Introduction

Infertility is an important reproductive health issue that affects millions of individuals and couples globally [1]. It is the inability of a sexually active, non-contracepting couple to achieve pregnancy after 12 months of regular, unprotected penial-vaginal intercourse. Globally, it is estimated that about 12 per cent of couples in their reproductive age suffer from infertility [2]. The impact is on the physical, emotional and social health of the couple, with women largely bearing the brunt of society [3].

According to Nukunya [4], the traditional Ghanaian society is pro-natal. This implies that the ultimate purpose of marriage is to produce children who will continue the family name. Hence, it is quite rare to see a couple in Ghana choose voluntary childlessness. As such, it is postulated that married couples without children, most likely are dealing with issues of infertility [5]. The prevalence of infertility in a Ghanaian setting has been estimated to be 12.3 per cent with secondary infertility being higher [6].

Infertility can have devastating consequences, with individuals and couples often experiencing stigma, shame, anxiety, depression, ostracism, and low self-esteem [7, 8]. In cultures where the continuation of the family name through the birth of a child can safeguard marriage, guarantee inheritance rights, and serve as social security in old age, the stakes could not be higher [9].

Infertility is not just a medical condition; it is a deep-seated personal and socially embedded phenomenon. Whereas advancements in reproductive medicine have expanded treatment options [10, 11], the psychological and emotional dimensions of infertility are yet to be fully understood. Fertility treatments can be financially burdensome, physically demanding, and emotionally draining on couples [12]. Fertility treatment in Ghana can be financially burdensome as it is not covered under the National Health Insurance Scheme (NHIS) and couples have to fully pay for all services and treatment [13]. By unravelling the psychosocial contexts of infertility, this paper aims to uncover the nuances, offering insights that may guide clinicians, counsellors, and support groups in providing more comprehensive care. Our study is framed around the Social Ecological Model (SEM).

Materials and methods

This is a qualitative study that employed phenomenology as a study design to explore the social and psychological dimensions of couples dealing with infertility. Specifically, the study made use of descriptive phenomenology to describe the essence of infertility, capturing the commonalities of the lived experiences. In line with this design, in-depth descriptions of participants’ experiences were collected through interviews. This design was deemed appropriate since the focus of the study is to unravel the psycho-social burden of the phenomenon based on the lived experiences of infertile couples.

This study was conducted in Cape Coast, the regional capital of the Central region of Ghana. Cape Coast is a cosmopolitan city whose population is diverse due to its positive net migration [16]. About half of the participants interviewed in this study are residents of Cape Coast, and the remaining were referrals from other districts of the central region which is mostly populated by the Fante people, who are predominantly Christians [16].

The study population are all infertile couples who attended a fertility clinic in a tertiary facility in the study region during the study period. However, we excluded couples with infertility of less than a year as well as couples with secondary infertility. These people were excluded due to the focus of the study and the operational definition of infertility since couples who are unable to achieve pregnancy under a year are not considered infertile. Also, those with secondary infertility may have a different psycho-social burden as compared to women with primary infertility.

A purposive sampling technique was used to select the study participants. Data collection and preliminary analyses were done simultaneously to determine data saturation. The data collection and analyses were iterative and progressive so that saturation could be properly assessed. Saturation was reached at the 8^th interview. However, two additional interviews were conducted to affirm meaning saturation [17]. An interview guide was used for the data collection. All interviews were recorded on audiotape and then transcribed verbatim into Microsoft Word files. The few interviews that were in the local language were first translated into English by a language expert and played back to ensure that meanings were not lost during the translation process.

A total of ten (10) infertile couples were purposefully recruited for the study. Data was collected between 1^st February 2023 and 28^th February 2023 during clinic days. Participants were interviewed together as a couple unit. At the clinic, potential participants (couples) were approached, the purpose of the research was explained to them and their consents were sought. Couples who consented to participate in the study were then taken to a private room for the interview. A highly flexible semi-structured interview guide was used to elicit the responses from the participants. A relaxed conversation-like atmosphere was created and participants were encouraged to feel free to talk about the issues as much as possible. The duration of the interviews varied between 30 minutes to 60 minutes. All interview sessions were voice recorded and transcribed after the interview. In addition, the gestures and emotions exhibited by the participants were noted and incorporated into the transcripts. This allows us to better appreciate the contexts to adequately capture the psychological realities of the study participants.

The audio-recorded data was translated into English, in cases when the couples expressed themselves in the native language, i.e. (Asante Twi), and then transcribed verbatim to capture the exact responses of the study participants. We followed Morse, [17] strategy for qualitative data analysis. This included reading data thoroughly (more than once). This was then followed by inductive coding to identify areas of interest and clustering them by similar ideas. Then themes and categories were generated. The key tenets of the SEM which was used in the development of the theoretical framework, guided the second stage of the data analyses. The themes and categories that fell under the key tenets of the SEM were adequately sorted. Quotes were then attached to the various themes and categories.

To ensure reliability in the codes, we employed an inter-rater coding mechanism where PJA and AAD independently coded the data. All authors then met and reviewed the codes and the few inconsistencies in the codes were resolved together. The decision not to initially employ deductive coding (based on a predetermined coding scheme) was necessary to avoid imposing the theoretical framework on the data but to allow themes to emerge freely. The results are presented based on the emerged themes and categories and discussed within the ambit of the Social Ecological Model (SEM) which was used as a theoretical framework for the study.

This research has received ethical approval from the Cape Coast Teaching Hospital Institutional Review Board (REF: CCTHERC/EC/2023/011). Written informed consent was obtained from all the study participants before the interviews. The transcripts were anonymized by bracketing all names and identities. Unique codes were then assigned to each participant’s transcript for easy identification and retrieval of information.

Results

In total, 10 infertile couples were interviewed. Table 1 summarizes the background characteristics of the couples.

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Table 1. Characteristics of the participants.

https://doi.org/10.1371/journal.pone.0297428.t001

From the data analysis, three themes and nine sub-themes emerged. Table 2 summarizes the themes and subthemes (code book).

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Table 2. Themes and subthemes from the infertile couples.

https://doi.org/10.1371/journal.pone.0297428.t002

Discussions

The current study seeks to explore the psychosocial burden of infertility by drawing from the perspectives of infertile couples in the Central region of Ghana. To the best of our knowledge, this is one of the few studies which focuses on the experiences of couples living with infertility in Ghana. Our study revealed that the psychological burden of infertility largely emanates from the family, the society, and self-inflicted, with the family being the main source of psychological stress to infertile couples. This finding is consistent with documented evidence from Iran that couples dealing with infertility face pressures from family, friends, their partners, as well as themselves [3].

Of note in the present study is the evidence that the family either deliberately or unintentionally exert enormous psychological stress on infertile couples. It was evident that close family relations often knowingly or unknowingly cause psychological stress for infertile couples. A study by Lei, et al., [19] reported that family adaptability has a negative correlation with infertility-related stress in women. Indeed, psychological stress as a result of infertility has been found to have adverse effects on a couple’s quality of life and their relationship with the family [20]. Studies have also reported that women seem to experience more infertility-related psychological stress than their male partners [21, 22].

We also found that infertile couples often self-stigmatized which leads to psychological stress. Taebi et al., [3] reported that infertile women are faced with social and self-stigma which often negatively impact their psycho-social wellbeing and self-esteem. It is a predictor of anxiety, depression, and psychological distress [8]. This is consistent with this current study which also shows that most of the infertile women looked down on themselves because their fellow women have children while they are unable to achieve pregnancy. Taebi, et al., [3] reported that infertile women had feelings of incompleteness and defect.

Our study also revealed that society somewhat places stress on infertile women. According to a study conducted in Iran by Bakhtiyar, et al., [23] infertility does not have much social health impact on infertile women. The study reported that infertility has a psychologically and physically negative impact, but no considerable social impact. This is not consistent with what we found in the present study where infertility has considerable negative social impact, especially on women. The disparity could be due to differences in context as the Ghanaian culture and understanding of infertility may be different from that of Iran. The fact that infertile women experience more psychological stress than their male partners may be a result of gender roles and sex-role identification [24].

Traditionally, motherhood (the ability to produce live birth) is more closely linked to femininity than fatherhood is linked to masculinity [22]. A previous study conducted in Ghana also revealed that infertility has social implications for the affected couples. The social effects of infertility on couples include exclusion, verbal and physical abuse and divorce [25]. This is partly consistent with the findings of the current study where it was evident that infertile couples felt socially excluded, especially when it comes to the attitudes of their colleagues at the workplace. However, our study did not find any form of physical abuse, nor did we record any divorce, although, one out of the twenty participants feared her husband would leave her due to her infertility.

Also of note in the present study is the evidence that the church is a source of stressors for infertile couples. This finding is rather surprising given that Roudsari and Allan [26] reported that for infertile couples, religion provides an avenue to maintain hope and give meaning to their sufferings. Religious infertile women regard their condition/predicament as an enriching experience for attaining spiritual growth [26]. This disparity may be due to the previous study’s emphasis on counselling as a key part of support for infertile women. Therefore, conscious efforts (including pastors/preachers being sensitive to social issues) need to be made by the church if it wants to be a source of hope for infertile women.

Our study also revealed that infertility exerts an enormous psychological impact on couples which often results in desperation and depression, especially among infertile women. This is consistent with existing literature which highlights that infertility is associated with a myriad of psychological problems, including feelings of guilt, anxiety, and depression [27]. This highlights the need for psychotherapy even before medical treatment of infertility is initiated as studies have linked the failure of fertility treatment to psychological distress [28]. It is important to note that in the current study, the participants were infertile couples who were actively seeking treatment. As such, they were more likely to feel the psychological impact of infertility, leading to desperation and depression. The impact may not be so pronounced on couples who have resigned to fate and not actively seeking treatment for their infertility issues. Furthermore, in instances where the barrier to treatment is financial, couples that cannot afford the costs of treatment could have a more severe negative psychological impact than those able to pay for the treatment [27].

Several coping mechanisms were adopted by infertile couples in our study setting. This includes; self-motivation, active avoidance, united in grief by supporting each other, and active engagement in church and religious activities. Our study resonates with Taebi, et al., [3] who revealed that some women internalize the stigma and it takes a toll on their self-esteem and may lead them to social isolation. They also added that infertile couples have feelings of shame, inferiority, worthlessness and loss of control. This is because, in numerous settings, childbearing is seen as a symbol of virtue and prestige. Evidence from Turkey points to infertile women resorting to active involvement in religious activities as a coping strategy as they experienced stigma and hopelessness due to infertility [29].

The present study also revealed that as part of the coping strategy, infertile couples united in grief and provided support for each other. The evidence suggests that this strategy works better when husbands are supportive of their wives. This reinforces the misconception that women need support from men but not the other way around when the cause of infertility lies with the man. This misconception often heightened the psychosocial burden of infertility on women more than men [30].

It is important that infertile couples adopt appropriate coping strategies to deal with their infertility. Maladaptive coping strategies may not positively affect psychological health among infertile couples [31]. It is also important to note that women’s self-blame and self-focused rumination strategies have a negative impact on women’s psychological health [32]. In a study by Pedro, it was reported that infertile women had difficulties with friends with children and often experienced social withdrawal at social functions such as family and friends’ gatherings due to feelings of being marginalized [33]. There is also documented evidence to suggest that infertile women deliberately avoided discussions related to family or children as a way of protecting themselves from uncomfortable conversations that could negatively impact their psychological health [34].

Theoretically, although the source of stigma seems to be mainly from the interpersonal level (i.e., family, friends and society), this study also showed that the same interpersonal-level relationship (especially the family) played an important role in helping infertile couples to cope with their situation. It is important to note that in instances where stress and tension appeared to be from the family, they were often not direct and usually unintentional. Again, while the church was a source of stress for infertile couples, it also served as an avenue for infertile couples to cope with their situation.

Even though our study offers important insight into the psychosocial burden of infertility, drawing from couples’ perspectives, there are some inherent limitations. Our study participants were recruited from a single fertility clinic in southern Ghana. Even though the study setting is multi-ethnic, we were not able to explore in detail the dynamics of the various cultural systems and their influence on the psychological health of infertile couples. It is also important to note that the experiences shared in this paper are exclusively from infertile couples attending a fertility clinic. Infertile couples who are not actively seeking solutions could have different experiences and perspectives on this important social phenomenon. However, we could not include them in this study as access to them is practically almost impossible due to social and cultural sensitivities surrounding infertility. Also, due to the qualitative design that was employed with a small sample size, the results cannot be generalized. However, these limitations do not diminish the importance of the evidence presented since our goal is to unravel the phenomenon rather than to generalise it.

Conclusion

Infertility exerts a considerable negative psychosocial burden on couples, especially women. The interpersonal level which includes family, friends and colleagues serves as the main source of psychological stressors for infertile couples. Couples with infertility resort to reduced social interaction through the adoption of active avoidance as a strategy to cope with their problems. Infertility is not just a medical condition; it is also a deep-seated personal and socially embedded phenomenon. Therefore, programmes aimed at addressing fertility treatment should consciously consider addressing the psychosocial burden of infertility through education targeting actors, especially interpersonal-level actors. Also, fertility healthcare professionals should provide comprehensive care (including psychological therapy) to affected couples.

Acknowledgments

The authors express appreciation to the management of the study health facilities and the study participants who shared their perspectives with us.