Improvements in health and mortality, known as the health transition, played important roles in the rise of modern contraceptive prevalence across countries. We describe key mechanisms and selected research evidence that show how health transitions helped shape contraceptive transitions around the world. Mechanisms include how decreases in child mortality rates affect the motivation to use contraception and how the organization and expansion of health care affect key barriers to contraceptive use. Substantial increases in child survival resulting from health transitions increase demand for deliberate fertility regulation and contraceptive use. Improved access to primary health care, particularly maternal and child health services and expansion into rural communities, was associated with increases in modern method use. Country-specific policies that affected the organization and delivery of health care led to the dominance of particular modern methods in some countries. Empirical evidence is limited on how the quality of health care has affected aggregate level increases in modern method use. Using modern contraceptive prevalence to define the contraceptive transition reflects current data limitations but future research on the relationship of health transitions with macrolevel contraceptive prevalence trends may be able to incorporate more comprehensive aspects of how health transitions impact contraceptive choice and agency.

Broad and aspirational targets to meet health service needs are useful for advocacy, but setting measurable, time-defined targets for accelerated yet feasible progress is necessary for national monitoring and planning purposes. Information from probabilistic projections of health outcomes and service coverage can be used to set country-specific targets that reflect different starting points and rates of change. We show the utility of this approach in an application to contraceptive coverage in 131 low- and middle-income countries (LMICs) and the related cost and impact of different coverage scenarios. We use the sustainable development goal (SDG) indicator of the proportion of women who have their need for family planning satisfied with modern contraception. The results show that accelerated progress targets would collectively result in 83% of the need satisfied in 2030 for LMICs, which is 5% points higher than the projected level based on the current pace of progress. This translated into 41 million fewer women with an unmet need for modern methods and 14 million fewer unintended pregnancies. Annual direct costs would be $480 million more in 2030 to support contraceptive services compared with costs in 2030 based on the current pace of progress. As governments plan and budget for expanded health service coverage, information from probabilistic projections can guide them in setting measurable, ambitious yet realistic targets that are relevant to their particular contexts.

The COVID-19 pandemic has disproportionate effects on people living in low- and middle-income countries (LMICs), exacerbating weak health systems. We conducted a scoping review to identify, map, and synthesise studies in LMICs that measured the impact of COVID-19 on demand for, provision of, and access to contraceptive and abortion-related services, and reproductive outcomes of these impacts. Using a pre-established protocol, we searched bibliographic databases (December 2019-February 2021) and key grey literature sources (December 2019-April 2021). Of 71 studies included, the majority (61%) were not peer-reviewed, and 42% were based in Africa, 35% in Asia, 17% were multi-region, and 6% were in Latin America and the Caribbean. Most studies were based on data through June 2020. The magnitude of contraceptive service-related impacts varied widely across 55 studies (24 of which also included information on abortion). Nearly all studies assessing changes over time to contraceptive service provision noted declines of varying magnitude, but severe disruptions were relatively uncommon or of limited duration. Twenty-six studies addressed the impacts of COVID-19 on abortion and postabortion care (PAC). Overall, studies found increases in demand, reductions in provision and increases in barriers to accessing these services. The use of abortion services declined, but the use of PAC was more mixed with some studies finding increases compared to pre-COVID-19 levels. The impacts of COVID-19 varied substantially, including the country context, health service, and population studied. Continued monitoring is needed to assess impacts on these key health services, as the COVID-19 pandemic evolves.

The novel coronavirus (SARS-CoV-2) that causes COVID-19 has spread rapidly since emerging in late 2019, leading the World Health Organization (WHO) to declare the disease a global pandemic on March 11, 2020. Governments around the world have had to quickly adapt and respond to curb transmission of the virus and to provide care for the many who have been infected. The strain that the outbreak imposes on health systems will undoubtedly impact the sexual and reproductive health of individuals living in low- and middle-income countries (LMICs); however, sexual and reproductive health will also be affected by societal responses to the pandemic, such as local or national lockdowns that force health services to shut down if they are not deemed essential, as well as the consequences of physical distancing, travel restrictions and economic slowdowns.

Reducing inequalities in health service coverage is central to achieving the larger goal of universal health coverage. Reproductive health services are part of evidence-based health interventions that comprise a minimum set of essential health interventions that all countries should be able to provide. This paper shows patterns in inequalities in three essential reproductive health services that span a continuum of care—contraceptive use, antenatal care during pregnancy and delivery at a health facility. We highlight coverage gaps and their impacts across geographical regions, key population subgroups and measures of inequality. We focus on reproductive age women (15–49 years) in 10 geographical regions in Africa, Asia and Latin America and the Caribbean. We examine inequalities by age (15–19, 20–24, 25–34 and 35–49 years), household wealth quintile, residence (rural or urban) and parity. Data on service coverage and the population in need are from 84 nationally representative surveys. Our results show that dominant inequalities in contraceptive coverage are varied, and include large disparities and impact by age group, compared with maternal health services, where inequalities are largest by economic status and urban–rural residence. Using multiple measures of inequality (relative, absolute and population impact) not only helps to show if there are consistent patterns in inequalities but also whether few or many different approaches are needed to reduce these inequalities and where resources could be prioritised to reach the largest number of people in need.

Ibrahim Abubakar*, Robert W Aldridge*, Delan Devakumar*, Miriam Orcutt*, Rachel Burns, Mauricio L Barreto, Poonam Dhavan, Fouad M Fouad, Nora Groce, Yan Guo, Sally Hargreaves, Michael Knipper, J Jaime Miranda, Nyovani Madise, Bernadette Kumar, Davide Mosca†, Terry McGovern, Leonard Rubenstein, Peter Sammonds, Susan M Sawyer, Kabir Sheikh, Stephen Tollman, Paul Spiegel, Cathy Zimmerman*, on behalf of the UCL–Lancet Commission on Migration and Health‡

Background Abortion-related mortality is one of the main causes of maternal mortality worldwide. Laws often restrict the provision of safe abortion care, yet post-abortion care is a service that all countries have committed to provide to manage abortion complications. There is minimal evidence on the capacity of national health systems to provide post-abortion care. Methods We did a multicountry analysis of data from nationally representative Service Provision Assessment surveys done between 2007 to 2017 in ten countries across three regions (Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda). Data were available for all ten countries from 2007 to 2015. We included facilities offering childbirth delivery services and classified facilities as primary or referral level. We measured signal functions for post-abortion care (the availability of key equipment and ability to perform services) to assess the proportion of primary-level and referral-level facilities in each country with the capacity to provide basic and comprehensive post-abortion care, respectively. We calculated the proportion of facilities providing each post-abortion care signal function to examine specific gaps in service provision. Findings There are critical gaps in the provision of post-abortion care at all facilities that offer delivery services. In seven (70%) of ten countries, less than 10% of primary-level facilities could provide basic post-abortion care, and in eight (80%) of ten countries less than 40% of referral-level facilities could provide comprehensive post-abortion care. In no country could all referral facilities provide all the essential services that need to be included in basic post-abortion care. Interpretation The capacity of primary-level and referral-level health facilities to provide basic and comprehensive post-abortion care, respectively, is low. The results highlight the gap between political commitments to address the consequences of unsafe abortion and the capacity of health systems to provide post-abortion care. Increasing the provision of good-quality post-abortion care is essential to reduce the level of abortion-related morbidity and mortality. Copyright Copyright (c) 2018 The Author(s). Published by Elsevier Ltd.

Key Points This report presents scenarios of adolescent contraceptive use through 2030 to highlight the potential impact and costs associated with overall increased contraceptive use among adolescents and an increased use of long-acting, reversible contraceptives (LARCs), specifically. Under a scenario that assumes the most likely level of modern contraceptive use to be reached in a particular year (median values of probabilistic projections), the number of adolescent women using modern contraceptives in developing regions would reach 19.8 million in 2030, and 57% of adolescent women would have their need for modern contraception met. The total annual cost of services in 2030 for the projected 19.8 million modern method users would be an estimated $310 million. The cost would be lower, at $275 million, if 20% of adolescent women using short-acting methods were to choose LARCs. An estimated 7.1 million unintended pregnancies would be averted under this scenario. Because LARCs are highly effective, a shift toward use of these methods would avert an additional 300,000 unintended pregnancies. Under a scenario with accelerated growth in modern contraceptive use among adolescent women in developing regions, the number of modern method users would reach 27.1 million in 2030, and the proportion of adolescent women whose need for modern contraception would be met would rise to 79%. Contraceptive services for the 27.1 million modern method users in 2030 would cost an estimated $412 million. The cost would drop to $365 million under an assumption of increased LARC use. In 2030, an estimated 9.6 million unintended pregnancies would be averted under this accelerated growth scenario, and an additional 400,000 unintended pregnancies would be averted with a shift to LARC use.