Violence and Its Related Factors in Infertile Women Attending Infertility Centers: A Cross-Sectional Study

Introduction

Failure to achieve a successful pregnancy after a year of regular and unprotected sex is defined as infertility (1). Although male and female causes of infertility are roughly at the same proportion (2), women are often thought to be responsible for couples' infertility (3). Even in male infertility, women are more likely to face family and social problems and endure the main burden of infertility (4). Therefore, women are more likely experience psychological and social stressors due to infertility and its treatment (5-7). Infertility can cause psychological problems, including depression, anxiety, fear, anger, hatred, aggression, shame, despair, low self-esteem, emotional imbalance, and guilt feelings (8-11). 

 Regarding the social dimension, the consequences of infertility can be the social stigma, social isolation, and disturbance in social relationships because of blame, loss of social status, and even violence (12-14). The World Health Organization defines violence against women as any violent and gender-based behavior that causes physical, sexual, or psychological harm or any suffering to women. As this type of behavior is within the framework of the family and between the husband and wife, it is interpreted as spousal abuse, which is the most common type of violence (15, 16).

Male violence in the family context involves a variety of dimensions, including physical violence (kicking, pushing, assaulting by hand or other means), psychological violence (threatening, humiliating, verbal blaming, scandal), social violence (controlling women's behavior, social isolation, prohibition of communication with others), economic violence (eliminating financial in dependence, preventing economic participation), and sexual violence (sexual activity by force and without consent of a woman) (17).

Domestic violence against women has always been regarded as a concern not only in developing societies but also in developed societies, based on cultural and indigenous components (18). Various statistics have been reported concerning the prevalence of violence against infertile women. The results of a meta-analysis showed that the prevalence of violence was equal to 47.163% (95% CI 34.660 to 59.850%)(19). Also, the prevalence rates of violence for non-immigrant Jewish people in Israel were reported as 18.5% and 1.5% for psychological and physical violence, respectively (20). In a study on infertile women in Turkey, the prevalence rates of psychological, sexual, and physical violence were 76.5%, 4.4%, and 17.6%, respectively (13). In a study in Egypt, the prevalence rates of psychological, sexual, and physical violence were 8%, 1%, and 21.4%, respectively (21).

 In Iran, various studies also show violence against women. In a study in Rasht City, the prevalence rates of psychological, sexual, and physical violence were 44.13%, 30.09%, and 33.88%, respectively (22). In another study in Mazandaran Province, the prevalence rates of psychological, sexual, and physical violence were 85.8%, 28.2%, and 25.9%, respectively (23).

Although infertility seems to be related to couples, the family and their relatives, whether willingly or unwillingly, with their annoying behaviors, can affect infertility problem and especially infertile women. Rejection, confrontation with wrong beliefs, interference, getting labels and blame, treacherous acts of the family and the community that can harm many infertile couples, especially women, create a new dimension of violence against infertile women (22, 24).

Different studies have been carried out on the factors related to violence against infertile women all over the world. The results showed that among various factors related to violence, some are infertility related, and some are not. These infertile-related factors are unwilling marriage (arranged marriage vs. love marriage), age of married couples, and duration of the marriage. Addiction, ethnicity, education, monthly income, duration of infertility, and spouse’s job are other correlated factors with violence (3, 13, 21, 25, 26). However, some other studies did not report any relationship between the incidence of violence and individual factors or infertility related factors (2, 27, 28).

Cultural, geographical, and ethnic factors affect the type, frequency, or severity of violence. Besides, there is the widespread nature of violence and its negative consequences on women and society and lack of adequate studies with completely specific violence collection tools for infertile women in Iran. Considering these issues, the present study aimed to investigate the extent of violence against infertile women and its related factors. Armed with the results of this study, the health care team, including physicians and midwives, could consider the symptoms of abusing husband and their violence towards women.

Materials and Methods

This cross-sectional study was conducted on 245 women with primary
 infertility, who referred to the infertility centers in Rasht City, Iran. The target population was a group of infertile women with primary infertility referred to the infertility centers in Rasht City (Infertility Clinic of Alzahra Hospital and Mehr Infertility Institute) from September to December 2017. These two centers are the most equipped and referral infertility treatment centers in Guilan province. The sample size was based on the results of Feizbakhsh et al (3), by considering α 95% confidence interval and the estimated error rate of 6%, which was determined as 245.  Based on the number of monthly referring patients to each center, 81 patients were considered as referring to the Infertility Clinic of Alzahra Hospital and 164 patients to Mehr Infertility Institute.

Sequential sampling method was adopted in which a group of subjects who were available in selected infertility centers was picked in a given time interval. The inclusion criteria for the participants consisted of having primary infertility and the absence of spouse‘s infertility confirmed by the gynecologist based on preclinical assessment of the male and female reproductive system (sperm analysis, hormonal tests, radiography, ultrasound), having writing literacy, lacking stepchild, and the willing to fill in the informed consent form completely. The exclusion criteria included lack of consent for participation in the study and delivering incomplete questionnaires.

A two-part self-structured questionnaire was used in the data collection procedure. The first part was designed to collect demographic characteristics of the couples which consisted of 26 questions about age, occupation, education, ethnicity, average monthly income, age at time the current marriage, the number of marriages, current drug consumption or the history of drugs abuse (cigarettes, opium, heroin) , having a  family relationship with each other before marriage (family marriage/blood relative), duration of married life,  satisfaction with their marriage, history of husband’s conviction or being imprisoned, history of physical violence in their families before  wedding, housing status, family type, duration of infertility, duration of infertility treatment, frequency of infertility treatment attempts (such as in vitro fertilization ,intrauterine insemination, gamete intra fallopian transfer, zygote intra fallopian transfer, intra cytoplasmic sperm injection , and  ovum donation).

The second part designed by Onat (24) is "Infertile Women’s Exposure to Violence Determination Scale "It consists of 31 questions in 5 domains; Domestic violence (11 questions), Social pressure (7 questions), Punishment (6 questions), Exposure to traditional practices (4 questions), and Exclusion (3 questions), which are specifically dedicated to infertile women at risk of violence. The answers to the questions in this scale are scored based on a 5-point Likert- type scale (never = 1, rarely =2, sometimes = 3, often = 4, always = 5). The total score was calculated from 31 to 155, which was obtained by adding points of all items; the higher the score means the more exposure to violence.  To determine the amount of violence in each area, the sum of the obtained points was used in response to the items in that area and ultimately the level of violence in each area was reported as a mean value.

To determine the validity of the scale, the method of face and content validity was used. The first and second part (after translation and back translation) of the questionnaire was investigated by 12 academic faculty members of the Guilan University of Medical Sciences. After collecting the suggestions and making the necessary corrections, the final tool was adjusted. Also, to ensure the validity of the second part of the questionnaire, content validity index (CVI) and content validity ratio (CVR) for every single question were used to calculate the content validity index. About CVI, all questions in three sections had the simplicity, clarity, and relevance values of more than 0.92, and the CVR obtained in all questions was above 83.3%.

To measure the reliability of questionnaire, two methods used were the Cronbach alpha (to assess the internal consistency) and test-retest (to evaluate the repeatability) after completing the questionnaire by 20 eligible infertile women.

 Regarding the reliability evaluation by test-retest method, 20 samples were investigated in two stages with 14 days intervals and retest reliability coefficients in all domains was obtained as domestic violence (93.5%), social pressure (92%), punishment (93%), exposure to traditional practices (97%), exclusion (87%), and the total questionnaire (96%). These figures indicate the reliability of the questionnaire. Also, the Pearson correlation coefficients was used to examine the correlation between the results of the evaluation tests in every domain of the scale, including domestic violence (r = 0.996), social pressure (r = 0.992), punishment (r = 0.991), exposure to traditional practices (r = 0.996), and exclusion (r = 0.967), which indicated that the correlation between the scores before and after the significance level is 0.01 and the reliability of the questionnaire is significant.

The School of Nursing and Midwifery of Guilan University of Medical Sciences approved the study project, and the Research Deputy of the related university issued a permit. With the presence of a researcher at the Rasht infertility centres, the research samples were assured that their personal information would remain completely confidential and be used exclusively for this research project. After filling the informed consent form, all of the eligible infertile women were asked to complete the questionnaires.

The obtained data were analyzed using descriptive statistics (frequency, percentage, mean, and standard deviation) and inferential statistics, including the Kolmogorov-Smirnovtest, the Spearman correlation coefficient, Mann-Whitney test, and Kruskal-Wallis (to examine the correlation between demographic data and total violence score). Logistic regression model was used to determine the predictors of violence. In this model, the total score of violence was classified into two categories below average (mean 50.93) and above average, and then the predictors of violence related to the logistics regression model by Backward LR method with the probability of variable entry and exit in the model equal to 0.05 and 0.1 were performed. Data analysis was done in SPSS version 22. Statistical significant level was set at less than 0.05.

Results

Of 1200 infertile women referring to the Al-Zahra Hospital (Infertility Clinic) and Mehr Infertility Institute, 245 eligible infertile women participated in the study. The mean± SD age of the women was 30.38 ± 6.05 years ranged   18-49 years, the spouse age (year) 33.56±6.22, monthly income 550±360, the duration of marriage (year) 6.96±4.36, the age of women at the time of the current marriage (year) 23.42±5.61, the age of spouse at the time of the current marriage (year) 26.60±5.56, duration of infertility (month) 60.17±49.09 and Duration of infertility treatment (month) 46.26±45.11.

The study results showed that 66.1% of women were housewives; 42% of women had a university education. About 88.6% of the women married willingly, and 43.3% tried more than two times for infertility treatment (Table1).

The study results also showed that the mean± SD total score of violence against women was 50.93 ± 18.76 (Table2).

 Because of the unequal number of questions in different domains of the questionnaire, to compare the score of violence between domains, the percentage of each domain was calculated, and then the Friedman's statistical test was used for comparison. The results of this test showed a significant difference between the domains (P=0.0001). According to the results of this test, the highest and lowest scores were found in the field of exposure to traditional practices (44.37%) and domestic violence (26.98%), respectively.  

There was a direct relationship between the total score of violence and the duration of the marriage (P=0.001, r=0.215), duration of infertility (P=0.0001, r=0.250) and duration of infertility treatment (P=0. 0001, r=0.231), while there was a reverse relationship between the total score of violence and age of the women at the time of marriage (P=0.008,
 r=-0.169) and the age of the men at the time of marriage (P=0.0001, r=-0 . 239) (Table 3).

Also, there was a significant relationship between the total score of violence and the  women’s job (P= 0.05), husbands' job (P=0.006),  women’s education (P=0.016),  husbands’ education (P=0.019), family relationship with husband (P=0.012), marital satisfaction (P=0.036), and the frequency of infertility treatment (P=0.016) , so that the highest mean ranked score of violence was observed in women who were farmer  or  worker with  low education and  the husbands who were  unemployed  with low education.

Women who were a family member of their spouse, as well as women who were unwillingly married (arranged marriage vs. love marriage) had experienced more violence.

Increasing the frequency of infertility treatment attempts also increased the incidence of violence against women (Table 4). Among the factors studied in the univariate analysis, the most important predictors of violence, were the duration of marriage (P=0.008) are the age of the spouse at the time

of marriage (p=0.048) and the occupation of the spouse (P=0.071).   As the increase of each year since marriage, the chance of violence increases 1.09 times (OR = 1.091, CI 95%; 1.023-1. 163), the age of men at the time of marriage decreases each year, the chance of violence increases 1.060 times (OR = 1.060, CI 95%; 1.001 - 1.125), and the spouse’s job (workless) increases the chance of violence by 1.22 times (OR = 01.22, CI 95%; 0 .983-1.52) (Table5).

Discussion

Infertility is not merely a gynecological disorder and may lead to inappropriate consequences for couples and violence against infertile women. This study aimed to determine violence and its related factors in infertile women referring to infertility center of Rasht City in Iran. The mean± SD age of the women was 30.38 ± 6.05 years (age range: 18-49 y), and the mean± SD age of their husbands was 33.56 ± 6.22 years (age range: 21-56 y). The study results also showed that 20% of women and 31.8% of husbands were employees; 42% of women and 44.1% of their husbands had a university education. About 88.6% of the women willingly married, and 43.3% had more than two times infertility treatment attempts.

In our study, the mean± SD total score of violence was 50.93 ± 18.76. A study in Turkey showed the mean ± SD total score of violence was 40.5 ± 9.9 (29). In meta-analysis study in Iran, the score of violence was reported higher than fertile group (30). In both of them, the highest mean score belonged to domestic violence.

Perhaps differences in the culture of the societies have caused these differences. In some societies, the patriarchal culture and its dominance in all aspects of life have forced women to accept the violence as part of masculinity and the characteristics of manhood as well as man’s authority, therefore, the likelihood of husband’s violence against women in such a culture is greater (31). On the other hand, in some societies, people consider childbearing as one of the most prominent features of women. Therefore, in the case of fertility, women are always considered as the faulty one, so the woman is feeling pressure from the people around (32). Therefore, in such a culture, the probability of violence against infertile women is higher than the other types of societies.

The results of Moghaddam et al. (3) and Akyuz et al. (35) studies indicate that with increasing the duration of the marriage, infertility, and infertility treatment, the mean score of violence increases which is consistent with the results of this study. While in studies in Pakistan (33) and Turkey (2), there was no significant relationship between violence and duration of the marriage. Also, in Ardabily et al. (28) and Sami et al. (33) studies, there was no significant relationship between violence and duration of infertility. Finally, in Yildizhan et al. (2) study, no significant relationship was found between violence and duration of infertility. These differences can be due to the difference between the study tools used and the cultural differences in the communities under study.

Moreover, the results of our study show a reverse correlation between the total score of violence and the age of couples at the time of marriage, so that with the increase in the age of the couples, the mean total score of violence decreases. Similar to this study, the results of studies by Ozturk et al. (34) and Akyuz et al. (35) show that the lower age at the time of marriage the reason for the higher incidence of violence against women. However, in another study (36), there was no significant relationship between the amount of violence and the age of the married couples. The age of the couples at the time of marriage can be a correlate because of the following reasons. First, the lower age of men and women is usually accompanied by a lack of wisdom and knowledge; next, young men have a lower level of behavioral control; and finally, the power of male and female adaptation is weaker at   younger ages, all of which can be the source of more violence against women (31).

 Regarding the women's job in the present study, the lowest level of violence was observed among female employees and the highest rate of violence in female workers and farmers.  Similar to this study, Moghadam et al. (3), Akpinar et al. (13), and Alijani et al. (23) reported that the incidence of violence against employed women was far lower than that of housewives. However, in the study of Ardabily et al. (28) and Sami et al. (33) no significant association was found between violence and employment status.

Also, the husband’s job was the factor having the least effect on the level of violence, and the highest rate of violence was seen in unemployed men. In line with this study, Moghadam et al. (3) results also indicate that the highest rates of violence are observed in families with unemployed or worker husbands while Aduloju et al. (27) did not find a significant relationship between male violent behavior and husband’s occupation.

In this context, treatment costs of infertility is a stressful factor that can lead to conflicts between couples, especially if the cause of infertility the woman, and when the husband should pay for the treatment. Thus, the treatment cost is one of the effective factors in the incidence of violence against infertile women. As a result, financial independence among women can be considered as one of the factors reducing violence against women (3). In many societies, providing living expenses is the responsibility of men (16). Therefore, in such a culture, man's unemployment and its economic problems are important factors in the occurrence of family tensions and incitement of violence among infertile couples (31).

Moreover, the results of this study showed that low level of education of women and their husbands was accompanied by an increase in violence, which is in line with the results of the Iliyasu et al. study (25). However, Ardabily et al. (28) and Alijani et al. (23) did not report any significant relationship between the amount of violence and the education of women. Also, Ozturk et al. study (34), there was no statistically significant relationship between the amount of violence and the education level of the husband. So, it can be said that in educated families, the level of occurrence of violent acts is low because they know the ways to cope with conflicts in relationships (31).

 Likewise, Sheikhan et al. (37) reported that the rate of violence in women with   unwilling marriage is more than women who chose their spouse with satisfaction. However, no significant relationship was reported between violence and marriage type in Akpinar et al. study (13). Perhaps having sincere relationships and emotional attachment with close people, especially the wife/husband, is one of the basic needs of every human being that makes the relationship between couples joyful, friendly, reliable, sympathetic and prevents marital conflicts between them. On the other hand, forced marriage makes it difficult for couples to reconcile and thus decrease marital satisfaction, which is also considered as one of the bases for violence (31).

Also, the results of this study showed that the higher the number of infertility treatment attempts, the more the incidence of violence against infertile women. Sheikhan et al.(37) and Ozturk et al. (34)  reported that the amount of violence in infertile women who had a history of  fertility treatment was significantly higher than those who never used fertility treatments, which is consistent with the findings in this study. In Ozgoli et al. study (36), the incidence of violence against infertile women increases by reducing the frequency of fertility treatments, which is the opposite of the results of the present study.

The results also showed that the level of violence was higher in women who have a family relationship with their husbands, while another study in Iran (39) did not report any connection between violence and having a familial relationship with the spouse. It seems that the social and cultural statuses of some societies are in such a way that there are a lot of dependencies between the parents’ families and the couples’ new family (after the marriage of the children). Although this is effective in protecting the family from dependent families, sometimes interference on the part of the parent’s family leads to many problems (31). Perhaps having a family relationship with husband will provide the basis for more families’ interventions, which will cause more family problems and violence among infertile couples.

Logistic regression model was used to determine the predictors of violence. The most important predictors increase the likelihood of violence by increasing each year since marriage (1.09 times), by decreasing each year the age of men at marriage (0.94 times), and the occupation (workless) of the wife (0.82 times).

Due to the duration of marriage, the results obtained in the present study are consistent with the study of Sheikhan et al. (37), while in the study of Alijani et al. (23) the duration of marriage was not recognized as a risk factor for violence against infertile women.The results obtained in the study of Akies et al. (35), and Sheikhan et al. (37) showed that the marriage of a spouse at a younger age increases the likelihood of violence, while in the study of ElKateeb et al.  In Egypt (21) and Alijani et al, In Mazandaran (23), the age of the man at the time of marriage was not recognized.As well as, Ilyasu et al. (25) found that male unemployment increases the chances of violence against infertile women, while in the study, Akar et al. (17) and Adoljeh et al. (27), the occupation of the spouse was not recognized as a risk factor for violence against infertile women.

 The weaknesses of this study might be that participants not have given accurate information about smoking, alcohol and drugs due to social ugliness in this country. Also, the mental condition of the participants in completing the questionnaire, which may affect the accuracy of the answers and its control, is not in the hands of them. The questionnaire used in this study, in addition to spousal violence, is to assess the various dimensions of violence against infertile women in general, so the results provide comprehensive and useful information for managers to pay attention to infertile mental health, which could be the strength of this study.

Conclusion

In our study, the participating women reported less violence compared to women in the other studies in Iran. The different result of this study might be due to the use of different tools in other studies or higher educational levels among women. Therefore, our tool is recommended to be applied in further studies. Health care providers should prevent this aspect of infertility by becoming aware of the risk factors of violence against women. Besides, to prevent the occurrence of violence against infertile women, it is recommended to establish the counseling centers in health care clinics. Economic and social empowerment of women are based on   increasing the awareness of couples regarding infertility. Emphasizing more intimate marital relationships is another factor in reducing the incidence of violence against infertile women (37).

Acknowledgements

This study was financially supported by Guilan University of Medical Sciences, Rasht, Iran. We would like to thank the officials and employees of Shahid Beheshti School of Nursing and Midwifery, Al-Zahra Hospital Infertility Clinic, Mehr Infertility Institute of Guilan, and all the study participants. This article is the results of a research project approved by grant number of 96030602 and ethical code of No.IR.GUMS.REC.1395.128.

Conflicts of interest

Authors declared no conflicts of interest.