Infertility is a major challenge among couples, especially in developing countries. Globally, it is estimated that about 15% of women in their childbearing age are affected by infertility and the prevalence is expected to increase to 7.7 million by 2025 despite the available treatments such as Assisted Reproductive Technologies (ART) (1). Sub-Saharan Africa is one of the regions with the highest infertility prevalence (1). However, countries differ in the prevalence rate. For example, Gambia has an estimated 9 percent infertility rate, 21.2 percent in North-Western Ethiopia (2) and between 20 percent and 30 percent in Nigeria (3). In Ghana, the infertility prevalence rate is 11.8 percent among women and 15 percent among men (4).
Traditionally, the main causes of infertility have been ascribed to witchcraft, co-wives, envious neighbours, in-laws and past lovers (5). Voodoo, curses by ancestors or deities, evil spirits are recognised as the other traditional causes of infertility (6). Scientifically, infertility may be the results of genetic abnormalities, infections and sexual behaviour among others. Infertility among women is commonly caused by lack of ovulation, sexually transmitted infections, fibroids, sickle cell disease (7; 8) whiles in males, low sperm count and semen quality have been identified as the commonest causes of infertility (9).
Previous studies have argued that infertile women face social stigmatisation, economic hardships, social segregation and violence or expelled from marital homes (10; 11). In some Ghanaian societies, infertile women could be subjected to physical and emotional abuse (12). These practices depict that the Ghanaian society is against childlessness hence, their adverse treatments and attitudes towards people with fertility problems.
To avoid the challenges associated with infertility in Traditional African society, women explored various ways to achieve parenthood in the past. For example, a wife’s engagement in extramarital relations to have a child due to the infertility situation of the husband was overlooked (13). In the same way, a cleansing ritual was held to sanction a child born out of wedlock by a wife to an infertile husband (14). A similar tradition persisted among the Lo Dagaa tribe in Northern Ghana where a man becomes the legal father to all children born to a woman as long as he has paid the bride wealth (15).
In some other cultures, an infertile couple has the opportunity to bring up children as their own even though such children may not be related to them biologically. For example, a younger sister or a relative of an infertile wife may be brought into the marriage to bear children for the infertile couple (16). Another means adopted by infertile women to solve their infertility challenge in the Traditional African society was to marry or engage other women and claim ownership of all her offspring (17). This kind of relationship existed in different forms. For instance, a woman who has given birth to males could marry another woman to bear female children for her and vice versa.
Re-marriage and/or divorce are considered as other possible means of solving infertility challenges (18). Others also relied on adoption as an alternative way of coping with infertility although it was less accepted in the developing world (19). The use of herbal and/or complementary and alternative medicines (CAM) to treat infertility or enhance fertility was also practised (20)
Additionally, waxing and waning of the moon were believed to influence a woman’s fertility. Based on this notion, traditional astrologists were consulted for the provision of the rightful days in the month for sexual intercourse that would result in pregnancy (21). From the discussions, it appears that equal reproductive roles of both men and women in achieving pregnancy were not recognised in the past. Reproduction was thought to be the sole role and responsibility of the woman. Due to this reason, fertility rituals and traditions mostly targeted females.
However, in present times, the notion of reproduction has changed. Scientists have ascertained that reproduction required the male sperm and female oocyte. As a result, infertility is medically addressed as a couple’s issue rather than blaming it on the woman.
For many couples who are faced with infertility, conventional medical therapies, including various Assisted Reproductive Technologies (ART) are explored. Assisted Reproductive Technology is defined as “all treatments or procedures that include in vitro handling of both human oocytes and sperm, or embryos, to establish a pregnancy. These include, but not limited to, in vitro fertilization and embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer, tubal embryo transfer, gamete and embryo cryopreservation, oocyte and embryo donation, and gestational surrogacy. ART does not include assisted insemination (artificial insemination) using sperm from either a woman’s partner or a sperm donor” (22). Since 1978, ART has provided an alternative solution for many couples that are faced with fertility problems (23). By 2010, 55 percent of countries in the world were offering In-Vitro Fertilisation (IVF) services (24).
In Ghana, the first fertility hospital was established in 1995 and by 2017, the total number of fertility hospitals has increased to 12 (25). The recent upsurge in the number of fertility hospitals in Ghana probably suggests that despite the physical, social and financial challenges of accessing ART, the services are desirable due to the premium put on children in the country (26). However, scientific studies about this topical area in Ghana is limited. As a result, this study seeks to explore the self-reported experiences of undergoing ART treatment in Ghana. Assessing the experiences of women who seek ART treatment is useful since it tends to inform service providers to better understand clients' needs, expectations and challenges. It may also provide firm grounds for improvement in the areas of provision and utilisation of ART in Ghana.
The behavioural model of health services utilisation (27), which was revised by (28) underpins this study. The import of the framework is that an individual’s decision to seek infertility treatment depended on three interrelated factors: (a) predisposing factors (i.e. age, gender, socioeconomic status, health beliefs); (b) enabling factors (insurance, income status, access to medical care, and other individuals, family, and community resources) and (c) perceived and evaluated need (such as perception of a problem or an existing health condition). The model opines that an individual’s ability to utilise fertility treatment is based on a personal decision that is influenced by his/her role in society as well as the existence of the needed services at a particular time.
The predisposing factors are grounded on the fact that the tendency for an individual or a family to use health services can emanate from a set of personal characteristics. Individual predisposing characteristics are grouped into three distinct collections. These are demographic characteristics (age, marital status, religion and sex), social conditions and perceptual influence in terms of belief (27). These sets of variables come together to determine the social status of the individual in the society, lifestyle, physical and social environments and the use of health services. In the utilisation of ART, an individual’s predisposing factors may play a significant role to utilise service but there must be enabling characteristics such as financial resources to enhance utilisation. The financial resource includes an individual’s income, wealth and health insurance status.
On the other hand, institutional factors which consider service availability, organisation and delivery of services, workforces and accessibility also come to play in the treatment of infertility. In most cases, when these factors are favourable, individuals with infertility tend to utilise ART services more and vice versa.
The final factor which was considered by the model was the need factors. At the individual level, (29) distinguished between the perceived need for health services (i.e., how people perceive and experience their general health, functional state and the symptoms the condition presents) and evaluated need (i.e., professional assessments and objective measurements of patients’ health status and need for medical care). All things being equal, after self and medical assessments have proven the need for ART treatment, infertile women are likely to seek treatment.
The model was modified to include three mutually related characteristics: health care system, use of health services and consumer satisfaction (30). Further, the updated model also predicted that consumer satisfaction comes to play and this particular factor had the potential to motivate health care users in making a choice whenever they are confronted with a health problem. In summary, the model established that the characteristics of users and that of health service providers have a direct correlation with the utilisation of ART treatment.