Fertility care in the Gambia: From policy to practice?

The Gambia, a small country in West Africa, has recently approved a new national reproductive health strategic plan that includes, for the first time, fertility care and infertility management as one of the key priorities to improve and maintain the reproductive health of women, men, adolescents and children in the country.

Infertility is a stigmatised condition in the Gambia as well as in many regions of sub-Saharan Africa. Data on the prevalence, despite being outdated, show that approximately 12 percent of Gambian women live with involuntary infertility. Ethnographic research carried out in the country since 2017 by Dr Susan Dierickx, researcher from the Institute of Tropical Medicine, Antwerp, Belgium, and her colleagues, illustrates how infertility impacts on the social, emotional and financial life of individuals, particularly that of women (see here and here).

Gambian women with infertility are socially stigmatised and suffer, in certain cases, from marital and extended-family violence. Furthermore, health policy attention to infertility has been undervalued for a long time and fertility care implementation has not previously been listed as a priority in the Gambian health system.

In light of the above, I began my PhD research at the University of Sheffield in 2019 by exploring the availability of infertility services and investigating factors associated with successful implementation of fertility care. This research project, supervised by Dr Julie Balen, Dr Susan Dierickx and Professor Allan Pacey, and completed in 2023, has found that multiple factors affect policy and practice intentions toward infertility.

These include an absence of a budget dedicated to fertility care, gaps in fertility care awareness and education among health workers/policymakers and community members, insufficient specialised fertility care training for health providers, a lack of a mechanism to collect and report data on infertility, and a minimal involvement of men in infertility management.

Moreover, in the Gambia, the vast majority of sophisticated diagnostic services and treatments for infertility are provided by the private sector. Due to high costs, this limits access to infertility care to a privileged few. Assisted reproductive technologies, the first line treatment for male-factor infertility and for female tubal blockage, are not currently available in the country. Nor is there a dedicated national fertility society, or specific guidelines to manage fertility issues.

However, drawing on findings generated by my research and the research of other, the current Gambian health leadership – in particular the director of health services at the Ministry of Health, Dr Mustapha Bittaye, and the programme manager for reproductive, maternal, neonatal, child and adolescent health, Dr Musa Marena – have shown a growing interest in infertility, heavily influencing the inclusion of fertility care in the most recent reproductive health strategic plan (2022-2026).

This interest was further supported by the creation of the Interdisciplinary Network on Fertility Care in the Global South, also known as Fertility Care For All, led by Dr Balen with support from the White Rose Collaboration Fund and colleagues from the Universities of Sheffield, Leeds and York as well as the University of Ghana, University of the Gambia and others. The network has brought together more than 60 members from across 16 countries, a majority of which are considered low income, to conduct and develop various fertility care-related activities and research.

With the recognition of infertility as a health priority for its citizens, the Gambia entered a new phase of its move towards universal access to sexual and reproductive health and rights as a main component of universal health coverage. The next steps must be to increase the availability of infertility services in public health facilities, establish mechanisms of financial protection covering fertility care (partially or totally), and create stronger fertility awareness programmes in both urban and rural areas of the country.

Lastly, the experience in the Gambia, may serve as a positive example, with lessons learned applied to other countries in the region (where appropriate) that share similarities in terms of health system development and infertility prevalence.