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Objective In the United States, restrictive abortion policies are concentrated in a subset of states. Little research has examined how people who consider abortion make sense of abortion obtainability and the extent of regulation of abortion care in their state. Study design We conducted in-depth interviews with 30 pregnant women in Maryland, a state with high abortion service availability and few policies restricting abortion, and 28 pregnant women in Louisiana, a state with low service availability and numerous restrictions, who had considered but not obtained an abortion for their pregnancy. We analyzed findings using inductive qualitative analytic techniques. Results All participants were financially struggling. Most participants in Maryland considered abortion easy to get, while a plurality of participants in Louisiana considered abortion difficult to get. Yet, despite their measurable differences in access, participants in both states considered abortion generally obtainable. Participants in Louisiana who thought abortion difficult to get, but nonetheless obtainable, cited strategies that they already employed for other challenges in their lives as options for overcoming abortion barriers. Conclusions Pregnant women who consider abortion and are subject to restrictions do not necessarily perceive restrictions as barriers. Their accounts illustrate how those impacted by restrictions adapt to constraints on their reproductive autonomy just as they manage many other challenges that restrict their freedom to live self-determined lives. Implications Financially struggling pregnant people who considered abortion in Louisiana did not perceive restrictions as barriers to abortion, illustrating the broader adoption of strategies to deal with constraints among women living on low incomes.

To assess adolescent awareness of the safety of self-removal of intrauterine contraception (IUC) and explore associations with sociodemographic characteristics, IUC knowledge, and personal experience using an IUC.We recruited women aged 15 to 20 years from 21 U.S. states and Washington, D.C. Participants completed an online survey assessing their communication with peers about contraception and knowledge and use of IUCs.Few (11%, 95% CI 9%-13%) adolescents knew that IUC self-removal is safe, whether or not they had personally used an IUC (14% vs 8%, p = 0.01). Knowledge that IUCs do not protect users from sexually transmitted infections (99% vs 91%, p0.001) and that IUCs can be removed early (99% vs 88%, p0.001) was higher among adolescents who had used an IUC than those who had not. Knowledge that IUC use does not adversely affect fertility after IUC removal (86% vs 63%, p0.001) and that IUCs are more effective than birth control pills (82% vs 50%, p0.001) also differed by personal experience with an IUC. Awareness of the safety of IUC self-removal was not associated with overall knowledge of IUCs. However, adolescents who knew that IUCs are more effective than birth control pills were more likely to be aware of the safety of IUC self-removal (OR = 1.85, 95% CI 1.12-3.05).Adolescent women in the U.S. possess incomplete knowledge of many important aspects of IUC use, and awareness of the safety of IUC self-removal is particularly low, even among those who have used an IUC.Efforts to increase adolescent knowledge of IUC should include information about the safety of IUC self-removal in order to safeguard adolescents' reproductive autonomy.

People with chronic medical illnesses are at particularly high risk for adverse pregnancy outcomes, yet current clinical approaches largely fail to identify and support their individualized reproductive and pregnancy goals. Instead, the predominant approach to pregnancy in subspecialty medicine is disease centered rather than patient centered. To better meet the individual needs and preferences of people with childbearing potential who have chronic medical conditions, we advocate in this article for a paradigm shift in subspecialty care that honors individuals' reproductive autonomy and human right of reproduction.

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.

Objective The Zika Contraception Access Network (Z-CAN) was a short-term emergency response intervention that used contraception to prevent unintended pregnancy to reduce Zika-related adverse birth outcomes during the 2016 2017 Zika virus outbreak in Puerto Rico. Strategies and safeguards were developed to ensure women who chose long-acting reversible contraception (LARC) had access to no-cost removal, if desired, after Z-CAN ended. Study Design We assessed the number of women who chose LARC at their initial Z-CAN visit who filed complaints regarding challenges with LARC removal within 30-months after the Z-CAN program ended. Complaints and program responses were categorized. Results Of the 29,221 women who received Z-CAN services, 20,381 chose a LARC method at their initial visit (IUD = 12,276 and implant = 8105). Between September 2017 and February 2020, 63 patient complaints were logged, mostly due to LARC removal charges (76.2%) which were generally (71.4%) determined to be inappropriate charges. All complaints filed were resolved allowing LARC removal within an average of 28 days. Conclusion Safeguards to ensure prompt LARC removal when desired are critical to ensure women s reproductive autonomy. Implications Strategies and safeguards used by Z-CAN to ensure women have access to LARC removal might be used by other contraception programs to prevent reproductive coercion and promote reproductive autonomy to best meet the reproductive needs of women.

Screening for rare diseases first began more than 50 years ago with neonatal bloodspot screening (NBS) for phenylketonuria, and carrier screening for Tay-Sachs disease, sickle cell anaemia and β-thalassaemia. NBS’s primary aim is health gain for children, while carrier screening enables autonomous reproductive choice. While screening can be beneficial, it also has the potential to cause harm and thus decisions are needed on whether a specific screening is worthwhile. These decisions are usually based on screening principles and criteria. Technological developments, both treatment driven and test driven, have led to expansions in neonatal screening and carrier screening. This article demonstrates how the dynamics and expansions in NBS and carrier screening have challenged four well-known screening criteria (treatment, test, target population and programme evaluation), and the decision-making based on them. We show that shifting perspectives on screening criteria for NBS as well as carrier screening lead to converging debates in these separate fields. For example, the child is traditionally considered to be the beneficiary in NBS, but the family and society can also benefit. Vice versa, carrier screening may be driven by disease prevention, rather than reproductive autonomy, raising cross-disciplinary questions regarding potential beneficiaries and which diseases to include. In addition, the stakeholders from these separate fields vary: Globally NBS is often governed as a public health programme while carrier screening is usually available via medical professionals. The article concludes with a call for an exchange of vision and knowledge among all stakeholders of both fields to attune the dynamics of screening.

The COVID-19 pandemic has swept across the world, altering nearly every facet of contemporary life and causing behavioral and socioeconomic changes that seemed unthinkable a few months ago. The increased risks for human health include not just the dangers posed by the virus itself, but also the upheaval to the broader health care and societal landscapes, which has threatened access to critical sexual and reproductive health services. In this viewpoint, we describe how the pandemic has already posed challenges to reproductive autonomy in both the United States and globally, and then offer insights on how it may do so in the future. We conclude with a call not only to resist a rollback of access to reproductive health care during this pandemic, but to center a broad conception of reproductive autonomy in sexual and reproductive health research, policies and programs moving forward.

Objective: To describe ethical approaches to the issue of pregnancy termination after prenatal detection of cleft lip ± palate. Results: Gynecologists and cleft surgeons are sometimes confronted with the demand for a pregnancy termination after ultrasound detection of an isolated cleft lip/cleft palate. In this article, we discuss different ethical theories and principles that can be applied to the dilemma at hand. We formulate recommendations that will respect the right to autonomy of the pregnant woman and at the same time acknowledge that a termination of pregnancy for a cleft lip may in most cases not be the best option. Conclusion: The recognition of each person’s right to reproductive autonomy also entails that clinicians should make sure that prospective parents are provided with up-to-date and relevant clinical information.

Objective The perspectives and experiences of intrauterine device (IUD) users who consider IUD self-removal are largely unknown. This study describes the reasons for IUD self-removal as documented in internet forums by IUD users discussing self-removal. Study design This qualitative study used an internet search strategy to document IUD users’ reasons for self-removal in the United States. We employed a content analysis of online data using inductive and deductive qualitative techniques to examine the reasons why IUD users consider self-removal. Results Search results initially identified 235 websites, of which 28 had online health or parenting forums with content related to IUD self-removal. Individual websites contained between 1 and 637 posts by between 1 and 454 individual users. IUD users described a variety of reasons for IUD discontinuation including undesired symptoms or side effects as well as planning for pregnancy. IUD users discussed difficulties accessing provider-removal because of cost or lack of appointment availability. IUD users also discussed how reading about others’ successful self-removal experiences or approval by medical providers made self-removal a feasible or acceptable option. Conclusions Some IUD users utilize online forums for advice about IUD removal, and attempt IUD self-removal due to side effects or because they desire pregnancy. Lack of access to a provider led some patients to attempt self-removal who may have preferred provider-removal. Implications For those who prefer self-removal, anticipatory counseling from a clinician regarding self-removal might be useful and reassuring. Improving access to self-removal may help preserve reproductive autonomy for those who face barriers to IUD removal in the clinical setting.

Objectives To evaluate perceptions of long-acting reversible contraceptives (LARC) among women receiving medication for opioid use disorder. Study design Cross-sectional survey of 200 women receiving medication for opioid use disorder in Vermont. Results A considerable proportion of women receiving medication for opioid use disorder in Vermont reported previous use of an IUD (40%) and/or a subdermal contraceptive implant (16%); the majority of prior LARC users were satisfied with their IUD (68%) or their implant (74%). Of the 38% of participants who had never considered IUD use, 85% percent (64/75) said that they knew nothing or only a little about IUDs. Of the 61% of participants who had never considered an implant, 81% percent (98/121) said that they knew nothing or only a little about the contraceptive method. The most commonly reported reasons for a lack of interest in the IUD and/or implant were concerns about side effects and preference for a woman-controlled method. Conclusions Gaps in LARC knowledge are common among those who have not used LARCs and concerns about side effects and preferences for a woman-controlled method limit some women’s interest in these contraceptives. Additionally, reasons for dissatisfaction among past users are generally similar for IUD and implant and include irregular bleeding and having a bad experience with the method. Implications Efforts to increase awareness of LARC methods among women receiving medication for opioid use disorder should address concerns about side effects and reproductive autonomy and encourage satisfied LARC users to share their experiences with their social networks.

In this case note, I analyse the judgement of the Supreme Court of India in Z v. State of Bihar. I focus on the important contribution that the case makes in the context of reproductive health rights of women, and in particular, victims of rape. I argue that the case provides a foundation for further development of the law on various issues of reproductive rights and compensation jurisprudence for state failures in guaranteeing statutory and constitutional rights of women, including victims of rape. I further argue that the case also provides a framework for adjudication of cases in the criminal justice system, which involve pregnant women.

Objective This study describes access and barriers to intrauterine device (IUD) removal appointments in 10 mid-sized cities in the United States. Study Design This mystery caller study utilized a sampling frame of health centers in 10 mid-sized cities gathered from 3 search engines. We gathered data about the timing of the next available appointment, the requirements for additional appointments prior to IUD removal, and the out-of-pocket cost. We used descriptive statistics to describe the availability and cost of IUD removal visits, and compared results between primary care clinics and family planning or gynecology clinics. Any additional information regarding why a visit was not available or other requirements for IUD removal that was provided to the researcher was also recorded. Results Of 229 clinics included for analysis, 60.7% could offer an IUD removal appointment to the mystery caller, and the majority of these could provide an initial appointment within 2 weeks (61.2%), with a median of 10 days. Of clinics offering IUD removal, 17.3% required more than one visit before removing the IUD, and 43.2% confirmed that IUD removal would occur at the first visit. Five clinics (5.6%) reported that they would not remove an IUD that was not placed at their clinic. Sliding scale fees were offered at 16.3% of clinics. For the clinics that cited an out-of-pocket cost and did not offer sliding scale fees, the median cost of the IUD removal was $262, with a range of $50 to over $1000. Neither appointment availability nor cost differed between primary care and family planning or gynecology clinics. Conclusions Overall, timely IUD removal appointments were available at the clinics we sampled, but both financial and clinic policy barriers to IUD removal were documented, including the need for multiple appointments and the total out-of-pocket costs. Implications In our current climate focused on improving access to IUDs, it is essential to address and reduce barriers to IUD removal when desired, in order to preserve reproductive autonomy.

The Medicaid program covers more than 70 million people and is the largest single health insurance payer for pregnancy and delivery in the United States. In this issue of the Journal, Margerison et al. (Am J Epidemiol. 2021;190(8):1488–1498) investigate the extent to which expansion of Medicaid coverage to nonpregnant low-income adults under the Affordable Care Act may have improved prepregnancy or birth outcomes. They found that Medicaid expansions by states were not associated with changes in prepregnancy health, including smoking and obesity. Similarly, there were no changes in preterm birth or small or large size for gestational age attributable to Medicaid expansion. Results were consistent across a range of model specifications and with allowance for different lag times between Medicaid expansion and pregnancy. The results are consistent with prior research finding that pregnancy-specific Medicaid expansions did not uniformly translate to improved pregnancy and birth outcomes. Results should be interpreted in light of the limited contribution that medical services make to overall health and well-being. To reduce the high rates of adverse pregnancy and child health outcomes in the United States, Medicaid policy must move toward a reproductive autonomy framework that shifts the focus away from pregnancy-specific benefits and toward a comprehensive and patient-empowering reproductive health paradigm.

The aim of this article is to argue that one of the central arguments against company-sponsored non-medical egg freezing, namely that this practice is contrary to the reproductive autonomy of women, can be difficult to sustain under certain conditions. More specifically, we argue that company-sponsored egg freezing is not necessarily in conflict with the most common requirements for autonomous choice. That is, there is no reason to assume that employees cannot be adequately informed beforehand about what is scientifically known about the practice, and/or that they lack the required capacity to understand and process this information. Although they may feel a certain pressure to comply with the wishes of their employer, this concern can plausibly be alleviated through privacy regulations. In any event, such pressure is arguably not stronger than or relevantly different from other types of pressure on the labour market that most people readily accept as being ethically acceptable. Finally, we argue that company-sponsored non-medical egg freezing may mitigate certain types of oppressive socialization, although it may well perpetuate others, and should in any case arguably be dealt with through guidelines and counselling, which would ensure that women make autonomous choices when companies offer egg freezing.

In March 2019, the German Gemeinsamer Bundesausschuss (G‑BA; Federal Joint Committee) presented the result of the method assessment process on non-invasive prenatal testing (NIPT). The aim of this method assessment process was to decide whether NIPT should become a publicly funded procedure of routine prenatal care. The G‑BA decided in favor of NIPT, making the implementation of NIPT very likely, provided that other healthcare and political institutions also agree. This development could be interpreted as empowering from the perspective of reproductive autonomy, since NIPT allows pregnant women to obtain valuable information on the health of the fetus in a fast and easy manner and without the risks of invasive methods. However, the routinization of NIPT also implies ethical challenges. Will the routinization lead to a normalization of prenatal quality control? Will it lead to an expansion to women outside the high-risk group? What would be the ethical implications of such a development? How should physicians, geneticists, and patients deal with the increased amount of obtainable information? What are the implications for choice and decision-making in the prenatal care context? In this paper, we analyze the ethical aspects of the routinization of NIPT, focusing on information and the counseling process, the burden of choice, and the threats to reproductive autonomy by societal interests linked to NIPT.

Background: Pregnancy coercion (PC), defined as a restriction of women's reproductive autonomy, may be associated with increased HIV and sexually transmitted infection (STI) risk. However, there are few empirical studies defining the association between PC and HIV risk, particularly among vulnerable African American women. Setting and Methods: African American women (N = 560), ages 17–24, completed an audio computer-assisted self-interview assessing PC prevalence and its association with HIV/STI risk. Women were screened for prevalent STIs using polymerase chain reaction assays. Multivariate logistic and linear regressions evaluated the association of PC and multiple HIV/STI risk-associated outcomes. Results: Women who had experienced PC in the last 3 months, relative to those not experiencing PC, were 78% more likely to test positive for an STI [adjusted odds ratio = 1.78, 95% confidence interval (CI) = 1.10 to 2.90]. Among women who experienced PC, odds of noncondom use in their last sexual encounter were 3.45-fold greater relative to women not experiencing PC (95% CI = 1.55 to 7.85). Women who experienced PC had lower condom use intentions (coefficient, −1.31, P = 0.002), greater fear of condom negotiation, and perceived more barriers to condom use (coefficients, 3.89 and 5.74, respectively, both P < 0.001). Women who experienced PC had 1.98 (95% CI = 1.22 to 3.21) and 1.82 (95% CI = 1.09 to 3.04) odds of depression and HIV worry relative to women not experiencing PC. Conclusion: Among African American women, PC was associated with a range of adverse sexual health outcomes and HIV/STI-related behaviors and attitudes. The findings underscore the need for promoting gender-equitable social norms in HIV prevention interventions.

International guidelines recommend that prenatal screening for fetal abnormalities should only be offered within a non-directive framework aimed at enabling women in making meaningful reproductive choices. Whilst this position is widely endorsed, developments in cell-free fetal DNA based Non-Invasive Prenatal Testing are now raising questions about its continued suitability for guiding screening policy and practice. This issue is most apparent within debates on the scope of the screening offer. Implied by the aim of enabling meaningful reproductive choices is the idea that screening services should support women in accessing prenatal tests that best enable them to realize the types of reproductive choice that they find important. However, beyond whatever options meet the quality standards required for facilitating an informed decision, the remaining criteria of facilitating autonomous choice is strictly non-directive. As a result, policy makers receive little indication prior to consultation with each individual woman, about what conditions should be prioritized during the offer of screening. In this paper we try to address this issue by using the capabilities approach to further specify the non-directive aim of enabling meaningful reproductive choice. The resulting framework is then used to assess the relative importance of offering prenatal screening where concerning different types of genetic condition. We conclude that greater priority may be ascribed to offering prenatal screening for conditions that more significantly diminish a woman's central capabilities. It follows that serious congenital and earlier-onset conditions are more likely to fulfill these criteria.

Background A substantial number of severely debilitating and often ultimately fatal inborn errors of metabolism (IEMs) still lack an effective disease-modifying treatment. Informing couples before a pregnancy about an increased risk of having a child with an inherited disorder is now feasible by preconception expanded carrier screening (ECS). While knowledge about carrier status enhances reproductive autonomy, it may also result in ethical dilemmas. The purpose of this study was to assess the attitudes of the general Dutch population towards preconception ECS and to investigate which factors influence these attitudes. Methods Data collection was carried out in collaboration with a market research agency. In total, 1188 Dutch individuals of reproductive age (18–45 years) were invited by email to complete an online ECS questionnaire in 2016. Prior to the start of the questionnaire, a written explanation of the concepts of autosomal recessive (AR) inheritance, carrier status and ECS was presented. Results The questionnaire was completed by 781 individuals (65.7%), of whom 31% indicated they would take an ECS test themselves. In addition, 55% agreed that ECS should be offered to all prospective parents. The most frequently selected argument in favor of ECS (47.2%) was that participants want to spare a child from a life with a severe hereditary disorder. The reason most often mentioned not to participate in ECS (48%) was that participants reported not having a hereditary disorder in the family. The majority preferred receiving individual test results above a couple-based disclosure method in which participants receive the carrier status results only when they are a carrier couple of the same disorder. Participants with religious beliefs were less likely to participate in ECS, whereas participants who were considering a (future) pregnancy were more likely to participate. Conclusion Our study demonstrates an overall positive attitude among participants of reproductive age in the general Dutch population towards preconception ECS. A striking misconception is that many of the participants believe that ECS is of interest only for those with a positive family history of one of the hereditary disorders. This finding emphasizes the importance of providing understandable, balanced information and education to the general public regarding the concepts of inheritance when presenting the option of carrier screening. Our results provide valuable insights that can be used in the debate about the responsible implementation of preconception ECS for AR disorders, including IEMs.

First mapping the main ethical issues surrounding prenatal testing, we then analyze which concerns are specific to non-invasive methods. Presupposing the privatization premise for reproductive autonomy in fundamentally liberal societies, we go on to specify common concerns about non-invasive prenatal testing (NIPT) covered by the term ‘routinization’, and conceptually unravel the frequently expressed worry of increasing ‘pressure’ to test and/or terminate affected pregnancies. We argue that mindful decision-making should be a key educational goal (not only) of NIPT counseling which could be achieved through stepwise disclosure. In addition, we identify indirect social pressure as the most plausible threat to reproductive freedom. While continuous efforts need to be made to prevent such pressure – not least by ensuring balanced availability of options –, restricting testing options, and thus freedom of choice, cannot be the answer to this concern. Lastly, we suggest abandoning the vague term ‘routinization’ and instead focusing on specified concerns to enable a fruitful debate.

By implementation of non-invasive prenatal testing (NIPT) for the diagnosis of Down syndrome (DS) in maternity care, an ethical debate is newly inflamed how to deal with this information. Fears of the consequences of an increased use of NIPT are justified with the same arguments when amniocentesis and preimplantation genetic diagnosis (PGD) were introduced decades ago. It can be expected that the prevalence of people with DS would significantly increase in Western societies as a result of the increasing age of pregnant women and the improved medical care for people with DS. The net effect as to whether an increasing uptake of NIPT will result in more abortions of fetuses with trisomy 21 cannot be reliably estimated. This holds true since more and more couples will use results of NIPT for information only, but will not opt for termination of pregnancy. Although parents love their children with DS, in a society where reproductive autonomy is seen as an achievement, access to NIPT cannot be limited. On this background, comprehensive and qualified pretest counseling is vital, also to avoid possible stigmatization of people with DS and as the resulting consequence to avoid feared deterioration in their living conditions, for which, however, there is no evidence to date. The personal view of a mother of a child with DS illustrates the complexity in dealing with NIPT, which does not allow simple answers and must be understood as a challenge for society as a whole.

ObjectiveTo describe the implementation and results of a proactive patient outreach project to offer self-administered, depot medroxyprogesterone (DMPA) subcutaneous (SC) to interested patients at a California safety-net clinic following expanded state Medicaid coverage.Study designWe contacted non-pregnant patients at an urban, safety-net hospital-based primary care clinic who had been prescribed DMPA intramuscular (IM) in the past year to gauge interest in self-administered DMPA-SC. Interested patients received a prescription for DMPA-SC and a telehealth appointment with a clinic provider to learn self-injection. We recorded patient interest in DMPA-SC, completed appointments, and completed first injections. We conducted initial outreach in May, 2020 and recorded appointment attendance and completed injections through August, 2020.ResultsOf 90 eligible patients (age 17-54), we successfully contacted and discussed DMPA-SC with 70 (78%). Twenty-six (37%) patients expressed interest in DMPA-SC and scheduled telehealth appointments to learn to self-administer the medication. Fifteen (58%) of those interested (21% of the total) successfully self-injected DMPA-SC. Of the 44 (63%) patients not interested in DMPA-SC, the three most common reasons were fear of self-injection (n = 23 [52%]), wanting to stop DMPA (n = 11 [25%]), and satisfaction with DMPA-IM (n = 6 [14%]).ConclusionThere is interest in and successful initiation of self-administered DMPA-SC among patients at an urban safety net hospital-based primary care clinic who have used DMPA-IM in the last year.ImplicationsOur data provide evidence for the interest and successful first injection rate after offering self-administered DMPA-SC to patients on DMPA-IM. Expanding coverage of self-administered DMPA-SC could increase patient-centeredness and accessibility of contraception as well as reduce patient anxiety around COVID-19 transmission without losing contraceptive access.

Structured Abstract Study Objective To examine the association between reproductive autonomy and adolescent receptivity towards long acting reversible contraceptive (LARC) methods. Design A survey assessing sexual history and contraceptive practices/knowledge/attitudes was administered. Reproductive autonomy was measured with an adapted validated scale. Setting Adolescent medicine clinic in an urban academic medical center in the Midwestern United States. Participants Girls ages 14-21 years presenting for well or contraceptive visits. Main Outcome Measures Primary outcome was a favorable rating towards the question “How much do you like the idea of LARC for yourself?” Primary independent variable was the reproductive autonomy decision-making subscale score (higher score indicating increased autonomy). Results Eighty-nine participants with a mean age of 16 years completed surveys. Almost all (92%) identified as African American. At study enrollment 56.2% were using Depo-Provera, 15.7% oral contraceptives, 3.4% implants, and 24.7% no method. Only 13.5% of participants liked the idea of LARC for themselves. The mean score on the decision-making subscale was 9 (range 4-12). In bivariable analysis, age was associated with decision-making subscale score, but was not retained as a confounder in multivariable analysis. The odds of liking LARC decreased by 30% with each unit increase in autonomy decision-making subscale score (OR 0.70, 95% CI 0.52 to 0.94, p=0.02). Conclusion Our findings suggest that adolescents with higher reproductive autonomy, as measured by score on the decision-making subscale, were less likely to favor LARC. Further research should explore participants’ perceptions of autonomy and the relational dynamics between adolescents and their parents/partners in contraceptive choice.

Background Preconception Expanded Carrier Screening (ECS) is a genetic test offered to a general population or to couples who have no known risk of recessive and X-linked genetic diseases and are interested in becoming parents. A test may screen for carrier status of several autosomal recessive diseases at one go. Such a program has been piloted in the Netherlands and may become a reality in more European countries in the future. The ethical rationale for such tests is that they enhance reproductive autonomy. The dominant conception of autonomy is individual-based. However, at the clinic, people deciding on preconception ECS will be counselled together and are expected to make a joint decision, as a couple. The aim of the present study was to develop an understanding of autonomous decisions made by couples in the context of reproductive technologies in general and of preconception ECS in particular. Further, to shed light on what occurs in reproductive clinics and suggest concrete implications for healthcare professionals. Main text Based on the shift in emphasis from individual autonomy to relational autonomy, a notion of couple autonomy was suggested and some features of this concept were outlined. First, that both partners are individually autonomous and that the decision is reached through a communicative process. In this process each partner should feel free to express his or her concerns and preferences, so no one partner dominates the discussion. Further, there should be adequate time for the couple to negotiate possible differences and conclude that the decision is right for them. The final decision should be reached through consensus of both partners without coercion, manipulation or miscommunication. Through concrete examples, the suggested notion of couple autonomy was applied to diverse clinical situations. Conclusions A notion of couple autonomy can be fruitful for healthcare professionals by structuring their attention to and support of a couple who is required to make an autonomous joint decision concerning preconception ECS. A normative implication for healthcare staff is to allow the necessary time for decision-making and to promote a dialogue that can increase the power of the weaker part in a relationship.

Purpose: Reproductive autonomy is associated with educational attainment, advanced employment, and well-being. While U.S. Latinas use contraception to control their own childbearing and have reported a desire to do so, they often use it inconsistently and have the lowest rates of contraceptive use of any group. Reasons previously cited for why Latinas do not use contraception compared with non-Latino white women include lack of access, lack of knowledge, language barriers, emphasis on large families, machismo, and religiosity. These reasons are often overly simplistic and can lead to widespread generalizations about Latinas. Methods: Using focus groups and semistructured interviews from November 2014 through June 2015, this study describes the family planning perspectives and experiences of 16 Latinas living in Baltimore and recruited from two federally qualified health centers. A social determinant of health framework was used to guide identification of important concepts and explain findings. Results: Results demonstrated that respondents reported contraceptive agency and claimed autonomy over their bodies; described a sense of responsibility and often expressed caution about having families too large to care for; expressed educational and career aspirations; and perceived contraception as critical for the postponement of childbearing to achieve their goals. Conclusion: The patient/provider encounter should include communication that recognizes all patient preferences and lived experiences to support vulnerable and/or marginalized Latinas in their desires to control their own childbearing and life choices.

Introduction In August 2019, the city council in Jackson, Mississippi passed a 15-foot buffer, 8-foot bubble and 100-foot quiet zone ordinance for all health clinics, aimed at discouraging protestor activity outside the state's only licensed abortion facility. After a series of legal challenges, Jackson repealed the ordinance in November 2020. We sought to learn about patients’ encounters with protestors and how the ordinance would have affected their experiences obtaining abortion care. Method Prior to passage of the ordinance, patients seeking care at the Mississippi facility enrolled in a prospective study on their access to abortion care and contraception; we invited participants completing the 6-month follow-up survey after August 2019 to participate in an in-depth interview about their experiences with protestors at their visits. During the phone interviews, we asked participants about their encounters with protestors and the role of escorts and clinic security in mitigating interactions; we also provided a description of the city ordinance and then asked how this might have changed their experience had it been in place when they were obtaining care. We analyzed interview transcripts for content and themes using both inductive and deductive approaches. Results Of the 30 participants interviewed, the majority said they expected to see protesters at their visits; however, they frequently noted they were surprised by the number of protestors crowding the street and sidewalk near the facility and how close protestors were able to get to patients. Participants overwhelmingly described protesters as “pushy and determined,” and some remarked they felt unsafe because they thought protestors were unpredictable and were aware of violence that had taken place at other facilities. Parking in the clinic lot or on the street largely shaped the intensity of patients’ interactions with protestors. While most participants expressed a strong sense of reproductive autonomy, they also noted that protestors’ presence and comments had a negative emotional impact. Participants credited clinic escorts and security with mitigating these negative experiences by demonstrating concern about patients’ wellbeing, validating their abortion decision and preventing more involved encounters, but a few expressed that needing to have escorts, in general, increased their safety concerns. Nearly all participants stated that the city ordinance would have had a positive effect on their experience, noting they would have felt more at ease, safer, and had the privacy they desired. Conclusions Prior to the passage of Jackson's city ordinance, protestors created stressful and negative experiences for the majority of study participants seeking abortion care, even though the facility adopted strategies aimed at ameliorating protestors’ impacts on patients. Although the city ordinance was short-lived, these results indicate that patients need additional protections to ensure they can obtain essential health care with respect.

In a project The Hastings Center is now running on the future of prenatal testing, we are encountering clear examples, both in established law and in the practices of individual providers, of failures to respect women's reproductive autonomy: when testing is not offered to certain demographics of women, for instance, or when the choices of women to terminate or continue pregnancies are prohibited or otherwise not supported. But this project also raises puzzles for reproductive autonomy. We have learned that some clinicians and patients do not discuss the fact that prenatal testing can lead to a decision about whether to terminate a pregnancy-they just don't talk about it. And while the decision whether to agree to prenatal screening and diagnostic testing is to be made with women's free and informed consent, many screening tests have been routinized in such a way that some women do not even recall agreeing to testing, while others feel that agreeing to testing is what their clinicians expect of them or that the testing is necessary to protect themselves and their families from the significant financial hardship of raising a child with a disability. In the face of these pressures, can one really say that women are freely choosing to undergo testing or are freely choosing to continue or terminate a pregnancy following receipt of test results? The reality of these pressures is requiring us to consider expanding the scope of our investigation beyond the clinical encounter to the broader context-to think harder about what reproductive autonomy means and how best to enhance it.

The article deals with the issue of the artificial termination of pregnancy through the prism of, typically, conflicting relations between the subjects involved and their interests. It specifically addresses the most contentious and morally-ethically as well as legally complicated relationship between the pregnant woman (the future mother) and the embryo or pre-embryo. The article explains the positions of legal theory and jurisprudence in Slovenia and abroad regarding the status of an embryo as a legal person. The authoress moreover touches the question of legal status of the (potential future) father of such an embryo and presents regulations dealing with artificial termination of pregnancy in domestic and comparative law. Through a schematic summary of typical characteristics of such regulations around the world, which greatly differs in details, the author highlights their basic characteristics as well as individual trends in the field.

This paper is based on fieldwork conducted in a Scandinavian private sperm bank that operates independently of assisted reproduction clinics. The fact that it is openly run as a business has consequences for the perspective from which the genetic material is offered. It also mediates the relationship with individual recipients of the sperm. The existence of this sperm bank conflicts with the views of Spanish biomedical professionals, who argue that it is only possible to offer health and safety guarantees regarding samples and traceability of donations in authorized clinics in order to avoid the risks of incest and consanguinity

In this essay, I argue that pronatalism—a social bias in favor of gestational motherhood—and geneticism—a social bias in favor of genetic motherhood—are conceptually and operationally distinct social forces that influence some women's reproductive decision making. Each of these social forces shapes the reproductive landscape, relates differently to women's identities, and causes different social stigmatization and harm. Pronatalism and geneticism warrant feminist concern because they can compromise some women's reproductive autonomy and well-being. I suggest that combating pronatalism and geneticism will require different sets of media, policy, education, and health care practice strategies.

Background: Contraception is important for reproductive autonomy, yet many Latinas do not use contraception consistently despite research reporting a desire to do so. Factors varying in priority and value come into play during contraceptive decision making. When measuring these, relevant survey items may vary by populations. Aim: This study focused on developing an ethnically responsive, patient-centered, content-valid survey for measuring factors that influence contraceptive decision making among immigrant Latinas. Method: Nonpregnant self-identified Latinas ages 15 to 24 years in Baltimore, MD, were recruited from a family planning facility. Using the theory of planned behavior as a theoretical framework and prior formative research, initial survey items were drafted (Step 1). Content validation and cognitive interviewing procedures (Step 2 and Step 3) were used to develop final items. Results: Final items (27) were content-validated by the target population; items reflect important factors and relevant contexts affecting contraceptive decision making among Latinas in Baltimore. Discussion: These theory-based items provide an important contribution to the literature because they measure and explore factors related to contraceptive decision making in an understudied population. Providers might consider these factors during counseling to build patient-centered communication. These items might serve to measure responses to theory of planned behavior–based interventions designed to improve the contraceptive counseling of Latinas.

In many countries, prenatal testing for certain fetal abnormalities is offered via publicly funded screening programs. The concept of reproductive autonomy is regarded as providing a justificatory basis for many such programs. The purpose of this study is to re-examine the normative basis of public prenatal screening for fetal abnormalities by changing our perspective from that of autonomy to obligation. After clarifying the understanding of autonomy adopted in the justification for public prenatal screening programs, we identify two problems concerning this justification: first, the extent to which the government is obliged to meet this demand is not evident; and, second, it is not clear whether the provision of public screening is the most appropriate way to promote autonomy. Next, to tackle these problems, we focus on Onora O'Neill's argument of rights and obligations. Drawing on this argument, we show that, in addressing the problems above, it is important to change our normative perspective from rights or autonomy to obligation. Our argument will show that since the government does not have an incontrovertibly fundamental obligation to promote autonomy, this obligation needs to be constrained in terms of compatibility with other fundamental obligations. In addition, even if a government is obliged to promote autonomy to some degree, there could be more appropriate means to achieve it than providing public prenatal screening; therefore, it is not necessary for government obligations to extend to the provision of public prenatal screening.

Objective Prior qualitative research with women incarcerated at Rikers Island Jail asked women to anticipate their future contraceptive needs and pregnancy desires upon re-entering the community. We conduct this follow-up study to understand better the actual contraceptive needs and pregnancy desires experienced by women after incarceration. Study Design We conducted semi-structured in-depth interviews in New York City in 2014 with 10 women incarcerated within the past three years. We coded transcripts using an iterative process, identified emerging themes, and stopped recruitment after reaching thematic saturation. Results Most participants desired to wait to become pregnant until they had stable housing, income, and employment. A few faced systemic barriers to obtaining contraception, including the process of re-applying for insurance and obtaining medical appointments. For many, incarceration disrupted their use of contraception, insurance status, and relationship with trusted medical providers. Most women lacked trust in the new health professionals they encountered after incarceration. Conclusions Incarceration disrupted medical care in general, and contraceptive care in particular. Assistance should be provided to re-apply for insurance, make appointments, and support women to see trusted health professionals. Implications Incarceration further disenfranchises an already marginalized community through disrupting access to medical care and constrains women’s reproductive autonomy long after return to the community.

Background Unintended pregnancies are associated with poorer obstetric outcomes and are sometimes measured at a population level as a surrogate marker for reproductive autonomy and access to health services, including contraception. Aboriginal Australians face many disparities in health outcomes, including in reproductive health and antenatal care. We aimed to explore the formation and expression of pregnancy intentions in an Aboriginal population to inform health service improvements. Methods Semi-structured interviews were conducted with 27 remote-dwelling Aboriginal women, aged 18–49 years. Content analysis was conducted; key themes were discussed with groups of women from participating communities to refine interpretation. Results Most (19/27) participants expressed pregnancy intentions congruent with reported contraceptive behaviour while eight expressed ambivalent or uncertain intentions. Intentions were shaped by traditional kinship practices, reproductive autonomy and desired family formation. Younger women tended to aspire to smaller family sizes than older women and support was expressed for the postponement of first pregnancy to achieve other life goals. Women in these communities hold strong traditional beliefs, including regarding conception, but did not use traditional methods of contraception in place of modern methods. Reproductive coercion, in the form of pressure to fall pregnant, was recognised as an important issue by women in the community. Conclusion Consultation strategies that promote rapport, allow space for uncertainty and are inclusive of important personal and cultural contexts are likely to improve shared understanding of pregnancy intention. Universal screening for reproductive coercion and broad counselling on contraceptive options (including discrete methods) may reduce unmet need for contraception. Community approaches supporting reproductive autonomy that is inclusive of men, and enhanced educational and occupational opportunities for young women are needed.

One of the important developments in assisted reproductive technology is the technique of oocyte preservation, which enables women to preserve their eggs when there is a threat of becoming infertile in the future. In spite of the still experimental status of this procedure, fertility clinics widely recommend it to healthy women who wish to postpone childbearing for social reasons. Since in fertility clinic’s websites appear extensive recommendations and promotion about this technology, it seems important to analyze their online persuasive communication. Our analysis applies a mixed methodology of content and discourse analysis from a framing theory perspective. It provides an in-depth analysis of the content of fertility clinics’ websites in Spain, describing their communication/information strategies regarding fertility preservation for social reasons. The present article confirms the inconsistency that exists in terms of the clarity of the information given by these websites, since the information is framed intending to attract more women to the egg freezing services.

While IUDs are incredibly safe and highly effective forms of birth control for all individuals, including adolescents and young adults, and have higher continuation rates compared to non-LARC methods, many medical providers still believe that they are inappropriate for use with adolescent and young patients. This lack of knowledge has the potential to negatively impact an adolescent’s or young adult’s reproductive autonomy. In addition, patients and families continue to have concerns around IUD safety based on myths of previous decades and complications from devices no longer available. This chapter will address some of the potential gaps in patient and provider knowledge, including a review of IUD efficacy and eligibility based on resources from the Center for Disease Control and Prevention, a list of resources for evidence-based guidelines, and a discussion of common IUD myths.

Population-based preconception genetic carrier screening programmes (PCS) with expanded panels are currently being developed in the Netherlands. This form of genetic screening for recessive traits differs from other forms of genetic testing and screening in that it is offered to persons not known to have an increased risk of being carriers of genetic traits for severe recessive diseases and in that they include tests for a large number of traits, potentially several hundred. This raises several ethical issues around justice, consequences, and autonomy. It will be argued that most of these ethical problems call for cautious reflection when setting up PCS and similar programmes within preconception care. It is moreover argued that it is ethically problematic to have an official aim and failing to mention possibly legitimate public aims that actually drive the development of PCS.

In the last decade-plus, there has been growing enthusiasm for long-acting reversible contraceptive methods as the solution to unintended pregnancy in the United States. Contraceptive access efforts have primarily focused on addressing provider and policy barriers to long-acting reversible contraception and have promoted long-acting reversible contraception as first-line methods through marketing and tiered-effectiveness counseling. A next generation of contraceptive access efforts has the opportunity to move beyond this siloed focus on long-acting reversible contraception toward a focus on equity and person-centeredness. Here we define a new framework for increasing equitable access to high-quality, person-centered contraceptive care that includes programmatic elements necessary to provide information and services to address the barriers to accessing quality care, organized into a four-part continuum. The continuum is contextualized within structural, systematic, and social factors that influence experience of contraceptive care. We aim to provide a practical framework for researchers, program implementers, and policy makers to develop and evaluate efforts to improve equitable access to and quality of contraceptive care. Initiatives can intentionally be cognizant of broader structural and social factors that will influence their success and the likelihood of negative unintended consequences for marginalized groups and thus deliberately work to design programs that meet all people's contraceptive needs and support reproductive autonomy.

Smoking is frequently presented as being particularly problematic when the smoker is a pregnant woman because of the potential harm to the future child. This premise is used to justify targeting pregnant women with a unique approach to smoking cessation including policies such as the routine testing of all pregnant women for carbon monoxide at every antenatal appointment. This paper examines the evidence that such policies are justified by the aim of harm prevention and argues that targeting pregnant women in this way is likely to do more harm than good. Routine carbon monoxide testing is particularly problematic as it sends a message to pregnant women that they cannot be trusted either to truthfully answer questions as to whether or not they smoke, or to make decisions in the best interests of themselves and their future children in the way that non-pregnant individuals are. Further, if the aim is to reduce rates of prenatal harm, the evidence suggests that adopting a supportive and empowering approach to prenatal care is the most effective way to achieve this, something that the current policies aimed at pregnant women are in conflict with.

Background The introduction of non-invasive prenatal testing (NIPT) for foetal aneuploidies is currently changing the field of prenatal screening in many countries. As it is non-invasive, safe and accurate, this technique allows for a broad implementation of first-trimester prenatal screening, which raises ethical issues, related, for instance, to informed choice and adverse societal consequences. This article offers an account of a leading international ethical framework for prenatal screening, examines how this framework is used by professionals working in the field of NIPT, and presents ethical guidance for the expansion of the scope of prenatal screening in practice. Methods A comparative analysis of authoritative documents is combined with 15 semi-structured interviews with professionals in the field of prenatal screening in the Netherlands. Data were recorded, transcribed verbatim and analysed using thematic analysis. Results The current ethical framework consists of four pillars: the aim of screening, the proportionality of the test, justice, and societal aspects. Respondents recognised and supported this framework in practice, but expressed some concerns. Professionals felt that pregnant women do not always make informed choices, while this is seen as central to reproductive autonomy (the aim of screening), and that pre-test counselling practices stand in need of improvement. Respondents believed that the benefits of NIPT, and of an expansion of its scope, outweigh the harms (proportionality), which are thought to be acceptable. They felt that the out-of-pocket financial contribution currently required by pregnant women constitutes a barrier to access to NIPT, which disproportionally affects those of a lower socioeconomic status (justice). Finally, professionals recognised but did not share concerns about a rising pressure to test or discrimination of disabled persons (societal aspects). Conclusions Four types of limits to the scope of NIPT are proposed: NIPT should generate only test outcomes that are relevant to reproductive decision-making, informed choice should be (made) possible through adequate pre-test counselling, the rights of future children should be respected, and equal access should be guaranteed. Although the focus of the interview study is on the Dutch healthcare setting, insights and conclusions can be applied internationally and to other healthcare systems.

In recent years, growing evidence for the safety and efficiency of oocyte vitrification has made this technique be increasingly proposed for fertility preservation (FP). The populations who could benefit from FP include oncological patients who need the option to preserve their gametes before undergoing potential sterilizing treatment, patients with non-oncologic conditions requiring gonadotoxic chemotherapy and women who wish to delay their motherhood for a variety of reasons. By vitrifying oocytes, women have the chance to conceive in the future, have their own genetic offspring and maintain their reproductive autonomy. This review focuses on describing current knowledge on oocyte vitrification as a means to preserve female fertility. We present the general experience of our group and others in FP for both oncological and non-oncological reasons.

With the new and highly accurate noninvasive prenatal test (NIPT), new options for screening become available. I contend that the current state of the art of NIPT is already in need of a thorough ethical investigation and that there are different points to consider before any chromosomal or subchromosomal condition is added to the screening panel of a publicly funded screening program. Moreover, the application of certain ethical principles makes the inclusion of some conditions unethical in a privately funded scheme, even if such screening would enhance a woman's reproductive autonomy. On the one hand, a screening program aimed solely at the detection of Down syndrome is subject to the technological imperative and should be reassessed in the light of technologies that allow for the detection of conditions that are at least as severe. On the other hand, some chromosomal conditions should not be included in any screening programs, because this would violate certain ethical principles, such as the right of the future child to genetic privacy. ispartof: JOURNAL OF MEDICINE AND PHILOSOPHY vol:43 issue:1 pages:8-21 ispartof: location:United States status: published

If the central purpose of non-invasive prenatal testing (NIPT) is to deliver improved reproductive autonomy – by facilitating enhanced choice between the continuation and termination of pregnancy – any public-funded regime ought to be compatible with the legal grounds for decision-making in this context. It is problematic for a State to facilitate access to information that would or is likely to result in legal dilemmas and conceptual issues for those using these tests. Public-funded testing should not be available for purposes that would be or are likely to be ‘incompatible’ with any framework for lawful abortion. In England and Wales, those incompatible purposes currently include the identification of (1) gender in the absence of other genetic factors and (2) specific abnormality that is unlikely to yield serious disability at birth. Consequently, expansion of the NIPT regime to include these purposes should entail changes in the legal framework for abortion.

While NIPT is being implemented rapidly, the implementation of a corresponding specialized counselling process in many respects lags behind. As a consequence, legal requirements and other testing conditions sometimes are not fulfilled adequately. The reported case illustrates the importance of trained personnel in the counselling and NIPT process and shows so far neglected risks for the pregnant woman and her reproductive autonomy.

Non-invasive prenatal testing on the basis of cell-free DNA of placental origin (NIPT) changed the landscape of prenatal care and is seen as superior to all other up to now implemented prenatal screening procedures - at least in the high-risk population. NIPT has spread almost worldwide commercially, but only in a few countries the costs of NIPT are covered by insurance companies. Such financial barriers in prenatal testing can lead to significant restrictions to the average range of opportunities of pregnant women and couples, which on an intersubjective level can be defined as unfair discrimination and on an individual level weakens reproductive autonomy. Given that enabling reproductive autonomy is the main ethical justification for offering prenatal (genetic) testing, these barriers are not only an issue of justice in health care, but are potentially counteracting the primary purpose of these testing procedures.

Since the 1970s, prenatal testing has been integrated into many health care systems on the basis of two competing and largely irreconcilable rationales. The reproductive autonomy rationale focuses on nondirective counseling and consent as ways to ensure that women's decisions about testing and subsequent care are informed and free of undue pressures. It also represents an easily understandable and ethically convincing basis for widespread access to prenatal testing, since the value of autonomy is well established in Western bioethics and widely recognized by funders of health care. In contrast, the public health rationale approaches prenatal testing as designed to reduce the incidence of certain conditions in the population to reduce the burden of disease. This rationale emphasizes the societal consequences of reproduction and the aggregate impact of women's individual reproductive decisions on the overall health of future populations. In this essay, I argue that, despite what could be seen as a persistent failure to meet the ideals of reproductive autonomy, resisting the public health rationale as a basis for prenatal screening is ethically and pragmatically crucial. I recommend policy mechanisms that can enhance reproductive autonomy at a societal level to support choice at the individual level.

Objective This study describes the perspectives of patients and providers about intrauterine device (IUD) self-removal. Study design This qualitative study is a subanalysis of two datasets from a single project, which included semistructured individual interviews with 15 patients and 12 physicians. We derived the data for this analysis from portions of the interviews pertaining to IUD self-removal and provider removal. We analyzed data using deductive and inductive techniques to perform content and thematic analyses. Results The majority of patients and physicians cited both concerns about and potential benefits of IUD self-removal. Patients cited concerns about safety as the reason they did not wish to remove their own IUD, but physicians did not share these concerns; instead, physicians were apprehensive about not being involved in the discussion to remove the IUD. Both patients and physicians valued having the provider “in the loop” and reported fears about hasty or coerced removal. Conclusions IUD self-removal is an option that some patients may be interested in. Addressing concerns about safety may make self-removal more appealing to some patients. Addressing physicians' concern about “hasty” removal may require additional training so that providers are better able to support patients' decision making around contraceptive use. Implications The option of self-removal could have a positive impact on reproductive autonomy and patient decision making.