ARSRHI Journal

1.                  Introduction

Since1994, the recommendations of the International Conference on Population and Development, and the resolutions of the World Health Organization[1]has been giving to universal access to reproductive health a crucial role in the social and economic development of communities. Since then, UNFPA, together with a wide range of partners from the international community, works toward promoting universal access to sexual and reproductive health and reproductive rights, including family planning, in order to ensure every individual has the right to make their own choices about their sexual and reproductive health and when they decide to have children, women must have access to services that can help them have a fit pregnancy, safe delivery and healthy baby. This led to make it an essential goal in Global Agendas, in particular the Millennium Development Goals (MDG5) and the Sustainable Development Goals3 and 5 and their targets.

In this context, the health department of the Kingdom of Morocco has set up the Reproductive Health National Strategy for 2011-2021[2], which has confirmed the political will for a reorganization and reorientation of reproductive health programs and services to provide a range of integrated preventive, promotional and curative services to meet the needs and expectations of the target population throughout the cycle of life.

The adoption of the definition of Reproductive Health implying having a responsible, satisfying and safe sexuality, in addition of the freedom of giving birth freely; incites to a repositioning of family planning to encompass both components of birth spacing as well as the management of couples’ infertility[3].Indeed, while the availability of a wide range of contraceptive products made it easier to avoid undesired pregnancies, the inadequacy of assisted procreation servicesis an issue for the ones with a difficulty to procreate.

In Morocco, according to the 2011 Constitution"[4]Access to healthcare and the protection of the health of citizens is a constitutional right". In the same vein, the reportof UNFPA on the state of the world's population[5], stresses that inequalities in sexual and reproductive health and rights, may undermine the goals of the entire international community. Knowing that the 2030 Agenda aspires to a better future, in which, all stakeholders, consider abolishing barriers and correcting disparities. The same SWOP report clearly underlines and draws the attention of the world that without prioritizing the most disadvantaged populations, to reduce inequalities, the achievement of the SDGs is likely to be hindered.

Evaluations of previous national-level strategies for changing indicators of reproductive health components have shown that the main circumstances of failures are related to inequalities, quality of services and inequity in access to services of care.The 2014 census[6]shows that Morocco is in an advanced demographic transition. The decline in fertility (Fertility Rate = 2.21 children per woman) is also accompanied by an extension of age at first marriage (28 years). These demographic movements also take place in a context marked by the issue of couples' infertility (12 to 15% of couples)[7].

In addition, the cares provided toinfertile couples require the implementation of a population policy specifically for couples wishing to be parents.

Based on aRights approach, a group of actors led a very lively debate on the issue.

This article, based on a literature review, describes how a vastmobilization, involving several actors including the Government, the Scientific Society, the Civil Society and the UN agencies represented by UNFP, all activists for the same cause; made recognize that the infertility of the couple is a problem of public health in Morocco.

2.      Methods

Our description carried out in January 2018, is based on a descriptive and qualitative method consisting of an analysis of the process about reflections and discussions and mobilization, concerninga vast advocacy and mobilization, involving several actors including the Government, the Scientific Society, the Civil Society and the UN agencies represented by UNFPA, and all activists for the same cause; made recognize that the infertility of the couple is a problem of public health in Morocco.

Our findings are the basis for data collected using two distinct tools: documentary review of the various reports of different meetings,several analysesmade in this regard, and semi-structured qualitative interviews. The matching method is the strategy chosen for the analysis of the data.

3.      Results

Since 2016, a broad mobilization has created a debate around the issue ofcouples’ infertility with the involvement of a multitude of actors to advocate for a Right to reproductive health,with its medical, social, economic and demographic dimensions. The couples concerned are confronted with a multitude of barrierswhich can be financial, geographical and cultural.

For its part, the scientific community represented by the Moroccan Society of Reproductive Medicine who shared in 2016 on the occasion of its First National Congress, the results of its survey carried out in the field of reproductive health and which showed that the Infertility affects 15% to 17% of Moroccan couples.The President of this learned society has appealed to the authorities to lift the veil on the infertility disease often not recognized as a component of family planning and which is often a source of social and family pressures[8].The survey was conducted among 1034 couple’s aged 25 to 45 in 40 cities covering all regions of Morocco. The results of this survey show that one in three Moroccans think that there is no treatment for infertility, more than one third of infertile people (37%) are not able to discuss the subject to their surroundings (lack of dialogue and social taboo). In addition, women are often considered as the sole responsible when the child does not arrive.

At the same time, the civil society represented by the Moroccan Association of Aspirants for Maternity and Paternity (MAPA) has undertaken advocacy actions that rhyme with the research data in this area. The President of MAPA reports that "Giving life is not always an easy thing for many couples in Morocco. The proof is that there are infertile couples who cannot take the first step towards sterility care. Therefore, the first step is to open the door to this category of people and give them the chance to procreate”.

MAPA has sent a memorandum in the form of a claim book to the Head of Government and the Minister of Health to explain the problem of the couples who suffer from fertilization difficulties.

The drafting of this memorandum is the result of a national solidarity campaign, in the form of a petition of solidarity to support the claims of people who can’t procreate.

This petition of solidarity was signed by couples aspiring to maternity and paternity, their family members, journalists, doctors, pharmacists, trade unionists, health industry actors, and citizens’ sensitive to this issue, but also associative actors, consumer NGOs, nurses, students, lawyers.... And groups of associations active in defense of the right to health and protection of public health, women's associations and representatives of elected women.

Faced with this awareness, the government represented by the health department has considered theset-up of medically assisted procreation in public hospitals.

He played the role of regulator and presented a draft Law N ° 14-47 on the medically assisted procreation that was adopted by the government council in the course of 2017. The law aims at respecting personal data, the penalization of practices constituting an affront to the dignity and the human security. In addition of, the definition of the conditions for the use ofmedically assisted procreation. This project recognizes that infertility is a pathology that must be treated and reimbursed by social welfare institutions[9].

In addition, the first public center of medically assisted procreation was inaugurated, whose activities are carried out within the framework of the public service in a very structured way. This initiative has reduced the shortcomings recorded from diagnosis to therapy.

The Director of the National Reproductive Health Center under the Rabat University Hospital testifies that since the opening of the center "the number of couples treated for infertility is around 780 with 228 cycles and a pregnancy rate of about 25% close to international performances”[10].

Faced with this eminent need, the National Family Planning Program was aware of the need for the accreditation of medically assisted procreationestablishments to be able to practice the techniques of the medically assisted procreationaccording to standards predefined by the law.

This is how UNFPA, United Nations agency mandated the follow up on the implementation of the ICPD recommendations whose focus isachieving universal access to Sexual and Reproductive Health (SRH), the promotion of reproductive rights, monitoring population dynamics, adopting the human rights approach and gender equality.

Soin the field, UNFPA with the support of the National Reproductive Health Center, developed a benchmarking with a specialized center for the treatment of infertility in Belgium as international renown in the field has been established and the reference system for the operating and organizational standards.

4.      Discussion

In family planning programs and family well-being measures and actions, the rights-based and gender-based approach, are imperative when discussing the treatment of infertility.The effort that the state had made birth spaces could also be fruitful for dealing with the couple's infertility problems in Morocco.Since its establishment in 1966, the National Family Planning Program in Morocco has considered that the population is a strategic variable of the process of economic and social development. This considerable effort has enabled Morocco to considerably reduce its fertility. Indeed, it has gone from an exceptionally high level of 7 children per woman in 1962 to 2.21 in 2014.

Urban Rate fertility is even below the replacement level of generations with 2.01 children per woman against 2, 55 in rural areas.In this dynamic, the global commitment to the ICPD (1994) recalls the worldwide mobilization rather towards the recognition of the rights of women to procreation than towards the mastery of demography.

Currently, clinically, the WHO defines infertility as "a disease of the reproductive system defined by the impossibility of achieving clinical pregnancy after twelve months or more of regular and unprotected intercourse". It is a purely medical definition and the social situation is hardly taken into consideration.According to the World Health Organization (WHO), 15% to 17% of couples of reproductive age are affected by infertility which is almost 80 million people worldwide. This implies that 825,000 Moroccans would be affected by the disease.In Morocco, medically assisted procreation has existed for over 30 years mainly in theprivate sector’s facilities with only 18 centers throughout the country and the cost remains exorbitant. This poses serious challenges with regard to accessibility and affordability for aspirants to maternity and paternity.

It is a multidisciplinary intervention requiring the intervention of several specialists such as urologists,andrologists, gynecologists and biologist, in addition to midwives, nurses and health program managers. This method of procreation is beyond the reach of the majority of infertile couples who can’t afford the cost of various successive attempts at PMA. In addition, this cost is increased by travel expenses for couples to major cities with centers that providemedically assisted procreation. Unfortunately, it is a health problem that is not covered by health insurance, private insurance or public authorities.

5.      Conclusion

This example of mobilization has taken a big step forward in Morocco to guarantee the universal right to medically assisted procreation and ensuring reproductive rights for all. Infertility,as a public health issue, with its socio-economic consequences, isno longer absent from public debates and national health policy priorities. Finally, the decision-makers and various stakeholders became health-conscious and socially-conscious about the importance of making the services of diagnosis and treatment of this “Pathology”at the same level as the means put at the disposal of the Moroccans to address their family planning - often unsatisfied- needs, particularly among vulnerablepopulations.

1.       UNFPA (1994) Recommendations of the International Conference on Population and Development (ICPD).

2.       (2011)Ministry of Health Morocco:National Strategy for Reproductive Health 2011-2020.

3.       (2018) WHO: Memorandum N ° 351

4.       (2011) General Secretariat of the Government: Article 31 of the Constitution of the Kingdom of Morocco.

5.       UNFPA(2017) State of the World Population Report; Worlds apart/Reproductive health and rights in an era of inequality.

6.       (2014) High Commission for Planning: General Census of Population and Housing.

7.       (2016) Moroccan Society of Reproductive Medicine: Survey carried out in the field of Reproductive Health.

8.       Procreation: Morocco unveils infertility(2015)Survey conducted by the Moroccan Society of Reproductive Medicine.

9.       Ministère de la santé (2016) Projet de Loi N°47-14 relatifà la PMA, version 25 février.

10.    Economiste (2016) Assistance médicaleà la procréation: Les hôpitaux publics relèvent le défi des «bébéséprouvettes».