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Sexual and reproductive health services during outbreaks, epidemics, and pandemics in sub-Saharan Africa: a literature scoping review

Background The COVID-19 pandemic could worsen adolescent sexual and reproductive health (ASRH). We sought evidence on the indirect impacts of previous infectious disease epidemics and the current COVID-19 pandemic on the uptake of ASRH in sub-Saharan Africa (SSA) to design relevant digital solutions. Methods We undertook a literature scoping review to synthesize evidence on the indirect impacts of COVID-19 on ASRH in SSA per the Arksey and O’Malley framework and PRISMA reporting guidelines. We conducted the search on PubMed, Embase, Google Scholar, and ResearchGate in June and November 2020. We included all peer-reviewed, English-language primary studies on the indirect impacts of infectious disease epidemics on the uptake of sexual and reproductive health (SRH) in SSA. Results We included 21 of 42 identified studies. Sixteen studies (76.2%) quantitatively assessed utilization and access to SRH during epidemics. Five studies (2 [9.6%] qualitative and 3 [14.3%] mixed methods) explored factors affecting SRH services. All studies focused on adult populations, most often on labor and delivery (n = 13 [61.9%]) and family planning (n = 8 [38.1%]) outcomes. Although we sought out to assess all outbreaks, epidemics, and pandemics, the only relevant studies took place during the West African Ebola pandemic (n = 17 [80.9%]) and COVID-19 pandemic (n = 4 [19.0%]). One study (4.8%) highlighted adolescent-specific outcomes and condom use. Most studies found declined access to and utilization of facility delivery, antenatal care, family planning, and HIV care. One study noted an increase in adolescent pregnancies. However, other studies noted similar, or even increasing trends in access to and utilization of other SRH services (family planning visits; HIV diagnosis; ART initiation) during epidemics. Barriers to SRH uptake included factors such as a reduced ability to pay for care due to lost income, travel restrictions, and fear of infection. Supply-side barriers included lack of open facilities, workers, commodities, and services. Community-based peer delivery systems, telemedicine, and transport services improved SRH uptake. Conclusion Access to SRH services during epidemics among adolescents and young people in SSA is understudied. We found that no studies focused on SRH outcomes of abortion, emergency contraception, sexually transmitted infections, or cervical cancer. To improve access to and utilization of SRH during pandemics, we recommend the following; in terms of research, key standardized SRH indicators should be included in routine data collection, routine data should be disaggregated by age, gender, and geography to understand gaps in ASRH service delivery, and additional rigorous epidemiological and social-behavioral studies should be conducted. On implementation, community-based peer delivery systems and telemedicine, internet-based, and other technological solutions may better reach adolescent and young people in SSA. Supplementary Information The online version contains supplementary material available at 10.1186/s13643-022-02035-x.


Plain English summary
Adolescents and young people face barriers to accessing sexual and reproductive health (SRH) services such as birth control, condoms, HIV/AIDS and sexually transmitted infection (STI) testing. Changes in health care, social policy, and household's economic status due to infectious disease epidemics may further reduce access to SRH services by young people. We conducted a literature scoping review on the impacts of past epidemics on SRH to anticipate and mitigate the indirect impacts of COVID-19 on SRH among young people. We conducted a search of literature related to SRH services during infectious disease epidemics in sub-Saharan Africa (SSA) and found 21 studies. Included studies focused on adult populations with only one study specific to adolescents. Our review showed that utilization and access to labor, delivery, and antenatal services decreased dramatically during the Ebola outbreak with long-lasting detrimental effects. Barriers to care included increased costs of care, difficulty traveling distances due to lockdowns, fear of infection, and a lack of operating facilities, workers, supplies, and services. The evidence for adult populations suggests that adolescents and young people may face heightened challenges to accessing SRH services during epidemics which may lead to poor health outcomes. This review highlights key areas for future research programs and policies.

Background
Globally, adolescents and young people (AYP) bear a disproportionate burden of adverse sexual and reproductive health (SRH) outcomes [1,2]. Of the estimated 1.8 billion early adolescents and young people (aged [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] worldwide, 90% live in low-and middle-income countries (LMICs) [3]. In sub-Saharan Africa, early adolescents (aged 10-19 years) constitute a significant proportion (25%) of the total population [4]. AYP experience adverse SRH outcomes due to early sexual debut and marriage, risky sexual behavior including multiple sexual partnerships and insufficient condom/contraceptive use [5,6]. Adolescent girls face additional vulnerabilities including violence by intimate partners and non-partners, early and unintended pregnancy, and sexually transmitted infections (STIs)/HIV [7,8]. Restrictive policies, an absence of adolescent friendly SRH services, and other factors (cultural, societal, and religious) may inhibit utilization of SRH services by young people [9]. On an individual level, AYP may be unable to access care due to distance and a lack of income, or may be unwilling to due to stigma, shame, and misinformation [9,10]. Although many national and international bodies have prioritized AYP health, improvements in SRH outcomes and access to related services have been limited [8].
The COVID-19 pandemic in Zambia and other LMICs, specifically prevention measures, are expected to exacerbate barriers to SRH services and contribute to poor health outcomes among AYP [11][12][13]. Prior studies have found that essential services decline during epidemics. The West Africa Ebola pandemic made a notable impact on services including a disruption of childhood immunizations, significant reductions in maternal health services, and declines in malaria care seeking, all of which may have collectively contributed to more deaths than the virus itself [14][15][16][17]. Public health measures in an epidemic such as quarantines, school closures, and reallocation of resources towards emergency services, compromise essential services, which are dependent on functional and accessible health facilities [14]. Fear of contracting the infection, restriction of movement, distrust, and violence/mistreatment may further prevent the availability and utilization of essential services [15][16][17][18]. Thus, public health crises such as the ongoing COVID-19 pandemic could exacerbate barriers to SRH services and worsen AYP health [11][12][13].
Prior observational and modeling studies suggest that essential health services may decline during the COVID-19 epidemic, resulting in larger negative impacts on morbidity and mortality [19][20][21]. We undertook a literature scoping review to identify and synthesize knowledge on the indirect impacts of epidemics on access to and utilization of SRH services by AYP in SSA to design appropriate digital solutions. This scoping review highlights knowledge gaps and evidence to inform research, programming, and policies in Zambia, and other LMICs, during the ongoing COVID-19 pandemic to improve SRH outcomes in this key population.
following; in terms of research, key standardized SRH indicators should be included in routine data collection, routine data should be disaggregated by age, gender, and geography to understand gaps in ASRH service delivery, and additional rigorous epidemiological and social-behavioral studies should be conducted. On implementation, communitybased peer delivery systems and telemedicine, internet-based, and other technological solutions may better reach adolescent and young people in SSA.

Methods
We conducted a scoping review driven to systematically map the literature on SRH services for AYP during public health crises. We aimed to describe gaps in research to guide further research, program, and policy opportunities during the ongoing COVID-19 pandemic [22]. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist [12] and a widely used methodological framework for scoping studies: the Arksey and O'Malley Framework (2005). Further, we considered more recent specific recommendations for strengthening the framework in our review stages [23]. We applied Arksey and O'Malley's five recommended stages of scoping reviews, as outlined below.

Research study identification
We developed research questions to guide the scoping review. The objective of conducting this scoping review was to understand access and utilization of SRH services among AYP during health crises. However, due to lack of literature during initial searches, we expanded the study to include adult (≥ 25 years of age) populations. Our specific research questions were the following: (1) what is the landscape of access to, and utilization of, SRH services during COVID-19 and prior public health crises in SSA? (2) What factors have contributed to access to and utilization of SRH during COVID-19 and prior public health crises in SSA?

Literature identification
We conducted a full systematic search of relevant indexed peer-reviewed publications from June 15 to 30, 2020. Given how quickly COVID-19 literature evolved, we conducted another search from November 24 to 30 in three academic databases: (1) PubMed/MEDLINE (National Library of Medicine); (2) EMBASE (Excerpta Medica dataBASE); (3) Google Scholar. In addition, we searched ResearchGate and reference lists of articles for additional relevant studies. Search terms included the following population: adolescents (10-19 years); young people (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24); and the general population. SRH outcomes included sexual behavior; contraceptive use; pregnancy; labor and delivery; HIV/AIDS; STIs; and gender-based violence. In terms of context, the review included any studies that collected data during epidemics in SSA. The aim of this scoping review was to understand indirect impacts of public health crises, including outbreaks, epidemics, and pandemics. Direct relationships between public health crises and SRH were excluded from review. We have included the main search terms in Table 1.

Study selection
Studies were included based on the inclusion and exclusion criteria highlighted in Table 2. Included studies were limited to English-language, peer reviewed publications that could be accessed via a library service with primary data (e.g., quantitative, qualitative). Commentary articles, grey literature, and any studies not reporting primary data (i.e., modeling studies, systematic reviews) were excluded. Two team members (AM and MN) independently and systematically searched for all articles in the three databases and in ResearchGate using the search terms and inclusion/exclusion criteria.

Data presentation
All relevant search results were exported into an electronic spreadsheet to manage and ensure completeness. Two reviewers (AM and MN) screened titles and abstracts with literature identification rules to ensure articles met the inclusion criteria. After screening, a review of full-text articles was conducted independently by both members to ensure the article met pre-determined criteria for inclusion. Discordant determinations were resolved through discussion and did not need a third reviewer. Reasons for not including an article were documented.
The results of the search are reported below and presented in a Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) flow diagram in Fig. 1.
After articles were selected, the reviewers independently conducted data extraction of the following variables: year; author; abstract; country/region; population/ sample; type of study; type of data collected; key findings on utilization and access to SRH; factors (barriers and facilitators) related to SRH; and other interesting findings related to the research questions.
The team has summarized the findings below using the thematic areas that emerged through a priori themes informed by the research questions (i.e., deductive analysis) and those arising from the literature (i.e., inductive analysis).

Scoping review results
We identified 51 relevant studies across PubMed, Embase, ResearchGate, and Google Scholar platforms, which met the search criteria for assessing SRH services during epidemics. After removing duplicates, 42 records remained, of which 12 were excluded due to inaccessibility or lack of relevance. Of the 30 full-text articles  Table 1 Search terms a a The full search string included all variations of the search terms and associated acronyms b The focus of this review was initially on adolescents and young people, but given very few relevant studies, the population was broadened c We expected all relevant outbreaks (e.g., cholera, Ebola) but would be captured with terms such as "pandemic", "epidemic" and "outbreak" reviewed, 9 did not meet the inclusion/exclusion criteria described in Table 2. The final literature review included 21 peer-reviewed scientific papers across seven countries . There were 17 articles on Ebola Virus Disease (EVD) covering three countries -Sierra Leone, Guinea, and Liberia [26][27][28][29][30][31][33][34][35][36][37][38][39][40][41][42][43]. Four studies focused on COVID-19 and covered Ethiopia, Kenya, Nigeria, and South Africa [24,25,32,44]. All studies investigated how epidemics impacted utilization and access to health services, including SRH services, with some studies also assessing general health outcomes (e.g., patient admissions and causes of death). A summary of the included studies can be found in Table 3. All studies were published between 2015 to 2020 and used an observational design. Most studies focused on EVD (n = 17, 80.9%), and took place in West Africa (Guinea, Liberia, and Sierra Leone were the geographic focus in 5, 9, and 6 studies, respectively). The most studied outcomes in quantitative studies (n = 16) were labor and delivery (n = 12, 61.9%), family planning (n = 7, 33.3%), antenatal care (n = 6, 28.6%), and HIV (n = 6, 28.6%). Study details including authors, the epidemic, location, population, setting, data collection, and outcomes are included in Table 4.

SRH access and utilization results
We have summarized the detailed results on access and utilization varied by SRH outcome in Supplementary Materials 1.

Labor and delivery
Of the 18 studies (16 quantitative and 2 mixed methods), many showed a decline in facility deliveries in the Ebola period compared to the pre-Ebola period [28,26,30,31,33,35,38]. One study also showed a statistically significant increase in institutional deliveries in a rural district in Sierra Leone, potentially due to few Ebola cases, but a negative trend in the transition from Ebola to post-Ebola [43]. A study on COVID-19 showed that facility deliveries remained stable at the start of the COVID-19 epidemic in Ethiopia [24]. Complications such as gynecology emergency [24], pregnancy complications [26], major direct obstetric complications (MDOC) cases [43] and cesarean-sections [28,31,43] each decreased during Ebola compared to the post-Ebola period. Other studies showed that maternal admissions [43] as well as obstetric access [41] declined during outbreak periods.

Maternal mortality
Similarly, mixed findings on maternal mortality emerged with two studies showing an increase [26,35] and one study showing a reduction in maternal deaths during Ebola with a significant increase after Ebola [43].

Antenatal care (ANC)
ANC services were dramatically reduced during the EVD epidemic compared to the pre-Ebola period [24,31,33]. This was consistent for ANC visit 1, 2, 3 or more visits [24,26,30]. The post-Ebola period saw a slight increase in ANC 1 and 3 visits compared to the intra-Ebola phase in Guinea [30].

Family Planning
Between pre-and post-Ebola periods, new and continuing family planning visitations increased in health centers but decreased in hospitals [26]. One study showed a decline in family planning consultations during the Ebola outbreak compared to pre-Ebola period in rural Sierra Leone [43]. During the COVID-19 outbreak, we found conflicting results across countries. While a study from rural South Africa reported an increase in daily clinic visitations for family planning [44], another reported that at a referral hospital in Dessie town, Ethiopia, family planning visits decreased by more than 95% after the implementation of COVID-19 precautions [24]. All the studies reported a decline in the utilization of all types of contraception during the EVD epidemic compared to the post-Ebola period. This included a stockout of modern contraceptives (i.e., injectables, pills, condoms) in most facilities [26] and a decrease in distribution of implants and contraception pills and the associated couple-years of protection (CYP) [27]. One study showed that the distribution of male condoms fell during the EVD epidemic to 22% compared to a pre-Ebola average of 51% [27].

HIV services
Two studies showed a decline in HIV-related facility visits in the Ebola period compared to the pre-Ebola period [37,39]. However, Siedner (2020) reported an increase in HIV related visits with reduced COVID-19 restrictions [44]. HIV testing decreased during the Ebola outbreak compared to the pre-Ebola period across all the studies that reported on HIV testing [26,34,36,37]. HIV diagnosis showed a significant decline in one study [36] while another showed similar trends in diagnosis between pre-Ebola and post-Ebola periods [34]. There was a significant drop in newly enrolled patients on ART in most of the studies [34,37,39]. While one study showed a decline in ART initiation among TB patients newly diagnosed with HIV in Liberia [36], analysis of Liberia's DHIS data showed increased ART initiation among people presenting to healthcare facilities during and after the EVD outbreak [34].

Adolescents
As aforementioned, we identified a gap in the literature in regard to adolescent-specific studies. One mixed-methods study revealed significant increase in the mean teenage pregnancies per chiefdom in Moyamba district of Sierra Leone during the Ebola outbreak (173 pregnancies) compared to the pre-Ebola phase (137 pregnancies), p < 0.03 [31]. Respondents to qualitative interviews opined that since schools had closed, sexual activity particularly involving young girls and older men had increased. The authors cautioned that the apparent 25% increase in teenage pregnancy may be an underestimate given pregnancy requires clinical diagnosis (i.e., may be delayed if care-seeking is delayed) and because schools were subsequently closed again due to the outbreak.

Results: barriers and facilitators related to access to and utilization of SRH during epidemics
Seven studies discussed barriers and facilitators affecting SRH utilization during epidemics. Table 5 summarizes barriers and facilities and Supplementary Materials 2 present detailed findings by study and factor.

Barriers
Across countries, the COVID-19 pandemic increased cost of medicines and supplies. A study noted that individuals working in the informal sector could not afford to buy medicine due to a lack of income after COVID-19 restrictions were imposed, while the health facility could not pay the higher costs of supplies [25]. Several studies noted an increased challenge in traveling to healthcare facilities, especially among those who lived more than 10 km away, or those affected by poor road conditions, limited transport, and movement restrictions [25,32,40,42]. Fear of nosocomial infection prevented health service access and utilization across settings and populations for both COVID-19 and Ebola epidemics [25,40,41]. In a study of 15 counties in Liberia, nearly 60% of participants from rural areas and 24% from urban areas cited fear of Ebola infection as the major barrier to care seeking [41]. In other settings, many study participants did not trust the health system and believed circulating rumors that healthcare workers gave children the virus through immunizations [31]. Also, others stated that they did not believe that they would receive high quality care through the public health system [31,42]. In addition to epidemic-specific barriers, socio-demographic factors such as low household wealth status and low maternal education were associated with decreased odds of facility delivery during Ebola [40].
Several supply-side issues affected healthcare access and utilization including healthcare facilities closing and/or reducing hours during the EVD and COVID-19 epidemics [25,32,41]. Other studies noted reductions in services including reproductive and maternal care, HIV testing, and delivery services [25,26,31]. Lastly, participants noted the reductions in contraceptive and pregnancy testing supply chains affected their ability to access them when needed during the COVID-19 pandemic [32].

Facilitators
Some health system responses demonstrated promising facilitators for increasing access to SRH services during epidemics. During the COVID-19 outbreak in Kenya, phone consultations and an emergency phone number to access free taxi transfers at night addressed transportation difficulties for pregnant women [25]. Similarly, the West African Ebola epidemic saw an increased use of traditional birth attendants, community health workers, and traditional healers for prenatal care, deliveries, and child services [41,42]. However, while community health workers filled an important gap in SRH services, they did not receive the support they needed to ensure safe home deliveries or referrals to facility-based deliveries [41,42].

Discussion
Overall, this comprehensive scoping review revealed the scarcity of literature on SRH services during epidemics in SSA. The studies covered two pandemics (Ebola and COVID-19) though there have been several other disease outbreaks, such as influenza, bubonic plague, cholera, yellow fever, meningitis, measles, rift valley fever, and polio in SSA [45]. Similarly, the literature lacked variety in SRH outcomes. Nearly all studies assessed facility delivery, family planning, antenatal care, or HIV, with no studies evaluating sexually transmitted infections or cervical cancer screening, abortion care, or gender-based violence care. This paucity of information is particularly worrying given evidence from prior humanitarian crises that such care is essential to prevent unintended pregnancies, unsafe abortions, complications, intimate partner violence, and other adverse health outcomes [46][47][48][49][50]. Further, as noted, no studies focused exclusively on AYP's access to and utilization of SRH, despite the alarms raised regarding heightened vulnerabilities of this population [1,2].
Globally, governments are taking unprecedented measures to limit the spread of the COVID-19 virus, while health and social systems are struggling to cope with rising caseloads, supply chain bottlenecks, movement restrictions, and economic difficulties. In humanitarian/ fragile settings and LMICs, where systems are already weak, the epidemic may cause more collateral and longlasting damage without thoughtful and comprehensive SRH services. In a recent mathematical modeling study, Riley et al. (2020) estimated a 10% proportional decline in use of contraceptive methods in LMICs during the COVID-19 pandemic [19]. Across 132 LMICs, this reduced access would result in nearly 49 million women having an unmet need for modern contraceptives and 15 million women having unintended pregnancies over the course of a year during the COVID-19 pandemic (ibid). A 10% decline in service coverage would result in an estimated 1.7 million additional major obstetric complications and 28,000 maternal deaths [19]. Concerningly, these estimates do not take into account the increased risk of adverse health outcomes associated with adolescent pregnancies and births, which would likely mean even higher numbers and worse outcomes among adolescent girls. Further, other investigators have estimated that COVID-19 disruption could led to a 10% increase in HIV mortality, nearly 77,000 deaths in the next year [20,21].
This review confirms that leaving SRH unaddressed amid a public health crisis impacts access and utilization during and after the epidemic. Many studies included in this scoping review showed that access to SRH services, notably facility delivery and antenatal care declined during the early and post Ebola outbreak phases in West Africa. However, some better-funded services such as HIV and family planning were more resilient. Methodological differences such as setting/ sample (e.g., facility-based vs. national), analysis techniques (e.g., difference in difference, times series), and the number and types of SRH services create variability in observed magnitude and direction of impact. Health system context and temporality may also account for the observed differences. For instance, in Ethiopia, facility-level deliveries remained stable early in the epidemic, but gynecological emergency visits decreased; in Guinea health centers performing better than hospitals; and, in Sierra-Leone government facilities performed better than private, not-for-profit facilities  Commentaries; systematic reviews; meta-analyses; scoping reviews; modeling studies Time limit Any time None during the peak, but worse during the slow-down of the Ebola epidemic [24,26]. Furthermore, urbanicity could explain utilization, for instance, both fewer Ebola cases and higher SRH utilization was observed in rural Sierra Leone while an increased fear of nosocomial infections may have adversely affected SRH utilization in rural Liberia [41,43]. Importantly, there are indications that fear of exposure and depleted resources (e.g., staff, supplies) limited the supply of services while the fear of nosocomial infection and loss of livelihood limited the demand for SRH services. However, under these circumstances, accessible, and trusted community healthcare workers met SRH needs, albeit with insufficient training and resources. The findings from this scoping review led us to provide clear recommendations for SRH service delivery to AYP during pandemics as listed in Fig. 2 [51,52]. Firstly, this review found that adolescent's access to SRH services during epidemics have received little attention, as highlighted in the several knowledge gaps. This review highlights the need for studies to assess the unique needs, barriers, and facilitators which AYP may encounter during epidemics. Observational studies which can collect or leverage rapid data on utilization of SRH services for both AYP and the general population can inform localized responses. This data should be disaggregated by sex, age, and geography to further understand the heterogeneity in service delivery between sub-populations. This is particularly relevant for AYP, as numerous shortcomings in AYP health measurement have been identified. These include inconsistent indicators, poor harmonization with existing data, and data that is not well aligned to needs [53]. Relatedly, consistent documentation which enables real-time feedback and quality improvement can greatly improve access to and quality of services. Lastly, studies should aim to follow best practices in epidemiological reporting for observational studies (i.e., Strengthening the Reporting of Observational Studies in Epidemiology [STROBE]) [52]. We found that the reporting of methods and outcomes across studies was largely inadequate and varied greatly, making comparisons and generalizations challenging in this scoping review. These issues also limit the ability to conduct future, more rigorous reviews (i.e., systematic reviews, meta-analyses) which would have required an assessment of bias and commentary on the quality of the articles.
Beyond data and research recommendations, we have outlined two key areas which may improve AYP health during epidemics. Firstly, we recommend leveraging existing community-based peer delivery systems to increase access to prophylactics, contraceptives, and ART. Our scoping review found that formal healthcare utilization decreased across several outcome areas, while simultaneously home-based services (namely, deliveries) increased. This was likely due to both demand-side issues (i.e., fear of infection), and supply-side issues (i.e., closed facilities). This finding is well-aligned with other calls for increased demandgeneration and community-based activities alongside existing facility-based offerings, to improve AYP SRH access [54]. Secondly, we recommend integrating telemedicine, internet-based, and other technological solutions to reach AYP. There is strong evidence to support the use of mobile Health (mHealth) programs targeting AYP SRH [55]. Prior mHealth interventions have aimed     Findings not reported by outcome area for qualitative studies c In South Africa, a level 5 order is considered a shelter in place order which includes closure of schools and non-essential businesses and restrictions on movement and public transportation. Residents were instructed to remain in their homes unless they were "performing an essential service, obtaining an essential good, or seeking emergency, lifesaving, or chronic care. " At the end of April, South Africa moved to level 4, then level 3 which lifted several restrictions. Level 4 allowed for some businesses and transportation to open. Level 3 included the opening of many establishments (e.g., cinemas, restaurants, gyms) and increased access to local and long-distance travel Ng'andu et al. Systematic Reviews (2022) 11:161 to increased knowledge sharing and behavior change and link AYP to essential SRH services. Given the widespread use of mHealth interventions in LMICs, there is an existing infrastructure which could potentially be used to build epidemic-specific mHealth interventions and reduce barriers to care for this key population, particularly during public health crises.  Figure 2 presents the Donabedian Structure-Process-Outcome (SPO) model [56], a conceptual framework to summarize and organize our recommendations to improve AYP health during pandemics. We postulate "structure" in terms of (1) consistent documentation and representation of key SRH data elements; (2) standardized methods to measure access and utilization of SRH services using the STROBE statement; (3) disaggregation of routinely collected SRH data by age, sex, and location; (4) provision for rapid data collection during emergencies (e.g., funding, scientific support, and swift ethical approval); (5) institution of community-based peer delivery systems for prophylactics contraceptives and ART/other chronic illnesses; and (6) development and implementation of telemedicine, mHealth, and other technological solutions for hard-to-reach populations that impact directly on "process". The processes include continuous quality improvement (QI) based on real-time feedback, common understanding of unmet SRH needs by sub-populations (i.e., gap identification), and provision of services relevant to the unique needs of populations including adolescents (i.e., differentiated care). The structures and processes will contribute to increased access to and quality of SRH services.

Recommendations
This review had several limitations. We may have missed additional relevant studies through our inclusion of only peer-reviewed, English language, and full-text publications. For example, we did not have any studies related to the recent Ebola epidemic in DRC, which may have been a result of the peer-review inclusion criteria. Relatedly, though we searched for relevant articles several times throughout the study (in June and November 2020), some articles may not have been included in this analysis given how quickly and continuously the literature has evolved for COVID-19. Also, we did not assess the rigor or quality of these studies, indicating that this does not represent as rigorous of a process that would be expected for a systematic review. Most studies relied on routine facility-level data, which may have issues with data quality and completeness. Despite these limitations, our study highlights that SRH services will be disrupted and access to and utilization of services will decrease without deliberate efforts to address the needs of all seeking care, particularly AYP and adolescent females.

Conclusion
Indirect effects of infectious disease public health crises can be long term. It is critical that support for access to and utilization of SRH services be maintained or, better still, improved during epidemics. Particularly, services which address the unique needs of AYP are markedly absent. Findings suggest that more data and research in SSA are needed to understand SRH access and utilization. Data should be disaggregated by age, sex, and urbanicity and account for methodological and cultural/contextual differences to quickly understand gaps and develop localized responses. Recommendations to improve AYP SRH access include leveraging existing community-based delivery systems and technological approaches to increase access, knowledge, and promote behavior change during epidemics. Without targeted efforts to improve access, adverse SRH outcomes will increase, reversing recent progress in SSA and LMICs.