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FREQUENCY AND DETERMINANTS OF DEPRESSIVE ILLNESS AMONG INFERTILE WOMEN.

Byline: Adnan Khan, Ijaz-ur-Rehman, Muhammad Ilyas, Hussain Ahmad, Muhammad Marwat and Ghazi Khan

KEY WORDS: Infertility; Depressive illness.

INTRODUCTION

WHO declares a sexually active, non-contraceptive using, non-lactating woman to be infertile if she is unable to give birth to a live baby after twelve months of regular non-protected intercourse. Primary infertility is infertility in a couple who have never had a child.1 Secondary infertility means that a sexually active, non-contraceptive using, non-lactating woman, having a child but now she is unable to become pregnant despite regular, non-protected intercourse for at least twelve months.2

Incapability of have a child, can lead to major psychological disturbances like depression, in any gender. Depression has significant association with infertility.2 Infertility is both medically and socially a significant problem. Infertility is found in 10-15% of the couples in their life time. It is a stressful condition leading to different psychological problems and badly affects patient's quality of life.3

It is estimated that about 86.8 percent of infertile women develop anxiety and 40.8 percent develop depression.4 In a study conducted in Karachi, depression rate was almost 62% in infertile women. Out of them 53% were affected by major depression.5

The significance of this study was to provide local data about presence of depression in infertile women and to draw attention of the treating physicians and gynecologists towards this co-morbid depression which significantly affects patient's quality of life.Following were the research questions of this study.

1. What is the frequency of depression among infertile women in sample and population?

2. Is there any difference between the sample and population in the frequency of depression among infertile women?

3. Is there any association between presence of depression and age groups among infertile women in population?

4. Is there any association between presence of depression and level of education among infertile women in population?

5. Is there any association between presence of depression and infertility duration among infertile women in population?

The objectives of our study were to determine the frequency of depression among infertile women and association of depression among infertile women with age, level of education, and duration of infertility.

Null hypotheses were;

H1: There is no statistically significant difference between sample and population in frequency of depression among infertile women.

H2: There is no association between presence of depression and age groups.

H3: There is no association between presence of depression and level of education.

H4: There is no association between presence of depression and duration of infertility.

MATERIALS AND METHODS

This comparative cross sectional study was conducted at Department of Psychiatry, Gomal Medical College, D.I.Khan, Pakistan from 1st January 2018 to 31st December 2018. Sample size was calculated to be 145, using 40.8% proportion of infertile women having depression4, 95% confidence interval and 8% margin of error, with the help of Raosoft sample size calculator.13 The sample was collected through non-probability consecutive sampling. The inclusion criteria included women in the age group 18 to 40 years, married for not less than one year, and having primary infertility. Women having secondary infertility, and those who were suffering from depression before their marriage were excluded from the study. Approval from ethical committee was taken. Out patient Department of Gynecology and Obstetrics, District Headquarter Teaching Hospital D.i.Khan was our data collection site. The consent of the participating women was sought before inclusion.

Depression among patients with infertility was recorded through PHQ-9 scale. PHQ-9 (Patient Health Questionnaire) is among one of the several self-reported depression scoring instruments. It has nine items each item score from 0-3 depending upon the severity of depression. The total score is 27. A score of 0-4 is considered as no depression, 5-9 as mild, 10-14 as moderate depression and a score of 15-27 as severe depression. Demographic variables were age groups (<25 years, 25-34 years, and 35-40 years), education (uneducated, primary, middle, matric or above), infertility duration (1-3 years, 4-6 years, 7-9 years, 10 years or above) and presence of depression (yes/no).

All the four variables, being categorical were analyzed by frequency and percentage. Estimation of parameter for proportion for population was given as confidence interval at confidence level of 95%.The difference between frequency of depression in infertile women between sample and population was analyzed by chi-square goodness-of-fit test. Association of depression with age, level of education and duration of infertility was analyzed among infertile women by Chi-square test of independence (association). Data was analyzed by SPSS version 25.

RESULTS

Out of 145 infertile women. 122 (84.1%;78.15-90.05%) had depression whereas 23 (15.9%;9.95-21.85%) had no depression. Thirty seven out of 145 (25.52%) women in the age group <25 years had depression, 76 out of 145 (52.41%)women in the age group 25-34 years had depression, and 9 out of 145 (6.21%) women in the age group 35-40 years had depression. Twenty five out of 145 (17.24%) infertile women in the uneducated category had depression, 28 out of 145 (19.31%) infertile women in the pri- mary education category had depression whereas 16 (11.03%) and 53 (36.55%) infertile women in the middle and matriculation and above categories respectively had depression.

Fifty six out of 145 (38.62%) infertile women in the 1-3 years infertility duration category had depression, 31 (21.37%), 17 (11.72%) and 18 (12.41%) infertile women in the 4-6 years, 7-9 years and [greater than or equal to]10 years respectively had depression. The observed frequency of depression in a sample of infertile women was compared to the expected frequency of the population by chi-square goodness-of-fit test at alpha 0.05. H proved to be false, hence rejected, showing that the observed counts of depression have not a good fit to the expected counts. In other words the difference between the observed and expected counts for depression frequency among infertile women was statistically significant. The expected counts were taken from a study by Ali HS, et al from Karachi, Pakistan. (Table 1)

Association of depression with age groups was analyzed through chi-square test of association. H02 proved to be true, hence accepted, showing that the presence of depression was not associated to age groups. (Table 2)

Association of depression with education was analyzed through chi-square test of association. H3 proved to be true, hence accepted, showing that the presence of depression was not associated to level of education. (Table 3)

Association of depression with infertility duration was analyzed through chi-square test of association. H4 proved to be false, hence rejected, showing that the presence of depression was associated to infertility duration. (Table 4)

Table 1: Comparison of observed (sample) to expected (population) frequency of depression in infertile women in D.I.Khan, Pakistan (n=145).

###Observed###Expected

Depression###Chi-Square Value###Degree of freedom###P-value

###frequency###frequency

No###23###55.1###0.000

###30.162###1

Yes###122###89.9###H01 rejected

Total###145###145###Chi-square goodness-of-fit test

Table 2: Association between presence of depression and age groups in infertile women in D.I.Khan, Pakistan (n=145).

###Depression

Age in years###Rows Totals###Chi-Square Value###Degree of freedom###P-value

###Yes###No

<25###37###5###42###0.346

25-34###76###18###94###2.123###2

35-40###9###0###9###H02 accepted

Column Totals###122###23###145###Chi-square test of independence (association)

Table 3: Association between presence of depression and level of education in infertile women in D.I.Khan, Pakistan (n=145).

###Depression###Rows

Educational status###Chi-Square Value###Degree of freedom###P-value

###Yes###No###Totals

Uneducated###25###2###27

###0.535

Primary education###28###5###33

###2.186###3

Middle###16###3###19

###H03 accepted

Matriculation or more###53###13###66

Column Totals###122###23###145###Chi-square test of independence (association)

Table 4: Association between presence of depression and duration of infertility in infertile women in D.I.Khan, Pakistan (n=145).

Infertility duration###Depression###Rows

###Chi-Square Value###Degree of freedom###P-value

(in years)###Yes###No###Totals

1-3###56###18###74

###0.014

4-6###31###5###36

###10.674###3

7-9###17###0###17

###H04 rejected

10 or more###18###0###18

Column Totals###122###23###145###Chi-square test of independence (association)

DISCUSSION

Results of the present study show that 84.1% infertile women are depressed. Several local studies have shown similar results. These include Ali et al5 (2015) and Erdem et al.4 The women suffering from infertility pass through a significant social stigma and it always earns a bad name for them even if this is a male factor infertility. A study conducted in India has highlighted this fact.6 This is a common tradition in most of the countries in South Asia that a woman will get respect and security in her in-laws home only after she is able to reproduce.7 Although the birth of a child is celebrated by the whole family, if the woman fails to give birth to a desired number of children or the desired sex of children the woman alone is considered to be responsible for this which can be a source of threat for her status in the family.

Large number of studies have been conducted, mostly in eastern countries, which highlight the fact that most of the women seek treatment for their infertility only because of the negative reactions of their family members and close relatives. These negative comments from the family members also have a major impact on the women psychology and thus leading to the symptoms of depression.8 Evidence from Some other studies have delineated the fact that poor husband support or negative reactions by the husband lead to depression in women suffering from infertility.9

In underdeveloped countries most of the research is focused on the role of relatives in causing depression among women suffering from infertility. A Chinese study concluded that although there exist a lot of difference in culture, ethnicity and religious beliefs between Chinese and Western societies, the response of Chinese couples to infertility was not much different from that of Western couples. However in Chinese society the role of parents-in-law was much positive in determining marital satisfaction.10

Nowadays a shift can be seen from the old system of joint families to nuclear families even in developing countries like Iran, especially among people who belong to the lower socioeconomic groups. Extended families offer greater authority to the husband's relatives, and thus they get a chance to interfere in the domestic problems of couples. A study was conducted in Pakistan upon why women with secondary infertility seek treatment and it was found that in 22.6% cases family pressure was responsible for health seeking, while in 20.4% cases the reason behind seeking treatment for infertility was the desire of husbands or in-laws for a son.11

A case was reported in Karachi, Pakistan, where a woman was compelled by her mother in-law to get treatment for her infertility even in the first month of their marriage.12

CONCLUSION

Frequency of depression in infertile women was high especially in women having infertility duration of 1-3 years. The difference in frequency of depression between the sample and population was statistically significant. Presence of depression was associated with infertility duration.

REFERENCES

1. Alhassan A, Ziblim AR, Muntaka S. A survey on depression among infertile women in Ghana. BMC women's health 2014;14(1):1.

2. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys 2012;9(12):e1001356. doi: 10.1371/journal. pmed.1001356. Epub 2012 Dec 18.

3. Aarts JW, Van Empel IW, Boivin J, Nelen WL, Kremer JA, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Hum Reprod 2011; 26:1112-8. doi: 10.1093/humrep/der051. Epub 2011 Mar 3.

4. Erdem K, Apay SE. A sectional study: the relationship between perceived social support and depression in turkish infertile women. Int J Fertil Steril. 2014 Oct;8(3):303-14. Epub 2014 Nov 1.

5. Ali HS, Shams H, Kessani LV, Ali R. prevalence and predicators among pakistani infertile women. Infertility 2015; 13:11.

6. Riessman CK. Stigma and everyday resistance practices: Childless women in South India. Gender and society 2000; 14:111-35.

7. Unisa S. Childlessness in Andhra pardesh, India: treatment-seeking and consequences. Reproductive Health Matters 1999; 7:54-64.

8. Guz H, Ozkan A, Sarisoy G, Yanik F, Yanik A. Psychiatric symptoms in Turkish infertile women. J Psychosom Obstet Gynaecol 2003; 24:267-71.

9. Gulseren L, Cetinay P, Tokatlioglu B, Sarikaya OO, Gulseren S, Kurt S. Depression and anxiety levels in infertile Turkish women. J Reprod Med 2006; 51:421-6.

10. Lee TY, Sun GH. Psychosocial response of Chinese infertile husbands and wives. Arch Androl 2000; 45:143-8.

11. Sami N, Ali TS. Health seeking behavior of couples with secondary infertility. J Coll Physicians Surg Pak 2006; 16:261-4.

12. Bhatti LI, Fikree FF, Khan A. The quest of infertile women in squatter settlements of Karachi, Pakistan: a qualitative study. Soc Sci Med 1999; 49:637-49.

13. RaosoftA(r) sample size calculator. Seattle, WA, USA: Raosoft Inc.; 2004. Available at: http://www. raosoft.com/samplesize.html
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Publication:Gomal Journal of Medical Sciences
Date:Sep 30, 2018
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