Barriers and facilitators for the inclusion of fertility care in reproductive health policies in Africa: a qualitative evidence synthesis

Abstract

BACKGROUND Infertility affects over 50 million couples worldwide and impacts people’s social and emotional wellbeing. In low- and middle-income countries, particularly across Africa, the inclusion of fertility care into reproductive health (RH) policies remains fragmented or non-existent. OBJECTIVE AND RATIONALE This review aims to provide a framework for understanding the inclusion (or lack thereof) of fertility care in RH policies in African settings. It synthesizes the barriers and facilitators to such inclusion, with a view to uncovering the positioning of fertility care in broader health systems and on the agendas of key stakeholders such as health policymakers and practitioners. SEARCH METHODS A qualitative evidence synthesis was performed, systematically searching papers and grey literature. Searches were conducted in MEDLINE, EMBASE, CINAHL, Web of Science and Scopus between February and April 2020. No date restrictions were applied. Language was limited to publications written in English and French. Two reviewers independently screened titles and abstracts, and extracted data, applying thematic coding. The quality of the included papers was evaluated using The Joanna Briggs Institute Checklist for Text and Opinion Papers. OUTCOMES The search identified 744 papers, of which 20 were included. Findings were organized under four cross-cutting categories, namely: perceived importance of infertility; influence of policy context; resource availability and access; and perceived quality of care. Across these categories, key barriers to the inclusion of fertility care in RH policies were limited political commitment, under-recognition of the burden of infertility and high costs associated with ART. Conversely, facilitators comprised specialized training on infertility for healthcare providers, standard procedures for ART safety and guidelines and North–South/South–South collaborations. WIDER IMPLICATIONS The inclusion of fertility care in African RH policies depends upon factors that include the recognition of infertility as a disease, strong political engagement and proactivity and affordability of ART through opportunities for partnership with the private sector, which ease costs on the public health system. Further qualitative and quantitative research, including context-specific analysis and in-depth comparative approaches across diverse African countries, will help to delineate differential impacts of local and global factors on fertility care to address this neglected RH issue.

The fertility care gap in the Global South: lessons from The Gambia, West Africa, and ways forward to establish fertility care for all

“…1), including researchers from different academic disciplines, health practitioners, policymakers, lawyers, activists, patient representatives, and other stakeholders. The network brings together the work of infertility experts with decades of experience in the area [6][7][8][9][10][11][12][13] with that of infertility students and Early Career Researchers [3,[14][15][16][17][18][19][20] . In The Gambia, Balen, Ceesay, Dierickx, and colleagues have conducted research on infertility since 2016, including ethnographic studies, socio-legal analysis (Benbow et al, unpublished data), and health policy and systems research [21] .…”

“…Research conducted in partnership with Safe Haven Foundation, a Gambian nongovernmental organization focussing on infertility and early pregnancy loss, fostered The Gambia's National Infertility Awareness Week campaign. More recently, health policy and systems research conducted in the framework of Afferri's PhD included: (i) a systematic review of qualitative evidence [3] ; (ii) a national survey of infertility services in The Gambia [20] ; and (iii) qualitative research with health care practitioners and other health system stakeholders (Afferri et al, unpublished data). Importantly, the network and the aforementioned research include active participation of senior national health policymakers and international stakeholders with outputs directly informing policy development in The Gambia [21] (Bittaye and Marena, personal communication, December 2022).…”

“…It remains largely overlooked in terms of global health policy and practice, despite having been endorsed as a core component of sexual and reproductive health almost 30 years ago at the landmark 1994 International Conference on Population and Development (ICDP) [2] . The provision of a comprehensive package of care that includes awareness, prevention, and management of infertility, the so-called "fertility care package" is fragmented or almost completely absent, especially across much of sub-Saharan Africa [3] . Reasons for this include, among others, powerful discourses around overpopulation, high costs of assisted reproductive technologies [4] , a lack of political interest or commitment, high social stigma attached to infertility, and gendered norms, expectations, and biases [5] .…”

Access to infertility care services towards Universal Health Coverage is a right and not an option

“…A stakeholder raised the possibility that global goals and donor priorities may influence the government's SRH strategy, as the prevention and management of infertility has recently gained prominence in international priorities [25]:…”

Promising Perinatal Outcome after Using a Simplified Low-Cost IVF Culture System Specifically Designed for Resource-Poor Countries

“…To increase access and affordability, we urgently need more simplified and cheaper IVF procedures. According to a recent qualitative evidence-based assessment, thekey barriers to the inclusion of fertility care in reproductive health policies in LMIC were (i) the insufficient interest of politicians and healthcare providers, (ii) the failure to adequately recognize the burden of infertility, and (iii) high costs associated with ART [ 9 ]. Recent WHO studies and statements clearly indicate an urgent need to improve the availability, quality, and accessibility of ART worldwide.…”