Gaps in integration of sexual and reproductive health and rights into climate change research in sub-Saharan Africa: A scoping review

13 Sub-Saharan Africa is faced with triple challenges of high vulnerability to climate change (CC) impacts, high 14 levels of inequality and poor sexual and reproductive health and rights (SRHR) outcomes. Climate change can 15 worsen SRHR situation for high-risk groups such as women, children, adolescent girls and people living with 16 HIV. This scoping review takes stock of the state of research on the intersection between CC and SRHR in SSA 17 with a view of identifying gaps and opportunities for effective evidence generation and integration in climate 18 actions. The review followed Arksey and O’Malley framework. Data charting was conducted using Population, 19 Exposure, Comparator, Outcome tool in Covidence. Thirty-seven (37) studies were reviewed, 57% were 20 quantitative while 41% and 2% used qualitative and mixed methods respectively. SRHR components 21 investigated include maternal newborn and child health at 43% (n=16), HIV at 19% (n=7), gender-based 22 violence at 11% (n=4), and fertility intentions and outcomes at 11% (n=4). SRHR elements that are under-23 researched in the context of CC include access to and uptake of contraceptives, post abortion care, harmful 24 practices (child marriages and female genital mutilation), menstrual health, pregnancy losses, bodily autonomy, 25 and (in)fertility. Drought, floods, heat stress and rainfall seasonality have received fair attention in research, yet 26 impacts of climate hazards like tropical cyclones, wildfires and salt-water intrusion are missing in research. 27 There is inadequate research at the intersection of CC and SRHR hindering progress towards climate resilience 28 and attainment of good health and well-being for all. Effective and equitable integration requires that SRHR 29 issues be recognized, and deliberate investments (research, policies, programs, interventions and financing) put 30 in place to address the critical SRHR gaps and climate vulnerabilities to enhance resilience. 31 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. 2

32 Impacts of climate change (CC) on human systems continue to increase in unprecedented ways and magnitude 33 [1]. Climate-related events such as severe droughts, heavy rainfall, floods, cyclones, heatwaves, wildfires, and 34 saltwater intrusion cause morbidity and mortality affecting millions of people globally [1]. Sub-Saharan Africa 35 (SSA) region is worst affected by the vagaries of CC. The region is characterized by acute water stress, food 36 insecurity, and climate-induced diseases, especially in areas with high population density and poverty rates [2]. 37 Climate change impacts such as heat stress, rainfall variability and drought are common in the West African 38 region, and have been linked to persistent food insecurity and water-related challenges [2]. Similarly, the East 39 and Southern Africa region experiences extreme weather events (EWE) such as drought and floods, cyclones 40 and rising temperatures, which have been associated with adverse impacts on water availability, livelihoods, 41 food security and health [2]. Other notable impacts of CC in SSA include loss of habitation, forced 42 displacements and unplanned migrations, infrastructural damages, inaccessible health facilities, disrupted health 43 services, and deteriorating mental health [1,3]. It is noteworthy that these CC impacts disproportionately affect 44 countries or regions that contribute the least to climate change [3,4]. Additionally, vulnerabilities to climate-45 related risks vary by gender, age, religion, socioeconomic, and disability status [5]. 46 47 Climate change has the potential to reverse gains made in the health sector. It can exacerbate unmet need for 48 sexual and reproductive health and rights (SRHR), especially in low- and middle-income countries due to 49 higher levels of poverty and income inequality, and weak healthcare systems [6]. Sexual and reproductive 50 health is a state of physical, emotional, mental, and social wellbeing in relation to all aspects of sexuality and 51 reproduction, not merely the absence of disease, dysfunction, or infirmity [7]. Core elements of SRHR include 52 maternal, newborn and child health (MNCH); safe abortion services; family planning; prevention and 53 management of sexually transmitted infections (STIs) including human immunodeficiency virus (HIV); 54 prevention and management of infertility; prevention and management of cancers of the reproductive system; 55 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 3 detecting and preventing Gender Based Violence (GBV), forced marriage, transactional sex, and sex 56 trafficking. Sub-Saharan Africa has made great progress in SRHR over the past two decades. The gains include 57 a 33% reduction in maternal mortality, increased coverage of child immunizations, decline in malaria-related 58 child mortality, a drop in HIV incidence, and a two-fold increase in contraceptive uptake [8]. Therefore, if not 59 taken into consideration, climate change can water down the gains made in SRHR. 60 61 Impacts of CC disproportionately affect the most vulnerable populations. In SSA, women, children and 62 adolescents, particularly girls, face heightened vulnerability due to the impacts of climate risks [1]. Literature 63 shows that climate extremes directly affect women and girls’ health by increasing the risk of maternal or infant 64 injury or death, disrupting access to family planning and HIV care, decreasing reproductive autonomy and 65 resulting in poor menstrual hygiene [9]. Climate-related extreme events may also have an indirect impact on 66 maternal and newborn health, for example, adverse birth outcomes such as preterm births and low birth weights, 67 increased GBV including intimate partner violence (IPV), increased HIV transmission rates [9], increased 68 unintended pregnancies, and unsafe abortions [10]. Given Africa's high vulnerability to climate change, its low 69 adaptive capacity, and existing high levels of inequality, the already critical state of SRHR in the region will 70 likely deteriorate further [1]. Addressing this challenge requires efforts that focus on addressing the critical 71 SRHR-CC intersection gaps and empowering women and girls to make informed decisions and choices about 72 their sexual and reproductive health. 73 74 Achieving universal health care, including SRHR is a major pathway for individual, community, and 75 institutional climate resilience [11]. This can occur through increased access to and uptake of modern 76 contraceptives, better antenatal care services, improved post abortion care, and reduced SGBV and HIV 77 transmission. These factors improve women’s and girls’ health and enhance their control and decision-making 78 powers over sexual and reproductive health matters [12]. Consequently, improved access to SRHR increases 79 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 4 women’s and girls’ ability to engage in empowerment activities like education, income generation, employment 80 opportunities, and access to resources [9], factors that promote climate resilience. Further, access to child health 81 services like vaccinations and preventive care can reduce vulnerabilities of at-risk populations to climate-related 82 diseases like malaria and diarrhea that afflict millions of children in the region. Therefore, identifying and 83 reducing unmet need for SRHR contributes to climate change resilience and improves communities’ and health 84 systems’ adaptive capacity through improved health and well-being of women, girls and children, including 85 increased access to health services, education, nutrition, and family planning [13]. 86 87 It was until 2021 that health was brought at the center of global climate discussions during United Nations 88 Framework Convention on Climate Change (UNFCCC) Conference of Parties (COP26). Over the years, CC 89 change research and funding have been skewed towards sectors such as agriculture, water, and energy with 90 health sector getting minimal attention. Furthermore, within health research, focus has been on climate-sensitive 91 and infectious diseases such as malaria and cholera [14,15], other health aspects such as SRHR remaining under 92 documented. In 2023, United Nations called for accelerated research on MNCH [16], one of the key elements of 93 SRHR. The recent occurrences in global climate change spaces point to the gaps in CC and SRHR intersection 94 research that need be urgently addressed. Therefore, this scoping review takes stock of the state of research on 95 the intersection between CC impacts, and SRHR outcomes in sub-Sahara Africa and identifies gaps and 96 opportunities for effective SRHR-CC evidence generation, and integration in climate change and health policies, 97 plans, and interventions at all levels. We analyze published documents on the impacts of climate change on 98 SRHR to explore the state of research at the intersection and explore gaps and opportunities for their integration 99 in the region. 100 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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101 Database search 102 The study identified publications integrating SRHR in climate change research in SSA using Arksey and 103 O’Malley framework for scoping reviews [17]. Electronic databases for peer reviewed journal articles and 104 reports were searched to identify relevant literature using MyLOFT with the support of Kenyatta University 105 Librarians. A first search of journal databases including Pubmed, Elsevier, Springer, Wiley, Taylor and Francis, 106 Oxford Academic Journals, African Journals Online, ScienceDirect, JSTOR, and Saje Journals was done in 107 May 2024 using CC and SRHR key words (S1 Table). The search was restricted to the period between January 108 2010 to April 2024 consistent with availability of evidence. A second search was conducted in PubMed (S2 109 Table) using specific SRHR terms derived from Starrs [7] such as maternal, newborn, and child health; abortion 110 care; family planning; HIV; infertility; cancers of the reproductive system; gender based violence including 111 intimate partner violence; forced or early marriage, transactional sex and sex trafficking in addition to climate 112 change search terms to identify additional studies investigating impacts of climate change on various SRHR 113 components that might have been left out during first search. Peer-reviewed journal articles at the intersection 114 of climate change and individual components of SRHR were included. The accessed documents were analyzed 115 to identify the state of SRHR-CC integration in research and gaps and potential entry points for comprehensive 116 integration. 117 Search strategy and selection criteria 118 The search strategy used key words and subject headings relating to climate change and SRHR based on 119 definition provided in this review. Reports generated from the search were managed in Mendeley online library 120 (https://www.mendeley.com/search/) and then uploaded in Covidence (https://www.covidence.org/) for analysis. 121 Records were subjected to first stage screening by a single reviewer using laid-out inclusion and exclusion 122 criteria. Selection and screening of journal articles and reports followed the checklist recommended by 123 Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews (PRISMA-124 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 6 ScR) [18]. Records having qualitative, quantitative, mixed method approaches, short communications, 125 commentaries, reviews, and meta-analyses were analyzed in the first stage of the review. Studies were included 126 in the full-text review if (i) they were on climate change (including climate extremes, events, and disaster) and 127 mentioned at least one aspect of SRHR; (ii) they were on SRHR or its components and mentioned climate 128 change hazards (iii) if they were conducted in SSA region and those published in English. Documents were 129 excluded if they solely explored climate change or SRHR and if they were not conducted in the region. Reviews, 130 commentaries, abstracts, reproductive studies on animals and plants and publications without full-text articles 131 were also excluded. Excluded reports did not meet the data charting criteria. 132 Data charting and synthesis 133 Data charting was conducted using a data extraction template developed following the Population, Exposure, 134 Comparator, Outcome (PECO) framework in Covidence. Data extraction template was pretested, and 135 adjustments made before commencing the data extraction process. Data extracted included study details (author, 136 year of publication, setting), data source, data collection method, climate change event(s), study population, 137 impacts of climate event(s), SRHR element(s), and SRHR outcomes. Data extraction, review and synthesis were 138 conducted sequentially by a single reviewer. Data synthesis followed a thematic analysis of SRHR domains. 139 PRISMA-2020 flowchart was used to illustrate article selection process. 140 141 The search yielded 8822 records. A total of 7589 ineligible and 735 duplicate reports were removed. Four 142 hundred ninety-eight (498) articles were screened by title and abstract followed by full-text assessment of 117 143 articles for eligibility. Thirty-seven (37) articles were retained for data extraction (Fig 1). Some excluded 144 articles were reviews and meta-analysis [19–21], commentary or editorial [22–24], while others did not include 145 both CC and SRHR in their content [25–28]. 146 147 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 7 Fig 1. PRISMA 2020 flow chart showing document screening and eligibility assessment process. 148 149 Ethical consideration 150 The study did not require ethical approval as it did not entail research on human subjects. 151 152

153 Study characteristics 154 S3 Table summarized characteristics of 37 studies included in the review. Majority of the studies (81%, n=30) 155 were published after the year 2020. Fifty seven percent (57%, n= 21) were quantitative studies while 41% 156 (n=15) were qualitative studies and one study used mixed methods approach. Quantitative studies applied cross-157 sectional, case control, case series, longitudinal, and cohort study designs. Table 1 shows the distribution of 158 studies at the intersection between CC and SRHR by country in the SSA region. Four articles were regional 159 studies [29–32] while three were global studies with reference to SSA [33–35]. The SRHR components 160 investigated were MNCH (43%; n=16), HIV (19%, n=7), GBV including IPV and violence against women and 161 girls (VAWG) (11%; n=4), and fertility intentions and outcomes (11%; n=4). Sixteen percent (16%; n=6) of the 162 articles were studies on multiple SRHR elements including MNCH combined with fertility and HIV [36]; HIV 163 and GBV [37]; early marriage, MNCH and FP[38]; HIV, GBV and MNCH [39], and MNCH and GBV [40]. 164 Impacts of extreme heat, drought, changing rainfall patterns and floods were the main climate hazards studied in 165 24%, 24%, 14% and 11% of the articles respectively. Other studies either combined multiple CC risks (19%) or 166 assessed climate change impact collectively (8%). 167 Table 1. Characteristics of studies included in the review 168 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 8 169 170 Maternal newborn and child health 171 The metrices assessed under MNCH included child health outcomes [46,47,63], antenatal health and 172 experiences [35,49,50,60], knowledge levels [41], access to healthcare [59,61], breastfeeding and childcare 173 Study characteristics Quantitative studies 57% (n=21) Qualitative studies 41% (n=15) Mixed methods 2% (n=1) MNCH 43% (n=16) FP 11% (n=4) HIV 19% (n=7) GBV 11% (n=4) Multiple elements 16% (n=6) Region Drought Floods Rainfall changes Heat stress Extreme weather events (floods and drought) More than two climate hazards West Africa MNCH [41–44] GBV-VAWG [45] MNCH [46] East Africa MNCH [47] GBV/MNCH [40] IPV [48] MNCH [49] MNCH [50– 52] West and East Africa Fertility/ FP intentions [53] Southern Africa Multiple elements [38,54] HIV [37,55– 57,57] HIV [58] MNCH [59] MNCH [60,61] HIV [62] Multiple Elements [36] East and Southern Africa MNCH [63] IPV [64] Multiple elements [39] SSA region IPV [29] MNCH [35] MNCH [32] Reproductive outcomes [31,33] Reproductive goals [30] Multiple elements [34] . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 9 practices [42], and interventions to address adverse effects of climate-related events [51] (Fig 2). Studies 174 showed that exposure to heat stress during the third trimester of pregnancy reduces birthweight [46,63]. The 175 length and strength of heat waves adversely affects birthweight. Ambient temperatures greater than 35°C were 176 associated with increased odds of wasting and underweight among children under 5 years [32]. A positive 177 impact of higher seasonal Normalized Difference Vegetation Index (NDVI) on birthweight was reported in Mali 178 [46]. In Kenya, a study investigating early gestational exposure to severe drought on child health outcomes 179 showed that exposed children had lower body weight compared to non-exposed siblings [47]. Food insecurity 180 was a strong CC impact pathway affecting maternal health and child health outcomes. In Uganda, indigenous 181 women had the greatest negative maternal-infant health outcomes resulting from CC-related food insecurity 182 compared to non-indigenous women [49]. 183 184 Fig 2. Attributes investigated under Maternal Newborn and Child Health (MNCH) component 185 186 Studies in Zambia and Mozambique investigated the influence of floods [59] and rainfall seasonality [41] on 187 access to and utilization of maternal health services. Floods were found to hinder access to maternal health 188 services. Similarly, low numbers of institutional deliveries were reported to occur during rainy season. The 189 effect was greater for deliveries compared with antenatal care (ANC) visits since women were isolated from 190 accessing delivery facilities. A study conducted in South Africa showed that rainfall seasonality affected ANC 191 attendance with lowest visits ≤ 4 occurring during rainy seasons [60]. The rains not only cause infrastructural 192 damage and limit access to health facilities but also correspond to low food availability and increased 193 agricultural labor, factors that are associated with adverse birth outcomes such as reduced birth weight and head 194 circumference [60]. Another study analyzing impact of floods found that exposure to floods during pregnancy 195 increased the risk of pregnancy loss due to injuries or trauma following flood events. The risk was greater for 196 women outside peak reproductive age (<21 years) and among those in rural areas [35]. A study conducted in 197 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 10 Kenya documented the lived experiences of pregnant women under extreme heat [50]. The study showed that 198 heat stress disrupts social and interpersonal relations reducing quality of selfcare and childcare. 199 200 Studies exploring perceptions and knowledge about health impacts of extreme heat on MNCH reported lack of 201 awareness among women in Burkina Faso [43] and communities in Kenya [51]. In Kenya, high ambient 202 temperature was associated with early introduction of alternative foods to infants younger than 6 months and 203 reduction in Kangaroo care [52]. Similarly, extreme heat was reported as a barrier to exclusive breastfeeding 204 and a cause of early introduction of supplemental fluids for infants under 6 months [42]. 205 206 Gender-based violence 207 Studies investigated the influence of floods and drought on intimate partner violence (IPV) and VAWG. A 208 study in rural Kenya found that women in agriculture had greatest risk of experiencing physical and sexual 209 violence compared to urban counterparts when exposed to floods [48]. A similar study exploring the 210 relationship between extreme weather and IPV in Uganda, Zimbabwe and Mozambique reported that EWE such 211 as floods and drought increase violence against women and girls by affecting their access to income and 212 employment [64]. Economic burden and displacements that result from EWE are the underlying factors that 213 cause high prevalence of IPV. Another study found that severe drought was associated with greater risk of 214 sexual violence [29]. The risk of violence increased with severity of drought and frequency of floods, an 215 occurrence attributed to increased conflicts in households experiencing soring commodity prices and scarcity of 216 resources. A study in Chad examined the association between violence and women’s resilience to climatic 217 events and found that violence exposes women and girls to adverse consequences such as reproductive health 218 injuries and morbidities [45]. The study further reported that socio-cultural practices hinder women from fully 219 participating in decision-making processes and exercising control over financial resources, thereby reducing 220 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 11 their capacity to cope with crises. Climate change impacts limit access to care and reduces resources needed for 221 survival, thus widening SRH gaps for women and girls. 222 223 Sexually transmitted infections including HIV 224 Research on HIV has been going on for decades, however, studies integrating impacts of CC risks are more 225 recent as revealed in this review. Studies reviewed focused on HIV prevention, management and service 226 provision, with drought being the main CC risk investigated followed by floods and changes in rainfall trends. 227 HIV dimensions examined were transactional sex and HIV prevalence [56], HIV prevention, management and 228 care [37,55], adverse HIV outcomes on people on anti-retroviral therapy (ART) [62], institutional capacities to 229 provide HIV services and care [57], climate impact on PLHIV and service provision [58,65]. A study in Malawi 230 reported that drought increases HIV prevalence by 15%, with the effect being mediated by risky sexual 231 behavior like transactional sex [56]. Transactional sex is a key exposure pathway between climate change and 232 HIV infections [37,56]. A similar study in Lesotho found that living in drought stricken areas was associated 233 with higher HIV incidence among young female (aged 15-24) [37]. A report from South Africa found that 234 drought negatively affected HIV treatment adherence by disrupting income, livelihoods and food systems, thus, 235 increasing the risk of ill-health [55,65] and higher odds of unsuppressed viral load. The adverse HIV outcomes 236 were accompanied by high mortality among PLHIV on ART and exacerbated by depressed rainfall or drought 237 [62]. A study in Namibia reported that floods negatively impacted HIV service provision and care by limiting 238 access to facilities, leading to reduced HIV testing, thereby weakening prevention of mother to child 239 transmissions (PMTCT) efforts, and disrupting access to treatment [58]. 240 Family planning 241 Studies analyzing the impacts of climate change on reproductive health (RH) were regional [30,31] and national 242 in scope [53,54]. This review did not find studies that directly assessed the impacts of CC on access to and 243 uptake of family planning (FP) services in the SSA region. However, fertility intentions and reproductive goals 244 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 12 [30,53], life course transition [54], and inclusion of RH in policies [31,33] were the FP proxies investigated. 245 Studies reported an association between a good growing season and increased desire to bear children in future 246 and a higher likelihood of FP discontinuation [53]. In contrast, exposure to extreme temperature was associated 247 with low fertility preference and low ideal family size [30]. Studies showed that fertility goals varied across 248 SSA region and among populations in response to CC hazards. In Malawi, exposure to drought increased 249 adolescent’s transition into first birth and young women's transition into cohabitations and marriages, behaviors 250 linked to resource constraint (food and income) experienced during drought [54]. A study assessing the status of 251 inclusion of RH in climate change policies in Africa reported that RH was not adequately recognized or 252 included in climate change adaptation strategies [31]. Another study reported that only 14% of countries in SSA 253 included actions and strategies to slow population growth in the Nationally Determined Contributions (NDCs) 254 submitted in 2020 and that data scarcity is an impediment to FP reporting and integration into policy [33]. 255 Early marriages, risky sexual behaviors and other SRHR components 256 Only two (2) studies analyzed the impact of climate change on early marriages. In Zambia, economic 257 consequences of drought such as reduced household income and food insecurity increased women’s 258 vulnerability to transactional sex and early child marriages [38]. In Malawi, a study reported early sexual debut, 259 and accelerated transition into unions among adolescents and young women exposed to drought [54]. Crop yield 260 reductions, psychosocial stress, limited food and liveli hood resources were the factors that accelerated early 261 marriage and childbearing among young women (under 24 years). A study assessing health consequences of 262 large-scale displacements observed that CC is not adequately addressed in health care planning and proposed 263 the need for robust political and governance solutions to health needs in humanitarian setting [40]. This review 264 found a dearth of information on the impacts of CC on harmful practices like female genital mutilation (FGM) 265 and other SRHR elements like menstrual health, sex trafficking, infertility, abortion care, and cancers of the 266 reproductive system. 267 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 13 268

269 This scoping review provides a synthesis of the impacts of climate change on SRHR outcomes in SSA region. 270 The review documents studies conducted on the intersection, identifies gaps and proposes recommendations for 271 effective integration of SRHR in CC research policy and interventions for climate resilience. In relation to 272 climate change research, maternal, newborn and child health (MNCH) was the most researched SRHR 273 component (n=16) followed by HIV prevention and care (n=7), reproductive goals (n=4), and GBV (n=4). A 274 recent study conducted in the LMICs corroborates this finding [66]. The focus on MNCH and HIV may be 275 related to the high-level political commitments to reducing maternal and under-five mortality as well as the 276 global strategy on HIV prevention and response. Drought, heat stress, changing rainfall seasons and floods were 277 the most studied climate change events. Studies reviewed investigated direct impacts and exposure pathways of 278 climate change on SRHR outcomes. Direct impacts included effects on access to maternal and child health 279 services, effects on biological mechanisms modulating SRHR outcomes, heat stress effects, and immediate and 280 long-term physical and mental health impacts. Exposure pathways assessed were food insecurity, diminishing 281 livelihood resources, undernutrition, increasing commodity (e.g. food) prices, economic shocks, displacements 282 and migrations. Adverse SRHR outcomes resulting from climate risks examined included changing fertility 283 goals and choices, poor prenatal and child health, disrupted service delivery, changing sexual behavior patterns, 284 adverse birth outcomes like still births, pre-term births and low birth weight, increasing physical and sexual 285 violence, early sexual debut and early entry into unions, human morbidity, and mortality. 286 287 This scoping review showed that SRHR has not been effectively and equitably addressed in climate change 288 research in SSA. There is a narrow range of SRHR components in the studies reviewed; much of SRHR 289 research is still siloed while CC policy and actions hardly recognize or largely exclude SRHR issues. Neonatal 290 and child health outcomes, antenatal health and experiences, awareness and knowledge levels, access to 291 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 14 maternal health services, and neonatal-care and self-care were the dimensions investigated under MNCH. 292 Biological mechanisms by which drought and heat stress impact maternal and child health included changes in 293 gene function [47] and reduction in placental blood flow [44] causing adverse birth outcomes like reduced 294 gestational age and increased chances of pre-term birth [63]. Behavioral outcomes like reduced ANC visits and 295 facility-based deliveries [38] were additional ways that led to adverse birth outcomes. Although drought ranks 296 third among climate disaster risks in Africa [67], it causes the greatest mortality, affects millions of people, 297 destroys livelihoods, increases food insecurity, and reduces income [68] factors that negatively affect maternal 298 and child health outcomes. Heat stress poses a potential threat to health and wellbeing of pregnant women and 299 infants and can weaken gains made in reducing maternal and neonatal mortality and morbidity in the region. 300 Normalized Difference Vegetation Index, a substitute for food security status positively corelates with birth 301 outcomes. Thus, seasonal NDVI can be incorporated in early warning systems to trigger early actions and 302 interventions such as supplementation for pregnant women and children [69]. 303 304 The review further showed that sexual and physical violence continue to be perpetrated on young women in 305 diverse settings, with rural women bearing a heavy burden compared to their urban counterparts [70]. Most 306 studies reviewed focused on IPV, with violence meted by non-partners and violence against adolescent girls 307 remaining understudied. Economic loses and forced displacement are the pathways through which EWE 308 perpetuate violence against women and girls. Rural women, especially those in agriculture, were at the greatest 309 risk of experiencing physical and sexual violence [71]. Socio-cultural practices [72], political, and economic 310 barriers [73] aggravate GBV and gender inequality, and should thus be addressed together in climate actions. 311 312 Individuals facing EWE have higher likelihood of exposure to HIV infection [22]. On the one hand, drought 313 increases HIV incidence by contributing to risky sexual behaviors and affecting HIV treatment adherence. On 314 the other hand, floods disrupt HIV service provision and care by limiting access to facilities, HIV testing and 315 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 15 treatment [74]. Consequently, understanding the relationship between EWE and transmission of HIV can better 316 position HIV prevention services and programs such as pre-exposure prophylaxis (PrEP) to cater for the needs 317 of at-risk persons who experience these events [22]. Despite the steady progress made on HIV control over the 318 past decades, climate change poses a new threat to the efforts on reducing HIV epidemic globally [75]. 319 Collective actions addressing to both HIV prevention and climate actions will require anticipatory planning 320 while taking into consideration equity, human rights and justice to deliver climate-proof HIV prevention 321 programs, services, care and support in geographic areas under climate crisis [75]. 322 323 Currently, there are limited country-based studies in SSA evaluating the link between climate change and FP 324 use. While most studies investigated FP aspects such as fertility intentions and reproductive goals, there were no 325 studies linking unmet need for FP and climate risks. Yet, there is great overlap between high fertility, high 326 population growth, high unmet need for FP and high climate vulnerability and risks in many parts of the region 327 [76]. Evidence suggests that CC may worsen factors (socioeconomic, education, mobility, employment, and 328 land tenure) associated with uptake of and access to FP [77]. Recognition of impacts of population growth and 329 inclusion of reproductive health (including FP) in national climate change policies and plans provide a basis for 330 addressing unmet need for FP. Climate change adaptation and health interventions targeted to poor women 331 without formal education can increase the uptake of modern contraceptives and improve SRHR outcomes 332 necessary for climate resilience [78]. Climate change mitigation and adaptation actions should be cognizant of 333 the need to integrate population, health and development needs in the region. 334 335 Drought and dwindling rainfall have been associated with increased vulnerability of girls to forced or early 336 marriages and accelerated transition into marriages and childbearing by young women. Poverty, religion, 337 culture, and lack of access to education were the main drivers to child marriage in SSA. Most child marriages 338 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 16 occurred in countries across the Sahel, a region ravaged by extreme drought and poverty [79]. Environmental 339 and climate crises are known to worsen drivers of early marriages. It is therefore imperative that actions that 340 tackle child marriages should take into consideration their connection to climate change and vice versa [10]. 341 Gaps in climate change and SRHR research 342 Impacts of CC on SRHR outcomes have not been adequately investigated to inform policy and actions. 343 Compared to South Asia and other parts of the world, there are no studies in SSA examining the linkages 344 between saltwater intrusion and maternal and child health outcomes [80–82]. There is also inadequate evidence 345 on impacts of climate hazards on SRH outcomes such as GBV, HIV outcomes (biological and behavioral), 346 access to and uptake of family planning, fertility/infertility, and harmful practices like child marriage and FGM. 347 Climate change risks and subsequent SRHR outcomes are diverse and vary from West to East and Southern 348 Africa thus require contextualization of CC actions and SRHR interventions [30]. The potential impacts of 349 extreme temperatures on male fertility, health of PLHIV, ART use and health-seeking behaviors are some of the 350 understudied SRHR elements that future research should investigate. Furthermore, impacts of CC or EWE on 351 menstrual health, pregnancy losses, bodily autonomy, male infertility, harmful practices (sex trafficking), 352 SRHR outcomes for adolescent girls and minority groups such as indigenous women, persons with disability 353 and sexual minorities are additional dimensions that should be considered in future research. Research should 354 focus on data disaggregation and underserved, marginalized or minority groups. Further still, there is a shortage 355 of data on other climate change hazards such as cyclones, fire weather and air pollution on SRHR outcomes. 356 Mediating factors such as biological mechanisms, behavior changes, and social and economic factors should 357 also be addressed to reveal nuanced relationships with SRHR elements. 358 359 Lived experiences of vulnerable persons in high-risk areas should be documented to support policy and actions 360 to address their SRHR needs. Contextualization of SRHR outcomes is needed for informed decision-making 361 and development of effective and appropriate interventions. Research should also explore the impacts of 362 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 17 meteorological conditions such as temperature, humidity and solar radiation to identify synergies and combined 363 impacts on SRHR outcomes. A knowledge gap exists on intersecting issues such as culture that exacerbate 364 impacts of CC and widen the gap in addressing SRHR needs. Evidence on factors such as gender, age, and other 365 social, biological and economic characteristics that modulate climate-SRHR impacts are needed to inform the 366 design of targeted interventions for specific groups. Low awareness and knowledge levels among at-risk 367 population like pregnant women, health care providers and communities on health impacts of climate hazards 368 need to be addressed [42,52]. Awareness levels and knowledge on the effects of climate extremes on pregnancy 369 loss [83], and mental health [84] need further investigations. Increased awareness will dispel misinformation on 370 impacts of CC on maternal and child health outcomes. In addition, studies on climate change, migration and 371 SRHR nexus in fragile settings should incorporate displaced or migrant persons’ and host communities’ 372 experiences and engage them in the design of policy and programs for sustainability. 373 374 Still, research on CC-SRHR intersection is yet to benefit from the support of global climate funding sources 375 such as adaptation fund, green climate fund, and global environment facility. The funding can be achieved if 376 governments recognize and include SRHR in their national and sub-national policies, plans and programs. 377 Inclusion of SRHR in national adaptation plans, NDCs and other long-term development plans promotes SRHR, 378 wellbeing of all and supports achievement of Sustainable Development Goals SDG 3 and 13. Financing of CC-379 SRHR interventions should benefit from support from both local and international sources. 380

381 This scoping review identified research studies at the intersection between CC and SRHR in sub-Saharan Africa. 382 The search focused on peer-reviewed journal articles published in electronic databases. Due to budget 383 constraints, data extraction was conducted by a single reviewer and the search did not include grey literature, 384 consequently, some documents may have not been captured. The search was also limited to studies published in 385 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 18 English leaving out potential studies published in other languages. Given that the topic is nascent, a systematic 386 review may have resulted in exclusion of publications considered not rigorous yet had important insights, thus a 387 scoping review was conducted. Quality assessment was not conducted. This may have limited reporting on 388 certainty of evidences included. Some of the studies reviewed did not incorporate climate data to validate CC in 389 the study locations. In other cases, at risk population such migrants or host communities were not represented 390 among study respondents. The scales at which some of the studies were conducted weakened the application of 391 recommendations due to lack of contextualization and heterogeneity of research settings. 392 393

394 This scoping review reveals that since 2020 there has been a significant increase in research on the intersection 395 between climate change and SRHR signaling a move towards inclusivity. Majority of the studies are on a 396 narrow range of SRHR components, domains encompassing rights and choices are largely under researched. 397 Drought, floods, heat stress and rainfall seasonality have received a fair attention in climate change research, 398 however, impacts of other climate hazards such as tropical cyclones, fire weather and salt-water intrusion are 399 missing. Intervention research is inadequate hindering progress towards climate resilience and attainment of 400 universal access to SRHR. Consequently, effective and equitable CC-SRHR research integration will require 401 recognition and inclusion of population growth impacts and SRHR needs in national and sub-national climate 402 change policies, plans and actions in SSA, and in the medium-term and long-term national development plans, 403 and integration of climate change in health policies and plans. 404 405

406 The research team thank Kenyatta University librarians for their support during database search. 407 408 . CC-BY 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted February 26, 2025. ; https://doi.org/10.1101/2025.02.26.25322673doi: medRxiv preprint 19

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