Interoperability in a Post-Roe Era: Sustaining Progress While Protecting Reproductive Health Information

This Viewpoint proposes a solution to better safeguard reproductive health information in patient records that are now more complete owing to the interoperability of health information exchange networks.

How can countries create outbreak response policies that are sensitive to maternal health?

Ensuring women’s need for sexual and reproductive healthcare are met should be a priority during disease outbreaks, say Maira L S Takemoto and colleagues

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.

Young women's reproductive health conversations: Roles of maternal figures and clinical practices

OBJECTIVE

To explore the role of clinical providers and mothers on young women's ability to have confidential, candid reproductive health conversations with their providers.

METHODS

We conducted 14 focus groups with 48 women aged 15-28 years (n = 9), and 32 reproductive healthcare workers (n = 5). Focus groups were audio recorded and transcribed. Data were analyzed using inductive coding and thematic analyses. We examined findings through the lens of paternalism, a theory that illustrates adults' role in children's autonomy and wellbeing.

RESULTS

Mothers have a substantial impact on young women's health values, knowledge, and empowerment. Young women reported bringing information from their mothers into patient-provider health discussions. Clinical best practices included intermingled components of office policies, state laws, and clinical guidelines, which supported health workers' actions to have confidential conversations. There were variations in how health workers engaged young women in a confidential conversation within the exam room.

CONCLUSIONS

Both young women and health workers benefit from situations in which health workers firmly ask the parent to leave the exam room for a private conversation with the patient. Young women reported this improves their comfort in asking the questions they need to make the best decision for themselves. Clinic leadership needs to ensure that confidentiality surrounding young women's reproductive health is uniform throughout their practice and integrated into patient flow.

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.

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.

Sexual and reproductive rights under attack: the advance of political and moral conservatism in Brazil

This article discusses political setbacks related to sexual and reproductive health and rights that have occurred in Brazil in the last 5 years (2014-2018) resulting from the significant role played by Christian (Evangelical and Catholic) parliamentarians in the legislative branch. Political initiatives aimed at prohibiting the affirmation of sexual and reproductive rights, while also curtailing debate about sexuality and gender in schools and universities, have raised "moral panic" within some elements of Brazilian society. The discursive strategies used around so-called "gender ideology" stimulated the formation of civil organisations which promote morality based on right-wing political positions. For this study, we looked at official documents and bibliographic material to examine how issues related to abortion rights, health care in cases of sexual violence, the prevention of sexually transmitted infections and homosexual citizenship are currently being suppressed, compromising the defence and advancement of the sexual and reproductive rights of women and the LGBTI+ population. The results point to the steady weakening of public policies that had become law in the 1980s, a time of Brazilian re-democratisation after two decades of military dictatorship. A wide range of civil, political and social rights, which saw significant growth and consolidation over the last 20 years, were rolled back after the resurgence of the extreme right wing in the federal legislature, culminating in the election of the current president in October 2018. However, social movements have increased in strength in the last few decades, especially the black feminist and LGBTI+ rights movements. These movements continue to provide political resistance, striving to affirm and protect all sexual and reproductive rights achieved to date.

Implementing safe abortion in Ghana: "We must tell our story and tell it well"

In the first years of the new century, the Ministry of Health/Ghana Health Service determined to reduce abortion-associated morbidity and mortality by increasing access to safe care. This was accomplished by interpreting Ghana's restrictive law so that more women qualified for legal services; by framing this effort in public health terms; by bundling abortion together with contraception and postabortion care in a comprehensive package of services; and by training new cadres of health workers to provide manual vacuum aspiration and medical abortion. The Ministry of Health/Ghana Health Service convened medical and midwifery societies, nongovernmental organizations, and bilateral agencies to implement this plan, while retaining the leadership role. However, because of provider shortages, aggravated by conscientious objection, and because many still do not understand when abortion can be legally provided, some women still resort to unsafe care. Nonetheless, Ghana provides an example of the critical role of political will in redressing harms from unsafe abortion.

Reproductive Health Policy in Tunisia: Women's Right to Reproductive Health and Gender Empowerment

Although Tunisia is regarded as a pioneer in the Middle East and North Africa in terms of women's status and rights, including sexual and reproductive health and rights, evidence points to a number of persisting challenges. This article uses the Health Rights of Women Assessment Instrument (HeRWAI) to analyze Tunisia's reproductive health policy between 1994 and 2014. It explores the extent to which reproductive rights have been incorporated into the country's reproductive health policy, the gaps in the implementation of this policy, and the influence of this policy on gender empowerment. Our results reveal that progress has been slow in terms of incorporating reproductive rights into the national reproductive health policy. Furthermore, the implementation of this policy has fallen short, as demonstrated by regional inequities in the accessibility and availability of reproductive health services, the low quality of maternal health care services, and discriminatory practices. Finally, the government's lack of meaningful engagement in advancing gender empowerment stands in the way as the main challenge to gender equality in Tunisia.

Tasmania's Reproductive Health (Access to Terminations) Act 2013: An analysis of conscientious objection to abortion and the "obligation to refer"

This article focuses on Tasmania's Reproductive Health (Access to Terminations) Act 2013, which decriminalises abortion in that State. The article first provides an overview of the Tasmanian legislation, comparing it with Victoria's Abortion Law Reform Act 2008. It then provides a more in-depth analysis of a doctor's right to "conscientious objection" and the requirement in both Acts of an "obligation to refer". The article concludes that ultimately, as a democratic society, it is important that both a woman's right to terminate a pregnancy and a doctor's right to freedom of conscience is respected. Where these rights conflict, as is the case when a doctor with a conscientious objection to abortion is confronted with a patient who seeks information about abortion, they must be balanced. The Victorian and Tasmanian Acts represent a considered and reasonable approach to balancing the rights at issue.

[The Incidence of Biomedical Advances in Women. Some Reflections on the Spanish Legislation]

This article will examine how and to what extent advances in biomedical sciences have played a role in transforming the status of women. It will highlight the positive aspects of these transformations but it will also examine the issues which are currently debated and which, in my opinion, require calm and considered reflection.

How does religious affiliation affect women's attitudes toward reproductive health policy? Implications for the Affordable Care Act

BACKGROUND

Supreme Court cases challenging the Affordable Care Act (ACA) mandate for employer-provided reproductive health care have focused on religiously based opposition to coverage. Little is known about women's perspectives on such reproductive health policies.

STUDY DESIGN

Data were drawn from the Women's Health Care Experiences and Preferences survey, a randomly selected, nationally representative sample of 1078 US women aged 18-55 years. We examined associations between religious affiliation and attitudes toward employer-provided insurance coverage of contraception and abortion services as well as the exclusion of religious institutions from this coverage. We used chi-square and multivariable logistic regression for analysis.

RESULTS

Respondents self-identified as Baptist (18%), Protestant (Other Mainline, 17%), Catholic (17%), Other Christian (20%), Religious, Non-Christian (7%) or No Affiliation (21%). Religious affiliation was associated with proportions of agreement for contraception (p=.03), abortion (p<.01) and religious exclusion (p<.01) policies. In multivariable models, differences in the odds of agreement varied across religious affiliations and frequency of service attendance. For example, compared to non-affiliated women, Baptists and Other Nondenominational Christians (but not Catholics) had lower odds of agreement with employer coverage of contraception (OR 0.63, 95% CI 0.4-0.1 and OR 0.57, CI 0.4-0.9, respectively); women who attended services weekly or more than weekly had lower odds of agreement (OR 0.53, 95% CI 0.3-0.8 and OR 0.33, CI 0.2-0.6, respectively), compared to less frequent attenders.

CONCLUSIONS

Recent religiously motivated legal challenges to employer-provided reproductive health care coverage may not represent the attitudes of many religious women.

IMPLICATIONS

Recent challenges to the ACA contraceptive mandate appear to equate religious belief with opposition to employer-sponsored reproductive health coverage, but women's views are more complex.

Ensuring youth's right to participation and promotion of youth leadership in the development of sexual and reproductive health policies and programs

The purpose of this article was to reflect on the concepts of adolescence and youth, summarize models and frameworks developed to conceptualize youth participation, and assess research that has attempted to evaluate the implementation and impact of youth participation in the field of sexual and reproductive health and rights (SRHR). We searched and critically reviewed relevant published reports and "gray literature" from the period 2000-2013. "Young people" are commonly defined as those between the ages of 10 and 24 years, but what it means to be a young person varies largely across cultures and depends on a range of socioeconomic factors. Several conceptual frameworks have been developed to better understand youth participation, and some frameworks are designed to monitor youth development programs that have youth participation as a key component. Although none of them are SRHR specific, they have the potential to be adapted and applied also for adolescents' SRHR programs. The most monitored and evaluated intervention type is peer education programs, but the effectiveness of the approach is questioned. There are few attempts to systematically evaluate youth participation, and clear indicators and better methodologies still need to be developed. More research and documentation as well as the adoption of innovative practices for involving youth in sexual and reproductive health programs are needed. Participation is a right and should not only be evaluated in terms of effectiveness and impact. Youth participation in program and policy development should still be a priority.

Eggs and Abortion: "Women-Protective" Language Used by Opponents in Legislative Debates over Reproductive Health

In this paper we undertake an examination of the presence of similar "women-protective" discourses in policy debates occurring over two bills on reproductive-related topics considered during the 2013 California legislature session. The first bill (AB154), now signed into law, allows nurse practitioners, certified nurse midwives, and physician assistants to perform first-trimester aspiration abortions. The second bill (AB926), had it passed, would remove the prohibition on paying women for providing eggs to be used for research purposes. Using frame analysis we find evidence of similar protective arguments by opponents of both bills, although these advocates do not share ideological positions on abortion rights or women's autonomy. In the case of AB154, anti-abortion advocates use language and frames that call for protecting the health of women against the imputed interests of the "abortion industry." In the case of AB926, feminists and pro-choice advocates evoke similar frameworks for the protection of women against the interests of the "medical research industry." Both sides argue for the "protection of women," from opposing positions on the rights and autonomy of women in relationship to reproductive freedom.

Sexuality education: emerging trends in evidence and practice

The International Conference on Population and Development and related resolutions have repeatedly called on governments to provide adolescents and young people with comprehensive sexuality education (CSE). Drawing from these documents, reviews and meta-analyses of program evaluations, and situation analyses, this article summarizes the elements, effectiveness, quality, and country-level coverage of CSE. Throughout, it highlights the matter of a gender and rights perspective in CSE. It presents the policy and evidence-based rationales for emphasizing gender, power, and rights within programs--including citing an analysis finding that such an approach has a greater likelihood of reducing rates of sexually transmitted infections and unintended pregnancy--and notes a recent shift toward this approach. It discusses the logic of an "empowerment approach to CSE" that seeks to empower young people--especially girls and other marginalized young people--to see themselves and others as equal members in their relationships, able to protect their own health, and as individuals capable of engaging as active participants in society.

Advancing sexual health through human rights: the role of the law

Since the International Conference on Population and Development, definitions of sexuality and sexual health have been greatly elaborated alongside widely accepted recognition that sexual health requires respect, protection and fulfilment of human rights. Considerable progress has also been made in enacting or changing laws that affect sexuality and sexual health, in line with human rights standards. These measures include legal guarantees against non-discrimination and violence, decriminalisation of consensual sexual conduct and guaranteeing availability, accessibility, acceptability and quality of sexual health information and services to all. Such legal actions have had positive effects on health and specifically on sexual health, particularly for marginalised populations. Yet in all regions of the world, laws still exist which jeopardise health, including sexual health, and violate human rights. In order to ensure accountability for the rights and health of their populations, states have an obligation to bring their laws into line with international, regional and national human rights standards. These rights-based legal guarantees, while insufficient alone, are essential for effective systems of accountability, achieving positive sexual health outcomes and the respect and protection of human rights.

Striking a balance: conscientious objection and reproductive health care from the Colombian perspective

Conscientious Objection or conscientious refusal (CO) in access to reproductive health care is at the center of current legal debates worldwide. In countries such as the US and the UK, constitutional dilemmas surrounding CO in the context of reproductive health services reveal inadequate policy frameworks for balancing CO rights with women's rights to access contraception and abortion. The Colombian Constitutional Court's holistic jurisprudence regarding CO standards has applied international human rights norms so as to not only protect women's reproductive rights as fundamental rights, but to also introduce clear limits for the exercise of CO in health care settings. This paper reviews Latin American lines of regulation in Argentina, Uruguay, and Mexico City to argue that the Colombian Court's jurisprudence offers a strong guidance for future comprehensive policy approaches that aim to effectively balance tensions between CO and women's reproductive rights.

Sexually transmitted infections: progress and challenges since the 1994 International Conference on Population and Development (ICPD)

BACKGROUND

Despite being recognized as an important challenge at the 1994 International Conference on Population and Development (ICPD), sexually transmitted ınfections (STIs) other than HIV are one of the most neglected dimensions of sexual and reproductive health. STIs, often undiagnosed and untreated, have especially harmful consequences for women and their neonates.

PROGRESS SINCE ICPD

During the last two decades, substantial knowledge and experience have accumulated in behavior change programming during the global response to the HIV epidemic which can also be used for prevention of STIs. There has been progress in development and implementation of vaccines against certain STIs such as hepatitis B and the human papilloma virus. Development of a rapid, point-of-care test for syphilis has opened the door to control this infection.

CHALLENGES

The estimated annual incidence of non-HIV STIs has increased by nearly 50% during the period 1995-2008. The growth in STIs has been aggrevated by a combination of factors: lack of accurate, inexpensive diagnostic tests, particularly for chlamydia and gonorrhea; lack of investment to strengthen health systems that can deliver services for diagnosis and management of STIs; absence of surveillance and reporting systems in the majority of countries; political, socioeconomic and cultural barriers that limit recognition of STIs as an important public health problem; and failure to implement policies that are known to work.

RECOMMENDATIONS

Governments, donors and the international community should give higher priority to preventing STIs and HIV; fully implementing behavior change interventions that are known to work; ensuring access of young people to information and services; investing in development of inexpensive technologies for STI diagnosis,treatment and vaccines; and strengthening STI surveillance, including of microbial resistance.

The impact of official development aid on maternal and reproductive health outcomes: a systematic review

BACKGROUND

Progress toward meeting Millennium Development Goal 5, which aims to improve maternal and reproductive health outcomes, is behind schedule. This is despite ever increasing volumes of official development aid targeting the goal, calling into question the distribution and efficacy of aid. The 2005 Paris Declaration on Aid Effectiveness represented a global commitment to reform aid practices in order to improve development outcomes, encouraging a shift toward collaborative aid arrangements which support the national plans of aid recipient countries (and discouraging unaligned donor projects).

METHODS AND FINDINGS

We conducted a systematic review to summarise the evidence of the impact on MDG 5 outcomes of official development aid delivered in line with Paris aid effectiveness principles and to compare this with the impact of aid in general on MDG 5 outcomes. Searches of electronic databases identified 30 studies reporting aid-funded interventions designed to improve maternal and reproductive health outcomes. Aid interventions appear to be associated with small improvements in the MDG indicators, although it is not clear whether changes are happening because of the manner in which aid is delivered. The data do not allow for a meaningful comparison between Paris style and general aid. The review identified discernible gaps in the evidence base on aid interventions targeting MDG 5, notably on indicators MDG 5.4 (adolescent birth rate) and 5.6 (unmet need for family planning).

DISCUSSION

This review presents the first systematic review of the impact of official development aid delivered according to the Paris principles and aid delivered outside this framework on MDG 5 outcomes. Its findings point to major gaps in the evidence base and should be used to inform new approaches and methodologies aimed at measuring the impact of official development aid.

[Prevention and protection of workers' reproductive health]

The article mentiones issues of preserving and strengthening the reproductive health of women workers, dealed by researchers of the laboratory, established in 1974. It describes the developed concept of the reproductive health problems and scientific research areas, developed documents, including legislative fields, formulates main prospects of the laboratory to meet the requirements of the present moment. Noted the role of the Problem Commission "Scientific basis for the reproductive health of workers", in the work of the Scientific Council on medical and environmental issues of workers' health.

Political contexts surrounding Title X, the national family planning program, over the past four decades: oral histories with key stakeholders in Florida

INTRODUCTION

Title X, enacted in 1970, remains the only policy devoted solely to providing voluntary and confidential family planning and related preventative services to all those in need. Despite Title X's significant public health achievements, this policy continues to receive scrutiny and faces political, financial, and social challenges. This study explores key stakeholders' perceptions regarding the political contexts that have surrounded Title X over its historical maturation.

METHODS

Six oral histories were conducted with key stakeholders in Florida using a semi structured interview guide developed from Title X's legislative history, McPhail's Feminist Policy Analysis Framework, and the literature. Oral histories were audio recorded, transcribed, and analyzed using open, axial, and selective coding in NVivo 8.

RESULTS

Participants identified and discussed the following political topics and controversies that they perceived have directly or indirectly affected Title X: abortion, adolescents, parental notification, school-based clinics, abstinence-only education, political administrations, and family planning methods.

DISCUSSION

Participants' recollections regarding the political contexts that have surrounded Title X over the past 4 decades provided a broad yet rich description of the barriers that exist with fulfilling this policy. Such opposition hinders Title X's ability to support women's right to reproductive health. Practitioners play a key role in advocating for family planning services and should understand the political issues hindering reproductive health policies and the need to translate family planning services as a basic human right.

Analysis of the relationship between neonaticide and denial of pregnancy using data from judicial files

OBJECTIVES

Using judicial files on neonaticides, (1) to examine the frequency of the association between neonaticide and denial of pregnancy; (2) to assess the accuracy of the concept of denial of pregnancy; (3) to examine its usefulness in programs to prevent neonaticides.

METHODS

Quantitative and qualitative analyses of data collected from judicial files during a population-based study carried out in 26 courts in 3 regions of France over a 5-year period.

RESULTS

There were 32 cases of neonaticides identified; 24, perpetrated by 22 mothers, were solved by police investigation. Aged 26 years on average, the mothers had occupations that resembled those of the general population and 17 had jobs, 13 were multiparous and 11 lived in a couple relationship. No effective contraception was used by women in 20 cases. Psychopathology was rare but mothers shared a personality profile marked by immaturity, dependency, weak self esteem, absence of affective support, psychological isolation and poor communication with partners. No pregnancy was registered nor prenatal care followed. Two (perhaps 3) pregnancies were undiscovered until delivery. No typical denial of pregnancy was observed in the other cases. Pregnancies were experienced in secrecy, with conflicting feelings of desire and rejection of the infant and an inability to ask for help. Those around the mothers, often aware of the pregnancy, offered none. In the absence of parallel clinical data, it is not possible to calculate the frequency of the association between neonaticide and denial of pregnancy.

CONCLUSIONS

The term 'denial of pregnancy' cannot fully reflect the complexity of emotions and feelings felt by all perpetrators of neonaticide and is used differently by different professionals. The term itself and its excessive generalization contribute to pathologizing women while absolving those around them and has little operational value in preventing neonaticides. The authors suggest rethinking the terms presently used to describe the phenomenon of pregnancy denial.

Nigerian lawyers and reproductive health rights: a survey of knowledge, practices and opinions on law reforms among the bar and bench in north eastern Nigeria

The objective of this study was to determine the knowledge and attitudes of practicing Nigerian lawyers towards issues relating to reproductive health and reproductive rights, and their opinions about abortion law reform. It was a population- based study which consisted of interviews with practicing lawyers in north-east Nigeria. The results showed poor knowledge of issues related to reproductive health and reproductive rights among the lawyers. However, the majority (56.9%) disagreed that a woman can practice family planning without the consent of her husband. The prevalence of contraceptive use among the lawyers was low and attitude to abortion law not satisfactory. Only few lawyers (22.4%) supported safe abortion in cases of failed contraception. We conclude that reproductive health advocates must target legal professionals with a view to educating them on issues relating to sexual and reproductive health and rights. Lawyers in Nigeria should undergo capacity building in reproductive health laws and be encouraged to specialize in reproductive rights protection as obtainable in other developed countries.

Approaching 4 decades of legislation in the national family planning program: an analysis of Title X's history from 1970 to 2008

Family planning is an important public health activity. Title X (Pub L No. 91-572), enacted in 1970, remains the only national family planning program in the United States dedicated to providing voluntary and confidential services to all individuals. We conducted a thematic analysis of Title X's legislative history. Of 293 federal bills included in the legislative history, only 20 (6.8%) were enacted into law. Regardless of the proposed challenges, limited changes have been adopted. Except for technical amendments, bills involving restrictions accounted for the highest percentage of enacted bills, demonstrating efforts to undermine reproductive health rights. Title X requires political will and bipartisan support if it is to continue to protect individuals' reproductive rights.