Executive summary of research findings*
Linda Rae Bennett, Budi Wiweko, Aucky Hinting,IB Putra Adnyana, Mulyoto Pangestu
Indonesia has high levels of biological need for infertility treatment, great sociological and psychological demand for children, and yet existing infertility services are underutilized. In 2011, Indonesia had 16 government registered fertility clinics with state of the art technology. However, utilization of these services remains very low when compared to elsewhere in the region. For instance, Singapore with a population of 5 million recorded 2500 IVF cycles in 2010, while Indonesia with a population of 237 million performed 2627 cycles in the same year. The highest number of IVF cycles in the region for 2010 was in Vietnam where 6000 cycles were performed.
Access to adequate comprehensive reproductive health services, including infertility care, is a basic reproductive right regardless of the economic circumstances in which individuals are born into. Thus, identifying and implementing strategies to improve access to assisted reproductive technology (ART) in Indonesia is imperative. A key objective of this research was to improve our understanding of infertility patients’ patterns of health seeking behaviour and their patterns of access to infertility treatment in Indonesia, in order to highlight the possibilities for improving access.
An interviewer-administered survey was conducted with 212 female infertility patients recruited through 3 Indonesian infertility clinics between July and September 2011. Participants were self-selected and data was subject to descriptive statistical analysis. In a nutshell, our sample was well educated, affluent and predominantly urban. This confirmed our expectations that women with lower incomes, less education and those living in more remote areas would be less likely to access infertility clinics, and subsequently would be less likely to be recruited for the survey.
The survey investigated a range of factors relevant to accessing infertility care, including: 1) the timing of initial presentation to obstetrician/gynaecologists (OBSGYN); 2) the types of providers visited by fertility patients and patterns of referral; 3) the number of OBSGYN visited by patients and their rationale for seeing multiple providers; 4) barriers to access reported by patients; 5) patterns of travel for infertility care; and 6) cost and access to care.
Timing of presentation among female infertility patients
The median age of marriage for women in the sample was only 26 years old and that the median age of women at their first visit to an OBSGYN for fertility care was 28 years. The mean number of months women waited after marriage before seeking infertility care was 25 and the median number of months was 12. These findings are important in terms of shifting false, but widespread attitudes, which lay the blame for compromised fertility and failed infertility treatment on women as individuals who are perceived as either marrying or seeking out infertility care too late.
Number of OBSGYN visited
The mean number of OBSGYN visited by women was 3 and the median number visited was 2. Thus, most patients had seen between 1 and 3 specialists, 20% had seen between 4 to 6 OBSGYN, while the highest number of OBSGYN visited by a respondent was 12. These results indicate that switching between different providers was common and was the experience of 87% of 212 women. While 27 out of 212 respondents reported having visited a general practitioner (GP) for fertility concerns, only 17 respondents out of 212 (or 8%) reported having received a GP referral to an OBSGYN.
Reasons for changing doctors
The most common reason reported for switching between doctors was perceived treatment failure, reported by 32% of 139 respondents. By dropping out of treatment cycles, due to their frustration with not falling pregnant quickly, many women are moving between different doctors and not receiving the recommended progression of care.
Barriers to accessing care
We asked all respondents if they had ever felt worried or frightened about visiting an OBSGYN. A total of 84 respondents (or 40% of 212) answered yes. Of these 84 women, 77 also provided reasons as to why they felt worried or frightened, and the most significant reason by far was fear of a sterile diagnosis. Patients also reported fear of vaginal examinations and of embarrassment.
Cost and access to care
A total of 19% of 212 respondents stated that they had found it difficult to pay for infertility care, 26% of 212 respondents reported having to save money to finance infertility care, and 4% of 212 women reported borrowing money to assist them in meeting the costs of care. In sum, 40% of the sample of 212 reported that they could not easily pay for infertility care out of their regular income. A move towards lower cost infertility care in Indonesia is essential to ensure equity of access, particularly considering the fact that over 50% of this sample were from high socioeconomic groups.
Patterns of travel for fertility care
Less than half the sample accessed infertility care without having to travel outside their own district, and 54% of patients had to travel substantial distances. These findings reflect the concentration of services in large cities in Java and Bali and indicate that further geographical expansion of services is required to improve access.
Our findings highlighted 4 key areas of opportunity for improving access to infertility care. Firstly, greater patient education about the nature and progression of infertility care is required. Secondly, increased resources in terms of the number and distribution of infertility clinics would reduce the substantial travel required to access infertility care. Thirdly, improvements in the financial accessibility of infertility care will promote ease of access. Finally, the expansion of poorly developed referral systems would also enhance the efficiency with which patients are able to access appropriate care.
This research was partially financed by the Australian Research Council and the AusAID International Seminar Support Scheme.
* A full discussion of the research findings and their implications for improving access to ART in Indonesia is presented in the forthcoming article “Indonesian infertility patients’ health seeking behaviour and patterns of access to biomedical infertility care: An interviewer administered survey conducted in three clinics” in the journal Reproductive Health.