Lale Say

Background: The adoption of digital systems requires processes for quality assurance and uptake of standards to achieve universal health coverage. The World Health Organization developed the Digital Adaptation Kits (DAKs) within the SMART (Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable) guidelines framework to support the uptake of standards and recommendations through digital systems. DAKs are a software-neutral mechanism for translating narrative guidelines to support the design of digital systems. However, a systematic process is needed to implement and ensure the impact of DAKs in country contexts. Objective: This paper details the structured process and stepwise approach to customize the DAKs to the national program and digital context in 5 countries in Africa with diverse program guideline uptake and significant digital health investments: Ethiopia, Ghana, Malawi, Zambia, and Zimbabwe. All these countries have existing digital systems, which have the potential to be updated with the DAKs. Methods: A DAK assessment tool was developed and used to assess guideline digitization readiness and opportunities for system uptake in each country. Multistakeholder teams were established to conduct the content review and alignment of the generic DAK to national guidelines and protocols through a series of stakeholder consultations, including stakeholder orientation, content review and alignment, content validation, and software update meetings. Implementation (Results): Country adaptation processes identified requirements for national-level contextualization and highlighted opportunities for refinement of DAKs. Quality assurance of the content during the content review and validation processes ensured alignment with national protocols. Adaptation processes also facilitated the adoption of the DAKs approach into national guidelines and strategic documents for sexual and reproductive health. Conclusions: Country experiences offered early insights into the opportunities and benefits of a structured approach to digitalizing primary health care services. They also highlighted how this process can be continuously refined and sustained to enhance country-level impact.

Introduction: This study aimed to provide an overview of the research landscape and to identify research gaps linking climate change events and sexual and reproductive health and rights (SRHR) in low-income and middle-income countries (LMICs), where the negative impacts of climate change are most severe. Methods: We conducted a scoping review to map research studies that link climate change events or factors and SRHR aspects in LMICs. We performed a structured literature search across six databases to identify relevant peer-reviewed publications between January 1994 and 6 September 2023. The literature search yielded 14 674 peer-reviewed articles. After screening, 75 articles were included, spanning 99 countries across the globe. Results: Climate change events such as extreme temperatures, drought, rainfall shocks, cyclones and floods were found to be associated with negative maternal and newborn health outcomes ranging from reduced or low birth weight, preterm births and low Apgar scores, to lack of pregnancy care, pregnancy complications, stillbirths, and newborn and maternal deaths. Associations were also found between climate-related events and increased gender-based violence and HIV prevalence, as well as fertility decisions and harmful practices such as female genital mutilations and early and forced marriages. About two-thirds (48/75) of the articles were from the African or Western Pacific regions. The main research gaps on climate change-related events and SRHR included abortion, reproductive cancers and contraception use. Conclusion: Complementing existing evidence with targeted research to fill these knowledge gaps could enhance mitigation programmes and policies.

Background: Artificial intelligence (AI) has emerged as a transformative force across the health sector and has garnered significant attention within sexual and reproductive health and rights (SRHR) due to polarizing views on its opportunities to advance care and the heightened risks and implications it brings to people’s well-being and bodily autonomy. As the fields of AI and SRHR evolve, clarity is needed to bridge our understanding of how AI is being used within this historically politicized health area and raise visibility on the critical issues that can facilitate its responsible and meaningful use. Objective: This paper presents the protocol for a scoping review to synthesize empirical studies that focus on the intersection of AI and SRHR. The review aims to identify the characteristics of AI systems and tools applied within SRHR, regarding health domains, intended purpose, target users, AI data life cycle, and evidence on benefits and harms. Methods: The scoping review follows the standard methodology developed by Arksey and O’Malley. We will search the following electronic databases: MEDLINE (PubMed), Scopus, Web of Science, and CINAHL. Inclusion criteria comprise the use of AI systems and tools in sexual and reproductive health and clear methodology describing either quantitative or qualitative approaches, including program descriptions. Studies will be excluded if they focus entirely on digital interventions that do not explicitly use AI systems and tools, are about robotics or nonhuman subjects, or are commentaries. We will not exclude articles based on geographic location, language, or publication date. The study will present the uses of AI across sexual and reproductive health domains, the intended purpose of the AI system and tools, and maturity within the AI life cycle. Outcome measures will be reported on the effect, accuracy, acceptability, resource use, and feasibility of studies that have deployed and evaluated AI systems and tools. Ethical and legal considerations, as well as findings from qualitative studies, will be synthesized through a narrative thematic analysis. We will use the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) format for the publication of the findings. Results: The database searches resulted in 12,793 records when the searches were conducted in October 2023. Screening is underway, and the analysis is expected to be completed by July 2024. Conclusions: The findings will provide key insights on usage patterns and evidence on the use of AI in SRHR, as well as convey key ethical, safety, and legal considerations. The outcomes of this scoping review are contributing to a technical brief developed by the World Health Organization and will guide future research and practice in this highly charged area of work. Trial Registration: OSF Registries osf.io/ma4d9; https://osf.io/ma4d9 International Registered Report Identifier (IRRID): PRR1-10.2196/53888

Objective: To quantify the extent of incompleteness and misclassification of maternal and pregnancy related deaths, and to identify general and context-specific factors associated with incompleteness and/or misclassification of maternal death data. Methods: We conducted a systematic review of incompleteness and/or misclassification of maternal and pregnancy-related deaths. We conducted a narrative synthesis to identify methods used to capture and classify maternal deaths, as well as general and context specific factors affecting the completeness and misclassification of maternal death recording. We conducted a meta-analysis of proportions to obtain estimates of incompleteness and misclassification of maternal death recording, overall and disaggregated by income and surveillance system types. Findings: Of 2872 title-abstracts identified, 29 were eligible for inclusions in the qualitative synthesis, and 20 in the meta-analysis. Included studies relied principally on record linkage and review for identifying deaths, and on review of medical records and verbal autopsies to correctly classify cause of death. Deaths to women towards the extremes of the reproductive age range, those not classified by a medical examiner or a coroner, and those from minority ethnic groups in their setting were more likely misclassified or unrecorded. In the meta-analysis, we found maternal death recording to be incomplete by 34% (95% CI: 28–48), with 60% sensitivity (95% CI: 31–81.). Overall, we found maternal mortality was under-estimated by 39% (95% CI: 30–48) due to incompleteness and/or misclassification. Reporting of deaths away from the intrapartum, due to indirect causes or occurring at home were less complete than their counterparts. There was substantial between and within group variability across most results. Conclusion: Maternal deaths were under-estimated in almost all contexts, but the extent varied across settings. Countries should aim towards establishing Civil Registration and Vital Statistics systems where they are not instituted. Efforts to improve the completeness and accuracy of maternal cause of death recording, such as Confidential Enquiries into Maternal Deaths, are needed even where CRVS is considered to be well-functioning.

BACKGROUND Artificial intelligence (AI) has emerged as a transformative force across the health sector and has garnered significant attention within sexual and reproductive health and rights (SRHR) due to polarizing views on its opportunities to advance care and the heightened risks and implications it brings to people’s well-being and bodily autonomy. As the fields of AI and SRHR evolve, clarity is needed to bridge our understanding of how AI is being used within this historically politicized health area and raise visibility on the critical issues that can facilitate its responsible and meaningful use. OBJECTIVE This paper presents the protocol for a scoping review to synthesize empirical studies that focus on the intersection of AI and SRHR. The review aims to identify the characteristics of AI systems and tools applied within SRHR, regarding health domains, intended purpose, target users, AI data life cycle, and evidence on benefits and harms. METHODS The scoping review follows the standard methodology developed by Arksey and O’Malley. We will search the following electronic databases: MEDLINE (PubMed), Scopus, Web of Science, and CINAHL. Inclusion criteria comprise the use of AI systems and tools in sexual and reproductive health and clear methodology describing either quantitative or qualitative approaches, including program descriptions. Studies will be excluded if they focus entirely on digital interventions that do not explicitly use AI systems and tools, are about robotics or nonhuman subjects, or are commentaries. We will not exclude articles based on geographic location, language, or publication date. The study will present the uses of AI across sexual and reproductive health domains, the intended purpose of the AI system and tools, and maturity within the AI life cycle. Outcome measures will be reported on the effect, accuracy, acceptability, resource use, and feasibility of studies that have deployed and evaluated AI systems and tools. Ethical and legal considerations, as well as findings from qualitative studies, will be synthesized through a narrative thematic analysis. We will use the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) format for the publication of the findings. RESULTS The database searches resulted in 12,793 records when the searches were conducted in October 2023. Screening is underway, and the analysis is expected to be completed by July 2024. CONCLUSIONS The findings will provide key insights on usage patterns and evidence on the use of AI in SRHR, as well as convey key ethical, safety, and legal considerations. The outcomes of this scoping review are contributing to a technical brief developed by the World Health Organization and will guide future research and practice in this highly charged area of work. CLINICALTRIAL OSF Registries osf.io/ma4d9; https://osf.io/ma4d9 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/53888

Introduction In 2019, over 70 million people were forcibly displaced worldwide. Women and girls comprise nearly half of this population and are at heightened risk of negative sexual and reproductive health outcomes. With the collapse of health systems, reduced resources and increased vulnerabilities from displacement, there is a need to strengthen current practices and ensure the delivery of comprehensive sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) services. Recognising the need for consistency in data collection, analysis and use, the WHO developed a list of core SRMNCAH monitoring and evaluation indicators for services and outcomes in humanitarian settings. This research will explore the feasibility of collecting this core set of SRMNCAH indicators in displacement contexts. Methods and analysis We will undertake a multimethods qualitative study in seven humanitarian settings: Afghanistan, Albania, Bangladesh, Cameroon, the Democratic Republic of the Congo, Iraq and Jordan. We selected sites that reflect diversity in geographic region, sociocultural characteristics, primary location(s) of displaced persons and nature and phase of the crisis. Our study consists of four components: key informant interviews, facility assessments, observational sessions at select facilities and focus group discussions with front-line healthcare personnel. We will analyse our data using descriptive statistics and for content and themes. We will begin by analysing data from each setting separately and will then combine these data to explore concordant and discordant results, triangulate findings and develop global recommendations. Ethics and dissemination The University of Ottawa’s Research Ethics Board and the Research Project Review Panel (RP 2) of the World Health Organization-Department of Sexual and Reproductive Health as well as local IRBs of PIs’ research institutions reviewed and approved this protocol. We intend to disseminate findings through workshops at the WHO country, regional and headquarter levels, as well as through local, national and international conferences, workshops, peer-reviewed publications, and reports.

The COVID-19 pandemic is having significant direct and associated effects on many health outcomes, including maternal mortality. As a useful marker of healthcare system functionality, trends in mat...

Background: An estimated 70.8 million people are forcibly displaced worldwide, 75% of whom are women and children. Prioritizing a global research agenda to inform guidance, service delivery, access to and quality of services is essential to improve the survival and health of women, children and adolescents in humanitarian settings.Method: A mixed-methods design was adapted from the Child Health and Nutrition Research Initiative (CHNRI) methodology to solicit priority research questions across the sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) domains in humanitarian settings. The first step (CHNRI) involved data collection and scoring of perceived priority questions, using a web-based survey over two rounds (first, to generate the questions and secondly, to score them). Over 1000 stakeholders from across the globe were approached; 177 took part in the first survey and 69 took part in the second. These research questions were prioritized by generating a research prioritization score (RPP) across four dimensions: answerability, program feasibility, public health relevance and equity. A Delphi process of 29 experts followed, where the 50 scored and prioritized CHRNI research questions were shortlisted. The top five questions from the CHNRI scored list for each SRMNCAH domain were voted on, rendering a final list per domain.Results: A total of 280 questions were generated. Generated questions covered sexual and reproductive health (SRH) (n = 90, 32.1%), maternal health (n = 75, 26.8%), newborn health (n = 42, 15.0%), child health (n = 43, 15.4%), and non-SRH aspects of adolescent health (n = 31, 11.1%). A shortlist of the top ten prioritized questions for each domain were generated on the basis of the computed RPPs. During the Delphi process, the prioritized questions, based on the CHNRI process, were further refined. Five questions from the shortlist of each of the SRMNCAH domain were formulated, resulting in 25 priority questions across SRMNCAH. For example, one of the prioritized SRH shortlisted and prioritized research question included: “What are effective strategies to implement good quality comprehensive contraceptive services (long-acting, short-acting and EC) for women and girls in humanitarian settings?”Conclusion: Data needs, effective intervention strategies and approaches, as well as greater efficiency and quality during delivery of care in humanitarian settings were prioritized. The findings from this research provide guidance for researchers, program implementers, as well as donor agencies on SRMNCAH research priorities in humanitarian settings. A global research agenda could save the lives of those who are at greatest risk and vulnerability as well as increase opportunities for translation and innovation for SRMNCAH in humanitarian settings.

Background: Monitoring Sustainable Development Goal indicators (SDGs) and their targets plays an important role in understanding and advocating for improved health outcomes for all countries. We present the United Nations (UN) Inter-agency groups’ efforts to support countries to report on SDG health indicators, project progress towards 2030 targets and build country accountability for action. Objective: We highlight common principles and practices of each Inter-agency group and the progress made towards SDG 3 targets using seven health indicators as examples. The indicators used provide examples of best practice for modelling estimates and projections using standard methods, transparent data collection and country consultations. Methods: Practices common to the UN agencies include multi-UN agency participation, expert groups to advise on estimation methods, transparent publication of methods and data inputs, use of UN-derived population estimates, country consultations, and a common reporting platform to present results. Our seven examples illustrate how estimates, using mostly Bayesian models, make use of country data to track progress towards SDG targets for 2030. Results: Progress has been made over the past decade. However, none of the seven indicators are on track to achieve their respective SDG targets by 2030. Accelerated efforts are needed, especially in low- and middle-income countries, to reduce the burden of maternal, child, communicable and noncommunicable disease mortality, and to provide access to modern methods of family planning to all women. Conclusion: Our analysis shows the benefit of UN interagency monitoring which prioritizes transparent country data sources, UN population estimates and life tables, and rigorous but replicable modelling methods. Countries are supported to build capacity for data collection, analysis and reporting. Through these monitoring efforts we support countries to tackle even the most intransient health issues, including the pandemic caused by SARS-CoV-2 that is reversing the hard-earned gains of all countries.

Population health surveys are rarely comprehensive in addressing sexual health, and population-representative surveys often lack standardized measures for collecting comparable data across countries. We present a sexual health survey instrument and implementation considerations for population-level sexual health research. The brief, comprehensive sexual health survey and consensus statement was developed via a multi-step process (an open call, a hackathon, and a modified Delphi process). The survey items, domains, entire instruments, and implementation considerations to develop a sexual health survey were solicited via a global crowdsourcing open call. The open call received 175 contributions from 49 countries. Following review of submissions from the open call, 18 finalists and eight facilitators with expertise in sexual health research, especially in low and middle-income countries (LMICs), were invited to a 3-day hackathon to harmonize a survey instrument. Consensus was achieved through an iterative, modified Delphi process that included three rounds of online surveys. The entire process resulted in a 19-item consensus statement and a 10-minute sexual health survey instrument. This is the first global consensus on a sexual and reproductive health survey instrument that can be used to generate cross-national comparative data in both high-income and LMICs. The inclusive process identified priority domains for improvement and can inform the design of sexual and reproductive health programs and contextually relevant data for comparable research across countries. Key points: – National population-representative surveys assessing sexual practices, behaviours and health-related outcomes focus on high-income countries and different sexual health measures are often used. – There is a lack of population-level representative sexual health research in low- and middle-income countries. – Existing comparable data on sexual practices and behaviours across countries are limited due to the absence of a standardized global sexual health survey instrument. – We report the global consensus on a set of core sexual health items within a 10-minute survey instrument that accommodates the needs and priorities of people from LMICs and various legal and cultural contexts across countries. – The consensus process breaks new ground in terms of incorporating feedback from diverse individuals using a crowdsourcing open call and hackathon process.