Title: LIVED EXPERIENCES AND COPING STRATEGIES OF PERSONS SEEKING
INFERTILITY TREATMENT IN THE KUMASI METROPOLIS: A DESCRIPTIVE
PHENOMENOLOGICAL STUDY
Version: 5 Date: 06 Oct 2021
Reviewer's report:
The paper describes the infertility experiences of women undergoing biomedical fertility
treatment, focusing on the emotional and social challenges women face, in addition to the coping
strategies they adopt.
The background of the paper thoroughly tackles the topic of the psycho-social difficulties for
women experiencing infertility, particularly in the West African region of Ghana. This gives
good backing for this study to understand these experiences and how women cope going through
infertility care.
I would have like a bit more of a broad take on the background. What is Kumasi like? How
accessible, in terms of cost, geography, and knowledge about ARTs, are fertility clinics in this
area? Abstract in background claims that a growing number of people are seeking biomedical
infertility treatment in Ghana, but nowhere in the paper is this mentioned, or evidence given.
I think this section needs some organizational work to make its argument clearer. Currently
some of the topics jump somewhat, moving from statistics on primary and secondary infertility
in Ghana to marital problems to the social and cultural imperative to procreate in marriages. I’d
also like to note that the paper starts with a definition that infertility of a problem of “married
people,” which I would like to challenge. Even unmarried people can experience infertility, not
to mention the ‘social infertility’ of uncoupled or single people. I would suggest the author edit
and restructure this section among the main points they wish to emphasize: the prevalence of
infertility; the social pressure to procreate and the social visibility of the inability to procreate in
a marriage; and the psychosocial challenges to women experiencing infertility. I would suggest
inclusion of some of the work of Trudie Gerrits, a medical anthropologist that has done research
on ART usage in Ghana.
The method section holds quite well. There are a few questions that I still had when reading
it. Again, I think the authors need to explain the Kumasi setting and some of the particulars of
that setting. What are the differences materially between public and private clinics? Do these
hospitals just serve the metropolis area or do they have a larger catchment (ie, does the population
of patients come far for treatment?)? The study design should delineate a bit more about how
participants recruited. When did this fieldwork take place? Were patients approached in the
clinic? Or were they referred to the researchers by the doctors? Did anyone refuse participation
or later retract their participation? There is an emphasis as well on the diagnosis. I would switch
to “experiencing infertility”. They may experience it, but the medical diagnosis may of course
lay with their male partners. Within ethical considerations, I’m wondering – considering much
of the paper is about the social stigma of infertility – if any participants had concerns about
anonymity or if there were any special considerations to ensure anonymity and confidentiality
(aside from the pseudonyms)? Was this part of the design in having interviews as hospitals?
The results are interesting and a unique insight into the experiences of women undergoing
fertility treatment in Ghana. The impression I was left with through these women’s testimonies
was how much time and mental space infertility occupied, beyond even the physical demands
of treatment. Many of the women emphasized the enduring and overwhelming constant and
intrusive thoughts about their infertility status (Talata and Susan). In the write up, I would
delineate how many of the women express some of the findings. For instance, “most participants
described how they worry about their diagnosis…” (Page 9). How many of the 19? Or how many
expressed that sex “lost its role in the marriage”? I think delineating the number of participants
would sharpen and specify the findings. Structurally, create some paragraphs centered around
clear points and topics. Otherwise, at present, each section is one long paragraph, and it’s hard
to read and absorb the multiple themes being presented.
Further along in social experiences, the paper would be improved with more structure around
key points: marital dilemmas and problems, social stigma, intrusive comments from community
members. I think structuring and drawing out these key themes would make the paper’s
contribution clearer. There is quite some mention of faith and spiritual support systems, but the
religious character of Ghana is never quite described.
I think the Discussion could be structured more clearly and the text tightened. While the section
is meant to situate the findings and points to the implication of the findings of this study, I
found much of it — arguably too much - was dedicated to others work. What makes the findings
of this study compelling and interesting? Yes, some of this needs to situate others work and
other contexts, but the authors can really use this section to highlight what made their findings
interesting in context of larger discussions of psychosocial support for ART treatment, the social
and psychological challenges for women experiencing infertility (particularly in the African
context), and the availability and suitability of various coping strategies. I was never quite clear
what the key debates were that this paper could enliven. Finally, there was quite some discussion
about psycho-social support for infertile women. And the authors conclude that “mindfulness”
would assist women. But I was never clear what mindfulness entailed. Indeed, the word first
arrives on page 21 in this recommendation. Is there possibility that these findings can contribute
to advocating for support for ART patients in these hospitals? Or greater public health campaigns
on the prevalence of infertility, the distress it causes, and the availability of ART treatment? I
think the authors do well to point to the need for further research on the efficacy of interventions
in the distress of patients.
In sum, I think a thorough revision of the paper is needed. Sections can be structured more
clearly around ideas that feed into a larger argument in the paper. The value of this paper – how
it enriches current literature on infertility experiences, particularly in Africa – needs to be more
clearly articulated throughout. Florence Naab’s work, for instance, is mentioned and used but
could be a clearer touchstone to compare with. Also Trudie Gerrits, who has researched ART
usage in Ghana, would be a key author.
Some details:
ARTs – assisted reproductive technologies – are not named as such. The authors should make
sure that they use the accepted vocabulary so that their paper is incorporated into the global
discussion on ARTs in Africa and the emotional experiences of infertility.  This includes
"primary" and "secondary" infertility. And infertility, not "barrenness", as well as women, not
"ladies".
Reference 3 – which the authors use to make the argument that prevalence of infertility is as
high as 30% - is a McKinsey article on the Nigerian economy and not relevant to infertility.
More specificity, what qualifies as a ‘coping strategy’. Is there a discussion within the literature
on psychosocial support for infertility treatment in Africa that this paper should be targeting?
Also what of the cultural relevance, availability, and meaningfulness of psychosocial support?
For instance, in the Global North, there has been much discussion of the online, anonymous
support groups, or in person support groups. Would such a system work in this setting?