Advancing sexual and reproductive health and rights in Africa

Abstract

Sexual and reproductive health and rights (SRHR) are fundamental yet inadequately realized across Africa, undermining well-being, economic stability, and autonomy. This editorial synthesizes findings from 24 studies in a special collection, highlighting persistent challenges and innovative solutions. Key issues in family planning include low contraceptive uptake and discontinuation, particularly among women with HIV and adolescents, exacerbated by social pressures and systemic exclusion of marginalized groups like LGBTQ+ individuals and persons with disabilities. For comprehensive abortion care, access to quality post-abortion services remains low, though provider training shows promise for improving skills. Systemic inequities are evident in limited pre-exposure prophylaxis awareness, HIV-related fertility disparities, and high rates of gender-based violence (GBV), which is linked to adverse outcomes like repeat adolescent pregnancies. Evidence underscores that fragmented interventions fail; progress requires integrated, community-driven approaches. This includes combining HIV, mental health, and family planning services, empowering communities through peer-led networks, and implementing robust accountability mechanisms. Prioritizing the needs of marginalized populations—including adolescents, GBV survivors, and persons with disabilities—through inclusive policies, sustainable financing, and multi-level interventions is essential to building equitable SRHR systems that leave no one behind.

Introduction

Sexual and reproductive health and rights (SRHR) are fundamental for individuals of all genders throughout their lifespans. ¹ The five core aspects of SRHR include improving antenatal, perinatal, postpartum and newborn care; providing high-quality services for family planning, including infertility services; eliminating unsafe abortion; addressing sexually transmitted infections (STIs) including HIV, reproductive tract infections, cervical cancer and other gynecological morbidities; and promoting sexual health. Across Africa, inadequate SRHR undermines personal well-being, economic stability, and individual autonomy. ² Significant challenges persist in achieving optimal SRHR outcomes, including shortages of skilled healthcare providers, limited access to family planning services, preventable pregnancy complications, and barriers to comprehensive abortion care. However, transformative opportunities exist through strengthening service quality and delivery models, expanding community-based care, implementing evidence-based policies, and reducing preventable morbidity and mortality.

This editorial synthesizes findings from 24 studies published in the special collection, “Sexual and Reproductive Health Across Africa: Challenges and Opportunities,” in Therapeutic Advances in Reproductive Health and Women’s Health. These studies span family planning, comprehensive abortion care, and broader SRHR challenges. Collectively, these studies, conducted in Uganda, Rwanda, Kenya, Tanzania, Zimbabwe, Botswana, Burkina Faso, Zambia, and beyond, highlight both persistent gaps and innovative solutions.

Family planning: Bridging access and autonomy

Family planning services across Africa face intersecting barriers, from socioeconomic disparities to systemic exclusion. In northern Uganda, Acayo et al. ³ found that only 24.4% of women with HIV used modern contraceptives, with referrals to nearby health facilities and prior use significantly predicting uptake. Similarly, Solomon et al. ⁴ documented a 32.3% discontinuation rate among Tanzanian adolescents, primarily due to side effects and menstrual changes. These findings underscore the need for improved counseling and side effect management. However, even when services are available, social pressure limits autonomy, as seen in a study by Lambert et al. ⁵ in Tanzania where 76.9% of women discussed family planning with partners yet faced pervasive community influences.

Marginalized groups experienced compounded challenges in accessing and using contraceptives. In Zimbabwe, Khozah and Nunu ⁶ identified that lesbian and bisexual women encounter stigma and a lack of tailored services, while Bazakare et al. ⁷ found that a large proportion (67.4%) of visually impaired girls in Rwanda had alarmingly low menstrual hygiene knowledge. Conversely, empowerment-based interventions showed promise: employed women in Botswana had 1.77 times higher odds of consistent condom use, ⁸ while Ethiopian women with greater education and labor participation were more likely to use contraceptives. ⁹ Integrating mental health screening and disability considerations into family planning programs also showed promise, as demonstrated by Luwedde et al. ¹⁰ in Uganda, where 87.7% of women with severe mental illness used contraceptives, albeit with complex medication interactions.

Comprehensive abortion care: Quality and equity

Access to safe abortion and post-abortion care (PAC) remains inconsistent. In Uganda, Jackline et al. ¹¹ found that only 21.1% of women in their sample received the full PAC package, with being afforded a private space and partner support doubling uptake. Person-centered care, as measured by Udho et al., ¹² weakly correlated with satisfaction (r = 0.21), highlighting systemic communication gaps.

Training healthcare providers is critical to enhance clinician skills. Bucyebucye et al. ¹³ showed that clinician training in Rwanda improved abortion knowledge, while Pebolo et al. ¹⁴ demonstrated that simulation-based training in Uganda boosted emergency obstetric skills by 14%. However, structural barriers persist, particularly for adolescents. Nshutiyukuri et al.^15,16 in 2 studies reported that 36% of pregnancies in Rwanda’s Eastern Province were among teenagers, with poverty and sexual violence as key drivers. There is a need to scale high-quality, private PAC services and invest in competency-based training to reduce maternal mortality.

Sexual and reproductive health and rights: Addressing systemic inequities

SRHR disparities are particularly evident in relation to HIV. In Burkina Faso, Ekholuenetale et al. ¹⁷ reported that only 8.2% of women in their study were aware of pre-exposure prophylaxis (PrEP), with education and media exposure as key predictors. Similarly, Mulemena et al. demonstrated that fertility intentions among Zambian women varied by HIV status; that is, 42.1% for HIV-positive women versus 55.5% for HIV-negative women, highlighting the need for integrated HIV–SRHR counseling. ¹⁸ In Northern Uganda, Kumakech et al. found that only 73.3% of young women with HIV disclosed their status to their sexual partners, with mutual knowledge about HIV status increasing the odds of disclosure. ¹⁹

Gender-based violence (GBV) further complicates SRHR access. Owusu-Antwi et al. ²⁰ reported that 64.9% of university students in 6 African countries experienced psychological violence, yet only 29.5% sought formal help. In Uganda, Ramachandran et al. ²¹ linked violence to repeat adolescent pregnancies (adjusted odd ratio = 4.67), emphasizing the need for trauma-informed care. Buser et al.’s ²² scoping review of 173 qualitative studies provides critical context, identifying multi-level factors influencing SRHR in Uganda. At the individual level, knowledge gaps and risky behaviors persist, while interpersonal factors like partner communication and healthcare access can create additional barriers. This comprehensive analysis underscores the need for interventions addressing all levels of the socioecological system, from individual knowledge to policy reform.

Recent studies also highlight persistent challenges as well as innovative solutions in African SRHR services. Significant service gaps persist, as shown by Sohaili et al.’s ²³ findings of alarmingly high Chlamydia prevalence (2%–51%) with stark urban–rural disparities, underscoring the need for integrated STI screening. However, studies in the collection highlight successes in this space. Ach et al. ²⁴ established diagnostic precision for poly-cystic ovarian syndrome in North Africa with an 18-follicle cutoff (68.1% sensitivity, 100% specificity), demonstrating advancements in reproductive health diagnostics. Acen et al. ²⁵ identified education as a powerful SRHR lever, with health science students in Uganda showing 4.27 times higher emergency contraception use, suggesting the transformative potential of targeted SRH training.

The path forward: Integration and accountability

Evidence shows that fragmented interventions fail to address intersecting vulnerabilities. Achieving good SRHR in Africa demands integrated, community-driven approaches coupled with strong accountability mechanisms. First, health systems must break down silos by combining HIV, mental health, and family planning services, as demonstrated by Luwedde et al. ¹⁰ in Uganda’s integration of contraceptive care into mental health services and Mulemena et al. in Zambia’s HIV-fertility counseling. Second, empowering communities through peer-led GBV support networks, as evidenced by Owusu-Antwi et al. ²⁰ across six African countries, and parent–provider partnerships for adolescent SRHR, as shown by Uzayisenga et al. ²⁶ in Rwanda, can bridge gaps in health systems. Third, implementing standardized monitoring systems that track socioecological indicators, from contraceptive autonomy to PAC will support the measurement and tracking of progress.

By prioritizing the needs of the most marginalized populations, including women with disabilities, LGBTQ+ individuals, adolescents, and GBV survivors, African nations can build inclusive SRHR systems that uphold the fundamental principle of leaving no one behind. This requires political commitment to policy reform, sustainable financing for community-based programs, and innovative service delivery models that respond to the realities of diverse populations. Building on findings from the study of Buser et al., ²² successful programs must address individual, interpersonal, and structural factors simultaneously.