A survey on depression among infertile women in Ghana

Infertility as defined by WHO and others is the inability of a sexually active non-contraceptive using, non-lactating woman to have a live birth after 12 or more months of regular sexual intercourse [1, 2]. The type and prevalence of infertility varies widely from one country to the other. In Sub-Saharan Africa, secondary infertility is the most prevalent type of infertility [3, 4]. Secondary infertility is defined as the inability of a sexually active non-contraceptive using woman who has previously had a live birth to have a child despite cohabitation and the wish to become pregnant for at least 12 months [2, 5‐7]. The inability to have children is undeniably a very distressing experience in both men and women which can lead to major psychological disorders such as depression. Depression is said to be a major problem associated with infertility especially in Africa where children are highly valued for socio-cultural and economic reasons [6, 8‐10]. Childlessness often creates enormous problems for couples; especially for the women who are generally blamed for the infertility status of couples [11, 12]. Infertility is of particular concern in Africa and Ghana in particular because of the extent of the problem and social stigma attached to it. Motherhood in Ghana is often the only way for women to enhance their status within their family and community. In some communities, the stigma of childlessness is so great that infertile women are socially isolated and neglected [13]. Studies from communities in Egypt [8], Nigeria [14], Mozambique [15] and the Gambia [16] showed that infertile women are often excluded from social events and ceremonies or may even be despised and perceived as inauspicious. Available evidence suggests that the social and psychological consequences of infertility are particularly profound for African women as compared to men [8, 17].

Depression as a psychological consequences of infertility may play a significant role in the life of an infertile person and could subsequently affect the mutual relationship and the quality of life of a couple [18]. In some parts of Africa and elsewhere studies have demonstrated the psycho-social impact of infertility among infertile women [19]. In Ghana however, little is known about the prevalence and extent of depression among infertile women as well as factors that may predispose infertile women to depression. The aim of the present study was to determine the prevalence and severity of depression among Ghanaian infertile women in relation to duration of infertility and other socio-demographic characteristics in a cosmopolitan Ghanaian setting.

This cross-sectional study was conducted from December 2012 to April 2013, involving 100 infertile women who were purposively recruited among patients attending the fertility clinic at the Obstetrics and Gynaecology unit of the Tamale Teaching Hospital in Ghana. After approval by the Ethics committee of the Hospital, informed consent of the respondents was obtained after explaining the purpose of the study to them. In order to be included in the study, respondents should have met the classical definition of infertility defined by the WHO as the inability of a sexual active non-contraceptive using woman to have a live birth after 12 or more months of regular sexual intercourse without a male factor. Women who had male factor infertility were excluded. In this study live birth was used as a measure of proven fertility (Because couples desire children, not simply pregnancies, infertility affects couples regardless of whether the aetiology lies in conception or in the progression of the pregnancy). Primary infertility as used in the present study refers to the inability of a sexually active non-contraceptive using and non-lactating woman to have a live birth after 12 or more months of regular sexual intercourse and secondary infertility refers to situation where a couple who has previously had a live birth but is subsequently unable to have one despite cohabitation and the wish to become pregnant for at least 12 months or more months.

Socio-demographic information including age, duration of infertility, marital status, educational level, type of marriage, number of previous children and religion were obtained from the respondents. The occupation, monthly income, whether the subjects were presenting with primary or secondary infertility were also obtained. Data relating to psychological impact of infertility was obtained using the Beck Depression Inventories (BDI).

The purpose of the present study was to determine the prevalence and severity of depression and its relationship to socio-demographic characteristics among a population of Ghanaian infertile women. In Ghana like other resource poor countries where children are highly valued for cultural, social and economic reasons, childlessness often creates huge problems for couples; especially for the women who are generally blamed for the infertility [14, 22]. The stigma of childlessness is so great in Ghana that infertile women are socially isolated and neglected even by the people who are suppose to support them such as their husbands and extended family. Motherhood is often the only way for women to enhance their status within their family and community. These societal pressures may have some psychosocial impact on the infertile women in our society. To the best of our knowledge however this is the first cross-sectional study that has assessed depression among Ghanaian infertile women using the BDI. The finding of a high depression prevalence of 62.0% among the infertile women in the present study buttresses the psychological challenges that childless women are confronted with. This finding is consistent with the work of Guerra et al. [23] which also found about 67.0% depression among infertile women in China. The prevalence of depression in the present study is however higher than the findings of Ramezanzadeh et al. [19] which showed a prevalence of 40.8% among infertile women in Iran. The high prevalence of depression in the present study could be attributable to the societal and family demand on Ghanaian women to have their own children. In Ghana, children are seen as a form of social security in old age and as a means of perpetuating the family lineage. An additional reason could be due to the fact that this study was conducted in an area dominated by people practising the Islamic faith, where family status especially childbearing is very important and valuable. Here having children stabilizes family and increases marital satisfaction. Childless women therefore stand a risk of disrespectful treatment and stigmatization especially from relatives of the husband and may even lead to a divorce or another wife being brought into the marriage as permitted by Islamic law [19].

The mean depression score was high among women age 26 years and above and tended to be higher as the women advance in age. The mean score of depression however had a negative correlation with educational level as women who attained higher education had lower depression scores. Studies have shown that female fertility is at its peak around the ages of 26-35 years and infertility becomes more pronounced after the age of 35 [24, 25]. The knowledge that their fertility may be declining after this age may put the women under some kind of psychological pressure which could have contributed to this high depression as noted in the present study. In most societies, higher education increases an individual’s chance of securing a well-paid and stable job which may relief the psychological impact of the infertility and this may explain the trend as observed in the present study with respect to mean depression score having a negative relation with educational and employment status. According to Ramezanzadeh et al. [19] housewives may experience more psychological signs of depression and anxiety more than those who work outside of the home. This finding is similar to the work of other researchers who have found a similar trend of depression with age as well as educational status [19, 26].

Duration of infertility had a significant positive correlation with the mean BDI score (r = 0.4736, P = 0.001, 95%CI = 0.216 to 0.667). Women who had infertility duration of 3 years and above showed more depression. Several studies have also reported similar observations in different infertile populations [18, 23, 26, 27]. During the early stages of being diagnosed with infertility the hopefulness of the woman for a successful outcome of medical intervention is higher. However, as the intervention progresses without a success combined with the stress of moving from one hospital to the other, they may become psychologically stress up with fading hopes of conception.

Previous studies have shown that primary infertility is not common in Ghana compare to secondary infertility [22]. This was in conformity with the present study where 62.0% of the women presented with secondary infertility. The type of infertility presented also had a significant influence on the mean depression score among the study subjects with women presenting with primary infertility having more psychological signs of depression. In primary infertility the woman has not been able to have a live birth putting into question her womanhood. This seemingly lost of identity as a woman is enough grounds for divorce in our society and can thus be a solid ground for serious psychological problems as shown in the present study.

In conclusion, the prevalence of depression among the infertile women is high, especially among infertile women age 26 and above, those who are less educated, those with primary infertility, as well as those who have been diagnosed as infertile for more than 3 years. Interventions to decrease and prevent the development of severe depression among these patients should be considered.