Institutional barriers to assisted reproductive technology access in rural South Africa: a qualitative study of medical officers’ perspectives

Background Access to assisted reproductive technologies (ARTs) remains highly unequal globally, with rural populations facing significant geographic, financial, and institutional barriers to fertility care. In South Africa, despite constitutional guarantees of access to reproductive healthcare, advanced fertility services remain concentrated in urban centres and the private healthcare sector, limiting access for many rural communities. Methods This qualitative study explored institutional barriers to ART access from the perspectives of medical officers working in the uMhlabuyalingana Local Municipality, KwaZulu-Natal, South Africa. Semi-structured interviews were conducted with 12 medical officers and analysed using thematic analysis. Institutional Theory provided the conceptual lens through which findings were interpreted. Results Three major themes emerged from the analysis: (1) limited scope of infertility management in rural healthcare facilities, constrained by infrastructure, personnel, and resource limitations; (2) inadequate patient and provider education, resulting in low fertility awareness and delayed care-seeking; and (3) weak health system capacity, characterised by fragmented referral pathways, workforce shortages, and limited access to specialised fertility services. Participants described how these barriers collectively restrict the availability, accessibility, and continuity of infertility care for rural populations. Conclusion The findings demonstrate that inequitable access to ART in rural South Africa is shaped not only by geographic distance but also by broader institutional arrangements that systematically disadvantage rural communities. Strengthening health system capacity, decentralising selected fertility services, improving referral systems, and integrating infertility education into primary healthcare are critical steps toward advancing reproductive justice and achieving equitable access to reproductive healthcare.