The impact of socio-economic characteristics on Sudanese women’s use of complementary and alternative medicine for self-management of infertility

doi:10.21203/rs.3.rs-4690490/v1

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The impact of socio-economic characteristics on Sudanese women’s use of complementary and alternative medicine for self-management of infertility

https://doi.org/10.21203/rs.3.rs-4690490/v1

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Background

Although Sudanese women have rich experience in the use of complementary and alternative medicine for self-management of infertility, but still literature discussing this issue is scarce. Therefore, this study aimed to fill this gap by examining the association of socioeconomic characteristics of Sudanese women with, as well as their predictability of, use of complementary and alternative medicine for self-management of infertility.

Methods

This was a cross-sectional study involving 203 infertile women attending infertility clinics in Khartoum State, Sudan. The interviewers administered questionnaire comprised two parts: the first sought to collect data on self-management strategies of infertility, and the second sought to collect personal data of the respondents. Association between socioeconomic characteristics and use of self-management strategies for treatment of infertility were assessed using one-way analysis of variance (ANOVA), while determinants of that usage were assessed using simple linear regression.

Results

Age of the majority of respondents clustered at the two middle groups (28–37 and 38–47). Few of the respondents had education less than primary (3.0%), while those with higher education representing almost half of the sample (49.8%). ANOVA showed that while only education level was independently associated with the factors that influence Sudanese women’s selection of infertility self-management strategies (p = 0.008 and p = 0.030), all socioeconomic characteristics were associated with the types of strategies Sudanese women use for self-management of their infertility. Simple linear regression results showed that all socioeconomic factors had predictive power (p < 0.05) when correlated with Sudanese women perceptions about strategies used for self-management of infertility.

Conclusions

Socioeconomic factors that potentially impact Sudanese women’s strategies used in self-management of infertility were identified. Results highlighted the association of Sudanese women’s strategies used in self-management of infertility with socioeconomic characteristics of the respondents. The study offered policymakers with information to re-examine the loose or relax rules governing the complementary and alternative medicine use in the societies of developing countries in general and Sudan in specific, as the culture of these societies seems to encourage the usage of self-management strategies.

Complementary and alternative medicine

Infertility

Self-management strategies

Sudan

Treatment seeking

Infertility is commonly defined as the inability of a couple to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse [1]. It is a growing problem estimated to affect about 15% of couples in childbearing age [2]. The World Health Organization (WHO) reported that about 80 million people worldwide have infertility problems [3]. A more recent study gave an estimate of about 80 − 168 million of people suffering from infertility [4]. Reports collected between 1990 and 2017 from 195 countries showed that infertility cases were increasing [5]. These reports about continuing increase in the cases of infertility worldwide had led the WHO to declare infertility as a worldwide reproductive health problem [6]. However, infertility do not distribute evenly all around the world, but the prevalence and incidence of infertility vary dramatically between countries and regions [7, 8]. Estimates suggest that in the developing world, the overall burden of infertility is over three times higher than developed countries. It is even higher in Africa than in other continents and range from 20–35% [9–11]. In sub-Saharan Africa, the prevalence of infertility varies from 2.5% or greater in Guinea, Mozambique, Angola, Gabon, Cameroon, and the Central African Republic to around 10–30% in Nigeria [7, 12]. In Sudan, which is a sub-Saharan country, literature showed that the burden of infertility among couples varied significantly [13–15]. Reports recorded by different studies showed that overall infertility in Sudan widely varied from 10.4–18% [16, 17].

In addition to be an important public health issue, infertility in Africa, especially for women, had serious social consequences [18]. African societies, Sudan is not an exception, highly emphasizing parenthood. This because children in those societies, in addition to caring for older parents, are considered as economic security for their parents in their old age. Even in societies with social support systems, children are expected to provide care for the elderly [19]. Therefore, with the view of the importance attached to parenthood in African societies, it is not surprising for women suffering from infertility to face psychological, familial and community pressure leading them to seek, in addition to conventional medicine, various traditional treatment strategies [20, 21].

Although high prevalence rates of childlessness among married women were reported long time ago [22], but infertility is an emergent issue in Sudan. Sudanese women encounter challenges associated with an extremely complicated combination of socio-cultural values and inadequate health care services that not only contribute to their infertility problem but also prevent them from getting formal treatments to manage or cure it. Some of the challenges that Sudanese women encounter in their health care seeking include low literacy rate, poverty, inaccessibility and unavailability of health care services in general and reproductive health care services in particular, and stigma attached to infertility and seeking formal health care for it.

Although Sudanese women have rich experience in the use of complementary and alternative medicine (CAM) for self-management of infertility [23], but still literature discussing this issue is scarce. An understanding of the effects of socioeconomic factors on infertility self-management seeking behavior is crucial in order to inform policy and help public health policy makers mitigate any expected problem resulted from self-management in a better way. Therefore, this study is an attempt to assess the impact of socioeconomic factors on infertility self-management seeking behavior among Sudanese women.

Design and setting

This was a descriptive cross-sectional study conducted between July and August 2017 with the aim of investigating the perspectives of infertile Sudanese women on CAM seeking behaviour based on their socioeconomic characteristics, specifically: age, educational level, and economic status. It involved women who visited five private fertility centres in Khartoum State (Banoon Centre, Al-Estishari Centre, Al-Sir Abu Al-Hassan Centre, Al-Neel Centre, and Aadam and Hawaa Centre). Fertility and reproductive centres in Khartoum State were selected for several reasons. First, most of the infertility clinics operating in Khartoum; second, the largest hospitals, both public and private, are located in Khartoum; and third, the majority of physicians with obstetrics and gynecology specialty, especially those with sub-specialty in infertility, are based in Khartoum. Therefore, women with infertility problems from all regions in Sudan come to Khartoum for treatment and this improve the representativeness of the sample. Inclusion criteria were agree to participate, age above eighteen years, and have infertility problem. Exclusion criteria were those who have depression or communication problems. Using Raosoft software for calculating the sample size and considering 95% as a confidence level, 5% as a margin of error and 85% as a response distribution, our sample size is 195. A sample of 203 participants was interviewed using a convenient sampling procedure.

Data collection

The instrument used in this study was a survey questionnaire designed to measure Sudanese women’s perceptions about strategies used in self-management of infertility.

Items of the questionnaire were adopted from previously validated instruments in the literature [24, 25]. The questionnaire was organized in two parts. Part 1 sought data on how Sudanese women perceive their experience with self-management of infertility, factors that influence Sudanese women’s selection and use of self-management strategies, types of strategies Sudanese women use for infertility self-management, and Sudanese women’s perspectives on the effectiveness or harmfulness of infertility self-management strategies. Part 2 of the questionnaire sought to collect personal data of the respondents.

All non-demographic variables were measured on a 5-point Likert scale. The questionnaire was initially developed in English. Translation and back-translation was conducted to ensure accuracy. Prior to the distribution of the survey, the instrument was subjected to face validation by five experts from Directorate of Health Research - Ministry of Health - Khartoum State. These experts were requested to make suggestions on the relevance, adequacy, language level, content and comprehensiveness of the questionnaire items. The questionnaire was pre-tested among women possessing similar population characteristics to test the feasibility, reliability and validity of the proposed study design. The items of the questionnaire were tested for reliability using Cronbach's alpha, with an overall reliability coefficient of 0.628, indicating good reliability. The interviewers were recruited and given a formal training.

Statistical analysis

Data were entered, coded and analyzed using the Statistical Package for Social Sciences (SPSS), version 18 that used to analyze the preliminary data and run one-way ANOVA and simple regression. Variables that had P value ≤ 0.05 were considered statistically significant. Descriptive analysis (Frequencies/percentages) was conducted for the demographic data.

Before running the inferential analysis, continuous data was investigated for normality by observing the Q-Q Plot and the histogram. It was noted that the Q-Q Plot was straight and the histogram was normally distributed, suggesting normality of the data. The Skewness value for each continuous variable was checked. The Skewness value of all the continuous variables fell between − 0.4 and + 0.6, suggesting that they were normally distributed. In order to examine the mean difference in Sudanese women’s perceptions about strategies used in self-management of infertility that might exist among women's groups according to their socioeconomic characteristics, ANOVA was utilized. Correlation between socioeconomic characteristics of women and their perceptions about strategies used in self-management of infertility were determined using simple linear regression. Before carrying out the simple linear regression analysis, it was made sure that the tolerance value for the three independent variables are 0.834, 0.758 and 0.900 which are not less than 0.10; therefore, we have not violated the multicollinearity assumption. This is also supported by the VIF values, which are 1.200, 1.320 and 1.111 which are well below the cut-off of 10.

Ethical consideration

The study was approved by the Research Ethics Committee in the Department of Health Research, Ministry of Health, Khartoum State. The consent for interviewing the women was taken from the General Directorate for Private Clinics, Doctors in-charge of infertility clinics and from the infertile women. The participants were interviewed at the clinic premises during follow-up clinic visits.

A total of 203 participants seeking infertility treatment were contacted at fertility and reproductive clinics. Sample size was supposed to be 196 but data collectors were acquainted with extra number of questionnaires to compensate for those who refuse to complete the questionnaire.

Demographic profile

The age of the respondents clustered at the two middle groups (28–37 and 38–47), while those with older age (> 47) were the least. To some extent, the participants distributed evenly all through the groups regarding their annual income. Few of the respondents had education less than primary (3.0%), while those with higher education representing almost half of the sample (49.8%). Details of the participants' socioeconomic characteristics were presented in Table 1 below.

Table 1

Demographic Profile of the Sample
Variable	Category	Response Information
Age	18–27	43 (21.2%)
	28–37	71 (35.0%)
	38–47	73 (36.0%)
	> 47	16 (7.9%)
Education levels	Pre-elementary	6 (3.0%)
	Primary	29 (14.3%)
	Secondary	67 (33.0%)
	Higher education	101 (49.8%)
Economic status (SDG/Year)	< 1800	28 (13.8%)
	1800–3600	56 (27.6%)
	3600–54000	52 (25.6%)
	54000–72000	35 (17.2%)
	> 72000	32 (15.8%)

Insert Table 1 here

Results of the one-way ANOVA indicated that there was no significant difference in variables measuring Sudanese women’s experience regarding self-management of infertility based on age, education level, or economic status.

The one-way ANOVA also was employed to investigate the impact of respondents’ socioeconomic characteristics on the factors that influence their selection of infertility self-management strategies. With exception of education levels, no significant difference was observed among other socioeconomic groups. The results of the ANOVA test indicated there was significance difference in the means of educational levels of respondents among the two factors; "My relatives and friends think that I should use self-management of infertility" and "The unaffordability of modern strategy of infertility management cause Sudanese women to try self-management strategy" (F = 3.583, 2.086 and p = 0.008, 0.030 respectively). Because the findings were significant, a Tukey’s honestly significant difference (HSD) post hoc test was employed to determine which groups were significantly different from each other. Tukey HSD post hoc test indicated that education level group primary differed significantly form secondary and higher education level groups (p < 0.029 and 0.048 respectively).

With regard to variables measuring types of strategies Sudanese women use for self-management of their infertility, results of one-way ANOVA showed significant differences in the means among all socio-demographic characteristics of the respondents. Tukey's HSD post hoc test indicated that age group '> 47' differed significantly form all other age groups (p = 0.021, 0.001 and 0.018 for age groups 18–27, 28–37 and 38–47 respectively). The remaining pairs of groups did not demonstrate significant differences. Tukey's HSD post hoc test showed that pre-elementary education level differed significantly form secondary and higher education levels (p = 0.005 and < 0.001 respectively). Also, primary education level group differ significantly from secondary education level (p = 0.038). The remaining pairs of groups did not demonstrate significant differences. Tukey's HSD post hoc test revealed that economic status group '< $600/year' differed significantly in the way they perceive types of strategies Sudanese women use for self-management of their infertility form '$1201 – $1800/year' and '> $2400/year' groups (p = 0.008 and 0.002 respectively). Also, '$600 – $1200/year' differ significantly from '$1201 – $1800/year' and '> $2400' groups (p = 0.026 and 0.006 respectively). Again '$1201 – $1800/year' differ significantly from '> $2400/year' group (p = 0.021). The remaining pairs of groups did not demonstrate significant differences.

When it came to Sudanese women’s perspectives on the effectiveness/harmfulness of self-management strategies, results of one-way ANOVA showed that only in the variable measuring “Self-management of infertility can be dangerous” revealed significant differences among means of age and education level groups (p = 0.000 and 0.007 respectively). Tukey's HSD post hoc test indicated that age groups '> 47' differed significantly form all other age groups (p < 0.001). The remaining pairs of groups did not demonstrate significant differences. Also, Tukey's HSD post hoc test indicated that pre-elementary education level group differed significantly form higher education level group (p = 0.022). The remaining pairs of groups did not demonstrate significant differences. Results of one-way ANOVA test for the perceptions of Sudanese women’s about strategies used in self-management of infertility based on socio-economic variables were summarized in Table 2 below.

Table 2

Association between socioeconomic characteristics of the Sudanese women and their perceptions toward self-management of infertility
	Age		Education levels		Economic status
	F	P	F	P	F	P
Sudanese Women’s Experience Regarding Self-management of Infertility
Sudanese women’s experience with self-management strategies of infertility is rich	0.617	0.605	1.812	0.128	2.032	0.091
Sudanese women use different strategies to manage different types of infertility	0.749	0.524	1.665	0.160	0.899	0.466
Sudanese women often use self-management strategies to manage infertility	1.852	0.139	0.862	0.487	2.041	0.090
Factors that Influence Sudanese Women’s Selection of Infertility Self-management Strategies
The most probable reason that causes women to use self-management strategies to manage their infertility is the unsuccessful use of modern medicine	1.531	0.208	0.813	0.518	0.269	0.898
My relatives and friends approve my decision on self-management of infertility	1.256	0.291	1.205	0.310	0.905	0.462
My relatives and friends think that I should use self-management of infertility	0.603	0.614	3.583	0.008	0.342	0.849
The unaffordability of modern strategy of infertility management cause Sudanese women to try self-management strategy	1.832	0.143	2.086	0.030	0.973	0.423
The unavailability of modern strategy of infertility management cause Sudanese women to try self-management strategy	2.599	0.053	2.729	0.084	1.175	0.323
There are a lot of contestations exist between women and others over self-management choices on infertility	0.561	0.641	1.108	0.354	2.078	0.085
Types of strategies Sudanese women use for self-management of their infertility
The best strategy for self-management of infertility is herbs that enhance fertility prescribed by the traditional herbalist	4.848	0.003	5.511	0.000	5.865	0.000
The best strategy for self-management of infertility is conventional medicines recommended by relatives and friends who had experience with these medicines	3.637	0.014	2.704	0.032	2.670	0.033
The best strategy for self-management of infertility is Qura’an and Sunna treatment provided by Shaik	3.355	0.020	3.548	0.008	2.070	0.086
Sudanese women’s perspectives on the effectiveness/harmfulness of self-management strategies they use to manage their infertility
My cognitive knowledge about self-management of infertility does not encourage its use	0.998	0.395	0.152	0.962	0.777	0.541
Self-management of infertility can be dangerous	8.185	0.000	3.624	0.007	0.990	0.414

Insert Table 2 here

Simple linear regression was carried out to assess the predictive factors associated with Sudanese women perceptions about strategies used for self-management of infertility. Both education and economic status were found to be significant predictors of the variable "Sudanese women’s experience with self-management strategies of infertility is rich" (p < 0.05). Standardized beta values, which illustrate the separate contribution of each independent predictor revealed that economic status (β = 0.181; p = 0.010) had the greatest contribution of unique variance, followed by education level (β = 0.166; p = 0.018)

When the variables measuring factors that influence Sudanese women’s selection of infertility self-management strategies, and variables measuring types of strategies Sudanese women use for self-management of their infertility were correlated with socio-economic characteristics of the respondents, both education level and economic status were found to be significant predictors (p < 0.05).

In case of Sudanese women’s perspectives on the effectiveness/harmfulness of self-management strategies they use to manage their infertility, only the variable "Self-management of infertility can be dangerous" was significantly predicted by age and education level. Standardized beta values showed that age (β = 0.263; p < 0.001) had the greatest contribution of unique variance, while education level is slightly lower (β = − 0.252; p < 0.001). The positive Beta results with age variable indicates that with older age influence increased, while the negative beta value for education level variable indicates with lower education levels influence increased. Details of the results of the regression analysis were shown in Table 3 below.

Table 3

Correlation between socioeconomic characteristics of the Sudanese women and their perceptions toward self-management of infertility
	Age		Education levels		Economic status
	β	P	β	P	β	P
Sudanese Women’s Experience Regarding Self-management of Infertility
Sudanese women’s experience with self-management strategies of infertility is rich	-0.048	0.499	0.166	0.018	0.181	0.010
Sudanese women use different strategies to manage different types of infertility	0.015	0.830	-0.041	0.562	-0.104	0.140
Sudanese women often use self-management strategies to manage infertility	-0.100	0.156	0.048	0.500	-0.041	0.562
Factors that Influence Sudanese Women’s Selection of Infertility Self-management Strategies
The most probable reason that causes women to use self-management strategies to manage their infertility is the unsuccessful use of modern medicine	-0.023	0.749	0.101	0.152	-0.023	0.743
My relatives and friends approve my decision on self-management of infertility	0.083	0.240	− .073	0.303	.006	0.930
My relatives and friends think that I should use self-management of infertility	0.080	0.256	0.160	0.022	0.050	0.478
The unaffordability of modern strategy of infertility management cause Sudanese women to try self-management strategy	-0.056	0.424	0.155	0.027	0.065	0.356
The unavailability of modern strategy of infertility management cause Sudanese women to try self-management strategy	-0.064	0.367	0.188	0.007	0.103	0.144
There are a lot of contestations exist between women and others over self-management choices on infertility	0.015	0.832	-0.098	0.168	-0.171	0.015
Types of strategies Sudanese women use for self-management of their infertility
The best strategy for self-management of infertility is herbs that enhance fertility prescribed by the traditional herbalist	-0.158	0.024	0.292	0.000	0.287	0.015
The best strategy for self-management of infertility is conventional medicines recommended by relatives and friends who had experience with these medicines	0.003	0.968	0.198	0.005	0.128	0.070
The best strategy for self-management of infertility is Qura’an and Sunna treatment provided by Shaik	-0.113	0.107	0.192	0.006	0.101	0.153
Sudanese women’s perspectives on the effectiveness/harmfulness of self-management strategies they use to manage their infertility
My cognitive knowledge about self-management of infertility does not encourage its use	-0.030	0.675	0.001	0.987	0.046	0.514
Self-management of infertility can be dangerous	0.263	0.000	-0.252	0.000	-0.065	0.358

Insert Table 3 here

This study explored the determinants of use of self-management strategies among infertile women in Sudan. It revealed that only older respondents differ significantly from younger age groups respondents in the way they perceive types of strategies Sudanese women use for self-management of their infertility. This finding has logical support as it is expected that increase in age will correlate with an increase in frequency of visits to both hospitals and traditional healers. In addition, older people can be expected to have a more traditional lifestyle and, therefore, to be more likely to contact a traditional healer when they are ill. In support for this result, several studies reported that older women are more likely to use CAM [26–29]. Contradicting results where CAM users were younger were also reported in the literature [30–32].

The current study showed that respondents with primary education level differ significantly in the way they perceive factors that influence Sudanese women’s selection of self-management strategies form secondary and higher education level groups (p < 0.029 and 0.048 respectively). Also pre-elementary and primary education level groups differed significantly in the way they perceive types of strategies Sudanese women use for self-management of their infertility form secondary and higher education level groups. Again pre-elementary education level group differed significantly in the way they perceive effectiveness of self-management strategies they use to manage their infertility form higher education level group. This finding is supported by the theoretical assumption that people with a higher level of education have more knowledge about modern medicine, and thus make less use of traditional medicine. In addition, several studies documented that respondents who are better educated visit traditional healers less frequently [26, 27]. However, other studies showed contrasting views with users of CAM are more likely to be respondents who are well-educated [30, 31].

Although affordability is an important component in use of health care services, but most of the variables tested against economic status of the participants in this study failed to give significant difference between low and high-income respondents. Only the variable “types of strategies Sudanese women use for self-management of infertility” showed significant difference with low income groups differ from high income. This finding is supported by other studies reported that women with low monthly income were more likely to be associated with herbal medicine use [33, 34].

In the present study, the variable (Sudanese women’s experience with self-management strategies of infertility is rich) was significantly correlated with both education level and economic status. This is consistent with the literature as association between demographic and socioeconomic characters, and experience with health care seeking behavior in case of infertility had been documented in a study reported a positive association between socioeconomic status and education level with seeking help in Assisted Reproduction centers [35].

The current study revealed that there is significant correlation between education level and the dependent variable "my relatives and friends think that I should use self-management of infertility". This indicates that education level character is making a significant unique contribution to the prediction of this dependent variable. The positive beta result indicates that with higher education levels influence increased. This finding is supported by a study conducted in Sierra Leone documented that the participating women mentioned family members and friends as the main factors influence their decision to use herbal medicine [34]. This is logical as in Africa, community including family and friends, defines womanhood as the ability of giving birth to a child. Therefore, women unable to bear children may experience psychological distress and difficulties in coping due to a perceived inability to fulfil their prescribed gender role [36–38]. In addition, it was reported in the literature that in Africa older family members have the major role in decision-making regarding reproductive health [39]. This makes use of CAM is often a family rather than an individual decision.

The same correlation was revealed between education level and the dependent variables: "the unaffordability of modern strategy of infertility management cause Sudanese women to try self-management strategy" and "the unavailability of modern strategy of infertility management cause Sudanese women to try self-management strategy". These results were supported by several studies reported that the proximity of the hospital and low cost of alternative medicine are the major factors that push infertile women into using alternative medicine for self-management of infertility [29, 40, 41].

Therefore, it can be said that in Sudan education level of the woman does not contradict the effects of family and friends, availability, and affordability on women choice of self-management strategies. On the contrary, higher education level encourage the use of self-management strategies. The high use of herbal medicine among highly educated women may be due to high exposure and high knowledge about risk and benefits of herbal medicine use, which make highly educated women able to make well-informed choices. These findings are supported by a study conducted in Uganda and reported association between higher education and use of herbal medicine [28]. However, contradicting results were also documented in other studies reported that herbal medicine users were more likely to be less educated [33, 34].

When types of self-management strategies were correlated with socioeconomic characters of the respondents, the first type which is herbs prescribed by the traditional herbalist produced statistically significant correlation with all socioeconomic characters. The p value is less than 0.05 for age, education level and economic status. This indicates that all independent variables are making significant unique contribution to the prediction of the dependent variable. This is the only variable in this study to be found to have significant association with all socio-economic characters. This is consistent with previous literature which has also documented association between use of herbs prescribed by traditional herbalists and socio-economic characteristics of respondents in several studies conducted in developed and developing countries [42, 43]. However, the negative beta result for economic status indicates that with lower economic status influence increased. This result is supported by several studies showed that women who had higher income were less likely to use alternative medicine [29, 44]. However, contrary findings were also reported where household income was positively correlated with alternative medicine use [45].

Limitations of this study include social desirability bias and being a clinic-based study. The respondents were selected from five infertility clinics located in Khartoum; therefore, their views and opinions may not fully reflect those of the other infertile women who never seek formal treatment. However, despite these limitations, this study is the first in Sudan to examine the impact of socio-economic characteristics on Sudanese women's use of self-management strategies for treatment of infertility.

This study identified socioeconomic factors that potentially impact Sudanese women’s strategies used in self-management of infertility. Results highlight the association of Sudanese women’s strategies used in self-management of infertility with socioeconomic characteristics of the respondents. Significant differences were shown between older and younger respondents; pre-elementary/ elementary and secondary/ higher education respondents; and low and high income on the way they perceived strategies used in self-management of infertility. In addition, all socioeconomic characteristics were found to be positive predictors of strategies used in self-management of infertility. This study offered policymakers with information to re-examine the loose or relax rules governing the CAM use in developing countries, as the culture of these societies seems to encourage the usage of self-management strategies. In addition, there is a need to explore the potential benefits and risks of CAM use.

ANOVA

Analysis of variance

CAM

Complementary and alternative medicine

WHO

World Health Organization

Ethics approval and consent to participate

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no conflicts of interest to disclose.

Funding

This work received no funding.

Authors’ contributions

S.A.M.B. designed the study and implemented the research. E.I.M.H. designed the study and supervised the interpretation of the results. G.O.E. designed the study and supervised the interpretation of the results. A.A.A. wrote the draft of the manuscript and analysed the results. All authors discussed the results and contributed to the review of the final manuscript.

Acknowledgments

We appreciate the valuable assistance of the senior employers in the Department of Health Research, Ministry of Health, Khartoum State who helped in recruiting the data collectors and facilitated contacts with fertility clinics.

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No competing interests reported.

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The impact of socio-economic characteristics on Sudanese women’s use of complementary and alternative medicine for self-management of infertility

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