Abstract
Background
Infertility is a significant reproductive health challenge in Indonesia and is frequently accompanied by social stigma and cultural expectations that influence how couples seek care. Gender norms and unequal access to healthcare resources may further shape treatment-seeking behavior. This study aimed to examine healthcare-seeking behavior among infertile couples and assess gender-related differences in access to infertility services, particularly regarding financial barriers, discrimination, cultural factors, gender sensitivity in healthcare delivery, and knowledge about infertility.
Design and methods
A cross-sectional survey was conducted among 250 infertile couples seeking treatment in five hospitals in Central Java, Indonesia, between April and June 2023. Eligible participants were couples (women and men) aged 20-45 years who had experienced infertility for more than one year and were actively seeking treatment. Individuals undergoing in vitro fertilization (IVF), those with malignancy, and those who were pregnant were excluded. Data were collected through structured interviews and analyzed using bivariate and multivariable logistic regression with SPSS version 25.
Results
Bivariate analysis showed that perceived discrimination (p=0.009) and gender sensitivity in healthcare services (p=0.003) were significantly associated with gender differences in access to infertility care. In multivariable analysis, gender sensitivity remained the only factor significantly associated with gender differences in access to infertility services (OR=0.139; 95% CI: 0.020–0.964; p=0.046).
Conclusion
Gender sensitivity within healthcare services was associated with differences in access to infertility care, although this finding should be interpreted cautiously. Gender-responsive approaches may support more equitable access to infertility treatment.
Keywords: attitude, hospital, infertility, Indonesia, social stigma
Introduction
Infertility is defined as the inability to conceive after a year of regular, unprotected sexual intercourse. 1 In Indonesia, infertility affects a substantial proportion of couples of reproductive age, with an estimated prevalence of 10–15%. Beyond its medical implications, infertility carries significant social consequences within the Indonesian context. The inability to conceive is often perceived as a personal failure, leading to social stigma, particularly toward women. Despite its relatively high prevalence, access to specialized fertility education remains limited, contributing to persistent myths, misconceptions, and negative attitudes toward infertility and its treatment within Indonesian society. 2
Infertility is not only a medical condition but also a source of considerable psychological and social burden. Individuals experiencing infertility frequently report elevated stress related to treatment, emotional distress, relationship strain, and feelings of isolation due to limited social support or social exclusion. Furthermore, infertility treatment is often prolonged, lasting months or even years, and outcomes remain uncertain, which may intensify psychological and financial pressures on affected couples. 3
Although numerous studies have highlighted the importance of patient education in infertility care, limited research has explored patients’ knowledge of infertility and their information-seeking behaviors, particularly in low-resource healthcare settings where health literacy may be limited. As a result, estimates of infertility prevalence in Indonesia vary depending on whether they are derived from biomedical care utilization data or from population-based demographic surveys. 4
Providing healthcare services that incorporate patient education has long been recognized as a fundamental responsibility of healthcare providers and represents a key component of patient empowerment. 5 Reproductive healthcare is among the most commonly sought medical services worldwide. 6 For couples who recognize their infertility, the subsequent step typically involves actively seeking information regarding available diagnostic and treatment options. However, access to infertility care is often constrained by multiple barriers, including socioeconomic status, geographic location, cultural and religious norms, income disparities, sexual orientation, and variability in treatment availability and outcomes.1,7 In Indonesia, one of the major challenges faced by individuals experiencing infertility is the limited availability and accessibility of reliable information regarding fertility treatments. 8 In this context, advances in assisted reproductive technology (ART) have emerged as important medical interventions for the diagnosis, treatment, and prevention of infertility. 9
Nevertheless, couples undergoing infertility treatment frequently encounter a range of challenges, including gender-related, economic, social, spiritual, and psychological stressors.10–12 Evidence suggests that women often experience a greater burden than men in the context of infertility, particularly due to stigma and social expectations surrounding reproduction.13,14 For example, previous studies have reported that women undergoing infertility treatment tend to have lower quality-of-life scores compared with their male partners. 15
This study aimed to examine healthcare-seeking behavior among infertile couples and to analyze gender-related differences in access to infertility services in Central Java, Indonesia. Specifically, the study explores how financial constraints, discrimination, cultural influences, gender sensitivity, and knowledge shape patterns of infertility care utilization.
Methods
Study design
The data analyzed in this study were derived from the Survey on Health Knowledge of Infertility Patients and Access Patterns of Fertility Care, conducted between April and June 2023. The survey instrument was developed in Indonesian to assess infertility-related knowledge and patterns of access to fertility care.
The development and refinement of the survey questionnaire involved a collaborative process among obstetricians and gynecologists, trained survey interviewers, and volunteers who participated in pilot testing. Feedback obtained during the trial phase was used to improve the clarity, relevance, and comprehensibility of the survey items. This study represents an exploratory investigation conducted in Central Java, Indonesia, and is considered innovative in the local context because it explicitly focuses on infertility from a couple-centered perspective rather than examining women alone.
Research place and time
The study was conducted in five hospitals located in Central Java, Indonesia, between April and June 2023.
Participants
This study included 250 infertile couples receiving infertility-related care at the participating hospitals. Participants were recruited from outpatient obstetrics and gynecology clinics.
Data were collected using structured, interviewer-administered questionnaires conducted by trained research personnel. The questionnaire examined participants’ pathways to infertility care, including the timing of the first consultation with an obstetrician–gynecologist, types of healthcare facilities visited, frequency of visits to healthcare providers (doctors, midwives, or nurses), participation in infertility treatment, treatment-related costs, perceived barriers to accessing infertility services, and overall patterns of infertility care utilization.
The inclusion criteria were:
• Couples experiencing infertility for more than one year
• Female partner aged 20–45 years
• Willingness to participate and provide informed consent
• Ability to complete the interview
Couples were excluded if either partner had a diagnosed malignant disease, if the couple was currently undergoing an in vitro fertilization (IVF) program, or if the female partner was pregnant at the time of data collection.
Questionnaire and variable definitions
The questionnaire consisted primarily of closed-ended questions with predefined response options. Face validity was assessed through review by clinicians and public health researchers with expertise in infertility care. Prior to the main data collection, the questionnaire was pilot tested among a small group of infertile couples to ensure clarity, cultural appropriateness, and ease of interpretation. Minor revisions were made based on participant feedback.
Gender sensitivity referred to participants’ perceptions of gendered norms and expectations in infertility care, including whether infertility was viewed mainly as a woman’s responsibility and whether gender shaped support or treatment-related decisions. This construct captured the perceived gendered context of infertility care rather than direct mistreatment.
Discrimination referred to self-reported experiences of unfair or stigmatizing treatment related to infertility, such as blame, judgment, exclusion, or differential treatment from family members, the community, or healthcare providers. This construct captured direct experiences of negative treatment rather than broader perceptions of gender norms.
Access to infertility services was assessed using several indicators, including distance to healthcare facilities, frequency of visits to healthcare providers, financial costs of infertility treatment, availability of information about infertility care, and the perceived adequacy of referral pathways. These indicators were used to identify barriers and facilitators affecting couples’ ability to access infertility services.
Statistic analysis
All statistical analyses were performed using IBM SPSS Statistics version 25. Descriptive statistics were used to summarize participants’ characteristics. Bivariate associations between variables were examined using chi-square tests.
Gender was treated as the dependent variable and coded as 0 = men and 1 = women. Independent variables were coded as follows: financial status (0 = good, 1 = poor), discrimination (0 = no, 1 = yes), culture (0 = no, 1 = yes), gender sensitivity (0 = no, 1 = yes), and knowledge (0 = good, 1 = poor). For each variable, the reference category was coded as 0.
Multivariable logistic regression analysis was performed to identify factors independently associated with gender differences in access to infertility services. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported. An OR <1 indicates an inverse association relative to the reference category. Statistical significance was set at p < 0.05.
Results
Participant characteristics
A total of 250 infertile couples participated in the study. The demographic and socioeconomic characteristics of the participants are summarized in Table 1. The majority of participants were aged 30–39 years (41.2%), followed by those under 30 years (33.6%), 40–49 years (16%), 50–59 years (7.6%), and ≥60 years (1.6%). Most participants had completed higher education (Diploma/Undergraduate/Postgraduate; 64.4%), followed by high school (15.2%), middle school (10.4%), and elementary school (10%).
Table 1.
Participant characteristics.
| Parameter | N (%) |
|---|---|
| Age (year) | |
| <30 | 84 (33.6) |
| 30-39 | 103 (41.2) |
| 40-49 | 40 (16) |
| 50-59 | 19 (7.6) |
| ≥60 | 4 (1.6) |
| Education | |
| Elementary school | 25 (10) |
| Middle schools | 26 (10.4) |
| High schools | 38 (15.2) |
| Diploma/undergraduate/postgraduate | 161 (64.4) |
| Occupation | |
| Teacher | 4 (1.6) |
| Civil servant | 35 (14) |
| Private sector workers | 138 (55.2) |
| Labor | 6 (2.4) |
| Entrepreneur | 12 (4.8) |
| Housewife | 48 (19.2) |
| Army | 1 (0.4) |
| Students | 3 (1.2) |
| Nurse | 3 (1.2) |
| Distance to Infertility Care (km) | |
| <1 | 54 (21.6) |
| 1-15 | 187 (74.8) |
| >15 | 9 (3.6) |
| Number of Visits to Infertility Care | |
| 0 | 41 (16.4) |
| 1-3 | 145 (58) |
| 4 | 33 (13.2) |
| 5 | 16 (6.4) |
| 6 | 9 (3.6) |
| ≥7 | 6 (2.4) |
Regarding occupation, the largest proportion were private-sector workers (55.2%), followed by housewives (19.2%), civil servants (14%), self-employed/entrepreneurs (4.8%), laborers (2.4%), teachers (1.6%), students (1.2%), nurses (1.2%), and military personnel (0.4%). Most participants resided 1–15 km from infertility services (74.8%), with 21.6% living within 1 km and 3.6% traveling more than 15 km. The majority of couples had attended infertility services 1–3 times (58%), while 16.4% had never visited infertility services (Table 1).
Bivariate analysis
Bivariate analyses examined associations between gender and key independent variables, including financial status, discrimination, cultural factors, gender sensitivity, and knowledge (Table 2).
• There was no significant difference between men and women regarding financial access to infertility services (p = 0.616) or cultural factors (p = 0.225).
• Discrimination differed significantly by gender (p = 0.009), with women reporting higher levels of perceived stigma and unfair treatment related to infertility.
• Gender sensitivity also differed significantly between men and women (p = 0.003), reflecting women’s greater perceived social and familial expectations in seeking infertility care.
• Knowledge of infertility did not significantly differ by gender (p = 0.815).
Table 2.
Bivariate associations between gender and independent variables.
| Characteristics | Financial | p | Discrimination | p | Culture | p | Gender sensitivity | p | Knowledge | p | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Good | Bad | No | Yes | No | Yes | No | Yes | Good | Bad | ||||||
| Gender | |||||||||||||||
| Men | 14 | 22 | 0.616 | 2 | 34 | 0.009* | 18 | 18 | 0.225 | 3 | 33 | 0.003* | 13 | 23 | 0.815 |
| Women | 174 | 140 | | 1 | 213 | | 130 | 84 | | 2 | 212 | | 73 | 141 | |
*significant p<0.05.
Multivariable logistic regression
Multivariable logistic regression was performed to identify factors independently associated with gender differences in infertility service access (Table 3). After adjusting for all covariates, gender sensitivity remained significantly associated with gender differences in access to infertility care (OR = 0.139, 95% CI 0.020–0.964, p = 0.046). Other factors, including financial status, discrimination, culture, and knowledge, were not statistically significant in the adjusted model (p > 0.05).
Table 3.
Multivariable logistic regression analysis of gender differences in infertility service access.
| Variable | OR | 95% CI | p | |
|---|---|---|---|---|
| Lower | Upper | |||
| Financial | 0.890 | 0.394 | 2.011 | 0.780 |
| Discrimination | 0.150 | 0.011 | 2.070 | 0.157 |
| Culture | 1.372 | 0.601 | 3.133 | 0.452 |
| Gender Sensitivity | 0.139 | 0.020 | 0.964 | 0.046* |
| Knowledge | 0.868 | 0.383 | 1.964 | 0.734 |
*significant p<0.05.
These results indicate that perceived gender sensitivity is a key determinant of differences in infertility service utilization between men and women, whereas other factors such as financial status, culture, and knowledge did not independently influence access.
Discussion
Infertility is increasingly recognized not only as a biomedical condition but also as a psychosocial experience that may substantially affect emotional well-being, marital relationships, and social identity.16–18 Previous research has consistently demonstrated that infertility is associated with elevated levels of anxiety, depression, diminished self-esteem, social isolation, and reduced quality of life.17–20 These psychological stressors may also interact with neuroendocrine pathways, potentially influencing reproductive function and treatment outcomes.19,20 These psychological burdens of infertility are often intensified in sociocultural contexts where childbearing is closely linked to gender identity, marital stability, and social status.21,22
The principal finding of this study was that gender sensitivity was associated with gender differences in access to infertility services, even after adjusting for financial constraints, perceived discrimination, cultural influences, and knowledge-related factors. However, this finding should be interpreted cautiously, given the borderline statistical significance and wide confidence interval. This finding suggests that gender sensitivity may be relevant to understanding differences in healthcare-seeking behavior, alongside structural and economic barriers. In many societies, including Indonesia, infertility is frequently attributed primarily to women, despite the well-documented contribution of male factors to infertility diagnoses. Such gendered social norms may help explain differences in which partner assumes responsibility for seeking treatment, who initiates contact with healthcare providers, and how infertility services are accessed and utilized.16,22
Although discrimination was significantly associated with gender in the bivariate analysis, this relationship did not remain significant in the multivariable model. This finding may reflect some conceptual overlap between discrimination and gender sensitivity, as experiences of stigma, blame, and social judgment may occur within broader gender norms and expectations. Consistent with previous research, women experiencing infertility more frequently report self-blame, social pressure, and stigmatization compared with men.23,24 These observations suggest that gender-related perceptions and norms may be more closely associated with patterns of access to infertility services than isolated experiences of discrimination.
Indonesia’s sociocultural expectations surrounding marriage and childbearing, combined with geographic, economic, and educational disparities, may be related to unequal access to reproductive health services, particularly in regions outside major urban centers. Variability in healthcare infrastructure and the availability of trained reproductive health specialists may also be associated with delays in the diagnosis and management of infertility and persistent barriers to care. 25 While financial and structural constraints remain important factors associated with healthcare access,26,27 the present findings suggest that gender-related perceptions and social norms should also be considered when seeking to support more equitable utilization of infertility services.
We acknowledge that our perspectives as Indonesian researchers specializing in reproductive health may shape the interpretation of these findings. Our professional engagement with infertile patients and healthcare providers has informed our understanding of the cultural and structural challenges surrounding infertility care in Indonesia. This positional awareness underscores the importance of culturally sensitive, gender-responsive, and patient-centered approaches in the delivery of infertility services.
Several limitations should be considered when interpreting the results of this study. First, the findings may not be fully generalizable to other countries or sociocultural contexts, given Indonesia’s distinct social norms and healthcare system characteristics. Second, this study did not comprehensively examine additional determinants of access to infertility care, such as broader socioeconomic inequalities, geographic barriers, or variations in regional healthcare infrastructure. Third, because this study used a cross-sectional design, the observed relationships should be interpreted as associations rather than causal effects. Future research incorporating additional contextual factors and longitudinal approaches may provide a more comprehensive understanding of disparities in infertility care utilization.
Conclusion
Gender sensitivity was associated with gender differences in access to infertility services in Central Java, Indonesia. These findings suggest that gender sensitivity is associated with how infertile couples access care, although this association should be interpreted cautiously. Greater attention to gender dynamics in patient education, counseling, and clinical practice may support more equitable access to infertility services in similar sociocultural contexts.
Acknowledgments
We want to thank Universitas Sebelas Maret for their support in this study.
Footnotes
Author contributions: Contributions U.R.B: the study’s design, writing - original draft, funding acquisition, developed the research methodology, supervised data collection, and managed the overall project. E.M.: collecting and curating the data, performing statistical analysis, funding acquisition. T.P: The interviews and surveys with participants, coordinated with the participating hospitals, and funding acquisition. A.L: revising and editing the manuscript, validating the data accuracy and integrity, funding acquisition. M.P: Provided necessary resources, assisted in the manuscript review, and contributed to developing the research methodology. C.H: obtained ethical approval for the study, and participated in the data collection process. I.N: involved in data analysis, managing software tools for data processing, and writing parts of the initial manuscript draft. M.D: participated in the investigation, contributed to refining the methodology, and reviewed and edited the manuscript. A.Z.J: managed project administration tasks, provided necessary resources, and contributed to interviews and surveys with participants. S.T.A: responsible for creating visual representations of the data and curating the data for analysis. C.E.N: participated in data collection and contributed to coordinating with the participating hospitals. All authors have read and agreed to the published version of the manuscript.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by Universitas Sebelas Maret under the international collaborative research grant, number 228/UN27.22/PT.01.03/2023.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
ORCID iD
Uki Retno Budihastuti https://orcid.org/0000-0003-0611-7464
Ethical considerations
The Institutional Review Board (IRB) Dr. Moewardi General Hospital approved the study with IRB No. 703/V/HREC/2023. Informed consent was obtained from all participants upon their enrollment.
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