Explaining the Fifth Circuit Court of Appeals Ruling on Mifepristone Access.

This Viewpoint summarizes the Fifth Circuit Court of Appeals ruling on access to mifepristone, the first of 2 pills used in medication abortion.

Abortion Clinics Are Moving From States With Bans to Those Without, Raising Questions About Whether Bans Can Be Enforced Across State Lines.

This Medical News feature discusses the flight of clinics from states with abortion bans to those without them.

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'.

Foreign ideology vs. national priority: impacts of the US Global Gag Rule on Nepal's sexual and reproductive healthcare system.

In recent decades, bold steps taken by the government of Nepal to liberalise its abortion law and increase the affordability and accessibility of safe abortion and family planning have contributed to significant improvements in maternal mortality and other sexual and reproductive health (SRH) outcomes. The Trump administration's Global Gag Rule (GGR) - which prohibits foreign non-governmental organisations (NGOs) from receiving US global health assistance unless they certify that they will not use funding from any source to engage in service delivery, counselling, referral, or advocacy related to abortion - threatens this progress. This paper examines the impact of the GGR on civil society, NGOs, and SRH service delivery in Nepal. We conducted 205 semi-structured in-depth interviews in 2 phases (August-September 2018, and June-September 2019), and across 22 districts. Interview participants included NGO programme managers, government employees, facility managers and service providers in the NGO and private sectors, and service providers in public sector facilities. This large, two-phased study complements existing anecdotal research by capturing impacts of the GGR as they evolved over the course of a year, and by surfacing pathways through which this policy affects SRH outcomes. We found that low policy awareness and a considerable chilling effect cut across levels of the Nepali health system and exacerbated impacts caused by routine implementation of the GGR, undermining the ecology of SRH service delivery in Nepal as well as national sovereignty.

Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar.

Madagascar's health system is highly dependent on donor funding, especially from the United States (US), and relies on a few nongovernmental organisations (NGOs) to provide contraceptive services in remote areas of the country. The Trump administration reinstated and expanded the Global Gag Rule (GGR) in 2017; this policy requires non-US NGOs receiving US global health funding to certify that neither they nor their sub-grantees will provide, counsel or refer for abortion as a method of family planning. Evidence of the impact of the GGR in a country with restrictive abortion laws, like Madagascar - which has no explicit exception to save the woman's life - is limited. Researchers conducted semi-structured interviews with 259 representatives of the Ministry of Health and NGOs, public and private health providers, community health workers and contraceptive clients in Antananarivo and eight districts between May 2019 and March 2020. Interviews highlighted the impact of the GGR on NGOs that did not certify the policy and lost their US funding. This reduction in funding led to fewer contraceptive service delivery points, including mobile outreach services, a critical component of care in rural areas. Public and private health providers reported increased contraceptive stockouts and fees charged to clients. Although the GGR is ostensibly about abortion, it has reduced access to contraception for the Malagasy population. This is one of few studies to directly document the impact on women who themselves described their increased difficulties obtaining contraception ultimately resulting in discontinuation of contraceptive use, unintended pregnancies and unsafe abortions.

Birth and birth-related obstetrical characteristics in southwestern China associated with the current adjustment of family planning policy: a 7-year retrospective study.

In China, the adjustment of the family planning policy was expected to increase the number of births and trigger a change in the demographic and obstetrical background of pregnant women. The policy itself, and corresponding background variations of the pregnant mothers, might have various influences on certain birth-related characteristics. Moreover, the adaption of the medical system to the policy needs to be demonstrated. To address these issues, over 50,000 individual records from January 2012 to December 2018 were collected from a large tertiary care centre of southwest China as a representative. The monthly numbers of deliveries and births showed stabilized patterns after remarkable upward trends. Policy-sensitive women, among whom older age and multiparity were typical features, contributed considerably to the remarkable additional births. Indeed, multivariable logistic regression analysis identified the child policy and these two background characteristics as factors influencing CS (caesarean section) rate and certain pregnancy complications or adverse outcomes. After the implementation of the two-child policy, a care provider was faced with fewer but more difficult cases. Briefly speaking, more individual-based studies on family planning policy and more efforts to improve obstetrical service are needed to better guide clinical practice in the new era.

From bad to worse: global governance of abortion and the Global Gag Rule.

The Trump Administration's Protecting Life in Global Health Assistance (PLGHA) significantly expands the "Global Gag Rule" - and, in so doing, weakens the global governance of abortion. By chilling debate, reducing transparency, ghettoising sexual and reproductive health and rights work, and interfering with research, PLGHA makes an already bad context demonstrably worse. Individual women suffer the most, as PLGHA inhibits ongoing efforts to reduce abortion-related morbidity and mortality.

Foreign assistance or attack? Impact of the expanded Global Gag Rule on sexual and reproductive health and rights in Kenya.

In 2017, the Trump Administration reinstated and expanded the Global Gag Rule (GGR). This policy requires non-governmental organisations (NGOs) not based in the US to certify that they will not provide, counsel, refer, or advocate for abortion as a method of family planning in order to receive most categories of US global health assistance. Robust empirical evidence demonstrating the policy's impacts is acutely lacking. This paper describes the effects of the expanded GGR policy in Kenya eighteen months after its reinstatement. We conducted semi-structured interviews with purposively selected representatives of US- and non-US-based NGOs, as well as managers and health providers at public and private health facilities, between September 2018 and March 2019. Organisations reported critical funding loss as they were forced to choose between US government-funded projects and projects supporting safe abortion. This resulted in the fragmentation of sexual and reproductive health and HIV services, and closure of some service delivery programmes. At public and private health facilities, participants reported staffing shortages and increased stock-outs of family planning and safe abortion commodities. The expanded GGR's effects transcended abortion care by also disrupting collaboration and health promotion activities, strengthening opposition to sexual and reproductive health and rights in some segments of Kenyan civil society and government. Our findings indicate that the GGR exposes and exacerbates the weaknesses and vulnerabilities of the Kenyan health system, and illuminates the need for action to mitigate these harms.

The Global Gag Rule: The death trap for comprehensive sexual and reproductive healthcare and way to overcome the US gag rule.

The United States of America (USA) is one of the largest bilateral donors in the field of global health assistance. There are beneficiaries in 70 countries around the world. In 2015, the USA released US$638 million for the improvement of global health status by promoting family planning services. Unfortunately, in 2017, Trump administration reinstated Mexico City Policy/Global Gag Rule (GGR). This policy prevents non-US nongovernmental organizations (NGOs) from receiving US health financial assistance if they have any relationship with abortion-related services. This restriction pushed millions of lives into great danger due to the lack of comprehensive family planning services, especially lack of abortion-related services. This article has attempted to let the readers know about the impacts of GGR around the world and how global leaders are trying to overcome the harmful effects of this rule. Finally, it proposes some solutions to the impacts of the extension of Mexico City Policy.

Mandatory pre-abortion counseling is a barrier to accessing safe abortion services.

Empirical research showcases that pre-abortion counseling scarcely reverses the woman's decision either to terminate a pregnancy or not. Growing evidence regarding the high levels of decisional certainty among women seeking abortions renders a careful rethink of the place of mandatory pre-abortion counseling packages. Mandatory counseling packages, when inscribed in the laws, at times contain false information that can deter women from going in for safe abortions. Mandatory waiting times indirectly label opting for an abortion as not being the right thing to do. In areas where abortion stigma from health care providers and communities remains highly prevalent, women are forced to incur extra expenses by travelling to other countries. I argue that pre-abortion counseling on opting-in grounds is ethically sound (enhances the woman's reproductive autonomy), since most clients in need of abortions are certain on their decisions before the abortion care provider and do not regret these decisions after the process. Regrets are prone to be more prevalent in areas with high unsafe abortion practices, generally due to complications from excessive bleeding, pain, and post abortion infections. Allowing systematic mandatory pre-abortion counseling practice as the rule in a competent adult is unjustified ethically and empirically, is time consuming and presents the legality of abortions in most settings an oxymoron.