Document Type : Original Article
Authors
1 Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
2 Division of Health and Social Care, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
Abstract
Keywords
Infertility is recognized around the world as
a distressing experience with the potential for
threatening individual, marital, family and social
stability (
The aims of infertility counselling therefore
are to explore, understand and resolve issues
arising from infertility and infertility treatment,
and to clarify ways of dealing with the problem
more effectively (
Also the UK Department of Health evidencebased
clinical practice guideline has mentioned
that the government is aware of the evidence of
the benefits of counselling and believes that it
can play a valuable role in helping patients make
informed reproductive decisions and understand
their implications (
Despite the aforementioned agreements on the
necessity of counselling infertile couples, very
few patients use these services when made available
to them (
The reasons for not using psychosocial counselling
services have been investigated by Boivin
et al. (1999) (
The reliance on one’s ability and resources,
which has been reported by infertile patients
in the aforementioned literature, could be discussed
in relation to individuals’ religion and
spirituality. Religion is a particular doctrinal
framework which guides sacred beliefs and
practices about a higher power or God. It is a
system of beliefs and practices that structure
how people worship. Spirituality refers to the
beliefs and practices that connect people with
sacred and meaningful entities beyond themselves.
These beliefs and practices often create
a relationship with a supreme power which
gives meaning and purpose to life (
Latifnejad Roudsari et al. have argued that
infertile women turning their attention to religious
and spiritual beliefs show connectedness
to a higher being who can be trusted and believed,
as a source of strength, guidance, and
support (
In this regard, Hynie and Burns have argued
that religious beliefs may provide limits on the
acceptability of various treatment options (
Thus far, little research has examined the influence
of religiosity on the experience of infertility
(
Grounded theory was the methodological approach
that underpinned and guided this research.
Grounded theory is a qualitative research method
that is useful for generating research-based
knowledge about the behavioural patterns that
shape social processes as people interact with
each other (
The study settings were two referral hospitals in London and one Iranian Infertility Research Centre in Mashhad. To explore the experiences of infertile women regarding counselling in a wider religious context and a larger ethnic mixture it was decided to recruit the participants from the multifaith society of the UK and the religious community of Iran.
Participants were thirty infertile women with primary or secondary infertility, who had been diagnosed as infertile through preliminary tests by their general practitioners. Women who were infertile due to a physiological problem in the female, male or both and those who were infertile due to unknown causes, irrespective of the duration for which they had been trying to become pregnant, were recruited. Women with an adopted child or with a newly positive pregnancy test, who no longer struggled with fertility problems during the study period, were excluded from the study. In addition, women who might not adequately understand verbal explanations or written information given in English were not included in the study.
Participants were affiliated to different denominations of two monotheistic religions, i.e. Islam (six Shiites and six Sunnis), and Christianity (ten Protestants, six Catholics and two Orthodoxies). Having chosen grounded theory as the methodological approach, the sample size was determined by purposive and theoretical sampling and data saturation. To maintain diversity in participants’ recruitment it was endeavoured to consider the diversity in terms of participants’ age, social class and ethnic background, in addition to their religious affiliations. A summary profile of all participants has been demonstrated in table 1. To recruit women, they were given an invitation letter and the patient information sheet. They were given time to study the information sheet and the opportunity to ask questions from the researcher. If they were interested in taking part in the study, they were interviewed after their appointment, or alternatively an appointment was arranged with the researcher in the future.
In this study a combination of data sources including formal interview, observation of nonverbal behaviours during the interviews and the writing of post-interview notes and diaries, were used to collect the data. All interviews were conducted by the first author who is a midwife lecturer/ researcher with experience in interviewing infertile women. She was trained at the University of Surrey, UK as a qualitative researcher and supervised by an experienced qualitative researcher (the second author).
Interviews were conducted face-to-face in one of the interview rooms of the fertility clinics allocated for this purpose, using a semi-structured interview guide. In order to keep the natural flow of the dialogue between the participants and researcher, the questions about religion and spirituality were introduced when the interviewee spontaneously mentioned God, religion or spirituality as a resource for managing emotions. If no reference to God, religiosity or spirituality was made by the participant, then the researcher asked the related questions at the end of the interview. Participants were asked about how their religious and spiritual beliefs may affect the way they perceive infertility, the strategies that they use for coping with their fertility problem and their viewpoints on getting help from counselling services. Each interview took on average between 45 and 60 minutes and was audio-taped and transcribed fully for data analysis. It is noteworthy that the interviews related to the Iranian participants were carried out in Persian. Then after data transcription they were translated from Persian to English by the first author whose native language is in the same dialect of the interviewees, and who had been trained for this purpose at Language Centre, University of Surrey, UK. This could minimize inherent threats to the validity of cross-language translation. To validate the translation, two translated interviews were also checked by two native Persian speakers who were experts in English in Iran, as well as two native English academics in the UK.
Data analysis was accomplished adopting Strauss and Corbin’s mode of grounded theory that included three levels of open, axial and selective coding. It was concurrently carried out by data collection, i.e. the data collected were transcribed and analyzed immediately after each interview. One reason for this practice was that in grounded theory the incoming information from participants determines the information which should be sought. For quality assurance of transcription, transcripts were reviewed by both two researchers. Using the constant comparative method, data were coded line by line. Codes were grouped together in categories and the constant comparison of categories continued as the properties of each category emerged. As comparison went on, hypotheses about the relationships among concepts were generated and checked against raw data. To avoid potential misrepresentation of data and in order to seek consensus between the researchers, the codes, subcategories and categories were further discussed, which led to refinement of the scheme of abstracted categories.
Lincoln and Guba’s key concepts of rigour including
credibility, conformability and transferability
were used to support the enhancement of
data analysis quality (
Frequency distribution of participants’ demographic characteristics
Age (year) | Marital status | Education | Occupation | Ethnicity | |||||
---|---|---|---|---|---|---|---|---|---|
6 | Married | 27 | High school | 12 | Employed | 27 | White British | 5 | |
10 | Partnership | 3 | College | 3 | Housewife | 3 | Asian | 7 | |
11 | University | 15 | African | 6 | |||||
3 | European | 4 | |||||||
Asian British | 4 | ||||||||
African British | 4 | ||||||||
Religion | Religious/Spiritual score | Infertility factor | Infertility duration | Type of infertility | |||||
6 | 14-33 | Female | 19 | <5 years | 16 | Primary | 26 | ||
6 | 34-52 | 1 | Male | 4 | 5 to 10 years | 3 | Secondary | 4 | |
10 | 53-70 | 4 | Both | 3 | ≥10 years | 11 | |||
6 | 25 | Unknown | 4 | ||||||
2 | |||||||||
The study was approved by Research Ethics Committees of Queen Charlotte’s and Chelsea Hospital, Elizabeth Garrett Anderson and Obstetrical Hospital and University of Surrey. All participants signed the informed consent form and were assured that anonymity and confidentiality would be maintained. They could refuse to participate or withdraw from the study at any time without prejudice to their clinical treatment.
Through analysis three categories emerged including: appraising the meaning of infertility religiously, applying religious coping strategies, and gaining a faith-based strength. These were encompassed in the core category of ‘relying on a higher being’. The core concept was that the majority of religious infertile women believed in a supreme power, who can be called to for assistance in the occasion of devastation and desperation in their lives. This made the experiences of infertile women who were affiliated to different religious faiths, congruent and well-matched.
The findings of this study showed that participants
using a religious/spiritual meaningmaking
framework tried to reappraise their illness
religiously and spiritually. They trusted a
higher power who can protect individuals, and
endeavoured to gradually accept themselves as
infertile. They gave a sacred meaning to everything
in their life, had a particular loving relationship
with God and considered every Godgiven
phenomenon as a gift, believing in the
logic behind it. They viewed their infertility as
God’s will and believed that nothing can happen
without God’s contribution as He has absolute
control over people’s lives; thus people should
accept what God has decreed for them. In addition
to this, participants in the current study
talked about an internal knowing, certainty and
assurance that they will be blessed by a compassionate
and merciful God, either through having
a child or in other ways as
They contemplated that they should accept
God’s plan with enthusiasm as His will is the most
advantageous course for their lives, because they
are being loved by God and He knows
This worldview resulted in optimism and positive thinking which empowered the women in their journey to be able to accept their identity as infertile. Gradually they tried to take responsibility and control over all aspects of their lives by adopting some strategies to cope with infertility. They employed a wide spectrum of religious coping strategies, which are rooted in their religious teachings. These strategies consisted of a combination of positive and negative religious coping strategies which enhanced their emotional capability and as a consequence helped them to overcome their stressful situation.
Positive religious coping strategies included
benevolent religious reappraisal:
In the other hand, some religious participants
adopted negative religious coping strategies
including demonic reappraisal:
A range of non-religious coping strategies such
as ignorance:
Having adopted these varieties of coping resources
helped infertile women to obtain a feeling
of self-confidence and empowerment and
consequently the ability to manage their emotions.
One of the Baptist participants commented:
The other issue that the majority of the religious
participants discussed was the sufficiency
of their religious teachings as the best
source of counselling:
They believed that they were able to find everything
in their holy book:
It is worthwhile to say that some of the religious
participants were even eager to help
other people struggling with fertility problems,
and it showed their emotional strength. In this
regard, one Baptist participant said
In contrast, some religious infertile women
acknowledged counsellors’ help and support,
but they liked religious issues to be addressed
in their counselling sessions. One of the Christian
participants (Church of England) indicated
her hesitancy in choosing either somebody who
is an expert in infertility counselling or someone
who is a strong religious person but with
less expertise. Nevertheless, her preference in
both cases was having the opportunity to talk
about God, because she believed that life does
not make sense for her without God:
Research studies have shown that religion and
spirituality are highly valuable for many people
during their confrontation with crisis, trauma
and grief (
However, little research has examined the influence of religious beliefs on the experience of
infertility and patients’ decisions regarding its
treatment. Also, very little is known about considering
religious concepts in infertility counselling.
Molock who has investigated the religious
and cultural aspects of infertility in the African-
American community argues that spirituality
is a very important cultural value for African
Americans (
The findings of this study showed how religious
and spiritual frames of reference transformed infertile
women’s views of infertility from an unbearable
life crisis to a tolerable process which
can be dealt with in order to achieve spiritual
growth and development. This notion is congruent
with what Sewpaul mentioned regarding infertile
women who reappraised infertility as an opportunity
for re-evaluation of one’s life, values and
relationship with God and as a challenge which
provided the opportunity for positive change
(
The findings of this study highlighted that religious
participants achieved feelings of optimism
and peace regarding the emotional burden of infertility
by adopting religious/ spiritual coping
strategies, which arise from their religious teachings
and divine outlook on life. This finding is
in agreement with what Domar et al. observed
(
A further finding of this study was that most
religious infertile women felt that their religious
coping resources were sufficient to manage the
strain of their infertility. They experienced their
religious teachings and holy book as the best
source of counselling and believed that they
have religiously been taught how to manage
life crises. Also the support that they received
through their religious husbands, congregation
and clergies resulted in less reliance on formal
support resources like counselling services.
Boivin et al. in her study entitled:
It is worthwhile to point out that in this study
some of the participants expressed their desire
and wish for religious and spiritual topics
to be addressed in counselling. Puchalski,
with regard to paying attention to the spiritual
concerns of patients, has argued that spirituality
may be a dynamic force in the patients’
understanding of illness and can affect their
decision-making for treatment. Therefore an
understanding of patients’ spirituality is integral
to their whole care (
Latifnejad Roudsari et al. have argued that
health professionals can encourage patients to
initiate discussion regarding their religious and
spiritual background, in addition to their medical
history (
In the process of exploring the religious and spiritual experiences of infertile women, it is important to keep the limitations of this study in mind. One potential limitation was the researcher’s reliance on participants’ self-reports of their religiosity and spirituality. The other issue was the relatively small sample size which is a common issue in qualitative methodologies. However, although the sample size was small, it was purposeful and the logic and power of purposeful sampling lies in selecting information-rich cases for in-depth study. Furthermore, in qualitative studies the researchers do not attempt to generalize their explanations in an empirical way; instead, they try to make a theoretical generalization which is more productive.
As infertility is a multifaceted problem and
results in multiple losses, health professionals
who are working in fertility clinics need to
consider all aspects of holistic care when caring
for women with fertility problems. Holistic
care considers not only the psychological, social
and cultural needs of individuals, but also
their religious and spiritual needs (