’ni to, meaning that only one person gives birth to a child, but many people take part in rearing the child²⁹ . This further underscore one of the focus group comment that “there is no adoption in our community except our relative children that are with us” About three decades ago, expert in social medicine have suggested the need to institutionalize child fostering³⁰ , and some state in the country have enacted law in this regard³¹ . Inspite of this, option of fostering is yet to be fully explored as an alternative infertility management in our setting.

Some would rather live with the infertility or engage in polygamy than to face the ridicule because of non-existence of organizational structure that is set out for adoption or even child fostering in our infertility clinics. This may not be unconnected with their concern of the possibility of the children wanting to return to their biological parent or may be claimed back by their biological parent. Furthermore, this belief may also, be due to the fact that adopted child will not be given his or her own share of family’s socio-cultural benefits/entitlements. For example, it will be extremely impossible for such a child in a royal family to aspire with other biological children. The rejection of adoption has also been reported elsewhere for religious 16 reasons . Awareness creation through media and use of other fora to provide information about the process/guideline and other benefits was suggested by the male group. The formulation and subsequent dissemination of the adoption law in Nigeria will further reassure the desiring couples. Involvement of all stakeholders especially community, traditional, religious and political leaders including women groups should be coopted at all stages to achieve a more robust law that will accommodate all views including protection against any cultural barriers.

Conclusion

Although none of the participants in this study had experienced adoption, however, most were opinion leaders within their community and this can provides the strengths that could be harnessed for policy implementation including mobilization of their community. These influential individual may be used as vanguards of positive disposition towards child adoption services. Based on these findings there is need for strong advocacy, enlightenment and community mobilization for improved awareness and utilization of adoption services.

Acknowledgement

This study received grant support from the Gates Institute, Johns Hopkins University School of Public Health, Baltimore, USA, through the Centre for Population and Reproductive Health, College of Medicine, University of Ibadan, Nigeria.

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