{"paper_id":"7d56dad5-3e30-4d26-bb1e-f9774929ba47","body_text":"1 \n \nGaps in integration of sexual and reproductive health and rights into 1 \nclimate change research in sub-Saharan Africa: A scoping review  2 \n 3 \nJacinter A. Amadi1,2,#a*, George Odwe1, Francis O. Onyango1, and Beth Kangwana1 4 \n 5 \n1 Population Council- Kenya, Nairobi, Kenya 6 \n2 Department of Plant Sciences, Kenyatta University, Nairobi, Kenya 7 \n#a Current address: Population Council- Kenya, Nairobi, Kenya 8 \n 9 \n* Corresponding Author   10 \nE-mail: jacinteramadi@popcouncil.org (JAA) 11 \n 12 \nAbstract 13 \nSub-Saharan Africa is faced with triple challenges of high vulnerability to climate change (CC) impacts, high 14 \nlevels of inequality and poor sexual and reproductive health and rights (SRHR) outcomes. Climate change can 15 \nworsen SRHR situation for high-risk groups such as women, children, adolescent girls and people living with 16 \nHIV. This scoping review takes stock of the state of research on the intersection between CC and SRHR in SSA 17 \nwith a view of identifying gaps and opportunities for effective evidence generation and integration in climate 18 \nactions. The review followed Arksey and O’Malley framework. Data charting was conducted using Population, 19 \nExposure, Comparator, Outcome tool in Covidence. Thirty-seven (37) studies were reviewed, 57% were 20 \nquantitative while 41% and 2% used qualitative and mixed methods respectively. SRHR components 21 \ninvestigated include maternal newborn and child health at 43% (n=16), HIV at 19% (n=7), gender-based 22 \nviolence  at 11% (n=4), and fertility intentions and outcomes at 11% (n=4). SRHR elements that are under-23 \nresearched in the context of CC include access to and uptake of contraceptives, post abortion care, harmful 24 \npractices (child marriages and female genital mutilation), menstrual health, pregnancy losses, bodily autonomy, 25 \nand (in)fertility. Drought, floods, heat stress and rainfall seasonality have received fair attention in research, yet 26 \nimpacts of climate hazards like tropical cyclones, wildfires and salt-water intrusion are missing in research. 27 \nThere is inadequate research at the intersection of CC and SRHR hindering progress towards climate resilience 28 \nand attainment of good health and well-being for all. Effective and equitable integration requires that SRHR 29 \nissues be recognized, and deliberate investments (research, policies, programs, interventions and financing) put 30 \nin place to address the critical SRHR gaps and climate vulnerabilities to enhance resilience. 31 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n  \n \n2 \n \nIntroduction 32 \nImpacts of climate change (CC) on human systems continue to increase in unprecedented ways and magnitude 33 \n[1]. Climate-related events such as severe droughts, heavy rainfall, floods, cyclones, heatwaves, wildfires, and 34 \nsaltwater intrusion cause morbidity and mortality affecting millions of people  globally [1]. Sub-Saharan Africa 35 \n(SSA) region is worst affected by the vagaries of CC. The region is characterized by acute water stress, food 36 \ninsecurity, and climate-induced diseases, especially in areas with high population density and poverty rates [2]. 37 \nClimate change impacts such as heat stress, rainfall variability and drought are common in the West African 38 \nregion, and have been linked to persistent food insecurity and water-related challenges [2]. Similarly, the East 39 \nand Southern Africa region experiences extreme weather events (EWE) such as drought and floods, cyclones 40 \nand rising temperatures, which have been associated with adverse impacts on water availability, livelihoods, 41 \nfood security and health [2]. Other notable impacts of CC in SSA include loss of habitation, forced 42 \ndisplacements and unplanned migrations, infrastructural damages, inaccessible health facilities, disrupted health 43 \nservices, and deteriorating mental health [1,3]. It is noteworthy that these CC impacts disproportionately affect 44 \ncountries or regions that contribute the least to climate change [3,4]. Additionally, vulnerabilities to climate-45 \nrelated risks vary by gender, age, religion, socioeconomic, and disability status [5].  46 \n 47 \nClimate change has the potential to reverse gains made in the health sector. It can exacerbate unmet need for 48 \nsexual and reproductive health and rights (SRHR), especially in low- and middle-income countries due to 49 \nhigher levels of poverty and income inequality, and weak healthcare systems [6]. Sexual and reproductive 50 \nhealth is a state of physical, emotional, mental, and social wellbeing in relation to all aspects of sexuality and 51 \nreproduction, not merely the absence of disease, dysfunction, or infirmity [7]. Core elements of SRHR include 52 \nmaternal, newborn and child health (MNCH); safe abortion services; family planning; prevention and 53 \nmanagement of sexually transmitted infections (STIs) including human immunodeficiency virus (HIV); 54 \nprevention and management of infertility; prevention and management of cancers of the reproductive system; 55 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n3 \n \ndetecting and preventing Gender Based Violence (GBV), forced marriage, transactional sex, and sex 56 \ntrafficking. Sub-Saharan Africa has made great progress in SRHR over the past two decades. The gains include 57 \na 33% reduction in maternal mortality, increased coverage of child immunizations, decline in malaria-related 58 \nchild mortality, a drop in HIV incidence, and a two-fold increase in contraceptive uptake [8]. Therefore, if not 59 \ntaken into consideration, climate change can water down the gains made in SRHR.  60 \n  61 \nImpacts of CC disproportionately affect the most vulnerable populations. In SSA, women, children and 62 \nadolescents, particularly girls, face heightened vulnerability due to the impacts of climate risks [1]. Literature 63 \nshows that climate extremes directly affect women and girls’ health by increasing the risk of maternal or infant 64 \ninjury or death, disrupting access to family planning and HIV care, decreasing reproductive autonomy and 65 \nresulting in poor menstrual hygiene [9]. Climate-related extreme events may also have an indirect impact on 66 \nmaternal and newborn health, for example, adverse birth outcomes such as preterm births and low birth weights, 67 \nincreased GBV including intimate partner violence (IPV), increased HIV transmission rates [9], increased 68 \nunintended pregnancies, and unsafe abortions [10]. Given Africa's high vulnerability to climate change, its low 69 \nadaptive capacity, and existing high levels of inequality, the already critical state of SRHR in the region will 70 \nlikely deteriorate further [1]. Addressing this challenge requires efforts that focus on addressing the critical 71 \nSRHR-CC intersection gaps and empowering women and girls to make informed decisions and choices about 72 \ntheir sexual and reproductive health.  73 \n 74 \nAchieving universal health care, including SRHR is a major pathway for  individual, community, and 75 \ninstitutional climate resilience [11]. This can occur through increased access to and uptake of modern 76 \ncontraceptives, better antenatal care services, improved post abortion care, and reduced SGBV and HIV 77 \ntransmission. These factors improve women’s and girls’ health and enhance their control and decision-making 78 \npowers over sexual and reproductive health matters [12]. Consequently, improved access to SRHR increases 79 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n4 \n \nwomen’s and girls’ ability to engage in empowerment activities like education, income generation, employment 80 \nopportunities, and access to resources [9], factors that promote climate resilience. Further, access to child health 81 \nservices like vaccinations and preventive care can reduce vulnerabilities of at-risk populations to climate-related 82 \ndiseases like malaria and diarrhea that afflict millions of children in the region. Therefore, identifying and 83 \nreducing unmet need for SRHR contributes to climate change resilience and improves communities’ and health 84 \nsystems’ adaptive capacity through improved health and well-being of women, girls and children, including 85 \nincreased access to health services, education, nutrition, and family planning [13].  86 \n 87 \nIt was until 2021 that health was brought at the center of global climate discussions during United Nations 88 \nFramework Convention on Climate Change (UNFCCC) Conference of Parties (COP26). Over the years, CC 89 \nchange research and funding have been skewed towards sectors such as agriculture, water, and energy with 90 \nhealth sector getting minimal attention. Furthermore, within health research, focus has been on climate-sensitive 91 \nand infectious diseases such as malaria and cholera [14,15], other health aspects such as SRHR remaining under 92 \ndocumented. In 2023, United Nations called for accelerated research on MNCH [16], one of the key elements of 93 \nSRHR. The recent occurrences in global climate change spaces point to the gaps in CC and SRHR intersection 94 \nresearch that need be urgently addressed. Therefore, this scoping review takes stock of the state of research on 95 \nthe intersection between CC impacts, and SRHR outcomes in sub-Sahara Africa and identifies gaps and 96 \nopportunities for effective SRHR-CC evidence generation, and integration in climate change and health policies, 97 \nplans, and interventions at all levels. We analyze published documents on the impacts of climate change on 98 \nSRHR to explore the state of research at the intersection and explore gaps and opportunities for their integration 99 \nin the region.  100 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n5 \n \nMaterials and methods  101 \nDatabase search 102 \nThe study identified publications integrating SRHR in climate change research in SSA using Arksey and 103 \nO’Malley framework for scoping reviews [17]. Electronic databases for peer reviewed journal articles and 104 \nreports were searched to identify relevant literature using MyLOFT with the support of Kenyatta University 105 \nLibrarians. A first search of journal databases including Pubmed, Elsevier, Springer, Wiley, Taylor and Francis, 106 \nOxford Academic Journals, African Journals Online, ScienceDirect, JSTOR, and Saje Journals was done in 107 \nMay 2024 using CC and SRHR key words (S1 Table). The search was restricted to the period between January 108 \n2010 to April 2024 consistent with availability of evidence. A second search was conducted in PubMed (S2 109 \nTable) using specific SRHR terms derived from Starrs [7] such as maternal, newborn, and child health; abortion 110 \ncare; family planning; HIV; infertility; cancers of the reproductive system; gender based violence including 111 \nintimate partner violence; forced or early marriage, transactional sex and sex trafficking in addition to climate 112 \nchange search terms to identify additional studies investigating impacts of climate change on various SRHR 113 \ncomponents that might have been left out during first search. Peer-reviewed journal articles at the intersection 114 \nof climate change and individual components of SRHR were included. The accessed documents were analyzed 115 \nto identify the state of SRHR-CC integration in research and gaps and potential entry points for comprehensive 116 \nintegration. 117 \nSearch strategy and selection criteria  118 \nThe search strategy used key words and subject headings relating to climate change and SRHR based on 119 \ndefinition provided in this review. Reports generated from the search were managed in Mendeley online library 120 \n(https://www.mendeley.com/search/) and then uploaded in Covidence (https://www.covidence.org/) for analysis. 121 \nRecords were subjected to first stage screening by a single reviewer using laid-out inclusion and exclusion 122 \ncriteria. Selection and screening of journal articles and reports followed the checklist recommended by 123 \nPreferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews (PRISMA-124 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n6 \n \nScR) [18]. Records having qualitative, quantitative, mixed method approaches, short communications, 125 \ncommentaries, reviews, and meta-analyses were analyzed in the first stage of the review. Studies were included 126 \nin the full-text review if (i) they were on climate change (including climate extremes, events, and disaster) and 127 \nmentioned at least one aspect of SRHR; (ii) they were on SRHR or its components and mentioned climate 128 \nchange hazards (iii) if they were conducted in SSA region and those published in English. Documents were 129 \nexcluded if they solely explored climate change or SRHR and if they were not conducted in the region. Reviews, 130 \ncommentaries, abstracts, reproductive studies on animals and plants and publications without full-text articles 131 \nwere also excluded. Excluded reports did not meet the data charting criteria. 132 \nData charting and synthesis 133 \nData charting was conducted using a data extraction template developed following the Population, Exposure, 134 \nComparator, Outcome (PECO) framework in Covidence. Data extraction template was pretested, and 135 \nadjustments made before commencing the data extraction process. Data extracted included study details (author, 136 \nyear of publication, setting), data source, data collection method, climate change event(s), study population, 137 \nimpacts of climate event(s), SRHR element(s), and SRHR outcomes. Data extraction, review and synthesis were 138 \nconducted sequentially by a single reviewer. Data synthesis followed a thematic analysis of SRHR domains. 139 \nPRISMA-2020  flowchart was used to illustrate article selection process. 140 \n 141 \nThe search yielded 8822 records. A total of 7589 ineligible and 735 duplicate reports were removed. Four 142 \nhundred ninety-eight (498) articles were screened by title and abstract followed by full-text assessment of 117 143 \narticles for eligibility. Thirty-seven (37) articles were retained for data extraction (Fig 1). Some excluded 144 \narticles were reviews and meta-analysis [19–21], commentary or editorial [22–24], while others did not include 145 \nboth CC and SRHR in their content [25–28].  146 \n 147 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n7 \n \nFig 1. PRISMA 2020 flow chart showing document screening and eligibility assessment process. 148 \n 149 \nEthical consideration 150 \nThe study did not require ethical approval as it did not entail research on human subjects. 151 \n 152 \nResults 153 \nStudy characteristics 154 \nS3 Table summarized characteristics of 37 studies included in the review. Majority of the studies (81%, n=30) 155 \nwere published after the year 2020. Fifty seven percent (57%, n= 21) were quantitative studies while 41% 156 \n(n=15) were qualitative studies and one study used mixed methods approach. Quantitative studies applied cross-157 \nsectional, case control, case series, longitudinal, and cohort study designs. Table 1 shows the distribution of 158 \nstudies at the intersection between CC and SRHR by country in the SSA region. Four articles were regional 159 \nstudies [29–32] while three were global studies with reference to SSA [33–35]. The SRHR components 160 \ninvestigated were MNCH (43%; n=16), HIV (19%, n=7), GBV including IPV and violence against women and 161 \ngirls (VAWG) (11%; n=4), and fertility intentions and outcomes (11%; n=4). Sixteen percent (16%; n=6) of the 162 \narticles were studies on multiple SRHR elements including MNCH combined with fertility and HIV [36]; HIV 163 \nand GBV [37]; early marriage, MNCH and FP[38]; HIV, GBV and MNCH [39], and MNCH and GBV [40]. 164 \nImpacts of extreme heat, drought, changing rainfall patterns and floods were the main climate hazards studied in 165 \n24%, 24%, 14% and 11% of the articles respectively. Other studies either combined multiple CC risks (19%) or 166 \nassessed climate change impact collectively (8%).  167 \nTable 1. Characteristics of studies included in the review 168 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n8 \n \n 169 \n 170 \nMaternal newborn and child health 171 \nThe metrices assessed under MNCH included child health outcomes [46,47,63], antenatal health and 172 \nexperiences [35,49,50,60], knowledge levels [41], access to healthcare [59,61], breastfeeding and childcare 173 \nStudy characteristics \nQuantitative \nstudies \n57% (n=21) \nQualitative \nstudies \n41% (n=15)\n \nMixed methods 2% (n=1)  \nMNCH 43% (n=16) \nFP 11% (n=4) \nHIV 19% (n=7) \nGBV 11% (n=4) \nMultiple elements 16% (n=6) \n  \nRegion Drought Floods Rainfall \nchanges \nHeat stress Extreme \nweather events \n(floods and \ndrought) \nMore than \ntwo climate \nhazards \nWest Africa    MNCH \n[41–44] \nGBV-VAWG \n[45]  \nMNCH [46]  \nEast Africa MNCH [47]   \nGBV/MNCH \n[40]  \nIPV [48]  MNCH [49]  MNCH [50–\n52] \n  \nWest and East \nAfrica \n  Fertility/ FP \nintentions \n[53] \n   \nSouthern Africa Multiple \nelements [38,54] \nHIV [37,55–\n57,57] \nHIV [58]   \nMNCH \n[59] \nMNCH \n[60,61] \nHIV [62]  \n  Multiple \nElements [36] \nEast and \nSouthern Africa \n   MNCH [63] IPV [64] Multiple \nelements [39]  \nSSA region IPV [29] MNCH \n[35] \n MNCH [32]   Reproductive \noutcomes \n[31,33] \nReproductive \ngoals [30] \nMultiple  \nelements [34] \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n9 \n \npractices [42], and interventions to address adverse effects of climate-related events [51] (Fig 2). Studies 174 \nshowed that exposure to heat stress during the third trimester of pregnancy reduces birthweight [46,63]. The 175 \nlength and strength of heat waves adversely affects birthweight. Ambient temperatures greater than 35°C were 176 \nassociated with increased  odds of wasting and underweight among children under 5 years [32]. A positive 177 \nimpact of higher seasonal Normalized Difference Vegetation Index (NDVI) on birthweight was reported in Mali 178 \n[46]. In Kenya, a study investigating early gestational exposure to severe drought on child health outcomes 179 \nshowed that exposed children had lower body weight compared to non-exposed siblings [47]. Food insecurity 180 \nwas a strong CC impact pathway affecting maternal health and child health outcomes. In Uganda, indigenous 181 \nwomen had the greatest negative maternal-infant health outcomes resulting from CC-related food insecurity 182 \ncompared to non-indigenous women [49].  183 \n 184 \nFig 2. Attributes investigated under Maternal Newborn and Child Health (MNCH) component 185 \n 186 \nStudies in Zambia and Mozambique investigated the influence of floods [59] and rainfall seasonality [41] on 187 \naccess to and utilization of maternal health services. Floods were found to hinder access to maternal health 188 \nservices. Similarly, low numbers of institutional deliveries were reported to occur during rainy season. The 189 \neffect was greater for deliveries compared with antenatal care (ANC) visits since women were isolated from 190 \naccessing delivery facilities. A study conducted in South Africa showed that rainfall seasonality affected ANC 191 \nattendance with lowest visits ≤  4 occurring during rainy seasons [60]. The rains not only cause infrastructural 192 \ndamage and limit access to health facilities but also correspond to low food availability and increased 193 \nagricultural labor, factors that are associated with adverse birth outcomes such as reduced birth weight and head 194 \ncircumference [60]. Another study analyzing impact of floods found that exposure to floods during pregnancy 195 \nincreased the risk of pregnancy loss due to injuries or trauma following flood events. The risk was greater for 196 \nwomen outside peak reproductive age (<21 years) and among those in rural areas [35]. A study conducted in 197 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n10 \n \nKenya documented the lived experiences of pregnant women under extreme heat [50]. The study showed that 198 \nheat stress disrupts social and interpersonal relations reducing quality of selfcare and childcare.   199 \n 200 \nStudies exploring perceptions and knowledge about health impacts of extreme heat on MNCH reported lack of 201 \nawareness among women in Burkina Faso  [43] and communities in Kenya [51]. In Kenya, high ambient 202 \ntemperature was associated with early introduction of alternative foods to infants younger than 6 months and 203 \nreduction in Kangaroo care [52]. Similarly, extreme heat was reported as a barrier to exclusive breastfeeding 204 \nand a cause of early introduction of supplemental fluids for infants under 6 months [42].  205 \n 206 \nGender-based violence 207 \nStudies investigated the influence of floods and drought on intimate partner violence (IPV) and VAWG. A 208 \nstudy in rural Kenya found that women in agriculture had greatest risk of experiencing physical and sexual 209 \nviolence compared to urban counterparts when exposed to floods [48]. A similar study exploring the 210 \nrelationship between extreme weather and IPV in Uganda, Zimbabwe and Mozambique reported that EWE such 211 \nas floods and drought increase violence against women and girls by affecting their access to income and 212 \nemployment [64]. Economic burden and displacements that result from EWE are the underlying factors that 213 \ncause high prevalence of IPV. Another study found that severe drought was associated with greater risk of 214 \nsexual violence [29]. The risk of violence increased with severity of drought and frequency of floods, an 215 \noccurrence attributed to increased conflicts in households experiencing soring commodity prices and scarcity of 216 \nresources. A study in Chad examined the association between violence and women’s resilience to climatic 217 \nevents and found that violence exposes women and girls to adverse consequences such as reproductive health 218 \ninjuries and morbidities [45]. The study further reported that socio-cultural practices hinder women from fully 219 \nparticipating in decision-making processes and exercising control over financial resources, thereby reducing 220 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n11 \n \ntheir capacity to cope with crises. Climate change impacts limit access to care and reduces resources needed for 221 \nsurvival, thus widening SRH gaps for women and girls.  222 \n 223 \nSexually transmitted infections including HIV 224 \nResearch on HIV has been going on for decades, however, studies integrating impacts of CC risks are more 225 \nrecent as revealed in this review. Studies reviewed focused on HIV prevention, management and service 226 \nprovision, with drought being the main CC risk investigated followed by floods and changes in rainfall trends. 227 \nHIV dimensions examined were transactional sex and HIV prevalence [56], HIV prevention, management and 228 \ncare [37,55], adverse HIV outcomes on people on anti-retroviral therapy (ART) [62],  institutional capacities to 229 \nprovide HIV services and care [57], climate impact on PLHIV and service provision [58,65]. A study in Malawi 230 \nreported that drought increases HIV prevalence by 15%, with the effect being mediated by risky sexual 231 \nbehavior like transactional sex [56]. Transactional sex is a key exposure pathway between climate change and 232 \nHIV infections [37,56]. A similar study in Lesotho found that living in drought stricken areas was associated 233 \nwith higher HIV incidence among young female (aged 15-24) [37]. A report from South Africa found that 234 \ndrought negatively affected HIV treatment adherence by disrupting income, livelihoods and food systems, thus, 235 \nincreasing the risk of ill-health [55,65] and higher odds of unsuppressed viral load. The adverse HIV outcomes 236 \nwere accompanied by high mortality among PLHIV on ART and exacerbated by depressed rainfall or drought 237 \n[62]. A study in Namibia reported that floods negatively impacted HIV service provision and care by limiting 238 \naccess to facilities, leading to reduced HIV testing, thereby weakening prevention of mother to child 239 \ntransmissions (PMTCT) efforts, and disrupting access to treatment [58].  240 \nFamily planning 241 \nStudies analyzing the impacts of climate change on reproductive health (RH) were regional [30,31] and national 242 \nin scope [53,54]. This review did not find studies that directly assessed the impacts of CC on access to and 243 \nuptake of family planning (FP) services in the SSA region. However, fertility intentions and reproductive goals 244 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n12 \n \n[30,53], life course transition [54], and inclusion of RH in policies [31,33] were the FP proxies investigated. 245 \nStudies reported an association between a good growing season and increased desire to bear children in future 246 \nand a higher likelihood of FP discontinuation [53]. In contrast, exposure to extreme temperature was associated 247 \nwith low fertility preference and low ideal family size [30]. Studies showed that fertility goals varied across 248 \nSSA region and among populations in response to CC hazards.  In Malawi, exposure to drought increased 249 \nadolescent’s transition into first birth and young women's transition into cohabitations and marriages, behaviors 250 \nlinked to resource constraint (food and income) experienced during drought [54]. A study assessing the status of 251 \ninclusion of RH in climate change policies in Africa reported that RH was not adequately recognized or 252 \nincluded in climate change adaptation strategies [31]. Another study reported that only 14% of countries in SSA 253 \nincluded actions and strategies to slow population growth in the Nationally Determined Contributions (NDCs) 254 \nsubmitted in 2020 and that data scarcity is an impediment to FP reporting and integration into policy [33]. 255 \nEarly marriages, risky sexual behaviors and other SRHR components  256 \nOnly two (2) studies analyzed the impact of climate change on early marriages. In Zambia, economic 257 \nconsequences of drought such as reduced household income and food insecurity increased women’s 258 \nvulnerability to transactional sex and early child marriages [38]. In Malawi, a study reported early sexual debut, 259 \nand accelerated transition into unions among adolescents and young women exposed to drought [54]. Crop yield 260 \nreductions, psychosocial stress, limited food and liveli hood resources were the factors that accelerated early 261 \nmarriage and childbearing among young women (under 24 years). A study assessing health consequences of 262 \nlarge-scale displacements observed that CC is not adequately addressed in health care planning and proposed 263 \nthe need for robust political and governance solutions to health needs in humanitarian setting [40]. This review 264 \nfound a dearth of information on the impacts of CC on harmful practices like female genital mutilation (FGM) 265 \nand other SRHR elements like menstrual health, sex trafficking, infertility, abortion care, and cancers of the 266 \nreproductive system.  267 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n13 \n \n 268 \nDiscussion 269 \nThis scoping review provides a synthesis of the impacts of climate change on SRHR outcomes in SSA region. 270 \nThe review documents studies conducted on the intersection, identifies gaps and proposes recommendations for 271 \neffective integration of SRHR in CC research policy and interventions for climate resilience. In relation to 272 \nclimate change research, maternal, newborn and child health (MNCH) was the most researched SRHR 273 \ncomponent (n=16) followed by HIV prevention and care (n=7), reproductive goals (n=4), and GBV (n=4). A 274 \nrecent study conducted in the LMICs corroborates this finding [66]. The focus on  MNCH and HIV may be 275 \nrelated to the  high-level political commitments to reducing maternal and under-five mortality as well as the 276 \nglobal strategy on HIV prevention and response. Drought, heat stress, changing rainfall seasons and floods were 277 \nthe most studied climate change events. Studies reviewed investigated direct impacts and exposure pathways of 278 \nclimate change on SRHR outcomes. Direct impacts included effects on access to maternal and child health 279 \nservices, effects on biological mechanisms modulating SRHR outcomes, heat stress effects, and immediate and 280 \nlong-term physical and mental health impacts. Exposure pathways assessed were food insecurity, diminishing 281 \nlivelihood resources, undernutrition, increasing commodity (e.g. food) prices, economic shocks, displacements 282 \nand migrations. Adverse SRHR outcomes resulting from climate risks examined included changing fertility 283 \ngoals and choices, poor prenatal and child health, disrupted service delivery, changing sexual behavior patterns, 284 \nadverse birth outcomes like still births, pre-term births and low birth weight, increasing physical and sexual 285 \nviolence, early sexual debut and early entry into unions, human morbidity, and mortality.  286 \n 287 \nThis scoping review showed that SRHR has not been effectively and equitably addressed in climate change 288 \nresearch in SSA. There is a narrow range of SRHR components in the studies reviewed; much of SRHR 289 \nresearch is still siloed while CC policy and actions hardly recognize or largely exclude SRHR issues. Neonatal 290 \nand child health outcomes, antenatal health and experiences, awareness and knowledge levels, access to 291 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n14 \n \nmaternal health services, and neonatal-care and self-care were the dimensions investigated under MNCH. 292 \nBiological mechanisms by which drought and heat stress impact maternal and child health included changes in 293 \ngene function [47] and reduction in placental blood flow [44] causing adverse birth outcomes like reduced 294 \ngestational age and increased chances of pre-term birth [63]. Behavioral outcomes like reduced ANC visits and 295 \nfacility-based deliveries [38] were additional ways that led to adverse birth outcomes. Although drought ranks 296 \nthird among climate disaster risks in Africa [67], it causes the greatest mortality, affects millions of people, 297 \ndestroys livelihoods, increases food insecurity, and reduces income [68]  factors that negatively affect maternal 298 \nand child health outcomes. Heat stress poses a potential threat to health and wellbeing of pregnant women and 299 \ninfants and can weaken gains made in reducing maternal and neonatal mortality and morbidity in the region. 300 \nNormalized Difference Vegetation Index, a substitute for food security status positively corelates with birth 301 \noutcomes. Thus, seasonal NDVI can be incorporated in early warning systems to trigger early actions and 302 \ninterventions such as supplementation for pregnant women and children [69].  303 \n 304 \nThe review further showed that sexual and physical violence continue to be perpetrated on young women in 305 \ndiverse settings, with rural women bearing a heavy burden compared to their urban counterparts [70]. Most 306 \nstudies reviewed focused on IPV, with violence meted by non-partners and violence against adolescent girls 307 \nremaining understudied. Economic loses and forced displacement are the pathways through which EWE 308 \nperpetuate violence against women and girls. Rural women, especially those in agriculture, were at the greatest 309 \nrisk of experiencing physical and sexual violence [71]. Socio-cultural practices [72], political, and economic 310 \nbarriers [73] aggravate GBV and gender inequality, and should thus be addressed together in climate actions.  311 \n 312 \nIndividuals facing EWE have higher likelihood of exposure to HIV infection [22]. On the one hand, drought 313 \nincreases HIV incidence by contributing to risky sexual behaviors and affecting HIV treatment adherence. On 314 \nthe other hand, floods disrupt HIV service provision and care by limiting access to facilities, HIV testing and 315 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n15 \n \ntreatment [74]. Consequently, understanding the relationship between EWE and transmission of HIV can better 316 \nposition HIV prevention services and programs such as pre-exposure prophylaxis (PrEP) to cater for the needs 317 \nof at-risk persons who experience these events [22]. Despite the steady progress made on HIV control over the 318 \npast decades, climate change poses a new threat to the efforts on reducing HIV epidemic globally [75]. 319 \nCollective actions addressing to both HIV prevention and climate actions will require anticipatory planning 320 \nwhile taking into consideration equity, human rights and justice to deliver climate-proof HIV prevention 321 \nprograms, services, care and support in geographic areas under climate crisis [75].  322 \n 323 \nCurrently, there are limited country-based studies in SSA evaluating the link between climate change and FP 324 \nuse. While most studies investigated FP aspects such as fertility intentions and reproductive goals, there were no 325 \nstudies linking unmet need for FP and climate risks. Yet, there is great overlap between high fertility, high 326 \npopulation growth, high unmet need for FP and high climate vulnerability and risks in many parts of the region 327 \n[76]. Evidence suggests that CC may worsen factors (socioeconomic, education, mobility, employment, and 328 \nland tenure) associated with uptake of and access to FP [77]. Recognition of impacts of population growth and 329 \ninclusion of reproductive health (including FP) in national climate change policies and plans provide a basis for 330 \naddressing unmet need for FP. Climate change adaptation and health interventions targeted to poor women 331 \nwithout formal education can increase the uptake of modern contraceptives and improve SRHR outcomes 332 \nnecessary for climate resilience [78]. Climate change mitigation and adaptation actions should be cognizant of 333 \nthe need to integrate population, health and development needs in the region. 334 \n 335 \nDrought and dwindling rainfall have been associated with increased vulnerability of girls to forced or early 336 \nmarriages and accelerated transition into marriages and childbearing by young women. Poverty, religion, 337 \nculture, and lack of access to education were the main drivers to child marriage in SSA. Most child marriages 338 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n16 \n \noccurred in countries across the Sahel, a region ravaged by extreme drought and poverty [79]. Environmental 339 \nand climate crises are known to worsen drivers of early marriages. It is therefore imperative that actions  that 340 \ntackle child marriages should take into consideration their connection to climate change and vice versa [10]. 341 \nGaps in climate change and SRHR research 342 \nImpacts of CC on SRHR outcomes have not been adequately investigated to inform policy and actions. 343 \nCompared to South Asia and other parts of the world, there are no studies in SSA examining the linkages 344 \nbetween saltwater intrusion and maternal and child health outcomes [80–82]. There is also inadequate evidence 345 \non impacts of climate hazards on SRH outcomes such as GBV, HIV outcomes (biological and behavioral), 346 \naccess to and uptake of family planning, fertility/infertility, and harmful practices like child marriage and FGM. 347 \nClimate change risks and subsequent SRHR outcomes are diverse and vary from West to East and Southern 348 \nAfrica thus require contextualization of CC actions and SRHR interventions [30]. The potential impacts of 349 \nextreme temperatures on male fertility, health of PLHIV, ART use and health-seeking behaviors are some of the 350 \nunderstudied SRHR elements that future research should investigate. Furthermore, impacts of CC or EWE on 351 \nmenstrual health, pregnancy losses, bodily autonomy, male infertility, harmful practices (sex trafficking), 352 \nSRHR outcomes for adolescent girls and minority groups such as indigenous women, persons with disability 353 \nand sexual minorities are additional dimensions that should be considered in future research. Research should 354 \nfocus on data disaggregation and  underserved, marginalized or minority groups. Further still, there is a shortage 355 \nof data on other climate change hazards such as cyclones, fire weather and air pollution on SRHR outcomes. 356 \nMediating factors such as biological mechanisms, behavior changes, and social and economic factors should 357 \nalso be addressed to reveal nuanced relationships with SRHR elements.  358 \n 359 \nLived experiences of vulnerable persons in high-risk areas should be documented to support policy and actions 360 \nto address their SRHR needs. Contextualization of SRHR outcomes is needed for informed decision-making 361 \nand development of effective and appropriate interventions. Research should also explore the impacts of 362 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n17 \n \nmeteorological conditions such as temperature, humidity and solar radiation to identify synergies and combined 363 \nimpacts on SRHR outcomes. A knowledge gap exists on intersecting issues such as culture that exacerbate 364 \nimpacts of CC and widen the gap in addressing SRHR needs. Evidence on factors such as gender, age, and other 365 \nsocial, biological and economic characteristics that modulate climate-SRHR impacts are needed to inform the 366 \ndesign of targeted interventions for specific groups. Low awareness and knowledge levels among at-risk 367 \npopulation like pregnant women, health care providers and communities on health impacts of climate hazards 368 \nneed to be addressed [42,52]. Awareness levels and knowledge on the effects of climate extremes on pregnancy 369 \nloss [83], and mental health [84] need further investigations. Increased awareness will dispel misinformation on 370 \nimpacts of CC on maternal and child health outcomes. In addition, studies on climate change, migration and 371 \nSRHR nexus in fragile settings should incorporate displaced or migrant persons’ and host communities’ 372 \nexperiences and engage them in the design of policy and programs for sustainability.  373 \n 374 \nStill, research on CC-SRHR intersection is yet to benefit from the support of global climate funding sources 375 \nsuch as adaptation fund, green climate fund, and global environment facility. The funding can be achieved if 376 \ngovernments recognize and include SRHR in their national and sub-national policies, plans and programs. 377 \nInclusion of SRHR in national adaptation plans, NDCs and other long-term development plans promotes SRHR, 378 \nwellbeing of all and supports achievement of Sustainable Development Goals SDG 3 and 13. Financing of CC-379 \nSRHR interventions should benefit from support from both local and international sources.  380 \nLimitations 381 \nThis scoping review identified research studies at the intersection between CC and SRHR in sub-Saharan Africa. 382 \nThe search focused on peer-reviewed journal articles published in electronic databases. Due to budget 383 \nconstraints, data extraction was conducted by a single reviewer and the search did not include grey literature, 384 \nconsequently, some documents may have not been captured. The search was also limited to studies published in 385 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n18 \n \nEnglish leaving out potential studies published in other languages. Given that the topic is nascent, a systematic 386 \nreview may have resulted in exclusion of publications considered not rigorous yet had important insights, thus a 387 \nscoping review was conducted. Quality assessment was not conducted. This may have limited reporting on 388 \ncertainty of evidences included. Some of the studies reviewed did not incorporate climate data to validate CC in 389 \nthe study locations. In other cases, at risk population such migrants or host communities were not represented 390 \namong study respondents. The scales at which some of the studies were conducted weakened the application of 391 \nrecommendations due to lack of contextualization and heterogeneity of research settings.  392 \n 393 \nConclusions  394 \nThis scoping review reveals that since 2020 there has been a significant increase in research on the intersection 395 \nbetween climate change and SRHR signaling a move towards inclusivity. Majority of the studies are on a 396 \nnarrow range of SRHR components, domains encompassing rights and choices are largely under researched. 397 \nDrought, floods, heat stress and rainfall seasonality have received a fair attention in climate change research, 398 \nhowever, impacts of other climate hazards such as tropical cyclones, fire weather and salt-water intrusion are 399 \nmissing. Intervention research is inadequate hindering progress towards climate resilience and attainment of 400 \nuniversal access to SRHR. Consequently, effective and equitable CC-SRHR research integration will require 401 \nrecognition and inclusion of population growth impacts and SRHR needs in national and sub-national climate 402 \nchange policies, plans and actions in SSA, and in the medium-term and long-term national development plans, 403 \nand integration of  climate change in health policies and plans.  404 \n 405 \nAcknowledgements 406 \nThe research team thank Kenyatta University librarians for their support during database search. 407 \n 408 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n19 \n \nReferences 409 \n1.  IPCC. Summary for Policymakers: Synthesis Report. Clim Change 2023 Synth Rep Contrib Work Groups 410 \nII III Sixth Assess Rep Intergov Panel Clim Change. 2023;1–34.  411 \n2.  Dickerson S, Cannon M, O’Neill B. Climate change risks to human development in sub-Saharan Africa: a 412 \nreview of the literature. Clim Dev. 2021;14:571–98.  413 \n3.  WHO. Gender, climate change and health. Geneva: WHO Press; 2014.  414 \n4.  Austin KF, Noble MD, Berndt VK. Drying Climates and Gendered Suffering: Links Between Drought, 415 \nFood Insecurity, and Women’s HIV in Less-Developed Countries. Soc Indic Res. 2021 Feb 1;154(1):313–416 \n34.  417 \n5.  Arias, P.A., Bellouin, N., Coppola, E., Jones, R.G., Krinner, G., Marotzke, J., et al.,. Technical Summary. 418 \nIn Climate Change 2021: The Physical Science Basis. Contribution of Working Group I to the Sixth 419 \nAssessment Report of the Intergovernmental Panel on Climate Change [Masson-Delmotte, V., P. Zhai, A. 420 \nPirani, S.L. Connors, C. Péan, S. Berger, et al., (eds.)]. Cambridge, UK and New York USA: Cambridge 421 \nUniversity Press; 2021 p. 35–144.  422 \n6.  Bianco G, Espinoza-Chávez RM, Ashigbie PG, Junio H, Borhani C, Miles-Richardson S, et al. Projected 423 \nimpact of climate change on human health in low- and middle-income countries: a systematic review. BMJ 424 \nGlob Health. 2024 Oct 2;8(Suppl 3):e015550.  425 \n7.  Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, et al. Accelerate progress—sexual and 426 \nreproductive health and rights for all: report of the Guttmacher–Lancet Commission. The Lancet. 2018 Jun 427 \n30;391(10140):2642–92.  428 \n8.  WHO. Sexual and Reproductive Health Fact Sheet. 2020 May; Available from: 429 \nhttps://www.afro.who.int/sites/default/files/2020-06/Sexual%20and%20reproductive%20health-430 \n%20Fact%20sheet%2028-05-2020.pdf 431 \n9.  Desai Z, Zhang Y. Climate Change and Women’s Health: A Scoping Review. GeoHealth. 2021 Sep 1;5(9).  432 \n10.  Pope DH, McMullen H, Baschieri A, Philipose A, Udeh C, Diallo J, et al. What is the current evidence for 433 \nthe relationship between the climate and environmental crises and child marriage? A scoping review. Glob 434 \nPublic Health. 2022;18(1).  435 \n11.  Chersich MF, Wright CY. Climate change adaptation in South Africa: a case study on the role of the 436 \nhealth sector. Glob Health. 2019 Mar 19;15(1).  437 \n12.  Habte A, Hailegebreal S, Simegn AE. Predictors of maternal health services uptake in West African 438 \nregion: a multilevel multinomial regression analysis of demographic health survey reports. Reprod Health. 439 \n2024;21(1).  440 \n13.  WHO. Accelerating universal access to Sexual and Reproductive Health. 2013.  441 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n20 \n \n14.  Parham PE, Michael E. Modeling the Effects of Weather and Climate Change on Malaria Transmission. 442 \nEnviron Health Perspect. 2010 May;118(5):620–6.  443 \n15.  Liang L, Gong P. Climate change and human infectious diseases: A synthesis of research findings from 444 \nglobal and spatio-temporal perspectives. Environ Int. 2017 Jun 1;103:99–108.  445 \n16.  WHO, UNICEF, UNFPA, UNDP-UNFPA-UNICEP-WHO-WORLD BANK Human Reproduction 446 \nProgramme. Protecting maternal, newborn and child health from the impacts of climate change: A call for 447 \naction [Internet]. 2023 [cited 2025 Feb 17]. Available from: 448 \nhttps://www.who.int/publications/i/item/9789240085350 449 \n17.  Arksey H, O’Malley L. Scoping Studies: Towards a Methodological Framework. Int J Soc Res Methodol - 450 \nINT J SOC RES METHODOL. 2005;8:19–32.  451 \n18.  Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, 452 \nWeeks L, Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, 453 \nGarritty C, Lewin S, Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriarty J, Clifford T, 454 \nTunçalp Ö, Straus SE. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and 455 \nExplanation. Ann Intern Med. 2018;169(7):467–73.  456 \n19.  Quinn T, Heath S, Adger WN, Abu M, Butler C, Codjoe SNA, et al. Health and wellbeing implications of 457 \nadaptation to flood risk. Ambio. 2023 May 1;52(5):952–62.  458 \n20.  Brown ME, Grace K, Shively G, Johnson KB, Carroll M. Using satellite remote sensing and household 459 \nsurvey data to assess human health and nutrition response to environmental change. Popul Environ. 460 \n2014;36(1):48–72.  461 \n21.  Sorensen C, Murray V, Lemery J, Balbus J. Climate change and women’s health: Impacts and policy 462 \ndirections. PLoS Med. 2018;15(7).  463 \n22.  Williams KM, Olisa AL, Wilcher R. Exploring linkages: addressing the relationship between the climate 464 \ncrisis and HIV prevention with recommendations for emerging pre-exposure prophylaxis programs. Front 465 \nReprod Health. 2024;6.  466 \n23.  Ebi KL, Sibanda E. Heavy Rainfall and HIV and Sexually Transmitted Infections in Sub-Saharan Africa - 467 \nPotential New Risk. JAMA Netw Open. 2022;5(9):E2230290.  468 \n24.  Burns PA, Mutunga C. Addressing the Impact of Climate Change on Sexual and Reproductive Health 469 \nAmong Adolescent Girls and Young Women in Low-and Middle-Income Countries. Glob Health Sci Pract 470 \n[Internet]. 2024;12(1). Available from: www.ghspjournal.org 471 \n25.  Renzaho AMN, Kamara JK, Doh D, Bukuluki P, Mahumud RA, Galukande M. Do Community-based 472 \nLivelihood Interventions Affect Sexual and Reproductive Health and Rights of Young People in Slum 473 \nAreas of Uganda: a Difference-in-difference with Kernel Propensity Score Matching Analysis. J Urban 474 \nHealth. 2022;99(1):164–89.  475 \n26.  Dean S, Rudan I, Althabe F, Webb Girard A, Howson C, Langer A, et al. Setting Research Priorities for 476 \nPreconception Care in Low- and Middle-Income Countries: Aiming to Reduce Maternal and Child 477 \nMortality and Morbidity. PLoS Med. 2013;10(9).  478 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n21 \n \n27.  Assefa GM, Muluneh MD, Tsegaye S, Abebe S, Makonnen M, Kidane W, et al. Does Voluntary Family 479 \nPlanning Contribute to Food Security? Evidence from Ethiopia. Nutrients. 2023;15(5).  480 \n28.  Firoz T, Vidler M, Makanga PT, Boene H, Chiaú R, Sevene E, et al. Community perspectives on the 481 \ndeterminants of maternal health in rural southern Mozambique: a qualitative study. Reprod Health. 482 \n2016;13:123–31.  483 \n29.  Epstein A, Bendavid E, Nash D, Charlebois ED, Weiser SD. Drought and intimate partner violence 484 \ntowards women in 19 countries in Sub-Saharan Africa during 2011-2018: A population-based study. PLoS 485 \nMed. 2020;17(3).  486 \n30.  Eissler S, Thiede BC, Strube J. Climatic variability and changing reproductive goals in Sub-Saharan 487 \nAfrica. Glob Environ Change. 2019;57.  488 \n31.  Mutunga C, Hardee K. Population and Reproductive Health in National Adaptation Programmes of Action 489 \n(NAPAs) for Climate Change in Africa. Vol. 14, African Journal of Reproductive Health. 2010 p. 133–45.  490 \n32.  Tusting LS, Bradley J, Bhatt S, Gibson HS, Weiss DJ, Shenton FC, et al. Environmental temperature and 491 \ngrowth faltering in African children: a cross-sectional study. Lancet Planet Health [Internet]. 2020;4. 492 \nAvailable from: www.thelancet.com/planetary-health 493 \n33.  Dodson J, Dérer P, Cafaro P, Götmark F. Population growth, family planning and the Paris Agreement: an 494 \nassessment of the nationally determined contributions (NDCs). Int Environ Agreem Polit Law Econ. 495 \n2022;22(3):561–76.  496 \n34.  World Health Organization. 2023 WHO review of health in Nationally Determined Contributions and 497 \nlong-term strategies: health at the heart of the Paris Agreement. Geneva: WHO; 2023.  498 \n35.  He C, Zhu Y, Zhou L, Bachwenkizi J, Schneider A, Chen R, Kan H. Flood exposure and pregnancy loss in 499 \n33 developing countries. Nat Commun. 2023;15(1).  500 \n36.  Pullanikkatil D, Kaneka B, Phalira W, Mkanthama C, Chiotha S. Linkages between Population, 501 \nReproductive Health, Gender and Climate Change Adaptation in Malawi; Case study from Lake Chilwa 502 \nBasin [Internet]. Zomba: LEAD SEA Publication; 2013. Available from: 503 \nhttps://www.researchgate.net/publication/282333556 504 \n37.  Low AJ, Frederix K, McCracken S, Manyau S, Gummerson E, Radin E, Davia S, Longwe H, Ahmed N, 505 \nParekh B, Findley S, Schwitters A. Association between severe drought and HIV prevention and care 506 \nbehaviors in Lesotho: A population-based survey 2016-2017. PLoS Med. 2019;16(1).  507 \n38.  Rosen JG, Mulenga D, Phiri L, Okpara N, Brander C, Chelwa N, Mbizvo MT. “Burnt by the scorching 508 \nsun”: climate-induced livelihood transformations, reproductive health, and fertility trajectories in drought-509 \naffected communities  of Zambia. BMC Public Health. 2021 Aug 3;21(1):1501.  510 \n39.  Trummer U, Ali T, Mosca D, Mukuruva B, Mwenyango H, Novak-Zezula S. Climate change aggravating 511 \nmigration and health issues in the African context: The views and direct experiences of a community of 512 \ninterest in the field. J Migr Health. 2023;7.  513 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n22 \n \n40.  Lindvall K, Kinsman J, Abraha A, Dalmar A, Abdullahi MF, Godefay H, et al. Health status and health 514 \ncare needs of drought-related migrants in the Horn of Africa—a qualitative investigation. Int J Environ 515 \nRes Public Health. 2020;17(16):1–18.  516 \n41.  Spencer S, Samateh T, Wabnitz K, Mayhew S, Allen H, Bonell A. The Challenges of Working in the Heat 517 \nWhilst Pregnant: Insights From Gambian Women Farmers in the Face of Climate Change. Front Public 518 \nHealth. 2022;10.  519 \n42.  Part C, Filippi V, Cresswell JA, Ganaba R, Hajat S, Nakstad B, et al. How do high ambient temperatures 520 \naffect infant feeding practices? A prospective cohort study of postpartum women in Bobo-Dioulasso, 521 \nBurkina Faso. BMJ Open. 2022;12(10).  522 \n43.  Kadio K, Filippi V, Congo M, Scorgie F, Roos N, Lusambili A, et al. Extreme heat, pregnancy and 523 \nwomen’s well-being in Burkina Faso: an ethnographical study. BMJ Glob Health. 2024;8(Suppl 3).  524 \n44.  Bonell A, Vannevel V, Sonko B, Mohammed N, Vicedo-Cabrera AM, Haines A, et al. A feasibility study 525 \nof the use of UmbiFlowTM to assess the impact of heat stress on fetoplacental blood flow in field studies. 526 \nInt J Gynecol Obstet. 2023;160(2):430–6.  527 \n45.  Masson VL, Benoudji C, Reyes SS, Bernard G. How violence against women and girls undermines 528 \nresilience to climate risks in Chad. Disasters. 2019;43(S3):S245–70.  529 \n46.  Grace K, Verdin A, Dorélien A, Davenport F, Funk C, Husak G. Exploring strategies for investigating the 530 \nmechanisms linking climate and individual-level child health outcomes: An analysis of birth weight in 531 \nMali. Demography. 2021;58(2):499–526.  532 \n47.  Straight B, Qiao X, Ngo D, Hilton CE, Olungah CO, Naugle A, et al. Epigenetic mechanisms underlying 533 \nthe association between maternal climate stress and child growth: characterizing severe drought and its 534 \nimpact on a Kenyan community engaging in a climate change-sensitive livelihood. Epigenetics. 535 \n2022;17(13):2421–33.  536 \n48.  Allen EM, Munala L, Henderson JR. Kenyan women bearing the cost of climate change. Int J Environ Res 537 \nPublic Health. 2021;18(23).  538 \n49.  Bryson JM, Patterson K, Berrang-Ford L, Lwasa S, Namanya DB, Twesigomwe S, et al. Seasonality, 539 \nclimate change, and food security during pregnancy among indigenous and non-indigenous women in rural 540 \nUganda: Implications for maternal-infant health. PLoS ONE. 2021;16(3).  541 \n50.  Scorgie F, Lusambili A, Luchters S, Khaemba P, Filippi V, Nakstad B, et al. “Mothers get really 542 \nexhausted!” The lived experience of pregnancy in extreme heat: Qualitative findings from Kilifi, Kenya. 543 \nSoc Sci Med. 2023;335.  544 \n51.  Lusambili A, Khaemba P, Agoi F, Oguna M, Nakstad B, Scorgie F, et al. Process and outputs from a 545 \ncommunity codesign workshop on reducing impact of heat exposure on pregnant and postpartum women 546 \nand newborns in Kilifi, Kenya. Front Public Health. 2023;11.  547 \n52.  Lusambili A, Kovats S, Nakstad B, Filippi V, Khaemba P, Roos N, et al. Too hot to thrive: a qualitative 548 \ninquiry of community perspectives on the effect of high ambient temperature on postpartum women and 549 \nneonates in Kilifi, Kenya. BMC Pediatr. 2024;24(1).  550 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n23 \n \n53.  Brooks N, Grace K, Kristiansen D, Shukla S, Brown ME. Investigating the relationship between growing 551 \nseason quality and childbearing goals. Glob Environ Change. 2023;80.  552 \n54.  Andriano L, Behrman J. The effects of growing-season drought on young women’s life course transitions 553 \nin a sub-Saharan context. Popul Stud. 2020;74(3):331–50.  554 \n55.  Iwuji CC, Baisley K, Maoyi ML, Orievulu K, Mazibuko L, Ayeb-Karlsson S, et al. The Impact of Drought 555 \non HIV Care in Rural South Africa: An Interrupted Time Series Analysis. EcoHealth. 2023;20(2):178–93.  556 \n56.  Treibich C, Bell E, Lépine A, Blanc E. From a drought to HIV: An analysis of the effect of droughts on 557 \ntransactional sex and sexually transmitted infections in Malawi. SSM - Popul Health. 2022;19.  558 \n57.  Orievulu KS, Iwuji CC. Institutional Responses to Drought in a High HIV Prevalence Setting in Rural 559 \nSouth Africa. Rural South Afr Int J Env Res Public Health. 2022;19:434.  560 \n58.  Anthonj C, Nkongolo OT, Schmitz P, Hango JN, Kistemann T. The impact of flooding on people living 561 \nwith HIV: A case study from the Ohangwena Region, Namibia. Glob Health Action. 2015;8(1).  562 \n59.  Mroz EJ, Willis T, Thomas C, Janes C, Singini D, Njungu M, Smith M. Impacts of seasonal flooding on 563 \ngeographical access to maternal healthcare in the Barotse Floodplain, Zambia. Int J Health Geogr. 564 \n2023;22(1).  565 \n60.  Fahey CA, Chevrier J, Crause M, Obida M, Bornman R, Eskenazi B. Seasonality of antenatal care 566 \nattendance, maternal dietary intake, and fetal growth in the VHEMBE birth cohort, South Africa. PLoS 567 \nONE. 2019;14(9).  568 \n61.  Stone B, Sambo J, Sawadogo-Lewis T, Roberton T. When it rains, it pours: detecting seasonal patterns in 569 \nutilization of maternal healthcare in Mozambique using routine data. BMC Health Serv Res. 2020;20(1).  570 \n62.  Trickey A, Johnson LF, Fung F, Bonifacio R, Iwuji C, Biraro S, et al. Associations of inter-annual rainfall 571 \ndecreases with subsequent HIV outcomes for persons with HIV on antiretroviral therapy in Southern 572 \nAfrica: a collaborative analysis of cohort studies. BMC Infect Dis. 2023;23(1).  573 \n63.  Andriano L. On the Health Impacts of Climatic Shocks: How Heatwaves Reduce Birthweight in Sub-574 \nSaharan Africa. Popul Dev Rev. 2023;49(4):737–69.  575 \n64.  Munala L, Allen EM, Frederick AJ, Ng ũ njiri A. Climate Change, Extreme Weather, and Intimate Partner 576 \nViolence in East African Agrarian-Based Economies. Int J Environ Res Public Health. 2023;20(23).  577 \n65.  Orievulu K, Ayeb-Karlsson S, Ngwenya N, Ngema S, McGregor H, Adeagbo O, et al. Economic, social 578 \nand demographic impacts of drought on treatment adherence among people living with HIV in rural South 579 \nAfrica: A qualitative analysis. Clim Risk Manag. 2022;36.  580 \n66.  Arunda MA, Sorcher, Canabarro APF, Svallfors S, Endler M, Gemzell-Danielsson, et al. Climate change 581 \nand sexual and reproductive health and rights research in low-income and middle-income countries: a 582 \nscoping review. BMJ Public Health. 2024;2(2):e001090.  583 \n67.  World Meteorological Organization. State of the Global Climate 2023. State of the Global Climate 2023. 584 \n2024.  585 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n24 \n \n68.  Tofu DA, Haile F, Tolossa T. Livelihood vulnerability and socio-economic determinants of households to 586 \nclimate change-induced recurrent drought in Ethiopia. GeoJournal. 2023;88(5):5043–67.  587 \n69.  Hunter LM, Reid-Hresko J, Dickinson T. Environmental Change, Risky Sexual Behavior, and the HIV/ 588 \nAIDS Pandemic: Linkages Through Livelihoods in Rural Haiti. Popul Res Policy Rev. 2011;729–50.  589 \n70.  Stochero L, Pinto LW. “I suffered in silence and certainly all women are like that” - Silenced: 590 \nreproduction of, and breaking with, violence against women living in rural areas. Cienc Saude Coletiva. 591 \n2024;29(7):e02522024.  592 \n71.  Gurmu E, Endale S. Wife beating refusal among women of reproductive age in urban and rural Ethiopia. 593 \nBMC Int Health Hum Rights. 2017;17(1).  594 \n72.  Andreu-Pejó L, Valero-Chillerón MJ, González-Chordá VM, Mena Tudela D, Cervera Gasch A. 595 \nIntegrative review of the literature on screening for gender-based violence during pregnancy: Barriers, 596 \nfacilitators, and tools. Nurs Health Sci. 2022;24(3):564–78.  597 \n73.  Hulley J, Bailey L, Kirkman G, Gibbs GR, Gomersall T, Latif A, Jones A. Intimate Partner Violence and 598 \nBarriers to Help-Seeking Among Black, Asian, Minority Ethnic and Immigrant Women: A Qualitative 599 \nMetasynthesis of Global Research. Trauma Violence Abuse. 2023;24(2):1001–15.  600 \n74.  Logie CH, Toccalino D, MacKenzie F, Hasham A, Narasimhan M, Donkers H, Lorimer N, Malama K. 601 \nAssociations between climate change-related factors and sexual health: A scoping review. Glob Public 602 \nHealth. 2024;19(1).  603 \n75.  Guinto RR, Cahatol JJF, Lazaro KYMS, Salazar AFNC. Pathways linking climate change and HIV/AIDS: 604 \nAn updated conceptual framework and implications for the Philippines. J Clim Change Health. 2022;6.  605 \n76.  Price R. The linkages between population change and climate change in Africa. K4D Helpdesk Report 900. 606 \nInstitute of Development Studies. Brighton, UK: Institute of Development Studies; 2020.  607 \n77.  Patterson KP, Mogelgaard K, Kabiswa C, Ruyoka R. Building resilience through family planning and 608 \nclimate adaptation finance: systematic review and opportunity analysis. Lancet Planet Health [Internet]. 609 \n2019 [cited 2024 Aug 12];3. Available from: https://doi.org/10.1016/S2542-5196(19)30155-X 610 \n78.  Negash WD, Eshetu HB, Asmamaw DB. Predictors of modern contraceptive use among reproductive age 611 \nwomen in high fertility countries in sub-Saharan Africa: evidence from demographic and health surveys. 612 \nBMC Womens Health. 2022;22(1).  613 \n79.  Asare LA, Forkuor JB. The social consequences of climate change: a qualitative analysis of early girl child 614 \nmarriage as an informal adaptation strategy among rural communities in Northern Ghana. Cogent Soc Sci. 615 \n2024;10(1):2319703.  616 \n80.  Pinchoff J, Shamsudduha M, Hossain SMI, Shohag AAM, Warren CE. Spatio-temporal patterns of pre-617 \neclampsia and eclampsia in relation to drinking water salinity at the district level in Bangladesh from 2016 618 \nto 2018. Popul Environ. 2019;41(2):235–51.  619 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n  \n \n25 \n \n81.  Naser AM, Wang Q, Shamsudduha M, Chellaraj G, Joseph G. Modeling the Relationship of Groundwater 620 \nSalinity to Neonatal and Infant Mortality From the Bangladesh Demographic Health Survey 2000 to 2014. 621 \nGeoHealth. 2020;4(2):1–12.  622 \n82.  Thompson DA, Cwiertny DM, Davis HA, Grant A, Land D, Landsteiner SJ, Latta DE, Hunter SK, Jones 623 \nMP, Lehmler HJ, Santillan MK, Santillan DA. Sodium concentrations in municipal drinking water are 624 \nassociated with an increased risk of preeclampsia. Environ Adv. 2022;9(April):100306.  625 \n83.  Dresser C, Mahalingaiah S, Nadeau KC. Preterm and Early-Term Birth, Heat Waves, and Our Changing 626 \nClimate. JAMA Netw Open. 2024;7(5):e2412026.  627 \n84.  Pinchoff J, Regules R, Gomez-Ugarte AC, Abularrage TF, Bojorquez-Chapela I. Coping with climate 628 \nchange: The role of climate related stressors in affecting the mental health of young people in Mexico. 629 \nPLOS Glob Public Health. 2023 Sep 27;3(9):e0002219.  630 \n 631 \nSupporting information 632 \nS1 Table. Search terms used during document screening. 633 \nS2 Table. Additional search terms used during a second search conducted in PubMed. 634 \nS3 Table. Characteristics of 37 studies included in the review. 635 \n 636 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}