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doi:10.1093/humrep/den204

Human Reproduction 2008

False perceptions and common misunderstandings surrounding the subject of infertility in developing countries Willem Ombelet1,† Genk Institute for Fertility Technologies, Schiepse Bos 2, 3600 Genk, Belgium 1

Correspondence address. E-mail: willem.ombelet@telenet.be

Although the consequences of the problem of childlessness are more pronounced in developing countries when compared with Western societies, local health care providers and international organizations pay little attention on this issue. The limited budgets for reproductive health care are mostly restricted to family planning and mother care. The most common misunderstanding is the ‘overpopulation-issue’. It is generally believed that the expected growth of the world population puts a real burden on the issue of infertility treatment in resource-poor countries, although recent UN reports clearly show that in most developing countries the fertility rate is dropping significantly and will fall below the threshold of 2.0 by 2050. It seems that the expected population growth in developing countries in the next decades is rather due to population ageing and not to high fertility rates. Another important issue surrounding infertility in developing countries is the so-called ‘limited resources argument’. Because the problem of childlessness is a major health problem in most developing countries, a re-arrangement of the global reproductive health care budget should be requested from local governments and international organizations taking into account the urgent need for a go-together of more successful family-planning policies and affordable simplified ART methods. Keywords: affordable; assisted reproduction; developing countries; limited resources; population growth

Introduction In developing countries, unwanted childlessness creates a more profound problem when compared with Western societies. This is related to the fact that having children in developing countries has an important influence not only on the personal wellbeing of a couple, but also and even more pronounced on the women’s status within the couple, within the extended family and the community at large (van Balen and Gerrits, 2001). Children are highly valued for socio-cultural and economic reasons and childlessness often leads to psychological, social and economical burden, especially for women (Dyer et al., 2002, 2004, 2005). The social stigma of childlessness still leads to isolation and abandonment in many developing countries (Ebomoyi and Adetoro, 1990; Leke et al., 1993; van Balen and Gerrits, 2001; Giwa-Osagie, 2002; Daar and Merali, 2002), but the magnitude of the problem differs between different geographic areas because of different †

Chairman of the scientific committee of the Flemish Society of Obstetrics and Gynaecology. Coordinator of the ESHRE Special Task Force on ‘Developing countries and infertility’

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religious, ethical and sociocultural influences (Leke et al., 1993; Serour, 2002, 2006). Although the United Nations International Conference on Population and Development in Cairo in 1994 agreed on making reproductive health care universally available no later than 2015 (Table I), the progress that was made since than has fallen a long way short of the original goal (Fathalla, 2007). Until very recently the problem of infertility in developing countries has been ignored at all levels of health care management, not only in the developing countries themselves but also from an international viewpoint. This attitude of local governments in developing countries can be explained by a serious underestimation of the problem of childlessness and a lack of facilities and affordable treatment options. Even more important is the observation that in almost all resource-poor countries infertility is not a priority for the health authorities and the only destination of the limited resources spent on reproductive health is primary health care with two main objectives: to promote family planning services and to reduce maternal mortality and morbidity. This is easy understandable by the fact that the most common underlying

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False perceptions and common misunderstandings

Table I. Important citations and recommendations by different international organizations on the issue of infertility in developing countries. Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family (UN declaration of Human Rights, Article 16.1a) Infertility should be recognized as a Public Health issue worldwide, including developing countries (WHO meeting, Geneva, 2001b) Reproductive health implies that people have the capability to reproduce and the freedom to decide if, when and how often to do so (UN International Conference for Population and Development, Cairo, 1994c) a

www.un.org/rights; bVayena et al. (2002b); cUN. Report of the international conference on population and development, Cairo, Egypt, 1994 (www.iisd.ca/cairo.html).

cause for female and male infertility in developing countries, especially in sub-Saharan Africa, are sexually transmitted infections (STDs), unsafe abortions and post-partum infections (WHO, 1987; Nachtigall, 2006). Considering the international society, until now reproductive health strategies in Western countries focused on reducing total fertility rates in developing countries while infertility care received little or no attention (Hamberger and Janson, 1997). Because infertility as such is not directly life-threatening there is a widespread belief that infertility is not a pressing problem in poor developing countries where fatal and contagious diseases remain uncontrolled neglecting totally the social, psychological, economical and personal burden of childless women (Vayena et al., 2002b; Anonymous 2006). The second argument of Western societies and international organizations holds that supporting infertility treatment is unacceptable in countries struggling to decrease their fertility rate and failing to support their fast-growing populations, although recent figures of the United Nations show that in the great majority of developing countries the mean fertility rate nowadays already dropped significantly and is expected to decline to less that 2.0 by mid-century (http://esa.un.org/ unpp/). Another argument against the use of new assisted reproductive technologies (ART) in developing countries is the ‘limited resources argument’. In most developing countries, the problems of infectious diseases such as malaria, tuberculosis, gonorrhoea and HIV are still very prevalent and therefore most people believe that it should be questioned if expensive techniques with a low success rate, such as ART, can be justified in countries where poverty is still an important issue. The strong competition for funding is a reality in most resourcepoor countries leaving little space for expensive infertility treatment (Fig. 1). Consequently, international non-profit organizations will only focus on education, family planning, prevention of infertility and improvement of mother-care rather than giving support to make ART affordable and accessible for a large part of the population. Population growth perception The idea of infertility treatment in developing countries often evokes a feeling of discomfort and disbelief. There is no

Figure 1: Different factors responsible for the limited interest in the development of a ART in developing countries. HIV, human immunodeficiency virus; tbc, tuberculosis.

doubt that during the next decades the world population will grow from 6.5 billion inhabitants to .9 billion before the year 2050 (http://esa.un.org/unpp/). This increase will be most prominent in the poorest areas such as sub-Saharan Africa and South East Asia. According to the 2006 revision of the ‘World population prospects’ by the United Nations, the population of the more developed countries will decline slowly by 1 million a year by 2050, although that of the developing world would be adding 35 million annually, 22 million of whom would be absorbed by the least developed countries. The population of the less developed regions is projected to rise from 5.4 billion in 2007 to 7.9 billion in 2050. The global fertility rate (number of children per woman) in developing countries was 5.0 in 1950– 1955 and declined to 2.65 in 2000 – 2005. This rate is projected to decline further to 2.05 per woman by 2045 – 2050, i.e. below the replacement level of 2.1. In the majority of developing countries the mean fertility rate has already dropped as low as 2.58 per woman and is expected to decline to 1.92 by mid-century. The expected population growth in developing countries can therefore not be attributed to high fertility rates in the first instance anymore. As in most developed countries, an improved life expectancy, at least in the great majority of countries, will be the most important factor considering world population growth (http://esa.un.org/unpp/). Even in the least developed countries life expectancy is going to rise from an average of 51 years currently to 67 years in 2045 – 2050 which highlights the important issue of population ageing. In the context of overpopulation, another plea against the implementation of affordable infertility treatment is the argument that infertile people should adopt children instead of having their own children, given the large number of children in developing countries that are available for adoption. However, most reports indicate that adoption is not the answer in most developing countries because of socio-cultural reasons. On the other hand, proposing adoption as the only alternative for infertile couples denies the importance of reproductive anatomy and puts social responsibility for overpopulation unjustly on the infertile couples (Daar and Merali, 2002). 9


Ombelet

Competition for funding—the limited resources argument Bilateral tubal blockage and male infertility due to STDs are the leading causes of infertility in developing countries. While ART remains the most effective intervention for these conditions, funding remains a contested issue. This can be explained by the scarcity of health resources against a backdrop of limited funds. Some people believe that the infertile couple should be encouraged to courageously accept their condition of childlessness rather than be offered intervention (Tangwa, 2002). Most health care providers argue that the limited recourses should only be given to programmes focusing on reducing STDs, post-partum and post-abortion complications rather than offering high-technology treatments to infertile couples (Okonofua, 1996). According to many, training health care workers to carry out systematic evaluation and treatment protocols, making a correct diagnosis, offering counselling and conduct basic treatments might be possible and successful without adding to existing health care costs. Nevertheless, even in developed countries, the best prevention campaigns cannot entirely solve the problem of infertility. This is even more important in developing countries because the incidence of infection-related infertility is much higher resulting in a more important need for ART, unfortunately the most expensive treatment option. While prevention of STDs and pregnancy-related sepsis is a reproductive health priority, public investment in infertility treatment must also become a subject for discussion. For most developing countries, a large majority of the population cannot afford infertility treatment since new reproductive technologies are either unavailable or very costly (Malpani and Malpani, 1992; Van Balen and Gerrits, 2001; Nachtigall, 2006). Making ART less expensive, safe and affordable will be the key of success (Hovatta and Cooke, 2006; Pilcher, 2006; Ombelet and Campo, 2007). We have to acknowledge that if we do not succeed in substantially simplify ART procedures public funding of infertility-related health care will be restricted to education and preventative care because of cost-effectiveness considerations. In developing countries, even more than in developed countries, infertile couples do not have the right to the most effective treatment, regardless of cost, but to the most costeffective treatment, taking into account the cost implications for the health care system of that specific country (Pennings and Ombelet, 2007).

The go-together of infertility treatment and family planning/mother care programmes Considering the problem of infertility in developing countries, most local health care providers focus on primary health care such as the reduction of maternal mortality and the promotion of family planning. Moreover, international funding is restricted to what is thought women should have, potentially neglecting what women really want. In many rural areas of developing countries women see the problem of childlessness as far more important than the problem of excessive fertility indicating that infertility is indeed a major social and 10

healthcare problem in developing countries (Bergstrom, 1992; Daar and Merali, 2002; Aboulghar, 2005). When we succeed to develop simplified methods of infertility management and affordable ART, we will face a unique opportunity to move beyond the current status, which tends to focus on infertility prevention and health education, towards offering effective treatment. Moreover, infertility management, comprising both prevention and intervention, should be integrated into existing sexual and reproductive health care programmes. It will be very important to give the right message to the local authorities and to the international community: less children for couples with a high fertility potential, offering children for the childless couples. Importantly, the role of traditional healers should not be overlooked in this process. In many developing countries traditional healers are highly respected members of the community who often have the advantage over their Western counterparts of speaking the local language and living in the same culture as their patients (van Balen and Gerrits, 2001). Their cooperation may be pivotal to the success in the development of new health strategies.

Infertility in developing countries: the local government’s task The first priority is and should remain prevention rather than cure of infertility. It has been shown that a better education is the most effective and ethically desirable way of curtailing population growth (Macklin, 1995). On the other hand, education on reproductive health should also be promoted by the government and implemented at schools and at primary health care facilities. Education in sexuality and safe sex are the best measures to prepare the adolescent and to prevent infertility. Prevention of infertility can be organized by actions aiming at reducing the rate of STDs in the population and by improving the obstetrical and perinatal care. It is the duty of the local governments to make infertility discussable and accepted as a disease, taking into account the social and psychological suffering. Although the United Nations International Conference on Population and Development in 1994 (Cairo) clearly highlighted ‘prevention and appropriate treatment of infertility where feasible’ and despite the recommendations of the WHO meeting on ‘Medical, Ethical and Social Aspects of Assisted Reproduction’, Geneva, 2001 (Vayena et al., 2002a) almost no progress is made in education and service in South East Asia and sub-Saharan Africa due to a lack of guidelines or concrete actions and programmes (Fathalla et al., 2006). In most developing countries the public health service agenda is very distant from the people’s agenda. Due to a lack of interest of health care providers, a lot of infertile patients are prone to exploitation and potentially damaging practices (Van Balen and Gerrits, 2001; van Zandvoort et al., 2001), another important reason for asking local politicians to support the idea of simplified infertility treatment.


False perceptions and common misunderstandings

Conclusion While recognizing the important and crucial role of education and prevention, the issue of infertility in developing countries requires greater attention at national and international levels for reasons of social justice. Even if we succeed in making infertility diagnosis and treatment affordable for a large part of the population in developing countries, a lot of questions concerning this issue will remain the same and a lot of people still throw doubt upon the value of affordable ART in resource-poor countries, in most cases using the limited resources argument. With respect to public health, evidence supports the compelling need for infertility treatment beyond prevention in developing countries. Cost-effectiveness will be crucial. To examine the possibility of low-cost ART should be supported by local and international communities because ART will be the last hope to achieve a child for many couples.

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false perceptions