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Research Design and Method
To authentically answer the research question, it was important for me to enter the participants’ context to better understand their experiences from their point of view (Morris, Leung, Ames, & Lickel, 1999). This meant that I could not adopt a distantiatedetic research position, but rather, as I considered the subjective nature of couples’ fertility treatment experiences, the clearer it became that this study would fall within a qualitative research domain. Qualitative research explores subjective, lived experiences, thrusting the researcher out of a controlled laboratory environment into the very context of the phenomenon being explored (Creswell & Clark,2011). Furthermore, qualitative research engages in exploring, describing and interpreting personal experiences of participants (Smith, 2004).
REFLECTIONS
I am fascinated. As a child, I enjoyed consciously walking barefooted on the grass because I wanted to feel the crunch of the grass on my soles, not just hear it. I wanted to know how different things felt before I made up my mind about options that life confronted me with. I wanted to know why my parents had to sneak their one set of friends in to our home and why we had to sneak in to a certain suburb to visit them too. Growing up in Apartheid South Africa as a white immigrant child, I asked many questions and got answers -not always ones that I fully understood – and I remember challenging many things. Perhaps I am defending myself a little, but when I was critical of things, I was asking so that I could understand… so that I could “get it”.
Admittedly I have relied on my senses a lot; what I see, hear, smell, feel, and taste physically has always informed my attempts at understanding my world. As I share my thoughts here I am reminded of long drives with my Dad as a young girl. The car became a place of excitement and enquiry about many things. Questions I would ask him, sometimes stimulated by things I would see on the road, or by the conversations we would have, or something I heard on the radio… it would inevitably stir up commentary and wonder. I was around nine years old when, after hearing the radio commentator on the news broadcast “Elton John has announced that he is homosexual”, I asked my dad what this word meant. He explained in a way that I could understand the concept. Our conversation jarred many questions. Our entire trip was navigated by a question I put to my dad: “So, do you think when he writes love songs, he is writing them about the man he loves?” I further asked him about the incongruence of Elton John’s music videos that had him singing love songs to a woman, when these songs may have expressed the love he felt for a man. I wanted to make sense of experiences; inconsistencies-and-all. Curiosity is part of my identity. Wanting to understand how someone experiences something has been with me for as long as my mind can relay back these experiences.
Overview of Involuntary Childlessness
An investigation of the medical literature on childlessness led me down varied avenues, each meandering and interconnected, and all leading back to a central plane: a Rubik’s Cube highlighting the conundrum of infertility. Each square of the Rubik’s represents an intricate facet to be considered in prevention, understanding, assessing, and treating this reproductive puzzle. In order to begin to understand the global picture of this puzzle, it became increasingly apparent to me that if we work in the field of reproductive health, a universally accepted working definition of infertility is important, not only for conducting research, but also in assessment and treatment protocols. The departure point: “defining infertility”, presented a collage of criterion that is employed within the fields involved in reproductive health. The definition of infertility differs within the various contexts and fields it is being examined in. This has implications for how research in to the phenomenon is conducted and what facet will be researched. It has further bearing on the research findings and how they are recorded and reported. Comparative studies can be arduous when attempting to determine the prevalence of infertility between countries (Gurunath, Pandian, Anderson, & Bhattacharya, 2011). This can further compromise the management of infertility in the long run, posing a challenge when attempting to standardise procedures, and when comparing outcomes of procedures in different regions and countries (Charlish & Davies, 2007; Gurunath et al., 2011; Marchbanks, Petersen, & Rubin, 1989; Reis, Xavier, Coelho, & Montenegro, 2013; Zegers-Hochschild et al., 2009).Therefore, consideration of the contributors to the collage of definitions is important, as each has unique insights within their areas of specialisation.
The Childless Couple in Sub-Saharan Africa
Reproductive health can be described as a state of physical, mental and social wellbeing, pertaining to all matters regarding the reproductive system. It not only includes the absence of disease, but encompasses the individual’s right to reproduce, and includes free will to decide when and how often to reproduce. Conversely, infertility continues to be experienced as a global problem affecting between 60-80 million men and women, with the vast majority residing in resource-poor countries (Sharma et al., 2009). In 2002, an estimated 186 million ever-married women of reproductive age (15 – 49 years) presented with either primary or secondary infertility (Rutstein &Shah, 2004). Recent surveys demonstrated that the global prevalence of infertility can be quantified at approximately 9% (Hammarberg & Kirkman, 2013).
Causes of Non-Conception
In tackling the Rubik’s cube and exploring further how it can be understood in different fields that work within reproductive health, these meanderings have led to exploration of another side to the cube: delving in to the possible causes of infertility. Research contributions from the Health Sciences by-and-large examine the organic causes of infertility, demonstrating that infertility can be largely attributed to endocrinological, genetic, anatomical, and immunological factors (Agboghoroma & Giwa-Osagie, 2012; Ombelet & Campo, 2007). Adjunct to the causes of infertility, identification and consideration of the source of the infertility is important as it has treatment implications.
Reproductive Tract Infections
History tells a long story of the existence of STIs around the world. For example, the first well documented Syphilis epidemic occurred in Europe in 1493. During this epidemic, it was not known how the disease was transmitted. Socially, it was believed that women afflicted with the disease, for example, were sinners and criminals (Swinton, Garnett, Brunham, & Anderson, 1992). Whilst communities still hold strong social beliefs regarding STIs today, we have come a long way in our biological understanding of STIs, not only in ascertaining how the infections are transmitted, but also the impact the infections have on general and reproductive health.
Environmental Factors
Amongst the list of preventable factors that have been flagged as possibly contributing to infertility in both partners, are those that fall under the umbrella term of environmental causes. When considering environmental factors, a distinction can be made between the external environments (the environments individuals are in contact with and the physiological impact this contact can have on the individual), and internal environment (constituting the physiological system of the individual and the impact of the internal environment on fertility). Lifestyle factors, where an individual is in contact with an environmental element, or introduces a foreign element in to their internal environment, can potentially have a negative impact on conception, depending on the environmental factor. Lifestyle factors can affect reproductive health, and careful examination of some of these factors illustrates the impact of exposure on the individual (Demouzon & Logerotlebrun, 1992; Negro-Vilar, 1993; Rosenthal, 2002; Sultana, et al., 2011).
TABLE OF CONTENTS :
- PART A
- PROLOGUE
- Them
- CHAPTER 1: INTRODUCTION
- Encountering Infertility
- Introduction
- Research Problem
- Research Question
- Setting
- Motivation
- Research Motivation
- Professional Motivation
- Goals
- Primary Goal
- Secondary Goals
- Research Design and Method
- Structure of the Study
- Conclusion
- PART B
- REFLECTIONS
- CHAPTER 2: LITERATURE REVIEW I
- Exploring Medical Sciences Literature
- Introduction
- Overview of Involuntary Childlessness
- The Childless Couple in Sub-Saharan Africa
- Causes of Non-Conception
- Reproductive Tract Infections
- Health Practices
- Environmental Factors
- Socio-cultural Factors
- Assessment and Treatment of Delayed Conception
- First Line Medical Management
- Routine Fertility Treatment
- Assisted Reproductive Treatment (ART)
- Insemination: Artificial Insemination (AI) and Intrauterine Insemination (IUI)
- Donor Insemination (DI)
- In-Vitro Fertilisation (IVF)
- The Impact of Limited Economic Resources on the Provision andAccessibility of
- Fertility Treatment in Africa
- Conclusion
- CHAPTER 3: LITERATURE REVIEW II
- Exploring Psycho-Social-Spiritual Literature
- Introduction
- Psychological System
- Psychological Perspectives
- Psychogenic infertility theories
- Psychological consequences theories
- Psychological cyclical model
- Grief and bereavement approaches
- Chronic infertility-specific grief model
- Integration of infertility into the sense-of-self-model
- Stress and coping theories
- Social construction and stigma theories
- Family system theories
- Stage theory
- Research Trends
- Experiencing Fertility Treatment
- Critique
- The Void
- Sociological System
- A Tale of Two Worlds: Infertility Experiences Across Borders
- Pronatalism
- Economy
- Gatekeepers
- Patriarchy
- Fertility Treatment Experiences
- Factors mediating access and provision of care
- The underrepresentation of minorities
- The plight of the poor
- Cultural practices
- Factors influencing treatment seeking
- Factors mediating the termination of treatment
- Spiritual System
- Spirituality
- Barren
- Science with a Conscience
- The Middle East
- India
- Africa
- Judaism
- Catholicism
- Conclusion
- PART C
- CHAPTER 4: RESEARCH METHODOLOGY
- Introduction
- Researcher
- Paradigm
- Ontology
- Epistemology
- Methodology
- Foundations of Interpretive Phenomenological Analysis (IPA)
- Interpretive Phenomenological Analysis (IPA)
- Interpretive Phenomenological Analysis (IPA)
- Interpretive Phenomenological Analysis (IPA)
- Axiology
- Rhetoric
- Methods
- Permission Phase
- Invitation Phase
- Information Phase
- Participants
- Sampling criteria
- Sampling method
- Research participants
- Research Phase
- Interviewing the participants
- Interviewing venues
- Interviewing process
- Interviewing structure
- Transcribing the interviews
- Analysing the interviews
- Initial stage: Multiple reading and note making
- Second stage: Transforming notes into emergent themes
- Third stage: Looking for relationships between themes
- Final stage: The narrative account
- Reporting the findings
- Quality
- Guidelines
- Journal
- Supervision
- Ethics
- Research Permission
- Voluntary Participation
- Participant Privacy
- Informed Consent
- Psychological Support
- Material Storage
- Conclusion
- PART D
- REFLECTIONS
- Introduction
- The Interviews: What I Planned Is Not Entirely What Happened
- Ashton and Kerry-Lee (Couple A): Initiation
- Zethu and Bernard (Couple B): Intense Triad
- Lesedi and Graeme (Couple C): Silent Partner
- George and Mapuleng (Couple D): Distance from the Pain
- Keketso and Refiliwe (Couple E): A Story of Difficulty
- Rozalia and Bongani (Couple F): Willing to be the Biggest Loser
- Lebogang and Sipho (Couple H): Marching On
- Logan and Mieke (Couple G): Against the Odds
- Identification of Themes
- Conclusion
- CHAPTER 5: FINDINGS
- Contexts Shaping the Participants’ Experiences of Fertility Treatment
- Introduction
- Context Matters
- Private Healthcare Context
- No Financial Buffering: An Unaffordable Treatment Option
- Medical aid limitations
- Absence of personal accounts
- A Disappointing Option
- Patient care
- The low-cost option
- Public Healthcare Context
- Comprehensive Service Experiences
- Preconceived perceptions
- Professional conduct
- Engaging consultant opinions
- An alternative experience
- Conversational Service Experiences
- Informative Service Experiences
- Creating participant understanding
- Creating participant certainty
- Facilitative Service Experiences
- Creating rapport through personalised consultations
- Creating empathic consultations
- Creating opportunities during consultations
- Creating unintended paradoxical experiences
- The importance of communication during consultations
- Conclusion
- CHAPTER 6: FINDINGS
- Couples’ Shared Fertility Treatment Experiences
- Introduction
- Interpersonal Awareness:Experiencing My Partner During Fertility Treatment
- Male Partner Experiences of Their Partner During Fertility Treatment
- Concern and helplessness
- Insecurity
- Frustration
- Female Partner Experiences of Their Partner During Fertility Treatment
- Support
- Insecurity
- Interpersonal Awareness:Coupleship Experiences of Fertility Treatment
- Experiencing Fertility Treatment as a Challenging Endeavour
- All-consuming intrusive process
- Invasion of space, time, and thoughts
- Financially challenging process
- Challenges of the treated body
- Experiencing a reproductive hurdle
- Acquiring an unwanted illness identity
- Bystander
- Emotionally challenging process
- Experiencing emotional lows
- Pain and difficulty
- Anxiety and stress
- Sorrow and disappointment
- Experiencing emotional highs
- Hope
- Experiencing Fertility Treatment as a Coping Opportunity
- Communication as a coping strategy
- Conflict resolution as a coping strategy
- Stress management as a coping strategy
- Positive treatment outlook as a coping strategy
- Experiencing Social Contexts During Fertility Treatment
- Couples’ experiences of family during fertility treatment
- Expectations
- Closeness
- Judgement
- Privacy
- Coping
- Couple’s experiences of friendship during fertility treatment
- Lack of understanding
- Avoidant communication
- New friendships
- Coping
- Couples’ experiences of work during fertility treatment
- Personal development
- Clashes
- Judgement
- Privacy
- Coping
- Couples’ experiences of community during fertility treatment
- Expectations
- Probing
- Judgement
- Coping
- Couples’ experiences of spirituality during fertility treatment
- Expectations
- Disapproval
- Connectedness
- Coping
- Conclusion
- PART E
- CHAPTER 7: DISCUSSION
- Reflecting on Collective Sharing
- Introduction
- How and Why I Did It
- What I Found and How It Mattered:Answering the Research Question
- Findings that were Congruent with Existing Literature
- Contexts shaping the participants experiences of fertility treatment
- Private healthcare experiences which support the literature
- Public healthcare experiences which support literature
- Couples’ shared fertility treatment experiences
- Experiencing my partner: Findings which support the literature
- Coupleship experiences of fertility treatment which support the literature
- Social contexts shaping couples’ fertility treatment experiences which support
- the literature
- Surprising Findings
- Contexts shaping the participants’ experiences of fertility treatment
- Surprising private healthcare experiences
- Surprising public healthcare experiences
- The Contribution to Psychology
- Contributions to the Body of Literature
- Methodological Contribution
- The Implications for Practice
- Development of Short-term Supportive Interventions
- Integrated approach to counselling and support
- Treatment is a coupleship experience: Recognise men as equal partners
- Utilise easily understood language when working with couples
- Provide psycho-educational function
- The Limitations of My Research
- Interview Setting
- Interview Media
- Drop-out Rate
- 360 Degree View
- The Research Implications and Recommendations
- Conclusion
- EPILOGUE: US
- REFERENCES
- Appendix A: Staff Structure of Reproductive and Endochrine Unit (REU)
- Appendix B: Research Persmission and Ethical Approval
- Appendix C: Invitation Letter to Participants
- Appendix D: Research Information Letter and Consent
- Appendix E: Interview Schedule
- Appendix F: Support Services
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Involuntary childlessness: An interpretive phenomenological inquiry into couples’ experiences of infertility treatment in the South African public health sector
