Rights based approaches to sexual and reproductive health in low and middle-income countries: A systematic review

  • PLoS ONE, Volume 16, No. 4 April, Year 2021

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Study Justification:
This systematic review aims to provide evidence on the effectiveness of rights-based approaches to sexual and reproductive health in low and middle-income countries. The study is justified by the importance of empowering women and girls and ensuring access to sexual and reproductive health and rights, as outlined in the Sustainable Development Goals (Goal 5). By identifying interventions that have been effective in improving outcomes such as HIV testing uptake, condom use, and awareness of rights, this review can inform policy and program development in this area.
Highlights:
– The study identified 24 interventions that used rights-based approaches for sexual and reproductive health in low and middle-income countries.
– Some interventions were found to be effective in improving outcomes such as HIV testing uptake, condom use, and awareness of rights.
– However, the evidence was of poor quality, and all included studies were at high, critical, or serious risk of bias.
– No study included outcomes related to gender-based violence.
– The review highlights the urgent need for high-quality controlled studies in this area.
Recommendations:
Based on the findings of this review, the following recommendations can be made:
1. Conduct high-quality controlled studies: There is a need for well-designed studies that rigorously evaluate the effectiveness of rights-based approaches to sexual and reproductive health in low and middle-income countries. These studies should address the limitations identified in the reviewed studies and include outcomes related to gender-based violence.
2. Improve reporting and transparency: Future studies should adhere to reporting guidelines such as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to ensure transparency and facilitate the synthesis of evidence.
3. Strengthen research capacity: Efforts should be made to build research capacity in low and middle-income countries to conduct high-quality studies in the field of sexual and reproductive health. This can be achieved through training programs, collaborations, and funding support.
Key Role Players:
To address the recommendations, the following key role players are needed:
1. Researchers: Researchers with expertise in sexual and reproductive health, human rights, and study design are essential for conducting high-quality studies.
2. Policy Makers: Policy makers at national and international levels play a crucial role in incorporating evidence-based recommendations into policies and programs.
3. Funding Agencies: Funding agencies can provide financial support for research studies and capacity-building initiatives.
4. Non-Governmental Organizations (NGOs): NGOs working in the field of sexual and reproductive health can contribute to the implementation of rights-based approaches and support research efforts.
5. Academic Institutions: Academic institutions can provide research infrastructure, expertise, and training opportunities for researchers and students.
Cost Items for Planning Recommendations:
While the actual cost of implementing the recommendations cannot be estimated without specific details, the following cost items should be considered in planning:
1. Research Grants: Funding is required to support research studies, including personnel salaries, data collection, analysis, and dissemination of findings.
2. Training Programs: Resources are needed to develop and deliver training programs to build research capacity in low and middle-income countries.
3. Collaboration and Networking: Costs associated with establishing collaborations and networks between researchers, policy makers, NGOs, and academic institutions should be considered.
4. Advocacy and Awareness Campaigns: Funds may be required to raise awareness about the importance of rights-based approaches to sexual and reproductive health and advocate for policy changes.
5. Monitoring and Evaluation: Resources should be allocated for monitoring and evaluating the implementation of rights-based interventions and assessing their impact.
Please note that the above cost items are general considerations and may vary depending on the specific context and scope of the recommendations.

The strength of evidence for this abstract is 4 out of 10.
The evidence in the abstract is rated as 4 due to the poor quality of the included studies and the considerable risk of bias. To improve the strength of the evidence, the following actionable steps can be taken: 1. Conduct high-quality controlled studies in the area of rights-based approaches to sexual and reproductive health in low and middle-income countries. 2. Address the risk of bias by ensuring rigorous study design and implementation. 3. Include gender-based violence outcomes in future studies. 4. Consider including a diverse range of languages in the search strategy to minimize language restrictions. 5. Consider including grey literature to capture additional relevant studies.

Introduction The Sustainable Development Goals, which are grounded in human rights, involve empowering women and girls and ensuring that everyone can access sexual and reproductive health and rights (Goal 5). This is the first systematic review reporting interventions involving rights-based approaches for sexual and reproductive health issues including gender-based violence, maternity, HIV and sexually transmitted infections in low and middle-income countries. Aims To describe the evidence on rights-based approaches to sexual and reproductive health in low and middle-income countries. Methods EMBASE, MEDLINE and Web of Science were searched until 9/1/2020. Inclusion criteria were: • Study design: any interventional study. • Population: females aged over 15 living in low and middle-income countries. • Intervention: a “rights-based approach” (defined by the author) and/or interventions that the author explicitly stated related to “rights”. • Comparator: clusters in which no intervention or fewer components of an intervention were in place, or individuals not exposed to interventions, or exposed to fewer intervention components. • Outcome: Sexual and reproductive health related outcomes. A narrative synthesis of included studies was undertaken, and outcomes mapped to identify evidence gaps. The systematic review protocol was registered on PROSPERO (CRD42019158950). Results Database searching identified 17,212 records, and 13,404 studies remained after de-duplication. Twenty-four studies were included after title and abstract, full-text and reference-list screening by two authors independently. Rights-based interventions were effective for some included outcomes, but evidence was of poor quality. Testing uptake for HIV and/or other sexually transmitted infections, condom use, and awareness of rights improved with intervention, but all relevant studies were at high, critical or serious risk of bias. No study included gender-based violence outcomes. Conclusion Considerable risk of bias in all studies means results must be interpreted with caution. High-quality controlled studies are needed urgently in this area.

The systematic review protocol was registered with PROSPERO on 4/12/2019 (CRD42019158950) [15]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed, as described in the PRISMA flow diagram (Fig 1) and checklist (S1 File). EMBASE, MEDLINE and Web of Science were searched from inception until 9/1/2020. Search terms included medical subject headings or equivalent and free text terms including sexual health, gender-based violence, maternal health, human rights and more, combined using Boolean operators (S2 File). Search terms were chosen to cover the subject areas of contraception, pregnancy, STIs, awareness of rights, violence and mental health. Reference lists of included studies and relevant identified systematic reviews were screened to identify any further studies not identified in the initial search. There were no language restrictions. Reviews of published studies in languages other than English were conducted by the authors themselves (French, Portuguese) or a University of Warwick colleague, Dr Yen-Fu Chen, (Mandarin). The search strategy was reviewed by a specialist academic librarian. Searches were adapted for each database. Grey literature was not included due to the anticipated lack of detail in the methods of published studies, and anticipated lack of independence of published evaluations (for example, evaluations published by those running an intervention as part of seeking further funding for their organisation or intervention). Following database searches, titles and abstracts were screened by two reviewers independently. Each included full-text article was then reviewed by two reviewers independently. At each state, if there were discrepancies regarding inclusion/exclusion decisions, they were addressed initially via discussion, and if necessary via a third author. Rayyan Systematic Review Web App [17] and Microsoft Excel were used to record decisions. Data were extracted by two reviewers independently onto a data extraction tool developed by the authors which included basic study details (journal, dates, authors, and location, sample size, population, study design, study duration, interventions, statistical analysis, results, ethics and funding). Only relevant results pertaining to populations eligible for inclusion in this systematic review were extracted- for example, where data was collected for males and females, only data presented on females were extracted. A narrative synthesis of included studies was undertaken. Due to study heterogeneity, meta-analysis was not undertaken. Outcomes were mapped to identify evidence gaps. Effectiveness of identified interventions was examined based on the author’s choice of outcomes. Quality and risk of bias was assessed by two reviewers independently using the RoB-2 tool for cluster-randomised studies [18], and the ROBINS-I tool for non-randomised studies [19]. Uncontrolled before-and-after studies based on two cross-sectional surveys were given an overall assessment of serious or critical risk of bias [20]. Disagreements were addressed via discussion and if necessary via a third author. All studies were classed as high, serious or critical risk of bias, meaning that due to issues with the quality of the studies, there was a substantial risk that included studies overestimated or underestimated the true effect of the interventions. The risk of bias in cluster RCTs and non-randomised interventional studies is displayed in S1 and S2 Tables respectively. Uncontrolled cross-sectional before-and-after studies were all classified as serious or critical risk of bias (S3 Table).

Based on the provided description, the systematic review identified several innovations and interventions that can be used to improve access to maternal health. These include:

1. Rights-based approaches: The review found that interventions based on human rights principles were effective in improving sexual and reproductive health outcomes. Implementing rights-based approaches can help ensure that women have access to comprehensive maternal health services and are empowered to make informed decisions about their reproductive health.

2. Testing uptake for HIV and other sexually transmitted infections (STIs): The review found that interventions aimed at increasing testing uptake for HIV and STIs were effective. This can be achieved through innovative strategies such as mobile clinics, community-based testing programs, and self-testing kits.

3. Condom use promotion: The review identified interventions that successfully increased condom use, which is crucial for preventing both unintended pregnancies and the transmission of STIs. Innovative approaches to promote condom use can include social marketing campaigns, distribution of free condoms, and integrating condom provision into existing maternal health services.

4. Awareness of rights: The review highlighted the importance of interventions that increase awareness of sexual and reproductive rights. This can be achieved through community education programs, training healthcare providers on human rights principles, and incorporating rights-based education into school curricula.

5. Gender-based violence prevention: Although the review did not find any studies specifically addressing gender-based violence outcomes, addressing this issue is crucial for improving maternal health. Innovative interventions can include community-based programs, survivor-centered support services, and training healthcare providers to identify and respond to cases of gender-based violence.

It is important to note that the review identified a considerable risk of bias in the included studies, indicating a need for high-quality controlled studies in this area.
AI Innovations Description
Based on the information provided, the systematic review titled “Rights based approaches to sexual and reproductive health in low and middle-income countries: A systematic review” highlights the need for rights-based approaches to improve access to sexual and reproductive health in low and middle-income countries. The review found that while rights-based interventions were effective for some outcomes such as testing uptake for HIV and/or other sexually transmitted infections, condom use, and awareness of rights, the evidence was of poor quality and there were considerable risks of bias in the included studies.

To develop this recommendation into an innovation to improve access to maternal health, it is important to focus on implementing rights-based approaches specifically targeting maternal health issues in low and middle-income countries. This could involve:

1. Strengthening healthcare systems: Enhancing the capacity and infrastructure of healthcare systems to provide comprehensive maternal health services, including antenatal care, skilled birth attendance, emergency obstetric care, and postnatal care. This can be achieved through training healthcare providers, improving facilities, and ensuring the availability of essential medicines and supplies.

2. Promoting women’s rights and empowerment: Empowering women and girls by promoting their rights to make informed decisions about their reproductive health, including family planning, pregnancy, and childbirth. This can be done through education, awareness campaigns, and community engagement to challenge harmful gender norms and practices that hinder access to maternal health services.

3. Addressing socio-economic barriers: Tackling socio-economic barriers that prevent women from accessing maternal health services, such as poverty, lack of transportation, and distance to healthcare facilities. This can be achieved through targeted interventions, such as providing financial support for transportation or implementing mobile health clinics in remote areas.

4. Improving quality of care: Ensuring that maternal health services are of high quality, respectful, and culturally sensitive. This involves training healthcare providers on respectful maternity care, promoting evidence-based practices, and monitoring and evaluating the quality of care provided.

5. Strengthening data collection and research: Investing in data collection and research to better understand the barriers and challenges to accessing maternal health services in specific contexts. This can inform evidence-based interventions and policies to improve access and outcomes.

Overall, the innovation should focus on integrating rights-based approaches into existing maternal health programs and policies, while also addressing the specific needs and challenges faced by women in low and middle-income countries. Collaboration between governments, healthcare providers, civil society organizations, and international partners is crucial for the successful implementation of such innovations.
AI Innovations Methodology
The systematic review described in the provided text aims to examine the evidence on rights-based approaches to sexual and reproductive health in low and middle-income countries. The review includes interventions related to gender-based violence, maternity, HIV, and sexually transmitted infections. The methodology used in this review involves the following steps:

1. Search Strategy: The authors conducted a comprehensive search of three databases (EMBASE, MEDLINE, and Web of Science) from inception until September 1, 2020. The search terms used included medical subject headings and free text terms related to sexual health, gender-based violence, maternal health, human rights, and more. Boolean operators were used to combine the search terms.

2. Inclusion Criteria: The inclusion criteria for selecting studies were as follows:
– Study design: Any interventional study.
– Population: Females aged over 15 living in low and middle-income countries.
– Intervention: Studies that involved a “rights-based approach” as defined by the author, or interventions explicitly stated to be related to “rights”.
– Comparator: Clusters without interventions or with fewer intervention components, or individuals not exposed to interventions.
– Outcome: Sexual and reproductive health-related outcomes.

3. Study Selection: After the initial database search, the authors identified 17,212 records. After removing duplicates and screening titles and abstracts, 13,404 studies remained. The full-text articles of these studies were then reviewed by two independent reviewers. Discrepancies in inclusion/exclusion decisions were resolved through discussion or consultation with a third author.

4. Data Extraction: Data from the included studies were extracted using a tool developed by the authors. The extracted information included study details, sample size, population characteristics, study design, interventions, statistical analysis, results, ethics, and funding. Only data relevant to the populations eligible for inclusion in the review were extracted.

5. Data Synthesis: Due to heterogeneity among the included studies, a narrative synthesis was conducted instead of a meta-analysis. The outcomes of the interventions were mapped to identify evidence gaps.

6. Risk of Bias Assessment: The risk of bias in the included studies was assessed independently by two reviewers using the RoB-2 tool for cluster-randomized studies and the ROBINS-I tool for non-randomized studies. Uncontrolled before-and-after studies based on two cross-sectional surveys were assessed for risk of bias. Disagreements were resolved through discussion or consultation with a third author.

7. Results and Conclusion: The findings of the included studies were summarized, taking into account the risk of bias. The authors noted that the evidence on rights-based approaches to sexual and reproductive health in low and middle-income countries was of poor quality, with a considerable risk of bias in all studies. They emphasized the need for high-quality controlled studies in this area.

In summary, the methodology used in this systematic review involved a comprehensive search strategy, rigorous study selection criteria, data extraction, risk of bias assessment, and a narrative synthesis of the findings.

Statistics:
Citations: 2
Authors: 7
Identifiers:
DOI: 10.1371/journal.pone.0250976
Research Areas:
Community Interventions, Disparities, Genetics and Genomics, Health System and Policy, Infectious Diseases, Maternal and Child Health, Mental Health, Sexual and Reproductive Health, Social Determinants
Study Design:
Cross Sectional Study, Narrative Study, Phenomenological Study, randomised-control-trial
Study Approach:
Mixed-methods, Qualitative, Quantitative, Systematic Review
Participants Gender:
Female
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