Title: Women’s experiences of living with involuntary childlessness in Uganda: A qualitative
phenomenological study
Version: 3 Date: 01 Jun 2022
Reviewer's report:
This article offers an interesting qualitative research on 15 women experiencing involuntary
childlessness in Uganda. It is an important topic, and yet, to my knowledge it is rarely discussed
in scientific literature.
I would recommend this article’s publication after the authors proceed to minor revisions which
I have listed below.
INTRODUCTION
The introduction is clear and presents a good overview of the subject but lacks some important
aspects on the topic:
- The authors report that the « the estimated number of couples with involuntary childlessness
increased from 42.0 million couples to 48.5 million couples in 2010 » Why is that so? How can
this raise be explained?
- The authors state that “involuntary childlessness is one of the leading indications for
gynaecologic clinic visits in Uganda” Considering the subject, it would be interesting for
the authors to develop the possibilities of couples to apply for medically assisted procreation
techniques in Hospitals in Uganda: what are the possibilities (IVF process, etc…?) Is it
expensive? What kind of financial support can they get from the government, if any? Etc…?
METHOD
- Considering the subject, it would be interesting to specify if the “obstetrics and gynecology
services in Uganda” of the Kawempe National Referral hospital offers a unit dedicated to
medically assisted procreation techniques and what kind of techniques (IUI? IVF process?
ICSI?) ?
- « The study was conducted among women who were seeking fertility treatment at Kawempe
National Referral Hospital. » Again, it would be interesting to specify what kind of fertility
treatment is available?
- « These included women who had lived with involuntary childlessness for a period of more than
one year and those with no living child » As according to the definition provided by the authors
“involuntary childlessness” includes situations of woman’s inability to carry a pregnancy to term
which refers to situations of miscarriage, what do the authors mean by “no living child”? Please
clarify this sentence.
- « The criteria for purposive sampling were based on the number of years lived with involuntary
childlessness. » Why did the authors choose this criterion? Could the authors please detail what
is purposive sampling?
- “A total of 18 participants were approached, and only 15 were accepted to participate in the
study.” Why were 3 women excluded from the study?
- « Participants were identified and sampled from the gynecologic clinic register. » Based on
which criteria? Moreover, from what I understand the women were recruited from the clinic
register according to the date they consulted, it would be interesting to specify when they started
the medical consultations. Because although the authors specify the duration of involuntary
childlessness for the women they do not specify since when they have been seeking medical help.
Indeed, if the woman has been getting medical help for 10 years, she might not have the same
perception of her experience as the one who just started 2 months prior to the study, especially
regarding coping strategies.
- It would be interesting to provide the semi structured questionnaire.
- It would be interesting to specify the approximate length of the interviews: please specify how
long were the interviews (1h?)
RESULTS
- « My husband has requested to marry another woman » I would suggest the authors to move
this code to the theme “Marital instability” or to rephrase this code into “lack of consideration
as a married women” or something similar.
- Internalized Stigma l. 273: please remove “participant 10,”
- Financial constraints: As financial constraints of the fertility treatments are evoked by the
participants of the study, and as I said before I think it should be mentioned in the introduction,
with more details on the organization of the Uganda Health system regarding fertility treatments
and financial supports regarding these treatments.
- 80% of the women are self-employed, what does that mean? Are they independent financially?
Please clarify.
DISCUSSION
- “Women, in this study was blamed,” : just a little correction : women, in this study "were"
blamed
- The discussion is interesting as it compares the results with existing literature on the subject
in other countries and shows some similarities, but it doesn’t sufficiently put forward the added
value of this research findings compared to other studies.
- It also fails, in my opinion, to give any perspective or hypothesis on the causes of these women
extreme suffering. The cultural  hypothesis raised in the introduction  “In Uganda, the existing
pronatalist ontology dictates that the sole purpose of marriage is for procreation[10]” would
be interesting to be more deeply discussed I think. Indeed, authors compare their results with
many studies led in the African continent or other developing countries but none in European
countries, or North America for example. Is it because it is not an issue there? Or if it is, are
findings very different from the ones of the studies led in African countries? If so, why according
to the authors? It would be interesting to compare.
- Moreover, I would suggest the authors to propose more elaborated therapeutical options for
these women, based on strong literature references. They briefly suggest offering group therapies
- « This requires counselors and nurses on the team working on involuntarily childless women
to provide psychological and emotional support to enable these women to go through this
experience without affecting their daily living, more so, they should be provided with a calm
setting within the hospital where they can meet and share experiences and covert their negative
experiences into positive experiences. », - but readers would appreciate more details regarding
such options, supported by experienced devices in other hospitals.
- The discussion also lacks a “limitation” section.
CONCLUSION
The conclusion is a bit too long in my opinion, and doesn’t add anything to the article, it is only a
brief abstract of the results. It should be shortened and should open to something new, something
left for the reader to think about and reflect upon, maybe regarding financial solutions that the
government could offer to these women, or regarding the social status of women in Uganda
apparently only considered for their conception abilities - which can be shocking in times when
some women actually decide not to have children like in some European countries where more
and more women get sterilized.