Health systems recovery from COVID-19: a window of opportunity for (in)fertility care.

From the onset, medical and human rights experts and organisations warned of the immediate and potential impacts of the COVID-19 pandemic on sexual and reproductive health and rights (SRHR). Yet most gave little or no attention to fertility-related health care,[1] despite it affecting up to 180 million couples worldwide.[2] Even before the pandemic, infertility was already one of the most understudied and underfunded aspects of SRHR.

Access to fertility services: a right or a privilege?

The right to reproduce has been recognised for over 70 years, first appearing in the 1948 UN Universal Declaration of Human Rights. This gives rise to positive state obligations to remove unnecessary barriers to fertility services, yet there are large disparities in how countries recognise and protect this right.

With half of the world’s population being without universal health coverage and infertility services being excluded from many essential service packages,[3] funding is one of the biggest barriers. For instance, in India, Nigeria[4,5] and other low- and middle-income countries, fertility care is often not on the health financing agenda at all, and even international organisations providing sexual and reproductive health services tend to overlook it.[6] This situation is exacerbated by the almost complete absence of infertility care from international discourses on SRHR, which means that there is limited advocacy for the inclusion of fertility care in service packages. People in high-income countries also face financial barriers to fertility care, for example in countries like Ireland and Switzerland, which do not offer public funding for assisted reproduction technologies (ARTs),[7] or the USA, where health care financing is primarily from private sources, health care costs are high, and insurance coverage for ARTs often limited.[8] Even where fertility care is publicly funded, access may be limited by factors such as age or the existence of previous children.[7]

Sociocultural, legal and/or ideological factors linked to social identifiers such as race, class, ability, marital status, sexual orientation or identity may also result in some groups being explicitly or implicitly excluded from access to fertility care. Heteronormative and gender binary notions of parenthood[9] and restrictive definitions of suitability for motherhood or what a family should look like, could mean that LGBTQIA+ people face barriers, as is the case in various European countries where access is legally restricted to heterosexual couples.[7] Implicit barriers can also limit the access of certain populations to fertility services. In the USA, for instance, access to reproductive technologies for HIV seropositive individuals is extremely limited because few clinics offer such services, in spite of recommendations for these services to be offered to HIV-infected individuals and couples.[10] In Britain, the case of the 22-week pregnant, disabled, single, black woman who was instructed against her own and her family’s wishes to have an abortion because the judge felt it was in “her best interests”, exemplifies how perceptions of suitability for motherhood can influence access to reproductive rights. The Court of Appeal later overturned the lower court’s ruling, but if this woman had wanted fertility treatment, it is unlikely that it would have been made available to her.[11]

Post-COVID health systems recovery: an opportunity to build back better

Currently, many people are unable to exercise their right to reproduce because of a lack of access to treatment for infertility. This situation is set to worsen post-COVID, given that many countries suspended fertility services as part of measures to limit the impact of the disease,[12,13] with repercussions for intending parents who may lose their access because they no longer meet eligibility conditions like age. Furthermore, the unprecedented scale of measures that have been deployed globally in response to the pandemic will likely have an impact on the future availability of both domestic and foreign resources and, consequently, the willingness and ability of governments to invest in the health sector. At the individual level, the increase in under/unemployment and job insecurity will mean that fewer people have financial access to infertility treatment. Post-COVID recovery nevertheless represents an opportunity for countries to identify and rectify weaknesses in pre-pandemic health systems and build back better. For fertility services, this will require action in five key areas.

There must be explicit recognition that sexual and reproductive health imperatively includes treatment for infertility and related services.

Since health needs are likely to increase from ongoing disruptions to the health system and the impact of COVID containment measures on the determinants of health, efforts must be made to ensure that fertility services are not (further) deprioritised, and defunded within the health system.

Efforts must be made to ensure that fertility services are included in health policy reforms and other health systems interventions as part of the post-COVID-19 recovery. The new health system should be financed in a way that promotes equity and guarantees universal health coverage for infertility treatment.[14] This may require advocacy and renewed discussions on the ethical principles and procedures for the fair allocation and distribution of resources.[15]

Efforts must be made to address non-financial barriers which limit those who have traditionally been denied access to fertility services. This may require legal reform, to repeal laws and policies that criminalise, obstruct or undermine universal access to fertility services. It may also be necessary to revisit debates on suitability for parenthood and the socially acceptable family. This would require adopting a holistic intersectional approach to SRHR.[16]

Finally, efforts must be made to improve the quality of fertility services. They must become people-centred[17] and based on an integrated service delivery model, in which health workers collaborate to deliver seamless, comprehensive fertility services which are embedded within the wider context of sexual and reproductive health care.

Post-COVID recovery provides a window of opportunity to build transformative health systems. We submit that quality fertility services can and should have a place within this transformation.