The Decision-making Pathway and Enablers to the Utilization of Assisted Reproductive Technology in Lagos Metropolis: an interpretive phenomenological study

doi:10.21203/rs.3.rs-3268867/v1

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The Decision-making Pathway and Enablers to the Utilization of Assisted Reproductive Technology in Lagos Metropolis: an interpretive phenomenological study

https://doi.org/10.21203/rs.3.rs-3268867/v1

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Background

Women experiencing infertility face barriers to access Assisted Reproductive Technology (ART) services in Nigeria. Despite these barriers, some still access these services. This study explored the decision-making pathway and enablers of the use of ARTs among such persons in Lagos.

Methods

Using an interpretive phenomenological approach, we explored the decision-making process and enablers motivating the use of ART services among women who have experienced infertility. An open-ended structured in-depth interview guide was used to collect data that were analyzed thematically.

Results

Findings revealed that the decision-making pathway involved personal, interpersonal or relational thought processes to use Assisted Reproductive Technology for assisted conception and enablers which were a mix of emotional support from the mother, spouses, social pressures, information about health condition, professional and lay suggestions all contributed to the eventual use of ARTs.

Conclusion

Results of this study indicate that infertile women received different forms of support that enabled the use of ARTs. However, women who used ART services experienced several psychosocial challenges. These ARTs have given infertile and childless couples some ray of hope and the chance to escape the burden and social stigma of childlessness. This study recommends that public health professionals collaborate with ART service providers in providing psychosocial care in addition to basic clinical care. Future studies can explore the perspectives of significant others as they played a key role in the decision and motivated ART use.

Assisted Conception

Assisted Reproductive Technology

Decision

Infertility

Qualitative Study

Women

Around the world and particularly in Africa, where childless couples are seen as incomplete, the inability to have children has become a personal misfortune for them and particularly women [1]. This societal shame can have major repercussions on the private anguish of childless couples [2]. In a bid to disengage from these challenges, some infertile persons seek Assisted Reproductive Technology (ART), which involves therapies or procedures that include managing human sperm and eggs in vitro to induce pregnancy and overcome innate barriers to pregnancy [3].

Globally, ten of every seventy couples experience some form of infertility [4]. In Africa, infertility affects 15—30% of the population [5]. Couples who are having trouble conceiving may endure health issues such as weight loss, high blood pressure, anxiety, sadness, and mental illnesses, as well as sometimes even mortality and detrimental health conditions [6]. However, these infertility-related illnesses are no longer as prevalent because of technological advancements known as Assisted Reproductive Technologies (ARTs). These services, which offer alternative mechanisms for conceptions for these couples, are increasingly being used to aid infertile couples begin conception [7, 8].

The introduction of assisted reproductive technologies has led to a reduction in infertility cases of more than 50%, giving couples who previously had no possibility of becoming parents an opportunity to do so [9]. Despite the successes recorded from ART, sub-Saharan Africa still has the lowest ART adoption rate, with only 71 cycles per million people per year as at the latest report [10]. Many access barriers to ARTs still exist in Nigeria as well as other nations in Sub-Saharan Africa, and include financial barriers as a directly associated factor [11, 12, 13]. Deficient health systems, a number of conflicting health goals, absence of third-party funding plans, far more private ART clinics than public ones, and homes with low purchasing power [14] including psycho-cognitive barriers such as lack of knowledge and beliefs [11]are further contributing factors.

In Nigeria, equal and fair access to reproductive technology has been and is still problematic, and it is rarely given top priority in public health benefits programs [15, 16]. Also, the cost of receiving therapy and establishing this technology in Nigeria where they are most required prevents their widespread use [17]. The few available studies on ART in Nigeria have focused mainly on the Knowledge, Perception, Attitude, Willingness, and ethical issues related to the use of ARTs [18, 19, 20]. Studies detailing the experiences of the affected are very limited and virtually nonexistent. Thus, we have not been able to subjectively unearth the person-centered perspectives of infertility and health-seeking behaviors. This study sought to explore the experiences of women who have lived through infertility to understand the decision pathway to using ARTs and what, despite the barriers, motivated them to seek ART services.

Study design

Alfred Schutz’s phenomenology theory was used in this study [21]. This theoretical approach allowed us to conceptualize each participant's experiences based on their respective social world. The individual's experiences constitute a given social phenomenon as these individuals' social worlds are reconstructed by their personal experiences. As a result, the design allowed for greater comprehension of the decision-making pathway in the use of ARTs and enablers of using these services from the participants’ social context.

Study setting

This work was conducted in a support group; this private support group provides men and women going through infertility a safe place to live through the challenges of infertility. It provides referral services and atmosphere to share experiences with others going through similar life events. Coping strategies are also shared, which provide an additional resource.

The population of the study and sampling technique

Women who had sought ART services by the time of the study were purposively recruited to provide insights on their experiences related to the study’s objectives. This was done by sending a notice of research to the support group chat page on WhatsApp. Those who desired to be part of the study and consented (confirmed when they returned responses privately to lead since no direct contact was allowed by the researchers) participated. These women reached out to the Administrator privately and were thereafter sent the instrument which they filled accordingly and returned to her private Whatsapp phone line.

Data collection

A structured interview guide was developed to capture responses on the decision-making process and enablers in the use of ARTs. The interview guide was designed to collect data on participants ‘personal data and clinical characteristics’ and a description of their decision pathways to use and enablers that motivated the eventual use of ARTs. The interview guide was reviewed by AUC and ASO, and was thereafter pilot-tested before its use in the study. The complete data collection took two weeks. All responses were collated and returned via email. These were downloaded to a password-protected personal computer.

Data analysis

The data were analyzed manually using the procedures stated by [22, 23]. After the data were collected, they were transcribed verbatim, and transcripts were read three times by each team member to get a sense of the general flow of experiences. By the fourth reading, the transcriptions were then read again purposefully to assign codes which began with the first transcript. This was then used to code other transcripts accordingly, beginning with a key code and its sub themes until all transcripts wereread and an agreement was reached by all authors on saturation.

Trustworthiness

Trustworthiness was achieved; first through dependability where the researchers attempted to provide a clear coding description of the analysis using coding schemes to allow repetition. In addition, a detailed description of the methodological processes has been aforementioned including a clear description of the study setting and provision of responses without altering the language construct/tense. Secondly, through credibility where the findings of the study were discussed among team members until an agreement was reached on consistency of findings. The authors attempted to achieve credibility through respondent checks, however this could not be achieved, since researchers were not allowed direct contact with the respondents even after all efforts were made to bridge that gap.

Socio-Demographic Characteristics of Respondents

The participant's mean age was 32.72 ± 5.33 years. Half of the participants (50%) was of Igbo ethnic group. All of them (100%) had BSc educational qualifications and were married. More than half of the participants (66.7%) had a formal employment status. Most of them 16 (88.9%) had primary infertility and 10 (55.6%) had three or more treatment attempts. (Table 1)

Table 1

Socio-demographic Characteristics of the Respondents (N = 18)
Socio-demographic characteristics	N (%)
Age 18–25 26–33 34–41 42–49	1(5.60) 11(61.30) 5(27.95) 1(5.60)
Ethnicity Igbo Yoruba Hausa Others	9(50.0) 4(22.20) 5(27.80) 0(0.00)
Employment status No employment Formal employment Informal employment	0(0.00) 12(66.70) 6(33.30)
Marital status Single Married Divorced	0(0.00) 18(100) 0(0.00)
Educational status No education Primary Secondary Tertiary	0(0.00) 0(0.00) 0(0.00) 18(100.0)
Duration of infertility Primary Secondary	16(88.9) 2(11.10)
Number of attempts 1 2 3	6(33.3) 2(11.10) 10(55.6)

Two themes- the decision to use ARTs and enablers with sub-themes are outlined below (Table 2).

Table 2

Themes and Sub-themes
Themes	Sub-themes
The decision to Use of ARTs	Personal
	Inter-personal
	Relational
Enablers to use ARTs	Social support (Emotional, Informational, and Appraisal
	Inter-personal influences (social pressure, expectations, healthy role models)
	Information about underlying illness requiring use of ART
	Professional recommendation
	Lay suggestion

Decision to Use

This theme was used to depict the personal, interpersonal, and mutual elements in the pathway of decisions taken by the participants to use ARTs. The personal as a sub-theme described different things from the person’s perspective that led to the participant's decision to use ART, the inter-personal explained the roles people played in the pathway of the decision to use ART and the relational defined the involvement of spouses and immediate family members in the participant's decision that led to the use of ART.

Some participants described how they were restless and felt inadequate about their situation most of the time. The feeling of not having a child after several years of marriage and failed treatment attempts rekindled their quest for a child and resilience to use ARTs.

“I told myself that one more push had every virtue. I decided to embark on this journey once more, especially considering the availability of frozen eggs. I was given a mild prescription for this seventh trial because there were eggs available”. (Participant, A)

“I started my third cycle of resiliency that was fueled by prayers. I wouldn't give up on my goal of being a mother”. (Participant, A)

Another participant expressed that;

“As soon as I learned about IVF treatment, I embarked on it because I was growing restless with my emotions of inadequacy and helplessness”. (Participant, B)

“My first IVF attempt, at age 20, was unsuccessful. I never gave up since I was desperate to start a family”. (Participant, D)

Some of the participants explained how their inability to birth a child the was the problem and they were determined to become a parent while others were proud of their personal qualities and pictured themselves as wonderful mothers

“Even though I was aware of how poor my odds were, I wasn't going to let that stop me from pursuing my desire to become a parent”. (Participant, F)

Another affirmed that

“I was certain that I wanted to have children and that I would be a wonderful mother”. (Participant, L)

Inter-personal:

Participants also shared how the experiences of family members, siblings, an

friends with ARTs buttressed their decision to use it.

“My husband and I decided to ask our family members, friends and siblings who have used ARTs about their experiences and what they said helped in building our faith to use ARTs”. (Participant, P)

Relational:

Most Participants explained how they made a joint decision with their spouse and went about all their treatments together.

“My husband and I decided to seek medical attention after six years of bedroom struggles. We began our adventure at the Lagos University Teaching Hospital (LUTH) where we underwent clinical testing and inspections”. (Participant, A)

Another participant recalled that

“We started trying to get pregnant, but it never worked out. Without wasting any time, my husband and I headed to a reproductive clinic”. (Participant, D)

A different Participant described

“I recognized something was wrong with me, we tried for five years to give our child a sibling and when nothing was happening, we decided to use IVF”. (Participant, G)

“So, after a year of not conceiving, we decided to seek fertility treatment because we had plans

To expand our family”. (Participant, O)

Enablers to use Assisted Reproductive Technologies

Social Support (emotional):

Participants recalled how their husband's advice not to give up, their mother's consolation after failed attempts, and involvement in a group motivated her to use ART.

A participant said that

“My husband's advice to never give up was something I clung to. I thus tried one more”. (Participant, C)

Another participant explained that

“I confided in my mother and I started my third cycle of resiliency that was fueled by prayers. I wouldn't give up on my goal of being a mother”. (Participant, A)

A different participant mentioned that

“My big sister introduced me to a group where we had other people going through what I was going through. It became a bit easier rubbing minds with these sisters, we encourage ourselves together and nobody is left behind, advising each other, clocking in of smoothies, praying together and spicing up our marriage”. (Participant, Q)

Social Support (informational)

Some participants appreciated those who gave them relevant information, positive disposition from their parents, awaiting a positive result from natural birth engineered them to use ART.

“Returning to conventional medicine… At the time, we were receiving treatment at the Ghana police hospital from a specialist, which was strongly recommended by several people”. (Participant, I)

Social Support (Appraisal)

One of the participants described how the testimonies of women helped to build her faith in IVF

“I have been following testimonies of women who were not Nigerians online who had similar issues as mine because most Nigerian women do not like to talk about issues like this, their testimonies helped to build my faith and hope so I decided not to give up”. (Participant, R)

Inter-personal Influences

Participants described how her mother-in-law's words, statements, and behaviors of people, and hurtful words from people ended their productive break and they opted for ART.

“A few years later, when my mother-in-law came visiting, she noticed the kids playing. She was open about her desires. Don't ever think I don't want more grandchildren, she warned me. My productive break was over with that one sentence. Once more, I went for it. Twins were born following the third round of reproductive treatment”. (Participant, B)

Another participant stated that

“When I started to observe nuances in people’s statements and behaviors, my unfolding realities became evident”. (Participant, A)

The fourth participant disclosed that

“I've always thought that IVF babies are never healthy. My mother's friend used in vitro

fertilization (IVF), but the child was born prematurely, this made me consider IVF”.

(Participant, D)

A different participant added that

“As the years passed, everyone around me seemed to be happier and had children”. (Participant, E)

Another participant mentioned that

“No positive test results in the first month. No positive test was found in the second month. Around the same time, spouses started making pregnancy announcements. Each month I cried”. (Participant, L)

Another participant described how

“It is not just a loss of a baby but the loss of a dream, words people said to me broke my heart such as why don’t you want to have a baby? When are you going to have a baby? it was a difficult decision”. (Participant, N)

Information on underlying illness conditions requiring ART

Participants expressed how they felt sad when they heard that they were ill and their partners were ill as well

A participant disclosed

“There, the doctor informed us that he had a condition called non-motile per slide, which refers to a lack of active sperm cells in his semen. My husband's semen was frozen at that time so that viable sperm cells could be harvested as we started a new cycle”. (Participant, D)

One of the participants described

“I understood that my eggs are infertile and I will never be able to conceive”. (Participant, E)

A different participant expressed

“I had never considered using my body for scientific conception since I had spontaneously given birth to my first child. Yet, results showed that my right Fallopian tube was obstructed”. (Participant, G)

Another participant mentioned that

“My doctor identified PCOS after I got married and had trouble conceiving. I was informed by the fertility clinic we visited that my eggs were infertile; therefore, we had to choose the donor option”. (Participant, H)

Another Participant explained that

“In 2018, I underwent laparoscopy and hysteroscopy to examine the inside of the uterus to diagnose further treatment or surgery. During this process, it was revealed that my tubes were blocked and beaded. The fertility doctor suggested IVF”. (Participant, M)

Professional Recommendation

Participants did not forget to mention how helpful their doctors were to them even after failed attempts

The sixteenth participant explained that

“We had discussions with my doctor and she recommended some herbs for us to use. After months of taking the herbs and they did not work so the doctor encouraged us to go for IVF

but we told her that there was no money”. (Participant, P)

Another Participant shared that

“My doctor identified PCOS after I got married and had trouble conceiving. IVF was suggested to us, but my husband was first hesitant to attempt it. Afterwards, he consented”.

(Participant, H)

A different participant mentioned that

“I located a good clinic in my area, registered and started treatment. The first attempt was not successful and the doctors suggested I tried it again; I underwent the second attempt and it was successful”. (Participant, R)

Lay Suggestions

Some of the Participants were excited and expressed how their sister and neighbors suggested IVF and encouraged them to use it

One of the Participants disclosed that

“In March 2022, my sister came to visit me and she suggested IVF and I was hesitant at first”.

(Participant, Q)

Another participant included that

“At the time, we were receiving treatment at the Ghana police hospital from a specialist, which was strongly recommended by several people”. (Participant, I)

This qualitative study was aimed at exploring the decision making pathway in the use of ART and enablers influencing women's decision to utilize ARTs. Data were analyzed inductively and the following themes were derived. Two major themes evolved; (1) the Decision to use with sub-themes of personal, interpersonal, and mutual actors in the decision pathway to use ART, (2) Enablers to use ARTs with sub-themes of social support, appraisal, inter-personal, informational, professional and lay influencers.This study revealed that all participants had made a personal, mutual, or inter-personal decision to use ARTs for assisted conception, and factors such as emotional support from the mother, and spouses, social pressure, information about health conditions, professional suggestions, and lay suggestions enabled their decision to materialize into the eventual use of ART service.

The study found that women who have used ART have had a whirlwind of mixed experiences resulting from their inability to conceive, decisions they made and the enablers to use ART. Although many of the women decided to use ART on their own, some of them wanted their husbands to be part of the decision-making process while others were in joint agreement with their husbands. Participants revealed that their decisions originated from their aspirations, feelings of restlessness and inadequacies, desperations, desires to become a parent, and knowledge, while others mentioned that both they and their spouses decided to use ARTs for treatment, and even after several failed attempts did not give up. In Chile, their decisions were more physician-driven. They preferred their doctors to make decisions for them and did not like to be forced, this was because of the trust they have in the physicians and also fear of the consequences that might result from their personal decisions made [9].

The participants reported that they were sad, depressed, angry, and worried a lot about their situation and were dissatisfied after failed attempts. These psychological manifestations are comparable to those reported in another study [25], who found that women admitted to worrying about their infertility issue. The majority of the participants in a related study [26] reported experiencing severe unhappiness and dissatisfaction as a result of their failure to conceive.

The participants reported other emotional moments where they cried, yelled, read their Bibles, and meditated to always feel better as a result of their condition, which assisted them in coping with their unmet expectations. The same strategies were used by the participants in a similar study [27] to help them deal with their disappointments. Generally, most women experience numerous negative feelings. However, while experiencing these negative feelings, some are able to engage in spiritually positive activities which may aid the journey through the dark.

Most of the participants received support from their husbands which helped them during their treatments and after failed attempts. Despite their husbands' desperation about their circumstances, they continued to treat their marriages with respect. The vast majority of the husbands were praised for being the best, considerate, and encouraging. Because of this, many participants did not feel pressured by their husbands to have a divorce or get remarried, as has been documented in other studies [28, 29].

The findings also revealed that one of the challenges faced by the participants while they used ART was the financial burden associated with it. Funding ART for the majority of the women required making sacrifices and seeking financial assistance. These results are in line with those of [30], who found that when it came to the financial challenges they faced, some participants noted how expensive it was for them to raise money for the therapy. Some people had to obtain bank loans to pay for their ART because their insurance did not cover the cost of their care. Some people had to reevaluate their goals in life, forgoing getting a car or a house in favor of starting a family. There have always been financial implications for ART treatment, however, the desire to have children seems to have always been a major driver despite this challenge [31]. This high cost oftentimes limits access and results in inequalities, where the more well-offs often have better access. Consequently, resolutions on infertility are limited to the wealthy [31, 32].

Other individuals play critical roles in the use of ART apart from the women's decision to use it. This study showed that the husbands of the women played important roles by giving them both material and emotional support throughout the procedure.They also received emotional, informational, and appraisal support from the mother, family members, and friends that strengthened them to continue their journey for a child until pregnancy and delivery were achieved. This observation is consistent with research by [33] who found that other individuals played important roles such as providing financial, and emotional support and referrals.

The women in this study indicated that their mother-in-law's expectations, social pressures in the form of hurtful words, nuances in people's statements and behavior, baby announcements by spouses in church, and false prescriptions from sister-in-law prompted their use of ARTs. This is complemented by another study[34] which found that women were worried because some of the comments made by their peers, such as comparing them to their friends who got married in the same year, made them feel inferior. However in other studies, religion and the desire for satisfaction of a significant other in polygamy were enablers to the utilization of ARTs [35]. Women elsewhere were unperturbed and turned negative nuances into positive behavioral outcomes. The negative nuances rather, prompted the use of ARTs and in some cases increased usage [36].

More than half of the participants did not actively read or learn about infertility through other means but from healthcare professionals. This seems commonplace as others have reported the same mechanisms of information [37, 38, 39].

During the ART process, medical professionals offered their assistance as well. The study revealed that the doctors gave rapid attention to the women until a successful pregnancy and delivery were achieved. This result is comparable to one by Anaman-Torgbor[33], who discovered that women receiving ART were inspired by the helpful attitudes displayed by doctors and nurses. Furthermore, support was received from lay influencers who fueled their use of ARTs. While a study [29] reported that women were willing to discuss their challenges with others, an earlier study[40] reported opposing views, where women felt uncomfortable discussing with others as they feared being mocked. Some women also preferred discussing solely with spouses [41, 42].

Study limitations

This study focused on an in-depth understanding of experiences among women with infertility who chose to access ART services. The findings provide us with a deeper understanding of how women eventually decide to use ART services as they live through infertility and what prompts have existed in their journey. However, this study is not without its limitations. The study did not include a vast group of females who are actively using ARTs and male partners who may have actively participated in the decisions in conception. Rather, this study collected data on infertility experiences among women within a support group. Thus, findings may not be generalized to the wider population or women in other support groups. Also, the interview guide was sent online via WhatsApp, therefore women who did not have access to the internet or WhatsApp-enabled devices or who may have had faulty devices were unable to participate in this research which limited opportunities for other women to contribute in sharing experiences. Face-to-face interactions provide the researcher with a direct observation of participant's unspoken expressions which assist further in deciphering meanings. After several attempts at interacting face-to-face with participants failed, the researcher resorted to indirect communication which limited covert and overt observations which could have provided a richer environment of study for this qualitative approach of research.

Women who have used ART services in this study setting experienced several psychosocial challenges in the pathway to accessing ARTs. However, these women received different forms of support which enabled the use of ARTs. These ARTs have given infertile and childless couples a glimmer of hope and the chance to escape the strain and stigma of childlessness in society. This study recommends that public health professionals collaborate with ART service providers in providing psychosocial care in addition to basic clinical care. Future studies can explore the perspectives of significant others as they played key important roles in the decision and motivated ART use.

Ethical Approval and consent to participate

All methods were carried out following relevant guidelines and regulations. Ethics approval, with reference number BUHREC (BUHREC852/22) was obtained from the Health Research and Ethics Committee (BUHREC) at Babcock University, Nigeria. Approval was also obtained from the support group admin where the data was collected. Participants were informed that participation in the study was absolutely voluntary; therefore informed consent was obtained from all the participants in the study. Participants' anonymity and confidentiality were ensured first since researchers were not allowed direct contact with the women and secondly no names were included in the responses, except other socio-demographic details used to describe the basic characteristics of respondents. Consent was confirmed when respondents returned responses privately to the data collector.

Availability of data and materials

In case required the datasets used/or analysed in this study can be obtained from the Lead Author upon reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

No external financial support was obtained for this research nor its publication

Authors' contributions

AUC and ASO conceptualized and designed the study. AUC, ASO, LSA, and SN were involved in data analysis, drafting the manuscript, and approving the final manuscript. SN submitted the manuscript. All authors read and approved the final manuscript before dissemination.

Acknowledgments

The authors would like to express their appreciation to the participants and team leads for their cooperation and assistance in data collection during this study period.

Consent for publication

Not applicable

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No competing interests reported.

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The Decision-making Pathway and Enablers to the Utilization of Assisted Reproductive Technology in Lagos Metropolis: an interpretive phenomenological study

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Abstract

Background

Methods

Results

Conclusion

Background

Methods

Data analysis

RESULTS

Socio-Demographic Characteristics of Respondents

Decision to Use

Inter-personal:

Relational:

To expand our family”. (Participant, O)

Enablers to use Assisted Reproductive Technologies

Social Support (emotional):

Social Support (informational)

Social Support (Appraisal)

Inter-personal Influences

(Participant, D)

Information on underlying illness conditions requiring ART

Professional Recommendation

but we told her that there was no money”. (Participant, P)

(Participant, H)

Lay Suggestions

(Participant, Q)

Discussion

Study limitations

Conclusion

Declarations

References

Additional Declarations

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