Assiut Med. J. Vol. (31), No. (2), May 2007
USE OF ALTERNATIVE THERAPIES FOR INFERTILITY AND ASSOCIATED FACTORS AMONG WOMEN
IN ASSIUTUNIVERSITYHOSPITAL
Sahar Mohamed Nagieb*, Hoda Diab Fahmy Ibrahim**
*Department of Reproductive Health Nursing, Faculty of Nursing, AssiutUniversity
** Department of Community Health Nursing, Faculty of Nursing, AssiutUniversity
ABSTRACT
This study aimed to shed light on the various alternative therapies for infertility used among women, in addition to identify the factors that might be related to use of alternative therapies among women attending Assiut University Hospital, Obstetrics and Gynecology Clinics. The study had been conducted at outpatient clinics of Obstetrics and Gynecology in AssiutUniversityHospital. Any woman attending the clinic with the inclusion criterion of having infertility, primary or secondary was eligible for inclusion in the study sample. A convenience sample of 81 women fulfilling these criteria was consecutively recruited. An interview questionnaire sheet was developed by the investigators to collect data. The sheet included four sections divided to: first section for the socio demographic characteristics of women, second section on menstrual history of women, third section for the obstetric history for secondary infertility cases and the last section was concerned with infertility and alternative therapies. Data were collected during the period from the beginning of October 2006 to the end of January 2007. The study showed that the age of studied women ranged between 16 and 58 years, (85.2%) were housewives and (56.8%) were illiterate. Also the study revealed that (77.8%) had primary infertility while (22.2%) had secondary infertility. In (79.0%) of the sample, the wife was the cause of infertility. It was clear that (43.2%) of the study sample have consulted physician but (65.4%) of them have reported using alternative therapies as visiting holy shrines as a religious practice, going to cemeteries, using "hegab" and medicinal herbs. As the results show, neighbors were the main source of advice about the alternative therapies (56.6%). The study recommended that successful infertility programs should include health education about the causes of infertility in both men and women and where best to seek care. Alternative therapies must be provided with proper training, facilities backup for referral to any health resource for the common goal of improving the community health.
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Assiut Med. J. Vol. (31), No. (2), May 2007
INTRODUCTION
Infertility places women at risk of social and familial displacement, and omen clearly bear the greatest burden of infertility. Childlessness was found to result in perceived role failure, with social and emotional consequences for both men and women, and often resulted in social stigmatisation of the couple, particularly of the woman (Papreen et al, 2000).
Inhorn and Buss 1993& Apfel and Keylor, 2002) have integrated medical anthropological and analytical epidemiological methods, forms of data analysis, and interpretive insights to examine the culture-specific behavioral factors that place poor, urban Egyptian women at risk of infertility. Multiple causes of infertility exist across the physiological-psychological spectrum. There is no simple psychodynamic causality.
The field of assisted reproduction is one of the fastest growing areas in medicine. The rapid transfer of assisted conception technologies, such as in vitro fertilization to developing countries is not restricted merely to the modalities of offering potential biomedical resolution of infertility but includes, more crucially, how clinicians and infertile consumers assimilate the "Western technoscience" of conception (Bharadwaj, 2006). The development of new techniques may be able to improve the chances of an infertile couple towards achieving a pregnancy (Dutney, 2007). Therefore, it is important to those who practice reproduction techniques to learn about the different religious attitudes related to reproductive health problems (Schenker, 2000).
Moreover, in western societies, medical breakthroughs give couples with fertility problems a good chance to have a child. However, in many developing societies adequate medical treatment is only available for the upper classes, and many women keep going to traditional healers. In addition, the social consequences of childlessness are much greater than in western societies (van Balen and Visser, 1997). In Arab communities, several cultural factors, derived mainly from the subordinate position of women, have been shown to affect the prevalence, clinical picture, health seeking behaviour, course and management of psychopathology in women. Furthermore, stigmatized women have less access to care and suffer from a worse social outcome (Douki et al, 2007).
Three decades ago, Early (1988) has explored the symbolic structure of the baladi (traditional) cultural system in Egypt as revealed in everyday narratives, with a focus on baladi curative action. The body is seen as a dynamic organism through which both foreign objects and physiological entities can move. The body should be in balance, as with any humorally-influenced system, and so baladi cures aim to restore normal balance and functioning of the body.
Female infertility is a common problem not easily treated by conventional medicine. Women often seek alternative therapies to help address these conditions, with some evidence on their efficacy (Sidani and Campbell, 2002). Despite all the marvelous advancements in modern medicine, traditional medicine has always been practiced. Complementary and alternative therapies are gaining acceptance in the US and other countries, both among health providers and consumers (Beal, 1998). It is becoming an established intervention modality within the contemporary health care system (Murphy et al, 1999). A 1997 survey revealed that 40% of Americans use some type of complementary therapy or medicine and that many use such therapies in conjunction with treatments prescribed to them by conventional medical practitioners (Steinberg and Beal, 2003). In a study of the trends in alternative medicine use in the United States between 1990 and 1997, it was found that the use of at least 1 of 16 alternative therapies during the previous year increased from 33.8% in 1990 to 42.1% in 1997. The therapies increasing the most included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. The probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3% (Eisenberg et al, 1998).
More than 70% of the developing world's population still depends on the complementary and alternative systems of medicine (CAM). Alternative therapies have been utilized by people in Pakistan who have faith in spiritual healers, clergymen, hakeems, homeopaths or even many quacks. These are the first choice for problems such as infertility, and many other ailments. The traditional medicine sector has become an important source of health care (Shaikh and Hatcher, 2005).
From the providers’ side, in a survey of 120 licensed certified nurse-midwives in North Carolina, 93.9% of the respondents have reported recommending complementary and alternative medicine to their pregnant patients in the past year, and 57.3% have reported recommending complementary and alternative medicine to more than 10% of patients (Allaire et al, 2000).
Complementary and alternative medicine (CAM) therapy vary widely, with acupuncture, chiropractic, herbal medicine, and homeopathy among the more prominent modalities. CAM therapies are used in addition to and/or instead of the more conventional forms of medical care available in U.S. hospitals or licensed physicians' offices. A rapidly increasing interest in CAM has led to a nascent movement aimed at integrating various CAM therapies with the conventional health care system. In WashingtonState, for example, health insurance coverage for CAM therapies has been mandated, and a number of "integrated" delivery systems have been born. Similar processes are occurring in Canada, Europe, and Australia, and indeed within middle and upper level socioeconomic strata worldwide (Barrett, 2003).
Plants have been used worldwide for treatment of various human ailments since antiquity. Their use is still quite prevalent in developing countries in the form of traditional/folkloric system of medicine. Intensive chemical and pharmacological studies on traditional/folkloric medicinal plants during the last 5 decades have led to the validation of traditional claims in many cases and facilitated identification of their active principles (Maurya et al, 2004). Some medicinal plants used to effect conception/ contraception include Striga astiatica (contraceptive); Eurycoma longifolia (male virility); and a mixture of lengkuas, mengkudu masak, black pepper seeds, ginger, salt, and 2 eggs (increase libido). Women in Malaysia take jamu to preserve their body shape and to provide nutrition during pregnancy. Praneem causes local cell-mediated immunity in the uterus (Chaing et al, 1994).
Yoga and meditation can help women experiencing the challenges of infertility. The practice of meditation and relaxation can help increase the clarity of the mind, maintain healthy body chemistry, and give patients the patience to undergo the rigors of infertility treatments (Khalsa, 2003). Self-management and peer group support are other described as strategies used by infertile women to manage infertility (Allan, 2007).
Nevertheless, although alternative medicine is holistic in its approach to the individual, while medicine is biomedical, viewing the body mechanistically, alternative therapies are not without risk, and many are an unknown quantity. Mothers often feel that their own wants and values are disregarded because of professional or administrative pressure. Midwives should not prescribe alternative medicines or practice any therapies unless properly trained and then only if it is not in breach of hospital or health authority policy. Increasingly, midwives are involved in formulating new policies, so enabling the promotion of beneficial change (Blatch, 1994).
Significance of the study
Reproductive health problems, including infertility, offer opportunities for clinical applications of alternative approaches. Many midwives and nurses are interested in these approaches and have sought out special training (Beal, 1998). Complementary and alternative therapies are increasingly used by many pregnant women; however, limited research is available on many therapies (Moore, 2002). There is a need for further research exploring the relationship between complementary and alternative medicine (CAM) use and women's health (Adams et al, 2003).
Aims of the study
The present study aimed to:
- Shed light on the various alternative therapies for infertility used among women.
- Identify factors that might be related to use of alternative therapies among women attending AssiutUniversityHospital, Obstetrics and Gynecology Clinics.
SUBJECTS AND METHODS
Research design
A cross-sectional descriptive research design was used.
Study setting:
The study was conducted at the outpatient clinic of obstetrics and gynecology in Assiut university hospital.
Subjects and sample:
Any woman attending the study setting with the inclusion criterion of having infertility, either primary or secondary, was eligible for inclusion in the study sample. A convenience sample of 81 women fulfilling these criteria was consecutively recruited.
Data collection tools:
After reviewing the relevant literature, an interview questionnaire sheet was developed specifically by the investigators to collect data related to this study. The sheet included a section for the socio-demographic characteristics of women such as age, job status, and level of education. Also the sheet included a section on menstrual history of women as age of menarche by year, period and cycle of menstruation, rhythm, and causes of irregularity. There was also a section for the obstetric history for secondary infertility cases. The last section was concerned with infertility and alternative therapies. It included the types and causes of infertility, whether the woman consulted physician or not, the investigations done, the type of treatments prescribed by physician, in addition to the use of alternative recipes, their types, usefulness, and sources of advice. Women were also asked about their belief in talisman or magic charm (Hegab).
Methods:
An official letter was issued from the Faculty of Nursing, AssiutUniversity, to the director of University Hospitals for the permission to collect the data from the outpatient clinic of obstetrics and gynecology. When permission was secured, researchers started a pilot study to test the applicability and clarity of the questionnaire and for estimating the time needed to fill the sheet. This was carried out on ten women not included in the main study. No major changes were done in the tools according to the results of the pilot study.
Before selecting a woman in the study sample, she was approached by one of the researchers who explained to her the study purpose, and reassured her about confidentiality of any obtained information, and the freedom to participate or not. After verbal consent was obtained, interview was conducted in a private place at the outpatient clinic. Data were collected during the period from the beginning of October2006 to the end of January 2007. Interviewing was done three days per week, and the average time taken for filling the sheet was 15 to 20 minutes.
Statistical analysis:
Data entry was done using Epi-Info 6.04 computer software package, while statistical analysis was done using SPSS 10.0 statistical software package. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations for quantitative variables. Qualitative variables were compared using chi-square test. Whenever the expected values in one or more of the cells in a 2x2 tables was less than 5, Fisher exact test was used instead. Statistical significance was considered at p-value <0.05.
RESULTS
The age of studied women ranged between 16 and 58 years, with slightly more than two-thirds of them (69.1%) being 25 years old or more (table 1). The majority were housewives (85.2%), and more than half of them were illiterate (56.8%).
Concerning menstrual history, table 2 shows that the meanSD age at menarche was 13.11.6 years. The period of menstrual flow ranged between 2 and 14 days, with a meanSD 5.01.8 days. Also, the meanSD cycle duration was 29.18.2 days. Most of the women had regular cycles (76.5%). For those women with secondary infertility, they mostly had only one pregnancy (72.2%), and one living child (61.1%).
According to table 3, more than three-fourth of the women in the sample had primary infertility (77.8%). In the majority of the cases, the wife was the cause of infertility (79.0%). Less than half of the women have consulted physician (43.2%), but more than three-fourth did some investigations (76.0%). In more than half of the women who had consulted a physician, no treatment was prescribed (54.1%). Ovarian stimulants were the most commonly prescribed remedies (18.9%).
Table 4 shows that slightly less than two-thirds of the women in the study sample have reported using alternative therapies (65.4%). The most commonly reported was visiting holy shrines as a religious practice (35.8%). A similar percentage have reported going to cemeteries (35.8%) as a myth or ritual. Also, another third have reported crossing water (34.0%), and 17.0% had a talisman or “hegab.” Medicinal herbs were used by only 11.3% of the women. Only less than one-fifth of the women believed in Hegab (18.5%). As the table shows, neighbors were the main source of advice about the alternative therapies (56.6%), while 7.5% have reported doctors as sources of advice.
The factors that might be related to use of alternative therapies are illustrated in table 5. Although most illiterate women (73.9%) and most of those who have not consulted physician (73.9%) used alternative therapies, these differences did not reach statistical significance. However, the use of alternative therapies was significantly higher when the cause of infertility was the wife (p=0.04), and conversely, it was significantly lower when the cause was the husband (p=0.002).
Concerning women’s belief in talisman (hegab), table 6 indicates that it was only statistically significantly related to their education (p=0.04). It is evident that about two-third of illiterate women believed in it (64.2%), compared to only 35.8% of the educated ones.
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Assiut Med. J. Vol. (31), No. (2), May 2007
Table 1: Socio-demographic characteristics of women in the study sample
Frequency(n=81) / PercentAge (years):
<25 / 25 / 30.9
25+ / 49 / 69.1
Range / 16.0-58.0
MeanSD / 28.6±8.1
Job status:
Housewife / 69 / 85.2
Working / 12 / 14.8
Education:
Illiterate / 46 / 56.8
Educated / 35 / 43.2
Table 2: Menstrual history of women in the study sample
Frequency(n=81) / PercentAge at menarche (years):
Range / 11.0-20.0
meanSD / 13.1±1.6
Period (days):
Range / 2-14
meanSD / 5.0±1.8
Cycle (days):
Range / 15-75
meanSD / 29.1±8.2
Regularity:
Regular / 62 / 76.5
Irregular / 19 / 23.5
Gravidity (n=18 secondary infertility):
1 / 13 / 72.2
2 / 5 / 27.8
Number of living children (n=18 secondary infertility):
0 / 5 / 27.8
1 / 11 / 61.1
2 / 2 / 11.1
Table 3: Types, causes, and management of infertility among women in the study sample.
Frequency(n=81) / PercentInfertility type:
Primary / 63 / 77.8
Secondary / 18 / 22.2
Cause of infertility:
Unknown / 4 / 4.9
Husband / 8 / 9.9
Wife / 64 / 79.0
Both / 5 / 6.2
Consulted physician:
No / 46 / 56.8
Yes / 35 / 43.2
Investigations done / 52 / 76.0
Treatments prescribed by physician (n=35):@
None / 20 / 54.1
Ovarian stimulants / 7 / 18.9
Surgery / 6 / 16.2
Hormones / 4 / 10.8
(@) Not mutually exclusive
Table 4: Relation between women’s socio-demographic characteristics and their belief in talisman (hegab).
Believe in talisman (hegab) / Chi square / p-valueNo (n=66) / Yes (n=15)
No. / % / No. / %
Age (years):
<25 / 19 / 76.0 / 6 / 24.0
25+ / 47 / 83.9 / 9 / 16.1 / Fisher / 0.54
Job status:
Housewife / 55 / 79.7 / 14 / 20.3
Working / 11 / 91.7 / 1 / 8.3 / Fisher / 0.45
Education:
Illiterate / 34 / 73.9 / 12 / 26.1
Educated / 32 / 91.4 / 3 / 8.6 / 4.04 / 0.04*
Type of infertility:
Primary / 52 / 82.5 / 11 / 17.5
Secondary / 14 / 77.8 / 4 / 22.2 / Fisher / 0.73
Consulted physician:
No / 38 / 82.6 / 8 / 17.4
Yes / 28 / 80.0 / 7 / 20.0 / 0.09 / 0.76
(*) Statistically significant at p<0.05
Table 5: Use of alternative therapies for infertility among women in the study sample.
Frequency(n=81) / PercentUse of alternative therapies:
No / 28 / 34.6
Yes / 53 / 65.4
Therapies used (n=53):@
Faith and religious:
Visiting holy shrines / 19 / 35.8
Drinking Zamzam water / 1 / 1.9
Myths and rituals:
Going to cemeteries / 19 / 35.8
Crossing water / 18 / 34.0
Talisman or talisman (hegab) / 9 / 17.0
Rolling down from mountain / 9 / 17.0
Asking imposters / 8 / 15.1
“Scary pan” / 4 / 7.5
Looking at a dead infant / 2 / 3.8
Asking snails / 2 / 3.8
Slaughtering red rooster and feeding it to a child / 2 / 3.8
Getting scared from a snake / 1 / 1.9
Herbal and other intakes:
Medicinal herbs / 6 / 11.3
Drinking ass milk / 4 / 7.5
Drinking egg / 2 / 3.8
Eating part of an eggplant and burying rest / 1 / 1.9
Drinking camel milk / 1 / 1.9
Drinking ghee / 1 / 1.9
Drinking urine from a parturient woman / 1 / 1.9
Sources of advice (n=53):@
Neighbors / 30 / 56.6
Mother in law / 15 / 28.3
Mother / 10 / 18.9
Doctor / 4 / 7.5
Grandmother / 3 / 5.7
Usefulness (n=53):
Not useful / 43 / 81.1
Useful / 10 / 18.9
Believe in talisman (Hegab):
No / 66 / 81.5
Yes / 15 / 18.5
(@) Not mutually exclusive