Assessing the Emotional and Mental Well-being of Infertility in Waiting Mothers; Olabisi Onabanjo University Teaching Hospital (OOUTH)
Chapter One
Objectives
Broad Objective
To determine the emotional effects of infertility, its impact on marital and social relationships among infertile women attending OOUTH at the Oyo state referral hospital.
Specific Objectives
Among infertile women attending OOUTH at the Oyo state Referral Hospital to determine:
- The emotional effects resulting from infertility
- The effects of infertility on women’s marital relationships
- The effects of infertility on women’s social interactions
CHAPTER TWO
LITERATURE REVIEW
Emotional Effects of Infertility
By use of the QoL questionnaire from infertile couples Namdar et al., found that the general well-being of about a half of the women indicated some form of the disorder (10). They face the risk of feelings of worry, instability, and dysfunction socially and sometimes depression. Major factors influencing the QoL included monthly earnings, level of education, and location of residence (rural/urban). As shown by the findings of a qualitative study of sub- fertile couples by Loke et al, participants reported feelings of emptiness, remorse, self-blame, and felt they are cut off from the ‘world of the fertile people’(11). The couples also agreed to the fact that the sub-fertility problem had effects on their marital relations. They blamed themselves for not seeking care early. Some couples discovered alternative ways to fill their ‘loss’ and deal with their circumstances, while others rationalized it by unearthing excuses that approved of them being infertile.
In a bid to explain how Iranian infertile women respond to infertility psychosocially; Hasanpoor-Azghdy et al used a qualitative content analysis study(12). The results themes were summarized into four topics: cognitive responses arising from infertility itself, cognitive responses to the treatment process, emotional-affective responses arising from infertility, and emotional-affective responses to the treatment process. The psychosocial health of couples with infertility in Jordan was examined by Mahadeen et al.(13). They used a cross-sectional descriptive study to evaluate data on perceived social support, depression, stress, and coping mechanisms. More than a half (66%) of couples had average to the above-average levels of depression. They experienced an outstanding level of psychological distress, and a low level of life satisfaction, but were significantly optimistic that the fertility problem is short-term.
Couples had a medium level of coping mechanism, they perceived highly of their families’ social support.
Marital Relationships and Infertility
Several factors affect the psychosocial impact of fertility problems on women. As reported by Winkelman et al. Personal distress as well as sexual dysfunction were significantly higher in women who had female-only factor as the cause of infertility(14). This was noted to be high also among women of age less than 40 years. It is also clear that having a child earlier and infertility lasting for longer periods lowered these distresses but worsened levels of marital distress. Infertility may result in repercussions like exclusion socially, separation, and abuse both physical and verbal (15). Gender differences may exist in terms of infertility’s sequel on marriage relations as well as a couple’s quality of life. However contrary to this, a comparison of Turkish couples (fertile vs. Infertile) by Gu¨ liz Onat et al. Found no difference in gender regarding QoL for these couples (16). Both groups scored well when das was used and more so was better among infertile women than their fertile counterparts. In almost all domains regarding QoL infertile men scored higher than their fertile counterparts. A positive correlation was noted between the scores of das and QoL. There is a high prevalence of depression in women with infertility and family dysfunction is negatively associated with its severity. Lack of support from husband and in-laws also contribute to the likelihood of depression and anxiety.
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There exists a predictive effect of stress that is related to stress on both emotional and marital distress(17). This was according to Gana and Jakubowska in their study done in France consisting of 150 infertile men and women. They used structural equation modeling to estimate this relationship. However, stress relating to infertility was found to have more impact on emotional distress than on marital satisfaction.
CHAPTER THREE
RESEARCH METHODOLOGY
Study Design
A mixed-method approach was used to assess the psychosocial status of infertile women. It will be a partial concurrent, dominantly qualitative mixed method design. The quantitative data obtained was useful in quantifying the psychosocial problems and helped uncover the pattern of responses. This was used to formulate facts that can be generalized to a larger sample population. On the other hand, the qualitative method helped in further understanding and getting insight into the underlying women’s feelings and opinions. For the quantitative aspect, it was a cross-sectional descriptive study design, while the qualitative one was an exploratory method by use of a phenomenological approach. This explains how individuals interpret lived happenings/experiences and how they are conveyed (Parahoo 1997). It is a qualitative, inductive methodology to elicit participants’ experiences, attributing meanings to participants’ narratives, presenting an overall picture of the phenomenon under study (Omery 1983, Munhall & Olier 1986). Data were collected from women diagnosed with infertility.
Study Population
The study population was women seeking care for the problem of infertility at the Oyo state referral hospital. There is a concentrate of women coming from as far as the refugee camps seeking the services every Tuesday at the facility. In this gynecological outpatient clinic, approximately 32 patients with infertility are attended to monthly. Due to the nature of the societal and cultural expectations that “infertility is a female problem” men rarely present themselves for visits. This, emanates from a community that is highly patriarchal, and the likelihood of feminine socio-economic suppression and extreme socio-cultural negative consequences. This, therefore, makes this population very suitable for fulfilling the objectives of this study.
CHAPTER FOUR
RESULTS
Introduction
In this chapter, we highlight the demographic information, FertiQol scores and themes identified from the FGDs of infertile women at Oyo state referral hospital.
CHAPTER FIVE
DISCUSSION
Emotional effects of infertility
Participants of this study scored low on the emotional subscale of the FertiQoL. The findings were also consistent with the emergent themes during the FGDs.
Stress
Participants in this study felt that they were more stressed than their male counterparts because mainly they thought of the fact that they have a limited period to be able to conceive. This is supported by Kamel and Sylwia (17), who reported that women (M=145.43, SD=24.80) had higher fertility-related stress than men (M=136.53, SD=23.64), F(1, 148)=5.08, p=.026. They had more stress regarding their infertility more so if the partner was new to them. This could be explained by them believing that children will strengthen their marriage and provide happiness as is in African societies
Depression, anxiety, sadness, and despair
This was caused by the feeling that their husband will leave them sooner or later to look for a second wife, and those who were in polygamous marriages felt frustrated by the mocking comments the husband makes regarding their infertility. They felt constant worry regarding their condition and wondered why others are having children and they are not. This is comparable to the results of Mahadeen (13) who showed couples had alarming rates of moderate to severe depression that merit clinical evaluation and follow-up; (29.4%) – moderate depressive symptoms and (70.6%)-severe depressive symptoms. The findings were also similar to that of Hasanpoor (12) where infertile women experienced sadness one way or the other due to expressed worries by the family members, the bitter reactions of their community, or being blamed by their husbands for infertility. As is in our findings, Anokye (15) also reported 40% of these women felt their life had been put on hold, 28% indicated that infertility has led to low self-esteem while 17% mentioned distress, and 15% mentioned depression. Florence in Ghana (24) also reported similar findings of high levels of depressive symptoms.
Emotional insecurity, self-pity, and resentment
Infertile couples were lonely and felt bored by just spending time with their partners in the house alone. Sometimes they question themselves why they even need to work and get an income since they don’t have a child to raise. Sometimes participants got angry in case their periods came after some delay. They felt the money was useless and was not of use once you attain old age. This is similar to findings from a study by Hasanpoor who reported infertile women had feelings of loneliness and guilt and felt their home was silent from morning to night(12). Repeated failures (to conceive) were also frustrating for some of the participants in his study.
Beliefs, hope, faith, and religion
Participants in the study had good levels of hope that their infertility problem is temporary. They were optimistic that with the Help of God they shall eventually have a child. They had God to fall back on. Those who have a child before were thankful for what they had and hoped to get more and those without any also hoped they will be gifted someday with the help of the treatment they were receiving. They also had this belief that if a person is not meant to have a child with someone by God they won’t, even though they could both be having no issues (with infertility). These findings were similar to those of a study by
Mahadeen in which couples had a high level of optimism, with a mean score of 34.0 (6.3) (13).
Effects of infertility on women’s marital relationships
The FertiQoL score for the relational domain was slightly above average. This shows that despite their infertility status they had a moderate level of satisfaction in their marriages.
Although during the FGDs the participants were generally a bit reserved regarding their marital relationship, it was apparent from the emerging themes the issues they faced. Women feared that the husband will marry another woman eventually if they don’t give birth to a child for them. This could lead to marital conflict (21) including threats of divorce and hence delay in the management. The men were also blaming them entirely and weren’t ready to see a doctor. This could explain why the women were working so hard to find out about their problems and find a solution so that they can conceive.
As explained also by P.K Koigi in a Nigerian study, the prolonged duration of effective communication (with a spouse) on the difficulty in conception (≥ 25 months), as well as a blame from the male spouse is able to cause a delay in treatment of these couples(21).
Effects of infertility on women’s social relationships
In our study, it was found that infertile women scored high in the social relation’s domain of the FertiQoL. This might have caused a large overall score of quality of life among infertile women in our study. However, this high score might be explained by the fact that women were getting good support from their own families. This was apparent from the FGDs.
In a study done in Ghana it was found that social effects of infertility on the lives of respondents revealed that 56% believed infertility has led to social exclusion, 41% they are subjected to verbal and physical abuse and 3% indicated that it has led to marriage breakdown (divorce)(15). This was the case in our study too.
Relationship with members of the community
From this study, infertile women felt that some behaviors of the people were traumatizing, like being told they were using family planning or they could get annoyed by kids constantly asking them why they are not having babies. Sometimes people could mock them that they don’t know the pain of childbirth and hence have no compassion towards other kids. This was similar to the study by Hasanpor in 2014 in which sometimes participants were upset by hearing about the pregnancy or childbirth of a woman, like the kids, and humiliating behaviors of some people (12).
Due to societal pressure to have kids, they are uneasy attending social events. They usually ask themselves why others are having kids and they are not. They also felt inferior to other women. This is also in support of Ochieng’s study who concluded that children were a form of social status and gave couples pressure to have them. Anokye R. also reported that infertile women had a feeling that their life was not in motion because they did not attend any functions again and were not invited to certain programs leading to social exclusion.
The findings of the FertiQoL results are similar to a case-control study in which the social health dimension of life quality among infertile women attained a higher score than that of the control group(5). This could be due to the high perception of perceived social support from others(13).
From the FGDs it was apparent that there was good family support, especially from their own families. They are mainly advised to go see a doctor and get help. This was similar to a study by Fatima who found that regarding in-laws and relatives where 57.3% insisted on consulting a good gynaecologist, 29.8% had no family pressure, 11.3% insisted the male partners remarry, and 1.8% insisted the husbands divorce their wives(18). However, in our study we, found that most of the pressure came from the in-laws to a point of advising the husband to get a second wife. This is in support of Fehintola A. O. et al. 2017, who found that 79% of the infertile women were under pressure to get pregnant from their mothers-in-law (40%)(20).
Relationship with friends
Generally infertile women in Oyo state felt that they were not getting psychological support from friends and it was difficult for them to make friends. All they did was ask them if they had a child already, hence causing societal pressure to have a child. Others gave suggestions for divorce. The findings were comparable to the study by Mahadeen who found that the perception of social support from friends was low, with a score of 18.0 (5.2)(13).
Relationship with family
Own families were supportive of these infertile women and mostly advised them to go see a doctor and get help. There was a high perception of perceived social support from family(13). However, this was conflicting with a study by Fatima P in 2015 in which, regarding in-laws and relatives; 57.3% insisted on consulting a good gynaecologist, 29.8% had no family pressure, 11.3% insisted the male partners remarry, and 1.8% insisted the husbands divorce their wives(18).
Theoretical framework and the findings
Grounded theory of identity as infertile
Women in this study were generally stressed and worried about their infertility status that it was the main issue that affected their relationship with other people. Regarding friends, they were unable to make new friends, the few they had were not supportive, they felt uneasy attending social events and they were constantly worried that their partner will leave them someday. This is in support of the hypothesis of the Grounded theory of identity as infertile. According to this theory, women who are distressed by their infertility status assume themselves as infertile as a form of their identity. By so doing they detach themselves from other important positions for example being a friend, partner, or family member. This will eventually lead to social isolation. These identities become less important while the identity as infertile becomes central This theory also hypothesizes that infertile women may even push their career identities to the periphery while infertility takes the central role putting them at risk for social isolation. These study findings, established that women were even questioning why they have to work and get an income since they did not have children to support. This also supports the core hypothesis of the grounded theory.
Conclusion
Infertile women in Oyo state faced several challenges arising from their infertility status, that in turn affect their fertility quality of life.
They faced negative emotions including depression, anger, anxiety, sadness, despair, stress, self-pity, and resentment. However, they were hopeful that one day their prayer/wishes to bear a child (more children) will be answered by God.
In Oyo state infertile women had poor social relationships and their marital relationships were negatively affected.
Recommendations
Psychological support should be offered to infertile women. Counselors and/or psychologists should be stationed at infertility clinics.
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