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Obstetrics and
Gynaecology Cases - Reviews
Research Article: Open Access
ClinMed
International Library
Citation: Obioha JA, Ikechebelu JI, Eleje GU, Joe-Ikechebelu NN (2014) Knowledge
and Attitude of Nurses towards In-vitro Fertilization: A Prospective Cohort Study Gynecol
Cases Rev 1:006
Received: September 09, 2014: Accepted: October 30, 2014: Published: October 31,
2014
Copyright: © 2014 Obioha JA. This is an open-access article distributed under the terms
of the Creative Commons Attribution License, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original author and source are credited.
Obioha et al. Obstet Gynecol cases Rev 2014, 1:1
Knowledge and Attitude of Nurses towards In-vitro Fertilization: A
Prospective Cohort Study
Obioha Joy A1, Ikechebelu Joseph I2, Eleje George Uchenna2* and Joe-Ikechebelu Ngozi N3
1Departments of Nursing, School of Nursing, Nnamdi Azikiwe University Teaching Hospital, Nigeria
2Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nigeria
3Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital, Nigeria
*Corresponding author: Eleje George Uchenna, Departments of Obstetrics and Gynecology, Nnamdi Azikiwe
University Teaching Hospital, PMB 5025, Nnewi, Anambra State, Nigeria, Tel: +234-806-811-7444; E-mail:
georgel21@yahoo.com
Introduction
Knowledge and attitude of nurses can have a profound impact
on the quality of healthcare received by patients undergoing in vitro
fertilization (IVF) techniques [1]. Information on these factors are
essential for future planning of in-house training programs and also
for improving the quality of care a patient receives [2-4].
e rst successful birth following IVF occurred in 1978 [5,6].
However, more than 250,000 babies have been born since then as a
result of using the IVF technique [5-7]. IVF oers infertile couples
a chance to have a child who is biologically related to them. Robert
G. Edwards, the doctor who developed the treatment, was awarded
the Nobel Prize in Physiology or Medicine in 2010 [6,7]. While some
have recorded success, some have recorded adverse consequences
of this treatment [8,9]. In Nigeria, health care workers, particularly
nurses, are taking care of patients undergoing IVF procedures on a
routine basis. is is particularly true of tertiary care hospital [10,11].
e IVF nurse plays a signicant role in the care received by
both recipient and donor, acting as the coordinator for IVF cycles
and providing direct care to both patients [10,11]. According to one
study, the nurse is the professional who spends the most time with
donors as compared with physicians and mental health professionals
[10]. ey are also greatly involved in donor/recipient matching
[10]. In another study, 73% of nurses practicing in infertility settings
described their primary role as direct patient care [11]. e success of
IVF is the birth of healthy baby (ies) and such condition can only be
met with the role each health workers play in the procedure [11-13].
Over the years, there has been increasing number of facilities
that oer IVF treatments in developing countries but only very
few are in the public tertiary hospitals. e establishment of more
IVF centers in the government owned hospitals in Nigeria is in
progress. However, it has been observed that the fear arising from
lack of knowledge led to discriminatory behaviour towards women
embarking on IVF procedures [12]. Unless this gap in knowledge
attached to the IVF practice is tackled eectively, the increased
demand for the procedure cannot be met. Better knowledge and
Abstract
Background: The use of In-Vitro Fertilization (IVF) is now
becoming a popular experience in developing countries. Little or
no research has been conducted to ascertain nurses’ knowledge
or practices regarding this emerging fertility technology in Nigeria.
Objectives: This study determined the knowledge and attitude of
nurses regarding IVF.
Material and methods: A descriptive cross sectional study was
conducted in Nnamdi Azikiwe University Teaching Hospital,
Nnewi, south-east Nigeria. Nurses who worked in various wards
and clinics, had at least one year of experience in practice were
asked to complete the questionnaires. The wards and clinics in the
hospital were contacted and the questionnaires were distributed
and collected. Data was collected using pre-tested questionnaires
with the 5-point Likert scale. Analysis was done using Epi info 2008
version 3.5.1.
Results: Of the 133 questionnaires distributed, 122 (92.4%) were
completed and returned. The mean age of the respondents was
35.6 (5.1) years. Of the 122 respondents, 116 (95.1%) have heard
of IVF while 6 (4.9%) have not heard of it. Of the 116 respondents
who have heard of IVF, 100 (86.2%) correctly knew the denition of
IVF. Sixty three (51.6%) nurses have been in practice for more than
5 years while twenty one (17.2%) nurses were single. Statistically
signicant difference exist between their knowledge of IVF and the
marital status and age of nurses (p<0.05). Eighty nine (76.2%) of
the 116 respondents believed that IVF gives an infertile couple an
opportunity to have children, 20 (17.2%) believed that it could be
used to determine the gender of a child, while 8 (9.6%) agreed
that IVF could be used to treat genetic disorders. Analysis of their
attitude revealed a grand mean score of 2.2 (negative).
Conclusions: Majority of the nurses had a good knowledge of
IVF but with a strong negative attitude towards its use. IVF training
would be a useful step in improving nurses’ attitudes regarding IVF.
Key messages: Majority of the nurses had a good knowledge of
IVF but with a negative attitude towards its use by single mothers
and in sex selection. With the growing demand for IVF services in
our environment, nurses should be adequately trained to enable
them disseminate appropriate information on IVF to clients.
Keywords
In vitro fertilization, Knowledge, Attitude, Infertility, Nurses
• Page 2 of 5 •Obioha et al. Obstet Gynecol cases Rev 2014, 1:1
attitude of nurses can be expected to result in improved compliance
with the standard procedures and universal precaution practices by
them. Hence, knowledge and attitude of nurses regarding IVF can
have profound impact on the quality of patient care and follow up
practices undertaken by health care providers. Additionally, the
nurses understanding and attitudes regarding IVF are yet to be
studied in Nigeria. us, measuring nurses’ knowledge and attitude
may help in optimizing the health of couples before commencement
of IVF cycle which ultimately will improve the chance of achieving
success [14,15].
e authors therefore determined the level of knowledge and
attitude of nurses in a teaching Hospital regarding IVF. It is believed
that this study will form a useful guide to healthcare givers in
developing country settings in educating them on the treatment of
infertility and improved nurses’-patients’ care.
Material and Methods
is is a cross-sectional study descriptive research by which
survey method was used which looked into the knowledge and
attitude of nurses in Nnamdi Azikiwe University Teaching Hospital,
Nnewi, south-east Nigeria. Nnamdi Azikiwe University Teaching
Hospital, Nnewi is the only federal government tertiary hospital that
serves as a referral centre to other hospitals in the state and environs.
e study population comprised of all the registered nurses in the
clinical area who were present at the time of study (March 2009) from
the rank of Chief Nursing Ocer to nursing ocer class II. Dierent
sections of the hospital were used and these include; out- patient
department, surgical/medical units (ie medical, surgical, paediatrics,
labour ward and lying-wards). ese were used because all the nurses
are registered midwives and have come in contact with women
requiring a form of family planning.
Sample size was calculated using stata soware (stata version 10).
A medium eect size (.30) was required for this study. e power
level was set on .80, and the conventional α=.05 was specied. On the
basis of this, the minimum required sample size for this study was set
to 135 nurses.
e target population of nurses in the various clinical areas
of at least one year of experience was 167 as the time of the study.
However, a total of 35 nurses were on leave and so were not present
during the study period, with the result that only 132 nurses were
used in the study.
One hundred percent samples were used because of the small
number of the population. is was in line with what Shelley and
Johnson [16] said in studies involving small population that all the
elements can be and should be included in the samples, convert
sampling was used, that is the questionnaires were given only to those
nurses that were present and on duty. e study used a prospective
design, where participants’ knowledge and attitudes towards In vitro
fertilization were assessed at baseline.
Permission was obtained from the Head of Nursing service of the
hospital to use the nurses as study population. Aer receiving ethical
approval from the institution’s ethical committee, questionnaires
were distributed to those on each shi in dierent sections of
the hospital general out-patient clinic and the surgical/medical/
paediatric/antenatal/gynaecology clinics. Only the nurses who
gave informed consent were given questionnaires. Only permanent
employees were recruited.
e questionnaire was pre-tested before nal distribution.
During the pre-test, the rst questionnaire dra was checked for
the content validity of it and ease of use. Feedback from the nurses
(n=10) was incorporated into a revised version of the questionnaire.
e questionnaire consisted of two sections-A and B. Section A
collected information on the personal prole of the respondents
which was presented in a close-ended form, while section B was on
the knowledge of IVF and attitude of nurses presented in open-ended
form. ey were also requested not to communicate with each other
while lling out the questionnaire and not to compare answers aer
lling out the questionnaire. ey were also requested not to write
their names on the questionnaire to maintain anonymity. Participants
were given a concise written explanation of the study’s background
and purposes and were requested to answer all questions. ey were
informed that their replies would be kept condential and that, if they
did not desire to participate, they could submit a blank questionnaire.
Completing the questionnaire was taken as consent to participate.
Questions were easy to understand, and the questionnaire required
10 minutes or less to complete. Participation was voluntary, and no
incentives were given for participation.
e data instrument was presented in a 5-point Likert scale
requesting respondents to tick which item(s) apply to them. e
self reported attitude of nurses was measured using a Likert scale
and graded from 4= strongly agreed (SA); agreed (A)=3; undecided
(U)=2, strongly disagree (SD)=1 to disagreed (D)=0 [17].
is contains a number of statements made about the IVF and for
each statement the respondents are required to indicate her degree or
level of agreement or disagreement with it using the above-mentioned
response alternatives. Aer the questionnaires are completed, each
item was analysed separately. Weights or scores were assigned to the
various points on each scale. e higher the score, the more positive
or favourable is the subjects’ attitude. A respondent’s score on the
instrument was the sum of the weights assigned to all the scale points
she checked.
All data were entered using the Epi info 2008 version 3.5.1 (v
3.5.1; Epi Info, Centers for Disease Control and Prevention, Atlanta,
GA). Responses to all the items were converted to a percentage
indicating the proportion of correct responses versus other responses.
e qualitative data were presented as frequencies and percentages.
e calculated scores were presented as mean and standard deviation
(SD) aer checking for normality in distribution. Analysis was also
made by categories in order of importance from positive to negative
statements.
e weighted mean (X)=∑ fx
∑
was calculated.
Where F= Frequency of responses of particular category on the
scale
X=Assumed weight
∑=Summation
Chi-square test was done where appropriate. e level of
signicance was accepted when p-value is <0.05 using Mantel-
Haenszel
Results
Of the 132 questionnaires distributed, only 122 (92.4%) were
correctly lled and used for nal analysis. Ten questionnaires had
inadequate data. e mean age of the respondents was 35.6 ± 5.1
years (range 21 to 55, median 31 and mode 32). e mean total years
of service were 6.38 years (range 0.1 to 21.0, median 5 and mode 1).
Amongst respondents who had worked in the infertility clinic, the
mean period of service in infertility clinic was 1.1 years (range 0.1 to
6, median 0.5 and mode 0.1). e demographic characteristics of the
subjects are shown in table 1.
irty two (26.2%) nurses were nulliparous, while 90 (73.8%)
were parous. Sixty three (51.6%) nurses have been in practice for
more than 5 years while 59 (48.4%) nurses have been in practice for at
least 5 years. Twenty one (17.2%) nurses were single while 101 were
married. ere was a statistically signicant dierence between the
knowledge of the nurses on IVF and the marital status and age of
nurses (p<0.05).is is shown in table 3. Majority of nurses who were
married have correct knowledge of IVF.
Of the 122 respondents, 116 (95.1%) were aware of the term IVF
• Page 3 of 5 •Obioha et al. Obstet Gynecol cases Rev 2014, 1:1
while 6 (4.9%) have not heard of it. Of the 116 respondents who were
aware of IVF, 100 (86.2%) correctly knew the denition of IVF while
others did not know. is is shown in table 2.
Further questions regarding the benets of IVF were posed to
the 116 respondents who were aware of IVF. Eighty nine (76.2%) of
the 116 respondents believed that IVF gives an infertile couple an
opportunity to have a child, 20 (17.2%) believed that it determines the
gender of a child, 14 (12.1%) only believed that it involves the use of
articial methods to fertilize an ovum, while 8 (9.6%) agreed that IVF
could be used to treat genetic disorders.
e attitude of the nurses was measured using the Likert scale
[16]. Any score in attitude below the acceptance mean (2.5) is
negative while a higher value is positive. is is shown in table 4. As
regards the attitude of nurses towards IVF, a grand mean score of 2.2
(negative) was gotten.
Discussion
Hospital nurses could play an important role in IVF cycle, because
they are close to the couple and have good knowledge of health
criteria, worries, symptoms, drugs and pregnancy complications that
could arise. Given their unique position in cycle control, treatment
and recording the problems of pregnancy, nurses are well placed
to monitor the patients’ response to IVF treatments. ey are oen
the source in alerting the responsible gynaecologist/physician about
possible complications. ere is thus a logical reason to involve
nurses and encourage them to contribute in IVF practice. e most
important nding in the present study was the nurses’ high knowledge
about IVF, while their attitude towards this subject was at a very low
level. us, more than 80% of the respondents knew that IVF is an
assisted reproductive technique that involves the use of articial
methods to fertilize an ovum. Similarly, a previous study by Macer
[13] in Japan on the knowledge of nurses regarding IVF revealed a
very high level of awareness of IVF and genetic engineering.
Unlike in a previous study by Mitchel et al. [7], graduate level
education was not correlated with perceived level of expertise but did
correlate with length of clinical experience in assisted reproductive
nursing and with certication. However, in our study the duration
of nursing practice, work experience in infertility clinic and previous
birth experience were not signicantly associated with the correct
knowledge of nurses on IVF. e short mean period of service in
infertility clinic of 1.1 years may have been responsible for the lack
of association. Also, prior to this study, the study hospital has not
started doing IVF practice.
As regards the attitude of nurses towards IVF, a grand mean score
of 2.2 (negative) shows that the nurses have a positive attitude towards
IVF even though it is expensive. In our study, a high percentage of
respondents (72.6%) believed that IVF gives an infertile couple an
opportunity to have a child and 17.2% think it can also determine the
gender of the child. ese ndings are worthy of note especially in our
environment where greater premium is placed on the sex of a child
especially among the infertile couples. Many couples may opt for IVF
on the sole aim of pre-implantation sex determination. Similarly,
despite the high level of awareness of IVF in Japan, however, up to
61% of the respondents were worried about research on IVF. e
major reason cited for rejection of IVF research in Japan was that
it was seen as interfering with nature, playing God or as unethical
[12,13].
In the present study, the ndings have implications for nurses
generally and to the health authority. Although, majority (95%) of
nurses have a good knowledge of IVF, there is still a negative attitude
towards its use to select the sex of a child and singles opting for
the procedure. e reasons for this negative attitude could not be
ascertained in our study. is nding contrasts with a previous study
by Khalili et al. [18] where the majority of participants in the study
had a positive attitude towards IVF treatment for infertile couples.
In IVF practice, the nurses give counseling in addition to routine
nursing care services, including group education and individual
interviews about treatment and coping strategies [18]. e nurses also
provide support by accompanying the women during the invasive
procedures [12,19].
Signicant age and marital status dierence were noted in levels
of knowledge and awareness regarding IVF. In view of the fact that
most nurses vary in dierent age groups, signicant dierence in the
knowledge and attitudes among dierent age categories was noted.
Similarly, in a study on nurses by Dillon et al. [20], it was found
that the attitude of nurses toward IVFs was signicantly aected by
age (p = .05), with older nurses attaining higher mean attitudinal
scores. e reasons for this peculiar nding could be the status of the
marital union. Age may be a function of their marital status as greater
number of the respondents will have been married at higher age since
their mean age was 35.6 ± 5.1 years. is then calls for further study.
Despite the low level of attitude of the nurses regarding the use of
IVF by single mothers and in sex selection, we expected better practice
in terms of monitoring IVF procedures and patients. is indicates
that IVF training would be a useful step in improving nurses’ attitudes
regarding IVF. Some eective measures to improve the situation could
be inclusion of IVF practices/ procedures into pre- and postgraduate
nursing continuing education programs and establishment of more
regional IVF centers in the teaching hospital which could eciently
stimulate IVF Practice. us, with the growing demand for IVF
services in developing countries, it is recommended that nurses in the
clinical areas should gain more sucient knowledge of IVF through
seminars and workshops, while, the health authorities should strive
to equip more health institutions with facilities appropriate for the
treatment of infertile women at all levels of care. In our future studies,
we plan to prepare a training program on IVF practices for the nurses
who participated in this study to be able to evaluate the inuence of
the education on all the measured parameters.
Limitations of the present analysis also need to be addressed. A
main weakness is that the majority of the variance in nurses’ knowledge
and attitudes could not be explained by our study. Moreover, the
use of a nonrandom convenience sample may threaten the external
validity of ndings. e response rate for this study was 92.4%, so
non responders may not necessarily aect any obtainable conclusion,
Demographic Characteristics n (%)
Parity
Nulliparous 32 (26.2)
Multiparous 90 (73.8)
Age (Years)
20-29 33 (27.0)
30-39 77 (63.1)
≥40 12 (9.9)
Marital Status
Single 21(17.2)
Married 101 (82.8)
Total duration of Service (Years)
≤5 59 (48.4)
6-10 45 (36.8)
11-15 11 (9.1)
16-20 5 (4.1)
≥21 2 (1.6)
Work experience in Infertility Clinic (years)
Yes 91 (74.6)
No 31 (25.4)
Table 1: Demographic characteristics of the study subjects (N=122).
S/N Responses n %
1. A way of making infertile couples have children. 15 12.9
2. An assisted reproductive technique that involves the use of
articial methods to fertilize an ovum.
100 86.2
3. A new experiment on human beings. 0 0.0
4. Others 1 0.9
Total 116 100.0
Table 2: The Respondents’ denition of IVF.
• Page 4 of 5 •Obioha et al. Obstet Gynecol cases Rev 2014, 1:1
as we are unaware of their attitudes toward IVF. Furthermore, the
current study excluded women less than one year student, who may
have technology skills gained from their recent school education.
However, including hem was technically dicult, as they were taking
basic science courses outside nursing. We agree that the statistical
data resulted in the present study is actual for developing countries
with their demographic specicity. According to our data, married
women are more informed when questioned on IVF in comparison
with the single even though the number of singles in this study was
several times less. e three denition of IVF assessed in this report
may be interpreted as not so accurate and as a whole, the statistical
data represents certain interest and can be applied with guard at the
organization of works in IVF clinics.
Finally, the selection of one research site in Nigeria may limit
the generalizability of ndings. Cultures that stress childlessness
may appear positively related to higher nurses’ attitude to IVF.
Furthermore, psychosocial factors such as marital stress and self-
esteem, or socioeconomic factors such as income and social class
could have explained more variance in the knowledge and attitude
which we did not evaluate in the present study. Another limitation
is the cross sectional study design, which does not permit drawing
conclusions between the inuencing factors and nurses’ knowledge
and attitudes and bias could have been introduced in the open-ended
questions assessing the respondent’s attitudes. Another limitation
of the study may have been the fact that our study did not claim to
represent all the nurses in the study hospital. However, considering
the fact that NAUTH, Nnewi is only federal tertiary hospital in the
state with the most qualied nurses, we can infer that most other
cities in Nigeria have even less knowledge about the IVF.
In conclusion, the results of the present study demonstrated
that nurses who participated in this study had sucient knowledge
about the denition, techniques, purposes and usefulness of IVF.
Signicant age and marital status dierence were noted in levels
of knowledge and awareness of IVF. Regarding the low level of
attitude regarding its use by single mothers and in sex selection, we
expected better practice in terms of monitoring IVF procedures and
patients. is indicates that IVF training would be a useful step in
improving nurses’ attitudes regarding IVF. In our future studies, we
plan to prepare a training program on IVF practices for the nurses
who participated in this study to be able to evaluate the inuence of
the education on all the measured parameters. Moreover, as attitudes
may change over time, a longitudinal approach should be conducted
to identify dierences in attitudes across time in future studies.
Acknowledgment
We wish to thank the nursing staff of Nnamdi Azikiwe University Teaching
Hospital, Nnewi who kindly participated in this study.
References
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Variable Incorrect response
n (%)
Correct Response
n (%)
Chi-square P-value
AGE
< 30 (years) 10 (8.6) 21 (18.1) 12.0263 *0.0005
≥30 (years) 6 (5.2) 79 (68.1)
Parity
Nulliparous 5 (4.3) 24 (20.7) 0.3833 0. 5358
Parous 11 (9.5) 76 (65.5)
Duration of Service (years)
≤5 years 7 (6.0) 52 0.3724 0.54170
>5 years 9 (7.8) 48 (41.4)
Marital Status
Single 10 11 24.4619 *0.0000
Married 6 89
Work Experience in Infertility Clinic (years)
Yes 13 77 0.1420 0.7063
No 3 23
Table 3: Correct responses of nurses to denition of IVF with respect to their parity, marital status, duration of service and work experience (Total subject in the study:
N=116#).
*=Signicance
#= Six (6) respondents have not heard of IVF.
S/N Attitude Responses SA A U D SD *Mean Acceptance
Mean
1. IVF should be
encouraged
56 52 6 1 1 3.4 Positive
2. Against any technique
that experiments with
human beings
1 12 52 48 1 1.7 Negative
3. IVF should be used to
select the sex of the
child
20 36 14 40 6 2.2 Negative
4. A child produced by
IVF will not be healthy
0 10 48 54 1 1.6 Negative
5. Single women should
be given access to IVF
1 20 36 42 14 1.5 Negative
6. We do not need IVF in
Nigeria
1 0 56 60 1 1.5 Negative
7. IVF is too expensive
and so could not be
recommended for any
body
4 8 52 52 6 1.6 Negative
8. Children produced via
IVF behave abnormally
0 0 66 50 1 1.6 Negative
Table 4: The Attitude of Nurses towards IVF.
Acceptance mean (X)=∑ fx
The *grand mean Score (items 1-8) = 2.2
• Page 5 of 5 •Obioha et al. Obstet Gynecol cases Rev 2014, 1:1
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