Introduction

Climate change, as defined by long term shifts in temperatures and weather patterns, is affecting everyone around the world and its significant impact on health and health systems has been documented [1–3]. Research shows that about 3.6 billion people already live in areas highly susceptible to the effects of climate change and about 13 million lives are lost each year as a result of climate change-related factors [4]. Recent literature suggests that climate change can impact sexual and reproductive health and rights (SRHR) –a broad area that is linked to overall health and wellbeing, such as sexuality and rights, including the prevention of harmful practices, reproduction and fertility, contraception and family planning, and abortion [5,6]. Climate-related events may, in turn, exacerbate persistent inequalities based on gender, disability status, sexual orientation, and age, among others [7,8]. Of note, climate factors including extreme temperatures, drought, rainfall shocks, cyclones and floods have been linked with adverse maternal and newborn health outcomes as well as increased cases of gender-based violence [6,9,10]. Some other studies speak to the lived experiences of populations negatively affected by climate events [11,12]. These impacts are often more severe for women with disabilities than those without. Fertility and contraceptive decisions have also been shown to be affected by climate change [6,13–17]. Climate change can also impact health infrastructure with a specific impact on SRHR access and outcomes [18]. However, even when data are available, they are sparse with regards to certain topical areas, types of evidence, and in using an intersectional approach, which includes considering race, gender, class, and other individual factors that shape experiences [7,19–22]. Data are also limited with regards to causal pathways and direct impact [6,7]. Importantly, the evidence is particularly limited regarding issues related to abortion, contraception, and reproductive cancers [6,7].

A first effort undertaken by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) and Karolinska Institutet to identify research priorities was completed in May 2023 where a group of experts from multiple countries convened online to discuss the research needs at the intersection between climate change and SRHR [19]. Participants to the consultation were identified through a mapping exercise, professional networks, and existing literature on climate change and SRHR [19]. During the consultation, a framework for guiding work at this nexus was developed and an agreement was reached with the experts that further work needed to be completed in order to more systematically prioritise questions for the research community to address. A consensus and priority setting process was agreed to allow for contributions from a large group of experts including those from a more diverse range of geographic regions and backgrounds and beyond those who participated in the 2023 consultation, through an iterative mechanism that enabled refinement of research priorities [23–26]. In order to engage a wider range of participants including those with lived experiences, the process, undertaken by the HRP Alliance for research capacity strengthening, engaged the Implementing Best Practices (IBP) Network and the African Institute for Development Policy (AFIDEP) [27–29]. The central aim of the activity was to support a climate change and SRHR research agenda setting exercise through expert consensus building on the most pressing gaps and key questions that could help develop actions and policies able to reduce the effect of climate change on SRHR. We anticipated that the process would also require some level of prioritisation to ensure that the most pressing questions were at the forefront of research. While these processes are often limited by the individuals participating and the potential inherent bias of those willing to contribute, they can still provide guidance for steering actions and helping set the research agenda through a systematic mechanism.

This article describes the process for developing a list of priority research questions that address climate change and SRHR as agreed upon by experts in the field.

Materials and methods

In 2024, we completed an iterative consensus building and prioritisation process utilising two related methodologies: the Delphi and the Child Health and Nutrition Research Initiative (CHNRI) methodologies [26,30,31]. We used a modified Delphi process to develop a set of research questions at the intersection of climate change and sexual and reproductive health based on existing research gaps, as identified in the scoping review conducted by the authors prior to this exercise [6]. As in other modified Delphi processes, we had a steering group (VB, NT, BO) who led the discussions. We followed a process through which we aimed to identify the problem area, select members for the panel, conduct several iterative rounds for consensus, and finalize with closing criteria [30]. We then used a modified CHNRI methodology to allow for further prioritization. We simplified some of the initial steps from the original CHNRI to better align with the preceding Delphi process, which allowed us to rank and prioritise the proposed list of questions following similar steps to what others have done [32]. The activities and analyses were led by a collaboration between the HRP Alliance (VB), the IBP Network (NT), and AFIDEP (BO and CM). All activities were planned to occur online using platforms such as Zoom or Microsoft Teams.

Results

This exercise was completed over three rounds between January and May 2024. Each of the rounds are reported below and S2 Fig presents a flowchart showing the number of respondents and response rates for each of the rounds.

Delphi round 1

Survey.

The first Delphi anonymous survey was sent to 100 participants on 04 March 2024, with a response deadline of 10 days. A total of 56 responses were received (54 in English and 2 in Spanish). Respondents were mostly female (70%, n = 39), aged 25–44 (54%, n = 30), working for an international NGO (36%, n = 20) or research or academic institution (27%, n = 15), were affiliated with an institution located in a high-income country (53%, n = 28), and had significant work experience, with 37% having 11–20 years and 28% having over 20 years (Table 1). While most respondents stated working at the global level (results not shown) many respondents’ countries of focus were Kenya and Uganda (Fig 1).

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Table 1. Sociodemographic characteristics of survey 1 respondents (N = 56).

https://doi.org/10.1371/journal.pclm.0000835.t001

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Fig 1. Countries of work focus (N = 54).

The question allowed for multiple responses; responses indicating “global” are not depicted in Fig 1. Disclaimer: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Note: this map was developed with WHO data under WHO copyright available under CC-BY 4.0 (https://gis-who.hub.arcgis.com/pages/whogeodatabase). The boundaries used can be found at this link: https://extranet.who.int/map/rest/services/GISC/WHO_ADMIN_BOUNDARIES/MapServer/0.

https://doi.org/10.1371/journal.pclm.0000835.g001

In Round 1, participants ranked priorities within three domains: SRHR thematic areas, research methodologies, and intersectionality issues (Fig 2). Participants ranked access to SRHR services as the top priority (score 8.69/10), followed by maternal and newborn health (score 7.93/10). Our analysis of free text identified five new categories (adolescent SRHR including comprehensive sexuality education, sexually transmitted infections/human immunodeficiency virus (STI/HIV), sexual health, and health systems). With regards to study designs to be prioritised, participants selected mixed methods designs in first place (score 7.49/10) followed by longitudinal study designs (score 7.43/10). New categories emerging from the free text sections included community/participatory based research, feminist research methodologies, simulation/modelling studies, and feasibility studies. Lastly, participants prioritised intersectionality issues placing gender in the first place (score 3.76/5) and equity in second (score 3.31/5). Emerging themes included age, race/ethnicity, and conflict/humanitarian settings (Fig 2).

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Fig 2. Participants’ top five priority (a) thematic areas, (b) research methodologies, and (c) intersectionality issues.

For (a) and (b) the maximum possible score was 10; for (c) the maximum possible score was 5. SRHR: sexual and reproductive health and rights; MNH: maternal and newborn health; GBV: gender-based violence; RCT: randomised controlled trial. ^‡includes child marriage and female genital mutilation. ^*includes endometriosis and menopause.

https://doi.org/10.1371/journal.pclm.0000835.g002

Online consultation.

Thirty-nine participants, plus hosts, attended the round one online consultation held on 18 March 2024. Results from the on online Zoom poll revealed that participants concurred with the findings of the first survey. During the online discussion participants also highlighted additional topics of importance that were not reflected as prominently in the survey, such as mental health, non-communicable diseases, and fertility care. In addition, participants reflected on the need to identify research priority questions first before discussing methodologies, resulting in a decision to not focus on research methods for subsequent rounds. Finally, as a result of the discussions during the online meeting, the group agreed that the following round should use climate change factors (extreme temperatures, draughts, floods, rainfall shocks, and cyclones/typhoons) as a starting point for consensus building and prioritisation.

Delphi round 2

Survey.

The second Delphi anonymous survey was sent to 100 participants in April 2024, and respondents were given two weeks to respond. A total of 36 responses were received (32 in English, 2 in French, and 2 in Spanish). Participants were asked to rank SRHR topic priorities for five different climate hazards: extreme temperatures, floods, rainfall shocks, cyclones/typhoons, and drought. For most climate change factors, maternal and newborn health emerged as the top research priority area: extreme temperatures (score 4.25/5), cyclones/typhoons (score 3.94/5), rainfall shocks (score 3.79/5), and floods (score 3.69/5). Gender-based violence was identified as the top priority for research regarding drought (score 3.83/5) while contraception emerged as a second priority for floods (score 3.47/5) and rainfall shocks (score 3.32/5) (Fig 3). Respondents were asked to identify specific research questions linking the climate change factor and SRHR dimension. A list of the proposed questions can be found in S4 Table.

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Fig 3. Participants’ SRHR areas of priority according to five climate change factors: (a) extreme temperatures, (b) cyclones/typhoons, (c) rainfall shocks, (d) floods, and (e) drought.

For all graphs, the maximum possible score was 5. MNH: maternal and newborn health; GBV: gender-based violence. Harmful practices includes child marriage and female genital mutilation.

https://doi.org/10.1371/journal.pclm.0000835.g003

Online consultation.

A total of 41 individuals, plus hosts from the coordinating institutions, took part in the second-round online consultation held on 08 May 2024 to discuss the results from the second survey. During that session, participants reacted to the survey findings and proposed research topics based on the prior discussions and emerging data from the survey. Online discussions identified research themes around access to services, impacts on health systems, and policy implications. For example, themes such as access to contraception or abortion services were raised along with how access to water and sanitation (WASH) services might impact SRHR outcomes. Several questions emerged around health worker wellbeing and the ability of community health workers to continue providing services during extreme weather events. There were also questions raised about the impact of climate events like extreme heat on the integrity of medicines and commodities such as contraceptive methods. Themes around policy included exploring how SRHR is integrated into National Adaptation Plans and how to ensure evidence-based messaging around extreme weather events and SRHR issues. Participants to the online meeting agreed to develop more specific research questions through a third round focusing on the prioritisation of those questions.

Modified CHNRI prioritisation survey

Survey.

A third, and final, anonymous survey was sent out to 100 individuals on 12 July 2024 and respondents were given two weeks to complete it. This survey followed a modified CHNRI prioritisation methodology incorporating 31 proposed questions based on suggestions from respondents to survey 2, discussions during the online consultation, and analysis of common themes. The 31 final questions were organized according to climate change factors: drought and SRHR; extreme temperatures and SRHR; floods and SRHR; rainfall and SRHR; typhoons/cyclones and SRHR; climate change, health systems, and SRHR; and other areas.

We received a total of 27 responses. The ten highest scoring research questions received a score of 90% or higher. Three of the prioritised research questions fell under the climate change, health systems, and SRHR category, followed by two each in the drought, floods, and additional areas categories. No questions under the rainfall and typhoons/cyclones categories were among the top ten questions. See Table 2 for the list of the ten prioritised research questions and S5 Table for the full list with individual scores.

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Table 2. List of ten prioritised research questions at the nexus of climate change and sexual and reproductive health and rights (N = 27).

https://doi.org/10.1371/journal.pclm.0000835.t002

Discussion

We aimed to build consensus and prioritise research questions linking climate change and its effects on sexual and reproductive health and rights. This effort involved a group of experts identified through a mapping exercise completed in 2023 and others that were identified through the networks of the coordinating institutions (HRP Alliance, IBP network, and AFIDEP). The final list of ten research questions that emerged reflected a mix of SRHR topic areas focusing certain climate change events, and health systems issues that will require a range of research methodologies. Unsurprisingly, this list focused on areas, aspects, and issues that reflect common interests in SRHR: impact on maternal and newborn health outcomes, the compounding effect of intersectionality on equality issues that result in GBV, issues around health service access that impact the provision of quality contraception and abortion care and menstrual health, and the impact on the biological aspects relating to fertility.

Access to contraceptive services and maternal and newborn health outcomes remained top SRHR research priorities at the intersection with climate change, as well as some emerging topics such as comprehensive sexuality education and fertility care. Specific to maternal and newborn health, there is growing evidence focusing on outcomes impacted by climate change –e.g., impact of extreme heat and prolonged drought on preterm birth. However, the literature is scarcer when it comes to the impact of climate change on contraceptive access [6,9,36]. There is some documented evidence that links the challenges in accessing contraception during floods and other climate related disasters [37,38]. Identified priorities centred around health system issues such as ways to increase access, decrease costs, and provide quality services under varying climate conditions. Lack of access to modern contraception may also lead to unintended pregnancy causing further complications for safe delivery and birth outcomes. While addressing GBV did not rise as the main priority area, it was also reported as important by the group. A systematic review of the impact of climate events on GBV revealed increased instances of GBV mostly as a result of stressors related to economic instability, food insecurity, increased exposure to men, and disruptions in infrastructure [39]. When examining intersectionality, respondents prioritised social categories such as poverty and gender norms in relation to climate effects on SRHR. While these intersectional aspects are well documented, addressing them in the context of climate change remains understudied [7,40].

In addition to the SRHR topic areas, respondents identified the need for specific research methodologies that could best respond to the prioritized questions, which had been raised earlier by the group participating in the 2023 consultation [19]. While the group decided not to focus on this aspect, discussions emerged in line with existing literature, regarding the need for longitudinal data that could help establish causality as well as the need to focus on participatory approaches that are informed and designed by the communities most affected by climate change and harmful reproductive health outcomes [7,19]. This exercise also documented other SRHR areas of note, including fertility. Studies have shown impacts of extreme heat on reduced ovarian reserves and on fertility overall and there have been links between climate conditions like extreme heat and carbon emissions on male infertility [14,41].

Importantly, some critical areas relating to SRHR did not rise as top priorities by the experts participating in this exercise, such as abortion, menstrual health, and sexual health. Further issues around WASH, commodities, and policies were mentioned but not prioritised. While the impact of climate change on access to safe abortion has been identified as a knowledge gap in the literature it was only included in the final list of priority questions as part of broader health system access issues [6,7]. Further, there is a growing body of evidence on menstrual health and access-related issues impacted by climate factors [42,43]. In contrast, while sexual health was mentioned by respondents during the online consultations none of the final questions address this specifically. Previous scoping reviews revealed that the evidence on broader aspects of sexual health remain understudied, including aspects relating to sexual orientation and gender identity and disability [6,10,21]. Yet, research documents that sexually and gender diverse persons may be disproportionately affected by climate change due to social and institutional exclusion and that meaningful participation of people with disabilities is achievable and can enhance the quality and relevance of programmes [10,44,45]. Finally, there was no discussion about climate change impacting mental health and reproduction intentions despite some research indicating that climate concerns are associated with less positive views on childbearing and desires for fewer or no children [15,46,47]. While this exercise focused on exploring the effect that climate change is having on SRHR, there is evidence specifically emerging from feminist scholars, urging to look at the sociopolitical aspects to ensure that the discourse does not attempt against reproductive rights and justice by framing SRHR as a mechanism to reduce the effect of climate change [48–50]. And finally, there are a number of distal impacts of climate change on SRHR, including climate-driven migration, which were not explored through this exercise but that are highly relevant in this space [5].

Further, most of the national adaptation and health national adaptation plans lack a comprehensive inclusion of SRHR domains and even when these do exist, they are mostly around maternal and newborn health, GBV, and infrequently around contraceptive access [51]. By 2024, no NAP/HNAPs included dimensions relating to abortion and only one did for comprehensive sexuality education revealing an important gap in both knowledge and policies able to address some critical aspects in SRHR [52]. This exercise highlighted how some SRHR areas continue to be understudied and without concerted efforts in trying to shed light on these, with a common understanding of climate factors affecting health, inequalities will continue to persist.

Conclusion

The Delphi and CHNRI prioritisation processes provided a systematic approach to identifying priority research questions linking the impact of key climate events with selected SRHR areas which will require specific research methodologies able to quickly result in action as well as that represent the communities most affected. The prioritised questions can help the research community focus evidence generation activities in the future, such that adaptation plans can be reflective of existing data. The gaps emerging from this activity should also serve as a guiding principle to ensure typically understudied elements of and populations affected by climate change and SRHR are prioritised to ensure countries are able to quickly adapt to the rapidly evolving environment. Finally, given the complexities of climate change and SRHR, country and community context will be important considerations in how this list of priorities and other research in this area moves forward in the future.

Supporting information

Acknowledgments

The Sexual and Reproductive Health and Rights and Climate Change Delphi consensus building group comprised: Vanessa Brizuela (HRP/WHO, Switzerland), Bernard Onyango (AFIDEP, Kenya), Clive Mutunga (AFIDEP, Kenya), Nandita Thatte (WHO, Switzerland), Anup Adhikari (Suruwat, Nepal), Fulbert Adjimehossou (CERRHUD, Benin), Mariam Afsar Alam (Swasti, India), Sono Aibe (Independent, United States), Anthony Ajayi (African Population and Health Research Center, Kenya), Liliana Andriano (University of Southampton, United Kingdom), Malachi Arunda (Karolinska Institutet, Sweden), Elena Ateva (Americares, United States), Sunnee Billingsley (Stockholm University, Sweden), Eleanor Blomstrom (Women Deliver, United States), Guy Bokongo (Population Media Center, Democratic Republic of the Congo), Sara Lavinia Brair (Al Neelain University, Sudan), Meg Brown (University of California Berkeley, United States), Zakia Bulhan (International Solidaarisuus Foundation, Somalia), Amos Channon (University of Southampton, United Kingdom), Raavi Chaturya (Swasti, India), Apolinar Contreras (Ipas, Bolivia), Tara Daniel (Women’s Environment and Development Organization, United States), Celine Delacroix (Population Institute, University of Ottawa, Canada), Rajesh Didiya (Suruwat, Nepal), Sally Dijkerman (Ipas, United States), Ethel Ambo Eno (Hope for Vulnerable Children’s Association, Cameroon), Lucia Fernandez-Renau (Scope Impact, Finland), Theo Gibbs (YLabs, United States), Natalie Hammond (Manchester Metropolitan University, United Kingdom), Emily Hannum (University of Pennsylvania, United States), Md Rabiul Haque (University of Dhaka, Bangladesh), Karen Hardee (Hardee Associates, United States), Carina Hirsch (Margaret Pyke Trust, United Kingdom), Julia Hochberger (Wemos, The Netherlands), Kelsey Holt (University of California San Francisco, United States), Hashim Hounkpatin (CERRHUD, Benin), Zhongwei Huang (NUHS, Singapore), Ini Huijts (Independent, The Netherlands), Sajjad Hussain (National University of Science and Technology, Pakistan), Karin Jacquin (Independent, United States), Alexa Johns (Asia Pacific Alliance for Sexual and Reproductive Health and Rights, Thailand), Ellen Kajura (ACORD, Uganda), Devadarsini Kannan (Centre for Sexuality and Health Research and Policies, India), Edna Kara (HRP/WHO, Switzerland), Sajed Karim (Share-Net, Bangladesh), Niona Nakuya Kasekende (Regenerate Africa, Uganda), Bonnie Keith (PATH, United States), Caron R. Kim (HRP/WHO, Switzerland), Kiattisak Kongwattanakul (Khon Kaen University, Thailand), Kirsten Krueger (FHI 360, United States), Betty Kyaddondo (National Population Council, Uganda), Cate Lane (Independent, United States), Gunta Lazdane (Riga Stradins University, Latvia), Carmen Logie (University of Toronto, Canada), Pisake Lumbiganon (Khon Kaen University, Thailand), Bidhu Mahapatra (Norwegian Refugee Council, Norway), Mai Mahmoud (FP2030, Egypt), Masuma Mamdani (Independent, United Kingdom), Suzana Manhiça (UNICAMP–CEMICAMP, Brazil), Irene Masaba (ChildFund, Uganda), Carl Massonneau (WHO, Switzerland), Nurul Khalida Mazlan (CARAM Asia, Malaysia), Charles M’poca Charles (UNICAMP–CEMICAMP, Brazil), Matías Mrejen (Institute for Health Policy Studies, Brazil), Moses Mugabi (Agency for Co-operation in Reach and Development, Uganda), James Muhumuza (ChildFund International, Uganda), Leso Munala (University of Minnesota, United States), Martha Mwammale (AmplifyChange, United Kingdom), Amrita Namasivayam (Halcyon Health Consulting, New Zealand), Edith Ngunjiri (Blue Ventures, Kenya), My Nguyen (Vietnam National University, Viet Nam), Kate O’Connell (EngenderHealth, Uganda), Oluwadamilola Olayemi (Medibeth Global Health Centre, Nigeria), Stephen Ombija (Medical Research Institute, Kenya), Mark Oyoo (ChildFund, Kenya), Rodolfo Pacagnella (UNICAMP, Brazil), Sami Pande (GIZ, Nepal), Stefania Paracchini (Médecins du Monde, Belgium), Paula Pateguana (Plug-in.Mz, Mozambique), Khusbu Poudel (Ipas, Nepal), Sumitra Poudel (Women’s Rehabilitation Center, Nepal), Ray Protim (Durbar Mahila Samanwaya Committee, India), Saruh Rusike (Ministry of Health, Rwanda), Habeeb Salami (Globalgreen Health Systems Ltd, Nigeria), Sarah Saleem (Aga Khan University, Pakistan), Shila Salim (Youth for Sustainable Development, Kenya), Miguel Alejandro Saquimux Contreras (UNICAMP–CEMICAMP, Brazil), Sam Sellers (Independent, United States), Joseph Severe (Union des Amis Socio-Culturels d’Action en Développement, Haiti), Md Atiqul Haq Shah (Shahjalal University of Science and Technology, Bangladesh), Sesilia Shirima (Young and Alive Initiative, Tanzania), Callie Simon (Save the Children, United States), Rachael Sorcher (International Medical Corps, United States), Lilian Sospeter (VSO, Tanzania), Jen Sothornwit (Khon Kaen University, Thailand), Selene Soto Rodriguez (Center for Reproductive Rights, United States), Sander Spanoghe (Flanders Chancellery and Foreign Office, Belgium), Vivienne Talsma (Geneva Centre for Security Policy, Nigeria), Rachel Taylor (Save the Children, United States), Samuel Tilahun (Population Media Center, Ethiopia), Krizia Vieri (Médecins du Monde, Belgium), Jane Wilbur (London School of Hygiene & Tropical Medicine, United Kingdom), Aimé Yedenou (Cotonou City Lab, Benin), and Anandi Yuvaraj (Independent, India).