'We are always desperate and will try anything to conceive': The convoluted and dynamic process of health seeking among women with infertility in the West Coast Region of The Gambia

Policy action points and approaches to promote fertility care in The Gambia: Findings from a mixed-methods study

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.

'It's about time': policymakers' and health practitioners' perspectives on implementing fertility care in the Gambian health system

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.

Treatment-seeking behaviour among infertile tribal women of Palghar district in India

Background

The tribal culture views health care practices differently from the mainstream. Infertile tribal women practice treatment-seeking behaviour that reflects the community's cultural access to and availability of treatment as well as customs to meet their health care needs. In the environment of rising awareness of infertility and numerous treatment options, this study aims to highlight the infertility treatment-seeking behaviour of tribal communities.

Data and methods

The study employed a mix methods approach to collect data from 153 tribal couples suffering with infertility (interview schedule) and the community (in-depth interviews-14 and focus group discussions-12). The data was analyzed using Stata 13.0, and NVivo 10. Results of the quantitative data were triangulated with qualitative data for writing.

Results

Many treatment options were available for infertility in the community. Generally, traditional healers (98.7%) were preferred over modern healthcare practitioners (35%). Community members usually guided infertile couples for choosing providers. Treatment practices were very different among primary infertile women than sub-fertile. Women frequently discontinued treatment and switched between providers because of unaffordability, poor connectivity, distance, travel time, time constraints, and non-supportive circumstances. The couples were advised to consume herbs, and eat or avoid certain food items, were given massage, burns on the abdomen (dagani), removed black blood (phasani) and other various rituals to appease spirits, get rid of ghosts while offering animal sacrifice, and conducting shidwa ritual. The mean expenditure on treatment was INR 18,374. If treatment did not yield any result, couple resorted to add another wife, divorce, accept childlessness and foster a child.

Conclusion

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 beliefs, and unequal access to healthcare resources.

Shared Decision-Making About Future Fertility in Childhood Cancer Survivorship: Perspectives of Parents in Uganda

Background: Despite a plethora of literature on barriers to addressing future fertility in childhood cancer survivors, the data are not representative of limited middle-income settings. Unique and context-specific factors may influence addressing future fertility care among childhood cancer survivors in Uganda. This study aimed to explore the experiences, attitudes, and perceptions of parents on their interactions with health providers about future fertility, as part of their child's cancer survivorship. Methods: Using grounded theory, semistructured interviews were conducted with parents of children diagnosed with cancer, <18 years of age, and not in the induction or consolidation phases of treatment. Transcripts were thematically analyzed. Results: A total of 20 participants were interviewed, with the majority identifying as female (n = 18). The global theme that arose was the importance of shared decision-making, and the key themes encompassing this were as follows: (1) importance of accurate information, (2) respect of autonomy, and (3) engagement and psychosocial support. Conclusion: In Uganda, parents of children with cancer value a multifaceted approach to satisfactory decision-making within the context of oncofertility.

Introducing assisted reproductive technologies in The Gambia, a survey on the perspectives of Gambian healthcare professionals and medical students

BACKGROUND

Infertility remains a global reproductive health burden with the highest prevalence in low and middle-income countries. In sub-Saharan Africa, the ability to procreate holds great societal importance. Couples, and particularly women, with infertility can face devastating challenges, leading to social stigma, isolation and/or divorce. However, attention to addressing infertility is lacking in sub-Saharan Africa. In The Gambia, where this study is based, little is known about the potential for introduction of assisted reproductive technologies (ART) in the public health sector.

METHODS

A quantitative survey was conducted using detailed questionnaires on infertility services available, staff knowledge, perceived barriers, and personal motivation to support assisted reproductive technologies. Data was collected electronically between April and June 2021 from healthcare providers (n = 70) in eleven health facilities throughout the country, as well as from medical students (n = 55) enrolled at The University of The Gambia.

RESULTS

Basic infertility services were found to be lacking in the rural areas. Furthermore, 39% of staff (n = 27) providing fertility care had not receive any formal training on the topic. However, 91% of staff (n = 64) showed interest in acquiring additional knowledge and had a positive attitude towards supporting the introduction of ART. Perceived challenges of doing so included: (i) the competing importance of other health priorities; and (ii) religious and cultural barriers.

CONCLUSION

This survey highlights that expansion of infertility services is needed, especially in rural areas. Staff perceived the introduction of ART as important, but this should be coupled with specialized training, as most medical staff had not received any formal infertility training. Future care providers (current medical students) showed both interest in ART and reported having received some basic training in infertility management. Given the reported lack of infrastructure and services, additional targeted investment in infertility care, including ART, will be needed to improve reproductive health for all, countrywide.

Lived experiences and coping strategies of persons seeking infertility treatment in the Kumasi metropolis: a descriptive phenomenological study

BACKGROUND

Women seeking fertility treatment face myriad challenges that they must adapt and adjust to daily. This aimed at exploring the experiences and coping strategies of such persons in the Kumasi. Metropolis.

METHODS

A qualitative approach was employed and a purposive sampling technique was used to select 19 participants. A semi-structured interview was used to collect data. The data collected were analyzed using Colaizzi's method of data analysis.

RESULTS

Persons living with infertility had emotional experiences of anxiety, stress, and depression. Socially, participants experienced isolation, stigma, societal pressure, and marital problems due to their inability to conceive. The key coping strategies adopted were spiritual (faith-based) and social support. Though formal child adoption can be an option, no participant preferred it as a coping strategy. Some participants also reported using herbal medicine before going to the fertility centre upon realizing that the approach was not helping in achieving their desired outcome.

CONCLUSION

Infertility is a source of suffering for most women diagnosed with it, resulting in significant negative experiences in their matrimonial homes, families, friends, and the community at large. Most participants rely on spiritual and social support as their immediate and basic coping strategies. Future research could evaluate the treatment and coping strategies and also determine the outcomes of other forms of treatment for infertility.

Indigenous practitioners' views on causes of female infertility

Background

The use of indigenous practices has increased remarkably throughout the world. Subsequently, society uses this practice for the treatment of various health problems, including infertility. This research focussed on the role of indigenous practitioners (IPs) using a holistic approach to explore the causes of infertility in women.

Aim

This study aimed to explore and describe the views of IPs on the causes of female infertility in Ngaka Modiri Molema health district.

Setting

The study was conducted in Ngaka Modiri Molema, North West Province, one of the most rural provinces in South Africa.

Methods

The study followed a qualitative explorative design. A purposive sampling technique identified five IPs who were experts in managing infertility. Individual semi-structured interviews were conducted, and data analysis used Creswell's method of qualitative data analysis.

Results

Findings revealed that IPs offered a wide range of services in the treatment and management of infertility among rural women. Hence, the following themes emerged, namely, history taking regarding infertility, treatment of infertility and holistic care on infertility.

Conclusion

The IPs are important providers of healthcare in the management of infertility in indigenous communities. The findings revealed that there are various causes of female infertility according to the indigenous healthcare system.

Contribution

In contribution, the study described the unique practices found in the community as executed by the IPs. This care focusses on holistic care, including treatment and continuous care for the healthcare user and the family. Noteworthy to mention, this holistic care extends to subsequent pregnancies. However, there is a need for further research to valorise the indigenous knowledge unearthed in this study.

Availability of services for the diagnosis and treatment of infertility in The Gambia`s public and private health facilities: a cross-sectional survey

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.

'With the kanyaleng and the help of god, you don't feel ashamed': women experiencing infertility in Casamance, Senegal

While the precarious situation of women with infertility in Sub-Saharan Africa is well documented, little is known about the ways in which such women show agency despite the challenges that infertility brings to their lives. This study provided a holistic understanding of the experiences of women with infertility living in a rural community in Casamance (Senegal), drawing attention towards both suffering as well as agency. Qualitative research methods were used, triangulating life-story interviews, participant observation and informal conversations. Findings showed that all women with infertility experienced emotional challenges. These emotional challenges were intertwined with social stigmatisation and troubled relationships with their families-in-law and within their marriages. However, women with infertility were not passive victims in these circumstances. The study identified several strategies used by women to cope with the challenges of infertility, including organising in kanyaleng groups, treatment seeking, fosterage, looking for religious and social support, becoming (financially) independent, avoidance and ignorance. These findings highlight the complexity of agency within a context of structural violence. Concrete measures to improve the lives of women with infertility should acknowledge the agency of women with infertility and involve such women while developing multi-component approaches addressing inequalities.

Men and infertility in The Gambia: Limited biomedical knowledge and awareness discourage male involvement and exacerbate gender-based impacts of infertility

Introduction

Infertility in Sub-Saharan Africa constitutes an important social and public health problem. Yet, there is a paucity of research on the experiences of men living with infertility, especially in West Africa. This study explored men’s aetiological knowledge, views and experiences of infertility in the West Coast region of The Gambia, West Africa.

Methodology

An explorative qualitative study was conducted among men living in the rural and urban communities of the West Coast region of The Gambia using in-depth interviews. Data collection and analysis were performed concurrently, and thematic data analysis was an iterative process carried out using NVivo 11 Analysis Software.

Results

Gambian men had generally poor knowledge of infertility, allocating it to God, spiritual powers and bodily (biomedical) factors. While societal norms meant that infertility was generally attributed to women, some men allocated male-factor infertility to poor sperm quality and impotence. Infertility threatened participants’ sense of masculinity and resulted in psychosocial distress, including stigma, feelings of isolation, and low self-esteem.

Conclusion

Normative gendered frameworks of infertility result in high levels of female responsibilisation in the Gambian context. Yet men diagnosed with infertility experience significant, often unrecognized, psychological and social distress. We therefore call for increased attention to male-factor infertility, and the promotion of male engagement with infertility-care and services, both of which are essential for successfully addressing infertility and it’s psychosocial consequences in The Gambia.

The Nairobi Summit and Reproductive Justice: Unmet Needs for People with Infertility

The Nairobi Summit, held in November 2019 and convened by the United Nations Fund for Population Activities, claims to have represented "all nations and peoples, and all segments" of society during its high-level conference. The overall aim of the summit was to mobilize political will and financial commitments that are urgently needed to "finally and fully" implement the 1994 International Conference on Population and Development (ICPD) Program of Action. Despite the recommendation by ICPD to incorporate infertility care in reproductive health services, the new Nairobi Statement largely neglects the topic of infertility. This is particularly troublesome as infertility is a global health problem affecting between 52.6 and 72.4 million couples worldwide, with a high prevalence in low- and middle-income settings. For many people around the world, infertility constitutes an emotional, social, and financial burden, yet appropriate services directed toward preventing and addressing infertility are often inaccessible, unaffordable, or nonexistent. With the impetus of a wider reproductive justice community, we call for the integration of infertility into global reproductive health research and practice, urging policy makers, practitioners, researchers, activists, and funders worldwide to bring focused attention to addressing challenges posed by a lack of safe, effective, and dignified fertility management among those in need.

Complementary medicine seeking behaviour among infertile women: A sudanese study

INTRODUCTION

It is not surprising in developing countries with psychological, familial and community pressure to produce child, infertile women, in addition to conventional medicine, seek various traditional methods and religious practices.This study was conducted in Sudan to explore the perspectives of currently married infertile Sudanese women on complementary medicine seeking behaviour with more emphasis on traditional self-management strategies.

METHODS

A cross-sectional survey involving 203 infertile women was conducted. Collection of data was performed by means of a specifically designed questionnaire using a convenient sampling method at the women's visits of infertility treatment clinics in Khartoum, Sudan.

RESULTS

Findings of the study revealed that 43.3% of participated women had rich experience with infertility self-management strategies, and 65.0% of them used these strategies to treat infertility. Also 59.1% of the participants mentioned unaffordability of modern treatment as a main factor for trying self-management strategies.

CONCLUSION

The study revealed women's rich experience and wide use of different types of self-management strategies together with formal infertility health care services either simultaneously or subsequently. Also, unaffordability of formal treatment services was reported as one of the most encouraging factors towards seeking traditional treatment options.

Engagement in Nonbiomedical Practices for Fertility Enhancement: A Scoping Review

Objectives: This scoping review aims to (1) describe the scope and coverage of the body of literature on nonbiomedical practices used for enhancing fertility, (2) summarize and map the existing evidence on the extent and types of nonbiomedical practices used, and (3) examine how the research on this topic has been conducted with particular attention paid to how participants are asked about their use of nonbiomedical practices for fertility enhancement. Design: We conducted a scoping review by which four databases were searched (PubMed, Psychinfo, Socindex, and CINHAL). Articles were screened for inclusion by two researchers through a title and abstract screening followed by a full-text screening. Data were extracted from included articles and results summarized and compared across studies and regions. Results: A total of 32 studies were identified from 16 countries in five regions of the world. The majority of studies were clinic-based, primarily recruiting participants from fertility clinics in urban and suburban areas. More than half of the studies included only women, a few studies included only men, and the remainder of studies included both men and women. Most quantitative studies reported the prevalence of nonbiomedical practice use, which ranged from 8% to 83%; however, there was variation across studies regarding the time frame for which these percentages were derived. Few studies reported on other measures of the extent of use such as duration or frequency. A variety of nonbiomedical practices were identified with biologically based treatments, particularly herbal medicine use, being the most common followed by religious and spiritual interventions. Regional differences were identified. Variation in the wording and format of the question(s) used in survey instruments asking participants about their use of nonbiomedical practices exists and may impact participants' reporting of use. Conclusions: Infertility affects millions of individuals worldwide often with severe social, emotional, and financial consequences. To enhance fertility and, in some cases, overcome infertility, many individuals and couples are engaging in a variety of nonbiomedical practices. This scoping review describes the scope and nature of the existing literature on the use of nonbiomedical practices for fertility enhancement and highlights important gaps and limitations in the conduct of this research. A more comprehensive and inclusive investigation of nonbiomedical practices for enhancing fertility is needed to improve our understanding of how individuals and couples are managing infertility, identify educational and counseling needs, and to improve research related to effectiveness and safety of nonbiomedical practices.

The fertile grounds of reproductive activism in The Gambia: A qualitative study of local key stakeholders' understandings and heterogeneous actions related to infertility

Introduction

While several studies have focussed on the experiences of women living with infertility, there is a paucity of information related to understandings, representations and actions of key stakeholders (i.e. organisations and individual actors involved in activities or professional care surrounding infertility) when it comes to infertility in Sub-Saharan Africa. This ethnographic study conducted in The Gambia, West Africa, focuses on how key stakeholders in the country understand infertility, and on their activities to improve the lives of people with infertility.

Methodology

This ethnographic study draws on primary and secondary data for thematic analysis. Primary qualitative data were collected using in-depth interviews, observations, informal conversations and group discussion with various stakeholders (i.e. health care providers and representatives of non-governmental, governmental and international organisations). Sources of secondary data included government and non-governmental reports and media outputs.

Results

Results illustrated that most key stakeholders had a good understanding of the cultural frameworks and social realities of women living with infertility, with less focus on, or awareness of, men’s experiences of infertility. We distinguished three different positions of these actors and organisations, first, the infertility supporters, i.e. those who despite political challenges and a lack of funding, initiated activities to raise awareness about the problems people with infertility are facing and aim to increase access to infertility services. The second are moderate supporters, i.e. those who recognise the problems infertility poses and whose organisations target some of the perceived causes of infertility (i.e. lack of health education and harmful cultural practices). A third group of neutral or moderate opponents consist mainly of formal health care providers who do not consider infertility a current priority, given many competing demands in the resource-constrained healthcare system.

Conclusion

While international donors still largely neglect the emotional and social implications of infertility in Sub-Saharan African countries, some local stakeholders are working to bring services closer to people with infertility. The efforts of these local stakeholders require support and integration, and should include engaging with different groups for widespread sensitisation to reduce stigma and promote attendance to health centres for reproductive health challenges.