Accelerate progress-sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission

Prevalence and types of sexual inactivity in Britain: analyses of national cross-sectional probability survey data

OBJECTIVES

To examine how prevalence and context of sexual inactivity varies across the life-course, assess dissatisfaction with sex life among those who are sexually inactive and identify associations with factors that may represent reasons for sexual inactivity.

DESIGN

Analysis of cross-sectional probability sample survey data.

SETTING

British general population.

PARTICIPANTS

14 623 participants (n men: 6045 unweighted, 7245 weighted), aged 16-74 years, of the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), undertaken in 2010-2012.

MAIN OUTCOME MEASURES

Sexual inactivity, defined as not reporting oral, vaginal or anal intercourse in the past year and further categorised into those who were sexually inexperienced (had never had sex), single or in a relationship.

RESULTS

Overall, 15.9% (weighted n 1155/7245) of men and 22.2% (1646/7410) of women were sexually inactive (p<0.001). The proportion of sexually inactive individuals who were sexually inexperienced was larger among men than women (26.3% (304/1155) vs 16.3% (268/1646)), while the proportion who were singles was larger among women (49.8% (820/1646) vs 40.4% (467/1155)). Sexual inexperience was the most common type of sexual inactivity in early adulthood, with this declining with age. A minority of those who had sexual experience but were sexually inactive-34.8% (293/842) of men and 23.6% (319/1349) of women-reported being dissatisfied with their sex lives. Associations with sexual inactivity was observed for a range of sociodemographics and sexual behaviours/attitudes, for example, religion, ethnicity, Body mass index, height, employment status and index of multiple deprivation; these associations varied by type of sexual inactivity and gender.

CONCLUSIONS

While sex is important for well-being, a non-negligible proportion of the population at all ages are sexually inactive, yet many are not dissatisfied with their situation, with implications for sex and relationship counselling.

Sexual health services in the Arab region: Availability, access, and utilisation

Sexual health is shaped by cultural, economic, and social norms in society. In the Arab region, cultural sensitivities and taboos surrounding sexuality are prominent and may prevent individuals from accessing and utilising sexual health services. It is important to map out available sexual health services to identify the challenges in availability, access, and treatment, and determine opportunities for improvement. We collected data on sexual health services through (1) relevant published and unpublished literature, (2) Arab media which included forums, websites, blogs and posts, and online surveys conducted in the Arab region, (3) a questionnaire emailed to sexual and reproductive health experts, organisations, clinics, and non-governmental organisations (NGOs), (4) phone and in-person formal and informal interviews with sexual health experts in the field, and (5) advice and recommendations from sexual health experts attending a World Health Organization (WHO) consultation meeting in Dubai related to sexual health in the Arab region. Although there is significant progress when it comes to the availability and provision of sexual health services in Arab countries, there is still a lot to be done to ensure that appropriate needs are met. This study discusses the implication of findings to inform programme and policy implementation in the region.

Post-abortion care: Ethical and legal duties

Women who experience complications from abortion, whether unlawful or lawful, induced or spontaneous, need immediate post-abortion care. Delay in providing care might cause women's avoidable disability, lost childbearing capacity, or death. Rendering care is not an abortion procedure nor illegal, and does not justify conscientious objection. Harm reduction strategies to reduce effects of unsafe abortion may legitimately inform women who might consider resort to abortifacient interventions of their rights to professional post-abortion care. Healthcare practitioners' refusal or failure to provide available care might constitute ethical misconduct and attract legal liability, for instance for negligence. States are responsible to ensure healthcare practitioners' and facilities' provision of post-abortion care, including both medical care and psychological support, delivered with compassion and respect for dignity, and to suppress stigmatization of patients and/or caregivers. Mandatory reporting of patients suspected of criminal abortion violates professional confidentiality. States' failures of indicated care might constitute human rights violations.

Availability of Services Related to Achieving Pregnancy in U.S. Publicly Funded Family Planning Clinics

BACKGROUND

Recognizing that quality family planning services should include services to help clients who want to become pregnant, the objective of our analysis was to examine the distribution of services related to achieving pregnancy at publicly funded family planning clinics in the United States.

METHODS

A nationally representative sample of publicly funded clinics was surveyed in 2013-2014 (n = 1615). Clinic administrators were asked about several clinical services and screenings related to achieving pregnancy: basic infertility services, reproductive life plan assessment, screening for body mass index, screening for sexually transmitted diseases, provision of natural family planning services, infertility treatment, and primary care services. The percentage of clinics offering each of these services was compared by Title X funding status; prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated after adjusting for clinic characteristics.

RESULTS

Compared to non-Title X clinics, Title X clinics were more likely to offer reproductive life plan assessment (adjusted PR [aPR], 1.62; 95% CI, 1.42-1.84), body mass index screening for men (aPR, 1.10; 95% CI, 1.01-1.21), screening for sexually transmitted diseases (aPRs ranged from 1.21 to 1.37), and preconception health care for men (aPR, 1.10; 95% CI, 1.01-1.20). Title X clinics were less likely to offer infertility treatment (aPR, 0.55; 95% CI, 0.40-0.74) and primary care services (aPR, 0.74; 95% CI, 0.68-0.80) and were just as likely to offer basic infertility services, preconception health care services for women, natural family planning, and body mass index screening in women.

CONCLUSIONS

The availability of selected services related to achieving pregnancy differed by Title X status. A follow-up assessment after publication of national family planning recommendations is underway.

Young people's health and risk behaviours in relation to their sexual orientation: A cross-sectional study of Thailand and Sweden

OBJECTIVES

This study examined the associations between sexual orientation of young people and their health and risk behaviours in Thailand and Sweden, and to explore similarities and differences between the countries.

STUDY DESIGN

A cross-sectional study using data from the Life and Health - Young surveys in Thailand and Sweden. Three different statistical analyses were used to examine the associations of the variables.

RESULTS

In total, 3869 students aged 16-18 years old were included: 1488 Thai students and 2381 Swedish students. Significantly more Thai (20%) than Swedish (9%) students identified themselves as bisexual, homosexual or unsure (p < .001). Bivariate analysis showed that, in Thailand, self-harm was more often reported by the homosexual, unsure, and bisexual groups than by the heterosexual group (p = .005). In Sweden, early sexual debut was more often reported by the unsure, bisexual, and homosexual groups than by the heterosexual group (p = .033). Multiple logistic regression analysis showed that homosexual and unsure sexual orientations were significantly associated with self-harm (p < .05) among Thai students. Unsure sexual orientation was significantly associated with early sexual debut (p = .04) among Swedish students. Multiple correspondence analysis indicated that sexual orientation was associated with health and risk behaviours, and varied by different subcategories of students' backgrounds such as country, sexual orientation, family structure and adult support.

CONCLUSIONS

Sexual minority young people reported more risk behaviours and poorer health than their heterosexual counterparts. The findings are useful for policy programmes on sexual and reproductive health and rights of young people.

Opportunities lost: Barriers to increasing the use of effective contraception in the Philippines

Background

In the Philippines, one in four pregnancies are unintended and 610 000 unsafe abortions are performed each year. This study explored the association between missed opportunities to provide family planning counseling, quality of counseling and its impact on utilization of effective contraception in the Philippines.

Methods

One-hundred-one nationally representative health facilities were randomly selected from five levels of the health system. Sexually-active women 18–49 years old, wanting to delay or limit childbearing, attending primary care clinics between April 24 and August 8, 2017 were included. Data on contraceptive use, counseling and availability were collected using interviews and facility assessments. Effective contraceptive methods were defined as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use.

Findings

849 women were recruited of whom 51.1% currently used effective contraceptive methods, 20.6% were former effective method users and 28.3% had never used an effective method. Of 1664 cumulative clinic visits reported by women in the previous year, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility, with 83.7% having a missed counseling opportunity on the day of the interview. Most women (55.9%) reported health concerns about modern contraception, with 2.9% receiving counseling addressing their concerns. Only 0.6% of former users and 2.1% never-users said they would consider starting a modern contraceptive in the future. Short and long acting reversible contraceptive methods were available in 93% and 68% of facilities respectively.

Conclusions

Missed opportunities to provide family planning counseling are widespread in the Philippines. Delivery of effective contraceptive methods requires that wider legal, policy, social, cultural, and structural barriers are addressed, coupled with systems approaches for improving availability and quality of counseling at all primary health care contacts.

The Extent to Which Performance-Based Financing Programs' Operations Manuals Reflect Rights-Based Principles: Implications for Family Planning Services

Rights principles should be prioritized and more clearly stated in performance-based financing (PBF) guidance and operational documents. Additional research, including development of validated measurement metrics, is needed to help PBF programs systematically align with rights-based approaches to health care including family planning.

Recognition is growing that development programs need to be guided by rights as well as to promote, protect, and fulfill them. Drawing from a content analysis of performance-based financing (PBF) implementation manuals, we quantify the extent to which these manuals use a rights perspective to frame family planning services. PBF is an adaptable service purchasing strategy that aims to improve equity and quality of health service provision. PBF can contribute toward achieving global family planning goals and has institutional support from multiple development partners including the Global Financing Facility in support of Every Woman Every Child. A review of 23 PBF implementation manuals finds that all documents are focused largely on the implementation of quality and accountability mechanisms, but few address issues of accessibility, availability, informed choice, acceptability, and/or nondiscrimination and equity. Notably, operational inclusion of agency, autonomy, empowerment, and/or voluntarism of health care clients is absent. Based on these findings, we argue that current PBF programs incorporate some mention of rights but are not systematically aligned with a rights-based approach. If PBF programs better reflected the importance of client-centered, rights-based programming, program performance could be improved and risk of infringing rights could be reduced. Given the mixed evidence for PBF benefits and the risk of perverse incentives in earlier PBF programs that were not aligned with rights-based approaches, we argue that greater attention to the rights principles of acceptability, accessibility, availability, and quality; accountability; agency and empowerment; equity and nondiscrimination; informed choice and decision making; participation; and privacy and confidentiality would improve health service delivery and health system performance for all stakeholders with clients at the center. Based on this review, we recommend making the rights-based approach explicit in PBF; progressively operationalizing rights, drawing from local experience; validating rights-based metrics to address measurement gaps; and recognizing the economic value of aligning PBF with rights principles. Such recommendations anchor an aspirational rights agenda with a practical PBF strategy on the need and opportunity for validated metrics.

Trends in heterosexual inexperience among young adults in Japan: analysis of national surveys, 1987-2015

BACKGROUND

It has been suggested that an increasing number of Japanese adults remain sexually inexperienced; however, no study has assessed this issue using nationally representative data.

METHODS

We used data from seven rounds of the National Fertility Survey of Japan, 1987-2015, and included adults aged 18-39 years (18-34 years in the 1987 survey) in the analyses (sample size 11,553-17,850 [1987-2010]; response rate 70.0-92.5%). For each survey year, sex and age group, we estimated the age-adjusted prevalence of heterosexual inexperience, defined as reporting no experience of sexual intercourse with someone of the opposite sex. We used logistic regression, adjusted for age, to identify factors associated with heterosexual inexperience in the 2010 survey. Information about same-sex sexual experience was not available.

RESULTS

Between 1992 and 2015, the age-standardized prevalence of heterosexual inexperience in adults aged 18-39 years increased from 21.7 to 24.6% for women (p-values for linear and quadratic trend < 0.05) and from 20.0 to 25.8% for men (p-values for trend < 0.05). Among those aged 30-34 years, the prevalence was 6.2% in 1987 and 11.9% in 2015 for women (p-values for trend ≥0.05) and 8.8% (1987) and 12.7% (2015) for men (p-values for trend ≥0.05). Among those aged 35-39 years, prevalence increased from 4.0% in 1992 to 8.9% in 2015 among women (p-values for trend < 0.05). The corresponding numbers for men in the same age group were 5.5 and 9.5%, respectively (p-values for trend ≥0.05). Among men aged 25-39 years, unemployment, temporary/part-time employment and lower income were associated with heterosexual inexperience.

CONCLUSIONS

The proportion of young Japanese adults with no experience of heterosexual intercourse had increased in the past two decades. Among adults in their thirties, around one in ten had no heterosexual experience. Unemployment, temporary/part-time employment and low income were associated with heterosexual inexperience among men. Further research is needed on the factors contributing to and the potential public health and demographic implications of the high proportion of the Japanese population that remains sexually inexperienced well into adult age.

Sexual and reproductive self care among women and girls: insights from ethnographic studies

Ethnographic studies examining how women manage their sexual and reproductive health can inform strategies to address unmet needs, say Anita Hardon and colleagues

A Critique of O'Byrne's Understanding of Ethnography and the Politics of Public Health Research

Patrick O'Byrne criticizes the use of ethnography in public health research focused on cultural groups. His main argument is that ethnography disciplines marginalized populations that do not respect the imperative of health. In this article, I argue that O'Byrne has an erroneous understanding of ethnography and the politics of scientific research. My main argument is that a methodology itself cannot discipline individuals. I argue that if data are used as a basis to develop problematic public health policies, the issue is the policies themselves and not the methodology used to collect the data. While O'Byrne discourages researchers from conducting health research like ethnography focused on cultural groups, I argue the exact opposite. This has to do with justice and equity for marginalized communities and the obligation to tailor health services for their specific needs, which may not be the same as those of the general population.

Female genital mutilation/cutting in Africa: A complex legal and ethical landscape

While international and regional human rights instruments have recognized female genital mutilation/cutting (FGM/C) as one of the most prevalent forms of violence against women and girls, in many African states FGM/C is a deeply entrenched cultural practice. There is a consensus against FGM, as evidenced by its criminalization in several African countries. The mere fact that the practice continues despite legislative measures to protect women and girls against FGM raises the question of whether change can be legislated. The present article summarizes the trends and effectiveness of FGM criminalization in Africa, including prohibition of medicalization of FGM. Against the backdrop of emerging debate on medicalization of FGM as a harm reduction strategy, we also examine its complex legal and ethical implications. The article argues that while criminalization may not be the best means of stopping FGM, it creates an enabling environment to facilitate the overall strategy of African governments in eradication of the practice.

Disability and Access to Sexual and Reproductive Health Services in Cameroon: A Mediation Analysis of the Role of Socioeconomic Factors

There is growing evidence showing that people with disabilities face more frequently socioeconomic inequities than their non-disabled peers. This study aims to examine to what extent socioeconomic consequences of disability contribute to poorer access to sexual and reproductive health (SRH) services for Cameroonian with disabilities and how these outcomes vary with disabilities characteristics and gender. It uses data from a population-based survey conducted in 2015 in Yaounde, Cameroon. Mediation analysis was performed to determine how much of the total association between disability and the use, satisfaction and difficulties to access SRH services was mediated by education level, material wellbeing lifetime work participation and availability of social support. Overall, disability was associated with deprivation for all socioeconomic factors assessed though significant variation with the nature and severity of the functional limitations was observed. Lower education level and restricted lifetime work mediated a large part of the association between disability and lower use of HIV testing and of family planning. By contrast, while people with disabilities reported more difficulties to use a SRH service, no mediating was identified. In conclusion, Cameroonians with disabilities since childhood have restricted access to SRH services resulting from socioeconomic factors occurring early during the life-course.

Female subfertility

Subfertility is common and affects one in six couples, half of whom lack an explanation for their delay in conceiving. Developments in the diagnosis and treatment of subfertility over the past 50 years have been truly remarkable. Indeed, current generations of couples with subfertility are more fortunate than previous generations, as they have many more opportunities to become parents. The timely access to effective treatment for subfertility is important as many couples have a narrow window of opportunity before the age-related effects of subfertility limit the likelihood of success. Assisted reproduction can overcome the barriers to fertility caused by tubal disease and low sperm count, but little progress has been made in reducing the effect of increasing age on ovarian function. The next 5-10 years will likely see further increases in birth rates in women with subfertility, a greater awareness of lifestyle factors and a possible refinement of current assisted reproduction techniques and the development of new ones. Such progress will bring challenging questions regarding the potential benefits and harms of treatments involving germ cell manipulation, artificial gametes, genetic screening of embryos and gene editing of embryos. We hope to see a major increase in fertility awareness, access to safe and cost-effective fertility care in low-income countries and a reduction in the current disparity of access to fertility care.

Million Migrants study of healthcare and mortality outcomes in non-EU migrants and refugees to England: Analysis protocol for a linked population-based cohort study of 1.5 million migrants

Background: In 2017, 15.6% of the people living in England were born abroad, yet we have a limited understanding of their use of health services and subsequent health conditions. This linked population-based cohort study aims to describe the hospital-based healthcare and mortality outcomes of 1.5 million non-European Union (EU) migrants and refugees in England. Methods and analysis: We will link four data sources: first, non-EU migrant tuberculosis pre-entry screening data; second, refugee pre-entry health assessment data; third, national hospital episode statistics; and fourth, Office of National Statistics death records. Using this linked dataset, we will then generate a population-based cohort to examine hospital-based events and mortality outcomes in England between Jan 1, 2006, and Dec 31, 2017. We will compare outcomes across three groups in our analyses: 1) non-EU international migrants, 2) refugees, and 3) general population of England. Ethics and dissemination: We will obtain approval to use unconsented patient identifiable data from the Secretary of State for Health through the Confidentiality Advisory Group and the National Health Service Research Ethics Committee. After data linkage, we will destroy identifying data and undertake all analyses using the pseudonymised dataset. The results will provide policy makers and civil society with detailed information about the health needs of non-EU international migrants and refugees in England.

Associations between contraception and stunting in Guatemala: secondary analysis of the 2014-2015 Demographic and Health Survey

BACKGROUND

There has been limited research on the relationship between contraception and child growth in low-income and middle-income countries (LMICs). This study examines the association between contraception and child linear growth in Guatemala, an LMIC with a very high prevalence of child stunting. We hypothesise that contraceptive use is associated with better child linear growth and less stunting in Guatemala.

METHODS

Using representative national data on 12 440 children 0-59 months of age from the 2014-2015 Demographic and Health Survey in Guatemala, we constructed multivariable linear and Poisson regression models to assess whether child linear growth and stunting were associated with contraception variables. All models were adjusted for a comprehensive set of prespecified confounding variables.

RESULTS

Contraceptive use was generally associated with modest, statistically significant greater height-for-age z-score. Current use of a modern method for at least 15 months was associated with a prevalence ratio of stunting of 0.87 (95% CI 0.81 to 0.94; p<0.001), and prior use of a modern method was associated with a prevalence ratio of stunting of 0.93 (95% CI 0.87 to 0.98; p<0.05). The severe stunting models found generally similar associations with modern contraceptive use as the stunting models. There was no significant association between use of a modern method for less than 15 months and the prevalence ratio of stunting or severe stunting.

CONCLUSIONS

Contraceptive use was associated with better child linear growth and less child stunting in Guatemala. In addition to the human rights imperative to expand contraceptive access and choice, family planning merits further study as a strategy to improve child growth in Guatemala and other countries with high prevalence of stunting.

A missed opportunity? Lack of knowledge about sexual and reproductive health services among immigrant women in Sweden

OBJECTIVE

Poor sexual and reproductive health (SRH) among immigrant women is often related to limited access, or suboptimal use of healthcare services. This study investigates the knowledge about and use of sexual and reproductive healthcare services among immigrant women in Sweden.

METHOD

A cross-sectional study of 288 immigrant women. A structured questionnaire was distributed among immigrants speaking Arabic, Dari, Somali or English registered at Swedish language schools for immigrants. Data collection took place in 19 strategically selected schools in Sweden. Descriptive statistics, chi-square tests, and logistic regressions were used for the analysis.

RESULTS

About one-third of the immigrant women reported lack of knowledge of where to go for contraceptive counselling. Experiencing lack of emotional social support and not having had children was associated with this lack of knowledge. An even higher proportion (56%) lacked knowledge of where to go to be HIV tested, and this was associated with not having participated in a health examination. Almost 25% stated that their culture kept them back from using contraception.

CONCLUSION

Lack of knowledge of where to turn for contraceptive counselling and HIV testing among immigrant women participating in Swedish language schools for immigrants could be considered as a missed opportunity, as all citizens in Sweden have free access to these services. New health policies and strategies should aim to increase knowledge of SRH services among immigrants. Swedish language schools could play an important role in increasing knowledge of SRH-related information as many new immigrants become students during their first years in Sweden.

Recent advances in improving the effectiveness and reducing the complications of abortion

When conducted in a legal setting and under safe conditions, abortion is an extremely effective and safe procedure. Tragically, almost half of all abortions that take place in the world are conducted under unsafe conditions, mostly in countries where abortion is illegal or highly restricted. These unsafe abortions are a major cause of maternal death and disability. Restricting a woman’s access to abortion does not prevent abortion but simply leads to more unsafe abortions. Barriers to safe abortion are many but include legal barriers, health policy barriers, shortages of trained healthcare workers, and stigma surrounding abortion. This commentary will consider some recent advances to improve access to safe abortion as well as refinements in abortion methods and service delivery in settings where safe abortion is available that further improve the care and wellbeing of women who seek abortion.