Tazeen S. Ali  ( Department of Community Health Sciences, The Aga Khan University, Karachi. )
Neelofar Sami  ( Department of Community Health Sciences, The Aga Khan University, Karachi. )

Objective: To explore the perceptions and experiences of couples with secondary infertility regarding adoption practices; to estimate the prevalence of adoption among couples with secondary infertility, and to study the adopted child preference pattern.

Methods: To fulfill the objectives of the study both qualitative and quantitative study designs were utilized. In qualitative explorative study design, three Focus Group discussions were conducted with married fertile women to explore their perceptions for adoption practices. Moreover, eight in-depth interviews were conducted with women with secondary infertility to explore their experiences. For quantitative methodology, a case series of 400 secondary infertile couples was conducted.

Results: Qualitative methodology result suggests that adoption is the last option for infertile couples. Couples often take this as a "Totka", that when they adopt a child, they could end up having their own baby. The husband's family is usually preferred for adopting a child. The results of quantitative component suggest that the prevalence of adoption among 400 women is 7%. Less than half of the respondents (49.3%) reported to ever having thought of adopting a child to cope with the secondary infertility. The main decision maker for adoption of child is the husband (17%) and the mother-in-law (68%). Though majority of these women (72.5%) were supported by their husbands, however, in-laws and relatives were reluctant to pursue this option and less than one third (29%) of these women had a support from them.

Conclusions: This study concludes that couples ever thought of or opted for adoption after prolonged duration of secondary infertility. In cses where the condition cannot be treated, it is necessary to counsel, not only the couple but also the in-laws (JPMA 57:55;2007).

Infertility is one of the major reproductive health problems in Pakistan with a prevalence of nearly 22%. The prevalence of primary infertility is 4% and that of secondary infertility is 18%.1 Reproduction is a natural biological urge and is considered to be a basic human need.2 In many parts of the world including South Asia, the woman is thought to be responsible for procreation and only then is she able to achieve her cultural and social identities.3 Moreover, procreation is presumed to be an integral part of a stable marital relationship and a woman gains prestige and security in her husband's home only after she succeeds in proving her fertility. Also the typical Asian tradition still demands that all marriages result in children, preferably male ones. The patrilineal systems in Asian countries produce a strong desire for sons to continue the family line4 and are regarded as sources of income and security in old age. Pakistan's culture is not different from those of other Asian countries. The blame for absence of, desired number and sex of children is unquestioningly placed on the woman and this becomes a threat to her status in society leading to serious consequences such as husband's remarrying, divorce,5 emotional harassment,6 and deprivation of her inheritance or being returned to her parents.7 This is true for primary as well as secondary infertility cases. Secondary infertility becomes particularly important where the previous pregnancies end up in poor outcome such as abortions, stillbirths, neonatal or infantile deaths or the live births of daughters only.8-11 Studies have revealed that severe emotional harassment in the form of ostracism from family celebrations, taunting and stigmatization, negative attitude as well as beating, withholding of food and health care12 is experienced by a large number of such women in their marital homes. This results in immense psychological trauma12 leading to low self-esteem, insecurity and lack of self-confidence in such women.

The process of medical diagnosis and treatment of an infertile woman further aggravates the situation. While receiving expensive treatment the couple hopes that the woman would conceive soon, which leads to feelings of helplessness and powerlessness if unsuccessful.13-15

Even though hi-tech facilities have provided successful treatment to many infertile couples, it is certain that a proportion of them will remain childless. These couples would be in dire need to learn how to cope with infertility; adoption is one of the coping mechanisms. Although infertility is reported to be associated with social, physical and mental trauma,

adoption still remains unacceptable due to complex social and cultural barriers.
Adoption is still a new concept in our society; it may be from within or out of the family. Adoption within the family is preferably acceptable.16 Not only is adoption one of the coping mechanisms for the infertile couples it is also important for the adopted children as they would be receiving appropriate care in the form of good nutrition, education, and status in society17,18, which many of them otherwise would have been deprived of due to lack of family support.

However, adoption continues to remain an undesirable option due to various reasons. The links between an adopted child and the social parent become a public, vocal, and visible admission of infertility that cannot be subsumed.19 Moreover, the process of adoption is so lengthy and complicated that many couples decide not to adopt or are unable to fulfill the legal requirements. In Pakistan, so far, we have dearth of knowledge about adoption practices. Therefore a study was conducted with the following objectives: to explore the perceptions and experiences of couples with a secondary infertility regarding adoption practices; to estimate the prevalence of adoption among couples with secondary infertility; and to study adopted child preference patterns.

To meet the study questions both qualitative and quantitative study designs were used.
A. Qualitative Methodology
Focus group discussion and in-depth interviews were conducted.
Focus Group Discussions (FGDs)
A total of five FGDs were conducted with currently married women within the age group of 15-35 years who had had at least two live births. One FGD was conducted with women from each of the areas in the vicinity of Qatar, Sobharaj, Jinnah, Liyari General and The Aga Khan University hospitals.

In-Depth Interviews (IDIs) A total of ten in-depth interviews were conducted with identified secondary infertile women within the age group of 15-35 years at facilities included in the study. At each facility, two women were interviewed.

Study investigators conducted FGDs and IDIs by using self developed specific structured guidelines. The guidelines were originally developed in English and translated into Urdu and were pre-tested in the form of a dry run. Modifications were made in the guidelines where questions required further probing. All FGDs and IDIs were audio taped. Notes were taken by a note taker.

Each FGD had about 8-10 participants. In-depth interviews were conducted on one to one basis. The local health workers helped in the identification of women according to the selection criteria and in the organization and formation of groups. Before each discussion and interview women were informed about the study and their verbal consent was obtained prior to their participation and for recording the information.

B. Quantitative Methodology
Using case series study design, data was collected from March - June 2004. The sample size calculation was done on the bases of matched case control study, to identify the risk factors for secondary infertility. However, the data of adoption practices were collected from cases only. Therefore a sample of 400 women was analyzed for our adoption related study objectives.

The inclusion criteria for cases were, currently married women within the age of 15-35 years with at least one previous conception irrespective of outcome and attending an infertility clinic. The cases of secondary infertility were identified from Sobharaj, Aga Khan University, Jinnah, Liyari General and Qatar hospitals. The data was collected on structured pre-tested questionnaire which was developed after analyses of qualitative study. The pre-testing was performed on 10% of the sample. Information was collected by trained data collectors. The data collectors were certified to collect data after a number of assessments.

The consent for interviewing the cases was taken from the Medical Superintendents of the hospitals, doctor In-charge of infertility clinics and from the infertile women. The cases were interviewed at the clinic premises either on the day they attended the clinic, after laparoscopic examination, at the time of discharge or on follow-up clinic visits.
The data was edited at field and at office levels by investigators. Data was double entered in epi-info and checked for error rate. Later this was analyzed using Statistical Package Scientific Software version 10 (SPSS).

Qualitative
Description for characteristics
The mean age and parity of participants of Focus group discussion was 28.6 years and 4.4 respectively. Nearly 56.7% of the participants were literate. Among participants of in-depth the mean age was 32.4 years. Half of the respondents had one live birth while remaining had no live births. The literacy rate among them was 59.5 percent (Table 1).

[(0)]

Themes from FGDs
Generally women were of the opinion that infertile couples do not opt for adoption. Adoption could be an option for primary infertile couples but not for those with secondary infertility as women had previously conceived at least once so there was always a hope of another pregnancy. Some women said that the reason was that it was a 'totka' that a couple gets its own baby as a gift from God after adopting a child. Women generally reported that in-laws did not allow the couple to adopt. The mother in law preferred another wife for their son rather than adopt someone's child, even when the son was responsible for the infertility. Children were usually adopted from husband's family (inter-family adoption).

Themes from IDIs
None of the women reported to have adopted a child. In response to the question whether they had ever thought of adoption, two women responded that they had thought about this. These women had discussed the matter with their husbands who supported them but when the matter was discussed with the in laws, they were against the option.

Quantitative
Description for characteristics
A total of 400 cases of secondary infertility were enrolled from five infertility clinics of tertiary care hospitals including Jinnah Hospital (n=183, 45.8%), Liyari General Hospital (n=59, 14.8%), Sobharaj Hospital (n=50, 12.5%), Qatar Hospital (n=90, 22.5%) and Aga Khan University Hospital (n= 18, 4.5%).

A majority of the study subjects belonged to Urdu speaking community (48%), followed by Punjabi (21%), Balochi (13%), Pathan (12%) and a few Sindhis (6%). The mean age of subjects was 28.9 years + 4.3 standard deviation. Half of the cases were illiterate (48.3%) whereas only 29% of their husbands were illiterate. Majority of the respondents were housewives (87.5%) and had been married for 5 to 9 years (Table 2).

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[(2)]

Pregnancy outcome
A total of 883 pregnancies were reported by the 400 study subjects with a mean of 2.19 (+SD 1.45). A total of 195 out of 400 women had at least one live birth and remaining 205 women were nulliparous. Regarding pregnancy outcomes, 42% cases had the abortions, 12% still births and 20% infant or neonatal deaths (Figure).

Adoption as a coping mechanism for infertility
Half of the respondents (49.3%) reported to ever thought of adopting a child to cope with the secondary infertility. A majority of these women (72.5%) were supported by their husbands when they discussed the matter of adoption with them. However, the in-laws of less than one third (29%) of these women supported the suggestion for adoption. When specifically asked about who would be the decision maker for adopting a child, majority responded that it was the in-laws. Regarding the place from where the child could be adopted, a majority of the women mentioned that it had to be from the husband's family. The other possible places could be orphanages, friends and the women's family. A majority of the women who reported to have considered for adoption were over the age of 35 years and had been married for more than 5 years (Table 3).

[(3)]

Only 28 respondents mentioned that they had already adopted a child, when 197 had thought of adoption. Those who adopted or thought of were supported by their husbands most of the time, whereas support from in-laws was limited. Regarding the pregnancy outcome, the only difference between the two groups was that all those women who had already adopted a child at the time of interview did not have a live child.

Limitations
As this study is to our knowledge, the first of its kind in Pakistan, the authors confronted certain research limitations, one of which was the availability of the published material on this subject. Thus the study is exclusively based on original data collected from the selected sample. In addition, the authors were not able to collect in-depth data on family dynamics and social taboos. Furthermore, during the selection of cases a selection bias occurred: cases have been selected from hospitals only. This could not enable the authors to bring in results from those who never visited hospitals.

Our study shows that half of the women who have either thought of or have adopted a child are illiterate. The high level of illiteracy affects not only their health seeking behaviour but their status in the family too so they are not in a position to decide. In this study nearly 50% women reported to have ever thought of adoption and only a small proportion (7%) of women had adopted a child. The main reasons for the inability of the women who wished to adopt a child were the resistance from the husband's family for adoption in general and place of adoption in particular. Most of the husbands agreed with their wives to opt for adoption but could not support their wives because of the unwillingness of their own family. Moreover, it is presumed that a woman can never love a child she has not given birth to. In addition, it is preferred to adopt a child from the husband's family which is the 'true blood' and so is close to be the real child.20 Similar results were observed in our study too. Thus, it would be important to counsel not only the infertile couples but their family members, that adoption could be one of the coping mechanisms for the family especially for the women. A study conducted in India has shared the results that counseling does help the couples and their families to opt for adoption as one of the coping mechanisms in cases of infertility.21

A majority of the women in our study reported that they started thinking of adoption after the age of 35 years and had been married for more than 5 years. This shows a natural trend that a woman waits for a certain time period with the hope of having her own child before opting for adoption.

The women who had a daughter adopted a boy because it is presumed that a son can take care of the parents and sisters. This seems a regional problem as identified by other studies too that boys are preferred to girls.22,23

Adoption is a sensitive issue and puts the families and peoples in a difficult position to make a decision in this context. Not only the process of adoption is lengthy in Pakistan, it leads to various consequences for the Muslim communities e.g. due to the exclusion of inheritance rights for the adopted child. These result in adoption not to be a common practice in Pakistan. Therefore, there is a need of further studies involving religious leaders for clarifying the myths and ambiguities related to the issue. Only then awareness could be created among people how Islam supports the issue. Though Government of Pakistan does not have any adoption policy, few non governmental organizations in major urban cities take care of the orphans and assist infertile couples for adopting them if they are willing to. However, the couple has to follow and abide by the procedures set by the NGO which are for the benefit of the adopted child as well as for the adoptee parents and their families. Many people find these processes difficult to pursue. There is a need to create awareness among the general population and among infertile couples about such organizations and their procedures. Moreover, the government and NGOs could work in collaboration to make the adoption process transparent and easy.

This study concludes that after prolonged duration and treatment of secondary infertility, when couples think of adoption it is not supported by the elders in the family. If they support it, they prefer the adoption from husband's family. In case of absences of adoption from family, the families think of adoption from orphanages.

This study recommends need of appropriate counseling regarding adoption for infertile couples and their families, particularly where infertility is probably not curable. Moreover, those couples who agree to adopt a child should be guided appropriately for fostering services and the appropriate places for these services. In addition, there is a need of further studies to understand the complex socio-economical and religious understanding of adoption among infertile couples.

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