Knowledge, attitude and practice of child adoption among men and women attending the infertility clinic at the University of Benin Teaching Hospital, Benin City

Objective: to determine the knowledge, attitude and practice of child adoption among men and women attending the infertility clinic at the University of Benin Teaching Hospital, Benin City. Methods: This was a cross-sectional descriptive


INTRODUCTION
Infertility affects 8 to 12% of couples worldwide and 1 it is a major reproductive health challenge. It is a source of psychosocial burden to the affected couple especially in Africa where so much emphasis is placed on childbearing. In our society, the absence of a desired pregnancy rapidly becomes the source of intense frustration and early consultation to a 2 physician with its associated social stigma. There are currently different methods of infertility treatment including the use of assisted reproductive techniques. The cost of management of infertility in developing countries which includes countless number of investigations is quite high. Women from this country who are therefore unable to take care of the financial implications of assisted reproduction are therefore left in profound depression. Management of infertility is poor in Sub-Saharan Africa mainly as a result of poor diagnostic and 3 treatment facilities, lack of expertise and poverty. Despite recent advances in infertility treatment, it is certain that some couples will remain childless which have major psychological implications especially in settings where fertility and 4 childbearing is highly valued.
Many infertile couples continue to hope for their biological children while those in orphanages continue to hope for adoptive homes. Even in developed countries, this has also become a 5 problem. Child adoption is probably one of the pathways to safe motherhood, bearing in mind the challenges associated with pregnancy particularly maternal mortality. For same sex couples, child adoption appears to be the only means of having children although this is largely dependent on 6 legislation regarding this union.
Child adoption refers to a process by which a child is brought into a family by one or more adults, not 7 biological parents, but recognised by law as such. Nigeria currently has an extensive law on child adoption. The child right act stipulates that the adopted child will change his name to that of the adoptive parents, right to inheritance of an adopted child, inability for someone to marry his/her adopted child, the child to be adopted should have no surviving parent and that the guardian of the child should consent to adoption. It also states that a married couple where each of them has attained the age of twenty-five years may apply for adoption. A single person, if he has attained the age of thirty-five years provided that the child to be adopted is of the same sex as the person adopting may also apply for 8 adoption.
Some factors that necessitate adoption include infertility, the desire to care for children in need, urge for a particular gender and genetic abnormalities in someone's biological child. However there are challenges to child adoption which include social stigma, fear of confidentiality, refusal of family members to give their consent, fear of illegitimacy, legal issues, religious reasons, psychologically unacceptable, poverty, hope for natural conception, child may decide to trace the biological parents later in future and to some people child adoption is an aberration and culturally 7,9 unacceptable. There is a poor adoption rate in Nigeria hence there is a need to know the factors militating against child adoption especially among men and women who are being treated for 10 infertility.
Psychological morbidity associated with infertility is quite enormous. Infertility is probably the most serious reproductive health challenge of any woman. The childless couples suffer from personal, interpersonal, social and religious problems thus bringing a sense of failure to them. In some cultural settings in Africa, infertile couples are not allowed to take lead role in important family functions and 11 events, infact they are often socially ostracised. Child adoption may probably help in mitigating some of the effects of infertility.
The aim of this study was to determine the knowledge, attitude and practice of child adoption among men and women attending infertility clinic at the University of Benin Teaching Hospital, Benin City A total of 285 questionnaires were distributed in this study however 264 were correctly filled and therefore analysed.

MATERIALS AND METHODS
The respondents were selected by simple random sampling method as they presented to the clinic. Every second client that presented for infertility treatment was recruited into the study.
Data from questionnaire was collated and entered into a spread sheet which was analysed using the Statistical Package for Social Sciences (SPSS 2 Version 21). Test for association was done using x and p value < 0.05 was considered statistically significant. For the purpose of this study, a scale was introduced to check how distressed the respondents were as a result of infertility. A score of <4 was regarded as mild distress, 4 -6 was moderate, while 7 and above was regarded as severe distress.

RESULTS
A total of 264 questionnaires were analysed.  The type of infertility that was mostly encountered was secondary (78.8%) as shown in table 2. Out of the 214 females, 77.1% had secondary infertility while out of the 50 males 86% had secondary infertility. Using the infertility distress score described in the methodology, 80.3% of respondents had moderate to severe distress as a result of infertility. Majority of the men and women interviewed did not have a child (70.8%) and all were married. Of all the respondents, 16.3% of the study population had spent more than 10 years in marriage. The mean duration of infertility was 5.6 years.
Out of the 264 respondents, only 95.5% had heard of child adoption (86% of males and 87.9% of females). The media/internet was a major source of information regarding child adoption as seen in 76% of males and 46.3% of females (table 2). Two hundred and thirty-eight (92% of males and 89.7% of females) correctly agreed that child adoption involves taking responsibility as a parent towards a child that is not biologically theirs and 239 (92% of males and 90.2% of females) also correctly knew that an adopted child bears the name of the adoptive parents. Only eighty nine (32.2% of females and 40% of males) correctly knew that the adoption law in Nigeria states that the applicant should be at least 25 years of age/ may be required to be 21 years older than the child to be adopted. A hundred and twelve respondents (40.7% of females and 50 % of males) wrongly thought they would be required to pay for adoption while 181 (68.2% of females and 70% of males) correctly knew that someone can not marry his adopted child. Two hundred and twenty three respondents (86.4% of females and 76% of male respondents) believe correctly that an adopted child had a right to inheritance. Those who correctly knew that an adopted child bears the name of the adoptive parents were 239 (90.2% of females and 92% of males). Only 34 (13.1% of females and 12% of males) wrongfully thought that someone could marry his/her adopted child. perceived that the society had a negative attitude towards child adoption. About half of the respondents (64% of men and 48%of women) believe natural parenthood is superior to adoptive parenthood. A hundred and eighteen (36% of males and 32% of females) could substitute an adopted child for a biological child and 209 (80% of males and 79% of females) were indifferent regarding the sex of child that can be adopted.
The major reasons given by 158 respondents who were not favourably disposed to child adoption were hope for their own biological child in 47 (20.1% of females and 8% of males), child may decide to trace biological parents 21 (8.9% of females and 4% of males) and the fact that child adoption was not a solution to their infertility 18 (6.1% of females and 10% of males) as shown in table 3. Other reasons were social stigma, fear of confidentiality, legal issues, no similarity to adopted child, religious reasons, culturally unacceptable, refusal of family members and uncertainty about child's heredity. Thirty seven respondents (20% of males and 12.6% of females) would prefer to exhaust all other options of infertility treatment before considering child adoption. Fifteen respondents (12% of males and 4.2% of females) would rather choose to remain childless in the worse instance than to adopt a child. Only 2 respondents (one male and one female) had adopted a child. Of these 2 children that have been, the male/female ratio was 1:1. These 2 respondents have had a good experience and were willing to adopt more. Increasing level of education was significantly associated with a positive attitude towards child adoption among female respondents, p = 0.005; but this was not same in males p = 0.8) as shown in table 4 and 5. Age, ethnic group, number of children and duration of infertility did not influence the attitude towards child adoption for both males and females (p > 0.05). Sex of respondents did not significantly affect their attitude towards child adoption, (p = 0.2).  which is less than the mean age for this study.
The mean duration of infertility in this study was 5.6 years. This is similar to previous studies which showed a mean duration of infertility ranging from 9,14,15 5.3 to 6.6 years.
Most of the respondents had no child and majority had never been pregnant before. In a related study conducted in south western Nigeria, 78% of respondents had primary 15 infertility. In a related study conducted in Lagos (Nigeria), although most respondents had secondary Similarly in a study conducted in Cameroon, 89.7% of respondents had heard of child adoption. The situation is not different in Iran as a similar study reported that 96% of 17 respondents have heard of child adoption. This is similar to findings from a previous study in India which showed that 89% of couples have heard of 18 child adoption. Despite being aware of child adoption a good number of respondents do not know it's true meaning. Only 6.8% of respondents correctly knew that payment is not required for child adoption. A study conducted in southern Nigeria showed that despite a high awareness of child adoption, only 55.6% of respondents had a good 9 knowledge of child adoption. Also, in a related study from Enugu, only 27.3% of respondents knew the correct meaning of child adoption despite the 10 high level of awareness. In that same study, only 46.6% knew its legality and 21.6% knew the processes it entails. In northern Nigeria some authors reported that 62% of respondents were 19 aware of the laws governing child adoption.
The media was the most likely source of information regarding child adoption in the index study which is 17 also similar to findings from previous studies. This is not surprising due to current technological advancement, making the media/internet a rapid source of information for the general population. Other useful sources of information regarding child adoption identified in this study were friends/family members and hospital staff.
In this study, 82% of males and 89.3% of females had a positive attitude towards child adoption although only 44% of males and 39.3% of females were willing to adopt a child while 12% of males and 4.2% of females would rather remain childless if adoption was the only option left for them. This shows that even when there is a positive attitude towards child adoption, people may be unwilling to adopt children. A related study from Enugu, Nigeria showed a favourable disposition to child adoption in 10 30.7% of respondents. Studies from northern Nigeria showed that 28.4% were willing to adopt a child whereas 70.4% believed that child adoption 13,16 was good in a related study from a similar setting. In another study conducted in Ibadan, Nigeria, only 3 17% of respondents were willing to adopt. The findings of this study are also similar to that of a related study in Cameroon which found that 70.6% of respondents were in favour of child adoption but 48.7% did not want to adopt a child despite being in 3 favour. In a related study from India, 77% of infertile couples had a positive opinion about child adoption, however only 54% were willing to 18 adopt. In a related study conducted in Iran, only 36% of men and 43.5% of women expressed their satisfaction with child adoption as an alternative to 12 infertility treatment. Infertile couples often see child adoption as an unfavourable phenomenon and would rather exhaust all other options for management of infertility with child adoption as the last resort when other modalities for treatment of infertility have failed. Also most available studies regarding child adoption were conducted among women while the index study explored the views of both infertile men and women which could account for the difference. In some Nigerian cultures, a woman is made to prove her womanhood through 14 motherhood.
Factors identified in this study to be militating against child adoption are hope for one's biological child, child may decide to trace biological parents and the fact that child adoption was not a solution to their infertility. Other obstacles to child adoption identified in this study include fear of stigmatization, legal issues and the belief that one has no similarity to an adopted child. Previous studies have also cited similar challenges to child 3,7,9,11,20 adoption Christians who were the majority of respondents in this study may be unwilling to adopt a child as they may interpret child adoption as lack 14 of faith. Some women may think that deciding to adopt a child means they have lost in the struggle to get their own children.
The positive disposition to child adoption recorded in majority of respondents did not transform into a high adoption rate as only 2(0.8%) of respondents had adopted a child in the past. The two respondents that had adopted a child in the past did not show any bias for sex. This is similar to findings in northern Nigeria where only 1.2% of infertile couple had adopted a child in the past. In a related study from southern Nigeria, 7% of respondents had adopted a 11 child in the past. The adoption rate was 4.5% in a 10 similar study conducted in Enugu, Nigeria. In Lagos, Nigeria, a related study showed that only 13.9% of respondents had adopted or attempted to 10 adopt a child. The findings of this study are comparable to that from Cameroon which showed only 1% of respondents had adopted a child despite the high proportion of respondents in that study 20 were in favour of child adoption. The issue of poor practice of child adoption may be a vicious cycle as couples are more likely to adopt if they have seen 3 others do the same. Community mobilization, advocacy and favourable laws will help in 3 improving child adoption practices. In the index study, increasing level of education had a positive influence on child adoption among female respondents. Although increasing age was associated with a positive attitude towards child adoption, this was not found to be statistically significant. These findings are in consonant with a previous study conducted in Nigeria in which willingness to adopt was not significantly associated 14 with age and duration of infertility. In that same study respondents with a higher level of education were more willing to adopt a child. In a previous studies conducted among women in Nigeria, factors significantly associated with a favourable attitude to child adoption include absence of a living child, maternal age >35 years and duration of infertility >5 10,15 years. These were similar to findings in a related 18 study conducted in India. Sex of respondents did not significantly influence their attitude towards child adoption.

CONCLUSION
Majority of infertile men and women in this study were aware of child adoption although the willingness to adopt a child was rather low. Adoption was rarely practiced among the respondents. Unfavourable factors for child adoption noted in this study among men and women include hope for one's biological child, child may decide to trace biological parents and the fact that child adoption was not a solution to infertility. Only level of education influenced willingness to adopt a child among female respondents. Sex of respondents did not significantly influence their attitude towards child adoption. A few men and women would rather choose to remain childless than to adopt a child if this was the last option for treatment of their infertility.

Author contribution:
MEI and IOI contributed to design, planning, conduct and data analysis. MEI wrote the first manuscript which was modified by IOI. Both authors read and approved the final manuscript.