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Background The impact of cultural norms on women’s health, particularly their reproductive health, has long been acknowledged. However, due to extensive data requirements, creating an index to capture these cultural norms at the national level has proved challenging, making it difficult to calculate these indices for small communities within a nation. This paper proposes a new contextual index, which uses data from regularly fielded large-scale surveys, to evaluate the restrictive cultural rules that limit women’s health and well-being opportunities within the context of their small communities. Methods The GCCI is a compositional index that combines the prevalence of five culturally restrictive women’s attributes at the community level using factor analysis. Egypt was adopted as a case study using data from the Egyptian Family Health Survey 2021. The Wagstaff concentration index assessed the GCCI’s validity in reflecting the inequalities in reproductive health risks. Multilevel logistic analysis was used to determine the index’s ability to explain the community-level variability in multiparity (having 5 + children). Results The five indicators showed high internal consistency, with a Cronbach’s alpha of 0.72. The factor combining the five indicators accounted for 72.7% of the total variances. The index was effective in capturing the inequality in reproductive health risks among the 47 communities in Egypt, with a positive Wagstaff concentration index that exceeded 10% for the move from the least to the most restrictive communities in Egypt. The multilevel analysis showed that the community level captured 11% of the variability in multiparity, of which the GCCI index explained 51%. This suggests that the GCCI index can account for a significant portion of the community-specific factors that contribute to reproductive health disparities. Conclusion The GCCI index, with its simple structure and reliance on regularly available large-scale data, offers strong evidence of the significant effect of the gendered cultural context in explaining inequality in women’s reproductive health risks. It has successfully pinpointed communities that limit women’s health and well-being opportunities. Adopting a similar approach to capture the cultural context could provide substantial support for the development of culturally sensitive and tailored interventions that address the cumulative effects of restrictive cultural norms across different communities. Plain English Summary The impact of cultural norms on women’s health, particularly their reproductive health, has long been acknowledged. However, due to extensive data requirements, creating an index to assess these restrictive cultural norms at the national level has proved challenging. This has made it difficult to calculate these indexes for small communities within a nation. This paper proposes a new contextual index to evaluate the restrictive cultural rules that limit women’s health and well-being opportunities within the context of their small communities. The new CGGI index is a composite index at the community level, reflecting the collective attributes of the community regarding women’s position in society and the household. Data for these attributes are regularly available in large-scale data sets conducted in many developing countries, such as the Demographic and Health Surveys. These attributes pertain to early marriage, approval of wife-beating, lack of decision-making power, exposure to violence, and low educational attainment. The index was applied to the 2021 Egyptian Family Health Survey data and successfully identified inequality in reproductive health risks across the index range. It also explained more than half of the community-based variability in having five or more children. These findings show that adopting similar indexes that capture the social and cultural norms in communities can help identify vulnerable communities where women are more exposed to reproductive health risks due to their cultural context, enabling the proper tailoring of interventions and service provision.

Background Access to sexual and reproductive health (SRH) services is recognized as a fundamental human right and a core priority within global health agendas, particularly under the Sustainable Development Goals (SDGs). Despite significant legal advances such as the Convention on the Rights of Persons with Disabilities women with motor disabilities continue to face persistent marginalization, especially in low- and middle-income African countries. This systematic review aims to identify the barriers and facilitating factors influencing their access to SRH services. Methods Following PRISMA guidelines and registered with PROSPERO (CRD42024555816), this review adopted a Population, Concept, Context (PCC) search strategy. Studies published between 2001 and 2024 in English and French were retrieved from major electronic databases and grey literature sources. Data extraction and methodological assessment were conducted independently by multiple reviewers. A narrative synthesis was used for qualitative findings and a descriptive approach for quantitative data. Results Twenty-eight studies covering eleven African countries were included. The main barriers identified were grouped into five categories: physical and logistical constraints, social and attitudinal barriers, institutional limitations, economic hardships, and informational and communication barriers. Key facilitating factors included healthcare provider training, infrastructure adaptation, community mobilization, and the development of inclusive public health policies. Conclusion This review highlights the urgent need to embed disability inclusion within national SRH policies and to promote multisectoral strategies that address the systemic inequalities limiting access for women with motor disabilities.

Background Transgender (trans) and gender diverse people face significant obstacles when accessing sexual and reproductive health (SRH) services. This review aims to systematically identify and characterise the specific barriers to SRH barriers across a range of service domains. Methods A systematic literature search was carried across MEDLINE, CINAHL, Embase, PsycInfo and Global Index Medicus for studies published up until Aug 17, 2023. We included qualitative, quantitative and mixed-methods studies that illustrated which barriers to SRH services trans and gender diverse people face. Relevant data were extracted and examined using an inductive approach by which organic themes emerged across the SRH service domains. Quality assessment was carried out using the Critical Appraisal Skill Programme (CASP) checklists. Findings A total of 53 studies examining barriers to SRH services were deemed eligible for inclusion. This consisted of 20 studies relating to fertility care, two to abortion care, four to contraception, 15 to reproductive cancer screening, nine to antenatal, intrapartum and postnatal care and three spanning multiple domains of SRH. Eight studies were deemed to be moderate quality, the remaining 45 were high quality. 49 of the included studies were conducted exclusively in high-income countries. 40 studies were conducted from the perspectives of trans and gender diverse people, 10 from that of health providers whilst three incorporated both. Participants included for analysis ranged in age from 18 to 78 years. Domain specific and cross-cutting barriers were described throughout the included studies, including financial accessibility, lack of provider knowledge and education, limited information availability, systemic and interpersonal discrimination, cis-normative and gender biased health system practices and dysphoria associated with treatments and procedures. Interpretation Trans and gender diverse people face substantial barriers to SRH services that prohibit them from fully exercising their reproductive rights. The evidence collated by this review demonstrates that whilst some barriers are shared with cisgender women, trans and gender diverse people face unique barriers to accessing SRH services. Both systems- and individual-level reform is necessary to improve not only gender responsiveness but also gender-inclusivity.

Background Gender-affirming hormones do not completely suppress fertility in transgender and gender diverse individuals, highlighting the need for counseling on pregnancy risk and contraceptive options. However, research on current contraceptive care is limited. Studies from the US have identified several barriers to care as well as facilitators, but no studies on this topic have yet been conducted in Europe. This study examined transgender and gender diverse contraceptive care in Germany from the perspective of healthcare providers, assessing its importance and their roles in it, as well as exploring barriers and facilitators. Methods Thirty semistructured qualitative interviews with German healthcare providers were conducted between December 2023 and February 2024. The interview guide included questions on contraceptive care for transgender and gender diverse individuals. Data were analyzed using structuring qualitative content analysis (Kuckartz) with deductive and inductive category development. Results Most interviewees highlighted the need for contraceptive care, depending on various factors such as the type of gender-affirming care applied, sexual practices, and transgender and gender diverse individuals’ desire for pregnancy prevention. Half of the interviewees also offered contraceptive care (depending on their specialization). Numerous barriers to contraceptive care, such as a lack of awareness of contraceptive needs, insufficient research and training programs for medical staff, have been reported, highlighting the importance of facilitators for care such as the implementation of contraceptive counseling as a standard protocol. Conclusion To improve contraceptive care for transgender and gender diverse individuals, the establishment of clear structures and responsibilities, more research, and qualifications among the involved specialties are needed. To gain a comprehensive understanding of the care situation, future research should include the perspectives of transgender and gender diverse individuals. Trial registration We obtained the approval of the Hamburg Medical Council (“Ärztekammer Hamburg”) to conduct our study by means of a “scientific case” (2023-300381-WF, September 11th 2023). Plain english summary Transgender and gender diverse people experience persistent incongruence between their experienced gender identity and their sex assigned at birth - diagnosed as gender incongruence. Many use gender-affirming hormones, such as testosterone or estrogen, to match gender identity and body. These hormones decrease the ability to get pregnant but do not stop it completely. That’s why it is important to give this population information about pregnancy risks and contraceptive options. So far, most research on this topic has come from the US, but little is known about the situation in Europe. This study looked at how healthcare providers in Germany think about contraceptive care for transgender and gender diverse people and how they experience care provision. Thirty healthcare providers (medical doctors and psychologists) in Germany were interviewed between December 2023 and February 2024. Most healthcare providers said they believed contraceptive care was important for transgender and gender diverse people, depending on factors like the type of hormones used and sexual practices, and half of the healthcare providers also offered contraceptive care. Some common challenges included a lack of knowledge about contraception for transgender and gender diverse people, lack of research, and limited training of medical staff. Healthcare providers said that better contraceptive care for transgender and gender-diverse people in Germany needs more research, clear protocols or guidelines, as well as more training for healthcare providers. Future studies should also ask transgender and gender diverse people themselves about their needs and experiences.

Background The core principles and key indicators of Respectful Maternity Care (RMC), particularly in low-income settings, are under-researched. Validated core principles and indicators are crucial for measuring RMC, especially in contexts where workforce shortages, infrastructure gaps, and sociocultural factors impact the care. Thus, this study aimed to identify and validate the core principles and indicators of RMC in resource-limited settings. Methods A three-round Delphi study was conducted. Maternity care professionals (midwives, educators, researchers, and obstetricians) based in Ethiopia ( n  = 33) were recruited via email through professional networks. Original peer-reviewed research published in English-language journals between 2010 and 2024 was reviewed and used to generate 75 initial indicators, which were securely uploaded to Qualtrics ® for digital distribution. The indicators were evaluated on a four-point Likert scale for importance, relevance, and clarity. Responses were analysed and reported back to the participants for round two. After analysing the second-round results, the final version was shared with the participants for the third round. The third round did not generate any new information or ideas. Participants were also invited to provide feedback and suggest additional core principles and indicators that they considered missing. Results In the first round, 75 indicators were assessed. The Item-level Content Validity Indexes ranged from 0.66 to 1.00 for importance and relevance, and 0.90 to 1.00 for clarity. The Scale-level Content Validity Index was 0.94 for importance and relevance and 0.98 for clarity. Three indicators were eliminated in round one; 12 were merged, and three remained unchanged. Two new indicators were added to the items. Thirteen core principles of RMC were proposed, and ten were accepted. Sixty indicators aligned with the ten core principles of RMC were finalised for round two. After round two, 11 indicators were removed, leading to a final list of 49 indicators. The third round generated no further revisions to the questionnaire. Conclusion The ten core principles and forty-nine indicators validated in this study provide a robust blueprint for the consistent implementation and monitoring of RMC. This validated framework also provides a timely, evidence-based response to the WHO’s call for the most valid and responsive RMC indicators in clinical settings. Future research should assess the core principles and indicators’ validity and reliability across diverse contexts.

Background It is estimated that 30% of women globally have experienced sexual violence (SV) and many of these cases result in sexual violence related pregnancies (SVRP). Social and structural inequities may impact access to reproductive healthcare for those who become pregnant as a result of SV. Methods Using Bronfenbrenner’s Bioecological Systems Theory as an organizing framework, we conducted a rapid review to identify barriers to accessing reproductive healthcare after SV. We reviewed studies published between 2010 and 2024, synthesizing results from PubMed, PsychInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Educational Resources Information Center (ERIC), Scopus, Global Health, and Embase. A total of 15 studies met the following inclusion criteria: (a) published in a peer-reviewed journal between January 2010 and February 2024, (b) written in English, and (c) evaluated barriers to reproductive healthcare services and resources for people who become pregnant as a result of SV. Study populations were located both within and outside the US. Results The primary barriers identified included: lack of access to care, lack of provider training in trauma-informed care, fear of stigmatization, victim blaming, internalized shame, and retaliation. Conclusions This review can be used to understand specific barriers to reproductive healthcare for those who have experienced SV and the level or levels at which they are functioning. These findings can be used to tailor reproductive health policy, training, and community-based interventions aimed at mitigating and/or eliminating these barriers.

Introduction Violence against women (VAW) is a manifestation of power relations. One in three women experience physical or sexual violence at least once globally. This concern poses a substantial barrier to accomplishing target 5.2 of the Sustainable Development Goals (SDGs) to eliminate all forms of VAW. This escalates in humanitarian crises settings. Despite the importance there is a dearth of evidence about VAW in refugee settings in Ethiopia. Methods A community-based cross-sectional study was conducted between March and August 2023 in Asayta, Ethiopia. The study population consisted of 867 women, including Eritrean refugees residing in Asayta camp and women from the surrounding Afar pastoralist host community. A multistage compact segmentation technique was employed to collect data. Logistic regression and latent class analysis (LCA) were used for advanced analysis. Results Overall, 231 (33%), or 1 out of 3 women ‘ever’ experienced physical or sexual violence. Married women (AOR = 19.80; 95% CI: 2.18, 166), age group 24–49 years (AOR = 4.0; 95% CI: 1.28 ,12.54), better women’s education (AOR = 2.89; 95% CI: 1.40, 5.96), contraceptive use (AOR = 2.17; 95% CI: 1.07–4.42), history of childhood abuse (AOR = 43; 95% CI: 19.24, 96.39) and husband’s substance use (khat) (AOR = 3.49 (2.09–5.87) were associated with an increased risk for VAW. On the other hand, better income (AOR = 0.35; 95% CI: 0.19, 0.67), being pregnant (AOR = 0.26; 95% CI: 0.14, 0.48) and access to referral services (AOR = 0.26; 95% CI: 0.11, 0.60) showed protective effect from VAW. The likelihood of VAW is found to be almost 15 times higher (AOR: 15.64, 95% CI: 1.52, 161) among women constituted in class seven (multiple violence group) of the LCA model. Conclusion VAW was found to be a prevalent problem among Eritrean refugee women in Asayta refugee camp, Ethiopia. Despite wide variations in the magnitude of the problem, risk exposures seem similar across studies. Women’s age, marital status, income level, history of childhood abuse, husband`s substance use and access to sexual and reproductive health (SRH) services, including contraceptive use—were strongly associated with VAW. Multi-level violence prevention programs are needed. These should focus on challenging harmful gender norms, preventing childhood abuse, empowering women economically and socially, and tailored community awareness about the link between substance use and VAW.

Background Equitable and ethical access to in-vitro fertilization (IVF) remains challenging globally. Existing evaluation frameworks often overlook critical dimensions of reproductive justice. This study develops and validates a Universal IVF Justice Framework, designed to systematically evaluate national IVF policies regarding equity and reproductive autonomy. Methods We conducted a systematic literature review (PubMed, Scopus; January 1, 2010 to June 11, 2025) to identify key policy dimensions and indicators, followed by expert consultations and pilot testing to ensure reliability. The framework was validated through comprehensive document reviews and double-coding of IVF policies from 24 diverse countries. Visualization tools were created to illustrate outcomes. Results Analysis revealed three overarching dimensions that shape national IVF policy outcomes: economic and structural conditions, cultural and social contexts, and healthcare system factors. Substantial variation emerged across countries. At the micro-level, country-specific analyses exposed targeted strengths and weaknesses, supporting localized reform efforts. Visualizations such as radar and scatter plots highlighted performance disparities. At the macro-level, high-income countries generally scored higher, driven by broader insurance coverage, inclusive legal protections, and greater geographic access. In contrast, low- and middle-income countries often faced challenges in affordability, rural service delivery, LGBTQ+ inclusivity, and psychosocial support. Conclusions The Universal IVF Justice Framework offers an empirically-grounded and ethically informed approach for evaluating IVF policies globally. By clearly identifying policy strengths and critical gaps, it supports evidence-based decision-making and targeted reforms aimed at enhancing equity and reproductive autonomy in IVF services worldwide.

Background In Iran, restrictive abortion laws have led to widespread unsafe abortions, posing significant health risks. The 2021 Family and Youth Protection Law further restricted access to reproductive health services in an effort to boost birth rates. The purpose of this qualitative study is to explore the reasons women sought abortions in an illegal context, based on their own experiences. Methods This exploratory qualitative study involved in-depth interviews with 46 women in Kermanshah, Iran, between April and August 2024. All participants had experienced incomplete abortions after undergoing unsafe procedures. Data were analyzed using conventional content analysis and thematic analysis with MAXQDA 10 software to identify key themes in the women's experiences. To ensure the study's rigor, we applied Guba and Lincoln’s criteria, including credibility, dependability, confirmability, and transferability. Results Five main themes emerged from the interviews: economic hardship, pursuit of a prosperous life, unstable marital relationships, health and fertility issues, and cultural factors. Economic challenges, such as unemployment and lack of basic necessities, were the most frequently cited reasons for seeking unsafe abortions. Health issues, including unplanned pregnancies and fear of fetal anomalies, also played a significant role, alongside cultural stigmas related to age, illegitimacy, and gender preferences. Conclusion This study sheds light on the multifaceted factors driving unsafe abortions in Iran following pronatalist policy changes. A holistic approach is recommended to address the interconnected economic, social, and cultural challenges that contribute to this issue. By implementing such comprehensive strategies, policymakers and stakeholders can work to reduce the prevalence of unsafe abortion practices and foster improved health and well-being for women.

Background Sexual and gender minoritized (SGM) people, including but not limited to lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people assigned female at birth (AFAB), experience a greater burden of cervical cancer relative to their heterosexual and cisgender counterparts. However, they face pronounced systemic barriers to regular cervical cancer screening. Although evidence-based clinical guidelines play an integral role in the implementation of preventive measures, existing United States (U.S.) cervical cancer screening guidelines do not consider the specific experiences, needs, and contexts of SGM AFAB people concerning cervical cancer outcomes nor cervical cancer screening. Thus, it is imperative to determine how cervical cancer screening guidelines can be revised to better address the unique and specific cervical cancer prevention needs of SGM AFAB people in the U.S. Methods We conducted virtual key informant interviews to elicit recommendations for advancing SGM health equity in developing and implementing cervical cancer screening guidelines from healthcare equity leaders ( N  = 18), including half with expertise in SGM AFAB people’s healthcare. Interviews were analyzed using a template-style thematic analysis approach to develop themes and sub-themes. Results Healthcare equity leaders provided three key recommendations for advancing SGM health equity in the development and implementation of U.S. cervical cancer screening guidelines. Healthcare equity leaders recommended prioritizing community and person-centered strategies, including engaging SGM communities in the development of the guidelines and using SGM-affirming approaches in their implementation. Revising language that (re)produces harmful normative and exclusionary assumptions about gender and sexuality in the context of cervical cancer screening guidelines was also recommended. Lastly, leaders recommended a range of strategies to mitigate systemic barriers to cervical cancer screening among SGM AFAB people, including collecting and utilizing representative data on SGM AFAB people’s needs, experiences, and contexts to develop the guidelines and ensure cultural responsiveness in the delivery of cervical cancer screening to SGM AFAB people across healthcare systems. Conclusion This study's findings can contribute to improving and advancing health equity in cervical cancer screening for SGM AFAB populations through the community-centered development of inclusive, evidence-based guidelines and their person-centered implementation in clinical settings. Plain Language summary Sexual and gender minoritized (SGM) people, including but not limited to lesbian, gay, bisexual, transgender and queer (LGBTQ+) people assigned female at birth (AFAB) experience a greater burden of cervical cancer relative to their heterosexual and cisgender counterparts; yet, they face pronounced barriers to regular cervical cancer screening. Although clinical guidelines play an integral role in the implementation of preventive measures, including screening for cervical cancer, existing United States (U.S.) cervical cancer screening guidelines do not take into account the specific experiences, needs, and contexts of SGM AFAB people. Thus, it is imperative to determine how cervical cancer screening guidelines can be improved to better address the unique and specific cervical cancer prevention needs of SGM AFAB people in the U.S. We conducted virtual key informant interviews with healthcare equity leaders ( N  = 18) in medicine, public health research, and policy to learn more about the ways in which cervical cancer screening guidelines could better meet the needs of SGM AFAB people in the U.S. These healthcare equity leaders recommended (1) including the SGM AFAB community in the development of the guidelines (2), avoiding harmful assumptions about SGM people and cervical cancer risk in the guidelines and (3) implementing the guidelines in ways that reduce barriers and increase cultural responsiveness in cervical cancer screening among SGM AFAB people. These valuable insights from healthcare equity leaders provide actionable insights for improving SGM health equity in the development and implementation of U.S. cervical cancer screening guidelines.