BACKGROUND: Global regional and national estimates of prevalence of and tends in infertility are needed to target prevention and treatment efforts. By applying a consistent algorithm to demographic and reproductive surveys available from developed and developing countries we estimate infertility prevalence and trends 1990 to 2010 by country and region. METHODS AND FINDINGS: We accessed and analyzed household survey data from 277 demographic and reproductive health surveys using a consistent algorithm to calculate infertility. We used a demographic infertility measure with live birth as the outcome and a 5-y exposure period based on union status contraceptive use and desire for a child. We corrected for biases arising from the use of incomplete information on past union status and contraceptive use. We used a Bayesian hierarchical model to estimate prevalence of and trends in infertility in 190 countries and territories. In 2010 among women 20-44 y of age who were exposed to the risk of pregnancy 1.9% (95% uncertainty interval 1.7% 2.2%) were unable to attain a live birth (primary infertility). Out of women who had had at least one live birth and were exposed to the risk of pregnancy 10.5% (9.5% 11.7%) were unable to have another child (secondary infertility). Infertility prevalence was highest in South Asia Sub-Saharan Africa North Africa/Middle East and Central/Eastern Europe and Central Asia. Levels of infertility in 2010 were similar to those in 1990 in most world regions apart from declines in primary and secondary infertility in Sub-Saharan Africa and primary infertility in South Asia (posterior probability [pp] >/=0.99). Although there were no statistically significant changes in the prevalence of infertility in most regions amongst women who were exposed to the risk of pregnancy reduced child-seeking behavior resulted in a reduction of primary infertility among all women from 1.6% to 1.5% (pp=0.90) and a reduction of secondary infertility among all women from 3.9% to 3.0% (pp>0.99) from 1990 to 2010. Due to population growth however the absolute number of couples affected by infertility increased from 42.0 million (39.6 million 44.8 million) in 1990 to 48.5 million (45.0 million 52.6 million) in 2010. Limitations of the study include gaps in survey data for some countries and the use of proxies to determine exposure to pregnancy. CONCLUSIONS: We analyzed demographic and reproductive household survey data to reveal global patterns and trends in infertility. Independent from population growth and worldwide declines in the preferred number of children we found little evidence of changes in infertility over two decades apart from in the regions of Sub-Saharan Africa and South Asia. Further research is needed to identify the etiological causes of these patterns and trends.

/pdf/national-regional-and-global-trends-in-infertility-3p18vigqmq.pdf

National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys

Background Infertility is estimated to affect as many as 186 million people worldwide. Although male infertility contributes to more than half of all cases of global childlessness, infertility remains a woman's social burden. Unfortunately, areas of the world with the highest rates of infertility are often those with poor access to assisted reproductive techniques (ARTs). In such settings, women may be abandoned to their childless destinies. However, emerging data suggest that making ART accessible and affordable is an important gender intervention. To that end, this article presents an overview of what we know about global infertility, ART and changing gender relations, posing five key questions: (i) why is infertility an ongoing global reproductive health problem? (ii) What are the gender effects of infertility, and are they changing over time? (iii) What do we know about the globalization of ART to resource-poor settings? (iv) How are new global initiatives attempting to improve access to IVF? (v) Finally, what can be done to overcome infertility, help the infertile and enhance low-cost IVF (LCIVF) activism? Methods An exhaustive literature review using MEDLINE, Google Scholar and the keyword search function provided through the Yale University Library (i.e. which scans multiple databases simultaneously) identified 103 peer-reviewed journal articles and 37 monographs, chapters and reports from the years 2000-2014 in the areas of: (i) infertility demography, (ii) ART in low-resource settings, (iii) gender and infertility in low-resource settings and (iv) the rise of LCIVF initiatives. International Federation of Fertility Societies Surveillance reports were particularly helpful in identifying important global trends in IVF clinic distribution between 2002 and 2010. Additionally, a series of articles published by scholars who are tracking global cross-border reproductive care (CBRC) trends, as well as others who are involved in the growing LCIVF movement, were invaluable. Results Recent global demographic surveys indicate that infertility remains an ongoing reproductive problem, with six key demographic features. Despite the massive global expansion of ART services over the past decade (2005-2015), ART remains inaccessible in many parts of the world, particularly in sub-Saharan Africa, where IVF clinics are still absent in most countries. For women living in such ART-poor settings, the gender effects of infertility may be devastating. In contrast, in ART-rich regions such as the Middle East, the negative gender effects of infertility are diminishing over time, especially with state subsidization of ART. Furthermore, men are increasingly acknowledging their male infertility and seeking ICSI. Thus, access to ART may ameliorate gender discrimination, especially in the Global South. To that end, a number of clinician-led, LCIVF initiatives are in development to provide affordable ART, particularly in Africa. Without access to LCIVF, many infertile couples must incur catastrophic expenditures to fund their IVF, or engage in CBRC to seek lower-cost IVF elsewhere. Conclusions Given the present realities, three future directions for research and intervention are suggested: (i) address the preventable causes of infertility, (ii) provide support and alternatives for the infertile and (iii) encourage new LCIVF initiatives to improve availability, affordability and acceptability of ART around the globe.

http://fertility.com.br/wp-content/uploads/2015/03/reuniao-fevereiro-16-edson.pdf

Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century

Periodic estimation of the incidence of global unintended pregnancy can help demonstrate the need for and impact of family planning programs. We draw upon multiple sources of data to estimate pregnancy incidence by intention status and outcome at worldwide, regional, and subregional levels in 2012 and to assess recent trends using previously published estimates for 2008 and 1995. We find that 213 million pregnancies occurred in 2012, up slightly from 211 million in 2008. The global pregnancy rate decreased only slightly from 2008 to 2012, after declining substantially between 1995 and 2008. Eighty-five million pregnancies, representing 40 percent of all pregnancies, were unintended in 2012. Of these, 50 percent ended in abortion, 13 percent ended in miscarriage, and 38 percent resulted in an unplanned birth. The unintended pregnancy rate continued to decline in Africa and in the Latin America and Caribbean region. If the aims of the London Summit on Family Planning are carried out, the incidence of unwanted and mistimed pregnancies should decline in the coming years.

/pdf/intended-and-unintended-pregnancies-worldwide-in-2012-and-4iiskd9hvb.pdf

Intended and unintended pregnancies worldwide in 2012 and recent trends.

This article provides a critical review of studies assessing the effects of unintended pregnancy on the health of infants, children, and parents in developed and developing countries. A framework for determining and measuring the pathways between unintended pregnancy and future health outcomes is outlined. The review highlights persistent gaps in the literature, indicating a need for more studies in developing countries and for further research to assess the impact of unintended pregnancy on parental health and long-term health outcomes for children and families. The challenges in measuring and assessing these health impacts are also discussed, highlighting avenues in which further research efforts could substantially bolster existing knowledge.

The effects of unintended pregnancy on infant, child, and parental health: a review of the literature.

https://www.who.int/reproductivehealth/topics/unsafe_abortion/article_unsafe_abortion.pdf

Unsafe abortion: the preventable pandemic

CONTEXT: In 2005, Ethiopia's parliament amended the penal code to expand the circumstances in which abortion is legal. Although the country has expanded access to abortion and postabortion care, the last estimates of abortion incidence date from 2008. METHODS: Data were collected in 2014 from a nationally representative sample of 822 facilities that provide abortion or postabortion care, and from 82 key informants knowledgeable about abortion services in Ethiopia. The Abortion Incidence Complications Methodology and the Prospective Morbidity Methodology were used to estimate the incidence of abortion in Ethiopia and assess trends since 2008. RESULTS: An estimated 620,300 induced abortions were performed in Ethiopia in 2014. The annual abortion rate was 28 per 1,000 women aged 15-49, an increase from 22 per 1,000 in 2008, and was highest in urban regions (Addis Ababa, Dire Dawa and Harari). Between 2008 and 2014, the proportion of abortions occurring in facilities rose from 27% to 53%, and the number of such abortions increased substantially; nonetheless, an estimated 294,100 abortions occurred outside of health facilities in 2014. The number of women receiving treatment for complications from induced abortion nearly doubled between 2008 and 2014, from 52,600 to 103,600. Thirty-eight percent of pregnancies were unintended in 2014, a slight decline from 42% in 2008. CONCLUSIONS: Although the increases in the number of women obtaining legal abortions and postabortion care are consistent with improvements in women's access to health care, a substantial number of abortions continue to occur outside of health facilities, a reality that must be addressed. International Perspectives on Sexual and Reproductive Health, 2016, 42(3):111-120. Prior to the reform of the country's abortion law, abortion was allowed in Ethiopia only if two physicians, including at least one gynecologist, agreed that pregnancy termination would avert "grave or imminent danger" to the woman. (1) The revised law, enacted by Ethiopia's parliament in 2005, allows a woman to obtain a safe, legal abortion if she became pregnant through rape or incest, has physical or mental disabilities, would be putting her life or physical health at risk if she continues her pregnancy, or is younger than 18 and physically or mentally unprepared for childbirth. (2) The reform has resulted in an expansion of comprehensive abortion care and postabortion care (*) services throughout the health care system. The reform also represents a step toward reducing maternal mortality, a public health issue requiring urgent attention in a country with a maternal mortality ratio of 353 maternal deaths per 100,000 live births. ([dagger]3) Although the proportion of these deaths that are due to unsafe abortion is unknown, a recent estimate based on data from the World Health Organization (4) suggests that 9% of maternal deaths in Sub-Saharan Africa are the result of complications from unsafe abortion. (5) After the revision of the abortion law, the Ethiopian Ministry of Health developed and disseminated national guidelines for provision of legal and safe abortion care. These guidelines, which are based on World Health Organization standards, outline appropriate abortion methods at various stages of pregnancy. They also recommend training health care workers for their roles in service provision; equipping health care facilities to provide reliable, high-quality care, and ensuring that they have a sustainable supply of necessary equipment and medications; introducing and expanding the availability of medication abortion; enabling private-sector providers to expand services; and integrating abortion and postabortion contraceptive services with existing reproductive health services. (6,7) The guidelines were revised in 2014 to update the clinical regimens and gestational limits for medication abortion, expand the provision of second-trimester services and authorize integrated emergency surgical officers (a type of midlevel provider) to provide comprehensive abortion care. …

/pdf/the-estimated-incidence-of-induced-abortion-in-ethiopia-2014-44j9t7dwqm.pdf

The Estimated Incidence of Induced Abortion in Ethiopia, 2014: Changes in the Provision of Services Since 2008.

Unmet need and demand for family planning were analyzed for 27 developing countries in which Demographic and Health Surveys were conducted between 1990 and 1994. The report includes an introduction and a discussion of 1) the concept and measurement of unmet need; 2) estimates of unmet need and demand for married women; 3) covariates of unmet need (age number of children contraceptive usage residence and education); 4) the composition of need in terms of use of contraception exposure and intention to use and reasons for not intending to use any method; and 5) trends in unmet need for married women in the eight countries for which data were analyzed in a 1991 report on the same subject. This analysis expands the parameters of the 1991 report by describing the measurement and estimates of unmet need for never-married and formerly married women as well as married women. Estimates of unmet need regardless of marital status are then presented for various sub-Saharan countries. This report also disaggregates need into various components such as the need for motivational or information or educational efforts. The demographic significance of unmet need is then considered through the development of models of unmet need satisfied and estimation of total demand under different assumptions. Methods for estimating the implied fertility reduction are covered and the fertility implications are noted. The major findings of the analysis are that unmet need has declined in a small but consistent manner. The unmet need of never-married women in sub-Saharan Africa ranges from 9% to 17%. Formerly married women show a 14% need across all countries. Unmet need in married women reaches 29% in sub-Saharan Africa and 19% in other regions. Following the most likely scenario for the satisfaction of unmet needs leads to an estimation of a 17% decline in the total fertility rate in 14 sub-Saharan countries and an 18% decline across all 27 countries considered. Thus satisfying unmet need would cover 50% of the gap towards replacement fertility levels in some countries and 25% in sub-Saharan Africa.

Unmet need: 1990-1994.

CONTEXT: Periodic assessments of abortion incidence are essential for monitoring trends in unintended pregnancy and gaps in contraceptive services and use. METHODS: Statistics and estimates of legal induced abortions in 2008 were compiled for 64 of the 77 countries in which legal abortion is generally available; these 64 are home to 98% of women aged 15-44 who live in the countries eligible for inclusion. Data sources included reports or completed questionnaires from national statistical offices and nationally representative surveys. The completeness of official figures was assessed by in-country and regional experts. Trends since 1996 and 2003 were examined. RESULTS: Of the 77 countries with liberal abortion laws, 36 are in the developing world. In 2008, abortion rates in the 25 countries with complete records--all of which were developed--ranged from seven (Germany and Switzerland) to 30 (Estonia) per 1,000 women aged 15-44.Abortion rates declined in most of the 20 countries with consistently reliable information on trends between 1996 and 2008; declines were generally steeper than increases, although the pace of decline slowed after 2003.The highest observed abortion rates were in developing countries with incomplete estimates. For most developing countries that had liberal laws, the reported abortion rates were incomplete and varied widely. CONCLUSIONS: High abortion rates in some countries, and small increases in rates in others, indicate a great need for more effective family planning services for these populations. Reliable data collection systems, needed to ensure that trends can be effectively monitored, are lacking in many countries. International Perspectives on Sexual and Reproductive Health, 2011, 37(2):84-94, doi: 10.1363/3708411 The incidence of induced abortion is an important indicator of the frequency with which women experience unintended pregnancies, and it can point to gaps in contraceptive services and effective contraceptive use. Periodic assessments of abortion incidence are therefore essential for monitoring trends in these critical aspects of the wellbeing of women and couples. However, documentation of this incidence is often unavailable or incomplete, in part because of the sensitive nature of abortion. Although it is extremely difficult to obtain reliable counts of the numbers of procedures performed in countries that have highly restrictive abortion laws, abortion data collection systems or other means of abortion estimation are in place in most countries that have liberal laws. This review presents the most recent available official statistics and national estimates of the level of abortion in all countries and major territories where legal abortion was generally available in 2008--settings where abortion was legal without restriction as to reason or on socioeconomic grounds; or where abortion was legal to preserve a woman's physical or mental health, if the law was interpreted liberally. A recent analysis estimated that about 60% of women of childbearing age live in countries with liberal abortion laws.(1) Another 3% live in countries whose abortion laws are interpreted liberally such that legal abortion is generally available. The quality of abortion statistics varies greatly, and the completeness of the statistics depends on such factors as whether abortion reporting is voluntary or required by law; whether medication abortions are reliably reported; whether clinicians face consequences for failure to report abortions, such as lack of reimbursement for services rendered; whether reporting systems include services provided in the private sector (and, if not, the proportion of abortions performed in the private sector); and whether abortion stigma negatively influences reporting. The completeness of reporting can change over time if circumstances that influence reporting change. In our analyses, we assess the completeness of abortion reports and whether the quality of reporting has changed substantially over time. …

/pdf/legal-abortion-worldwide-in-2008-levels-and-recent-trends-19uq29r52v.pdf

Legal abortion worldwide in 2008: levels and recent trends.

This report is a review of reproductive preferences in 56 developing countries conducted by DHS between 1990 and 2000. Several measures of preferences are used the ideal number of children the population of women who want no more children the planning status of recent births and the wanted total fertility rate. For 35 countries that have conducted more than one survey trends in preferences have been documented. And for a subset of mostly Sub-Saharan African countries men’s reproductive attitudes are also described. In general the number of children desired is declining in most Asian and Latin American countries. There is also evidence of a desire for smaller families in southern and eastern Africa but little change in the preference for large families is evident in western and middle Africa. Unwanted fertility is highest in the countries of northern Africa and western Asia as well as in Latin America; unwanted births are still uncommon in sub-Saharan Africa particularly in western and middle Africa. A comparison of wanted fertility rates with recent actual fertility shows a potential for further declines in fertility and impending replacement levels in many Asian and Latin American populations. Men’s reproductive preferences in Africa tend to be higher than those of women and are also higher in polygymous marriages. In every country studied couples with the wife wanting to stop childbearing with husbands who want more children are more numerous than the opposite combination. (excerpt)

/pdf/reproductive-preferences-in-developing-countries-at-the-turn-5ef3ru10uo.pdf

Reproductive preferences in developing countries at the turn of the century

CONTEXT: Periodic assessments of abortion incidence are essential for monitoring trends in unintended pregnancy and gaps in contraceptive services and use. METHODS: Statistics and estimates of legal induced abortions in 2008 were compiled for 64 of the 77 countries in which legal abortion is generally available; the 64 are home to 98% of women aged 15-44 who live in the countries eligible for inclusion. Data sources included reports or completed questionnaires from national statistical offices and nationally representative surveys. The completeness of official figures was assessed by in-country and regional experts. Trends since 1996 and 2003 were examined. RESULTS: Of the 77 countries with liberal abortion laws 36 are in the developing world. In 2008 abortion rates in the 25 countries with complete records-all of which were developed-ranged from seven (Germany and Switzerland) to 30 (Estonia) per 1000 women aged 15-44. Abortion rates declined in about half of the 20 countries with consistently reliable information on trends between 1996 and 2008; declines were generally steeper than increases although the pace of decline slowed after 2003. The highest observed abortion rates were in developing countries with incomplete estimates. For most developing countries that had liberal laws the reported abortion rates were incomplete and varied widely. CONCLUSIONS: High abortion rates in some countries and small increases in rates in others indicate a great need for more effective family planning services for these populations. Reliable data collection systems needed to ensure that trends can be effectively monitored are lacking in many countries. Copyright (c) 2011 by the Guttmacher Institute.

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The Estimated Incidence of Induced Abortion in Ethiopia, 2014: Changes in the Provision of Services Since 2008.

Unmet need: 1990-1994.

Legal abortion worldwide in 2008: levels and recent trends.

Reproductive preferences in developing countries at the turn of the century

Legal abortion worldwide in 2008: levels and recent trends.