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Maternal Health and Well-Being  

Samuel Akombeng Ojong, Bridgette Wamakima, Cheryl A. Moyer, and Marleen Temmerman

Maternal health and well-being refers to the physical, psychological, and emotional well-being of women during pregnancy, childbirth, and the postnatal period, as well as the absence of any morbidities or death either due to pregnancy or its management. Despite making a comparatively late appearance on the international global policy agenda, maternal health and well-being has progressively become a global health policy priority following Deborah Maine’s revolutionary article on maternal mortality. Consequently, key international policy events from Alma Ata to the International Conference on Population and Development events, through the Millennium Development Goals to the Sustainable Development Goals (SDGs) in the last decade have consecrated women’s inalienable right to safe and respectful health services. Also, the growing focus on rights-based care against the backdrop of the need to ensure equity in all communities worldwide has led to an evolution in policy focus, calling on health systems to not only protect women and girls from preventable deaths but to also empower them to thrive, all while recognizing their unique role is ensuring the positive transformation of the communities in which they live. This increasing policy attention has contributed to a disproportionate yet marked reduction in global maternal mortality and morbidity statistics over the last 30 years. However, if the world is to achieve its 2030 SDGs women’s health and gender equality agendas, it is important to recognize that the broad concept of women’s health cannot be limited to the rather narrow window of pregnancy, childbirth, and the postpartum period. While there are huge gaps in all resource-type settings in promoting and protecting women’s agency and autonomy, the fact remains that in addition to ensuring the availability of and access to high-quality maternal health services, women’s health outcomes are inextricably linked to their decision-making power on key issues such as when to become sexually active, the use of contraception, whether or not they want to achieve pregnancy and childbirth, and access to safe abortion care services. Additionally, the growing burden of noncommunicable diseases and the increasing occurrence of worldwide pandemics are providing novel challenges to the health and well-being of the world’s most vulnerable women and girls, thus creating the need to ensure resilient health systems that are considerate of the rights and wishes of the world’s women and girls.


Monitoring and Evaluation of Sexual and Reproductive Health Programs  

Janine Barden-O'Fallon and Erin McCallum

Monitoring and evaluation (M&E) can be defined as the systematic collection, analysis, and use of data to answer questions about program performance and achievements. An M&E system encompasses all the activities related to setting up, collecting, reporting, and using program information. A robust, well-functioning M&E system can provide program stakeholders with the information necessary to carry out a responsive and successful program intervention and is therefore a critical tool for program management. There are many tools and techniques needed for successful M&E of sexual and reproductive health (SRH) programs. These include frameworks to visually depict the organization of the program, its context and goals, and the logic of its M&E system. Essential practices of M&E also include continuous stakeholder engagement, the development of indicators to measure program activities and outcomes, the collection and use of data to calculate the indicators, and the design and implementation of evaluation research to assess the benefits of the program. Over time, language around “M&E” has evolved, and multiple variations of the phrase are in use, including “MEL” (monitoring, evaluation, and learning), “MER” (monitoring, evaluation, and reporting), and “MERL” (monitoring, evaluation, research, and learning), to name but a few. These terms bring to the forefront a particular emphasis of the M&E system, with an apparent trend toward the use of “MEL” to emphasize the importance of organizational learning. Despite this trend, “M&E” continues to be the most widely known and understood phrase and implicitly includes activities such as learning, research, and reporting within a robust system.


Newborn Mortality  

Li Liu, Lucia Hug, Diana Yeung, and Danzhen You

As under-5 mortality declines globally, newborn or neonatal mortality is becoming increasingly important. Depending on measurement and empirical data sources, calculation of the magnitude and trend of all-cause and cause-specific neonatal mortality ranges from direct methods to model-based estimates. From 1990 to 2019, the global neonatal mortality rate decreased by 52%, though wide regional variations persist, with sub-Saharan Africa (SSA) consistently experiencing the highest neonatal mortality rates, followed by Southern Asia, accounting for 79% of the 2.4 million total newborn deaths in 2019. Globally, most deaths in 2019 are due to preterm birth complications (36%), intrapartum-related events (24%), congenital abnormalities (10%), pneumonia (8%), and sepsis (7%). Since 2000, in low- and middle-income regions like Central Asia and South Asia and SSA, most deaths were avoided through declines in intrapartum-related events (3.4% and 1.9% AARR [average annual rate of reduction from 2000 to 2019], respectively) and preterm birth complications (2.9% and 1.9% AARR, respectively); whereas high-income regions like Europe, Northern America, Eastern Asia and South-Eastern Asia were more rapidly able to reduce deaths due to congenital abnormalities (2.8% and 3.2% AARR, respectively). More investment is urgently required to improve data collection and data quality, as well as to leverage supporting empirical data with statistical modeling to improve the validity of neonatal mortality and cause-of-death estimates.


Obstetric Fistula  

Chi Chiung Grace Chen and René Génadry

Obstetric fistula (OF) is a condition that remains prevalent in non-industrialized nations, mainly in sub-Saharan Africa and Southeast Asia where proper and timely obstetrical care is inaccessible, unavailable, or inadequate. The reasons for the delay vary from country to country where poverty remains a common thread, and understanding the many factors leading to the development of OF is critical in preventing this scourge that has been all but eliminated in industrialized nations. Preventive measures can be effective when developed in conjunction with local resources and expertise and should include patient education and empowerment in addition to educating and equipping healthcare providers. In the absence of such measures, patients develop an « obstructed labor injury complex » involving the genital, urinary, and gastrointestinal tracts. Many troublesome health consequences arise from this complex, including skin lesions from the caustic effects of urine, endocrine abnormalities such as amenorrhea and infertility, neuropsychological consequences such as depression and suicide, and musculoskeletal impairments such as foot drop and contractures. Globally, evidence-based interventions are needed to address the debilitating and persistent medical, psychological, and social effects of this condition on its sufferers. While surgery offers the amelioration of symptoms, many patients may not have access to such care due to lack of funds, knowledge of surgical options, or availability of surgical facility. Even after successful repair of the fistula, patients may still suffer from persistent incontinence, stigma, and socio-economic hardship requiring special programs for support, rehabilitation, and reintegration. Additionally, the patients who are deemed inoperable require special counseling and care. Consensus is needed on standardizing care and outcome measures to improve the quality of care and to evaluate programs directed toward prevention that will render this condition obsolete.


Operationalizing Human Rights in Sexual and Reproductive Health and Rights Programming: An Example from a Global Family Planning Partnership  

Karen Hardee

The International Conference on Population and Development (ICPD), which has guided programming on sexual reproductive health and rights (SRHR) for 25 years, reinforced that governments have a role to play in addressing population issues but in ways that respect human rights and address social and gender inequities. The shift at ICPD was partly in response to excesses that had occurred in some family planning programs, resulting in human rights abuses. The 2012 London Summit on Family Planning refocused attention on family planning as a crucial component of SRHR and, in part due to significant pushback on the announcement of a goal of reaching an additional 120 million women and girls with contraception by 2020 in the world’s poorest countries, ignited work to ensure that programming to achieve this ambitious goal would be grounded in respecting, protecting, and fulfilling human rights. This attention to human rights has been maintained in Family Planning 2030 (FP2030), the follow on to Family Planning 2020 (FP2020). While challenges remain, particularly in light of pushback on reproductive rights, widespread work over the past decade to identify human rights principles and standards related to family planning, integrate them into programming, strengthen accountability, and incorporate rights into monitoring and evaluation has improved family planning programs.


Pregnancy and Non-Sexually Transmitted Infections  

Ana Luiza Vilela Borges, Christiane Borges do Nascimento Chofakian, and Ana Paula Sayuri Sato

The focus on non-sexually transmitted infections during pregnancy is relevant, as they are one of the main causes of fetal and neonatal morbidity and mortality in many regions of the world, especially in low- and middle-income countries, respecting no national boundaries. While their possible vertical transmission may lead to adverse pregnancy outcomes, congenital rubella syndrome, measles, mumps, varicella, influenza, Zika virus, dengue, malaria, and toxoplasmosis are all preventable by measures such as vector control or improvement in sanitation, education, and socioeconomic status. Some are likewise preventable by specific vaccines already available, which can be administered in the first years of childhood. A package for intervention also includes adequate preconception care, routine antenatal screening, diagnosis, and treatment during pregnancy. Non-sexually transmitted diseases during pregnancy have different worldwide distributions and occasionally display as emerging or re-emerging diseases. Their epidemiological and clinical aspects, as well as evidence-based prevention and control measures, are relevant to settings with ongoing transmission or those about to be in vulnerable situations. Non-sexually transmitted infections are major public and global health concerns as potential causes of epidemics or pandemics, with numerous social, economic, and societal impacts..


Preterm Birth: Epidemiology, Risk Factors, Pathogenesis, and Prevention  

Xiaojing Zeng, Wen Jiang, Xiaoqing He, and Jun Zhang

Preterm birth is a significant global public health issue. It is defined by the World Health Organization as infants born alive before 37 completed weeks of gestation. The preterm birth rate varies significantly across countries and regions. Globally, an estimated 13.4 million babies were born preterm in 2020 (i.e., 1 in 10 babies worldwide was preterm birth). It is the leading cause of under-5 child mortality worldwide, and preterm infants are particularly vulnerable to respiratory complications, feeding difficulty, poor body temperature regulation, and high risk of infection. Both genetic and nongenetic factors (exposome factors) contribute to the risk of preterm birth. Social and behavioral factors, medical and pregnancy conditions, and environmental exposures are common nongenetic risk factors for preterm birth. Individuals from certain ethnic and racial groups, in low- and middle-income countries, or with a low socioeconomic status are at an increased risk of having preterm birth, and social determinants of health are the root causes of these factors. Existing pregnancy complications, history of preterm birth, and other medical conditions are also common risk factors. Environmental exposures such as air pollution, climate change, and endocrine-disrupting chemicals have been increasingly realized as potential risk factors for preterm birth. Various pathological events in different feto-maternal systems have been reported to be involved in the development of preterm birth. Immunopathogenesis plays a pivotal role, and both pathogenic and nonpathogenic inflammation can induce preterm birth. Oxidative stress, decidual hemorrhage and vascular lesions, uterine overdistension, and cervical insufficiency have all been proposed to contribute to the pathophysiology of preterm birth. Prevention strategies for preterm birth include primary prevention aimed at the modifiable risk factors at the individual and societal levels and therapeutic approaches using pharmaceuticals and mechanical interventions, such as progesterone and cervical cerclage. A comprehensive approach is still needed to reduce the global disease burden of preterm birth.


Public Health Impact of Breastfeeding  

Colin Binns and Mi Kyung Lee

Breastfeeding is one of the best public health “buys” available for countries at all levels of development. In the first year of life, appropriate infant nutrition (exclusive breastfeeding to around 6 months) reduces infant mortality and hospital admissions by 50% or more. Early life nutrition has important influences, including on childhood illnesses, obesity, cognitive development, hospitalizations, and later chronic disease. Breastfeeding is consistent with the historical cultural practices of all societies, and its benefits of breastfeeding last a lifetime. While the development of infant formula has been of benefit to some infants, its inappropriate promotion has resulted in a decline of breastfeeding, and, as a result, health gains in many countries have not been as great as they could have been. The health benefits of breastfeeding will provide some protection against the effects of climate change, which will cause a decline in potable water supplies and increases in the incidence of some infections. Infant formula production has very high environmental costs, while breastfeeding as well as being the best infant feeding intervention also has very low environmental impact. An important part of the sustainable development agenda must be to promote breastfeeding and its benefits and to reverse the inappropriate promotion and use of infant formula.


Risky Sexual Behaviors: Trends Among Young People (10–24 Years) in Four East African Countries  

Fredrick E. Makumbi, Sarah Nabukeera, Justine N. Bukenya, and Simon Peter Sebina Kibira

The future of sub-Saharan Africa depends on the health of young people (10–24 years) who form about one-third of the region’s population. This large population of young people is a potential asset for social-economic development if appropriate investments and social empowerment can be provided. Despite the vast opportunities, young people are faced with enormous social, economic, and health challenges. Young people’s health increasingly remains important especially with the use and misuse of narcotics (drugs and alcohol) a key risk factor for risky sexual behaviors (RSBs). RSBs are defined as behaviors that increase one’s risk of contracting sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) and unintended pregnancies. RSBs include multiple sex partners, sex without a condom, alcohol use with sex, sex initiation before age 15, nonuse of modern contraceptives, and early marriage (before age 18 years). RSBs are reportedly influenced by a number of factors including lack of access to accurate, customized HIV information and prevention services, socioeconomic reasons, lack of parental control, peer pressure, and lack of youth-friendly recreational facilities. The consequences or impact of RSB, especially among the adolescents and young people, include poor health (STIs including HIV/AIDS, unintended pregnancies, unsafe abortions, maternal deaths, and mental health such as psychological distress), and negative social and economic challenges (nonenrollment and nonretention in school and early child marriage). Understanding the trends in RSBs can provide insights in how well available interventions and policies have minimized their consequences among adolescents, and lay a basis to further develop more innovative and effective strategies especially in low-income countries.


Sex and Conception Probability  

Justin C. Konje and Oladipo A. Ladipo

Central to the survival of any species is the ability to procreate. In most cases, procreation is sexual, involving a process that ensures appropriate and timed contact between the male and female gametes. Successful human reproduction is premised on sexual intercourse occurring at a time when there is a receptive endometrium as well as an ovum ready for fertilization by spermatozoa. This time window of the menstrual cycle known as the fertile or fecund window is poorly defined and highly variable from one individual to another. Furthermore, while spermatogenesis is a continuous process, the impact of too frequent intercourse (defined as that occurring more than every 2 to 3 days) on fertilization has often been thought to be associated with a decreased fertilization potential of spermatozoa. Current evidence challenges previously held views on the fertile window and how it is determined, the timing of intercourse and how it is related to conception and miscarriages, the length of the luteal phase, and the precise time period during which the chances of fertilization are highest in any given menstrual cycle. The ability of spermatozoa to survive in the female genital tract for 5 days means fertilization can occur up to 5 days from sexual intercourse. During each menstrual cycle, there is a window of 5 to 6 days for fertilization to occur, and this period is defined not by the length of the cycle but by the timing of ovulation, with the chances of fertilization highest with intercourse occurring 1 to 2 days before ovulation.


Sexual and Reproductive Health in China  

Qianling Zhou, Chu-Yao Jin, and Hai-Jun Wang

Databases of PubMed, Scopus, and China National Knowledge Infrastructure (CNKI) were used to search relevant articles on sexual and reproductive health (SRH) in China published from 2005 to the present (2021), based on the World Health Organization’s (WHO) Operational Framework on Sexual Health and Its Linkages to Reproductive Health. The following results were found. (a) SRH education and information among the Chinese were insufficient, in particular regarding contraception, pregnancy, and sexually transmitted diseases (STDs). Adolescents, migrants, and the rural population had insufficient knowledge of SRH. (b) Fertility care services were mainly available in large cities, in urban areas, and for married couples. Services targeted for rural-to-urban migrants, rural residents, and the disabled and elderly are needed. (c) A total of 22.4% of youths aged 15–24 had premarital sexual intercourse, and the age of first sexual intercourse was decreasing. Risky sexual behaviors included multiple partners, casual and commercial sex, and having sex after drinking alcohol. (d) The contraceptive practice rate of women aged 15–49 in China was higher than the world’s corresponding figure. However, contraceptive use among young people was low (only 32.3% among unmarried women). (e) Unmarried pregnancy induced by low contraceptive practice is a critical issue in China. (f) Induced abortion was the major consequence of unmarried pregnancy. The rate of induced abortion among the general population in 2016 was 28.13‰, and the rate among unmarried women was increasing annually. (g) There were 958,000 HIV-infected cases in China as of October 2019. Sexual transmission was the major transmission route of HIV-AIDS. More men than women were infected. Men having sex with men comprised the high-risk group of sexual transmission of HIV-AIDS. (h) Gender-based violence including intimate partner violence (IPV), sexual violence, sexual coercion, and child sexual abuse (CSA) might be underreported in China, since many victims were afraid to seek help as well as due to limited services. Legal and regulatory measures should therefore be taken to prevent and reduce gender-based violence. For future perspectives of SRH in China, it is important to pay attention to SRH education and services. An up-to-date national survey on SRH is needed to reflect the current situation and to capture changes over the past decade. Most of the current research has been conducted among adolescents, and more studies are needed among other groups, such as the disabled, the elderly, and homosexual populations.


Sexual and Reproductive Health in India  

Shireen Jejeebhoy, K. G. Santhya, and A. J. Francis Zavier

India has demonstrated its commitment to improving the sexual and reproductive health of its population. Its policy and program environment has shifted from a narrow focus on family planning to a broader orientation that stresses sexual and reproductive health and the exercise of rights. Significant strides have been made. The total fertility rate is 2.2 (2015–2016) and has reached replacement level in 18 of its 29 states. The age structure places the country in the advantageous position of being able to reap the demographic dividend. Maternal, neonatal, and perinatal mortality have declined, child marriage has declined steeply, contraceptive use and skilled attendance at delivery have increased, and HIV prevalence estimates suggest that the situation is not as dire as assumed earlier. Yet there is a long way to go. Notwithstanding impressive improvements, pregnancy-related outcomes, both in terms of maternal and neonatal mortality and morbidity, remain unacceptably high. Postpartum care eludes many women. Contraceptive practice patterns reflect a continued focus on female sterilization, limited use of male methods, limited use of non-terminal methods, and persisting unmet need. The overwhelming majority of abortions take place outside of legally sanctioned provider and facility structures. Over one-quarter of young women continues to marry in childhood. Comprehensive sexuality education reaches few adolescents, and in general, sexual and reproductive health promoting information needs are poorly met. Access to and quality of services, as well as the exercise of informed choice are far from optimal. Inequities are widespread, and certain geographies, as well as the poor, the rural, the young, and the socially excluded are notably disadvantaged. Moving forward and, in particular, achieving national goals and SDGs 3 and 5 require multi-pronged efforts to accelerate the pace of change in all of these dimensions of health and rights.


Social and Gender Norms Influencing Sexual and Reproductive Health: Conceptual Approaches, Intervention Strategies, and Evidence  

Shaon Lahiri, Elizabeth Costenbader, and Jeffrey B. Bingenheimer

Research in diverse fields has examined how social and gender norms, broadly defined as informal rules of acceptable behavior in a given group or society, may influence sexual and reproductive health outcomes. One set of conceptual and empirical approaches has focused on perceptions of how commonly others perform a behavior and the extent to which others support or approve of the behavior. Another set of approaches has focused on how social norms emerge from structures of gender and power that characterize the social institutions within which individuals are embedded. Interventions intended to improve sexual and reproductive health outcomes by shifting social and gender norms have been applied across a wide range of populations and settings and to a diverse set of behaviors, including female genital mutilation/cutting, the use of modern contraceptive methods, and behavioral risk reduction for HIV. Norms-based intervention strategies have been implemented at multiple socioecological levels and have taken a variety of forms, including leveraging the influence of prominent individuals, using community activities or mass media to shift attitudes, and introducing legislation or policies that facilitate the changing of social norms. Recent advances in social and gender norms scholarship include the integration of previously disparate conceptual and empirical approaches into a unified multilevel framework. Although challenges remain in measuring social and gender norms and studying their impacts on sexual and reproductive health-related behaviors across cultures, the research will continue to shape policies and programs that impact sexual and reproductive health globally.


Substance Use and Use Disorders in Pregnancy in Two Cultural Contexts: The United States and Afghanistan  

Elisabeth Johnson, Abdul Subor Momand, and Hendree E. Jones

Women in all countries use substances, and for some women, such use continues during pregnancy. When substance use impairs life functioning and becomes a use disorder, regardless of the type of substance, effective treatments are available (e.g., medication to treat opioid and alcohol use disorders and behavioral approaches to treat tobacco, stimulant, and other substances). In two very different cultural contexts, the United States and Afghanistan, pregnant women face common issues when using substances and seeking and/or receiving help for problem substance use. In both countries, and around the world, many women who have substance use disorders during and after pregnancy face tremendous stigma and discrimination. Yet, similarly, in both the United States and Afghanistan, when women receive integrated medical and behavioral health care for their substance use disorder, they and their children have more optimized opportunities for healthy life outcomes.


Surveys in Low- and Middle-Income Countries  

Madeleine Short Fabic, Yoonjoung Choi, and Fredrick Makumbi

Sexual and reproductive health (SRH) surveys around the world, especially in low- and middle-income countries, have been and continue to be the primary sources of data about individual-, community-, and population-level sexual and reproductive health. Beginning with the Knowledge, Attitudes, and Practices surveys of the late 1950s, SRH surveys have been crucial tools for informing public health programming, healthcare delivery, public policy, and more. Additionally, major demographic and health modeling and estimation efforts rely on SRH survey data, as have thousands of research studies. For more than half a century, surveys have met major SRH information needs, especially in low- and middle-income countries. And even as the world has achieved impressive information technology advances, increasing by orders of magnitude the depth and breadth of data collected and analyzed, the necessity and importance of surveys have not waned. As of 2021, four major internationally comparable SRH survey platforms are operating in low- and middle-income countries—the Demographic and Health Surveys Program (DHS), Multiple-Indicator Cluster Survey (MICS), Population-Based HIV Impact Assessment (PHIA), and Performance Monitoring for Action (PMA). Among these platforms, DHS collects the widest range of data on population, health, and nutrition, followed by MICS. PHIA collects the most HIV-related data. And PMA’s family planning data are collected with the most frequency. These population-based household surveys are rich data sources, collecting data to measure a wide range of SRH indicators—from contraceptive prevalence to HIV prevalence, from cervical cancer screening rates to skilled birth delivery rates, from age at menarche to age at first sex, and more. As with other surveys, SRH surveys are imperfect; selection bias, recall bias, social desirability bias, interviewer bias, and misclassification bias and error can represent major concerns. Furthermore, thorny issues persist across the decades, including perpetual historic, measurement, and methodological concerns. To provide a few examples with regard to history, because the major survey programs have historically been led by donors and multilateral organizations based in the Global North, survey content and implementation have been closely connected with donor priorities, which may not align with local priorities. Regarding measurement, maternal mortality data are highly valued and best collected through complete vital registration systems, but many low- and middle-income countries do not have complete systems and therefore rely on estimates collected through household surveys and censuses. And regarding methods, because most surveys offer only a snapshot in time, with the primary purpose of monitoring key indicators using a representative sample, most analyses of survey data can only show correlation and association rather than causation. Opportunities abound for ongoing innovation to address potential biases and persistent thorny issues. Finally, the SHR field has been and continues to be a global leader for survey development and implementation. If past is prelude, SRH surveys will be invaluable sources of knowledge for decades to come.


The Demography of Fertility  

Visseho Adjiwanou and Ben Malinga John

From the first billion people in the world in 1800 to the projected 9.7 billion people in 2050, the world’s population has passed through various stages. However, the different stages have not been the same for each global region or for every country within the same region. On one side of the spectrum is the fertility transition in Europe and North America, where the decline has been steady, with the median total fertility rate (TFR) declining from 2.80 children per woman in 1950–1955 to 1.66 in 2015–2020. In this region, childbearing is no longer the final goal of marriage, and this change has been accompanied by the emergence of new forms of union. The fertility rate is below the level of replacement in almost all the countries. On the other side of the spectrum is sub-Saharan Africa, where fertility has declined slowly and has stalled in various countries since the 2000s. The median TFR in the region declined from 6.51 children per woman in 1950–1955 to 4.72 in 2015–2020. In this region, this trend is associated with slower increase of the age at first marriage and in of the modern contraception. The fertility transition and its associated factors in the other regions of the world fluctuate between these two scenarios.