UCLA

Globally, more than 180 million people experience infertility, the condition of being unable to conceive a pregnancy within 1-2 years of attempting to do so (Inhorn & Patrizio, 2015). In Malawi, a small country in south-eastern Africa, approximately 20% of women reported experiencing difficulty becoming pregnant or infertility in studies conducted in 2005 and 2014-2015 (Barden-O’Fallon, 2005b; Rao et al., 2017). At the same time, 40% of pregnancies in Malawi are considered unintended (National Statistics Office (NSO) [Malawi] and ICF, 2017). This dissertation uses a hybrid exploratory-explanatory mixed methods study design. The first study uses qualitative in-depth interview data from the Umoyo Wa Thanzi (UTHA) research program in a rural area of Central Malawi, and the second and third studies use quantitative cross-sectional and longitudinal survey data from the same population. Together, the three studies explore how infertility and perceived fecundity influence how women make reproductive decisions with their current and future fertility desires in mind. The three studies provide insight into how perceptions of fecundity (ability to become pregnant) and experiences of infertility (not conceiving a pregnancy after two or more years of trying), influence women’s contraceptive use, incidence of a subsequent pregnancies, and pregnancy planning/intention. The first study, which analyzed 20 in-depth interviews from women in the UTHA cohort, showed how women’s perceptions of fecundity and experiences of infertility influenced not only whether she used contraception or not, but how she used contraception in an effort to manage her fertility. The second study explored the association between ever experiencing infertility, perceived certainty of pregnancy, and contraceptive use. Women who reported ever experiencing infertility had 44% lower odds of current contraceptive use than women who did not report infertility (AOR: 0.56; 95% CI: 0.39-0.83). Women who reported ‘no chance/unlikely’ that they would become pregnant within one year of not using contraception had 70% lower odds of contraceptive use compared to women who were ‘certain’ they would become pregnant within a year (AOR: 0.30; 95% CI: 0.10-0.92). These findings led to the third study, which explored associations between ever experiencing infertility at Wave 1 (2014-15) and reporting a subsequent pregnancy by the final wave of data collection in 2019. In this study, women’s reports of ever experiencing infertility did not have a significant relationship with reporting a subsequent pregnancy (AOR: 0.89; p>0.05). Additionally, there were no statistically significant differences in retrospective pregnancy planning/intentions between women who did and did not report ever experiencing infertility (p>0.05). Together, the three studies reveal the importance of perceptions and experiences of fecundity and infertility in influencing women’s reproductive decisions.