Introduction: Reproduction related stress and issues are often overlooked but play pivotal role in healthy couple relationship as well as for the physical and mental health of an individual. Societal matters like these are familiar world wide in the main in developing nations. In our study, we looked into the influence and psychological impact of undue reproductive related pressure from in-laws on women and its association with the maturity level of women in terms of age and delay in first pregnancy.

Methodology: This is the cross-sectional observational study. Data was gathered through a self-administered questionnaire after taking consent. Stress levels were characterised by Perceived Stress Scale (PSS).

Results: 28.3 % females suffered from low level stress, 45.2% were having moderate level of stress and 26.5 % had high level of stress. High level of stress was found to be more among females of 31-40 years (35.3%) as compared to age group 18-20 years (14%), p vale 0.02. The stress level was noted to be higher with increasing year of delay in conceiving after marriage. Furthermore, insulting and degrading was found to be the most common abuse from in-laws on respective female making up to 60.4 %.

Conclusion: Women should be made aware of their reproductive and sexual rights. Knowledge, perspective and behavioural alterations in both men and women are needed for procuring the harmonious bonding of men and women.

Keywords: subfertility, stress, depression, reproduction

PSS, perceived stress scale

Reproductive issues related pressure from society has remained one of the major issue among women in most of the communities.¹ However, in some cases this becomes the increasing consequence of the social and psychological impact on the women with each passing day.² Especially it can be even more painful for those who desperately want to have a baby but are unable to conceive due to various reasons. Overall, pressure is as a whole on couple but bit more on women. Women especially in under developed countries are subject to various abuse from the society in the main by in-laws. Restrictive social norms and strategic constraints imposed restricts her mobility and ability to form social connections especially those related to health, fertility, and family planning.^3,4 This pressure can sometimes cause family fights and leading to social isolation to avoid conflicts. Given the fact that these women experience various forms of mockery in the family and society, their self-isolation may be justifiable but inappropriate for their own social, emotional and psychological health. Further, some are exposed to domestic violence, leading to further decrease in their self esteem and the development of inadequacy. As a result, marriages are put under intense psychological pressure and can be a reason for increasing level of stress causing marital instability and divorce.⁵

Social issues like these are common world wide especially in underdeveloped countries including Pakistan. However, no such study done to evaluate this matter among Pakistani women, who are particularly vulnerable to such issues. Here, we aim to explore this sensitive issue among the people of rural parts of Pakistan as this might guide us in identifying the core causes and steps needed to decrease such social issues. Further, this study directed to ascertain the interconnection of depression with inadequacy of various reproductive rights in married women of Pakistan. Therefore, resolution should be aimed towards screening and identify women who are jeopardized for psychological affliction, so that they can be backed by personalized individual, family or marital counseling.

This is the cross sectional observational study conducted in rural areas of Pakistan after ethical approval. The sampling technique used was non probability consecutive sampling. Total 1000 married women in reproductive age were included. All those with psychological issue, chronic medical condition and history of any anomalous child were excluded from the study. Data was gathered through a self-administered questionnaire after taking consent and fully explaining the use of this interview data for research purpose and confidentiality was ensured. Moreover, stress levels in our patients were characterised by Perceived Stress Scale (PSS), a standard self-reported questionnaire designed to measure the degree to which individuals appraise situations in their lives as stressful. Individual scores on the PSS ranged from 0 to 40. Scores ranging from 0-13 represents low stress. Scores ranging from 14-26 and 27-40 were contemplated as moderate stress and high perceived stress. Data was analysed using SPSS 21.

Total 1000 married females of reproductive age between 18- 40 years were included. Out of these 114 were of age group 18-20 years, 487 were of age group 21-30 and 399 were of age group 31-40 (p value 0.04). Further, 478 females had education till primary level, 302 had till intermediate level while 220 graduate level participants included (p value 0.01). Moreover, number of years of delay in first child after marriage is as shown in Table 1.

Among 1000 females, 28.3 % (283) suffered from low level stress, 45.2% (452) were having moderate level of stress and 26.5 % (265) had high level of stress as shown in Figure 1. On further stratification, high level of stress was found to be more among females of 31-40 years (35.3%) as compared to age group 18-20 years (14%), p vale 0.02. However moderate level of stress was somehow comparable among all age groups. Moreover, the level of stress was increasing with each year in the delay of first child after marriage. The stress level more than 2 years delay was significantly associated with higher level of stress as compared to the first two years of delay, p value <0.02. However, the level of stress among females with different education level was not found to be drastically different Table 2.

Figure 1 Level of stress among women regarding reproductive concerns.

Further analysis showed the breakdown of abuse from in-laws on respective female, as shown in figure. Insulting and degrading was found to be the most common abuse making up to 60.4 %. The restrictions from preventing couple from family planning methods was reported in 49.6%. Moreover, 33.4 % reported the undue social restrictions implemented from in-laws on them followed by cut down of good quality food (24.1%) and holding possessions from her (24%), threatening regarding husband leaving her (32%) and second marriage of husband (20.2%). Moreover, 18% also reported regarding physical abuse Figure 2.

Figure 2 Type and percentage of abuse encountered.

Sexual and reproductive equability requires knock down of inequity, challenging the uneven freedom of power and concluding discountenance. Various studies disclose the untoward inference of control and interference from society on women`s reproductive decisions.¹ Moreover, numerous forms of abuse implied on women due reproductive delays have been reported. The most common being insulting and humiliating the women, undue restrictions and threatening.  Such ill treatment has also been linked to have consequential associations with the depression leading to psychological health issues and social isolations due to inadequacy to conceive as per society time frames.^6,7 Further, World Health Organization (WHO) published notably phenomenal levels of emotional distress and suicidal intentions among women who were vulnerable to partner violence.⁸

Stress may turn down a woman's likelihood of becoming pregnant and stress may be one factor that can affect the conception odds. The release of stress hormones can lead to physiological changes that impact one`s reproductive health. Also reported by various studies that abuse and lack of support from husband and in-laws and family preference particularly for a male child are strongly associated factors for depression among women in the South Asian region.⁹ This further predispose more vulnerable women to develop poor mental health. Also, domestic violence was positively correlated with psychiatric problems.¹⁰ Moreover, abuse by spouse or in-laws substantially contributed to depression amid married women.¹¹ Further, domestic violence was significantly linked with poor mental and reproductive health.² A study reported that women may be treated as low status and may suffer discrimination due to subfertility issues.¹² Moreover, deprivations commonly imposed on women are to set limits on to the supply of food, impounding her to the house, divorcing or separating her along with the other humiliations or physical abuse.¹³ In our study, we looked into the influence and psychological impact of undue reproductive related pressure from in-laws on women and its association with the maturity level of women of marriage in terms of age, education level of women and the delay in first pregnancy after the marriage. We found the stress level was escalating with increasing age. Besides, we noted the increased stress levels among older age group with more than 2 years delay in conceiving as compared to those at younger age group. Though, found no significant association with the education level.

Lack of decision-making power in women lead to restrained emotions leading to downturn of mental state. Moreover, cultural and social norms in a society can reinforce reproductive control and may link individual and family behaviour. Pakistani women living in rural areas are particularly vulnerable to violence because of their comparably trivial social position and lack of recognition about their legal rights. Therefore, knowledge, attitudes and behavioural changes in both men and women are essential settings for attaining the harmonious relationship of men and women. Full involvement and collaboration of both women and men is essential in productive and reproductive life.^14–16 These finding emphasis to the need of uplifting women empowerment levels by investing more and more in her education and financial independence. The current study had potential limitations. First, the result of the present study is only limited to localised rural women. Secondly, the current study could not assess the difference in level of resilience of women and also to incorporate it with the education and deprivation level of the family as a whole.

Women should be made aware of their reproductive and sexual rights, and married women should be asked screening questions regarding domestic abuse. Physicians can help to provide counseling and educational materials on reproductive rights to bridge this gap.  Moreover, we require international and national law to assure women’s rights to freedom from all forms of discrimination, security, information and education; and access to health care. Additionally, guidance regarding helping women escape from situations of domestic violence, and of safeguarding activity should also be provided.

None.

The authors declares that there is no conflict of interest.

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