Restricted access to assisted reproductive technology and fertility preservation: legal and ethical issues.

Access to assisted reproductive technology (ART) and fertility preservation remains restricted in middle and low income countries. We sought to review the status of ART and fertility preservation in Brazil, considering social indicators and legislative issues that may hinder the universal access to these services. Although the Brazilian Constitution expressly provides the right to health, and ordinary law ensures the state is obliged to support family planning, access to services related to ART and fertility preservation is neither easy nor egalitarian in Brazil. Only a handful of public hospitals provide free ART, and their capacity far from meets demand. Health insurance does not cover ART, and the cost of private care is unaffordable to most people. Brazilian law supports, but does not command, the state provision of ART and fertility preservation to guarantee the right to family planning; therefore, the availability of state-funded treatments is still scarce, reinforcing social disparities. Economic projections suggest that including ART in the Brazilian health system is affordable and may actually become profitable to the state in the long term, not to mention the ethical imperative of recognizing infertility as a disease, with no reason to be excluded from a health system that claims to be 'universal'.

Integration of Catholic Values and Professional Obligations in the Provision of Family Planning Services: A Qualitative Study.

Importance: Religious leaders of the Catholic church created guidelines for practicing medicine, that involve reproductive care restrictions that may conflict with professional obligations. Objective: To explore how Catholic obstetrician-gynecologists integrate their religious values and professional obligations related to family planning services. Design, Setting, and Participants: In this qualitative investigation, in 2018, US-based obstetrician-gynecologists were recruited through an online survey and were invited to participate in audio-recorded telephone interviews using a semistructured interview guide. Participants were obstetrician-gynecologists who self-identified as Catholic and reported providing reproductive health care as follows: (1) provide natural family planning only (low practitioners), (2) provide additional contraceptive methods (moderate practitioners), and (3) provide family planning services including abortion (high practitioners). The study purposively sampled those with higher self-reported religiosity. Data were analyzed from November 2018 to February 2019. Main Outcomes and Measures: The primary outcome was understanding how participants describe integration of Catholic values with family planning service provision. The telephone interviews explored their integration of Catholic values and professional obligations, and 3 coders analyzed the responses using grounded theory. Results: Among the 34 Catholic obstetrician-gynecologists interviewed (27 women [79.4%]), there were 10 low, 15 moderate, and 9 high practitioners from 19 states. Participants' description of morality was consistent with Albert Bandura's Social-Cognitive Theory of Moral Thought and Action. The findings were used to create a modified framework. Within each group of physicians, 3 themes demonstrating their reconciliations between Catholic values and professional obligations emerged; each of these themes reflected one of the medical ethical principles of autonomy, beneficence, nonmaleficence, or justice. All 10 low practitioners primarily promoted natural family planning approaches to avoid iatrogenic risks and none provided abortion, reflecting nonmaleficence. Alternatively, moderate practitioners focused on nonmaleficence by offering contraception to prevent abortions. High practitioners primarily promoted patient autonomy by separating religious doctrine from medical practice. All had concerns for beneficence. In each group, 1 of the 4 medical ethical principles was underrepresented. Conclusions and Relevance: In this qualitative analysis, Catholic obstetrician-gynecologists establish their family planning care provision practices by emphasizing certain moral and/or ethical principles over others. These findings highlight how physician morality in the realm of family planning service provision often involves certain religious and/or professional reconciliations. Understanding the dilemmas Catholic obstetrician-gynecologists face can guide professional development efforts and inform ongoing discussions about conscientious objection and provision.

Incentivised sterilisation: lessons from India and for the future.

Family planning programmes in India have historically been target-driven and incentive-based with sterilisation seen as a key component of controlling population growth. This opinion paper uses India as the backcloth to examine the ethics of using incentive policy measures to promote and secure sterilisations within communities. Whilst we acknowledge that these measures have some value in reproductive health care, their use raises specific issues and wider concerns where the outcome is likely to be permanent and life changing for the acceptor.

The 'Converted Unbelievers': Catholics in Family Planning in French-Speaking Belgium (1947-73).

This paper looks at the journey of eleven counsellors in marital counselling centres in French-speaking Belgium, from the creation of the centres in 1953, to the 1970s, when contraception became legal, and abortion became a public issue. At the time of Humanae Vitae, groups of volunteers, working within Catholic organisations where counselling took place, began to structure their activity around Carl Rogers's ethics of client-centred therapy, placing their religious ideology in a secondary position to focus on the problems experienced by the couples and women they were receiving in the centres. These were often challenges they were experiencing themselves in their own lives. The reiteration of the Catholic orthodox view on contraception through Humanae Vitae marked a gap between the counsellors and the Church. This contribution questions the identity-related tension of Catholics working in conjugal counselling centres and the type of commitments they made to both the conjugal centres and the Church in a moment where family planning was debated both in the Church and politically.

Ethical dilemmas and legal aspects in contraceptive counselling for women with intellectual disability-Focus group interviews among midwives in Sweden.

BACKGROUND: Few studies have explored ethical and legal issues in contraceptive counselling among women with intellectual disability (ID). This study aimed to gain a deeper understanding of these issues during midwifery contraceptive counselling. METHOD: The present authors interviewed 19 midwives in five focus groups in Sweden 2016 - 2017 and analysed data with content analysis. RESULTS: The participants expressed that women with intellectual disability have equal right to relationships and sexual expressions, but feared exposure to sexual exploitation/abuse. They experienced ethical dilemmas related to principles of fairness and autonomy, but strived to provide assistance in spite of the women's cognitive impairment, presence of supporting persons and uncertainty of optimal counselling. Organizational support was insufficient. CONCLUSIONS: The midwives experienced ambivalence, uncertainty and ethical dilemmas in their counselling. They were, however, aware of legal aspects and strived for the women's best interest, right to self-determination and autonomous choices. The participants wanted better professional teamwork and support.

Research priorities and potential methodologies to inform care in subsequent pregnancies following stillbirth: a web-based survey of healthcare professionals, researchers and advocates.

OBJECTIVES: To identify research priorities and explore potential methodologies to inform care in subsequent pregnancies following a stillbirth. DESIGN: Web-based survey by invitation. PARTICIPANTS: Multidisciplinary panel of 79 individuals involved in stillbirth research, clinical practice and/or advocacy from the international stillbirth research community (response rate=64%). OUTCOME MEASURES: Importance of 16 candidate research topics and perceived utility and appropriateness of randomised controlled trial (RCT) methodology for the evaluation of four pertinent interventions: (1) medical therapies for placental dysfunction (eg, antiplatelet agents); (2) additional antepartum fetal surveillance (eg, ultrasound scans); (3) early planned birth from 37 weeks' gestation and (4) different forms of psychosocial support for parents and families. RESULTS: Candidate research topics that were rated as 'important and urgent' by the greatest proportion of participants were: medical therapies for placental dysfunction (81%); additional antepartum fetal surveillance (80%); the development of a core outcomes dataset for stillbirth research (79%); targeted antenatal interventions for women who have risk factors (79%) and calculating the risk of recurrent stillbirth according to specific causes of index stillbirth (79%). Whether RCT methodologies were considered appropriate for the four selected interventions varied depending on the criterion being assessed. For example, while 72% of respondents felt that RCTs were 'the best way' to evaluate medical therapies for placental dysfunction, fewer respondents (63%) deemed RCTs ethical in this context, and approximately only half (52%) felt that such RCTs were feasible. There was considerably less support for RCT methodology for the evaluation of different forms of psychosocial support, which was reinforced by free-text comments. CONCLUSIONS: Five priority research topics to inform care in pregnancies after stillbirth were identified. There was support for RCTs in this area, but the panel remained divided on the ethics and feasibility of such trials. Engagement with parents and families is a critical next step.

The Medical Termination of Pregnancy Act: Need to keep pace with technology.

In the summer of 2017, the Supreme Court of India denied permission to abort a 26-week-old foetus, detected with Down syndrome at 22 weeks, to a family which already had a child with special needs, on the grounds that the 20-week mark specified in The Medical Termination of Pregnancy Act of 1971 had been crossed. An Act well formulated and ahead of its time at inception seems not to have kept pace with technology and to be in need of change. We argue that by denying the abortion the Court did not adhere to the core principle of ethics-respect for autonomy, beneficence, non-malfeasance, and justice-as the mother was not allowed to decide for herself and was forced to abide by the decision taken by the court.

Conscientious objection to abortion, the law and its implementation in Victoria, Australia: perspectives of abortion service providers.

BACKGROUND: In Victoria, Australia, the law regulating abortion was reformed in 2008, and a clause ('Section 8') was introduced requiring doctors with a conscientious objection to abortion to refer women to another provider. This study reports the views of abortion experts on the operation of Section 8 of the Abortion Law Reform Act in Victoria. METHODS: Nineteen semi-structured qualitative interviews were conducted with purposively selected Victorian abortion experts in 2015. Interviews explored the impact of abortion law reform on service provision, including the understanding and implementation of Section 8. Interviews were transcribed verbatim and analysed thematically. RESULTS: The majority of participants described Section 8 as a mechanism to protect women's right to abortion, rather than a mechanism to protect doctors' rights. All agreed that most doctors would not let moral or religious beliefs impact on their patients, and yet all could detail negative experiences related to Section 8. The negative experiences arose because doctors had: directly contravened the law by not referring; attempted to make women feel guilty; attempted to delay women's access; or claimed an objection for reasons other than conscience. Use or misuse of conscientious objection by Government telephone staff, pharmacists, institutions, and political groups was also reported. CONCLUSION: Some doctors are not complying with Section 8, with adverse effects on access to care for some women. Further research is needed to inform strategies for improving compliance with the law in order to facilitate timely access to abortion services.

Regret, shame, and denials of women's voluntary sterilization.

Women face extraordinary difficulty in seeking sterilization as physicians routinely deny them the procedure. Physicians defend such denials by citing the possibility of future regret, a well-studied phenomenon in women's sterilization literature. Regret is, however, a problematic emotion upon which to deny reproductive freedom as regret is neither satisfactorily defined and measured, nor is it centered in analogous cases regarding men's decision to undergo sterilization or the decision of women to undergo fertility treatment. Why then is regret such a concern in the voluntary sterilization of women? I argue that regret is centered in women's voluntary sterilization due to pronatalism or expectations that womanhood means motherhood. Women seeking voluntary sterilization are regarded as a deviant identity that rejects what is taken to be their essential role of motherhood and they are thus seen as vulnerable to regret.

Social Freezing in Medical Practice. Experiences and Attitudes of Gynecologists in Germany.

Surveys of the German public have revealed a high acceptance of social freezing, i.e. oocyte conservation without medical indication. Up to now, there are no investigations available on the experiences and attitudes of health professionals towards social freezing. Between August 2015 and January 2016, we surveyed gynecologists Germany-wide on the topic social freezing. Five gynecologists specialized in reproductive medicine and five office-based gynecologists in standard care were chosen for the survey. The survey was conducted with an explorative, qualitative research design. The demand for social freezing in Germany is low. With regard to their fertility age, most women attend consultations too late, they have only little previous knowledge and false expectations. The gynecologists consider it the duty of society and politics to provide for the compatibility of family and work. They relate late parenthood to disadvantages primarily for the children. A majority of the gynecologists interviewed tend to advise natural reproduction. Social freezing is often mistaken as a kind of fertility insurance. Thus, it is necessary that physicians inform women early about the possibilities and limitations of social freezing. In the first place, social freezing is not a medical or medical-ethical topic. Women consider the method as a possibility to ensure the compatibility of family and work. This compatibility should be mostly perceived as a political topic. It cannot be a medical task to solve this issue. In fact, a debate in society as a whole is necessary that includes all relevant actors.

Sexual and Reproductive Health Services and Related Health Information on Pregnancy Resource Center Websites: A Statewide Content Analysis.

BACKGROUND: Pregnancy resource centers (PRCs) are nonprofit organizations with a primary mission of promoting childbirth among pregnant women. Given a new state grant program to publicly fund PRCs, we analyzed Georgia PRC websites to describe advertised services and related health information. METHODS: We systematically identified all accessible Georgia PRC websites available from April to June 2016. Entire websites were obtained and coded using defined protocols. RESULTS: Of 64 reviewed websites, pregnancy tests and testing (98%) and options counseling (84%) were most frequently advertised. However, 58% of sites did not provide notice that PRCs do not provide or refer for abortion, and 53% included false or misleading statements regarding the need to make a decision about abortion or links between abortion and mental health problems or breast cancer. Advertised contraceptive services were limited to counseling about natural family planning (3%) and emergency contraception (14%). Most sites (89%) did not provide notice that PRCs do not provide or refer for contraceptives. Two sites (3%) advertised unproven "abortion reversal" services. Approximately 63% advertised ultrasound examinations, 22% sexually transmitted infection testing, and 5% sexually transmitted infection treatment. None promoted consistent and correct condom use; 78% with content about condoms included statements that seemed to be designed to undermine confidence in condom effectiveness. Approximately 84% advertised educational programs, and 61% material resources. CONCLUSIONS: Georgia PRC websites contain high levels of false and misleading health information; the advertised services do not seem to align with prevailing medical guidelines. Public funding for PRCs, an increasing national trend, should be rigorously examined. Increased regulation may be warranted to ensure quality health information and services.

Family Planning as a Human Right: Knowledge for Better Decision-making by Cuban Adolescents.

Translated from the Spanish (original title, Saber para decidir mejor) and reprinted from Revista Mujeres, July 12, 2018. Original available at: http://www.mujeres.co.cu/art.php?NzMwNg.

What Are Risks and Benefits of Not Incorporating Information about Population Growth and Its Impact on Climate Change into Reproductive Care?

Fears about the impact of family planning decisions on the environment are not new. Concerns about population growth have often been conflated with concerns about the increasing demographic influence of specific feared or marginalized groups, leading to subsequent unjust treatment of those targeted populations. In clinical encounters such as this case, in which the patient expresses concerns about having another child in light of the effect of population growth on climate change, it is not appropriate for the clinician to impose environmental protection values on a patient's reproductive decision making, as this risks undermining her autonomy as well as perpetuating injustice. When a patient raises such worries, however, the physician's responsibility is to elicit and try to understand the patient's preferences and then to offer treatment choices that align with those values.

Impact of population growth and population ethics on climate change mitigation policy.

Future population growth is uncertain and matters for climate policy: higher growth entails more emissions and means more people will be vulnerable to climate-related impacts. We show that how future population is valued importantly determines mitigation decisions. Using the Dynamic Integrated Climate-Economy model, we explore two approaches to valuing population: a discounted version of total utilitarianism (TU), which considers total wellbeing and is standard in social cost of carbon dioxide (SCC) models, and of average utilitarianism (AU), which ignores population size and sums only each time period's discounted average wellbeing. Under both approaches, as population increases the SCC increases, but optimal peak temperature decreases. The effect is larger under TU, because it responds to the fact that a larger population means climate change hurts more people: for example, in 2025, assuming the United Nations (UN)-high rather than UN-low population scenario entails an increase in the SCC of 85% under TU vs. 5% under AU. The difference in the SCC between the two population scenarios under TU is comparable to commonly debated decisions regarding time discounting. Additionally, we estimate the avoided mitigation costs implied by plausible reductions in population growth, finding that large near-term savings ($billions annually) occur under TU; savings under AU emerge in the more distant future. These savings are larger than spending shortfalls for human development policies that may lower fertility. Finally, we show that whether lowering population growth entails overall improvements in wellbeing-rather than merely cost savings-again depends on the ethical approach to valuing population.

Patient understanding of genetic information influences reproductive decision making in retinoblastoma.

BACKGROUND: Retinoblastoma is the most common malignant tumour of the eye in childhood, with nearly all bilateral tumours and around 17% to 18% of unilateral tumours due to an oncogenic mutation in the RB1 gene in the germline. Genetic testing enables accurate risk assessment and optimal clinical management for the affected individual, siblings, and future offspring. MATERIAL AND METHODS: We carried out the first UK-wide audit of understanding of genetic testing in individuals with retinoblastoma. A total of 292 individuals aged 16 to 45 years were included. RESULTS: Patients with bilateral disease were significantly more likely to understand the implications of retinoblastoma for siblings and children. There was a significant association between not knowing the results of genetic testing or not understanding the implications and not having children, particularly in women. Surprisingly, this was also true for individuals treated for unilateral disease with a low risk of retinoblastoma for their offspring. CONCLUSION: We are concerned that individuals may be making life choices based on insufficient information regarding risks of retinoblastoma and reproductive options. We suggest that improvement in transition care is needed to enable individuals to make informed reproductive decisions and to ensure optimal care for children born at risk of retinoblastoma.

Understanding low uptake of contraceptives in resource-limited settings: a mixed-methods study in rural Burundi.

BACKGROUND: Family planning can reduce deaths, improve health, and facilitate economic development in resource-limited settings. Yet, modern contraceptive methods are often underused. This mixed-methods study, conducted in rural Burundi, sought to explain low uptake of contraceptives by identifying utilization barriers. Results may inform development of family planning interventions in Burundi and elsewhere. METHODS: We investigated uptake of contraceptives among women of reproductive age in two rural districts of Burundi, using an explanatory sequential, mixed-methods research design. We first assessed availability and utilization rates of modern contraceptives through a facility-based survey in 39 health clinics. Barriers to uptake of contraceptives were then explored through qualitative interviews (N = 10) and focus groups (N = 7). RESULTS: Contraceptives were generally available in the 39 clinics studied, yet uptake of family planning averaged only 2.96%. Greater uptake was positively associated with the number of health professionals engaged and trained in family planning service provision, and with the number of different types of contraceptives available. Four uptake barriers were identified: (1) lack of providers to administer contraception, (2) lack of fit between available and preferred contraceptive methods, (3) a climate of fear surrounding contraceptive use, and (4) provider refusal to offer family planning services. CONCLUSIONS: Where resources are scarce, availability of modern contraceptives alone will likely not ensure uptake. Interventions addressing multiple uptake barriers simultaneously have the greatest chance of success. In rural Burundi, examples are community distribution of contraceptive methods, public information campaigns, improved training for health professionals and community health workers, and strengthening of the health infrastructure.

[Ethical issues of oocyte donation].

The birth and development of oocyte donation technology have brought hope for women with poor ovarian reserve and repeated failure for in vitro fertilization, as well as for those with chromosomal abnormalities, premature ovarian failure, or at perimenopausal or menopausal stages. It has not only preserved their reproductive right, but also stabilized their families and increased social harmony. However, this technology does not only involve infertile couples themselves, but also social and ethical issues concerning their families and the society. This paper has reviewed and discussed the hot issues concerning oocyte donation, e.g., source of eggs, compensation for donors, prerequisites for recipients and donors, privacy of donors, and made suggestions for further improvement for the administration of oocyte donation.