Infertility, or the inability to become pregnant after unprotected cohabitation for 12 months (1), is a universal public health challenge that transcends cultures and affects millions worldwide (2). Estimates suggests that more than 48 million couples and 186 million individuals live with infertility across globe (3) with an overall prevalence of 9% (4). Infertility can be divided into primary or secondary; where primary infertility includes inability to conceive, while secondary infertility refers to failure to conceive following a previous pregnancy. Globally, the primary and secondary infertility rate of women aged 20–44 is 1.9% and 10.5% respectively (3). In developed countries, the prevalence of infertility ranges from 3.5% to 16.7%, and from 6.9% to 9.3% in the developing world (5). In India, the infertility prevalence stands at 8.9% (6, 7). Factors like sexual history, lifestyle (stress, obesity) and cultural background of the people and postponing parenthood increase the prevalence of infertility (8, 9).

Infertility are attributable to both men and women; their experiences differ significantly. Regardless of the medical causes of infertility, men are rarely considered infertile, and the obligation to negotiate with infertility falls on woman (10). She endures majority of the fertility testing and treatment (11). Studies report that infertility has several social, economic, and psychological implications (12, 13) particular in the societies, including India, where it carries significant social stigma (14).

The social consequences can be grave as parenthood is desirable in many societies; children are expected to provide care and maintain their parents, while being part of the social support system (6). They also carry family's name and inheritance and perform the parents' last rites (15). Owing to the importance of children, infertility touches all aspects of a childless couple's life, including their status, respect, and authority (6). Many childless couples, especially women, experience violence, divorce, social stigma, emotional stress, depression, anxiety, low self-esteem, a sense of failure, and exclusion (16). They are ostracized and lose their status in the family and society.

Due to familial and societal pressures, many infertile women or couples resort to different treatment options and practices. The choice of treatment is strongly influenced by their awareness and knowledge of biomedical, faith-based, and traditional options (17). The attitude towards treatment seeking is also influenced by social structure, socialisation, and experience with infertility and childbearing (18). Forced by social pressures, childless couples often undergo repeated “trial and error” treatments (19).

As advanced investigations are fundamental for the treatment of infertility, the availability of allopathic treatment services is essential (4). Across the developing world, there exist wide disparities in the quality, availability, and delivery of infertility services; hence, most infertile people have poor access to effective treatment (20). In India, modern infertility treatment including ART is available in both public and private sectors. The public sector offers this treatment through tertiary hospitals/medical colleges and a few basic investigations at lower levels (21, 22). However, the quality of treatment in the public health sector, the only treatment affordable for rural and poor Indians, is relatively poor. Treatment facilities outside the government health systems are prohibitively expensive because of which they primarily cater to the educated elite who can afford such treatment. Literature suggests that ART services are not accessible to the majority of infertile couples due to the high cost of treatments in addition to cultural, religious and legal barriers (23). The cost also forces several couples to stop the treatment or shift to other treatment options (20). A nationally-representative Indian study, using data from the Demographic and Health Survey, revealed that in rural India, the treatment of infertile women begins with allopathy and ends with traditional healers (24).

Couples with primary infertility are usually more interested in treatment than those with secondary infertility (25), irrespective of who the infertile person is among the couple. Though there is an awareness among couples of the possibility of infertility when pregnancy is delayed (26), women are less knowledgeable about the causes of infertility and the options for treatment (27) However, it is usually the woman who initiates the first contact with a practitioner (28). Strong cultural beliefs and healthcare-related factors are crucial in deciding the treatment mode. Conventional methods and religious practices include consultations with unqualified herbal and spiritual (traditional) healers and diviners and visits to religious places like temples, churches, or mosques (12). Infertile couples may also observe tantric rites, wear charms, visit astrologers, and follow prescribed rituals (29) as community strongly believe that supernatural powers cause infertility.

In resource-poor rural communities, there is an overwhelming dependence on traditional healers, irrespective of caste and class (30). Low education, insufficient knowledge and awareness (31), residence in remote areas, dependence on agriculture, and different belief systems make the tribal population distinct from the other sections of the population. According to a study conducted in Madhya Pradesh, tribal communities exhibited a higher prevalence of infertility compared to other populations, which may result in distinct patterns of coping or treatment within these communities (32). In the background of rising awareness of infertility and numerous treatment options, few Indian studies have explored the infertility treatment-seeking behaviour of tribal communities. The study aims to bridge this gap by examining the treatment-seeking behaviour of infertile tribal couples and understanding the hardships faced by them during treatment.

The study's theoretical framework is anchored on a socio-cultural perspective that recognizes the influence of cultural beliefs, norms, and practices on the experiences of infertility treatment in tribal communities. The study aims to generate a comprehensive understanding of infertility treatment and its impact on tribal couples’ lives, as well as to identify the cultural factors that shape their practivces and attitudes towards infertility and its treatment. The mixed-methods approach employed in this study is well-suited to capture the complexities of the cultural and social dynamics underlying the experiences of infertility treatment among tribal communities. The findings of this study can inform the development of culturally sensitive interventions and policies to address infertility-related issues in tribal communities, particularly in resource-poor settings like Jawhar tehsil.

Profile of the respondents: Mean age of the respondents in the sample was 29.8 years. Average age gap between husband and wife was 3.4 years. Fifty-four percent respondents were literate and 68.6% had exposure to mass media (television, newspapers, radio). Seventy-one percent respondents belonged to Warli tribe. On an average respondents were married for 12.5 (±7.5) years. Nearly 65% respondents were undernourished and only 2% had high BMI.

Treatment options for infertility in the study area: Several traditional and medical treatment options are available for couples with infertility in the study area. Infertile couples first access the options (primarily traditional treatment), which are available within their own village. Once traditional treatment does not yield any result (pregnancy), one of the spouses goes out of the village to seek alternative healthcare services (traditional or modern). Treatment is frequently switched between wife and husband (although men are rarely consulted or undergo any long-term treatment) and traditional and modern. The community members usually guide such couples while choosing treatment providers. The treatment options for infertile couples in the tehsil are described in Table 1.

Treatment-seeking behaviour for infertility: Except two, all infertile respondents sought treatment from a faith/traditional healer, locally known as bhagat (Table 2). A handful respondents (44.2% of primary infertile and 30.9% of sub-fertile) also sought treatment from the allopathic stream. However, the majority did not continue with it. On an average, couples consulted 0.4 allopathic practitioners and 4.4 faith healers. Couples with primary infertility visited more faith healers (5.8) than sub-fertile women (3.8). Median number of consultations were 22 over 3.5 years. About half of the respondents consulted a treatment provider for infertility after 24 to 36 months of marriage/last pregnancy or birth. Most sought treatment within their taluka because of less travel time. The usual travel time to reach a provider was still as high as one to two hours and they walked the distance for treatment.

The primary reasons for discontinuing a treatment and frequently switching between health providers included unaffordability, poor connectivity, long distance or travel time, time constraints, and non-supportive circumstances (have to travel alone or have an unsupportive husband) (Figure 1). Even if a couple was referred to a public healthcare facility in a nearby district, they would not have sufficient money to travel to the facility or start treatment. There was also a fear to travel to new places as most tribal respondents never travelled outside their village or tehsil. Additionally, the couples hesitated in sharing their problems with unknown people (formal healthcare providers). Community too generally discouraged couples from leaving the village, usually with the stories of theft, cheating, and fraud. Despite the barriers, a few couples consulted a doctor; however, they could not comply with the treatment protocols and procedures because of their high expectation of getting cured with a single pill or in one visit. After realising that the expectation could not be met, the couple withdrew from the treatment.

Those who visited government facilities were unhappy with the quality of care received. Many respondents mentioned (off the record) that they received harsh treatment from healthcare professionals. Patients from a particular section of the society (primarily rich/higher community) received preferential treatment, while the others were ignored. They also complained of paramedical staff being drunk on duty. Some respondents said they stopped the treatment because they did not like being scolded by the doctors over the dagani (burn marks on the abdomen). Based on the opinion of community members, the differences in treatments received from faith healers and doctors can be categorised as (a) accessibility and affordability, (b) convenience, (c) trust and respect between patient and service provider, (d) features of the treatment, and (e) side effects of the treatment.

Another primary infertile woman aged 23 years, who had been having treatment for four years, added: “When we visit the local PHC (Public Health Centre), the doctor is often absent. The doctor at a nearby PHC resides far away. In case of an emergency, especially at night, he does not respond to calls. In fact, no one in the PHC attends to us. Therefore, we need to travel to the sub-district by bike and private care, 15 km away from home, for any emergency. Considering the state of affairs at the government facilities and the distance to the private health centre, we decided to visit the bhagat only.” (translated).

Generally, faith healers were preferred over practitioners of modern medicine because of the perceptions that the causes of infertility lie in supernatural influences and witchcraft, the faith healers take better care of patients, and their treatment is effective. A 32-year-old illiterate woman with two children said, “No government hospital (sub-district level healthcare centre) gives [us] as much attention as bhagat [does]” (Translated). Other reasons for preferring these healers were privacy, proximity to home, recommendation of family and friends, affordability of treatment, and absence of side effects (Figure 2).

Traditional treatment, rituals, and restrictions: Of the women who visited faith healers, 91.4% followed treatment advice. The couples were advised to consume certain herbs (96%) and eat or avoid certain food items (61.6%). A bhutgath was identified in 86.1% and massage was given to 88.1% respondents. The women said they were comfortable with the faith healers touching them. Fifty-three percent received burns on the abdomen (dagani) and had black blood (phasani) removed. The faith healers performed various rituals to appease spirits, get rid of ghosts and offered animal sacrifice (Table 3). The rituals are carried out in the following order: witchcraft, prayer, offerings, massages, advice, herbal medicines, and amulets.

At last, the final ritual named shidwa³ is performed. The sidh (Bauhinia Racemose) tree is the preferred site for performing the shidwa (Table 4). This ritual can also be performed at the infertile couple's or faith healer's home, or in forest or farm. About 13% of the respondents had the shidwa ritual on full-moon (Poornima) or no-moon (Amavasya) nights. The Diwali festival is the most popular time to conduct this ritual (44.2%) because it comes after harvesting season and people are relatively free during that time. However, the ritual should be performed as early as possible because delay is not appreciated. Breaking coconuts and slaughtering or releasing a cock/goat/chicken are the main offerings during shidwa.

The treatments administered by the bhagat are not without side effects. Some women reported nausea or loss of consciousness after consuming the herbs. Others reported swelling of the eyes, restlessness, and severe pain in the abdomen. A woman also feels restless or gets severe pain after dagni. The frequent demands for money and alcohol from the bhagat also create difficulties for many infertile couples. The traditional healer advises infertile couples to observe certain restrictions during the course of treatment (Table 5). These restrictions are mostly associated with women's behaviour in public places and at home as also with grooming, clothing, and food.

The community members were vocal in their opinion that the women should follow the bhagat's advice strictly and avoid quarrels with other women. It was believed that the restrictions were good for developing harmony in the community. The analysis indicates that infertile women are often advised to avoid non-vegetarian food items like eggs, chicken, meat, red blood fish, Singada, and dry fish like Bombil. Specifically, foods or spices of white and yellow colours, such as coconut, turmeric, salt, and oil, are to be avoided. These restrictions are to be followed even after the completion of the infertility treatment, during pregnancy, and until the infant is six months old and starts consuming supplementary food.

Other treatment characteristics: Of those seeking treatment from the formal health care system, 74.6% infertile women were prescribed medicines for menstrual problems, and 58.2% got laboratory tests (Table 6). Injections were given to more than one-third of infertile women; 16.4% were advised surgery. Nearly one-fifth were told to take an ultrasonography examination. Only 20.9% of the husbands received any treatment for infertility (39.5% primary infertile, 13.6% sub-fertile). Women from a higher standard of living had two times higher chances to avail treatment from an allopathic stream, while other background characteristics like type of infertility, age, literacy, type of tribe, and body mass index were not statistically (table not provided).

Cost of treatment and results: The cost of treatment included cost for travel, medication, consultation, hospitalisation, food, ritual, and gifts. The mean expenditure on treatment was INR 18,374. Most respondents met the treatment expenditure from their earnings. About 48.3% borrowed money, and 21.9% sold some of their belongings to meet treatment expenses.

At the time of the study, more than half of primary infertile women respondents were still taking treatment. Nearly 44% primary infertile women reported that they had discontinued treatment and were looking for other options. About 92.6% of the sub-fertile women had discontinued the treatment (Table 5) because of successful conception. There is a particular pattern and flow in the treatment-seeking behaviour of infertile couples, as shown in Figure 3. A couple waits for 24 months after marriage or forming a union to conceive. If the woman fails to conceive, the couple first consults a bhagat and then visits a medical practitioner for treatment. If the treatment does not lead to a pregnancy, the couple again changes the provider. After 3–4 years of treatment, the further course of action depends on the husband's support. The couple may continue the treatment or decide on one of four actions: the man may bring another wife; the union may end; the couple may come to terms with their childlessness and stop trying; the couple may foster a child.

Children and parenthood are desirable because of several socio-cultural reasons (34). The experience of infertility can be distressing for couples, especially women who suffer from it (13). Appropriate treatment with a timely diagnosis can help couples to have children. However, research suggests that of the total infertile women worldwide, only 56% seek modern medical care (35) that is result oriented. The present paper presents treatment practices related to infertility in the tribal communities of western India.

In the study area, treatment seeking for infertility was universal; except two, all women sought treatment. Multiple treatment options were available, including modern as well as traditional. Treatment options available within the village were the first choice for the infertile couples. This made traditional healers the first contact point to start treatment for infertility. Almost all (98.7%) couples sought treatment from traditional healers within the village or in nearby villages within walking distance. These findings align with the studies which found that infertile women first visit traditional healers and then a hospital (36, 37). Despite the revolution in modern medicine and technology, there has been an overwhelming dependence on traditional or spiritual healers for treatment, irrespective of caste and class, in resource-poor rural communities (12, 38–42).

Treatment seeking from the allopathic stream was limited to one-third of the respondents, much lower than reported by other studies conducted on various other communities (4, 43). It was mainly primary infertile women who sought treatment from the allopathic stream rather than sub-fertile women. This difference may be because of the higher desire of the former to have a child than the latter. The results also show that women with a higher standard of living had higher chances of availing treatment from the allopathic stream. Various studies have established that allopathic treatment seeking is highly associated with higher income groups and general or open castes (20, 24).

People generally chose a treatment provider based on the availability, accessibility, affordability, features and side effects of the treatment and trust and respect between the patient and the treatment provider (20, 40). In the study, infertile couples faced enormous challenges while seeking support from the formal healthcare system. Firstly, the community discouraged them from seeking treatment from the formal system by narrating stories of theft, cheating, bias, unreasonable behaviour of the public sector staff, poor infrastructure, and so on. Secondly, women did not feel comfortable travelling outside the village or taluka because of lack of exposure, limited education, poor connectivity, unaffordability, and side effects of allopathic medicines. Those who somehow managed to go to the formal health system did not believe in long-term care. Such couples were also often chastised by the medical professionals (generally not appreciated) for having availed unsafe treatments from traditional healers, which resulted in burn marks or restrictions on consuming certain food items. There was also a belief that no expert care was available to solve their problems.

The reasons for choosing traditional providers/faith healers included privacy, proximity to treatment, advice from family and friends, and other benefits such as affordability and no side effect. The community also favoured faith healers over allopathy providers because of good care and effective treatment. Literature from Africa revealed that majority women used traditional methods for infertility treatment and demographic characteristics, infertility duration, husbands' relatives' pressure and cheap cost of traditional medical treatment encouraged use of traditional method (44). Couples switched between several healthcare providers either because they could not afford the treatment, could not travel long distances, or because they did not have time to visit a certain provider or had non-supportive conditions in the family or treatment did not yield the result. This is evident from the fact that, on average, women visited 0.4 allopathic and 4.4 traditional providers in 3.5 years, making 22 visits. Primary infertile couples visited more providers (6.9) than sub-fertile couples (4.3). This finding is in line with the findings of other Indian studies (4, 24, 45). Abandonment of a treatment was mainly because of the psychological burden, sense of futility of the treatment (46), and high cost of the treatment (47).

Health-seeking in infertility care is seen from a curative aspect rather than a preventive or rehabilitative perspective. Our study also presents the curative aspects of infertility treatment. The curative aspects include giving a wide range of herbal medicines and providing physiotherapeutic and naturopathic care. Similar to other studies (48), the current study shows that herbal medicines are the main course of treatment in the study area. The openness of the problem in the community has made choices and options to manage infertility easily available. The women follow each piece of advice given by a healer. The advice of the bhagat includes following certain restrictions, withdrawing from specific food items, and performing rituals related to witchcraft on a full moon or no moon night.

Furthermore, the women consume herbs, receive Bhutgath massages, sacrifice animals or birds, and offer alcohol and money as part of the treatment. These practices, that are very common in the study villages, have some side effects. Side effects include nausea, swelling of the eyes, and restlessness. Because of the dagani (burn), women experience extreme pain. The constant demand for money and alcohol from the bhagat creates many problems.

Primary infertile and young women avail services from more providers and have treatment for a longer duration than sub-fertile women. As the desire to have children is higher among primary infertile couples than secondary, treatment seeking is also high among them (4, 28, 41, 43). The literature suggests that treatment seeking for infertility generally starts within 1–3 years of marriage (4, 21). In our study, half of the primary infertile and sub-fertile women start the treatment after 24 and 36 months of marriage, respectively. Women are the primary care seekers for infertility, and men's involvement in treatment seeking seems to be very limited. A study by Pasch (49) made similar findings, whereby husbands had low infertility treatment-seeking instances, and most of the treatment was done for the wife. It indicates that women feel more pressure from family and community to seek infertility treatment (37). Hence, infertility may be more stressful for women than men (50).

More than half of the primary infertile women were still taking treatment at the time of the survey, and nearly 42% said they had discontinued the treatment and would look for other options. The options included bringing a co-wife, fostering a child, accepting childlessness, or abandoning each other. These coping mechanisms are unique to the tribal communities in the region. A tribal specific study highlighted that coping mechanisms for infertility, such as child adoption, are primarily influenced by perceived causes of infertility. Though this study did not find such association.

Though the study area is not far from two metropolitan cities, Mumbai and Thane, modernisation, urbanisation, education, and technological advancements have not touched the lives of the people of Jawhar. These villages are not even sufficiently connected with the outer world. The level of education is extremely low, people live below the poverty line, and women's role is measured by procreation. Different myths and cultural malpractices still exist in these rural tribal areas. The community plays a significant role in an individual's life. With supportive attitudes in the community, infertile women suffer less. Lack of resources and constant pressure for childbearing from the community and family push these women to avail services from traditional healers in unsafe and unhygienic conditions. Receiving treatment from formal health care providers, higher literacy, better coping mechanisms, and better support mechanisms have been seen to enable these women to live happily. The local authorities should strive to work towards the socio-economic development of the tribal communities and provide good healthcare services at their doorstep. The infertility problem needs to be understood in the context of poverty, tribal belief, and unequal access to healthcare resources.