'God helps those who help themselves'… religion and Assisted Reproductive Technology usage amongst urban Ghanaians.

Assisted Reproductive Technology (ART) is increasingly becoming a viable option for infertile couples in Ghana. There exists significant literature that explores the gender, legal, religious and socio-cultural implications of ART usage. In this paper, we expand the discourse on the nexus between religion and ART usage by looking at how the former is used as a frame of reference in the decision-making process, as well as how it is employed to explain treatment successes and failures. Irrespective of religious orientation, there was a general acceptance of ART by participants in the study-with exceptions only when it came to some aspects of the procedure. Even here, participants' desperate desire to have children, tended to engender some accommodation of procedures they were uncomfortable with because of their religious beliefs. Thus, in contrast to some studies that suggest religion as interfering with ART use, we posit that religion is not an inhibiting factor to ART usage. On the contrary, it is an enabling factor, engendering the agentic attitude of participants to find a solution to their infertility in ART; as well as providing the strength to endure the physical and emotional discomfort associated with the biomedical process of conception and childbirth. In this context, religion thus provides participants with a frame of reference to navigate the spaces between decision-making, treatment processes and outcomes, and attributions of responsibility for the outcomes whatever they may be.

Introduction

The past four decades have seen a significant rise in the use of Assisted Reproductive Technologies (ARTs) in both developed and developing countries. In Ghana, the first successful IVF procedure was done in 1995 and since then, many privately owned fertility clinics have sprung up mainly in the capital, Accra and a few other urban areas. To date, there are about 19 fertility centres located mainly in Accra with a few in Kumasi, Takoradi and more recently, Ho. The increasing numbers of these treatment centres and their continuous existence mean that more Ghanaians are ready to use and are demanding ARTs in solving their infertility problems. In spite of the spread of these Western technologies in non-Western countries, only a few studies have been conducted in non-Western societies to examine the socio-cultural factors that influence their use and their impacts in these societies. In Ghana, the few studies that have been conducted focused on the transnational operation of IVF clinics in Ghana [1, 2], as well as challenges experienced by clients undergoing ART treatment in Ghana [3]. In these studies, the authors describe the ways in which private fertility clinics in Ghana rely on medical professionals from Western countries to complement their local experts who albeit received training from Western countries to operate the clinics. Some of the challenges experienced by Ghanaian men and women accessing infertility treatment via ART include the high cost of treatment associated with it, the long distance to treatment centres, disturbances in their daily routine and work amongst others. Although religion permeates every aspect of the Ghanaian society, very little is known about the interplay between religion and ART treatment in Ghana. The current paper thus, seeks to address this lacuna in the extant opus by examining the role of religious beliefs in the acceptance or rejection of ARTs.

Indeed, religion and morality have been found to affect the acceptability of ARTs in many societies outside Ghana. Among the Christian population of Israel for instance, the biblical commandment to “be fruitful and multiply” has been the driving force behind the acceptability of ARTs both legally and socially [4]. This, coupled with the pronatalist culture of Israel stemming from the political desire to populate in order to occupy the vast lands seized from their Arab neighbours, has encouraged more births especially for the infertile through the use of ARTs [5]. ART services are thus highly subsidized to encourage more people to utilize them [6].

Issues of morality associated with the use of donor material for ART procedures also come to play among the Sunni Moslem population in Egypt. The use of donor semen is deemed inappropriate and equated with adultery, which is against existing religious and moral principles [7]. In other non-Moslem but traditional African societies, a similar belief was found to exist [8, 9]. Likewise, in Italy, the strong influence of the Catholic church has led to restrictions in certain aspects of assisted reproductive treatment for infertility such as cryopreservation and third-party donations [7]. However, Shia Moslem laws in Iran and Lebanon have permitted third party donations to facilitate conception using ARTs [10].

In this paper, an analysis is made of how respondents utilizing ART treatments understand and negotiate treatment with particular reference to any existing tensions and/or apparent equanimities that exist between religion and biomedicine. By so doing, we aim to contribute to the literature on the nexus between religion and modernity (with particular reference to ART treatment) as practiced, experienced, and understood by our Ghanaian respondents.

The religious landscape in Ghana and the theory of agency

Prior to the advent of Christianity and Islam in Ghana via the work of colonialists/missionaries and trading activities respectively, Ghanaians practiced African Traditional Religion. In Ghanaian traditional religion, the hierarchy of authority which formed the basis of the religion consisted of different supernatural beings namely the Supreme Being, the nature gods, the ancestors and the other gods [11]. Each of them had a role to play in the fertility of the individual. Although the Supreme Being was regarded as the omnipotent, he was believed to work through the other deities since he was too powerful to be approached directly. The ancestors are believed to give children to the living for the continuation of the lineage. Believers therefore pray to the ancestors for fertility. Among the Akans, this is referred to as ‘abawotum’ [12]. In addition, there are fertility gods that are believed to endow people with fertility. Anyone desirous of children therefore prays to such gods and offers the necessary sacrifices for obtaining such blessings from the gods. Children born through these means could then be named after these gods. Some trees are also believed to be inhabited by spirits which make people fertile [13]. Cutting down such trees therefore meant invoking the wrath of the spirit dwelling in the tree and punishment for this act came in the form of infertility [13].

Furthermore, the ancestors and the gods are believed to bless ‘good’ people with many offspring. However, one form of punishment for evil was seen in the inability to conceive. As Caldwell and Caldwell [14] put it, traditional African religion affects fertility behaviour in the sense that, fertility is equated with virtue and spiritual approval whereas reproductive failure or cessation is regarded as a consequence of sin.

Apart from the role of these deities in the fertility of the individual, witchcraft is also believed to have the potential to negatively impact fertility. Witches are regarded as forces of darkness that cause evil and misfortune to others. One of such misfortunes could be infertility. Sackey [15], reports that the common belief in traditional Ghanaian society was that witchcraft was responsible for infertility. Okonofua, Harris et al. [16] in their research in Nigeria, also reported that witchcraft was often blamed for one’s infertility. One way of combatting the effects of witches and to secure one’s fertility was through the use of charms or amulets also referred to as suman in Akan [12]. These may be objects worn on or around different parts of the body and believed to be the repository of power derived from the gods or spirits.

In modern times, very few Ghanaians still practise African Traditional Religion (5.2%) with majority of them being Christians (71.2%) and a few (17.6%) being Moslems (GSS, 2012). With the advent of Christianity and Islam into the country, religious beliefs associated with infertility and its treatment have correspondingly shifted to align with Christian and Islamic beliefs. According to Christian beliefs, man was admonished by his creator to “be fruitful and multiply….” (Genesis 1:28). The primary value of a woman in biblical times lay in her chastity and after marriage, her reproductive ability. These may explain the desire to reproduce on one hand and the negative reactions that one suffers from members of the society if this God-given obligation is not fulfilled. Evidence from the Christian Bible suggests that God blesses his people with the capacity to reproduce when they act according to His will. “Your wife will be like a fruitful vine within your house…” (Psalm 128:3) and “…. none of your men or women will be childless….” (Deuteronomy 7: 14) are a few examples to that effect.

Furthermore, Islamic beliefs and practices associated with infertility and its treatment are similar to that of Traditional religious beliefs as well as Christian beliefs. In the Quran, it is written “…. we cause whom we will rest in the womb for an appointed term, then do we bring you out as babes……” (Quran 22:5). ‘We’ here refers to Allah or the Moslem God. This also brings to the fore the issue of conception being controlled by a supernatural being namely Allah. Likewise, barrenness is seen as a decree from Allah, “…He leaves barren whom He wills… (Quran 42:50). However, this situation of infertility may not necessarily be a consequence of one’s disobedience. Rather, Allah is seen as all-knowing and competent and His actions can therefore not be questioned. Such occurrences may therefore be seen as a test of faith.

According to the WIN/Gallup 2017 survey report which explored religious beliefs of over 66,000 people in 68 countries across the world, Ghana is ranked amongst the top ten most religious countries in the world with 94% of its populace professing to be religious. In addition, various scholars have pointed out the important role that religion plays in the life of the African. Opoku [17] notes that, religion is at the root of African culture and is the determining principle of African life; Africans are engaged in religion in whatever they do leading to Professor Idowu describing them as a people who are religious in all things [17]. Parrinder [18] states that Africans are incurably religious, whereas Mbiti [19] describes Africans as notoriously religious.

In addition to the knowledge of the percentage of Ghanaians that adhere to the three major religions prevalent in the country today and the realisation of the high levels of religiosity in the country, is the emergence of the relatively new independent Christian churches or pentecostal-charismatic churches. These churches are becoming more appealing to the Ghanaian and by extension the African because according to Meyer [20], these churches seem to offer a more ‘authentic,’ Africanized version of Christianity than do the presumably Western oriented mainline churches. An important point worth noting here is that current pentecostal-charismatic churches (PCCs) appear to derive their mass appeal at least, partly from propagating a ‘complete break with the past’. The emergence of these new independent Christian churches brought about a shift from the erstwhile drive of converting traditional religious practitioners to Christianity to what is now generally a situation of converting orthodox Christians to the new form of Christianity which hinges on prosperity. According to this theology, financial prosperity, health and well-being are blessings from God to his faithful ones. The theology also challenges adherents to be in charge of their own destinies while at the same time demanding their rights from God as His children [21]. With its focus on the individual, the prosperity gospel in Ghana, especially, continues to erase traditional social arrangements that foster communalism and collective endeavours. The effects of this orientation is the emergence of Assisted Reproductive Technologies in Africa which have come in to replace the more collective and communalistic strategies of solving infertility that existed in traditional African societies [22]. Another characteristic of these pentecostal-charismatic churches is the strong belief in the prowess of the head/lead pastor to intercede successfully on behalf of members to resolve various health, socioeconomic, and cultural problems.

Bearing in mind these differences in religious orientation of Ghanaians and the beliefs associated with them, this study sought to analyse the role of religion in the decision-making process towards the utilisation of ARTs in Ghana. For instance, do Ghanaian Christians and Moslems accessing ARTs differ in their attitudes towards ARTs? Do Ghanaian Catholics and Pentecostal-Charismatics accessing ARTs differ in their attitudes towards ARTs? These form the basis for this study.

The capacity of participants to act independently and make decisions of their own free choice to address their infertility reflects the sociological theory of agency. This theory is adopted as the sociological lens through which we appraise the attitude of participants in this study. The agency theory, first formulated in the academic economic literature, has been deployed in several disciplines including sociology to explain the motives, actions and interrelationships between actors in several social contexts. Gidden’s model of agency and action emphasises the agency of human beings and the feature of ‘intentionality’ as a process. Such intentionality suggests that humans have definite goals during the course of their action. The ‘reflexive monitoring’ of action provides the rationalisation of action- i.e., humans capabilities to explain or give reasons for their conduct. A third concept of the agency theory of action, the ‘motivation of action’, speaks to the potential for action- i.e. individuals’ capabilities to undertake the intended action. Thus, in any given situation, the grounds for action (rationalisation of action), motives for action (factors that engender action) and motivation for action (capabilities) are at play. These basic tenets of the agency action theory emphasise initiative, freedom, and creativity of individuals. In this paper, we adopt these concepts and ideas to demonstrate how couples, through intentionality, self-regulation and reflexiveness have sought to become parents through ART use irrespective of their religion. Thus, while participants’ desire to become parents may have been influenced by the external pressures from their social systems, the agentic act to ‘help oneself in order to be helped by God’ permeated the decision-making process and the explanations participants gave to the outcomes of their use of ARTs.

Methods

The study was conducted in a hospital setting in Accra, Ghana. The hospital was selected due to its approach to solving infertility, and thereby aimed to capture the behavior of Ghanaians seeking infertility treatment via Assisted Reproductive Technologies. The use of Assisted Reproductive Technologies (ART) is gradually increasing in Ghana, with more advanced options being based in private health facilities. The study site is one such privately-owned modern fertility clinic providing advanced ARTs, such as In-Vitro fertilization (IVF)—a procedure that involves the retrieval of eggs from a woman’s ovaries and fertilizing them with sperm; and Intra Cytoplasmic Sperm Injection (ICSI)–a procedure that involves the direct injection of the sperm into the cytoplasm of the egg.

Participants

Participants were restricted to 15 persons from married heterosexual couples. It also included 4 key informant interviews made up of an IVF specialist, an embryologist, a Catholic priest, and a pastor from a charismatic church. The IVF specialist and embryologist were purposively selected from the hospital that respondents were selected from. They were the key consultants in the hospital for anyone who needed fertility care. The Catholic priest was selected from a Catholic church close to the facility on the basis that clients may reach out to that church for their spiritual needs based on its proximity to the fertility centre. Finally, the pastor from the charismatic church was selected on the basis of the fact that, he organizes a yearly spiritual program for infertile couples seeking to have their own children under the theme: ‘Operation 1000 babies’. The sampling was influenced by the need to understand the experiences of infertile married men and women from their own perspectives rather than achieving a representative sample.

Procedure

Semi-structured in-depth interviews were the main mode of data collection. Respondents were mainly asked questions relating to the decision-making process towards seeking treatment and the role and reactions of their partners and family members. One-on-one interviews were conducted with participants in any one of these three languages, English, Twi and Ewe. All interviews transcribed directly into English.

During the interview process, 13 interviews were digitally recorded (with 2 participants declining). Notes were also taken during the interviews and read back to the respondents to confirm that they were consistent with the views of the respondents thus achieving respondent validation. Interviews lasted from 40 to 140 minutes (mean 90 minutes). Interviews were held in the facility, while the clients were either on admission or after an IVF or ICSI procedure. Two critical considerations for reflections of positionality in this study related to the researcher’s outsider status deriving from gender and the status of not seeking help for infertility as were the participants. It was noticed that female participants were relatively much more relaxed (compared to their male partners) speaking to a fellow woman about their experiences of infertility and health seeking behavior, even if they perceived that the researchers did not have similar challenges of infertility. The men however appeared ‘economical’ with information which was attributed to the outsider factors named early on. To mitigate the implications of this for the study, the services of the embryologist who is a male was engaged, to sit in during the interviews and to ask some of the questions. This proved to be quite useful.

It was mainly women who took part in the study because interviews were conducted while these women were still on admission at the hospital after a successful embryo transfer. It was part of the requirement from the facility that clients stayed in the hospital five days after the IVF or ICSI procedure to ensure they were resting as this they believe, could improve upon the success of the procedures. This time allowed them to be in a relaxed atmosphere and more receptive towards participating in the interviews since they had free time available. Although interviews were scheduled with their partners, they seldom made the time for it as they were constantly on the move attending to their normal duties and spent a short time on their visits to the hospital. They expressed the fact that, talking to their wives was enough since in their words ‘my wife has said everything, and I do not have any new thing to say’. This is understandable given the Ghanaian cultural context whereby it is women who bear the brunt for infertility most and as such fits aptly into the maxim ‘(s) he who feels it, knows it’.

Data analysis

Thematic analysis of data was employed following the guidelines provided by Braun and Clarke [23], namely, getting to know the data, generating codes, searching, reviewing and defining themes, and finally, writing up the findings [24]. After this, manual data coding began under appropriate potential themes, driven by theory and informed by the interview guide and research questions [23]. Where necessary, themes were modified to reflect the codes they contained and to reduce overlap. The analyses thus involved searching for repeated patterns of meanings.

Ethical considerations

Ethical clearance was received from the Institutional Review Board of the Noguchi Memorial Institute for Medical Research, University of Ghana. Respondents who took part in the study signed and one participant who was semi-literate, thumb printed a consent form to show that they willingly took part in the study. To ensure anonymity, respondents names have been changed and identifying details removed.

Findings

Characteristics of participants

As presented in Table 1, the study involved 15 participants, all of whom were in heterosexual marriage unions. Overall, interviews were conducted with 13 females and 2 couples (interviewed together so recorded as 1 patient journey). Participants’ age ranged between 20 and 59 with most of them between the 30–49 age bracket. Years of marriage to their current partner at the time of the study also ranged between 0 and 34 years with majority of them having been in their current union for less than 10 years. With respect to their infertility status, majority of the respondents [10] were experiencing primary infertility that is, had no child of their own and 5, secondary infertility, that is, were unable to have another child after one successful live birth. Respondents were mostly Christians [13] with 4 out of these being Catholics and the remaining 9 being Protestants. There were also 2 Muslims.

Table 1

Socio-demographic characteristics of respondents.

Item Description	Fertility clinic using ART (n = 15)
Males	0
Females	13
Couple	2
Age of respondents:
20–29	1
30–39	7
40–49	5
50–59	2
Years of marriage:
0–4	3
5–9	5
10–14	4
15–19	1
20–24	1
25–29	0
30–34	1
Primary Infertility	10
Secondary Infertility	5
Religious Affiliation
Catholic	4
Charismatic/Pentecostal	9
Moslem	2
Source: Field interviews

In terms of their socio-economic background, participants were mainly middle to high income earners with their occupation ranging from bankers, insurance managers, entrepreneurs, mining company workers and a few who were either living/working in the United Kingdom and other parts of Europe with their spouses. This is understandable as IVF treatment costs in Ghana are borne solely by the couple with no form of health insurance covering any aspect of the treatment.

Religion and ART

Religion was found to play three major roles in the quest for conception via Assisted Reproductive Technologies, namely, deciding whether or not to use ART; explaining treatment successes; and coming to terms with treatment failures.

To use or not to use ART

The findings from the study suggested that among Christians, acceptability of ARTs may vary according to denomination. It was found, for instance, that some Catholic clients of fertility clinics had reservations towards IVF procedures based on the ‘unnaturalness’ of it and the fear of going against religious doctrines. Catholics accessing ART treatment expressed initial discomfort with the idea of artificial insemination and only went ahead with it after receiving assurance from the doctor that, embryos that are discarded are not viable. This puts them at ease because to them, discarding unused embryos is tantamount to abortion. Those who were unsure, found a way of seeking clarity from their priests prior to the commencement of the treatment. For instance, one of our respondents stated:

I went to my parish priest for special blessings just before coming in for the procedure. He prayed with me and gave me God’s blessings. If he felt it was against Catholic beliefs, he wouldn’t have gone ahead to bless me or am I lying? I don’t think the church frowns on it and so neither do I. That is why I was able to ask God for his help so that everything will work out well.

Respondents belonging to other Christian religious denominations, such as. the protestants did not express any reservations based on their religious beliefs towards the use of ARTs as treatment options for infertility. When asked if she felt being a pastor’s wife meant she need not undergo infertility treatment using ARTs, 37-year-old Jennifer replied:

No way!! It is even written in the bible that God helps those who help themselves. It is God who has given the doctor the wisdom to discover medicine to treat the sick. If today the doctor is telling me that he can use my eggs and my husband’s sperms to give us a baby using scientific technology, why not? I don’t see any problem here. In fact, I’m sure by now God is looking down at me and saying…Ah my daughter, you have done well! I will bless the work of your hands! (laughs with joy). I know he has done it for me already.

At a Christian religious ceremony to pray for divine intervention for the fruit of the womb dubbed ‘operation 1000 babies’ organized by the International Prophetic Centre, a Charismatic church, participants were enjoined to bring along baby clothes of the required gender to church- blue for a baby boy and pink for a baby girl. According to the pastor,

If you are here and you have been going to the hospital, looking for a baby and the doctor says you should come and do IVF, my sister, my brother, you better come along with two, three, four different clothes according to the color that you want. In fact, you can bring one blue, one pink, two blue one pink…. If you want twins, triplets, whatever number you want. Do not limit God, bring as many as you want. God can do it.

Moslem clients were not left out of IVF and ICSI procedures. They were found accessing IVF and ICSI treatments in cases of both male and female factor infertility. One Moslem man encountered on one of the visits to a fertility clinic was in a polygynous marriage. Although he had seven children with his first wife, his second wife of ten years was childless. According to him,

No, no, no, this has nothing to do with my religion. I want her to undergo an IVF procedure so that she can also have a child of her own. I love her very much and I want her to be happy. I know if she also gives birth, she will be happy. I want to bring honor to her. So we came to see the doctor so that he can help her. He said one of her fallopian tubes is blocked but through IVF, she can get pregnant. I don’t believe there is anywhere in the Quran that Allah speaks against this. No!

After the decision has been taken to access ART treatment, male clients are required to produce semen samples by either masturbating or having sexual relations with their spouses within the hospital. Key informant interviews with the embryologist revealed that Moslem clients expressed more discomfort with the idea of masturbation which led to some withdrawing from treatment without considering the possibility of the production of semen via sexual intercourse with their partners within the hospital. According to him,

Some men do not like the idea that they have to masturbate to produce their semen for analysis. I’ve realized it is mostly so with our Moslem clients. I am not a Moslem but I think there must be something about masturbation written in the Quran because as soon as I tell them, they shake their heads and tell me no, they cannot do it.

In addition, the data revealed that, Moslems accessing IVF treatment did not subscribe to the use of donor material. This is because it was against religious doctrines to involve a third party in the fertilization process. This was seen as adultery. Key informants revealed that it is in very rare cases, Moslem clients accessed donor IVF procedures.

Explaining treatment successes—God is the ultimate healer

Treatment successes were understood not only in terms of the capabilities of science and technology but more importantly in religious terms as the ultimate hand of God being at work.

The role of a supreme being in the success of IVF/ICSI treatments is seen in the local names that respondents indicated they would give to such children. Two respondents revealed they would name their children Nukunu—an Ewe name meaning ‘a wonderful thing/creation’. This aptly expresses the sentiments of the expectant parents regarding the means of conception. Others had also selected Ghanaian names with religious undertones to express their sentiments towards God’s role in the process of achieving desired conception. Ghanaian names such as Seyram (God has blessed me), Aseye (Praise Him), Nyamekye (God’s gift) and Nhyira (God’s blessings) were some of the names that respondents had chosen for their children.

A divine hand is also seen to be at play throughout every step of the process beginning from the medications taken in preparation for the procedure, through conception to successful gestation and delivery. Aside having undergone a successful IVF procedure and having carried the baby in her womb for 29 weeks, Akuvi’s experience at labour and successful vaginal delivery was the icing on the cake for her desire to experience motherhood. At 57, the doctor had advised her to have a caesarean birth but she had convinced him she would try and give birth naturally. She narrated her experience with such joy and in such detail. During her week-long stay at the hospital following the birth, she was easily noticeable as she was often found walking up and down the corridors between the neo-natal intensive care unit where her pre-mature baby was receiving care. She would be seen waving her white handkerchief amidst songs of praises to God for his goodness. According to her,

“…it is God ooo, it is God. At long last, my dream has come to pass, my dream has come to pass, it is all in the past now”.

Likewise, multiple pregnancies and births were interpreted as additional blessings from God. Despite the fact that transfers of more than one embryo at a time is the norm (except in few cases where only one embryo is available for transfer), the ability for more than one embryo to be implanted is regarded as divinely coordinated. For Adzo, after ten years of a childless marriage, God had finally blessed her not with one, but two babies. By so doing, He has brought happiness to her and shamed all those who were ridiculing her because of her childlessness. The sentiments of Adzo is thus a representation of how participants attributed treatment successes to God and how multiple births were considered to be extra blessings from God.

Coming to terms with treatment failures

When procedures are not successful, clients again fall on religion as an explanatory model. However, the supernatural entity (God) is never seen as opposed to their desire to have children. Rather, it is blamed on circumstances such as timing. Although they could not explain why they were unsuccessful at that particular point in time, as one of the respondents put it, “God’s time is the best, His ways are not our ways”. This meant one had to keep trying until the right time when God chooses to ‘endorse’ the conception and birth. Laureen, who miscarried each one of her triplets after almost eight weeks of pregnancy expressed a similar sentiment. Although it was a very painful experience, since she lost them, one after the other, she expresses joy at the opportunity to also feel what it is like to be pregnant even if for a short time. According to her,

“Only God knows why I lost all three of them and in such a manner. Especially Lisa/ Seyram, the last one. I was so sure that she would survive because each time the doctor did a scan, we could hear her heartbeat. I kept saying, God, as for this one, do not take her away. But in the long run, the doctor discovered she was growing outside my uterus and I could have died if the baby had survived. That is why I was bleeding so much. So I believe that, despite the fact that they all didn’t survive, at the end of the day, God knows best that is why I am still alive today”.

Service providers were never blamed for treatment failures. This may probably be because, the doctor had told the clients over and over again that,

We (the specialist together with his team) have done everything that is humanly and scientifically possible and can only do so much. The rest is up to God.

Clients and service providers thus interpreted and understood treatment failures in scientific and more importantly in religious terms as well. As indicated by the pastor:

Is it everyone who will give birth? There are examples of people in the Bible who never had children. Everyone has a purpose on this earth and for all you know, God’s plan for such people is different. It could be that, they have been brought here to take care of the many orphans out there who do not have anyone to take care of them.

Discussion

The main objective of this study was to explore the role of religious beliefs on the utilization of ART treatment as a solution to infertility. The religious beliefs of clients showed a general acceptance of the procedure. It is often regarded as the work of God through man. The IVF specialist was seen as one who was utilizing the knowledge that God had endowed man with to cater for their needs. The Catholic Church is known to be against anything artificial that aims at interfering with the process of reproduction. Catholics do not subscribe to the use of contraceptives to prevent conception and are also against abortion equating it to the sin of murder (www.catholic.com/tracts/abortion-birth-control). In addition, the manipulation of human embryos ex-vivo and the discarding of excess embryos are against Catholic doctrines [25]. The Catholic Church’s position on this explains why some (albeit very few) felt uncomfortable with some aspects of the process. Their change in acceptability of the procedure was borne more out of the need to have children than religious doctrines.

In her study of the intersections between religion and modernity, Roberts [26], discovered that, in the strong Catholic state of Ecuador, there was a stable separation between the church and the state in the area of IVF treatments. As such, despite the existence of strong Catholic sentiments for both patients and practitioners, these did not influence the acceptance of IVF in a negative way. In addition, the services of religious leaders were employed to aid in fertilisation and implantation. Despite the fact that Ghana does not possess the identity of being a Catholic state, such similarities in the separation of church doctrines and actual practice in the field of IVF treatments is useful in providing an understanding of the synergies between religion and science in varying contexts.

Respondents belonging to other Christian religious denominations did not express any reservations towards the procedure based on their religious beliefs. This may be because, other Christian denominations are not as dogmatic in orientation in the area of reproduction and the non-interference of human agents in the process. Perhaps, for all groups of believers, their high levels of education could also explain their openness to new scientific information.

Furthermore, religious explanations that clients accessing IVF and ICSI give are often evident at all three stages of treatment namely before treatment, after a successful procedure and also after an unsuccessful procedure. Before treatment, clients often explained their decision to undergo the procedure with the common Christian phrase that says “God helps those who help themselves”. This means that they did not see the scientific procedure as in opposition to God’s will. Religion is therefore not a conflicting system but a complementing one. Religious faith is also important in providing a source of strength to cope with the emotional and physical pains associated with treatment.

In Moslem marriages whereby polygyny is practiced, female factor infertility can be resolved simply by marrying another wife. However, this is not always the case. This means that religious rules permitting polygyny do not always prevent Moslems from accessing IVF treatment. In other words, female factor infertility as evidenced in the case of the Moslem man in a polygynous marriage who was seeking treatment for his second wife of 10 years, posed no threat to the marriage for the woman.

For the Moslem also, masturbation is regarded as sin since it is tantamount to having an extra marital affair.

In addition, the data revealed that, Moslems accessing IVF treatment did not subscribe to the use of donor material. This is because it was against religious doctrines to involve a third party in the fertilization process. This was seen as adultery and is in tandem with findings amongst the Sunni Moslems where it was considered illegal to use donor material [10]. However, the extent to which such religious doctrines are strictly adhered to is also of interest. Key informants revealed that, in very rare cases, Moslem clients accessed donor IVF procedures. This attitude could again be attributed to the greater need to have a child.

Kahn [27] in her study of Orthodox Jews in New York who were undergoing infertility treatment found that a common Jewish principle influenced the way both doctors and patients interpret treatment successes and failures. This Jewish religious principle enjoined believers to exert the most effort at whatever task they were performing in order to achieve a desired outcome. However, God determined the ultimate success of that effort.

According to Adjah [28], the name that Ghanaians give to their children is determined by a number of factors including the circumstances surrounding the birth of the child as well as the parents’ beliefs and ideas. Names based on parents’ beliefs and ideas are otherwise referred to as allusive names. Allusive names do not have a direct bearing on the child but rather portray the parents’ ideas about man’s relationship with God amongst other things [29]. The origin of such names can be likened to the coming of Christianity [30]. The Ghanaian thus ended up responding to this new religion by adopting Christian names in local languages. These two factors surrounding the naming of a child in Ghana explains the behaviour of the participants in this study. It is apparent that, their choices of names for their children that will be borne out of a successful IVF/ICSI procedure stems from the circumstances surrounding the birth as well as their beliefs and ideas about God.

Limitations

As with most qualitative studies, this study does not seek to generalise that, amongst Ghanaians, religion is supportive of ART usage. The study focused on users of ART and how their decisions to use ART took into account their religious beliefs. The study is thus limited in scope as it excludes infertile persons who are not seeking treatment. Further studies may thus be needed to document if our findings hold true for infertile persons who are not seeking ART treatment. Again, this study did not explore how individuals not seeking ART might compare with ART users at the study site i.e. whether the religious background of infertile couples impact perceived uptake of fertility services at fertility clinics/hospitals thus the need for further studies in that regard.

Conclusion

In analyzing the effects of Western biomedical treatment options for the infertile and their acceptability and utilization in the Ghanaian context, varying considerations emerged. These were influenced by existing social, cultural and religious beliefs. Socio-culturally, based on the overarching desire to be biological parents, clients navigated their way around treatment options in such a way as to reduce dissonance to the barest minimum. The different worlds of science and religion were also found to be necessary synergies that supplement/complement one another rather than being in opposition.

In sum, the major beliefs associated with infertility and its treatment in Ghana point to the belief in fertility being orchestrated by a supernatural entity. For that matter, believers rely on these deities and their representatives in ensuring their fertility. In times when the potential for fertility is challenged, they again draw on religious beliefs and practices in the hope of obtaining a cure for their infertility.

13 Apr 2021

PONE-D-20-36012

‘God helps those who help themselves’… religion and ART usage amongst urban Ghanaians

PLOS ONE

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Reviewer #2: Yes

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Reviewer #1: Review

This manuscript describes the attitudes of couples in Ghana using Assisted Reproductive Technology to become pregnant, and how their religious affiliation affects these attitudes. This is a highly important but sensitive topic, which makes it hard to systematically collect data – I think the author do the subject justice with their data analysis and their differentiated discussion. I enjoyed reading the ethnographic descriptions, and I think they capture the struggles of these couples while undergoing ART. I therefore think this work deserves publication. To improve it even further, I would recommend bolstering the manuscript with additional information in places and add more differentiated reflections on different factors that might have influenced the attitudes of the participants – mainly on participant social class and the ethnographer’s own role. It would be good to discuss how representative the sample is for Ghana. I will describe recommended changes below.

L.21 – I would not start the Abstract with ‘ART’ because many readers will not know what this is right away.

L.35 – The manuscript jumps between ‘decision-making’ and ‘decision making’.

L.49 – It would be good to extend on these studies about ART in Ghana and the challenges experienced by couples – this is important in setting the stage for the whole article, so adding one or two sentences would be well justified.

L.56 – The article treats ‘non-Western’ as a unified block, but this is clearly not the case when it comes to morality and reproduction. There is also subsequently only a discussion of Abrahamic monotheistic religions. What about polytheistic or atheistic countries (especially India and China should have extensive use of ARTs)? What about different communities within other countries (e.g., contrasts between Catholic and Protestant believers in South American countries)? For example, later in the text there is a sentence about intersectionality in Ecuador. It feels like the argument the authors are trying to make in the Discussion could be improved if the manuscript is embedded better in a global context – similar processes will be at work around the world, but currently we only learn about a handful of countries.

L.161 – This whole paragraph (‘On the whole,…’) seems to be more interpretation based on the data than actually part of the Introduction, so it feels out of place. There also seems to be some value judgment in this – when the authors describe the new independent churches as ‘not being an opium’, this seems like a criticism of traditional churches. I would scrap this paragraph and replace it with a description of the research hypotheses based on the preceding discussion of different religious attitudes – would we expect differences between different religious groups? It would also be good to discuss upfront the methodology of this study – it is hard to get quantitative data on this topic so ethnography is a very good way forward, but it comes with a number of problems in this case (selection bias, the role of the ethnographer; see below) and it would be good to describe why this method was considered appropriate nevertheless.

L.169 – It would be useful to get more information in the text about the ‘sociological theory of agency’, what it entails, and how it is employed here. It feels like this piece of information is dropped on the reader, without citation or clear explanation, even though it seemingly is the main explanatory theory used in the manuscript. Has this theory been employed for ART decisions before, or the actions of religious people in moral contexts? While the Introduction is rich with descriptions of the religious landscape in Ghana, the formal framework under which the authors interpret is mainly implied.

L.180: Again, it clearly is very hard to get these data, and the authors have done a fantastic job getting those interviews. However, the fact that all the interviews were collected in one facility and only with couples who have already decided to use ART causes a host of problems. The main two are:

a) Couples in Accra who can afford ART might have different religions, but they are more urbane and probably more wealthy than the average couple in Ghana, and they probably have a higher level of education and access to fertility-related information (I make the assumption here that IVF is expensive in Ghana). So, the sample is varied when it comes to religion, but quite homogenous with regard to other factors. The assumption underlying the manuscript is that religion matters when it comes to these decisions and that couples interpret their religion as a way to improve their fertility, but what if that is not the case for less wealthy or more rural populations? In that case, the manuscript does only reflect a very particular slice of Ghana’s society, and that needs to be discussed and the discussion needs to be more nuanced.

b) By only choosing couples who decided to undergo ART, the authors face a selection bias: only couples whose religious feelings and communities allowed them to do ART are even interviewed, and they will obviously have a positive attitude to the subject. So, to make the conclusion that religion is a supportive factor in ART might be premature: we do not currently know what keeps other couples from attempting IVF. It might be that 95% of people reject ART based on their religion, but because the authors only interview 5%, they will not notice this in their interviews. Again, there is not much the authors can do about this, given the difficulties of getting data, but this possibility needs to be discussed and where possible, additional evidence needs to be presented to rule this out.

L.185 - I would include a brief description of what IVF and ICSI stand for, because they have different religious implication later on.

L.186 - How were key informants selected?

L.192 - The authors need to discuss their own role in this process more and potential biases that could have been introduced into the results by their own positionality. For example, later we learn that almost only women sat down for interviews, and men only as part of couples. This is worrisome and probably to do with cultural aspects and the role of the interviewer, but again this needs a nuanced discussion.

L.215 - Does the thumbprint indicate that some participants were not literate? It feels like that is a matter worth discussing, as this could bias their responses (e.g., more dependent on community leaders to determine their attitude, more dependent on clinic staff to detail the moral implications for them).

L.227 - Could you explain what primary and secondary infertility are in this context?

Table 1: There are many striking characteristics in this table that need to be explained in a more differentiated way, I think. First, the large age and relationship history ranges: presumably, these couples differ dramatically in why they attempt ART, how often they have tried in the past, societal pressures, and so on. The article is not specifically designed to address these questions, but presumably a couple that has been trying for pregnancy for 30 years might have a very different outlook on what is permissible than one that has been trying for 2 years, and might get very different advice from their community.

Analyses and Discussions: Based on the mentioned uncertainties introduced by the method, I think the manuscript would benefit from a more detailed discussion of how representative the sentiments of the couples and their religious attitudes are for Ghana, and whether the sample selection process might have biased the interviews towards those who interpret their religion in pro-fertility way. Also, especially for the Pentecostal religions, where most couples will be converts, it is possible that participants actually joined the particular church that was most positive towards their fight with infertility and promised them to solve it.

Reviewer #2: An important question is whether the study meets the PLoS ONE data policy; the authors note limitations on the availability of the data. If those restrictions do not meet PLoS ONE data requirements, then publication criteria would preclude publishing the manuscript. Apart from that, the manuscript offers a well-structured, substantive, qualitative evaluation of a sample of Ghanians seeking and being treated with ART and how that relates to their religious beliefs. The introduction and discussion sections situate the study well, and reference both relevant findings and concepts in Ghana as well as other comparative settings. The take-away empirical points are made clearly, with illustrative quotations also useful.

The manuscript could benefit from a modest copyediting process to clean up some occasional stray commas and minor language elements, but overall the manuscript is quite readable and easy to follow. As far as other comments related to modest potential edits, please comment how common ART is in Ghana, what form(s) of ART were employed by study participants (a table in the results just points to primary and secondary fertility without providing more information), and how those services are paid for (the manuscript says in a private facility, so I am guessing this is out-of-pocket which in turn warrants brief comment on the socioeconomic backgrounds of those who can access such services).

Are there any indications how representative this particular sample's findings are relative to other Ghanian ART service providers? Since all but 2 patients who were participated were women, please comment on the general ART services and demographics of those who use those services at the facility (e.g., are most patients women, or might the present sample say something more about difficulties of recruiting males who use ART?).

The sample of patients only includes, by nature of the study design, those who have used ART. The study does not include patients who, perhaps by virtue of religious beliefs, elected not to receive ART. Based on the interviews with the four key informants, did they offer any insights about how commonly patients decline ART due to religious beliefs? If so, please share more from that vantage in the results.

**********

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10 Jul 2021

We would like to thank the reviewers for taking time off their schedules to provide us with comments that has helped in strengthening the paper. We have addressed all comments adequately in the revised manuscript. We provide summaries of how we have responded to the comments below and referred to the appropriate section where such responses could be seen. Please note that these references are made in relation to the marked copy and not the clean copy. Thank you.

Reviewer #1: Review

This manuscript describes the attitudes of couples in Ghana using Assisted Reproductive Technology to become pregnant, and how their religious affiliation affects these attitudes. This is a highly important but sensitive topic, which makes it hard to systematically collect data – I think the author do the subject justice with their data analysis and their differentiated discussion. I enjoyed reading the ethnographic descriptions, and I think they capture the struggles of these couples while undergoing ART. I therefore think this work deserves publication. To improve it even further, I would recommend bolstering the manuscript with additional information in places and add more differentiated reflections on different factors that might have influenced the attitudes of the participants – mainly on participant social class and the ethnographer’s own role. It would be good to discuss how representative the sample is for Ghana. I will describe recommended changes below.

L.21 – I would not start the Abstract with ‘ART’ because many readers will not know what this is right away.

Abstract has been revised to read Assisted Reproductive Technology

L.35 – The manuscript jumps between ‘decision-making’ and ‘decision making’.

The manuscript is now consistent with the use of decision-making

L.49 – It would be good to extend on these studies about ART in Ghana and the challenges experienced by couples – this is important in setting the stage for the whole article, so adding one or two sentences would be well justified.

This has been done. See lines 52-57

L.56 – The article treats ‘non-Western’ as a unified block, but this is clearly not the case when it comes to morality and reproduction. There is also subsequently only a discussion of Abrahamic monotheistic religions. What about polytheistic or atheistic countries (especially India and China should have extensive use of ARTs)? What about different communities within other countries (e.g., contrasts between Catholic and Protestant believers in South American countries)? For example, later in the text there is a sentence about intersectionality in Ecuador. It feels like the argument the authors are trying to make in the Discussion could be improved if the manuscript is embedded better in a global context – similar processes will be at work around the world, but currently we only learn about a handful of countries.

This has been rectified. The sentence now reads, “in many societies outside Ghana…”. See lines 63-64

L.161 – This whole paragraph (‘On the whol,…’) seems to be more interpretation based on the data than actually part of the Introduction, so it feels out of place. There also seems to be some value judgment in this – when the authors describe the new independent churches as ‘not being an opium’, this seems like a criticism of traditional churches. I would scrap this paragraph and replace it with a description of the research hypotheses based on the preceding discussion of different religious attitudes – would we expect differences between different religious groups? It would also be good to discuss upfront the methodology of this study – it is hard to get quantitative data on this topic so ethnography is a very good way forward, but it comes with a number of problems in this case (selection bias, the role of the ethnographer; see below) and it would be good to describe why this method was considered appropriate nevertheless.

The paragraph has been deleted and a description of the main research question have been included as suggested. See lines 176 to 181

L.169 – It would be useful to get more information in the text about the ‘sociological theory of agency’, what it entails, and how it is employed here. It feels like this piece of information is dropped on the reader, without citation or clear explanation, even though it seemingly is the main explanatory theory used in the manuscript. Has this theory been employed for ART decisions before, or the actions of religious people in moral contexts? While the Introduction is rich with descriptions of the religious landscape in Ghana, the formal framework under which the authors interpret is mainly implied.

The issues raised here have been addressed. The key tenets of the agency theory employed in this paper have been stated and explained, as has the relevant citation. See lines 187-201

L.180: Again, it clearly is very hard to get these data, and the authors have done a fantastic job getting those interviews. However, the fact that all the interviews were collected in one facility and only with couples who have already decided to use ART causes a host of problems. The main two are:

a) Couples in Accra who can afford ART might have different religions, but they are more urbane and probably more wealthy than the average couple in Ghana, and they probably have a higher level of education and access to fertility-related information (I make the assumption here that IVF is expensive in Ghana). So, the sample is varied when it comes to religion, but quite homogenous with regard to other factors. The assumption underlying the manuscript is that religion matters when it comes to these decisions and that couples interpret their religion as a way to improve their fertility, but what if that is not the case for less wealthy or more rural populations? In that case, the manuscript does only reflect a very particular slice of Ghana’s society, and that needs to be discussed and the discussion needs to be more nuanced.

As rightly pointed out the reviewer, and as indicated in lines 55-56 of the manuscript, cost of ART is very high in Ghana and it is borne wholly out of pocket. This means that it is only the upper-middle and upper classes who are able to afford. The less wealthy and the more rural dwellers irrespective of their religious positions cannot afford it. Probably if the paper were to focus on religious beliefs of both users and non-users on ART, then it would have been imperative to interview non-users as well.

However, the current paper focuses on users and how their decisions to use ART took into account their religious beliefs. Indeed, the findings show how religious beliefs influenced the choice of ART (e.g. use of donor gametes), and how some had to confer with their pastors and priests to ensure they are not breaching any religious doctrine. Moreover, considering the stigma and the psychological stress that infertile persons, especially women go through in the society, the only place where it is relatively easy to identify and recruit infertile persons is fertility hospitals. Meanwhile, the inclusion of key informants ensured that information on why some people might have refused treatment after visiting the hospital were gleaned.

In sum, our focus in this paper is not to obtain a representative sample (see lines 225-227), but to understand the experiences of infertile couples, who we admit are obviously not a homogenous category even in terms of the kinds of infertility experienced and/or in the choice of solutions utilised.

However, we understand the point of view of the reviewer as well, and we have therefore stated this possible bias in the limitations of the study. See lines 500 – 506.

b) By only choosing couples who decided to undergo ART, the authors face a selection bias: only couples whose religious feelings and communities allowed them to do ART are even interviewed, and they will obviously have a positive attitude to the subject. So, to make the conclusion that religion is a supportive factor in ART might be premature: we do not currently know what keeps other couples from attempting IVF. It might be that 95% of people reject ART based on their religion, but because the authors only interview 5%, they will not notice this in their interviews. Again, there is not much the authors can do about this, given the difficulties of getting data, but this possibility needs to be discussed and where possible, additional evidence needs to be presented to rule this out.

L.185 - I would include a brief description of what IVF and ICSI stand for, because they have different religious implication later on.

This has been provided. See lines 208 - 211

L.186 - How were key informants selected?

The selection procedure for the key informants in this study has been described. See lines 214 - 221

L.192 - The authors need to discuss their own role in this process more and potential biases that could have been introduced into the results by their own positionality. For example, later we learn that almost only women sat down for interviews, and men only as part of couples. This is worrisome and probably to do with cultural aspects and the role of the interviewer, but again this needs a nuanced discussion.

This has been done. See lines 236-245

L.215 - Does the thumbprint indicate that some participants were not literate? It feels like that is a matter worth discussing, as this could bias their responses (e.g., more dependent on community leaders to determine their attitude, more dependent on clinic staff to detail the moral implications for them).

One participant was semi-literate and preferred to thumb print rather than sign. This interview was conducted in the local language thus ruling out any issues of lack of understanding of the questions she was being asked. In addition, this particular participant is a resident of the United Kingdom having lived and worked there for more than 15 years and her decision to do the procedure in Ghana was borne out of the relatively cheaper cost associated with it in Ghana as compared to the UK. In addition, she had tried the procedure in the past year in Ghana but lost the pregnancy when she went back to the United Kingdom. She was back in the country to try it again and this time, was prepared to stay in Ghana a bit longer if she got pregnant from the procedure.

L.227 - Could you explain what primary and secondary infertility are in this context?

This has been done. See lines 287-288

Table 1: There are many striking characteristics in this table that need to be explained in a more differentiated way, I think. First, the large age and relationship history ranges: presumably, these couples differ dramatically in why they attempt ART, how often they have tried in the past, societal pressures, and so on. The article is not specifically designed to address these questions, but presumably a couple that has been trying for pregnancy for 30 years might have a very different outlook on what is permissible than one that has been trying for 2 years, and might get very different advice from their community.

In another article, these nuances are clearly argued out to demonstrate how years of marriage and other factors such as cost of treatment, waiting and hoping etc. all work together to define the treatment seeking behaviour of these infertile couples (see Hiadzi & Boafo, 2020). As such, while the points raised are appreciated, the analysis of the data showed that, the journey towards achieving desired conception was affected by different things at different stages of the process. However, the single underlying factor that always informed the respondent irrespective of other mediating factors was the need to fulfil their societal mandate of childbearing. Interviews conducted showed that, decisions to access ART were mostly informed by cost of treatment and knowledge about the service. This present article seeks to argue how infertile couples rationalise their use of different forms of ARTs bearing in mind their religious beliefs. As such, the essence of this article is to enrich the literature on the use of ARTs from a religious lens.

Analyses and Discussions: Based on the mentioned uncertainties introduced by the method, I think the manuscript would benefit from a more detailed discussion of how representative the sentiments of the couples and their religious attitudes are for Ghana, and whether the sample selection process might have biased the interviews towards those who interpret their religion in pro-fertility way. Also, especially for the Pentecostal religions, where most couples will be converts, it is possible that participants actually joined the particular church that was most positive towards their fight with infertility and promised them to solve it.

This study is part of a bigger study on the health seeking behaviour of infertile Ghanaians in urban Ghana. While respondents who were seeking infertility treatment other than ART were asked about their religious views on ART, it was discovered that, their knowledge of ART was very limited thus their responses could not incorporated into this manuscript.

Reviewer #2: An important question is whether the study meets the PLoS ONE data policy; the authors note limitations on the availability of the data. If those restrictions do not meet PLoS ONE data requirements, then publication criteria would preclude publishing the manuscript. Apart from that, the manuscript offers a well-structured, substantive, qualitative evaluation of a sample of Ghanians seeking and being treated with ART and how that relates to their religious beliefs. The introduction and discussion sections situate the study well, and reference both relevant findings and concepts in Ghana as well as other comparative settings. The take-away empirical points are made clearly, with illustrative quotations also useful.

The manuscript could benefit from a modest copyediting process to clean up some occasional stray commas and minor language elements, but overall the manuscript is quite readable and easy to follow. As far as other comments related to modest potential edits, please comment how common ART is in Ghana, what form(s) of ART were employed by study participants (a table in the results just points to primary and secondary fertility without providing more information), and how those services are paid for (the manuscript says in a private facility, so I am guessing this is out-of-pocket which in turn warrants brief comment on the socioeconomic backgrounds of those who can access such services).

This has been done. See lines 291-295

In addition, the forms of ART treatment employed by participants have been stated in various parts of the text namely IVF and/or ICSI

Are there any indications how representative this particular sample's findings are relative to other Ghanian ART service providers? Since all but 2 patients who were participated were women, please comment on the general ART services and demographics of those who use those services at the facility (e.g., are most patients women, or might the present sample say something more about difficulties of recruiting males who use ART?).

The reason why there was more females than males has been explained adequately in the methodology (see lines 250-261). We have also explained that the focus of this study was not to achieve representativeness. 262 – 273.

The sample of patients only includes, by nature of the study design, those who have used ART. The study does not include patients who, perhaps by virtue of religious beliefs, elected not to receive ART. Based on the interviews with the four key informants, did they offer any insights about how commonly patients decline ART due to religious beliefs? If so, please share more from that vantage in the results.

This is similar to a point raised by reviewer 1 and has been addressed.

However, in addition, the manuscript contains a key informant’s view that was explored about patients’ response to ART based on religious views. The manuscript reports that, according to the key informant Moslem clients out rightly refused treatment that involved masturbation to produce semen since it was against their religious beliefs. See lines 362-369

________________________________________

Submitted filename: Responses to Reviwers Comments_Religion and ART 16th June.docx

Click here for additional data file.

22 Sep 2021

PONE-D-20-36012R1‘God helps those who help themselves’… religion and ART usage amongst urban GhanaiansPLOS ONE

Dear Dr. Boafo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Many thanks for the accurate revision of this manuscript. One of the reviewers still has some minor comments (mainly linguistic) that need to be addressed before I can make a decision about publication.

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Academic Editor

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Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: In this resubmission, the authors have provided more information about the sociodemographic characteristics of the sample, which is important with respect to the question of generalizability. The authors have addressed some of the other points raised by the other reviewer and myself. I do not advocate for the necessity of further substantive edits. However, the manuscript has some typos and awkward phrasings that warrant copyediting. Some examples include: a) capitalizating "catholic" as "Catholic"; b) lines 249-251 and thereabouts: there is some redundancy and errant phrasing concerning "they often appeared economical"; c) line 267: "lot of time on hands to while away" could be shortened to something like "had free time available"; d) around line 518 and subsequently: the limitations passage is a bit awkward such as "this study does not seek to make generalize..." plus the key point could still be clearer that it is unclear how findings from individuals not seeking ART might compare with those in the manuscript among ART users at even the very facility (e.g., no data on whether religious background impacts perceived "uptake" of services even at the single recruitment facility). This all said, if such copyedits can be made then as noted previously I believe this manuscript makes a qualitative contribution to its purported topic, and does so with interesting and well-presented empirical details (e.g., Results).

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Reviewer #2: No

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7 Oct 2021

Reviewer #2:

a) capitalizating "catholic" as "Catholic";

This has been done. See lines 215 and 216.

b) lines 249-251 and thereabouts: there is some redundancy and errant phrasing concerning "they often appeared economical";

The entire sentence in line 244 and 245 has been deleted thus correcting the redundancy and errant phrasing

c) line 267: "lot of time on hands to while away" could be shortened to something like "had free time available"; This has been done

d) around line 518 and subsequently: the limitations passage is a bit awkward such as "this study does not seek to make generalize..."

This has been corrected to read…..’this study does not seek to generalize…’

e) the key point could still be clearer that it is unclear how findings from individuals not seeking ART might compare with those in the manuscript among ART users at even the very facility (e.g., no data on whether religious background impacts perceived "uptake" of services even at the single recruitment facility).

This has been done to make the point clearer. See lines 504-506

Copy editing on the manuscript has been done with all typos and awkward phrasings corrected.

9 Nov 2021

‘God helps those who help themselves’… religion and Assisted Reproductive Technology usage amongst urban Ghanaians

PONE-D-20-36012R2

Dear Dr. Boafo,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Sara Rubinelli

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

1 Dec 2021

PONE-D-20-36012R2

‘God helps those who help themselves’… religion and Assisted Reproductive Technology usage amongst urban Ghanaians

Dear Dr. Boafo:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Sara Rubinelli

Academic Editor

PLOS ONE