Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings.
Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.
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Community-Oriented Primary Health Care for Improving Maternal, Newborn, and Child Health
Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta
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Comprehensive Abortion Care
Nathalie Kapp, Mariana Romero, Shamala Dupte, Allison Shaber, and Daniel Grossman
Abortion is a common part of people’s reproductive lives, regardless of where they live in the world.
When using World Health Organization-recommended methods of either surgical or medical abortion, procedures are very safe and effective, and providers do not need a lot of information or testing to provide quality services. Both medical and surgical methods may be used to induce or to treat incomplete abortion. Although both methods are safe and effective, they have different characteristics and acceptability; therefore, clients should be given the choice of method in settings where it is possible.
Service delivery can include provision of surgical and medical abortion services by many cadres of providers, from nurses and midwives to physicians. Most people (generally around 90%) seek induced abortion before 12 weeks’ gestation, during which time medical abortion can be safely provided either through an in-person clinical encounter or through telemedicine, and there is emerging evidence of safe over-the-counter-like use.
Postabortion care includes the timely management of an unsafe or spontaneous abortion (spontaneous loss of pregnancy) that has happened or is in progress; it has been a global strategy to reduce the morbidity and mortality related to less safe abortions. For all people having an abortion, postabortion care includes information and voluntary provision of postabortion contraception or other desired reproductive health services.
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Contraceptive Technology
Timothee Fruhauf and Holly A. Rankin
Contraceptive technology refers to tools that are used to delay or prevent pregnancy. Modern contraceptive technology encompasses female or male sterilization, intrauterine devices, contraceptive implants, contraceptive pills, contraceptive patches, intravaginal rings, diaphragms, external or internal condoms, emergency contraception, and certain fertility awareness–based methods. Duration of these methods’ effects varies from permanent and irreversible to long-lasting and reversible to short term with day-to-day reversibility. The efficacy of modern contraceptive technologies at preventing pregnancy ranges between 76% and 99.95% during the first year of typical use. Mechanisms of action vary from physically impeding meeting of sperm and oocyte to use of exogenous reproductive hormones to alter fertility. Contraceptive counseling for the selection of a method should adopt a shared decision-making framework and can consider advantages, disadvantages, contraindications, and side effects of a method to align with a patient’s contraceptive use goals. Certain clinical contexts, such as post-abortion, postpartum, adolescent patients, and patients with elevated body mass index have contraceptive nuances that are important to consider. Finally, contraceptive technology has many non-contraceptive benefits that provide additional indications for their use.
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Demographic Transition in India: Insights Into Population Growth, Composition, and Its Major Drivers
Usha Ram and Faujdar Ram
Globally, countries have followed demographic transition theory and transitioned from high levels of fertility and mortality to lower levels. These changes have resulted in the improved health and well-being of people in the form of extended longevity and considerable improvements in survival at all ages, specifically among children and through lower fertility, which empowers women. India, the second most populous country after China, covers 2.4% of the global surface area and holds 18% of the world’s population. The United Nations 2019 medium variant population estimates revealed that India would surpass China in the year 2030 and would maintain the first rank after 2030. The population of India would peak at 1.65 billion in 2061 and would begin to decline thereafter and reach 1.44 billion in the year 2100. Thus, India’s experience will pose significant challenges for the global community, which has expressed its concern about India’s rising population size and persistent higher fertility and mortality levels. India is a country of wide socioeconomic and demographic diversity across its states. The four large states of Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan accounted for 37% of the country’s total population in 2011 and continue to exhibit above replacement fertility (that is, the total fertility rate, TFR, of greater than 2.1 children per woman) and higher mortality levels and thus have great potential for future population growth. For example, nationally, the life expectancy at birth in India is below 70 years (lagging by more than 3 years when compared to the world average), but the states of Uttar Pradesh and Rajasthan have an average life expectancy of around 65–66 years.
The spatial distribution of India’s population would have a more significant influence on its future political and economic scenario. The population growth rate in Kerala may turn negative around 2036, in Andhra Pradesh (including the newly created state of Telangana) around 2041, and in Karnataka and Tamil Nadu around 2046. Conversely, Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan would have 764 million people in 2061 (45% of the national total) by the time India’s population reaches around 1.65 billion. Nationally, the total fertility rate declined from about 6.5 in early 1960 to 2.3 children per woman in 2016, a result of the massive efforts to improve comprehensive maternal and child health programs and nationwide implementation of the national health mission with a greater focus on social determinants of health. However, childhood mortality rates continue to be unacceptably high in Uttar Pradesh, Bihar, Rajasthan, and Madhya Pradesh (for every 1,000 live births, 43 to 55 children die in these states before celebrating their 5th birthday). Intertwined programmatic interventions that focus on female education and child survival are essential to yield desired fertility and mortality in several states that have experienced higher levels. These changes would be crucial for India to stabilize its population before reaching 1.65 billion. India’s demographic journey through the path of the classical demographic transition suggests that India is very close to achieving replacement fertility.
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Engaging Men in Sexual and Reproductive Health
Tim Shand and Arik V. Marcell
Engaging men in sexual and reproductive health (SRH) across the life span is necessary for meeting men’s own SRH needs, including: prevention of STIs, HIV, unintended pregnancy, and reproductive system cancers; prevention and management of infertility and male sexual dysfunction; and promotion of men’s sexual health and broader well-being. Engaging men is also important given their relationship to others, particularly their partners and families, enabling men to: equitably support contraceptive use and family planning and to share responsibilities for healthy sexuality and reproduction; improve maternal, newborn, and child health; prevent mother-to-child transmission of HIV; and advocate for sexual and reproductive rights for all. Engaging men is also critical to achieving gender equality and challenging inequitable power dynamics and harmful gender norms that can undermine women’s SRH outcomes, rights, and autonomy and that can discourage help- and health-seeking behaviors among men.
Evidence shows that engaging men in SRH can effectively improve health and equality outcomes, particularly for women and children. Approaches to involving men are most effective when they take a gender transformative approach, work at the personal, social, structural, and cultural levels, address specific life stages, and reflect a broad approach to sexuality, masculinities, and gender. While there has been growth in the field of men’s engagement since 2010, it has primarily focused on men’s role as supportive to their partners’ SRH. There remains a gap in evidence and practice around better engaging men as SRH clients and service users in their own right, including providing high-quality and accessible male-friendly services. A greater focus is required within global and national policy, research, programs, and services to scale up, institutionalize, and standardize approaches to engaging men in SRH.
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Experimental and Intervention Studies of Couples and Family Planning in Low- and Middle-Income Countries: A Systematic Review
Stan Becker and Dana Sarnak
The vast majority of births in the world occur within marriages or stable partnerships. Yet family planning programs have largely ignored the male partner. One justification for this nearly exclusive focus on women has been that almost all of the modern contraceptive methods are female-oriented. In contrast, studies of fertility preferences within couples that included a later follow-up have shown that men’s fertility preferences are important for predicting subsequent births. Interspousal communication can be key to resolving differences in desired family size and for promoting open contraceptive use.
Experimental studies with couples on family planning education and/or counseling show higher contraceptive prevalence or continuation in the couples groups than in the women-only groups, though the differences are not always significant statistically. Other intervention studies have varying designs and mixed results. The purpose of this systematic review is to summarize the research findings on interventions with couples on reproductive health from experimental and pre–post observational studies. An important conclusion is that couples education and counseling are critical components for involving male partners. There is a need for systematic research on couples using a standardized intervention and fixed follow-up times and including analyses of cost-effectiveness.
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Gender-Based Violence
Phyu Phyu Oo
Gender-based violence (GBV) is a significant global public health and human rights problem, predominantly affecting women and girls worldwide across various age groups. While GBV manifests in various forms, intimate partner violence and domestic violence are the two most common forms that are widely studied and discussed in the research and policymaking processes due to the disturbingly high prevalence. The World Health Organization (WHO) estimated that 736 million women and girls globally are affected by IPV and non-partner sexual violence, even though the statistics vary across different regions . While the knowledge in understanding the prevalence and patterns of GBV has been improved over time, gathering reliable data on certain forms of GBV like femicide, rape, early marriage, sexual violence in situations of armed conflict, and trafficking in women and girls remains challenging . This data limitation stems primarily from socio-cultural norms that stigmatize the experiences of GBV survivors and a male-dominated culture that obstructs survivors from reporting and seeking help. The data gap is more notable for male survivors, despite studies showing that men and boys often fall victim to various forms of GBV, particularly in armed conflicts.
GBV in any form against any gender produces immediate, short-term, and lasting physical, mental, and social consequences for survivors, their families, and communities. A swift and comprehensive response to GBV can mitigate specific health risks, such as HIV/AIDS transmission and unintended pregnancies, significantly reducing the public health burden. However, survivors often face immense challenges in accessing appropriate care due to limited availability and accessibility. The barriers to seeking care are compounded by negative societal perceptions of GBV survivors and limited legal protection mechanisms. Unequal gender norms and discriminatory practices against women and girls in most societies are the fundamental cause of GBV while several intersecting factors like age, ethnicity, education, social beliefs, and cultural norms significantly influence the manifestation of GBV. Eliminating GBV is a complex process that requires a multidimensional approach at the individual, community, and societal levels. The most effective strategies involve transforming social norms, reforming laws, and empowering women through awareness-raising and state policies. However, resistance stemming from deeply embedded male-dominated cultures and a lack of political will among state actors often pose obstacles to effective prevention efforts. Research plays a crucial role and dedicating resources to fill knowledge gaps and evaluating ongoing practices will enhance the understanding of effective measures for preventing and responding to GBV.
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Global Epidemiology of Induced Abortion
Suzanne O. Bell, Mridula Shankar, and Caroline Moreau
Induced abortion is a common reproductive experience, with more than 73 million abortions occurring each year globally. Worldwide, the annual abortion incidence decreased in the 1990s and the early decades of the 21st century, but this decline has been driven by high-resource settings, whereas abortion rates in low- and middle-resource countries have remained stable. Induced abortion is a very safe procedure when performed according to World Health Organization guidelines; however, legal restrictions, stigma, cost, lack of resources, and poor health system accountability limit the availability, accessibility, and use of quality abortion care services. Even as women’s use of safer self-managed medication abortion options becomes more common in some parts of the world, 45% of all abortions annually are unsafe, nearly all of which occur in low- and middle-resource settings, where unsafe abortion remains a primary cause of maternal death. Beyond country-level legal and health care system factors, significant disparities exist in women’s reliance on unsafe abortion. Even among women who receive a safe abortion, quality of care is often poor. Yet abortion’s precarious status as a health care service and its clandestine practice have precluded a systematic focus on quality monitoring and evaluation of service inputs. Improving abortion and postabortion care quality is essential to meeting this reproductive health need, as are efforts to prevent abortion-related mortality and morbidity more broadly. This requires a three-tier approach: primary prevention to reduce unintended pregnancy, secondary prevention to make abortion procedures safer, and tertiary prevention to reduce the negative sequelae of unsafe abortion procedures. Strategies include two complementary approaches: vulnerability reduction and harm reduction, the first focusing on the root causes of unsafe abortion by addressing the determinants of unwanted pregnancy and clandestine abortion, while the latter addresses the harmful consequences of clandestine abortion. Political commitments to extend service coverage of abortion and postabortion care need to be implemented through actions that build the public health system’s capacity. Beyond the model of receiving care exclusively in clinical settings, models of guided self-managed abortion are expanding the capacity of individuals to take evidence-based actions to terminate their pregnancies safely and without the threat of judgment. Research has strived to keep up with the changes in the abortion care landscape, but there remains a continuing need to improve methodologies to generate robust evidence to identify and address inequities in abortion care and its health consequences in a diversified landscape. Doing so will provide information for stakeholders to take actions toward a new era of health care reforms that repositions abortion as an integral component of sexual and reproductive health care.
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HIV Ed: A Global Perspective
Ralph J. DiClemente and Nihari Patel
At the end of 2016, there were approximately 36.7 million people living with HIV worldwide with 1.6 million people being newly infected. In the same year, 1 million people died from HIV-related causes globally. The vast prevalence of HIV calls for an urgent need to develop and implement prevention programs aimed at reducing risk behaviors. Bronfenbrenner’s socio-ecological model provides an organizing framework to discuss HIV prevention interventions implemented at the individual, relational, community, and societal level. Historically, many interventions in the field of public health have targeted the individual level. Individual-level interventions promote behavior change by enhancing HIV knowledge, attitudes, and beliefs and by motivating the adoption of preventative behaviors. Relational-level interventions focus on behavior change by using peers, partners, or family members to encourage HIV-preventative practices. At the community-level, prevention interventions aim to reduce HIV vulnerability by changing HIV-risk behaviors within schools, workplaces, or neighborhoods. Lastly, societal interventions attempt to change policies and laws to enable HIV-preventative practices.
While previous interventions implemented in each of these domains have proven to be effective, a multipronged approach to HIV prevention is needed such that it tackles the complex interplay between the individual and their social and physical environment. Ideally, a multipronged intervention strategy would consist of interventions at different levels that complement each other to synergistically reinforce risk reduction while simultaneously creating an environment that promotes behavior change. Multilevel interventions provide a promising avenue for researchers and program developers to consider all levels of influences on an individual’s behavior and design a comprehensive HIV risk-reduction program.
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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.
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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.
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Social and Behavior Change Communication in Sexual and Reproductive Health
Suruchi Sood and Jose Rimon II
Social and behavior change communication (SBCC) is a core public health strategy not just for interventions designed to prevent, control, and treat disease but also for addressing the social determinants of health. Quality SBCC interventions are based on some common design, implementation, and evaluation best practices. The evidence base for using SBCC for sexual and reproductive health (SRH) includes, among other programs, family planning, maternal and neonatal health, and HIV/AIDS. Three global SBCC interventions—one on each of these topics—are presented as exemplars of best practices in public health communication programs designed to improve individual health behaviors and enable social change.
These SBCC programs employed cross-cutting approaches covering different levels of the social-ecological model while tackling multiple related health issues. While emphasizing individual roles and responsibilities, recognizing the importance of the cultural, social, and political context within which individuals live and work allowed these interventions to address social and gender norms. All three were theory-based and evidence-driven. They applied constructs from social and behavior change (SBC) theories to model causal pathways and stages or steps of behavior and community-level change. In addition, they relied on comprehensive, mixed-methods research throughout the project cycle. Other best practices included intersectoral collaboration and steps to ensure scale-up and sustainability.
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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.
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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.
