In Sudan, having children is a social obligation to the extent that marriage is considered incomplete when there are no children. In addition, the pronatalist culture continues to persist, especially in rural areas, thereby making the burden of infertility even more pronounced. This creates an endless search for conception from various treatment options. At the same time, social values are placing high emphasis on biological parenthood while still praising the traditional ways of dealing with infertility. This study explored the experiences of infertile married women and their perceptions about self-management of infertility, factors that influence selection and use of self-management strategies, types of self-management strategies, and effectiveness or harmfulness of self-management strategies.
The study has proved that Sudanese women experience with self-management of infertility is very rich. The finding that majority of the participants mentioned that Sudanese women use self-management strategies to treat infertility has strong support in the literature which had reported use of a variety of self-management strategies, especially modalities which perceived by women as natural [22–24]. However, despite the reported high use of traditional treatment options, researchers believe actual use is still higher. This is because it is documented in the literature that use of self-management strategies is under-reported because those who use complementary and alternative medicine to treat their infertility do not disclose use of these strategies even to the fertility specialists they consult [25–28].
When it comes to factors that may lead women to go for self-management strategies, unaffordability of modern treatment options was mentioned by the majority of the women participated in the study as a factor pushing women suffering from infertility problem towards trying self-management strategies. In fact unaffordability of modern treatment strategies of infertility, especially reproductive technologies, is widely reported in the literature in both developed and developing countries. For example, a study conducted in the United States reported that out of the fifty states of the country only fourteen give insurance coverage for assisted reproductive technologies [29]. This uncovered cost is prohibitive and may result in only very few numbers chose to go for infertility treatment via this means. Also a study conducted in the United Kingdom revealed similar findings of prohibitive unaffordable cost experienced by low income earning British South Asians who wish to utilize assisted reproductive technologies service as infertility treatment option [30]. Other studies conducted in other parts of Europe documented similar experiences [31].
The situation in developing countries is even more severe with regard to unaffordability of modern treatment options of infertility. This is because national health insurance in those countries rarely covers infertility treatment [32, 33]. For example, in Egypt, the neighbouring country of Sudan, a single trial of in-vitro fertilization could cost more than twice the annual income of the average Egyptian [32]. Similar findings were reported in Nigeria and Ghana [34, 35].
The issue of unaffordability of modern infertility treatment options is exacerbated by the low success rates of procedures across regions. For example, success rates of assisted reproductive technologies are estimated at 27% in the United States [29] and around 20% in Latin America [36]. When it comes to the Sub-Saharan Africa region, where Sudan is located, success rates of in vitro fertilization procedures are estimated at between 5% and 15% [34]. This therefore complicate further the issue of unaffordability as it leads to a situation of repeated in vitro fertilization procedures making it more difficult for the average citizen to be able to afford it. In addition, repeated failure of this modern treatment procedures also bring mixed feelings of hope followed by despair when success is not achieved after every trial which may lead to dropping modern treatment options altogether and shifting to self-management strategies as had been shown in the current study where more than half (53.7%) of participating women viewed the unsuccessful use of modern medicine as a possible cause for trying self-management strategies. It is also reported in the previous literature the use of complementary or alternative medicine as a consequence of dissatisfaction with, or poor outcomes associated with modern medicine [37, 38].
Sudanese societies are very conservative and exhibit high level of religiosity in their perceptions about infertility. Additionally, infertile women at a point during their treatment seeking journey fed up with the lack of success with formal treatment services and thus become more inclined towards spiritual efforts based on the belief that God is the ultimate giver of children. Therefore, it is not surprising for Sudanese women to put Qura’an and Sunna treatment provided by Shaikh as the top preference among other types of self-management strategies. A Shiakh is a traditional healer closely connected with the muslim faith. Shaikhs provide treatments, most often something connected with Qura’an reciting, or Qura’an writings prepared to be worn on the body as amulets, or concoctions drinks. They are widely consulted by many Sundanese for all kinds of problems. However, these traditional beliefs connected with ‘Shaikhs’ are common throughout African continent, although the way the help presented by ‘Shaikhs’ may differ from region to another. In the neighbouring Egypt, Shaikhs deals with a mysterious infertility cause called ‘Kabsa’ [39], and in Zimbabwe Shaikh represented by the ‘nganga’ who treat the infertility problem due to the annoyance of the ancestors because the husband has failed to pay enough bride price [40]. Other studies in other developing countries outside Africa reported that women follow religious practices, either simultaneously or subsequently, when allopathic treatment does not work [41, 42]. Also in Sudan many societies had a belief that infertility attribute external supernatural agents operate out of envy and jealousy. The only remedy in such situations is religious practices provided by Shiakhs.
One of the interesting issues revealed in this study that was not been addressed in the previous literature is that one-quarter of the respondents agreed with the statement “The best strategy for self-management of infertility is conventional medicines recommended by relative and friends who had experience with these medicines”. In fact use of conventional medicines based on the recommendations of relatives and friends for several treatment purposes is not uncommon in Sudan and deserve further study.
However, despite all that rich experience and wide use of self-management strategies to treat infertility, the study revealed that more than half of the respondents perceive self-management strategies of infertility as dangerous. Also, slightly less than half (42.9%) agreed with the statement that their ‘cognitive knowledge about self-management of infertility does not encourage its use’. These negative perceptions about safety of self-management strategies of infertility may look contradicting with the wide use, but it can be explained in light of the pressure from husbands, in-laws and society in general to conceive. A study conducted in Jordan revealed similar findings that in spite of the risk encountered when using herbal medicine with conventional medicine, participants still using them [43]. In addition, the unsuccessful previous trials or decreased potential of conventional medical interventions may lead to that some women become ‘desperate’ to try anything to achieve the desired motherhood. Support of these findings has been widely documented in previous literature [14, 44–47].