Infertility is a reproductive health disorder and a global public health problem that affects men, women and couples, regardless of their national, ethnic, racial, religious, social and national belonging.1 There are several definitions of infertility2 as a result of many studies from different disciplinary backgrounds (clinical/medical, demographic, anthropology/sociology), making it challenging for scholars to agree on a single measurement approach.1-3 This situation is further complicated as the term “infertility” is used synonymously with sterility, infecundity and childlessness in the literature.4 The World Health Organization (WHO) acknowledges the problem of multiple definitions of infertility and the need for revision.5 From a clinical/medical perspective, infertility is the inability to achieve conception after at least 12 months of unprotected intercourse.5 However, this medical definition is limited, given that infertility also has a socio-cultural construction which can mean different things to couples and individuals within specific cultural communities.6 A female can be considered infertile from a medical perspective although she does not think of herself as such. From a socio-cultural dimension, infertility includes whatever hinders a woman from attaining her reproductive goals.6 For the purpose of this review, we will consider the clinical and socio-cultural dimensions of infertility.
Globally, it has been established that about 186 million people experience infertility, with an average rate of between eight and 12%, while in Africa, some studies suggest the burden to be about 30–40%.7-8 Africa is now considered by some demographers as the “infertility belt” because of the prevalence of this condition experienced within the continent.7 There are several factors associated with the cause of infertility, with national and regional variations, and these are commonly grouped into two main categories. The first relates to anatomical, genetic, endocrinological and immunological problems, while the second includes a number of preventive problems such as reproductive tract infections (like sexually transmitted infections), risky healthcare practices and exposure to toxic substances, either in the diet or environment.9 In sub-Saharan Africa, infection-related tube damage is the most common cause of infertility.10 Besides the two main categories, socio-cultural factors also have important contributions to the cause of infertility in Africa.11
The WHO has classified infertility into two sub-categories: primary and secondary. The former is the inability of a women who has never had a child to achieve a pregnancy after more than one year of unprotected intercourse, while the latter is the failure to bear a child, which can be a result of being unable to become pregnant or carry a pregnancy to live birth after having a child.12 Both categories of infertility affect couples and women in Africa.13 A study based on survey data from 28 African countries found that while primary infertility was more than 3% in less than a third of the 28 countries, secondary infertility was more than 5% for women aged 20–40 years old.13
Infertility can be prevented depending on the type of factors responsible for its cause. In cases where the leading causes are linked to infection, measures can be taken to reduce the prevalence of sexually transmitted diseases (STDs) like chlamydia and gonorrhea, and other reproductive tract infections.9 Pelvic inflammatory diseases can also be prevented through education and counselling.9 Postpartum infection can be reduced by encouraging safer birth practices, training and educating births attendants on good hygiene practices and immediate referral of complicated cases. Promoting family planning and use of contraceptives can reduce post-abortion infections.9,11
Several methods are being used to manage infertility which can be summarized under three main categories: chemotherapy-related treatment, surgery and assistive reproductive treatment (ART).9 The chemotherapy-related treatment includes drugs such as clomiphene citrate to induce ovulation. Other treatment methods include intra-uterine insemination, controlled stimulation, monitoring of cycles and timing of intercourse to different cervical secretions.7,9,14 Surgery is recommended as a treatment method, depending on the severity of the damage.9 In relation to ARTs, invitro fertilization (IVF) is one of the treatments commonly used to address the problem of infertility, especially in high income economies. However, the cost of ARTs remains high and inaccessible to many couples suffering from infertility in Africa.14 Despite the existence of various methods to manage infertility, it has still been very challenging to patients in terms of affordability, availability and treatment failures.15 Faced with these challenges, some couples and individuals also attempt traditional treatment and healing from Christian churches.16
Infertility is an economic, psychological and socio-cultural burden on women who suffer from this disorder. Economically considered, the cost of treatment is high and many women have to self-fund due to their husband/partner's inadequate income. In countries like Cameroon, Nigeria, Botswana, Gambia, Mozambique and Rwanda, infertile women are very often divorced, leaving them without any access to residence, inheritance, economic security and domestic support.17 From the psychological perspective, women experiencing infertility commonly suffer from depression, stress, trauma anxiety and aggression.18 In regards to socio-cultural consequences, infertile women are stigmatized, abandoned, cheated, insulted, maltreated, vandalized and humiliated.6,14,19-21 Because of the way infertility has been culturally constructed and perceived in many African societies, women suffer the most when there is a fertility problem between couples, even if it has been medically proven that her husband/partner is the cause.8-9,14,19-21
The psychological, socio-cultural and economic torment that infertile women experience in Africa are unjustified and indicate that infertility is more than a clinical problem. As many women still do not have access to infertility treatment and care facilities, coupled with concerns about limited successful treatment rates, living with this disorder becomes a huge burden.15 Consequently, there is need for policy makers and clinicians to be aware of the experiences of women living with infertility (WLWI) in order to design and implement effective interventions. Furthermore, this awareness could be enhanced if the required and available evidence is synthesized.
A preliminary search for qualitative systematic reviews on our current review topic was undertaken. The JBI Database of Systematic Reviews and Implementation Reports (JBISRIR), the Cochrane Library, and the databases CINAHL, PubMed and PROSPERO were searched and no systematic review directly on the experiences of WLWI in Africa was found. However, we identified five reviews, with four of them related to this topic and one entirely different to our current review. The four reviews differed in their objective and methodology to our proposed review topic. The areas of interest were: the limitation of infertility treatment,15 the experience of infertility,20 infertility as a woman's issue in Africa21 and biomedical infertility care in Africa.22 Although one of the reviews focused on the experience of infertility,20 the author's concern was to assess current literature on infertility to determine if the social construction of infertility has been given sufficient attention. This follows a critique of the dominant biomedical model in infertility literature for more than two decades. The other three reviews explored aspects of infertility related to women and treatment with superficial data.15,21-22 Furthermore, they all combined African and Western cases, and concentrated only on biomedical aspects of treatment. In addition, all the four reviews were literature reviews, without a detailed search methodology, which means their findings may not be void of bias. The last review4 dwelled on the epidemiological aspects of infertility which had very little to do with the experiences of WLWI. Overall, none of the reviews substantially addressed the experiences of WLWI in Africa using a clearly defined and detailed systematic review methodology. It is based on these epistemological and methodological lapses that we think synthesized evidence on the experiences of infertile women in Africa from a holistic perspective is lacking, despite the existence of primary research studies.16,19,23-29
The absence of holistic, qualitative synthesized evidence on the experiences of infertile women in Africa can impede the implementation of interventions aimed at the effective management of infertility. When policymakers and clinicians are not aware of what infertile women experience regarding the causes, treatment and their social relations in Africa, decision-making and actions will likely ignore the predicament of these women in their daily lives. Clinicians are often more interested in the medical components of the infertility patient, which end up limiting interventions to provider-based healthcare services.25 This clinical-focused intervention model for a complex socio-medical phenomenon like infertility does not do sufficient justice to the suffering of these women who cannot escape the wrath of society with their current conditions. It is based on the relevance of this review topic and the problems it seeks to address that we are proposing this systematic review.
This review will investigate the experiences of living with infertility (primary and secondary) in Africa. Participants involved will be women with infertility who have been medically diagnosed as living with this condition. The age will be between 20 and 49 years as most studies have considered this age group.30 Empirical studies that focus on the lived experience of women (both positive and negative) as a result of their inability to bear a child or have children will be considered. Particular attention will be given to studies that address the causes and treatment of female infertility, and its consequences on social relationships. The aim of this review is to synthesize the best available evidence on the experiences of WLWI in Africa.
This review will consider studies with a focus on infertile women (20–49 years), regardless of their marital status, who reside in any part of the African continent. Therefore, infertile men residing in Africa, as well as infertile women residing outside of Africa will be excluded from this review. Additionally, fertile men and women will be excluded from this review.
Phenomena of interest
The focus of this review will be the experiences of WLWI, with a particular attention on the causes and treatment of infertility, and how this reproductive health disorder shapes social relationships.
Qualitative studies conducted in health facilities (hospitals and health centers) and community settings within the African context.
Types of studies
This review will consider any qualitative study (e.g. phenomenology, ethnography, narrative analysis, ethnomethodology, phenomenography, critical interpretive research, grounded theory or feminist analysis) that investigates the experiences of WLWI. Only studies published in English will be considered for this review as we are currently unable to translate studies published in other languages. There will be no lower and upper date limit for this review as infertility is a problem that has existed in Africa for more than a century.31
The methodology that will guide the presentation, conduct and synthesis of this qualitative systematic review will be the Joanna Briggs Institute (JBI) approach to the conduct of qualitative systematic reviews found in the JBI Reviewer's Manual.32 The JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) tool will be used at various stages in the review production process as required and necessary.
The search strategy will locate both published and unpublished studies, and will comprise three steps. It will begin with a search in MEDLINE and CINAHL, followed by an analysis of text words contained in the title and abstract, and of indexed terms used to describe the articles. A second search using all the identified key words and index terms will be undertaken across all included databases. Finally, the reference list of all identified studies and reports will be searched for additional studies.
Databases to be searched for published studies will include: PubMed, CINAHL, Embase, PsycINFO, Sociological abstracts, BioMed Central and Current Contents. Unpublished studies will be searched from MedNar, Science Direct, Wiley Online Library, Web of Science, Index to Thesis, ProQuest Dissertations and Theses, WHO and Government Reports. The search strategy for one of the databases is found in Appendix I.
At the end of the search, all identified citations will be collated and uploaded into a reference management system and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that meet or could potentially meet the inclusion criteria will be retrieved in full and their details imported into JBI SUMARI. The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Where full text studies are identified but inaccessible, the corresponding author will be contacted through email to request a copy. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Assessment of methodological quality
Qualitative papers selected for critical appraisal will be assessed by two independent reviewers for methodological validity using the JBI SUMARI standardized critical appraisal tool for qualitative evidence.32 Any disagreements about the inclusion of a study will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data for clarification, where required. The results of critical appraisal will be reported in narrative form and in a table.
Data will be extracted from included studies using the standardized JBI data extraction tool for qualitative evidence in JBI SUMARI.32 The extraction will be completed by two independent reviewers on a word document, after which the two reviewers will meet to compare the extracted data prior to entry into the JBI SUMARI data extraction form. This is to ensure consistency during the extraction process and also to avoid losing data in the case of an interruption in electricity supply.
Data to be extracted will include specific details about the geographical location, setting, phenomena of interest, culture, population, methodology, method of data analysis used in primary study and the author's conclusion. Each finding will be extracted verbatim and accompanied by an illustration that informs the findings. A level of credibility will be allocated to each finding. Findings will either be described as unequivocal (findings and accompanying illustrations that are beyond reasonable doubt) or credible (findings whose accompanying illustrations lack a clear association) as recommended in the JBI Reviewer's Manual.32 Furthermore, all unsupported findings (findings not backed by an illustration) will be extracted and not included in the review. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of primary studies will be contacted for clarification or missing information, if necessary.
After extraction, qualitative research findings will, where possible, be pooled using JBI SUMARI.32 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning.32 These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice and policy. Where textual pooling is not possible the findings will be presented in narrative form.
Assessing certainty in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.33 The Summary of Findings will include the major elements of the review and detail how the ConQual score is developed. Included in the table will be the title, population, phenomena of interest and context for the specific review.33 Each synthesized finding from the review will be presented along with the type of research informing it, a score for dependability and credibility, and the overall ConQual score.
Appendix I: Search strategy for MEDLINE
1. Gurunath S, Pandian Z, Anderson RA, Bhattacharya S. Defining infertility. a systematic review of prevalence studies. Hum Reprod Update
2011; 17 5:575–588.
2. Larsen U. Research on Infertility: which definition should we use? Fertil Steril
2005; 83 4:847–852.
3. Mascarenhas MN, Cheung H, Mathers CD, Stevens GA. Measuring infertility in populations: constructing a standard definition for use with demographic and reproductive health surveys. Popul Heath Met
2012; 17 10:1–11.
4. Belsey MA. The epidemiology of infertility: a review with particular reference to sub-Saharan Africa
. Bull World Health Organ
5. WHO. Multiple definition of infertility [internet.]. Geneva: World Health Organization; 2016.
6. Greil A, MaQuillan J, Slauson-Blevins K. The social construction of infertility. Socio Comp
2011; 5 8:736–746.
7. Inhorn MC, Patrizio P. Infertility around the globe: new thinking on gender, reproductive technologies, and global movements in the 21st century. Hum Reprod Update
2015; 21 4:411–426.
8. Dyer SJ, Abrahams N, Hoffman M, Vanderspy ZN. Infertility in South Africa
: women's reproductive health knowledge and treatment seeking behavior for involuntary childlessness. Hum Reprod
2002; 17 6: 1657–1652.
9. Sharma S, Mittal S, Aggarwal P. Management
of infertility in low resource countries. Int J Obstet Gynecol
2009; 116 1:77–83.
10. Healy DL, Trounson AO, Andersen AN. Female infertility: causes
and treatment. The Lancet
11. Program for Appropriate Technology in Health (PATH). Infertility in developing countries. Outlook
1997; 15 3:1–9.
12. WHO. Infertility definitions and terminology. [internet.]. Geneva: World Health Organization; 2016.
13. Larsen U. Primary and secondary infertility in sub-Saharan Africa
. Int J Epide
14. Inhorn MC. Right to assistive reproductive technology: overcoming infertility in low resource countries. Int J Obstet Gynecol
15. Peddie VL, Porter M. Limitations of infertility treatment: psychological, social and cultural. Therapy
2007; 4 3:313–322.
16. Okonofua FE, Harris D, Odebiyi A, Kane T, Snow RC. The social meaning of infertility in South West Nigeria. Health Trans Rev
17. Dyer SJ, Patel M. The economic impact of infertility on women in developing countries: a literature review. Int J Obstet Gynecol
2012; 4 2:102–109.
18. Sultan S, Tahir A. Psychological consequences of infertility. Hellenic J Psych
19. Kimani V, Olenja J. Infertility: cultural dimensions and impact on women in selected communities in Kenya. The Afri Anthropo
2001; 8 2:200–214.
20. Greil AL, Slauson-Blevins K, McQuillan J. The experience of infertility: a review of recent literature. Socio Health Illn
2010; 32 1:140–162.
21. Chimbatata NBW, Malimba C. Infertility in sub-Saharan Africa
: A woman's issue for how long? A qualitative review of literature. Open J Socio Scie
22. Gerrits T, Shaw M. Biomedical infertility care in sub-Saharan Africa
: a social science review of current practices, experiences
and viewpoints. Int J Obstet Gynecol
2010; 2 3:194–207.
23. Fledderjohann JJ. “Zero is no good for me”: Implications of infertility in Ghana. Hum Reprod
2012; 27 5:1383–1390.
24. Umeora O, Igberase G, Okogbenin S, Obu I. Cultural misconceptions and emotional burden of infertility in South East Nigeria. The Inter J of Gynecol and Obstet
2001; 10 2:1–7.
25. Sundby J. Infertility in the Gambia: Traditional and modern health care. Pat Educ and Counsel
26. Tabong PT, Adongo PB. Understanding the social meaning of infertility and childbearing: A qualitative study of the perception of childbearing and childlessness in Northern Ghana. PLoS Med
2013; 8 1:
27. Ernestina S, Donkor ES, Sandall J. Coping strategies of women seeking Infertility treatment in Southern Ghana. Afri J of Reprod Health
2009; 13 4:81–93.
28. Gerrits T. Social and cultural aspects of infertility in Mozambique. Pat Educ and counsel
29. Koster-Oyekan W. Infertility among Yoruba women: Perceptions on causes
, treatment and consequences. Afri J of Reprod Health
1999; 3 1:13–26.
30. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global Trends in infertility prevalence since 1990: A systematic analysis of 277 health surveys. PLoS Med
2012; 9 12:e10001356.
31. Lesthaeghe R. The fertility transition in sub-Saharan Africa
into the 21st
Century. Research report; Population Studies Centre, University of Michigan, Institute of Social Research 2014; 14–823.
32. The Joanna Briggs Institute, Lockwood C, Porrit K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M. Aromataris E, Munn Z, et al. Chapter 2: Systematic reviews of qualitative evidence. Joanna Briggs Institute Reviewer's Manual
2017; Available from https://reviewersmanual.joannabriggs.org/
. [cited 2017, August 13].
33. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC