Infertility is commonly assumed to affect Western people significantly more than the population in the Global South, mainly due to recurrent narratives that portray Global South groups as “hyper fertile” (1). These stereotypical narratives of reproduction about and around Africa ignore both the fundamental heterogeneity of people(s) and people’s experiences and scientific evidence underlying the importance of infertility rates in Global South countries (2). Infertility is defined by the World Health Organisation as “a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse” (3). Causes of infertility in low and middle income countries (LMICs) range from factors such as age or lifestyle, to fallopian tube occlusions due to sexually transmitted infections or postpartum infections (4). Some of these determinants could be partially prevented by improving access to quality reproductive health care. However, others can only be discovered once a person starts experiencing difficulties getting pregnant (4). In this context, the accessibility of assisted reproductive technology (ART) has been extensively discussed both in relation to its cost and its implications in terms of inequality between the rich and the poor on the national level and low- and high-income countries in the international sphere (3). ARTs are defined as a range of methods that involve handling gametes (eggs), sperm, or embryos outside the human body to facilitate pregnancy (3).
Globally, sixty to eighty million people suffer from infertility, and the majority of them reside in LMICs (2). The United Nations found that 17.5% of adults may experience infertility throughout their lives (3). This results in one out of six couples reporting infertility problems worldwide (3). Across sub-Saharan Africa, infertility rates vary considerably from region to region. While in Gambia the estimated prevalence of infertility is 9%, in regions such as South Africa, Nigeria, and Ethiopia, infertility affects between 15% and 30% of the population (3). Yet, the majority of couples experiencing infertility in sub-Saharan Africa are precluded from accessing quality ART treatment options due to a variety of socio-economic and structural determinants (3).
Hence, this blog post aims to assess how access to ART, specifically in sub-Saharan Africa, is not only limited by economic constraints but also by social, cultural, and structural factors that are frequently overlooked and outside of an individual’s scope of action. To support the previous statement, an approach based on the Reproductive Justice framework will be applied.
Reproductive Justice Framework
The Reproductive Justice framework was developed in the 1990s following a conceptual transition from family planning to reproductive health with emphasis on a women-centered and rights-based approach (5). It argues against white women’s presumption that their experiences are universal and applicable to all women (6). The fundamental concept underlying the framework is that of reproductive justice, defined as the splicing of reproductive rights and social justice (3,7). This newly built concept of reproductive justice is underpinned by three fundamental values: the right to have a child, the right not to have a child, and the right to parent children in a safe and healthy environment (7). Moreover, it acknowledges how people’s reproductive capacity is dependent on factors largely beyond the individual’s control, such as class, race, gender, sexuality, or access to healthcare (7). Ultimately, reproductive justice draws upon a human rights framework to highlight and oppose racial, gender, and class prejudices resulting in structural inequalities (7).
In the context of infertility and ART, the reproductive justice framework recognizes safe and dignified fertility management as a fundamental human right (7). Moreover, it acknowledges that gender and race stereotypes are reinforced under the pretence of objective scientific progress. Thus, while the use of ART is frequently advised to wealthy white couples, poorer women and black women may struggle to receive a diagnosis of infertility in the first place (6). Overall, ART can be defined as a double-edged sword in the context of infertility and reproductive rights: on one hand, it may support reproductive justice by, in theory, enabling anyone who wishes to have a child to do so regardless of marital status, sexual orientation, or health challenges. On the other hand, it can also be seen as reproducing economic, social, and cultural inequalities, depending on how it is implemented. In this way, ART can be seen to promote the reproductive rights of some over others (8).
Given this framework of analysis, the next section evaluates the challenges faced by couples in LMICs and, more specifically, sub-Saharan Africa in accessing quality ART.
Access to ARTs in sub-Saharan Africa
In sub-Saharan Africa, the relevance of infertility as a public health concern is often overlooked in the context of other pressing priorities, such as the prevention and control of fatal infectious and chronic diseases like AIDS, tuberculosis, and malaria. In settings where these diseases remain uncontrolled, infertility is often regarded as a lesser priority (2). Public health agendas typically focus on addressing life-threatening health concerns at the population level, but in doing so, they may fail to recognize the challenges faced by those suffering from chronic but non-fatal conditions such as infertility (2). Moreover, despite infertility being disregarded as a lower priority, infertility rates are notably high in many sub-Saharan African regions, making it an issue that should not be overlooked but rather acknowledged alongside other critical health challenges (3).
Furthermore, in sub-Saharan Africa, the experience of infertility can be translated into an unmanageable social stigma (2). In African societies where having children is an essential social expectation, childlessness is often perceived as an unacceptable deviation from traditional social and cultural norms (3). As a result of infertility, couples may experience severe limitations in their participation in their family and community’s social life. Moreover, although men also suffer those repercussions, women tend to be the ones experiencing most of the blame for the inability to procreate (3). Motherhood is often considered an essential element to affirm a woman’s social status, and women who are unable to become pregnant are therefore perceived to have failed to fulfill their role in society, resulting in severe social repercussions such as divorce, polygamy, or social exclusion (4). As a result, the demand for infertility treatments and ART is high, to the extent that in some sub-Saharan African clinics, infertility is the primary determinant of up to 25% of gynaecological visits (2).
The negative social and cultural ramifications of infertility in the sub-Saharan African context underline the necessity for states to provide access to affordable fertility treatments (3). However, national reproductive healthcare agendas rarely recognize the right of people to procreate as much as contraception and abortion discourses (3). National priorities are commonly skewed toward the prevention of pregnancy, thus failing to recognize infertility as an equally important public health concern. Consequently, those who wish to have a child are left alone, dealing with a variety of financial, social, and structural constraints that exponentially impact marginalized and low-income groups (3). Across sub-Saharan Africa, structural systems of oppression such as racism, sexism, poverty, and legacies of colonization and apartheid frequently cause poor women to be the objects of coercive reproductive health interventions, coercive contraception, and fertility reduction measures (4).
ART services in LMICs are generally limited, and if present, are predominantly offered by the private sector. Although some sub-Saharan African countries, such as South Africa, offer fertility treatments through the public sector, the waiting lists are unbearably long, the referral system is complex and lengthy, and the public facilities lack modern resources, thus limiting the effectiveness of fertility treatments (3). As a result, dependence on the private sector for effective fertility treatments has led to a two-tiered system that provides the wealthy with excellent resources for exorbitant prices and leaves the poor lacking any functional governmental recognition and support (3). Thus, in LMICs, ARTs commonly contribute to enhancing stratified reproduction dynamics, which entail the facilitation of reproduction for elites over marginalised and lower-income groups (1).
From a reproductive justice point of view, such national parameters limit people’s reproductive autonomy and capabilities by structurally precluding them from building a family based on their own preferences and reproductive choices (3). These systemic barriers perpetuate a form of reproductive inequality, where marginalized and low-income groups are disproportionately excluded from accessing fertility treatments, thus reinforcing stratified reproduction. Addressing these injustices requires integrating fertility treatments into public health systems, challenging the socioeconomic and structural constraints that limit access to ART, and implementing new policies to acknowledge the value of all reproductive rights, including the right to have children.
Conclusion
In conclusion, infertility is a significant yet often overlooked public health issue in sub-Saharan Africa, where social and cultural norms often place severe pressure on individuals, particularly women, to procreate. Despite the high demand for infertility treatments, access to ARTs remains limited by economic, structural, and cultural constraints. The lack of affordable, accessible, and equitable ART services perpetuates reproductive inequalities, disproportionately affecting marginalized and low-income groups.
The application of the Reproductive Justice framework underscores how ART can easily contribute to exacerbating systemic inequalities in reproductive healthcare. Hence, there is an urgent need for transformative approaches to address the socioeconomic, cultural, and structural barriers limiting access to fertility treatments. Prioritizing ART within public health systems, alongside contraception and abortion, is essential to recognizing infertility as a critical public health concern. Integrating ART into national health agendas requires addressing structural inequalities, from the privatization of fertility treatments to the extensive impacts of racism, sexism, and colonial legacies. Strategies that emphasize reproductive rights for all must be adopted, ensuring that access to ART is not a privilege reserved for the wealthy but a fundamental right accessible to everyone.
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