This was a hospital-based cross-sectional study conducted from the 14th of March to the 6th of April 2023 at the outpatient consultation unit of CHRACERH, which is a tertiary healthcare facility situated in the Ngousso neighbourhood of Yaoundé, the capital city of Cameroon. CHRACERH is a tertiary healthcare facility that provides scientific-based treatment, research and teaching of medical students and resident doctors. It is made up of a gynaecological ward, a labour room with five beds, two delivery rooms, a neonatal intensive care unit, and five operating theatres (one for obstetrics and four for gynecologic surgical procedures). It also has two hospitalisation wards, a unit for assisted reproductive technology (ART), a laboratory, echography rooms, a blood bank, an emergency unit, and an outpatient consultation unit. The building, which has five floors, is made up of specialized equipment to conduct its various missions, including endoscopic surgery, in vitro fertilization, and pelvic reconstructive surgery.

The study population consisted of all infertile women attending the outpatient consultation unit of CHRACERH and those receiving IVF/ICSI treatment during the study period. All women who gave their consent to participate in the study were included. We excluded from the study all infertile women who did not consent to the study and those whose questionnaires had missing data.

The sample size was calculated using Cochran’s formula for a cross-sectional study (n = z²pq/e²). Using an estimated proportion “p” of psychosocial effects of infertility of 11.2% from a study by Olowokere et al. in Nigeria, [14] the calculated minimum sample size was 153 participants (n = [1.96² × 0.112 [1 − 0.112]]/ 0.05² = 153). The sampling technique was consecutive, involving all women who met the inclusion criteria during the data collection period.

The questionnaire was administered to 10% of the calculated sample size (15 participants) for content comprehension and validity. Questions that were ambiguous or not well understood by participants were modified. Secondly, the GHQ-28 that we used to study mental health is a questionnaire that had already been validated.

After obtaining ethical clearance from the Institutional Review Board of the Faculty of Health Sciences of the University of Buea (ref. no. 2023/1935-01/UB/SG/ IRB) and administrative authorization from the Dean of the Faculty of Health Sciences (ref. no. 2023/227/UB/VD/RC/FHS) and from the Managing Director of CHRACERH Yaoundé, Women that came for infertility consultation and those that were already on IVF/ICSI treatment protocols were approached, and the objectives, inclusion criteria, risks, and benefits of the study were explained to them, and they could withdraw from the study at any time. Those who accepted to be part of the study signed an informed consent or verbal consent. Participant enrollment was done daily by the principal investigator during the data collection period.

Data collection was done using a structured questionnaire available in French and English divided into 3 sections (A, B, C). Sections A and C were preconceived and for section B, we used the General Health Questionnaire (GHQ) 28. The GHQ-28 was developed in a few countries by Goldberg and Williams, in 1988, and has been translated into about 38 languages, and over 50 validity studies published.

Section A: Sociodemographic characteristics of participants (age, parity, occupation, educational level, marital status, religion, source of pressure, type of infertility, etc.).

Section B: General evaluation of psychological state.

Section C: Psychological support and coping strategies.

At the end of the study, basic information regarding infertility and various coping strategies (the importance of psychologists, social workers, etc.) was given to the study participants. We also highlighted the limitations of prayer and getting busy as coping strategies. This study has been conducted according to the ethical principles of the Helsinki Declaration [22] .

The collected data was coded, double-entered, and analyzed using the statistical package for the social sciences (SPSS) version 25. Descriptive statistics was used where categorical data (occupation, educational level, religion) were presented as frequencies and percentages, whereas continuous variables (age, duration of infertility, etc.) were expressed as means, standard deviation, and range. A chi-square test was used to determine associations between coping strategies and psychological disorders. Statistical significance was set at P < 0.05.

The ages of the participants ranged from 22 to 60 years, with a mean age of 39.52 ± 7.64 years. Less than half, 80 (42.11%) of the participants were in the age group of 31 - 40 years; 128 (67.37%) were married; And 150 (78.94%) worked either in the public or private sector or as traders. Furthermore, 120 (63.16%) participants had a university education and 185 (97.37%) were Christians ( Table 1 ).

The majority 140 (73.7%) of participants had never given birth, 123 (64.7%) had a duration of infertility ranging from 1 to 10 years, 101 (53.2%) had secondary infertility, 91 (47.9%) believed they were responsible for infertility, and 185 (97.4%) did not receive any form of psychotherapy ( Table 2 ).

NB: Some items have multiple responses.

The main sources of support for participants were from family 76.8%, husband/partner 72.6%, and friends 49.5%. Only 3.2% of participants consulted a psychologist while 2.6% were with an infertility support group. However, only 1.1% had no source of support ( Figure 2 ).

As regards coping strategies for infertility, 89.5% used prayer, 48.5% preferred getting busy, 25.8% adoption, and 10.5% went for infertility treatment while 2.1% had no strategy ( Figure 3 ).

Among the 76 (40%) participants with psychological disorders, 70 (36.84%) used prayer as a coping strategy (P = 0.335), 37 (19.47%) getting busy (p = 0.953), 19 (10.0%) adoption (p = 0.839), 11 (5.79%) certain treatments (p = 0.148) and 2 (1.05%) had no strategy (p = 0.680). There was no statistically significant association between coping strategies and psychological disorders among study participants p > 0.05 ( Table 3 ).

The mean age of participants was 39.55 ± 7.6 years. This finding is not consistent with the 35.0 ± 6.14 years reported by Olowokere et al. in Nigeria [14] and the 36.5 ± 2.8 years reported by Agostini et al., in Italy [26] . This could be explained by the fact that the level of schooling for girls is increasing in our environment, so women start motherhood a little later. The majority of participants 67.4% in this study were married. Other studies have shown that married people tend to have more positive mental health outcomes than those who are single, separated, divorced, widowed and widower (p = 0.000, 95% CI = −0.116 - 0.2563) [27] . Mental health advantages accrue as individuals move from less attachment to more attachment. Marriage has the most benefits in part because relationships provide social integration and heightened feelings of self-worth [27] . However, in this study, the association between demographic characteristics and psychological disorder did not show any statistical significance (p > 0.05). The duration of infertility among study participants ranged from 1 - 20 years with a mean duration of infertility of 10.27 ± 7.8 years. This finding is not consistent with the mean duration of 4.1 ± 3.52 years and range of 1 - 5 years reported by Olowokore et al., in Nigeria [14] . This can be explained by the delay in seeking medical attention, lack of enough medical expertise and financial deterrents for optimal management of infertility. Patients come to CHRACERH, a tertiary (referral) healthcare facility relatively late after attending other hospitals, traditional or spiritual remedies.

Social support can be a critical component of how a woman adjusts to the unexpected stress of infertility. Findings from this study revealed that most participants received support mainly from their family members 76.8%, husbands/partners 72.6% and friends 49.5% while only 3.2% of participants consulted a psychologist. Similar findings were reported by Olowokere et al., in Nigeria where the main source of emotional support was from the husband (59.8%) and family members (34.2%) [14] . In addition, Anokye et al., reported that the main source of emotional support was from family, [28] while Karaca et al. in Asia reported that husbands were responsible for 92% of emotional support among infertile couples [29] . This similarity could be because family members and husbands constitute two groups that are usually closer to the participants, therefore, can be involved or aware of the difficulties that participants are going through. Also, the stress of infertility may bring them together and strengthen their relationship. In addition, only a few women got support from a psychologist.

In an Australian study, a highly motivated sample of women actively sought alternative forms of support. The Traditional Chinese Medicine approach to infertility management increased women’s sense of autonomy and control through education and continuity of care. However, the need for greater societal understanding and support remained [30] . Another study shows that infertility-related stress levels and perceived social support have a direct effect on the choice of coping strategies in Vietnamese women diagnosed with infertility [31] . However, these studies were conducted in high-income countries that may be better equipped to handle mental health issues regarding infertility. This is different in Cameroon (sub-Saharan Africa) where women are held responsible for infertility issues and the family of the husband (or both families) impose stress on the woman (or the couple) and even more so for the woman who is most often left alone. Given the lack of well-codified psychological and social support, women feel obliged to fall back on work or prayer.

Furthermore, mental health is still a taboo subject in Cameroon. It is not common for patients to seek attention from health professionals spontaneously (and even less so from a mental health professional) if there is no prior medical referral.

Other studies have reported that among infertile patients receiving IVF treatment the impact on mental health increases with treatment duration and number of unsuccessful attempts and therefore there should be a greater emphasis on mental health support for couples who have undergone multiple treatment cycles [32] . Therefore, there is a need to integrate medical staff or caregivers in the infertility treatment team [20] [33] [34] [35] . CHRACERH is a tertiary care public healthcare facility in Yaoundé-Cameroon, that specialised in the treatment of infertility using assisted reproductive technology (IVF-ET/ICSI), but there is a lack of skilled trained medical psychologists/psychiatrists or mental health specialists and sociologists that could be part of the Infertility/IVF team mostly due to the absence of an ongoing training program. There are also no support groups in our infertility clinic, though some participants may not like to share their problems publicly. This fact highlights the need for the FELICIA intervention that is ongoing in Nigeria to be integrated in Cameroon because it favours task shifting where community health workers and nurses could be trained to deliver a cost-effective and holistic mental health care to patients treated for infertility [18] [19] .

Most studies report a positive association between religiosity and spirituality and aspects of mental health such as higher life satisfaction and meaning in life, a lower prevalence of anxiety and depression, suicidal tendencies, substance abuse and better cognitive functioning [36] [37] [38] [39] . Though currently, epidemiology is at the forefront of providing robust evidence showing that associations between religion and health are causal [40] . The most prevalent coping strategies adopted in this study were prayer 89.5% followed by getting busy 48.4%. This is consistent with Olowokere et al., in Nigeria, who reported that prayer (89.5%) and getting busy (82.98%) were the coping strategies in their study [14] . A study in Ghana reported that, besides biomedical causes of infertility, witchcraft and spiritual causes have also been cited. Patients seek help from traditional and religious healers (churches, meditation, and prayer) for spiritual redress [41] [42] . People with high levels of religious involvement, religious silence and intrinsic religious motivation are at reduced risk for depressive disorders [43] [44] . This suggests that religious involvement might exert a protective effect against the incidence and persistence of depressive symptoms or disorders [43] . Notwithstanding, religious service attendance is associated with fewer depressive feelings, but the opposite is true for frequency of prayer. Second, the association between religiosity and depression is moderated by the religious context. In less religious regions, depressive symptoms relate less to service attendance than in highly religious regions, while the frequency of praying relates to more depressive symptoms in regions with lower levels of religiosity [44] . In Cameroon, infertility and IVF centres are inaccessible (found only in Yaoundé and Douala) and it is challenging for people who live in remote areas to get to these locations. Furthermore, there is a dearth of understanding regarding the various assisted reproductive technology (ART) procedures (IUI and IVF), their costs, and treatment outcomes in Cameroon. Besides, the customs and beliefs of the indigenes of Cameroon could also be important, and people find it difficult to accept the unknown [45] . In Cameroon, infertility/IVF treatment users’ attitudes differ according to their ethnic and religious backgrounds because there are several denominations in Cameroon, ranging from Christianity to Islam and animism.

The current study found that 95.8% of participants were Christians. Other studies have shown that religion may inhibit a person from acting on suicidal ideas by providing access to a supportive community, shaping a person’s beliefs about suicide, providing a source of hope, and providing ways to interpret suffering [46] . However, another study reported that infertile women lost faith in God [47] .

Getting busy was noted in 48.4% of study participants. This is a form of diversional therapy or denial used by the women to take their minds off the problem. This has also been reported previously [47] . However, another study reported that: 1) Creating more space or removing oneself from reminders of infertility; 2) Establishing regulations in effect to gain control; 3) Trying to boost one’s own ego by performing at the top or being the best; 4) Searching for the root cause of infertility; 5) Caving in to emotions; and 6) sharing the load with others are ways of coping with infertility among infertile women [48] .

To the best of our knowledge, this is the first study of its kind in Cameroon regarding support systems and coping strategies of infertile women. The study will provide baseline data for stakeholders in Cameroon regarding the support systems and coping strategies for infertility. Further research should focus on a qualitative study by using in-depth interviews and focus group discussions to elucidate patients’ views and partners on the support systems and coping strategies of infertility.

This is a single-centre study; therefore, the results may not be generalized to the whole of Cameroon. The study targeted only females, not taking into consideration the perspective and experiences of infertile couples and their partners. The small sample size may not permit certain conclusions.