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.

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.

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.

Emergency contraception: unresolved clinical, ethical and legal quandaries still linger.

Emergency contraception (EC) has been prescribed for decades, in order to lessen the risk of unplanned and unwanted pregnancy following unprotected intercourse, ordinary contraceptive failure, or rape. EC and the linked aspect of unintended pregnancy undoubtedly constitute highly relevant public health issues, in that they involve women's self-determination, reproductive freedom and family planning. Most European countries regulate EC access quite effectively, with solid information campaigns and supply mechanisms, based on various recommendations from international institutions herein examined. However, there is still disagreement on whether EC drugs should be available without a physician's prescription and on the reimbursement policies that should be implemented. In addition, the rights of health care professionals who object to EC on conscience grounds have been subject to considerable legal and ethical scrutiny, in light of their potential to damage patients who need EC drugs in a timely fashion. Ultimately, reproductive health, freedom and conscience-based refusal on the part of operators are elements that have proven extremely hard to reconcile; hence, it is essential to strike a reasonable balance for the sake of everyone's rights and well-being.

Maternal mortality, abortion access, and optimizing care in an increasingly restrictive United States: A review of the current climate.

The United States is facing a national crisis related to increasing rates of maternal morbidity and mortality. Over the past few years, significant focus has been turned to initiatives that aim to address maternal morbidity and mortality rates. In parallel, the United States has seen a significant increase in restrictive abortion access state laws. The link between abortion restrictions and worsening maternal outcomes has been proposed. This review article outlines the national crisis of maternal morbidity and mortality, the potential role of limiting abortion access in this crisis, and the significant racial, socioeconomic, and geographical disparities that exist.

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.

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.

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.

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.

Title X Regulatory Changes and Their Impact on Adolescent Health.

Title X of the Public Health Act has provided access to confidential reproductive care for low-income adolescents and adults since 1970, helping to bring adolescent pregnancy rates to historic lows. Recent regulatory changes in program funding eligibility and provider counseling options may reverse this trend. This policy brief will address the history and impact of Title X funding on adolescent access to reproductive health care, explain the implications of these recent regulatory changes in Title X implementation, and encourage advocacy to protect health care provider practice and adolescent access to confidential care.

Getting youth PrEPared: adolescent consent laws and implications for the availability of PrEP among youth in countries outside of the United States.

INTRODUCTION: Youth under the age of 25 are at high risk for HIV infection. While pre-exposure prophylaxis (PrEP) has the potential to curb new infections within this population, it is unclear how country-specific laws and policies that govern youth access to sexual and reproductive health (SRH) services impact access to PrEP. The purpose of this review was to analyse laws and policies concerning PrEP implementation and SRH services available to youth in countries with a high HIV incidence. To the best of our knowledge this is the first systematic assessment of country-level policies that impact the availability of PrEP to adolescent populations. METHODS: We conducted a review of national policies published on or before 12 June 2018 that could impact adolescents' access to PrEP, SRH services and ability to consent to medical intervention. Countries were included if: (1) there was a high incidence of HIV; (2) they had active PrEP trials or PrEP was available for distribution; (3) information regarding PrEP guidelines were publicly available. We also included a selected number of countries with lower adolescent HIV incidence. Internet and legal database searches were used to identify policies relevant to adolescent PrEP (e.g. age of consent to HIV testing). RESULTS AND DISCUSSION: Fifteen countries were selected for inclusion in this review. Countries varied considerably in their respective laws and policies governing adolescents' access to PrEP, HIV testing and SRH services. Six countries had specific polices around the provision of PrEP to youth under the age of 18. Five countries required people to be 18 years or older to access HIV testing, and six countries had specific laws addressing adolescent consent for- and access to- contraceptives. CONCLUSIONS: Adolescents' access to PrEP without parental consent remains limited or uncertain in many countries where this biomedical intervention is needed. Observational and qualitative studies are needed to determine if and how adolescent consent laws are followed in relation to adolescent PrEP provisions. Intensified efforts to amend laws that limit adolescent access to PrEP and restrict the establishment of national guidelines supporting adolescent PrEP are also needed to address the epidemic in this group.

Out of the Freezer and into the Policy Fire: Quandaries in Reproductive Cryopreservation.

The field of assisted reproduction is advancing rapidly and is ripe for regulation and guidance. In 2018, over four thousand frozen eggs and embryos were lost to approximately one thousand patients at Ahuja University Hospital in Cleveland, Ohio, due to an accidental thaw of a cryopreservation tank. The precedent that will be set by the Ahuja class-action case is significant for both past events and future possibilities and is core to the discussion of policy involving the cryopreservation of gametes and embryos.

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.