Mother or nothing: the agony of infertility

Many infertile women in developing countries consider that, without children, their lives are without hope. Weiyuan Cui reports on the burden many of these women carry and the lack of affordable care.

Ann [not her real name] lives in Kampala, Uganda, with her husband and one child from her husband’s previous relationship. When she was married in 1996, Ann happily accepted his then four-year-old boy in the hope that one day she would have a biological child of her own. Unfortunately, in the early years of her marriage, she suffered several miscarriages including one that caused “extreme pain” and bleeding and rendered her unconscious.

“When I woke up, I found myself in the hospital. The doctor told me that I had an ectopic pregnancy. They had to take away the baby that was dying inside me,” she says. Later she was told that she would no longer be able to conceive.

Photoshare/Daniel Rhee

Ugandan women are not accepted by society unless they have a child.

“Ectopic pregnancy can lead to infertility but more common causes include tubal occlusion from reproductive tract infections, which are often sexually transmitted, postpartum complications or unsafe abortion practices,” says Dr Sheryl Vanderpoel from the Reproductive Health and Research Department at the World Health Organization (WHO). In countries such as India that have high rates of tuberculosis, genital tuberculosis is also a major, often undetected, cause of infertility.

Infertility affects up to 15% of reproductive-aged couples worldwide. WHO demographic studies from 2004 have shown that in sub-Saharan Africa, more than 30% of women aged 25–49 suffer from secondary infertility, the failure to conceive after an initial first pregnancy.

Although male infertility has been found to be the cause of a couple’s failure to conceive in about 50% of cases, the social burden “falls disproportionately on women,” according to Dr Mahmoud Fathalla, previous director of the Special Programme of Research, Development and Research Training in Human Reproduction based at WHO. “When a couple is unable to reproduce, the man may divorce his wife or take another wife if they live in a culture that permits polygamy,” he says.

In many cultures, childless women suffer discrimination, stigma and ostracism. For example, Ann was banned from attending her father-in-law’s funeral. “The relatives, when getting together, talk a lot about their children or being pregnant and having children. Those are the moments when I feel extremely isolated. So often, people do not regard you as a human. There is no respect,” she laments. “Women like me often have to bear the extra-marital relationships that our husbands tend to have. I have overheard other women talking about us as being cursed.”

According to Vanderpoel, “the stigmatization can be extreme in some countries, where infertile people are viewed as a burden on the socioeconomic well-being of a community. Stigma extends to the wider family, including siblings, parents and in-laws, who are deeply disappointed for the loss of continuity of their family and contribution to their community. This amplifies the guilt and shame felt by the infertile individual,” she says.

Rita Sembuya, founder of the Joyce Fertility Support Centre in Uganda, says that this frustration and agony is shared by all women who come to her centre. “Our culture demands that, for a woman to be socially acceptable, she should have at least one biological child,” says Sembuya. “Almost all cultures across Africa put emphasis on women having children … marriage without children is considered as a failure of the two individuals.”

Photoshare/Connelly La Mar

Infertility prevention should start with community health education, such as in this class in New Delhi, India.

Uganda is one of the countries in the “African infertility belt” that stretches across central Africa from the United Republic of Tanzania in the east to Gabon in the west. In this region a phenomenon described as “barrenness amid plenty” refers to the fact that infertility is often most prevalent where fertility rates are also high.

“In a world that needs vigorous control of population growth, concerns about infertility may seem odd, but the adoption of a small family norm makes the issue of involuntary infertility more pressing,” says Fathalla. “If couples are urged to postpone or widely space pregnancies, it is imperative that they should be helped to achieve pregnancy when they so decide, in the more limited time they will have available.”

Despite their importance, infertility prevention and care often remain neglected public health issues, or at least they rank low on the priority list, especially for low-income countries that are already under population pressure. Low fertility is becoming more common worldwide, particularly in ageing populations and many urban settings where women are having their first babies at older ages.

Health policy-makers are increasingly being urged to begin to integrate infertility prevention, care and treatment into the work being done to strengthen maternal, newborn and reproductive health-care systems.

For many infertile women, particularly those with problems such as blocked or severely scarred fallopian tubes where surgical tubal repair is either not successful or not advisable, in vitro fertilization (IVF) can help. This technology enables eggs to be fertilized directly by sperm outside the woman’s body, without the egg or sperm having to pass through a blocked tube. The fertilized embryo is then transferred back into the woman’s uterus.

Unfortunately for most women in developing countries, infertility services are not widely available and IVF is unaffordable. While optimal utilization of IVF is estimated to be around 1500 cycles per one million population per year, provision of the service falls significantly short in developing countries, according to Dr Gamal Serour, president of the International Federation of Gynaecology and Obstetrics (FIGO) and director of the International Islamic Center for Population Studies and Research at Al Azhar University in Cairo, Egypt.

Courtesy of Rita Sembuya

Rita Sembuya, founder of the Joyce Fertility Support Centre in Uganda.

“As the cost of establishing advanced infertility centres is very high, only a limited number of centres were established in some low- and middle-income countries and most remain in the private sector,” says Serour. In Uganda, an IVF service provider run by the Women’s International Hospital relies on foreign doctors from Belgium, Kenya and Nigeria who fly in and out of the country. “This raises the cost and is not sustainable,” says Sembuya.

The situation is further exacerbated by the lack of support women face, both emotional and financial. In sub-Saharan Africa “women are not encouraged by their male partners to seek modern technical treatments,” says Serour. Combined with the widespread lack of insurance coverage, seeking fertility care often means a lonely path for women wishing to conceive.

“My husband is not supportive at all. He knows he could have more children from other relationships if he wants,” says Ann, who sold her inheritance, a plot of land, to pay for one cycle of IVF. That cycle, costing Ann around US$ 4900, was not successful.

“At this rate, it will take me another nine years to save enough money for a second cycle, and by then I will be too old,” Ann cried out of despair. “We cannot afford it. I am going to die without my own biological child.”

For many infertile women in low-income countries, some hope may lie in the introduction of affordable infertility services. An inspiring example is Egypt, which has managed to reduce its population growth and expand infertility care at the same time. About 51 private and public infertility treatment centres have mushroomed in the past three decades. The busiest public centre, located in Al-Azhar University, Cairo, provides fertility care including subsidized IVF cycles for US$ 600 per cycle to serve hundreds of Egypt’s infertile couples every year.

In India, pioneer programmes have been able to cut costs by one third by giving low doses of hormones to stimulate ovulation. “While this produces fewer eggs, it is more patient-friendly and we manage to obtain acceptable levels of healthy live birth rates,” says Dr Suneeta Mittal, head of the Department of Obstetrics and Gynaecology at the All India Institute of Medical Sciences in New Delhi, India. Current costs of one IVF cycle are around 60 000 Indian rupees (US$ 1300), the equivalent of six months’ salary for some couples. Her clinic is working to reduce this cost to 20 000 rupees (US$ 430) and to develop a programme that targets prevention of infection and education about fertility. “There’s so much stigma attached to being infertile in India. It is so important to address this issue,” she says.

“Services to assist infertile couples need to be integrated and holistic – starting from the community level to demystify the cause and prevent infertility when possible, and to provide referral for affordable care if infertility is unavoidable,” Vanderpoel adds. “Infertility prevention also involves important lifestyle choices. The outcome of quality fertility care is a healthy birth. Maternal and newborn health does not begin during antenatal care, nor should it only be addressed at the time of birth. Rather, it starts with quality reproductive health care which includes pre-conception fertility care.”

Please respond with a paragraph to the following post, add citations and references.

The strength or validity of the best research evidence in an area depends on the quality and quantity of the studies that have been conducted in regards to that area. Quantitative studies provide the strongest research evidence. Systematic research reviews and meta-analyses of high quality, experimental studies provide the strongest or best research evidence used by expert clinicians in practice to determine best evidence-based practice. The weakest evidence comes from expert opinions, which can include expert clinicians’ opinions, or the opinions expressed in committee reports.

The levels of best research evidence listed from strongest to weakest are:

1. Systematic review of experimental studies
2. Meta-analysis of experimental, quasi-experimental and outcomes studies
3. Integrative reviews of experimental, quasi-experimental and outcomes studies
4. Single experimental study
5. Single quasi-experimental study
6. Meta-analysis of correlational studies
7. Integrative reviews of correlational and descriptive studies
8. Qualitative research meta-synthesis and meta-summaries
9. Single correlational study
10. Single qualitative or descriptive study
11. Opinions of respected authorities based on clinical evidence, reports of expert committees

References

Grove, S., Gray, J., & Burns, N. (2015). Understanding Nursing Research: Building an Evidence Based Practice. Retrieved from https://pageburstls.elsevier.com/#/books/978145577…

In your initial post, discuss how healthcare trends have impacted nursing education. Consider topics such as the aging population, advances in technology, and a move toward outpatient care and illness prevention, rather than inpatient care and illness treatment. How do you believe this might impact your future educational, academic, and career goals? Define career readiness for nursing practice. How have you already or can you prepare yourself for effective nursing practice amidst these emerging trends? What nursing roles interest you most that are outside of your current role/expertise? What additional knowledge/skills do you need to acquire to function effectively in these roles?

NO APA REQUIRED. APA REFERENCES REQUIRED

To Prepare:

• Review the video Crisis, Trauma, and Disaster Response: Sexual Trauma found in the Learning Resources for this week and consider how you might use this information to help you conceptualize the case study for this Assignment.
• Review the Case Study Jamie, Maria, and Sofia Luna, provided in the Learning Resources and use this Case Study to complete this Assignment.
• Review and use the Case Conceptualization Template provided in the Learning Resources and use this template to complete this Assignment.

Assignment:

In the Case Conceptualization Template, complete the following:

• Assessment
• Case Conceptualization
• Treatment Plan
• Interventions

Be sure to support your recommendations with specific references to the Learning Resources. Use proper APA format and citations.

Hello,

There are two exercises in English Literature and the instruction is listed below:

Please do it as the last time in length (one to two pages), it should not be too long just answer the questions. You only need to follow the instruction of each exercise and you will be fine. Please find the attached PowerPoint to find the pictures for the first exercise.

Here are the exercises:

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Exercise #1: Choose five (5) Maier photos and write three (3) first sentences for each which might serve to possibly start a story. Don’t write the story! Just write 5 first sentences — sentences that could “open” 5 different stories for each photo. In total, you’ll have 15 sentences when you’re done with this first assignment. I know the photos aren’t numbered or identified, so to let me know which photo you’re writing sentences for — please just give a brief description, like this …

Photo of 2 kids eating ice cream

1. They’d asked their mom if they could go along with her to meet the man but she’d said no and bought them off with ice cream cones.

2. Jimmy wanted chocolate, but his brother Timmy ordered first so he had to get vanilla.

3. The only time they were allowed ice cream was when grandma was coming to town.

Exercise #2: Write a brief (5-10 sentences) story about something that really did happen to you — and write it in 1st person (I/me/my/mine). It doesn’t have to be dramatic, just something that’s important enough to remember. Think of the “stock” stories you tell people when you first meet them. Maybe it’s about a certain holiday (the Thanksgiving grandma got drunk on punch) or the time you scored the winning points in a game, or the first time you saw your girlfriend/boyfriend. Anything will work. Then … rewrite the story in 3rd person (he/she/it, or give names). You can substitute pronouns, but as you do so you’ll find the story begins to change, morphing into “something else,” perhaps requiring stylistic and grammatical changes.

For instance, maybe my first sentence is “One Thanksgiving my grandma got drunk on punch. She kept asking me to refill her glass, so I did.” When I rewrite the story into 3rd person I’m going to have to do this: “One Thanksgiving Grandma Jones got drunk on punch. She kept asking her granddaughter to refill her glass, and her granddaughter did.” If I want to, I can give the granddaughter a name, like Susan: “One Thanksgiving Grandma Jones got drunk on punch. She kept asking Susan to refill her glass, and so her granddaughter did.” This assignment is good practice for writers, showing you how to switch POVs (points of view). Writers often play around with POVs as they try to get a good feel for the story. Should I tell it in first person? Or third person? Or even second person (sometimes a delicate or dicey challenge)?

Writers also play with TENSE — present or past are usually the choices. Do you want your story to take place “in the now,” in PRESENT TENSE? Or in the PAST TENSE? For example: “Grandma Jones got drunk on punch” is past tense, whereas “Grandma Jones is getting drunk on punch” is present tense, as if the action is happening right now. It doesn’t matter which tense you choose, however, for the most part you need to stick with that tense throughout the story. In other words, don’t wobble between present and past tenses, which is confusing for the reader and makes for tough reading.

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