Oti-Boadi and Oppong Asante BioPsychoSocial Medicine  (2017) 11:20 
DOI 10.1186/s13030-017-0105-9
RESEARCH Open Access
Psychological health and religious coping
of Ghanaian women with infertility
Mabel Oti-Boadi1 and Kwaku Oppong Asante2*
Abstract
Background: Infertility has been shown to have considerable psychological effects on the well-being of couples,
especially women. Religion has been found as a resource used by infertile women to cope with their distress. Little
research has examined the influence of religious coping on psychological distress among infertile women in Ghana.
This study examines the relationship between positive and negative religious coping and psychological health for
women with infertility problems in Ghana.
Methods: One hundred and fifty married women who were receiving assisted reproduction care in two specialized
clinics were recruited for this study. Participants were administered with the Brief Symptom Inventory and Brief
Religious Coping Scale to assess psychological health associated with infertility and religious coping respectively. A
hierarchical regression was performed to examine the relative contribution of the domains of psychological health
(i.e. somatization, anxiety and depression) in predicting negative religious coping and positive religious.
Results: The results showed that negative religious coping was significant and positively correlated with
somatization, depression and anxiety. Furthermore, a positive relationship also existed between positive religious
coping and somatization and anxiety but not depression. After controlling for age and duration of infertility,
somatization and anxiety predicted positive religious coping whilst all the domains of psychological health
(somatization, anxiety and depression) precited negative religious coping.
Conclusions: This study expanded on the existing literature by examining positive and negative religious coping
with psychological distress associated with infertility for women. These results underscore the need for health
professionals providing therapies for women with infertility to acknowledge and consider their religious beliefs as
this influences their mental health.
Keywords: Women, Infertility, Psychological distress, Religious coping, Quantitative
Background reproductive health problem [2]. These statistics high-
Infertility is perceived as a major health related problem lights the need for research in this unexplored area, as
that affects people across all cultures and societies. the experience and coping with infertility, has been
Globally, it is estimated that about 10% of couples of shown to have considerable psychological effects on the
reproductive age are unable to get pregnant or carry a well-being of couples, especially women [3, 4]. The
pregnancy to term [1]. The incidence of infertility varies psychological impact of infertility (e.g. depression and
around the world and studies have shown that majority anxiety) has not received much attention particularly
of those who suffer live in the developing countries in within the Ghanaian context.
Sub-Saharan Africa where about 5 to 30% couples are In Ghana, infertility is fast becoming pervasive among
infertile [1]. Despite Africa’s high population growth rate, the women population as an estimated 15% of women of
prevalence of infertility in Africa is high and this raises a childbearing age in Ghana experience infertility prob-
reason for concern as it comes across as a major lems [5]. According to the Ghana Demographic and
Health Survey [6], fertility rate among Ghanaian women
* Correspondence: kwappong@gmail.com
2 has dropped from 6.4 children per woman in 1998 to 4.0Department of Psychology, University of Ghana, P. O. Box LG 84Legon,
Accra, Ghana in 2008, making the trend the lowest in Sub-Saharan
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Oti-Boadi and Oppong Asante BioPsychoSocial Medicine  (2017) 11:20 Page 2 of 7
Africa. Infertility is generally defined as the failure to qualities [28]. Religious coping strategies can be adaptive
conceive after a year of regular sexual intercourse or maladaptive, hence, Pargament [28] categorized
without contraception [7] and this is perceived as often religious coping into two: positive and negative religious
caused by biological and other related factors in most coping strategies. Positive religious coping generally rest
western cultures [8]. However, in developing and under- on a secure relationship with whatever the individual
developed countries, as the case may be in Ghana, may hold sacred whilst and negative religious coping are
infertility may be linked to supernatural causes, punish- those that are reflective of tension, conflict, and struggle
ment from the gods for sins of the past, evil spirits, with the sacred [28].
witchcraft and God’s retribution [9, 10]. Research conducted in Ghana, shows that infertile
In many cultures around the world motherhood is an women experience severe psychological distress includ-
important goal for most women [11, 12], and in the ing depression, anxiety and stress [5, 14, 19, 20]. How-
Ghanaian society, a high premium is put on childbearing ever, there are sparse literatures on the relationship
among marriage couples, and the need for children is between psychological distress and religious coping,
expressed in African maxims as ‘there is no wealth taking into consideration that religion plays an integral
where there are no children’ [9]. Though many women part of life of Ghanaians in general. The study was there-
around the world are currently choosing not to have fore conducted to examine the relationship between the
children [13], voluntary childlessness is not common in psychological distress and the use of religious coping
Africa, as women who fail to bear children suffer humili- among a cross-section of Ghanaian women undergoing
ation and sometimes ridiculed and abused [9, 14, 15]. fertility treatment in Ghana. We hypothesized that
Research indicates that the experiences of infertile women facing fertility problems would experience higher
women prevents them from sharing with others what levels of psychological distress. There would also be a
they go through [5, 16] and this further translates into positive significant relationship between duration of
high levels of stress and depression [4, 17–21]. infertility, age and psychological distress (anxiety, de-
Demographic variables such duration of infertility and pression and somatization). There would be a negative
age have been found to be associated with anxiety and relationship between positive religious coping and
depression among women with infertility problems. psychological distress on one hand, and a positive rela-
Duration of infertility has been found to increase stress tionship between negative religious among women with
among infertile women [3, 18]. Similarly, as age of fertility problems on the other hand. The findings of the
infertile women increases, they tend to exhibit a higher study would contribute to existing knowledge in the re-
susceptibility to depression [22–24]. search area of religious coping and infertility. Addition-
Several empirical studies have revealed that women ally, the findings from this study would help in the
with infertility issues use religion to cope with their development of appropriate mental health and commu-
situation [2, 3, 5, 25], and that the use of religious coping nity interventions programmes for women experiencing
strategies have been significantly linked with less infertil- psychological distress as a result of their infertility.
ity distress and fewer depressive symptoms [2, 25]. Depression as used in this study refers to low moods
However, among other women, religion may increase that interfere with behaviour and general activity, and
their distress as they may use negative methods of somatization refers to physical symptoms that are caused
religious coping such as being angry at God for their by psychological or emotional factors such as anxiety
predicament [26, 27]. This suggests a relationship be- and depression.
tween religiosity and the psychological well-being of
women with infertility problems [25, 26]. Research has Methods
shown that among women with infertility issues who are Sample and procedure
also religious, the experience of infertility goes beyond A cross-sectional survey was conducted in 2013, involv-
the medical experience since they take it as a spiritual ing 150 women with fertility problems who were
crisis and a threat to the very core of their beliefs about purposively sampled among other patients attending two
self, life, and ultimate truths [27]. Religion plays an specialized assisted reproduction clinics in Accra,
integral role in the life of Africans and Ghanaians Ghana. Participants were included in the study if they
especially when dealing with stressful situations [9]. fulfilled the WHO definition of infertility which states
Thus, exploring the use of religious coping with the that the inability of a sexual active non-contraceptive
inability to have children would contribute to the sparse using woman to have a live birth after 12 or more
research in Ghana and also contribute to academic months of regular sexual intercourse without a male
literature. Religious coping refers to efforts made by factor. Thus, women with both primary infertility and
individuals to deal with life stressors in ways that are secondary infertility problems were included in the
associated with the divine or are imbued with divine-like study. Primary infertility as used in this study refers to
Oti-Boadi and Oppong Asante BioPsychoSocial Medicine  (2017) 11:20 Page 3 of 7
the inability of a sexually active, non–lactating and non- instrument have been found to be adequate and reported
contraceptive using woman to have a live birth after 12 internal consistency estimates ranging from 0.71 to 0.98
or more months of regular sexual intercourse, and across the nine dimensions [29]. The Cronbach alpha
secondary infertility refers to women who are having the reliability coefficient in this study is 0.98.
difficulty to have a live birth or hold pregnancy for full
term, even though they had previous had a live birth. Brief RCOPE
Women who had male factor infertility were excluded. The Brief Religious Coping Scale (Brief RCOPE), a self-
After approval was given by the hospital administra- report instrument was used to measure patterns of posi-
tion, the study was introduced to the participants. Those tive and negative religious coping, using seven items
who agreed to participate in the study gave a written each [30]. Positive religious coping strategies include
informed consent. Each questionnaire packet included a spiritual connection, seeking spiritual support, religious
letter from the researchers explaining the purpose and forgiveness, collaborative religious coping, benevolent
procedures for the study. The cover page of the religious appraisal, religious purification, and religious
questionnaire briefly explained the aims of the study and focus. Negative religious coping strategies are spiritual
provided instructions to the respondents on how to fill discontent (two items), punishing God reappraisal (two
it up. It also provided information about the researchers. items), interpersonal religious discontent, demonic re-
It also mentioned that anonymity and confidentiality appraisal, and reappraisal of God’s power. The individual
would be maintained, and that participation in the study items on positive and negative coping were combined to
was voluntary. Participants were clearly informed that yield one single summary score of positive and negative
they could stop participating in the study at any time coping, respectively. The Brief RCOPE has shown good
without any consequences to them. It also specified that psychometric properties in a variety of different samples
data collected from the study would be used only for [31, 32]. The present study found values of 0.73 and 0.71
research purposes. The data collection period lasted for for the positive and negative religious coping scale,
10 weeks. Ethical Clearance for the study was given by the respectively.
Ghana Technology University College and the Adminis-
trators of the two fertility clinics. Statistical analysis
Data analyses were conducted using Statistics Package
Measures for Social Sciences (SPSS) version 21.0. Descriptive sta-
Data was collected by means of a self-administered tistics were used to examine the demographic character-
structured questionnaire which includes questions istics of the sample. Pearson correlation coefficients
relating to sample demographics as well as questions on matrix was computed to examine the associations
religious coping and psychological distress. among the variables, especially the subscales of Brief
RCOPE, somatization, anxiety and depression. A
Demographic items hierarchical regression was performed to examine the
A socio-demographic questionnaire was designed by the relative contribution of the domains of psychological
authors to elicit information on socio-demographic health (i.e. somatization, anxiety and depression) in pre-
variables including participant’s age, level of education, dicting negative religious coping and positive religious.
employment status and duration of infertility. Following the entry of demographic variables (age and
duration of infertility), the next block of variables
The Brief Symptom Inventory (BSI 53) (somatization, anxiety and depression) was entered into
The BSI is a 53-item inventory [29] designed to assess the model. This procedure was followed to ensure that
psychological systems of psychiatric, medical, and nor- those variables that were strongly associated with nega-
mal individuals, was used to measure psychological tive and positive religious coping would account for
health. Responses are provided using a 5-point Likert unique variance beyond that accounted for by the demo-
scale that ranges from 0 = not at all to 4 = extremely graphic variables. Information is provided for the
true. The inventory assesses nine categories of psycho- standardized beta weight (β), the R2 and the ΔR2
logical symptoms (somatization, obsession-compulsion, accounted for in the model. All statistical tests were
interpersonal sensitivity, depression, anxiety, hostility, performed using two-tailed, and a p < 0.05 was
phobic anxiety, paranoid ideation and psychoticism). For considered statistically significant.
the purpose of this study only 3, subscales (somatization,
depression and anxiety) were used. Each subscale of the Results
BSI was calculated by adding up the responses on the Sample characteristics
items under each subscale and then dividing the total by The participants included a total of 150 women under-
the number of items. Validity and reliability of the going fertility treatment in Accra, Ghana (Table 1). This
Oti-Boadi and Oppong Asante BioPsychoSocial Medicine  (2017) 11:20 Page 4 of 7
Table 1 Demographic Characteristics of the study population also imply that psychological distress increases as
(n = 150) women with infertility grow older.
Characteristics N (%) or Mean (SD) The result as presented in Table 2 also shows that
Mean age in years 34.3 (5.67 positive religious coping was significantly related to
Ages (n, %) somatization (r = 0.381, p < 0.001), and anxiety
(r = 0.244, p < 0.01). This implies that women who use
< 30 35 (23.3)
positive religious coping strategies are more likely to
30 –35 52 (34.7) have high level of anxiety and somatization symptoms.
36 – 39 13 (8.7) Findings also revealed that negative religious coping was
40 – 44 50 (33.3) significant and positively correlated with age (r = 0.342,
Mean of infertility in years 5.8 (3.4) p < 0.05), duration of infertility (r = 0.220, p < 0.001),
Duration of Infertility somatization (r = 0.501, p < 0.001), depression
(r = 0.481, p < 0.001) and anxiety (r = 0.380, p < 0.001).
1–5 91 (60.7)
This result suggests that women with infertility prob-
6 – 10 18 (12.0) lems who uses negative religious coping are more likely
11– 15 41 (27.3) to have elevated levels of somatization, depression, and
Education anxiety.
Junior Secondary 20 (13.3)
Senior Secondary 48 (32.0) Predictors of positive and negative religious coping
Results of the hierarchical regression analyses are sum-
Tertiary 82 (54.7)
marized in Table 3. When positive religious coping was
Employment Status considered as an outcome variable, only age (β = 0.37,
Employed 130 (86.7) p < 0.05) was found to be a significant predictor in
Unemployed 20 (13.3) model 1 and accounted for 9.1% of the variance in posi-
tive religious coping; F(2, 117) = 5.83, p < 0.01. In model
represents a response rate of 85% (only 150 out of 176 2, in which the domains of psychological health (i.e.
agreed to take part in the study). Their ages ranged from somatization, anxiety and depression) was examined,
27 to 44 years (M = 34.3; SD = 5.67) and approximately statistically significant predictors for somatization
(67%) were in their 30s. Over half (53.3%) have had (β = 0.58, p < 0.05) and anxiety (β = 0.61, p < 0.05) were
tertiary education and a large majority of the women, found: The regression model accounted for 14.5% of the
86.7% were employed. The duration of infertility was variance in positive religious coping ΔR2 = 0.145,
found to 3–15 (M = 5.8; SD = 3.4) years. F(2117) = 4.8, p < 0.001.
When negative religious coping was considered as an
Relationship among variables in the study outcome variable, only duration of infertility (β = 0.28,
The results presented in Table 2 shows the relationship p < 0.05) was found to be a significant predictor in
between age, duration of infertility, and psychological model 1 and accounted for 7.5% of the variance in nega-
health. The findings age was positively associated with tive religious coping; F(2, 117) = 4.8, p < 0.05. In model
duration of infertility (r = 0.784, p < 0.001), somatization 2, in which the domains of psychological health was ex-
(r = 0.687, p < 0.001), depression (r = 0.241, p < 0.01) amined, statistically significant predictors for all the do-
and anxiety (r = 0.313, p < 0.001). This suggests that in- mains were found: somatization (β = 0.82, p < 0.01),
fertility among women increases with age. The results anxiety (β = 0.61, p < 0.01) and depression (β = 0.69,
Table 2 Relationship between age, duration of infertility, religious coping and psychological distress
Variables 1 2 3 4 5 6
1. Age 1 —————— —————— —————— —————— ——————
2. Duration of infertility .784*** 1 —————— —————— —————— ——————
3. PRCOPE .258*** .168* 1 —————— —————— ——————
4. NRCOPE .342* .220*** .234** 1 —————— ——————
5. Somatization .687*** .416*** .381*** .501*** 1 ——————
6. Depression .241** .222** .116 .481** .832*** 1
7. Anxiety .313*** .067 .244** .380*** .862*** .969***
PRCOPE Positive religious coping, NRCOPE Negative religious coping
*p < .05; **p < .01; ***p < .001
Oti-Boadi and Oppong Asante BioPsychoSocial Medicine  (2017) 11:20 Page 5 of 7
Table 3 Summary of hierarchical egression models results This study found that Ghanaian women with fertility
PRCOPE NRCOPE problems experience high levels of psychological
Total R2 = 0.091 Total R2 = 0.075 distress. This observation is consistent with a myriad of
β ΔR2 β ΔR2 previous findings which have consistently found that
Step 1 0.145 0.218 women with fertility problems experience higher levels
of psychological distress [4, 15–18]. A previous study in
Age 0.37* 0.11
Ghana showed that women with infertility problem do
Duration of infertility 0.09 0.28* not share their problems with others as a result of
Step 2 stigma [5]. Their inability to open up to others could be
Age 0.48* −0.14 a contributing factor to the elevated levels of psycho-
Duration of infertility 0.11 0.33* logical distress in this study. The study also revealed a
Somatization 0.58* 0.82** positive significant relationship between duration of
infertility, age and psychological distress (anxiety,
Anxiety 0.61* 0.61**
depression and somatization). Higher levels of psycho-
Depression ——— 0.69** logical distress were thus associated with aging, suggest-
PRCOPE Positive religious coping, NRCOPE Negative religious coping ing that older women were more likely to experience
*p < .05; **p < .01
higher levels of psychological distress than younger
women. This means that as a women grows old she is
p < 0.05). The regression model accounted for 21.8% of more likely to experience distress. This finding is
the variance in negative religious coping ΔR2 = 0.218, consistent with studies conducted elsewhere [22, 23]. A
F(2117) = 6.2, p < 0.001. plausible explanation for this observation is that many
women perceive their biological clocks to be ticking as
Discussion they wait to have children and may likely experience dis-
The purpose of this study was to examine the relation- tress as they do not know when they will have a child.
ship between religious coping strategies and psycho- Duration of infertility was also positively associated
logical distress associated with infertility among women with higher levels of depression, somatization and anx-
in Ghana. Few studies have investigated the relationship iety among women with infertility problems in the
among these variables within the Ghanaian context. The current study. This finding is consistent with previous
results showed that negative religious coping was studies [3, 18, 34, 35]. On the contrary, other studies
significant and positively correlated somatization, de- [22, 35] have found that the longer the period of infertil-
pression and anxiety. Furthermore, a positive relation- ity, the lower the levels of anxiety and depression experi-
ship also existed between positive religious coping and enced by infertile women. It could be explained that as
somatization and anxiety but not depression. Our women with infertility problems think of how long it is
findings also revealed that psychological distress taking them to bring forth their own children, they
(somatization, depression and anxiety) increase with age experience elevated level of psychological distress, and
of women and duration of infertility. especially in an African context where having your own
The Brief RCOPE scale [30] in this study had accept- children is seen as a validation of marriage [9]. Further,
ability reliability coefficient which is similar to studies during the early stages of being diagnosed with infertil-
conducted by Gardner et al. [31] with university students ity, the hopefulness of the woman for a successful
in New Zealand and Pearce, Singer and Prigerson [32] outcome of medical intervention is higher, but as the
with caregivers of cancer patients in the United States. intervention progresses without a success combined with
Despite its reliability, responses to individual items on the stress of moving from one hospital to the other, they
both negative and positive coping dimensions showed may become psychologically stressed up with fading
significant floor and ceiling effects. Negative skew and hopes of conception [19].
ceiling effects on the positive religious coping scale have Unexpectedly, the results indicated that positive reli-
also been reported in other studies using the Brief gious coping was predicted by both somatization and
RCOPE [32]. For example, Khan and Watson [33] anxiety. This finding is inconsistent with existing general
found that the average score of positive religious cop- consensus in literature where positive religious coping is
ing responses was 3.01 (SD = 0.59), out of a highest often associated with a reduction in depressive symp-
possible score of 4.00, a value similar to the average toms in infertile women [2, 3, 5, 25]. Plausible explana-
score in this study. Overall, these results suggest that tions for such discrepancies could be attributed to the
women with infertility problems uses high levels of measures used in the study and cultural differences.
positive religious coping strategies and low levels of Probably, some items found in the religious coping
negative religious coping. measure are not culturally sensitive to Ghanaian women.
Oti-Boadi and Oppong Asante BioPsychoSocial Medicine  (2017) 11:20 Page 6 of 7
Further, women with infertility may also experience high how women with fertility problems to ensure greater
levels of depression and anxiety either because their insight into this phenomenon and to understand better
prayers are not being answered by God or whether going why infertile women are more likely to employ religious
for fertility treatment will be endorsed by their religion. coping strategies. It may also be interested to explore
Religious women could also experience heightened dis- whether religiosity of infertile women increases their
tress from their religious communities which emphasizes psychological distress.
on childbearing as the ultimate outcome of marriage
and this could lead to the assertion that religious beliefs Conclusion
may increase the psychological distress of infertile The present study explored the relationships between psy-
women [30]. It is also like that these participants may chological distress and positive and negative religious cop-
have used high levels of positive religious coping as and ing among women with infertility problems in Ghana. The
when their stress levels increased. Thus, in their attempt results showed that psychological distress (somatization,
to respond to these levels of psychology distress, they depression and anxiety) in women with infertility in-
may engage in greater religious coping. creases with aging and duration of infertility. The results
The findings of the study also showed that negative re- also showed that negative religious coping was significant
ligious coping was associated with increasing levels of and positively correlated somatization, depression and
anxiety, depression and somatization. This outcome was anxiety. Furthermore, a positive relationship also existed
not surprising, as negative religious coping has been as- between positive religious coping and somatization and
sociated with poor mental health such as depression, anxiety but not depression. This is the first empirical study
anxiety, PTSD symptoms, pain and negative affect [30]. to examine women with infertility using both positive and
In Ghana and in most part of Africa, religion plays a negative religious coping strategies to deal with the psy-
very important role in the interpretation and experience chological challenges associated with infertility. Religiosity
of problems, and a woman’s inability to give birth within appears to play a significant role in the lives of Ghanaian
the first year of marriage may likely affect her religious infertile women. These results call attention to the need
beliefs. It is likely that participants might have ques- for more empirical research on the psychological distress
tioned the power of God or may have perceived their and religious coping link. Health professionals providing
situation as punishment from God. Given the socially therapies for women with infertility should acknowledge
undesirable nature of negative religious coping in the and consider their religious beliefs as this influences their
context infertility among women, it is especially note- mental health.
worthy that the use of negative religious coping was
related to poor psychological health. Acknowledgements
The authors acknowledge the co-operation and contribution of staffs of the
clinics and the numerous women who participated in this study.
Limitations and future directions
This study was beset with some limitations. First, the Funding
No funding received for this study.
small sample size was collected using purposive sam-
pling of clinical based participants, an indication that the Availability of data and materials
results are not generalizable to all women with infertility Data is available upon request.
problems in Ghana. Future studies investigating psycho- Authors’ contributions
logical health among women should include a large MO designed the study, collected data and wrote first draft of the
sample size and infertile women in the general popula- manuscript. KOA was involved with the data analysis of result and wrote the
first draft of the manuscript. All authors read, edited and approved the final
tion as responses from those in specialized clinics may manuscript.
be prone to sampling bias. Second, the cross-sectional
design used rules out the possibility to determine any Competing interests
cause-and-effect relationship between religious coping The authors declare that they have no competing interests.
and psychological distress. Third, the measures used Consent for publication
have not been used in Ghana. However, they were Not applicable.
chosen based on evidence of reliability and validity in in-
Ethics approval and consent to participate
fertility research whenever possible. Future research will Ethical Clearance for the study was given by the Ghana Technology
need to revisit the wording of the Brief RCOPE items to University College and the Administrators of the two fertility clinics. All the
avoid ceiling and floor effects. Fourth, the survey was participants provided written informed consent and other key ethical
principles were followed.
based on self-report, which were likely to be biased.
Knowing their medical history would have helped to ex-
Publisher’s Note
plain their psychological health problems. Finally, future Springer Nature remains neutral with regard to jurisdictional claims in
research should use a qualitative approach to explore published maps and institutional affiliations.
Oti-Boadi and Oppong Asante BioPsychoSocial Medicine  (2017) 11:20 Page 7 of 7
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