Sexual and reproductive health

Challenges – Addressing subfertility/infertility in developing countries

Portrait of a young woman in Myanmar
E. Petitpierre

“Limited information is available pertaining to the ways biomedical infertility care is supplied and used in different developing countries and within low resource contexts, though the number of studies in this area has increased over the last decade.“ Bringing “together insights from various local realities is required in order to increase understanding of factors and circumstances that are constraining, complicating and/or facilitating the provision and use of infertility services in different contexts.”

Developing country perspective

CRITICISM: “Infertility in developing countries raises distinct and complex problems beyond those well known to developed nations. The effects of infertility and the concomitant need for its health care management relate to the cultural realities of specific regions. While the relevance and need for assisted reproduction may be readily established, some challenge their use in developing nations.

This criticism is levelled on two grounds: First, given the overpopulation problem in many developing countries, it is argued that over fertility, rather than infertility, should be the focus of family planning programmes; and, Second, treating infertility through expensive treatments cannot be justified in low resource settings where other more pressing needs must be given priority.”

RESPONSE: “From an analysis of the suffering that arise from infertility, those criticisms of the use of {new, innovative technologies} can be rebutted. Infertility in developing countries is pervasive and a serious concern. Further, there is evidence that the infertility rates that are generally quoted are, in fact, underestimates.

The consequences of infertility in developing countries range from severe economic deprivation, to social isolation, to murder and suicide. It is suggested that the overpopulation and limited resource arguments falsely target assisted reproduction and lack a more comprehensive understanding of the public health, social, psychological, economic, political and moral issues that are involved.” Daar and Merali, from “Current practices and controversies in Assisted Reproduction, Report of a WHO Meeting” 2002.

Disproportionate burden placed on women - when men play a critical role

Disproportionately having an effect on women, the burden of disease of infertility is often assumed to be the fault of the woman, as pregnancy and child birth are manifested in the woman. Yet, “the male reproductive capacity was found to be deficient in not less than 50% of infertile couples.” (WHO Manual for the standardized investigation and diagnosis of the infertile couple)

It is imperative that each case of infertility is considered clinically as a couple, or in case of social infertility or third part reproduction, with regard to the clinical evaluation of the source of gametes and the gestational carrier/mother.

An inability to have a child or to become pregnant can result in being greatly ostracized; feared or shunned; may be used as grounds for divorce; may result in a mental disorder; can lead to suicide; and will often justify a denial to take part in family or community traditions.

In some societies, discrimination in the case of the female may take a form of denial of passage to adulthood: a girl will not pass into womanhood (regardless of age) if she cannot prove her fertility. This girl may no longer be considered marriageable and may become viewed as a burden on families, communities or societies.

Although quoted to be more stigmatizing in developing countries (WHO: Current practices and controversies in assisted reproduction), yet asking a question “Why are there are no children in your life - or in your relationship?” can be considered a culturally unacceptable question surrounded in secrecy and privacy in high-income and highly educated societies – also shaped by economic, cultural, religious and social factors.

Thus, childlessness or building a family is a choice – a sensitive choice which is framed and altered by society and environment – thus providing access to community and health care support to help realize a child-bearing choice remains a sensitive but important global public health challenge.