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Following the birth of the first \"test-tube baby\" in 1978, Assisted Reproductive Technologies became available to a small number of people in high-income countries able to afford the cost of private treatment, a period seen as the \"First Phase\" of ARTs. In the \"Second Phase,\" these treatments became increasingly available to cosmopolitan global elites. Today, this picture is changing - albeit slowly and unevenly - as ARTs are becoming more widely available. While, for many, accessing infertility treatments remains a dream, these are beginning to be viewed as a standard part of reproductive healthcare and family planning. This volume highlights this \"Third Phase\" - the opening up of ARTs to new constituencies in terms of ethnicity, geography, education, and class.

Infertility affects a remarkable one in four couples in developing countries. Psychological stress is a ubiquitous facet of life, and although stress affects us all at some point, prolonged or unmanageable stress may become harmful for some individuals, negatively impacting on their health, including fertility. For instance, women who struggle to conceive are twice as likely to suffer from emotional distress than fertile women. Assisted reproductive technology treatments place an additional physical, emotional, and financial burden of stress, particularly on women, who are often exposed to invasive techniques associated with treatment. Stress-reduction interventions can reduce negative affect and in some cases to improve in vitro fertilization outcomes. Although it has been well-established that stress negatively affects fertility in animal models, human research remains inconsistent due to individual differences and methodological flaws. Attempts to isolate single causal links between stress and infertility have not yet been successful due to their multifaceted etiologies. In this review, we will discuss the current literature in the field of stress-induced reproductive dysfunction based on animal and human models, and introduce a recently unexplored link between stress and infertility, the gut-derived hormone, ghrelin. We also present evidence from recent seminal studies demonstrating that ghrelin has a principal role in the stress response and reward processing, as well as in regulating reproductive function, and that these roles are tightly interlinked. Collectively, these data support the hypothesis that stress may negatively impact upon fertility at least in part by stimulating a dysregulation in ghrelin signaling.This review presents the current literature in the field of stress-induced reproductive dysfunction, and introduces a novel link between stress and infertility, the gut-derived hormone, ghrelin.

Social accountability approaches, which emphasize mutual responsibility and accountability by community members, health care workers, and local health officials for improving health outcomes in the community, are increasingly being employed in low-resource settings. We evaluated the effects of a social accountability approach, CARE's Community Score Card (CSC), on reproductive health outcomes in Ntcheu district, Malawi using a cluster-randomized control design. We matched 10 pairs of communities, randomly assigning one from each pair to intervention and control arms. We conducted two independent cross-sectional surveys of women who had given birth in the last 12 months, at baseline and at two years post-baseline. Using difference-in-difference (DiD) and local average treatment effect (LATE) estimates, we evaluated the effects on outcomes including modern contraceptive use, antenatal and postnatal care service utilization, and service satisfaction. We also evaluated changes in indicators developed by community members and service providers in the intervention areas. DiD analyses showed significantly greater improvements in the proportion of women receiving a home visit during pregnancy (B = 0.20, P < .01), receiving a postnatal visit (B = 0.06, P = .01), and overall service satisfaction (B = 0.16, P < .001) in intervention compared to control areas. LATE analyses estimated significant effects of the CSC intervention on home visits by health workers (114% higher in intervention compared to control) (B = 1.14, P < .001) and current use of modern contraceptives (57% higher) (B = 0.57, P < .01). All 13 community- and provider-developed indicators improved, with 6 of them showing significant improvements. By facilitating the relationship between community members, health service providers, and local government officials, the CSC contributed to important improvements in reproductive health-related outcomes. Further, the CSC builds mutual accountability, and ensures that solutions to problems are locally-relevant, locally-supported and feasible to implement.

Caesarean section (CS) rates continue to evoke worldwide concern because of their steady increase, lack of consensus on the appropriate CS rate and the associated additional short- and long-term risks and costs. We present the latest CS rates and trends over the last 24 years. We collected nationally-representative data on CS rates between 1990 to 2014 and calculated regional and subregional weighted averages. We conducted a longitudinal analysis calculating differences in CS rates as absolute change and as the average annual rate of increase (AARI). According to the latest data from 150 countries, currently 18.6% of all births occur by CS, ranging from 6% to 27.2% in the least and most developed regions, respectively. Latin America and the Caribbean region has the highest CS rates (40.5%), followed by Northern America (32.3%), Oceania (31.1%), Europe (25%), Asia (19.2%) and Africa (7.3%). Based on the data from 121 countries, the trend analysis showed that between 1990 and 2014, the global average CS rate increased 12.4% (from 6.7% to 19.1%) with an average annual rate of increase of 4.4%. The largest absolute increases occurred in Latin America and the Caribbean (19.4%, from 22.8% to 42.2%), followed by Asia (15.1%, from 4.4% to 19.5%), Oceania (14.1%, from 18.5% to 32.6%), Europe (13.8%, from 11.2% to 25%), Northern America (10%, from 22.3% to 32.3%) and Africa (4.5%, from 2.9% to 7.4%). Asia and Northern America were the regions with the highest and lowest average annual rate of increase (6.4% and 1.6%, respectively). The use of CS worldwide has increased to unprecedented levels although the gap between higher- and lower-resource settings remains. The information presented is essential to inform policy and global and regional strategies aimed at optimizing the use of CS.

This century is witnessing dramatic changes in the health needs of the world’s populations. The double burden of infectious and chronic diseases constitutes major causes of morbidity and mortality. Over the last two decades, there has been a rise in infectious diseases, including the severe acute respiratory syndrome virus (SARS), the H1N1 pandemic influenza, the Ebolavirus and the Covid-19 virus. These diseases have rapidly spread across the world and have reminded us of the unprecedented connectivity that defines our modern civilization. Though some countries have made substantial progress toward improving global surveillance for emerging infectious diseases (EIDs), the vast majority of Low-and Middle-income Countries (LMICs) with fragile health systems and various system-related bottlenecks remain vulnerable to outbreaks and, as such, experience dramatic social and economic consequences when they are reported. Lessons learned from past outbreaks suggest that gender inequalities are common across a range of health issues relating to Sexual and Reproductive Health and Rights (SRHR), with women being particularly disadvantaged, partially due to the burden placed on them. Though these countries are striving to improve their health systems and be more inclusive to this vulnerable group, the national/ global outbreaks have burdened the overall system and thus paralyzed normal services dedicated to the delivery of Sexual and Reproductive Health (SRH) services. In this paper, we discuss the global commitments to SRH, the impact of the EIDs on the LMICs, the failure in the delivery of SRH services, and the strategies for successful implementation of recovery plans that must address the specific and differentiated needs of women and girls in resource-poor settings.

Information about the incidence of induced abortion is needed to motivate and inform efforts to help women avoid unintended pregnancies and to monitor progress toward that end. We estimate subregional, regional, and global levels and trends in abortion incidence for 1990 to 2014, and abortion rates in subgroups of women. We use the results to estimate the proportion of pregnancies that end in abortion and examine whether abortion rates vary in countries grouped by the legal status of abortion. We requested abortion data from government agencies and compiled data from international sources and nationally representative studies. With data for 1069 country-years, we estimated incidence using a Bayesian hierarchical time series model whereby the overall abortion rate is a function of the modelled rates in subgroups of women of reproductive age defined by their marital status and contraceptive need and use, and the sizes of these subgroups. We estimated that 35 abortions (90% uncertainty interval [UI] 33 to 44) occurred annually per 1000 women aged 15–44 years worldwide in 2010–14, which was 5 points less than 40 (39–48) in 1990–94 (90% UI for decline −11 to 0). Because of population growth, the annual number of abortions worldwide increased by 5·9 million (90% UI −1·3 to 15·4), from 50·4 million in 1990–94 (48·6 to 59·9) to 56·3 million (52·4 to 70·0) in 2010–14. In the developed world, the abortion rate declined 19 points (−26 to −14), from 46 (41 to 59) to 27 (24 to 37). In the developing world, we found a non-significant 2 point decline (90% UI −9 to 4) in the rate from 39 (37 to 47) to 37 (34 to 46). Some 25% (90% UI 23 to 29) of pregnancies ended in abortion in 2010–14. Globally, 73% (90% UI 59 to 82) of abortions were obtained by married women in 2010–14 compared with 27% (18 to 41) obtained by unmarried women. We did not observe an association between the abortion rates for 2010–14 and the grounds under which abortion is legally allowed. Abortion rates have declined significantly since 1990 in the developed world but not in the developing world. Ensuring access to sexual and reproductive health care could help millions of women avoid unintended pregnancies and ensure access to safe abortion. UK Government, Dutch Ministry of Foreign Affairs, Norwegian Agency for Development Cooperation, The David and Lucile Packard Foundation, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Background Migrants and refugees face unprecedented inequalities in accessing sexual and reproductive health (SRH) in developed and developing countries. Most attention has focused on the rich world perspective, while there are huge numbers of migrants and refugees moving towards less developed countries. This article synthesizes the barriers to proper SRH care from low and middle-income countries perspective. Methods We performed a systematic review of articles containing primary source qualitative and quantitative studies with thick qualitative descriptions. Articles from various databases, including PubMed, Science Direct, HINARI, and Google Scholar, published between 2012 and 2022 were included. Because the context differed, we excluded articles dealing with migrants and refugees from low- and middle-income countries living in high-income countries. To select articles, a preferred reporting item for systematic reviews and meta-analyses (PRISMA) was used. The articles’ quality was assessed using the standard QASP checklist. We used a socio-ecological model to investigate barriers at various levels, and thematic analysis was used to identify the strongest themes at each level of the model. This synthesis is registered under PROSPERO number CRD42022341460. Results We selected fifteen articles from a total of 985 for the final analysis. The results show that despite the diversity of the participants’ homes and countries of origin, their experiences using SRH services were quite similar. Most female migrants and refugees claimed to have encountered discrimination from service providers, and linguistic and cultural obstacles played a significant role in their experiences. In nations lacking universal healthcare coverage, the cost of care was a barrier to the use of SRH services. Other main obstacles to using SRH services were a lack of knowledge about these programs, worries about privacy, inadequate communication, stigma in the community, and gender-related power imbalances. Conclusion To enhance the use of SRH by female migrants and refugees, it is vital to provide person-centered care and involve husbands, parents, in-laws, and communities in SRH coproduction. Training on cultural competency, compassion, and respect must be provided to healthcare personnel. Increasing financial access for migrant and refugee healthcare is crucial, as is meeting their basic requirements.

Background Comprehensive sexuality education (CSE) plays a critical role in promoting youth and adolescent's sexual and reproductive health and wellbeing. However, little is known about the enablers and barriers affecting the integration of CSE into educational programmes. The aim of this review is to explore positive and negative factors influencing the integration of CSE into national curricula and educational systems in low- and middle-income countries. Methods We conducted a systematic literature review (January 2010 to August 2022). The results accord with the Preferred Reporting Items for Systematic Reviews and Meta-analysis standards for systematic reviews. Data were retrieved from the PubMed, Cochrane, Google Scholar, and Web of Hinari databases. The search yielded 442 publications, of which 34 met the inclusion criteria for full-text screening. The review is guided by an established conceptual framework that incorporates the integration of health innovations into health systems. Data were analysed using a thematic synthesis approach. Results The magnitude of the problem is evidenced by sexual and reproductive health challenges such as high teenage pregnancies, early marriages, and sexually transmitted infections. Awareness of these challenges can facilitate the development of interventions and the implementation and integration of CSE. Reported aspects of the interventions include core CSE content, delivery methods, training materials and resources, and various teacher-training factors. Reasons for adoption include perceived benefits of CSE, experiences and characteristics of both teachers and learners, and religious, social and cultural factors. Broad system characteristics include strengthening links between schools and health facilities, school and community-based collaboration, coordination of CSE implementation, and the monitoring and evaluation of CSE. Ultimately, the availability of resources, national policies and laws, international agendas, and political commitment will impact upon the extent and level of integration. Conclusion Social, economic, cultural, political, legal, and financial contextual factors influence the implementation and integration of CSE into national curricula and educational systems. Stakeholder collaboration and involvement in the design and appropriateness of interventions is critical. Plain language summary Adolescents and young people, especially those from low and middle-income countries (LMICs) face sexual and reproductive health (SRH) challenges. This review identifies factors that impact upon the integration of comprehensive sexuality education (CSE) into national curricula and educational systems in LMICs. A total of 442 original articles, published between 2010 and August 2022, were sourced from various databases. Thirty-four articles met the inclusion criteria. Social, economic, cultural, political, legal and financial factors are major enablers and barriers affecting the integration of CSE into educational systems in LMICs. Authorities in many countries are motivated to develop CSE interventions to help reduce SRH issues such as teenage pregnancies, early marriages, HIV/AIDS, and sexually transmitted infections (Yakubu and Salisu in Reprod Health 15:15, 2018;Herat in Reprod Health 15:1–4, 2018;). The rollout of CSE interventions is highly dependent on the availability of training resources, manuals, skilled teachers, and financing. In addition, the perception of teachers, students, politicians, and the community, influences the integration of interventions. This review shows that the involvement of key players in teaching is vital for successful implementation, as is building working relationships between teachers and community actors. Such collaborations enable the integrated delivery of SRH services. Insufficient monitoring and evaluation systems affects the quality of the implementation and therefore the success of CSE. We believe that community involvement in the development, implementation, monitoring, and evaluation of CSE is a major enabler for successful implementation and integration. Recognising and acknowledging the importance of political, social, legal and financial factors is critical for sustainable CSE integration.

Reducing maternal mortality and providing universal access to reproductive health in resource poor settings has been severely constrained by a shortage of health workers required to deliver interventions. The aim of this article is to determine evidence to optimize health worker roles through task shifting/sharing to address Millennium Development Goal 5 and reduce maternal mortality and provide universal access to reproductive health. A narrative synthesis of peer-reviewed literature from 2000 to 2011 was undertaken with retrieved documents assessed using an inclusion/exclusion criterion and quality appraisal guided by critical assessment tools. Concepts were analysed thematically. The analysis identified a focus on clinical tasks (the delivery of obstetric surgery, anaesthesia and abortion) that were shifted to and/or shared with doctors, non-physician clinicians, nurses and midwives. Findings indicate that shifting and sharing these tasks may increase access to and availability of maternal and reproductive health (MRH) services without compromising performance or patient outcomes and may be cost effective. However, a number of issues and barriers were identified with health workers calling for improved in-service training, supervision, career progression and incentive packages to better support their practice. Collaborative approaches involving community members and health workers at all levels have the potential to deliver MRH interventions effectively if accompanied by ongoing investment in the health care system.