COMMENTARY: The importance of fertility treatment in the developing world
Health is defined in the Constitution of the World Health Organization (WHO) as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease of infirmity’.1 Reproductive health, therefore, implies that people have the ability to reproduce, to regulate their fertility and to practice and enjoy sexual relationships. The ability to reproduce is a basic element of reproductive health. Infertility, in itself, may not threaten physical health, but it can have a serious impact on mental and social health.
In Western countries, childlessness has a profound influence on the personal wellbeing of the women and men concerned. Recent studies have shown that in developing countries (where children are highly valued for economic and socio-cultural as well as personal reasons) childlessness often creates enormous problems for the women and men involved, within the couple, the extended family and the community at large.2 Childless women particularly suffer, not only because they are generally blamed for the infertility, but also because motherhood is often the only way for women to enhance their status within the family and community. In many areas, childlessness is associated with marked social stigma and may lead to isolation and neglect.2 In many parts of the developing world (e.g. Nigeria3 and Laos4) infertile women are despised, perceived as evil beings and excluded from societal events. Childless women complain about domestic violence and disrespectful treatment by husbands and families-in-law; others are abandoned by their husbands or end up as a second wife in a polygamous marriage.2
The scale of the problem
Infertility is a problem of global proportions, affecting on average 8–12% of couples worldwide. In some societies, however—particularly those in the ‘infertility belt’ of sub-Saharan Africa—as many as one-third of all couples are unable to conceive.5 In recent years epidemiological surveys have demonstrated that sub-fertility is also a problem for many women in Third World countries.6 In several, this problem has the highest prevalence of any ‘population problem’. Field experiences show that in many rural areas of the Third World women see the problem of childlessness as far more important than the problem of over-fertility.6,7 In many developing countries around 10% of all women's visits to doctors (all categories of medical doctors) are related to problems of childlessness.8
The aetiology of infertility
In the developing world, the most common and important cause of acquired infertility is preventable pelvic infection as a result of sexually transmitted diseases, unsafe abortion or puerperal infection.9 The type and mode of infection varies from one developing country to another, but in sub-Saharan Africa, sexually transmitted infections are the main cause of infertility.2 In other developing countries, post-abortive and postpartum infections with salpingitis are more common. Non-sterile evacuation of the uterine cavity at abortion or delivery may be complicated by bacterial contamination, with ensuing fever, endometritis and ultimately salpingitis.8 Thus, illegal abortion is one of the most important causal factors in secondary infertility.10 Abortions and deliveries performed by untrained people in rural areas greatly increase the risk of post-abortive or postpartum infertility.8
A review of iatrogenic infertility in Western Europe suggests that iatrogenic causes of infertility may be responsible for 5% of the total.11 In Africa, however, the rate may be much higher. In one Egyptian study 15.5% of the infertile couples investigated had iatrogenic causes.12 Several factors contribute to this high incidence of iatrogenic infertility among the Egyptian couples. First, this study was conducted in two large infertility referral centres that deal mostly with complicated cases, many of whom have had previous treatments already. Second, there is a high prevalence of folk methods of infertility treatment, many of which may worsen the problem rather than help.13 And finally there appear to be high rates of medical malpractice in the management of infertility in the developing world. Unregulated private practices offer considerable potential for making large profits from infertile women, and this can attract doctors who are more interested in wealth than ‘good practice’. This, combined with a lack of proper training of doctors in new techniques, may be responsible for this.14
The problem of infertility treatment
In discussions about infertility care in developing countries, the focus is often on prevention. Reproductive tract infections, particularly sexually transmitted diseases, are the leading preventable cause of infertility. In a WHO multinational study it was found that 60% of infertile women in sub-Saharan Africa had diagnoses that could be attributed to infection.15
The quality of health care services plays an important role in the prevention of genital tract infection. However, services offered by trained health workers for pregnancy, delivery and childcare are often inaccessible to pregnant women in developing countries. WHO data show that there are large sectors of the population in developing countries with poor coverage of services. Wide variations in the coverage of maternity care services exist both between and within geographic areas with overall only 58% of the births worldwide being attended by trained personnel.
There is wide consensus on the need to reduce maternal mortality and the health services, which are being expanded to reach this goal will also help in reducing postpartum and post-abortive infections. Four countries, namely Bolivia, Yunan in China, Egypt and Jamaica, have halved their maternal mortality rates in less than 10 years, starting from levels over 200.16 It is expected that the incidence of infertility will also now drop in these countries due to reduced rates of infection after delivery and abortion.
The treatment of established cases of infertility in the Third World will continue to be a difficult problem. This is largely because the new assisted reproduction technologies (ARTs) such as IVF represent the only solution to most cases of tubal and male infertility. But introducing new technologies for the diagnosis and treatment of infertility is expensive and demands a specialised and well-organised medical and paramedical staff. Not only are there important biological, medical and technical requirements, but a constant supply of resources has to be guaranteed, the materials have to be of good quality and services have to be accessible and affordable. In short, for ART to cover a whole country the standard of reproductive health care must not just be of very high quality, but the socio-cultural and economic context must also be appropriate.2
Despite these constraints, ART services are rapidly spreading to the pronatalist developing societies, where children are highly desired, parenthood is culturally mandatory and childlessness socially unacceptable. There are, however, considerable problems with the practice and utilisation of ART in developing countries on the ‘receiving end’ of global reproductive technology transfer. In most developing countries, ARTs are either unavailable or only available for patients who can afford them. In reality the cost is out of the reach of the vast majority of people and the general and specialised government health care services are generally inadequate to provide them. This problem is not restricted to a few countries—the high cost of ART is a problem throughout the world. A study of women in the United States who did not pursue a second IVF cycle after the first had failed found that the major reason was financial.17 The cost of IVF varies widely between countries both due to different ways of calculating costs and because of differences in wages, equipment and prices. In developing countries, although the cost of one trial of IVF is very much lower than that in Europe, the majority of people still cannot afford this treatment because of the low per capita income.
The public health agenda
Treatment of infertility (especially by ARTs) is not a priority for the health authorities in the developing world, who instead focus their limited resources on primary health care. Currently in reproductive health, their two main objectives are to reduce maternal mortality and morbidity and to promote family planning. This, however, contrasts with the public's agenda.
In the developed world, the government health service agenda is rarely different from that of the people, with any differences usually being small. In the developing world, however, most women consider that infertility treatment is of utmost importance. For most, the treatment of infertility comes first, even before the treatment of their own illnesses (irrespective of whether they could even lead to serious morbidity or death).8 In contrast, infertility treatment comes low down on the health authorities' agendas. And where they do show interest, they are mainly interested in the prevention of infertility as a part of general measures to improve reproductive health. Competition for available resources between high-technology medicine on the one hand and routine primary health services on the other has created severe stresses within the health care system. But under pressure from society over 50 private IVF centres are now operating in Egypt. In addition, a few IVF centres have opened in universities and in the public health sector offering services at relatively low cost.
Only time will tell whether the increased provision of ARTs in the developing world will reduce the price to levels affordable by large numbers of the population. Without donor aid it is unlikely that this will occur, and for most donors infertility treatment in the over populated developing world is not considered equal to the treatment of ‘serious’ health hazards. However, political pressure in the 1990s led to anti-retroviral drugs becoming available to large numbers of the worlds poor, a concept unimaginable just a few years earlier. Now, in the new millennium, will the same happen for fertility techniques so that the international donor communities start to provide not what they think women should have, but what the women really want?