A qualitative systematic review of the sociocultural barriers accessing ART experienced among subfertile women across Africa and Europe

A qualitative systematic review of the sociocultural barriers accessing ART experienced among subfertile women across Africa and Europe | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review A qualitative systematic review of the sociocultural barriers accessing ART experienced among subfertile women across Africa and Europe Katrina Ihebunezie This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7919549/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background In many countries across Sub-Saharan Africa and Europe, women with subfertility search relentlessly for treatment. However, few studies consider how the experience of subfertility and accessing Assisted Reproductive Technology (ART) is formed by their social positions. Effective strategies that address sociocultural barriers to ART are required to mitigate its potential long-term physical, financial and psychological effects in order to inform the design of more inclusive as well as supportive interventions. Methods Databases representing the disciplines of medicine, nursing and social sciences as well as grey literature were searched for English language citations from 1978 to 02 October 2025 using keywords related to infertility, Europe and Africa. Results Of 493 citations identified, 11 qualitative papers being included. Most of the studies (73%) were conducted in Nigeria, Ghana, The Gambia, Mozambique and Botswana. Sociocultural aspects explored include factors associated with religious and cultural proscriptions, such as spirituality, medical pluralism and adoption and fostering. Factors related to social strain include marital strain and social support. The complex health seeking behaviours of women revealed they sought biomedical and holistic treatment as well as help from religious places of worship. Although treatment choice was related to the perceived aetiology of subfertility, it was also influenced by beliefs, family and social networks. Those from a lower socioeconomic background who faced barriers to treatment were also more likely to be confronted with intimate partner violence. Conclusion By highlighting how in particular scenarios, certain groups experience greater psychosocial barriers accessing ART and thus are more vulnerable than others, an intersectional approach that informs public health strategies and social policy may be promoted. Health authorities may need to further invest in working with organisations, like the British Fertility Society, to provide information and counselling on issues related to infertility prevention and treatment. The availability of locally applicable guidelines for infertility management at all levels of the health system would facilitate such steps to better integrate care and widen engagement. Patient Experience Infert* Africa Europe Mental* Qualitative Review Health-Seeking Behaviour British Fertility Society ART IVF Figures Figure 1 Figure 2 Figure 3 Lay Summary In this review, subfertility is understood to be a condition where women are unable to bear or have children following previous pregnancies. Not much is known about which women report fears of subfertility or how it affects the actions they take to get better, such as provider type sought. To learn more about it, studies between 1978 and 2025 were searched to explore the experiences of women who use European and African healthcare systems whilst they cope with being unable to have children (subfertile) and deal with potential stigma, physical and emotional abuse from their family and community. I found that 493 articles seemed appropriate but after screening these articles only included 11 in this review. I found that Nigeria, Ghana, The Gambia, Mozambique and Botswana produced the most studies on the psychological and social impact of accessing ART as a subfertile woman. Being subfertile affected how subfertile women were treated by their partners, relatives and friends in different ways depending on their wealth, education and religion. Results showed the risk of developing long-term mental health and financial issues whilst accessing fertility treatment (ART) may vary according to where you live in the country. As being able to use ART was dependent on their ability to find, be seen by a helpful doctor and pay, ART was limited mostly to women able to afford it without help from the government. Fear also influenced how they sought treatment. For example, the fear that their subfertility was God’s punishment for past misbehaviour and the lack of affordable, high quality ART services nearby led some women to seek traditional healing and spiritual mediation despite the risk of financial exploitation or harm. Poorer women were found more likely to face abuse from their partner, family-in-law and community. Muslim women in particular feared that their husband would divorce them or marry an additional wife. As a result, women, particularly those of African origin were vulnerable to emotional and physical abuse and suffered greater financial consequences. This review helps to ensure better understanding among those providing services about how to target, prioritise and allocate money to better meet the needs of subfertile women across Africa and Europe whose access to ART is strongly influenced by their sociocultural background. Background Subfertility is defined as a disease of the reproductive system and a failure to conceive after 12 months of regular unprotected sexual intercourse [1;2]. The majority of couples that present with a fertility problem have relative subfertility with a reduced chance of conception because of one or more factors in either one or both partners rather than absolute infertility [3]. A study initiated by the World Health Organisation, WHO, estimated that 1.9% of women aged 20–44 years old, which equates to 20 million couples, are affected by primary subfertility worldwide [4]. In a study combining data from 47 demographic and health surveys in developing countries it was estimated that 186 million ever-married women of reproductive age (15–49) suffered primary of secondary subfertility [5;6]. In parts of Sub-Saharan Africa, infertility prevalence rates of 30–40% have been reported [6]. However, the inaction surrounding infertility and the dearth of fertility treatment centres across resource-poor countries is often rationalised in terms of population control, limited healthcare resources and the burden of other life threatening diseases [7]. This silence may also reflect a eugenic position that views infertile poor people as being unworthy of treatment because overcoming infertility contradicts Western interests in global population control [7,8]. Additionally, it is likely that religious and cultural proscriptions that render infertility as taboo or stigmatic serves to conceal the full extent of the problem [9]. For instance, in Tanzania, evil forces are thought to cause infertility [10]. As the fertility of the immigrant generation often declines with duration of residence, ethnic minority women usually have a lower fertility than counterparts in their countries of origin [11]. Furthermore, the generation born in the country of resettlement often have lower fertility than that of the generation born in their country of origin [11]. As fecundity is generally greater in Africa, there is a possibility that women of African origin may find it more difficult to discuss their infertility problems within their communities and may internalise their problems [11; 12;13]. This may have psychological consequences. Although some infertility studies have highlighted no significant differences between individuals from the general population and IVF patients, authors suggest this may be attributed to the ‘healthy patient effect’ in which those selected for fertility treatment tend to be physically and mentally healthy [14;15;16;17;18]. Research suggests that it is possible women undergoing IVF may possibly feel increased pressure to underreport socially stigmatised conditions such as mental illness [14]. Although infertility across different ethnicities of women and its associated treatment yield numerous psychosocial challenges, unlike other areas of medicine, there is a paucity of robust evidence related to the relationship between ethnicity and the experience of accessing treatment [19]. It is possible that the under-reporting of ethnicity may have contributed to the under-studying of race as a potential factor driving a possible difference in the experience between different ethnicities of subfertile women accessing fertility services. For example, most treatment protocols are based on research studies conducted on ethnicities and races that are not representative of the general population [19]. There are few published studies highlighting ethnicity as a determinant factor of importance in the risk of suicidal ideation among subfertile women accessing and utilising fertility treatment. Most published data pool different ethnicities under wider categories that are significantly racially and ethnically different [19]. For example, women from Bangladesh and Japan fall under one homogenous group, ‘Asian’, resulting in a number of under-represented ethnic groups [19]. Generalising these diverse communities into one homogenous group is problematised by the complex intersectionality of their identities. These intersecting ‘sites of oppression’ which include their economic, sexual, marital, citizenship and residential statuses as well as their linguistic, cultural and religious backgrounds further affect their ability to access treatment [20]. For this reason, applying the conclusion and practices of research studies based on the population of Northern America, where the majority of the population is Caucasian, to populations across other continents with varying ethnicities may be problematic [19]. Recognition of how cultural, political, structural and economic constraints may affect their reproductive rights as well as the extent of access to health care may be important. In societies in which with race and class inequalities are embedded, the impact of increasing ossification of public services, employment and social mobility resultantly has a significant effect on Black African women. This is because prevailing beliefs shape public policy and practice around the desires, needs and reproductive capacities of Black African women. In other words the social context in which African women in Europe potentially reproduce, is politically fraught as racialised discourse of their alleged aberrant motherhood erodes their full reproductive freedoms and rights [21]. Although a survey released by HFEA in 2018 revealed that 19% of women accessing infertility treatment were Asian, Mixed, African or Caribbean, just 1.9% and 0.4% were of African and Caribbean descent respectively [22]. This is in contrast to 55.6% and 2.1% of those identifying as White British and Irish respectively [22]. Empirical evidence suggests mental health disparities are the likeliest in migrants and ethnic minorities who have often experienced physical and emotional trauma or suffer indicators of social disadvantage [23;24;25]. These indicators include the degree of social isolation, unemployment and social class [25;26]. A cohort analysis of the risk of adult suicide between 1982 and 2002 found that one in ten suicides recorded in UK general practice is attributable to severe mental illness, SMI [27] As ethnic minorities are at greater risk of all psychotic illnesses and improving the lives of people living with mental illness is a public health priority, it is now important to explore the social context in which subfertile African women in Europe access fertility treatment [24;26;28;29]. Appreciating how the historical function of race may add to the contemporary reproductive experiences of nulliparous and primiparous women whose bodies not only continue to remain sites in the exercise of state power but the subject of stigmatisation within African communities may be vital. Empirical evidence suggests that psychological strain incurred by the mismatch between expectation and the (short-lived) reality of motherhood may be pronounced in Black women who suffer significantly high rates of spontaneous abortion after ART [19;30;31]. As poor treatment outcomes for Black women increase their risk of chronic depression, it is possible that racialised disparities in their reproductive choices, health and care may be a source of traumatic stress that affects their psychological risk profile. This finding suggests that long-term mental health may be a useful marker of success in addressing existing treatment and outcome inequalities. It is also indicative of the imminent need to frame the relationship between these racialised disparities and the long-term psychological effect of ART on subfertile African women within a broader context. Furthermore, from the 1980s onwards, as market models gained more influence on the provision of health care, further repositioning of the patient resulted in conflict between the individual and collective views of the patient. It appears that individual patient choice has edged out collective patient voice. Although the demands of the individual patient may be irreconcilable with all patients, whether there is enough shared similarity between them to allow the merging of subgroups under a broad category is an open question [32]. For this reason, exploring how different ethnicities of subfertile women across Europe and Africa define quality care when evaluating their ability to access treatment may be important. As fecundity is generally greater in Africa, there is a possibility that women belonging to these ethnicities will find it more difficult to discuss infertility issues within their communities [33;34]. Internalising their problems may have psychological consequences. Additionally, there is a possibility that subfertile African women may be relatively 'invisible’ to policy makers and conventional demographic perspectives on fertility within Europe [35]. This review will question whether these patients perceive that they receive an appropriate level of care that tailors fertility treatment around their position in a racialised society or their specific experience as an African woman in their community. This is important as it has been reported that non-representative samples, a failure to study culturally distinct populations and little regard for the ‘social construction of fertility’ characterise literature specifically focused on infertility [36]. Additionally, as empirical evidence suggests immigrant women are at a higher risk of mental illness than those who are non-immigrant, there is a possibility that migrant women in Europe may be at greater risk of suicide [23;25;26;37]. In this way, this review aims to highlight the issues that arise from pooling different ethnicities under wide categories and avoid failing to reach saturation . Hence, the main aim of this review is to explore how socio-cultural factors, structural racism and ability to access ART among subfertile women across Africa and Europe might differ and whether there is a difference in their risk of developing mental illness. The objective is to build on the WHO International Classification of Functioning, Disability and Health framework, WHO ICF, to appreciate the factors that may affect the longer-term needs of subfertile women accessing ART and the complexity of their experiences. The WHO ICF, which is a conceptual model for defining and understanding health, recognises how biological, psychological and social influences affect health [38]. A qualitative systematic review exploring the meaning different ethnicities of subfertile women across Africa and Europe attach to care using their own words, rather than predefined concepts, may provide richer definitions that can be incorporated into practice and policy to resolve perceived barriers and improve their access to ART. For this reason, the identification and selection of papers will be determined mainly by the perceived care different groups receive rather than pre-defined concepts and standards in order to gain a broad understanding of how this issue impacts women across different regions. The purpose of this would be to surmise the benefit of using either a patient-centred or a globally recognised definition to understand how different ethnicities of subfertile women across Europe and Africa define quality care when evaluating their ability to access treatment. Although the definitions of care are varied and contested, the aspects of care that will be explored in this review will focus around the actions taken within formal institutional healthcare systems and indigenous treatment which individuals access to improve health and wellbeing [Additional File 1] [39]. Of the two dimensions of care (access and effectiveness), access will be focused upon. The meaning respondents attach to quality will be considered important components alongside their ability to access health structures and required processes of care [Additional File 1] [39]. However, as care for individuals must be placed within the context of providing health care for the population, applying their concepts of 'access' to a set of performance indicators designed to reflect the opportunity cost of providing care for an individual or group of patients may be important [Additional File 1]. Therefore, incorporating both global and patient-centred meanings of the quality of care may be beneficial as it may allow a framework enabling a better understanding of the meaning of the indicators and the aspects of care that may not have been covered. Method Search strategy The author developed a search strategy in consultation with a specialist librarian. Literature searches were conducted on databases such as EMBASE; MEDLINE; ASSIA; ERIC; CINAHL and Pubmed. Peer-reviewed fertility journals were also searched. The search terms are highlighted in [Additional File 2]. Additionally, grey literature (e.g., unpublished theses) were searched and researchers in the field were emailed for any peer-reviewed, published research. Searches were conducted between August and October 2025. The inclusion criteria outlined in Appendix I included: studies reported in English between 1978 and 2025; both primary and secondary qualitative studies; participants included females diagnosed with primary or secondary infertility; women from African countries with the highest number of registered IVF units [40]; countries that had high rates of out-migration to the UK at the time IVF was introduced were also included as their treatment experience may have differed from that of more recent migrants [Additional File 3] [41; 42]; countries which have a similar healthcare system as the UK as well as a history of colonialism [43; 44]; women without partners so as to prioritise the needs of those that are underrepresented in those seeking treatment in the UK [Additional File 4] [45]. Studies were excluded where the primary outcome was the efficacy of the trialed treatment or where the population was ethnically undefined [Additional File 5]. Study selection Search results were exported to Rayyan (http://rayyan.qcri.org) for further evaluation. A total of 493 articles were imported to Rayyan, and 17 duplicates were detected and removed. Of these, 40 were reviewed at the full text stage and a further 24 excluded, leaving a total of 16 included studies. A further 10 records were found through a hand search reference list. After applying the pre-defined inclusion criteria, 29 of these articles were excluded [Additional File 5]. The most common reason for excluding studies at the full text stage included a lack of clarity related to nationality, gender, religion or race of the participants as well as being a systematic review or article. A total of 11 studies were selected for this systematic review [34;46–55]. Data extraction Prior to synthesis, details about study design, participants (number and characteristics), study context (timing, location, experience, severity of mental illness and other conditions) and findings from each paper (views of the participant and author interpretation of findings from the abstract, results and discussion) were independently extracted and imported into a data extraction form in Microsoft Word. The selection process, including search results and reasons for exclusion at each stage of screening is presented in a PRISMA flow diagram (Fig. 1). Charting the data and reporting the findings Following thematic synthesis, the reviewer read the full-text versions of the 11 articles and charted the data [56]. The data were charted using a charting form. The comprehensiveness of the form was evaluated before the consistency of data extraction was compared. The charting form was deemed appropriate and no changes were made to the chart. Data extraction appeared consistent. Author then summarised the data, as reported in the next section. Study characteristics Eleven studies were finally included in this review, which are referred to first author and year of publication (Table 1 and Table 2). Most of the studies were conducted in West Africa (n = 4) and Southern Africa (n = 3). Within West Africa, one study was conducted in Ghana, two in The Gambia and one in Nigeria. Within Southern Africa, two were conducted in Mozambique and one in Botswana. The remaining four were conducted in Cameroon, Central Africa (n = 1), The Netherlands, Europe (n = 1) and the UK, Europe (n = 2). Four studies used semi-structured interviews [34;48;53;55], one was an unstructured interview [51], one was a structured interview [50], one was described as an in-depth interview [54], one was an ethnography [52] and two involved a combination of interview, observation with informal conversation and group discussion [46;47]. Three of the studies were conducted during the time periods 1993 to 1999 [51;54;55], five during 2001 to 2018 [34;46;47;52;53] whilst the dates were unstated for two studies [48;50]. As the standard epidemiological and demographical conceptualisations of infertility, subfertility, miscarriage and stillbirth were not always meaningful for people living in low- and middle-income countries, those who believed they were infertile (regardless of the duration of their fertility issues or number of living children) were included [34;46;47;50;51;52;53;54;55]. Of the studies, 8 implemented purposive sampling through hospitals where women sought gynaecological and obstetric services, community leaders and healers. Purposive sampling here was implemented to identify and select women particularly knowledgable about infertility or subfertility, were available and willing to participate as well as capable of expressing their experiences expressively and reflectively [57;58]. One study recruited consecutive women who considered themselves infertile from part of the population close to hand [50]. The sampling method of one study was unstated [53]. The number of infertile women included in each study varied from 5 to 107. Critical Appraisal Critical appraisal was carried out using the 'Critical Appraisal Skills Program' (CASP) tool for qualitative studies. Points were assigned to each indicator and an overall score was used to assess quality (Fig. 2). Five were 'low' quality and were conducted in Mozambique, Ghana, Nigeria and Botswana. Six were 'medium' quality and were conducted in Cameroon, UK, Amsterdam and The Gambia [Additional File 6]. Four of the five 'low’ quality studies were earlier publications, perhaps reflecting changes in study reporting standards over time. None of the studies included scored the total of 10 points ('high' quality). All the studies failed or were not clear enough in taking into consideration ethical issues. It is not acknowledged how the effects of the study on the participants during or after the study were handled. The studies which were deemed at high risk of bias had significant limitations relating to the critical examination of the role, potential bias and influence of the researcher during sample recruitment as well as data selection, collection and analysis. Additionally, age and the range of potential characteristics, such as psychiatric history, across a possibly heterogenous population was not described or analysed in sufficient detail. Although some women with fertility issues reported depressive symptoms such as worry, sadness and anxiety to suicide, it is possible women suffering with more severe symptoms may have made them less likely to take part. This would result in mental health issues being under reported in these studies and compromised transferability, as the audience is not given enough context and detail to determine whether their results apply to the wider population of subfertile African women in the two studies. Where the mental health of respondents were highlighted, medication, diagnoses, prior suicidal attempts were unmentioned. There were also common themes in terms of domains at low risk of bias [Additional File 6]. The definition and classification of access to care used international guidelines, which was often clear and well defined, helped identify deficiencies in the reporting standards of the studies. Similarly, the meaning of subfertility was based on the diverse perspectives of women experiencing it in their own language, rather than imposed clinical definitions. Therefore, although clinical definitions may have changed over time, using definitions that are also shaped by social and cultural context, results in an information-rich source highlighting the sociocultural barriers that subfertile women across Africa and Europe may experience [58;59]. Results When attempting to understand the potential barriers to fertility treatment, it is important to appreciate that a traditional religion that centres witches, spirits, sorcerers, spirits of ancestors and traditional healers is an important aspect of how women experience and cope with their subfertility (Table 3 and Table 4). Spirituality The emotional impact of infertility was felt by Ghanaian, Botswanan and Gambian women who tearfully reported loneliness and exhibited symptoms of depression ranging from crying and insomnia to neglected personal hygiene and suicidal ideation [34;46;51;54]. This lasted sometimes up to twenty years as they looked for treatments and imagined a painful childless future, without this source of fun, companionship and potential care at an older age [47]. Inability to talk about the stress and fear they experience because infertility is considered a taboo topic may have exacerbated their distress [47]. A deeper hidden meaning for their suffering is sought through prayer and spirituality in an attempt to overcome their ordeal [50;51]. Access to information relating to the prevention and aetiological understanding of infertility was limited and so women attributed it to: Supernatural ('kuntofengo'): African Traditionalism The origin of women's infertility is attributed to invisible spirits, colloquially called 'jinnoo' believed to target beautiful and talented Gambian women from birth [46]. Interviewees also complained community members accused them of being witches as they believed infertile women paid the highest price to participate in a credit and debt system of the 'witches club' to own other people’s existing or future children [46]. Some of the women perceived themselves as victims of 'black magic' from a marabout, a male healer affiliated with Islam, who are mainly associated with protection and treatment of afflictions caused by 'buwaa' and 'jinnii' [46] Co-wives and family members particularly mothers-in-laws were commonly accused of requesting affliction from marabouts. Mozambican and Dutch studies illustrated that infertility was believed to be caused by people, witches or sexual contact with the spirits, 'majini' or 'maleika', which prevented intercourse between spouses [54;55]. Botswanan and Ghanaian women also felt infertility was the consequence of chastisement by God, "petso ya Modimo", immoral behaviour, becoming pregnant at an early age, prior abortion, marrying a man without receiving 'lobulo' or not following ancestral traditions [34;51;52]. Authors also illustrated the importance of sacred places to infertile Gambian women as points of prayer or rituals, performed by herbalists, marabouts, kanyaleng kafooluand kankurangs. Religious faith and prayer were used as a means of coping with loss, disappointment, social condemnation and suicidal thoughts [50]. Spirituality: Natural Researchers describe folk illnesses as syndromes within a culture which provide an alternative aetiology, diagnosis or healing measure. These include natural causes, such as fibroids, 'seketoo' and 'buluntoo' [46]. Mozambican and Gambian respondents also identified a 'mismatch' between the blood of spouses, ‘norro', as the most pertinent and commented that the suffering from 'xilume' (menstrual cramps), vaginal itching and discharge women experienced were commonplace within polygamous marriages and the result of STDs [52;55]. Marital Strain Gambian and Botswanan women perceived that the cause of infertility was gendered and because they felt stigmatised by their community and spouses, they found it difficult to encourage their spouses to be tested, diagnosed and treated and struggled to share burdens with them due to fears of potential discord [46;47;51]. Authors suggest this may explain the reason woman were more likelier to seek ART than men. Women also complained that although gender roles prescribed that men should provide 'fish money’, they did not receive it and as a housewife, lacking economic strength, left them unable to negotiate in their relationship and vulnerable to the anxieties of abandonment or being able to afford ART [47]. Few marriages were able to manage the long-term impact of infertility. Some reported physical, emotional and financial abuse from community, partners and in-laws. A woman’s financial positioning and a man’s age, education, history of childlessness with other partners and ability to opt out of an arranged marriage affected the likelihood of these outcomes [34;46;47]. In practice, the consequences of extra-marital relationships were less severe for men. However, if husbands were the cause of infertility, it was better to secretly become pregnant with another man than risk divorce. Social support Gambian women in weaker financial positions were more likely to be restricted to traditional roles and be presented with less opportunity to escape the tension and hurtful comments from their in-laws and community members [46]. They were called 'a witch' and accused of 'eating their own children'. Being associated with witchcraft and immorality made respondents feel alienated. Ghanaian and Gambian women also expressed that they felt their friendships with fertile women were qualitatively different compared to those fertile women had with one another and complained of being excluded from ceremonies such as nthaara[34;55]. Unlike African respondents, UK respondents excluded themselves from their community not because they were threatened with the prospect of abuse but because they were afraid of being a burden [48; 50; 49; 51). Their perception of societal attitudes and mass media descriptions of PGD as a narcissistic 'designer baby' technique contributed to their self-consciousness and compelled them to prove to 'everyone' that undertaking PGD was an expression of parental obligation rather than self-interest [49]. Although community service, their career and temporarily discontinuing treatment helped women escape the psychological pain of 'denying' their needs, the longevity and effectiveness of this coping strategy was unclear. Discussion This review of the literature conducted systematically identified eleven qualitative studies exploring the barriers different ethnicities of subfertile women face when accessing ART in two low, three lower-middle and two high income countries across Africa and Europe (Appendix N Table 13.0). I found 11 articles that met my inclusion criteria. West Africa produced the most studies (n = 4), followed by Southern Africa (n = 3) and the UK (n = 2). The findings related to perceived barriers to care included religious and cultural proscriptions as well as social strain (Tables IV and VI). The characteristics and contextual factors of subfertile women in Africa and Europe associated with poor experience and barriers to care include age (> 45 - highest European age restriction for IVF); educational status (non university educated), area of residence (rural area); employment (low income or unsalaried); marital status (strained, polygamous, residing in different countries, arranged); lack of social and counselling support. Religious and cultural proscriptions associated with spirituality, adoption and fostering was a factor associated with barrier to access particularly in Nigerian, Botswanan, Mozambican, Ghanaians, Gambian and British women. Strained social interactions within their marriage, in-laws or relatives and community was also a factor associated with barrier to access heavily in Botswanan, British, Gambian and Ghanaian women. Synthesising information from the qualitative literature has provided considerable insight into the longer-term needs of subfertile women of different ethnicities accessing ART. The most striking findings of the synthesis reveals the ongoing difficulties women can face in coming to terms with being subfertile, accessing ART and how they adapt to life after ART: Ghanaian, Mozambican and Gambian (particularly Muslim) women in polygamous or arranged marriages who have expressed depressive symptoms, have little social support and limited alternative options to ART; Women undertaking newer forms of ART such as PGD. Insights into their complex belief systems show that the social network and positionality of subfertile women impact health seeking behaviour and their subsequent experience of and access to ART as affordability and availability of diagnosis and treatment dictates their pragmatism whilst searching for ART. Most African women, particularly Gambian, Mozambican and Nigerians, who attributed their subfertility to supernatural causes or folk illnesses (buluntoo and norro) and fibroids had limited knowledge about aetiology or treatment. The alternation and combination of therapies from indigenous healers and ART indicated that there was no preferred treatment. Their sometimes lengthy and intricate itineraries were guided by perceived improvements of their condition and suggests these women were more agentive than their European counterparts in attempting to remedy their situation, understand underlying causes of their subfertility. Although utilisation of healthcare services may vary by ethnicity, health inequalities for ethnic minority populations illustrate a strong association with socioeconomic disadvantage and low health literacy [60;61]. By collating the findings reported in individual studies, significant need for longer-term support was identified. Many of the respondents who conveyed needs in relation to longer-term care were a number of years post diagnosis, which suggests that needs may persist over a significant period of time in the absence of resolution. Aftercare, the Continuity of Care and Mental Health Findings suggest that the current resilience model implemented by ART clinics is inadequate in understanding the full impact of the barriers to access and experience of accessing ART varies between different ethnicities of women across Africa and Europe [48]. Results of this review demonstrate that the impact of subfertility goes beyond the individual into the relationships, mood and financial stability. Although the WHO ICF provides a framework for recognising factors that may affect the longer-term needs of subfertile women accessing ART, it does not appreciate the complexity of their experiences, as illustrated in the thematic synthesis. As a failure in any of the WHO ICF domains can lead to loss of health, findings from this review suggest that psychosocial factors also be considered in treatment, research and policy to further assist subfertile women accessing ART across Europe and Africa. This is because the review highlighted that the difficulties that subfertile women experience during and after ART, from coming to terms with their subfertility to feeling unable to overcome the loss of social status, roles as well as activities resulted in the deterioration of their mental health. This is consistent with empirical evidence that establishes that access to and knowledge of mental health services is poor as fertility specialist counselling offered by clinics tends to be inadequate and not patient-centred (British Fertility Society 2020). Evidence suggests that patient-centred care can relieve the emotional burden of infertility, which is often see in terms of poorer quality of life (QoL), higher anxiety and depression - outcomes African women are at significantly higher risk of developing [23;26;62–66]. More specifically, this may also benefit African migrants than non-migrants, who have less social support from family and hence would more likely rely more heavily on support provided at the treatment centre [23; 37;62]. Although there is significant overlap with the experience of different ethnicities of subfertile women, findings from this review revealed how the sociocultural experiences of women from lower socioeconomic backgrounds or African descent present a unique barrier, for instance, from participation in meaningful activities or maintenance of social networks. If they had a counsellor of the same country of origin, they may feel hesitant disclosing details due to fear of experiencing the same stigmatisation they may have faced (or are facing) within their family or community. It is important to highlight that homogenising African communities into one group based on continent or even country of origin is problematised by the complex intersectionality of their identities. Studies suggest that both Black and White people may be subject to implicit racial biases. For example, a US study demonstrated the social biases reflected in the implicit racial stereotypes of Black people where a preference for White people and against African Americans was observed among African American as well as White medical students and doctors [67–69]. Studies have shown that a physician’s racial biases against particular racial and ethnic minority patients is significantly related to the quality of care they provide to their patients [68]. As a result, patients may feel their access to quality care is restricted even amongst those who may share the same broad ethnic designation as the impact of cultural nuances and spiritual beliefs on treatment decision-making or relationship dynamics is not apart of the curriculum. Although every effort was made to locate studies relevant to this review, I concede that publications may have been overlooked. Furthermore, the quality of the synthesis is limited by the quality and reporting of the original studies [70]. For example, the results of the quality assessment highlighted the lack of reflexivity in some of the included studies. If the researcher has not critically reflected how their own position may have influenced the conduct or findings of the study, it is difficult to evaluate levels of researcher bias in study findings [71;72] (Appendix P Table 15.0). Conclusion In summary, over the past 47 years, 11 articles have been published on the sociocultural aspects of accessing ART across Africa and Europe. Most of these studies (73%) were conducted in Nigeria, Ghana, The Gambia, Mozambique and Botswana. Future research should explore the possible components of a longer-term term care intervention that is patient-centred for different ethnicities of subfertile women across Africa and Europe. Few studies explored how subfertile women manage sociocultural barriers during and after ART is required to further understand adaptation and adjustment during this time period and inform subsequent care strategies. Research comparing those who have temporarily and permanently stepped away from ART may better illuminate how resilience manifests among women and influences their decisions to end or continue treatment. Future research also ought to widen data collection within each ethnic community to include the views of community members who are more isolated from health and community support services and potentially have different perspectives from those that are represented in this systematic review. This is important because this review has demonstrated that beliefs about subfertility itself influence the decisions of different ethnicities of women and affect the support they can enlist. Clinicians may also draw on these findings to highlight the importance of maintaining the non-fertility aspects of their life and assess their resources for ART in order to prevent further depletion in their psychological well-being. The concept of candidacy as a means to understand access to healthcare services by vulnerable groups and eligibility for medical attention as well as intervention is a joint 'negotiation between individuals and health services' is a useful framework for interpreting these findings [61;73]. Extending understanding of how women, who are often under-represented with ART and research, adapt to the adversity they experience may aid clinicians in offering more culturally informed interventions [48;36]. Offering consultation about various evidence-based holistic methods such as indigenous herbalism and spiritual support may help integrate women’s need to gain control over their treatment and limit their exposure to exploitative services offering expensive or redundant solutions [48;74]. The incorporation of local disease classifications into public health messages may address former exclusion of folk illnesses in public health practice, resolve communication constraints with users and potential delays accessing ART. Systematically harnessing patients’ voices into clinical operations may, as with co-design or other forms of patient engagement hold greater promise for meaningful improvements to the patient experience [75]. However, it is important to highlight that attributing treatment choice to miseducation does not comprehensively represent their pragmatism considering existing structural inequalities and lack of integrated care. For this reason, this review suggests that while individuals should have the reproductive right to access publicly funded services, alternative forms of parenting and social identity should be publicly promoted for subfertile women across Africa and Europe. Declarations Consent for publication Not applicable as this is a review. Ethics approval and consent to participate Not applicable as this is a review. Funding Not applicable as this is a review Author Contribution KI synthesised the data critically reviewed, discussed and finalised the submitted manuscript, and (will) contribute to all revisions. Author agrees to be accountable for the work and to investigate and resolve any issues related to the accuracy or integrity of the work. 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Footnotes Please note, a number of ethnic groups may be under-represented to generate a conclusion that may be applicable to all African and Caribbean communities. Bride price Organisations solely consisting of women who have experienced child loss or fertility issues and perform rituals to beg God to heal them of their subfertility or child mortality issues through the exorcism of evil spiritual forces [46] Family of masquerades wearing a costume from tree bark fibres and leaves commonly associated with the spiritual world and perceived to have supernatural powers [46] Respondents reported that the symptoms of seketoo includes itching in the general area which could lead to bleeding; white discharge; small and bumpy structures within the vagina [46] Although little information about buluntoo is available, it is reported that abdominal back pain which is described as a stone in the womb, typically characterise this condition [46] Local term: Gonorrhoea [55] Money for the daily livelihood of the wife A ceremonial procedure for pregnant Macua girls that instructs their behaviour during pregnancy and labour [55] Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files StructuralSocioculturalTable1.docx SocioculturalTable3.docx StructuralSocioculturalTable2.docx SocioculturalTable4.docx StructuralSocioculturalAdditionalFile2.docx StructuralSocioculturalAdditionalFile4.docx StructuralSocioculturalAdditionalFile3.docx StructuralSocioculturalAdditionalFile1.docx StructuralSocioculturalAdditionalFile6.docx StructuralSocioculturalAdditionalFile8.docx StructuralSocioculturalAdditionalFile7.docx StructuralSocioculturalAdditionalFile5.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Summary","content":"\u003cp\u003eIn this review, subfertility is understood to be a condition where women are unable to bear or have children following previous pregnancies. Not much is known about which women report fears of subfertility or how it affects the actions they take to get better, such as provider type sought. To learn more about it, studies between 1978 and 2025 were searched to explore the experiences of women who use European and African healthcare systems whilst they cope with being unable to have children (subfertile) and deal with potential stigma, physical and emotional abuse from their family and community.\u003c/p\u003e\n\u003cp\u003eI found that 493 articles seemed appropriate but after screening these articles only included 11 in this review.\u003c/p\u003e\n\u003cp\u003eI found that Nigeria, Ghana, The Gambia, Mozambique and Botswana produced the most studies on the psychological and social impact of accessing ART as a subfertile woman.\u003c/p\u003e\n\u003cp\u003eBeing subfertile affected how subfertile women were treated by their partners, relatives and friends in different ways depending on their wealth, education and religion. Results showed the risk of developing long-term mental health and financial issues whilst accessing fertility treatment (ART) may vary according to where you live in the country. As being able to use ART was dependent on their ability to find, be seen by a helpful doctor and pay, ART was limited mostly to women able to afford it without help from the government. Fear also influenced how they sought treatment. For example, the fear that their subfertility was God’s punishment for past misbehaviour and the lack of affordable, high quality ART services nearby led some women to seek traditional healing and spiritual mediation despite the risk of financial exploitation or harm. Poorer women were found more likely to face abuse from their partner, family-in-law and community. \u0026nbsp;Muslim women in particular feared that their husband would divorce them or marry an additional wife. As a result, women, particularly those of African origin were vulnerable to emotional and physical abuse and suffered greater financial consequences.\u003c/p\u003e\n\u003cp\u003eThis review helps to ensure better understanding among those providing services about how to target, prioritise and allocate money to better meet the needs of subfertile women across Africa and Europe whose access to ART is strongly influenced by their sociocultural background.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eSubfertility is defined as a disease of the reproductive system and a failure to conceive after 12 months of regular unprotected sexual intercourse [1;2]. The majority of couples that present with a fertility problem have relative subfertility with a reduced chance of conception because of one or more factors in either one or both partners rather than absolute infertility [3]. A study initiated by the World Health Organisation, WHO, estimated that 1.9% of women aged 20\u0026ndash;44 years old, which equates to 20\u0026nbsp;million couples, are affected by primary subfertility worldwide [4]. In a study combining data from 47 demographic and health surveys in developing countries it was estimated that 186\u0026nbsp;million ever-married women of reproductive age (15\u0026ndash;49) suffered primary of secondary subfertility [5;6].\u003c/p\u003e\u003cp\u003eIn parts of Sub-Saharan Africa, infertility prevalence rates of 30\u0026ndash;40% have been reported [6]. However, the inaction surrounding infertility and the dearth of fertility treatment centres across resource-poor countries is often rationalised in terms of population control, limited healthcare resources and the burden of other life threatening diseases [7]. This silence may also reflect a eugenic position that views infertile poor people as being unworthy of treatment because overcoming infertility contradicts Western interests in global population control [7,8]. Additionally, it is likely that religious and cultural proscriptions that render infertility as taboo or stigmatic serves to conceal the full extent of the problem [9]. For instance, in Tanzania, evil forces are thought to cause infertility [10]. As the fertility of the immigrant generation often declines with duration of residence, ethnic minority women usually have a lower fertility than counterparts in their countries of origin [11]. Furthermore, the generation born in the country of resettlement often have lower fertility than that of the generation born in their country of origin [11]. As fecundity is generally greater in Africa, there is a possibility that women of African origin may find it more difficult to discuss their infertility problems within their communities and may internalise their problems [11; 12;13]. This may have psychological consequences. Although some infertility studies have highlighted no significant differences between individuals from the general population and IVF patients, authors suggest this may be attributed to the \u0026lsquo;healthy patient effect\u0026rsquo; in which those selected for fertility treatment tend to be physically and mentally healthy [14;15;16;17;18]. Research suggests that it is possible women undergoing IVF may possibly feel increased pressure to underreport socially stigmatised conditions such as mental illness [14].\u003c/p\u003e\u003cp\u003eAlthough infertility across different ethnicities of women and its associated treatment yield numerous psychosocial challenges, unlike other areas of medicine, there is a paucity of robust evidence related to the relationship between ethnicity and the experience of accessing treatment [19]. It is possible that the under-reporting of ethnicity may have contributed to the under-studying of race as a potential factor driving a possible difference in the experience between different ethnicities of subfertile women accessing fertility services. For example, most treatment protocols are based on research studies conducted on ethnicities and races that are not representative of the general population [19]. There are few published studies highlighting ethnicity as a determinant factor of importance in the risk of suicidal ideation among subfertile women accessing and utilising fertility treatment. Most published data pool different ethnicities under wider categories that are significantly racially and ethnically different [19]. For example, women from Bangladesh and Japan fall under one homogenous group, \u0026lsquo;Asian\u0026rsquo;, resulting in a number of under-represented ethnic groups [19]. Generalising these diverse communities into one homogenous group is problematised by the complex intersectionality of their identities. These intersecting \u0026lsquo;sites of oppression\u0026rsquo; which include their economic, sexual, marital, citizenship and residential statuses as well as their linguistic, cultural and religious backgrounds further affect their ability to access treatment [20]. For this reason, applying the conclusion and practices of research studies based on the population of Northern America, where the majority of the population is Caucasian, to populations across other continents with varying ethnicities may be problematic [19]. Recognition of how cultural, political, structural and economic constraints may affect their reproductive rights as well as the extent of access to health care may be important.\u003c/p\u003e\u003cp\u003eIn societies in which with race and class inequalities are embedded, the impact of increasing ossification of public services, employment and social mobility resultantly has a significant effect on Black African women. This is because prevailing beliefs shape public policy and practice around the desires, needs and reproductive capacities of Black African women. In other words the social context in which African women in Europe potentially reproduce, is politically fraught as racialised discourse of their alleged aberrant motherhood erodes their full reproductive freedoms and rights [21]. Although a survey released by HFEA in 2018 revealed that 19% of women accessing infertility treatment were Asian, Mixed, African or Caribbean, just 1.9% and 0.4% were of African and Caribbean descent respectively [22]. This is in contrast to 55.6% and 2.1% of those identifying as White British and Irish respectively [22].\u003c/p\u003e\u003cp\u003eEmpirical evidence suggests mental health disparities are the likeliest in migrants and ethnic minorities who have often experienced physical and emotional trauma or suffer indicators of social disadvantage [23;24;25]. These indicators include the degree of social isolation, unemployment and social class [25;26]. A cohort analysis of the risk of adult suicide between 1982 and 2002 found that one in ten suicides recorded in UK general practice is attributable to severe mental illness, SMI [27] As ethnic minorities are at greater risk of all psychotic illnesses and improving the lives of people living with mental illness is a public health priority, it is now important to explore the social context in which subfertile African women in Europe access fertility treatment [24;26;28;29].\u003c/p\u003e\u003cp\u003eAppreciating how the historical function of race may add to the contemporary reproductive experiences of nulliparous and primiparous women whose bodies not only continue to remain sites in the exercise of state power but the subject of stigmatisation within African communities may be vital. Empirical evidence suggests that psychological strain incurred by the mismatch between expectation and the (short-lived) reality of motherhood may be pronounced in Black women who suffer significantly high rates of spontaneous abortion after ART [19;30;31]. As poor treatment outcomes for Black women increase their risk of chronic depression, it is possible that racialised disparities in their reproductive choices, health and care may be a source of traumatic stress that affects their psychological risk profile. This finding suggests that long-term mental health may be a useful marker of success in addressing existing treatment and outcome inequalities. It is also indicative of the imminent need to frame the relationship between these racialised disparities and the long-term psychological effect of ART on subfertile African women within a broader context. Furthermore, from the 1980s onwards, as market models gained more influence on the provision of health care, further repositioning of the patient resulted in conflict between the individual and collective views of the patient. It appears that individual patient choice has edged out collective patient voice. Although the demands of the individual patient may be irreconcilable with all patients, whether there is enough shared similarity between them to allow the merging of subgroups under a broad category is an open question [32]. For this reason, exploring how different ethnicities of subfertile women across Europe and Africa define quality care when evaluating their ability to access treatment may be important.\u003c/p\u003e\u003cp\u003eAs fecundity is generally greater in Africa, there is a possibility that women belonging to these ethnicities will find it more difficult to discuss infertility issues within their communities [33;34]. Internalising their problems may have psychological consequences. Additionally, there is a possibility that subfertile African women may be relatively 'invisible\u0026rsquo; to policy makers and conventional demographic perspectives on fertility within Europe [35]. This review will question whether these patients perceive that they receive an appropriate level of care that tailors fertility treatment around their position in a racialised society or their specific experience as an African woman in their community. This is important as it has been reported that non-representative samples, a failure to study culturally distinct populations and little regard for the \u0026lsquo;social construction of fertility\u0026rsquo; characterise literature specifically focused on infertility [36]. Additionally, as empirical evidence suggests immigrant women are at a higher risk of mental illness than those who are non-immigrant, there is a possibility that migrant women in Europe may be at greater risk of suicide [23;25;26;37]. In this way, this review aims to highlight the issues that arise from pooling different ethnicities under wide categories and avoid failing to reach saturation\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e. Hence, the main aim of this review is to explore how socio-cultural factors, structural racism and ability to access ART among subfertile women across Africa and Europe might differ and whether there is a difference in their risk of developing mental illness.\u003c/p\u003e\u003cp\u003eThe objective is to build on the WHO International Classification of Functioning, Disability and Health framework, WHO ICF, to appreciate the factors that may affect the longer-term needs of subfertile women accessing ART and the complexity of their experiences. The WHO ICF, which is a conceptual model for defining and understanding health, recognises how biological, psychological and social influences affect health [38]. A qualitative systematic review exploring the meaning different ethnicities of subfertile women across Africa and Europe attach to care using their own words, rather than predefined concepts, may provide richer definitions that can be incorporated into practice and policy to resolve perceived barriers and improve their access to ART. For this reason, the identification and selection of papers will be determined mainly by the perceived care different groups receive rather than pre-defined concepts and standards in order to gain a broad understanding of how this issue impacts women across different regions. The purpose of this would be to surmise the benefit of using either a patient-centred or a globally recognised definition to understand how different ethnicities of subfertile women across Europe and Africa define quality care when evaluating their ability to access treatment.\u003c/p\u003e\u003cp\u003eAlthough the definitions of care are varied and contested, the aspects of care that will be explored in this review will focus around the actions taken within formal institutional healthcare systems and indigenous treatment which individuals access to improve health and wellbeing [Additional File 1] [39]. Of the two dimensions of care (access and effectiveness), access will be focused upon. The meaning respondents attach to quality will be considered important components alongside their ability to access health structures and required processes of care [Additional File 1] [39]. However, as care for individuals must be placed within the context of providing health care for the population, applying their concepts of 'access' to a set of performance indicators designed to reflect the opportunity cost of providing care for an individual or group of patients may be important [Additional File 1]. Therefore, incorporating both global and patient-centred meanings of the quality of care may be beneficial as it may allow a framework enabling a better understanding of the meaning of the indicators and the aspects of care that may not have been covered.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eSearch strategy\u003c/p\u003e\n\u003cp\u003eThe author developed a search strategy in consultation with a specialist librarian. Literature searches were conducted on databases such as EMBASE; MEDLINE; ASSIA; ERIC; CINAHL and Pubmed. Peer-reviewed fertility journals were also searched. The search terms are highlighted in [Additional File 2]. Additionally, grey literature (e.g., unpublished theses) were searched and researchers in the field were emailed for any peer-reviewed, published research. Searches were conducted between August and October 2025.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria outlined in Appendix I included: studies reported in English between 1978 and 2025; both primary and secondary qualitative studies; participants included females diagnosed with primary or secondary infertility; women from African countries with the highest number of registered IVF units [40]; countries that had high rates of out-migration to the UK at the time IVF was introduced were also included as their treatment experience may have differed from that of more recent migrants [Additional File 3] [41; 42]; countries which have a similar healthcare system as the UK as well as a history of colonialism [43; 44]; women without partners so as to prioritise the needs of those that are underrepresented in those seeking treatment in the UK [Additional File 4] [45]. Studies were excluded where the primary outcome was the efficacy of the trialed treatment or where the population was ethnically undefined [Additional File 5].\u003c/p\u003e\n\u003cp\u003eStudy selection\u003c/p\u003e\n\u003cp\u003eSearch results were exported to Rayyan (http://rayyan.qcri.org) for further evaluation. A total of 493 articles were imported to Rayyan, and 17 duplicates were detected and removed. Of these, 40 were reviewed at the full text stage and a further 24 excluded, leaving a total of 16 included studies. A further 10 records were found through a hand search reference list. After applying the pre-defined inclusion criteria, 29 of these articles were excluded [Additional File 5]. The most common reason for excluding studies at the full text stage included a lack of clarity related to nationality, gender, religion or race of the participants as well as being a systematic review or article. A total of 11 studies were selected for this systematic review [34;46\u0026ndash;55].\u003c/p\u003e\n\u003cp\u003eData extraction\u003c/p\u003e\n\u003cp\u003ePrior to synthesis, details about study design, participants (number and characteristics), study context (timing, location, experience, severity of mental illness and other conditions) and findings from each paper (views of the participant and author interpretation of findings from the abstract, results and discussion) were independently extracted and imported into a data extraction form in Microsoft Word. The selection process, including search results and reasons for exclusion at each stage of screening is presented in a PRISMA flow diagram (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003eCharting the data and reporting the findings\u003c/p\u003e\n\u003cp\u003eFollowing thematic synthesis, the reviewer read the full-text versions of the 11 articles and charted the data [56]. The data were charted using a charting form. The comprehensiveness of the form was evaluated before the consistency of data extraction was compared. The charting form was deemed appropriate and no changes were made to the chart. Data extraction appeared consistent. Author then summarised the data, as reported in the next section.\u003c/p\u003e\n\u003cp\u003eStudy characteristics\u003c/p\u003e\n\u003cp\u003eEleven studies were finally included in this review, which are referred to first author and year of publication (Table\u0026nbsp;1 and Table\u0026nbsp;2).\u003c/p\u003e\n\u003cdiv\u003e\u003c/div\u003e\n\u003cp\u003eMost of the studies were conducted in West Africa (n\u0026thinsp;=\u0026thinsp;4) and Southern Africa (n\u0026thinsp;=\u0026thinsp;3). Within West Africa, one study was conducted in Ghana, two in The Gambia and one in Nigeria. Within Southern Africa, two were conducted in Mozambique and one in Botswana. The remaining four were conducted in Cameroon, Central Africa (n\u0026thinsp;=\u0026thinsp;1), The Netherlands, Europe (n\u0026thinsp;=\u0026thinsp;1) and the UK, Europe (n\u0026thinsp;=\u0026thinsp;2).\u003c/p\u003e\n\u003cp\u003eFour studies used semi-structured interviews [34;48;53;55], one was an unstructured interview [51], one was a structured interview [50], one was described as an in-depth interview [54], one was an ethnography [52] and two involved a combination of interview, observation with informal conversation and group discussion [46;47]. Three of the studies were conducted during the time periods 1993 to 1999 [51;54;55], five during 2001 to 2018 [34;46;47;52;53] whilst the dates were unstated for two studies [48;50].\u003c/p\u003e\n\u003cp\u003eAs the standard epidemiological and demographical conceptualisations of infertility, subfertility, miscarriage and stillbirth were not always meaningful for people living in low- and middle-income countries, those who believed they were infertile (regardless of the duration of their fertility issues or number of living children) were included [34;46;47;50;51;52;53;54;55]. Of the studies, 8 implemented purposive sampling through hospitals where women sought gynaecological and obstetric services, community leaders and healers. Purposive sampling here was implemented to identify and select women particularly knowledgable about infertility or subfertility, were available and willing to participate as well as capable of expressing their experiences expressively and reflectively [57;58]. One study recruited consecutive women who considered themselves infertile from part of the population close to hand [50]. The sampling method of one study was unstated [53]. The number of infertile women included in each study varied from 5 to 107.\u003c/p\u003e\n\u003cp\u003eCritical Appraisal\u003c/p\u003e\n\u003cp\u003eCritical appraisal was carried out using the \u0026apos;Critical Appraisal Skills Program\u0026apos; (CASP) tool for qualitative studies. Points were assigned to each indicator and an overall score was used to assess quality (Fig.\u0026nbsp;2).\u003c/p\u003e\n\u003cp\u003eFive were \u0026apos;low\u0026apos; quality and were conducted in Mozambique, Ghana, Nigeria and Botswana. Six were \u0026apos;medium\u0026apos; quality and were conducted in Cameroon, UK, Amsterdam and The Gambia [Additional File 6]. Four of the five \u0026apos;low\u0026rsquo; quality studies were earlier publications, perhaps reflecting changes in study reporting standards over time. None of the studies included scored the total of 10 points (\u0026apos;high\u0026apos; quality). All the studies failed or were not clear enough in taking into consideration ethical issues. It is not acknowledged how the effects of the study on the participants during or after the study were handled. The studies which were deemed at high risk of bias had significant limitations relating to the critical examination of the role, potential bias and influence of the researcher during sample recruitment as well as data selection, collection and analysis.\u003c/p\u003e\n\u003cp\u003eAdditionally, age and the range of potential characteristics, such as psychiatric history, across a possibly heterogenous population was not described or analysed in sufficient detail. Although some women with fertility issues reported depressive symptoms such as worry, sadness and anxiety to suicide, it is possible women suffering with more severe symptoms may have made them less likely to take part. This would result in mental health issues being under reported in these studies and compromised transferability, as the audience is not given enough context and detail to determine whether their results apply to the wider population of subfertile African women in the two studies. Where the mental health of respondents were highlighted, medication, diagnoses, prior suicidal attempts were unmentioned.\u003c/p\u003e\n\u003cp\u003eThere were also common themes in terms of domains at low risk of bias [Additional File 6]. The definition and classification of access to care used international guidelines, which was often clear and well defined, helped identify deficiencies in the reporting standards of the studies. Similarly, the meaning of subfertility was based on the diverse perspectives of women experiencing it in their own language, rather than imposed clinical definitions. Therefore, although clinical definitions may have changed over time, using definitions that are also shaped by social and cultural context, results in an information-rich source highlighting the sociocultural barriers that subfertile women across Africa and Europe may experience [58;59].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWhen attempting to understand the potential barriers to fertility treatment, it is important to appreciate that a traditional religion that centres witches, spirits, sorcerers, spirits of ancestors and traditional healers is an important aspect of how women experience and cope with their subfertility (Table\u0026nbsp;3 and Table\u0026nbsp;4).\u003c/p\u003e\n\u003cdiv\u003e\u003c/div\u003e\n\u003cdiv\u003e\u003c/div\u003e\n\u003cp\u003eSpirituality\u003c/p\u003e\n\u003cp\u003eThe emotional impact of infertility was felt by Ghanaian, Botswanan and Gambian women who tearfully reported loneliness and exhibited symptoms of depression ranging from crying and insomnia to neglected personal hygiene and suicidal ideation [34;46;51;54]. This lasted sometimes up to twenty years as they looked for treatments and imagined a painful childless future, without this source of fun, companionship and potential care at an older age [47]. Inability to talk about the stress and fear they experience because infertility is considered a taboo topic may have exacerbated their distress [47]. A deeper hidden meaning for their suffering is sought through prayer and spirituality in an attempt to overcome their ordeal [50;51]. Access to information relating to the prevention and aetiological understanding of infertility was limited and so women attributed it to:\u003c/p\u003e\n\u003cp\u003eSupernatural (\u0026apos;kuntofengo\u0026apos;): African Traditionalism\u003c/p\u003e\n\u003cp\u003eThe origin of women\u0026apos;s infertility is attributed to invisible spirits, colloquially called \u0026apos;jinnoo\u0026apos; believed to target beautiful and talented Gambian women from birth [46]. Interviewees also complained community members accused them of being witches as they believed infertile women paid the highest price to participate in a credit and debt system of the \u0026apos;witches club\u0026apos; to own other people\u0026rsquo;s existing or future children [46]. Some of the women perceived themselves as victims of \u0026apos;black magic\u0026apos; from a marabout, a male healer affiliated with Islam, who are mainly associated with protection and treatment of afflictions caused by \u0026apos;buwaa\u0026apos; and \u0026apos;jinnii\u0026apos; [46] Co-wives and family members particularly mothers-in-laws were commonly accused of requesting affliction from marabouts. Mozambican and Dutch studies illustrated that infertility was believed to be caused by people, witches or sexual contact with the spirits, \u0026apos;majini\u0026apos; or \u0026apos;maleika\u0026apos;, which prevented intercourse between spouses [54;55]. Botswanan and Ghanaian women also felt infertility was the consequence of chastisement by God, \u0026quot;petso ya Modimo\u0026quot;, immoral behaviour, becoming pregnant at an early age, prior abortion, marrying a man without receiving \u0026apos;lobulo\u0026apos; or not following ancestral traditions [34;51;52]. Authors also illustrated the importance of sacred places to infertile Gambian women as points of prayer or rituals, performed by herbalists, marabouts, kanyaleng kafooluand kankurangs. Religious faith and prayer were used as a means of coping with loss, disappointment, social condemnation and suicidal thoughts [50].\u003c/p\u003e\n\u003cp\u003eSpirituality: Natural\u003c/p\u003e\n\u003cp\u003eResearchers describe folk illnesses as syndromes within a culture which provide an alternative aetiology, diagnosis or healing measure. These include natural causes, such as fibroids, \u0026apos;seketoo\u0026apos; and \u0026apos;buluntoo\u0026apos; [46]. Mozambican and Gambian respondents also identified a \u0026apos;mismatch\u0026apos; between the blood of spouses, \u0026lsquo;norro\u0026apos;, as the most pertinent and commented that the suffering from \u0026apos;xilume\u0026apos; (menstrual cramps), vaginal itching and discharge women experienced were commonplace within polygamous marriages and the result of STDs [52;55].\u003c/p\u003e\n\u003cp\u003eMarital Strain\u003c/p\u003e\n\u003cp\u003eGambian and Botswanan women perceived that the cause of infertility was gendered and because they felt stigmatised by their community and spouses, they found it difficult to encourage their spouses to be tested, diagnosed and treated and struggled to share burdens with them due to fears of potential discord [46;47;51]. Authors suggest this may explain the reason woman were more likelier to seek ART than men. Women also complained that although gender roles prescribed that men should provide \u0026apos;fish money\u0026rsquo;, they did not receive it and as a housewife, lacking economic strength, left them unable to negotiate in their relationship and vulnerable to the anxieties of abandonment or being able to afford ART [47]. Few marriages were able to manage the long-term impact of infertility. Some reported physical, emotional and financial abuse from community, partners and in-laws. A woman\u0026rsquo;s financial positioning and a man\u0026rsquo;s age, education, history of childlessness with other partners and ability to opt out of an arranged marriage affected the likelihood of these outcomes [34;46;47]. In practice, the consequences of extra-marital relationships were less severe for men. However, if husbands were the cause of infertility, it was better to secretly become pregnant with another man than risk divorce.\u003c/p\u003e\n\u003cp\u003eSocial support\u003c/p\u003e\n\u003cp\u003eGambian women in weaker financial positions were more likely to be restricted to traditional roles and be presented with less opportunity to escape the tension and hurtful comments from their in-laws and community members [46]. They were called \u0026apos;a witch\u0026apos; and accused of \u0026apos;eating their own children\u0026apos;. Being associated with witchcraft and immorality made respondents feel alienated.\u003c/p\u003e\n\u003cp\u003eGhanaian and Gambian women also expressed that they felt their friendships with fertile women were qualitatively different compared to those fertile women had with one another and complained of being excluded from ceremonies such as nthaara[34;55]. Unlike African respondents, UK respondents excluded themselves from their community not because they were threatened with the prospect of abuse but because they were afraid of being a burden [48; 50; 49; 51). Their perception of societal attitudes and mass media descriptions of PGD as a narcissistic \u0026apos;designer baby\u0026apos; technique contributed to their self-consciousness and compelled them to prove to \u0026apos;everyone\u0026apos; that undertaking PGD was an expression of parental obligation rather than self-interest [49]. Although community service, their career and temporarily discontinuing treatment helped women escape the psychological pain of \u0026apos;denying\u0026apos; their needs, the longevity and effectiveness of this coping strategy was unclear.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis review of the literature conducted systematically identified eleven qualitative studies exploring the barriers different ethnicities of subfertile women face when accessing ART in two low, three lower-middle and two high income countries across Africa and Europe (Appendix N Table\u0026nbsp;13.0). I found 11 articles that met my inclusion criteria. West Africa produced the most studies (n\u0026thinsp;=\u0026thinsp;4), followed by Southern Africa (n\u0026thinsp;=\u0026thinsp;3) and the UK (n\u0026thinsp;=\u0026thinsp;2).\u003c/p\u003e\u003cp\u003eThe findings related to perceived barriers to care included religious and cultural proscriptions as well as social strain (Tables IV and VI). The characteristics and contextual factors of subfertile women in Africa and Europe associated with poor experience and barriers to care include age (\u0026gt;\u0026thinsp;45 - highest European age restriction for IVF); educational status (non university educated), area of residence (rural area); employment (low income or unsalaried); marital status (strained, polygamous, residing in different countries, arranged); lack of social and counselling support. Religious and cultural proscriptions associated with spirituality, adoption and fostering was a factor associated with barrier to access particularly in Nigerian, Botswanan, Mozambican, Ghanaians, Gambian and British women. Strained social interactions within their marriage, in-laws or relatives and community was also a factor associated with barrier to access heavily in Botswanan, British, Gambian and Ghanaian women.\u003c/p\u003e\u003cp\u003eSynthesising information from the qualitative literature has provided considerable insight into the longer-term needs of subfertile women of different ethnicities accessing ART. The most striking findings of the synthesis reveals the ongoing difficulties women can face in coming to terms with being subfertile, accessing ART and how they adapt to life after ART:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eGhanaian, Mozambican and Gambian (particularly Muslim) women in polygamous or arranged marriages who have expressed depressive symptoms, have little social support and limited alternative options to ART;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWomen undertaking newer forms of ART such as PGD.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eInsights into their complex belief systems show that the social network and positionality of subfertile women impact health seeking behaviour and their subsequent experience of and access to ART as affordability and availability of diagnosis and treatment dictates their pragmatism whilst searching for ART. Most African women, particularly Gambian, Mozambican and Nigerians, who attributed their subfertility to supernatural causes or folk illnesses (buluntoo and norro) and fibroids had limited knowledge about aetiology or treatment. The alternation and combination of therapies from indigenous healers and ART indicated that there was no preferred treatment. Their sometimes lengthy and intricate itineraries were guided by perceived improvements of their condition and suggests these women were more agentive than their European counterparts in attempting to remedy their situation, understand underlying causes of their subfertility. Although utilisation of healthcare services may vary by ethnicity, health inequalities for ethnic minority populations illustrate a strong association with socioeconomic disadvantage and low health literacy [60;61]. By collating the findings reported in individual studies, significant need for longer-term support was identified. Many of the respondents who conveyed needs in relation to longer-term care were a number of years post diagnosis, which suggests that needs may persist over a significant period of time in the absence of resolution.\u003c/p\u003e\u003cp\u003eAftercare, the Continuity of Care and Mental Health\u003c/p\u003e\u003cp\u003eFindings suggest that the current resilience model implemented by ART clinics is inadequate in understanding the full impact of the barriers to access and experience of accessing ART varies between different ethnicities of women across Africa and Europe [48]. Results of this review demonstrate that the impact of subfertility goes beyond the individual into the relationships, mood and financial stability.\u003c/p\u003e\u003cp\u003eAlthough the WHO ICF provides a framework for recognising factors that may affect the longer-term needs of subfertile women accessing ART, it does not appreciate the complexity of their experiences, as illustrated in the thematic synthesis. As a failure in any of the WHO ICF domains can lead to loss of health, findings from this review suggest that psychosocial factors also be considered in treatment, research and policy to further assist subfertile women accessing ART across Europe and Africa. This is because the review highlighted that the difficulties that subfertile women experience during and after ART, from coming to terms with their subfertility to feeling unable to overcome the loss of social status, roles as well as activities resulted in the deterioration of their mental health. This is consistent with empirical evidence that establishes that access to and knowledge of mental health services is poor as fertility specialist counselling offered by clinics tends to be inadequate and not patient-centred (British Fertility Society 2020). Evidence suggests that patient-centred care can relieve the emotional burden of infertility, which is often see in terms of poorer quality of life (QoL), higher anxiety and depression - outcomes African women are at significantly higher risk of developing [23;26;62\u0026ndash;66]. More specifically, this may also benefit African migrants than non-migrants, who have less social support from family and hence would more likely rely more heavily on support provided at the treatment centre [23; 37;62].\u003c/p\u003e\u003cp\u003eAlthough there is significant overlap with the experience of different ethnicities of subfertile women, findings from this review revealed how the sociocultural experiences of women from lower socioeconomic backgrounds or African descent present a unique barrier, for instance, from participation in meaningful activities or maintenance of social networks. If they had a counsellor of the same country of origin, they may feel hesitant disclosing details due to fear of experiencing the same stigmatisation they may have faced (or are facing) within their family or community. It is important to highlight that homogenising African communities into one group based on continent or even country of origin is problematised by the complex intersectionality of their identities. Studies suggest that both Black and White people may be subject to implicit racial biases. For example, a US study demonstrated the social biases reflected in the implicit racial stereotypes of Black people where a preference for White people and against African Americans was observed among African American as well as White medical students and doctors [67\u0026ndash;69]. Studies have shown that a physician\u0026rsquo;s racial biases against particular racial and ethnic minority patients is significantly related to the quality of care they provide to their patients [68]. As a result, patients may feel their access to quality care is restricted even amongst those who may share the same broad ethnic designation as the impact of cultural nuances and spiritual beliefs on treatment decision-making or relationship dynamics is not apart of the curriculum.\u003c/p\u003e\u003cp\u003eAlthough every effort was made to locate studies relevant to this review, I concede that publications may have been overlooked. Furthermore, the quality of the synthesis is limited by the quality and reporting of the original studies [70]. For example, the results of the quality assessment highlighted the lack of reflexivity in some of the included studies. If the researcher has not critically reflected how their own position may have influenced the conduct or findings of the study, it is difficult to evaluate levels of researcher bias in study findings [71;72] (Appendix P Table\u0026nbsp;15.0).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, over the past 47 years, 11 articles have been published on the sociocultural aspects of accessing ART across Africa and Europe. Most of these studies (73%) were conducted in Nigeria, Ghana, The Gambia, Mozambique and Botswana.\u003c/p\u003e\u003cp\u003eFuture research should explore the possible components of a longer-term term care intervention that is patient-centred for different ethnicities of subfertile women across Africa and Europe. Few studies explored how subfertile women manage sociocultural barriers during and after ART is required to further understand adaptation and adjustment during this time period and inform subsequent care strategies. Research comparing those who have temporarily and permanently stepped away from ART may better illuminate how resilience manifests among women and influences their decisions to end or continue treatment. Future research also ought to widen data collection within each ethnic community to include the views of community members who are more isolated from health and community support services and potentially have different perspectives from those that are represented in this systematic review. This is important because this review has demonstrated that beliefs about subfertility itself influence the decisions of different ethnicities of women and affect the support they can enlist.\u003c/p\u003e\u003cp\u003eClinicians may also draw on these findings to highlight the importance of maintaining the non-fertility aspects of their life and assess their resources for ART in order to prevent further depletion in their psychological well-being. The concept of candidacy as a means to understand access to healthcare services by vulnerable groups and eligibility for medical attention as well as intervention is a joint 'negotiation between individuals and health services' is a useful framework for interpreting these findings [61;73]. Extending understanding of how women, who are often under-represented with ART and research, adapt to the adversity they experience may aid clinicians in offering more culturally informed interventions [48;36]. Offering consultation about various evidence-based holistic methods such as indigenous herbalism and spiritual support may help integrate women\u0026rsquo;s need to gain control over their treatment and limit their exposure to exploitative services offering expensive or redundant solutions [48;74]. The incorporation of local disease classifications into public health messages may address former exclusion of folk illnesses in public health practice, resolve communication constraints with users and potential delays accessing ART. Systematically harnessing patients\u0026rsquo; voices into clinical operations may, as with co-design or other forms of patient engagement hold greater promise for meaningful improvements to the patient experience [75]. However, it is important to highlight that attributing treatment choice to miseducation does not comprehensively represent their pragmatism considering existing structural inequalities and lack of integrated care. For this reason, this review suggests that while individuals should have the reproductive right to access publicly funded services, alternative forms of parenting and social identity should be publicly promoted for subfertile women across Africa and Europe.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable as this is a review.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eNot applicable as this is a review.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNot applicable as this is a review\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKI synthesised the data critically reviewed, discussed and finalised the submitted manuscript, and (will) contribute to all revisions. Author agrees to be accountable for the work and to investigate and resolve any issues related to the accuracy or integrity of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable as this is a review\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eAll data generated or analysed during this study are included in this\u003c/p\u003e\u003cp\u003epublished article [and its supplementary information files]\u003c/p\u003e\u003cp\u003eCompeting interests\u003c/p\u003e\u003cp\u003eNot applicable as this is a review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRoomaney R, Salie M, Jenkins D, Mutumba-Nakalembe MJ, Volks C, Holland N, Silingile K. 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Nurs Standard. 2009;23(23):42\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDixon-Woods M, Kirk D, Agarwal S, Annandale E, Arthur T, Harvey J, Hsu R, Katbamma S, Olsen R, Smith L, Riley R, Sutto A. Vulnerable groups and access to health care: a critical interpretive review. London: NHS Service Delivery and Organisation R\u0026amp;D Programme; 2005.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eClark NA, Will M, Moravek MB, Fisseha S. A systematic review of the evidence for complementary and alternative medicine in infertility. Int J Gynecol Obstet. 2013;122:202\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijgo.2013.03.032\u003c/span\u003e\u003cspan address=\"10.1016/j.ijgo.2013.03.032\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu JJ, Rotteau L, Bell CM, Shojania KG. Putting out fires: A qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals. BMJ Qual Saf. 2019;28(11):894\u0026ndash;900. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjqs-2018-008801\u003c/span\u003e\u003cspan address=\"10.1136/bmjqs-2018-008801\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Please note, a number of ethnic groups may be under-represented to generate a conclusion that may be applicable to all African and Caribbean communities.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Bride price\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Organisations solely consisting of women who have experienced child loss or fertility issues and perform rituals to beg God to heal them of their subfertility or child mortality issues through the exorcism of evil spiritual forces [46]\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Family of masquerades wearing a costume from tree bark fibres and leaves commonly associated with the spiritual world and perceived to have supernatural powers [46]\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Respondents reported that the symptoms of seketoo includes itching in the general area which could lead to bleeding; white discharge; small and bumpy structures within the vagina [46]\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Although little information about buluntoo is available, it is reported that abdominal back pain which is described as a stone in the womb, typically characterise this condition [46]\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Local term: Gonorrhoea [55]\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Money for the daily livelihood of the wife\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e A ceremonial procedure for pregnant Macua girls that instructs their behaviour during pregnancy and labour [55]\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Patient Experience, Infert*, Africa, Europe, Mental*, Qualitative Review, Health-Seeking Behaviour, British Fertility Society, ART, IVF","lastPublishedDoi":"10.21203/rs.3.rs-7919549/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7919549/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIn many countries across Sub-Saharan Africa and Europe, women with subfertility search relentlessly for treatment. However, few studies consider how the experience of subfertility and accessing Assisted Reproductive Technology (ART) is formed by their social positions. Effective strategies that address sociocultural barriers to ART are required to mitigate its potential long-term physical, financial and psychological effects in order to inform the design of more inclusive as well as supportive interventions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eDatabases representing the disciplines of medicine, nursing and social sciences as well as grey literature were searched for English language citations from 1978 to 02 October 2025 using keywords related to infertility, Europe and Africa.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf 493 citations identified, 11 qualitative papers being included. Most of the studies (73%) were conducted in Nigeria, Ghana, The Gambia, Mozambique and Botswana. Sociocultural aspects explored include factors associated with religious and cultural proscriptions, such as spirituality, medical pluralism and adoption and fostering. Factors related to social strain include marital strain and social support. The complex health seeking behaviours of women revealed they sought biomedical and holistic treatment as well as help from religious places of worship. Although treatment choice was related to the perceived aetiology of subfertility, it was also influenced by beliefs, family and social networks. Those from a lower socioeconomic background who faced barriers to treatment were also more likely to be confronted with intimate partner violence.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eBy highlighting how in particular scenarios, certain groups experience greater psychosocial barriers accessing ART and thus are more vulnerable than others, an intersectional approach that informs public health strategies and social policy may be promoted. Health authorities may need to further invest in working with organisations, like the British Fertility Society, to provide information and counselling on issues related to infertility prevention and treatment. The availability of locally applicable guidelines for infertility management at all levels of the health system would facilitate such steps to better integrate care and widen engagement.\u003c/p\u003e","manuscriptTitle":"A qualitative systematic review of the sociocultural barriers accessing ART experienced among subfertile women across Africa and Europe","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-25 17:33:54","doi":"10.21203/rs.3.rs-7919549/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f731699b-255b-4c4c-95d8-ed5eea119ebb","owner":[],"postedDate":"October 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-30T08:23:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-25 17:33:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7919549","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7919549","identity":"rs-7919549","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}