Reproductive Autonomy and Insurer Denials of Care: The Fine Line Between Oversight and Interference.

A blueprint for a new model of sexual and reproductive health care in subspecialty medicine.

BackgroundForced displacement impacts the health, rights and safety of women, which is further compounded by gender inequality. In particular, this has consequences for forcibly displaced women’s reproductive health once resettled in a new country. To ensure the reproductive health and rights of forcibly displaced women during and after resettlement, there must be careful consideration of their reproductive decision-making taking into account the context and environment of the host country.AimThis scoping review aimed to explore the influences on reproductive decision-making among forcibly displaced women resettling in high-income countries.MethodA scoping review was conducted following the PRISMA-ScR for reporting. EBSCO was used to search databases covering global health, health policy, psychology, sociology, and philosophy for articles published from 1 January 2012 to 27 April 2022. Data extracted from each article included author(s), year of publication, publication type, aims/objectives, study design, sampling method, data collection or eligibility criteria, study population (i.e., sample size and characteristics), migration status, country(ies) of origin, host country(ies), key findings and limitations. Two independent reviewers screened all articles against eligibility criteria using Covidence. Data charting and thematic analysis were performed independently by one reviewer.FindingsNineteen articles published between 2013 and 2022 mostly conducted in the United States (36.8%) and Australia (21.1%), with the majority reporting on qualitative findings (68.4%), and women from a wide array of countries and cultures (most commonly African countries) were included. Influences on women’s reproductive decision-making related to the contexts before displacement, during displacement, and after arrival, with influences on women’s reproductive decision-making identified specific to the context. The influences before displacement included conflict; religious beliefs; socio-cultural gendered expectations; and external control over reproductive autonomy. During displacement influences included paternalism and access to education. Influences after arrival included pressure, restriction, coercion; knowledge and misconceptions; patriarchal power dynamics; and seeking empowerment. An adapted socio-ecological model was developed to interpret the findings.ConclusionThis review highlights the complexity and nuances within forcibly displaced women’s experiences which influence their reproductive decision-making. Further research may review the evidence base to provide guidance for healthcare professionals and health policies aimed at empowering women to make autonomous reproductive decisions; develop training for healthcare professionals to prevent pressure, restriction and coercion of women’s reproductive autonomy; and inform development of policy that takes an intersectional approach to women’s health rights and gender equality.

BackgroundReproductive coercion (RC) refers to behaviours that interfere with an individual’s autonomy over their reproductive health and decision-making. While traditionally attributed to partners or families, emerging research has highlighted the potential role healthcare providers may play in perpetrating and perpetuating RC. This study aims to explore the perspectives of Australian healthcare providers who deliver reproductive healthcare, focusing on their understanding of provider bias and coercion in the context of reproductive decision-making, both within their own practice and among their peers.MethodsThis qualitative study used semi-structured interviews to gather insights from 18 healthcare providers, including general practitioners, nurses, and obstetricians/gynaecologists who deliver reproductive healthcare services in Australia. Participants were purposively sampled to capture a range of perspectives, selecting individuals from different healthcare roles with experience in reproductive healthcare provision. Interviews were analysed using reflexive thematic analysis and themes were constructed through an inductive approach.ResultsThree key themes were identified: (1) Explicit refusals and their impact on reproductive autonomy, where participants described how refusal to provide or refer for services like abortion, sterilisation or long-acting contraception undermined patients’ reproductive choices; (2) Implicit bias shaping reproductive decision-making, with participants reflecting on how unconscious biases influenced contraceptive counselling and other reproductive health decisions, often leading to coercive practices; and (3) Oversight and misinformation enabling coercion, where participants noted that a lack of awareness or incorrect assumptions about patient needs could unintentionally collude with coercive dynamics.ConclusionsThis research highlights the complex ways healthcare providers may, often unintentionally, undermine reproductive autonomy through biased guidance, non-referral, or restrictive practices. Addressing both explicit and implicit provider biases is essential for fostering person-centred, non-coercive reproductive healthcare. Our findings underscore the need for healthcare systems to prioritise bias and reflective practice training, along with corresponding clinical guidance for providers. This must be supported by institutional safeguards, such as enforceable referral mechanisms and bias-aware education to ensure reproductive decisions are respected and supported in practice. By actively dismantling coercive practices, healthcare providers can ensure that the care they provide respects and upholds patients’ reproductive intentions and autonomy.

Voices on Zika: Reproductive Autonomy and Shared Decision-Making During an Evolving Epidemic.

to analyze the reproductive autonomy of women during the COVID-19 pandemic, considering sociodemographic, clinical, and reproductive factors. a quantitative study with a cross-sectional design, conducted with 314 women aged 18 to 49 years old. Data were collected through an online questionnaire containing sociodemographic, clinical, and reproductive data, as well as the Reproductive Autonomy Scale. The Mann-Whitney and Student's t tests were used to compare variables. significant differences were found between the average scores of "decision-making" and marital status (p = <0.001); and "absence of coercion" and "communication" with age group (p = 0.03 e <0.001), residence (p = <0.001 and <0.01), schooling level (p = 0.02 e 0.02), pregnancy (p = <0.001 e 0.04) and contraception (p = 0.02 e <0.001). not having a sexual partner positively influenced autonomy in reproductive decision-making during the COVID-19 pandemic. Women of younger age, living in the capital, with higher education levels, who had never been pregnant, and who used contraceptives during the pandemic showed greater autonomy in the absence of coercion and communication. It was possible to identify the groups that require greater attention and interventions to support their sexual health and reproductive choices. (1) A high reproductive autonomy score was observed even during the pandemic. (2) Not having a stable partner positively influenced reproductive decision-making. (3) Women living in the capital, of younger age, and with lower education levels experienced less coercion. (4) Being nulligravida and using contraception were associated with less coercion and better communication. (5) The use of an online tool during the pandemic expanded the program's reach to women.

Respecting patient autonomy is a central part of the Royal College of Nursing's definition of nursing (RCN, 2003). Although autonomy is a fundamental ethical principle in health care, it stands alongside the principles of beneficence, non-maleficence and justice (Wilmot, 2003), and these principles may be interpreted differently by individuals and professional groups. In seeking to promote patient autonomy, it is therefore necessary for nurses to consider how these principles interlink, and to understand the potentially differing interpretations that they may encounter in practice. This article sets out to address these issues and suggests that facilitating patient autonomy includes engaging in debates which include uncertainties, considering the resource implications of patient autonomy and the responsibilities that patients have themselves. It also identifies that nurses who aim to promote patient autonomy and holistic decision making need to be able to facilitate discussion that may include questioning the dominant biomedical view of health. This will be problematic if nurses do not themselves feel empowered or autonomous.

INTRODUCTION This chapter turns to some of the conceptual enigmas of customary international law identified in Part One. It sketches a normative theory of the authority of customary international law that takes into account the fundamental ethical principles articulated in Chapter 5 and the insights into the concept of authoritative norms explored in Chapter 4. As part of this normative theory I suggest a revised definition of customary international law. Taken together, this theory and that definition will provide the keys to solve many of these conceptual puzzles. A REVISED DEFINITION OF CUSTOMARY INTERNATIONAL LAW A new normative theory should be guided by three main principles. First, traditional rules for identifying customary international law should be accorded significant respect. The reason is that these traditional rules are supported by a number of fundamental ethical principles, including states' membership in a global community of states. Second, however, fundamental ethical principles in international law ought to be used as a guide in interpreting and applying the traditional rules of customary law formation and in identifying the content of customary law. Third, these fundamental ethical principles suggest that, from a long-term perspective, it would be ideal for states to help customary law evolve so that it better reflects and implements these ethical principles. But this is a normative ideal regarding future lawmaking; it does not require, as we will see, that fundamental ethical principles themselves be regarded as norms of customary law.

The Canadian Code of Ethics for Psychologists (Canadian Psychological Association, CPA, 2000) has been the subject of several recent investigations. This work has focused, for example, on the validity of its hierarchical organization of ethical principles. In the present research, we subjected the code to both a content and a functional grammar analysis. Our content analysis was aimed at determining the theoretical ethical orientation (i.e., deontological, teleological or caring) of each statement in the document, while the functional grammar analysis provided information about implicit messages embedded within the code. We contrasted the results of our analysis with those of previous work on the code of ethics adopted by the Canadian Medical Association (CMA). We concluded that, compared to CMA's code, the CPA document has greater educational value, is less authoritarian, provides a clear rationale for ethical behaviour, and is more empowering to the decision-maker. We argue that the results of our functional grammar and content analyses have implications for future attempts to improve ethics codes for psychology and other professions. Many organizations and most national professional associations have adopted codes of ethics. Such documents serve an educational function (e.g., O'Neill, 1998) and communicate important expectations to the membership of these organizations. Codes also serve to facilitate a profession's ability to self-regulate. They may also function as a means by which members can question their own personal values as they relate to their professional role (Meyer, 1987). Externally, codes of ethics assure the public, clients, and other stakeholders that members of a profession are competent, have a high level of integrity, and are able to enforce high moral standards (Pettifor, 1996). Codes of ethics also help professionals commit publicly and explicitly to their association's values, norms, beliefs, and philosophy and make them accountable (Dunbar, 1998; Pettifor, 1996). The Canadian Code of Ethics for Psychologists (Canadian Psychological Association, 1986, 2000) was designed to incorporate the collective wisdom of Canadian psychologists (Sinclair, Poisner, GilmourBarrett, & Randall, 1987). Sinclair et al. (1987) described the methodology that was used in the code's development. Briefly, the process involved the creation of 37 vignettes describing hypothetical ethical dilemmas. The dilemmas related to the ethical principles that were articulated in the 1977 edition of the code adopted by the American Psychological Association (APA, 1977). They also involved conflicts between ethical principles as well as psychological practice issues and situations involving innovative but untested approaches. Sinclair et al. formulated questions to elicit self-accepted ethical principles. They asked 400 Canadian psychologists to each respond to a series of questions about a portion of the vignettes. One hundred and twenty-five agreed to participate but only 59 responses were received. The researchers submitted these responses to a content analysis that focused on the reasons provided for the courses of action selected by the respondents. They organized the relevant statements into categories that reflected superordinate ethical principles. The resulting document consisted of four fundamental ethical principles (Respect for the Dignity of Persons, Responsible Caring, Integrity in Relationships, and Responsibility to Society). A consultative process with provincial regulatory bodies supported the validity of the document. Although the code has since undergone revisions, it still is based largely on the original document and its four fundamental ethical principles (CPA, 2000). The CPA (1986, 2000) code has received plenty of praise for its coherence, organization, and unique features (e.g., Booth, 1998; Dixon, 1998; Hadjistavropoulos & Malloy, 2000; Sinclair, 1998; Wassenaar, 1998); however, empirical research (e. …

The autonomy of women in sexual and reproductive decision-making within family settings may represent gender equality and reproductive health relief. The theory of gender and power was used to identify socio-economic factors that influence women’s decision-making on sex and family size. A survey of 568 married and cohabiting women was conducted in Mahikeng, South Africa in 2012. Structured questionnaires were used in data collection and were analysed using descriptive statistics and binary logistic regression methods. The Findings of the study revealed 60.7% and 70.1% women participate in decisions on sex and on size of family respectively. Perceptions husbands had the right to sex, experience sexual violence, being in religious and traditional unions had negative impacts on women’s sexual autonomy. Employed women and reporting choosing of partners significantly enhanced women’s sexual autonomy. Traditional union, experienced of sexual violence sex, perceptions that husbands had right to sex, increasing age, and number of living children significantly reduced women’s decision-making autonomy on family size. The findings partially validated the sexual division of constructs of labour and power in the theory of gender and power. We recommend that women need to be empowered socially and economically to decide freely on sex and family size as indicators of sexual and reproductive health.

Variability in the conceptualization and measurement of women's empowerment has resulted in inconsistent findings regarding the relationships between empowerment and sexual and reproductive health outcomes. Reproductive autonomy-a specific measure of empowerment-and its role in modern contraceptive use have rarely been assessed in Sub-Saharan contexts. Survey data were collected from a sample of 325 urban Ghanaian women aged 15-24 recruited from health facilities and schools in Kumasi and Accra in March 2015. Bivariate and multivariable logistic regression analyses were used to examine associations between two adapted reproductive autonomy subscales-decision making and communication-and women's use of modern contraceptives at last sex, controlling for demographic, reproductive and social context (i.e., approval of and stigma toward adolescent sexual and reproductive health) covariates. In multivariable analyses, reproductive autonomy decision making-but not reproductive autonomy communication-was positively associated with women's modern contraceptive use at last sex (odds ratio, 1.1); age, having been employed in the last seven days and living in Kumasi were also positively associated with modern contraceptive use (1.1-9.8), whereas ever having had a previous pregnancy was negatively associated with the outcome (0.3). Reproductive autonomy decision making remained positively associated with contraceptive use in a subsequent model that included social approval of adolescent sexual and reproductive health (1.1), but not in models that included stigma toward adolescent sexual and reproductive health. The reproductive autonomy construct, and the decision-making subscale in particular, demonstrated relevance for family planning outcomes among young women in Ghana and may have utility in global settings. Future research should explore reproductive autonomy communication and the potential confounding effects of social context.

Study question Even when considering the right to reproduction as a negative right are there actions to be taken in order achieve a better reproductive autonomy? Summary answer Specific actions become a necessary positivisation of the right to reproduction. Ensuring socio-economic stability and promoting specific education are key parameters for promoting fertility. What is known already The reproductive autonomy of individuals consists of being able to choose the number of children desired and the appropriate timing between deliveries. However, there are many factors that prevent reproductive autonomy from being fully developed in Spain, being the country with the second lowest fertility indicator in Europe. There are texts that argue that reproductive autonomy should be approached from a Human Rights perspective and urge governments to adopt positive measures in accordance. However, the European Court of Human Rights' rulings on this issue are far from this perspective. Nevertheless, states have obligations to enhance the reproductive autonomy of individuals. Study design, size, duration In order to stablish this position, we studied the Spanish demographic and fertility indicator data and examined the existing Spanish laws regarding assisted reproductive techniques (such as Law 14/2006), the European Court of Human Rights' ruling on this matter, United Nations consensus related to this field, the Guttmacher-Lancet commission and recommendations of scientific societies such as ESHRE. Participants/materials, setting, methods Bibliography was achieved using the European Court Human Rights' ruling HUDOC database, the Spanish State Official Newsletter and United Nations Library, between others. Socio-economic and demographic indexes were obtained with Eurostat and the Spanish National Statistics Office. Selected legal aspects were included in the revision and manuscript. Main results and the role of chance The Spanish socio-economic panorama is unfavorable for the emancipation of young people and the consequent formation of families with offspring, which aggravates the existing demographic crisis and generational turnover. Importantly, people are not being fully autonomous in their reproductive decisions, mainly due to a lack of information and foresight regarding real fertility and infertility expectations. States must ensure comprehensive sexual and reproductive health promotion, which includes reproductive autonomy. The wide range of rights that constitute the so-called reproductive rights is encompassed within the framework of human rights. However, the right to reproduction is not always considered as a positive right, although the legislator must ensure that people can fully exercise their autonomy. The fact that the full positivisation of the right to reproduction is not considered does not exempt the State from obligations to ensure the reproductive autonomy of its citizens. Therefore, the positivisation of the right to reproduction must ensure socio-economic stability and reproductive health education, thus preventing future infertility problems. Public and private clinics and health centers must be provided with the necessary means to diagnose possible reproductive pathologies. Education and economic stability are solutions to most of the problems related to population growth and infertility. Limitations, reasons for caution In this study we have interpreted international Law, soft-law and reccommendations according to the actual Spanish socio-economic and demographic context, which may not be adequate to extrapolate to other countries or populations. Wider implications of the findings To consider the right to reproduction as a positive right may mean converting the State into a provider of resources for this purpose. However, positivisation of the right to reproduction materializes in education and socio-economic stability, actions worth considering, such as creating public campaigns aimed at fertility education and awareness. Trial registration number Not applicable

A PROPOSED ROLE FOR FUNDAMENTAL ETHICAL PRINCIPLES IN DETERMINING OPINIO JURIS In Chapter 6 I sketched a role for fundamental ethical principles as a basis of obligation of customary international law. I now explore the role of these principles in identifying customary international legal norms, and especially opinio juris . The role of fundamental ethical principles in ascertaining opinio juris may be specified as follows. First, we should look for evidence about states' own perspectives on the role of fundamental ethical principles in supporting a particular rule. If this evidence is clear, then we should defer to states' own evaluation of this role for ethical principles so long as it is reasonable. If the evidence is unclear about whether states believe a particular norm is desirable to implement immediately or in the near future as an authoritative legal rule and is also ambiguous concerning their evaluation of the relationship between the rule and fundamental ethical principles, then certain presumptions should come into play. If the norm objectively has a direct and significant impact on fundamental ethical principles, either positive or negative, this impact is a reason to presume that states either favor or disfavor implementation of the norm as a legal rule. Moreover, if a norm directly helps to fulfill these principles, then it should be presumed that states desire that it have at least persuasive authority. This presumption is warranted by states' widespread rhetorical endorsement of fundamental ethical principles.

Ethical principles in health research and review process

Background:There is an increasing emphasis on promoting women’s autonomy in reproductive decision-making, particularly given global efforts to increase contraceptive access and uptake. Scales to quantify autonomy have inconsistently included the effect of external influences and focused primarily on influences of partners.Objectives:This study aimed to gain greater depth in understanding how influences including and beyond a woman’s partner affect her contraceptive decision-making, as well as how external influences can overlap and further complicate contraceptive decision-making.Design:A phenomenological, qualitative study in which in-depth interviews were conducted in three phases from May 2021 to February 2022 with women living in northwest Tanzania who had varying histories of contraceptive use or non-use.Methods:One-on-one, in-depth interviews were conducted in Swahili, the national language of Tanzania, by trained female interviewers. Interviews were digitally recorded, transcribed, translated into English, and independently coded by three investigators. Analysis was conducted using NVivo. The codes developed from the transcripts were grouped into overarching themes with supporting illustrative quotes.Results:A total of 72 women were interviewed. Partners were the most influential in women’s family planning decision-making, followed by friends, relatives, community religious leaders, and healthcare providers. Out of the 52 women with a partner who had ever used family planning, 76.9% had discussed their desire to use family planning with their partner and nearly all reported strong pressures to use or not to use family planning from partners, family, and friends. Rarely, participants stated that they were devoid of any influence.Conclusion:In rural Tanzania, women’s decision-making about family planning was highly impacted by external influences, including not only partners but also family, friends, and community. Indicators of women’s reproductive autonomy and measurements of interventions to promote contraceptive use should incorporate measures of these external influences.

Treating abortion as a matter of reproductive autonomy is essential to promoting health, complying with medical ethics, and advancing human rights. When pregnant people can make autonomous decisions about their pregnancies, their health and human rights outcomes improve. Additionally, medical providers that support autonomous sexual and reproductive health decision-making can provide care in line with the highest ethical standards and promote pregnant individuals' human rights. This article highlights Amnesty International's updated institutional abortion policy which uses a reproductive autonomy frame to promote the full realization of human rights for all pregnant people. The policy relies on decades of evidence, the organization's learning from abortion research and advocacy around the world, and evolving human rights law and standards. While not specifically developed for a medical audience, Amnesty International's updated policy can be a useful resource for providers who seek to promote reproductive autonomy and achieve better health outcomes for their patients.