Quality of life of Sudanese patients attending a fertility clinic: a mixed methods study

Figures & data

Figure 1. Flowchart demonstrating the recruitment and analysis processes used in the study. This figure shows that 86 patients were approached to participate in the survey, of whom 4 declined and 82 completed the survey. The figure also shows that 22 patients were approached to participate in the interview, of whom 2 decline and 20 completed the interviews. Quantitative analysis was conducted for the whole sample, n = 102 and qualitative analysis was conducted for the interview sample, n = 20. Qualitative analysis led to an understanding of the interconnectedness of the themes that emerged. Mixed methods analysis like triangulation, used interview data to explain results of quantitative analysis (regression).

Table 1. Sample characteristics of the study population, including demographic, medical and reproductive history.

Characteristic		Mean (SD)
Age	All	33.89 (7.82) years
	Women	31.96 (6.36) years
	Men	38.57 (8.94) years
Duration of marriage^a		4.62 (3.46) years
Duration of infertility		4.03 (3.29) years
Gender (N = 102)	Women	70.6
	Men	29.4
Principal residence	Urban	71.6
	Rural	28.4
Highest achieved education	Secondary or less	31.4
	More than secondary	68.6
Consanguineous marriage	YES	52.9
	NO	47.1
*Female genital mutilation (N = 58^b)	YES	96.6
	NO	3.4
Source of infertility^c	Female factor only	34.3
	All other sources	65.7
Previous pregnancy (N = 73^d)	YES	30.6
	NO	69.4

Note: SD = standard deviation; N = sample size; N = 102 unless otherwise specified.

^a All participants were married at the time of the study but not necessarily presented at the clinic with their spouse.

^b Only 58 women were asked if they had undergone Female Genital Mutilation.

^c Self-reported by the participant, when asked what diagnosis of infertility they had received.

^d Only women participants were asked about previous pregnancies.

Figure 2. Distribution and Mean FertiQoL core and domain scores for the sample, n = 102. This box and whisker plot shows the distribution of the FertiQoL core and domain scores in this sample. In this figure, minimum (lower whisker), first quartile (bottom of the box), median (line in the middle of the box), third quartile (top of the box) and maximum (upper whisker) are displayed. Means are written in the centre of each box. The dots indicate outliers in the sample. The * and + indicate that paired t-tests of means for those scores were statistically significant at p < 0.05.

Figure 3. Distribution of FertiQoL core score by GENDER. This figure shows the difference in the distribution of FertiQoL core scores for men and women. The blue distribution is for women’s scores and the overlay outline distribution is for men’s scores. The figure shows that both distributions were skewed to the right (higher scores), however, most men scored much higher than women, and women had a wider distribution of scores. This indicated that in this sample, while both men and women reported high scores, on average men scored higher than women and there was more variability in the women’s scores.

Table 2. Regression model demonstrating the relationship between FertiQoL core and domain scores with the health and socio-demographic variables.

Variables	Beta coefficient (unstandardized) for FertiQoL Scores (n = 102)
	Core score	Emotional domain	Relational domain	Social domain	Mind/body domain
Age > 35 years	4.02	7.35	−0.65	4.07	3.23
Woman	−9.05**	−13.88**	−8.55**	−6.17	−9.32
Urban	−1.07	−1.49	3.13	−3.75	−0.80
Education > Secondary school	5.68*	6.97	2.40	4.77	7.84*
Duration of infertility > 1 year	1.16	2.15	4.52	0.32	−3.07
Infertility (female factor only)	−4.68	−7.17	2.17	−5.92	−7.73*
Consanguineous marriage	3.20	3.32	4.23	0.89	4.59
Mean	76.02	71.61	78.06	78.88	74.06

Note: FertiQoL = Fertility Quality of Life Tool; *p < 0.10; **p < 0.05.

Table 3. Analytic scheme for themes that emerged from qualitative data analysis displaying the four themes, sample sub-themes, codes and quotes.

Analytic scheme
Theme	Sample sub-theme	Code	Quote
1. Sense of ‘something missing’	Something missing	Emotional – something is missing – incomplete family	‘it has affected me from the emotional side, one doesn’t feel at ease emotionally, as if something is missing, yes settled, working, the whole family is well, socially OK, everything is excellent but one feels something is missing.’
2. Spousal bond continuum	Unmet need for spousal bond	Relational – desire to have a child – make husband feel a ‘man’ Relational – desire to have a child – to please husband	‘I want to have a baby, I want to be settled, I want my husband to feel he is a man, with a home, family, kids.’ ‘I want to do this thing for my husband to make him happy with this thing. Not because I have a strong desire to get pregnant, especially at this time’
3. Social pressure	Pressure to conform to social norms	Social – expectation – have children	‘in-laws, family, ‘you still haven’t become pregnant? You’re not three yet? Don’t you want to go to the doctors? You’re not concerned about this issue?’’
4. Coping strategies	Faith based coping	Coping – Faith – Surrendering to God’s will	‘I feel like why haven’t I had [a child], but this thing is from God (God’s will), all of it.’

Table 4. Illustrative quotes demonstrating when faith-based coping and non-faith-based coping were used in relation to the other three main themes.

Type of coping (description)	Themes
	Social pressure	Internal distress (Sense of ‘something missing’)	Spousal (Spousal bond continuum)
Faith based coping: Using faith as a way to accept one’s situation	1: in-laws, family, ‘you still haven’t become pregnant? You’re not 3 yet? Don’t you want to go to the doctors? You’re not concerned about this issue?’ inside you, you wish you could become a mother, there isn’t a woman who doesn’t wish to become a mother. But I have surrendered to the fact that this thing is within God’s hands, when it comes it comes. What God wants will come, so the worry … everything is coming from God.	4: walahi, maybe for a while I have been emotionally uncomfortable/uneasy. But in the end this is God’s will, I used to get nervous (uneasy) after the miscarriages, because I used to get pregnant and miscarry and I didn’t know the reason, and the tests were clean, I used to get nervous, but after I had the baby (still born after 9 months’ gestation) it was fine. Alhamdulillah (thank God), God willed it so (that the baby would die in-utero), my reaction was a’adee (normal).	RRB: Ok so this thing upsets you, that he could marry again or something? 12: maybe, of course I get upset RRB: what do you feel? 12: I feel like there is something lacking in me (less than or inferior) to begin with, I feel like why haven’t I had, but this thing is from God (God’s will), all of it.
Non-Faith based coping: Using non-faith coping mechanisms like meaning making or behavioural change to accept one’s situation	15: yes, I want a baby, but I think it’s early, I just got married.	13: Bit by bit, it gets more a’adee (acceptable, bearable), but in the first months, every time it came (period), I would be in a state of worry and disturbance that pregnancy hadn’t occurred. 5: I feel I can still have a baby, there is lots of hope. 16: I look at myself (situation) and see that I’m not mustagira (not residing together), if we lived together of course there would be (kids). 17: I feel like I haven’t been going (to treatment) yet, I have just started (being at the clinic), so I’ve not lost hope yet, going well so far.	11: of course, they ask him, but he doesn’t show (tell) me at all. And of course, this is not something that needs (explanation), he communicates it to me with humour so as not to hurt my feelings.

Note: FQ = FertiQoL; RRB = Interviewer.

Figure 4. Conceptual framework for qualitative analysis, the thematic map of interconnectedness of themes. In this figure, the thematic map illustrates the interconnectedness of the four main themes that emerged through thematic analysis. The figure shows that the impact of infertility on social or spousal relationships would require coping if it led to a state of internal distress. The figure also shows that spousal and social themes overlapped.

Table 5. Triangulation of thematic analysis of coping by gender, using illustrative quotes to help explain results of the regression analysis that identified gender as an independent factor associated with FertiQoL core, emotional and relational domain scores.

Triangulation of thematic analysis of coping by gender^a
Themes unique to each gender	Quotes from men	Quotes from women	Potential explanation for why and how Gender was associated with FQ scores
Denial of impact of infertility	RRB: I want you to tell me how you feel this issue has affected your life, e.g. emotionally, with each other, socially etc. 18: walahi for me I don’t feel there is an effect, ya’anee (sort of) no effect, nothing, yeah RRB: not in any aspect of your life? 18: nothing at all When asked about how infertility has affected his life PT 8 answered one question and shrugged at all attempts to elaborate further. RRB: has your fertility problem affected your life? 8: yes it has an effect, but not 100% effect	None	This denial of problems by men can help explain why men scored higher in the core score, because they would have denied an impact in the FQ as they did in the interview. This appears to be independent of whether there was an impact or not. Meaning that regardless of whether you ask in interview open ended questions or FQ there is less reporting of impact (which could be underreporting or just that it has less impact).
Themes common to both genders	Quotes from men	Quotes from women
1. Emotional (Sense of something missing)	2: it’s been 5 years and God has not given me a child, and this is what’s affecting me, a lot for me, it’s really hard for me … you have kids, you raise them, you educate them so that when they grow up they can carry you (take care of you) … it makes me feel upset and unable to concentrate	12: walahi, yes it upsets me, but not emotional problems or something like that, thank God. I mean I haven’t had a baby … why … something like that. I’ve been searching for treatment for how long now, I’m just imploring God. 13: So, the emotional effect is always huge. I can’t tell you, with every period you have this emotional reaction (infee3al, like an outburst) and zahaj (literally translates to boredom but is used to describe being emotionally upset) and disturbance (meaning emotional disturbance), just this awful thing (state). 7: you mean not having a baby? Walahi, it has affected me from the emotional side, one doesn’t feel at ease emotionally, as if something is missing, yes settled, working, the whole family is well, socially OK, everything is excellent but one feels something is missing.	Only one of the three men reported an emotional impact, while almost all women did (14 of 17, 82.4%) which can help explain why women scored lower on the FQ emotional domain
2. Spousal bond continuum	RRB: which aspect do you feel has been affected the most? 2: with my wife and society (and he didn’t elaborate despite further probing)	RRB: so how has it affected your relationship with your husband? 1: No, not at all, at some point there was pressure that ‘this woman has not had a child’, ‘you should get married’. 13: walahi (oath), I desire a baby, of course, I wish for this thing, and mostly to make my husband happy, because he likes this thing more, but I like kids, but not to that extent (as much as her husband). I feel the disappointment because I want to do this thing for my husband to make him happy with this thing. Not because I have a strong desire to get pregnant, especially at this time	Only one of the three men reported a spousal impact, while almost all women (15 of 17, 88.2%) reported some spousal impact, which can help explain why women scored lower on the FQ relational domain
3. Social pressure	RRB: which aspect do you feel has been affected the most? 2: with my wife and society (and he didn’t elaborate despite further probing)	20: walahi, with my husband I have no problem, but with social relationships, whenever I meet someone they always ask ‘aha not three yet? What’s happening? What have you done so far (regarding treatment)?’ they always ask questions. 4: yes, it has affected me, people’s questions, even my immediate family (parents, siblings) have told me to try to seek medical help abroad ‘go get this checked out, maybe there is something (that can be done)’ In the clarification of the social isolation question of the FQ: RRB: what I mean is that do you avoid social situations like weddings and such? 9: I just go straight away Then for the social pressure question of the FQ: 9: yes, they talk, but not my family RRB: people outside the family? 9: yes RRB: does this thing upset you? 9: yes, but not a lot Then after I showed her the results of the FQ: RRB: ok on the social side 91%, so not much impact at all. What do you think about that? 9: shrugs RRB: I mean do you agree there is not much impact in this area? 9: yes RRB: so it’s not having an impact, in spite of the comments, you’re continuing with your life as always? 9: yes, continuing as always RRB: but what they say bothers you? 9: yes	Only one of the three men reported a social impact, while almost all women (12 of 17, 70.6%) reported some social impact. However, it appeared that the codes all related to being asked too many questions and the pressure this creates, while the FQ social domain questions mainly pertain to social engagement. It would appear that in Sudan, where social engagements are perceived as obligations, regardless of what impact the social pressure might have this doesn’t change the level of engagement and this can help explain why women and men’s score on the FQ social domain didn’t differ as can be seen from the interview with PT 9.
4. Coping strategies	2: it’s been 5 years and God has not given me a child, and this is what’s affecting me, a lot for me, it’s really hard for me RRB: when you look at these results, how does it make you feel? 8: a really wonderful feeling	1: inside you, you wish you could become a mother, there isn’t a women who doesn’t wish to become a mother. But I have surrendered to the fact that this thing is within God’s hands, when it comes it comes. What God wants will come, so the worry … everything is coming from God. 16: I look at myself (situation) and see that I’m not mustagira (not residing together), if we lived together of course there would be (kids).	It appears that both men and women used faith based and non-faith based coping.

Note: FQ = FertiQoL; RRB = Interviewer.

^a Regression analysis identified Gender as an independent factor associated with FertiQoL core scores, emotional and relational domain scores, meaning women and men scored significantly different on these three scores. This table provides illustrative quotes to help explain the difference between men and women in this sample.