Fertility Among Orphans in Rural Malawi: Challenging Common Assumptions About Risk and Mechanisms

International Perspectives on Sexual and Reproductive Health 170 vated rates of pregnancy and STIs (including HIV) among maternal orphans, but not among paternal orphans;3,4 and a third found that risk emerged for paternal orphans only if the father’s death had occurred when the child was younger than 12.6 Qualitative research is needed to better understand orphans’ emotional response to their mother’s death, how this response influences their desire to have children, and how social norms and context guide this process. Studies of fertility, particularly within the context of HIV, often exclude men. However, given that men typically have greater power than women in making marital reproductive decisions, the fertility preferences of male orphans may shift demographic trends far more than those of female orphans. Our findings highlight the possibility that male orphans are reformulating their fertility desires and potentially modifying their reproductive behavior as a result of maternal loss. We did not find an association between orphanhood and worry about HIV, suggesting that fertility desires may be driven by alternative pathways. Future work could shed light on the relationship between orphanhood and fertility by explicitly measuring underlying motivations for elevated fertility desires (e.g., normalcy) and examining whether motivations are similar among both men and women. For example, lineage preservation may be important for men with HIV, whereas women’s fertility preferences may be more related to their health.70 The importance of a gendered lens is also highlighted by our curious finding that among women, recent orphanhood was associated with pregnancy intentions, but not with realized childbearing. Given that this discrepancy was not present among men, a potential explanation is that women face greater barriers to achieving their desired fertility. Men still dominate contraceptive and fertility decisions,71,72 particularly during the early years of a marriage.73 Women who want fewer children than their husband does may fear violent reprisals if they use contraceptives;71,74–76 those who want more children may be constrained by their partner’s stated or assumed preferences. This explanation is consistent with a substantial body of literature on relationship power dynamics and fertility outcomes in Sub-Saharan Africa.77–79 An alternative explanation for the discrepancy between desired and actual fertility among recently orphaned women is that in 2006, women’s preferences had changed in response to a parental death, but the women had not yet had time to realize these new preferences. Support for the latter theory comes from the 2010 survey data: By this time, female orphans had had significantly more children than their nonorphaned counterparts had. The study was conducted in rural Malawi, where women marry and bear children at an early age. This may have influenced the strength of the above findings and may partially explain deviations from past research from neighboring countries. Only one other study has examined pregnancy outcomes among orphans in Malawi; it, too, found no differences between female orphans and nonorphans.7 DISCUSSION Previous studies have reported differences in fertility by orphan status; this study investigated two potential mechanisms that may individually or collectively underlie this association. We found no evidence of a structural vulnerability mechanism: Only limited educational and economic deficits were present in our sample, and these did not translate into riskier sexual behaviors among orphans than among nonorphans. We did, however, find empirical support for the role of orphanhood in shaping fertility outcomes: Compared with nonorphans, orphans both had greater fertility desires and had had a greater number of children. This is the first study to demonstrate elevated fertility desires among orphans living in areas characterized by high HIV prevalence. This finding suggests that orphans may exercise greater agency over reproductive outcomes than previously thought, though we caution that these decisions are still made within very constrained and difficult circumstances. Fertility preferences were sensitive to both the type and duration of orphanhood. Only orphans who had lost their mother in the past five years reported wanting a greater number of children than nonorphans did. Previous research has similarly underscored the need for a nuanced view of orphanhood: Two studies have demonstrated eleTABLE 5. Odds ratios and risk differences (with standard errors) from multivariate regressions examining associations of orphanhood status and selected covariates with fertility-related behaviors among Malawian women aged 15–25