Data collection

Data for this study were collected by the primary author from January to June 2020. Ethical approval was granted by the Ethical Committee of the Faculty of Political and Social Sciences at Ghent University, Belgium under no. 2017−37. Permission to conduct research in the community was obtained from the relevant authorities through the Health Services Academy, Pakistan (the host institution). Participant recruitment began in the first week of January 2020 and concluded in the last week of March 2020. Target women, their partners, and older women were contacted through lady health workers (LHWs) [57], while the staff of the Basic Health Units (BHU) were approached directly.

The purpose of the study was explained to the research participants, and their consent was obtained—either in writing (for literate participants) or orally (for illiterate participants). A form was prepared for the informed consent including information of the researcher, institution’s information, host institution’s information, study participants’ rights, i.e., they are willingly participating in the study, they have information regarding the research study, they can ask questions regarding it, they can quit it anytime and some more similar items. It also included the information regarding research study. I collected informed consent from all study participants written. The literate persons read and signed the consent.

Legal representative of the illiterate persons read and signed the consent on behalf of the participants (legal representative read the form, discuss it with ‘to be participants’, discuss with researcher and signed it).

A cover letter, prepared in consensus with all authors, was read aloud by the primary author to the participants prior to conducting interviews and focus group discussions (FGDs).

This article is based on 15 semi-structured, in-depth interviews with childless women (both primary and secondary infertility, as well as three women who conceived after many years of fertility treatments), and six FGDs involving 12 partners, four healers, and 16 older women. The interview participants (Table 1) were diverse.

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Table 1. Participant’ demographics.

https://doi.org/10.1371/journal.pone.0326698.t001

All interviews and FGDs were conducted and moderated by the first author (RS), who is of Pakistani origin. This allowed her to explore themes in a culturally appropriate manner, as she could easily connect with the women. Additionally, as a mother of two, she was better able to address sensitive topics such as motherhood, sexual life, and health-related issues.

In Pakistani society, married women generally feel more comfortable discussing reproductive and sexual matters, especially with other women. Being a mother often allows them to engage in these discussions more openly, as their status as a mother provides a common ground. On the other hand, childless women may feel differently. They might share their emotions, experiences, and struggles more cautiously, believing that a researcher who is a mother may not fully understand their situation due to differing life experiences.

RS introduced herself several times as a researcher (not a health practitioner or gynaecologist), yet the women often perceived her as someone knowledgeable about health matters and sought her advice. The participants showed a strong interest in the study and provided detailed responses to the questions. All interviews were conducted in a private room within the participants’ homes to minimise external pressures from family members. The interviews lasted between 35 and 60 minutes and were conducted either in the local language (Punjabi) or the national language (Urdu), based on the participants’ preferences. RS is fluent in both languages.

All interviews and FGDs were recorded after obtaining consent from the participants. RS transcribed the interviews and FGDs in the local/national language, and then translated them fully into English [58]. Key terms and proverbs were transcribed following the methodology of Al-Amer, Ramjan, Glew, Darwish, and Salamonson [58]. Two language experts—proficient in both the local/national language and English—rechecked all transcriptions, also in line with Al-Amer, Ramjan, Glew, Darwish, and Salamonson [58].

In order to maintain the confidentiality of participants, all interviews were anonymised prior to being submitted for language review. Each interview was assigned a unique code, and all personal identifiers, including names, ages, and marital statuses, were removed. This coding system was consistently applied throughout the data analysis process to ensure the privacy of participants was protected. The use of codes was a key measure to safeguard the anonymity and confidentiality of the participants involved in the study.

Furthermore, this study focuses on an underprivileged segment of society, namely childless women. The researcher empathised deeply with their challenges and sought to give voice to their experiences through this research. During the analysis process, numerous accounts of hardship and struggle emerged, reflecting the difficulties these women face. The researcher made a conscious effort to document their experiences faithfully, neither exaggerating nor minimising their struggles. To ensure the authenticity of the representation, the researcher remained attentive to the women’s own narratives, prioritising their expressions and perspectives throughout the study.

Data analysis

The data were inductively analysed using thematic analysis, following the steps outlined by Braun and Clarke [59], and conducted by the first author. Initially, the interviews and FGD excerpts were read iteratively to facilitate familiarisation. In the second stage, the data were coded by assigning initial codes, starting with an interview (coding based on the information in the excerpts). After coding five to six interviews, the codes were consolidated to create a coding tree. All authors evaluated these codes, which resulted in a final coding tree. The remaining data were then coded in accordance with the established coding tree.

In the third stage, similar codes were grouped based on shared information. For example, codes related to treatment practices were grouped together under an overarching code, which helped identify emerging themes. During the fourth stage, the themes were refined. Some themes were merged to construct a coherent narrative, while others, which lacked coherence, were broken down into codes again to ensure better thematic alignment or to form new themes. For instance, codes related to ‘women’s bodies perceived as problematic’ and ‘the behaviour of family members towards women during certain occasions’ appeared to overlap. These codes were restructured and merged into new themes: ‘women following treatments’ and ‘gender dynamics’.

In the fifth step, the themes were finalised and named. At this stage, the major themes of the article were agreed upon by all authors. Finally, these themes were organised coherently to structure the article, with their alignment contributing to the overall story flow.

The discourses (constitution) of marriage pointing towards motherhood

A first theme that we discerned in our dataset is the dominant discourse that equates marriage with the expectation of motherhood. This theme illustrates the first point of performativity theory: that cultural discourses serve as – in Butler’s terms- constitution and community members are socialised to follow these. Community members state that a woman is supposed to become a mother as soon as possible after marriage, as was stated in a FGD:

“A girl becomes a woman after becoming a mother.” (FGD1, participant 2)

The excerpt shows that marriage is considered an entry point to motherhood. A woman entering a marital relationship has to take the responsibility to become a mother. By doing so, she is performing womanhood, in line with the ‘constitution.’ This responsibility is also illustrated in other discursive forms like prayers and jokes. Participants stated that the prayers given to women during a marriage ceremony are all related to motherhood. Examples of prayers given are:

“God bestow you children; god bestow you a son.” (FGD 3, participant 5)

The excerpt shows that the prayers given by older women remind a young woman and inscribe her to become a mother from this point onward in her life. The ceremonies and rituals with repeated prayers of motherhood together form the ‘constitution’ that assign her to achieve the status of a mother. Moreover, during these ceremonies, emphasis is placed on other women who already hold a significant social standing. Specifically, married women cohabiting with their spouses who are already raising healthy children are invited to participate in the performance of these ritual, as stated by this woman:

“My aunt called me to apply henna at my cousin’s hand during her mehndi (ceremony)…because I have two sons.” (Interviewee 6)

In Pakistani cultural traditions, certain rituals are performed upon a bride’s arrival at her in-laws’ home, signifying her integration into the new family and societal expectations. One such ritual involves placing a young (male) child, typically between the ages of three months to two years, in the bride’s lap. This ritual symbolically reinforces the expectation that the bride will soon take on the role of motherhood. The ritual, often performed on the bride’s first day at her in-laws’ home, serves not only as a welcoming gesture but also as a subtle imposition of the societal role of a mother, reflecting the cultural emphasis on fertility and procreation. These ceremonies, rituals, and activities prompt the bride to reflect on her future responsibilities. As she transitions from girlhood to married womanhood, she is expected to fulfill the duties and obligations tied to her new family role, particularly those concerning her in-laws.

Similarly, the woman’s friends, either married or unmarried, make jokes relevant to her life after marriage.

“Next year, you will have a shining son or a fairy-like daughter.” (Interviewee 8)

The above-mentioned excerpt shows that around the time of marriage, jokes, talks, and communication all revolves around marriage and having children. Friends of the woman expect her to have a child in the coming years and married friends share their experiences in the shift of their relationship after having a child. These friends expressed that after becoming mothers, their husbands became more caring and affectionate towards them. This shift in dynamics made them feel empowered. Participants use several words and proverbs while discussing this theme are: chand sa beta (beautiful son), pari (beautiful daughter), maan hona aik ezaz he (motherhood is an honour), bacha zanjeer he jo mann baap ko bandhta he (child is a chain that joins parents), maan banna her ourat ka haq he (a woman has a right to become a mother), maan ke peron ke neeche jannat he (mother has heaven under her feet), khana peena to maan behnen bhi deti hen per oulaad sirf biwi deti he (mother and sister of a man can fulfil other duties but wife can give him the children).

Hence, marriage is regarded as the initial step or initiation into motherhood, as societal expectations dictate that every married woman is expected to bear children to continue the family and lineage. Consequently, each married woman assumes the responsibility of perpetuating the family line by ensuring the birth of a child [1–4]. Attaining the status of motherhood is thus seen as an obligatory task for women [1–4], with the community insisting on the fulfilment of this task shortly after marriage.

The bride in limbo

This theme focuses on the transitional state of women when they are neither bride nor mother. This theme has a connection with the first point of performativity theory: means cultural discourses serve as ‘constitution’ where individuals are trained and scrutinised in a strict manner according to the cultural discourses. It highlights how family and community members begin questioning the fertility and social status of women shortly after marriage. Participants stated that after marriage, the most anticipated news is the bride’s pregnancy. As a result, neighbours often inquire about pregnancy, directing questions to the mother-in-law, married sisters-in-law, or the bride herself. This point was discussed in a FGD:

“Relatives (women) ask the mother-in-law, ‘Is there any good news?’” (FGD 2, Participant 1)

These excerpt illustrate the community’s intense curiosity about a newlywed bride’s potential pregnancy. Sometimes, they even interpret the bride’s visit outside the in-laws’ home as a possible trip to the hospital for pregnancy-related reasons.

Another participant shared:

“I went to my sister’s home for lunch (she arranged it for the new couple)…When I came back, the elderly neighbour asked, ‘Are you coming from the hospital?’” (Interviewee 2)

The community shows a vested interest in the fertility of the new bride. Many older women compare the pregnancies of different newlywed couples, drawing attention to those who have not yet conceived. One woman shared:

“After six years of marriage, I was still not pregnant….Women who got married around the same time as me, or even after, all have children now…but I don’t.” (Interviewee 5)

This excerpts reveals that community members often compare women based on pregnancy status, number of children, and the time between marriage and first pregnancy. When a woman does not conceive within two or three years, suspicions arise, casting doubt on her fertility. After five to six years, such women are labelled as ‘childless’ and are seen as needing medical intervention to conceive. This underscores the societal expectation for women to transition quickly from bride to mother, rather than remaining in a liminal phase.

Participants used various phrases when discussing this theme: kuch he (are you pregnant?), koi khabar (do you have news, implying pregnancy), tu wi koch ker le (you should do something to become pregnant), tere wass di gaal nae (pregnancy is not your concern), rab kher kare, waya noun 5−4 saal ho gaye ne (God bless her; she’s been married for about five years), koi masla wi ho sakda ae (she may have an issue, possibly infertility), saas noun tayaan kerna chahi de (her mother-in-law should focus on this matter).

Since these women do not fulfil the role of ‘motherhood’ as expected, and thus deviate from gendered norms, they face potential stigmatisation, as discussed extensively elsewhere [1,2]. This theme reflects that the community typically expects a child from a newly married woman within one year of marriage. A ‘waiting period’ of up to two years is accepted without suspicion, during which a woman is expected to give birth or at least announce a pregnancy. After this, the community’s suspicions about her fertility increase with each passing year. Over time, the woman is seen as someone who has failed to fulfil her expected role, intensifying the stigma she faces [1,2].

Treatment seeking as an expression to achieve motherhood

This theme explores women’s experiences with health-seeking and communication surrounding treatments in their journey to become mothers, specifically those who cannot conceive within what society considers the ‘right time’ — typically a few years after marriage. This theme relates to the second point of performativity theory, ‘discursive constraint’, in which women replicate the behaviours. The women make efforts to provide a ‘biological child’ as expected by society. These women, in attempting to meet gender expectations, seek out and follow various treatments.

A woman stated that:

“I have visited many doctors, but every doctor told me a different (medical) problem. I took medicine from each doctor and used it.” (Interviewee 10)

Another woman shared her story:

“I contacted religious leaders. I took amulets. If someone recommended a hakeem (herbalist), I would visit him for treatment. [...] I consulted all the gynaecologists practicing in the nearby city… you know, I had hope while following each treatment… but I wept every time at the end when there was no news of pregnancy.” (Interviewee 8)

The above-mentioned excerpts shows that childless women were following the treatments ranging from home remedies to bio-medical medication. In seeking treatment, they turn to a variety of options, including home remedies, religious practices, herbal treatments, and modern medicine. Studies indicate that women use herbal decoctions, apply pastes to their bodies, and receive massages [16–19]. They also consume charmed water, jaggery, black pepper, and visit religious places, such as shrines, for prayers [60,61]. These treatments are often repeated multiple times over the years. Thus, these women start following treatments soon after marriage and repeatedly shift among various healing categories and practitioners. Their accounts show a wide array of treatments pursued in their efforts to become mothers similar to other regions [13,15,62–67]. Furthermore, treatment-seeking is a journey fraught with emotion and grief. Each treatment begins with hope, but every unsuccessful outcome brings sorrow. As women, they feel compelled to continue, pressured by societal norms not to abandon their pursuit of motherhood. The repetition of treatments following is a way of motherhood performativity and complying the norms of ‘mother in making’.

Women also shared that their male partners are not subjected to the same expectations for medical consultations. Typically, male partners only seek medical advice if a gynaecologist explicitly requests it. One woman recounted:

“The doctor asked for my husband’s lab reports... I took his report to the doctor, who said, ‘...your husband has weak sperm.’” (Interviewee 1)

This excerpt shows that although male partners may contribute to infertility, they often seek treatment only upon a doctor’s recommendation. Community expects women to prioritise proving their fertility. By doing so, women are following the gendered scripted norms of society. Participants also expressed that even if their husbands have fertility issues, women are still encouraged to seek treatments and consult various healers, either traditional or professional. Consequently, these women may also face suspicion regarding their fertility. As one woman explained:

“My mother-in-law send both of us to the doctor…..My husband is taking medicine, but I go to the doctor with him.” (Interviewee 4)

Thus, women are recurrently expected to demonstrate their physical fitness, fulfilling their prescribed gender role of a ‘mother in the making.’

Furthermore, women have to follow the cultural discourses while discussing the cause of childlessness and physical fitness. It is the cultural expectation that a woman should elaborate regarding her physical fitness and treatment cycles daily and occasionally. At the same time, she is socially sanctioned to does not discuss her husband’s infertility as a cause of childlessness. This announcement is seen as inappropriate culturally. A woman shared:

“Sister… it’s a daily routine… I tell other women about each treatment, from the first to the last… I feel sad every time… but people don’t understand; they just suggest another treatment.” (Interviewee 8)

Another woman shared:

“My husband has an issue of low sperms (low sperm count)…..I am physically fit. But we at home know that he has this problem.” (Interviewee 4)

The excerpt above indicates that women assure community members of their physical fitness and future potential to bear a biological child. Consequently, women often find themselves emphasising their well-being by repeatedly affirming the practitioner’s statement that they are in good physical condition and have no medical issues. However, participants also expressed that they are not permitted to discuss their husbands’ physical condition, especially when the husband has been diagnosed with infertility issues [61,68–70]. Cultural norms restrict childless women and demand a different type of behaviour from them. In such cases, the woman is expected to stay silent about her husband’s infertility and to endure the pain when, in public gatherings, community members discuss her childlessness. By protecting their husbands and bearing the full burden of childlessness, these women are conforming to prescribed cultural expectations.

Another participant stated:

“Every time someone asks about my pregnancy… I feel heartbroken… I start crying… it happens automatically… but I notice people show sympathy right after I cry.” (Interviewee 9).

Above-mentioned excerpt shows that women express grief openly, crying when discussing their childlessness, which is perceived by the community as a very explicit form of performing the desired role (by woman). Feelings of grief [71] are seen (in the community) having a desire for motherhood. Community members, in response, suggest that they seek more healers and continue treatment. Thus, women bear the burden of childlessness [1,2,69,72,73] to comply the scripted role of motherhood.

Furthermore, expressions commonly used in this context, such as Allah kher kare ga (God will do better for you), Allah kabhi toh sunay ga (God will hear you one day), and Harakat mein barkat hai (There is blessing in effort), encourage women to keep searching for more treatments. These phrases reinforce the expectation for women to continue their journey, seeking solutions tirelessly.

Love for other’s children as a motherly characteristic

This theme has a connection with the second point of performativity theory-‘discursive constraint’. It discusses the expectation that women must display mamta (motherly instinct) and affection for children. By doing so, even childless women can fulfill the expected gender role by showing affection for others’ children. Community members shared that a woman’s behaviour toward other children suggests a desire to become a mother. One woman explained:

“I love children very much…I usually take care of my husband’s brothers’ children...the older women say to me, ‘You love children so much…God will bless you with a child.’” (Interviewee 12)

Another woman state:

“My husband has three brothers, all married, so we have many children at home…I stay busy with them…I care for them when their mothers go to visit neighbours or the market…sometimes I feel tired, but I never refuse…they might feel hurt.” (Interviewee 3)

These excerpts illustrate that when women display nurturing behaviour, it is socially appreciated as an expression of their desire for motherhood. Conversely, any perceived lack of affection is met with criticism, with childless women being labelled as ‘unfit mothers.’ Negative reactions often provoke painful taunts, such as tum maa banne ke qabil nahi ho (you are not capable of becoming a mother). Such remarks emotionally burden these women, who respond by actively portraying a nurturing image, conforming to the societal expectation of a ‘mother in the making.’

As noted, childless women are expected to show constant affection toward other children. This demand often encroaches upon their personal lives. For example, when family members live in the same compound, they frequently leave their children with these women while they go out (to visit neighbours, relatives or the market), assuming they will take care of the children. These women fulfill this role by feeding, storytelling, playing and attending to the children’s needs. Participants shared that they often sacrifice their rest time to care for their siblings’ children. Thus, showing love and care for children is regarded as an essential aspect of motherhood, and by doing so, these women comply with this societal expectation.

Adopting motherhood

This theme is connected with the third point of the performativity theory ‘subversion’. It discusses the solution of childlessness through adoption. Society offers adoption as an option for childless couples who have tried extensively to conceive but remain unsuccessful. Participants shared that some couples choose to adopt children after many years of marriage. One woman stated:

“I should adopt a child; the idea came to me suddenly. I discussed it with my husband... he agreed... and then I adopted my sister-in-law’s child.” (Interviewee 4)

“Sister! I think about adoption. But my husband does not agree... I have tried many times to persuade him, but he has refused.” (Interviewee 6)

These excerpts illustrate that adoption is a viable option within the community. Some childless women in the community have chosen to adopt, consistent with findings in previous studies [8,13,14,74–77]. Women who adopted children from their own siblings or relatives are enacting motherhood in a way that diverges from traditional norms, as they do not replicate the scripted role of a biological mother. This variation in the practice of motherhood suggests that culture permits some flexibility from established norms. However, individuals are still constrained from freely deviating from these norms.

In this community, cultural discourses strongly influence deviations from traditional norms, especially regarding childless women considering adoption. Following specific guidelines—such as adopting a child of the same caste and religion, knowing the biological parents and preferring familial ties—is essential. A woman expressed her wish as follows:

“Sister, I wish to adopt a child but you know we could not find a child in our siblings for adoption. We could not adopt a child from outside our family.” (Interviewee 13)

Obtaining consent from the husband and parents-in-law is also critical for adoption. Some women refrain from adopting due to factors like family approval and the availability of children. In some regions adoption is common [78,79] and these nations such as US, India and South Africa impose strict rules on couples who adopt children [78–81]. India has launched a digital system with record of the children that could be adopted [82]. In US the adoption is done through foster houses [78]. Unlike these regions where adoption is more common [78–80], this community imposes strict standards on adoption for childless women. It is seen as a family matter. Similarly, in Bangladesh, women wish to adopt a child but they are supposed to follow the decisions of their husband and families [67,73]. Nahar documented that adoption is unpopular in South Asian countries [67].

The community employs specific terms to discuss this theme, indicating the subversion of traditional scripts by women. These words reflect a (accepted) deviation from social norms. Examples include saggi maan nai (not a biological mother), lepalak/goed laya/mangya (adopted child), and saggi oulad nahi (not a biological child). Additionally, discussions often reference the relationship between the child and woman, such as bhateeja/bhanja (son of her brother/sister) and jeth/deyoor/nannaan da munda/kuri (son/daughter of her husband’s brother/sister).

The use of terminology in this theme shows that the adopted child is never considered the own child of the woman, rather, the adopted child, to some extent, satisfy her mothering feelings. Also, the woman behaviour towards that child shows the community that she has mothering qualities. The woman through her caring behaviour, bringing up a child and remain busy with child whole day explicitly fulfil her role of a mother as expected by the society. Although, the woman cannot provide a biological child but her connection to the adopted child gives her a footing in the family and society. Mostly, the adopted children belongs to husband’s lineage, so in this way she maintains a connection with the in-laws family.