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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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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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Gerrits T, Kroes H, Russell S, van Rooij F. Breaking the silence around infertility: a scoping review of interventions addressing infertility-related gendered stigmatisation in low- and middle-income countries. Sex Reprod Health Matters 2023; 31:2134629. [PMID: 36811853 PMCID: PMC9970193 DOI: 10.1080/26410397.2022.2134629] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Infertility is a reproductive health concern that deserves attention, as reconfirmed by the 2018 report of the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights (SRHR). However, governments and SRHR organisations tend to neglect infertility. We conducted a scoping review of existing interventions aiming to decrease the stigmatisation of infertility in low- and middle-income countries (LMICs). The review consisted of a combination of research methods: academic database (Embase, Socological abstracts, google scholar; resulting in 15 articles), Google and social media searches, and primary data collection (18 key informant interviews and 3 focus group discussions). The results distinguish between infertility stigma interventions targeted at intrapersonal, interpersonal and structural levels of stigma. The review shows that published studies on interventions tackling infertility stigmatisation in LMICs are rare. Nevertheless, we found several interventions at intra- and interpersonal levels aiming to support women and men to cope with and mitigate infertility stigmatisation (e.g. counselling, telephone hotlines, and support groups). A limited number of interventions addressed stigmatisation at a structural level (e.g. empowering infertile women to become financially independent). The review suggests that infertility destigmatisation interventions need to be implemented across all levels. Interventions geared to individuals experiencing infertility should include women and men and also be offered beyond the clinical setting; and interventions should also aim to combat stigmatising attitudes of family or community members. At the structural level, interventions could aim to empower women, reshape masculinities and improve access to and quality of comprehensive fertility care. Interventions should be undertaken by policymakers, professionals, activists, and others working on infertility in LMICs, and accompanied with evaluation research to assess their effectiveness.
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Affiliation(s)
- Trudie Gerrits
- Associate Professor, Department of Anthropology, University of Amsterdam, Amsterdam, Netherlands,Correspondence:
| | - Hilde Kroes
- Independent Consultant, Sexual and Reproductive Health and Rights, Eefde, Netherlands
| | - Steve Russell
- Associate Professor, School of International Development, University of East Anglia, Norwich, UK
| | - Floor van Rooij
- Assistant Professor, Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, Netherlands
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Hiadzi RA, Woodward B, Akrong GB. Ethical issues surrounding the use of assisted reproductive technologies in Ghana: An analysis of the experiences of clients and service providers. Heliyon 2023; 9:e13767. [PMID: 36865469 PMCID: PMC9970979 DOI: 10.1016/j.heliyon.2023.e13767] [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: 08/27/2022] [Revised: 02/03/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
Since the advent of Assisted Reproductive Technologies (ART) in Ghana about three decades ago, IVF and ICSI treatments have enabled infertile Ghanaian couples to fulfill their aspirations and dreams of having children. In this extremely pronatalist society, ART has provided relief to many childless couples by reducing, if not eliminating, the shame of childlessness that they would otherwise have to suffer. However, as the provision and utilization of ART continue to increase, so do worries regarding the ethical difficulties surrounding this field of medicine, which challenge cultural ideals and personal desires. The study explores client and service provider experiences with ART in urban Ghana. Observation and in-depth interviews were employed to collect data, and the ethical dimensions of people's experiences relative to Ghanaian cultural and ethical values were analyzed. The results show that the provision of ART services for heterosexual couples in marital unions, the availability of PGT for sickle cell clients, the preference for multiple births emerging from embryo transfers, the lower preference for cryopreservation, the high cost of ART treatment, and the need for regulation of the provision of ART services in Ghana were some of the ethical concerns expressed by both clients and service providers.
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Affiliation(s)
| | | | - Godwin Banafo Akrong
- School of Management and Economics, University of Electronic Science and Technology of China, Chengdu, 611731, China,Corresponding author.
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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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