COPING STRATEGIES OF CLIENTS WITH FERTILITY CHALLENGES ATTENDING OBSTETRIC AND GYNECOLOGICAL CLINIC

ABSTRACT
This study was on coping strategies of clients with fertility challenges attending Obstetric and Gynaecological clinic of University of Maiduguri Teaching Hospital. The objectives of the study were to ascertain the use of escape/avoidance coping strategy by couples with fertility challenges, determine the use of self controlling coping strategy by couples with fertility challenges, determine if couples with fertility challenges use social seeking support as a coping strategy and assess if couples with fertility challenges use positive reappraisal as a coping strategy. A descriptive survey design was used for the study. A sample size of 232 respondents was used for the study which was calculated from the target population of 456 using power analysis. The instrument for data collection was adapted from Folkman and Lazarus ways of coping. The face and content validity were determined by the supervisor, psychologist and a consultant in Obstetric and Gynaecological clinic in UMTH. The results were presented in tables as percentages, means and standard deviation. Pearson Chi-square and Fisher’s Exact test were used to determine the association between coping strategies based on gender at 0.05 level of significance. Major findings of the study revealed that males used most coping strategies than the females. The analysis shows 57% of males and 31.1% of females drinks smokes and indulges in drugs as escape/avoidance coping strategy. There was significant difference in the used of this coping strategy (P=0.000). Similarly, there was significant difference in the use of self controlling coping strategy as P=0.000, where 79.2% of males and 50.3% of females avoid people who trouble them about pregnancy and children. However, there was no significant difference in the used of social seeking support as 75% of males and 92.2% of females ask people with similar problem for advice with P=0.080. In the same vein, 64.9% of males and 89.2% of females used praying to God to change the situation as a positive reappraisal coping strategy with P=0.087. In conclusion, escape/avoidance and self control coping strategies were used more by men and there was no difference in use of social seeking support and positive reappraisal coping strategies. It was recommended that where couples cannot achieve pregnancy on their own, they should go for assisted reproduction.

CHAPTER ONE
INTRODUCTION
Background to the Study
Infertility is perceived as a problem across virtually all cultures and societies and affects an estimated 10-15% of couples of reproductive age (Bovine, Bunting, Collins & Negron, 2007). It has been viewed differently in different cultures. The population in the developed and developing countries hold different attitudes regarding infertility. In developing countries, infertility may be linked to an act of God, punishment for sins of the past, prolonged use of contraceptives, and the result of witchcraft which is causing childlessness, whereas people in developed countries view infertility as caused by biological and other related factors like excessive alcoholism, lack of cooperation between the man and the woman during sexual intercourse (Bovine, Bunting, Collins & Negron, 2007). No matter the culture, infertility is viewed as an enormous problem by couples everywhere.
According to Dhont, Van der Wijgert, Coene, Gasarabwe & Temmerman, (2010) children are seen as blessings of marriage and in some societies of the world; it is even believed that they are symbols of God’s approval and blessings on marriages. Under normal circumstances, it is the choice of each individual and couple, within their own sense of conscience, to determine if they intend pregnancy and if so, the size of their family unit and the timing of when to have a child or children. However, in many African cultures, married couples who are unable to bear children shortly a few years after marriage are faced with all forms of unfriendly pressure from the family and social groups which could lead to unnecessary frustration, resentment and depression.
Apart from the rare cases when couples deliberately decide not to have children, inability to bear children has been the cause of many failed marriages and even destroyed many homes. It affects the self-esteem of a man, dampens his sense of control and also throws a woman into total confusion, frustration and anxiety. It is therefore an issue that should not be taken lightly by both the man and the woman. Many women believe that without children, life is without hope (Marida & Ulla, 2008).
World Health Organization, 1987 as cited in Tabong & Adongo, (2013) defined infertility as failure to conceive after one year of regular unprotected sexual intercourse in the absence of known reproductive pathology. However epidemiological studies have revealed that in a normal population of heterosexually active women who are not using birth control methods, 25% will become pregnant in the first month, 63% within six months and 80% within one year. By the end of the second year, 85% to 90% will have conceived (National collaboration center for women and children heath, 2012). Because some couples who are not infertile may not be able to conceive within the first year of unprotected sex, World Health Organization (WHO) therefore recommends the epidemiological definition of infertility, which is the inability to conceive within two years of exposure to pregnancy (WHO, 1987 in Tabong & Adongo, 2013).Individuals who are thought to be infertile are generally relegated to an inferior status, and stigmatized with many labels. As a result, childlessness has varied consequences through its effects in the society and on life style of individuals. Though in some cases, the childless life style enhances life satisfaction for some individuals, yet it is diminishing for others for whom parenthood is a personal goal (Aysel & Gul, 2015)

Graham (2015) noted that, parenthood is one of the major transitions in adult life for both men and women. The stress of the non fulfillment of a wish for a child has been associated with emotional related problems, sexual dysfunction and social isolation. Couples passing through the stress of infertility challenges experience stigma, sense of loss, and diminished self esteem in the society. Among couples with infertility challenges in general, women show higher levels of distress than their men partners. They experience sense of loss of identity and have pronounced feelings of incompleteness and incompetence.
However, infertility is a significant medical problem that affects many couples and has multiple aspects including physical, emotional, financial, social and psychological effects (Omu & Omu, 2010). Experience of fertility challenges is a stressful condition itself, becoming particularly traumatic with previous pregnancies ending up in abortions, stillbirths and neonatal/infant deaths (Rouchou & Brittany, 2013). Receiving a diagnosis of infertility is a significant life crisis (Alesi, 2007). Feeling of grief and loss are very common as couples come to terms with the fact that they are not able to conceive. Infertility may result in a decrease in quality of life and an increase in marital discord and sexual dysfunction (Sameer, Trupti & Surendranths, 2010).

For many couples, infertility is undeniably a major life crisis and psychologically stressful (Holstein, Christensen & Boivin, 2011a). It has been reported to cause depression, pain and the promise of often unfulfilled dreams in women. It is a lonely place for individuals and couples because “infertility is often a silent and solitary crucible, since it is not visible, life threatening or disfiguring” (Mogobe, 2010). Studies have found infertile women to be more neurotic, dependent and anxious than fertile women, experiencing conflict over their femininity and fear associated with reproduction. Others studies have similarly come to negative conclusions regarding the relationship between psychological factors and infertility (Noble, 2009).Worldwide, more than 70 million couples suffer from infertility. In sub-Saharan Africa, the prevalence differs widely from 9% in the Gambia, 21.2% in north-western Ethiopia, 11.8% among women and 15.8% among men in Ghana and between 20 and 30% in Nigeria (National collaboration center for women and children health, 2012). In African culture, the meaning of marriage is only fulfilled if the woman conceives and bears children as they are seen as sources of power and pride as well as assurance of family continuity. Anthropological and sociological studies bear testimony to the considerable suffering associated with involuntary childlessness due to negative psychosocial consequences such as marital instability, abuse and stigmatization (Dyer, Abraham, Hoffman & Van der Spy, 2012).
In Nigeria, the prevalence of infertility has been studied in demographic surveys, epidemiological surveys and through clinical observation (Okonofua, 2010). The Nigeria demographic and health survey for the period 2006-2010 reported a prevalence rate of primary infertility of 22.7% in 15-49 years old women and 7.1% in 25-49 years old (Okonofua, 2010). The inability to have children affects both men and women across the globe and lead to distress and depression as well as discrimination and ostracism (Cui, 2010). In order to deal with the stress of infertility, couples adopt various coping strategies.
According to Jordan & Revenson (2013) Coping strategies are ways in which one learns to deal with stressful situations. Every one copes with stress differently. Over time, people construct coping strategies that are good for mental wellness. Coping with infertility is often challenging because “infertility can be conceptualized as a chronic, unpredictable, and (personally or medically) uncontrollable stressor that may exceed the couple’s coping resources”. Carrol, Robinson, Marshall, Callister, Olsen, and Dyches, (2011) noted the following coping strategies including distancing themselves from reminders of infertility (such as avoidance of families with children), instituting measures for regaining control,acting to increase feeling of self-worth in other areas of their lives such as achieving professional success, trying to find meaning in infertility, or sharing the burden with others.
Many people have reported encountering a number of stressors associated with the medical diagnosis of infertility. These stressors include but not limited to stress related to endurance, sexual functioning, quality of their relationship and changes in their social and family as well as family networks (Newton, Sherrad & Glavac, 2014). The severity and frequency of these stressors can contribute to negative outcomes such as psychological distress or marital dissatisfaction. To curb the potential negative consequences of excessive infertility stress, couples often use a number of coping strategies. This study investigated the various coping strategies utilised by clients with fertility challenges attending Obstetrics and Gynaecological (O and G) clinic of University of Maiduguri Teaching Hospital (UMTH).

Statement of Problem
Fertility challenges are the most frequent reason for gynaecological consultation in Nigeria (Okonofua, 2010). However, experiences from actual clinical practice indicate that, infertility is a major burden on clinical service delivery in Nigeria (Ajayi, 2013). More than 50% of gynaecological caseload consultation and over 80% of laparoscopic investigations are as a result of infertility (Obiechina, Okoye & Emelife, 2009).
Individuals who are thought to be infertile are generally relegated to an inferior status, and stigmatized experiencing sense of loss, and diminished self esteem in their community. Among people with fertility challenges in general, women show higher levels of distress than their men partners (Aysel & Gul, 2015). Married individuals experience sense of loss of identity and have pronounced feelings of incompleteness and incompetence. In 2014, while supervising students during the clinical posting in Obstetric and Gynaecological clinic of UMTH for six weeks, the researcher observed that 30% of the clients that came for consultation had fertility challenges and these raised questions in the mind of the researcher on how clients with fertility challenges cope with infertility. Which coping strategies do they adopt? Are there differences in the use of coping strategies based on gender? This study attempted to address these questions.

Purpose of the Study
The purpose of this study was to determine the coping strategies adopted by clients with fertility challenges attending Obstetrics and Gynaecological clinic of UMTH.
Objectives of the Study
1. Ascertain the use of escape/avoidance coping strategy by clients with fertility challenges.
2. Determine the use of self-controlling coping strategy by clients with fertility challenges.                   3. Determine if clients with fertility challenges use seeking social support as a coping strategy.
4. Assess if clients with fertility challenges use positive reappraisal as a coping strategy.

Research Questions
1. What type of escape/avoidance coping strategies do clients with fertility challenges use in coping?
2. To what extent do clients with fertility challenges use self controlling strategies in coping?
3. Which of the seeking social support coping strategies do clients with fertility challenges seek to use in coping?
4. To what extent do clients with fertility challenges use positive reappraisal to cope?

Hypothesis
There is no significant difference based on gender and the use of coping strategies of clients with fertility challenges.

Significance of the Study
The result of this study will reveal how clients cope with infertility challenges using various coping strategies and as well help to improve the coping strategies of people with fertility challenges by identifying positive coping strategies which will be accessible when the work is published. The society and significant orders will also accept individuals with fertility challenges and give the necessary social and psychological support needed by them. The findings from this study will be communicated to the health team of Obstetric and Gynaecological clinic of UMTH which will assist them not only to give assistance in reproductive treatment but also gives psychological counseling to people with fertility challenges.

Scope of Study
This study is confined to assessing the coping strategies of clients with fertility challenges attending Obstetric and Gynaecological clinic of UMTH. It focuses both on primary and secondary infertility. Four coping strategies adapted from Lazarus and Folkman eight coping strategies of infertile couples will be utilized. The study will be confined to clients with fertility challenges attending the Obstetric and Gynaecological clinic of UMTH.

Operational Definitions of Terms
1. Coping strategies of clients with fertility challenges; refer to the way men and women adjust to the stress of not having children. These coping strategies specifically refer to the use of Lazarus and Folkman’s (2005) four out of eight coping strategies which have been adapted in this study. The four coping strategies have been adapted because the researcher thinks they suit the environment in which data will be collected. The coping strategies include;
Escape-avoidance; refer to clients directing their attention away from the problem as a reality e.g. not participating in discussion involving pregnancy or children.

COPING STRATEGIES OF CLIENTS WITH FERTILITY CHALLENGES ATTENDING OBSTETRIC AND GYNECOLOGICAL CLINIC