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Whittaker A, Gerrits T, Hammarberg K, Manderson L. Access to assisted reproductive technologies in sub-Saharan Africa: fertility professionals' views. Sex Reprod Health Matters 2024; 32:2355790. [PMID: 38864373 PMCID: PMC11172248 DOI: 10.1080/26410397.2024.2355790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
Across sub-Saharan Africa, there remains disagreement among local expert providers over the best ways to improve access to assisted reproduction in low-income contexts. Semi-structured qualitative interviews were conducted between 2021 and 2023 with 19 fertility specialists and 11 embryologists and one clinic manager from South Africa, Zimbabwe, Namibia, Kenya, Ethiopia and Uganda to explore issues surrounding access and potential low-cost IVF options. Lack of access to ART was variously conceptualised as a problem of high cost of treatment; lack of public funding for medical services and medication; poor policy awareness and prioritisation of fertility problems; a shortage of ART clinics and well-trained expert staff; the need for patients to travel long distances; and over-servicing within the largely privatised sector. All fertility specialists agreed that government funding for public sector assisted reproduction services was necessary to address access in the region. Other suggestions included: reduced medication costs by using mild stimulation protocols and oocyte retrievals under sedation instead of general anaesthetics. Insufficient data on low-cost interventions was cited as a barrier to their implementation. The lack of skilled embryologists on the continent was considered a major limitation to expanding ART services and the success of low-cost IVF systems. Very few specialists suggested that profits of pharmaceutical companies or ART clinics might be reduced to lessen the costs of treatments.
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Affiliation(s)
- Andrea Whittaker
- Professor of Anthropology, School of Social Sciences, Monash University, Melbourne, Australia
| | - Trudie Gerrits
- Associate Professor, Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Amsterdam, Netherlands
| | - Karin Hammarberg
- Senior Research Fellow, Global and Women’s Health, Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lenore Manderson
- Distinguished Professor of Public Health and Medical Anthropology, School of Public Health, The University of the Witwatersrand, Johannesburg, South Africa and Professorial Adjunct, School of Social Sciences, Monash University, Melbourne, Australia
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Bell SO, Larson E, Bittle D, Moreau C, Omoluabi E, OlaOlorun FM, Akilimali P, Kibira SPS, Makumbi F, Guiella G, Mosso R, Gichangi P, Anglewicz P. Care-seeking for difficulties conceiving in sub-Saharan Africa: findings from population-based surveys in eight geographies. Hum Reprod 2024; 39:1712-1723. [PMID: 38986015 PMCID: PMC11291947 DOI: 10.1093/humrep/deae084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/19/2024] [Indexed: 07/12/2024] Open
Abstract
STUDY QUESTION What is the nature of women's care-seeking for difficulties conceiving in sub-Saharan Africa (SSA), including the correlates of seeking biomedical infertility care at a health facility? SUMMARY ANSWER Care-seeking for difficulties getting pregnant was low, much of which involved traditional or religious sources of care, with evidence of sociodemographic disparities in receipt of biomedical care. WHAT IS KNOWN ALREADY Nearly all research on infertility care-seeking patterns in SSA is limited to clinic-based studies among the minority of people in these settings who obtain facility-based services. In the absence of population-based data on infertility care-seeking, we are unable to determine the demand for services and disparities in the use of more effective biomedical sources of care. STUDY DESIGN, SIZE, DURATION We used cross-sectional, population-based data from the Performance Monitoring for Action (PMA) female survey in eight geographies in SSA, including nationally representative data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda and regionally representative data from two provinces in the Democratic Republic of the Congo (DRC) (Kinshasa and Kongo Central) and two states in Nigeria (Kano and Lagos). We employed a multi-stage cluster random sampling design with probability proportional to size selection of clusters within each geography to produce representative samples of women aged 15-49. Samples ranged from 1144 in Kano, Nigeria, to 9489 in Kenya. PMA collected these data between November 2021 and December 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS We restricted the sample to women who had ever had sex, with analytic samples ranging from 854 in Kano to 8,059 in Kenya, then conducted descriptive and bivariable analyses to examine characteristics of those who sought care for difficulties getting pregnant. Among those who reported seeking care, we conducted bivariable and multivariable logistic regression analyses to determine factors associated with receipt of biomedical services from a health facility. All analyses were conducted separately by geography. MAIN RESULTS AND THE ROLE OF CHANCE Our study found low levels of care-seeking for difficulties getting pregnant among sexually active women in eight geographies in SSA, ranging from 3.7% (Kenya) to 15.3% (Côte d'Ivoire). Of this, 51.8% (Burkina Faso) to 86.7% (Kinshasa) involved receipt of biomedical services in health facilities. While many factors were consistently associated with infertility care-seeking from any source across geographies, factors associated with receipt of biomedical care specifically were less pronounced. This may be a result of the highly limited sources of infertility services in SSA; thus, even privileged groups may struggle to obtain effective treatment for difficulties getting pregnant. However, we did observe disparities in biomedical care-seeking in our bivariable results in several geographies, with the wealthiest women, those with more education, and those residing in urban areas generally more likely to have sought biomedical care for difficulties getting pregnant. LIMITATIONS, REASONS FOR CAUTION Our data lacked details on the nature of the services received and outcomes, and we do not have information on reasons why women chose the sources they did. Small samples of women who sought care limited our power to detect significant differences in care-seeking by women's characteristics in several geographies. WIDER IMPLICATIONS OF THE FINDINGS Infertility and access to appropriate treatment are issues of reproductive health and human rights. While our results do not indicate to what extent use of non-biomedical sources of care is driven by preferences, cost, or lack of accessible services, it is clear from our results and existing literature that more needs to be done to ensure access to affordable, quality, cost-effective infertility services in SSA. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Suzanne O Bell
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth Larson
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dory Bittle
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caroline Moreau
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, INSERM, Villejuif, France
| | - Elizabeth Omoluabi
- Statistics and Population Studies Department, University of the Western Cape, Cape Town, South Africa
| | - Funmilola M OlaOlorun
- Department of Community Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Pierre Akilimali
- Patrick Kayembe Research Center, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Simon P S Kibira
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population, Joseph Ki-Zerbo University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Rosine Mosso
- Educational and Teaching Department, École Nationale de Statistiques et d’Economie Appliquee (ENSEA), Abidjan, Cote d'Ivoire
| | - Peter Gichangi
- Department of Environment and Health Sciences, Technical University of Mombasa, Mombasa, Kenya
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Philip Anglewicz
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Afferri A, Dierickx S, Bittaye M, Marena M, Pacey AA, Balen J. Policy action points and approaches to promote fertility care in The Gambia: Findings from a mixed-methods study. PLoS One 2024; 19:e0301700. [PMID: 38743724 PMCID: PMC11093356 DOI: 10.1371/journal.pone.0301700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 03/20/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION In the Global South, (in)fertility care is scarcely recognized as a priority, yet the government of The Gambia has recently included it as one of the key priorities in its reproductive health strategic plan. This inclusion appears to be the result of years of engagement between policy actors, academic researchers, and activists in the field of reproductive health and specifically of infertility. However, the operationalization of the strategic plan may be hampered by multiple factors. The research aims to identify and analyze challenges that may impede the effective implementation of the strategic plan, thereby providing policy action points and practical guidance into the operationalization of (in)fertility care in the context of The Gambia's health system. METHODS This is a mixed-methods study with data from a survey and semi-structured interviews collected between 2020 and 2021 in The Gambia that were separately published. In this paper, we present the triangulation of quantitative and qualitative data using a convergence coding matrix to identify relevant policy action points. RESULTS Six fertility care policy action points, driven by data, arose from the triangulation and interpretation process, specifically: (i) establishing and maintaining political commitment and national priority for fertility care; (ii) creating awareness and increasing the involvement of men in SRH and fertility; (iii) ensuring data-driven health policymaking; (iv) offering and regulating affordable IVF alternatives; (v) improving knowledge of and means for fertility care provision; and (vi) enhancing the collaboration among stakeholders and building links with the private healthcare sector. CONCLUSION This study found the implementation of the fertility care-related activities in the reproductive health strategic plan may face challenges that require careful mitigation through a holistic approach. Such an approach conceptualizes infertility not just as a biomedical issue but as a broader one that incorporates educational and socio-emotional aspects, including male and (not only) female involvement in sexual and reproductive health. Moreover, it is supported by a comprehensive health management information system that includes capturing data on the demand for, and access to, infertility services in The Gambia health system.
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Affiliation(s)
- Anna Afferri
- School of Health and Related Research–ScHARR, The University of Sheffield, Sheffield, United Kingdom
| | - Susan Dierickx
- Institute of Tropical Medicine, Antwerp, Belgium
- Department of Clinical Sciences, Research Centre Gender, Diversity and Intersectionality—RHEA, Vrije Universiteit Brussel, Brussel, Belgium
| | - Mustapha Bittaye
- Ministry of Health, Banjul, The Gambia
- School of Medicine and Allied Health Sciences, University of The Gambia, Banjul, The Gambia
| | - Musa Marena
- Ministry of Health, Banjul, The Gambia
- School of Medicine and Allied Health Sciences, University of The Gambia, Banjul, The Gambia
| | - Allan Antony Pacey
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Julie Balen
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, United Kingdom
- Medical Research Council–MRC Unit The Gambia at LSHTM, Fajara, The Gambia
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Huang R, Yu JY, He WC, Liu RH. Feasibility analysis of China's medical insurance coverage of assisted reproductive technology. Sci Rep 2024; 14:7998. [PMID: 38580689 PMCID: PMC10997767 DOI: 10.1038/s41598-024-58640-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 04/01/2024] [Indexed: 04/07/2024] Open
Abstract
There are millions of patients experiencing infertility in China, but assisted reproductive technology (ART) is performed at the patient's expense and is difficult to afford. With the sharp decline in China's birth rate, there is a growing controversy over the inclusion of ART in medical insurance (MI). This study aims to explore the feasibility of ART coverage by MI for the first time. We obtained basic data such as the prevalence of infertility, the cost of ART, and the success rate in China with the method of meta-analysis and consulting the government bulletin. Then, we calculated the number of infertile couples in China and the total financial expenditure of MI covering ART. Finally, we discussed the feasibility of coverage, and analyzed the population growth and economic benefits after coverage. According to our research results, it was estimated that there were 4.102-11.792 million infertile couples in China, with an annual increase of 1.189-1.867 million. If MI covered ART, the fund would pay 72.313-207.878 billion yuan, accounting for 2-6% of the current fund balance, and the subsequent annual payment would be 20.961-32.913 billion yuan, accounting for 4-7% of the annual fund balance. This was assuming that all infertile couples would undergo ART, and the actual cost would be lower. The financial input‒output ratio would be 13.022. Benefiting from the inclusion of ART in MI coverage, there would be 3.348-9.624 million new live infants, and 8-13% newborns would be born every year thereafter, which means that by 2050, 37-65 million people would be born. Due to its affordable cost, high cost-effectiveness and favourable population growth, it may be feasible to include ART in MI.
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Affiliation(s)
- Rong Huang
- Department of Laboratory, Panyu Hexian Memorial Hospital of Guangzhou, Guangzhou, 511400, China
| | - Jing-Yun Yu
- Department of Health Care, Dongguan Maternal and Child Health Care Hospital, Dongguan, 523112, China
| | - Wei-Chao He
- Department of Health Care, Dongguan Maternal and Child Health Care Hospital, Dongguan, 523112, China
| | - Ri-Hui Liu
- Medical Insurance Office, Human Resources and Social Security Bureau of Guangzhou's Nansha District, No.15 Huanshi Avenue Middle, Nansha District, Guangzhou City, 511466, Guangdong, China.
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Afferri A, Dierickx S, Allen H, Bittaye M, Marena M, Pacey A, Balen J. 'It's about time': policymakers' and health practitioners' perspectives on implementing fertility care in the Gambian health system. BMC Health Serv Res 2024; 24:282. [PMID: 38443896 PMCID: PMC10916196 DOI: 10.1186/s12913-024-10701-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/09/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Infertility is a major health issue worldwide, yet very few examples of interventions addressing infertility in the Global South have been documented to date. In The Gambia, West Africa, infertility is recognised as a burden and the health authorities have included it in several health policies and the new National Reproductive Health Strategy however, a detailed operationalisation plan for fertility care has not yet been established. Here, we aim to understand and document the factors that influence the implementation of fertility care in The Gambia. METHODS We conducted 46 semi-structured interviews with policymakers, implementers, and health practitioners in both the public and private sectors from July to November 2021. The interviews were transcribed, anonymised and analysed with NVivo Pro version 1.6.1. The analysis was initially inductive, with themes arising from the coding categorised according to the WHO health systems building blocks framework. RESULTS This study identified several barriers to a successful implementation of fertility care in The Gambia, including (i) a lack of routinely collected infertility data; (ii) an absence of financial protection mechanisms for patients, and/or a specific budget for infertility; (iii) limited cooperation between the public and private sectors in the provision of fertility care; and (iv) gaps in fertility care training among health practitioners. Conversely, enablers included: (i) strong national infertility leadership; and (ii) the integration of infertility care within public reproductive health services. CONCLUSION The Gambian health system is not yet in the position to support a comprehensive fertility care package in its public health facilities. Several aspects of the implementation of fertility care must be considered in operationalising the health strategy including the systematic collection of infertility data, fertility awareness, and the provision of specialised fertility care training. Furthermore, a stronger partnership between the public and private sectors must be developed. Given the increasing availability of assisted reproductive technologies in the sub-Saharan Africa region, and the tendency to locate these technologies in the private sector, further research is needed to understand and identify the processes underlying the implementation of fertility care and to foster better integration with the existing health system.
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Affiliation(s)
- Anna Afferri
- School of Health and Related Research- ScHARR, The University of Sheffield, Sheffield, UK.
| | - Susan Dierickx
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Research Centre Gender, Diversity and Intersectionality - RHEA, Vrije Universiteit, Brussel, Belgium
| | - Haddijatou Allen
- Medical Research Council- MRC Unit The Gambia at LSHTM, Fajara, The Gambia
| | - Mustapha Bittaye
- The Gambia Ministry of Health, Banjul, The Gambia
- School of Medicine and Allied Health Sciences, University of The Gambia, Banjul, The Gambia
| | - Musa Marena
- The Gambia Ministry of Health, Banjul, The Gambia
- School of Medicine and Allied Health Sciences, University of The Gambia, Banjul, The Gambia
| | - Allan Pacey
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Julie Balen
- Medical Research Council- MRC Unit The Gambia at LSHTM, Fajara, The Gambia
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, UK
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Fauser BCJM, Adamson GD, Boivin J, Chambers GM, de Geyter C, Dyer S, Inhorn MC, Schmidt L, Serour GI, Tarlatzis B, Zegers-Hochschild F. Declining global fertility rates and the implications for family planning and family building: an IFFS consensus document based on a narrative review of the literature. Hum Reprod Update 2024; 30:153-173. [PMID: 38197291 PMCID: PMC10905510 DOI: 10.1093/humupd/dmad028] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 09/25/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Family-planning policies have focused on contraceptive approaches to avoid unintended pregnancies, postpone, or terminate pregnancies and mitigate population growth. These policies have contributed to significantly slowing world population growth. Presently, half the countries worldwide exhibit a fertility rate below replacement level. Not including the effects of migration, many countries are predicted to have a population decline of >50% from 2017 to 2100, causing demographic changes with profound societal implications. Policies that optimize chances to have a child when desired increase fertility rates and are gaining interest as a family-building method. Increasingly, countries have implemented child-friendly policies (mainly financial incentives in addition to public funding of fertility treatment in a limited number of countries) to mitigate decreasing national populations. However, the extent of public spending on child benefits varies greatly from country to country. To our knowledge, this International Federation of Fertility Societies (IFFS) consensus document represents the first attempt to describe major disparities in access to fertility care in the context of the global trend of decreasing growth in the world population, based on a narrative review of the existing literature. OBJECTIVE AND RATIONALE The concept of family building, the process by which individuals or couples create or expand their families, has been largely ignored in family-planning paradigms. Family building encompasses various methods and options for individuals or couples who wish to have children. It can involve biological means, such as natural conception, as well as ART, surrogacy, adoption, and foster care. Family-building acknowledges the diverse ways in which individuals or couples can create their desired family and reflects the understanding that there is no one-size-fits-all approach to building a family. Developing education programs for young adults to increase family-building awareness and prevent infertility is urgently needed. Recommendations are provided and important knowledge gaps identified to provide professionals, the public, and policymakers with a comprehensive understanding of the role of child-friendly policies. SEARCH METHODS A narrative review of the existing literature was performed by invited global leaders who themselves significantly contributed to this research field. Each section of the review was prepared by two to three experts, each of whom searched the published literature (PubMed) for peer reviewed full papers and reviews. Sections were discussed monthly by all authors and quarterly by the review board. The final document was prepared following discussions among all team members during a hybrid invitational meeting where full consensus was reached. OUTCOMES Major advances in fertility care have dramatically improved family-building opportunities since the 1990s. Although up to 10% of all children are born as a result of fertility care in some wealthy countries, there is great variation in access to care. The high cost to patients of infertility treatment renders it unaffordable for most. Preliminary studies point to the increasing contribution of fertility care to the global population and the associated economic benefits for society. WIDER IMPLICATIONS Fertility care has rarely been discussed in the context of a rapid decrease in world population growth. Soon, most countries will have an average number of children per woman far below the replacement level. While this may have a beneficial impact on the environment, underpopulation is of great concern in many countries. Although governments have implemented child-friendly policies, distinct discrepancies in access to fertility care remain.
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Affiliation(s)
- Bart C J M Fauser
- University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | | | | | | | | | - Silke Dyer
- Groot Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Majangara Karaga R, Archary P, Gwet Bell E, Khrouf M, Loto O, Wada I, Dyer S. The status of ART in the public health sector in Africa: a multi-country survey. Reprod Biomed Online 2023; 47:103213. [PMID: 37236886 DOI: 10.1016/j.rbmo.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/02/2023] [Accepted: 04/06/2023] [Indexed: 05/28/2023]
Abstract
RESEARCH QUESTION What is the current availability of treatment with assisted reproductive technology (ART) in the public sector in Africa, and what are the facilitators and barriers towards its provision? DESIGN Cross-sectional quantitative and qualitative data were collected in two phases from February 2020 to October 2021. Key informants were identified from countries known to provide ART in Africa based on data from the African Network and Registry for Assisted Reproductive Technology and the 2019 Surveillance from the International Federation of Fertility Societies. Quantitative data were collected via a structured questionnaire (Phase 1); public centre-specific quantitative and qualitative data were then collected via a semi-structured questionnaire followed by a virtual interview (Phase 2). Data were analysed descriptively. RESULTS Informants from 18 countries reported the existence of 185 ART centres in 16 countries. Twenty-four centres (13.0%) in 10 of 16 countries (62.5%) were public. The majority of public centres (20/22 [90.9%]) reporting on ART performed <500 ART cycles per annum. Although public institutions covered most of the cost for ART, copayments from patients were universally required. The number of ART cycles per annum was inversely correlated to the copayment. Lack of policy and legislation, high costs and bureaucratic obstacles were identified by participants as the leading challenges in the delivery of public service ART. CONCLUSION Lack of public ART services leads to chronic and profound health inequities. Enablers of public service ART in the region are the same known to support ART services in general, namely policy and legislation, appropriate funding and good health service infrastructure. Addressing these requires the collated efforts of many stakeholders.
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Affiliation(s)
- Rumbidzai Majangara Karaga
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Paversan Archary
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; African Network and Registry for Assisted Reproductive Technology, Cape Town, South Africa
| | - Ernestine Gwet Bell
- Groupe Interafricain d'Etude, de Recherche et d'Application sur la Fertilité, Lome, Togo
| | - Mohamed Khrouf
- Groupe d'Etude de la Fertilité de la Société Tunisienne de Gynécologie Obstétrique, Tunis, Tunisia
| | - Olabisi Loto
- Department of Obstetrics and Gynaecology, Obafemi Awolowo University, Ile-Ife, Nigeria; Association for Fertility and Reproductive Health, Lagos, Nigeria
| | - Ibrahim Wada
- Association for Fertility and Reproductive Health, Lagos, Nigeria
| | - Silke Dyer
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; African Network and Registry for Assisted Reproductive Technology, Cape Town, South Africa
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Bosenge-Nguma JD, O'yandjo AM, Sihalikyolo J, Otuli NL, Ntokamunda K, Agasa B, Bosunga K. Tertiary care for infertile couples: aetiological diagnoses and conventional treatment outcomes in Kisangani, Democratic Republic of the Congo. Contracept Reprod Med 2023; 8:36. [PMID: 37461069 DOI: 10.1186/s40834-023-00236-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/12/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND In sub-Saharan Africa, tubal factors are described as the main aetiological factors of infertility. Under these conditions, medically assisted procreation is particularly indicated. However, Assisted Reproductive Technology centres are less available. Thus, infertile couples are quickly oriented towards available alternative conventional treatments. The present study aimed to determine the aetiological factors of infertility, the outcomes of the therapeutic options offered, and the factors associated with the success of conventional treatment among infertile couples seeking tertiary care in Kisangani. METHODS A cross-sectional study was conducted at two tertiary health facilities in Kisangani. Infertile couples who provided consent underwent specific examinations necessary for the exploration of infertility and were treated and followed up for a minimum of 6 months. The therapeutic options that were offered were expectant attitude, medical treatment, surgical treatment or transfer to an in vitro fertilization unit. The pregnancy diagnosis was performed by ultrasound. RESULTS A total of 272 infertile couples underwent specific examinations, were treated and were followed up for a minimum of 6 months. Many determinant causes were mostly linked to wives rather than husbands. Overall, only 34 women among 211 who were treated became pregnant during the follow-up period; 61 couples were advised to resort to IVF or adoption, but the couples for whom expectant the attitude was indicated immediately rejected it. The patients who therapeutically succeeded at the end of the treatment were those who were younger than 35 years (OR = 2.27; 95% CI = 1.06-4.87; P = 0.017), had a duration of infertility of less than five years (OR = 6.08; 95% CI = 1.79-20.69; P = 0.001) and had secondary infertility (OR = 6.08; 95% CI = 1.79-20.69; P = 0.001). CONCLUSION Kisangani faces a major issue in the treatment of infertility. Treatment of patients using conventional methods is limited by the predominance of tubal factors as aetiological determinants of infertility. The low pregnancy rate found in this study provided additional evidence of this. This paper represents a serious plea to national policy-makers to encourage them to pay attention to issues surrounding infertility.
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Affiliation(s)
- Jean-Didier Bosenge-Nguma
- Department of Obstetrics and Gynecology, Faculty of Medicine and Pharmacy, University of Kisangani, P.O. Box 2012, Kisangani, Democratic Republic of the Congo.
| | - Antoine Modia O'yandjo
- Department of Obstetrics and Gynecology, Faculty of Medicine and Pharmacy, University of Kisangani, P.O. Box 2012, Kisangani, Democratic Republic of the Congo
| | - Juakali Sihalikyolo
- Department of Obstetrics and Gynecology, Faculty of Medicine and Pharmacy, University of Kisangani, P.O. Box 2012, Kisangani, Democratic Republic of the Congo
| | - Noël Labama Otuli
- Department of Obstetrics and Gynecology, Faculty of Medicine and Pharmacy, University of Kisangani, P.O. Box 2012, Kisangani, Democratic Republic of the Congo
| | - Kadima Ntokamunda
- Department of Clinical Pharmacology, University of Rwanda, Kigali, Rwanda
| | - Batina Agasa
- Department of Internal Medicine, Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo
| | - Katenga Bosunga
- Department of Obstetrics and Gynecology, Faculty of Medicine and Pharmacy, University of Kisangani, P.O. Box 2012, Kisangani, Democratic Republic of the Congo
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Ombelet W, Goemaes R, Fomenko E, Campo R. Perinatal Outcome of Singletons Born after Using a Simplified Low-Cost IVF Culture System and All Singletons Born in Flanders (Belgium) between 2012 and 2020. J Clin Med 2023; 12:jcm12113683. [PMID: 37297877 DOI: 10.3390/jcm12113683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/16/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND We developed a simplified IVF culture system (SCS) which has proven to be effective and safe in a selected IVF cohort. METHODS Preterm birth (PTB) and low birth weight (LBW) of 175 singletons born after using the SCS, 104 after fresh embryo transfer (ET), and 71 after frozen embryo transfer, were compared with all singletons born in Flanders between 2012 and 2020 conceived after natural conception, ovarian stimulation (OS), and assisted reproduction (IVF/ICSI). FINDINGS The proportion of preterm (<37 weeks) births was significantly higher in the case of IVF or ICSI, followed by hormonal treatment, compared to spontaneous pregnancies. There was no significant difference in PTB between SCS and any of the other groups. Concerning the average birth weight we found no significant difference between singletons born after natural conception and SCS. However, a significant difference in average birth weight was found between SCS singletons and singletons born after IVF, ICSI and hormonal treatment, with a significantly higher birth weight in the SCS group. This difference was also observed in the proportion of babies weighing less than 2500 g, with significantly more LBW babies in the IVF and ICSI group compared to the SCS newborns. INTERPRETATION Taking into account the small series, PTB and LBW rates in SCS singletons were found to be comparable with singletons born after natural conception. Compared to babies born after ovarian stimulation and IVF/ICSI, SCS singletons had a lower PTB and LBW rates, although the differences were not significant for PTB. Our results confirm previous reports on reassuring perinatal outcomes after using the SCS technology.
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Affiliation(s)
- Willem Ombelet
- Genk Institute for Fertility Technology, Department of Obstetrics and Gynaecology, ZOL Hospitals, 3600 Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590 Diepenbeek, Belgium
| | - Régine Goemaes
- Centre for Perinatal Epidemiology (SPE), Koning Albert II-laan 35 Box 29, 1030 Brussels, Belgium
| | - Elizaveta Fomenko
- Centre for Perinatal Epidemiology (SPE), Koning Albert II-laan 35 Box 29, 1030 Brussels, Belgium
| | - Rudi Campo
- Genk Institute for Fertility Technology, Department of Obstetrics and Gynaecology, ZOL Hospitals, 3600 Genk, Belgium
- Life Expert Centre, Schipvaartstraat, 3000 Leuven, Belgium
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Promising Perinatal Outcome after Using a Simplified Low-Cost IVF Culture System Specifically Designed for Resource-Poor Countries. J Clin Med 2023; 12:jcm12062264. [PMID: 36983264 PMCID: PMC10059708 DOI: 10.3390/jcm12062264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Assisted reproductive techniques services are often not accessible to the majority of infertile couples in Low and Middle Income Countries (LMIC) due to high costs. Lowering IVF laboratory costs is a crucial step to make IVF affordable for a larger part of the world population. We developed a simplified culture system (SCS) which has proven to be effective, and the next step is to prove its safety.Methods: Preterm birth (PTB) and low birthweight (LBW) of 176 singletons born after using the SCS, 105 after fresh embryo transfer (fresh ET), and 71 after frozen embryo transfer (frozen ET) were compared with all IVF/ICSI singletons born in Belgium between 2013 and 2018. When comparing our 105 SCS babies born after fresh ET with all Belgian babies born after conventional IVF only, we also adjusted for 7 risk factors known to influence perinatal outcome, namelythe mother’s age, day of transfer, pituitary inhibition protocol, rank of cycles, number of oocytes retrieved, number of embryos transferred, and gender of the baby.Findings: Before adjustment, we found a significantly higher PTB (10.2% vs. 3.8%, OR 2.852, 95% CI [1.042–7.803], p-value 0.0413) and LBW (9.8% vs. 2.9%, OR 3.692, 95% CI [1.163–11.721], p-value 0.0267) in the conventional IVF group versus SCS after fresh ET. After adjusting for seven risk parameters, these differences remained significant (PTB: OR 2.627, 95% CI [1.013–6.816], p-value 0.0471) and LBW: OR 3.267, 95% CI [1.118–9.549], p-value 0.0305). PTB and LBW between both groups was not significantly different for singletons born after frozen ET. Interpretation: Taking into account the small series, PTB and LBW rates in SCS singletons in FRET cycles are very reassuring and significantly lower compared to babies born after conventional IVF in Belgium. Being aware of its effectiveness, our results offer a good perspective for SCS to become an important tool to implement low-cost IVF in LMIC.
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Afferri A, Allen H, Dierickx S, Bittaye M, Marena M, Pacey A, Balen J. Availability of services for the diagnosis and treatment of infertility in The Gambia`s public and private health facilities: a cross-sectional survey. BMC Health Serv Res 2022; 22:1127. [PMID: 36071443 PMCID: PMC9450453 DOI: 10.1186/s12913-022-08514-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/31/2022] [Indexed: 12/01/2022] Open
Abstract
Background Infertility is a long-standing reproductive health issue, which affects both men and women worldwide and it is especially problematic in the Global South. In sub-Saharan Africa, understanding the current availability of diagnostic and treatment services for infertility is important because this could guide health systems to improve access to fertility care for all. Yet, few studies have explicitly started from a health system perspective to grasp the availability and integration of infertility services in sub-Saharan Africa. This quantitative study, the first in The Gambia, West Africa, examines the availability of infertility services in public and private facilities as part of a wider endeavour to improve fertility care policy and practice in the country. Methods A cross-sectional survey using Qualtrics was administered to 38 health facilities. The survey was carried out between March and August 2021 and involved closed-ended questions. Data analysis consisted of descriptive statistics and t-tests performed using SPSS version 26. Results A total of 25 facilities (66%) offered infertility services, of which 13 (52%) were public and 12 (47%) private. Although the availability of screening tests was similar between health institutions, most diagnostic and treatment services were available only in the private sector. Treatment services included: (i) ovarian stimulation (n = 16, 42%); (ii) reversal of tubal ligation and/or blockage (tuboplasty) (n = 4, 11%); and (iii) intrauterine insemination (n = 3, 8%). Assisted reproductive technologies such as IVF and ICSI were not available in public or private sectors. The Gambian health management information system lacked a dedicated space to capture data on infertility. Reported barriers to integration of infertility services in existing reproductive health services included a lack of specialised training, an absence of national guidance on infertility management, and a shortage of appropriate equipment, supplies, and medication. Conclusions The availability of infertility services in The Gambia follows a trajectory that is similar to other SSA countries in which services are mostly obtainable through the private sector. Yet, access to private care is expensive and geographically restricted, which exacerbates inequalities in accessing fertility care for all. Improving the provision of infertility services in the public sector requires systematically capturing data on infertility and investing in the provision of a full-range fertility care package. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08514-0.
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Affiliation(s)
- Anna Afferri
- School of Health and Related Research - ScHARR, The University of Sheffield, Sheffield, UK.
| | - Haddijatou Allen
- Medical Research Council - MRC The Gambia Unit, Fajara, The Gambia
| | - Susan Dierickx
- Research Centre Gender, Diversity and Intersectionality - RHEA, Vrije Universiteit Brussel, Ixelles, Belgium
| | - Mustapha Bittaye
- The Gambia Ministry of Health, Banjul, The Gambia.,School of Medicine and Allied Health Sciences, University of The Gambia, Banjul, The Gambia
| | - Musa Marena
- The Gambia Ministry of Health, Banjul, The Gambia.,School of Medicine and Allied Health Sciences, University of The Gambia, Banjul, The Gambia
| | - Allan Pacey
- Department of Oncology and Metabolism, The Medical School, The University of Sheffield, Sheffield, UK
| | - Julie Balen
- School of Health and Related Research - ScHARR, The University of Sheffield, Sheffield, UK
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Bezad R, Omrani SE, Benbella A, Assarag B. Access to infertility care services towards Universal Health Coverage is a right and not an option. BMC Health Serv Res 2022; 22:1089. [PMID: 36008812 PMCID: PMC9414098 DOI: 10.1186/s12913-022-08456-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 07/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background In Morocco, the national health plan 2025 was developed to promote Sexual and Reproductive Health (SRH) services for all. The principal aim was to achieve the Universal Health Coverage of SRH by 2030. For many years, health authorities’ efforts had focused on reducing maternal mortality through a widespread access to antenatal and obstetric care and family planning services. This has resulted in a significant gap between the availability of SRH components, namely obstetric and family planning care, and access to infertility services including Assisted Reproductive Technology (ART). The objective of this study is to answer two important questions. First, why some SRH programs and services are given priority by international and national political leaders while infertility care receives little attention; second, what are the factors that influence this prioritization? Methods We used Shiffman and Smith’s framework composed of four elements: the strength of the actors involved in the initiative, the power of the ideas they use to represent the health problem, the nature of the political contexts in which they operate and the characteristics of the services. We added a fifth element to the framework, the outcome. We applied this framework to the case of infertility services in Morocco. We conducted a desk review and interviews with actors involved in SRH and infertility care advocates as well as with decision makers involved in implementing Universal Health Coverage (UHC). Results Our results showed that despite the efforts made by the advocates of infertility care; the enactment in 2019 of a law regulating infertility care services; and the presence of two Assisted Reproductive Technology Units in the public sector, infertility services remain at an early stage of development hampered by multiple challenges. Among others, a lack of political entrepreneurs to ensure a strong leadership; the political windows were often missed; community members lacked consensus on a coherent public positioning of the problem, and advocates' perception and power of the idea lacked evidence and precise indicators of the problem. Conclusion To ensure the convergence and alignment of all stakeholders, it is recommended to translate the regulation of infertility into measurable activities with defined human and financial resources, equitable fertility health coverage, and quality fertility care to respond to women and infertile couples’ needs, rights and dignity.
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Affiliation(s)
- Rachid Bezad
- Obstetrics and Gynecology, Assisted Reproductive Technology Unit of the Reproductive Health Center, University Hospital Ibn Sina, Rabat, Morocco. .,Faculty of Medicine and Pharmacy, University Mohamed V, Rabat, Morocco.
| | - Sanae El Omrani
- Maternal and Neonatal Health, University Ibn Tofail, Kenitra, Morocco.,The Association Together for Reproductive Health (ESR), Rabat, Morocco
| | - Amal Benbella
- Obstetrics and Gynecology, Assisted Reproductive Technology Unit of the Reproductive Health Center, University Hospital Ibn Sina, Rabat, Morocco.,Faculty of Medicine and Pharmacy, University Mohamed V, Rabat, Morocco
| | - Bouchra Assarag
- The Association Together for Reproductive Health (ESR), National School of Public Health, Rabat, Morocco
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