Secondary Infertility and Reproductive Health Gaps in Tanzania: Facility-Based Evidence Supporting WHO’s Call for Equitable Infertility Care

Abstract

Background: Infertility is a major but overlooked reproductive health issue in sub‑Saharan Africa, with secondary infertility commonly arising from preventable reproductive tract infections and postpartum complications. Access to advanced treatments such as in vitro fertilization is scarce and unaffordable, reflecting deeper health‑system gaps. This study estimated the prevalence and determinants of female infertility in randomly sampled public and private hospitals in Kinondoni District, Dar es Salaam, to generate facility‑level evidence aligned with WHO’s call for equitable, rights‑based infertility care. Methods: We conducted a cross‑sectional study among 791 women aged 18–49 years attending outpatient reproductive health clinics at three randomly selected hospitals. Standardized questionnaires captured sociodemographic, reproductive, and clinical histories. Infertility was defined using WHO criteria. Prevalence estimates were calculated with 95% confidence intervals (CIs), and site‑level differences were assessed using χ² tests and cluster‑adjusted p‑values. Determinants of infertility were examined using Poisson regression with robust variance to obtain crude and adjusted prevalence ratios (cPR, aPR). Results: The prevalence of any infertility was 27.8% (95% CI 25.1–31.4%), driven largely by secondary infertility (22.9%), while primary infertility was uncommon (4.9%). Prevalence varied significantly across facilities (cluster‑adjusted p = 0.01). Independent correlates included duration of attempting pregnancy (aPR 2.10 for 1–5 years; 2.80 for ≥6 years), history of STI (aPR 1.45, 95% CI 1.22–1.72), postpartum sepsis (aPR 1.28, 95% CI 1.03–1.59), and PID/gynecologic conditions (aPR 6.82, 95% CI 2.31–12.13). Women aged 25–34 had higher infertility prevalence than those aged 18–24 (aPR 1.40, 95% CI 1.21–1.69). Conclusion: Female infertility, predominantly secondary infertility, is common in Kinondoni District and strongly associated with preventable infection‑related morbidity. Strengthening STI prevention, postpartum infection control, and early infertility screening, alongside expanding equitable infertility services, is essential to reducing the burden and advancing rights‑based reproductive health care in Tanzania.