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The scientific basis of the reproductive revolution in Sub-Saharan Africa

challenges and opportunities

Olobo-Lalobo, James H., MBChB, MSc, MRCOG, MBA

Global Reproductive Health: July 2019 - Volume 4 - Issue 2 - p e31
doi: 10.1097/GRH.0000000000000031
Commentary
Open

Paragon Hospital Kampala, Kampala, Uganda

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 10 April 2019

Corresponding author. Address: 6B/7B Luthuli 5th Close, Bugolobi, Kampala 21387, Uganda. Tel.: +256 781250593. E-mail address: j.olobolalobo@gmail.com (J.H. Olobo-Lalobo).

This is an open access article distributed under the Creative Commons Attribution-NoDerivatives License 4.0, which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author. http://creativecommons.org/licenses/by-nd/4.0/

Received September 4, 2018

Accepted November 27, 2018

The word revolution is attention seeking, provocative, and hair-raising. With reference to reproductive revolution, it becomes quite the topic. See, the outcome of the application of the exploding scientific knowledge and related skill to the sperm and egg, the building blocks of reproduction, have triggered phenomenal societal transformation to the individual (fertile and infertile citizens), and the family (traditional, single parent, and new-form families). And at the national level the opportunity for the development of direct and in-direct policies to manage overpopulation is catapulted within realizable grasp. This phenomenon and its related multilevel health impact are nothing short of revolutionary.

From the developmental angle, the reproductive revolution has been crucial to the rise in modernity alongside the well-known economic or industrial and political revolutions. Close examination of the Internet revolution, reveals a technology, that has boasted of connecting mankind globally, albeit with variable levels of penetration, bandwidth, efficiency and price, especially, in Sub-Saharan Africa. In fact it can be argued that sociability has dramatically increased. Reproductive revolution is of a similar global magnitude, albeit slower in speed and laden with unmet challenges notably so in Sub-Saharan Africa. The degree of contraceptive penetration in this region will be discussed later.

Central to reflections on the challenges and opportunities of the reproductive revolution, is the question of who initiates and controls it? In other words, what exactly sets and sustains the great revolutionary match and keeps it rolling? Examining the situation in Sub-Saharan Africa, in particular, the underlying cultural nuance regarding (in) fertility is that the parents construct the child biologically and the child constructs the parent socially, and therein defining the mother’s femininity. Inability to have a biological child is considered a curse for the individual, the family and community1. From the foregoing observation, the defining elements of the reproductive revolution featuring family planning, assisted reproductive technology (ART) and lately stem cell research are both a biological/scientific construct, and a sociocultural system. So what preciously triggered the reproductive revolution worldwide?

At the individual level, over the centuries lovers had tried all kinds of unappealing tricks to prevent pregnancy. It was not until the 1960s that reliable and relatively safe contraceptive method, now known as the “Pill” was introduced in the United States in 1960 and in the United Kingdom in 1961, and the bond between sexual intercourse and reproduction was broken. It was then that the revolution was born, call it the first reproductive revolution.

At the national level, the opportunity to manage uncontrolled population growth emerged to relieve population pressure that had been building up over the centuries which finally exploded between 1950 and 1987, when the world population doubled from 2.5 to 5 billion in just 37 years, in a little >1 generation2. While this period was marked by a peak population growth worldwide of 2% starting in 1962, in Sub-Saharan Africa, however, the current growth rate above 3% represents the magnitude of the overpopulation as measured against slower rates of economic growth.

Notwithstanding the foregoing overpopulation data, Pope Paul VI, in a high profile intervention, warned that contraception would lead to promiscuity, loss of respect for life and the family3. He further told of a breakdown of essential social structures. The march of history suggests this apprehension was, in many respects, unjustifiable. No women anywhere in the world have set their underwear ablaze, as a result of the introduction of the pill or other family planning devices.

No, it certainly has not happened. In fact, the said promiscuity to the extent feared has not taken place in the 60 years of contraceptive practice. Instead, by 2015, up to 64% and 33%, respectively, of married and in-union women of reproduction worldwide and in Africa were using some form of contraception4. In the same analysis, 12% of married or in-union women worldwide were estimated to have had unmet need for family planning. However, in contrast the unmet contraceptive need by geographical region was highest at 24% in Sub-Saharan Africa. That’s double the world average, and represents reproductive opportunity as well as a challenge.

Closer examination of the above data, invites the conclusion that the contraceptive practice in Sub-Saharan Africa has most certainly passed the dawn of the revolution, the darkest day of the revolution. But in a counterpunch, it also means that contraceptive prevalence, in the subcontinent, has not reached the zenith of the revolution, the highest point of the revolution. Its projected that despite the prevalence of contraception increasing in Africa until 2030, the unmet need for family planning will remain high and above 20% in all regions of Sub-Saharan Africa, except in Eastern Africa, where it is projected to decrease from 24% to 18% between 2015 and 2030. So, Africa needs further gearing to address the unfinished family planning revolution. Detail analysis of challenges and the root causes therein are beyond the scope of this paper.

Projected contraceptive prevalence in Sub-Saharan Africa 2015–20304.

Table

Table

Just, over 25 years after the introduction of the contraceptive pill, the birth, on July 25, 1978 of Louise Brown, a living miracle weighing in at 5 lb 12 oz, marked the beginning of the second reproductive revolution that eliminated intercourse and other natural or in vivo physiological processes from reproduction. And today, 40 years on, with over 8 million children born worldwide using this technology, and ART continues to make headlines around the globe5. That means so many infertile citizens are now fertile citizens, and most importantly free from the stigma of childlessness. Indeed, this is the essence of a social benefit undergirding the social construct of the reproductive revolution as argued earlier. But crucially, access to ART is severely constrained by its costs, and worldwide, only the state of Israel offers unlimited publically funded in vitro fertilization (IVF) access6.

From the angle of religious based ethics, the fact that Louise Brown’s body is similar in all ways to that of a child conceived naturally and that she has had children of her own via the natural reproductive process means ART and natural conception are equipoised, and, therefore, should be regarded that way when resolving ethical dilemmas.

In scope, IVF provided the technological platform for ever-widening applications and thus fueling further revolution in the reproductive sphere such as:

  • Shared/donated gametes and embryos that uncouples gene transmission from the reproductive process and leads to reinterpretation of kinship.
  • Surrogacy that uncouples gestation and birthing processes from motherhood/parenthood.
  • Stem cell research with potential for wide-ranging genetic and therapeutic applications.

Epistemologically, the wider application of the technology of assisted reproduction means that reproductive revolution has become reproductive itself. And the ethical debate is concurrently amplified to accommodate and make sense of the sociocultural shift entailed.

The 1977 Noble Prize winning independent researches by Roger Guillemin and Andrew Schally and the concomitant development of radio-immunoassays for peptide hormones by Rosalyn Yalow, opened new vistas, within biological and medical research far beyond the borders of reproduction7,8. Medical control of ovulation became the treatment hub for ART, which in turn provided spare eggs and embryos needed for embryo and stem cell research. In essence reproductive revolution is being reproductive, once again and the notion of reproductive revolution being in a state of permanent revolution begins to gain currency. So much said about revolution as a situational change that is sudden and/or momentous. What does reproductive health care offer to the meaning of revolution denoting the motion turning around an axis?

Rotation motion around an axis is an alternative genre for the word revolution. Boiled down, the axis around which reproductive revolution debate rotates in low resource Sub-Saharan Africa is dominated, in academic literature, media and among policy makers, by the governance mechanisms of health care systems, the resource allocation question, the dilemma in prioritizing pressing developmental policies and programs, and the perennial collision between religious ethics and moral good determinism that is informed and supported by principles of individual liberty and autonomy to access and exercise reproductive rights freely. Such debate will continue to inform and shape the axes of the reproductive revolution in Africa.

On the question of revolution as a rotational motion around any of the axes identified, it has been observed, in the developed world, that counter-revolutionary interventions are on the match against evidence-based ART practice. For example, intracytoplasmic sperm injection is now the standard IVF treatment in Italy, Germany, Czech Republic, Slovenia, and Belgium, thus it trumps the conventional IVF treatment process without any objective merit behind it9,10. The use of supplemental infertility treatment labeled “adds-on” generates spirited debate regarding commercialization of IVF treatment11,12. The new source of danger to the ART revolution appears to be the quality of knowledge not the lack of it, which is propelling IVF supplemental treatment options to collide with evidence-based care. The other challenge to reproductive revolution is consumerism as women opt for egg freezing to delay motherhood, in the hope that ART will enable them to build a family beyond the reproductive clock.

In conclusion, the zenith of the reproductive revolution in Sub-Saharan Africa is achievable. The opportunities and challenges outlined above, albeit abridged, should be proof enough. The benefit of the revolution to Africa lie in the achievement of the highest quality of life beyond child rearing underpinned by sustainable health and wealth within stable and more productive gender sensitive communities of fertile and infertile citizens.

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Conflict of interest disclosures

The author declares that there is no financial conflict of interest with regard to the content of this report.

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Copyright © 2019 The Authors. Published by Wolters Kluwer on behalf of the International Federation of Fertility Societies. All rights reserved.