CHAPTER ONE

 INTRODUCTION

1.1 Background of the Study

 Infertility is considered as one of the six maternal morbidity neglected within developing countries (Hardee, Gay, & Blanc, 2012). It affects the  entire women`s life (Hoseinighochani & Zargham, 2014). It is reported as being 16 times more frequent than maternal mortality (Hardee, et al., 2012). Globally, 56% of women with infertility are having problem seeking help (Boivin Bunting, Collins, & Nygren, 2007).

Clinically, infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse  (Godwin, Montoro, Mudershpach, Paulson, & Roy, 2010). Demographically, infertility can be  defined as, an inability to become pregnant, within five years of exposure based upon a consistent union status, lack of contraceptive use, non-lactating and maintaining a desire for a child (Shea & Shah, 2004; World Health Organization, 2014a). From the epidemiological perspective, infertility is defined as inability of a woman of reproductive age who is at risk of pregnancy, to conceive despite continuous unprotected sexual intercourse for two years or more  (World Health Organization, 2014b).

Infertility can be primary or secondary. Primary infertility is the inability to conceive in a couple who have had no previous pregnancy (Hart, Norman, Callander, & Ramsden, 2000). Whereas secondary infertility is the inability to conceive in a couple who have had at least one previous pregnancy which may have ended in live birth, still birth, miscarriage, ectopic pregnancy or induced abortion (Hart et al., 2000).

       Globally, about 9% of the population suffer from infertility (World Health Organization (WHO), 2009; Nygren, 2007). It is estimated that, about seventy two million (72,000,000) women are affected with infertility and majority are from developing countries (Boivin et al., 2007; World Health Organization, 2009). It is also estimated that 10% of  women are affected with infertility worldwide (World Health Organization, 2014b). In 2010, among women aged 20–44years that were exposed to the risk of pregnancy, 1.9% were unable to conceive. Out of women who had had at least one live birth and were exposed to the risk of pregnancy, 10.5% were unable to conceive again (Mascarenhas, Flaxman, Boerma,Vanderpoel, & Stevens, 2012).  In the United Kingdom (UK), 2.4% of women aged 40–55 years had unresolved

infertility with no pregnancies (primary), and a further 1.9% had been pregnant but not achieved a live birth (Oakley, Doyle, & Maconochie, 2008). According to the Center for Disease Control and Prevention (2013), approximately 10% or 6.1 million women in the United States struggle

with infertility.

        In Africa the prevalence  rate of infertility may be as high as 20-30% in some areas, and vary from region to region even within the same country (Leke, 2014). Infertility prevalence is highest in South Asia, Sub-Saharan Africa, North Africa/Middle East, and Central/Eastern Europe and Central Asia (Mascarenhas et al., 2012). In  sub‐Saharan Africa, primary infertility is much less prevalent than secondary infertility (Akwame, 2013; Hollos & Larsen, 2008). These disparities are reported to be the result of the high prevalence of untreated sexually transmitted infections, abortion and postpartum infections (Callister, 2010; World Health Organization, 2014b).  It has been reported that, the exact prevalence of infertility in developing countries is unknown due to a lack of registration and scarcity of empirical investigations in the area (Ombelet, Cooke, Dyer, Serour, & Devroey, 2008). 

 The overall burden of infertility is significant, likely underestimated, and has not displayed any decrease over the last 20 years (World Health Organization, 2014b). Infertility causes great worry and sorrow for many couples in Africa, especially for the women. Medical evidence shows that men and women usually have the same rates of infertility (Human Life Foundation, 2013).Yet African tradition continues to view infertility as a woman’s fault (Human Life Foundation (HLF), 2013).

 Regardless of its medical causes, infertility causes women in African societies a personal grief and frustration, depression, social stigma, social isolation, and often serious economic deprivation (Cousineau & Domar, 2007; Hollos & Larsen, 2008; Hollos, Larsen, Obono, & Whitehouse, 2009; Naab, Roger, & Heidrich, 2013; World Health Organization, 2009). There is a difference in  partners` perceptions of infertility and their distress, and which is associated with their  psychological adjustment of the fertility problem (Benyamini, Gozlan, & Kokia, 2011). There is also the feeling of disgrace, shame and finally divorce (Akwame, 2013). In Nigeria, depression and anxiety were significantly higher among women who were divorced due to primary infertility and had a negative attitude towards adoption (Rouchou, 2013).

  In USA, psychosocial effects of infertility among women include shock, grief, depression, anger, and frustration, as well as a loss of a sense of control over one’s destiny

(Ferland & Caron, 2013; Lindsey & Driskill, 2013; Miles, Keitel, Jackson, Harris, & Licciardi, 2009). Women`s effects of infertility can  result in feelings of extreme isolation, where many women feel like an outsider in a world that seems to only welcome parents and children

(Ferland & Caron, 2013).

 Women in Africa  suffer psychological distress and trauma  resulting from spouses, relatives, and neighbours (Dhont, 2011). If the husband takes a second wife, the first wife may then have trauma from living in a polygamous and abusive marriage (Dhont, 2011). A study in

Rwanda found negative consequences of infertility for both men and women (Dhont, 2011). Compared to western societies, infertile women in Third World countries feel a deeper depth of guilt, shame, worthlessness and depression (Rouchou, 2013). Every South African woman admitted to intense emotions such as anger, profound sadness, bitterness, loneliness and desperation (Rouchou, 2013). Some women confessed that they have had suicidal thoughts, while others were inconsolable when speaking of lost relationships and broken marriages (Rouchou, 2013).

In West Africa, women also suffer psychosocial problems of infertility. For instance, in Ghana, Infertile women report facing severe social stigma, social isolation, anxiety, depression, marital strain and a range of mental health difficulties (Fledderjohann, 2011; Rouchou, 2013; Naab et al., 2013). Many women feel that they shoulder a disproportionate share of the blame for infertility and, by extension face greater social consequences than male partners for difficulties conceiving (Fledderjohann, 2011; Rouchou, 2013; Naab et al., 2013). 

  In Nigeria, psychological distress of infertility is significantly higher among couples with infertility compared with their fertile counterparts (Omoaregba, Morakiny, James, Lawani, & Morakinyo, 2011). Infertile women who had previously sought help from a traditional or faithbased healer for infertility were more likely to experience probable psychological distress (Omoaregba et al., 2011). In Nigeria, the levels of anxiety and depression among women with infertility  varies according to individuals` beliefs and religion, For instance, anxiety and depression are lower among religious couple but higher symptoms were predicted among couples who were previously exposed to couples counseling and higher number of wives

(Ramazanzadeh, Noorbala, Abedinia, & Naghizadeh, 2009; Upkong & Orji, 2007).  Psychological suffering is a significant and sometimes debilitating consequence of infertility in Nigeria. For instance, almost 50% of infertile women in Nigeria have been diagnosed with depression (Upkong, & Orji, 2007). Women`s beliefs about infertility have been reported to have an effect on their psychosocial health and contribute in varying degrees to their levels of depression, anxiety, stress, stigma and social isolation (Naab et al., 2013). Some risk factors for infertility have been reported. In Turkey,  35-50% of students thought that smoking, alcohol, stress, sexually transmitted diseases, infections, pollution, chemicals, radiation and cancer treatment could be risk factors for fertility (Gungor, Rathfisch, Kizilkaya Beji, Yarar, & Karamanoglu, 2013). Advanced age and obesity were seen as risk factors for women (Gungor, et al., 2013). Half of the students believed that infertility is preventable (Gungor et al., 2013).

  Major causes of infertility as reported by Nigerians are medical and supernatural. Medical causes include family planning, especially the use of oral contraceptives, abortion and the use of drugs. Supernatural causes have also been implicated. For instance a person could be punished by offended witches, wizards or elders. Infertility could also be caused by powers of darkness, called ‘juju’ and behavioural factors such as sexual intercourse outside of marriage which is construed as immoral (Liu, Theobald, Odukogbe, & Nieuwenhuis, 2009). Likewise in northern Nigeria, majority of  respondents in a study perceived infertility as a disease (Illiyasu et al., 2013). Only 18.1%  of the respondents considered couple infertile after one year of marriage (Illiyasu et al., 2013). Causes of infertility mentioned by participants included paranormal events, suprapubic pain, induced abortion, sexually transmitted infections, blocked tubes and irregular menstrual cycles (Illiyasu et al., 2013).

 African women have negative effects of infertility. For instance, in Tanzania, women suffer lack of respect in the community, verbal abuse and considered as useless (Hollos et al, 2008). In Ghana, women with infertility suffer high level of stress, social stigma and depression (Naab et al, 2013; Naab, 2011). Nigerian women experience psychological torture, verbal abuse, ridicule, physical abuse and deprivation ( Anozie,  Ameh, Kene, et al.,  2007).

 Women apply religious coping strategies and gain a faith-based strength to adapt to the effect of infertility. For example, in Iran religious women with infertility experienced infertility as an enriching experience for spiritual growth (Roudsari & Allan, 2011). This perspective helped them to acquire a feeling of self-confidence and strength to manage their emotions (Roudsari & Allan, 2011). Some other coping strategies adopted by women with infertility are being optimistic (i.e. women try to think positively and hope that things will get better), and selfreliant (i.e. women keep feelings to themselves and want to be alone to think things out) (Lee, Wang, Kuo, Lee, & Lee, 2010).

 Efforts to assist the women with infertility to deal with the emotional impact of infertility should include preparing them to deal with the interactions and communications from those in their environments (Khalifa & Ahmed, 2012). This preparation may be particularly more relevant for rural dwellers who experience infertility because of the sense of closeness of community members that is so prevalent (Khalifa & Ahmed, 2012).

 In southern Nigeria, infertility distress was high among couple who are infertile, so also depression and anxiety were significantly higher among women who were divorced due to primary infertility and had a negative attitude towards adoption (Omoaregba et al., 2011).

Nigerian women perceived infertility to be caused by medical and supernatural factors (Omoaregba et al., 2011). 

Majority of the studies related to infertility in Nigeria were conducted in southern part of the country which has different cultural background with those in the northern part where this study was conducted. Yet little is known about the effects of women with infertility in Kwara State. Therefore, this study explored the psychosocial effects of women with infertility and their coping strategies in Kwara State.

1.2 Statement of Problem

 African women with infertility have been subjected to domestic violence due to infertility (Sahin, Yildizhan, Adali, Kolusari, Kurdoglu,  & Yildizhan, 2009). Couples with infertility live in fear and anxiety about the infertility diagnosis, treatment process, and treatment outcome (Ozcelik, Karamustafalıoğlu, & Ozcelik, 2007). This situation may cause conflict between the spouses, a decrease in self-esteem, frequency of sexual intercourse, and the development of feelings of inadequacy in a female or a male. As a result, the bonds of marriage are put under psychological pressure (Holter, Anderheim, Bergh, & Moller, 2006; Moghadam, Salsali, Erdabili, Ramezanzadeh, & Veismoradi, 2011). Therefore, it can be a reason for marital incompatibility and also divorce (Holter et al., 2006; Moghadam et al., 2011). Domestic violence of women with infertility include psychological torture, verbal abuse, ridicule, physical abuse and deprivation (Anozie, et al. 2007). Infertility is also associated with frustration, pain, social ostracism, stigma, marital instability, and suicide (Moyo, 2014).

A Report in Nigeria has shown that, infertility has a serious social, psychological and economic impact on women and men's lives (Liu et al, 2009). Infertile women prioritize the psychological impact of infertility while infertile men prioritize the economic impact, and reported spending between 55-100% of their income to address infertility (Moghadam et al.,2011). The prevalence of psychiatric morbidity was 46.4% in infertile women, 37.5% and 42.9% were cases of anxiety and depression respectively (Upkong & Orji, 2007). 

It has been established that, the socio-demographic variables of women with infertility contributed to the prediction of psychiatric morbidity, because of the effects of age, not having at least one child and poor support from spouse (Upkong & Orji, 2007). Nigerian women with infertility have higher level of anxiety and depression (Fatoye et al., 2008; Omoaregba, James, & Morakinyo, 2011). Infertile women in southern parts of Nigeria are not considered as part of the community and are not even buried in town land (Hollos et al., 2014). There are variations in the extent to which childlessness is considered to be problematic in different regions of Nigeria (Hollos, & Larsen, 2008).

Despite the psychological and social problems associated with infertility, women are reported to have adopted various coping strategies which further increase their distress. While some of the strategies may not impose pressure on the women directly but to their partners (Donkor & Sandall, 2009). This means that, adopting inappropriate coping strategies may cause marital instability and separation.

If the impacts of infertility on women are known in other parts of Africa and Nigeria, what is the situation in Kwara State? Currently, little is known about women`s psychosocial effects and impacts of infertility in Kwara State state. Thus, this study explored the psychosocial effects of women with infertility and their coping strategies in Kwara State.

1.3 Research Purpose

The purpose of this study was to explore the psychosocial effects and describe the coping strategies of women with infertility in Shao Community, Kwara State, Nigeria.

1.4 Research Objectives:

The specific objectives of this study are to:

1.      Ascertain the psychological effects of women with infertility in Shao community

2.      Explore the social effects of women with infertility in Shao Community

3.      Investigate the coping strategies adopted by women with infertility in Shao Community

4.      Find out the health-seeking behavior of women with infertility in Shao Community

1.5 Research Questions

1.      What are the psychological effects of women with infertility in Shao community, Kwara State?

2.      What are the social effects of women with infertility in Shao community, Kwara State?

3.      What are the coping strategies adopted by women with infertility in Shao community, Kwara State?

4.      What are the health seeking behaviours of women with infertility in Shao Community?

1.6 Significance of the Study

         The findings of this study may assist health practitioners in gaining more knowledge on the psychosocial effects of women and contribute towards providing directed psychosocial care and health education. Providing and promoting psychosocial care is of crucial importance for reducing anxiety related to infertility and preventing complications such as depression and physical problems like hypertension and psychiatric disorders. Thus, the findings will assist nurses in designing and providing health educational programmes targeting and strengthening women psychologically and offer ways for effective community integration. It will also help in providing counseling on more effective ways of adaptation. The findings may also contribute to the body of knowledge in the area of infertility and pave the way for further research. 

1.7 Operational Definition

Psychological effects: Factors that contribute to the instability and border one`s mind

 Social effects: Factors leading to ineffective interaction with one`s physical environment

 Infertility: Inability to give birth despite all efforts to do so.

Anxiety: A state of fear, doubt, worries, thinking too much and feeling weakness due to

infertility

Stress: State of frequent crying, confusion, disturbances, and insomnia as a result of infertility

Depression: Infertility related sadness, angry, irritability, loneliness, lack of happiness, and loss of interest in communication 

Social Stigma: Negative understanding attached to infertility

Social Isolation: Lack of involvement in social interaction or activities

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