{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T12:53:23Z","timestamp":1791636803057,"version":"4.3.4"},"reference-count":116,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T00:00:00Z","timestamp":1791590400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004423","name":"World Health Organization","doi-asserted-by":"publisher","award":["203750842"],"award-info":[{"award-number":["203750842"]}],"id":[{"id":"10.13039\/100004423","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Infertility is a prevalent reproductive health condition that affects one in six people worldwide. Despite recent increasing recognition of the global burden of infertility, a large fertility care gap remains, with limited understanding of the determinants of care-seeking among those who require infertility services to achieve their desired family size.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBJECTIVE AND RATIONALE<\/jats:title>\n                    <jats:p>To date, there has been no comprehensive global thematic synthesis specifically focused on the qualitative evidence regarding determinants of fertility care-seeking. This review aims to identify and to systematize these determinants across diverse populations, settings, and health systems, drawing on a candidacy-informed framework to support more equitable, person-centred fertility care. The research question focuses on what determinants shape care-seeking among people with infertility and how these can be utilized to guide interventions, services, and future research.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>SEARCH METHODS<\/jats:title>\n                    <jats:p>Seven databases were searched up to May 2026, complemented by citation tracking, to identify qualitative and mixed-methods studies documenting determinants of fertility care-seeking among affected individuals and couples. The quality of included studies was appraised using the Joanna Briggs Institute checklist; data were inductively coded and thematically synthesized, mapped to socio-ecological levels, and interpreted through a candidacy lens. Confidence of the evidence in each synthesized finding was assessed using GRADE-CERQual.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OUTCOMES<\/jats:title>\n                    <jats:p>Twenty-seven studies from low-, middle-, and high-income countries involving users of biomedical, traditional, complementary, and cross-border fertility care were included. Determinants of care-seeking clustered into six domains: individual (e.g. personal fulfilment, fertility knowledge, age, psychological factors, gender norms); relational (e.g. couple dynamics, decision-making, negotiation, gendered power relations, masculinity norms); socio-cultural (e.g. stigma, social expectations, familial, and peer influences); socio-economic (e.g. financial barriers, health insurance coverage); health system and therapeutic (e.g. service quality, treatment costs, medical pluralism, public\u2013private sector dynamics, availability of Medically Assisted Reproduction\/ART, geographical accessibility, waiting times); and policy and political (e.g. infertility inclusion in national policies, regulatory frameworks, cross-border fertility care). Care pathways were typically non-linear, gendered, and diverse, characterized by delayed recognition of infertility as a health concern, medical pluralism, care interruptions, and re-engagement over time, often at considerable emotional and financial cost.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>WIDER IMPLICATIONS<\/jats:title>\n                    <jats:p>Multiple individual, relational, social, and structural determinants affect care-seeking for infertility. Multi-level policy, financing, and service delivery interventions are needed to address stigma, gendered norms, financial hardship, regulatory barriers, and often fragmented, pluralistic care pathways. This synthesis offers a candidacy-informed, multi-domain framework to guide context-sensitive interventions, including integrating infertility into universal health coverage, strengthening regulation of cross-border care, and embedding culturally competent, patient-centred fertility care within sexual and reproductive health programmes, and health systems.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>REGISTRATION NUMBER<\/jats:title>\n                    <jats:p>CRD420251163735.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/humupd\/dmag031","type":"journal-article","created":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T11:08:42Z","timestamp":1789384122000},"source":"Crossref","is-referenced-by-count":0,"title":["Delayed, fragmented, inequitable: a global qualitative systematic synthesis of fertility care pathways and determinants"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0306-6705","authenticated-orcid":false,"given":"Anna","family":"Afferri","sequence":"first","affiliation":[{"name":"School of Nursing, Midwifery, Allied, and Public Health (SoNMAPH), Canterbury Christ Church University , Canterbury,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5146-5946","authenticated-orcid":false,"given":"Joanna","family":"Apps","sequence":"additional","affiliation":[{"name":"The Graduate College, Canterbury Christ Church University , Canterbury,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4395-2955","authenticated-orcid":false,"given":"Michelle","family":"Crowther","sequence":"additional","affiliation":[{"name":"Student Life and Library Services, Canterbury Christ Church University , Canterbury,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5812-0529","authenticated-orcid":false,"given":"Gitau","family":"Mburu","sequence":"additional","affiliation":[{"name":"Department of Sexual, Reproductive, Maternal, Child and Adolescent Health and Ageing, World Health Organization , Geneva,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James","family":"Kiarie","sequence":"additional","affiliation":[{"name":"Department of Sexual, Reproductive, Maternal, Child and Adolescent Health and Ageing, World Health Organization , Geneva,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4736-8465","authenticated-orcid":false,"given":"Julie","family":"Balen","sequence":"additional","affiliation":[{"name":"School of Nursing, Midwifery, Allied, and Public Health (SoNMAPH), Canterbury Christ Church University , 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