Fertility Awareness and Perceptions among Procreant Age Group in Western India: An Exploration with Mixed Methodology.

BACKGROUND: In India, fertility rate demonstrates a descending trend whereas there is upsurge in infertility rate. In addition, a knowledge gap concerning fertility has been identified among the current generation. AIM: To quantify the fertility awareness and in-depth exploration of perceptions about fertility among procreant age group.
MATERIALS AND METHODS: Explanatory mixed method design with sequential data collection, nested sampling technique was assumed. Purposive sampling was incorporated to recruit 1000 participants into the prospective cohort study. Awareness was measured using fertility knowledge questionnaire, while qualitative data were collected by in-depth interview of 28 participants until data saturation. The study was intact in terms of ethical compliance.
RESULTS: Sociodemographic data revealed that the mean age of the respondents was 31.33 ± 6.4 years, 59.6% were female, 78.3% were married, 61.5% completed their university education, 76.0% were working. The mean of overall fertility awareness score was 50.2 ± 13.5. There was no statistical difference in responses of the subgroups (P > 0.05) and only educational status was significantly associated (P = 0.001*) with awareness scores. Perceptions pertinent to fertility were evidently varying amongst the general group and couples accessing fertility treatment, which subsequently was elucidated with the qualitative thematic analysis.
CONCLUSION: Procreant age group of western India demonstrated low to average fertility awareness. Assertive recommendations were proposed for fertility awareness initiatives across both genders, irrespective of educational status. Copyright:

INTRODUCTION

Health literacy as mandate avowed by World Health Organization was highlighted in the 9th Global conference on health promotion. Understanding health needs and accessing treatment augments health of individuals and families. Inadequate awareness especially about health-related facets always poses a threat to the poorer health consequences and lesser proportion of people accessing treatment at right time. Fertility awareness is one such overlooked entity.[1]

The speculation across the globe about the infertility rate is approximately 15% amongst the procreant age group, one amid six couples are affected in developing countries. In India, there is a variance in infertility prevalence from 3.9% to 16.8% across different states.[2] Modernization and acumens about career independence are snowballing on to burden.[3] A recent tendency among them was observed wherein first-time parenthood was considered in late thirties.[4567] As child conception is deferred for considerable time giving priority to professional goals, it deteriorates the probability of natural conception and subsequently requires specialized treatment to help the couples.[3] Statistics are available, emphasized the fact that there was downward trend in the total fertility rate, i.e. 1.7.[8] Scarce, incorrect information, and myths prevailing in the society further delays the decision-making for parenthood and the process of accessing therapeutic consultation in appropriate time.[9] There are further evidence of lower levels of health awareness among low resource settings and individuals with lower academic qualification.[7] Looking into all the aspects, it is apparent that infertility is progressively becoming alarming and a public health issue.

Two of the systematic reviews highlighted the factual statistics across the western world about the knowledge pertaining to fertility. Limited information was known to the respondents relating to fertility, results emphasized that fertility awareness was low to average.[1011] Indian scenario is equally consistent in terms of poor knowledge, as results of a study showed that only 17% of the respondents were familiar about ovulation, and only 8% could comprehend progressive age was a threat to nonconception. Only fewer were conversant about assisted reproductive treatment.[6] The awareness was further on lesser scores when surveys were conducted in rural areas.[12] Additionally, a knowledge gap concerning fertility has been identified among the current generation.[13]

With a comprehensive appraisal of literature, it was observed that the women experiencing infertility and accessing fertility treatment have eventually attained a certain level of awareness. There is scarcity of documentation about fertility awareness across younger cohorts, employed professionals, and infertile counterparts especially with the Indian context. The current study was undertaken to encompass a wider range of samples precisely the general set, i.e. collegiate students, working population, and childless couples accessing treatment. The present study was conceptualized with the intend to appraise the fertility awareness, compare it across the cohorts and provide insights into their perceptions about fertility and treatment.

MATERIALS AND METHODS

Study design and study population

Execution of explanatory mixed-method design with sequential data collection (QUAN-' qual) was done.[14] The qualitative data were collected to support the quantitative findings. The study was amalgamated at results interpretation stage. The present study was a part of the longitudinal study from October 2018 to December 2020 in numerous phases. Settings for data assemblage were corporate offices, colleges, and a super-specialized fertility clinic.

Ethical clearance and informed consent

Consented respondents in the procreant age group, i.e. 20–50 years without offspring, well-versed with English/Hindi/Marathi were counted in for the study. Employees and students on leave, patients with old registration in the outpatient department were excluded. This survey was a segment of a research permitted by Ethics Committee for Research on Human Subjects at MGM Institute of Health Sciences, Kamothe, Navi Mumbai, approval letter: MGMIHS/RES/02/2017-18 dated 20.03.2018. Before commencing of the project, all written approvals were secured from authorities. Prior to the interviews, respondents were briefed with the study goals and an informed consent was obtained. Concealment was the highest precedence of the study and they could pull out from the project as wanted.

Research instrument

Research instruments were baseline demographic profile sheet and a Fertility Knowledge questionnaire (FKQ) to elicit pertinent awareness among the procreant age group. The FKQ consisted of four sections, precisely on concept and risk factors, ovulation-related facets, diagnostics, and fertility treatment. Correct statement was awarded one mark. It was available in English and Hindi and Marathi (Cronbach's alpha internal consistency r = 0.82).

Data collection

A sequential approach was used for gathering data, 1196 participants were screened for the study. 1000 respondents precisely 596 females, 404 males were finally involved through purposive sampling technique for quantitative component. Out of 1000 respondents, 320 were employees at corporate offices, 80 were undergoing graduation studies, remaining 600 were trying for conception, accessing specialized treatment for infertility. The corporate employees and students accessed the online version of the questionnaire. Qualitative data were collected by in-depth interview of 28 respondents, using nested sampling until data saturation. Ten respondents were from corporate offices at different working levels, four were students and 14 were patients at fertility center. Audio recording of interviews was subsequently transcribed and analyzed by conventional thematic analysis. Maximal variation, peer debriefing, and third-party review of transcripts were done to confirm trustworthiness of the data.

Statistical analysis

IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. Released 2012 was used for analysis. Categorical variables were stated as frequency and percentage, continuous variables as mean and standard deviations. Comparisons were done using Kruskal–Wallis test. Statistical significance was inferred with P < 0.05.

RESULTS

Quantitative data analysis

Data were analyzed for 1000 respondents with 100% participation. 31.33 ± 6.4 years was the average age of all the respondents in the study. Demographic profile of the study respondents is as below:

Apart from Table 1, few more findings were derived. The body mass index was determined, which revealed 11.25% of the students, 42.8% of working group, 49.6% wives and 58.6% husbands were overweight. Among the working women in corporate offices, around 33.1% were consuming alcohol frequently and 19.1% were smokers. In order to conform compliance with investigations and frequent hospital visits, 27.4% females under treatment had quit from work, another 5.0% had enrolled with professional courses to remain engaged. The reason for infertility identified was mainly female related causes 39.3%, male related 22%, unknown cause 17.7%, and remaining was combined cause. Polycystic ovarian syndrome (27.3%) was the leading cause for infertility among females and oligospermia (27.3%) among males.

Table 1

Demographics profile of respondents (n=1000)

Variables	Working group (n=320)	Students (n=80)	Wife (n=300)	Husband (n=300)
Age (mean±SD)	30.2±5.3	21.1±0.94	31.17±5.4	35.4±5.6
20-24	49 (15.3)	80 (100)	38 (12.7)	2 (0.7)
25-29	111 (34.7)	0	80 (26.7)	38 (12.7)
30-34	82 (25.6)	0	94 (31.3)	114 (38.0)
35-39	60 (18.8)	0	67 (22.3)	68 (22.6)
40-44	18 (5.6)	0	20 (6.7)	57 (19.0)
45-50	0	0	1 (0.3)	21 (7.0)
Gender
Female	222 (69.4)	74 (92.5)	300 (100)	0
Male	98 (30.6)	6 (7.5)	0	300 (100)
Marital status
Single	105 (32.8)	77 (96.3)	0	0
In-relationship	29 (9.1)	3 (3.7)	0	0
Married	183 (57.2)	0	300 (100)	300 (100)
Divorced	3 (0.9)	0	0	0
Education
Nongraduate	8 (2.5)	80 (100)	147 (49)	150 (50)
Graduate or more	312 (97.5)	0	153 (51)	150 (50)
Occupation
Student	0	80 (100)	15 (5.0)	0
Homemaker	0	0	145 (48.3)	0
Working	320 (100)	0	140 (46.7)	300 (100)
Personal habits
None	225 (70.3)	77 (96.2)	296 (98.7)	167 (55.7)
Smoking	9 (2.8)	3 (3.8)	0	27 (9.0)
Alcohol	31 (9.7)	0	4 (1.3)	72 (24.0)
Both	25 (7.8)	0	0	34 (11.3)

SD: Standard deviation

Awareness related to fertility was quantified using fertility FKQ. Table 2 depicts the average scores of the four groups as per subsections of the tool.

Table 2

Average scores as per the subsection of fertility knowledge questionnaire

FKQ	Mean±SD
	Working group (n=320)	Students (n=80)	Wife (n=300)	Husband (n=300)
Section A	59.2±20.2	61.25±18.2	57.3±18.6	54.4±22.3
Section B	43.3±23.7	55.0±17.3	53.7±15.5	48.3±14.9
Section C	43.3±20.8	40.4±17.3	46.4±24.8	49.0±23.5
Section D	36.25±19.9	30.0±23.4	43.8±22.2	46.9±22.9
Total	48.8±12.2	50.4±12.0	51.6±14.3	50.9±14.3

SD: Standard deviation, FKQ: Fertility knowledge questionnaire

The final scores apparently displayed variance, with female patients as better scorers. This was further validated using Kruskal–Wallis Test. For sections pertinent to risk factors, ovulation-related and treatment questions, the P values were 0.001 evidencing a significant difference whereas diagnostics section and final scores had no significant difference (P > 0.05).

The average of fertility awareness scores of 1000 respondents was 50.2 ± 13.5 [Figure 1]. Furthermore, awareness scores were associated with variables such as gender, age and educational status by using Kruskal–Wallis test as shown in Table 3, only educational status was significantly associated (P = 0.001). In order to determine the perceptions, the responses of working group and students were merged, on the other hand, the responses of wives and husbands were clubbed [Figure 2]. It was evident that perspectives were entirely different related to fertility.

Figure 1

The fertility awareness scores of 1000 respondents (error bars represent standard deviations)

Table 3

Association of variables with awareness scores

Demographics	Awareness
	Risk factors	Ovulation related	Diagnostics	Treatment options	Overall
Gender
χ2	4.85	21.8	4.2	8.4	1.97
P	0.03	0.001	0.04	0.004	0.16
Age
χ2	4.3	6.7	5.1	31.8	6.8
P	0.513	0.23	0.39	0.001	0.233
Education*
χ2	68.7	38.5	50.9	4.08	102.2
P	0.001	0.001	0.001	0.04	0.001

*Significant association in terms of education status

Figure 2

Perception about fertility

Qualitative data analysis

Audio recordings of in-depth interviews were done for 28 participants to gather data related to their perceptions about fertility. Recordings were transcribed, coded and content analysis was done to reveal following themes: (Few important verbatims are as below).

Delay pregnancy by choice

I would undeniably defer the pregnancy with the thought that I need to look into the professional progress, I aspire going abroad for better opportunities, then marriage and later when all is ok, I can have baby anytime, which is not before mid-thirties (Age 22, female, student).

I am yet not ready for having a baby, we have consciously decided to delay my pregnancy until we are stable in our relationship and financially sound to take up the responsibility. I am perfectly fine and can have a baby at any point of time we decide (Age 37 years, female, middle-level manager).

It is very unfortunate I am struggling so badly just to have a baby, when the entire world is blessed. At younger age, I had no awareness about issues in pregnancy due to older age than 30 years. I had absolutely no idea, that delaying on decision for pregnancy would become so miserable. Had I known…. (sobs) (41 years, female, working)

Priorities

Oh no…pregnancy and childbirth would be latter in my wish list, career after this course is what I am aiming at (23 years female, student).

I have really not given a serious thought about it, at this juncture my work is very demanding, which needs my time, having said that…childbirth is not something I am looking at…may be after my next promotion it will be considered (39 years, manager, married female).

Having a baby is top most priority, I am experiencing immense family and societal pressure, which is very depressive. I definitely regret to have delayed initially and later it became so stressful to pass through all this (37 year female, married, undergoing treatment).

Gamete freezing

I have not really thought about it, 10–15 years later maybe it will be a regular practice which I may consider (21 years female student).

Freezing may be an option, if my partner is fine with it, we may consider if needed (34 years, male, in-relationship).

Perhaps I am surely going to take it up, right now I can't afford to compromise with my work with freezing at least the eggs will be fine. Later I take a decision for pregnancy (29 years, female, HR executive).

My eggs are already frozen, as we are undergoing fertility treatment, it will be transferred once my uterus is good to accept. I wish I had all things naturally done….so many ifs and buts are there now, even though I am undergoing good treatment (36 years female).

Fertility awareness program

Definitely need of the present generation to know about fertility, risk factors, and perhaps treatment options well in advance. Internet provides voluminous information in overstated form but the right awareness will always help (student 23 years).

We are so ignorant even knowing many things about the infertility. The concept and awareness must be known to each individual after teenage. Indian society per-se, pregnancy and baby are essentials, AMH value should be known rather than the horoscopes. It is better to know real facts and plan early than to delay and regret (couple undergoing treatment).

Meta inferences

The average awareness score of the respondents was low, i.e. 50.2 ± 13.5 and a changing trend in perception towards fertility was recognized. Subsequently, findings were supplemented by the qualitative analysis outcomes, wherein the respondents had expressed that there was dearth of correct information amid the existing generation about fertility. There is definitely an intense necessity among the Indian population to be aware of the fertility facets.

DISCUSSION

Demographic characteristics revealed that average age of the respondents was 31.33 ± 6.4 years, most of them, i.e. 29% were in the age group of 30–34 years, 59.6% were female, 78.3% were married, 61.5% completed their university education, 76.0% were working. Similar respondent characteristics were seen in studies from America, Japan, Portugal, and Iran.[15161718] Around 47.1% of the respondents were overweight, which corresponds with the BMI status of respondents in a study conducted by Valsangkar et al.[19] Among working women, 33.1% and 19.1% were habitual to alcohol and cigarette smoking respectively. Being overweight, use of alcohol and cigarette may always turn a threat towards deterioration in fertility.

The reason for infertility recognized was predominantly female linked cause 45%, male related 23%, idiopathic cause 17.7% and remaining was combined cause. These statistics were analogous with outcome of study conducted by Karabulut et al.[20] Polycystic ovarian syndrome (27.3%) was the foremost cause for infertility among females and oligospermia (27.3%) among males. Another Indian study emphasized PCOS as core cause.[21]

Among 1000 respondents, the working group was the poorest scorer with average correct responses of 48.8 ± 12.2, which was comparable with 44.5% responses of Japanese population.[16] The students scored little better, i.e. 50.4 ± 12.0, which was in-line with the findings of studies conducted in Canada, Israel, and America, considering students as samples.[222324] The men scored 50.9 ± 14.3 on average, which was similar to conclusions of a study conducted by Daniluk and Koert[25] The counterpart females, on average answered correctly with 51.6 ± 14.3, which was similar to findings of studies by Bunting and Boivin, Vassard et al. where in female participants scored better than males.[2627] On contrary study by Wiltshire et al. had women respondents with poorer scores of 38.15 ± 20.36 and studies by Ezabadi et al. and Zhou et al. had male respondents as better scorers.[41828] A study at Ottawa University revealed that female and male respondents both had analogous and lower scores, this finding was similar to the present study as all the groups had statistically nonsignificant difference.[29]

In totality, it was evident that the respondents had fairer awareness (around 58%) about risk factors leading to childlessness, most were aware that age, obesity, stress, personal habits were leading risks, only few were aware about microwave, fast foods, preservatives. The other three sections were poorly responded with correct answers. The key verdicts of this study confirm that awareness related to fertility was low, i.e. around 50.2% among the procreant group of western India, which was as comparable as the results of studies across globe which was 49.9% in Canada, around 50% in Denmark, 55% China, 47.9%–50% in Australia, <50% in Portugal and around 52% in America.[5173031323334] Only three studies conducted in rural India revealed results lesser than 20%.[61235]

The general group was reluctant toward pregnancy whereas the couples accessing treatment were keen for pregnancy. Assertive recommendations were made for fertility awareness initiatives across both genders, irrespective of educational status. Similar endorsements were seen in a study done by Ezabadi et al.[18]

Strength and limitation

The strength of the study appeared from a diversity of cohort samples, with larger sample size and explanatory mixed-method design. The design provided the completeness to the study, wherein the fertility awareness was measured and along with it the perceptions related to fertility were explored in-depth.

Limitation per se, employees were selected only with corporate job profile, students were from two colleges only, and treatment accessing couples were selected from single hospital which might count for selection bias.

CONCLUSION

Poor awareness pertinent to fertility among procreant age group of western India was inferred from the study. The subgroups were similar in awareness responses, which predominantly emphasized conducting fertility awareness programs incorporated in educational curriculum to provide adequate and appropriate information.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.