Ensuring Equitable Access to Reproductive Health and Assisted Reproduction for Women with Fertility Challenges: Towards a More Just and Health-Equitable Zimbabwe
Tawanda Mbewe, MA
Lecturer and PhD Candidate, University of Zimbabwe (Harare, Zimbabwe)
Abstract
Even though access to reproductive health is a fundamental aspect of social justice, women in Zimbabwe continue to bear the pain and effects of fertility challenges. This normally takes a toll on their health and well-being. The struggle for women is well-documented, but the plight of women with fertility challenges has not been given adequate attention. Access to health care has been a perennial challenge in Zimbabwe, but the ordeal of women with fertility challenges is further compounded. Societal perception of fertility challenges has made it difficult for those with fertility challenges, and most of the brunt has been on women. Developments in medicine through assisted reproduction have been a relief to such couples, but access to such technologies has been minimal in Zimbabwe. The paper argues that reproductive health is a key aspect of social justice. Women in Africa should enjoy their reproductive rights, health equity, and bodily autonomy so that they are spared from social pressure associated with fertility challenges. The work will highlight the fate of women with infertility in Africa and how access to reproductive health can be a panacea to issues of social injustices suffered by such women. The paper also highlights ways in which these assisted reproductive technologies can be adopted and adapted to effectively address fertility challenges in Africa.
Keywords: Social Justice, Reproductive Health, Health Equity
___________________________
Introduction
Efforts to mitigate social injustices against women have been a welcome development, and Africa is making strides in prioritising the elevation of the status of women. Despite this positive and welcome initiative, there remain areas of concern as far as women’s issues are concerned. Reproductive rights remain an area that still needs adequate attention if the women’s empowerment discourse is to be a success story in Zimbabwe. Fertility challenges have remained a thorn in the flesh of women who usually suffer the most. Africa, being a traditionally patriarchal society, tends to treat men and women differently, and this is certainly a miscarriage of reproductive justice. This paper explores how the response to fertility challenges has become a serious reproductive rights issue in Sub-Saharan Africa in general and Zimbabwe in particular. Access to reproductive healthcare has not been given the due attention it requires, and this has led to serious reproductive injustices. This paper traces the place and value of fertility treatment in the African setup and argues that a typically African value system recognizes and place value on the importance and central role of motherhood and procreative ability, that on its own is a sign that Africans place a lot of value of reproductive justice and should be used as a basis for advocating for reproductive rights for women in Zimbabwe. This should be used as a justification for demanding changes in healthcare policies and an advocacy for reproductive justice for women in Zimbabwe, thereby striving towards health equity and reproductive justice.
___________________________
Women and Infertility in Zimbabwe
Infertility is a global challenge that affects a substantial number of people around the globe. According to WHO data, more than 180 million couples in developing countries suffer from primary or secondary infertility. Dyer et al [1657-2020] rightly acknowledge that infertility is a major reproductive health problem in Africa. For Ombelet [258-2011], Infertility care is probably the most neglected and underestimated health care issue in developing countries, and Zimbabwe is no exception to this. Again, it’s a healthy problem that usually affects men and women disproportionally. Attitudes towards people with fertility challenges, especially women with fertility problems, are an area that still needs serious attention. For Maponya [2021:36], marriage is considered a duty in African traditional communities, procreation is what completes and validates it, and without children, a marriage is considered incomplete. In a way, fertility, pregnancy, birth, and child rearing are cultural achievements. In most Zimbabwean societies, motherhood is essential to validating one’s heterosexuality and gaining stature, and females without a child are marginalised and unrecognised. Such is the plight of women who face fertility challenges in Zimbabwe.
The Report of the Commission on Women’s Health in the African Region [2002:35] notes that Infertility is a major public health problem in the African Region, as failure to conceive often generates frustration and emotional stress as well as a sensation of guilt and resentment; infertility may even lead to divorce. Another most important point noted by the report is that despite the impressive roll call of conventions and initiatives, the good intentions have often failed to result in change. The present work intends to work on bringing the desired change for women with fertility challenges in Zimbabwe.
___________________________
Reproductive Justice and the Zimbabwean Value System
This paper seeks to critically examine the framework of reproductive justice and see how it can yield insights and apply to the Zimbabwean value system. The concept of justice is essential for a thriving society. For Rawls, justice is the first virtue of social institutions. Rawls believed that a just society is one where institutions are designed and operated in a way that respects and upholds justice [Bentley 1972:67]. Reproductive justice is a term that was developed by black American women, and they developed its framework in 1994. The paper argues that the framework has the potential to unlock some of the treasures hidden in the Zimbabwean value system and can therefore be used to propose and advance a good justification for the advocacy of reproductive health rights for African women and Zimbabwean women in particular. In the same vein, it can also be used to bring out some of the shortcomings in the value system that might give room for moral progress. According to Perrit and Eugene [2022:02], the framework of reproductive justice holds that decision-making about sexual and reproductive health is shaped by both the conditions of one’s community and the context of their life. The reproductive justice framework is anchored on four core tenets, namely:
The present effort argues that since this framework was advanced in an American setup, it relates well to the African and Zimbabwean context and setup. The four core tenets of the framework fit perfectly in the Zimbabwean setup and worldview, save for the second one. Let’s briefly consider the first two pillars and relate them to the Zimbabwean value system so that we can justify the need to advocate for reproductive justice in Zimbabwe.
The Right to Have Children
The main pillar of the framework is the idea that having children is a right that every person is entitled to. It’s a right that we usually take for granted when everything is equal. It’s usually a typical African conception of marriage that it must lead to procreation. Fertility challenges usually make it difficult for one to enjoy the right to have children. In the traditional Zimbabwe setup, several interventions were put in place to alleviate infertility challenges. All these interventions point to a societal desire for persons with fertility challenges to enjoy the right to have children. With advances in technology, it has become imperative for people to find it easier than before to enjoy the right to have children. Access to these reproductive technologies has been very minimal, and more still needs to be done in this respect.
The issue of access to assisted reproductive technologies in Zimbabwe can be considered a social justice challenge that calls for addressing the imbalance. Due to the high costs of assisted reproduction in Zimbabwe, a large number of women with fertility challenges are finding it difficult to access fertility treatment. This is against the traditional approach to addressing the challenge. Previously, fertility issues were communal and family issues, and it was the duty of the community and family to address the anomaly. Recent interventions have changed everything, and it’s now an individual issue, coupled with poverty; the individual is now left more vulnerable. It is hoped that the social justice framework, when it’s properly applied to the plight of women facing fertility challenges, can indeed reshape perceptions and attitudes towards the challenge. So, the argument is that reproductive health and fertility treatment should be treated as a social justice issue. Social justice discourse has to strongly highlight the plight of such women. Zimbabwean women with fertility challenges ought to be given special treatment, as this has always been part of our traditional value system to treat them as such.
The Right Not to Have Children
The second pillar of the reproductive justice framework has to do with the right not to have children. The framework also recognises the right not to have children. It entails that not having children is a choice that people must exercise. This right is based on the assumption that a right to have also entails a right not to have. It has to be admitted that this one is not a popular idea in Africa, and Zimbabwe in particular. This idea hinges on the Western idea of individual liberty, which entails that even when it comes to reproduction, the individual ought to determine their reproductive health decisions. In a typical African setup, the society or community normally precedes the individual. This is not to say that the individual is not important, but to some extent, society normally determines the good for the individuals. Thus, for Mbiti [1969:174] marriage is ‘the point where all the members of a given community meet: the departed, the living and yet to be born.’ Here, marriage is conceptualised as the foundation of African communities; a bedrock that sees both the formation and the continuation of the existence of African people.
Reproduction is regarded as a duty that one owes to society. For Fortes [1978:23], ‘the achievement of parenthood is regarded as a sine qua non for the attainment of the full development as a complete person to which all aspire’. According to Sande and Matwaya [2002:48], children are regarded as sacred gifts from Mwari (Shona Supreme Being); hence, both men and women have a moral duty to perpetuate progeny. Failure to perform the duty is not usually tolerated by society. Zimbabwe, like other African societies. To decide not to have children is plainly regarded as neglecting one’s duty of ensuring the perpetuation of the clan. In some cases, it is regarded as an act of selfishness that goes against the principle of the common good. In such cases, an individual will be regarded as seeking to further their own interests at the expense of societal interests. It has to be noted that the idea of pushing for the common good normally results in the violation of individual rights. In the case of women with fertility challenges, this conception normally exposes them and puts them under a lot of societal pressure. There is a need to strike a balance between societal expectations and individual rights. Recognising the right not to have children makes life easier even for those with fertility challenges, as it can be viewed as a choice.
Patriarchy and Reproductive Violence
Biological, medical, and socio-cultural variables can all have an impact on infertility. Patriarchy as a socio-cultural system greatly shapes societal response and shapes attitudes towards infertility. The Zimbabwean society, like other black societies, is pronatalist in nature and motherhood under patriarchy is compulsory [Robert 1993:20], where patriarchy is a social system characterised by relations of power and authority of men over women [Inhorn 1996:36]. The nature and character of patriarchy usually manifest their ugly side when it comes to fertility challenges. The situation of infertile couples is under no circumstances ameliorated. Due to its nature, women are usually at the receiving even though men are not spared from the catastrophic expectation of the system. Man is, however, better placed as it is a system that normally favours them. For Srishti [2023:63], as a social system, patriarchy perpetuates gender inequalities and power imbalances between men and women. Malhotra [2023:46] notes that a major factor here is that women bear children for the patriline they marry into. In the majority of cases, when the man is infertile, the woman is encouraged to have children for him either by a close relative or, in some cases, any other man of her choice, especially in situations where the infertility of the male gender is to be kept secret. But in a situation where the woman is infertile, the husband is permitted by culture and tradition to marry another woman who would give him children [Kenneth 2020:15]. The commonly mentioned justification for these tendencies is how the marriage setup is designed in the African setup.
Payment of Bride Price
Most of the challenges and inequalities faced by women have been associated with the payment of brideprice. In the Zimbabwean setup, like in most African societies, males are supposed to pay brideprice, which is locally referred to as lobola/roora. Goody and Tambiah [1973:76] describe bridewealth, sometimes used interchangeably with marriage payment or brideprice, as prestations, gifts/goods and services that are transferred from the groom’s kin to the bride’s family. Traditionally, brideprice was a way of solidifying the union between the two families, as well as to give legitimacy to the union. But recent developments have led to the commercialisation of the whole thing. Scholars have often debated whether this practice is still relevant in today’s society. Of interest to this work is the link between the payment of the pride prize and its impact on women’s reproductive health and wellbeing.
After payment of the bride price, the couple is expected to bear children. In fact, the belief is that a woman is supposed to bear children for a man who has paid the bride price for her. This compounds the plight of couples who experience fertility challenges. In such a scenario, the woman would have failed to live up to societal expectations. In more severe cases, the groom may even file for divorce and claim back their pride prize. Horne et al [2013:46] note that although the basis of a legitimate marriage arguably brings dignity and respect to women and men and their offspring, the payment of bride wealth is frequently perceived and portrayed as the bane of women in most patrilineal societies. Women who face fertility challenges are usually under pressure and suffer a lot due to this patriarchal practice.
Some scholars have argued for the abolition of the practice to ensure that women are empowered, but other scholars are of the view that this may actually worsen the woman’s position in a marriage setup. This present project takes a middle approach between these two extremes. The practice must be practised and stick to its intended traditional purpose, and avoid commercialising it. It should be done in a way that commodifies women. If women’s reproductive health is to be prioritised, there is a need to avoid turning them into commodities that can be bought or sold. People should stop putting a price tag on women, but they just have to respect the reproductive role played by women. By doing so, women will not bear the brunt of fertility challenges. In any case, reproductive justice demands that reproductive health care be easily accessible to such women. The Zimbabwean government and healthcare providers have to take seriously the plight of women with fertility challenges.
Polygamy
Due to the patriarchal nature of the Zimbabwean society, men are also allowed to marry more than one wife and not the other way round. In the case of a couple facing fertility challenges, it also means that a man can marry a second woman to try and bear children. Again, this has a bearing on the well-being of the concerned women. The situation is even worse if the second wife manages to conceive. The logical conclusion would be that it was the woman’s fault. Women are not accorded such a chance, so it is the position of this paper that such a situation can only be salvaged by giving women more affordable and easily accessible reproductive health services. Assisted reproduction becomes a tool that can be used to ensure that justice is served for women. Rawls’ second pimples of justice. It’s a tool that can be used to restore women’s dignity, as it normally deals with different kinds of fertility challenges. Even if it is a problem with the man, several options are available to salvage the situation.
___________________________
The Concept of Motherhood in Zimbabwe
Closely linked and tied to fertility/infertility is the concept of motherhood. Parry [2005:340] described it within a pronatalist society as follows: ‘Motherhood is considered the defining element of true womanhood.’ In Zimbabwe, being a purely pronatalist society, the status of childless women has not been a good one, as they fail to live up to societal expectations and aspirations. Bell [2019:635] argues that women usually preserve their womanhood through reliance on essentialist notions of gender. This is in line with McFadden [1994:40], who notes that in most African societies (Zimbabwe included), motherhood is essential to validating one’s heterosexuality and gaining stature, and females without a child are marginalised and unrecognised. In Zimbabwe, like most developing societies, especially having children may be the key to women achieving adult status and gaining acceptance in the Community [Hollos 2023:47]. According to Sundby and Jacobus [2001:44], in southern Africa, the birth of children gives a woman the right to share in her husband’s property and wealth. In Yoruba culture, the adult woman’s role depends on motherhood because children are essential to the continuation of lineages [Pearce 1999:34]. In Zimbabwe, infertility can be a source of poverty for women [Feldman-Savelsberg 2002]. Because fertility is so central to women’s identities in developing countries, women and men with fertility problems may resist labelling themselves infertile [Barden-O’Fallon 2005].
The link between fertility and motherhood poses challenges for women facing fertility issues, as they are often perceived as socially inferior. They are treated as subhumans who are not entitled to the full rights and privileges enjoyed by other women with children. This societal expectation for motherhood is enough justification for championing access to reproductive health and assisted reproduction for women with fertility challenges. Access to assisted reproduction techniques such as IVF will ensure that the societal expectation for motherhood is achievable. This is good for the well-being of women with fertility challenges, as they can also live according to societal aspirations and can be regarded as full members of the community. The idea of reproductive is rooted in the Zimbabwean conception of motherhood.
___________________________
Conclusion
Access to reproductive technology, and in vitro fertilisation (IVF) in particular, can substantially benefit people’s well-being in Zimbabwe. Dealing with challenges associated with infertility is, in a way, a step towards the realisation of the Sustainable Goals, as they are integrated goals. In this regard, it is imperative for governments, especially the Zimbabwean government, to come up with appropriate policy infrastructure to effectively deal with the challenges associated with infertility. By doing so this makes the development goal number 5 a reality as this will go a long way in ensuring universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences [Whiteford & Lois Gonzalez 1995:30]. This paper has demonstrated the link between the reproductive framework and the Zimbabwean cultural and reproductive worldview. This sets a strong justification for reproductive justice for women in Zimbabwe, as it is something that resonates with our cultural and moral reasoning. Reproductive justice ensures that Zimbabwean values premised on the philosophy of ubuntu/hunhu are realised. Ubuntu/hunhu philosophy ensures the common good, including women with fertility challenges. The philosophy promotes equity and justice in the distribution of reproductive health and access to assisted reproduction. In this regard, the paper calls for a health policy that upholds the rights of women that are premised and rooted in our cultural values. This ensures justice and dignity for women when it comes to reproductive matters.
___________________________
References
Bell, A. V., 2019. “I’m not really 100% a woman if I can’t have a kid”: Infertility and the intersection of gender, identity, and the body, Gender & Society 33(4): 629–651.
Bentley, D. J., 1973. John Rawls: A Theory of Justice, University of Pennsylvania Law Review 121: 1070–1078.
Dyer, S. J., Abrahams, N., Hoffman, M. and van der Spuy, Z. M., 2002. Infertility in South Africa: women’s reproductive health knowledge and treatment-seeking behaviour for involuntary childlessness, Human Reproduction 17(6): 1657–1662.
Fortes, M., 1978. Parenthood, marriage and fertility in West Africa, Journal of Development Studies 14(4): 121–149.
Hollos, M., 2003. Profiles of infertility in southern Nigeria: women’s voices from Amakiri, African Journal of Reproductive Health 7(2): 46–56.
Inhorn, M. C., 1996. Infertility and Patriarchy: The Cultural Politics of Gender and Family Life in Egypt. Philadelphia: University of Pennsylvania Press.
Malhotra, A., Vanneman, R. and Kishor, S., 1995. Fertility, dimensions of patriarchy, and development in India, Population and Development Review.
Maponya, D. T., 2021. The African woman’s plight of reproduction: A philosophical analysis of marriage, procreation and womanhood, Agenda 35(3): 82–91.
Mbiti, J. S., 1969. African Religions and Philosophy. London: Heinemann; New York: Praeger.
McFadden, P., 1994. Motherhood as a choice, Southern Africa Political & Economic Monthly 7(9): 40–41.
Okwuosa, I. K., 2020. An Ethical Evaluation of Traditional Surrogacy in Igbo Culture, South East Nigeria, Sapientia Global Journal of Arts, Humanities and Development Studies (SGOJAHDS) 3(2): 13–24.
Ombelet, W., 2011. Global access to infertility care in developing countries: a case of human rights, equity and social justice, Facts, Views & Vision in ObGyn 3(4): 257.
Parry, D. C., 2005. Work, leisure, and support groups: An examination of the ways women with infertility respond to pronatalist ideology, Sex Roles 53(5): 337–346.
Roberts, D. E., 1993. Racism and Patriarchy in the Meaning of Motherhood, American University Journal of Gender and Law 1: 11–38.
Sande, N. and Takawira-Matwaya, Y. W., 2022. Assisted reproductive technologies, infertility and women in Zimbabwe, in Religion, Women’s Health Rights, and Sustainable Development in Zimbabwe: Volume 2, Cham: Springer International Publishing, pp. 33–50.
Shrishti, R. P., 2023. Infertility and patriarchy in India: Causes and Consequences, International Journal of Health Sciences & Research 13: 353.
Whiteford, L. M. and Gonzalez, L., 1995. Stigma: the hidden burden of infertility, Social Science & Medicine 40(1): 27–36.
World Health Organisation, Regional Office for Africa. 2012. Addressing the Challenge of Women’s Health in Africa: Report of the Commission on Women’s Health in the African Region. Brazzaville: WHO Regional Office for Africa.