‘It’s Not by Choice’: The Hidden Struggle of Infertility in Malawi

LILONGWE, Malawi—For almost two decades, Chisomo has waited for something she once believed would happen naturally: becoming pregnant.

She got married in December 2007 and remembers having her last menstrual period that same month, around the time of her wedding. After that, her periods stopped, writes Zuleika Nanguwo.

At first, she believed it was only a matter of time before they returned. But as the months and years passed without menstruation or pregnancy, she began seeking medical help. What followed was a long journey of consultations, investigations and fertility treatments.

Chisomo is a pseudonym used to protect her identity. She requested anonymity because of the sensitive and deeply personal nature of her experience.

Over the years, she underwent several fertility treatments, including hormonal treatment and ovarian drilling, hoping to improve her chances of conceiving. Each treatment brought renewed hope that perhaps this time would be different.

But she is still waiting.

“Facing fertility challenges since 2008 has been one of the most difficult experiences of my life,” she says. “It has been a journey filled with hope, disappointment, questions, and moments when I wondered why this was happening to me.”

For Chisomo, infertility has been about more than the inability to become pregnant. It has affected her emotional wellbeing, her confidence and the way she sometimes views her relationships.

Despite her husband’s continued support, she says there have been moments when she has questioned whether he truly wants to remain with her or feels sorry for her because she has not been able to give him a child.

She knows these fears may not reflect how he feels, but they are insecurities she has carried throughout her journey.

Her experience reflects a wider reality for women facing infertility in Malawi, where the inability to conceive can become tied to questions of womanhood, identity and worth.

A problem affecting thousands

Infertility is not simply a private family matter or a woman’s failure to have children. It is a medical condition affecting both men and women.

Previous studies have estimated infertility in Malawi at around 17%, according to Dr Zaziwe Gunda, a sexual and reproductive medicine specialist.

At Gateway Clinic in Blantyre, Dr Gunda says at least 15 couples seek fertility services in a typical month. He describes the burden as approximately one in five couples struggling with infertility, while stressing that infertility can result from either male or female factors.

Globally, the World Health Organization estimates that approximately one in six people of reproductive age experience infertility during their lifetime. WHO defines infertility as the inability to achieve pregnancy after 12 months or more of regular, unprotected sexual intercourse.

Dr Gunda says the causes he encounters include hormonal and ovulatory disorders, thyroid disease, premature ovarian failure, obesity, tubal damage, age-related decline in fertility and endometriosis among women.

Among men, causes can include reduced or absent sperm, hormonal problems, infections, chronic conditions, lifestyle and environmental factors and varicocele.

But while infertility is a medical condition, its consequences can be deeply social.

Dr Gunda says the belief that infertility is automatically a woman’s problem persists because pregnancy is associated with women, leading people to assume that the woman must be responsible when conception does not occur.

But, he stresses, “infertility is a couple problem, not only a female problem.”

He says women experiencing infertility can face stigma, psychological distress, divorce and even physical and verbal abuse.

When society places the blame on women

Although Chisomo says she has not experienced direct discrimination, she has experienced the effects of social attitudes surrounding childbearing.

She has encountered assumptions that a woman who cannot conceive must have had abortions in the past or somehow damaged her reproductive health. She has also encountered beliefs that infertility may be caused by witchcraft or spiritual attacks.

“These beliefs have affected me emotionally because, even when nobody says them directly to me, knowing that people may make such assumptions makes me feel judged and misunderstood,” she says.

Before experiencing infertility herself, Chisomo says she knew very little about the condition.

She had assumed pregnancy was simply a natural process that would happen once a couple decided to start a family. She did not understand that fertility problems could result from conditions affecting either partner.

She now believes Malawi needs greater public awareness about infertility.

“Infertility is often treated as a source of shame rather than a medical condition,” she says.

The struggle to access fertility care

Dr Gunda says Malawi faces a shortage of health workers trained in fertility treatment, while fertility care is not prioritised enough within government institutions.

Diagnostic tools for male and female infertility are not readily available in public facilities, and fertility medications are often unavailable, forcing patients to purchase them themselves. Private treatment can also be expensive.

Chisomo knows this struggle firsthand.

She says that when she began seeking fertility care around 17 to 18 years ago, specialist services were difficult to access in public hospitals. Private facilities were more accessible, but the financial burden was significant.

She also remembers encounters with healthcare providers whom she felt were dismissive and lacked empathy.

“Seeking fertility care felt less like receiving medical help and more like fighting an uphill battle against healthcare professionals who lacked basic empathy for patients in distress,” she says.

One experience was different. An expatriate female gynaecologist at Daeyang Luke Hospital, she says, listened to her, treated her with compassion and gave her a sense of dignity.

Although the treatment did not result in pregnancy, Chisomo says the experience showed her what compassionate fertility care should look like.

More than a mother

For Chisomo, the struggle has not only been about accessing treatment. It has also been about how society defines a woman’s value.

Sandra Mapemba, a Sexual and Reproductive Health and Rights activist, says infertility should be understood as a public health and human rights issue rather than simply a private family matter.

“Infertility is a rights issue, not just a private matter; it affects dignity, health, and equality,” Mapemba says.

She says infertility can affect mental health, social inclusion and economic security, while women often carry much of the blame because of gender norms that equate womanhood with motherhood.

“Women unfairly carry the blame for infertility, facing stigma and violence despite men also being affected,” she says.

Mapemba says beliefs about witchcraft, past abortions and the idea that women are solely responsible for having children can deepen stigma and discourage people from seeking appropriate care.

She says infertility care in Malawi remains limited and expensive, with specialised services largely concentrated in private clinics.

She calls for infertility to be integrated into public sexual and reproductive health programmes, with greater investment in affordable diagnosis and treatment, trained healthcare providers, services beyond urban centres and psychosocial support for affected women and couples.

For women who have been made to feel less valuable because they cannot conceive, Mapemba has a simple message: “Your worth is not defined by childbearing; you are complete and deserving of respect. Never be convinced to not seek support.”

What needs to change?

Maziko Matemba, a Public Health Rights Activist, says infertility care remains a neglected area of Malawi’s public health system, creating inequalities for people who cannot afford private treatment.

“From a health rights perspective, the state of infertility care in Malawi is a stark example of systemic reproductive injustice and inequality,” Matemba says.

He says Malawi needs to make fertility care more accessible in public hospitals, including basic fertility screening, semen analysis, fertility medicines and referrals for advanced treatment.

He also says the health system needs to address preventable causes of infertility, including untreated sexually transmitted infections, complications from unsafe abortions and poorly managed postpartum infections.

Matemba says women continue to carry much of the blame despite men also being affected. He recommends couple-centred fertility assessments so that both partners are evaluated rather than automatically placing responsibility on the woman.

He also calls for greater public education involving traditional and faith leaders to challenge beliefs about witchcraft and other misconceptions surrounding infertility.

At policy level, Matemba says infertility needs greater attention through investment in affordable services, trained health workers, diagnostic equipment and fertility medicines.

These concerns are also reflected in the Ministry of Health’s assessment of the country’s fertility services.

Dr Owen Chikhwaza, Director of Reproductive Health in Malawi’s Ministry of Health, says infertility services are currently available at central hospitals, where couples experiencing difficulties conceiving can receive services free of charge.

However, he says the services remain limited, mainly addressing hormonal and structural causes of infertility, while more advanced treatments such as assisted reproduction are not yet available within the public system.

A major challenge, Chikhwaza says, is the shortage of specialists with advanced training in fertility medicine. He says Malawi’s existing policies and legal framework are not yet sufficiently clear to regulate assisted reproduction.

Chikhwaza says a proposed Public Health Act is currently moving through Cabinet and Parliament and could provide a legal foundation for regulating assisted reproduction once enacted.

He also says Malawi needs to invest in advanced graduate-level training for local doctors. Because assisted reproductive technologies are expensive, he suggests that government could work with specialised private institutions through Memorandums of Understanding to expand access to such services.

His response highlights a gap between the availability of basic infertility care and access to advanced fertility treatment in Malawi.

‘It’s not by choice’

For almost 18 years, Chisomo’s journey has been marked by treatment, disappointment, hope and uncertainty.

But her story is about more than wanting to become a mother.

It is about what happens when society makes motherhood a measure of a woman’s worth. It is about the assumptions made about her body, the stigma she has had to navigate and the insecurities that infertility has sometimes created within her relationships.

Her mother and sisters have supported her emotionally, financially and spiritually throughout the journey, while her husband has also remained supportive.

Yet the emotional scars remain. Her message to other women, families and the wider Malawian public is simple: “It’s not by choice.”

Infertility may affect a woman’s ability to become a mother, but it should never determine her value as a woman. Women experiencing infertility deserve accurate information, compassionate healthcare, dignity, emotional support and freedom from stigma.

They are more than their ability to become mothers.