Abstract

Introduction: In African contexts, infertility is frequently interpreted through external explanations, with couples often seeking to externalize the origin of the problem in order to alleviate the narcissistic distress it causes. From a biomedical perspective, infertility is defined as the inability to conceive after at least one year of regular unprotected sexual intercourse. According to the World Health Organization (WHO), it affects approximately 80 million people worldwide, representing nearly 10% of couples. The objective of our study was to identify the socio-cultural representations of infertility observed among women in relationships. Materials and Methods: This is a prospective, cross-sectional and descriptive study carried out over the period from October 11, 2021 to October 17, 2022 at the maternity ward of the National Hospital Center “Dalal Jamm” in Dakar. Women in a relationship for one year who were consulted for pregnancy and those followed for infertility were included. Data was collected by direct interview, with the KOBO application, processed and analyzed using Excel and SPSS software. Results: Out of a total of 100 women surveyed, the average age was 34 years. The 30 - 37-year-old age group was the most represented (37%). The secondary education level was the most represented (31%). The liberal profession was 37%, Muslim women 95% and those in their first marriage 85%. Women had been cohabiting with their partner for more than 5 years in 54% of cases. Primary infertility was 61%. Thirty-six patients (36%) consulted after one year of waiting. Regarding the explanation given for infertility, seventy-one patients (71%) knew the responsibility for their infertility. According to them, it was linked to the woman in 51% of cases rather than being due to divine will (65%). The child represents a blessing, or one who will ensure the perpetuity of the family (69%) and motherhood offers the status of being a “real woman” (37%). Forty-seven patients (47%) had consulted a traditional practitioner. The explanation most often found among traditional practitioners was “possession by an evil demon” (68.1%). The treatment most prescribed by traditional practitioners was bath water (25%). The type of help expressed by the patients was medical (68%), financial (37%) and spiritual (23%). Conclusion: The treatment of infertility in African societies where traditional beliefs still occupy an important place, the caregivers must consider the different socio-cultural representations of the disease. Psychoeducation of patients must be at the heart of care to help not only raise awareness about the phenomenon but also to reduce waiting times for gynecological consultations and dropouts from follow-up.

Keywords

Couple Infertility, Woman, Senegal, Socio-Cultural Representations

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1. Introduction

In Africa, the couple in need of a child (especially the partner) tries to locate the origin of the problem externally with the aim of alleviating the narcissistic wound relating to their infertility [1]. Infertility is defined as the absence of spontaneous pregnancy after at least one year of regular sexual intercourse without any form of contraception [2]. The WHO estimates that infertility affects 80 million people in the world, or one in ten couples [3]. Beyond its biomedical dimension, infertility also represents an experience deeply marked by psychological, social and cultural issues, particularly in societies where procreation occupies a central place in the construction of individual and marital identity. The objective of our study was to identify the socio-cultural representations of infertility observed among Senegalese women in relationships.

2. Materials and Methods

This was a prospective, cross-sectional and descriptive study carried out over a period of one year from October 11, 2021 to October 17, 2022 at the gynecology-obstetrics department of the National Hospital Center “Dalal Jamm” in Dakar. We included all women who had been in a relationship for at least a year and who had consulted the service for the desire to become pregnant and those affected and fully followed for couple infertility who had agreed to participate in the study. The data were collected by direct interview based on a questionnaire considering all the variables studied. The data collected was entered into the KOBO collection application, then processed and analyzed using Excel and SPSS software and the results are presented in proportion form. The respondents’ participation was based on their free and informed consent. Before the questions were asked, they were informed of the study’s objectives, their participation, and the respect for anonymity and the confidentiality of the information that would be collected. For our study, an authorization request was sent to the authorities of the National Hospital Center “Dalal Jamm” who gave their approval following the opinion of the bioethics committee.

3. Results

3.1. Sociodemographic Aspects

In our study, we interviewed 100 women. The average age of the patients was 34 years, with extreme ages of 18 and 47 years. The most represented age group was 30 - 37 years old (Table 1).

Table 1. Distribution of patients according to their age group.

Most of our patients, i.e. 82%, were educated, most often up to secondary school (Table 2).

Table 2. Distribution of patients according to their level of study.

Thirty-seven patients (37%) practiced a liberal profession, and thirty-one patients (31%) were unemployed (Table 3).

Table 3. Distribution of patients according to their profession.

Ninety-five patients (95%) were Muslim, and five (5%) were Christian. Most patients were in their first marriage (85%), the rest (15%) had already experienced a divorce in their history. The reason for divorce was related to infertility in 27% of cases.

Forty-six patients (46%) had cohabited with their partner for less than 5 years and seven patients (7%) had cohabited for more than 15 years (Figure 1).

Figure 1. Distribution of patients according to the number of years of cohabitation with the spouse (N = 100).

Sixty-one patients (61%) had never had a pregnancy.

Thirty-six patients (36%) consulted after one year of waiting (Table 4).

Table 4. Distribution of patients according to waiting time before consulting a gynecologist.

3.2. Social Representations

Among the one hundred patients interviewed, seventy-one patients (71%) knew the responsibility for their infertility (Origin of couple infertility). According to them, the responsibility was linked to the woman in 51% of cases (Figure 2).

Figure 2. Distribution of responsibility for infertility (N = 71).

Sixty-nine patients (69%) said that giving birth is a blessing, that it is the child who ensures the perpetuity of the family. Fifty-nine patients (59%) said that the child consolidates the couple and gives security to the parents by ensuring their survival. Other patients (24%) reported diverse and varied opinions, for example: “the child is the one who will pray for them after their death”, “he is the woman’s wealth”, “he is the one who encourages you to stay at your home” (Table 5).

Table 5. Social representations of childbirth (N = 100).

Twenty patients (20%) said that being a mother means being worthy near your husband, 37 patients (37%) said that it proves that they are real, complete women.

Most of the other responses on the advantage of motherhood were diverse and varied; we find terms like responsibility, privilege, joy, luck, happiness, and blessing (Table 6).

Table 6. Social representations of motherhood (N = 100).

Most patients (65%) thought their infertility was due to divine will, eighteen patients (18%) thought it was linked to a disease they carried, and two patients (2%) had no explanation (Table 7).

Table 7. Explanations of infertility according to the woman (N = 100).

Forty-seven patients (47%) had consulted a marabout or traditional healer. The explanations most often found were “possession by an evil demon” (68.1%) or “black magic” (34%) (Table 8).

The most prescribed treatment was bath water (25%) and amulets (24%) (Figure 3).

The type of help most often expressed was medical help in 68% of cases, followed by financial aid (37%) (Table 9).

Table 8. Explanations of infertility according to traditional practitioners (N = 47).

Figure 3. Distribution of patients according to treatments prescribed by the traditional practitioner (N = 47).

Table 9. Distribution of patients according to the type of help desired (N = 100).

4. Discussion

4.1. Sociodemographic Aspects

In our study, we found an average age of 34 years with extremes of 18 and 47 years. The most represented age group was 30 - 37 years old, i.e. 37%. These results are close to those obtained by many Senegalese authors, notably Diop, Dia, Dieng, and Faye [4]-[7]. Diop in 2013, in his study on the hysterosalpingography profile of female infertility at the Pikine CHN, found an average age of 32 years with extremes of 17 and 47 years, an age range of 35 - 47 more represented.

Dia in 2018 in his study on medically assisted procreation: IVF-Senegal activity report from 2007-2017, noted an average age of 34.13 years and a more representative age range of 30 - 34 years.

Dieng, in his 2019 study on the psychometric evaluation of stress linked to infertility in a sample of patients in Dakar, found an average age of 31.48 years; the most represented age group was that of 25 - 35 years.

Faye, in her 2019 study on the contribution of 2D ultrasound in the exploration of female infertility at the Pikine CHN, obtained an average age of 31.7 years with an age range of 30 - 39 years more represented.

As elsewhere in Africa, these results are not far from certain Congolese authors, Ghanaian and Cameroonian [8]-[12].

In Cameroon, Priso E. et al. found in 2015 the average age of patients to be 34 years ±13.4 with extremes of 18 - 49 years and a more representative age range of 29 - 34 years.

The Congolese Bruce Wembulua Shinga, in his study carried out in 2012, obtained an average age of 31.1 years.

In Ghana, a study carried out by Alhassan A et al. in 2014, on depression associated with infertility in women, found an average age of 30.5 years with a more represented age group of 20 - 30 years (48%) followed by that of 31 - 35 years (32%).

In Cameroon, Nana in 2011 found an average age of 30.76 years ± 6.68. This is similar to the result of his fellow citizen Ella in 2017 who found an average age of 32.42 years ± 5.47.

Concerning the relationship between age and fertility, fertility is highest between 20 and 25 years [13]. It decreases with the age of the woman [14]. The chances of one pregnancy occurring per cycle are 30% at age 25, 20% at age 35, and 1% - 2% at age 45 [15]. So, the chances of pregnancy are very low beyond the age of 40, even for IVF [16]. Our data show that the age at which women are having children is rising. The reasons could be explained by the desire to have a career, the reluctance of business leaders to employ a pregnant woman, the advance of contraception or even prolonged studies.

These constraints should lead us to think about creating financial or material measures to support any pregnant woman who wants a long professional career, and to make creches available in different workplaces.

The most represented level of study was secondary, i.e. 31%, followed by higher and primary level in equal proportions, i.e. 28%. The percentage of women having reached the higher level is comparable to that obtained by Dieng [6], i.e. 27.9%. In his study, we noted a high proportion of women who were not in school, i.e. 39.6%. A study carried out in Germany showed a significant proportion of patients having reached the higher level, i.e. 26.8% [17]. Ngo Um Meka et al. [18] in Cameroon in 2016 obtained 65% of women with higher education.

This is how we can agree on the fact that studies play a significant role in slowing down procreation among women. This is what these results from different authors that could show.

Even if it is a big idea, we can suggest that the creation of creches within universities and higher education centers could be a good support measure. Raising awareness among women wishing to pursue long studies could also be a good one. Because we most often see among women a fear of combining study and procreation.

In our series, the liberal profession was the most represented, i.e. 37%, followed by those without professions with a percentage of 31%. These results were similar to those obtained by Faye [7], in which 48.4% were housewives. Ngo Um Meka et al. [18] also obtained a high proportion of employed women (76%). The profession of our patients allows us to have an idea of their income in order to understand certain aspects (assessment not done or delayed, abandonment of follow-up). The financial profile of our women raises the issue of financial accessibility of reproductive health care. Certainly, our study is not interested in the cost of care, but we have encountered a number of cases whose assessment is not carried out in time due to a lack of resources; hence, the need to subsidize these examinations or promote income-generating activities for women in order to facilitate access to infertility care.

In our study, the patients were predominantly Muslim, i.e. 95%. These results could be explained by the fact that Islam is the predominant religion in Senegal [19]. We can say that there is no religious particularity in infertility: “Infertility has no religion.”

In our series, 46% of patients had cohabited with their partner for less than 5 years, 85% of patients were in their first marriage. Infertility was the reason for divorce in 27% of cases.

Kougbeagbédé [20] made the same observation in his study on the psychological experience of female infertility within couples at Saint Luc hospital in Cotonou, where 23.44% of women received suggestions for separation. Numerous studies have shown that in Africa, infertility is a common cause of divorce [21]-[23].

We should then review the primary objective of marriage, especially in Africa. Instead of the primacy of the child over everything, we should certainly advocate reciprocal love, the stability of the couple and cultivate respect towards each other.

The Demographic and Health Surveys conducted in Senegal and published in 2012 estimate that primary infertility in Senegal is not very high and concerns 2.5% of women in union [3]. Many authors have made the same observation [24]. This was not the case in our study where primary infertility was found in 61% of cases. Like Faye [7] who obtained 57.4%, Hind I. [25] in his study carried out in 2017 obtained 72% for primary infertility in Touba, 54.10% in Diourbel and 51% in Ndioum (Podor department, Saint-Louis region). Dieng [6] had found 75.7%. Diop [4] in 2013 found 59% primary infertility and 41% secondary infertility. J.M. Afoutou et al. [26] in their study on the place of the direct post-coital Hühner test in the assessment of marital sterility in the African environment in Senegal in relation to 2593 cases, found that primary infertility was more than twice as high as secondary infertility.

The large number of cases of primary infertility could be explained by such a high rate of educated women in our sample. This means that most educated women are aware of the time limit for talking about infertility, but also of the use of modern medicine to deal with it.

4.2. Socio-Cultural Representations

Regarding the social representation around the child, we had 69% of women who think that the child is a blessing and that it ensures the perpetuity of the family; 59% think that the child consolidates the couple and gives security to the parents by ensuring their survival.

These results are close to those of Kougbeagbédé [20] where for 34.38% of women the child represented happiness, for 29.69% the child had a social value and for 15.63% the child was the one who improves the image of the family. According to Traoré et al., the birth of a child in Africa is a source of joy and helps maintain a certain harmony in the household [27]. The child represents the descendants of the family, and according to Fonteneau et al. [28], his absence causes great trauma. These results demonstrate the central place of procreation in marriage and in African society in general.

Concerning the advantage of maternity, we see that this question has generated a lot of reactions from patients. In Africa, being a woman and being a mother do not give the same advantages. According to F. Heritier, echoed by Brochard [21], in the Samo society of Cameroon in the 1970s, infertile women were refused the status of women and were buried when they died in the children’s cemetery.

In our study, we found that for 37 women, “being a mother” means “being a real woman”. For 20 women, it is “being worthy of your husband”. These results show the importance for these women of being mothers and confirm the central position of procreation in marriage. According to certain authors such as Mbow and Touré, motherhood will allow women to be more respected in their home, to regain their self-esteem, because for them it will always remain a debt that they owe to their in-laws and to society [23].

This leads us to conclude that the way African societies generally interpret the concept of femininity is inextricably linked to women’s procreation. The role of changing mentality should then be carried out by intellectuals in general and health specialists.

We had 97 patients who believe that their infertility is not linked to an experienced event. Here, we are referring to certain types of infertility linked to the unconscious blocking of the woman and her fertility for fear of reliving a traumatic event experienced. As developed by certain authors such as S. Freud in his work “New conferences on psychoanalysis” [29].

When it comes to women’s explanation for their infertility, the majority (65%) believe it is divine will. We noted a few who think that it is a supernatural cause: black magic (4%), demonic possession (6%). Supernatural causes are often cited in Africa as the cause of infertility [27]. Nana [11] had 36.9% of women equating their infertility with witchcraft and 25% with a curse. In the study by Ngo Um Meka et al. [18], 84% of women considered infertility to be a spell and 79% to a curse.

This leads us to think that Africans have difficulty converging their thinking towards scientific knowledge of this disease. This problem will only be solved if we can understand the causal relationship of the disease; that is to say if an illness occurs, this is because there is a medically explainable and treatable cause.

In our series, 47 patients (47%) had consulted a traditional practitioner. This is explained by the fact that in Africa, infertility sometimes finds its explanation in the supernatural. These are beliefs that are still present in the minds of the population. In fact, some women believe they are possessed by an evil demon that can only be treated by traditional healers. In our study, we had 32 women (68.1%) for whom traditional practitioners equated their infertility to possession by an evil demon and 16 women (34%) to witchcraft. Just like Nana [11] in Cameroon who found 25% cases of curses and 36.9% witchcraft. The in-laws are often accused, especially if the union does not please certain members of the family.

The frequentation of women among traditional practitioners could also be explained by their satisfactory results as reported by other people around them.

These traditional practitioners are known for the time and support they give to their clients, apart from their accessibility through their lower consultation cost and their proximity to the population [23] [30]. This psychological support could lead to a reduction in stress and consequently lead to pregnancy, because stress can lead to anovulatory cycles and maintain infertility [13].

From there, medical staff should give much more time to these patients who need to express their feelings, to share their suffering and their experiences. Thus, gynecologists must adopt the Rogerian approach, that is, active listening. Apart from this attention to be given to patients, we can also add the reduction in treatment costs. Accessibility to reproductive health specialists could further encourage their attendance at care structures.

Regarding the treatments most prescribed by traditional practitioners, we noted in our series: treatments based on bathing water (25%), amulets (24%), decoctions (18%) and offerings to make (18%).

Raising awareness about the dangers of herbal medicine on fertility could reduce the use of these products and at the same time limit the use of these traditional practitioners. Because it can be caused by toxicity but also by tubal obstruction.

5 Conclusion

The treatment of infertility in African societies where traditional beliefs still occupy an important place, it is imperative that caregivers must take into account the different socio-cultural representations of the disease. Psychoeducation of patients must be at the heart of care to help not only raise awareness about the phenomenon but also to reduce the waiting time for gynecological consultation and dropouts from follow-up.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References