Pains of the bane of infertile women in Southwest Nigeria: a qualitative approach

INTRODUCTION

The Holy Bible recorded in Genesis 30 verse 1 that Rachael cried to her husband: “give me a child or I die”. This record illustrates that since ancient times a high premium is placed on having children. In essence, children are regarded as one’s identity, and in fact, are the vehicles of self perpetuation.^[1] This is particularly relevant in African society where children are regarded as a way of dealing with mortality, and highly valued for socioeconomic reasons.^[2,3] The Yoruba tribe of southwest Nigeria views children as “ade ori” meaning crown worn on the head.

An epidemiological definition of infertility has been recommended by the World Health Organization (WHO) as the inability to conceive within two years of exposure to pregnancy.^[4] Infertility is a growing issue of major public health concern and affects an estimated 10%–15% of couples of reproductive age.^[5,6] Worldwide, more than 70 million couples suffer from infertility, the majority being residents of developing countries.^[7] The prevalence of infertility in sub-Saharan African varies widely from 9% in the Gambia, 21.2% in Northwestern Ethiopia to 30% in Nigeria.^[8,9,10]

In traditional African societies where infertility is mainly regarded as a curse, infertility often results in significant distress that may affect the overall existence of a couple, with the woman carrying the largest burden of suffering.^[11,12] Earlier study from the region where this present study was done among the Ekiti of southwest Nigeria reported women were treated as outcast, after they die, and their bodies are buried on the outskirt of the town with those of the people experiencing mental illness.^[13] Outside African culture, in the Middle East, women’s social status, dignity and self-esteem depend on her ability to procreate.^[14]

Due to grieving which remains invisible for most parts, inability to achieve pregnancy is usually coupled with low self-confidence, depression, sexual problems, feeling of shame or guilt and lack of communication with friends and family members.^[15] Studies in Sub-Saharan Africa have established the occurrence of psychological stressors as common consequence of infertility.^[16,17] The associated psychological distress often experienced by infertile women or couples is due to inability to achieve the desired social role.^[18] Reproductive failure has very far reaching social implication in Nigeria where, traditionally, the main reason for marriage is to have children irrespective of whether or not the couple is in love.^[19]

This study explored the viewpoints, and the psychological burden of infertility that exposes the bane and pains of infertile women, with a view to understanding their concerns. Literature suggests that infertility is more stressful for women than for men and most of therapeutic procedures are performed on females thus causing more anxiety and depression in women.^[20,21] This study adopted a qualitative approach to investigate the experience of women who were undergoing treatment for infertility at a tertiary health facility in southwest Nigeria.

SUBJECTS AND METHODS

A qualitative approach was adopted for profound exploration with a view to appraising their holistic subjective experiences of infertility. This methodological framework provides tools for profound exploration of human experiences so as to enable appraisal of actual and totality of experiences of the participants. The participants in the study were recruited through purposive sampling method that enabled maximum variation as it regarded the varying types, causes, treatment and, duration of infertility as experienced by the participants. The inclusion criteria for the study were (i) participants have been mentally stable for two years or more, (ii) psychosexual history revealed inability to conceive at least one year after marriage, (iii) diagnosis of infertility by specialist(s); (iv) participants consented to interview process. Exclusion criteria included individuals who refused to give verbal or written consent.

Recruited participants were interacted with in Yoruba language (the native and predominant language in the area of study) except for five of the participants who were interviewed in English language because they were not fluent in Yoruba language. The eventual translation and back translation of the responses in Yoruba language into English language was done by the first author who is proficient in both languages.

An interview proforma was filled by the interviewer to capture the sociodemographic and sexual history of each of the participants. An in-depth, face-to face, interview was adopted with a sound recorder and back-up notes. The participants were encouraged to be relaxed while they relate their experiences concerning infertility. A close observation of body language was made to detect any emotional distress in some of the participants as they recounted their infertility experiences. Such reactions were promptly addressed by the first author through counselling. The focus of the study exploration was: “Do tell me your experiences with infertility”. Further explorative questions were asked to clarify and guide the focus of the interview.

Ethical approval for the study was sought and obtained from the ethics committee of the authors’ tertiary institution. Informed consents were given by the participants after the authors had explained the entire process of the interview concerning this study. The participants were also made to understand that their confidentiality and rights to decline participation at any stage of the interaction were guaranteed. All documentations related to the study were carefully handled.

RESULTS

The study started with thirty-nine participants who gave consent but four later declined and another three participants had to be excluded due to profound emotional reactions that would not allow them to complete the interview session. The study was completed with only thirty-two women living with infertility. The sociodemographic variables of the participants are shown in Table 1 and Table 2 shows some aspects of the gynaecological history of the participants.

Table 1 Sociodemographic variables of the participants

Table 2 Some aspects of gynaecological history of participants

The mean age of participants was 34.0 ± 5.52 years and age ranged between 28 to 47 years. Thirteen (41%) of the participants had primary infertility and nineteen (59%) had secondary infertility. Mean duration of infertility was 4.19 ± 2.25 with a range of between 1 to 17 years, and their treatment ranged between 4 months to 14 years. Only four (21%) of the 19 participants with secondary infertility had a living child each.

In spite of the majority of the participants admitting coital frequency between three and four times weekly, 27(84%) of the participants considered their sexual experience with spouse unsatisfying. Four-fifth of the women in this study expressed their dislike for adoption. About a third of the participants were not aware of the outcome of the results of infertility investigations of their spouses. However, about three-quarter of the participants admitted spouse were supportive. Only seven of the thirty-two participants had their spouses accompanied them, at least once, to the clinic while duration of this study.

Emerging themes

A total of 43 significant statements were noted and were sorted into eight main themes. Discerned themes and examples of related statements by the participants are shown in Table 3.

Table 3 Themes and examples of statements

DISCUSSION

Similar to findings in some earlier studies which had observed overwhelming negative experiences, this study revealed, among others challenges, problems of isolation, anxiety, shame, low self-esteem, anger cum resentment, and hopelessness. Negative consequences of infertility are common in developing countries.^[23]

CONCLUSION

Infertility can be painful as it affects every aspect of life and relationship of couples living with infertility. It would require a multi-disciplinary approach to relieve the pains, and alleviate the baneful experience of infertile couples. The pains and hurt feelings of infertility are the banes of this seemingly normal part of life. It is worthwhile for people who have no experience of infertility to understand that those who feel it know it. No doubt, the psychological distress of infertility may manifest in couples living with infertility. Regarding the reality of distress and associated experience of psychosocial stressors, it is important, therefore, mental health practitioners are also engaged to participate in the holistic management of infertile couples. The myriads of psychological problems faced by infertile couples are not insurmountable if, and only if, people, including medical practitioners, who do not have challenge of infertility are rather sensitive to the plights of infertile couples.