Rights based approaches to sexual and reproductive health in low and middle-income countries: A systematic review

Persistent inequities in maternal mortality in Latin America and the Caribbean, 1990-2019

BACKGROUND

Despite the resources and personnel mobilized in Latin America and the Caribbean to reduce the maternal mortality ratio (MMR, maternal deaths per 100 000 live births) in women aged 10-54 years by 75% between 2000 and 2015, the region failed to meet the Millenium Development Goals (MDGs) due to persistent barriers to access quality reproductive, maternal, and neonatal health services.

METHODS

Using 1990-2019 data from the Global Burden of Disease project, we carried out a two-stepwise analysis to (a) identify the differences in the MMR temporal patterns and (b) assess its relationship with selected indicators: government health expenditure (GHE), the GHE as percentage of gross domestic product (GDP), the availability of human resources for health (HRH), the coverage of effective interventions to reduce maternal mortality, and the level of economic development of each country.

FINDINGS

In the descriptive analysis, we observed a heterogeneous overall reduction of MMR in the region between 1990 and 2019 and heterogeneous overall increases in the GHE, GHE/GDP, and HRH availability. The correlation analysis showed a close, negative, and dependent association of the economic development level between the MMR and GHE per capita, the percentage of GHE to GDP, the availability of HRH, and the coverage of SBA. We observed the lowest MMRs when GHE as a percentage of GDP was close to 3% or about US$400 GHE per capita, HRH availability of 6 doctors, nurses, and midwives per 1,000 inhabitants, and skilled birth attendance levels above 90%.

CONCLUSIONS

Within the framework of the Sustainable Development Goals (SDGs) agenda, health policies aimed at the effective reduction of maternal mortality should consider allocating more resources as a necessary but not sufficient condition to achieve the goals and should prioritize the implementation of new forms of care with a gender and rights approach, as well as strengthening actions focused on vulnerable groups.

Human rights and HIV: rhetoric or determinants?

International donors and UN agencies emphasise the importance of human rights as a key determinant of HIV vulnerability and of access, uptake and retention in HIV prevention and treatment services. Yet, the extent to which HIV researchers are incorporating rights into their research, the specific rights being examined and the frequency of research assessing rights-based approaches, is unknown.

METHODS

We examined all articles published in the five highest impact-factor HIV journals: (1) Lancet HIV; (2) AIDS and Behavior; (3) AIDS; (4) Journal of the International AIDS Society (JIAS); and (5) Journal of Acquired Immune Deficiency Syndromes (JAIDS), between 1 January 2017 and 31 December 2022, for reference to 'human right(s)' or 'right(s)'. We analysed articles to assess: (1) what populations were identified in relation to specific human rights concerns; (2) what specific rights were mentioned; (3) whether researchers cited specific legal frameworks; and (4) if and what types of rights-based interventions were examined.

RESULTS

Overall, 2.8% (n=224) of the 8080 articles reviewed included a mention of 'human right(s)' or 'right(s)'. Forty-two per cent of these (n=94) were original research articles. The most common key population discussed was men who have sex with men (33 articles), followed by sex workers (21 articles) and transgender people (14 articles). Of the 94 articles, 11 mentioned the right to health and nine referenced reproductive rights. Few articles identified a specific authority-whether in national, regional or international law-for the basis of the rights cited. Fourteen articles discussed rights-based interventions.

CONCLUSION

Despite global recognition of the importance of human rights to HIV outcomes, few HIV researchers publishing in the top five cited HIV journals include attention to human rights, or rights-based interventions, in their research. When rights are mentioned, it is often without specificity or recognition of the legal basis for human rights.

Knowledge of Sexual and Reproductive Health Rights Among University Students: A Cross-Sectional Study in Southeast Ethiopia

Background

In many situations, it can still be challenging to talk about sexual and reproductive health rights, and the little scientific research available indicates that university students have a poor understanding of these issues. Therefore, the aim of this study was to assess the knowledge of sexual and reproductive health rights among university students in southeast Ethiopia.

Methodology

From February to March 2022, 483 study participants took part in an institutionally based cross-sectional study. The study participants were chosen using a SRS method. EpiData version 4.6.2.0 was used to enter data, and SPSS version 26.0 was used to analyze it. A bivariate and multivariable binary logistic regression model was used to identify factors associated with SRHR knowledge. The odds ratio and a 95% confidence interval were used to calculate the significance level.

Results

The optimal level of knowledge on SRHR was discovered to be 52.1% [95% CI (47.32-55.08)] among university students in southeast Ethiopia. The multivariate binary logistic analysis indicated that being urban in the origin of residency [AOR=1.52, 95% CI (1.02-1.14)], being a health student [AOR= 12.21, 95% CI (7.27-14.88)], attending secondary school in private [AOR=6.12, 95% CI (1.02-1.14)], accessibility of a RH club on campus [AOR=6.12, 95% CI (1.02-1.14)] and participating in RH club [AOR=3.95, 95% CI (3.47-5.90)] to be variables that are strongly related to the optimal level of knowledge.

Conclusion and Recommendation

Four out of ten students had poor knowledge of SRHR. The variables associated with a high level of knowledge about SRHR were urban residency, health students, attending a private secondary school, the availability of a RH club on campus, and participation in a RH club. Including sexual education in the non-health department's course, establishing RH clubs on campus, and encouraging participation of students in these clubs are recommended.

A realist review of interventions targeting maternal health in low- and middle-income countries

Maternal mortality is disproportionately higher in low- and middle-income countries compared to other parts of the world. International research efforts are reflective of the urgency to improve global maternal outcomes. The existing literature of maternal health interventions in low- and middle-income countries targets a variety of populations and intervention types. However, there is a notable lack of systemic reviews that examine the wider contextual and mechanistic factors that have contributed to the outcomes produced by interventions. This article aims to use realist synthesis design to identify and examine the relationships between the contexts, mechanisms and outcomes of maternal health interventions conducted in low- and middle-income countries. This will inform evidence-based practice for future maternal health interventions. In May 2022, we searched four electronic databases for systematic reviews of maternal health interventions in low- and middle-income countries published in the last 5 years. We used open and axial coding of contexts, mechanisms and outcomes to develop an explanatory framework for intervention effectiveness. After eligibility screening and full-text analysis, 44 papers were included. The majority of effective interventions reported good healthcare system contexts, especially the importance of infrastructural capacity to implement and sustain the intervention. Most intervention designs used increasing knowledge and awareness at an individual and healthcare-provider level to produce intended outcomes. The majority of outcomes reported related to uptake of healthcare services by women. All mechanism themes had a relationship with this outcome. Health system infrastructure must be considered in interventions to ensure effective implementation and sustainability. Healthcare-seeking behaviours are embedded within social and cultural norms, environmental conditions, family influences and provider attitudes. Therefore, effective engagement with communities and families is important to create new norms surrounding pregnancy and delivery. Future research should explore community mobilization and involvement to enable tailored interventions with optimal contextual fit.

Structural Interventions to Enable Adolescent Contraceptive Use in LMICs: A Mid-Range Theory to Support Intervention Development and Evaluation

Enabling contraceptive use is critical for addressing high adolescent pregnancy rates in low- and middle-income countries (LMICs). Broader or 'upstream' determinants, such as poverty, education, and social norms, can affect the knowledge, attitudes, motivation, and ability to access and use contraception. Structural interventions aim to address these broader determinants, e.g., through poverty alleviation from livelihood training or cash transfers, increasing school participation, or changing social norms. We conducted an evidence synthesis using intervention component analysis, a case-based approach, following a systematic mapping of the evidence base. We identified 17 studies with 29 structural intervention arms, which reported adolescent contraceptive use outcomes compared to a control group or baseline. It was not possible to identify with certainty which interventions were 'likely effective' or 'likely ineffective' due to the high heterogeneity of the methods. We built on an existing framework of family planning use to propose three steps to designing interventions: (1) tailor interventions to adolescents' life stages; (2) assess the baseline situation; and (3) select appropriate activities to match the gaps. These steps will aid developers and evaluators of structural adolescent contraceptive interventions to develop an evidence base that is of use across a wide range of settings and use scenarios.

Realising sexual and reproductive health and rights of adolescent girls and young women living in slums in Uganda: a qualitative study

Background

Sexual and reproductive health and rights are critical entitlements best supported through human rights-based approaches empowering rights-holders to claim their rights and duty bearers to fulfil their obligations. Implementing these requires information on the current needs and challenges faced by those seeking to claim their sexual and reproductive health and rights. We aimed to identify the underlying factors influencing the realisation of sexual and reproductive health and rights for adolescent girls and young women living Ugandan slums by: (1) exploring the role of relevant service providers and stakeholders; and (2) uncovering knowledge and gaps in protecting adolescent girls’ and young women’s sexual and reproductive health and rights.

Methods

Qualitative data were collected through focus groups and interviews focused on current knowledge, behaviours and attitudes towards sexual and reproductive health and rights among adolescent girls and young women, service providers and stakeholders. Data were analysed thematically using NVivo software. Ten in-depth interviews were conducted with key informants; two focus groups were held with adolescent girls and young women living in two slums in Uganda (21 participants in total); and three focus groups were held with community leaders, service providers, teachers and parents (30 participants in total).

Results

Adolescent girls and young women lacked information regarding their sexual health, services available, and redress mechanisms for rights violations. Formal sources of information were frequently inaccessible. Family members were sometimes the source of rights violations, and informal methods of redressing rights were often sought. Stigma and fear were common features both in healthcare and in the pursuit of formal justice, with duty-bearers habitually breaking confidentiality. Education and training were the predominant suggestions offered for change.

Conclusions

Adolescent girls and young women continue to face obstacles in achieving their full sexual and reproductive health and rights. Targeted interventions for the realisation of adolescent girls’ and young women’s sexual and reproductive health and rights can address underlying causes and positively shift attitudes to promote health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01174-z.

Every woman is entitled to good sexual and reproductive health. This involves being free from sexually transmitted infections, gender-based violence and maternal mortality, and able to access essential health services. In low and middle-income countries, adolescents comprise a fifth of the population, yet their sexual and reproductive health needs are often overlooked. Adolescent girls and young women are more likely to experience gender-based violence, sexually transmitted infections and poor access to sexual and reproductive health services. Those living in slums have even worse outcomes, but little evidence exists regarding the opportunities and barriers to improving sexual and reproductive health among adolescent girls and young women in a slum setting.

In this study, we conducted focus groups and interviews with 21 adolescent girls and young women living in two Ugandan slums, 10 individuals with an essential role, for example, at state level, as well as 30 other stakeholders including healthcare workers, teachers, parents, district leaders and community support officers working with adolescent girls and young women.

Results indicate that adolescent girls and young women lack information regarding their sexual health, what services are available and who and where to go if they experience violations such as sexual assault. In instances of sexual assault, fear and stigma prevented adolescent girls and young women from going to the police, and instead disputes were handled informally between families.

Participants in our focus groups and interviews felt that education and training were needed, and that health services need to improve. Interventions are necessary to improve adolescent girls’ and young women’s sexual and reproductive health in this setting.