THINKING OF SOMETHING TO SAY: PUBLIC AND PRIVATE NARRATIVES OF INFERTILITY

Autobiographical narratives of infertility are situated in both the private and public domains, particularly since the advent of assisted reproductive technology. Narratives of infertility told by 31 Australian women reveal that the tension between the public and the private is an uncomfortable one for the narrators. Infertile women must deal not only with the blow inflicted by infertility to their sense of self, but also with the difficulties of presenting a simple and coherent life story in the social world. The women expressed resentment at the public expectation that they should justify their desire to become mothers. Infertility support groups play a role in the construction and dissemination of a public narrative of infertility that is not pathological.     

What do women want? Women's experiences of infertility treatment

Finnish women's experiences of infertility treatment were investigated by examining their satisfaction and dissatisfaction, and their most positive and negative experiences with the treatment. Three hundred and forty four (16%) out of the 2,189 women respondents to a 1994 postal survey (response rate 74%) had experienced difficulties in having a baby. Two-thirds had sought medical help, generally from private gynaecologists. Less than half of the women were satisfied with the infertility treatment, expressing less satisfaction than is generally found among health care clients. Dissatisfied women were more often 35-39 years of age, in treatment during the study period, in treatment in public clinics and not successful in having a baby. However, about one-third of the women were unsure about or did not give their opinion in regard to satisfaction. The subsequent birth of a baby was the most common reason for satisfaction. The most positive treatment experience was respectful, empathic and personal care from the doctor. Unsatisfactory encounters with health care personnel were the main reasons for dissatisfaction and were most often cited as the most negative treatment experience. This dissatisfaction could reflect relatively young and healthy women's assertive attitudes toward infertility care services in the context of the intimacy and vulnerability of childlessness.     

Primary and secondary infertility in sub-Saharan Africa

BACKGROUND: No previous study has provided national estimates of the prevalence of primary and secondary infertility in sizeable areas of sub-Saharan Africa. METHODS: Primary infertility is measured by the proportion childless among women who entered their first marriage at least 7 years before date of censoring. Secondary infertility is measured by the 'subsequently infertile estimator' from parous ever-married women. Exposure begins at the age of the woman at the birth of her first child, and exposure ends when the woman is of an age, which is 5 years lower than her age at censoring. These last 5 years are used to determine her status as infertile or fertile at the last observation 5 years before censoring. A woman is considered infertile at last observation if she has had no livebirths during the last 5 years before censoring, otherwise she is considered fertile. A woman who has not given birth at age a or later is defined as being 'infertile subsequent to age a'. The index of the proportion subsequently infertile at age a is estimated as the number of women infertile subsequent to age a, divided by the total number of women observed at that age. Infertility is estimated for women age 20-44. RESULTS: Primary infertility is relatively low and it exceeds 3% in less than a third of the 28 African countries analysed. In contrast, elevated levels of secondary infertility prevail in most countries. Secondary infertility for women age 20-44 ranges from 5% in Togo to 23% in Central African Republic. CONCLUSIONS: It is feasible to gauge national levels of primary and secondary infertility from population based surveys including a birth history. The prevalence of infertility of pathological origin is so high in sub-Saharan Africa that infertility is not merely an individual concern, it is a public health problem.     

Women and private medicine

Women are higher users of private sector in-patient health care than men and the difference is more pronounced than in the NHS. This paper draws on data collected early in 1991 for a survey of private patients in one Regional Health Authority in England at a time when public health services were experiencing extensive reforms. Reasons for ‘going private’ identified by women centred around issues of privacy, level of care, and the ability to choose admission dates. While the reasons men gave were broadly similar, a closer examination revealed gender differences in their interpretations. These variations can be accounted for by the different socialisation, social roles and social position of men and women. It is concluded that health care needs and their interpretation are likely to be very different between groups of men and women, with divisions existing along lines of class, age and race as well as gender. Without an understanding of the differing health care needs and wants of these groups, the public sector will not be able to provide services that provide consumer satisfaction.     

Physician-patient communication in the prevention of female reproductive tract infections: some limitations

The objective of this study was to describe the information that women with tubal infertility recalled having received from physicians when they consulted for a reproductive tract infection (RTI) and the information physicians reported having provided to women consulting for RTIs. Interviews were conducted with 16 women presenting primary tubal infertility selected on the basis of purposeful sampling criteria. Also, 15 physicians working in the public health network in the city of Campinas, Brazil, were selected at random and interviewed. Analysis of the women's statements concerning previous RTI-related medical consultations showed that they did not recall having received any information on either prevention or the impact of RTI on their reproductive future. Analysis of interviews with physicians showed that the information they provided to women consulting for RTIs was incomplete and unclear. The information women recalled having received and that which physicians remembered having provided at the time of treating a patient with RTI was similar. In conclusion, these women lacked adequate or complete information and that it was probably not possible for them to adopt measures to avoid repetition of RTI and minimize risk of tubal infertility.     

Insurance coverage of special foods needed in the treatment of phenylketonuria.

Optimal medical management of phenylketonuria (PKU) requires the use of special low-phenylalanine foods for many years. For women with PKU, elevated maternal blood levels of phenylalanine even at conception can lead to fetal damage. Despite this need, private health insurance, Medicaid, and other public health programs often exclude the cost of these foods from their benefits. The New York State Department of Health conducted a survey of metabolic disorders treatment centers to elucidate the problems PKU patients have obtaining and paying for the special foods essential to their care. Payment for special foods was denied to nearly half of those with private health insurance policies and was covered for only 10 percent of Medicaid-eligibles. A public program for children with special health care needs covered these food costs in upstate New York but not in New York City. There is no program of assistance for adults who are not eligible for Medicaid and who do not have private insurance coverage of special foods. At present, many private health insurance policies and public programs do not cover the costs of low-phenylalanine foods other than infant formula. Payment for this essential part of the management of PKU should be mandated for all public programs for persons with chronic illnesses, public medical assistance (Medicaid) programs, and private health insurance. There is a need for a public program to assist adults with PKU who are not eligible for Medicaid and who do not have health insurance that covers these costs.     

Use of infertility services in the United States: 1995

CONTEXT: Both the demand for and the availability of infertility services in the United States increased during the 1980s and early 1990s. Understanding the factors that are related to service-seeking among women with current fertility problems would aid efforts to better provide services. METHODOLOGY: Data on U.S. women's use of infertility services were taken from the 1995 National Survey of Family Growth, a nationally representative survey of 10,847 women aged 15-44. For the 1,210 women who at the time of the interview reported having fertility problems, multivariate statistical modeling was used to identify the characteristics associated with their use of infertility services. RESULTS: Of the 6.7 million women with fertility problems in 1995, 42% had received some form of infertility services. The most common services ever received among these women were advice (60%) and diagnostic tests (50%), medical help to prevent miscarriage (44%) and drugs to induce ovulation (35%). The proportions of fertility-impaired women who had ever received infertility services were generally highest among those who were older, who had ever been married, who had graduated from college, who had a high income and who were non-Hispanic white. Multivariate analyses reveal that apparent differences by age and race or ethnicity in the unadjusted analysis disappear once the effects of women's marital status, income and private health insurance coverage are taken into account. CONCLUSION: Women who have ever used infertility services continue to represent a select group from among those with impaired fertility. Moreover, the vast majority of women with fertility problems who seek services receive noninvasive treatments that could be considered "low technology" interventions.     

Frustrated demand for postpartum female sterilization in Brazil

During the last three decades, Brazilians have relied almost exclusively on two contraceptive methods, the pill and female sterilization, with sterilization use increasing over time. Until a new law was passed in 1997, sterilization was virtually illegal and not covered by either public or private health insurance. It was, however, frequently provided in public and private hospitals in conjunction with a cesarean section. The new law regulating sterilization provided for reimbursement for interval sterilizations by public health insurance, but placed restrictions on availability intended to reduce the use of cesareans. These restrictions included the prohibition of postpartum sterilizations. This paper focuses on women's sterilization intentions during pregnancy and their experiences postpartum. In a prospective study of 1612 pregnant women carried out in four Brazilian cities, there was substantial demand for postpartum sterilization in both the private and public sectors among women who wanted no more children. However, public patients were much less likely to be sterilized than private patients. Thus, the new law may not have reduced inequities in access or, paradoxically, the incentive for unnecessary cesarean sections.     

Emotions, fertility, and the 1940s woman

This paper looks at the ways that women's reproductive issues, particularly sterility, were explained during the post-World War II period. In the absence of a clear physiological basis, sterility was depicted as a product of psychoanalytic causes rooted in women's psychology. When women were yearning for a reason for their infertility and desperate for effective treatments, a psychoanalytic framework treated deficiencies lurking in the field of infertility. Framing infertility within a psychiatric construct influenced how women were treated by their medical specialists and how they were perceived by a public that expected married women to reproduce. An infertile woman was already considered a failure by society. By establishing her illness within the context of her own repressed desires, she was no longer an unwitting victim, but a culprit.     

Infertility treatment and fertility-specific distress: A longitudinal analysis of a population-based sample of U.S. women

Because research on infertile women usually uses clinic-based samples of treatment seekers, it is difficult to sort out to what extent distress is the result of the condition of infertility itself and to what extent it is a consequence of the experience of infertility treatment. We use the National Survey of Fertility Barriers, a two-wave national probability sample of U.S. women, to disentangle the effects of infertility and infertility treatment on fertility-specific distress. Using a series of ANOVAs, we examine 266 infertile women who experienced infertility both at Wave 1 and at Wave 2, three years later. We compare eight groups of infertile women based on whether or not they have received treatment and on whether or not they have had a live birth. At Wave 1, infertile women who did not receive treatment and who had no live birth reported lower distress levels than women who received treatment at Wave 1 only, regardless of whether their infertility episode was followed by a live birth. At Wave 2, women who received no treatment have significantly lower fertility-specific distress than women who were treated at Wave 1 or at Waves 1 and 2, regardless of whether there was a subsequent live birth. Furthermore, fertility-specific distress did not increase over time among infertile women who did not receive treatment. The increase infertility-specific distress was significantly higher for women who received treatment at Wave 2 that was not followed by a live birth than for women who received no treatment or for women who received treatment at Wave 1 only. These patterns suggest that infertility treatment is associated with levels of distress over and above those associated with the state of being infertile in and of itself.     

Value of hysteroscopy in management of unexplained infertility

ObjectiveTo assess the value of hysteroscopy in unexplained infertility.Methods200 infertile women in whom standard infertility investigations revealed no abnormalities were included in the study between January 2009 and December 2013. All women underwent hysteroscopy for diagnosis and treatment of any uterine lesion which was previously undetected by hysterosalpingography (HSG). Treated women were followed up for one year during which pregnancy rate was determined. As all other causes that contribute to infertility (other than the subtle uterine lesions) were excluded. No other infertility treatment was performed during this period.ResultsOf the 200 women studied, hysteroscopy revealed abnormalities in 65 (33%) women. Most uterine abnormalities were mild adhesions, small submucous myomas and polyps and their incidence was greater in women aged ≥ 30 years and women with secondary infertility. The overall pregnancy rate in the treated women within one year of follow up was 46%.ConclusionAs a cause of unexplained infertility, subtle uterine abnormalities are diagnosed only during hysteroscopy and they are relatively common in infertility women. Although the presence of these abnormalities is not detected by the basic investigations for infertility, their correction seems to be necessary when infertility is desired and other infertility causes are excluded.     

Predictors of choice of public and private maternity care among nulliparous women in Ireland,and implications for maternity care and birth experience

Maternity care in Ireland is provided through a mixture of free public and fee-based private or semi-private services. We examined factors associated with choice of care pathway among nulliparous women and how this influences the care they receive and their experience of childbirth using data from a prospective cohort study. Complete data were available for 1,789 women on choice of care pathway and birth outcomes, and for 1,336 women on birth experience. Maternal age (marginal effect [ME] 1.6 percentage points [ppts], p < 0.01), socioeconomic status (ME 0.5ppts, p < 0.01) and being born in Ireland (ME 10.3ppts, p < 0.01) were all positively associated with choosing private care, but level of risk in early pregnancy did not influence this decision. Intervention rates in public and semi-private care were comparable, but women in private care were more likely to receive epidural anaesthesia (odds ratio [OR] 1.65, p < 0.01) and give birth by caesarean section (ratio of relative risks [RRR] 1.98, p < 0.01). Private care was also associated with longer hospital stays (28 % longer, p < 0.01). Increased risk was negatively correlated with birth experience in public and semi-private care, but not in private care. Policies promoting the allocation of maternity care resources by level of risk, along with the standardisation of clinical practice across care pathways, could reduce rates of obstetric intervention and address risk-based disparities in birth experience outcomes.     

Outcomes of enhanced prenatal services for Medicaid-eligible women in public and private settings.

OBJECTIVE: With changes in Medicaid, more low-income women are receiving prenatal care in private practice settings. The authors sought to determine whether private settings can provide the enhanced prenatal support services for low-income women that have been offered for decades in public settings. METHODS: The authors analyzed birth outcomes of Medicaid-eligible women receiving care from public and private providers certified to deliver enhanced prenatal care services, which included assessments of nutritional, psychosocial, and health educational risks and individualized counseling along with clinical care. Birth outcomes were compared by type of provider setting using multivariate logistic regression models to adjust for differences in risks and use of care. RESULTS: Among settings certified to deliver enhanced perinatal support services, private physicians'' offices had the best risk-adjusted birth outcomes and public health department clinics the worst, while public hospital clinics had outcomes no different from private physicians'' offices. Adjusted for prenatal care use, outcomes were still better for women seen in private physicians'' offices than for women seen in public health department clinics, community clinics, or private hospital clinics. CONCLUSIONS: The findings suggest that given a certification process, private providers can provide enhanced support services as effectively as providers in public practice settings.     

Correlates of C-section in Punjab: a disaggregated analysis at the level of rural-urban residential status and place of delivery

The World Health Organization-recommended rate of delivery by Caesarean section (C-Section) is 10–15% of all live births, but in Punjab, the largest province of Pakistan, this rate was 23% in 2014. The perception is that an inadequate public health sector forces women toward the private sector where C-Section is routinely conducted without valid medical reasons, posing risks to women’s health and incurring catastrophic out-of-pocket expenditures. This study identified the correlates of C-section delivery and whether they differed by the urban/rural residence of women and place of delivery (public vs. private). Using multivariate logistic regression analyses of data from the Multiple Indicators Cluster Survey (MICS) collected from June–October, 2014 for all women who gave birth in the prior two years (N = 10,558), we found that rich women were statistically no different from poor women in their odds of delivery by C-section in the generally more expensive private health facilities (adjusted odds ratio [aOR] 1.23; 95% confidence interval [CI] 0.88–1.71); rich women were more likely to deliver by C-section in the less expensive public health facilities (aOR 2.03; 95% CI 1.13–3.63). This paradox may reflect the inefficiency of the health system and suggests limited affordable alternatives for poor women in the public sector.     

Access policies and utilization patterns in prenatal and child delivery care in Mexico

In Mexico, people utilize public, private and traditional health providers interchangeably and in contrast to official access policies. Access policies for prenatal and child delivery services are evaluated using data from the National Health Survey of 1988. The study documents significant coverage gaps on the part of public providers with respect to their potential coverage, and especially, large cross-utilization of social security, Ministry of Health and private providers by beneficiaries. Child deliveries in Mexico are attended by a physician in only 66% of cases. The percentages are 85% for social security affiliates, 53% for women within reach of IMSS-Solidarity services (a relief programme for the rural poor) and only 31% for women with official access to private or Ministry of Health care, or beyond the reach of services. Seventy-eight per cent of medical deliveries by women affiliated to social security occur at their pre-paid facilities, while 14% deliver at extra cost with private physicians, contributing to 32% of deliveries so offered. Even though only 7% of insured women deliver at Ministry of Health facilities, this amounts to 20% of the Ministry's relief offer. In all, only 66% of affiliates use social security delivery services. On the other hand, 36% of deliveries by non-insured women are cared for by Ministry of Health providers, and 39% by the private sector; 22% of such deliveries occur in social security institutions, amounting to 18% of these institutions' care offer. These results indicate a wide departure between policy and fact, and the working of distributive and redistributive forces that impinge on the quality and efficiency of health care. Open access to the reproductive health services of all public institutions, with coordination among them and private providers, is suggested as a possible solution.     

Who gets screened during pregnancy for partner violence?

CONTEXT: Despite recommendations to screen prenatal care patients for partner violence, the prevalence of such screening is unknown. OBJECTIVES: To estimate the statewide prevalence of partner violence screening during prenatal care among a representative sample of North Carolina women with newborns and to compare women screened for partner violence with women not screened. DESIGN, SETTING, AND PARTICIPANTS: This investigation examines data gathered through the North Carolina Pregnancy Risk Assessment Monitoring System, a random sample of more than 2600 recently postpartum women who were delivered of newborns between July 1997 and December 1998. MAIN OUTCOME MEASURES: Self-reports of violence, health service factors, and sociodemographic characteristics. ANALYSIS: The prevalence of screening was computed, and odds ratios and 95% confidence intervals were used to examine bivariate and multivariable associations between being screened for partner violence and other factors. RESULTS: Thirty-seven percent of women reported being screened for partner violence during prenatal care. Logistic regression analysis found that women were more likely to be screened if they received prenatal care from (1) a public provider paid by a public source; (2) a private provider paid by a public source; or (3) a public provider paid by a private source. CONCLUSIONS: These findings suggest that the majority of prenatal care patients in North Carolina are not screened for partner violence. Screening appears to be most highly associated with whether a woman is a patient in the public sector or the private sector, and with the source of payment for prenatal care. Arch Fam Med. 2000;9:1093-1099     

Low blood lead concentration in association with infertility in women

This study investigated the relationship between low-level lead exposure and risk of infertility in women. Study participants consisted of 64 cases recruited at a private infertility clinic and 83 control women from the postpartum clinic unit at a medical center in Kaohsiung, Taiwan. With informed consent, venous blood samples were obtained from subjects, during their early follicular phases (the 1st to 5th days of the menstrual cycle), for measuring concentrations of lead and hormones. Information on other potential risk factors associated with infertility, including reproductive history, Chinese herbal Medicine use, dairy product consumption, residential environment, and sociodemographic status, was obtained during an in-person interview. The mean blood lead level (BLL) in infertile women was significantly higher than that in controls (3.55 vs 2.78 microg/dL, P=0.007). Compared to women with BLL < or = 2.5 microg/dL, women with BLL>2.5 microg/dL were associated with a threefold increased risk for infertility (adjusted odds ratio=2.94, 95% confidence interval 1.18-7.34), after controlling for age, body mass index, smoking, Chinese herbal Medicine use, and irregular menstruation. Women's BLL was a significant predictor of the serum estradiol concentration also. These findings suggest an important role of very low BLL in the risk of infertility in women.     

Infertility: from a personal to a public health problem

The inability to conceive a child is most often viewed as a private matter, but public health perspectives and skills can contribute greatly to our knowledge about infertility, and the development of effective and rational public policy for prevention, access to health care, and regulation of new technologies. We offer a primer of public health aspects of infertility in an effort to encourage the broad spectrum of public health professionals to become more knowledgeable about these topics and join in the national debate about preventive strategies, cost-benefit assessment, resource allocation, and ethics.