Background: The infertility treatment process is associated with various psychological, physical, social, moral, and financial challenges, especially for women. The women are likely to report low marital satisfaction and emotional distress due to fertility treatment demands. This study explored how infertile women described their treatment experience and how they coped with treatment demands as they underwent treatment at three gynecology outpatient clinics in Kenya. Methods: A qualitative phenomenological research design was used to analyze and describe women’s fertility treatment experiences. The data were collected through semi-structured in-depth interviews with 33 infertile women selected purposively. Trustworthiness of the findings was ensured using Guba and Lincoln’s criteria. The recorded interviews were transcribed verbatim and then analyzed using reflective thematic analysis, developed by Braun and Clarkes. Results: Three themes and 13 sub-themes related to women’s fertility treatment experiences and coping strategies were identified. The theme challenges encountered during fertility treatment have three sub-themes: emotional distressing, physical pain, and financial constraining. Theme impacts of fertility treatment on relationships have three sub-themes: relationship with their husband, relationship with their family, and relationship with their friends. Finally, coping with fertility treatment has six sub-themes: religious practices and personal faith, giving in to feelings, shifting focus, taking a break, staying with their relative’s children, and receiving support from others. Conclusion: The experiences of women undergoing treatment are multi-dimensional. Therefore, incorporating psychosocial interventions or counseling into the fertility treatment routine with National Health Insurance Fund cards may reduce the treatment burden, improving women’s psychological well-being and relationships with their husbands, family, and friends.
A descriptive phenomenological with thematic analysis approach was employed to understand better the experiences of infertile women seeking treatment at three government gynecology outpatient clinics: Kenyatta National Hospital, Thika Level 5 Hospital, and Kiambu Level 5 hospital in Kenya. These hospitals treat individuals experiencing primary or secondary infertility; although they do not offer ARTs, those women who need these services are referred to private hospitals. A qualitative descriptive approach was used because it was most appropriate to explore the experiences of infertile women pursuing treatment regarding how they describe, react, understand and cope with their experiences. The study population was mainly infertile women seeking treatment at Kenyatta National Hospital, Thika Level 5 Hospital, and Kiambu Level 5 hospital in Kenya. Women were selected through purposive sampling with maximum variation, meaning that the researchers identified and chose participants who could provide extensive information about the phenomenon. In this study, the phenomenon was the experience of women pursuing fertility treatment. Maximum variation was ensured by sampling different hospitals and selecting women of different ages, education, marital status, infertility duration, number of children, previous abortions, time spent undergoing treatment, cause of infertility, and current treatment. Data collection was carried out from October 2021 to January 2022. During this period, trained nurses working in the three gynecology clinics identified and approached potential participants. Those women who met the inclusion criteria and willing to participate were given informed consent forms to read and familiarize themselves with the study. The women were informed that participation was voluntary and was free to withdraw at any time during the study without their care being affected. They were also assured of their confidentiality and were told this was a minimal potential study with no long-term effects [16]. Participants joined the study after providing written informed consent. The time and date of the interview were arranged according to participant preference. Women were included in this study if they were aged 20–44 years, (2) diagnosed with infertility, (3) undergoing treatment, (4) and able to follow the instructions, and (5) had mobile phone access. Women were excluded if they (1) had unstable mental conditions during the study period and (2) could not read or speak English and Kiswahili. A semi-structured interview guide was developed based on the study objectives and a review of relevant literature. The interview guide consisted of two parts. Session A consisted of 10 questions related to the social-demographic and clinical characteristics of the participants. Session B consisted of six questions to elicit information on the experiences of infertile women pursuing treatment regarding how they describe, react, understand and cope with their experiences. For content validation, the interview guide was reviewed by a gynecologist, and a qualitative research expert and pilot tested before interviews (see Table Table11). The interview topic guide Study aims Queries and clarifications Personal data Please tell me about yourself: age, occupation, education, marital status, duration of infertility (years), number of living children, previous abortion, time spent undergoing treatment (years), cause of infertility, and current treatment Experiences of infertility treatment How did you know you had a problem with getting pregnant? Could you share how you felt when you were told you have infertility? Could you briefly describe the fertility treatment you are currently undergoing? Could you tell me about your fertility treatment experience? Please describe how infertility treatment has affected your relationship with your husbands, family members, others, or daily activities? Coping strategies utilized while pursuing treatment Please, tell me how you cope with the infertility treatment experiences? The first author (AN) conducted the individual in-depth semi-structured interviews under the supervision of a woman health specialist (YL). Based on the women’s preferences, 30 interviews were conducted through Zoom, while three were conducted by telephone because the participants had no access to smartphones or computers. Since study interviews were conducted virtually or by phone, women were requested to choose a quiet private room. The interviews were conducted in English and Kiswahili depending on women’s preferences, and most women preferred speaking in English. The first author (AN) is a female Ph.D. student in Maternal Child Health Nursing with an extensive qualitative research background. She completed her qualitative research coursework during the first year of her Ph.D. program. A total of 35 women were contacted, and all agreed to participate, but two declined to participate due to privacy concerns. Therefore, 33 in-depth interviews were conducted. However, data saturation was reached after 30 interviews; the first author (AN) conducted three more interviews to ensure data saturation, meaning that no new themes or information emerged from the last few interviews. Before the interview, the women were informed how the interview would be conducted and that the interview would be audio-recorded. Oral consent was obtained from the study participants. The women were asked for their personal information, including age, occupation, education, marital status, duration of infertility (years), number of living children, previous abortion, time spent undergoing treatment (years), cause of infertility, and current treatment. Subsequently, general and open-ended questions were asked using an interview guide. For those participants who declined audio-recording, their interviews were handwritten. The probing questions such as how, what do you mean, and please explain more were used to elicit further information. Detailed notes were taken during the interviews. The interviews lasted between 45 to 60 min. All interview transcripts were sent to women via E-mail or WhatsApp for feedback. All participants reported that the transcripts reflected their interview responses regarding their experiences and coping strategies and suggested no corrections or changes. In a qualitative study, researchers recognize the importance of reflexivity and transparency about their preoccupations and assumptions [17]. The first author (AN) was born and raised in Kenya and moved to China to pursue her Doctorate studies. She has experience in obstetrics and gynecology as a nurse. Notably, AN did not have any prior relationship with study participants. The second author (JN) has an experience in nursing, public health, and reproductive health. He is currently pursuing his Doctorate in Public health in Kenya. The third author (MK) is a senior nursing lecturer at a Kenyan university and has an extensive experience in qualitative research and mental health. The fourth author (YL) is a senior nursing lecturer in China and a women’s health expert. Her positionality as an outsider- a foreign researcher- made her add insightful observations during the interview and data analysis process. The audio-recorded interviews were transcribed verbatim in the original languages by two authors (AN and JN). The third author (MK) checked the accuracy of the transcripts. The four Kiswahili transcripts were translated into English and back-translated to Kiswahili to check for translation accuracy. The translation was done by two authors (AN and JN), fluent in the two languages, and used consensus to solve disagreements. Software coding NVivo 12 was used to facilitate data management and coding. The data were analyzed according to six phases of reflective thematic analysis described by Braun and Clarkes [18] (see Fig. 1). First, two authors (AN and JN) read each transcript several times to fully understand its content. Second, the AN and JN independently coded the whole data set. Phrases or sentences that described experiences of infertile women pursuing fertility treatment and how they coped with their experiences were labeled with a short description of the content. Third, AN, JN, and MK agreed to combine codes to generate data-derived themes. After generating the initial themes, AN and JN returned to the dataset to determine whether the themes were data-driven, made sense, overlapped, told a convincing story, answered the research questions, or were other themes within the data. Next, all authors defined and named the generated themes, as shown in Table Table2.2. They also assessed identified themes to determine whether data sufficiently supported them. As for producing the report, we adhered to the Standards for Reporting Qualitative Research guidelines (SRQR) [19]. After themes were generated, we conducted member checking, a qualitative research method in which research participants verified the authenticity of qualitative results. Participants confirmed that the generated themes reflected their opinion regarding how they described fertility treatment experiences and coped with their experiences. Notably, codes, subthemes, and themes were arrived at through consensus by all authors. An example of the reflective thematic analysis is shown in Table Table22. Six phases of reflective thematic analysis Reflective thematic analysis: from codes to themes To ensure the trustworthiness of the study findings, we used Guba and Lincoln’s criteria of credibility, transferability, dependability, and confirmability [20]. Credibility was achieved through member check, involvement of all authors in the data analysis process, the credibility of the authors and their professional background, reflexivity of authors, searching for disconfirming evidence, and prolonged engagement with data. Transferability was enhanced through purposive sampling with maximum variation, providing a detailed description of participants and the research process and continuously returning to the data. Dependability was achieved through accurate translations and transcription of interviewers and having three external qualitative research experts review the interview guide, raw data, and observational notes. Confirmability was achieved by maintaining a reflective journal during the research process, where the authors documented their reflexivity, bracketing, or relevant events during the study. The study was approved by the Xiangya Nursing School of Central South University Ethical Review Board, the National Commission for Science, Technology, and Innovation (NACOSTI), and the Kenyatta National Hospital-University of Nairobi Ethics Research Committee. Additional approval was obtained from the respective county and sub-county commissioners, the ministry of health in the respective countries, and research site hospitals. All women consented to participate and allowed the researchers to make follow-up contact to confirm the components and interpretation of the data analysis. All methods were carried out following relevant guidelines and regulations. The 33 women interviewed were aged between 21 and 44 years; 14 women were employed, 12 were entrepreneurs, and seven were housewives. Three women had primary education, 11 had secondary education, and 18 had diploma certificates and above. Twenty-three women were married, four were living with a male partner, four were separated, and two were divorced. The duration of infertility ranges from 2–14 years. One woman had two living children, 14 had one child, and the remainder had no child. Nine women had a history of abortion ranging between 1–3 times. The time spent undergoing treatment was between 1–10 years. Seventeen women indicated female factor infertility; six reported male-factor, five said both female and male-factor, and five reported their infertility was unexplained. Regarding the type of treatment, nine women reported receiving medical treatment, 14 were undergoing surgical treatment with their partners, and ten were pursuing ART. Table Table33 is a summary of the participant’s demographics and clinical characteristics. Participants characteristics *F Female; M* male; U* unexplained; ART* Assisted reproductive technology (ART) included in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI)
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