The impact of third-party authorization requirements on abortion-related outcomes: a synthesis of legal and health evidence.

OBJECTIVES: This review synthesizes legal and health evidence to demonstrate the health and human rights impacts of third-party authorization requirements (TPAs) on abortion seekers. RESULTS: The synthesized evidence substantiates the pre-existing position in international human rights law that requirements that abortion be authorized by third parties like parents, spouses, committees, and courts create barriers to abortion, should not be introduced at all, or should be repealed where they exist. CONCLUSIONS: The review establishes that rights-based regulation of abortion should not impose TPAs in any circumstances. Instead, the provision and management of abortion should be treated in a manner cognizant with the general principles of informed consent in international human rights law, presuming capacity in all adults regardless of marital status and treatment sought, and recognizing the evolving capacity of young people in line with their internationally-protected rights.

The Impact of 'conscientious objection' on abortion-related outcomes: A synthesis of legal and health evidence.

The World Health Organization (WHO) and international human rights bodies have long urged states to take steps to ensure that 'conscientious objection' does not undermine access to abortion in practice. This review uses an established methodology to identify and integrate evidence of the health and human rights impacts of the practice of conscientious objection/refusal. The evidence identified in this review suggests strongly that conscientious objection negatively affects the rights of abortion seekers and has negative implications for the rights of non-objecting health workers. This is exacerbated in situations where an exercise of 'conscience' goes beyond 'opting out' of providing care and extends into seeking to prevent abortion through dissuasion, misinformation, misdirection, delay, and sometimes abuse. The insights from this review suggest that states must take better and further action to centre abortion seekers in the regulation of conscientious objection, and to prevent and ensure accountability for rights-limiting manifestations of conscience that go beyond opting out of direct provision of abortion care in non-emergency settings.

The impact of criminalisation on abortion-related outcomes: a synthesis of legal and health evidence.

Abortion is criminalised to at least some degree in most countries. International human rights bodies have recognised that criminalisation results in the provision of poor-quality healthcare goods and services, is associated with lack of registration and unavailability of essential medicines including mifepristone and misoprostol, obstructs the provision of abortion information, obstructs training for abortion provision, is associated with delayed and unsafe abortion, and does not achieve its apparent aims of ether protecting abortion seekers from unsafe abortion or preventing abortion. Human rights bodies recommend decriminalisation, which is generally associated with reduced stigma, improved quality of care, and improved access to safe abortion. Drawing on insights from reproductive health, law, policy, and human rights, this review addresses knowledge gaps related to the health and non-health outcomes of criminalisation of abortion. This review identified evidence of the impacts of criminalisation of people seeking to access abortion and on abortion providers and considered whether, and if so how, this demonstrates the incompatibility of criminalisation with substantive requirements of international human rights law. Our analysis shows that criminalisation is associated with negative implications for health outcomes, health systems, and human rights enjoyment. It provides a further underpinning from empirical evidence of the harms of criminalisation that have already been identified by human rights bodies. It also provides additional evidence to support the WHO's recommendation for full decriminalisation of abortion.

The impact of mandatory waiting periods on abortion-related outcomes: a synthesis of legal and health evidence.

This review follows an established methodology for integrating human rights to address knowledge gaps related to the health and non-health outcomes of mandatory waiting periods (MWPs) for access to abortion. MWP is a requirement imposed by law, policy, or practice, to wait a specified amount of time between requesting and receiving abortion care. Recognizing that MWPs "demean[] women as competent decision-makers", the World Health Organization recommends against MWPs. International human rights bodies have similarly encouraged states to repeal and not to introduce MWPs, which they recognize as operating as barriers to accessing sexual and reproductive healthcare. This review of 34 studies published between 2010 and 2021, together with international human rights law, establishes the health and non-health harms of MWPs for people seeking abortion, including delayed abortion, opportunity costs, and disproportionate impact. Impacts on abortion providers include increased workloads and system costs.

The impact of provider restrictions on abortion-related outcomes: a synthesis of legal and health evidence.

Many components of abortion care in early pregnancy can safely be provided on an outpatient basis by mid-level providers or by pregnant people themselves. Yet, some states impose non-evidence-based provider restrictions, understood as legal or regulatory restrictions on who may provide or manage all or some aspects of abortion care. These restrictions are inconsistent with the World Health Organization's support for the optimization of the roles of various health workers, and do not usually reflect evidence-based determinations of who can provide abortion. As a matter of international human rights law, states should ensure that the regulation of abortion is evidence-based and proportionate, and disproportionate impacts must be remedied. Furthermore, states are obliged take steps to ensure women do not have to undergo unsafe abortion, to reduce maternal morbidity and mortality, and to effectively protect women and girls from the physical and mental risks associated with unsafe abortion. States must revise their laws to ensure this. Where laws restrict those with the training and competence to provide from participating in abortion care, they are prima facie arbitrary and disproportionate and thus in need of reform. This review, developed by experts in reproductive health, law, policy, and human rights, examined the impact of provider restrictions on people seeking abortion, and medical professionals. The evidence from this review suggests that provider restrictions have negative implications for access to quality abortion, contributing inter alia to delays and recourse to unsafe abortion. A human rights-based approach to abortion regulation would require the removal of overly restrictive provider restrictions. The review provides evidence that speaks to possible routes for regulatory reform by expanding the health workforce involved in abortion-related care, as well as expanding health workers' roles, both of which could improve timely access to first trimester surgical and medical abortion, reduce costs, save time, and reduce the need for travel.

This review identifies evidence of the impacts of provider restrictions on people seeking to access abortion and on abortion providers. It pursues a methodology designed to ensure the full integration of public health and human rights standards developed by the research team and published elsewhere. The evidence from this review points clearly to provider restrictions having negative implications for health outcomes, health systems, and human rights. This is especially important as international guidance provided by the WHO indicates best practice in provision and management of abortion and shows clearly that undue provider restrictions are not justified by reference to the nature and complexity of abortion.