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

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.

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.

Barriers and facilitators for the inclusion of fertility care in reproductive health policies in Africa: a qualitative evidence synthesis

BACKGROUND

Infertility affects over 50 million couples worldwide and impacts people's social and emotional wellbeing. In low- and middle-income countries, particularly across Africa, the inclusion of fertility care into reproductive health (RH) policies remains fragmented or non-existent.

OBJECTIVE AND RATIONALE

This review aims to provide a framework for understanding the inclusion (or lack thereof) of fertility care in RH policies in African settings. It synthesizes the barriers and facilitators to such inclusion, with a view to uncovering the positioning of fertility care in broader health systems and on the agendas of key stakeholders such as health policymakers and practitioners.

SEARCH METHODS

A qualitative evidence synthesis was performed, systematically searching papers and grey literature. Searches were conducted in MEDLINE, EMBASE, CINAHL, Web of Science and Scopus between February and April 2020. No date restrictions were applied. Language was limited to publications written in English and French. Two reviewers independently screened titles and abstracts, and extracted data, applying thematic coding. The quality of the included papers was evaluated using The Joanna Briggs Institute Checklist for Text and Opinion Papers.

OUTCOMES

The search identified 744 papers, of which 20 were included. Findings were organized under four cross-cutting categories, namely: perceived importance of infertility; influence of policy context; resource availability and access; and perceived quality of care. Across these categories, key barriers to the inclusion of fertility care in RH policies were limited political commitment, under-recognition of the burden of infertility and high costs associated with ART. Conversely, facilitators comprised specialized training on infertility for healthcare providers, standard procedures for ART safety and guidelines and North-South/South-South collaborations.

WIDER IMPLICATIONS

The inclusion of fertility care in African RH policies depends upon factors that include the recognition of infertility as a disease, strong political engagement and proactivity and affordability of ART through opportunities for partnership with the private sector, which ease costs on the public health system. Further qualitative and quantitative research, including context-specific analysis and in-depth comparative approaches across diverse African countries, will help to delineate differential impacts of local and global factors on fertility care to address this neglected RH issue.

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.