A review of management of infertility in Nigeria: framing the ethics of a national health policy

'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.

Breaking the silence around infertility: a scoping review of interventions addressing infertility-related gendered stigmatisation in low- and middle-income countries

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.

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.

Infertility policy analysis: a comparative study of selected lower middle- middle- and high-income countries

BACKGROUND

Infertility has recently become a salient but neglected global issue. Policies to address the sexual and reproductive health and rights (SRHR) are vital, especially in lower middle and middle-income countries (LMICs). Hence, the aim of this study was to compare the national infertility policies in the selected countries (LMICs comparing with high-income) to determine gaps or to confirm desirable policies in the given health systems.

METHODS

This study has executed a comparative policy analysis of infertility services using the universal health coverage framework (financial protection, population coverage, and service features) in three scopes (prevention, treatment, and supportive care). Seven countries that had infertility programs in their health sectors were selected.

RESULTS

The results showed that financial protection was good in high and middle-income countries, but in a lower middle income, and in one high-income country was poor. The findings also showed that health systems in the same countries had no infertility services for men. Preventive and supportive care services were neglected in LMICs by governments.

CONCLUSION

The findings indicate that income is not the only factor that fulfills universal health coverage for infertility care services. Perhaps to achieve equity in infertility care services, it should be seen as a universal human right to accomplish the right to have a child and to have a life with physical and mental health for all men and women.

The Case for Resource Sensitivity: Why It Is Ethical to Provide Cheaper, Less Effective Treatments in Global Health

When Dr. Hortense screens her patients in Chicago for cervical dysplasia and cancer, she conducts a pelvic exam, takes a sample of cervical cells, and sends them for Pap cytology and human papilloma virus DNA co-testing. But when she conducts cervical cancer screening in Botswana, she employs a much simpler diagnostic strategy. She applies acetic acid to highlight precancerous lesions and visually inspects the cervix-a technique known as the VIA (visual inspection with acetic acid) method. She treats suspicious lesions with cryotherapy. There are multiple reasons that Dr. Hortense uses VIA in developing countries. It requires no specialized laboratory facilities or highly trained personnel. With immediate results, there is no delay in diagnosis and treatment, ensuring that patients are not lost to follow-up. Most importantly, VIA is considerably cheaper than Pap and HPV co-testing. This difference in care between Chicago and Botswana presents an ethical dilemma in global health: is it ethically acceptable to provide some patients cheaper treatments that are less effective or more toxic than the treatments other patients receive? We argue that it is ethical to consider local resource constraints when deciding what interventions to provide. The provision of cheaper, less effective health care is frequently the most effective way of promoting health and realizing the ethical values of utility, equality, and priority to the worst off.

Association between leptin, obesity, hormonal interplay and male infertility

Male infertility is a major health problem worldwide. We investigated a possible association between leptin, obesity, hormonal interplay and male infertility. This cross-sectional study of 313 males (178 infertile and 135 fertile) was carried out in 2017. The subjects were categorised by body mass index (BMI) and body fat percentage (BF%) into normal weight, overweight and obese. Significantly higher levels of BMI and BF% (p-value < 0.001) and lower levels of FSH, LH, testosterone, and SHBG (p-value < 0.001) were found in infertile males. However, no significant difference was observed in leptin levels (p-value = 0.35). Leptin levels were significantly higher, and all the sex hormones were significantly lower (p-value < 0.001) in obese subjects, whereas according to BF% only leptin, FSH and SHBG were significantly different. Leptin showed a significant positive correlation with BMI and BF% (p < 0.001). A strong positive link to serum testosterone was found with age, FSH, and LH (p < 0.001) and a negative one with BMI and BF% (p < 0.001). In mutivariable anlaysis, after adjusting for the other covariates, a significant association between FSH and testosterone (p-value <0.001) was found. Serum leptin levels did not differ significantly in fertile and infertile groups, and no association was found with infertility. Furthermore, male obesity was found to be associated with infertility with the decrease in levels of sex hormones.

Infertility in the Global South: Raising awareness and generating insights for policy and practice

Infertility is a highly prevalent reproductive health condition in the global South, which often has a devastating impact on the people concerned. Yet, thus far it hardly received any attention from policy makers, Non-Governmental Organizations (NGOs) or donors working in the field of Sexual and Reproductive Health and Rights (SRHR). For this reason we have set up a project to increase knowledge and awareness about infertility and childlessness among those stakeholders and organizations and to generate insight into (possible) interventions in this field. The project received a grant by Share-Net International (the Knowledge Platform in the field of SRHR, funded by the Dutch Ministry of Foreign Affairs) and is a unique collaboration between universities, fertility clinics, fertility support groups and the Walking Egg Foundation. The project consists of multimethods studies in Ghana and Kenya as well as dissemination workshops and meetings in these countries and the Netherlands. The first workshops in Kenya have already taken place with successful feedback from stakeholders. In this commentary we provide insight into the project and the main points and recommendations discussed in the Workshops in Kenya.