Implications of the Law on Reproductive and Sexual Health.

The United States has a longstanding history of using laws to define the scope of government involvement in controlling personal matters related to sex and sexuality. Although the government serves a valuable role in protecting and promoting public health, sexual and reproductive health is unduly impacted by social stigma in ways that other fields of medicine are not. Consequently, this care is often singled out by legislation that limits rather than protects this care. Health care professionals are uniquely positioned to advocate for legal protection of the patient-provider relationship and for access to essential health care, including abortion, contraception, and gender-affirming care.

International migrants' right to sexual and reproductive health care.

International migration puts people's sexual and reproductive health (SRH), particularly those of women and children, at increased risk. However, many international migrants are denied access to timely and adequate SRH information, goods, and services by governments and/or service providers. This article reviews relevant international human rights treaties to argue that the barriers faced by migrants in accessing SRH care constitute violations of international law. It is well established that migrants are guaranteed access to SRH care as a part of their right to health, as well as the rights enjoyed by vulnerable populations. Increasingly, hindrance of migrants' access to SRH care is also recognized as a threat to their rights to life and equality with non-migrants. The case of Toussaint v Canada illustrates how governments may be held accountable by human rights treaty monitoring bodies when they fail to respect and fulfill migrants' right to SRH care.

Rights based approaches to sexual and reproductive health in low and middle-income countries: A systematic review.

INTRODUCTION: The Sustainable Development Goals, which are grounded in human rights, involve empowering women and girls and ensuring that everyone can access sexual and reproductive health and rights (Goal 5). This is the first systematic review reporting interventions involving rights-based approaches for sexual and reproductive health issues including gender-based violence, maternity, HIV and sexually transmitted infections in low and middle-income countries. AIMS: To describe the evidence on rights-based approaches to sexual and reproductive health in low and middle-income countries. METHODS: EMBASE, MEDLINE and Web of Science were searched until 9/1/2020. Inclusion criteria were: Study design: any interventional study.Population: females aged over 15 living in low and middle-income countries.Intervention: a "rights-based approach" (defined by the author) and/or interventions that the author explicitly stated related to "rights".Comparator: clusters in which no intervention or fewer components of an intervention were in place, or individuals not exposed to interventions, or exposed to fewer intervention components.Outcome: Sexual and reproductive health related outcomes. A narrative synthesis of included studies was undertaken, and outcomes mapped to identify evidence gaps. The systematic review protocol was registered on PROSPERO (CRD42019158950). RESULTS: Database searching identified 17,212 records, and 13,404 studies remained after de-duplication. Twenty-four studies were included after title and abstract, full-text and reference-list screening by two authors independently. Rights-based interventions were effective for some included outcomes, but evidence was of poor quality. Testing uptake for HIV and/or other sexually transmitted infections, condom use, and awareness of rights improved with intervention, but all relevant studies were at high, critical or serious risk of bias. No study included gender-based violence outcomes. CONCLUSION: Considerable risk of bias in all studies means results must be interpreted with caution. High-quality controlled studies are needed urgently in this area.

When accountability meets power: realizing sexual and reproductive health and rights.

This paper addresses a critical concern in realizing sexual and reproductive health and rights through policies and programs - the relationship between power and accountability. We examine accountability strategies for sexual and reproductive health and rights through the lens of power so that we might better understand and assess their actual working. Power often derives from deep structural inequalities, but also seeps into norms and beliefs, into what we 'know' as truth, and what we believe about the world and about ourselves within it. Power legitimizes hierarchy and authority, and manufactures consent. Its capillary action causes it to spread into every corner and social extremity, but also sets up the possibility of challenge and contestation.Using illustrative examples, we show that in some contexts accountability strategies may confront and transform adverse power relationships. In other contexts, power relations may be more resistant to change, giving rise to contestation, accommodation, negotiation or even subversion of the goals of accountability strategies. This raises an important question about measurement. How is one to assess the achievements of accountability strategies, given the shifting sands on which they are implemented?We argue that power-focused realist evaluations are needed that address four sets of questions about: i) the dimensions and sources of power that an accountability strategy confronts; ii) how power is built into the artefacts of the strategy - its objectives, rules, procedures, financing methods inter alia; iii) what incentives, disincentives and norms for behavior are set up by the interplay of the above; and iv) their consequences for the outcomes of the accountability strategy. We illustrate this approach through examples of performance, social and legal accountability strategies.

Leadership for success in transforming medical abortion policy in Canada.

OBJECTIVES: Mifepristone was approved for use in medical abortion by Health Canada in 2015. Approval was accompanied by regulations that prohibited pharmacist dispensing of the medication. Reproductive health advocates in Canada recognized this regulation would limit access to medical abortion and successfully worked to have this regulation removed in 2017. The purpose of this study was to assess the leadership involved in changing these regulations so that the success may be replicated by other groups advocating for health policy change. METHODS: This study involved a mixed methods instrumental design in the context of British Columbia, Canada. Our data collection included: a) interviews with seven key individuals, representing the organizations that worked in concert for change to Canadian mifepristone regulations, and b) document analysis of press articles, correspondence, briefing notes, and meeting minutes. We conducted a thematic analysis of transcripts of audio-recorded interviews. We identified strengths and weaknesses of the team dynamic using the Develop Coalitions, Achieve Results and Systems Transformation domains of the LEADS Framework. RESULTS: Our analysis of participant interviews indicates that autonomy, shared values, and clarity in communication were integral to the success of the group's work. Analysis using the LEADS Framework showed that individuals possessed many of the capabilities identified as being necessary for successful health policy leadership. A lack of post-project assessment was identified as a possible limitation and could be incorporated in future work to strengthen dynamics especially when a desired outcome is not achieved. Document analysis provided a clear time-line of the work completed and suggested that strong communication between team members was another key to success. CONCLUSIONS: The results of our analysis of the interviews and documents provide valuable insight into the workings of a successful group committed to a common goal. The existing collegial and trusting relationships between key stakeholders allowed for interdisciplinary collaboration, rapid mobilization, and identification of issues that facilitated successful Canadian global-first deregulation of mifepristone dispensing.

RoMoMatteR: Empowering Roma Girls' Mattering through Reproductive Justice.

Aim: To present a protocol study directed at tackling gender discrimination against Roma girls by empowering their mattering so they can envision their own futures and choose motherhood only if-and when-they are ready. Background: Motherhood among Roma girls (RGM) in Europe impoverishes their lives, puts them at risk of poor physical and mental health and precipitates school dropouts. Overwhelming evidence affirms that the conditions of poverty and the social exclusionary processes they suffer have a very important explanatory weight in their sexual and reproductive decisions. Methods: Through a Community-based Participatory Action Research design, 20-25 Roma girls will be recruited in each one of the four impoverished communities in Bulgaria, Romania and Spain. Data collection and analysis: Desk review about scientific evidences and policies will be carried out to frame the problem. Narratives of Roma women as well as baseline and end line interviews of girl participants will be collected through both qualitative and quantitative techniques. Quantitative data will be gathered through reliable scales of mattering, socio-political agency, satisfaction with life and self. A narrative analysis of the qualitative information generated in the interviews will be carried out. Expected results: (1) uncover contextual and psychosocial patterns of girl-motherhood among Roma women; (2) build critical thinking among Roma girls to actively participate in all decisions affecting them and advocate for their own gender rights within their communities; and (3) empower Roma girls and their significant adults to critically evaluate their own initiatives and provide feedback to their relevant stakeholders. Conclusions: Roma girls will improve their educational aspirations and achievements and their social status while respecting and enhancing Roma values.

Determinants of uptake of intermittent preventive treatment during pregnancy: a review.

Malaria in pregnancy (MiP) contributes to devastating maternal and neonatal outcomes. Coverage of intermittent preventive treatment during pregnancy (IPTp) remains alarmingly low. Data was compiled from MiP programme reviews and performed a literature search on access to and determinants of IPTp. National malaria control and reproductive health (RH) policies may be discordant. Integration may improve coverage. Medication stock-outs are a persistent problem. Quality improvement programmes are often not standardized. Capacity building varies across countries. Community engagement efforts primarily focus on promotion of services. The majority of challenges can be addressed at country level to improve IPTp coverage.

Association between plural legal systems and sexual and reproductive health outcomes for women and girls in Nigeria: A state-level ecological study.

Nigeria has a plural legal system in which various sources of law govern simultaneously. Inconsistent and conflicting legal frameworks can reinforce pre-existing health disparities in sexual and reproductive health (SRH). While previous studies indicate poor SRH outcomes for Nigerian women and girls, particularly in Northern states, the relationship between customary and religious law (CRL) and SRH has not been explored. We conducted a state-level ecological study to examine the relationship between CRL and SRH outcomes among women in 36 Nigerian states and the Federal Capital Territory of Abuja (n = 37), using publicly available Demographic and Health Survey data from 2013. Indicators were guided by published research and included contraception use among married women, total fertility rate, median age at first birth, receipt of antenatal care, delivery location, and comprehensive knowledge of HIV. To account for economic differences between states, crude linear regression models were compared to a multivariable model, adjusting for per capita GDP. All SRH outcomes, except comprehensive knowledge of HIV, were statistically significantly more negative in CRL states compared to non-CRL states, even after accounting for state-level GDP. In CRL states in 2013, compared to non-CRL states, the proportion of married women who used any method of contraception was 22.7 percentage points lower ([95% CI: -15.78 --29.64], p<0.001), a difference that persisted in a model adjusting for per capita GDP (b[adj] = -16.15, 95% CI: [-8.64 --23.66], p<0.001.). While this analysis of retrospective state-level data found robust associations between CRL and poor SRH outcomes, future research should incorporate prospective individual-level data to further elucidate these findings.

Infertility Services for Veterans: Policies, Challenges, and Opportunities.

Infertility prevalence and care needs among male and female Veterans are understudied topics. The Veterans Health Administration (VHA) medical benefits package covers full infertility evaluation and many infertility treatments for Veterans but not, by law, for their spouses. In vitro fertilization (IVF) is also specifically excluded from this medical benefits package by regulation. Congress passed a law in 2016 that allowed VHA to provide IVF to Veterans and their legal spouses, and broader infertility benefits to the legal spouse, if the Veteran has a service-connected condition associated with his or her infertility, with some limitations. As the Veteran population becomes increasingly female, research efforts in reproductive health, including infertility, are expanding and evolving. This includes a nationwide study currently underway examining infertility among male and female Veterans and associations with military-related trauma, such as injury, posttraumatic stress disorder, military sexual trauma, and toxin exposure. In this review, we describe the state of the science and policy on infertility care in the VHA along with challenges and opportunities that exist within the VHA system.

Shaping the abortion policy - competing discourses on the Zambian termination of pregnancy act.

INTRODUCTION: The Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds, but access to safe abortion services is limited and this constitutes a considerable problem for rights to sexual and reproductive health. The case of Zambia provides an opportunity to explore the relationship between a legal framework that permits abortion on diverse grounds, the moral and political disputes around abortion and access to sexual and reproductive health services. METHODS: This paper draws upon eleven months of ethnographic fieldwork in Zambia. The fieldwork included 28 open-ended interviews with key stakeholders as well as the collection of archival material related to the origins of Zambia's legal framework for abortion. The archival material and the interview data were analyzed thematically, using theoretical perspectives on discourse and the anthropology of policies. RESULTS: The study findings show that the Zambian case is not easily placed into standard categories of liberal or restrictive abortion laws. The archival material reveals that restrictive elements were in focus when the Zambian Termination of Pregnancy Act was passed (1972). The restrictive aspects of the law were emphasized further when Zambia was later declared as a Christian nation. Some of these restrictive elements are still readily recognized in today's abortion debate. Currently there are multiple opinions on whether Zambian abortion policy is liberal, restrictive or neither. The law emerges as ambiguous, and this ambiguity is actively used by both those working to increase access to safe and legal abortion services, and those who work to limit such access. Coupled with a lack of knowledge about the law, its ambiguity may work to reduce access to safe abortion services on the grounds permitted by the law. CONCLUSIONS: We argue that the Zambian Termination of Pregnancy Act is ambiguous and leaves much room for interpretation. This paper challenges the notion that the Zambian abortion law is liberal and opens up for further discussion on the relationship between how a law is described and perceived by the public, and the rights to health and services ensured by it.

The importance of access to comprehensive reproductive health care, including abortion: a statement from women's health professional organizations.

Barriers to women's reproductive health care access, particularly for termination of pregnancy, are increasing at the local, regional, and national levels through numerous institutional, legislative, and regulatory restrictions. Lack of access to reproductive health care has negative consequences for women's health. Twelve women's health care organizations affirm their support for access to comprehensive reproductive health care, including abortion.

[Reproductive Toxicological Research as Countermeasures to Declining Birth Rate].

Research into reproductive toxicology may lead to one of the countermeasures to the declining birth rate observed in industrialized countries. Some chemicals can pose risks to human reproduction that is a multistage process starting from the development of male and female germ cells to childbirth and the subsequent growth and development of the child. In Japan, the government has amended law enforcement, i.e., the Regulations on Labor Standards for Women, recently to improve protection for pregnant women against reproductive chemical hazards in workplaces. Male workers may also be protected against such hazards if appropriate risk assessment and the following management are performed as required by the Industrial Safety and Health Law. However, it remains a concern that an unexpected adverse outcome due to an unknown reproduction hazard may occur owing to the use of chemicals not listed in the regulations. This is because the toxicity of a large number of chemicals has not been entirely revealed. Moreover, it is often difficult to determine from a Safety Data Sheet for a product of interest whether the chemicals contained in the product do not have reproductive toxicity or the toxicity data are just not available because of lack of pertinent studies. Thus, researchers in the field of occupational and environmental health need to make effort to fill in such data gaps and to raise the awareness among the public the importance of experimental and epidemiological studies. Study designs for investigating subclinical effects, mechanisms of reproductive toxicity, exposure levels, and dose-response relationships to determine environmental standards are also required.

Crossing U.S. Borders While Pregnant: An Increasingly Complex Reality.

In response to the Eighth Amendment to the Constitution of Ireland, which states that the fetus and the mother have equal rights to life and that nearly all abortions are therefore illegal, many Irish feminists sported luggage tags that read "HEALTHCARE NOT AIRFARE." The expression-which recently became a popular twitter hashtag for pro-choice citizens of Ireland leading up to the historic referendum to repeal that abortion ban-refers to the fact that pregnant women from Ireland have long been forced to travel to other European countries in order to legally terminate their pregnancies. In the United States, there is also a deep and challenging relationship between borders and reproductive health. However, that relationship is not understood as clearly as it appears to be in the Irish context. We urgently need to pay careful attention to the interconnections between U.S. border politics and reproductive health care access and to take concrete steps to address resultant injustices.

The implementation of safe abortion services in Ethiopia.

In 2005, a new criminal code was established to align Ethiopia's laws with its new Constitution. Following a period of intense activism and debate, abortion remained criminalized, but several significant exceptions were made, allowing for the expansion and integration of services within the public health system. The passage of the law and the establishment of technical guidelines each served as essential steps in determining the extent to which services were implemented. The integration of safe abortion services expanded the scope of practice for multiple cadres of healthcare providers, including emergency surgical officers, nurses, and health extension workers. The political will of the Ministry of Health, the research produced by the Ethiopian Society of Obstetricians and Gynecologists, and the expertise of nongovernmental organizations were essential to the implementation of services.

"Referendum on Sunday, working group on Monday": A success story of implementing abortion services after legalization in Portugal.

A 2007 referendum legalized abortion in Portugal. Physicians played an important role advocating for legal reform and providing services thereafter. Implementers relied on a strong public health system with many gynecologists who required minimal training, and took decisions that allowed for rapid implementation. First, they emphasized medical abortion and integrated abortion into existing hospital obstetrics and gynecologic services, where eventual complications could be managed. They also offered immediate postabortion contraception, helping prevent criticism from abortion opponents who feared women would obtain multiple repeat abortions. Finally, they established referral networks guaranteeing access despite conscientious objection. Media campaigns were not needed as Portuguese women had good access to information. Portugal's success is largely due to key facilitators within a working group established by the Ministry of Health to implement the new law. Remaining challenges are the lack of choice between medical and surgical abortion, and some regions with relatively difficult geographic access to services.

Disabled persons in Ghanaian health strategies: reflections on the 2016 adolescent reproductive health policy.

The sexual and reproductive health (SRH) needs of persons with disabilities have received minimal attention from the Government of Ghana in the past. This was partly reinforced through reproductive health (RH) policies that did not well recognise disability inclusion and the inaccessibility of services for persons with disabilities. In acknowledgement of national and international RH policies, frameworks and legal instruments highlighting disability inclusion, the 2016 adolescent health policy document recognised the need to give attention to the SRH of adolescents and persons with disabilities. However, there is an absence of analysis of factors affecting adolescents with disabilities. Despite the lack of disability-specific indicators, and absence of data on adolescents with disabilities, interventions were developed which are poorly understood. This commentary argues that since we do not know the exact nature of SRH needs of adolescents with disabilities, the policy is unlikely to be successful in addressing existing inequities in access, quality of services and outcomes for adolescents with disabilities in Ghana. Recommendations are made for future improvements.

Factors impacting on menstrual hygiene and their implications for health promotion.

BACKGROUND: In the lives of women, puberty is marked by the onset of menarche. From this stage onwards until menopause, reproductive health and menstrual hygiene are important aspects of women's lives. In Zambia's Western Province, the natural process of menstruation is a taboo and dealt with secretly. Information and knowledge about menstruation and menstrual hygiene among adolescent girls is inadequate. This paper explores the factors influencing the understanding, experiences and practices of menstrual hygiene among adolescent girls in Mongu District, Western Province of Zambia. METHODS: An explorative study design was used by means of six focus group discussions conducted with 51 respondents, aged 13-20 years, from three secondary schools. Their age at menarche was 11-15. For data analysis thematic content analysis was used. RESULTS: The paper shows that the girls suffer from poor menstrual hygiene, originating from lack of knowledge, culture and tradition, and socio-economic and environmental constraints, leading to inconveniences, humiliation and stress. This leads to reduced school attendance and poor academic performance, or even drop outs, and ultimately infringes upon the girls' human rights. CONCLUSION: To address these shortcomings, a 'super setting approach' is recommended, in which a Health Promoting School could improve the girls' individual and group needs, and a community setting which would address the broader socio-economic, cultural and environmental conditions. This would enable creating a supportive environment for the girls to manage their periods. To successfully utilize the approach, all stakeholders (parents, teachers, children, governments and communities) should cooperate to generate context-specific solutions for creating safe menstrual care, and better and dignified conditions for adolescent girls. Therefore, this calls for comprehensive, strident advocacy for policy changes at national level, and mediation and involvement at community level.