Infertility in Sub-Saharan Africa: A Literature Review to Inform an SBC Program Approach

Recent data indicate that approximately 13.1% of individuals in Africa experience lifetime infertility, with the highest pooled estimate of period infertility at 16.4%, the highest globally. Infertility is a health problem of varying magnitude across and within regions of the world, with more than 186 million people and 45 million couples experiencing it, with the majority from low-and middle-income countries (LMIC). Individuals living with infertility may face high infertility-related stress, depressive symptoms, loneliness, sadness, social isolation, suicidal thoughts, and overall lower quality of life due to the increased pressure to bear children. Couples living with infertility face higher rates of divorce, separation, infidelity, and polygamy than those not living with infertility. Socially constructed beliefs about the causes of infertility are common across different contexts in Sub-Saharan Africa, often attributed to modern contraceptive use, abortion, belief in spiritual matters and witchcraft, and reckless behaviors during pregnancy or previous birth(s). Holding women responsible for infertility is well-documented in literature from the region, with fertility often perceived as a female inadequacy. Women who fail to have children for their husbands are regarded as failures in their marital role. Social norms and societal expectations place pressure on couples, especially women, to bear children upon marriage/union, and further marginalize men from the discourse on infertility. Because of a high social value on childbearing in Sub-Saharan Africa, there is pressure to prove fertility at an early age in some African countries. The health policy landscape on infertility in sub-Saharan Africa is mixed, with evidence sparse. There is little documentation of government programming that supports funding, attention, and awareness of infertility. SRH services in Sub-Saharan Africa do not include biomedical infertility treatment services within public health financing or strategy. Assisted reproductive technologies (ART), such as in vitro fertilization (IVF), are available in many countries but are centralized in urban areas, come with high cost and economic burden, and in some cases are unregulated. Outside of service provision, there is growing evidence that interventions that support women and men experiencing infertility can have a profound impact. Interventions include psychosocial approaches, peer support groups, mass media, and social media approaches, which seek to support those experiencing infertility, build assets, and spread awareness within communities. Overall, the lack of attention to infertility in Sub-Saharan Africa calls for further exploration and development of approaches to increase in/fertility awareness, reduce related stigma, and increase access to information and services so that individuals and couples can achieve their reproductive goals. The Agency for All Project is a five-year (2022-2027) USAID-funded project that generates evidence on the role of agency in effective SBC programming to improve health and well-being for individuals and communities. The project's goal is to improve and sustain health and agency for individuals and communities, advancing health and cross-sector development outcomes, including family planning and reproductive health, maternal, newborn, and child health, nutrition, infectious disease, and HIV/AIDS. Through locally led, equitable partnerships and innovative research, the Agency for All Project works to generate new evidence to understand agency and empowerment within health and SBC programs. The literature review was conducted to inform a future social and behavior change (SBC) intervention that supports women and couples to build agency to achieve their self-determined reproductive goals by increasing fertility-related knowledge and decreasing infertility-related stigma. The review sought to explore perceptions of infertility causes and myths, social consequences of infertility, and cross-cutting factors related to reproductive agency and infertility, and to identify SBC interventions addressing infertility. A total of 106 articles were included in the final review, with most of the available literature from West Africa, followed by East Africa and Southern Africa.