Experiences of Infertility in British and Pakistani Women: A Cross-Cultural Qualitative Analysis.

Health Care for Women International

ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20

Experiences of Infertility in British and Pakistani Women: A Cross-Cultural Qualitative Analysis Syeda Shahida Batool & Richard Oliver de Visser To cite this article: Syeda Shahida Batool & Richard Oliver de Visser (2014): Experiences of Infertility in British and Pakistani Women: A Cross-Cultural Qualitative Analysis, Health Care for Women International, DOI: 10.1080/07399332.2014.980890 To link to this article: http://dx.doi.org/10.1080/07399332.2014.980890

Accepted online: 23 Dec 2014.Published online: 26 Jan 2015.

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Date: 15 October 2015, At: 02:12

Health Care for Women International, 00:1–17, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2014.980890

Experiences of Infertility in British and Pakistani Women: A Cross-Cultural Qualitative Analysis SYEDA SHAHIDA BATOOL Downloaded by [University of Otago] at 02:12 15 October 2015

Department of Psychology, GC University Lahore, Lahore, Pakistan

RICHARD OLIVER de VISSER School of Psychology, University of Sussex, Falmer, UK

The psychosocial impact of infertility is affected by cultural factors. In this cross-cultural qualitative study we explored the experience of infertility among six women living in Pakistan and eight living in the UK. Although infertile women in the UK and Pakistan had many shared experiences related to their own desires for motherhood and the hopes of others, they also faced unique psychosocial challenges shaped by cultural context. Based on our findings, we suggest a need for further resources and networks to support women, particularly women living in cultures that allow women few fulfilling social roles other than motherhood. This article presents the findings of a cross-cultural study of the psychosocial impact of infertility as reported by women living in the UK and Pakistan. To our knowledge, it is the first cross-cultural qualitative study of the phenomenology of infertility using the same methods of data collection and analysis in two different cultures. We present results to highlight interesting similarities between British and Pakistani women but some important differences that reflect cultural differences. Millions of couples worldwide are infertile, that is, they are unable to achieve a pregnancy after 12 months of regular unprotected intercourse (Mascarenhas, Flaxman, Boerma, Vanderpoel, & Stevens, 2012). One in seven couples in the UK, and one-fifth of the married population in Pakistan, is affected by infertility (Ali et al., 2011; Human Fertilisation and Embryology Received 2 June 2014; accepted 15 October 2014. Address correspondence to Richard Oliver de Visser, School of Psychology, University of Sussex, Falmer BN1 9QH, UK. E-mail: [email protected] 1

Downloaded by [University of Otago] at 02:12 15 October 2015

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S. S. Batool and R. O. de Visser

Authority [HFEA], 2007). In most societies, childbearing is closely linked to womanhood and femininity (Inhorn & van Balen, 2002). Infertility has important psychosocial impacts, because it may be equated with failure of femininity on personal, interpersonal, or social levels (Greil, SlausonBlevins, & McQuillan, 2010; Inhorn & van Balen, 2002). Infertility can lead to feelings of disappointment, hopelessness, and social isolation (Fahami, Quchani, Ehsanpour, & Boroujeni, 2010; Hinton, Kurinczuk, & Ziebland, 2010; Khodakarami, Hashemi, Seddigh, Hamdiyeh, & Taheripanah, 2010) and may result in difficulties within women’s relationships and extended families (Chang & Mu, 2008; Loke, Yu, & Hayter, 2012). Research indicates that infertility affects women’s well-being more than men’s (Inhorn & van Balen, 2002). Women bear the major burden of grief, frustration, and blame. The effects of infertility may vary between societies and among individuals in the same society (Moura-Ramos, Gameiro, Canavarro, Soares, & Santos, 2012). Until relatively recently, having children was widely assumed to be an inevitable natural part of womanhood in the developed western world, but social changes mean that motherhood has become more a matter of choice, and women often delay it to pursue education and develop their careers (Gonzalez-Lopez, 2002; McDonnell, 2012). In contrast, the psychosocial impact of infertility may be greater in nonwestern countries such as Pakistan which give greater emphasis to fertility. A family in Pakistan is typically “extended” rather than “nuclear,” with stronger intra- and intergenerational ties (Dhami & Sheikh, 2000). In Pakistan, the birth of a child not only fulfills the desires of parents, but it also meets extended family expectations. Infertility is a grave issue because it threatens to hinder the development of ties believed to bind the matrimonial unit and the extended family. Research in Pakistan reveals that many infertile women experience marital conflicts and are the victim of verbal or physical abuse (Hakim & Faatehuddin, 2001). Furthermore, Pakistani men often hold misconceptions regarding infertility, considering it to be a women’s issue (Ali et al., 2011). The scientific literature illustrates that infertility is a socially constructed reality that needs to be explored further in varied global settings (Inhorn & van Balen, 2002). For example, a comparison of women in the UK and Pakistan could indicate which psychosocial impacts occur irrespective of context, and which appear to be more strongly affected by social, economic, political, and medical conditions (Batool & de Visser, 2014). These two settings were chosen as convenient proxies for world regions/cultures reflecting the authors’ backgrounds. The UK and Pakistan differ politically, economically, and culturally. The UK is a historically Christian culture that is becoming increasingly secular, whereas there is a continuing strong influence of Islam on Pakistani culture. To the best of our knowledge, a cross-cultural qualitative study of the phenomenology of infertility using the same methods of data collection and

Infertility in British and Pakistani Women

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analysis in two different cultures has not been conducted. Our aim was to explore the experiences of infertile women in two different cultures.

METHODS


Participants Participants were 14 involuntarily childless women who had been in a relationship for more than 2 years and were pursuing infertility treatment. Sampling was conducted in accordance with the focus of Interpretive Phenomenological Analysis (IPA; Smith, Flowers, & Larkin, 2009) on small homogeneous samples. The UK sample consisted of eight women aged 30–46, six of whom were undergoing in vitro fertilization (IVF). All were in committed relationships of 3–13 years duration, and six were married. The Pakistan sample consisted of six women aged 24–42. None were undergoing IVF, but two desired to do so. All were married (duration ranging from 2–15 years). In both samples, education ranged from secondary school to postgraduate degrees, and participants had a range of socioeconomic backgrounds.

Procedure Ethical approval was granted by the host universities in Pakistan and the UK. In Pakistan, snowball sampling was used, with the first participant suggested by a gynecologist. In the UK, five women were recruited after completing part of a larger mixed-methods study of infertility (Batool & de Visser, 2014), and three were contacted via snowball sampling. Written informed consent was obtained before all interviews. Semistructured in-depth interviews were conducted at a time and place convenient to the interviewee. Interviews lasting 50–90 minutes covered past and current desire for motherhood, experiences of diagnosis and treatment, impacts of infertility, and coping responses. Because interview dynamics and participant expectations can affect data collection, care was taken to establish an empathic relationship in which interviewees felt comfortable discussing their experiences (Smith et al., 2009). The interviewer ensured participants of confidentiality and explained that she was interested in their experiences rather than wanting to hear “right” or “wrong” answers. We were ultimately motivated by a desire to improve the psychosocial well-being of infertile women, but we conducted the study in a way that gave primary attention to participants’ accounts. Verbatim transcripts were analyzed via IPA (Smith et al., 2009), an approach concerned with the interpretation of the subjective meaning people assign to their experiences. Analysis is based on an idiographic casestudy approach (de Visser & Smith, 2006), and the method is suitable for


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cross-cultural studies (Tan, Ward, & Ziaian, 2010). Transcripts were coded and analyzed on a case-by-case basis. They were read repeatedly to identify emergent phenomenological themes that were then cluster analyzed interpretatively into higher-order themes according to their conceptual coherence. The first author did primary coding and discussed findings with the second author to develop an agreed-upon set of emergent higher-order themes. In IPA, assessment of reliability of analyses is not structured or quantified but is instead an iterative process in which all interpretation must be clearly grounded in the raw data. To promote rigor and consistency in analysis, a selection of interviews was independently coded by the first author, and regular discussion of the analytic process was conducted. Once all interviews had been coded, comparisons were made between cases from the same country to identify shared and unique themes. Comparisons were then made between the UK and Pakistani samples to identify themes reflecting common and divergent understanding and experiences in both countries.

RESULTS AND ANALYSIS Below we describe the five major themes that were identified through our analysis: each is described below and illustrated through quotes, with attention given to similarities and differences between the samples.

Desire for Motherhood Participants in both countries indicated that, since childhood, they had imagined becoming mothers. They suggested that their desire of motherhood was “natural” and that it usually materialized after puberty. Motherhood was also seen to have a social value, so most felt that they were missing an influential status that was “very powerful” (Lucy: UK, 30). Women indicated that the basic purpose of heterosexual cohabitation was to produce a child. Julia (UK, 40) noted that it was “the chief reason” for marriage, and Nadia (PK, 35) said that once married there was “no question of wanting or not wanting children.” Women in both samples noted that their own desires were accompanied by their awareness that others expected them to have children. Maria (UK, 39) said, “They never expressed it verbally, but used to give certain hints.” Pakistani women reiterated this and valued motherhood because of the status it gave them in the eyes of members of their (extended) family. Women in both countries felt that their desire for motherhood gradually increased after marriage as a result of increasing age and a sense of the monotony of everyday life without children: In the beginning we didn’t take it seriously, but after 6 months, I started feeling emptiness and boredom at home. . . . Life seemed to be aimless. (Abeera: Pk, 24)


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Response to Diagnosis When the possibility of being infertile arose, women reported being more proactive than their partners in seeking medical attention. Like several other British women, Maria (UK, 39) explained: “[When] I felt there could be a fertility problem. My husband said, ‘Don’t worry.’ I waited for 1 year and then I went to my doctor.” Pakistani women reported similar experiences:


The first time I visited the doctor, I was alone. My husband remained sitting in the car in the car park of the clinic. . . . I told him that the doctor also asked him for a check-up. He said, “I am all right. Doctors say all this to make money.” (Mehnaz: Pk, 42)

The leadership role of women (and the passive role of men) was evident in both samples, but it was particularly interesting in the Pakistani context, where men usually dominate and direct women’s lives. Infertility was experienced as a lack that made women feel incomplete and left them with a sense of failure and weakness. The diagnosis of infertility was experienced as a failure, and women from both countries felt intense negative emotions. For example, Tina described the psychosocial impact as “disastrous” for her current emotions and her vision of the future: I was shocked. I was not familiar with all this. I got quite ill for a few months: very tearful and very fearful regarding the future. (Tina: UK, 37) I am critical of my body in many ways . . . like it has failed me, while it was strong and healthy all my life. This one thing negates all other things about my body. (Tina: UK, 37)

Insecurities were obvious in both samples, but Pakistani women spoke specifically of their fears of marital breakdown based on a worry that their husband would leave them to find a new wife capable of bearing children and continuing patrilineal inheritance. Sara (Pk, 27) reported that she “started weeping in the clinic. . . . I developed a fear that my husband would leave me and marry another woman.” Infertility was experienced as a major bodily flaw. It undermined British women’s general well-being. Maria noted a mismatch between her external appearance of capacity and her internal feeling of incapacity that made her feel insecure: [What] I feel from the outside—I am a woman working full time in her late thirties—mismatches internally. Internally, I am dysfunctional. I sometimes feel somehow I am unproductive and uncreative in a broad way in my life, not just that something is not working in my ovaries. . . .

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If I am not a creative and productive person, it is quite inferior. I feel insecure without a child. (Maria: UK, 39)

Pakistani women lamented their lack of children. These women associated their physical strength with their reproductive ability. They noted how their sense of failure was not limited to the reproductive system, but that it had engulfed their whole life and overshadowed all other capacities and achievements. Nadia (Pk, 35) noted that she felt “incomplete and useless” and that “all the blessings are valueless if you don’t have a child.” When asked how their spouse or partner had reacted to the diagnosis, women in both samples reported that they remained composed, they did not express their own feelings, and they could not empathize with the women’s own distress. Sheena recalled the reaction of her spouse who was diagnosed to have weak sperm. It is interesting that, in her account, her husband “pretending to be Okay” was considered a “normal reaction,” and she put her own emotions aside to reassure him: [My husband] was more optimistic. I think he didn’t think there was a problem, though doctors said there was. He showed quite a normal reaction and said, “Don’t worry; this will be fine.” . . . I don’t think he realized how upsetting it is for me, and how anxious it is making me, because it was something related to him and he was pretending to be Okay. I didn’t really share with him, because I wanted him to be okay. (Sheena: UK, 32)

Although it was a shared issue, most women experienced infertility as a woman’s problem, and that they were alone in experiencing (or at least expressing) negative emotions. Men’s avoidance of the issue discouraged women from sharing their feelings with their partners and they had to suffer in silence: I can’t discuss it with my husband, as he is very strict on the issue and reprimands me for lamenting over it. I request him to come home earlier, because it is awful to stay alone at home after evening, but he keeps himself busy in office ‘til midnight. . . . I think he avoids me. (Nadia: Pk, 35)

Impact of Infertility Effects on self and relationship. As noted above, infertility had affected women physically and psychologically. Women in both countries showed signs of anxiety and depression. The latter was expressed in low energy, low mood, sleep disturbance, lack of fulfillment, sense of failure, loss of confidence, and apprehension about the future. Pakistani women also reported


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ideas of reference, that is, the sense that even if people do not explicitly refer to infertility, it feels like they are. The latter may have been influenced by different family structures and functions in Pakistan. When they were asked about the effect of infertility on their relationship, most women expressed mixed emotions:


It is a long journey, so we will have to go through this journey as a union for having children. We have become mutually closer to each other. It is very challenging for your relationship . . . in the physical relationship, it is more challenging. . . . You are in a physical relationship to get a baby, but you don’t get a baby. (Liza: UK, 40) He has become more caring due to this issue. He never ignores me and always gives me assurance of his love by bringing presents for me. I also take care of him. I prefer to do all his work, and in this way I feel satisfaction that I am returning something in response to his love and cooperation. He realizes I am upset. . . . He ignores my misconduct. (Abeera: Pk, 24)

British women seemed satisfied with their husbands’ support in the treatment process, but they felt a negative impact of infertility on their physical/sexual relationship. They thought that infertility had bound them together, but a lot was missing in their intimate relationship. Most Pakistani women thought that their relationship had improved in terms of reassurance of love and care. Public inquisition. British women felt indirect pressure to have children in the form of general questions and expressions of interest, whereas Pakistani women had to deal with direct pressure, especially from in-laws. It appeared that in the collectivist culture of Pakistan, extended family members interfered more in others’ personal lives. Henna (Pk, 37) was similar to other Pakistani women in having to endure frequent questioning: “Everybody raised the issue of children and made inquiries. . . . They said, ‘We want good news from your end now, we can’t wait.’ That was a very difficult moment.” Nadia (Pk, 35) noted that her in-laws often remind her of her infertility in insensitive ways, and that this attitude “makes me upset.” In contrast, British women depicted a different experience, believing that infertility was a private affair. Sheena (UK, 32) noted that although people occasionally ask if she and her husband want children, they tend to treat it as a “private affair,” and Julia (UK, 40) noted that her in-laws act in a way that shows that “they are quite conscious of pressure.” Women in both countries tried not to disclose their infertility to family members or the broader public. Sheena said that it upset her not to be honest

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when people ask her about having children, but it was easier to conceal the truth: We usually say, “Yes we want children, but not now.” It is the easiest thing for a person to hear. I feel like when answering people that way, I am not truthful. I lie more and it makes me quite upset. (Sheena: UK, 32)


For Pakistani women, the potential consequences of revealing infertility were severe and troubling. Many feared that if they could not produce a child then they would lose their husband and be spurned by his family: It might be shocking to them, so we haven’t told anything to our parents and in-laws, because they couldn’t tolerate it, especially my mother inlaw. . . . She will throw me out of her home if she knows about it. (Abeera: Pk, 24)

Women in both countries felt stigmatized. Scambler (1984) made an interesting and relevant distinction between felt stigma—internalized by individuals without expression from others—and enacted stigma that stems from intentional discrimination against the stigmatized. British women experienced felt stigma toward themselves, whereas Pakistani women faced enacted stigma because of the expectation of motherhood for married women. Many Pakistani women tried to live with a fac¸ade of confidence so as to avoid public criticism. Infertile women perceived the world as being full of reminders that motherhood was both normal and easy to attain. British and Pakistani women described how interaction with the “fertile world” caused dismay: I feel fine seeing children. It doesn’t affect me, but when I see a woman pregnant, I find it really, really hard. They just seem to be everywhere . . . going out for shopping, everybody seems to be pregnant. . . . I met a friend of mine, very heavily pregnant, I felt happy for her, but at the same time jealous of her condition. (Liza: UK, 40) When I see any woman in a state of pregnancy, it makes me upset. I wish to see myself in this condition. . . . When someone says, “This is my child,” at that time I think I am deprived of this possession. Whenever I listen to the news of newborns around me, I can’t sleep that night. . . . My sister and sister-in-law avoid coming to my home; perhaps they think I will cast evil eyes at their children. (Nadia: Pk, 35)

Routine interaction with the fertile world—especially pregnant women– reinforced women’s sense of inadequacy and isolation. Liza’s use of the word “everybody” is not meant literally, but it clearly conveys her emotional


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experience of exclusion from the fertile world. Pregnant women and babies were unavoidable reminders of their lack. Pakistani women reported that in Pakistan people keep a social distance from childless women because of a prevalent superstition that a childless woman could bring trouble and misfortune for small babies. Although the context and details differed for British and Pakistani women, exposure to the fertile world was distressing for infertile women in both countries. In order to avoid reminders of infertility, most British women gradually pulled away from friends and colleagues with young children, and they worked to create child-free social networks: I personally tend to be more reserved and stay more at home. Protect myself and not expose to a lot of people and things. . . . I think it has made me detached and unsocial. I feel out of place, probably when I am with my friends who have something to share together, you know, they have children. I think I am not very much like them. (Sheena: UK, 32)

In contrast, Pakistani women said that they were less able to restrict their social lives due to the presence of extended families and more closeknit social lives. Huma (Pk: 32) noted that although she would prefer to avoid gatherings, “Sometimes due to living with in-laws, you are bound to attend gatherings.” She found this very difficult.

Coping Responses Although infertility had affected British and Pakistani women’s psychosocial well-being, it had not crushed them: they had developed tactics to deal with their predicament. Emotion-focused coping. As suggested by quotes presented in the previous section, women often tried to push away reminders of their infertility by leaving social contexts in which children were present. They also explained how they tried to draw their attention away from their infertility by keeping themselves busy. They managed the emotional aspects of infertility by reconfiguring their social lives to include other valued tasks and allow other achievements. Active avoidance was a universal strategy and was illustrated by Maria (UK, 39): “I try to distract my attention by involving myself in another creative project. I try to make life more vibrant.” Women in both countries noted the importance of having other productive tasks: Sometimes I feel people are discussing me, I can’t manage myself, just leave the place . . . usually try to keep myself busy in the household. I can afford a maid, but I prefer to do all housework to pass good time. Work is a blessing for women like me. (Nadia: Pk, 35)


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Many women in Pakistan used religious coping (praying, recitation of the Quran), passive avoidance (surrender before Allah’s will), and meaningbased coping (e.g., being grateful for not being in a worse situation). The majority of Pakistani woman repeatedly used religious references and language. Susan was the only UK interviewee to use strong religious language: she was upset that God had deprived her of a child, and she had become cynical about her relationship with God. Pakistani women tended to feel that infertility had brought them closer to Allah despite their frustration. Nadia (Pk, 35) noted, “All is in the control of Allah,” and she went on to explain that infertility had strengthened her faith: “Due to this issue, I feel myself closer to religion and Allah. . . . I offer my prayers regularly and pray for a child. I think, if I didn’t have this platform, I would have died.” British women expressed a sense of control over their lives, and they were hopeful about effective treatment (see below). In contrast, Pakistani women seemed to be more fatalistic, which helps to explain their use of religion as an important source of meaning. Some Pakistani women believed so strongly in a just world—in which people are punished for bad deeds and rewarded for good deeds—that they devalued themselves and experienced guilt. Social support. Social support of some kind was available to women in both countries; however, the sources of support differed. Social support helped women to overcome feelings of inadequacy and failure: My Mum has absolutely been amazing. Her response made it easier for me to cope with. I didn’t feel judged by her anyway. I just feel supported. . . . I am more to [my partner] than just a walking womb. He doesn’t take me as someone who can produce a child for him . . . no . . . he takes me as a partner. It is quite positive for me knowing all that. (Tina: UK, 37) He assured me that he will not leave me due to this problem . . . . This all brought me out of this trauma. . . . It is only because of his support that I am alive and leading a normal life; otherwise, I am not strong enough to live with this strain. (Abeera: Pk, 24)

In the extracts above, it is clear that support from husbands and other family members was crucial for women’s well-being. Abeera’s account of her husband’s responses can be contrasted with her earlier account of her fear of rejection by her in-laws. If significant others are nonjudgmental, do not make demands for children, and reassure women of their importance as a person and a family member, then women feel supported. Although many women kept their infertility secret to avoid stigmatization and humiliation, they believed that sharing their grief with close trusted friends helped them to alleviate stress and provided them moral support. Liza (UK, 40) noted the importance of supportive friends and family: “I share


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this all with my sister and a good friend of mine having similar problems . . . . I talk to them what’s going on and it all helps me.” Sharing experiences and support with other infertile women was of particular benefit:


I share my feelings mostly with my sister and friend. . . . I have one close friend and we often meet each other. She married 2 years ago and still doesn’t have children. We used to console each other and [are a] source of moral support for each other. (Sara: Pk, 27)

The preference for spending time with other infertile women often meant disengaging from women with children, which is a strategy that could emphasize infertility and create a gulf between themselves and the fertile world. This explains the appeal of online infertility support networks among British women, so that they do not have to choose between fertile and infertile friends. Online support forums allowed British women to find emotional support from women suffering similar problems, and meant that they did not have to choose between fertile and infertile friends. Women in Pakistan did not report having access to such resources.

Treatment and Future Options Regardless of the cultural context and the availability of effective treatment, the characteristics of medical professionals were important to women in both countries. Patients had two standards against which they judged their doctors: competence and compassion. Women expected doctors to be sensitive to the emotional impact of infertility, to be humane, and to communicate a caring attitude: He was an old-fashioned doctor and I don’t really like him, not very much, but I needed him as an expert. . . . I felt I was not being treated as like I felt I should be, a person with feelings, as he treated me just as a biological machine. . . . You turn on this knob and that knob and don’t worry everything will be alright. I think I felt quite distant from that consultant. (Julia: UK, 40)

British women differentiated between competence and compassion. Julia found that it was not possible to find both qualities in one person, so she stayed with her consultant because she was satisfied with his level of competence. British women complained that their doctors tended to focus on the physiological aspects of infertility and paid little attention to personal and emotional aspects. Pakistani women, however, perceived their consultants as quite supportive and sensitive. They did not talk so much about competence, but they highlighted the importance of compassion. For example, Abeera (Pk, 24) noted, “My doctor is very kind-hearted. . . . He told me


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that I had rich chances of becoming a mother as I was quite young and had started treatment.” Women’s experiences were influenced by their expectations for the future. British women did not appear to imagine their future without a child who was biologically their own because they were confident that they would have access to effective reproductive technologies. Lucy (UK, 30) suggested, “Adoption is a third world phenomenon. In the UK there is very advanced technology. I will go for my own child artificially, if it is not going to happen naturally.” Women in Pakistan appeared to be more apprehensive. They were often unsure about the reason for their infertility and even if a clear diagnosis had been given, effective treatment was not always available. They expressed their social and religious reservations about IVF, which related to Islamic prohibition of donor insemination. Although adoption is one option for infertile women to satisfy their desire for motherhood, most women were committed to biological motherhood and assumed that their spouses were even more committed to this. Some women were open to the idea of adopting, but this was not their preferred route to parenthood:

I am in favor of adoption, but can’t adopt a child with some difficulty. Maybe the family of the child has some problems that are transferred to that child. These apprehensions stop me doing this. . . . My husband is more concerned about adopting the child. I don’t know if we could be good parents of that child emotionally. I want to be pregnant and give birth to my own child. (Maria: UK, 39)

Pakistani women seemed to be more concerned about carrying on the “family line” and preserving inheritance: for them, being childless was bad but more appealing than adoption. They were also occupied by the fear that an adopted child could leave them at any stage:

I never thought about adoption. My husband is also against it, because we have seen so many people who adopted a child, and when the child came to know about its real parents, she or he left them; rather, it’s better to live without a child. Issues of heritage also arise due to an adopted child. (Sara: Pk, 27)

As adoption is a collective decision for a couple, Pakistani women deferred to their spouses on the issue, and they perceived that their husbands were more rigid on the issue. This is an interesting contrast to women’s assumption of responsibility for infertility treatment.


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DISCUSSION The findings presented here illustrate that although infertile women in the United Kingdom and Pakistan had many shared experiences, they also experienced unique challenges shaped by their cultural contexts. The study supports the call for research to take into account cultural differences within the broader social context when investigating the impact of infertility (Inhorn & van Balen, 2002). Learning that long-held desires for motherhood were blocked evoked a sense of failure, which led to low mood and affected women’s physical and emotional relationships (Batool & de Visser, 2014; Inhorn, 2000; Jordan & Ferguson, 2006; Khodakarami et al., 2010; Loke et al., 2012). Most women complained that their partners could not empathize properly. Like women in other developed countries (Schmidt, Holstein, Christensen, & Boivin, 2005), most British women demonstrated that dealing with infertility treatment as a common goal had made them stronger as a couple. This reinforces the importance of conceptualizing infertility as a shared problem in clinical settings. One clear difference between samples was the influence of family and family-in-law. Social pressure from extended family and in-laws was more intense for Pakistani women than for British women: infertility appeared to be a personal tragedy for women in UK, but for Pakistani women it was also a family tragedy. British women seemed better able to treat infertility as a private issue: although they experienced “felt stigma,” there was not strong public scrutiny or family pressure. In contrast, Pakistani women were less able to maintain their privacy, and they experienced “enacted stigma” and social discrimination from in-laws and others (Scambler, 1984). Other studies have also highlighted heightened family pressures for infertile women in non-western contexts (Bhatti, Fikree, & Khan, 1999; Chang & Mu, 2008; Inhorn & van Balen, 2002). Women in the UK and Pakistan tended to use emotion-focused coping, perhaps because infertility is a low control stressor (Rapoport-Hubschman, Gidron, Reicher-Atir, Sapir, & Fisch, 2009), with control lower in Pakistan than in the UK. Some have recommended coping skills training for infertile women given its utility in other low control situations (Boivin, 2003; Cousineau & Domar, 2007; Whittemore, Grey, Lindemann, Ambrosino, & Jaser, 2010). Other researchers have demonstrated how differing religious traditions can shape coping with infertility (Fahami et al., 2010). Indeed, there were clear differences in the importance of faith-based coping. Most Pakistani women recounted how they were strengthened by religious practices, but they were often fatalistic about motherhood. British women viewed infertility as a purely medical problem: they did not appear to be fatalistic, and they did not report use of faith-based coping. This may reflect the fact that whereas the


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UK is becoming increasingly secular, there is a continuing strong influence of Islam on Pakistani culture. The finding that British women used online support to share their feelings and experiences and to enhance their knowledge of infertility and treatment matches previous research (Malik & Coulson, 2010; Martins, Peterson, Almeida, & Costa, 2011; Porter & Bhattacharya, 2008). Online support networks may play a valuable role in helping women to deal with emotional stresses and isolation experienced during and after treatment. It may be beneficial to encourage the development and use of such networks in Pakistan, especially given the common lack of family support. Excessive Internet use, however, can reinforce isolation among infertile women (Hinton et al., 2010). Our data suggest that the personal impact of infertility may be greater for women in patriarchal societies like Pakistan where motherhood is one of the few valued social roles available for women. Some British women noted that one response to infertility was to turn to other creative or professional interests. Pakistani women tended to have fewer options for fulfilling roles outside of the domestic sphere, and they also had fewer options for potentially effective fertility treatment. Thus, their more challenging current situations were accompanied by less positive views of the future. Our findings have implications for health professionals working with infertile women. Although British women were satisfied with available facilities and treatment and consultants’ levels of professional competence, they were very critical of physicians who ignored the emotional and interpersonal impact of infertility. Pakistani women were satisfied with the compassionate attitudes of their physicians, despite being dissatisfied with the available facilities and treatment options. Our data suggest that physicians should give individualized support to meet infertile women’s desire for patient-centered care regardless of whether they can offer effective treatment (Schmidt et al., 2003). Although our study has provided some important insights, it has some limitations. As is the case for all qualitative research, it may not be possible to generalize our findings to all infertile women in the UK and Pakistan, given that we focused on an opportunistic sample of women seeking infertility treatment. Our aim was not to produce a generalizable theory, but to examine the experience of infertility from women’s perspectives. Despite these caveats, it is important to note that our findings were generally in accordance with those of past research. Combinations of quantitative and qualitative methods and integration of their findings may lead to fuller understanding of the psychosocial impacts of infertility. Given our finding of the importance of cultural context, an interesting extension of the current study would be to examine the experiences of Pakistani women in the UK to determine the effects of acculturation on psychosocial aspects of infertility (Sam & Berry, 2010).


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We suggest that, based on our findings, culture influences the psychosocial experience of infertility. This suggests that although some psychosocial aspects of infertility may be common to all infertile women, the results from studies conducted in one culture may not be directly applicable in other cultural contexts. The results also suggest a need for further resources and networks to support women, particularly those living in cultures where women may have fewer opportunities for fulfilling activities outside of the family home.


FUNDING This research was supported by funding from the Higher Education Commission, Pakistan.

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