Abstract
We surveyed 169 women seeking infertility treatment in Central Tanzania using an abbreviated version of the Fertility Problem Inventory (FPI) to measure infertility-related stress. We compared our FPI results to similar studies in another high fertility country (Ghana) and in three low fertility countries (the US, Canada, and Italy).
Tanzanian women reported higher infertility-related stress than women in low-fertility countries but lower stress than Ghanaian women. Infertility-related stress is a serious concern for women in high-fertility countries, who experience greater pressure to have children. These findings underscore the need for increased access to infertility treatment and addressing community infertility norms.
Keywords: Infertility, stigma, sub-Saharan Africa, Fertility Problem Inventory
Introduction
Infertility affects 9-15% of couples worldwide, with the majority of cases occurring in low and middle income countries (LMIC) (1,2). Infertility in high fertility countries where childbirth is highly valued disproportionately affects women (2,3). Women facing infertility in these countries may experience psychological stress, social isolation, financial and resource deprivation, and identity crises(3). However, few cross-country comparisons of infertility stress exist, and only one study to date in sub-Saharan Africa applied a validated measure of infertility-related stress, the Fertility Problem Inventory (FPI) in Ghana (3).
To assess infertility-related stress, we surveyed 169 women seeking infertility treatment at a hospital in Central Tanzania from January to March 2020 using the FPI and compared our results to women studied in other contexts.
Methods
The FPI measures infertility-related stress across several domains (4). This widely-validated 46-item questionnaire is composed of statements with responses scored using a Likert Scale that ranges from strongly agree (6) to strongly disagree (1)(3,5). Item scores are summed for a global measure of infertility stress (range: 46-276).
An abbreviated FPI (18 items) was administered to women enrolled in a cross-sectional study of infertility risk factors and barriers to infertility treatment. The number of questions was reduced to avoid patient fatigue, and the average score for each domain was scaled to be comparable to the original 46-item questionnaire using a multiplier for the number of questions in each domain (4). Institutional Review Board approval was granted by the University of Minnesota and Tanzania’s National Institute for Medical Research. Patients or the public were not involved in study design, conduct, reporting, or dissemination plans.
Results
Tanzanian women reported the highest infertility-related stress in the Need for parenthood domain (FPI=45.09, SD=12.82), which describes being a parent as a primary/essential life goal. Social concern (FPI=34.81, SD=13.51) and Relationship Concern (FPI=31.33, SD=9.53) were also highly ranked in the Tanzanian group. These domains capture sensitivity to comments about infertility and feelings of isolation from family or peers. In an open-ended question, 5% of the women in the Tanzanian study recommended counseling family about infertility, including asking husbands not to leave their wives if they struggle with infertility. This finding was unique to our study.
We compared our results to recent studies reporting FPI scores for women seeking infertility treatment in low-fertility countries (United States and Italy), a study reporting FPI use in another high-fertility country (Ghana), and the study validating the FPI in Canada (1,3-5). All studies had large sample sizes (n>100), and study participants were similar ages (mean age 32-34). FPI results from different countries are presented in Figure 1. Women in Tanzania experienced higher global levels of infertility-related stress (mean FPI=158.57, SD=36.29) than women in the United States (mean FPI=127.67, SD=33.26) and Canada (mean FPI=134.4, SD=33.8) but lower levels than women in Ghana (mean FPI=172.5, SD=34.2) (3-5). We did not include the Italian study in our comparison of global infertility-related stress because authors did not include the sexual concern domain, which reduced the overall global score (1). Women in Tanzania had higher infertility-related stress scores in all domains compared to women in low-fertility countries, except for the sexual concern domain.
Figure 1.
A: FPI - Global Stress Scores* Across Countries; B: FPI Domains Across Countries.
*Global Stress is the sum of all FPI domain scores and may range from 46 to 247. Error bars indicate standard deviation of mean FPI. Global Scores not provided for Italy study.
**Results were only presented by the US study in disaggregated form by women’s infertility type, diminished ovarian reserve (DOR) and anatomical cause of infertility (ACI)]
Discussion While infertility causes psychosocial stress in all contexts, our study shows that women in high fertility settings like Tanzania are uniquely affected by infertility. Although the abbreviated survey administered in Tanzania may not completely capture dimensions in the full survey, clear trends emerged across domains. Variations noted above reflect differences in context and women’s characteristics. Social status and power possessed by women with higher education levels may reduce the impact of fertility-related stigma. About 49% of Tanzanian women surveyed had a tertiary level education or higher, compared to 10% of the women in Ghana (3). However, even in a more highly educated population in Tanzania, women experienced greater levels of domain-specific and global infertility stress compared to women in low-fertility countries. Because of infertility’s serious impact on women’s lives, increased access to infertility treatment, counseling for women and their families, and community education to raise awareness of infertility and address infertility norms are needed.
Highlights.
Infertility-related stress among women is higher in high-fertility countries
Fertility Problem Index domains of infertility-related stress differ by country
Need to address community norms around infertility and increase access to treatment
Acknowledgements:
The authors thank the participants and the staff at the Dodoma Christian Medical Center for their participation in the study.
Funding:
This work was supported by internal funding from the University of Minnesota’s Consortium on Law and Values, the Graduate School, and the School of Public Health. Additional salary support was provided by the Minnesota Population Center grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (P2CHD041023) and the National Institutes of Health’s National Center for Advancing Translational Sciences (TL1R002493 and UL1TR002494).
Footnotes
Competing Interests: None to declare.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
References
- 1.Zurlo MC, Cattaneo Della Volta MF, Vallone F. Factor structure and psychometric properties of the Fertility Problem Inventory–Short Form. Heal Psychol Open [Internet]. 2017. July 20;4(2):205510291773865. Available from: http://journals.sagepub.com/doi/10.1177/2055102917738657 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ombelet W, Cooke I, Dyer S, Serour G, Devroey P. Infertility and the provision of infertility medical services in developing countries. Hum Reprod Update [Internet]. 2008. September 29;14(6):605–21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569858/pdf/dmn042.pdf [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Donkor ES, Sandall J. The impact of perceived stigma and mediating social factors on infertility-related stress among women seeking infertility treatment in Southern Ghana. Soc Sci Med [Internet]. 2007. October 1 [cited 2018 Oct 26];65(8):1683–94. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0277953607003395 [DOI] [PubMed] [Google Scholar]
- 4.Newton CR, Sherrard W, Glavac IW. The Fertility Problem Inventory: measuring perceived infertility-related stress. Fertil Steril [Internet]. 1999;72(l):54–62. Available from: https://www.fertstert.org/article/S0015-0282(99)00164-8/pdf [DOI] [PubMed] [Google Scholar]
- 5.Nicoloro-SantaBarbara JM, Lobel M, Bocca S, Stelling JR, Pastore LM. Psychological and emotional concomitants of infertility diagnosis in women with diminished ovarian reserve or anatomical cause of infertility. Fertil Steril [Internet]. 2017; 108(1): 161–7. Available from: 10.1016/j.fertnstert.2017.05.008 [DOI] [PubMed] [Google Scholar]