The Role of Spiritual Experiences in Feeling of Failure and Infertility Stress among Infertile Women

Introduction nfertility is defined as the inability of a couple to conceive after a year of noncontraceptive regular intercourse (1). Although the prevalence of infertility has been reported differently in different parts of Iran, the overall prevalence of infertility in Iran is close to the global statistics and is reported to be about 13.2% (2). Infertility is a painful emotional experience accompanied by stress (3). Infertility stress includes the interaction of the physical conditions predisposing infertility with medical interventions, others' reactions, and individual psychological characteristics, which may spread over the years through any I Please Cite This Article As: Rezaei SM, Mosavinezhad SM, Ansari B. The Role of Spiritual Experiences in Feeling of Failure and Infertility Stress among Infertile Women. Health Spiritual Med Ethics. 2020;7(4):41-49. Abstract


The Role of Spiritual Experiences in Feeling of Failure and Infertility Stress among Infertile Women
Introduction nfertility is defined as the inability of a couple to conceive after a year of noncontraceptive regular intercourse (1). Although the prevalence of infertility has been reported differently in different parts of Iran, the overall prevalence of infertility in Iran is close to the global statistics and is reported to be about 13.2% (2). Infertility is a painful emotional experience accompanied by stress (3). Infertility stress includes the interaction of the physical conditions predisposing infertility with medical interventions, others' reactions, and individual psychological characteristics, which may spread over the years through any diagnostic intervention (4). This type of stress appears as a combination of five components, namely social anxiety, sexual anxiety, and communication anxiety, as well as the need to parenting and not accepting a childless lifestyle (5).
Infertility stress can lead to the disruption of the treatment process, frustration, and low selfesteem in infertile couples, or inefficiency of infertility treatments (6). The results of the literature review show that infertility and its treatment can cause confusion, frustration, depression, anxiety, hopelessness, feelings of guilt and worthlessness, feelings of helplessness, rejection, and defeat in life (7,8). The feeling of failure in individuals is originated not only from the loss of social status but also from the failure to achieve personal goals and desires (9). This feeling includes three components of feeling stagnant (ability and inability to start again after failure), feeling of loss (feelings in life's sensitive battles), and feeling of satisfaction (overcoming problems) (10). In this regard, the results of a study showed that infertility and its treatment process automatically leads to ambiguity in life and involves a variety of personal, familial, and social stresses and feelings of defeat, depression, loss, and anger. As a result, these factors lead to a decrease in the quality of life of individuals and create a crisis (11).
One of the factors that can help infertile women to go through the difficult period of diagnosis and treatment of infertility and the mentioned problems and feel safe, maybe their faith and belief, or in a word, spiritual experiences (12). Spirituality includes the emotional and personal expression of the sacred beliefs, which is often assessed by spiritual wellbeing, sense of peace, and spiritual harmony (13). The concept of spiritual experiences is defined as seeking meaning in life, which includes understanding the meaning of life, positive experience in life, feeling happy and satisfied with life, and feeling about life, such as hope, achievement, passion, and excitement (14).
The results of studies showed a significant relationship between daily spiritual experiences and perceived stress in veterans with posttraumatic stress disorder (PTSD) (15), a significant positive relationship between spiritual experience and stress coping style among university students (16), direct relationship between women's spirituality and infertility stress reduction in Brazilian infertile couples (17), role of showing gratitude to God and spiritual intelligence in increasing the tolerance of failure in Iranian university students (18), Iranian and British women use of religion and spirituality as resources to cope with infertility (19), and role of religious/spiritual beliefs in dealing with crisis and finding meaning and hope in adversity among infertile (20).
In general, infertility is one of the complex crises in couples' lives leading to deep emotional and psychological pressures, and as a result, to the feeling of failure among infertile couples (21). The World Health Organization has also criticized care models that pay less attention to religion and spirituality, noting that patients and physicians need to realize the value of such elements as faith, hope, and sorrow in the healing process (22). Therefore, it is highly important to pay attention to the role of spiritual experiences. Moreover, according to the literature review, no specific research has been conducted directly to investigate the relationship between these variables in the target community. This study aimed to determine the role of spiritual experiences in the feeling of failure and infertility stress among infertile women living in Birjand, Iran, and intended to answer the question of whether spiritual experiences play a role in the feelings of failure and infertility stress in infertile women living in Birjand?

Methods
The statistical population of this descriptive correlational study consisted of all infertile women referring to the Royesh Infertility Center, Birjand, in the spring of 2020. Considering the recommendation of choosing at least 100 cases in correlational research (23), a sample of 120 subjects were selected using the availability sampling method. The inclusion criteria were being diagnosed with infertility based on medical records, aging from 25-45 years, having the minimum literacy level, having an infertility period of one year or more, and being willing to enter the study. On the other hand, the exclusion criteria were the non-cooperation of the participants and the incompleteness of the questionnaires. The following questionnaires were used as data collection tools:
The total score of this scale ranges from 46-276, its cut-off score is considered 184, and an increase in the score indicates an increase in specific stress in infertile couples (24). Newton et al. confirmed the face and content validity of this tool, and obtained the internal correlation between perceived stress in social, sexual, communicational, not accepting a childless lifestyle, need to parenting, and general stress dimensions as 0.87, 0.77, 0.82, 0.80, 0.84, and 0.93, respectively (24).
The infertility stress questionnaire was validated by Alizadeh et al. in Iran and its content validity was confirmed by professors of Allameh Tabatabai and Kharazmi universities and Tehran Psychiatric Institute, Tehran, Iran. The reliability of this tool was assessed on a sample of 30 infertile cases using Cronbach's alpha coefficient method rendering for 0.78, 0.77, 0.78, 0.75, 0.84, and 0.91 for social, sexual, communicational, not accepting a childless lifestyle, need to parenting, and general stress dimensions, respectively (25).
Gilbert and Allen confirmed the construct validity of this instrument and estimated its reliability using Cronbach's alpha coefficient at 0.94 and 0.93 for women and men, respectively (26). This questionnaire has been validated by Tarsafi et al. on a population of 306 Iranians, and its content validity was confirmed by several professors of the Faculty of Psychology and Educational Sciences of Allameh Tabatabai University. The reliability of this tool, evaluated by Cronbach's alpha coefficient method, was 0.91, 0.91, and 0.92 for all subjects, females, and males, respectively (10).

Spiritual Experiences Scale
This 16-question scale, designed by Underwood and Teresi (2002), measures three factors of a sense of God's presence (items 1, 2, 4, 5, 6, 8, 9, 10, 11), a relationship with God (items 3, 7, 8, 12, 15), and responsibility towards others (items 13 and 14). This scale is scored on a 6-point Likert scale (often in a day=6 to never or almost never=1). Therefore, the total score of this scale ranges from 16 to 96, with higher scores suggesting more spiritual experiences (27). Underwood and Teresi confirmed the concurrent validity of this scale, and examined its internal stability using Cronbach's alpha coefficient method and reported the values of 0.94 and 0.95 in two performances (27). In Iran, Taghavi and Amiri confirmed the validity of the scale using simultaneous validity methods and factor analysis, as well as its reliability by test-retest, Spearman-Brown, and Cronbach's alpha coefficient methods and obtained the values of 0.96, 0.88, and 0.91, respectively (28).
This research was approved by the Birjand University of Medical Sciences, Birjand, Iran (IR.BUMS.REC.1399.039). After obtaining the necessary permissions to perform the research were obtained and the subjects' time of referral to the center was determined. Subsequently, the research process was explained to the subjects and the questionnaires were distributed among them. The questionnaires were filled out and collected at the same time and place. The required data were collected within four weeks.
In this study, the participants were taken informed consent, assured of the confidentiality of their information, and informed about study withdrawal possibility at any research stage. The gathered data were analyzed in SPSS software (version 22) using the descriptive statistics of mean and standard deviation and the inferential statistics of Pearson correlation coefficient and multiple regression analysis with the significance level of 0.05. To calculate the inferential statistics, initially, the null hypothesis was confirmed using the Kolmogorov-Smirnov test for normal distribution of scores, Durbin-Watson test for residual independence, and multicollinearity among predictor variables by tolerance and variance inflation factor (VIF)).
Based on the results of Table 1, all calculated correlation coefficients of spiritual experiences with feelings of failure and infertility stress were negative and significant. The obtained negative coefficients showed that there was an inverse relationship of spiritual experiences with feelings of failure and infertility stress (P-value<0.001). Kolmogorov-Smirnov test was used to check the normal distribution of scores, which indicated that the significance level of all variables was higher than 0.05. Therefore, the null hypothesis suggesting the non-normal distribution of scores was rejected (P-value<0.05).
To assess the effect of failure and infertility stress in infertile women living in Birjand through spiritual experiences, a multiple regression test was used. The Watson-Durbin statistic was used to examine the independence of the residuals. Given that this value was obtained between 1.5 and 2.5, the presumption of independence of the residuals was observed. To investigate the existence of multicollinearity among predictor variables, tolerance and (VIF) were applied, which according to the obtained results no deviation was observed from the multicollinearity assumption. According to Table 2. the F-value obtained for the regression model was 46.33, which was significant at the alpha level less than 0.01, showing that spiritual experiences could well explain the changes related to the feeling of failure and indicating the appropriateness of the proposed regression model. According to the estimated value of the adjusted Rsquared at 0.533, the components of spiritual experiences explain 53.3% of the variance of feeling failure. The standardized regression coefficient was calculated for the sense of God's presence (β=-0.374, P-value<0.01), relationship with God (β=-0.220, P-value <0.05), and responsibility towards others (β=-0.257, P-value<0.01). Therefore, spiritual experiences could negatively and significantly predict the feeling of failure in infertile women living in Birjand.  In Table 3, the obtained F-value for the regression model was 36.126, which was significant at the alpha level less than 0.01, showing that spiritual experiences could well explain the changes related to infertility stress and indicating the appropriateness of the proposed regression model. The adjusted Rsquare value was 0.470, which showed that the components of spiritual experiences explained 47% of the variance of infertility stress. The standardized regression coefficient was assessed for the sense of God's presence (β=-0.228, P-value<0.05), relationship with God (β=-0.205, P-value<0.05), and responsibility towards others (β=-0.365, P-value<0.01). Therefore, spiritual experiences could negatively and significantly predict infertility stress in infertile women living in Birjand.

Discussion
This study was conducted to determine the role of spiritual experiences in the feeling of failure and infertility stress among infertile women living in Birjand. The first finding of the study showed that the correlation coefficients between spiritual experiences and feeling of failure were negative and significant. Furthermore, the value of the standardized regression coefficient showed that spiritual experiences and their components (i.e., sense of God's presence, relationship with God, and responsibility towards others) negatively and significantly showed the feeling of defeat among the cases. Accordingly, it can be concluded that there was an inverse relationship between spiritual experiences and feelings of failure, and with an increase in spiritual experiences, the feeling of failure decreased. This finding is consistent with the results of other previous studies conducted in this domain. For example, Hojjati et al. (2017) showed that with the increase in daily spiritual experiences, the amount of PTSD decreased among veterans' spouses (15). The findings of a study performed by Fatehizadeh and Badiee (2016) indicated that there was a significant positive relationship between spiritual experience and coping styles adopted by university students (16).
The results of a study carried out in Brazilian infertile couples showed that the females' spirituality level was directly related to the reduction in infertility-related stress (17). In this respect, it can be said that spiritual experiences include such concepts as a connection with the divine power and feeling peace due to seeking help from God and feeling close to God. Therefore, an individual feels God's presence throughout the day and every moment of life and can adapt more to problems and solve the tensions and stresses of life (29). Regarding, the belief in a supreme power who is in control of situations greatly reduces the anxiety associated with various circumstances. In other words, people believe that by relying on God Almighty, they can control unmanageable situations and overcome life stress and pressures with the help of religious beliefs (30).
Spiritual experiences are considered a kind of adaptation and problem-solving techniques that lead to the achievement of inner and outer harmony and integration in people. Individuals using personal spiritual experiences can solve life crises and give meaning to life. Therefore, a spiritual tendency not only gives meaning to life but also reduces inappropriate and undesirable behaviors. The reason for these consequences would be the fact that religious confrontations and spiritual experiences lead to greater understanding and better coping with stress, resulting in the comfort of the soul and psyche due to the trust in God (31).
In this study, it was also revealed that spiritual experiences had a negative and significant relationship with infertility stress. Additionally, the value of the standardized regression coefficient showed that spiritual experiences and their components (i.e., sense of God's presence, relationship with God, and responsibility towards others) negatively and significantly show infertility stress in infertile women in Birjand; Therefore, it can be said that there is an inverse relationship between spiritual experiences and infertility stress, and an increase in spiritual experiences led to a decrease in infertility stress. This result was consistent with those of the previous studies conducted in this field. For instance, the findings of a study carried out by Salehi and Asghari Ebrahimabad indicated that religion and tolerance of emotional distress affected the psychological security of infertile women.
Reliance on God and spiritual resources can increase people's psychological security, and as a result, give such people a greater sense of control and mastery over the situations (18). A study was conducted on 30 infertile women from different denominations of Christianity and Islam in British and Iranian fertility clinics using interview-based theory. According to the results of the mentioned research, infertile women used a variety of religious and spiritual coping strategies to handle stress and infertility problems (19).
The findings of another research revealed that infertile women use their religious/ spiritual beliefs to deal with a crisis and find meaning and hope in adversity (20). Regarding this, it can be said that spiritual experiences lead to a connection with spiritual power, having meaning and purpose in life, inner peace and harmony, communication with others, controlling affairs and life, and having a hopeful outlook toward life. These resources make people feel more supported in dealing with stressful issues and situations and prepare themselves to deal effectively with problems and situations. In addition, they can accept more responsibility, assess their ability and efficiency, and at the appropriate time, adopt the necessary measures, including selfcontrol, distance from the problem, and confront directly with issues (16). In other words, spirituality, by targeting one's beliefs, helps people to evaluate negative events in new ways and have a stronger sense of control over the event, increase the threshold of ability and patience, and cognitively increase adaptability (32).
The spiritual person, by having thought, has a special intellect towards God, mankind, creation, and the interrelationship among them. Such an individual, by means of accessing the inner truth, can find divine direction for his whole life and enjoy special spiritual states, such as attracting God, altruism, reliance, and spiritual actualization, and consequently, enjoy more physical and mental health (33). If a person is religiously committed, his/her life becomes meaningful and purposeful, his/her depression decreases, inferiority diminishes, despair, hopelessness, and failure disappear he/she becomes eager for life, feels prosperous, strives to be useful to one's community (18), and achieves psychological security.
Considering that the statistical population of this study was infertile women in Birjand, the obtained results cannot be generalized to other regions and areas. Moreover, since the subjects of this study were only infertile women, the results cannot be applied to other communities and infertile men. It is also suggested that to reduce the feelings of failure and stress in infertile women, spiritual experiences be strengthened by holding workshops for such women in healthcare centers. It is recommended that future studies be conducted on a larger sample size with different religious denominations, including Christianity.

Conclusion
The results of the present study were indicative of the effective role of spiritual experiences on the rate of failure and infertility stress in infertile women. Accordingly, it can be concluded that the employment of religious and spiritual coping strategies in mental disorder conditions can help people greatly in confronting life adversity. In this respect, it is hoped that by the application of the findings of this study and serious cooperation of staff in the healthcare sector, to implement the Sharia rules that are now considered as religious care, we will notice the effect of such care and creation of a sense of peace and increased hope and psychological security in infertile women.