by Rosemarie Nave-Herz and Corinna Onnen-Isemann

Today, medicine not only provides reliable contraception, but also ensures through artificial insemination that the number of childless marriages in industrialised countries does not increase any further. The reasons why wives expose themselves to so-called IVF treatments (in vitro fertilisation), which are rarely successful, often only after a long period of contraception, are mostly due to a traditional family image, the fulfilment of which is often postponed for too long. This is one of the findings of a research project on "Reproductive medicine from a sociological perspective".

Remaining fatefully childless in a marriage has always been perceived as something "unnatural", "deviant". De facto, in all European cultures of the past, the aim of marriage was basically to produce offspring, so that entering into marriage was so naturally linked to having children that childlessness was not even a possible choice. Those who wanted to and/or should remain childless were already excluded from marriage, e.g. the temple virgins of the ancient Egyptians or Germanic tribes, the nuns and monks of Christian and Buddhist monasteries, as well as certain people for whom public marriage bans applied at certain times, such as servants, journeymen, officers etc. Childlessness in a marriage was therefore - as far as we can see from the history of mankind - generally due to medical reasons, and it was usually met with openly expressed or concealed contempt. Women in particular were blamed for childlessness in a marriage and were the most likely to be ostracised. In many cultures, childlessness in a marriage was also seen as grounds for divorce or as an opportunity to disown the woman.

Even in the Bible, infertility was described as a punishment from God (e.g. Genesis 20:29 and 31), and the devaluation of childless wives through the valorisation of mothers is documented by the example of Sarah and her maid Hagar, who had a child by and for Abraham instead of Sarah and disregarded Sarah for it.

This one-sided attribution of blame was common in our country until well into this century, although fertility disorders in men were already described in ancient Egyptian and ancient Indian medicine as well as in the Talmud, and medical writings from 1647 testify that even then people had very detailed knowledge of marital sterility caused by the husband.

The many superstitious recommendations and "medical" remedies also show how fearful and unfortunate the threat of childlessness in a marriage was, especially for women: magic rites, magic potions, pilgrimages, herbs, bathing cures and much more were supposed to provide relief.

The devaluation of childlessness and the associated devaluation of unmarried women was still very widespread in the last century. Even the representatives of the first women's movement adhered to the "destiny of women" as mothers. For example, Helene Lange, Gertrud Bäumer and other leading women of the first bourgeois women's movement clearly placed the future mother at the centre of education. This is why many representatives of the bourgeois women's movement tried to pave the way for childless and unmarried women to achieve "spiritual motherhood" - as they called it at the time - i.e. to create opportunities for gainful employment with regard to those academic appointments for which "maternal qualities" were necessary: Teacher, social worker, kindergarten teacher, etc. At the same time, this sent a very clear signal: Women could almost only gain recognition by being mothers - be it in biological terms or in a figurative way (= "spiritual motherhood").

Single, childless women were subjected to particular stigmatisation – particularly in the form of pity – after the Second World War. As a result of the disproportionate gender balance in the population, the old prejudices and labels of the ‘spinster’ resurfaced, namely regarding women who were deemed to have failed to fulfil the true purpose of a woman’s life: to be a mother. This development was only possible because, after the war – and not just in Germany – the family was accorded particularly high value, which was presumably due to the long separation between family members and the many situations of hardship and fear caused by the war. People longed for peace, security, understanding – for values that were believed to be embodied by the family. However, the high regard in which the family – and thus marriage and having children – was held automatically led to the devaluation of the alternative status of being ‘childless’. The extent to which this ideology prevailed right up into the 1950s is evident from the results of an opinion poll. When asked whether they regarded single people and those without children as ‘excluded from happiness’, 78 per cent agreed in 1953; in 1972, as many as 32 per cent answered ‘yes’ to the question ‘Do you believe that a woman must have children to be happy?’, and by 1984 this figure had fallen to just 23 per cent.

A change was brought about by the New Women’s Movement, some of whose representatives opposed the assumption of the maternal role. This view continues to hold sway amongst some women to this day, as shown by data from a study we conducted on the reasons for the use of highly technical reproductive medicine.

Since the end of the last century, the proportion of childless marriages has been rising steadily in almost all industrialised countries, and particularly in the Federal Republic of Germany. In 1989, 8.4 per cent of marriages remained childless; today, the figure stands at 18 per cent. According to model calculations, the proportion of marriages contracted after 1970 that will remain childless for good is estimated to be as high as 20 per cent. The rise in childlessness in Germany is even more evident when considering specific cohorts of women: Whilst only 9 per cent of women born in 1935 remained childless, this applies to 20.5 per cent of those born in 1955 and to approximately 25 per cent of those born in 1961, with the trend continuing to rise.

The reasons for childlessness may be medical or psychosomatic in nature. As we have already established in an earlier project, the conscious choice to remain childless in marriage appears to be rare in Germany; by contrast, there has been a sharp increase in temporary childlessness, i.e. the decision to postpone having children. Often, however, this desire is only made possible in the first place by medical reproductive technologies. Had these not been developed and applied, the proportion of childless marriages would have risen further. Over the last 10 years, the number of high-tech reproductive centres in Germany alone has increased tenfold.

Whilst initially only surgical and/or drug-based methods were available for treating childlessness, along with the option of artificial insemination, ‘in vitro fertilisation’ – also known as ‘test-tube fertilisation’. This method attempts to artificially induce pregnancy outside the human body under laboratory conditions. Since then, the range of treatments has expanded to include further procedures: GIFT in 1985, TET/ZIFT in 1986, and microinjections (ICSI – intracytoplasmic sperm injection) in the 1990s. As no standardised terminology has yet become established, the term ‘IVF’ is used synonymously in the following to refer to the methods IVF, GIFT, TET/ZIFT and ICSI.

The research project "Reproductive medicine from a sociological perspective" investigated, among other things, the conditions causing the sharp quantitative increase in IVF treatments from a sociological perspective and looked for theoretical explanations for the increasing use of this highly technical reproductive medicine.

Selected gynaecologists and reproductive physicians were interviewed, and a document analysis was carried out on the arguments put forward by statutory health insurance funds to finance the treatment of infertility. Above all, however, affected women were interviewed. The sample comprises a total of 52 qualitative and 273 written interviews.

Of the women surveyed who had undergone reproductive medical treatment, 62% had postponed their desire to have children for years in this partnership and were then, when they decided to have a child, predominantly at an age when they were less able to conceive. The gynaecologists in the interviews also emphasised that some of their patients had delayed the fulfilment of their desire to have children for too long with the help of contraceptives and were now at an age at which fertility and the ability to conceive were declining. The data from the current study therefore initially confirmed the results of an earlier study, according to which the vast majority of childless people did indeed associate a desire for children with marriage, but had initially postponed having children, particularly because of their high level of professional commitment. The data also showed that for those who had chosen this temporary childlessness, a family life with children should have a certain quality, that the women believed they could only be a good mother if they were no longer employed.

Both value orientations - traditional family orientation and high career commitment - are antagonistic and must lead to decision-making conflicts. However, this can result in temporary childlessness being chosen as a conflict resolution strategy - often even unconsciously - in order to avoid having to decide between divergent value orientations, possibly in the hope of being able to resolve this contradiction at a later date.

The decision conflict between divergent value orientations - career orientation versus traditional family orientation - is ultimately an expression of the fact that for those "temporarily" childless couples, macro-perspective changes become "visible" at the individual action level, namely the different changes in social subsystems. This is because the school, training and professional system has changed for women over time and their professional commitment has increased as a result; the family system, including the definition of the mother's role, has not changed to the same extent for women.

However, the chosen temporary childlessness can then lead to involuntary childlessness due to gynaecological or andrological changes in the meantime, e.g. due to illness (their own or their partner's), age or psychosomatic reasons, as was the case for 62% of the women surveyed who then underwent reproductive medical treatment.

Reproductive medicine has thus had a paradoxical effect: through the development of anticonceptives, it has initially offered the possibility of reliably preventing pregnancy, but for some women at the price that the inability to conceive can now only be reversed with its help.

With enormous personal stress, the interviewees strove for a correction; their wish was to found a "normal family", their own biological child. Adoption was rarely considered. The extent to which the "nuclear family" (= parents with biological children) can still be regarded as the ideal today, despite the plurality of practised lifestyles in our society, and the role of the mother can still have top priority, becomes particularly clear in the case of reproductive medicine patients. Incidentally, it is predominantly the women's desire to have children that acts as the "driving force" behind the desire to treat childlessness.

The data also confirm the findings of other studies: high-tech reproductive medicine is a life event that causes and also generates stress for the women concerned. Moreover, every stage of the treatment is associated with renewed uncertainty and, above all, the unpredictability of success.

However, the psychological strain is only ‘one side of the coin’; many women also complain of physical impairments and, above all, of the organisational ‘strain’. Above all, fertility treatment appears to lead, in some marriages, to sexuality becoming detached from the relationship or being reduced to a mere means for the sole purpose of procreation, a point which was expressed very clearly in some interviews. However, there are also statements to the contrary. Some women report that IVF treatment had a positive impact on their emotional and marital relationship, fostering greater closeness and openness.

Given the significant psychological, physical and other stress factors associated with fertility treatment, the question arises as to why women, even after an unsuccessful first round of treatment, go on to undergo a second, a third and sometimes even a fourth round, all of which are covered by health insurance. Among the reasons given by the women surveyed for continuing treatment, the fear of later self-reproach was particularly highlighted; as 79 per cent agreed with the statement: “Although I do not feel very well during the individual phases of treatment, I will not stop the treatment before all possible attempts have been exhausted, so as not to blame myself later.” The fear of failure and the hope of success clearly influence the ‘cost-benefit analysis’ in favour of further treatment if pregnancy does not occur. Added to this is the fact that the ‘benefit’ becomes all the more desirable the more ‘costs’ have been invested. This is presumably why 77 per cent of respondents agreed with the statement, “Every single step (in the treatment cycle) gives me renewed courage for the next one” – a hope reminiscent of the anticipation of winning the lottery – albeit with slightly better odds of success. This is because the success rates of high-tech reproductive medicine for treating infertility are low overall. The ‘baby-take-home rate’ fluctuates between 10 per cent and 15 per cent per year.

Nevertheless, as demonstrated, the traditional family unit with the biological mother remains a cultural goal of high priority. In the past, there were other ‘ways’ of forming a family, which were also accepted to a far greater extent than today: the adoption of children (e.g. those born out of wedlock; but also the giving away of children from poorer, large families to wealthy childless relatives was not subject to the same taboos as it is today). These ‘paths’ are now scarcely ‘viable’ for achieving the cultural goal of ‘family formation’. The options for adoption have declined radically; yet, like foster children, they are not regarded by many as a ‘substitute’ for ‘one’s own’ children. In this respect, it is understandable that reproductive medicine is sometimes seen as the only remaining means of adapting to the culturally prescribed goal of ‘family formation/parenthood’, at least as long as this goal itself is not called into question.

The authors

Prof. Dr. rer. pol. Dr. phil. h.c. Rosemarie Nave-Herz, a sociologist at the Institute of Sociology in Oldenburg, was appointed to the University of Oldenburg in 1975. Her academic career began in 1965, when she became a research assistant at the Max Planck Institute for Educational Research in Berlin. This was followed by her first post as a lecturer in Oldenburg (1967–1971) and her appointment to a chair in sociology (Cologne, 1971–1975). In the summer semester of 1985, she was a visiting professor at the University of Sussex in England. She has declined further appointments. She is a member of numerous academic committees and is currently Vice-President of the ‘Committee on Family Research’ of the International Sociological Association (ISA).

Dr Corinna Onnen-Isemann obtained her PhD from the University of Oldenburg, was a research fellow at Harvard University, Boston, and is currently working on her habilitation in the subject of sociology.