Care seeking behaviour of infertile couples attending a government infertility clinic in Delhi

INTRODUCTION

An estimated 72.4 million couples in the world suffer from involuntary childlessness, with an overall median worldwide prevalence of 9 percent. The prevalence rate in developed nations ranged from 3.5% to 16.7% and from 6.9 % to 9.3 % in less-developed nations.¹ The World Health Organization (WHO), in an Indian report, stated that infertility prevalence ranged from 3.9% to 16.8%, varying from one place to another.^2,3 The prevalence of infertility in India in recent studies was found to be 8.9 percent.^4,5

The infertility definition differs between demographic, epidemiological and clinical usage. Time period of one year of exposure is used in clinical studies, whereas in demographic and epidemiological studies five and two years of exposure period is taken respectively.^2,6

Urban regions have witnessed greater decline in fertility levels than rural. This can be attributed to various causes like increased age at pregnancy, increasing stress levels, and other more common factors such as overweight, alcohol and caffeine consumption, smoking, substance abuse, stress, environmental pollutants and oxidative stress.^7-11 There is rising trend to delay parenthood in order to gain socioeconomic development and greater interest in education, job and financial settlement. Most of the women now plan their first pregnancy after 30 years of age.¹²

Childlessness has serious demographic, social and health implications. When the children are not forthcoming relationships between couples can become strained. Childless couples are also excluded from participating in important family functions and events such as birthdays, christenings, and weddings of others children.³

Indian women were unaware of the ovulatory period and a very few considered age more than 35 years as a significant risk factor for infertility. Paucity of knowledge of when to seek treatment for infertility after trying for pregnancy, further delayed their decision to seek treatment.¹²

Help was sought from sources varying from home treatment, herbal and spiritual healers, traditional reproductive health specialists, diviners, priests and formal medical system (public and private; general practitioners and specialists).^13,14 In some societies, herbalist and traditional healers were mainly sought as treatment option for women.¹⁵ Availability, accessibility of various health care services, practitioners and their own or others' previous experiences with these services, too were factors influencing treatment seeking.^16-18

In India, apart from private sector the treatment for infertility is also available in public sector, however, is of relatively poor quality or lacking. These services are available in only some tertiary level facilities like medical colleges while few basic investigations are available at lower levels.^19,20 Patients face long queues and waiting periods for consultation and results. As they have to spend some amount in public sector anyways, they shift to private sector where more services are provide.²¹ Indian public health system does not offer adequate preventive, curative and counselling services for infertility, forcing people to seek help from private sector.²² Majority of the Indian urban and rural population sought private sector consultation first.²³ The high cost of treatment in these private clinics forces couples to stop the treatment in between and shift to other treatment option.²⁴ In the background of a rising trends of infertility care and preference for private sector, only few recent Indian studies exist in this geographical setting that explore the treatment seeking for infertility. This study aims at examining the treatment seeking behavior among infertile couples attending a government clinic in Delhi.

METHODS

After institute’s ethics committee clearance, an infertility clinic-based descriptive study was done from 15 October 2019 to 15 March 2020. The study population comprised of infertile couples where the female lied in reproductive age group 15-49 years, who availed out-patient department (OPD) service from National Institute of Health and Family Welfare clinic, Delhi. The facility provides diagnostic and treatment services for reproductive health where it runs a specialized outpatient department (OPD) for infertility care. Married couples willing to participate, where the couple was registered together with same case identification number were included. The couples registered for the first time during the data collection period were interviewed by a pretested, structured interview schedule for primary data. The purpose of the study was explained and informed consent was obtained from couples ensuring them that all the information will be kept confidential and will be used only for research purposes. The interview schedule comprised of three sections, sociodemographic profile, clinical profile, and assessment of treatment seeking behavior. Participants suffering from either primary or secondary infertility of one year or more were included. Taking infertility prevalence as 8% and considering non-response of 10%, a total of 196 infertile couples were interviewed.^4,5 Data was tabulated and analysed by using software like statistical package for the social sciences (SPSS) version 23.

The data was collected in special interview room in the infertility clinic that ensured privacy and confidentiality. It took 30-35 minutes to complete an interview.

A female was termed infertile when, despite regular unprotected sexual intercourse for 12 months or more, there was a failure to achieve a clinical pregnancy.²⁵ Primary infertility was defined as inability to become pregnant or carry a pregnancy to a live birth, including pregnancies that resulted in spontaneous miscarriages and still births. Inability to become pregnant or the inability to carry a pregnancy to a live birth following either a previous pregnancy or a previous ability to carry a pregnancy to a live birth was defined as secondary infertility.² The socioeconomic status of a couple was assessed by using modified Kuppuswamy scale-2019, which consists of a composite score of 3-29, that includes the education and occupation of the Family Head along with income per month of the family.

RESULTS

Socio–demographic profile

In Table 1, majority of female respondents were in the age group 25-29 years, had education up to graduation and were homemakers. Majority of males respondents were in the age group of 30-34 years, with education up to graduation and were private employees. A majority of the couples were Hindus living in a joint family. Study subjects mainly belonged to the general category followed by scheduled caste. Most of the couples were found to lie in the upper-lower socio-economic class.

#self-employed includes skilled workers, unskilled workers and farmers

Clinical profile of couples

Out of 196 couples, 156 (81%) of the couples had ever sought treatment while 40 (19%) couples sought treatment for the first time as they wanted to delay treatment by waiting for spontaneous conception. Table 2 indicates that majority of the couples co habiting for 2-5 years after marriage sought treatment for infertility. At most 5 years of infertility duration was seen in majority of the couples. Majority of the couples took some form of treatment within 1-3 years of marriage. A maximum of 73% females were primary infertile.

Treatment seeking behavior

A maximum of 6 consultations were recorded. Table 3 shows that majority (47.4%) of couples sought treatment by self-advice and on the advice of household members. Final decision to seek care was taken by both husband and wife (82%) mutually among couples. Higher percentage (72%) of wives felt pressurized from family to seek treatment as compared to husbands (47.8%).

Of the 81% couples who had ever sought any kind of treatment, only 20 (12.8%) husbands took separate consultations. Maximum number of consultations were done by wives, where majority had taken at least one. Before attending this clinic, majority (61.6%) of couples had consulted an allopathic private doctor while 17.6% and 12.2% couples consulted a govt. allopathic doctor and informal sector respectively. Couples were mainly referred to this government clinic by friends/neighbor (55%), who were also the source of such information. Thus, the couples’ source of information was by word of mouth.

Table 4 shows that private sector help was sought by majority of the couples for first five consecutive consultations. Very few couples preferred public or informal sector consultations. For their first consultation in a public sector, majority (44%) of couples preferred government medical colleges while in private sector, private clinics were preferred. Among the informal sector consultation, traditional birth attendants/dais were preferred the most. Total of 16 couples were involved in more than one simultaneous consultation at a time, frequency of which decreases with the increase in number of consultations. Mean duration of treatment was around 5 months for any consultation and an average of 10 visits for any particular consultation were made.

*Multiple responses received

DISCUSSION

The study showed that 80% of the study subjects had sought treatment before coming to this clinic. A maximum of 36% of the males were in the age group of 30-36 years and 40% females were of 25-29 years. This was consistent with a study, where 40% males in the age group 30-39 years and 59% females of age 20-29 years, availed health care facility.²⁶ In another study, majority of the couples with primary and secondary infertility were Hindus, followed by Muslims and Christians.²⁷ In this study also83% couples were Hindus followed by 16% Muslims and 1% Christians. The study subjects attending the clinic belonged to a category in decreasing order of general (45%), scheduled caste (18 %), OBC (17%) and scheduled tribe (1.5%). These were found consistent with a study, where women other than scheduled tribes and scheduled castes went for infertility treatment.⁴ A maximum of the couples in this study lived in joint families, similar to another Indian study where couples living in joint family was 72% and those living in nuclear family was 28%.²³

Majority of females (73%) attending the clinic had primary infertility while remaining (27%) had secondary infertility. This corroborated with studies where majority of the study population who availed health care facility were primary infertile.^23,26

In the study, allopathic treatment was the most common modality sought by infertile couples. Private sector allopathic treatment was preferred over government. This was found consistent with other Indian studies.^4,23,26-28

Out of total 196 couples, 20% had never sought any treatment before. The common reasons given were, wanted to wait and watch for spontaneous conception (82.5%), suffered financial constraints (15%), and were undergoing some other treatment (10%) and paucity of time (7.5%). Around 59 % of the participants waited for spontaneous conception and 21% underwent economic hardships in another study.²⁶ Yet in another study, economic hardship was cited as the most common reason for not availing infertility care service by the primary infertile couples and secondary infertile couples wanted to wait for spontaneous conception before doing so.²⁷ Majority of couples underwent investigations and treatment within 1-3 years after marriage. It was found in a study that women underwent investigations and treatment usually within 2-3 years of marriage.²⁹

Treatment seeking initiative was taken by 58% of the wives, 25% by both in the couple and 17% by the family/relatives, in one study.²³ It was found contrary to this study where equal percentage (47%) of the couples were either self-advised or were advised by the household members to seek treatment. But the final decision to seek care was done by both together, mutually.

In this study, 95% couples, had visited 1-4 agencies before they went to the specialized government clinic, and 78% had preferred treatment from allopathic private or government practitioners. Frequent switching between various agencies and simultaneous consultations was observed. Couples took informal sector consultation from traditional birth attendants, traditional practitioners and performed religious practices like pooja, havan, had read holy books at some point of time. Mean duration of treatment per consultation was 5 months and mean number of visits per consultation was 10. These finding were consistent with other studies.^23,29-31

80% couples in this study had experienced at most 5 years of infertility duration, similar toother studies where a majority of couples had infertility of 2-6 years’ duration.^23,32

Majority of the couples in the study, first preferred an allopathic treatment followed by informal treatment. This path was commonly seen in many Indian studies.^{4,23,26-28,30} This finding was inconsistent with few studies where most of the women first visited traditional healers and later went to a hospital.^13,14,17

In the study, sequential preference for infertility treatment with increasing consultations was private, informal and lastly public sector. This pathway of care sought was consistent with another Indian study.²³ The frequent switching of the provider in the early treatments, poses questions on the services given by the private practitioners. The frequent switch without successful results often drained the couples emotionally, physically and financially.

Similar to another study, a majority of the couples in this study felt socially pressurized to seek treatment.¹⁷ A higher percentage of the wives (72%) felt pressurized from the family to seek care than the husbands (48%). This could lead to higher stress levels in the females, thus suggesting that infertility was more stressful for women than it was for men.³³

In a study, the sources of referral to the tertiary care were, self (50%), relative/colleagues (25%), and doctors (25%).²³ Similarly, the couples in this study were ill informed on where to seek treatment from. Majority of (55%) couples were referred by friends/neighbor, 33% were referred by parents and relatives and 12% were referred by a doctor. In another study, neighbors were the main source of information on where to find infertility treatment, followed by self-decision on where to find treatment.³⁰

In this study the main source of information to seek treatment was by word of mouth that was done by friends and neighbors. This corroborated with studies where, own or other’s past personal experiences with infertility treatment determined where and how an individual would seek treatment in the future.^16-18

Limitations

Limitations of the study identified were: recall bias among cases where duration of infertility was prolonged; and since only couple registration was allowed at the clinic those potential cases were missed where only male/female partner came for consultation.

CONCLUSION

There is dominance of private sector in infertility care. A policy that promotes integration of infertility treatment with the existing wider reproductive and child health services should be advocated. Public sector facilities need to be strengthened, both at primary and secondary levels to make the care seeking more accessible equitable and affordable. A robust and well managed referral system is required, for which training and capacity building of health care provider at the district and below levels for infertility management and care is needed. Counselling services need to be an integral part of infertility care as infertile females face higher societal pressures and to equip couples to cope with associated anxiety and stress. The general public needs to be sensitized about the causes of infertility so that it no longer becomes a social stigma.

ACKNOWLEDGEMENTS

We would like to thank to all the staff members of the NIHFW clinic for their cooperation during data collection.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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