Conscientious objection and refusal to provide reproductive healthcare: A White Paper examining prevalence, health consequences, and policy responses

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Abstract

Global Doctors for Choice-a transnational network of physician advocates for reproductive health and rights-began exploring the phenomenon of conscience-based refusal of reproductive healthcare as a result of increasing reports of harms worldwide. The present White Paper examines the prevalence and impact of such refusal and reviews policy efforts to balance individual conscience, autonomy in reproductive decision making, safeguards for health, and professional medical integrity.

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Unsafe abortion: the preventable pandemic.

David A Grimes, Janie Benson, Susheela Singh … (2006)

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving women's health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves women's health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.

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Hospital admissions resulting from unsafe abortion: estimates from 13 developing countries.

Susheela Singh (2006)

Complications from unsafe abortion are believed to account for the largest proportion of hospital admissions for gynaecological services in developing countries. The WHO estimates that one in eight pregnancy-related deaths result from unsafe abortions. The social stigma and legal restrictions associated with abortion in many countries means that data on the magnitude of this problem are scarce; this article estimates the rate and numbers of hospital admissions resulting from unsafe abortions in developing countries to help quantify the problem. National estimates of abortion-related hospital admissions in women aged 15-44 years were compiled for 13 developing countries: Africa (Egypt, Nigeria, and Uganda), Asia (Bangladesh, Pakistan, and the Philippines), and Latin America and the Caribbean (Brazil, Chile, Colombia, Dominican Republic, Guatemala, Mexico, and Peru). These data were combined with supplementary data from five countries in sub-Saharan Africa (Burkina Faso, Ghana, Kenya, Nigeria, and South Africa) to give estimates for the three world regions. The annual hospitalisation rate varies from a low of about 3 per 1000 women in Bangladesh to a high of about 15 per 1000 in Egypt and Uganda. Nigeria, Pakistan, and the Philippines have rates of 4-7 per 1000, and two countries in Latin America with recent data have rates of almost 9 per 1000. In the developing world as a whole, an estimated five million women are admitted to hospital for treatment of complications from induced abortions each year. This equates to an average rate of 5.7 per 1000 women per year in all developing regions, excluding China. By comparison, in developed countries complications from abortion procedures or hospitalisation are rare. These results help quantify the magnitude of the adverse health effects of unsafe abortion in developing countries and highlight the need for improved access to post-abortion care. The provision of abortion services is changing to include the drug misoprostol and this could reduce the severity of abortion complications and the number of women who are hospitalised. Researchers will need to monitor these changes to provide countries with up-to-date information on illness and death from unsafe abortion. Improved contraceptive services are necessary to prevent unintended pregnancy. However, increasing access to safe abortion services is the most effective way of preventing the burden of unsafe abortion, and remains a high priority for developing countries.

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The economic impact of assisted reproductive technology: a review of selected developed countries.

Georgina Chambers, Elizabeth Sullivan, Osamu Ishihara … (2009)

To compare regulatory and economic aspects of assisted reproductive technologies (ART) in developed countries. Comparative policy and economic analysis. Couples undergoing ART treatment in the United States, Canada, United Kingdom, Scandinavia, Japan, and Australia. Description of regulatory and financing arrangements, cycle costs, cost-effectiveness ratios, total expenditure, utilization, and price elasticity. Regulation and financing of ART share few general characteristics in developed countries. The cost of treatment reflects the costliness of the underlying healthcare system rather than the regulatory or funding environment. The cost (in 2006 United States dollars) of a standard IVF cycle ranged from $12,513 in the United States to $3,956 in Japan. The cost per live birth was highest in the United States and United Kingdom ($41,132 and $40,364, respectively) and lowest in Scandinavia and Japan ($24,485 and $24,329, respectively). The cost of an IVF cycle after government subsidization ranged from 50% of annual disposable income in the United States to 6% in Australia. The cost of ART treatment did not exceed 0.25% of total healthcare expenditure in any country. Australia and Scandinavia were the only country/region to reach levels of utilization approximating demand, with North America meeting only 24% of estimated demand. Demand displayed variable price elasticity. Assisted reproductive technology is expensive from a patient perspective but not from a societal perspective. Only countries with funding arrangements that minimize out-of-pocket expenses met expected demand. Funding mechanisms should maximize efficiency and equity of access while minimizing the potential harm from multiple births.