Joe Strong

The displaced Rohingya population residing in Cox's Bazar, Bangladesh, must navigate their reproductive lives in this fragile context. This study examines the knowledge, attitudes and use of menstrual regulation/pregnancy termination services in four displaced persons' camps to understand women's engagement with these services and barriers to safe services using Bandura's social cognitive theory. We conducted a household, community-based survey with women of reproductive age in 2022 (n = 1173). Ninety-two percent of respondents knew that health facilities provide pregnancy terminations, yet knowledge about when access is permissible is incomplete. Only one-third knew that this service could be provided 11-12 weeks after last menstrual period, with most respondents believing that the cutoff was earlier. The respondents believed that menstrual regulation was provided only under certain conditions, and 99% stated that a husband's consent should be required for a woman to end a pregnancy (always or sometimes). One in five respondents (n = 223) knew someone who had ended a pregnancy since arriving in the camps. While knowledge about and support for pregnancy termination services are high, there is room for improvement in education about the conditions under which it can be accessed. The results fill a knowledge gap regarding the acceptability and use of pregnancy termination in the Bangladesh camps of displaced Rohingya.

Reproduction is tied to gendered social, economic, and political systems. Interrogating these connections is crucial for health policies and programmes that seek transformative change. Public health’s focus on biomedical vulnerabilities – how the body is susceptible to harm – is unable to capture the full and complex factors that contribute to reproductive inequities and injustices. Operationalising an understanding of vulnerability as a social process, this article examines how men conceptualise their own reproductive vulnerabilities and the implications this may have. This article draws on qualitative interviews with men, from a multi-method project on masculinities and sexual and reproductive health and rights in Accra, Ghana. Analysing men’s expressions of queerphobia through the lens of vulnerability, this article highlights the significant link between masculinities and reproduction. Masculinities are embedded in precarious, gendered economic systems and social and cultural institutions. Men’s experiences of the vulnerability of their masculinities in this context manifest as queerphobia and a (re)entrenchment of gendered norms around reproduction, which can perpetuate and exacerbate inequities and injustices. This article argues that using a more critical understanding of vulnerabilities makes visible the gendered systems and precarity that create key obstacles to reproductive health, rights, and justice.

Whether, how, and when a person comes to recognise they may be pregnant can have significant implications for their health and wellbeing. Little theoretical or empirical work has interrogated the time-bound, varied processes that lead to pregnancy recognition. We develop a novel conceptual framework, using an inductive saturation approach to review literature published between 2000 and 2023 and workshops with multi-disciplinary researchers and experts. Our framework comprises three overlapping domains: assessing the possibility of becoming pregnant; interpreting signs and symptoms of a (potential) pregnancy; and opportunities for pregnancy confirmation. The framework includes an individual’s trajectory to recognising a pregnancy, recognising there is no pregnancy following suspicion there may be, and not recognising a pregnancy that could be recognised through other means (e.g. using biomedical testing). It is inclusive of diverse conceptualisations of what constitutes a pregnancy. Within these intersecting domains, we map factors influencing trajectories operating at micro, meso, and macro levels, identifying the connections between individuals, communities, policies, health systems and institutional structures. While pregnancy duration is linear, time manifests in different ways across an individual’s trajectory. Individuals might experience one or all the domains of pregnancy recognition, different factors within those domains, and may encounter them in differing order. Individuals may move between states of recognition and non-recognition, and experience liminal states in between them. A better understanding of pregnancy recognition provides policy and care practitioners with new insights into care-seeking related to pregnancy.

The experiences and timings of pregnancy recognition trajectories have significant impacts on pregnancy-related care. Understanding individuals' contextually informed trajectories is crucial to their reproductive rights and service delivery needs. While many studies take pregnancy recognition as a starting point, capturing the complexities and nuances of these trajectories has received much less attention. This paper critically reflects on new approaches to capturing pregnancy recognition trajectories in two studies conducted between 2018-19, one in Nigeria with women aged 18 and over (n=394), and a three-country study with adolescents aged 10-19 in Ethiopia, Malawi, and Zambia (n=313). Pregnancy recognition trajectories were complex and involved multiple physical, material, and psychological recognition factors. Adolescents in the three-country study cited predominantly between two and four factors that led to their pregnancy recognition, with a range of one to seven factors. In the Nigeria study, 43.4% of respondents named two factors that led them to recognise they were pregnant, with a range of one to five factors. As pregnancy recognition is the starting point for many public health actions and interventions, it is imperative that future survey tools better capture this complex and poorly understood process. Our analyses suggest that questions should include response categories that capture physical, material, and psychological contributors to pregnancy recognition including open-ended responses to capture heretofore unidentified aspects of this process. Questions on the duration of time between recognition factors would be beneficial, as well as an understanding of what factors were most important to an individual when recognising a pregnancy.

Emergency contraceptive pills (ECP) are an essential and unique postcoital method of preventing pregnancy. Trends in supply data show that sales of ECP are increasing at faster rates globally than many other contraceptives. Yet nationally representative survey data suggest that ECP use has remained relatively static overtime, suggesting significant measure and reporting issues. Accurate measurement of ECP use is critical for informing policies and programs that provide people the choice and freedom to exercise their reproductive rights. There is an urgent need for a revision of ECP measurement to better capture the realities of people's contraceptive needs and desires. In this commentary, we outline the key reasons why surveys may be underreporting and misreporting ECP. We focus on issues around current method‐specific measurements, definition issues around “use” and problems with survey questions and prompt phraseology. We illustrate the importance of recognizing other postcoital methods and strategies that people use when trying to prevent a pregnancy, and the implications this has for ECP measurement. As ECP use evolves, we offer recommendations for survey revisions and further research that can ensure that ECP measurement is robust and able to provide accurate reporting in the future.

The standard measure of unmet need for contraception is not person‐centered and may not adequately represent women's contraceptive needs. To demonstrate the strength of a modified measure, we replicated the standard algorithm for unmet need, then created a person‐centered algorithm that considers (1) whether nonusers want to use contraception and (2) whether users want to use a different method. We applied the standard and person‐centered algorithms to a sample of 847 married Rohingya women aged 15–49 years living in camps in Cox's Bazar, Bangladesh, a population about whom little is known regarding contraceptive need. Forty‐six percent of respondents were currently using contraception. Among users, 14 percent wanted to use a different method and 36 percent of nonusers wanted to use a method. Using the standard algorithm, 39 percent had “unmet need,” 18 percent had “no need,” and 44 percent had “met need.” Using the person‐centered measure, 24 percent had “unmet need,” 38 percent had “no need,” and 38 percent had “met need.” The standard algorithm may overestimate unmet need among Rohingya nonusers, and the person‐centered measure provides evidence of method dissatisfaction among users. This measure also complements existing person‐centered measures of need and is an example of how incremental change can improve our understanding of women's contraceptive needs.

Since the International Conference on Population and Development in 1994, global policies, and agenda‐setting milestones have emphasized that universal sexual and reproductive health and rights (SRHR) are unattainable without the meaningful engagement and inclusion of men. Despite this, the field of SRHR continues to struggle with how and in what ways men can and should be included in research, programs, and policies. In this commentary, we argue that the programmatic focus of SRHR limits the capacity to produce the data and evidence needed to inform gender transformational change. For men to be meaningfully engaged with by SRHR, researchers need an analytic lens that can capture the manifestations and outcomes of gender and power. We consider the conceptual complementarities between two theoretical frameworks: hegemonic masculinities and Reproductive Justice. We contend that bringing together these conceptual approaches to men and SRHR offers an analytic framework to iterate and innovate approaches to research. Such changes will allow for a greater interrogation of gender and power and the production of data and evidence necessary to grapple with the ongoing injustices that curtail people's sexual and reproductive freedoms.

Lack of access to safe abortions continues to be a major sexual and reproductive health concern. Adolescents can face barriers to safe abortions due to the unique implications of their age. Understanding adolescent abortion experiences and care trajectories is critical. Qualitative and quantitative evidence is analysed from interviews with 313 adolescents aged 10–19 years who sought abortion-related care in public health facilities in Addis Ababa (Ethiopia), Lilongwe (Malawi), and Lusaka (Zambia) between April 2018 and September 2019. The trajectories framework is used to understand how adolescent abortion-related care-seeking differs across a range of socio-legal national contexts. A comparative study design incorporates varying levels of restriction on access to abortion: Ethiopia (legal on broad social or economic grounds, services implemented); Zambia (legal on broad social or economic grounds, complex services with barriers to implementation and information provision); and Malawi (legally highly restricted). Most adolescents (n = 97, 98%) in Ethiopia obtained a medically safe abortion, and most adolescents (n = 70, 64%) in Zambia and almost all adolescents (n = 94, 94%) in Malawi obtained a less medically safe abortion. There is a significant association between country and whether an adolescent tried to end a pregnancy before coming to the facility, X²(2, N = 313) = 135.93, p < 0.001. In Malawi 97% (n = 101) of adolescents had sought to end the pregnancy before coming to the facility, compared to 18% (n = 18) in Ethiopia. Cross-country variations in the relative safety of the abortion and type of care sought by adolescents reflect national laws, policies and service availability. The most facility-based abortions were recorded where care is most accessible (Ethiopia), and most non-facility-based and least safe abortions were recorded where care is the most restricted (Malawi). Across all countries, adolescents experienced delays to their care-seeking; 39% (n = 39), 71% (n = 74), and 66% (n = 73) in Ethiopia, Malawi, and Zambia respectively. Adolescents reported high levels of respectful treatment across countries, with a minority reporting negative experiences. A minority of adolescents in each country reported that unofficial money was paid to facility staff. There were different experiences of post-abortion contraception in the three countries, including an absence of choice. Adolescents’ trajectories – particularly those involving multiple attempts and barriers to achieving abortion care – require tenacity and determination. Our analyses show that less restrictive abortion policies and accessible abortion services improve adolescent chances to access abortion care.

In 2023, the World Health Organization, the United Nations Population Fund, and the United Nations Children’s Fund launched a call to action for key partners in health to work together to raise awareness and commit to addressing the risks of climate hazards on maternal, newborn, and child health (MNCH) [1] (Box 1). Box 1. We […]

Evidence regarding the impact of the private health sector on healthcare outcomes is often fragmented. Knowledge gaps remain around the impact of private sector care on health outcomes. This systematic review examines the quality of maternal, newborn, and child health (MNCH) care delivery by private sector providers. The review aims to systematically assess the evidence from studies reporting outcome data on morbidity and mortality among mothers, newborns, and children. Searches were conducted in eight electronic databases (Cumulative Index to Nursing and Allied Health, EconLit, Excerpta Medica Database, International Bibliography of the Social Science, Popline, PubMed, ScienceDirect, and Web of Science) and two websites and supplemented with hand-searches and expert recommendations. We conducted the searches and application of inclusion/exclusion criteria using the PRISMA method. For inclusion, studies in low- and middle-income countries must have examined at least one of the following primary outcomes: maternal morbidity, maternal mortality, newborn morbidity, newborn mortality, child morbidity, or child mortality. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 46 studies included, most studies were conducted in India, Bangladesh, Uganda, and Kenya. Thirty-six studies were quantitative, and over one-third implemented a specific intervention that went beyond the broad delivery of quality care in the private sector. Studies indicated that the outcomes of private sector delivery of MNCH care across health systems were mixed. Studies frequently reported on the utilization of health facilities for the treatment of morbidities. Interventions to improve MNCH care included improved coverage and contracting services, community-based training, and public–private partnerships. Studies often did not provide greater contextual detail, including the complexities and realities of people seeking care across provider types. Future research should disaggregate data on quality of care, as well as describe the methods and specific facility details in their sample.