Original Article

Traditional practices used by infertile women

in Turkey inr_797 383..387

S. Ayaz1 PhD & S.Yaman Efe2 MSN

1 Assistant Professor, 2 Specialist, Nursing Department, Faculty of Health Sciences, Gazi University, Ankara, Turkey

AYAZ S. & YAMAN EFE S. (2010) Traditional practices used by infertile women in Turkey. International
Nursing Review 57, 383–387

Background: Numerous traditional methods are used in the treatment of infertility around the world.
Aim: To identify the traditional practices of infertile women using one clinic in Ankara, Turkey.
Design and Methods: The population comprised all women (5700) who attended one infertility outpatient
clinic in 2007. The sample was calculated using sample calculation formula and 410 women were included in
the study. The survey method was used for data collection.
Findings: Of the responding women, 27.3% had tried a traditional practice, and 67.8% who tried traditional
practices used an herbal mixture. The reason for the women’s use of a traditional practice was ‘hope’ (66.9%),
and 15.2% of them had experienced an adverse effect related with traditional practice. Maternal education
level, perceived economic status, duration of marriage all significantly affected the use of traditional practices
(P < 0.05). The women who had received unsuccessful medical treatment for infertility and who had
experienced side effects after medical treatment had a higher rate of use of traditional practice (P < 0.05).
Conclusions: Almost one in three of the women who responded to the questionnaire had tried traditional
methods, and some experienced adverse effects related to the practice. For couples with infertility problems,
educational programmes and consultation services should be organized with respect to their traditional
culture. Women should be informed about the hazards of traditional practices and avoidance of harmful
practices, and continuous emotional support must be provided for infertile couples. In the future, nursing
staff should play a much larger role in these supportive services.

Keywords: Infertility, Social Factors, Traditional Practices, Turkey, Women

Introduction Shah 2004). In Turkey, approximately 17% of women aged 15–49

Infertility is an important public health problem that can result
in medical and psychosocial problems for both men and women.
The frequency of infertility varies from one community to
another. It was estimated that more than 186 million ever-
married women aged 15–49 years in developing countries were
infertile because of primary or secondary infertility (Rutstein &
Correspondence address: Sultan Ayaz, Gazi Üniversitesi Sağlık Bilimleri Fakültesi
Hemşirelik Bölümü, 06500 Beşevler, Ankara, Turkey; Tel: 00 90 312216 26 23;
Fax: 00 90 312216 26 36; E-mail: sultan@gazi.edu.tr.
years are estimated to have secondary infertility (Rutstein & Shah
2004).
Motherhood is the primer social role for women in many
countries, and it is known that female factors play a part in 40%
of infertility cases and male factors in approximately 40%
(Cedars & Jaffe 2005). However, especially in traditional com-
munities, the cause of infertility is frequently attributed to the
women only, and childless women may lose their social and
individual rights (Beal 1998; Günay et al. 2005).
Childbearing is an important goal of marriage and not being
able to have children may result in marital problems. Having a
child may provide some sense of stability for the marriage and

© 2010 The Authors. International Nursing Review © 2010 International Council of Nurses 383
384 S. Ayaz & S.Y. Efe
lead to an increase in marital satisfaction. In Eastern culture and
society, negative attitudes towards infertility are detrimental.
Having a child is psychologically or effectively essential for
women, and the absence of children may result in divorce or even
a second marriage (Ramezanzadeh et al. 2004; Van-Rooij et al.
2007). In Turkish society, having a child is one of the basic
building blocks of marriage. Children are seen as a necessity to
continue the bloodline. For this reason, a man who is unable to
have a child by his wife may divorce or marry a second woman
(fellow wife). In addition, the use of children as part of the
workforce, especially in rural areas, makes having children a
necessity. Women’s social status improves with every child to
whom they give birth, especially male children (Dikeçligil &
Çiğdem 1991).
All over the world there are numerous traditional methods
used in the treatment of infertility. Frequently applied methods
include various traditional drugs, acupuncture and some reli-
gious practices, such as sacrificing animals (Engin & Pasinlioğlu
2002; Gerrits 1997; Papreen et al. 2000; Sundby 1997). In Turkey,
consulting traditional midwives, consulting religious leaders,
having an amulet written, sacrificing animals and using tradi-
tional drugs are commonly used traditional practices for the
treatment of infertility. The frequency and types of traditional
practices may, however, vary from one community to another.
The frequency of traditional practices is expected to decrease as a
result of the increase in modern medical facilities and social
insurance systems (Günay et al. 2005). Therefore, nurses’ roles in
the process of diagnosis and treatment of infertility are beginning
to come into prominence. Nurses in private clinics have functions
such as providing psychological support, together with training
and consultation, for infertile couples. In Turkey, nursing services
are provided sufficiently in private clinics. However, because of a
lack of private infertility clinics and the high costs of treatment,
many individuals prefer public hospitals. In public hospitals,
nurses take part in the process of diagnosis and treatment but
cannot provide training and consultation services. This situation
can lead people to turn towards traditional practices. It is thought
that providing adequate information and consultation for
couples during the diagnosis and treatment process could lead to
a decrease in the use of traditional practices.
This investigation was carried out to determine the traditional
practices used by infertile couples, and the factors affecting the
frequency of their use.
Materials and methods
Design and sample
This descriptive study aimed to identify the traditional practices
of infertile women who attended one infertility outpatient clinic
© 2010 The Authors. International Nursing Review © 2010 International Council of Nurses
in Dr Zekai Tahir Burak Women’s Health Education and
Research Hospital located in Ankara, the capital of Turkey.
This hospital serves women from all parts of the country and
provides a modern and reliable health service specifically in the
areas of women’s health, such as prenatal care, childbirth, post-
partum care, infertility treatment, menopause and family plan-
ning, using recent research information and technology. The
infertility clinic of the hospital is one of the respected clinics for
reproductive health in the country and provides the service to
patients with primary and secondary amenorrhoea, premature
menopause and bleeding irregularities, in addition to couples
with infertility concerns.
The population of the study comprised all women (5700) who
attended for medical treatment at the infertility outpatient clinic
in the year 2007. The sample was calculated using sample calcu-
lation formula in universe-known situations (Sümbüloğlu &
Sümbüloğlu 2005) and calculated as 360. To increase reliability,
access to more participants was aimed for. For this reason, all
women who agreed to participate were included in the study. All
women were informed about the study, and their informed
consent was obtained. Eighty per cent of the women accepted to
attend the study, and, in total, 410 women formed the sample
group. The questionnaire was administered between 1 Septem-
ber and 30 September 2008.
Data collection
For data collection, a questionnaire prepared by researchers was
used based on data from the literature (Albayrak & Günay 2007;
Gerrits 1997; Kurçer et al. 1999). The questionnaire consisted of
two sections. The first on the socio-demographic characteristics
of the women; the second consisted of open-ended questions
about infertility and traditional practices related to infertility.
The questionnaire was pretested on a convenient group of infer-
tile women (n = 40) who attend the infertility outpatient clinic,
and then these women were excluded from the study sample. The
questions considered unclear were revised.
The questionnaire was given during face-to-face interviews
conducted at the outpatient clinic with the woman alone. Each
interview took between 20 and 30 min.
Ethical considerations
Ethical approval was obtained from the Dr Zekai Tahir Burak
Women’s Health Education and Research Hospital Local Ethics
Committee. Informed consent was obtained from the women
before they took part in the research. The study was conducted in
accordance with the principles of the Declaration of Helsinki.
Participation in this study was voluntary. Women enrolled were
informed about the aims of the research. They were told that data
Traditional practices of infertile women
collection would contribute to the improvement of family health
services and that all individual data would be completely
anonymous.
Statistical analysis
The Statistical Package for the Social Sciences version 11.5 (SPSS,
Inc., Chicago, IL, USA) was used to analyse the data. Percentages
were calculated and chi-square tests were carried out; P < 0.05
was considered statistically significant.
Findings
The mean age of the women in the study was 27.29 ⫾ 4.7 years.
Thirty-eight per cent of the women were in the 25–29 years age
group; 66.4% were elementary school graduates; 87.1% were
unemployed; 65.1% interpreted their socio-economic status as at
a ‘moderate level’; 67.1% lived in a nuclear family; and 73.9%
had lived most of their life in the urban area. Nearly 35% of the
husbands were graduates of elementary school; 42% and 23% of
them were university and high school graduates, respectively.
The duration of marriage of 27.8% of the women was 10 years
or longer; in 88.3% of the women, the duration of infertility was
less than 5 years. The rate of women with primary infertility was
87.8%, and in 41%, the infertility originated from the woman;
48% of the women expressed that they felt psychological and
social constraints from the neighbourhood because of their
infertility (Table S1).
Result show that 27.3% of the women had tried a traditional
practice. These included herbal mixtures (67.8%), pulling the
back (41%), intravaginal applications like herbal ovules (e.g.
wool, garlic and olive oil), and sitting over herbal mixture vapour
(16.9%). The herbs included in the mixture (stinging nettle,
daisy, mint, etc.) do not have any effect on the treatment of
infertility. For this reason, herbal mixtures used by the women
were to be considered traditional practice and not as comple-
mentary treatment. The reason for the women’s use of a tradi-
tional practice was ‘hope’ (66.9%), and 15.2% of them also
expressed an adverse reaction to the traditional practice
(Table S2).
When the use of traditional practices was evaluated according
to socio-demographic characteristics, their use decreased signifi-
cantly as the maternal education level increased (P < 0.05). As
the perceived economic status decreased and the duration of
marriage extended, the rate of using traditional practices
increased significantly (P < 0.05). The women who had received
unsuccessful medical treatment for infertility and who had expe-
rienced side effects after the medical treatment had a higher rate
of traditional practice use (P < 0.05) (Table S3).
No significant correlation was found between the use of tra-
ditional practices and the age of women, place of living, duration
© 2010 The Authors. International Nursing Review © 2010 International Council of Nurses
385
of infertility problem, type of infertility (primary or secondary)
and whether the infertility problem originated from the woman
or the man.
Discussion
The study was conducted with women who had been seen at the
hospital for the medical treatment of infertility. Traditional prac-
tices had been used by 27.3% of the women. This finding is
important because it shows that almost one in every three had
tried traditional practices. However, in previous studies per-
formed in Turkey, the rate of using traditional practices varied
between 28.7 and 66.6% (Albayrak & Günay 2007; Engin &
Pasinlioğlu 2002; Günay et al. 2005; Kurçer et al. 1999; Şenol
et al. 2004). In our study, the rate of traditional practice was
found to be lower. This result may be because previous studies
had been performed in rural areas and our sample group had the
possibility of accessing medical treatment.
Studies performed in other countries also demonstrated that
people with infertility problems tried traditional practices.
Schaffir et al. (2009) determined that 62.2% of infertility patients
used complementary therapies in China. McGee et al.’s study
(2007) indicates that 91.1% of Chinese women had used at least
one non-medical treatment method specifically for the purpose
of getting pregnant. Dyer et al. (2002) indicate that of the South
African women in their study, 16.6% had consulted a traditional
healer. Geelhoed et al. (2002) determined that 10.5% of respon-
dents in rural Ghana gave traditional or religious explana-
tions for infertility. In Gerrits’ study (1997) performed in
Mozambique, all of the interviewed infertile women visited tra-
ditional healers once or several times, while only half of them
went to the hospital. In Papreen et al. (2000), herbalists and
traditional healers were considered the leading treatment option
among urban slum populations in Bangladesh. Sami & Ali
(2006) determined that 39.5% of Pakistani couples seek help
from community midwives.
In our study, among the women who used traditional prac-
tices, there was a 15.2% rate of adverse effects. Engin & Pasinlio-
ğlu (2002) and Kurçer et al. (1999) also identified adverse effects
in their studies among Turkish women who used traditional
practices, which are also similar to our study. The post-treatment
complications were more common among women who con-
sulted non-physicians (Sami & Ali 2006). When some of the
traditional practices, which can be harmful, are evaluated,
‘pulling the back’ is a kind of traction and sometimes used for the
treatment of infertility by community midwives. If done, the
practice may leave permanent effects. Substances applied intra-
vaginally (e.g. wool, garlic and olive oil) and the vapour of sub-
stances such as chicken stool, tar or soap can also cause irritation
or infections. (Community midwifery in Turkey, which is an
386 S. Ayaz & S.Y. Efe
occupation that is learned through a master–apprentice relation-
ship, is performed by non-professionals and includes women’s
health practices. Although it is officially forbidden to perform
these practices, they are still alive especially in rural areas. We
would argue that qualified nurses should be available to educate
individuals about the possible health problems that can originate
from these traditional practices.)
Two-thirds (66.9%) of the women in our study stated that
their reason for using traditional practices was ‘hope’. Similarly,
Sami & Ali (2006) determined that for 54.2% of their respon-
dents the main reason for seeking treatment was ‘the wish to
become pregnant’.
Medical treatment for infertility is very expensive and takes a
great deal of time. Many couples who discontinued treatment in
Rajkhowa et al. (2006) stated that the reasons were especially lack
of success and lack of funding.
As discussed in the Introduction, having a child is important
for all, but especially for women. In traditional patriarchal com-
munities, fertility is the most important determinant of the
social status of the woman. There is great pressure on the child-
less woman from family members and relatives. Both the
woman’s own family and, especially, the husband’s family expect
a woman to have a child in a short time, and any delay in the
occurrence of pregnancy is generally attributed to the woman.
Childlessness threatens the woman’s social status in the family
and in the community. In these circumstances, the community
may consider as normal the remarriage of the husband after
divorce or, in some cases, even without divorce (Albayrak &
Günay 2007; Fido & Zahid 2004; Papreen et al. 2000; Van-Rooij
et al. 2007). In the face of this social pressure to have a child,
women’s ‘hopeful’ perception of traditional practices is not
unexpected.
In our study, the level of education was found to affect the
use of traditional practices; as the level of maternal education
increased, the rate of using traditional practices decreased sig-
nificantly. Similarly, Engin & Pasinlioğlu (2002) and Günay
et al. (2005) determined that the frequency of traditional prac-
tice use was higher in Turkish women whose educational level
was of primary school or lower, than in those women educated
to secondary school level or above. In Fido & Zahid’s study
(2004) in Kuwait, traditional healers were considered as the first
treatment choice among illiterate women, while educated
women opted for an infertility clinic for treatment. Sami & Ali
(2006) determined that most of the Pakistani women who con-
sulted non-physicians were illiterate (69.4%), as compared with
those who consulted a physician (37.8%). Nowadays, there are
possibilities to access information about infertility treatment in
various ways (education, media, etc.), and the information also
has its place in formal education. For these reasons, women who
© 2010 The Authors. International Nursing Review © 2010 International Council of Nurses
have higher education levels tend to avoid traditional treat-
ments for infertility.
We also determined that as the perceived economic status
decreases, the rate of practising traditional medicine increases.
Kurçer et al. (1999) also established in their study with Turkish
women that economic status affected the rate of traditional prac-
tices used, because infertility treatment is expensive.
Another factor affecting traditional practice use is the dura-
tion of marriage. As the duration of the marriage increased, the
rate of traditional practice use increased significantly. Kurçer
et al. (1999) and Günay et al. (2005) also obtained similar results
in their studies. In Turkish society, women are expected to have a
maternal role in the marriage establishment. Society expects
couples to have a child in the first years of marriage. As a result,
each year spent without children causes an increase in social and
psychological constraint (Guz et al. 2003; Ozkan & Baysal 2006;
Ramezanzadeh et al. 2004; Van-Rooij et al. 2004). In our study,
this pressure was felt in 48% of the women. This increase in
pressure forces couples towards treatment, and traditional prac-
tice rates increase in situations where couples are not obtaining a
result from medical treatment. Thus, in our study, the rate of
traditional practices increased in women who previously had
unsuccessful medical treatment for infertility and who had expe-
rienced side effects from the medical treatment. The difference
between the groups was significant (P < 0.05).
No correlation between the use of traditional practices and
women’s age, place of living, and the duration of infertility was
found.
Conclusion
In spite of fast-progressing medical and technological advances
in the treatment of infertility, almost one in three women in our
study experiencing infertility problems had tried traditional
methods, and some of these women had experienced adverse
effects related to the practice. Approximately half of the women
feel psychological and social constraints because of their infer-
tility and use traditional practices in the hope of having child.
Implications for practice
It is recommended that nurses who work in infertility outpatient
and inpatient clinics should be aware of the cultural factors
directing infertile couples to traditional practices and their
potential hazards. Training programmes and consultation ser-
vices should be organized with respect to culture, and women
should be informed about the hazards of traditional practices
and their avoidance. Consulting services should be developed in
the infertility clinics, and emotional support should be provided
for infertile couples. Nursing staff should play a much greater
role in supporting couples and providing them with important
Traditional practices of infertile women
information. Increasing the effectiveness, quality and availability
of medical services for infertility should lead to the eventual
reduction in the use of traditional practices. Meanwhile, health
education for these, sometimes desperate, couples should be
widely available in the fertility services.
Author contributions
Both authors actively contributed to the conception, design,
analysis and interpretation of the data, and the drafting of the
manuscript. S. Ayaz supervised the study. S. Yaman Efe per-
formed the data collection and data analysis. Both authors pro-
vided statistical expertise and made critical revisions for
important intellectual content.
References
Albayrak, E. & Günay, O. (2007) State and trait anxiety levels of childless
women in Kayseri, Turkey. The European Journal of Contraception &
Reproductive Health Care, 12 (4), 385–390.
Beal, M.W. (1998) Women’s use of complementary and alternative thera-
pies in reproductive health care. Journal of Midwifery & Women’s Health,
43 (3), 224–234.
Cedars, M. & Jaffe, R.B. (2005) Patient information page from the
hormone foundation: infertility and women. Journal of Clinical
Endocrinology & Metabolism, 90 (4): 0. Available at: http://
jcem.endojournals.org/cgi/content/full/90/4/0 (accessed 12 May 2009).
Dikeçligil, B. & Çiğdem, A. (1991) Aile Yazıları 4: Evlilik Kurumu Ve
İlişkileri. T.C. Başbakanlık Aile Araştırma Kurumu Yayınları, Ankara.
Dyer, S.J., Abrahams, N., Hoffman, M. & Van-Der-Spuy, Z.M.I. (2002)
Infertilite in South Africa: women’s reproductive health knowledge and
treatment-seeking behavior for involuntary childlessness. Human Repro-
duction, 17 (6), 1657–1662.
Engin, R. & Pasinlioğlu, T. (2002) Erzurum ve Yöresinde İnfertil Kadın-
ların İnfertilite ile İlgili Geleneksel İnanç ve Uygulamaları (Traditional
Beliefs and Practices of Infertile Women Regarding Infertility in
Erzurum Region). Atatürk Üniversitesi Hemşirelik Yüksekokulu Dergisi, 5,
1–10 (in Turkish).
Fido, A. & Zahid, M.A. (2004) Coping with infertility among Kuwaiti
women: cultural perspectives. International Journal of Social Psychiatry,
50 (4), 294–300.
Geelhoed, D.W., et al. (2002) Infertility in Rural Ghana. International
Journal of Gynecology and Obstetrics, 79 (2), 137–142.
Gerrits, T. (1997) Social and cultural aspects of infertility in Mozambique.
Patient Education and Counseling, 31 (1), 39–48.
Günay, O., Çetinkaya, F., Naçar, M. & Aydın, T. (2005) Modern and tradi-
tional practices of Turkish infertile couples. The European Journal of
Contraception and Reproductive Health Care, 10 (2), 105–110.
Guz, H., et al. (2003) Psychiatric symptoms in Turkish infertile women.
Journal of Psychosomatic Obstetrics and Gynecology, 24 (4), 267–271.
Kurçer, M.A., et al. (1999) İnfertil Kadınların Geleneksel Halk Kısırlık
Tedavileri Konusundaki Davranışları ve Etkileyen Faktörler [Behaviours
© 2010 The Authors. International Nursing Review © 2010 International Council of Nurses
387
of the infertile women with regard to traditional infertility treatments
and influencing factors]. Turgut Özal Tıp Merkezi Dergisi, 6 (3), 229–
232.
McGee, A., Schaffir, J. & Kennard, E. (2007) Use of non-medical treat-
ments by infertility patients. Fertility and Sterility, 88 (1), 268–269.
Ozkan, M. & Baysal, B. (2006) Emotional distress of infertile women in
Turkey. Clinical and Experimental Obstetrics & Gynecology, 33 (1),
44–46.
Papreen, N., et al. (2000) Living with infertility: experiences among urban
slum populations in Bangladesh. Reproductive Health Matters, 8 (15),
33–44.
Rajkhowa, M., Mcconnell, A. & Thomas, G.E. (2006) Reasons for discon-
tinuation of IVF treatment: a questionnaire study. Human Reproduction,
21 (2), 358–363.
Ramezanzadeh, F., et al. (2004) A survey of relationship between anxiety,
depression and duration of fertility. BMC Women’s Health, 4 (1), 9–15.
Rutstein, S.O. & Shah, I.H. (2004) Infecundity, Infertility and Childlessness
in Developing Countries. DHS Comparative Reports No. 9. ORC Macro
and the World Health Organization, Calverton, MD.
Sami, N. & Ali, T.S. (2006) Health seeking behaviour of couples with sec-
ondary infertility. Journal of the College of Physicians and Surgeons Paki-
stan, 16 (4), 261–264.
Schaffir, J., McGee, A. & Kennard, E. (2009) Use of non-medical treat-
ments by infertility patients. The Journal of Reproductive Medicine, 54
(7), 415–420.
Şenol, V., Ünalan, D., Çetinkaya, F. & Öztürk, Y. (2004) Kayseri İlinde Halk
Ebeliği ile İlgili Geleneksel Uygulamalar [Customs and applications on
public midwifery in Kayseri]. Klinik Gelişim, 17 (3/4), 47–55.
Sümbüloğlu, K. & Sümbüloğlu, V. (2005) Biyoistatistik. Hatiboğlu Yayıncı-
lık, Ankara.
Sundby, J. (1997) Infertility in the Gambia: traditional and modern health
care. Patient Education and Counseling, 31 (1), 29–37.
Van-Rooij, F.B., Van-Balen, F. & Hermanns, J.M.A. (2004) A review of
Islamic Middle Eastern migrants: traditional and religious cultural
beliefs about procreation in the context of infertility treatment. The
Journal of Reproductive and Infant Psychology, 22 (4), 321–331.
Van-Rooij, F.B., Van-Balen, F. & Hermanns, J.M.A. (2007) Emotional dis-
tress and infertility: Turkish migrant couples compared to Dutch
couples and couples in Western Turkey. Journal of Psychosomatic Obstet-
rics & Gynecology, 28 (2), 87–95.
Supporting information
Additional Supporting Information may be found in the online
version of this article:
Table S1 Women’s features related with infertility
Table S2 Women’s features related to traditional practice use
Table S3 Women’s use of traditional practices according to
socio-demographic characteristics
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