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doi:10.1093/humrep/dem279

Human Reproduction Vol.23, No.2 pp. 352–357, 2008 Advance Access publication on December 6, 2007

Motives for parenthood among couples attending a level 3 infertility clinic in the public health sector in South Africa Silke Dyer1,3, Ntebaleng Mokoena1, Johannes Maritz2 and Zephne van der Spuy1 1 Reproductive Medicine Unit, Department of Obstetrics and Gynaecology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Observatory 7925, South Africa; 2Medical Research Council, Biostatistics Unit, PO Box 19070, Tygerberg 7505, South Africa 3

Correspondence address. Tel: Ăž27-21-4046027; Fax: Ăž27-21-4486921; E-mail:silke.dyer@uct.ac.za

Keywords: Africa; child wish; gender; infertility; parenthood motives

Introduction Despite global reductions in fertility rates, parenthood remains a central life goal in most societies (Becker and Nachtigall, 1994; Edelmann et al., 1994; Daniluk, 1997; Fidler and Bernstein, 1999). African societies are particularly pronatalistic with high total fertility rates and low rates of voluntary childlessness (Sonko, 1994; Bambra, 1999). Notwithstanding this almost ubiquitous wish to reproduce, the underlying motives for parenthood are varied and may differ between individuals and societies. A number of theories, concepts and approaches have been utilized in order to address the question of what motivates men and women to have children (Veevers, 1973; Miller, 1994; van Balen and TrimbosKemper, 1995). From the perspective of the health sciences, infertile men and women represent a suitable cohort for the study of parenthood motives. According to studies conducted in Europe, fertile and infertile couples have largely similar reasons for wanting a child (Lalos et al., 1985; Colpin et al., 1998; Langdridge et al., 2000). Infertility, however, usually induces reflection on the desire for a child, thereby resulting in the manifestation of parenthood motives which often remain latent in the general population and thus difficult to study (van Balen and Trimbos-Kemper, 1995). In addition, studying 352

parenthood motives among infertile couples offers relevant insights into their difficulties and losses (van Balen, 2001). A number of studies have explored parenthood motives among infertile couples in Western industrialized countries (van Balen and Trimbos-Kemper, 1995; Colpin et al., 1998; Newton et al., 1992; Langdridge et al., 2000; van Balen, 2001). According to these, parenthood is mostly desired for the expected feelings of love and happiness, while motives relating to social reasons and norms feature less prominently. In comparison, studies from African countries emphasize the considerable role that successful human reproduction plays in the social context, frequently linking fertility with social status and wealth, and childlessness with negative social repercussions (Feldman-Savelsberg, 1994; Sonko, 1994; Gerrits, 1997; Okonofua et al., 1997; Sundby, 1997; Runganga et al., 2001; Dyer et al., 2002,2004; Hollos, 2003). It therefore appears that differences exist between Western industrialized and African countries, especially with regard to the social domain of parenthood motives. Any such conclusion is, however, limited by the fact that there is a paucity of formal research on parenthood motives from Africa (and no study from South Africa) and that existing data are extracted

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BACKGROUND: Most African countries are pronatalistic with high total fertility rates and a low prevalence of voluntary childlessness. At present, limited data exist relating to the reasons why men and women desire children. This study explores parenthood motives among infertile couples from an urban community in South Africa. METHODS: The parenthood-motivation list, an instrument developed in the Netherlands for the assessment of parenthood motives and strength of desire for a child, was administrated to 50 couples (100 participants) who presented to an infertility clinic in a tertiary referral centre. The instrument discerns six parenthood motives comprising happiness, well-being, identity, parenthood, continuity and social control. RESULTS: The majority of participants endorsed most of the motives. The categories happiness and parenthood were the most frequent motives. Women endorsed more motives simultaneously when compared with men. The categories happiness, well-being and social control correlated positively with strength of desire for a child. Most men and women expressed a strong desire for a child. CONCLUSIONS: Men and women desired children for many reasons and with similar intensity. This diversity and intensity of parenthood motives appears to be a reflection of the value of children in our communities and further our understanding of the implications of involuntary childlessness.


Motives for parenthood

almost exclusively from qualitative work on fertility and infertility involving women. The primary aim of this study was to assess parenthood motives among infertile men and women from an urban community in South Africa with the use of a structured instrument, the parenthood-motivation list (van Balen and TrimbosKemper, 1995). It was anticipated that the results of this study would provide novel information on parenthood motives in our communities, offer insight into possible gender differences with regard to these motives, and expand our understanding of the implications of involuntary childlessness. We furthermore hoped that a comparison between this study and other studies, utilizing the same instrument, would offer relevant insights relating to the similarities and differences in parenthood moves between Western industrialized and African countries.

The study was conducted at a tertiary infertility clinic in an academic centre, which provides comprehensive infertility treatment including assisted reproductive techniques (ART) to patients accessing public service health care in Cape Town, South Africa. In South Africa, the public health system offers health care to all patients who cannot afford or do not wish to access private facilities. Most of the patients within the public health system are from local, low-resourced communities. The community of Cape Town consists of three major ethnic groups. Approximately half of the population is of mixed ancestry (locally referred to as ‘coloured’), while 31.7% are black Africans and 18.8% are white. The languages most commonly spoken are Afrikaans, Xhosa and English. While Xhosa is the local black African language, many black Africans also speak English. The coloured and white population mostly speaks Afrikaans and/or English. The dominant religious affiliations are Christianity (85%) and Islam (13%) (Statistics South Africa, 2001). Fifty couples participated in this study. It was anticipated that this sample size would offer sufficient insight into parenthood motives among informants and allow us to explore whether the parenthood-motivation list could be applied in our setting. Study participants were recruited consecutively at the infertility clinic, immediately prior to their consultation with a medical practitioner. Recruitment was dependent on both partners being present and willing to participate. Written informed consent was obtained and emphasis was placed on the fact that information provided by the participants was confidential and would not influence their management at the clinic. Informants were interviewed alone and partners were given no opportunity to communicate with each other until both interviews were completed. All interviews were conducted in the preferred language of the informant by one multilingual professional nurse, who was not involved in the clinical service. Basic socio-demographic information was obtained from all participants and the parenthood-motivation list was administrated (van Balen and Trimbos-Kemper, 1995). Following personal communication, this instrument had been provided

Table 1. Parenthood-motivation list. Item

Motive

Ordera

It is nice to have children around To have unique relationship with the child Bringing up children brings happiness It makes the relationship with your partner complete Children make life complete It gives you a goal to live for It is obvious to have children It is a sign of being grown-up It is the nature of man/woman It fulfils motherly/fatherly feelings Parenthood is satisfying To experience pregnancy and birth Your environment (others, family) expect it of you Others around me have children To avoid being an outsider To continue the family name/tradition Not to be alone when you are old To have something of yourself continue living after you are dead

Happiness Happiness

1 10

Happiness

12

Well-being

3

Well-being Well-being Identity Identity Identity Parenthood Parenthood Parenthood Social control

8 13 4 14 16 2 6 11 9

Social control Social control Continuity

17 18 5

Continuity Continuity

7 15

a

Order in which item is asked in the list.

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Patients and Methods

for use in our study by one of the original authors. The parenthood-motivation list was originally based on a national survey on fertility and parenthood motives in the Netherlands, which included open-ended questions on the advantages and disadvantages of having children. Factor analysis of the responses identified eight categories of parenthood satisfaction. Further research and a shift of focus from parenthood satisfaction to parenthood motives resulted in the development of the parenthood-motivation list (van Balen, 1991). The parenthood-motivation list comprises 18 questions/ statements reflecting 6 parenthood motives as outlined in Table 1. The response to each of these 18 items is measured on a three-point scale (strong agreement, partial agreement and disagreement). A motive is considered to be present if the respondent strongly agrees with one or more of the three items referring to the particular motive. The six motives are constructed as follows: happiness refers to the expected feelings of affection and happiness in the relationship with children. Well-being comprises positive effects on the family relationship. Parenthood reflects being a mother or father as a source for life-fulfilment. Identity implies that children facilitate transition to adulthood and strengthen identity. Continuity comprises the wish to live on through children after death and to have support in old age. Lastly, social control refers to the implicit or explicit external pressure on the couple to procreate (van Balen and Trimbos-Kemper, 1995). The instrument also captures information on reflection and strength of desire for a child. The former is assessed by asking informants whether they think ‘never’, ‘sometimes’ or ‘often’ about why they want a child. Strength of desire is measured through Likert scales and the two questions ‘How strong is your wish to have a child/another child?’ (Six-point scale; 1 ¼ I do not really care that much; 6 ¼ I am willing to


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give absolutely everything for it) and ‘How do you currently feel about the fact that you may never have a child/another child of your own?’ (Seven-point scale; 1 ¼ It does not affect me; 7 ¼ It is the worst thing that ever happened to me). Analysis of the association between parenthood motives and strength of desire for a child provides insight into the strength of the different parenthood motives.

Results A total of 57 couples were asked to participate in the study. In six couples one or both partners declined to be interviewed and one couple was withdrawn after recruitment, as the male partner was unwilling to complete the interview despite his initial consent. The basic socio-demographic information of the 50 couples who represent the study group is summarized in Table 2. Women were significantly younger and more often had no live child when compared with their male partners (P , 0.05). Sixteen women and 22 men had at least one live child, but only six couples had a live child in union. No gender difference was observed with regard to education or occupational status. Couples had tried to conceive for an average of 4.6 years (range: 1 – 12 years). Thirty-seven couples were married by South African law, ten couples 354

Age (years) Mean Range Live children Yes No Population group Black Mixed ancestry Education 1– 7 years 8– 12 years Tertiary education Occupation Professional Skilled Semi-skilled/manual Not employed

Women, n ¼ 50

Men, n ¼ 50

P-value

29.5 20–38

32.9 21– 54

,0.005

16 34

22 28

,0.05

20 30

20 30

ns

6 40 4

5 39 6

ns

4 13 18 15

3 25 16 6

ns

ns, not significant.

lived in a common law marriage and three couples were married according to religious/cultural practices. The absence of white respondents was due to the fact that no white patient fulfilled the recruitment criteria during the study period. All six parenthood motives were frequently endorsed (Table 3). Social control was the parenthood motive with the lowest prevalence, but it was still present in over two-thirds of female and in over half of male respondents. Although women endorsed all motives more often than men, the differences were not statistically significant. The majority of respondents agreed with several motives simultaneously. None of the informants had a single motive, and 93 participants gave four or more motives for wanting a child. Female informants endorsed more motives simultaneously (mean 5.22) when compared with male informants (mean 4.80; P , 0.05). All but one informant had reflected on why they wanted a child, but women thought about this more frequently than men (P , 0.05). Women had a significantly higher mean score on the sixpoint Likert scale relating to the question ‘How strong is your wish for a child?’ when compared with men [women (mean + SD) score: 4.8 + 1.3; men: 4.3 + 1.2; P , 0.02). In contrast, no gender difference was observed on the second Likert scale (‘How do you currently feel about the fact that you may never have a child/another child of your own?’; women: 6.1 + 1.7; men: 5.9 + 1.4; P ¼ 0.57). A large

Table 3. The presence of parenthood motives among study participants. Parenthood motive

Women, n ¼ 50

Men, n ¼ 50

P-value

Happiness Parenthood Identity Well-being Continuity Social control

50 48 45 43 40 35

49 48 40 41 34 28

ns ns ns ns ns ns

ns, not significant.

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Statistical analysis In the original publication by van Balen and Trimbos-Kemper (1995), the validity of the six categories of parenthood motives was assessed through factor analysis with principal component analysis and varimax rotation. This analysis demonstrated that for infertile men and women living in the Netherlands the four categories happiness, continuity, social control and well-being were different factors or motives. Although according to the factor analysis, the categories parenthood and identity appeared to be a single motive, the authors elected to maintain the six categories of parenthood motives in their instrument ‘as these had been discerned in previous studies and on theoretical grounds’ (van Balen and Trimbos-Kemper, 1995). For the statistical analysis of this study, it was considered necessary to test the model of the parenthood-motivation list before applying it in the analysis of our data. The main objective of this test was to assess whether, in our study population, the 18 items coded for the six parenthood motives in the same way as in the original publication. We conducted both a latent trait analysis and a factor analysis. The statistical details of this approach have been published elsewhere (Maritz and Dyer, 2007). In both analyses, the results indicated a satisfactory fit of our data, and the model of the parenthood-motivation list was therefore assessed as being applicable to our study. The calculated factor scores were applied in the further analysis of the data. The paired t-test and the McNemar test were used in order to assess gender differences in the sociodemographic characteristics and in the parenthood motives. The association between the six parenthood motives and the strength of desire for a child was assessed via correlation coefficients between the factor scores and the Likert scale scores. A correlation coefficient of .0.286 was considered statistically significant (P , 0.05) and indicative of a motive being ‘strong’.

Table 2. Socio-demographic characteristics of male and female informants.


Motives for parenthood

Table 4. The association between parenthood motives and strength of desire for a child. Parenthood motive

Happiness Parenthood Identity Well-being Continuity Social control

Women, n ¼ 50

Men, n ¼ 50

Correlation coefficients

Correlation coefficients

Scale 1

Scale 2

Scale 1

Scale 2

0.495* 0.413* 0.305* 0.406* 0.076 0.289*

0.556* 0.128 0.190 0.173 0.145 0.319*

0.240 0.114 0.244 0.331* 0.183 0.286

0.135 0.154 0.054 0.052 0.134 0.305*

Scale 1, How strong is your wish to have a child/another child?; Scale 2, How do you currently feel about the fact that you may never have a child/ another child? *P , 0.05.

Discussion This is the first study from South Africa in which parenthood motives were explored in a structured manner among infertile couples. The results demonstrated that the majority of informants endorsed most of the parenthood motives and, therefore, had several motives for wanting a child. In addition, most participants expressed a strong desire for a child. These findings indicate that parenthood is deeply rooted in our community and that children are wanted for many reasons. All but one of the informants had reflected on why they wanted a child, in keeping with the hypothesis that infertility leads to the manifestation of latent parenthood motives (van Balen and TrimbosKemper, 1995). An analysis of the data by gender demonstrated few differences between men and women. No gender difference was observed in the frequency with which each of the six parenthood motives were endorsed. Women, however, endorsed more motives simultaneously when compared with men indicating that they may have more reasons (albeit not necessarily stronger reasons) for wanting a child. Women also spent more time reflecting on why they wanted a child and scored higher on strength of desire for a child on the first Likert scale. We do not have an explanation why a gender difference was observed on one but not the other scale measuring desire. We hypothesize that male respondents interpreted

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number of both men (n ¼ 29) and women (n ¼ 36) endorsed the highest score on this latter scale. Several positive associations were observed between the six parenthood motives and strength of desire for a child. As demonstrated in Table 4, among women all parenthood motives with the exception of continuity were positively associated with the first Likert scale, but only happiness and social control correlated with the second scale. Two significant associations between parenthood motive and strength of desire were observed in the male data. The motive ‘well-being’ correlated significantly with the first Likert scale, whereas endorsement of the motive ‘social control’ showed a significant association with the second Likert scale and almost reached statistical significance on the first scale.

‘giving absolutely everything’ (in order to have a child) as a poor solution to their childlessness, particularly when viewed against the backdrop of significant poverty in our communities. It is likely that the majority of men in this study were the head of households and, in our largely patriarchal communities, probably carried greater responsibility to (financially) support both their own and their extended families than their partners, and this may have influenced their answers. The absence of a gender difference on the second scale measuring strength of desire and the fact that the majority of both men and women rated infertility as their worst life experience, indicate that men were also profoundly affected by infertility. It must be considered that this observation may be influenced by bias since the study participants were men who were willing to present for infertility treatment, arguably because of negative experiences secondary to childlessness. On the other hand, this finding is in keeping with other studies from South Africa and Africa which have documented that, when acknowledged, male infertility is a dreaded condition which is often accompanied by profoundly humiliating and emasculating experiences (Runganga et al., 2001; Inhorn, 2003; Dyer et al., 2004; Inhorn, 2004; BardenO’Fallen, 2005). In their original work, van Balen and Trimbos-Kemper (1995) noted that the commonest motives for parenthood were not necessarily the strongest motives. In our study, the analysis of the association between parenthood motives and strength of desire for a child yielded a number of interesting observations. For women, happiness was both the strongest and the most frequently endorsed motive, thereby highlighting it as motive of central importance. Continuity was the single motive, which did not correlate with strength of desire for both men and women and, therefore, appears to be the least influential parenthood motive. In contrast, social control, although less frequently endorsed, was the only motive, which was positively associated with strength of desire on both scales for women and almost reached a significant association on both scales for men. This finding suggests that participants who wanted parenthood for reasons of social control had a particularly strong desire for a child. It can be speculated that this desire is generated by the fear or experience of negative social repercussions secondary to infertility. While even in the Western industrialized world data on parenthood motives are lacking, we identified some studies, referred to in the introduction, with which to compare our findings. In the Netherlands, van Balen and Trimbos-Kemper (1995) studied a cohort of 108 infertile couples utilizing the parenthood-motivation list. The most frequently endorsed motives were happiness (women: 84%, men: 78%), parenthood (women: 68%, men: 48%) and well-being (women: 56%, men: 48%). These three motives also correlated with strength of desire for both men and women. In addition, identity was a strong parenthood motive for women. Continuity was endorsed by 25% of women and 20% of men, while social control was infrequently mentioned (women: 10%; men: 2%). In a subsequent study from Belgium, the parenthood-motivation list was applied to mothers who had conceived either naturally or following ART (Colpin et al., 1998). In both groups, happiness


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parenthood-motivation list. Moreover, our factor analysis was underpinned by a second analytical approach using latent trait modelling. The observation that according to both analyses our data could be applied to the research instrument is encouraging and would suggest that parenthood motives are constructed similarly in South Africa and the Netherlands, although the frequency with which they are endorsed differs between the two countries. It must, however, be noted that some motives reflected in studies from other African countries were not captured by the parenthood-motivation list, and this should be considered in the planning of future research. Our findings apply to the group of men and women from an urban, culturally heterogeneous community in South Africa who had access to a tertiary infertility clinic within the public health system. The results can therefore not be extrapolated to all men and women in South Africa or Africa. It is possible that people who are not infertile, who do not seek treatment, who live in other areas and with fewer resources when compared with our setting differ in their reasons for desiring children. Further studies involving larger cohorts and different groups of informants are now required in order to expand the findings derived from this first study on parenthood motives in South Africa.

Acknowledgements We wish to thank Dr Frank van Balen from the University of Amsterdam for generously providing us with the parenthood-motivation list, which he had developed and tested. We are grateful to all the men and women who participated in the study and to Lulama Khephe who helped with the statistical analysis.

Funding Medical Research Council of South Africa and the University of Cape Town (University Research Committee and the Medical Faculty Research Committee).

References Bambra CS. Current status of reproductive behaviour in Africa. Hum Reprod Update 1999;5:1–20. Barden-O’Fallen J. Unmet fertility expectations and the perceptions of fertility problems in a Malawian village. Afr J Reprod Health 2005;9:14– 25. Becker G, Nachtigall RD. Born to be a mother: the cultural construction of risk in infertility treatment in the U.S. Soc Sci Med 1994;39:507– 518. Colpin H, De Munter A, Vandemeulebroecke L. Parenthood motives in IVF-mothers. J Psychosom Obstet Gynaecol 1998;19:19 –27. Daniluk J. Helping patients cope with infertility. Clin Obstet Gynecol 1997;40:661–672. Dyer SJ, Abrahams N, Hoffman M, van der Spuy ZM. Men leave me as I cannot have children: women’s experiences with involuntary childlessness. Hum Reprod 2002;17:1663– 1668. Dyer SJ, Abrahams N, Mokoena NE, van der Spuy ZM. You are a man because you have children: experiences, reproductive health knowledge and treatment-seeking behaviour among men suffering from couple infertility in South Africa. Hum Reprod 2004;19:960–967. Edelmann RJ, Humphrey M, Owens DJ. The meaning of parenthood and couples’ reactions to male infertility. Br J Med Psychol 1994;67:291–299. Feldman-Savelsberg P. Plundered kitchens and empty wombs: fear of infertility in the Cameroonian grassfields. Soc Sic Med 1994;39:463– 474. Fidler AT, Bernstein J. Infertility: from a personal to a public health problem. Public Health Rep 1999;114:494– 511.

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and well-being were the most frequently mentioned motives, and social control ranked lowest. Differences were observed with regard to identity and motherhood, which featured more strongly among ART mothers. In Canada, a similar instrument, the Reason-for-Parenthood questionnaire, was applied to a large group of infertile women and men (Newton et al., 1992). The leading parenthood motives fell within the domains of gender-role fulfilment, marital completion, parent-role-longing and alleviation of social pressure, with no gender difference in the data. Further insight through different research methods was provided by a study from the UK involving couples with and without fertility problems (Langdridge et al., 2000). Through open-ended questions and network analysis the authors demonstrated that in all participants the triad ‘give love, receive love and enjoyment of a child’ and the importance of becoming a family were central in the desire for a child. In contrast, none of the participants selected religion, social pressure or enhancement of masculinity/femininity as a motive for parenthood. While caution must be exercised in the comparison of these studies due to differences in research settings and methods, the results indicate that men and women living in Western industrialized countries wanted children for similar reasons and that the most frequent reasons related to personal happiness and fulfilment, and to dynamics within the conjugal relationship. This observation is in keeping with our own findings. With the exception of the Canadian study, social reasons appeared to be of less importance, and to this effect our data differ from these studies conducted in industrialized countries. We know of only one study from Africa with which to compare our findings. Following a series of focus-group discussions in Southwest Nigeria, Okonofua et al. (1997) reported that the reasons why people wanted to have children could be grouped into five major categories. These included continuation of the family lineage, assistance with work and domestic tasks, joy and companionship, old age security, to obey a religious command to reproduce and social status, the latter being particularly important for women. Studies on fertility and infertility from other African countries provide similar findings as well as additional motives, which include completion of marriage, securing inheritance and property rights and ensuring the proper conduct of funeral rituals (Feldman-Savelsberg, 1994; Sonko, 1994; Gerrits, 1997; Okonofua et al., 1997; Sundby, 1997; Koster-Oyekan, 1999; Runganga et al., 2001; Dyer et al., 2002, 2004; Hollos, 2003). These reports support the results of this study indicating that, in addition to motives relating to happiness and parenthood, other factors from the domain of culture, society, continuity and heredity remain central in the wish for children. This diversity of parenthood motives reflects the value of children in African communities and contributes to understanding why fertility rates remain high in many areas in Africa and why infertility is a dreaded condition. The parenthood-motivation list has not been formally validated in South Africa, and this is a limitation of our study. In addition, our study may be considered small for processing data through factor analysis. Our sample size is, however, within the range of other studies, which have utilized the


Motives for parenthood Gerrits T. Social and cultural aspects of infertility in Mozambique. Patient Educ Couns 1997;31:39– 48. Hollos M. Profiles of infertility in southern Nigeria: women’s voices from Amakiri. Afr J Reprod Health 2003;7:46–56. Inhorn MC. Global infertility and the globalization of new reproductive technologies: illustrations from Egypt. Soc Sci Med 2003;56:1837– 1851. Inhorn MC. Middle Eastern masculinities in the age of new reproductive technologies: male infertility and stigma in Egypt and Lebanon. Med Anthropol Q 2004;18:162–182. Koster-Oyekan W. Infertility among Yoruba women: Perceptions on causes, treatments and consequences. Afr J Reprod Health 1999;3:13– 16. Lalos A, Jacobsson L, Lalos O, von Schoultz B. The wish to have a child. A pilot-study of infertile couples. Acta Psychiatr Scand 1985;72:476–481. Langdridge D, Connolly K, Sheeran P. Reasons for wanting a child: a network analytical study. J Reprod Infant Psychol 2000;18:321– 338. Maritz JS, Dyer SJ. Application of a bivariate latent trait model. South African Statist J 2007;41:55– 63. Miller WB. Childbearing motivations, desires, and intentions: a theoretical framework. Genet Soc Gen Psychol Monogr 1994;120:223– 258. Newton CR, Hearn MT, Yuzpe AA, Houle M. Motives for parenthood and response to failed in vitro fertilization: implications for counseling. J Assist Reprod Genet 1992;9:24– 31.

Okonofua FE, Harris D, Odebiyi A, Kane T, Snow RC. The social meaning of infertility in Southwest Nigeria. Health Transit Rev 1997;7:205–220. Runganga AO, Sundby J, Aggleton P. Culture, identity and reproductive failure in Zimbabwe. Sexualities 2001;4:315– 332. Sonko S. Fertility and culture in sub-Saharan Africa: a review. Int Soc Sci J 1994;46:397– 411. Statistics South Africa 2001. Population Census 2001 (On-line). http://www. statssa.gov.za (January 2006, date last accessed) Sundby J. Infertility in the Gambia: traditional and modern health care. Patient Educ Couns 1997;31:29 –37. van Balen F. Een Leven Zonder Kinderen, Ongewilde Kinderloosheid: Beleving, Stress en Aanepassing. Assen, The Netherlands: Dekker and van de Vegt, 1991. van Balen F. Coping with Infertility. In Sexual and Reproductive Health. New Dehli: New Age International Limited Publishers, 2001,329– 336. van Balen F, Trimbos-Kemper TC. Involuntarily childless couples: their desire to have children and their motives. J Psychosom Obstet Gynaecol 1995;16:137– 144. Veevers JE. The social meanings of parenthood. Psychiatry 1973;36:291– 310. Submitted on March 16, 2007; resubmitted on July 31, 2007; accepted on August 8, 2007

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Motives for parenthood among couples attending a level 3infertility clinic in SA  

Motives for parenthood among couples attending a level 3infertility clinic in the public health sector in South Africa