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

Abstract Background Although there is an increasing awareness that subfertility constitutes a serious public health issue, few studies consider how the experience of different ethnicities of women experiencing subfertility and accessing Assisted Reproductive Technology (ART) is formed by their social positions. Effective strategies that address structural 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. Structural aspects explored include factors associated with the organisational structure of the healthcare system, such as access, affordability and availability. Factors related to patient-centred care (process) include alternative and complementary therapies as well as humanised care received. Factors connected to the consequences of care included the acceptability of care. The complex health seeking behaviours of women revealed they sought biomedical and holistic treatment as well as help from religious places of worship. While treatment choice was related to perceived aetiology of infertility, it was also strongly influenced by the perceived effectiveness, affordability and accessibility of available treatment as well as the duration of their subfertility. Conclusion By highlighting how in particular scenarios, certain groups experience greater structural 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.