Human Reproduction Vol.22, No.7 pp. 2033–2039, 2007
doi:10.1093/humrep/dem086
Advance Access publication on April 26, 2007
Reproductive health and midwives: Does occupational status differentiate their attitudes on assisted reproduction technologies from those of the general population? S. Papaharitou1,3, E. Nakopoulou1, M. Moraitou2, K. Hatzimouratidis1 and D. Hatzichristou1 1
Center for Sexual and Reproductive Health, Aristotle University of Thessaloniki, PO Box 367, Greece; 2Midwifery Department, School of Health Professions, Highest Technological Institute of Thessaloniki, Greece
3
Correspondence address: Center for Sexual and Reproductive Health, Aristotle University of Thessaloniki, Greece. Tel./Fax: þ30 2130 999099; E-mail:
[email protected]
BACKGROUND: Advancements within assisted reproduction technologies (ART) raise ethical questions; however, research on health care professionals’ attitudes towards their application is limited. This study aimed at assessing certified (CMs) and Student (SMs) midwives’ attitudes towards various aspects of ART as well as comparing them with public opinion. METHODS: The final sample included 567 female CMs and 605 women from the general population (age range: 25-62 years), 221 SMs and 209 female non-SMs (age range: 18-24 years). The questionnaire administered included socio-demographic information, items addressing knowledge issues and attitude statements. Data were analysed using principal components analysis, one-way analysis of variance and Friedman’s test, as well as multiple linear regression. RESULTS: Four attitudinal factors emerged: ‘genetic counselling’ (GC), ‘application of ART’, ‘moral dilemmas’ and ‘socio-ethical aspects’; occupational status did not affect attitudes towards GC, however SMs expressed more positive attitudes regarding the latter three factors (P < 0.001: 17.49, 14.14 and 11.55). Student groups expressed more negative attitudes for multifetal pregnancy reduction (SMs: 1.88 + 0.83; non-SMs: 2.17 + 0.77) whereas the other two groups were least favourable towards embryo donation (2.30 + 0.80, CM; 2.32 + 0.83, general population). Sex selection and the use of ART by menopausal or homosexual women were the least acceptable practices for all groups (P < 0.001). A high level of relevant knowledge was positively associated with ‘application of ART’ and acceptability of its use by specific population groups (b 5 0.469, b 5 0.19). Findings on factors influencing attitudinal patterns are further discussed. CONCLUSIONS: In this first attempt, it was revealed that CMs express the same conservative attitudes as the general population. Keywords: assisted reproduction technology application; genetic counselling; midwives; moral dilemmas; socio-ethical aspects
Introduction Since the emergence of IVF in 1978, the continuing development of assisted reproduction technologies (ART) led to complex ethical, legal and social issues related to their application. New IVF-based techniques detached conception from sexual intercourse and enabled the involvement of a third party in the reproduction process, challenging traditional family identity (Dickens, 2002; Gamal, 2002). Thus, an ongoing debate has evolved among specialized professionals, legislators, religious authorities and the general public. Ethical controversies centre mainly on genetic material donation, embryo research, surrogacy and human cloning (Fasouliotis and Schenker, 2000). However, there are limited empirical studies assessing public and professionals’ attitudes towards application of new technology (Kazen et al., 1995;
Zegers-Hochschild, 1999; Fonnest et al., 2000; Kovacs et al., 2003; Yogev et al., 2003; Isikoglou et al., 2006). Many countries realized that limits should be set to the use of ART and attempted to establish regulations for its acceptable practice (Schenker, 1997). In Greece, relevant legislation has only recently been voted (3089/12-2002 and 3305/01-2005) and there are few published data only on public intention to use new technologies (Chliaoutakis et al., 2002; Tzamalouka et al., 2005). Although health care professionals, directly or indirectly involved in assisted conception services, are likely to encounter ethical controversies, there is scarcity of information on their attitudes towards ART application (Fonnest et al., 2000; Yogev et al., 2003). As midwives’ public health role evolves, women are more likely to seek their advice when planning a
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conception (Sidebotham, 2002). Thus, midwives are expected to provide advice on all matters relating to fertility issues (Department of Health, 2001). Specifically in Greece, midwifery practice includes the provision of family planning and gynaecological care (i.e. annual exams, sexually transmitted diseases and fertility issues), counselling and support to women before and during pregnancy, labour and postpartum period as well as care for the newborn. Midwives work in a wide range of settings, such as women’s clinics in the private and public sector, health and family planning centres while the recent legislation on ART (3305/01-2005) instituted their employment also in fertility centres. Taking the above into consideration, the present study was primarily aimed at assessing certified midwives’ (CMs) and midwifery students’ (SMs) attitudes towards various aspects of ART. It also attempted to investigate the factors associated with attitudinal patterns. Women from the general population were also recruited together with female non-SMs in order to detect differences due to occupational status. Materials and Methods Participants The sample included female CMs and SMs. In order to detect possible attitude differences due to occupational influences, female students from different fields of study and women from the general population, matching CMs in age and education, were recruited. CMs were selected from the Graduate Registry of all CMs from the Midwifery department of the Highest Technological Institute of Thessaloniki (HTIT). Participating students included undergraduates attending the 4-y programme at the Midwifery department of the HTIT and students from different departments of Aristotle University of Thessaloniki. Finally, women registered in 26 randomly selected general practitioner (GP) private practices, located in Northern Greece, constituted the female sample from the general population. Measures A self-administered questionnaire was constructed, based on evidence from the literature (Fonnest et al., 2000; Dissanayke et al., 2002). The questionnaire was pilot-tested on 10 SMs and minor amendments were made in the wording of specific items. The final version included 59 different variables divided in three sections as follows: Socio-demographic information This section referred to sample’s age, family’s (parental or own) socio-economic position, marital and occupational status, place of origin, parents’ educational level and religiosity, as well as years of professional experience (applicable only to CMs). Additionally, a single item was used to assess relationship with religion, where participants had to choose among three responses ‘none’, ‘non-practicing believers’ and ‘practicing believers’. Finally, they were asked ‘whether they know a friend or relative who had undergone infertility treatment’. Information—knowledge issues. Participants had to evaluate, on a 4-point scale (1– 4, ‘not at all’ to ‘highly’), their knowledge level about the different ART and the relevant legislation recently voted in Greece. Data were collected regarding currently used information sources on ART and resources, which they find appropriate for updating. Also, they were asked to indicate
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among physicians, midwives and psychologists whom they consider the appropriate health professional for providing information about ART in the case of women and of men. Attitudes towards assisted reproduction. This section consisted of 18 statements measuring attitudes towards assisted reproduction and subfertility. The items addressed issues relating to provision of genetic services, various aspects of ART application (i.e. genetic material donation, cloning, surrogacy, sex selection and multifetal pregnancy reduction) and ethical dilemmas such as use of ART by women above the age of 40 or single women. It also included seven items assessing participants’ views regarding midwives’ involvement in infertility treatment. The degree of agreement/disagreement with each attitude/opinion statement was measured on a 4-point Likert-type scale that ranged from 1 (strongly disagree) to 4 (strongly agree). Higher scores indicated a more favourable attitude towards assisted reproduction. Procedure The data were collected over a 4-month period from September to December 2005. Completion of the questionnaire was voluntary and participants were assured of anonymity and confidentiality. An information sheet explaining the scope of the study was attached to the questionnaire. All students were approached in the auditoriums at the end of their lectures after tutors’ permission. They were handed an unmarked envelope with a questionnaire included and were instructed to put the completed form back into the envelope before returning it. Regarding the female sample from the general population, questionnaires were distributed to all women present in each GPs private practice during scheduled visits. Completed forms were dropped in a poll for privacy reasons. To preserve confidentiality, those wishing not to participate were asked to return a blank form. In most cases no blank forms were returned and therefore, response rates cannot be accurately estimated. Regarding CMs, they were contacted by phone to be informed about the study’s scope. Questionnaires were posted only to those who agreed to participate together with a stamped and pre-addressed return envelope. A 4-week period was given to return completed forms. After the deadline, a postal reminder was sent to the nonresponding midwives to request completion. Statistical analysis Data were analysed using the Statistical Package for the Social Sciences (version 13.0). A principal components analysis (PCA) with varimax rotation was used for the 18 attitude statements, in order to identify latent factors and to reduce the number of variables. Final factor solutions were based on factors with an eigenvalue .1.0 and each individual item was correlated with the factor concerned at the level of 0.4 or above. One-way analysis of variance was conducted to test for group differences in attitudinal patterns. The non-parametric Friedman test was performed to compare responses to individual items within each group. Multiple linear regression analysis, controlling for the effect of occupation, was selected to assess the relationship between independent and outcome variables. The attitudinal factors extracted by the PCA constituted the outcome variables. Sociodemographic characteristics, relationship with religion, self-evaluated knowledge about ART and having a friend or relative who has undergone infertility treatment were entered in the equation as predictors. Dichotomous dummy variables were created for each category of origin, socio-economic status and relationship with religion.
Reproductive health and midwives
Results A total of 1873 questionnaires were administered and 1602 were returned. In the CMs group, out of 821 questionnaires, 567 fully completed forms were returned (69% response rate). In the SMs group, 238 questionnaires were gathered; of which, 17 were excluded because they were poorly completed (92.9% response rate). Regarding the remaining two groups, 62 out of 667 questionnaires distributed to women from the general population had missing data whereas among female students from different fields of study, 23 out of 232 questionnaires gathered were incomplete (response rate 90.7 and 90.1%, respectively). The final sample consisted of 567 CMs, 221 SMs, 209 female students from different fields of study and 605 women from the general population. Detailed demographics for each group and working experience for the CMs group are presented in Table 1. Regarding information on ART, the majority of participants in the groups of women from the general population, SMs and non-SMs evaluated their knowledge as ‘poor’ (71, 77 and 82%, respectively); more than half of the CMs (52%) reported being adequately informed on ART issues. Attitudes towards assisted reproduction and subfertility Four factors emerged from the PCA accounting for 57% of the total variance (Table 2). The first factor, accounting for 18% of the variance, consisted of six items related to the acceptability of genetic material donation, surrogacy, multifetal pregnancy reduction and donor’s anonymity. It was labelled ‘application of ART’ since the items with the highest loadings referred to the application of ART. The second factor accounted for 15% of the variance and included statements about the use of
ART by specific population groups (i.e. women above the age 40 or single women) that might lead to changes in traditional family structures. Therefore, it was named ‘socioethical aspects’. The third factor (13% of the variance) comprised items regarding genetic services provision and was labelled ‘genetic counselling (GC)’. The fourth factor (11% of the variance) included items about cloning, sex selection, future use of cryopreserved gametes and posthumous reproduction. Since the highest loadings were on the latter, the factor was labelled ‘moral dilemmas’. All factors had high internal consistency across the participating groups with Cronbach’s Alpha ranging from 0.676 to 0.834. Results from the reliability analysis are presented in Table 3. The Kolmogorov– Smirnov test showed that scales’ scores distribution across groups satisfied the normality requirement (P . 0.05). Genetic counselling Groups did not differ significantly in their attitudes towards GC (P . 0.05). Frequency distributions revealed high levels of support for the provision of genetic services by all the participating students and the vast majority of CMs (97%, n ¼ 551) and the female sample from the general population (98%, n ¼ 594). Only 16 out of 567 CMs and 11 out of 605 women from the general population did not feel that GC is important for responsible reproductive decisions. The same proportion disagreed with the idea that GC should be a part of prenatal and family planning services. Application of ART and moral dilemmas One-way ANOVA showed that SMs, compared to the other participating groups, expressed significantly more positive
Table 1: Socio-demographic information across groups of women in the study
Age, mean (+SD) Years of professional experience in ART mean (+SD) Marital status, n (%) Single Casual relationship Stable relationship Married Family socio-economic status, n (%) Working class Middle-class Upper-class Place of origin, n (%) City Town Village Religion, n (%) None Believe but do not attend religious services Believe and attend religious services Ever employed by an infertility centre, n (%)
CM (n ¼ 0567)
Women: general population (n ¼ 605)
SM (n ¼ 221)
Other female students (n ¼ 209)
39.55 (+8.19) 13.69 (+8.69)
37.62 (+7.58) –
19.79 (+1.31) –
20.25 (+1.60) –
82 (14.5) 22 (3.9) 52 (9.2) 411 (72.5)
95 (15.7) 28 (4.6) 70 (11.6) 412 (68.1)
113 (51.1) 53 (24.0) 53 (24.0) 2 (0.9)
112 (53.6) 36 (17.2) 59 (28.2) 2 (1.0)
93(16.4) 448 (79.0) 26 (4.6)
141 (23.3) 426 (70.4) 38 (6.3)
58 (26.2) 142 (64.2) 21 (9.5)
34 (16.3) 159 (76.1) 16 (7.7)
119 (21.0) 257 (45.3) 191 (33.7)
236 (39.0) 222 (36.7) 147 (24.3)
66 (29.9) 88 (39.8) 67 (30.3)
84 (40.2) 80 (38.3) 45 (21.5)
37 (6.5) 241 (42.5) 289 (51.0)
32 (5.3) 307 (50.7) 266 (44.0)
11 (5.0) 113 (51.1) 97 (43.9)
15 (7.2) 126 (60.3) 68 (32.5)
20 (3.5)
–
–
–
CM, certified midwives; SM, student midwives.
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Table 2: Principal component analysis of the 18 attitude statements regarding assisted reproduction and subfertility Items
Factor 1
Factor 2 Factor 3
Factor 4
Sperm donation Oocyte donation Embryo donation Surrogacy Donor’s anonymity Multifetal pregnancy reduction Women’s age and ART use Menopausal women and ART use Single women and ART use Homosexual women and ART use GC results in more responsible reproductive decisions GC should be offered as part of prenatal and family planning services GC is both useful and necessary Reproductive cloning Therapeutic cloning Cryopreservation Posthumus reproduction Sex selection
0.867 0.879 0.746 0.645 0.628 0.686 – – – – –
– – – – – – 0.671 0.652 0.676 0.685 –
– – – – – – – – – – 0.724
– – – – – – – – – – –
–
–
0.803
–
– – – – – –
– – – – – –
0.774 – – – – –
– 20.515 0.525 0.617 0.717 0.573
Factor 1: application of ART, Factor 2: socio-ethical aspects, Factor 3: genetic counselling, Factor 4: moral dilemmas.
attitudes towards both ‘application of ART’ and ‘moral dilemmas’ [F(3, 1589) ¼ 26.44 and F(3, 1589) ¼ 104.25, respectively; P , 0.001] (Fig. 1). A more detailed analysis, using Friedman’s test, was conducted within each group, to test for differences between responses in individual items. Mean scores across groups are presented in Table 4 in order to indicate possible tendencies. It was revealed that for ‘application of ART’, CMs and women from the general population were least favourable towards embryo donation (2.30 + 0.80 and 2.32 + 0.83, respectively) followed by surrogacy, whereas both students groups expressed more negative attitudes for multifetal pregnancy reduction (SMs: 1.88 + 0.83 and non-SMs: 2.17 + 0.77). Donor’s anonymity had the highest acceptability across the participating groups, except SMs. Regarding ‘moral dilemmas’, CMs, women from the general population and non-SMs, reported reproductive cloning and sex selection to be the least acceptable practices (Table 4); SMs were less favourable only towards sex selection (2.28 + 0.77). Cryopreservation was also viewed negatively but only by the women from the general population. The majority of groups were more positive towards posthumous reproduction (Table 4).
Table 3: Reliability coefficients for the factors extracted by the PCA across participating groups
CMs Women (general population) SMs Other female students
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Application Socio-ethical GC of ART aspects
Moral dilemmas
0.746 0.750 0.691 0.743
0.747 0.741 0.716 0.724
0.741 0.763 0.704 0.769
0.834 0.828 0.676 0.785
Figure 1: Mean differences between participating groups in the attitudinal factors derived from the principal components analysis
Multiple regression analysis, controlling for occupation, was conducted to test the relationship between attitude scores and socio-demographic variables, self-evaluated knowledge about ART as well as having a friend or relative who has undergone infertility treatment. The models used were statistically significant (P , 0.001) explaining 6.6 and 17.3% of the total variance in the attitudes towards ‘application of ART’ and ‘moral dilemmas’ respectively. Results suggest that participants from rural areas were less favourable (r 2 ¼ 2 0.376) towards issues such as reproductive cloning, sex selection, future use of cryopreserved gametes, whereas being a SM and parents’ higher education were associated with increased acceptability of these practices (r 2 ¼ 2.916 and 0.129, respectively). Positive attitudes towards ‘application of ART’ were influenced by a high level of knowledge about assisted reproduction and having a friend or relative who has undergone infertility treatment (r 2 ¼ 0.469 and 0.401, respectively) while practicing believers expressed a more negative stance (r 2 ¼ 20.317). Socio-ethical aspects of assisted reproduction SMs appeared to be more liberal compared to the other groups regarding socio-ethical issues relating to assisted reproduction [F(3, 1590) ¼ 202.99, P , 0.001] (Fig. 1). However, analysing differences in responses to individual items, it was revealed that participants across all groups were less favourable (P , 0.001) towards use of ART by menopausal or homosexual women (Table 4). The regression model used, controlling for the effect of occupation, was statistically significant (P , 0.001) explaining 31% of the total variance in the attitudes towards socio-ethical issues. Results showed that parents’ religiosity, increased age and number of children were negatively associated with attitudes towards socio-ethical issues the use of ART by women above the age of 40, single, menopausal or homosexual women (Table 5). In contrast, those of the participants who described themselves as ’not religious’ and reported a high level of knowledge about ART, they expressed a more
Reproductive health and midwives
Table 4: Differences between responses in individual items within each group Items Application of ART Sperm donation Oocyte donation Embryo donation Surrogacy Donor’s anonymity Multifetal pregnancy reduction Moral dilemmas Reproductive cloning Therapeutic cloning Cryopreservation Posthumus reproduction Sex selection Socio-ethical aspects ART use by women above the age of 40 ART use by menopausal women ART use by single women ART use by homosexual women
CMs, mean (SD)
SMs, mean (SD)
General female sample, mean (SD)
Non-SMs, mean (SD)
2.69 (0.76) 2.73 (0.77) 2.30** (0.80) 2.40** (0.82) 3.16 (0.86) 2.52 (0.83)
3.23 (0.42) 3.06 (0.26) 3.48 (0.59) 3.39 (0.66) 2.41 (0.77) 1.88** (0.83)
2.61 (0.84) 2.68 (0.86) 2.32** (0.83) 2.41** (0.88) 3.18 (0.87) 2.25 (0.85)
2.65 (0.81) 2.75 (0.78) 2.24 (0.80) 2.61 (0.84) 3.25 (0.80) 2.17** (0.77)
1.62 (0.72) 2.38 (0.98) 2.91 (0.76) 2.24 (0.88) 1.95** (0.75)
3.48** (0.64) 3.02 (0.71) 2.67 (0.72) 2.70 (0.78) 2.28** (0.77)
1.59** (0.66) 2.43 (0.96) 1.59 (0.81) 2.24 (0.85) 1.84** (0.78)
1.66** (0.68) 2.78 (0.85) 2.71 (0.74) 2.25 (0.82) 1.82** (0.78)
2.15 (0.84) 1.62** (0.69) 2.41 (0.80) 1.69** (0.71)
2.88 (0.80) 2.74** (0.83) 3.12 (0.76) 2.86** (0.81)
2.13 (0.84) 1.63** (0.71) 2.41 (0.89) 1.68** (0.75)
2.14 (0.81) 1.67** (0.74) 2.47 (0.79) 1.87** (0.86)
**P , 0.001; Note: All items were assessed with a 4-point Likert scale—strongly disagree (1), disagree (2), agree (3) and strongly agree (4). Means and SDs are presented only for descriptive purposes, to indicate a tendency, and are not used for direct comparisons.
favourable attitude towards the use of ART by women above the age of 40 as well as single, menopausal or homosexual women (Table 5). Discussion Many of the ethical questions related to ART are similar all over the world; however individual attitudes are influenced by philosophical, economic, socio-cultural and religious differences. Therefore, it is important to investigate the factors that affect the views of the public and health care professionals. The present study contributes information regarding midwives’ attitudes (both SMs and CMs) towards various aspects of ART and attempts to investigate parameters associated with their attitudinal patterns. Females were also recruited from the general population for comparison purposes. Similarly to previous studies (Dissanayake et al., 2002), our data showed that GC was highly acceptable by all groups since almost unanimously participants agreed on its usefulness and
Table 5: Regression coefficients for the model assessing the association between socio-demographic profile and the composite scores in attitudinal factors related to ART Variables Constant term Age (y) Occupational status Midwifery students Others (base line) Number of children Relationship with religion None Other (base line) Parents’ religiosity Perceived knowledge level about ART r 2 (r 2 adjusted) ¼ 0.31 (0.30).
b
SEM
P-value
7.86 20.69 3.33
0.30 0.08 0.15
0.000 0.000 0.000
20.22 0.66
0.05 0.22
0.000 0.003
20.17 0.19
0.08 0.07
0.030 0.007
necessity. Contrary to the above, when asked about various aspects of ART, only SMs, compared to the other groups, expressed more positive attitudes towards all issues addressed (‘application of ART’, ‘moral dilemmas’ and ‘socio-ethical aspects’). On the other hand, the fact that CMs did not differ from the other groups on their attitudes, might indicate that personal factors, other than the nature of their occupation, have a confounding effect. Nevertheless, this is an issue of further investigation, since it is the first attempt to assess attitudes towards ART in this specific population. Interesting findings were revealed regarding differences between single items within each group. Consistent with previous reports (Chliaoutakis et al., 2002; Dissanayake et al., 2002), it was found that CMs and women from the general population were less favourable towards embryo donation and surrogacy. Both student groups on the other hand, disapproved of multifetal pregnancy reduction. This may be due to their consideration of that practice as abortion and a lack of information about the medical risks, social and psychological problems associated with multiple pregnancies (Fasouliotis and Schenker, 2000; Chliaoutakis et al., 2002). A general positive trend was revealed for donor’s anonymity which is consistent with previously published data and most ethical committees’ recommendations to maintain privacy (Westlander, 1998; Fasouliotis and Schenker, 2000; Fonnest et al., 2000; Skoog Svanberg et al., 2003). Yet, opposing views exist since donor’s anonymity is quite a controversial issue in assisted reproduction. Another issue associated with donor’s anonymity is disclosure to offspring, that also raises considerable debate. In the present study we did not assess attitudes towards disclosure to the child since in Greece, midwives provide care to women only till post-partum period; therefore, other health professionals such as child psychologists, will probably handle disclosure issues. Regarding moral dilemmas, our data showed that participants considered reproductive cloning and sex selection to be 2037
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the least acceptable practices. That is in line with studies conducted in the general population and health care professionals (Genuis et al., 1993; Fonnest et al., 2000; Dissanayake et al., 2002; Tzamalouka et al., 2005), reporting a strong opposition to reproductive cloning and sex selection. Both practices are considered to be unethical and raise concerns about physical and psychological harms (Sanchez-Sweatman, 2000; Pennings and de Wert, 2003). However, as in the case of surrogacy, acceptability of reproductive cloning and sex selection increases when they are used for therapeutic reasons or to avoid a sex-linked disease (Fasouliotis and Schenker, 2000; Katayama, 2001; Tzamalouka et al., 2005). Our data also revealed that, in accordance to previous reports (Zegers-Hochschild, 1999; Fonnest et al., 2000; Kovacs et al., 2003), participants across all groups expressed more negative attitudes towards the use of ART by menopausal and homosexual women. Proponents of that view usually focus on the child’s welfare; they argue that advanced maternal age is associated with increased maternal and fetal mortality, thus older women may lack the necessary resources to deal with the physical and psychological stress of parenting (Hope et al., 1995; Fasouliotis and Schenker, 2000). Those who object to the application of ART to homosexual women claim that such practices lead to deviating patterns from what is considered to be the normal traditional family structure (Dickens, 2002). However, there are studies reporting favourable views on the availability of ART to same-sex couples (Rowland and Ruffin, 1983; Kaplan et al., 2004; Heikkila et al., 2004). The model used in the present study to detect the effect of socio-demographic characteristics, irrespective of occupational status, showed that, consistent with previous reports (Genuis et al., 1993; Fonnest et al., 2000; Yogev et al., 2003; Tzamalouka et al., 2005), age, place of origin, relationship with religion and knowledge level are among the factors that influence participants’ attitudinal patterns. Older participants, practicing believers as well as those from rural areas, favoured restrictions of ART application and were more likely to oppose practices such as reproductive cloning and sex selection. Our finding could indicate that people with such a sociodemographic profile hold more conservative attitudes and may view ART as a threat to traditional values. We also found an association, though weak, between increased number of children and greater support for ART provision to women above the age of 40, single or homosexual women. Similarly, a study on infertile and parous women’s attitudes (Heikkila et al., 2004), showed that infertile women favoured the provision of infertility treatment to lesbian and homosexual couples, possibly influenced by their wish to help childless couples. Regarding self-evaluated knowledge, our study revealed that participants perceiving themselves to be adequately informed about ART were more positive towards ‘application of ART’ (i.e. genetic material donation, surrogacy and multifetal pregnancy reduction) and related socio-ethical aspects. Parents’ higher education and having a friend or relative who has undergone ART, also appeared to play a role in participants’ increased acceptability of specific methods of assisted 2038
reproduction. As it has been reported (Evans, 2002; Tzamalouka et al., 2005) having more education and increased knowledge about a topic can lead to liberal attitudes since knowing more may lead to less fear. Additionally, familiarity with specific conditions may also lead to the adoption of more favourable and less uncertain views. Thus, people knowing someone close to them who has undergone infertility treatment, are likely to engage in more thoughtful approaches to ART. It should be noted however, that the majority of participants across groups (above 71%), with the exception of CMs, perceived their knowledge level about ART as ‘low’. It has been reported that those who are least informed are unlikely to have structured and stable attitudes; nevertheless, they are willing to participate in a survey even regarding issues in which they lack interest or knowledge (Pardo et al., 2002). Studies showed that public support of ART varies according to the conditions of its use (Genuis et al., 1993). Thus, using single items to address various aspects of ART, could impede participants lacking relevant knowledge to understand the intent of questions asked. The different data collection strategies (telephone for CMs versus approach after lecture for all students) resulted in different response rates. It is possible that only midwives interested in this field completed the questionnaire; however, the same limitation may also apply to students. Additionally, female participants selected via GP private practices constitute a nonrandomized self-selected sample and therefore are not representative of the general population, thus limiting the generalizibility of our results. Ideally, a sample of over 2000 people from the general population should be used to provide a representative survey. Taking into consideration the above limitations and the lack of relevant published data on midwives’ views, interpretation of our findings should be made with caution. In conclusion, this first attempt to investigate SMs and CMs views on ART, revealed that personal factors (age, origin and religious beliefs) and provision of information are important in shaping their attitudes towards ART application. It was shown that CMs do not differentiate from the general population, expressing the same conservative attitudes. With their expanded health care role and increased accessibility, CMs are expected to care for women following infertility treatment. Therefore, it is important for CMs to become aware of their own values and how these might influence their clinical practice. Since innovations within ART continuously add new dimensions to the debate started with the emergence of IVF in the 1970s (Kuhse, 2002), additional research is needed on the knowledge, beliefs and attitudes among other health care professionals who are likely to encounter ethical controversies.
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