Population politics, reproductive governance and access to abortion in Turkey.

Turkey currently pursues an aggressive pronatalist population politics which has created wide-reaching reproductive governance regulating reproductive health care and family planning choices. One aspect of this orientation centres on restricting access to abortion services despite the fact that abortion is legal through ten weeks of pregnancy. This article uses nationwide data collected from mystery patient surveys administered to all public (in 2016 and 2020), and all private (2021) hospitals in the country to determine the availability of abortion services in Turkey. Less than half of all hospitals responding provided abortions to the full extent provided by law. Abortion without restriction as to reason was largely unavailable at public hospitals and the cost of care at private hospitals remained prohibitive for many. Among those hospitals we reached, in four provinces, there was no public or private hospital providing any type of abortion care. The most frequent explanation for the lack of abortion services was that abortion is illegal. This was particularly the case for public hospitals. Despite a 10-week cutoff for abortions, 39% of private hospitals responding to the survey invoked even earlier time limits creating further restrictions. The extreme pronatal orientation of the reproductive governance currently in place has created a state of reproductive injustice that makes enhanced access to abortion of vital importance.

Gestational age limits for abortion and cross-border reproductive care in Europe: a mixed-methods study.

OBJECTIVES: Little is known about the experiences of women who travel within Europe for abortion care from countries with relatively liberal laws. This paper aims to assess the primary reasons for travel among a sample of women who travelled from European countries with relatively liberal abortion laws to obtain abortion care mainly in the UK and the Netherlands. DESIGN: Multi-country, 5-year mixed methods study on barriers to legal abortion and travel for abortion. SETTING: UK, the Netherlands and Spain. POPULATION OR SAMPLE: We present quantitative data from 204 surveys, and qualitative data from 30 in-depth interviews with pregnant people who travelled to the UK, the Netherlands and Spain from countries where abortion is legal on broad grounds within specific gestational age (GA) limits. METHODS: Mixed-methods. MAIN OUTCOME MEASURES: GA when presenting at abortion clinic, primary reason for abortion-related travel. RESULTS: Study participants overwhelmingly reported travelling for abortion because they had exceeded GA limits in their country of residence. Participants also reported numerous delays and barriers to receiving care. CONCLUSIONS: Our findings highlight the need for policies that support access to abortion throughout pregnancy and illustrate that early access to it is necessary but not sufficient to meet people's reproductive health needs. FUNDING: This study is funded by the European Research Council (ERC). TWEETABLE ABSTRACT: This study shows that GA limits drive women from EU countries where abortion is legal to seek abortions abroad.

Affordable but Inaccessible? Contraception Deserts in the US States.

CONTEXT: This article focuses on whether, and the extent to which, the resources made available by Title X-the only federal policy aimed specifically at reproductive health care-are equitably accessible. Here, equitable means that barriers to accessing services are lowest for those people who need them most. METHODS: The authors use geographic information systems (GIS) and statistical/spatial analysis (specifically the integrated two-step floating catchment area [I2SFCA] method) to study the spatial and nonspatial accessibility of Title X clinics in 2018. FINDINGS: The authors find that contraception deserts vary across the states, with between 17% and 53% of the state population living in a desert. Furthermore, they find that low-income people and people of color are more likely to live in certain types of contraception deserts. CONCLUSIONS: The analyses reveal not only a wide range of sizes and shapes of contraception deserts across the US states but also a range of severity of inequity.

The highly complex issue of conscientious objection to abortion: can the recent European Court of Human Rights ruling Grimmark v. Sweden redefine the notions of care before freedom of conscience?

PURPOSE: The article aims to elaborate on two recent European Court of Human Rights (ECtHR) decisions which have rejected, on grounds of non-admissibility, the appeals by two Swedish midwives who refused to carry out abortion-related services, basing their refusal on conscientious objection, and to expound upon the legal and ethical underpinnings and core standards applied to the framing process of such a ECtHR decision. MATERIALS AND METHODS: By drawing upon relevant recommendations from international institutions, the authors have aimed to assess how the ECtHR rationale could affect the balance between CO and patient rights; searches have been conducted up until December 2020. RESULTS: In both decisions the European Court has asserted that the right to exercise conscientious objection must give way to the protection of the right to health of women seeking to have an abortion. CONCLUSIONS: ECtHR judges concluded that the failure to provide for a right to conscientious objection does not constitute, in fact, a violation of the more general right to freedom of thought, conscience and religion, if provided for by a state law to protect the right to health. The legal ethical and social ramifications of such a decision are of enormous magnitude.

Reproductive health and the politics of abortion.

This editorial provides an overview of a thematic series that brings attention to the persistently deficient and unequal access to sexual and reproductive health services for young women in sub-Saharan Africa. It represents an effort to analyze the multifaceted relationship between laws, policies and access to services in Ethiopia, Zambia and Tanzania. Using a comparative perspective and qualitative research methodology, the papers presented in this issue explore legal, political and social factors and circumstances that condition access to sexual and reproductive health services within and across the three countries. Through these examples we show the often inconsistent and even paradoxical relationship between the formal law and practices on the ground. Particular emphasis is placed on safe abortion services as an intensely politicized issue in global sexual and reproductive health. In addition to the presentation of the individual papers, this editorial comments on the global politics of abortion which represents a critical context for the regional and local developments in sexual and reproductive health policy and care provision in general, and for the contentious issue of abortion in particular.

Travel Time to Title X Facilities and Teenage Birth Rates in North Carolina.

OBJECTIVES: In the United States, Title X facilities are understood to be an effective starting point for improving teenagers' reproductive health outcomes, including unintended pregnancy. We investigate geographic accessibility of Title X facilities and the relationship between geographic accessibility of Title X facilities and teenage birth rates in the state of North Carolina (NC). METHODS: Vehicular travel time from each ZCTA to its nearest Title X facility was calculated using a geographic information system and summarized as the indicator of geographic accessibility. We used bivariate and multiple spatial lag regressions to evaluate the relationship between ZCTA-level teenage birth rates (n = 754) in 2016 and geographic accessibility to a Title X facility, as well as socioeconomic and demographic factors. RESULTS: Nearly 60% of teenage women lived 30 min or less from a Title X funded facility, while approximately 12% of women lived 60 min or more from the nearest facility. In the regression models, percent non-Hispanic White, percent Hispanic, percent in Poverty, percent not enrolled in school, and population density were associated with teenage birth rates; however, geographic accessibility was only associated in the bivariate model. CONCLUSIONS: Our findings show that geographic accessibility of Title X facilities is lower in NC than in other states. However, our results suggest that geographic accessibility is not related to teenage birth rates. Overall, these findings may indicate that publicly funded family planning facilities are underutilized by proximal populations or factors other than proximity act as a barrier to utilization.

What can be learned from the Chinese experience in response to infertility.

OBJECTIVES: The aims of the study were to reviews the history of China's population policy since 2011, and draw lessons from the Chinese experience in response to infertility. METHODS: Data from the Chinese infertility status survey report (2009) and national statistical yearbooks (2009-2019) are used to assess the severity of infertility and reproductive centers shortage in China. Lessons from China was informed by a review of existing literature. RESULTS: The proportion of couples suffering from infertility in China increased to 12.5% (166.8 million in 2009) from just 6.89% (86.6 million in 1988) two decades earlier, while the number of reproductive centers was one for every 3.1 million citizens. The total costs per live birth for medically assisted reproduction in Chinese public fertility clinics was 30,000 yuan in 2012. Among infertile couples, unemployed patients accounted for the largest proportion (21.9% in 2014). Currently in China, health regulations permit oocyte donation only from infertility patients who have 20 or more mature oocytes, of which at least 15 must be kept for their own treatment. CONCLUSION: It is necessary to integrate the reproductive health care of infertile people into the national public health service. In addition to relieving their economic burden, national policies should guide and support enterprises to guarantee employee medical leave for infertility. Growing numbers of bereaved older women who have lost their only child make it imperative to reconsider liberalizing the regulation of oocyte donation in China.

Food and Drug Administration v Alliance for Hippocratic Medicine-A Cautious Win for Reproductive Health Care and FDA Authority.

This Viewpoint discusses the recent US Supreme Court ruling allowing mifepristone­a drug used in medication abortion­to be widely available in the US, summarizes the history of challenges to the availability of mifepristone, and highlights reasons for concerns that remain after the Court's current ruling.

New Reproductive Privacy Rule to Protect Both Patients and Physicians.

This Viewpoint describes the newly finalized Reproductive Privacy Rule, a HIPAA regulatory update intended to prevent law enforcement in abortion-restrictive states from obtaining reproductive care medical records to prosecute patients and physicians.

Understanding the Impacts of the Supreme Court Case FDA v Alliance for Hippocratic Medicine.

This Viewpoint outlines the potential effects of the Supreme Court case regarding mifepristone restrictions: a decision for the FDA would allow current dispensing, while ruling against the FDA would severely curtail access to reproductive health options.

A critical review of conscientious objection and decriminalisation of abortion in Chile.

From 1989 through September 2017, Chile's highly restrictive abortion laws exposed women to victimisation and needlessly threatened their health, freedom and even lives. However, after decades of unsuccessful attempts to decriminalise abortion, legislation regulating pregnancy termination on three grounds was recently enacted. In the aftermath, an aggressive conservative drive designed to turn conscientious objection into a pivotal new obstacle, mounted during the congressional debate, has led to extensive, complex arguments about the validity and legitimacy of conscientious objection. This article offers a critical review of the emergence of conscientious objection and its likely policy and ethical implications. It posits the need to regulate conscientious objection through checks and balances designed to keep it from being turned into an ideological barrier meant to hinder women's access to critical healthcare.

Race and Assisted Reproduction: Implications for Population Health.

This Article emerges from Fordham Law Reviews Symposium on the fiftieth anniversary of Loving v. Virginia, the case that found antimiscegenation laws unconstitutional. Inspired by the need to interrogate the regulation of race in the context of family, this Article examines the diffuse regulatory environment around assisted reproductive technology (ART) that shapes procreative decisions and the inequalities that these decisions may engender. ART both centers biology and raises questions about how we imagine our racial futures in the context of family, community, and nation. Importantly, ART demonstrates how both the state and private actors shape family formation along racial lines. By placing a discussion about race and ART in the context of access to new health technologies, this Article argues that assisted reproduction has population-level effects that mirror broader racial disparities in health. In turn, this Article intervenes in a bioethics debate that frequently ignores inequalities in access when thinking through the consequences of ART. Part I presents a case study of the Sperm Bank of California (SBC) to demonstrate how ART represents a new mode of governing the family that facilitates and encourages the formation and creation of monoracial families. Part II borrows a public health analytic, the 'burdens of disease," to explain how the (re)production of monoracial families has consequences for health at the population level, especially when placed in the context of racially disparate access to ART services. Ultimately, this Article concludes that ART, as it is currently accessed and utilized, maintains racial orders with regard to health given the inequality in access to these services.

Use of Patient-Delivered Partner Therapy in US College Settings: Associations With Legality, Perceived Legality and Other Sexual and Reproductive Health Services.

BACKGROUND: Young adults, including college students, have higher rates of chlamydia than the general population. Patient-delivered partner therapy (PDPT) is a partner treatment option for sex partners of individuals diagnosed with chlamydia or gonorrhea. We examined college health center use of PDPT in a national sample of colleges. METHODS: During 2014 to 2015, we collected data from 482 colleges and universities (55% of 885 surveyed), weighting responses by institutional characteristics abstracted from a national database (eg, 2-year vs 4-year status). We asked whether the school had a student health center and which sexual and reproductive health (SRH) services were offered. We also assessed the legal and perceived legal status of PDPT in states where schools were located. We then estimated PDPT availability at student health centers and measured associations with legal status and SRH services. RESULTS: Most colleges (n = 367) reported having a student health center; PDPT was available at 36.6% of health centers and associated with perceived legality of PDPT in the state in which the college was located (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.17-18.28). Patient-delivered partner therapy was significantly associated with availability of SRH services, including sexually transmitted disease diagnosis and treatment of STI (56.2% vs 1.1%), gynecological services (60.3% vs 12.2%), and contraceptive services (57.8% vs 7.7%) (all P < .001). Compared with schools taking no action, PDPT was more likely to be available at schools that notified partners directly (OR, 8.29; 95% CI, 1.28-53.85), but not schools that asked patients to notify partners (OR, 3.47; 95% CI, 0.97-12.43). CONCLUSIONS: PDPT was more likely to be available in colleges that offered SRH services and where staff believed PDPT was legal. Further research could explore more precise conditions under which PDPT is used.

"Freedom to go where I want": improving access to sexual and reproductive health for women with disabilities in the Philippines.

Women with disabilities experience a range of violations of their sexual and reproductive rights. The Philippines ratified the United Nations Convention on the Rights of Persons with Disabilities and have laws in place to promote the rights to sexual and reproductive health and protection from violence. However, limited resourcing, and opposition to such laws undermine access to these rights for all women. Inadequate disability inclusion within policy and programming, and limited disability awareness of services, further impedes women with disabilities from attaining these rights. The W-DARE project (Women with Disability taking Action on REproductive and sexual health) was a three-year participatory action research program designed to (1) understand the sexual and reproductive health experiences and needs of women with disabilities; and (2) improve access to quality sexual and reproductive health, including violence response services, for women with disabilities in the Philippines. In response to the highlighted need for more information about sexual and reproductive health and greater access to services, the W-DARE team developed and implemented a pilot intervention focused on peer-facilitated Participatory Action Groups (PAGs) for women with disabilities. This paper focuses on the qualitative findings from the evaluation of this PAG intervention.

How do national contraception laws and policies address the contraceptive needs of adolescents in Paraguay?

BACKGROUND: The main objective is to examine how the Paraguayan laws, policies and regulations (hereafter referred to as normative guidance) specifically address adolescents and their contraceptive information and service needs using a human rights analytic framework. It must be noted that this paper examines the adolescent content of national laws, policies and regulations on contraception, not how they were applied. METHODS: The recommendations on "Ensuring human rights in the provision of contraceptive information and services" from the World Health Organization (WHO) were used as an analytic framework to assess current Paraguayan laws, policies and regulations. Three questions were explored: 1) whether the Paraguayan normative guidance relating to each WHO recommendation was present and specifically addressed adolescents 2) whether the normative guidance for each WHO recommendation was present but did not specifically address adolescents, or 3) whether Paraguayan normative guidance relating to each WHO recommendation was absent. This assessment led to the development of an analytic table which was used by the co-authors to generate conclusions and recommendations. RESULTS: The analysis found specific normative guidance for adolescents relating to six out of nine WHO summary recommendations and nine out of the 24 sub-recommendations. The guidance included strategies to overcome contraceptive service barriers and to improve access for displaced populations. Further, it supported gender-sensitive counselling, quality assurance processes, competency-based training, and monitoring and evaluation of programmes. CONCLUSIONS: Paraguay's contraception laws and policies are grounded in human rights principles. However, there are a number of aspects that need to be addressed in order to improve the quality of contraceptive provision and access for adolescents. Our recommendations include improving accessibility of contraceptive information and services, ensuring acceptability, quality, and accountability of contraceptive information and services, and promoting community and adolescent participation in contraceptive programmes and service delivery.

Fertility Counseling and Treatment for Certain Veterans and Spouses. Interim final rule.

The Department of Veterans Affairs (VA) amends its regulation regarding fertility counseling and treatment available to certain veterans and spouses. VA currently provides certain infertility services other than in vitro fertilization (IVF) to veterans as part of the medical benefits package. IVF is the process of fertilization by manually fertilizing an egg, and then transferring the embryo to the uterus. This interim final rulemaking adds a new section authorizing IVF for a veteran with a service-connected disability that results in the inability of the veteran to procreate without the use of fertility treatment. In addition, we add a new section stating that VA may provide fertility counseling and treatment using assisted reproductive technologies (ART), including IVF, to a spouse of a veteran with a service-connected disability that results in the inability of the veteran to procreate without the use of fertility treatment. VA will provide ART treatment, including IVF, to these veterans and spouses as specified in the Continuing Appropriations and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika Response and Preparedness Act to the extent such services are consistent with the services available to enrolled veterans under the medical benefits package.