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Abstract
There is a natural requirement for people to have children and it is profoundly impacted by social and strict estimations of each society (Mohammadpur & Ghodrati, 2018). Religious and cultural values which are unique to every community, play major roles. Having children prompts an ascent to societal position, marital security, social and financial assurance and it also facilitates to receive care at old age (Mohammadpur & Ghodrati, 2018). In most cultures, parenthood is an utmost important part of every adults life and it is obvious that those who are infertile would certainly have to deal with several social stigmatizations.
According to World Health Organization (2012), infertility is a state of sterility where an individual is unable to have a child after 12 months or more of unprotected sexual intercourse. Looking into the statistics, infertility is common in roughly 10% of couples worldwide, among them 55% will seek medications in the expectation of accomplishing parenthood (Vo, Tran, Le, Do and Le, 2019). The experience of infertility is an unwelcome interference to the individuals who anticipate that parenthood should be the key identity and Greil (1991) stated that an overwhelming majority of the couples are taken by surprise as a primary reaction to the acknowledgment of their infertility. Females after being diagnosed with infertility often experience elevated psychological symptoms most of which come under mental disorders like anxiety and depression (Mohammadpur & Ghodrati, 2018). As indicated by the World Health Organization (2012), depression is considered as one of the basic mental issues with the predominance among females being half higher than males and evaluated 350 million cases throughout the world. Women who are disabled in getting pregnant and giving birth to children face several negative life circumstances which include social isolation, stigmatization, marital instability, intimate partner violence or negligence, marital divorce, discrimination from the society (Hess, Ross & GilillandJr, 2018). All of these would contribute to the worsened psychological and physiological well-being. Therefore, this study emphasizes to compare the levels of depression among fertile and infertile females referred to IGMH.
The proposed model of infertility related stress by Newton, Sherrard & Glavac (1999) and master status model utilized with regard to infertility by McQuillan, Greil, White & Jacob (2003) provides the theoretical background for this study. The conceptual framework of both of the models is attached as Appendix A. The proposed model infertility related stress and master status model emphasizes how infertility leads to psychological distress. During the times when parenthood is considered as an ace status in the individual or by the community individuals live in, infertile females develop a strong need for parenthood and they completely reject the child-free lifestyle (McQuillan et al, 2003). The desire for having children will continuously remind them about the importance of parenthood and the fact that they are infertile. This can also be influenced by the representations of the society regarding the prominence of having children. When infertile women see others close to them, like family and friends having children and how their lives drastically changed after being blessed with kids, they will envy their life styles. All these factors will eventually lead to psychological distress such and increased depression among infertile females.
There are several researches conducted to examine the differences in mean depression levels of fertile and infertile females and the studies supported the theoretical framework. The cross-sectional study, which was conducted by Lakatos, Szigeti, Ujma, Sexty & Balog (2017), to compare the mental status of fertile and infertile females is a good example. The study used 134 primary infertile women and 91 fertile women and they were given three questionnaires to complete in order to track the mental status and interviews were held to find out the sources contributing to mental health. Data after being analyzed through t-test and linear regression showed that infertile women were younger but had significantly worse psychological well-being compared to fertile women among the participants. Age, social concern, maternal relationship and sexual concerns were reported factors associated with depression and anxiety in infertile women (Lakatos et al, 2017).
Another study by Mohammadpur and Ghodrati (2018) also showed that 75.9% of infertile females experienced depression to different severity levels. The study used a total of 385 infertile females aiming to examine the prevalence and severity of depression and also the factors affecting it among females diagnosed with infertility. With the help of the Becks Depression Inventory questionnaire, researchers calculated the severity of depression and a demographic sheet was given to evaluate the factors (Mohammadpur & Ghodrati, 2018). Total of 24.2% cases had not a single evidence of depression but among the remaining 75.9%, 11.7% had severe depression, 25.2% showed depression at a moderate level while 39% were reported of having mild depression (Mohammadpur & Ghodrati, 2018).
A much recent study conducted by using 401 infertile women also predicted high prevalence of depression (Vo, Tran, Le, Do and Le, 2019). It was a cross-sectional study in which PHQ-9 scale was used to calculate the individual depressive symptoms. Also, a face-to-face interview was carried out using structured questionnaires (Vo et al, 2019). The results showed 12.2% of participants having depression and it showed different levels contributing to the total percentage of prevalence with regard to the source of reproductive impairment and past experiences with substance abuse (Vo et al, 2019).
Three studies used only females as participants and also focused on finding the related factors of depression other than evaluating the depression levels. However, the sample size is significantly different in every study and the first study focused on comparing the depression levels by using fertile and infertile samples as participants.
According to a systematic review conducted by Greil (1997) infertility is a progressively distressing life experience for women contrasted with men. The literature included 22 studies done to evaluate the differences in the levels of distress between fertile and infertile samples of which 14 studies showed psychological distress such as depression and anxiety is higher among infertile participants (Greil 1997). With respect to basic findings of the systematic review infertile women are likely to be more depressed with low levels of self-esteem compared to infertile men. Griel (1997) also concluded that infertile women are more possibly to blame themselves as well as considering infertility as an unacceptable phenomenon.
Numerous studies have provided empirical evidence that psychological consequences associated with infertility is determined by several factors (Vo, Tran, Le, Do & Le, 2019; Mohammadpur & Ghodrati, 2018; Samani, Maroufizadeh, Navid & Amini, 2017). Under psychological consequences many studies examined the levels of anxiety (a sense of threat, excessive worrying) and depression (a sense of sadness, misery) and it is claimed that depression and anxiety is highly prevalent among infertile people (Vo, Tran, Le, Do & Le, 2019; Mohammadpur & Ghodrati, 2018; Samani, Maroufizadeh, Navid & Amini, 2017; Oladeji & OlaOlorun, 2018). Also, according to Neter and Goren (2017), females experience the mental impacts more paying little respect to which companion has reproductive impairment, since it is quite often females who undergoes obtrusive procedures. However, there is lack of researches conducted to examine this context in the Maldives. Hence this study will provide an understanding of the situation in the Maldives focusing only on Maldivian females.
The aim of this research is to compare the depression levels of fertile and infertile females referred to IGMH and with respect to existing literature it is hypothesized that the prevalence of depression would be higher in infertile females compared to fertile females.
Ethical consideration
Informed consent will e given to the participants prior to the initiation of the study and also ethical approval will be taken from Healthy Ministry prior to the conduction of the study. Participants will have their right to withdraw from the study anytime they want since participation is purely voluntary. Confidentiality and anonymity will be maintained through out and personal information of each participant will be under supervision ensuring that the only researcher will be able to access to it. If any ethical issue arises during the conduct of the study, it will be dealt accordingly.
Methods
Participants
Random sampling technique will be used to select the sample from the whole population of females who are diagnosed with primary infertility and females who had a miscarriage or a child within the last year. The sample will be selected between January 2019 to June 2019 and it will include females referred to IGMH. Since the exact population size is unknown the sample size would be auto calculated by Raosoft sample size calculator, that is 377. However, for the conduction of research exact population should be determined through the registers of IGMH. The inclusion criteria will be married females of age group of 18-45 years old and females who are not under any contraceptive methods. Married women are used because, according to the Maldivian cultural and religious values, people intend and try to have kids only after getting married and the age group is determined by several previous literatures. Exclusion criteria would be females previously diagnosed with depression, females who experienced continuous miscarriages of at least four and pregnant women and females who does not have a national identity card. Continuous miscarriage is a type of infertility and pregnancy is a critical time period in which females are more prone to depression
Design
A quantitative study based on open-ended questionnaires to calculate the depression levels of both groups, fertile and infertile Maldivian females.
Materials
The participants will be provided with consent forms to sign followed by a questionnaire designed for the collection of demographic data such as age, contraceptive methods, if used. Becks Depression Inventory is a standardized questionnaire which will be used to asses the severity of depression levels in both groups, the questionnaire is attached as Appendix B. This questionnaire contains 21 self-evaluated questions with four steps (0-3) Likert responses. The total would be used to determine the severity of depression each individual attains.
Procedure
Ethical approval will be taken from Health Ministry and IGMH prior to the conduct of the study. Participants will be randomly selected from IGMH. They will be contacted and information about the survey will be shared and those who are willing to take part voluntarily will be given date, time and location of the study. The survey will be conducted in the Dharumavantha Hospital. As soon the participants arrive they will be provided with consent forms and information about how the study will be continued. The demographic sheets will be given to complete followed by the Becks Inventory Questionnaire.
Results
The data will be analyzed using the statistical package for social sciences (SPSS) version 24 and statistical and descriptive will be generated at a significance level of 0.05. Independent samples t-test will be carried out to determine the differences in the levels of depression between fertile and infertile females. Tables and histograms or bar graphs will be generated to further evaluate the results. Mean, mode and standard deviations will be calculated. Severity percentages will also be calculated.
Discussion
Pre-existing literatures which were carried out to examine the depression levels comparing fertile and infertile females showed that depression levels are higher among infertile females compared to fertile females (Alhassan, A., Ziblim, A. R., Muntaka, S, 2014; Demyttenaere, Nijs, Evers-Kiebooms & Koninckx, 1991; Kazandi, Gunday, Mermer, Erturk & Ozkinay 2011; Mohammadpur & Ghodrati, 2018). These studies were done in different regions of the world consisting of several cultures and ethnicity hence, most probably this study would also yield in consistent results of the prior studies showing higher levels of depression in infertile females when compared. Since this research would be the very first study done in Maldives to establish the context of depression and infertility, it would be providing for the literature review that could be used to further to carry out more researches. A qualitative study can be conducted to collect more in-depth information on the factors associated with infertility in females.
Implication of the Study
This study will show the significance of the mental help even during the hospital visits since better psychological well-being is an important aspect of every individuals life. Infertile
Females will be more aware about the possibilities of them suffering from depression and they will also be more prone to seek help, if required. As it is going to be indicated by the outcomes, it will be alluring to build up psychological and psychiatric services in the IGMH for the individuals who are undergoing infertility treatments as well as for those being diagnosed. These facilities would be encouraged by decreasing the mental side effects of infertile females.
Conclusion
Infertility is one of the most stressful life events a female may have to come across which would result is lower psychological well-being. Depression is a mental disorder that is reported to be highly significant in infertile females. Hence, this research is a quantitative survey based on two open-ended questionnaires to collect data from fertile and infertile females referred to IGMH. The results will be analyzed through SPSS and t-test will e carried out. Since this study is the first study that will be conducted in Maldives, it will provide the inferential statistics regarding depression and infertility among Maldivian females.
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