mHealth technologies for pregnancy prevention: A challenge for patient-centred contraceptive counselling in Dutch general practice

BACKGROUND

A general practitioner (GP) standardly provides contraceptive counselling and care in the Netherlands. Recent years have seen the rise of mobile health technologies that aim to prevent pregnancy based on fertility awareness-based methods (FABMs). We lack high-quality evidence of these methods' effectiveness and clarity on how healthcare professionals include them in contraceptive counselling.

OBJECTIVES

To analyse how Dutch healthcare professionals include pregnancy-prevention mobile health technologies (mHealth contraception) in contraceptive counselling and to propose practice recommendations based on our findings.

METHODS

We used ethnographic methods, including semi-structured interviews with nine professionals who were recruited using purposive sampling, 10 observations of contraceptive counselling by four professionals, six observations of teaching sessions in medical training on contraception and reproductive health, one national clinical guideline, and seven Dutch patient decision aids. Data were collected between 2018 and 2021 and analysed inductively using praxiographic and thematic analysis.

RESULTS

In contraceptive counselling and care, professionals tended to blend two approaches: 1) individual patient-tailored treatment and 2) risk minimisation. When interviewed about mHealth contraception, most professionals prioritised risk minimisation and forewent tailored treatment. Some did not consider mHealth contraception or FABMs as contraceptives or deemed them inferior methods.

CONCLUSION

To minimise risk of unintended pregnancy, professionals hesitated to include mHealth contraception or other FABMs in contraceptive consultations. This may hamper adequate patient-centred counselling for patients with preference for mHealth contraception.Based on these results, we proposed recommendations that foster a patient-tailored approach to mHealth contraceptives.

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.

'Doing' kinship: heterosexual parents' experiences of non-genetic parenthood through donor conception

RESEARCH QUESTION

How do Dutch heterosexual parents who achieved parenthood through donor conception navigate non-genetic parenthood and kinship?

DESIGN

A qualitative in-depth semi-structured interview study was performed between September 2018 and January 2019 with both partners of 13 Dutch heterosexual couples where the male partner suffered from infertility and who conceived a child with the help of a sperm donor. Interview questions were based on literature and clinical experiences of experts in the field of donor conception. Interviews were transcribed and analysed using thematic analysis.

RESULTS

All parents navigated non-genetic parenthood through 'doing' kinship: they negotiated the importance of nature versus nurture with regards to donor conception and non-genetic parenthood. Most parents perceived genetics as irrelevant for experiencing parenthood, bonding with their children and the preferred role of the donor in their future lives. Yet most of them found genetics relevant for generating similarities between the father and the child, and for wanting the same donor for all their children to ensure a full genetic relation among them. Additionally, based on the donor's genetic bond with the child, some men were anxious about the donor's role in the child's future life and the consequences for their position as a non-genetic father. A few women perceived genetics as relevant in terms of possible inherited illnesses from the donor.

CONCLUSIONS

Parents experienced several ambiguities regarding the role of genetics in donor conception and navigated 'doing' kinship in various ways. These aspects need to be taken into consideration during the counselling of prospective parents planning to conceive with donor conception.

Reproductive travel to, from and within sub-Saharan Africa: A scoping review

Scholarly interest in reproductive travel has increased in recent years, but travel within, to and from the African continent has received much less attention. We reviewed the literature on cross-border reproductive travel to and from countries of sub-Saharan Africa in order to understand the local forms of this trade. Access to fertility care remains deeply stratified, which is an ongoing concern in a region with some of the highest rates of infertility. We found a wide variety of reasons for reproductive travel, including a lack of trusted local clinics. Destinations were chosen for reasons including historical movements for medical treatment broadly, diasporic circulations, pragmatic language reasons, and ties of former colonial relations. We describe the unique tempos of treatment in the region, ranging from some intended parents staying in receiving countries for some years to the short-term contingent support networks that reprotravellers develop during their treatment and travel. Unique to the region is the movement of medical professionals, such as the 'fly-in, fly-out' clinic staff to deliver fertility care. Future research should include practices and movements to presently neglected 'reprohubs', particularly Kenya and Nigeria; the impact of pandemic-related lockdowns and border closures on the movements of intended parents, reproductive assistors and reproductive material; and the impact of low-cost protocols on treatment access within the region. This scoping review provides insight into the relevant work on cross-border reproductive care in sub-Saharan Africa, where a unique combination of access factors, affordability, and sociocultural and geopolitical issues fashion individuals' and couples' cross-border reproductive travel within, to and from Africa.

Quantum circuits with many photons on a programmable nanophotonic chip

Growing interest in quantum computing for practical applications has led to a surge in the availability of programmable machines for executing quantum algorithms1,2. Present-day photonic quantum computers3-7 have been limited either to non-deterministic operation, low photon numbers and rates, or fixed random gate sequences. Here we introduce a full-stack hardware-software system for executing many-photon quantum circuit operations using integrated nanophotonics: a programmable chip, operating at room temperature and interfaced with a fully automated control system. The system enables remote users to execute quantum algorithms that require up to eight modes of strongly squeezed vacuum initialized as two-mode squeezed states in single temporal modes, a fully general and programmable four-mode interferometer, and photon number-resolving readout on all outputs. Detection of multi-photon events with photon numbers and rates exceeding any previous programmable quantum optical demonstration is made possible by strong squeezing and high sampling rates. We verify the non-classicality of the device output, and use the platform to carry out proof-of-principle demonstrations of three quantum algorithms: Gaussian boson sampling, molecular vibronic spectra and graph similarity8. These demonstrations validate the platform as a launchpad for scaling photonic technologies for quantum information processing.

The relationship between stigmatisation and quality of life in Ghanaian women and men with fertility problems: mediating role of coping strategies

INTRODUCTION

Fertility problems may have a devastating impact on the people involved. Specifically, in highly pronatalist settings like Ghana, the personal and social consequences are high. This study focused on the relationship between stigmatisation because of fertility problems and quality of life among Ghanaian women and men, and the possible mediating role of coping strategies.

METHODS

Participants (38 women, 11 men) were recruited with the help of a patient organisation and a hospital in Accra. Standardised instruments were used to measure the stigmatisation of having fertility problems, fertility quality of life and coping with fertility problems. Partial Pearson r correlations were conducted, followed by bootstrapped mediation analyses (PROCESS macro).

RESULTS

Stigmatisation was negatively correlated with fertility quality of life, and fertility quality of life was negatively correlated with active-avoidance coping. Active avoidance coping partially mediated the relationship between being stigmatised because of fertility problems and fertility quality of life.

CONCLUSIONS

Professionals working with people with fertility problems should pay more attention to how people are coping with experiences of stigmatisation.

The social and cultural meanings of infertility for men and women in Zambia: legacy, family and divine intervention

Despite the high prevalence of infertility within the sub-Saharan sterility belt, infertility in Zambia is understudied, particularly from a social perspective. Furthermore, few studies in sub-Saharan Africa include the infertility experiences of men. This article seeks to fill this gap by qualitatively describing the ways in which infertility in Zambia is socially and culturally loaded for both men and women. Demonstrating fertility is necessary to be considered a full adult, a real man or woman, and to leave a legacy after death. People in Zambia, including medical professionals, currently lack the necessary information and access to (or ability to provide) care to effectively resolve fertility issues. Infertile people manage their experience through a variety of social, emotional, spiritual, and medical strategies. However, no solution is considered adequate unless the intervention results in childbirth. In this way, infertility is about producing babies and the social meaning of that process, rather than the raising of children.

Broadband quadrature-squeezed vacuum and nonclassical photon number correlations from a nanophotonic device

We report demonstrations of both quadrature-squeezed vacuum and photon number difference squeezing generated in an integrated nanophotonic device. Squeezed light is generated via strongly driven spontaneous four-wave mixing below threshold in silicon nitride microring resonators. The generated light is characterized with both homodyne detection and direct measurements of photon statistics using photon number-resolving transition-edge sensors. We measure 1.0(1) decibels of broadband quadrature squeezing (~4 decibels inferred on-chip) and 1.5(3) decibels of photon number difference squeezing (~7 decibels inferred on-chip). Nearly single temporal mode operation is achieved, with measured raw unheralded second-order correlations g ⁽²⁾ as high as 1.95(1). Multiphoton events of over 10 photons are directly detected with rates exceeding any previous quantum optical demonstration using integrated nanophotonics. These results will have an enabling impact on scaling continuous variable quantum technology.

Knowing what the patient wants: a hospital ethnography studying physician culture in shared decision making in the Netherlands

OBJECTIVES

To study physician culture in relation to shared decision making (SDM) practice.

DESIGN

Execution of a hospital ethnography, combined with interviews and a study of clinical guidelines. Ten-week observations by an insider (physician) and an outsider (student medical anthropology) observer. The use of French sociologist Bourdieu's 'Theory of Practice' and its description of habitus, field and capital, as a lens for analysing physician culture.

SETTING

The gynaecological oncology department of a university hospital in the Netherlands. Observations were executed at meetings, as well as individual patient contacts.

PARTICIPANTS

Six gynaecological oncologists, three registrars and two specialised nurses. Nine of these professionals were also interviewed.

MAIN OUTCOME MEASURES

Common elements in physician habitus that influence the way SDM is being implemented.

RESULTS

Three main elements of physician habitus were identified. First of all, the 'emphasis on medical evidence' in group meetings as well as in patient encounters. Second 'acting as a team', which confronts the patient with the recommendations of a whole team of professionals. And lastly 'knowing what the patient wants', which describes how doctors act on what they think is best for patients instead of checking what patients actually want. Results were viewed in the light of how physicians deal with uncertainty by turning to medical evidence, as well as how the educational system stresses evidence-based medicine. Observations also highlighted the positive attitude doctors actually have towards SDM.

CONCLUSIONS

Certain features of physician culture hinder the correct implementation of SDM. Medical training and guidelines should put more emphasis on how to elicit patient perspective. Patient preferences should be addressed better in the patient workup, for example by giving them explicit attention first. This eventually could create a physician culture that is more helpful for SDM.

Detector-Agnostic Phase-Space Distributions

The representation of quantum states via phase-space functions constitutes an intuitive technique to characterize light. However, the reconstruction of such distributions is challenging as it demands specific types of detectors and detailed models thereof to account for their particular properties and imperfections. To overcome these obstacles, we derive and implement a measurement scheme that enables a reconstruction of phase-space distributions for arbitrary states whose functionality does not depend on the knowledge of the detectors, thus defining the notion of detector-agnostic phase-space distributions. Our theory presents a generalization of well-known phase-space quasiprobability distributions, such as the Wigner function. We implement our measurement protocol, using state-of-the-art transition-edge sensors without performing a detector characterization. Based on our approach, we reveal the characteristic features of heralded single- and two-photon states in phase space and certify their nonclassicality with high statistical significance.

Quantum-enhanced interferometry with large heralded photon-number states

Quantum phenomena such as entanglement can improve fundamental limits on the sensitivity of a measurement probe. In optical interferometry, a probe consisting of N entangled photons provides up to aN enhancement in phase sensitivity compared to a classical probe of the same energy. Here, we employ high-gain parametric down-conversion sources and photon-number-resolving detectors to perform interferometry with heralded quantum probes of sizes up to N = 8 (i.e. measuring up to 16-photon coincidences). Our probes are created by injecting heralded photon-number states into an interferometer, and in principle provide quantum-enhanced phase sensitivity even in the presence of significant optical loss. Our work paves the way towards quantum-enhanced interferometry using large entangled photonic states.

Quantum interference enables constant-time quantum information processing

It is an open question how fast information processing can be performed and whether quantum effects can speed up the best existing solutions. Signal extraction, analysis, and compression in diagnostics, astronomy, chemistry, and broadcasting build on the discrete Fourier transform. It is implemented with the fast Fourier transform (FFT) algorithm that assumes a periodic input of specific lengths, which rarely holds true. A lesser-known transform, the Kravchuk-Fourier (KT), allows one to operate on finite strings of arbitrary length. It is of high demand in digital image processing and computer vision but features a prohibitive runtime. Here, we report a one-step computation of a fractional quantum KT. The quantum d-nary (qudit) architecture we use comprises only one gate and offers processing time independent of the input size. The gate may use a multiphoton Hong-Ou-Mandel effect. Existing quantum technologies may scale it up toward diverse applications.

Being a donor-child: wishes for parental support, peer support and counseling

OBJECTIVES

We aimed at exploring the wishes of Dutch donor-conceived offspring for parental support, peer support and counseling and sought to contribute to the improvement of health care for all parties involved with assisted reproductive technologies.

METHODS

We held semi-structured in-depth interviews with 24 donor-conceived offspring (M_age = 26.9, range 17-41) born within father-mother, two-mother and single mother families. The majority of the donor offspring was conceived with semen of anonymous donors. All offspring were recruited by network organizations and snowball sampling. The interviews were fully transcribed and analyzed using the constant comparative method.

RESULTS

Donor-conceived offspring wished that their parents had talked openly about donor conception and had missed parental support. They wished that their parents would have received counseling before donor sperm treatment on how to talk with their children about donor conception in several stages of life. They valued the availability of peer contact to exchange stories with other donor-conceived offspring and would have liked assistance in getting access to trustworthy information about characteristics and identifying information of their donor. Donor-conceived offspring wished to know where to find specialist counseling when needed.

CONCLUSIONS

Peer support and counseling by professionals for donor-conceived offspring should be available for those who need it. The findings also support professional counseling for intended parents before treatment to improve parental support for donor-children.

Mothers' reproductive and medical history misinformation practices as strategies against healthcare providers' domination and humiliation in maternal care decision-making interactions: an ethnographic study in Southern Ghana

Background

Pregnant women can misinform or withhold their reproductive and medical information from providers when they interact with them during care decision-making interactions, although, the information clients reveal or withhold while seeking care plays a critical role in the quality of care provided. This study explored ‘how’ and ‘why’ pregnant women in Ghana control their past obstetric and reproductive information as they interact with providers at their first antenatal visit, and how this influences providers’ decision-making at the time and in subsequent care encounters.

Methods

This research was a case-study of two public hospitals in southern Ghana, using participant observation, conversations, interviews and focus group discussions with antenatal, delivery, and post-natal clients and providers over a 22-month period. The Ghana Health Service Ethical Review Committee gave ethical approval for the study (Ethical approval number: GHS-ERC: 03/01/12). Data analysis was conducted according to grounded theory.

Results

Many of the women in this study selectively controlled the reproductive, obstetric and social history information they shared with their provider at their first visit. They believed that telling a complete history might cause providers to verbally abuse them and they would be regarded in a negative light. Examples of the information controlled included concealing the actual number of children or self-induced abortions. The women adopted this behaviour as a resistance strategy to mitigate providers’ disrespectful treatment through verbal abuses and questioning women’s practices that contradicted providers’ biomedical ideologies. Secondly, they utilised this strategy to evade public humiliation because of inadequate privacy in the hospitals. The withheld information affected quality of care decision-making and care provision processes and outcomes, since misinformed providers were unaware of particular women’s risk profile.

Conclusion

Many mothers in this study withhold or misinform providers about their obstetric, reproductive and social information as a way to avoid receiving disrespectful maternal care and protect their privacy. Improving provider client relationship skills, empowering clients and providing adequate infrastructure to ensure privacy and confidentiality in hospitals, are critical to the provision of respectful maternal care.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1916-9) contains supplementary material, which is available to authorized users.

Counsellors' practices in donor sperm treatment

When intended parents choose to have donor sperm treatment (DST), this may entail wide-ranging and long-lasting psychosocial implications related to the social parent not having a genetic tie with the child, how to disclose donor-conception and future donor contact. Counselling by qualified professionals is recommended to help intended parents cope with these implications. The objective of this study is to present findings and insights about how counsellors execute their counselling practices. We performed a qualitative study that included 13 counsellors working in the 11 clinics offering DST in the Netherlands. We held a focus group discussion and individual face-to-face semi-structured interviews, which were fully transcribed and analysed using thematic analysis. The counsellors combined screening for eligibility and guidance within one session. They acted according to their individual knowledge and clinical experience and had different opinions on the issues they discussed with intended parents, which resulted in large practice variations. The counsellors were dependent on the admission policies of the clinics, which were mainly limited to regulating access to psychosocial counselling, which also lead to a variety of counselling practices. This means that evidence-based guidelines on counselling in DST need to be developed to provide consistent counselling with less practice variation.

Reproductive Travel to Ghana: Testimonies, Transnational Relationships, and Stratified Reproduction

In this article, I address reproductive travel to Ghana, based on research conducted in two private fertility clinics. Both clinics attract clients from West African countries as well as Ghanaian people living in the US and Europe. Their motivations to visit these clinics include positive "testimonies" about treatment results, "bioavailability" of matching donor material and surrogates, lower treatment costs and the circumvention of restricting regulations in the country of residence. Communication technologies are central in facilitating reproductive travel. Finally, I argue that the "international choreographies" of reproductive travel are co-shaped by the unique biographies and transnational relationships of the people involved.

Identification of nonclassical properties of light with multiplexing layouts

In Sperling et al. [Phys. Rev. Lett. 118, 163602 (2017)], we introduced and applied a detector-independent method to uncover nonclassicality. Here, we extend those techniques and give more details on the performed analysis. We derive a general theory of the positive-operator-valued measure that describes multiplexing layouts with arbitrary detectors. From the resulting quantum version of a multinomial statistics, we infer nonclassicality probes based on a matrix of normally ordered moments. We discuss these criteria and apply the theory to our data which are measured with superconducting transition-edge sensors. Our experiment produces heralded multiphoton states from a parametric down-conversion light source. We show that the known notions of sub-Poisson and sub-binomial light can be deduced from our general approach, and we establish the concept of sub-multinomial light, which is shown to outperform the former two concepts of nonclassicality for our data.

Detector-Independent Verification of Quantum Light

We introduce a method for the verification of nonclassical light which is independent of the complex interaction between the generated light and the material of the detectors. This is accomplished by means of a multiplexing arrangement. Its theoretical description yields that the coincidence statistics of this measurement layout is a mixture of multinomial distributions for any classical light field and any type of detector. This allows us to formulate bounds on the statistical properties of classical states. We apply our directly accessible method to heralded multiphoton states which are detected with a single multiplexing step only and two detectors, which are in our work superconducting transition-edge sensors. The nonclassicality of the generated light is verified and characterized through the violation of the classical bounds without the need for characterizing the used detectors.

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.

The Role of Trust in CenteringPregnancy: Building Interpersonal Trust Relationships in Group-Based Prenatal Care in The Netherlands

BACKGROUND

CenteringPregnancy (CP) is a specific model of group-based prenatal care for women, implemented in 44 midwifery practices in The Netherlands since 2011. Women have evaluated CP positively, especially in terms of social support, and improvements have been made in birthweight and preterm-birth outcomes; however, there is limited understanding as to why. The purpose of this study was to examine the mechanisms that create trusting relationships within CP to better understand CP outcomes and effectiveness.

METHODS

A qualitative study was conducted using in-depth interviews with 26 (former) CP participants, alongside observations of CP sessions. All interviews were transcribed and analyzed following open, axial, and selective coding.

RESULTS

Most women characterized trust as a positive expectation about how others would respond to sensitive information that was shared within the group. Trust emerged within the data as a multidimensional concept and several preconditions seemed crucial in building trusting relations: vulnerability, communication, reciprocity, chemistry, and atmosphere. The facilitating of interpersonal trust among CP participants enhanced group processes, especially as a basis for social support by which women said they were more eager to share sensitive information in a trusting environment.

CONCLUSIONS

Processes of trust were interwoven within various CP group dynamics. Trust facilitated social support which in turn enabled reassurance and the building of women's self-confidence.

Exploring parents' feelings about counseling in donor sperm treatment

INTRODUCTION

How do parents feel about psychosocial counseling during donor sperm treatment?

METHODS

We performed a qualitative study based on semi-structured in-depth interviews, conducted from July 2012 until August 2013, with 24 Dutch parents who had had children through donor sperm treatment between 2000 and 2012.

RESULTS

During counseling, parents sometimes felt screened for their eligibility for parenthood rather than guided, and therefore felt discouraged about bringing up topics that were important for them. Parents of all family types would value extended psychological counseling before and after successful donor sperm treatment, that is in several stages of parenthood. Only after childbirth topics such as disclosure, fear of rejection of the social parent and future contact of the child with the sperm donor became more pertinent.

CONCLUSIONS

Both before and after childbirth, parents of all family types would value expert advice on when and how to disclose. Psychosocial guidance should be offered separately from psychosocial screening for treatment eligibility and should be offered in several stages of parenthood.

Perceptions of oocyte banking from women intending to circumvent age-related fertility decline

INTRODUCTION

Women can now opt to bank their oocytes with the intention of increasing their chances of achieving a pregnancy after their fertility has declined. This exploratory study aimed to gain insight into how women, considering oocyte banking to circumvent age-related fertility decline, perceive this intervention.

MATERIAL AND METHODS

We conducted a qualitative study in a Dutch university medical center and held in-depth interviews with women on the waiting list for oocyte banking. We recorded the interviews, transcribed them verbatim and used thematic analysis.

RESULTS

All women were financially independent and lived in single-person urban households. They opted for oocyte banking because they wished to share parenthood with a future partner rather than becoming a single parent. This strong desire was key in their interpretation of all aspects of the intervention. Women set aside information about the limited success rates and potential risks, as they were optimistic about their own prognosis, thought that the chances for success were equally likely as the chances it would fail, and because of "anticipatory regret". They perceived oocyte banking as a "helping hand" to achieve shared parenthood. Although women found the costs of the intervention high, they were willing to invest their money to increase their chances for shared parenthood.

CONCLUSIONS

Oocyte banking allows women to circumvent age-related fertility decline. The prospect of potential shared parenthood overrules the perceived health risks and burden. Health professionals should take this into account when informing potential users of oocyte banking.

'Your health our concern, our health whose concern?': perceptions of injustice in organizational relationships and processes and frontline health worker motivation in Ghana

Taking a perspective of frontline health workers as internal clients within health systems, this study explored how perceived injustice in policy and organizational matters influence frontline health worker motivation and the consequent effect on workers’ attitudes and performance in delivering maternal and neonatal health care in public hospitals. It consisted of an ethnographic study in two public hospitals in Southern Ghana. Participant observation, conversation and in-depth interviews were conducted over a 16-month period. Ethical approval and consent were obtained from relevant persons and authorities. Qualitative analysis software Nvivo 8 was used for coding and analysis of data. Main themes identified in the analysis form the basis for interpreting and reporting study findings. Findings showed that most workers perceived injustice in distributive, procedural and interactional dimensions at various levels in the health system. At the national policy level this included poor conditions of service. At the hospital level, it included perceived inequity in distribution of incentives, lack of protection and respect for workers. These influenced frontline worker motivation negatively and sometimes led to poor response to client needs. However, intrinsically motivated workers overcame these challenges and responded positively to clients’ health care needs. It is important to recognize and conceptualize frontline workers in health systems as internal clients of the facilities and organizations within which they work. Their quality needs must be adequately met if they are to be highly motivated and supported to provide quality and responsive care to their clients. Meeting these quality needs of internal clients and creating a sense of fairness in governance arrangements between frontline workers, facilities and health system managers is crucial. Consequently, intervention measures such as creating more open door policies, involving frontline workers in decision making, recognizing their needs and challenges and working together to address them are critical.

Transnational connections of health professionals: medicoscapes and assisted reproduction in Ghana and Uganda

OBJECTIVES

Based on our comparative fieldwork in two private fertility clinics in Accra (Ghana) and Kampala (Uganda), we explore the transnational mobility of providers involved in assisted reproductive technologies (ARTs) and analyze how resulting transnational networks influence the realization and appropriation of these therapeutic treatments. By exploring these case studies from developing countries, this article intends to contribute to the field of studies that examine the diversification and complexity of migration and health care.

DESIGN

We first summarize the dynamics affecting the health-care systems in Ghana and Uganda over the last decades. Then, we describe the transnational mobility engaged in the two clinics. Through the case studies, we highlight how ARTs are realized and appropriated in the two receiving countries, and the role transnational contacts play within the negotiations of medical ethos and financial interests. By using the concept of medicoscapes, we analyze the worldwide connections between ART providers, the institutions they work in, their medical practices, artifacts, and their regimes of medical knowledge.

RESULT

Transnational professional contacts have been essential to the setup of both clinics offering ARTs in Ghana and Uganda. These contacts developed along colonial and post-colonial links, integrating also south-south relationship. The clinics' directors act as entrepreneurs and creative decision-makers who capitalize on their transnational professional network. The case studies show the diverse transnational entanglements in both clinics and demonstrate the frictions between the doctors' entrepreneurial interests, medical concerns and cultural values.

CONCLUSION

The transnational professional contacts expose both clinics to varying practices and debates, and make them into sites for negotiating distinct clinical practices. They provoke frictions between entrepreneurial interests and medical concerns including cultural values. In current medicoscapes, in a situation of full absence of any form of financial support and of any national ART regulation in Ghana and Uganda, clinic directors are in the position to apply those practices that fit their interests and local circumstances best.

Assisted reproductive technologies in Ghana: transnational undertakings, local practices and 'more affordable' IVF

The article sketches the origins and development of IVF in Ghana as a highly transnational undertaking. Movements are from and to Africa, involving human beings (providers and users), and also refer to other entities such as technologies, skills and knowledge. None of these movements are paid for using public money, neither are they subsidized by international health organizations. Currently, 'more affordable' IVF is being introduced into Ghana, on initiative of the first Association of Childless Couples of Ghana (ACCOG), in collaboration with the Belgium based non-profit organization the Walking Egg (tWE), representing another form of transnational networking. The article underlines the scarcity of well-trained embryologists in Ghana, which turns the embryologists' expertise and skills into a scarce and precious commodity and guarantees this expertise becomes a major challenge for the directors of the private clinics. Next to local Ghanaian couples, the clinics also attend to transnational reproductive travellers, including women and men from neighbouring countries and Ghanaians in the diaspora returning to their country of origin. Their manifold motivations to cross borders and visit the IVF clinics in Ghana provide insight into the structural conditions impeding or facilitating the use of assisted reproductive technologies at different local sites. Transnational movements also include the flow of new procreation practices (such as surrogacy and the use of donor material), which (re-)shape existing cultural and societal notions regarding kinship and the importance of blood/genetic ties. Finally, the article lists a number of thematic and theoretical issues which require further exploration and studies.

The ambiguity of patient-centred practices: the case of a Dutch fertility clinic

When in-vitro fertilization (IVF) was introduced in the 1970s, doctors were criticized for not properly informing prospective users about its possible risks and limited success rates as well as for medicalizing fertility problems. Nowadays, many fertility clinics are seeking to improve their accountability to stakeholders through patient-centred practices. Based on an ethnographic study of a Dutch fertility clinic, outspoken in its aims to provide patient-centred medicine and to empower clients, this paper addresses how patient-centred medicine affects couples' decision-making to use IVF and related reproductive technologies. The author contends that while patient-centred practices facilitate informed decision-making and support couples emotionally, they may also have unintended disciplining and normalizing effects. The information and support provided, the trust couples have in clinic staff, the ongoing visualization of conception mediated by medical technology--all can be seen as practices that strengthen lay people's 'medical gaze' in how they come to view their bodies, fertility problems and possible solutions. These unintended effects are labelled 'the ambiguity of patient-centeredness' as they (may) interfere with processes of autonomous decision-making.

The ambiguity of patient-centred practices: the case of a Dutch fertility clinic

When in-vitro fertilization (IVF) was introduced in the 1970s, doctors were criticized for not properly informing prospective users about its possible risks and limited success rates as well as for medicalizing fertility problems. Nowadays, many fertility clinics are seeking to improve their accountability to stakeholders through patient-centred practices. Based on an ethnographic study of a Dutch fertility clinic, outspoken in its aims to provide patient-centred medicine and to empower clients, this paper addresses how patient-centred medicine affects couples’ decision-making to use IVF and related reproductive technologies. The author contends that while patient-centred practices facilitate informed decision-making and support couples emotionally, they may also have unintended disciplining and normalizing effects. The information and support provided, the trust couples have in clinic staff, the ongoing visualization of conception mediated by medical technology – all can be seen as practices that strengthen lay people's ‘medical gaze’ in how they come to view their bodies, fertility problems and possible solutions. These unintended effects are labelled ‘the ambiguity of patient-centeredness’ as they (may) interfere with processes of autonomous decision-making.

Detection-loophole-free test of quantum nonlocality, and applications

We present a source of entangled photons that violates a Bell inequality free of the "fair-sampling" assumption, by over 7 standard deviations. This violation is the first reported experiment with photons to close the detection loophole, and we demonstrate enough "efficiency" overhead to eventually perform a fully loophole-free test of local realism. The entanglement quality is verified by maximally violating additional Bell tests, testing the upper limit of quantum correlations. Finally, we use the source to generate "device-independent" private quantum random numbers at rates over 4 orders of magnitude beyond previous experiments.

Biomedical infertility care in sub-Saharan Africa: a social science-- review of current practices, experiences and view points

Some sort of infertility treatments, including the use of advanced reproductive technologies (ARTs), is nowadays provided at several places in sub-Saharan Africa. Yet, to date only a few studies have actually looked into the way these treatments are offered, used and experienced. In this review article the authors present and discuss empirical study findings that give insight into the way biomedical infertility care is provided, considered, experienced and/or used in sub-Saharan African countries. They concentrate on four themes that were often referred to in the reviewed studies and underline the importance of taking into account the local sociocultural context and notions when developing and implementing infertility care, namely: counselling, male involvement, acceptability of ARTs and the use of donor material (semen and embryos). In the conclusion the authors emphasize the importance of preventing infertility as part of integrated reproductive health programs and the need to improve the quality of (low tech) infertility care in the public health sector by means of standardized guidelines, training of health staff and improved counselling. In addition, from a reproductive rights perspective, they support initiatives to introduce low cost ARTs to treat tubal factor related infertility. They also point to potential unintended side effects of the introduction of ARTs and the use of donor material in the sub-Saharan African context, affecting gender inequity and inequity between citizens from different social classes, and argue that such effects should be acknowledged and avoided by all possible means. Finally, they present an agenda for future social science research on this topic in sub-Saharan Africa.

Hunger, waiting time and transport costs: Time to confront challenges to ART adherence in Africa

Adherence levels in Africa have been found to be better than those in the US. However around one out of four ART users fail to achieve optimal adherence, risking drug resistance and negative treatment outcomes. A high demand for 2nd line treatments (currently ten times more expensive than 1st line ART) undermines the sustainability of African ART programs. There is an urgent need to identify context-specific constraints to adherence and implement interventions to address them. We used rapid appraisals (involving mainly qualitative methods) to find out why and when people do not adhere to ART in Uganda, Tanzania and Botswana. Multidisciplinary teams of researchers and local health professionals conducted the studies, involving a total of 54 semi-structured interviews with health workers, 73 semi-structured interviews with ARTusers and other key informants, 34 focus group discussions, and 218 exit interviews with ART users. All the facilities studied in Botswana, Tanzania and Uganda provide ARVs free of charge, but ART users report other related costs (e.g. transport expenditures, registration and user fees at the private health facilities, and lost wages due to long waiting times) as main obstacles to optimal adherence. Side effects and hunger in the initial treatment phase are an added concern. We further found that ART users find it hard to take their drugs when they are among people to whom they have not disclosed their HIV status, such as co-workers and friends. The research teams recommend that (i) health care workers inform patients better about adverse effects; (ii) ART programmes provide transport and food support to patients who are too poor to pay; (iii) recurrent costs to users be reduced by providing three-months, rather than the one-month refills once optimal adherence levels have been achieved; and (iv) pharmacists play an important role in this follow-up care.

Viewpoint: medical infertility care in low income countries: the case for concern in policy and practice

Based on published, 'grey' and anecdotal information, this paper explores some aspects of infertility, its medical treatment and their burden in poor countries. Many cases of infertility result from sexually transmitted infections (STI) and unsafe abortion and there is no doubt that their prevention and adequate treatment are of utmost importance, especially as effective infertility treatment, if any, comes at a high price for the consumer, materially as well as physically. Medical infertility interventions are apt to fail a free market of provision because of major information asymmetry. This renders patients in low-resource countries prone to exploitation, potentially damaging practices and waste of their savings. The authors argue that in countries struggling with limited funds and a range of pressing public health problems, public investment in infertility treatment should not have priority. But governments should take an active role in quality control and regulation of treatment practice, as well as invest in counseling skills for lower-level reproductive health staff to achieve rational referral of patients.

Quality of infertility care in poor-resource areas and the introduction of new reproductive technologies

The quality of infertility care is dependent upon adequate material resources and the appropriate use of it. In addition, a mutual understanding between physicians and patients is necessary. These imperatives are more salient in the era of the new reproductive technologies. However, in poor-resource areas these imperatives are insufficiently met. Moreover, in developing countries the negative consequences of childlessness are much stronger than in Western societies. Until recently, the problem of infertility in Third World countries has received little public attention. A plea is made for a stronger policy interest in Third World infertility care. In this it is important to focus on prevention, appropriate diagnosis and treatment at primary and secondary health-care level and to take the existing cultural beliefs into account.

Social and cultural aspects of infertility in Mozambique

Findings of an anthropological study of socio-cultural aspects of infertility among members of the matrilineal ethnic group Macua in the north of Mozambique are presented. Infertile women apply various strategies to have a child. Traditional healers are visited much more often than the modern hospital, and the explanations the infertile women themselves give for their infertility more often originated from the traditional healers than from the hospital staff. Almost all of the interviewed women commit adultery in the hope to conceive. Some of them apply fostering as a partial solution for childlessness. The Macua infertile women experience various consequences due to their infertility, of which exclusion from certain social activities and traditional ceremonies is perceived as a very problematic one. The matrilineal kinship system means that the husband and his family do not mistreat and repudiate her. Infertility must be considered as a serious reproductive health problem in Mozambique. For the long term preventive measures may be more influential than curative one. The findings of this study can be used to elaborate culturally sensitive health education programmes.