Affordability of Assisted Reproductive Treatment in the public health sector of a high and low-middle income country: A mixed-method study

Background: A number of interventions have been implemented to support women seeking assisted reproductive treatment (ART), with the aim of improving their mental health, thereby increasing the chances of conception in both High income and low-middle income countries. However, most of these interventions have failed to consider the financial implications of the treatment. This study aims to assess the prevalence of catastrophic ART expenditure and the cost burden of the treatment to the households.

Methods: A mixed-methods study utilising qualitative and quantitative designs. A total of 116 (UK=64, Nigeria=52) women took part in the quantitative cross-sectional survey, while a subsection of 32 (UK=15, Nigeria=17) from the 116 participants took part in the qualitative study. Survey participants were recruited using random sampling method, whereas purposive sampling was used to select women to take part in the qualitative arm of the study. Questionnaires were used to capture information on socio-economic status, monthly household non-food expenditure, subjective financial well-being (SFW) and out of pocket costs for the ART cycle. Payments for ART as a percentage of annual non-food expenditure was calculated to estimate catastrophic ART expenditure, and factors associated with SFW were identified. Follow up interviews were conducted using semi-structured open-ended questions. The descriptive analysis looked at the proportion of households experiencing catastrophic ART expenditure, while interviews were transcribed and analysed thematically.

Results: Descriptive results show that most Nigerian households incurred catastrophic expenditures, defined as an OPP of >40%; whereas, this did not occur among the UK cohort. The Nigerian households used various coping strategies which include depleting savings, borrowing money or contributions. Among the UK women, household income was predictive of SFW, with higher incomes associated with increased financial well-being. However, this was not observed among the Nigerian cohort. The interview findings supported the descriptive results. Both the UK and Nigerian women expressed similar concerns about the financial stress of funding the treatment. The key explanatory factors in both cases included that there was no certainty of a positive outcome after spending so much money, and the short term financial constraints affected their quality of life negatively.

Conclusion: Over 80% of Nigerian households experienced catastrophic ART expenditures, whereas most UK households did not. Not all couples who are unable to afford ART in low-middle income countries, forfeit it. ART counselling should include financial psychoanalysis, and cost-reducing strategies should be implemented in low-middle income settings.