SRHR: unmet needs and unfinished agendas
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2019)

There is something fascinating about looking at the world through the population lens. Last month, the UN released the 2019 World Population Prospects—a dizzying display of how and where humanity is expanding, contracting, and moving. World Population Day, on July 11, is an opportunity to reflect on these demographic megatrends and the substantial effects they can have on economic and social development. According to the report, humanity will reach 10 billion in 2050; the Indian population will exceed that of China around 2027; international migration is a steady component of population change; worldwide the over-65s outnumber the under-5s for the first time in history; and reductions in fertility in Asia, Latin America and the Caribbean, and even Africa, are providing unprecedented opportunities for economic growth as working-age adults become the largest population group. These demographic realities provide essential clues to what population-related policies and programmes should be prioritised and where. Front and centre are sexual and reproductive health and rights (SRHR), and this year, World Population Day celebrates the 25th anniversary of the International Conference on Population and Development (ICPD), which cemented the central role of SRHR in sustainable development. Family planning is core to both demography and SRHR, yet in a global environment short on human and financial resources, it is sometimes neglected. What should be a basic right for everyone—the ability to control their fertility and choose if and when they want a child—is also very much determined by the political environment. In this issue, Nina Brooks and colleagues tackle the thorny topic of the Mexico City Policy—the legislation that prevents US federal funding from being used overseas to support organisations that perform or counsel on abortion. Using data from 26 African countries over 20 years, they show how the abortion rate rose by 40% in countries exposed to the policy relative to women in low-exposure countries and to periods when the policy was removed—a pattern inversely mirrored by the prevalence of modern contraceptive use. The authors expand on the ramifications of these unintended consequences and implications for future policy in an associated podcast. But contraceptive use is not determined by policy only, and numerous more personal factors—knowledge, preferences, parity—add another layer of complexity. Even when access to contraceptives is secured, low continuation rates illustrate that family planning efforts must extend beyond capturing new users into ensuring that contraception remains an exercised right throughout the reproductive life. Also in this issue, Nguyen Toan Tran and colleagues present the results of the “Yam Daabo” cluster-randomised controlled trial assessing the effect of a package of low-tech participatory interventions for providers and women and their partners to strengthen primary care and enhance demand in post-partum contraceptive use in Burkina Faso. The strategy was effective: at 12 months, 55% of women who received the package were using a modern contraceptive, against 29% in those receiving routine care. These results add to the array of tools that decision-makers can use in addressing the unmet need for contraceptives. And we know that the unmet need is great. As Marleen Temmerman evokes in a Comment in this issue, progress in addressing it is unequal in different countries and will require a multifactorial approach. Given the diversity of needs and preferences, enlarging the range of available modern contraceptive methods may be useful. The results of the multicentre, open-label, phase 3 trials on the efficacy of the 1 year segesterone acetate and ethinylestradiol vaginal system presented in this issue are therefore welcome. In their Article, David Archer and colleagues show that the Pearl Index for women 35 years and younger was 2·98, with a contraceptive efficacy of 97·5%, for this ring-shaped, temperature-stable, woman-controlled contraceptive, opening up new opportunities to enhance access and reduce unmet need. The research presented in this issue is reassurance that the family planning side of SRHR is firmly on the agenda, in concrete ways. Yet there are still understudied areas to bring to light—infertility, for instance. As a panel at the recent Women Deliver conference discussed, infertility is a data-sparse, cross-cutting issue spanning health, rights, and justice spaces. A taboo subject in many cultures, it can all too often lead to familial disharmony and even domestic violence, as people lack information on the causes and are ill-equipped to support affected individuals. 25 years after the ICPD, the agenda is clearly unfinished, but the work continues. Efficacy of inactivated trivalent influenza vaccine in rural India: a 3-year cluster-randomised controlled trialIIV3 provided variable direct and indirect protection against influenza infection. Indirect protection was significant during the year of highest direct protection and should be considered when quantifying the effect of vaccination programmes. Full-Text PDF Open AccessEfficacy of the 1-year (13-cycle) segesterone acetate and ethinylestradiol contraceptive vaginal system: results of two multicentre, open-label, single-arm, phase 3 trialsThe segesterone acetate and ethinylestradiol contraceptive vaginal system is an effective contraceptive for 13 consecutive cycles of use. This new product adds to the contraceptive method mix and the 1-year duration of use means that women do not need to return to the clinic or pharmacy for refills every few months. Full-Text PDF Open AccessUSA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City PolicyOur findings suggest that curbing US assistance to family planning organisations, especially those that consider abortion as a method of family planning, increases abortion prevalence in sub-Saharan African countries most affected by the policy. Full-Text PDF Open AccessA new woman-controlled contraceptive vaginal ring: a global step forwardMore than 40 years ago, the development of contraceptive vaginal rings began, based on the fact that the vaginal epithelium can absorb steroid hormones and the capacity of elastomers to release these hormones at almost constant rates.1 The growing interest in woman-controlled contraceptive methods has supported and accelerated the process. Full-Text PDF Open Access