HRP annual report 2023

HEALTH FOR ALL UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction HRP annual report

UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction HRP annual report HRP annual report 2023 (HRP annual report) ISBN 978-92-4-009117-7 (electronic version) ISBN 978-92-4-009118-4 (print version) © World Health Organization 2024 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Foreword v Preface vii Introduction 1 Sexual and Reproductive Health and Rights in the Sustainable Development Goals 3 Chapter 1: Research leadership and knowledge management 5 Chapter 2: Contraception and fertility care 9 Chapter 3: Maternal and perinatal health 17 Chapter 4: Preventing unsafe abortion 23 Chapter 5: Rights and equality across the life course 29 Chapter 6: Sexual health and well-being across the life course 37 Chapter 7: Sexual and reproductive health integration in health systems 43 Chapter 8: Emerging diseases and sexual and reproductive health 49 Chapter 9: Building new audiences and stronger partnerships 53 Conclusion 63 Photo credits 64 Contents © W H O /C hr is tin e M cN ab I have had the privilege of working with HRP for almost 10 years and am deeply moved by the tangible benefits HRP brings to the lives of millions of people in low- and middle-income countries (LMICs). We should celebrate these achievements, while noting that much remains to be done to ensure that high- quality sexual and reproductive health (SRH) services can be accessed by all. There is global agreement that access to comprehensive SRH services is an essential element of universal health coverage. The Sustainable Development Goals cannot be achieved without gender equality and sexual and reproductive health and rights (SRHR). So how can we encourage more countries to incorporate comprehensive SRH services into primary health care? HRP exists to support countries to do exactly this. The programme supports and conducts research and contributes to evidence-based guidance that is freely available for all Member States and partners. These guidance documents are highly regarded, and eagerly taken up by national and subnational health authorities, international partner agencies and civil society actors. An essential feature of HRP’s success is its attention to the lived experience of those who are the subjects of its research or the intended beneficiaries of its guidance. It is this inclusive approach through rigorous research carried out to the highest scientific standards, and practical testing of guidelines and policies with experts and health workers in countries that makes its work so effective. Quality and impact are further enhanced by strong participation of national and local researchers, and by ensuring the use of a gender perspective and rights-based approach. HRP’s efforts in research capacity strengthening at both individual and institutional levels have further enhanced SRHR research in LMICs. In just the past year, HRP’s research has made important contributions to addressing leading causes of maternal mortality and morbidity, improving access to comprehensive abortion care, ensuring respectful care of pregnant women, enhancing evidence in relation to infertility, and addressing bottlenecks in the access to preferred contraceptive methods. Convening across different health systems, cultural settings and political priorities is a challenging task, but as chair of the Policy and Coordination Committee (PCC), which oversees HRP’s work, I have been inspired by the constructive discussion, responsive listening and collective guidance of representatives of our cosponsors and advisory bodies as well as PCC members and observers. HRP holds space to allow for diverse experiences coming together in fundamental agreement: that the need for evidence- and rights-based policies to advance SRHR is universal. I hope that readers will take from this annual report an understanding of HRP’s ongoing value, and that they will continue to support its research as a vital contributor to the global health landscape. Dr Teresa Soop Senior Research Advisor, Swedish International Development Cooperation Agency (Sida) and Chair of HRP’s Policy and Coordination Committee (2020–2024). Foreword © W H O /C hr is tin e M cN ab v © W H O /R ad a Ad ba r As an African woman, a mother, a nurse midwife and as a public health researcher, evidence generated through the United Nation’s Special Programme of Research, Development and Research Training in Human Reproduction (HRP) has had relevance and impact for me across all the stages of my life. I am now immensely proud to serve as HRP’s Director. Over the past five decades, since HRP’s establishment, we have undoubtedly been moving towards a world where all people can claim their right to comprehensive sexual and reproductive health, but we are also at risk of losing ground. If there is one message that I would like readers to take away from this annual report, it is that we must hold firm to proven solutions that make peoples’ health better and continue to identify approaches that work, to ensure lasting progress. I recognize that in the context of sexual and reproductive health and rights (SRHR), these statements may be viewed as controversial. Our research has often overlapped with debates on human rights, gender equality, bodily autonomy and sexuality. While often ahead of the curve, HRP always balances a progressive approach with solid scientific research and evidence. It is for this reason that the programme has retained its credibility and influence for more than 50 years. HRP is a unique organization that is cosponsored by five United Nations agencies – the United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), World Health Organization (WHO) and the World Bank. I want to pay tribute to our partners across these institutions, and to all Member States and civil society actors who support HRP, collaborate with us in research and implement our findings. It is through these important relationships that the work of HRP has meaning – our research is of benefit when it is used to make people’s lives better. HRP also plays a vital role in advancing SRHR components of high-level global health goals, including universal health coverage (UHC) and the 2030 Sustainable Development Goals. With many indicators currently badly off track, we will need to be innovative, adapt to changing global realities and work hard to make significant progress. It is clear to me that the work of HRP is as important as ever. As we review 2023 and look forward to 2024, we commit once again to continuing our work, with the goal of ensuring that all people can enjoy the best possible sexual and reproductive health and rights, throughout their lives. Dr Pascale Allotey Director, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) and the WHO Department of Sexual and Reproductive Health and Research (SRH). Preface © W H O /R ad a Ad ba r vii viii HRP annual report 2023 Credit © H RP /W H O /U m a Bi st a Introduction The United Nations Special Programme of Research, Development and Research Training in Human Reproduction, known as the Human Reproduction Programme or HRP, has been providing the world with research findings and guidance on sexual health and reproduction (SRH) for more than half a century. This annual report highlights the programme’s key achievements in 2023, and points to major ongoing research that will be completed in the next few years. For a complete list of published journal articles, please go to https://extranet.who.int/hrp/performance. Significant contributions by HRP to global research and guidance in 2023 include the following: Global infertility prevalence estimation: Publication of the first global estimate in more than a decade of the prevelance of infertility revealed that an estimated 1 in 6 people (around 17.5%) are affected by infertility at some time in their lives. The findings have led to further analysis of treatment standards and costs, which can amount to more than a year’s earnings in many low- and lower-middle-income countries. See Chapter 2. A game changing treatment package to prevent maternal mortality: Severe bleeding after childbirth, or postpartum haemorrhage (PPH), is the leading cause of maternal death, and this is preventable with appropriate and timely intervention. In response to stagnation in global progress on maternal mortality, HRP piloted a treatment package for early detection and treatment of PPH using the mnemonic acronym E-MOTIVE. See Chapter 3. Preventing unsafe abortions: Stopping unsafe abortions and improving access to comprehensive abortion care (CAC) worldwide is a key area of our work and HRP has contributed to a new WHO clinical practice handbook for quality abortion care, including digital tools and online training resources. See Chapter 4. The rise of self-care: Self-care is a rapidly expanding field in all areas of health care including SRH. HRP is conducting new research to inform guidance on self-testing, self-administered abortion medicines and self-administered contraceptive injections. These have significant potential to increase the access to SRH services that currently remain out of reach for millions. See Chapter 6. Empowering and training health workers: The role of health workers in delivering safe and effective SRH care is a core concern of HRP and we work to strengthen capacity and knowledge across the sector. HRP has contributed to new digital courses for health workers who care for survivors of intimate partner violence and sexual violence, provide CAC and respectful maternal care, as well as for those working to prevent female genital mutilation. These are just a few highlights of HRP’s work in 2023. The chapters of this annual report provide further information about HRP’s new and ongoing research, along with information about how HRP works with United Nations partners, Member States, civil society organizations, health practitioners, communities and fellow researchers around the world. We welcome your feedback, comments and questions. For more information, please contact: srhhrp@who.int 1 Credit viii HRP annual report 2023 © H RP /W H O /U m a Bi st a Sexual and Reproductive Health and Rights in the Sustainable Development Goals SDG 3: Good health and well-being Sexual and reproductive health has significant impacts on health and well-being. SDG 3 will not be achieved unless all people have access to the sexual and reproductive health (SRH) services that they need. SDG 5: Achieve gender equality and empower all women and girls Gender inequalities prevent women and girls from practising safer sex, limit their use of contraceptives, increase their risk of acquiring STIs including HIV, and underpin violence and harmful practices. See Chapter 5. SDG 4: Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all Comprehensive sexuality education (CSE) reduces sexually transmitted infections (STIs) and early sexual debut, and increases safer sexual behaviours. However, considerable resistance to CSE from governments, schools, teachers and parents is a barrier to scaling up CSE. See Chapter 6. SDG 6: Ensure availability and sustainable management of water and sanitation for all Menstrual health depends on access to improved water and sanitation for all, with implications across for progress in education, decent work, and gender equality. See Chapter 6. HRP annual report 2023 HRP’s mission – to achieve comprehensive sexual and reproductive health services for all – touches on a wide range of global health and inequality challenges. Addressing them is key to the achievement of the of the Sustainable Development Goals. SDG 8: Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all Contraception enables women to control their fertility and participate in life and work beyond motherhood. Lack of access to contraceptive services has far- reaching consequences and is intimately linked to social norms and issues of gender equality. See Chapter 2 and 5. SDG 10: Reduced inequality within and among countries Evidence-backed policy change is essential to addressing violence against women and girls and ending harmful practices based on gender inequality such as female genital mutilation and child marriage. See Chapter 5 SDG 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels Social accountability, informed consent, inclusion and human rights must be an explicit part of comprehensive sexual and reproductive health services. SDG 17: Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development Our partnership and collaboration with United Nations cosponsor agencies, new partnerships and ever-wider dissemination of research findings aim to support and revitalise the SDG agenda. See Chapter 9. 3 Chapter © W H O /B lin k M ed ia – C in dy L iu HRP annual report 2023 1 Research leadership and knowledge management The work carried out by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) meets the highest quality of research standards thanks to the wide range of expertise and support from the Research Leadership and Knowledge Management unit, particularly in the areas of biostatistics and data management. This team ensures the scientific rigour of research conducted or supported by HRP, such that the work of this unit is embedded in all the achievements highlighted throughout this annual report. The unit also manages electronic platforms for knowledge sharing and research infrastructure enhancement across HRP. To note some particularly relevant contributions in 2023, the team supported the research to determine global infertility prevalence estimates, the Global Study on Male Contraception, the global STI research priority-setting survey, and numerous clinical trials. Building research capacity in low- and middle-income countries Importantly, this team supports and strengthens sexual and reproductive health and rights (SRHR) research capacity in low- and middle-income countries (LMICs), while also producing innovative tools and platforms to disseminate and store data from supported studies. The HRP Alliance, the HRP Statistics Portal and the Research Projects Review Panel are three important structures that aim to foster collaboration and strengthen research capacity. 5 The HRP Alliance for Research Capacity Strengthening The HRP Alliance brings together research partners to support research capacity strengthening in LMICs. The HRP Alliance Advisory Board provides strategic support and reviews all HRP Alliance activities. The HRP Alliance capitalizes on and reinforces existing collaborations, providing long-term institutional grants to HRP Alliance hubs. The hubs support institutions in their respective regions, enabling them to strengthen their research capacity through training and workshops, scholarship support, and institutional mentorship and networking. The HRP Alliance also supports courses and occasional special research initiatives, all within the framework of SRHR implementation research. In its first five years (2017–2022), seven HRP Alliance hubs have been established worldwide, bringing together over 100 institutions, WHO country offices and WHO Collaboration Centres engaged in sexual and reproductive health research in LMICs. In total, over 330 junior and mid-level researchers and HRP Alliance fellows (205 female, 129 male) were trained through eight short courses offered by three hubs. doctoral (20 female, 19 male) and master’s students (23 female, 11 male) continue to receive support through the HRP Alliance. HRP Alliance hubs participated in 10 HRP research studies in 2023, providing opportunities for postgraduate students and/or early-career researchers. 6 HRP annual report 2023 HRP Statistics Portal In 2023, the HRP Statistics Knowledge Portal was made available to registered external users. The portal offers global guidelines and standard practices for research planning, data analysis, report synthesis and results interpretation. A series of “how to” videos are available on YouTube created to guide researchers through HRP’s full- cycle research process. Research Projects Review Panel The Research Projects Review Panel provides scientific, technical, ethical and financial review of research projects under consideration by HRP and WHO’s Department of Sexual and Reproductive Health and Research (SRH). The Panel assists HRP and SRH to foster recognition of universal ethical principles as well as scientific principles of good research practice. The type of research under consideration includes, but is not restricted to, basic, biomedical, epidemiological, social science, operations, implementation, health systems and programme development research.   Research leadership and knowledge management 7 Chapter © H RP /W H O /S ai yn a Ba sh ir HRP annual report 2023 2 Contraception and fertility care Access to safe and effective contraception was one of the first priorities of HRP when the programme began in the 1970s and, along with family planning, remains a major focus of its work today. Through all its research and dissemination activities in this thematic area, HRP aims to empower people to make informed decisions about their fertility choices and to review available evidence to ensure that contraception and fertility interventions are accessible, affordable, effective and safe. In the past 30 years, the availability of contraception has transformed the ability of women to control their fertility and participate in life and work beyond motherhood. However, there is still a significant unmet need for contraception, which limits women’s options and impacts individuals’ and couple’s rights to make informed choices about having children. This lack of access to contraceptive services has far-reaching consequences for many women and girls and is intimately linked to social norms and issues of gender equality. Improving access to contraception and family planning is not only about increasing access to products, but also about changing human behaviour and addressing institutional capacity and bottlenecks in health systems. 1 in 6 people are estimated to be affected by infertility. The unmet need for safe and effective contraception is estimated at 256 million women and girls 9 Fertility care Global infertility prevalence estimates In 2023, HRP published the global prevalence of infertility: an estimated 1 in 6 people globally (17.5%) are affected by the inability to have children at some point in their lives, sometimes with devastating consequences. This was one of the most widely reported pieces of HRP research during the year and has already prompted further study of the impacts of infertility and the costs of fertility treatment, and development of a WHO fertility care guideline, which is in progress. The ground-breaking report was released in April 2023, providing the first detailed insight into global infertility in more than 10 years, particularly in low- and middle-income countries (LMICs). It was based on an initial analysis of over 12 000 studies published between 1990 and 2021, leading to a selection of 133 studies for detailed analysis. From this, relevant data points were used to generate estimates of infertility over lifetimes and at specific periods. The analysis also indicated that in most countries, services to treat infertility are inadequate and the economic costs for individuals and couples seeking treatment were very high. Small regional differences in infertility prevalence were found, but significant gaps in available data meant that researchers were not confident that these differences were meaningful or conclusive. The many different methods used to measure infertility, lack of studies in some regions, and variations in definitions used in estimating infertility mean that further research is necessary. Understanding how individuals and couples experience infertility, and how these experiences vary by context, is essential in developing appropriate interventions. HRP’s preliminary work in response to the initial findings suggests that a combination of interventions will be needed to address individual needs (coping, agency), social issues (stigma, social norms) and policies (health care availability, affordability and legal frameworks). Understanding how individuals and couples experience infertility, and how these experiences vary by context, is essential in developing appropriate interventions. Infertility affects men and women and is defined by WHO as failure to achieve pregnancy after 12 months or more of regular unprotected sexual intercourse. 1990–2021 Infertility prevalence estimates 10 Data on infertility are of interest not only to affected individuals and their health-care providers; they are also relevant to the achievement of the Sustainable Development Goals. However, an HRP commentary makes the important point, from a human rights perspective, that fertility rates should not be used as a basis for offering or restricting access to either contraception or fertility care. It is an individual’s right to access contraception in settings with low birth rates as much as in settings with high birth rates, and the same is true for their right to access fertility care. Other HRP achievements and research activities on infertility in 2023 include the following. • Fertility care medicines were added to WHO’s Model List of Essential Medicines (EML): letrozole (for ovulation induction) and cabergoline and bromocriptine (for the management of infertility due to prolactinoma and other causes of hyperprolactinaemia). • A scoping study was conducted into the financial costs of fertility care in LMICs, starting with a review of costs in high-income countries. • A review was initiated on the topic of infertility in non-heteronormative groups, including same- sex partners, single individuals who are not in sexual/marital relationships and those with certain medical conditions, such as HIV-serodiscordant couples and cancer survivors. • Technical support was provided to India to develop a road map for setting up affordable fertility care services. • The first public provision of assisted reproductive technology in Rabat, Morocco was evaluated. • The Global Fertility Care Community of Practice was created – an online knowledge-sharing platform with over 900 members. • The WHO laboratory manual for the examination and processing of human semen was updated with additional trans-lations, having been first published in 1980. Services to treat infertility are inadequate and costs of treatment are often very high. Infertility often has devastating social and economic consequences. Contraception and fertility care 11 Contraception and family planning HRP is globally recognized for its leading role in research and guidance on contraception and family planning. Its key research outputs in 2023 include research on self-injected contraceptives and new male contraceptive methods. HRP research and technical assistance has also supported scale-up of family planning services. Self-injected contraceptives Depot-medroxyprogesterone acetate in its subcutaneous form (DMPA-SC) is a lower-dose, single use, injectable contraceptive that women and adolescent girls can be trained to administer themselves, offering protection against pregnancy for three months. For more information please see: https://www.who.int/ publications/i/item/WHO-SRH-22.2. Due to the option for self- injection, DMPA-SC has significant potential to improve access to contraception and give more women trol over their fertility. By reducing unmet need for contraception, improved access to DMPA-SC can contribute to key SDG targets and support universal health coverage (UHC) goals. At the request of the ministries of health in Burkina Faso, Ghana and Kenya, HRP has supported research on the introduction of DMPA-SC as part of a comprehensive approach to scaling up contraception access within their national health systems. Ethiopia, Madagascar and Mozambique are also expected to adapt and implement the global protocol that HRP has developed for this purpose. By reducing unmet need, improved access to DMPA- SC can contribute to the key targets within the SDGs and support Universal Health Care goals. 12 HRP annual report 2023 © H RP /W H O /U m a Bi st a WHO Global Study on Male Contraception (GSMC) Integrating new male contraceptive methods into existing family planning programmes will be key to enhancing equitable sharing of family planning responsibilities by men and their partners. The GSMC uses mixed research methods to explore men’s and women’s knowledge, attitudes and behaviours in relation to male contraceptives. It aims to provide current and comprehensive assessments to inform the positioning of new male contraceptive methods within the overall family planning method mix. Scaling up family planning The use of modern contraception by women of reproductive age (15–49 years) has almost doubled since 1990 from an estimated 467 million to 966 million. However, there are still around 256 million women and adolescent girls who want to delay or avoid pregnancy but who are using a traditional method of contraception or not using any contraceptive method; these women and girls are therefore considered to have an unmet need for family planning. Generally, the use of contraception is highest among women aged 25–44 and lowest among those younger than 25, such that the greatest unmet need is among young women and adolescents. HRP is conducting a range of studies and capacity-building activities to address bottlenecks and to scale up access to family planning. • Research is ongoing in Nigeria and Pakistan on the effectiveness of a family planning counselling package that aims to empower clients to make informed decisions. • Roll-out of family planning training packages has been undertaken in 11 countries; 10 countries have also participated in South–South information sharing on evidence-based family planning interventions. Two systematic reviews have been published on implementation strategies, facilitators and barriers to scaling up and sustaining (i) post-pregnancy family planning and (ii) demand generation. For a complete list of systematic reviews go to https://extranet.who.int/hrp/performance. • The recently updated (2022) Family planning: a global handbook for providers was translated into French, Spanish and Russian; introductory slides about key concepts and the new content in the updated handbook were also translated. • Contributed to the development of WHO global standards for female condoms. Generally, the use of contraception is highest among women aged 25–44 and lowest among those younger than 25. Contraception and fertility care 13 Family Planning Accelerator Plus Project (2022–2027) HRP coordinates the WHO Family Planning Accelerator Plus Project, which aims to accelerate and sustain access to evidence-based family planning practices and thus contribute to the attainment of Sustainable Development Goals (SDGs), specifically targets 3.1, 3.7 and 5.6, and the WHO 13th Global Programme of Work goal of having 1 billion more people covered by UHC. The project is supported by the Bill & Melinda Gates Foundation. 1 Family Planning Accelerator Plus focuses on self-care interventions, post-pregnancy and post-abortion family planning, task sharing across the health sector, social behaviour change communication, and adolescent and youth sexual and reproductive health and rights (SRHR). The project provides technical assistance coordination to help strengthen national capacity, while gender responsiveness and digitalization of the tools are systematically integrated across all focus areas. Key deliverables include: • scaling up and sustaining implementation of gender-responsive post-pregnancy family planning in 14 countries: Côte d’Ivoire, Ethiopia, India, Indonesia, Kenya, Madagascar, Nepal, Niger, Nigeria, Pakistan, Senegal, Timor-Leste, Uganda and the United Republic of Tanzania; • design, implementation, monitoring and review of adolescent and youth SRHR programmes in at least 15 countries by 2025; and • scaling up and sustaining social behaviour change communication around contraceptives and family planning methods. In addition, the project will accelerate uptake and scale-up of self-care interventions for SRHR and implementation of family planning task sharing and community-based services in selected countries. 1 Implementation partners include the United States Agency for International Development (USAID), the Bill & Melinda Gates Foundation, UNFPA, Family Planning 2030 (FP2030), the International Federation of Gynecology and Obstetrics (FIGO), the Global Financing Facility (GFF), Population Council and Expand Net. 14 HRP annual report 2023 Other HRP achievements in contraception and family planning Investing in family planning is often positioned as a cost-effective intervention for enhancing maternal and child health, improving the socioeconomic status of women, and contributing to sustainable development globally. Six systematic reviews commissioned by WHO have been submitted for publication – they synthesize and update evidence on relationship(s) between family planning use, women’s health outcomes, women’s socioeconomic status and sustainable development. The COVID-19 pandemic affected health service delivery around the world. HRP is carrying out research on key gaps and barriers to the delivery of sexual and reproductive health (SRH) services including contraception during the COVID-19 pandemic, with the objective of strengthening the responsiveness of health systems to future shocks. To enhance scale-up and integration of HIV-prevention services where family planning services are delivered, research is being carried out in Eswatini and South Africa to identify implementation gaps and challenges, and translate the evidence into practical, evidence-based strategies. Engagement with civil society organizations: the IBP Network • Housed within the Contraception and Fertility Care (CFC) Unit of HRP, the IBP Network engages with civil society organizations (CSOs), South-to-South learning exchanges and service integration. As such, the IBP Network has contributed towards understanding and addressing misinformation, disinformation and the anti-rights movement. • In 2023, the IBP Network contributed to the following outcomes and deliverables: • a systematic review to quantify how much contraception use is linked to the user’s concern about how it will affect their sex life; • co-hosting the first Director-General dialogue with CSOs on SRHR, bringing together over 600 participants from 105 countries as a precursor to the eventual launch of the larger WHO-wide CSO Commission, in which CFC and IBP staff continue to be active; • hosted over 15 webinars on a range of topics, including global infertility estimates, the family planning handbook, sexual health in pregnancy, SRH research priorities from CSO perspectives, and maternal health and climate change; and • provided technical support to the Young & Alive Initiative, as part of taking a more intentional power-shifting approach in 2023 to work directly with local organizations. Contraception and fertility care 15 Chapter © UN IC EF /U N I7 49 73 /N es bi tt HRP annual report 2023 3 Maternal and perinatal health Pregnancy and childbirth should not be considered as medical afflictions, yet 800 women still die every day from pregnancy-related causes – one woman every two minutes. Ninety-five percent of those deaths occur in low- and middle-income countries (LMICs). Most of these deaths are preventable with the right treatment at the right time. HRP’s work within maternal and perinatal health focuses on generating evidence to develop model packages of care that recognize that a person’s experience of care can be as important as clinical outcomes. This work optimizes the health and well-being of women and babies through pregnancy, childbirth and the postnatal period, specifically addressing the leading causes of maternal and perinatal mortality and morbidity: postpartum haemorrhage (PPH), pre-eclampsia and maternal sepsis. One woman dies every two minutes from pregnancy-related causes Postpartum haemorrhage (PPH) is extreme bleeding after childbirth and is the leading cause of maternal death. Maternal sepsis is a life-threatening condition caused by an infection during or soon after childbirth, abortion or miscarriage. Pre-eclampsia is a high blood pressure disorder that typically develops after 20 weeks into pregnancy. It can present serious risks to both mother and baby. In sub–Saharan Africa, a woman is 130 times more likely to die in pregnancy and childbirth than a woman in Europe or North America. © UN IC EF /U N I7 49 73 /N es bi tt 17 In 2023, HRP presented its findings on a new approach to the early detection and treatment of PPH. HRP’s research addressed three challenges often encountered in managing these cases: delay in diagnosis, delay in delivery of effective first-response treatments, and delay in escalation of care for continued bleeding. In collaboration with the University of Birmingham (in the United Kingdom of Great Britain and Northern Ireland), HRP tested a new approach in a multi-country trial involving over 200 000 women, managed at 80 hospitals in Kenya, Nigeria, South Africa and the United Republic of Tanzania. This new approach, captured in the acronym E-MOTIVE, resulted in dramatic improvements in maternal outcomes, with a 60% reduction in the risk of having one or more of the following: severe bleeding; need for surgery to stop excessive bleeding; or maternal death from bleeding. The main trial results were published in the New England Journal of Medicine accompanied by a WHO press release which attracted widespread media coverage. WHO Director-General Dr Tedros Adhanom PPH: Game- changing research and recommendations PPH: Global collaboration In 2023, working with WHO and stakeholders, HRP led the development and launch of The Roadmap to combat postpartum haemorrhage between 2023 and 2030 and an accountability site to track progress. The innovative approach began with a summit of the world’s leading experts and those working on and funding maternal health. The resulting Roadmap captured a broad consensus and offers a global plan centred on the maternal health goals and priorities of countries with a high burden of PPH. 18 HRP annual report 2023 A Roadmap to combat postpartum haemorrhage between 2023 and 2030 Ghebreyesus highlighted the HRP findings as a “game-changer in the global fight against postpartum haemorrhage” during the 2023 World Health Assembly. Based on findings from the E-MOTIVE trial, in December 2023 WHO released recommendations on the assessment of blood loss for PPH diagnosis and the use of a treatment bundle for the management of PPH. The evidence review, guideline development, and the publication and dissemination of these recommendations were fast-tracked and completed in a record period of six months. The recommendation on objective assessment of blood loss (in contrast to subjective assessment) for diagnosis of PPH is a bold update of an existing WHO recommendation, and the first of its kind by any international organization. Respectful care of pregnant and birthing women A growing body of evidence shows that the mistreatment of women in maternal health care is a reality worldwide. For several years, WHO and HRP have been documenting this human rights violation, and its impact on health and well-being. WHO’s guidelines on intrapartum care for a positive childbirth experience were published in 2018, and have been followed by the publication of a number of complementary products in 2023, including: • a toolkit for implementation and animated training video on the WHO Labour Care Guide; • an HRP and WHO special series of five papers in the journal PLOS Global Public Health on strategies to reduce mistreatment of women and improve respectful care, focusing on power dynamics, physical and verbal abuse, stigma and discrimination, effective communication and health system factors; and • two secondary analyses using the WHO and HRP multi-country study database on (i) the prevalence and factors associated with postpartum depression following mistreatment during facility-based childbirth and (ii) comparing observations to self-reporting of mistreatment during childbirth. Maternal and perinatal health 19 Long-term health impacts of pregnancy and childbirth In collaboration with Lancet Global Health and EClinicalMedicine, HRP published a four-part series in December 2023 titled Maternal health in the perinatal period and beyond. The series calls for expansion of focus beyond surviving childbirth, to address the broader impacts of pregnancy and childbirth that women experience. The series presents the scientific basis for the relationship between context and maternal health outcomes, and the need to look beyond the six- week postpartum period, using a holistic, human-rights-based approach to make further gains in maternal health. This focus on the woman acknowledges that, as well as being a leading cause of death among women in LMICs, pregnancy and childbirth confer a significant potential for suffering and disease many weeks and sometimes years after birth. 20 HRP annual report 2023 Climate change and adverse health outcomes A growing body of evidence links climate change to adverse maternal, newborn and child health (MNCH) outcomes, ranging from gestational hypertension and pre-eclampsia to preterm births, respiratory diseases and negative effects on learning and family function. In 2023, HRP joined the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF) and WHO in a call to action on the harmful effects of climate change on MNCH. To date, over 25 partners have signed a collective pledge on climate change and maternal health, and a statement was actively disseminated by partners at the 2023 United Nations Climate Change Conference (COP28). Protecting maternal, newborn and child health from the impacts of climate change A call for action Maternal and perinatal health 21 Flagship research projects and guideline development • Infections and sepsis are direct obstetric causes that reportedly account for 11% of all maternal deaths. Although maternal death is the final devastating outcome, there are multiple areas of poor quality of care that lead up to maternal sepsis, including inconsistent infection prevention, poor infection management, delayed diagnosis of sepsis, and inadequate sepsis management. HRP is co-leading an international collaboration to implement and evaluate at scale the Active Prevention and Treatment of Maternal Sepsis (APT-Sepsis) programme. The trial uses rigorous study methods and should be completed in early 2025, when a report of the findings is also anticipated. The study also includes health economic evaluations of the APT-Sepsis programme. • The New Antenatal Model in Africa and India (NAMAI) study is an ongoing project aiming to build the global evidence base on how to implement quality antenatal care (ANC) across different settings and to inform pathways for scaling up and strengthening health systems. This implementation research project is systematically introducing and testing the new WHO ANC model at the country level, in collaboration with Burkina Faso, India, Rwanda and Zambia. Read more about the protocol in this published paper. • While antenatal corticosteroids (ACS) are the cornerstone treatment for preventing neonatal deaths, they can be harmful if not administered correctly. HRP, in collaboration with WHO, is conducting a study to assess a multi-component implementation model for increasing safe coverage of ACS in women at risk of early preterm birth in low-resource settings. Twenty-four districts across Bangladesh, Ethiopia, Nigeria and Pakistan, involving more than 100 health-care facilities and over 400 000 women giving birth per district, will be randomized to the safe ACS delivery model or usual care. The study is due for completion and reporting in 2027. • In order to inform future WHO recommendations on the administration of ACS in the late preterm period, HRP, in collaboration with WHO, is looking into evidence on efficacy. Recruitment is under way across 39 hospitals in five countries: Bangladesh, India, Kenya, Nigeria and Pakistan. One third of the target sample size of 13 500 participants was reached in December 2023. Trial completion and reporting are expected by December 2026. • With the aim of reducing unnecessary caesarean sections, HRP is co-leading a multi-country study on the appropriate use of caesarean section through “QUALity DECision-making” (QUALI- DEC) in Argentina, Burkina Faso, Thailand and Viet Nam. Study implementation started in 2022 in 32 participating hospitals and will be completed in 2024. Several scientific manuscripts have been published in 2023 by country research teams, including Argentina and Thailand. • In addition, HRP is part of a consortium of partners implementing the C-SAFE project, which started in September 2022 under a five-year grant from the Medical Research Council. C-SAFE aims to design a strategy to promote: (i) appropriate caesarean section through accurate reporting and monitoring of indications for caesarean section, with mechanisms for feedback; (ii) safe caesarean section through intra-operative interventions; and (iii) reduction in unnecessary caesarean section by facilitating high-quality vaginal births, particularly assisted vaginal birth. • HRP is in the preparatory stage of a trial to evaluate whether heat-stable carbetocin (HSC) is non- inferior to oxytocin for treatment of PPH in women who receive HSC for PPH prophylaxis. Chapter © H RP /W H O /U m a Bi st a HRP annual report 2023 4 Preventing unsafe abortion The provision of comprehensive and safe abortion care is critical and life-saving. Conversely, prohibitions on access to quality abortion care put the lives of women and girls at risk and are a violation of their human rights to privacy, dignity and bodily autonomy. Even if not prohibited, lack of support and limited access to safe abortion care also present risks for women and girls seeking to terminate a pregnancy. Abortion is a common health intervention and is safe when carried out by a WHO-recommended method that is appropriate to the pregnancy duration, and by someone with the necessary skills and information. However, it is estimated that around 45% of all abortions are unsafe, and 97% of those unsafe abortions take place in developing countries in Africa, Asia and Latin America. Criminalization of abortion and lack of access to services, whether or not they are criminalized, denies women the right to make a choice, increases unsafe abortions, and means that data are not collected to inform policy-making. HRP advocates strongly for universal access to comprehensive abortion care (CAC) because it is integral to universal health coverage (UHC) and achievement of comprehensive sexual and reproductive health and rights (SRHR) for all. However, HRP’s analysis of the WHO Health Benefits Survey in 2023 showed that less than half of countries include abortion in their health benefits packages; indeed, among all SRH interventions, safe induced abortion is the least likely to be included. HRP therefore generates robust evidence and tools to support the development of enabling policy, legal and clinical environments for CAC. Of the estimated 73 million induced abortions that take place every year, almost half are unsafe. Of those unsafe abortions, an estimated one third are carried out by untrained persons, using dangerous and invasive methods. Most unsafe abortions (97%) occur in developing countries in Africa, Asia and Latin America. © H RP /W H O /U m a Bi st a 23 Quality abortion care In 2023, HRP supported countries to implement a new WHO clinical practice handbook for quality abortion care including use of the related tools (summary chart and pocket guide). At least 15 countries have used the handbook to update their own policy guidelines, legal frameworks and training manuals. HRP contributed to the design of a new WHO mobile phone application to support CAC. The WHO CAC Tool was launched in 2023 on Apple (iOS) and Google Play (Android). It provides step- by-step guidance for health workers and caregivers to assist with decision-making related to abortion care. The app is free to use and currently available in English; translated versions are forthcoming. In partnership with the WHO Academy, HRP also contributed to a new, online comprehensive training package on medical abortion care. The free, self-paced training package aims to equip health sector workers, such as community health workers, pharmacists, nurses and other medical practitioners, to provide safe, respectful and stigma-free abortion care. At least 15 countries have used the Clinical practice handbook to update their own policy guidelines, legal frameworks and training manuals. 24 HRP annual report 2023 © H RP /W H O /M ar ia G ut u A health systems approach to reducing unsafe abortion A special four-year initiative to reduce unsafe abortion in 10 focus countries was completed in 2023. This initiative was a unique example of country impact through partnership between ministries of health and other in- country stakeholders with HRP and WHO. HRP coordinated the programme of work for this initiative, applying a health system strengthening approach in Benin, Burkina Faso, India, Lao People’s Democratic Republic, Myanmar, Nepal, Pakistan, Rwanda, Sierra Leone and South Africa. Between 2019 and 2023, all 10 countries revised national standards and guidelines, while several changed their laws on abortion. All countries updated in-service training materials and developed face-to-face, blended, and digital training modules covering both clinical skills and values and attitudes. WHO’s Family planning and comprehensive abortion care toolkit for the primary health care workforce was developed in response to a request from countries involved in this initiative for a standardized document to support curriculum development. This has been widely disseminated since its launch in 2022 and is now being adapted regionally and used in countries to integrate competency-based training. Unsafe abortion typically remains underreported or misclassified. All 10 countries strengthened their maternal and perinatal death surveillance systems with particular attention to reporting deaths due to unsafe abortion. Seven of the countries also reviewed and revised their national score cards to include CAC and family planning indicators. All of the focus countries revised their national essential medicines lists to include mifepristone and misoprostol if they were not already listed, and several countries took steps towards increasing registration and market authorization of medical abortion products. For more detail, please see: https://www.who.int/activities/addressing-unsafe-abortion-through-a-health-systems-approach. Between 2019 and 2023, all 10 countries in the initiative revised national standards and guidelines. Preventing unsafe abortion 25 Family planning and comprehensive abortion care toolkit for the primary health care workforce Volume 1 Competencies © H RP /W H O /M ar ia G ut u Access to quality-assured abortion medicines HRP is leading global, coordinated action to ensure access to quality-assured abortion medicines. Consultations in 2022 identified five priority areas: supply, regulation, procurement, distribution and development of the evidence base. In 2023, HRP, the Swedish International Development Cooperation Agency (Sida), the Children’s Investment Fund Foundation (CIFF) and UNFPA convened 60 participants from 30 organizations to develop a global plan of action prioritizing outcomes around market visibility, evidence of the levels of supply and demand for prequalified medicines, the number of quality-assured products, procurement, and ensuring availability of internationally recognized monographs for mifepristone and misoprostol. HRP will continue to lead the coordination of this work. Evidence synthesized by HRP also contributed to the inclusion of intrauterine fetal death (IUFD) as an indication for the use of mifepristone and misoprostol in the 2023 WHO Essential Medicines List. This expands the available indications for these medicines and increases opportunities to make them accessible in countries worldwide. Normalizing abortion care, addressing stigma and misinformation HRP manages the Global Abortion Policies Database, an open access platform for all laws and policies related to abortion, designed to help stakeholders assess alignment with WHO guidance. HRP also supports the inclusion of abortion-related modules in population-based surveys. HRP also works with partners through social media to mainstream conversations about abortion and address stigma and misinformation. 26 HRP annual report 2023 In 2023, in collaboration with the United Nations office in Geneva, a first-ever photo exhibition on safe abortion was held at the Palais des Nations, titled, “Siding with science for healthy outcomes: celebrating access to safe abortion care for the health and rights of women and girls.” Preventing unsafe abortion 27 © H RP Chapter HRP annual report 2023 5 © H RP /W H O /S ai yn a Ba sh ir Rights and equality across the life course HRP works across its thematic areas of work with a view to strengthening evidence, addressing gender equality, and increasing the impact of rights-based approaches to sexual and reproductive health (SRH). It also builds evidence on specific aspects of gender inequality and human rights as they affect the health of people, especially women and girls, such as harmful practices like female genital mutilation (FGM) and child marriage, and violence against women and girls. In 2023, the work to advance rights and equality across the life course was broad and far-reaching, including strengthening evidence on preventing FGM through the health sector, contributing to evidence on adolescent SRH, including through comprehensive sexuality education, and supporting health systems to address violence against women and girls, including in the context of humanitarian crisis. HRP also aims to identify evidence gaps in addressing masculinities in the context of sexual and reproductive health and rights (SRHR) and to strengthen evidence on human rights principles related to the right to informed consent and bodily autonomy, among others. HRP also aims to strengthen evidence on human rights principles related to the right to informed consent and bodily autonomy, among others. Nearly 1 in every 3 women (age 15 and older) have experienced physical and/or sexual intimate partner violence or non-partner sexual violence at least once in their lifetime. Female genital mutilation affects over 200 million women and girls globally. No region is on track to meet the SDG target of eliminating child marriage by 2030. 29 © H RP /W H O /S ai yn a Ba sh ir Advancing evidence and norms on human rights and gender equality HRP is a key actor in advancing human rights standards as they relate to SRH. This includes its work on social accountability, informed consent, and ensuring that rights are an explicit part of all political commitments on SRH. The work on gender equality has focused on identifying evidence gaps related to masculinities and SRHR through an exercise to set priorities for the research agenda, which was completed in 2023. HRP has also developed thought pieces to unpack concepts of bodily autonomy and to operationalize how HRP can advance decolonization across its own research practices. Finally, this work has involved developing a toolkit jointly with the Special Programme for Research and Training in Tropical Diseases (TDR), to provide resources to help researchers integrate sex and gender considerations into health research. Key achievements in 2023 include: • launched a curated resource hub on Sex and Gender in Health Research to support efforts to incorporate sex and gender – and the ways they intersect with other forms of inequality and discrimination – into broader health research; • secured endorsement for WHO’s Abortion care guideline from United Nations human rights treaty bodies – in particular the Committee on the Elimination of Discrimination against Women (CEDAW), the Committee on the Elimination of Racial Discrimination (CERD) and the Human Rights Committee – with recommendations to countries recognized as human rights standards; • Worked to integrate HRP research into processes that review how countries enact human rights commitments. As such HRP supported Member State negotiations with providing relevant evidence-based normative standards to the Resolution of the Human Rights Council on preventing maternal mortality; and • published commentary on gender equality and SRH with a focus on bodily autonomy, making the case for a feminist, decolonizing approach “where public health and the feminist project of gender equality intersect”. The work on gender equality has focused on identifying evidence gaps related to masculinities and SRHR through an exercise to set priorities for the research agenda, which was completed in 2023. 30 HRP annual report 2023 Generally, the use of contraception is highest among women aged 25–44 and lowest among those younger than 25. Adolescent sexual health While there has been progress on key indicators related to adolescent sexual health in the past decade, it has been too slow and uneven across regions and sub-groups of adolescents. An HRP analysis of global progress on adolescent sexual health was published in 2023. Two of the key findings were that adolescent birth rates declined from 52 births per 1000 girls in 2010 to 42.5 in 2021, and use of modern contraceptives by girls aged 15–19 increased globally from 49% to 60% between 2010 and 2020. However, there are significant regional variations with less than 50% of girls in South Asia, sub-Saharan Africa, the Middle East and North Africa having access to modern contraceptive methods. There have been marked declines in the harmful practice of child marriage. Over the last decade, child marriage declined from approximately 25% globally in 2010 to 19% in 2020, but progress is slow, and no region is on track to meet the SDG target of eliminating child marriage by 2030. SRH and access to services for adolescents are hindered by unequal gender- and age-related power dynamics, and limited access to information and knowledge. Less than 50% of girls in South Asia, sub-Saharan Africa, the Middle East and North Africa having access to modern contraceptive methods. >50% Rights and equality across the life course 31 © H RP /W H O /M ar ia G ut u Adolescence is a life stage during which one’s sense of gender norms further develops and there is a window of opportunity to shape equitable attitudes and behaviours with the potential to alter SRH outcomes not only during adolescence but along the trajectory of adolescents’ growth into adulthood. Comprehensive sexuality education (CSE) is one intervention that can contribute to promoting respectful, consensual relationships that form the basis for positive SRH outcomes. Evidence shows that CSE, when implemented well, can reduce STIs and early sexual debut, and increase safer sexual behaviours. However, there is considerable resistance to its provision from governments, schools, teachers and parents, which is a barrier to scaling it up. CSE is needed both in schools and in informal settings for those who do not have access to formal education. HRP has therefore completed the first phase of a multi-country study in Colombia, Ethiopia, Ghana and Malawi which aimed to improve facilitation of CSE outside of schools. The findings showed that peer-to- peer education can work well in out-of-school settings when the teacher has similar characteristics and experiences to the student. Working with UNFPA, the second phase of the study will extend it to 11 countries, with HRP leading the research component in three countries and supporting intensive monitoring in two countries, while the remaining countries will conduct routine monitoring. HRP worked with all its cosponsors, other United Nations bodies, and nongovernmental organizations (NGOs) to create a unified voice on CSE. This included developing a Q&A website on CSE, and convening a meeting as a first step in developing a United Nations-wide approach to addressing misinformation and building support to overcome resistance to CSE. HRP also collaborated with the Inter Parliamentary Union (IPU) to advocate for global parliamentarians to call for access to CSE as a priority. Finally, HRP worked across NGOs and partners to assist them in generating their own statements in support of CSE, including: the International Association of Adolescent Health, the World Association for Sexual Health, the International Federation of Paediatric and Adolescent Gynaecology and the International Pediatric Association. Evidence shows that CSE, when implemented well, can reduce STIs and early sexual debut, and increase safer sexual behaviours 32 HRP annual report 2023 © In te r-P ar lia m en ta ry U ni on Generally, the use of contraception is highest among women aged 25–44 and lowest among those younger than 25. Preventing female genital mutilation HRP’s work on female genital mutilation (FGM) focuses on generating evidence on the health impacts of this harmful practice and human rights violation, how the health sector can manage the complications resulting from FGM, and how it can contribute to preventing FGM as well as not perpetuating medicalization of FGM. While FGM rates have declined among girls aged 15–19, regional and national variations are stark. In Northern Africa, FGM prevalence decreased from 92% in 2003 to 74% in 2018, but remains high. In sub-Saharan Africa, FGM prevalence decreased from 35% to 25% in the same period. It is encouraging to see that attitudes are changing. In Ethiopia, the proportion of adolescent girls supporting the continuation of FGM fell from over 50% in 2000 to just 13.6% in 2016. In Kenya, girls aged 15–19 are now four times less likely to have undergone FGM than women aged 45–49. These figures suggest a generational change in attitudes that needs to be expanded and sustained. WHO estimates that the cost of treating the health complications from FGM is around $US 1.4 billion per annum, a number that is expected to rise unless urgent action is taken. The growing medicalization of FGM – in other words, having it performed by health workers and doctors – is an alarming trend and presents new challenges to ending the practice. HRP has made training health workers and supporting them to prevent FGM a key priority. Nurses, community health workers and other health leaders can be vital allies in conveying accurate information to communities and preventing FGM. Evidence shows that training is effective in changing the attitudes and beliefs of primary care health workers towards FGM, thus contributing to changing the beliefs and attitudes of the communities they serve through person- centred communication. In Ethiopia, the proportion of adolescent girls supporting the continuation of FGM fell from over 50% in 2000 to just 13.6% in 2016. 50% 13.6% 2000 2016 Rights and equality across the life course 33 “Having a conversation and under- standing where a person is coming from is important.” Catherine Meng’anyi 34 HRP annual report 2023 Catherine Meng’anyi, a nurse in Kenya, is a survivor of FGM and now works to prevent the practice by speaking with patients and community groups. “Having a conversation and understanding where a person is coming from is important. When a patient comes in for services, we, as health workers, need to start up a conversation about female genital mutilation and address the issue. Having this conversation also means getting solutions from the community themselves. That is the only way we are going to end FGM and early marriage.” HRP anticipates that evidence generated in 2023, including 12 systematic reviews, will feed into the 2024 update of the 2016 WHO guideline on managing health complications of FGM. © Ca th er in e M en g’ an yi Generally, the use of contraception is highest among women aged 25–44 and lowest among those younger than 25. Violence against women Violence against women and girls is a serious public health problem and a violation of their human rights. HRP’s work focuses on building evidence on the prevalence and consequences of intimate partner violence and sexual violence, and on effective health system responses. Commitments to end violence against women HRP, through WHO, has shaped the gender-based violence (GBV) action coalition of the Generation Equality Forum. In 2023, at the Women Deliver conference, a joint workshop was implemented to advance the collective commitment on prevention of VAW, spearheaded by WHO and UN Women – the two United Nations co-leads of the GBV action coalition. Key achievements in 2023 include: • co-creation of a new online course “Using data to end violence against women” (in partnership with WHO, UN Women and the NGO Apolitical) aimed at public sector workers to improve their understanding of the main kinds of data and data collection methods used to track violence against women (VAW), and enable them to identify gaps in data and commonly under-researched forms of VAW and to articulate challenges and develop innovations in VAW data collection; • launched a new WHO e-learning course for health care providers to respond to VAW as part of HRP’s mandate to support health systems strengthening; • updated the Global Database on the Prevalence of Violence Against Women, which includes an interactive map of rates of intimate partner violence and non-partner sexual violence across the globe; • launched the comprehensive RESPECT Women website2 for all materials related to the Preventing Violence Against Women Framework, in collaboration with UN Women, UNFPA and the United Nations Development Programme (UNDP); • formed a partnership with the Sexual Violence Research Initiative to strengthen capacities of researchers on VAW from low- and middle-income countries; • provided technical support to 23 countries to address gender-based violence in health emergencies, including strengthening of health manager capacities to strengthen health systems response to gender based violence in 11 countries in the WHO European and Eastern Mediterranean Regions. 2 RESPECT supports the scaling up of evidence-informed strategies to prevent VAW. Rights and equality across the life course 35 Chapter HRP annual report 2023 6 © W H O /Y os hi S hi m iz u WHO defines sexual health as: “A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” Sexual health and well-being across the life course Sexual health is fundamental to people’s overall health and well-being throughout their lives, to the dignity of the individual and to the social and economic development of communities and countries. HRP’s work on sexual health and well-being across the life course is currently focused on sexually transmitted infections (STIs), sexuality, sexual identity and sexual pleasure. This work includes the development of STI-prevention tools such as vaccines and point-of-care tests, and is also expanding to include women’s health from pre-menarche to post-menopause and to address overlooked sexual health conditions, such as endometriosis. The team that covers this thematic area of work also leads cross-cutting areas of work, including on SRHR and outbreaks, climate change and self-care interventions. 500 million women and girls are without access to services and products to manage menstruation. More than a million sexually transmitted infections are acquired every day. 37 © W H O /Y os hi S hi m iz u Understanding sexual behaviours and practices In 2023, HRP completed its coordination of a 19-country study assessing acceptability and comprehension of a global questionnaire on sexual practices, behaviours and health-related outcomes. The study’s aim was to test and refine an instrument, relevant to diverse global contexts, in order to improve the quality and global standardization of data related to sexual practices. The questionnaire was refined and finalized based on study findings and, and thus in December 2023, HRP and WHO published the SHAPE questionnaire (Sexual Health Assessment of Practices and Experiences), which emerged from the study described above. The SHAPE publication consists primarily of the SHAPE questionnaire and implementation considerations, including content, population and survey modality (as well as implications of any variations from its intended use). REDCap and XLSForm templates of the questionnaire have been developed to facilitate adaptation and use for computer-assisted interviewing. Sexually transmitted infections – survey to assess global research priorities HRP, together with WHO, has been undertaking a global assessment to address the largest research gaps in the prevention, management and control of STIs. The aim of the project is to guide global funding and focus to where the need is greatest. HRP and WHO used a consultative approach with stakeholders across all WHO regions to generate a large number of ideas, which have been consolidated into 40 STI research priority areas. Six further research areas related to sexual transmission of the monkeypox virus were also generated. The priorities are now being written up in the form of a WHO global research agenda for STIs and plans are under way for financial support and implementation, with the support of the Research Leadership and Knowledge Management team. HRP, together with WHO, has been undertaking a global assessment to address the largest research gaps in the prevention, management and control of STIs. 38 HRP annual report 2023 STIs research and diagnostics Point-of-care tests for STIs are key to controlling and preventing STIs. HRP has been working to ensure these tests are not only available but also reliable. HRP has conducted the largest-ever study in the field of STI diagnosis across 15 countries, 30 sites and 20 000 participants. Eight scientific manuscripts were accepted for publication within the Supplement of BMC Infectious Diseases and presented at the 36th IUSTI Europe Congress 2023. Findings have already led to changes in national policies and practices in Malta and South Africa. With HRP support, WHO published Point-of-care tests for sexually transmitted infections: target product profiles. Due to shortages of benzathine penicillin, HRP is conducting an ongoing study in Brazil on an alternative treatment option for syphilis. As of October 2023, 300 patients were screened, of whom 147 were recruited to the study; recruitment is expected to end in March 2024. Elimination of cervical cancer – HPV vaccines and technologies for screening HRP has been advancing efforts to define the preferred product characteristics for therapeutic HPV vaccines that can clear HPV infection or cause regression of cervical pre-cancers. These vaccines could play an important role in cervical cancer prevention and elimination. HRP has also developed evidence for HPV self-sampling to improve cervical cancer screening. Sexual health and well-being across the life course 39 © Jo na th an T or go vn ik /I m ag es o f E m po w er m en t In 2023, a WHO preferred product characteristics document for therapeutic HPV vaccines was developed and posted for public consultation. A further qualitative assessment is under way, including in-depth interviews and focus group discussions with women, health workers and programme managers, as well as workshops in all WHO regions. Final modelling of the potential impact of therapeutic HPV vaccines has been completed and is currently being written up. This work has been implemented in collaboration with the Bill & Melinda Gates Foundation and the WHO Departments of Immunization, Vaccines and Biologicals (IVB), Global HIV, Hepatitis and STIs Programmes (HHS), Noncommunicable Diseases (NCD), and Research for Health (RFH). Cervical cancer can be eliminated as a public health problem if: 90% of girls are fully vaccinated with HPV vaccine by age 15 90% of women identified with cervical disease (pre- cancer or invasive cancer) receive treatment. 70% of women are screened with a high-performance test by 35 years of age and again by 45 years of age Source: Global strategy to accelerate the elimination of cervical cancer as a public health problem. Geneva: WHO; 2020 (https://www.who.int/publications/i/item/9789240014107). 40 HRP annual report 2023 GLOBAL STRATEGY TO ACCELERATE THE ELIMINATION OF CERVICAL CANCER AS A PUBLIC HEALTH PROBLEM 1 Global strategy to accelerate the elimination of cervical cancer as a public health problem Self-care and sexual and reproductive health and rights On average, individuals spend less than one hour a year with a health worker versus over 8700 hours a year in self-care. Self-care is a rapidly expanding area of health care with the potential to improve access to and use and uptake of contraception, diagnosis of STIs and self-managed medical abortion, in a safe, enabling environment, thus improving autonomy, agency and self-determination for people and communities. HRP, working with WHO, UNFPA, UNDP and the World Bank, issued an interagency statement at the 2023 World Health Summit in Berlin, emphasizing the potential of self-care interventions to improve health systems, people-centred care and primary health care, and to help deliver universal health coverage (UHC). HRP also published the self-care competency framework in three volumes, including the global competency standards, the knowledge guide and the training curriculum guide for health workers, to promote self-care options that are in addition to facility-based care. HRP was delighted to receive the 2023 WHO Director-General’s LEAD Innovation Award for the self-care wheel, a hybrid paper and digital solution to demystify self-care and strengthen links between self-care and facility- based care. 41 Self-care interventions for sexual and reproductive health and rights to advance universal health coverage: 2023 Joint statement by HRP, WHO, UNDP, UNFPA and the World Bank Self-care competency framework Volume 1. Global competency standards for health and care workers to support people’s self-care © H RP /W H O /U m a Bi st a Chapter HRP annual report 2023 7 © W H O /K ia na H ay er i Sexual and reproductive health integration in health systems It is within the context of the Sustainable Development Goals (SDGs) explicitly recognizing comprehensive sexual and reproductive health and rights (SRHR) as essential to health, gender equality and wider economic and social development, as well as universal health coverage (UHC), that HRP works with partners to support evidence-driven health systems strengthening relating to sexual and reproductive health (SRH) service delivery. This work includes defining SRH service packages, supporting their implementation and exploring different models of care and innovation, specifically digital technologies and artificial intelligence (AI). HRP also supports measurement of SRH services access and coverage, and related health conditions, including producing the global, regional and national maternal mortality estimates for monitoring SDG target 3.1, which is to reduce the global maternal mortality ratio to less than 70 per 100 000 live births by 2030. Universal health coverage HRP led the development of the WHO technical brief, Investing in sexual and reproductive health and rights: essential elements of universal health coverage (UHC) to support discussions at the 2023 United Nations high-level meeting on UHC. The brief called for a significant increase in annual investments in SRHR by both international donors and domestic governments, an enabling legal environment and the development of national health benefit packages or services that include comprehensive SRH care. It is estimated that a global package of SRH services that fully meets the needs of women in low- and middle-income countries (LMICs) would cost US$ 68.8 billion, or approximately US$ 10.60 per person annually, up from current spending of around US$ 4.80 per person per year. In collaboration with UNFPA and WHO, HRP also created and maintains the Learning by Sharing Portal. This is a global resource for success stories from around the world on the integration of SRHR within UHC, covering a range of topics including digital health, innovations and financing. A global package of sexual and reproductive health services that fully meets the needs of women in low- and middle-income countries would cost approximately US$ 10.60 per person annually. 43 © W H O /K ia na H ay er i Monitoring maternal mortality In February 2023, HRP led the publication of new global, regional and national estimates on the levels and trends of maternal mortality covering the period 2000 to 2020. These estimates were co-produced by WHO, UNICEF, UNFPA, the World Bank Group and the United Nations Department of Economic and Social Affairs (UN DESA), Population Division, with WHO as the lead/custodian agency. These estimates represent the official source of monitoring for progress towards SDG target 3.1 and were widely discussed and taken up by Member States and other stakeholders. The headline findings from this publication were that earlier progress in reducing maternal mortality achieved during the Millennium Development Goal (MDG) era between 2000 to 2015 has stalled in recent years: the world is not on track to meet the SDG target and major shifts in government and donor investment are needed in order to change the current trajectory. These findings prompted urgent action by the global community. See Chapter 3 Maternal and Perinatal Health for more information on HRP’s “game changing” contribution to addressing postpartum haemorrhage, a leading cause of maternal mortality. SDG indicator data monitoring As a co-custodian agency with UNICEF for SDG indicator 3.1.2 (the proportion of births attended by skilled health personnel), HRP and WHO annually update the joint indicator database. HRP also maintains other global databases related to maternal health indicators: at least four antenatal care (ANC) visits (ANC4+), early ANC (i.e. before 12 weeks of gestation), facility births, and caesarean section rates. The data series from these databases are used to inform programmatic and policy decisions, as well as modelling exercises for health system monitoring. Related reports published in 2023 included Tracking universal health coverage: 2023 global monitoring report. 44 HRP annual report 2023 Trends in maternal mortality 2000 to 2020 Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division Digitalizing SRH services within health systems Digital tools offer new ways for health workers to access and apply evidence-based recommendations more efficiently. However, translation of WHO guidelines and recommendations into software systems is often a subjective and costly process for ministries of health. HRP has established “SMART Guidelines” to improve the fidelity and uptake of WHO recommendations in standard-based digital systems. This includes an operational guide for translating WHO guidelines on SRH into a structured format that can be reviewed by health programme managers and software developers – these are known as “digital adaptation kits” (DAKs). DAKs are now being mainstreamed across WHO, in collaboration with the Digital Health and Innovations team. This methodology is being adopted for other health areas, including HIV, tuberculosis and immunization, and has already been incorporated within national digital systems in Malawi, Zambia and Zimbabwe. HRP is conducting research known as GUIDE – Guideline Uptake in Digital Ecosystems – to systematically adapt and incorporate the SMART Guidelines/DAKs into national digital systems. By using SRH as an exemplar for other health areas to follow, this implementation research aims to provide a replicable approach to digitizing primary health care services. Sexual and reproductive health integration in health systems 45 © UN IC EF /B ha rd w aj Maternal morbidity – monitoring a neglected issue In 2023, HRP developed a toolkit to support the qualitative measurement of maternal morbidities. Maternal morbidities are relatively neglected compared with maternal mortality, which is easier to define and measure and has been on the global health community’s agenda for much longer. This qualitative toolkit builds on previous research by HRP and supports researchers to produce example interview guides and other tools that can be adapted to different settings to understand women’s experiences of maternal morbidities and their perspectives about the intensity or urgency of their conditions. 46 HRP annual report 2023 © UN IC EF /H ar o Research on digital and artificial intelligence innovations In April 2023, HRP researchers published an article in npj Digital Medicine on the accuracy of a smartphone application for measuring blood pressure. The article found that, “Further research is needed to improve performance across different populations and integration within health systems”. As well as interrogating the accuracy of this app, this study represents the ongoing work HRP is doing in the digital space to ensure that technology advances in an equitable and accurate way across diverse settings. The rapid advance in the application of AI to all aspects of life raises questions around SRHR, including nuanced issues related to safeguarding bodily autonomy, navigating gendered digital divides, and regulating risks around the use of sensitive data. HRP convened a technical consultation on the potential opportunities and harms, emerging trends, risks and implications of AI in SRHR. Monitoring and evaluation in humanitarian crises At the end of 2022, an estimated 108.4 million people worldwide were forcibly displaced because of persecution, conflict, violence, human rights violations and events seriously disturbing public order. HRP is contributing to the establishment of accurate and routine information collection on the SRH needs of people in such situations and the services required to provide them with necessary health care. In 2023, a monitoring and evaluation framework for SRH and newborn and child health services and outcomes in humanitarian settings was published by HRP, based on pilot projects in Afghanistan, the Democratic Republic of the Congo and Yemen. Further work is under way to inform guidance on data collection and implementation. The rapid advance in the application of AI to all aspects of life raises questions around SRHR, including nuanced issues related to safeguarding bodily autonomy, navigating gendered digital divides, and regulating risks around the use of sensitive data. Sexual and reproductive health integration in health systems 47 © UN IC EF /H ar o Chapter HRP annual report 2023 8 © H RP /W H O /H ic km at u Emerging diseases and sexual and reproductive health HRP plays a critical role in research activities and the understanding of emerging diseases and their impacts on sexual and reproductive health (SRH). COVID-19, pregnancy and vaccination COVID-19 had a significant impact on pregnant women and on the provision of health services. In 2023, through the HRP Alliance, HRP recruited around 16 000 women in nine countries who were infected with COVID-19 for the WHO Multi-Country COVID-19 and Pregnancy Cohort Study. The purpose of the study is to address questions including: • Does having COVID-19 during pregnancy increase the risk of adverse pregnancy, perinatal, neonatal and/or postpartum outcomes? • What is the proportion of babies born to infected pregnant women that are also infected with SARS-CoV-2? • Does the risk of adverse pregnancy, perinatal, neonatal and/or postpartum outcomes differ according to whether or not COVID-19 vaccination is received during pregnancy? COVID-19 vaccination uptake among pregnant women has remained low in many settings. HRP is working with the Johns Hopkins Bloomberg School of Public Health to explore COVID-19 vaccine decision-making among pregnant and recently pregnant women across health-care facilities in Brazil, Ghana, Kenya and Pakistan. HRP, working through HRP Alliance, is also studying how COVID-19 affects women’s attitudes, needs and practices related to SRH, including pregnancy, pregnancy prevention, abortion and family planning. HRP recruited around 16 000 women in nine countries who were infected with COVID-19 for the WHO Multi-Country COVID-19 and Pregnancy Cohort Study. 49 © H RP /W H O /H ic km at u COVID-19 viral shedding in body fluids associated with sexual activity HRP conducted a review of over 10 000 patients from 31 countries to determine whether SARS- CoV-2, the virus that causes COVID-19, had been detected in body fluids associated with sexual activity. The purpose of the study was to understand viral persistence and infectivity, and to use this information to limit the spread of infection and inform clinical management. The review found that SARS-CoV-2 was present and persistent in body fluids involved in sexual activity (saliva, semen, vaginal secretion, urine, and feces/rectal secretions). 50 HRP annual report 2023 © H RP /W H O /S ai yn a Ba sh ir Zika virus persistence Zika virus (ZIKV) is transmitted by mosquitoes and outbreaks in the last decade have been associated with microcephaly in babies (smaller than normal head size) and other congenital malformations. Zika infection during pregnancy can also cause complications such as fetal loss, stillbirth and preterm birth. HRP has contributed to an important study of the persistence of ZIKV in plasma, urine, saliva, sweat, rectal swabs, vaginal secretions, breast milk and semen. The study also explores risk factors associated with prolonged viral persistence. A total of 260 individuals (184 women and 76 men) with confirmed Zika infection were followed for 12 months, providing valuable insights into the persistence and potential recurrence of Zika infection. The study highlights the need for continued monitoring and follow-up of individuals infected with ZIKV, and for effective prevention measures to reduce the risk of transmission. Emerging diseases and sexual and reproductive health 51 © H RP /W H O /S ai yn a Ba sh ir Chapter HRP annual report 2023 9 © H RP /W H O /M ar ia G ut u Building new audiences and stronger partnerships Working in close collaboration with our five United Nations cosponsor agencies, HRP is developing new partnerships and disseminating research findings and supplementary products ever more widely. These activities are essential elements in HRP’s Theory of Change (see pg 54 and 55). Marking 50 years of achievements In 2023, HRP celebrated its half-century legacy of contributions towards achieving sexual and reproductive health and rights (SRHR) for all. Celebratory activities documented the origins of HRP in contraception research, and its evolution well beyond reproductive health into a comprehensive approach to SRHR that has impacted millions of lives through the years – and continues to do so. An interactive timeline highlights HRP’s achievements since its start as a unit within WHO in 1965, then as a special programme of the United Nations since 1972. A version of this timeline was displayed at WHO headquarters in April and during the World Health Assembly in May at the Palais des Nations in Geneva. HRP employs many global SRHR experts. The HRP Expert Series presents short, accessible video interviews with these impressive thought leaders. 53 © H RP /W H O /M ar ia G ut u © H RP /W H O /A nt oi ne T ar dy HRP Theory of Change Actions across key thematic areas in sexual and reproductive health and rights Evidence-based normative guidelines, implementation tools and policy statementsEvidence is used/ applied internationally International changes in: National changes in: Evidence is used/ applied nationally Sexual and reproductive health and rights for all International partnerships and networks engaged New knowledge created Policies, practice, laws and fulfilmenet or rights Policies, practices, laws and fulfilment of rights Norms, attitudes, beliefs and behaviours Norms, attitudes, beliefs and behaviours Health systems, programmes and services Appropriate research agenda is set Improved and more visible global evidence base on SRHR Research evidence synthesised Partners engaged to stimulate and support country level action Enhanced national level capacity to generate and use evidence 54 HRP annual report 2023 Normative guidelines Evidence briefs and other guideline derivatives Global and regional estimatesInternational Country level Initiatives with cosponsors: 5 68 68 21 3 Papers in peer-reviewed scientific journals Individuals trained through HRP Alliance Ongoing research projects Female authors Female Female Principal investigators 53 Systematic reviews 157 334 146 Selected results from the Theory of Change 73% 48% 61% Building new audiences and stronger partnerships 55 Impact stories on “HRP at 50” delve into four major areas of HRP influence over the past five decades: Making science accessible In a section of HRP’s YouTube channel called “Journal articles explained”, there are short videos in which experts introduce recently published research to make the findings more accessible to a wider audience. Topics include: The full playlist is available here. Find more features and web stories telling the human impact of our work here. Penalties for abortion-related offences in 182 countries. Misclassification of maternal death Voucher-based family planning 56 HRP annual report 2023 HEALTH FOR ALL Since 1972, the UN cosponsored special programme, HRP, has pursued a vision of sexual and reproductive health and rights (SRHR) for all. This is the fourth in a series of stories to share key moments from HRP’s history and the impact of its work on advancing the attainment of SRHR. Find out more about the Human Reproduction Programme here. HRP at © J on at ha n To rg ov ni k/ G et ty Im ag es /I m ag es o f E m po w er m en t Celebrating the Impact of the Human Reproduction Programme Strengthening impact at country level HEALTH FOR ALL Since 1972, the UN cosponsored special programme, HRP, has pursued a vision of sexual and reproductive health and rights (SRHR) for all. This is the second in a series of stories to share key moments from HRP’s history and the impact of its work on advancing the attainment of SRHR. Find out more about the Human Reproduction Programme here. HRP at © W H O /Y os hi S hi m iz u Harnessing the power of science, research, data and digital technologies to improve sexual and reproductive health and rights Celebrating the Impact of the Human Reproduction Programme HEALTH FOR ALL Since 1972, the UN cosponsored special programme, HRP, has pursued a vision of sexual and reproductive health and rights (SRHR) for all. This is the third in a series of stories to share key moments from HRP’s history and the impact of its work on advancing the attainment of SRHR. Find out more about the Human Reproduction Programme here. HRP at © U N IC EF /P an jw an i Celebrating the Impact of the Human Reproduction Programme Sexual and reproductive health and rights in epidemic and pandemic preparedness and response HEALTH FOR ALL Celebrating the Impact of the Human Reproduction Programme Since 1972, the UN co-sponsored special programme, HRP, has pursued a vision of sexual and reproductive health and rights (SRHR) for all. This is the first in a series of stories to share key moments from HRP’s history and the impact of its work on advancing the attainment of SRHR. Find out more about the Human Reproduction Programme here. HRP at W H O / Y os hi S hi m iz u Sexual and reproductive health and rights across the life-course Expanding to new audiences In 2023, HRP started using LinkedIn in addition to Twitter/X. LinkedIn has become very helpful for engagement with academics and professionals, while X, formerly called Twitter, remains a space to engage with media and the general public. HRP has also revamped its newsletter and released seven issues in 2023: March, May, July, September, Special issue: FIGO, November, End of year. The mailing list is at 10 000 and growing, and engagement metrics are high – with a consistent open rate above 20% and reaching 33% for special issues. Subscribe here. Strengthening partnerships In an increasingly crowded global health landscape, faced with shrinking budgets and growing political challenges, advancing SRHR requires sustained and active coordination among stakeholders. With clear mandates that recognize our different strengths and priorities, HRP is strengthening existing partnerships and seeking new ones to respond to these demands. Together we work for evidence-based changes in health systems and attitudes that will deliver better health outcomes through enabling policy and legal environments. Building new audiences and stronger partnerships 57 © H RP /W H O / An to in e Ta rd y Some examples of HRP’s many partnership activities in 2023 with cosponsors, academic institutions, professional associations, civil society organizations, governments, parliamentary networks, funders and private sector entities are listed below. • There were more than 160 engagements with cosponsors and other United Nations partners internationally and nationally, across all of HRP’s technical areas of work – from facilitating the harmonization of SRHR indicators for services and outcomes evaluation in humanitarian settings, to treaty monitoring on safe abortion. • HRP provided decision-makers with evidence upon request, including briefings for Member States and testimony for the Standing Committee on Foreign Affairs and International Development of the House of Commons of Canada, on the SRHR of women globally. • SRHR advocacy partners were provided with science and data, and an SRHR resource finder was created so that stakeholders can more easily find the information they need. • HRP joined a multi-agency United Nations call to action on climate change and maternal, newborn and child health and supported development of an advocacy brief from the Partnership for Maternal, Newborn and Child Health (PMNCH). • HRP joined WHO in signing a memorandum of understanding with the European Parliamentary Forum for Sexual and Reproductive Rights (EPF) to strengthen the bridge between science and policy, and worked with parliamentarians as active contributors to health and rights through their core functions of legislation, advocacy, accountability and budget allocation. • HRP listened to end users, connecting their experiences to technical work and strategic planning, including the promotion of a WHO SRH Film Prize and the winning entry on sexual well-being, and convening a consultation on “Beyond our reproductive potential: the future of women’s sexual health” at the Women Deliver conference in Kigali, Rwanda. • HRP leveraged financing for SRHR, convened donors to coordinate on urgent issues including postpartum haemorrhage and medical abortion commodities, and joined UNFPA in the EPF SRHR Donor Funding Atlas (2023). 58 HRP annual report 2023 © H RP /W H O / An to in e Ta rd y FGM HRP website: 3.6 million users Users’ locations: United States India Mexico France United Kingdom Canada Phillipines Australia Peru 1. Fact sheets 2. Health topics: Analytics Most popular content: VAW Infertility Self-care MenopauseInfertility Polycystic- ovary- syndrome Endometriosis Cervical cancer Sexual health Abortion Building new audiences and stronger partnerships 59 © H RP /W H O / An to in e Ta rd y 1. Afghanistan 2. Argentina 3. Australia 4. Bangladesh 5. Botswana 6. Brazil 7. Burkina Faso 8. Cambodia 9. Canada 10. Central African Republic 11. Chile 12. China 13. Colombia 14. Côte d’Ivoire 15. Democratic Republic of the Congo 16. Djibouti 17. Egypt 18. Eswatini 19. Ethiopia 20. Ghana 21. Guatemala 22. Guinea 23. Honduras 24. India 25. Indonesia 26. Iraq 27. Italy 28. Jordan 29. Kenya 30. Kyrgyzstan 31. Lebanon Countries where HRP has active projects 32. Madagascar 33. Malawi 34. Malaysia 35. Mali 36. Mexico 37. Mongolia 38. Morocco 39. Mozambique 40. Myanmar 41. Namibia 42. Nepal 43. Niger 44. Nigeria 45. Pakistan 46. Peru 47. Philippines 48. Poland 49. Republic of Korea 50. Republic of Moldova 51. Romania 52. Rwanda 53. Senegal 54. Somalia 55. South Africa 56. State of Libya 57. Sudan 58. Syrian Arap Republic 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 66 67 68 69 70 28 72 73 72 65 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 66 67 68 69 70 28 72 73 72 65 59. Tajikistan 60. Thailand 61. Timor-Leste 62. Togo 63. Tunisia 64. Turkey 65. Uganda 66. Ukraine 67. United Kingdom of Great Britain 68. United Republic of Tanzania 69. Uruguay 70. Viet Nam 71. West Bank and Gaza Strip 72. Zambia 73. Zimbabwe HRP Donors 2022–2023 United Nations • United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) • United Nations Population Fund (UNFPA) • World Health Organization (WHO) Member States • Australia • Canada • China • Flanders, Belgium • India • Netherlands (Kingdom of the) • Norway • Sweden • Switzerland • Thailand • United Kingdom of Great Britain and Northern Ireland • United States of America Non-state actors • American Society for Reproductive Medicine • Bill and Melinda Gates Foundation • Children’s Investment Fund Foundation • David and Lucile Packard Foundation • Elrha • Guttmacher Institute • Johns Hopkins University • Karolinska Institute • Male Contraceptive Initiative • Mamta Health Institute for Mother and Child • Merck Sharp & Dohme Corp. • The Global Fund to Fight AIDS, Tuberculosis and Malaria • Unitaid • University of Birmingham 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 66 67 68 69 70 28 72 73 72 65 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 66 67 68 69 70 28 72 73 72 65 61 CreditCredit © W H O / G ue rc ho m N de bo HRP is proud to be part of a broad coalition of organizations working to ensure sexual and reproductive health and rights (SRHR) for all. HRP has always been a progressive force, unafraid to disrupt conventional thinking, but also committed to listening carefully to other perspectives, particularly of those with lived experience. The year 2024 is a landmark year for SRHR marking 30 years since the 1994 International Conference on Population Development (ICPD) in Cairo established the contemporary rights-based approach to SRHR that guides us today. Ten years later, in 2004, WHO’s first strategy on reproductive health, the Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets, was adopted by the 57th World Health Assembly. It is in this context of celebrating hard-won gains toward a healthier future that HRP will continue to expand global understanding of reproductive rights and sexual health by taking a forward-looking assessment of where we are, where we need to go and what we need to do to achieve universally agreed health and human development goals. In 2024, in collaboration with cosponsors, HRP is already working on how to harness the power of artificial intelligence (AI) to improve SRH services and will be asking what new products and innovations, like self-care and self-testing options, have the potential to significantly improve life for those in the most disadvantaged communities. This is the year to consider and address, in earnest, the impacts of climate change, conflict and persistent social and economic inequality on the achievement of SRHR goals. This is also the year to unify and collaborate, harnessing our strengths, in order to leave no one behind. Conclusion This is the year to consider and address, in earnest, the impacts of climate change, conflict and persistent social and economic inequality on the achievement of SRHR goals. Credit 63 Photo credits: Pg iv ©WHO/Christine McNab A midwife delivers care to remote Hay River in Canada’s Northwest Territories. Pg vi (intro) ©WHO/Rada Adbar A midwife listens to the heartbeat of a pregnant woman at the mobile clinic organized by WHO at the Garm Abak of Waras district in Bamiyan, Afghanistan. Pg viii ©HRP/WHO/Uma Bista Pabitra listens to family planning information provided by a “Mary Stopes Lady” health worker at a health post in rural. Pg 4 ©WHO/Blink Media – Cindy Liu A midwife poses inside the Cambodia-Japan Friendship Health Center of Chambok in Beng village in Cambodia. Pg 8 ©HRP/WHO/Saiyna Bashir A health worker gives a client birth control pills upon her request during a home visit in Pakistan. Pg 12 ©HRP/WHO/Uma Bista A health worker inserts a contraceptive implant at a health post in rural Nepal. Pg 16 ©UNICEF/UNI74973/Nesbitt A mother breastfeeds her four-month-old son in their home on the outskirts of Lusaka, Zambia. Pg 22 ©HRP/WHO/Uma Bista A mother of two recovers in a hospital in Nepal. She arrived in a critical condition following an unsafe abortion. Pg 24 ©HRP/WHO/Maria Gutu A gynecologist at National Resource Center YK Neovita in Chișinău, Moldova, consults a patient about an unplanned pregnancy. Pg 27 ©HRP A photo exhibit on access to comprehensive abortion care was on display at the Palais des Nations and brough together technical experts as well as representatives from Member States. Pg 28 ©HRP/WHO/Saiyna Bashir A health worker prepares to visit a community member who is pregnant in Bara Kahu, Islamabad. Pg 31 ©HRP/WHO/Maria Gutu A psychologist, consults with a patient at a health center in Comrat, Moldova. Pg 32 ©Inter-Parliamentary Union HRP expert, Dr Venkatraman Chandra-Mouli, speaks as part of a workshop on sexual and reproductive health at IPU46 Pg 34 ©Catherine Meng’anyi Catherine Meng’anyi at work in Kenya. Pg 36 ©WHO/Yoshi Shimizu Three generations of family in Mongolia. Pg 39 Jonathan Torgovnik/Images of Empowerment Community health worker during a home visit, providing family planning services and options to women in the community. This proactive program is supported by Reproductive Health Uganda. Pg 41 ©HRP/WHO/Uma Bista A woman has her blood pressure read at home in rural Nepal. Pg 42 ©WHO/Kiana Hayeri Inside a delivery room at Kabul’s Malalai National and Specialized Hospital, midwives in training help deliver babies under the supervision of the head midwife. Pg 45 ©UNICEF/Bhardwaj Meeting women’s emotional, psychological and clinical needs during childbirth. Pg 46 ©UNICEF/Haro A pregnant mother near flooded areas in Moosa Jessear village, Sindh Province, Pakistan. Noor’s first baby passed away due to complications during her first pregnancy; her second child died at only three days old when floods hit Pakistan in August 2022. Pg 48 ©HRP/WHO/Hickmatu A lab technician does blood grouping and documentation of test results at the Princess Christian Maternity hospital in Freetown, Sierra Leone. Pg 50 ©HRP/WHO/Saiyna Bashir A health worker enters data collected from her home visits into an electronic system at the Basic Health Unit in Bara Kahu, Islamabad. Pg 52 ©HRP/WHO/Maria Gutu A couple in the village health center in Avdarma, Moldova. Pg 53 ©HRP/WHO/Antoine Tardy HRP’s timeline highlighting 50 years of achievements was on display at WHO. Pg 57 ©HRP/WHO/ Antoine Tardy Delegates gather at the meeting of HRP’s Policy and Coordination Committee. Pg 58 ©HRP/WHO/ Antoine Tardy Dr Tedros Adhanom Ghebreyesus addresses HRP’s Policy and Coordination Committee. Pg 62 © WHO / Guerchom Ndebo Maisha, 57,stands in front of her shelter in Bulengo camp, about 15 kilometres from Goma in the east of the Democratic Republic of the Congo. HRP annual report 2023

Department of Sexual and Reproductive Health and Research World Health Organization 20 Avenue Appia 1211 Geneva 27 Switzerland Email: srhhrp@who.int www.who.int/hrp