About five years ago, I had occasion to meet with some of the senior staff administering women’s health programs for USAID in Kampala, Uganda. I was interested in finding out how infertility is addressed as a women’s health challenge in an area where healthcare is poorly resourced and basic medical needs across the population are difficult to meet. Not surprisingly, I was quickly told that their priorities were high fertility and maternal mortality. Indeed, they told me that infertility was not a problem for women in Uganda.
With limited budgets and serious public health challenges, we can imagine why USAID staff in Kampala responded that way to my questions. However, their dismissal of the significance of infertility for Ugandan women reflects a not uncommon ignorance of the relationship between fertility and infertility. In fact, high levels of infertility often co-exist with high levels of fertility. Twenty-nine of the thirty-one countries identified by the UN as high fertility countries are in Africa, where it is also estimated that one in four women experience some form of infertility.
Universal access to the continuum of reproductive healthcare by 2015 was identified among the UN Millennium Development Goals. But the question of whether, and to what extent, there is a social obligation to promote fertility or to guarantee universal access to infertility treatment (whatever the scope) continues to be contested. The World Health Organization has called infertility a “global public health issue,” but there is wide disagreement on the rationale for investing in the treatment of infertility—especially in resource-poor regions where local population pressures are thought to impede human development and ecological stability—as well as the relative priority of reproductive healthcare in efforts to provide universal access to basic health care.
Catholic perspectives on IVF
Catholic doctrine condemns virtually all forms of in vitro fertilization, on the grounds that therapeutic interventions that “replace the marital act” offend the dignity of the offspring and undermine the sanctity of marriage. To date, however, theological reflection on assisted reproduction has largely focused on what choices are or are not morally acceptable for Catholics. To be sure, questions such as “How should we judge the morality of donor-assisted IVF or commercial surrogacy?” and “Is it appropriate to freeze human embryos?” are important. But a focus on particular therapies and methods of intervention, or on the limits of individual autonomy, overlooks crucial dimensions of the lived experience of infertility globally. Moreover, much of Catholic reflection on assisted reproduction has lacked a critical gender lens.
As a consequence, there is insufficient attention to the multiple ways in which pressures to conceive or to assume the role of parent in pronatalist societies intersect with the flourishing global market in fertility services. My hosts at USAID were not aware of the scope of fertility treatments available in Kampala, or of the growing number of patients seeking treatment through assisted reproductive technologies. IVF was introduced in Uganda in 2004 at the Women’s Hospital International and Fertility Centre; by 2012, the center recorded more than 700 births through IVF. As in the United States, fertility services are not regulated and treatment is expensive. (Some researchers are working on developing cheaper methods, but virtually everywhere where fertility treatment is delivered primarily through private clinics, costs represent a significant portion of household income.) Insiders consider the global South to be the promising growing edge for the fertility market, both because of the prevalence of infertility and the potential to expand trade in gametes and reproductive services such as surrogacy.
The lived experience of infertility
Neither a quick dismissal of the significance of infertility nor a blanket condemnation of assisted reproduction will help us understand why individuals, especially women, are willing to make significant physical, emotional and financial sacrifices to pursue therapies that have a success rate (if measured by live births) of less than 40 percent, sometimes going against the teachings of a treasured religious faith. Attention to the gendered experience of infertility would illuminate the costs associated, especially in societies where high value is placed on bearing children, costs which are experienced differently by men and women, but which include stigma, the possibility of being abandoned by a spouse, vulnerability to violence at the hands of a partner or one’s in-laws, social insecurity and lack of status associated with the transition to adulthood.
A finer grained analysis would attend to the way in which the turn to IVF can undermine both investments in prevention and support for other means of resolving infertility. The most common form of infertility in Uganda is caused by blocked fallopian tubes—a type of infertility for which IVF is particularly well-suited. However, many cases of infertility of this kind can be averted by preventing or treating infections that lead to scarring. Failing to acknowledge infertility among basic health care needs for women misses an opportunity to educate, treat and provide the means for protecting fertility and plays directly into the tendency in modern medicine to privilege high tech rescue care.
Bringing assisted reproduction under a critical gender lens would also require a candid look at how religious images, narratives, teachings and practices shape experiences of infertility and childlessness, especially for women. Both Catholicism and Islam recognize the equal human dignity of men and women. Both have social justice traditions that call for advancing women’s status in society through investments in education, comprehensive health care and adequate nutrition. But both traditions can also be invoked to defend the subordination of wives to husbands, a primarily domestic role for women, the elevation of motherhood as women’s fulfillment, and the ceding of control over one’s own body. Promoting women’s full participation in society and honoring the ability to give life are not in necessary or fatal opposition. Still, we should be willing to acknowledge the places where our religious traditions are shoring up or legitimating the conditions under which infertility leads to stigma, social insecurity or vulnerability to domestic violence. We should also be willing to examine our rhetoric about the family. Catholicism has a conflicted view of the family—on the one hand privileging the communion of faith over biological ties, but on the other hand privileging the biological family (the family that results from the marital act) over the social family. Although the Catholic Church has been involved in the practice of adoption, there is little theological reflection on adoption in the context of ART.
Maura Ryan is the John Cardinal O’Hara, C.S.C. Associate Professor of Christian Ethics, and Associate Dean for the Humanities and Faculty Affairs at the University Notre Dame. Her primary interests are bioethics and health policy, feminist ethics, and fundamental moral theology.