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Geographic and socioeconomic inequalities in the coverage of contraception in Uttar Pradesh, India

Uttar Pradesh (UP) is the most populous state in India, with a historically lower level of family planning coverage than the national average. In recent decades, family planning coverage in UP has significantl...

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Using mobile health in primiparous women: effect on awareness, attitude and choice of delivery type, semi-experimental

One of the reasons for the increase in cesarean section is the lack of knowledge of mothers in choosing the type of delivery. The present study aimed to determine the effect of education through pregnancy appl...

Trends in prevalence of unmet need for family planning in India: patterns of change across 36 States and Union Territories, 1993–2021

Eliminating unmet need for family planning by 2030 is a global priority for ensuring healthy lives and promoting well-being for all at all ages. We estimate the sub-national trends in prevalence of unmet need ...

The 100 top-cited articles in menopausal syndrome: a bibliometric analysis

Significant scientific research has been conducted concerning menopausal syndrome(MPS), yet few bibliometric analyses have been performed. Our aim was to recognise the 100 most highly cited published articles ...

Exploring the decision-making process of female genital cosmetic procedures in Iranian women and constructing and validating a results-based logic model for a healthy public policy: a study protocol

Female genital cosmetic procedures have grown rapidly in most parts of the world. Professional organizations have issued warnings about the complications and long-term consequences of these practices. To be ab...

Predictors of maternal health services uptake in West African region: a multilevel multinomial regression analysis of demographic health survey reports

Pursuant to studies, receiving the three key maternal health services (Antenatal Care, Skilled Delivery Service, and Postnatal Care) in a continuum could prevent 71% of global maternal deaths. Despite the West...

Impact of postpartum weight change on metabolic syndrome and its components among women with recent gestational diabetes mellitus

While postpartum weight changes may affect the levels of metabolic parameters, the direct effects of weight changes in the postpartum period on changes in the prevalence rates of metabolic syndrome and its com...

Acceptance and commitment therapy adapted for women with infertility: a pilot study of the Infertility ACTion program

Approximately one in six couples are currently infertile, defined as unable to achieve pregnancy despite 12 or more months of active attempts to conceive. Experiencing infertility has been disproportionately a...

Determinants and predictive model of failure of surgical repair of obstetric vesico-vaginal fistula in the Democratic Republic of the Congo

Surgical repair of obstetric fistula aims to restore the anatomical and functional integrity of the urinary tract, enabling affected women to regain their dignity and quality of life. However, such repairs can...

Study protocol for the implementation of Centering Patients with Fibroids , a novel group education and empowerment program for patients with symptomatic uterine fibroids

Black women and people with uteri have utilized collectivistic and relational practices to improve health outcomes in the face of medical racism and discrimination for decades. However, there remains a need fo...

Women’s preference for a vaginal birth in Brazilian private hospitals: effects of a quality improvement project

In 2015, a quality improvement project called “Adequate Childbirth Project” (PPA) was implemented in Brazilian private hospitals in order to reduce cesarean sections without clinical indication. The PPA is str...

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Knowledge and perception of HPV vaccination among Lebanese mothers of children between nine and 17 years old

The human papillomavirus (HPV), a prevalent sexually transmitted infection, is linked to a wide range of diseases, with cervical cancer being the most common and serious one. HPV vaccination is crucial for pre...

Contextual determinants of generational continuation of female genital mutilation among women of reproductive age in nigeria: analysis of the 2018 demographic and health survey

Female genital mutilation (FGM) has negative health implications and has long been recognised as violating sexual rights. Despite the huge efforts expended on eradicating FGM, generational continuation of the ...

“You cannot stay with one person once you begin having sex at a young age”: the prevalence, correlates and effects of early sexual debut among children in Ghana

Children’s initiation of early sex has several negative implications on their sexual and reproductive health, growth and development. In Ghana, few studies on early sexual debut have focused on adolescents. Th...

Israeli students’ perceptions regarding sperm donation: dilemmas reflections with dominant demographic effect

Sperm donation has undergone significant medical and social transformations in recent decades. This study aimed to explore Israeli students’ perceptions towards sperm donation and investigate the potential inf...

Seeking information and services associated with reproductive health among rural Peruvian young adults: exploratory qualitative research from Amazonas, Peru

Sexual and reproductive health (SRH) literacy allows young adults to make informed decisions about health outcomes. In Peru, roughly one fifth of the population lives in rural areas, and little is known about ...

Caregivers’ concerns about the sexual and reproductive health of women with intellectual disability in Iran: a qualitative study

Women with intellectual disability (ID) have many sexual and reproductive problems. This study was conducted to explain the sexual and reproductive health considerations of women with ID from the perspective o...

Unraveling reproductive and maternal health challenges of women living with HIV/AIDS in Vietnam: a qualitative study

Human Immunodeficiency Virus (HIV) remains a significant public health concern worldwide. Women living with HIV/AIDS (WLHA) have the additional and unique need to seek sexual and reproductive health services. ...

Birth by caesarean section and semen quality in adulthood: a Danish population-based cohort study

The caesarean section (CS) rate has increased worldwide and there is an increasing public and scientific interest in the potential long-term health consequences for the offspring. CS is related to persistent a...

"I don't want my marriage to end": a qualitative investigation of the sociocultural factors influencing contraceptive use among married Rohingya women residing in refugee camps in Bangladesh

The timely provision of comprehensive contraceptive services to Rohingya women is impeded due to a lack of clarity and understanding of their traditional beliefs and cultural frameworks. Recognizing this chall...

The impact of gestational weeks of Coronavirus disease 2019 (COVID-19) infection on perinatal outcomes

To evaluate the relationship between coronavirus disease 2019 (COVID-19) infection at different time points during pregnancy and perinatal outcomes.

An integrated theory based-educational intervention to change intention to have a child: study protocol of a cluster randomized controlled trial

In high- and low-income countries, declining birth rates have become a global concern. Couples do not have enough information about the complications of delaying and reducing childbearing and this leads them t...

A comprehensive interventional program to improve the sexual function of women with endometriosis: a mixed-methods protocol study

Endometriosis is a chronic disease affecting 6–10% of women worldwide. Sexual dysfunction has been reported in a significant percentage of these patients. Thus, the present study will be conducted to design, i...

Ranking the dietary interventions by their effectiveness in the management of polycystic ovary syndrome: a systematic review and network meta-analysis

Polycystic ovary syndrome (PCOS) is a common condition in women, characterised by reproductive and metabolic dysfunction. While dietary approaches have been evaluated as a first-line treatment for patients wit...

To what extent did implementing a community-embedded intervention align with the goals and roles of stakeholders in adolescent sexual and reproductive health?

Adolescents’ sexual and reproductive health (SRH) needs are largely unmet due to poor access to SRH information and services. A multicomponent community-embedded intervention, comprising advocacy to policymake...

The psychosocial impact of male infertility on men undergoing ICSI treatment: a qualitative study

Male infertility is in 20–70% of cases the cause of a couple’s infertility. Severe forms of male infertility are best treated with Intracytoplasmic Sperm Injection (ICSI). The psychosocial impact of infertilit...

Influence of menstrual pain and symptoms on activities of daily living and work absenteeism: a cross-sectional study

To examine the prevalence of menstrual pain among women of reproductive age and its impact on their daily lives and professional responsibilities.

Development, implementation, and evaluation of the effectiveness of an intervention program to improve the sexual competence of young adult women about to get married: a protocol study

Having competence in initiating sexual interactions is one of the challenges of sexual health in any society. Given that the social, cultural, and religious background of some societies can prevent the acquisi...

Documentation of prenatal contraceptive counseling and fulfillment of permanent contraception: a retrospective cohort study

Barriers exist for the provision of surgery for permanent contraception in the postpartum period. Prenatal counseling has been associated with increased rates of fulfillment of desired postpartum contraception...

Acceptability of IV iron treatment for iron deficiency anaemia in pregnancy in Nigeria: a qualitative study with pregnant women, domestic decision-makers, and health care providers

Anaemia in pregnancy causes a significant burden of maternal morbidity and mortality in sub-Saharan Africa, with prevalence ranging from 25 to 45% in Nigeria. The main treatment, daily oral iron, is associated...

“They call me the ‘Great Queen’”: implementing the Malkia Klabu program to improve access to HIV self-testing and contraception for adolescent girls and young women in Tanzania

Adolescent girls and young woman (AGYW) comprise a significant proportion of new HIV infections and unintended pregnancies in sub-Saharan Africa yet face many barriers to accessing family planning and reproduc...

Reproductive autonomy and the experience of later-than-desired pregnancy: results from a cross-sectional survey of reproductive-aged women in Uganda

The focus of reproductive autonomy research has historically been on the experience of unintended pregnancy and use of contraceptive methods. However, this has led to the neglect of a different group of women ...

Explaining the experience of breastfeeding in women with gestational diabetes and designing and implementing an educational program based on planned behavior theory: a combined exploratory study protocol

Gestational diabetes is a type of carbohydrate intolerance that is diagnosed for the first time during pregnancy. Researches have shown that gestational diabetes is associated with many negative prenatal and b...

A loss-of-function variant in ZCWPW1 causes human male infertility with sperm head defect and high DNA fragmentation

Male infertility is a global health issue. The more causative genes related to human male infertility should be further explored. The essential role of Zcwpw1 in male mouse fertility has been established and t...

Menarche and reproductive health in Spanish Roma women from a reproductive justice perspective: a qualitative study

This study aimed to explore the perceptions of Roma women about their experience of menarche and reproductive health considering the principles of reproductive justice.

Women's voices and meanings of empowerment for reproductive decisions: a qualitative study in Mozambique

Women in Mozambique are often disempowered when it comes to making decisions concerning their lives, including their bodies and reproductive options. This study aimed to explore the views of women in Mozambiqu...

Weight development from childhood to motherhood—embodied experiences in women with pre-pregnancy obesity: a qualitative study

Pre-pregnancy obesity increases the risk of perinatal complications. Post-pregnancy is a time of preparation for the next pregnancy and lifestyle advice in antenatal care and postpartum follow-up is therefore ...

Exploring women’s interpretations of survey questions on pregnancy and pregnancy outcomes: cognitive interviews in Iganga Mayuge, Uganda

In 2021, Uganda’s neonatal mortality rate was approximately 19 deaths per 1000 live births, with an estimated stillbirth rate of 15.1 per 1000 total births. Data are critical for indicating areas where deaths ...

What is the impact of endometriosis and the AFS stage on cumulative pregnancy rates in IVF programs?

Endometriosis is commonly observed in infertile women and can be staged with regard to severity [e.g. according to the American Fertility Society (AFS) classification]. This condition can cause infertility thr...

Efficacy and safety of a novel pain management device, AT-04, for endometriosis-related pain: study protocol for a phase III randomized controlled trial

Endometriosis-related pain encompassing dysmenorrhea, dyspareunia, and chronic pelvic pain, reduces the quality of life in premenopausal women. Although treatment options for endometriosis alleviate this pain,...

Non-pharmacological labor pain relive methods: utilization and associated factors among midwives and maternity nurses in Najran, Saudi Arabia

Traditionally, pharmacological pain relief methods have been the most acceptable option for controlling labor pain, accompanied by numerous adverse consequences. Non-pharmacological labor pain relive methods c...

Attitude towards assisted reproductive technology: acceptance of donors eggs, sperms, and embryos as treatment of human infertility: a systematic review and meta-analysis

Assisted Reproductive Technology utilizes human sperm, eggs, or embryos in vitro to produce pregnancy. However, there is no evidence of the acceptance of these technologies by the community.

Designing, validation and evaluation of the expert system of “Healthy Menopause” and assessing its effect on the management of menopause symptoms: an exploratory mixed method study protocol

Menopause is a period of women’s life that has the especial physical, psychological and social challenges. So provision of an effective, practical and affordable way for meeting women’s related needs is import...

Maternal and fetal/neonatal outcomes in pregnancy, delivery and postpartum following bariatric surgery and comparison with pregnant women with obesity: a study protocol for a prospective cohort

Being obese can lead to various complications during pregnancy, such as Gestational Diabetes Mellitus (GDM), pregnancy induced hypertension (PIH), Pre-Eclampsia (PE), and Large Gestational Age (LGA). Although ...

Barriers and delays in access to abortion care: a cross-sectional study of people traveling to obtain care in England and the Netherlands from European countries where abortion is legal on broad grounds

This study characterized the extent to which (1) financial barriers and (2) abortion care-seeking within a person’s country of residence were associated with delays in abortion access among those travelling to...

The effectiveness of an m-Health intervention on the sexual and reproductive health of in-school adolescents: a cluster randomized controlled trial in Nigeria

The implementation of the country-wide comprehensive sexuality education (CSE) curriculum among in-school adolescents remains abysmally low and mHealth-based interventions are promising. We assessed the effect...

A qualitative assessment of the impact of a community-embedded intervention on beneficiaries' attitudes and beliefs about adolescent sexual reproductive health in Ebonyi State, Southeast, Nigeria

Adolescents and their communities in Ebonyi State, Nigeria have poor attitudes and beliefs towards adolescent sexual and reproductive health (SRH). This paper reports on the effects of a community-embedded int...

The effects of reproductive variables on child mortality in Ethiopia: evidence from demographic and health surveys from 2000 to 2016

Child mortality is a crucial indicator reflecting a country's health and socioeconomic status. Despite significant global improvements in reducing early childhood deaths, Southern Asia and sub-Saharan Africa s...

Determinants of preventive sexual behaviours among first year university students in Beira city, central Mozambique: a cross-sectional study

Understanding determinants of preventive sexual behaviours is important for intervention efforts to support these behaviours and, thereby, reduce STIs and HIV burden. In general, there is limited insight into ...

Identifying opportunities for prevention of adverse outcomes following female genital fistula repair: protocol for a mixed-methods study in Uganda

Female genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000-2 million women in lower-resource settings. Vesicovaginal fistula causes ur...

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Reproductive Health

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BMJ Sexual & Reproductive Health

is a multiprofessional global medical journal by BMJ and FSRH, publishing research, reviews and comment on sexual and reproductive health & contraception.

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BMJ Sexual & Reproductive Health is an international journal that promotes evidence-informed practice for contraception, abortion and all aspects of sexual and reproductive health. The journal publishes research papers, topical debates and commentaries to shape policy, improve patient-centred clinical care, and to set the stage for future areas of research. It is the official journal of the Faculty of Sexual and Reproductive Healthcare .

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32 An Overview of Sexual and Reproductive Health in the Context of Public Health Ethics

Leslie Meltzer Henry, JD, PhD, Professor, University of Maryland, Francis King Carey School of Law, Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland

Published: 11 February 2019
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Sexual and reproductive health is an important aspect of individual health and well-being, as well as a significant determinant of public health. This chapter uses a public health ethics lens to illuminate three examples of moral complexity arising in sexual and reproductive health: social justice, contested views of harms and benefits, and self-determination. The chapter also provides an overview of the four chapters in this dedicated section of The Oxford Handbook of Public Health Ethics . The section’s chapters provide a focused examination of public health ethics in the context of STI control measures, contraception, abortion, and pregnancy-related services.

Introduction

Since the mid-1990s, the concept of sexual and reproductive health has evolved from a limited focus on discrete health issues, such as maternal and child health, to a broad understanding of the many factors, such as gender inequality, that can affect people’s sexual and reproductive lives. The move toward a more expansive vision of sexual and reproductive health is frequently traced to the landmark 1994 United Nations International Conference on Population and Development (ICPD). In a paradigm shift, the ICPD replaced traditional fertility control programs, which emphasized demographic goals, with a “Programme of Action” (PoA) that not only placed the sexual and reproductive health of individuals —and particularly women and girls—at its core, but also affirmed sexual and reproductive health, reproductive rights, and gender equality as human rights and cornerstones of sustainable development (UN, 1994 ).

The PoA committed ICPD member states to providing universal access to a core set of health services: education related to sexuality and reproduction, prevention of sexually transmitted infections (STIs), family planning, safe abortion, and maternal and newborn care. Despite occasional setbacks, efforts to build on that vision continue. The United Nations 2030 Agenda for Sustainable Development includes universal access to sexual and reproductive health as a target (UN, 2015 ), and the 2018 report of the Guttmacher- Lancet Commission on Sexual and Reproductive Health and Rights calls for universal access to sexual and reproductive health, comprehensively defined as a state of “physical, emotional, mental, and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction, or infirmity” (Starrs et al., 2018 , 11).

Sexual and reproductive health is an important aspect of individual health and well-being, but it also functions as a significant determinant of public health. The intersection between the deeply personal consequences of sexual and reproductive ill health, and its profound affect on public health outcomes, is reflected in the chapters of this section of The Oxford Handbook of Public Health Ethics , which examines public health ethics in the context of STI control measures, contraception, abortion, and pregnancy-related services. Some of the ethical complexities arising across the spectrum of sexual and reproductive health more generally are highlighted below.

Ethical Complexities

Individual and public health outcomes associated with sexual and reproductive health have generally improved worldwide as a consequence of greater support for gender equality, wider access to educational opportunities, higher rates of contraceptive use, and lower incidences of maternal morbidity and mortality (Snow, Laski, and Mutumba, 2015 ). When examined through the lens of public health ethics, however, a number of moral considerations come into greater focus (Childress et al., 2002 ). Three of the many areas of moral complexity are highlighted as examples: social justice, contested views of harms and benefits, and self-determination. Although there is interplay between these moral considerations, they are presented individually for ease of understanding.

Social Justice

While improvements in aggregate sexual and reproductive health outcomes are noteworthy, they can conceal considerable global inequalities. Often, these disparities stem from economic, social, cultural, and structural determinants of health, several of which are briefly highlighted in the discussion that follows.

Wealth inequality is a significant determinant of sexual and reproductive health, both between and within countries. Women in low-income countries are more likely than those in high-income countries to have unmet contraceptive needs, unintended pregnancies, unsafe abortions, and inadequate maternity care (Singh, Darroch, and Ashford, 2014 ). Within countries, women living in poverty are similarly disadvantaged as compared to their wealthier counterparts (Singh, Darroch, and Ashford, 2014 ).

Globally, the most significant risk factor for poverty is female gender (Rogers, 2006 ). Gender norms continue to limit women’s access to education, information, employment, and health services. As a result, women remain disproportionately represented among the global poor. The “feminization of poverty” can prevent women from gaining influence and authority to challenge societal gender-power imbalances, which only reinforces the gender norms at the crux of their poverty (Pearce, 1978 , 28).

Women who are socially and economically dependent on men generally have less power to negotiate condom use and access contraception. Although they are at heightened risk for contracting STIs and having unintended pregnancies (Glasier et al., 2006 ), their social and financial dependency diminishes their ability to access sexual and reproductive health care services (Cottingham and Ravindran, 2011 ). They consequently face higher than average rates of morbidity and mortality associated with STI-related complications, unsafe abortions, and unattended births (Starrs et al., 2018 ). Women who carry unintended pregnancies to birth are also more likely to lose economic, educational, and social opportunities (Cook and Dickens, 2009 )—the very same factors that contribute to poverty, gender inequality, and dependency. Inequality begets further inequality, and women can become trapped in a socially unjust cycle from which it is increasingly difficult to escape.

Some populations are more likely than others to confront barriers to sexual and reproductive health information and services, and in turn to experience adverse health outcomes. Individuals whose communities view their sexual activities and identities as unacceptable (e.g., sex workers, men who have sex with men) are among those at highest risk because social stigma, discrimination, violence, and fear of criminal penalties can deter them from seeking health services (Starrs et al., 2018 ). Survivors of gender-based violence also report forgoing medical and legal services because of community perceptions of gender-based violence as a private matter, justified, or even a reason to shun or punish the survivor (Glasier et al., 2006 ).

Contested Views of Harms and Benefits

Sexual and reproductive health practices, programs, and policies raise some of the most contested issues in public discourse. Is it ethically permissible to provide HIV-prevention drugs to at-risk adolescents without parental consent? To require employers to provide employees with insurance that covers contraception? To use reproductive technology to enhance offspring? These and similar questions prompt disputes in health clinics and courts, religious venues and voting booths, and private conversations and public protests. Often at the crux of such debates are differing views about what constitutes harm, and what types of benefits, if any, can outweigh that harm.

Although moral considerations of harms and benefits are well-marked features on the “terrain of public health ethics” (Childress et al., 2002 , 170), addressing them in the context of sexual and reproductive health can prove especially challenging in several respects. The first is that sexuality and reproduction frequently implicate personal preferences, sociocultural attitudes, and religious beliefs in ways that can provoke visceral responses and reveal deep—and sometimes irreconcilable—divides about what constitutes harm. Public policies and laws involving sex education, same-sex marriage, and abortion are notoriously contentious in this regard, because they collide with contested values related to sexual activity, marriage, and human life itself.

A second, related difficulty involves how to assess competing harms and benefits, particularly when they are incommensurate. Sex education in public schools is proven to reduce adolescent pregnancy and STI transmission, but opponents argue that it violates their religious liberty by normalizing premarital sex. How should decision-makers resolve conflicts between the harms set forth by each side? Are some harms, such as intrusion on religious liberty, absolute constraints on government action? Or can public health benefits justify such an intrusion in some circumstances? Without concrete ethical guidance (Childress et al., 2002 ), it is unclear how to resolve such conflicts.

These challenges are compounded when population benefits are offered as a justification for government interventions in sexuality and reproduction. Throughout history, governments have appealed to the common good to justify policies that employ coercion, incentives, and disincentives to alter fertility rates. Some policies have deprived individuals of their ability to reproduce, based on factors such as race, class, or perceived mental health (e.g., US state sterilization laws), while other policies have forced women to continue pregnancies (e.g., Romania’s ban on contraception and abortion) or terminate pregnancies (e.g., China’s one-child policy) against their will. Collectively, they are a reminder that governments, and those subject to their policies, may have conflicting views about what constitutes population benefit.

Self-determination

Self-determination is a significant determinant of sexual and reproductive health. Often used interchangeably with “autonomy,” self-determination is the individual freedom to live in accordance with one’s own values and decisions. Much of the literature about self-determination focuses on whether a specific individual has the rational capacity to make a certain decision, from a set of options, in an informed and reasonable manner and without external coercion. That model, however, can overlook the range of ways in which background social conditions—such as poverty and gender inequality—can limit, or even eliminate, an individual’s ability to exercise self-determination with regard to a particular choice (Sherwin, 1998 ).

In the context of sexual and reproductive health, a number of factors can affect self-determination, three of which are mentioned here. To make informed decisions, individuals must have access to comprehensive and scientifically accurate information . Evidence-based sex education for adolescents is critical in this respect, as it dispels myths, confronts biases, and fosters informed decision-making (Starrs et al., 2018 ). Conversely, policies that prevent the dissemination of information about abortion availability, as well as laws that require the distribution of scientifically inaccurate information (e.g., a claim that abortion increases the risk of breast cancer), undermine informed decision-making and self-determination.

To exercise self-determination, individuals must be respected as persons with authority to make choices about their sexual and reproductive life, without discrimination, coercion, or violence . Laws and customs that require spousal consent before married women can access contraception, abortion, and sterilization services deny women authority to determine if and when they will have children, and also fail to respect them as persons. Stigmatization, discrimination, and the threat of violence—as well as laws that criminalize same-sex sexual activity, ban same-sex marriage, and require sterilization before transgender and intersex people can obtain birth certificates that match their preferred gender—constrain the choices of people with nonconforming sexual orientations and identities. Cultural practices such as child marriage and female genital cutting can also negatively impact self-determination by precluding girls, and the women they will become, from decisions that profoundly affect their sexual and reproductive health.

Self-determination not only requires access to information and the authority to make choices, but also the socioeconomic means to access those choices . A woman who continues her pregnancy because she cannot afford an abortion, the cost of which may include travel to a distant clinic (sometimes more than once) and child care expenses, has not made a fully autonomous choice. Her socioeconomic circumstances limit her to one option: pregnancy.

Chapter Overviews

The chapters in this section of The Oxford Handbook of Public Health Ethics provide a public health ethics perspective in each of four areas of sexual and reproductive health: STI control measures, contraception, abortion, and pregnancy-related services.

In “ Sexually Transmitted Infections and Public Health Ethics ,” Mary A. Ott and John Santelli examine STI control, which the authors define as public health programs, policies, and practices that aim to prevent, treat, and limit the transmissibility of STIs. Mandatory reporting, contact tracing, and outreach education are examples of STI control activities. In striving to maximize population sexual health, however, STI control activities can pose significant ethical challenges. Ott and Santelli offer thoughtful approaches that strive to balance the sexual health and well-being of populations with the liberty and equality interests of individuals.

In “ Contraception and Public Health Ethics ,” Saumya RamaRao and John Townsend focus on contraception, not only as a core component of public health, but also as a locus for ethical conflict between population goals and individual rights. Relying on the ethical principles of respect for persons, beneficence, and justice, they explore how tensions between public health goals and individual rights unfold in two contexts: routine contraceptive services and contraceptive research. The authors highlight the consequences of these tensions for health systems, providers, and contraceptive users, optimistically concluding that the relevant stakeholders can manage these conflicts in ways that are beneficial to all.

In “ Abortion and Public Health Ethics ,” Mahmoud F. Fathalla offers a global public health ethics perspective on abortion. Given the magnitude of public health harms resulting from unsafe abortion, and the health inequities and social injustices stemming from insufficient access to safe abortion, Fathalla argues that the global community has an obligation to address, and ultimately eliminate, unsafe abortion. That responsibility is heightened, he contends, by women calling on governments to address unsafe abortion, an international consensus that eliminating unsafe abortion is central to the global reproductive agenda, and economic data demonstrating that greater access to safe abortion produces cost savings. Fathalla concludes that the global community must stand with women as they assert their right to health.

In “ Access to Pregnancy-Related Services: Public Health Ethics Issues ,” Anne Drapkin Lyerly, Elana Jaffe, and Margaret Olivia Little address ethical challenges that arise when the value or utility of pregnancy-related services are contested. They first identify features of pregnancy-related care that contribute to such conflicts. For example, some pregnancy-related services, such as pregnancy termination due to fetal abnormality, involve a complex interplay between public health programs (e.g., prenatal screening) and individual women’s values, which are known to differ. Using prenatal testing and modes of childbirth to ground their discussion, the authors explore how societal and cultural values affect access to pregnancy-related care.

Since the mid-1990s, the international community has made progress toward the goals set forth at the ICPD, but the promise of universal access to sexual and reproductive health services remains elusive in much of the world. Public health ethics sheds light on the moral complexities involved in achieving that goal. It recognizes that factors such as poverty and gender inequality can lead to a cycle of systematic disadvantage, in which sexual and reproductive ill health is the result, and the cause, of other deprivations. Public health ethics also highlights tensions that arise when sexual and reproductive health issues collide with contested values, and it draws attention to the far-reaching political, economic, and individual health implications of those conflicts. Despite, and because of, these challenges to achieving universal sexual and reproductive health, a renewed and bold commitment to the ICPD’s vision is essential.

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Comparative analysis of social media-based interventions for adolescent reproductive health education

Affiliation.

1 Department of Media Sciences, Tamil Nadu, India.
PMID: 38583070
DOI: 10.29063/ajrh2024/v28i3.9

This research paper explores the impact of social media-based interventions on adolescent reproductive health education, acknowledging the digital residency of today's youth. Utilizing a Solomon Four Group Design, the study assesses the efficacy of tailored interventions on various digital platforms, emphasizing the value, impact, and relevance of innovative educational approaches, particularly those employed by social media. The paper highlights adolescents' pervasive presence on social media, including platforms such as Instagram, Twitter, and Facebook as integral components of their online experiences. Leveraging these platforms for health education is considered crucial, aligning with adolescents' digital behaviors and preferences. Ethical challenges in the digital health domain are discussed, underscoring the importance of privacy, consent, and responsible content creation. To tailor interventions effectively, the research explores platform-specific preferences, recognizing the diverse usage patterns among adolescents. The paper concludes with a comprehensive analysis of the intervention's impact, revealing significant improvements in reproductive health knowledge among participants exposed to social media-based education. In essence, the paper advocates for the integration of health education into the digital spaces where adolescents naturally reside, recognizing the transformative potential of social media in enhancing reproductive health knowledge.

Cette étude examine l'impact des interventions en santé reproductive pour les adolescents basées sur les médias sociaux, tenant compte de la résidence numérique de la jeunesse d'aujourd'hui. En utilisant un modèle de conception à quatre groupes de Solomon, l'étude évalue l'efficacité des interventions personnalisées sur différentes plateformes numériques, mettant l'accent sur la valeur, l'impact et la pertinence des approches pédagogiques innovantes, en particulier celles utilisées par les médias sociaux. Le document met en évidence la présence omniprésente des adolescents sur les médias sociaux, y compris des plateformes telles qu'Instagram, Twitter et Facebook, en tant que composants intégraux de leurs expériences en ligne. L'utilisation de ces plates-formes pour l'éducation à la santé est considérée comme cruciale, s'alignant sur les comportements numériques et les préférences des adolescents. Les défis éthiques dans le domaine de la santé numérique sont discutés, soulignant l'importance de la confidentialité, du consentement et de la création responsable de contenu. Pour adapter efficacement les interventions, la recherche explore les préférences spécifiques à chaque plateforme, reconnaissant les différents schémas d'utilisation chez les adolescents. Le document se termine par une analyse complète de l'impact de l'intervention, révélant des améliorations significatives des connaissances en santé reproductive parmi les participants exposés à l'éducation basée sur les médias sociaux. En essence, le document plaide en faveur de l'intégration de l'éducation à la santé dans les espaces numériques où les adolescents résident naturellement, reconnaissant le potentiel transformateur des médias sociaux dans l'amélioration des connaissances en santé reproductive.

Keywords: Adolescent health education; Digital platforms; Ethical challenges; Reproductive health knowledge; Social media interventions.

Educational Status
Health Education
Reproduction
Reproductive Health
Social Media*

Introduction
Conclusions
Article Information

Responses exclude missing and not applicable responses (see eTable 2 in Supplement 1 ).

Prevalence ratios (PRs) are estimated via bivariate log-binomial regression (see eTable 5 in Supplement 1 ).

Prevalence ratios (PR) are estimated via bivariate log-binomial regression (see eTable 5 in Supplement 1 ). HBC indicates hormonal birth control.

eTable 1. Demographic Comparison of Participants in the California Pharmacist Survey (2022) With External Data (2013-2017)

eTable 2. Pharmacist Attitudes About Birth Control and Medication Abortion Provision in the California Pharmacist Survey (n = 316), 2022

eTable 3. Attitudes About Birth Control and Medication Abortion Provision in the California Pharmacist Survey (N = 919) by Participant Type, 2022

eTable 4. Pharmacy Provision of Hormonal Contraception by Characteristics of Pharmacists and Community Pharmacies in the California Pharmacist Survey, 2022

eTable 5. Attitudes About Medication Abortion by Characteristics of Pharmacists and Community Pharmacies in the California Pharmacist Survey, 2022

eTable 6. Barriers to Hormonal Contraceptive Provision Among Pharmacists Who Reported Working in a Community Pharmacy That Does Not Provide Self-Administered Hormonal Contraception Without an Outside Provider’s Prescription (n = 149), 2022

eTable 7. Barriers to Hormonal Contraceptive Provision Among Pharmacists Who Reported Working in a Chain or Independent Community Pharmacy That Does Not Provide Self-Administered Hormonal Contraception Without an Outside Provider’s Prescription by Pharmacy Type (n = 142), 2022

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Cohen C , Hunter LA , Beltran RM, et al. Willingness of Pharmacists to Prescribe Medication Abortion in California. JAMA Netw Open. 2024;7(4):e246018. doi:10.1001/jamanetworkopen.2024.6018

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Willingness of Pharmacists to Prescribe Medication Abortion in California

1 Center on Reproductive Health, Law, and Policy, UCLA (University of California, Los Angeles) School of Law
2 School of Public Health, University of California, Berkeley
3 Luskin School of Public Affairs, UCLA
4 Now with School of Public Health, University of Minnesota, Minneapolis
5 Now with Malkia Klabu Program, University of California, San Francisco
6 Williams Institute, UCLA School of Law

Question Are pharmacists in California willing to prescribe medication abortion?

Findings In this cross-sectional survey study of 316 California community pharmacists, 193 of 280 (69%) were willing to prescribe medication abortion if permitted by law, but only 139 of 288 (48%) were confident in their knowledge and 115 of 285 (40%) were confident in their ability to do so. Despite greater willingness and confidence to prescribe hormonal birth control, only 144 of 308 pharmacists (47%) worked in pharmacies that provided these prescriptions; those who worked at pharmacies that did not provide these prescriptions reported knowledge or training, staffing or time, and payment for services as barriers.

Meaning These findings suggest that most pharmacists in California would be willing to prescribe medication abortion if legally permitted to do so; however, training and attention to pharmacy-level barriers may be needed.

Importance Nearly half of US states have restricted abortion access. Policy makers are exploring pathways to increase access to abortion and reproductive health care more broadly. Since 2016, California pharmacists could prescribe hormonal birth control, providing an opportunity to learn about the implementation of pharmacist-provided reproductive health care.

Objective To explore the feasibility of broadening pharmacist scope of practice to include prescribing medication abortion.

Design, Setting, and Participants A cross-sectional online survey was conducted from October 11 to December 20, 2022, among a convenience sample of California licensed community pharmacists to examine their attitudes toward, knowledge of, and confidence in prescribing hormonal birth control and reports of pharmacy-level practices.

Main Outcomes and Measures Descriptive analyses and log-binomial regression models were used to compare medication abortion and contraceptive provision attitudes by pharmacist and pharmacy characteristics.

Results Among the 316 pharmacists included in the analysis who worked at community pharmacies across California (mean [SD] age, 40.9 [12.0] years; 169 of 285 [59.3%] cisgender women; and 159 of 272 [58.5%] non-Hispanic Asian individuals), most (193 of 280 [68.9%]) indicated willingness to prescribe medication abortion to pharmacy clients if allowed by law. However, less than half were confident in their knowledge of medication abortion (139 of 288 [48.3%]) or their ability to prescribe it (115 of 285 [40.4%]). Pharmacists who indicated that providing access to hormonal birth control as a prescribing provider was important (263 of 289 [91.0%]) and were confident in their ability to prescribe it (207 of 290 [71.4%]) were 3.96 (95% CI, 1.80-8.73) times and 2.44 (95% CI, 1.56-3.82) times more likely to be willing to prescribe medication abortion and to express confidence in doing so, respectively. Although most pharmacists held favorable attitudes toward hormonal birth control, less than half (144 of 308 [46.8%]) worked in a pharmacy that provided prescriptions for hormonal birth control, and 149 who did not reported barriers such as lack of knowledge or training (65 [43.6%]), insufficient staff or time to add new services (58 [38.9%]), and lack of coverage for services (50 [33.6%]).

Conclusions and Relevance The findings of this cross-sectional survey study of California pharmacists suggest that most pharmacists were willing to prescribe medication abortion. However, future efforts to expand pharmacists’ scope of practice should include training to increase knowledge and confidence in prescribing medication abortion. Pharmacy-level barriers to hormonal birth control prescription, such as insurance coverage for pharmacist effort, should also be addressed, as they may serve as barriers to medication abortion access.

Following the US Supreme Court’s decision in Dobbs v Jackson Women’s Health, half of states have banned or severely restricted abortion care or are expected to do so. 1 As a result, clinicians in states where abortion remains legal are facing increased demand for services. 2 , 3 Policy makers are exploring how to increase access to abortion services and reproductive health care more broadly, while also contending with COVID-19–induced clinician burnout and workforce shortages. 4 , 5

Medication abortion accounts for more than half (54%) of all abortions in the US 6 and consists of a regimen of 2 medications—mifepristone and misoprostol—taken within days of each other. 7 Mifepristone has historically been subject to strict regulation under the US Food and Drug Administration Risk Evaluation and Mitigation Strategies program, which regulates how and where the drug can be dispensed, and by whom. 8 These federal regulations on mifepristone recently changed to remove a prior Risk Evaluation and Mitigation Strategies requirement that mifepristone be dispensed in person by a certified prescriber and to allow pharmacists at certified retail pharmacies to dispense mifepristone. 9 Provision of medication abortion in pharmacies thus represents an opportunity to increase access to abortion care and reduce the burden on the health care system. Although multiple lawsuits implicating the legal status of mifepristone and the conditions under which it can be dispensed have been filed across the country, an emergency order from the Supreme Court keeps regulations governing mifepristone unchanged while litigation is ongoing. 10

Both the American Medical Association and American College of Obstetricians and Gynecologists have expressed support for pharmacists dispensing medication abortion, 11 , 12 and pilot programs have shown that pharmacists can safely and effectively do so. 13 , 14 In these pilot programs, patients who received pharmacist-provided abortion medication and follow-up care reported having satisfactory abortion experiences. 13 , 14 Additionally, previous studies conducted in the US and Canada, 14 - 20 where dispensing of medication abortion by pharmacists has been legal since 2017, demonstrate pharmacists’ willingness to dispense medication abortion. Among US-based pharmacists, benefits to dispensing medication abortion include the ability to expand abortion access to patients, improve patients’ quality of care, streamline delivery of health care services, and make use of pharmacists’ expertise. 14 , 15 Pharmacists also identified potential barriers to medication abortion dispensing such as employer hesitancy, a lack of private space for patient consultations, safe follow-up for postabortion care, adequate staffing and training needs, established reimbursement mechanisms for medication abortion–related services, and having colleagues with religious, political, or personal objections to providing medication abortion. 14 , 16 , 20 Studies conducted in Canada found similar barriers to dispensing medication abortion among pharmacists, with the addition of having low demand among patients, drug shortages, and short expiration dates. 17 - 19 Indeed, more information is needed to inform public health efforts to expand the provision of medication abortion. Twenty-seven states, including California, currently allow pharmacists to prescribe hormonal contraceptives, affording a unique opportunity to learn about this pathway to reproductive health services. 21

This survey project, the California Pharmacist Study, gathered information about attitudes toward reproductive health services and medication abortion, the availability of pharmacist-prescribed self-administered hormonal contraceptives, and pharmacy-level contraceptive implementation obstacles from licensed community pharmacists. We hypothesized that pharmacists who held favorable attitudes and practices toward pharmacist-provided hormonal birth control would be more likely to hold favorable attitudes toward medication abortion. Information about implementation experiences with pharmacist prescription of hormonal birth control, which has been legal in California for nearly a decade, is presented and discussed relative to the potential to include medication abortion under an expanded scope of practice.

The cross-sectional California Pharmacist Study survey was conducted between October 11 and December 20, 2022, with a convenience sample of pharmacists and pharmacy students 18 years and older who reside in the State of California. A target sample size of 1000 was selected to enable comparisons of sexual and reproductive health service availability and training needs across regions of the state (ie, Los Angeles County, Greater Bay Area, other urban areas, and rural areas) with differing health service landscapes. A multistage recruitment plan included both online and in-person recruitment. In the first phase, participants were recruited through the California Society of Health-System Pharmacists and California Pharmacists Association membership email listservs and newsletters. Information about the study was distributed through flyers and presentations at the annual meetings of the American College of Clinical Pharmacy and the California Society of Health-System Pharmacists. During the second phase of recruitment, the survey link was shared on the social media channels of the California Society of Health-System Pharmacists and California Pharmacists Association and professional groups representing pharmacists in specific regions (eg, California’s rural Central Valley) and pharmacists of specific racial and ethnic identities (eg, Black or African American pharmacists).

Approval for this study was granted by the Office of the Human Research Protection Program Institutional Review Board at UCLA, with partner organizations holding reliance agreements. All participants indicated their consent to participate in Qualtrics after reviewing an information sheet and before initiating the survey; a waiver of written consent was obtained for study. This study followed the American Association for Public Opinion Research ( AAPOR ) reporting guidance for survey studies.

The survey was developed through an iterative process that included drafting by a core multidisciplinary team, feedback from the larger project team of pharmacist researchers and students, revision, and final review and edits to ensure question clarity and relevance to pharmacy practice and policy. Survey modules included demographic information (eg, self-reported age, sex assigned at birth, gender, race, Hispanic ethnicity); professional information (years of experience, training, whether currently practicing); knowledge, attitudes, and confidence in pharmacist prescribing of hormonal contraception, emergency contraception, and medication abortion; and pharmacy information (availability of pharmacist-prescribed reproductive health resources, implementation barriers, client characteristics).

Questions about sex assigned at birth and gender were used to classify respondents as cisgender women, cisgender men, and gender-fluid or nonbinary individuals; those who provided concordant responses to sex assigned at birth and gender were considered cisgender. Race options (select all that apply) included American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, White, other (specify), or prefer not to state. Participants were also asked if they identify as Hispanic or Latino. Participants were first classified as Hispanic or non-Hispanic. Non-Hispanic respondents were then categorized by single race selected or as multiracial. The demographic characteristics of pharmacists, including but not limited to race and ethnicity, may be correlated with attitudes toward reproductive health care and the demographic composition of pharmacy catchment areas and thus are relevant to understanding access to care.

After providing informed consent, participants completed a self-administered online Qualtrics survey. After completing the survey, participants had the option to enter their email address to receive a $20 gift card and/or enter weekly ($250) or grand prize ($500) raffles. Given that surveys administered online with monetary incentives are a common target of bot attacks, 22 automated fraud detection features offered by Qualtrics were used to identify and later exclude duplicate responses and bots. Only participants verified as valid following data cleaning procedures were included in the sample and were eligible for gift cards and raffle prizes.

Analyses were restricted to participants who reported being licensed and were currently or most recently working in a community pharmacy. This group of pharmacists was able to report on the availability of reproductive health resources and services in settings that are widely accessible to the public and represent those who can serve as a vehicle for distribution to the public (vs those who work, for example, in hospitals, mail order, or home care or who are in training and have yet to select an employment setting). However, to understand the broader views of this community of professionals, we also examined attitudes around contraception and medication abortion provision among all surveyed pharmacists and pharmacy students.

Descriptive analyses, including proportions (excluding missing and not applicable responses) with binomial or multinomial 95% CIs, were estimated. Log-binomial regression models were used to generate unadjusted prevalence ratios (PRs) comparing (1) participants’ report of whether their pharmacy provides self-administered hormonal contraception without an outside clinician’s prescription and (2) participants’ attitudes around medication abortion provision, by participant and pharmacy characteristics. All analyses were conducted in R, version 4.2.1 (R Project for Statistical Computing).

Out of the full sample of 919 participants, 316 reported being licensed pharmacists and were currently or most recently working in a community pharmacy. Of these 316 participants, the mean (SD) age was 40.9 (12.0) years (eTable 1 in Supplement 1 ). Among the 285 participants with available information, 169 (59.3% [95% CI, 53.7%-65.4%]) were cisgender women, 114 (40.0% [95% CI, 34.4%-46.1%]) were cisgender men, and 2 (0.7% [95% CI, 0.0-6.8%]) were gender-fluid or nonbinary. Among the 272 participants with race and ethnicity information available, 159 (58.5% [95% CI, 52.6%-64.6%]) were non-Hispanic Asian, 84 (30.9% [95% CI, 25.0%-37.0%] were non-Hispanic White, and 29 (10.7% [95% CI, 4.8%-16.8%]) were of other race or ethnicity (including Black or African American, Hispanic or Latino, Native Hawaiian or other Pacific Islander, multiracial, or other) ( Table ). Participants were demographically similar to California pharmacists (eTable 1 in Supplement 1 ). One hundred twenty-five of 296 participants (42.2% [95% CI, 36.5%-48.0%]) indicated that they could provide services in at least 1 language other than English ( Table ). Over half of participants (176 [55.7% (95% CI, 50.3%-61.6%)]) worked at chain pharmacies and 131 (41.5% [95% CI, 36.1%-47.4%]) worked at independent pharmacies in regions across California. Nearly half (144 of 296 [48.6% (95% CI, 42.9%-54.9%)]) worked at pharmacies where Medi-Cal was the primary insurance held by most clients.

As shown in Figure 1 , the community pharmacists surveyed in this project held favorable attitudes toward pharmacist-provided birth control, including hormonal birth control (263 of 289 [91.0% (95% CI, 87.1%-94.0%)] in favor) and emergency contraception (272 of 294 [92.5% (95% CI, 88.9%-95.3%)] in favor) (eTable 2 in Supplement 1 ). Slightly fewer participants reported confidence in their knowledge of hormonal birth control (249 of 296 [84.1% (95% CI, 79.5%-88.1%)]) and ability to prescribe birth control (207 of 290 [71.4% (95% CI, 65.8%-76.5%)]) than agreed that providing access to hormonal birth control as a prescribing provider was important (91.0%). Most participants (213 of 287 [74.2% (95% CI, 68.7%-79.2%)]) indicated their willingness to prescribe hormonal birth control to all pharmacy clients, regardless of age (in keeping with California law). Few participants indicated that prescribing birth control would violate their religious beliefs (32 of 276 [11.6% (95% CI, 8.1%-16.0%)]) or would mean that they are endorsing a lifestyle they do not support (26 of 284 [9.2% (95% CI, 6.1%-13.1%)]). Findings were similar in the broader sample of 919 pharmacists (eTable 3 in Supplement 1 ).

Slightly less than half of pharmacists (144 of 308 [46.8% (95% CI, 41.2%-52.9%)]) reported that the community pharmacy in which they work provided prescriptions for self-administered hormonal contraception (eg, birth control pills, patch, ring, or injection) ( Table ). Fewer pharmacists employed by independent pharmacies reported that their pharmacy furnished these prescriptions than those employed by chain pharmacies (51 of 127 [40.2%] vs 93 of 174 [53.4%]; prevalence ratio [PR], 0.75 [95% CI, 0.58-0.97]) (eTable 4 in Supplement 1 ). Slightly more than three-quarters of participants (243 of 308 [78.9% (95% CI, 74.7%-83.5%)]) reported that the pharmacies where they worked offered levonorgestrel emergency contraception (eg, Plan B One-Step) without an outside clinician’s prescription (ie, over-the-counter or pharmacist prescribed).

Most pharmacists (193 of 280 [68.9% (95% CI, 63.1%-74.3%)]) indicated that they would be willing to prescribe medication abortion to pharmacy clients if it were allowed by law ( Figure 1 and eTable 2 in Supplement 1 ). However, slightly less than half (139 of 288 [48.3% (95% CI, 42.4%-54.2%)]) were confident in their knowledge of medication abortion and only 115 of 285 (40.4% [95% CI, 34.6%-46.3%]) were confident in their ability to prescribe medication abortion.

Associations between pharmacist and pharmacy characteristics and attitudes toward medication abortion are displayed in Figure 2 and Figure 3 (eTable 5 in Supplement 1 ). A slightly larger proportion of non-Hispanic White pharmacists indicated a willingness to prescribe abortion medication if it were allowed by law than their non-Hispanic Asian peers (PR, 1.27 [95% CI, 1.08-1.50]) ( Figure 2 ). Larger proportions of pharmacists 45 years or older than those aged 20 to 34 years (PR, 1.46 [95% CI, 1.01-2.12]) and those who worked at independent pharmacies than those who worked in chain pharmacies (PR, 1.38 [95% CI, 1.04-1.82]) expressed confidence in their ability to prescribe abortion medications.

As hypothesized, pharmacist attitudes toward hormonal and emergency contraception were positively associated with attitudes toward medication abortion ( Figure 3 ). Pharmacists who agreed that providing access to hormonal contraception as a prescribing provider is important were 3.96 (95% CI, 1.80-8.73) times as likely to indicate willingness to prescribe abortion medication to pharmacy clients if allowed by law than those who disagreed. Those who were confident in their ability to prescribe birth control were 2.44 (95% CI, 1.56-3.82) times as likely to report confidence in their ability to prescribe abortion medication than those who were not. Although few pharmacists (n = 26) agreed that prescribing hormonal birth control would mean endorsing a lifestyle they do not support, those who did were more likely to report confidence in their ability to prescribe abortion medication (PR, 1.62 [95% CI, 1.13-2.34]).

Among participants at pharmacies that did not provide self-administered hormonal contraception (n = 149), the most frequently endorsed barriers to doing so were lack of knowledge or training (65 [43.6% (95% CI, 35.6%-51.7%)]), insufficient staff or time to add new services (58 [38.9% (95% CI, 31.5%-47.3%)]), and lack of insurance coverage for service provision (50 [33.6% (95% CI, 26.2%-41.3%)]) (eTable 6 in Supplement 1 ). Liability concerns (33 [22.1% (95% CI, 16.1%-29.0%)]), difficulty obtaining medical history (28 [18.8% (95% CI, 13.4%-25.4%)]), and not enough demand for the service among clients (27 [18.1% (95% CI, 12.8%-24.6%)]) were reported by some participants. Relatively few participants reported difficulty verifying medical eligibility (12 [8.1% (95% CI, 4.7%-12.6%)]), personal beliefs (10 [6.7% (95% CI, 3.4%-10.5%)]), and other barriers (4 [2.7% (95% CI, 0.7%-5.0%)]). Pharmacists who worked in chain pharmacies more often endorsed not enough staff or time to add services as a barrier to pharmacist-prescribed hormonal birth control than their peers who worked in independent pharmacies (36 of 72 [50.0%] vs 20 of 70 [28.6%]; PR, 1.75 [95% CI, 1.13-2.71]) (eTable 7 in Supplement 1 ).

Most licensed California pharmacists working at community pharmacies who participated in this study (68.9%) indicated their willingness to prescribe medication abortion if it were allowed by law. However, fewer than half were confident in their knowledge of or ability to prescribe abortion medication. Pharmacists who believed that prescribing hormonal birth control was important were also likely to report that they were willing to provide medication abortion, as hypothesized. Similarly, pharmacists who felt confident in their knowledge of and ability to prescribe self-administered hormonal birth control were also more confident in their knowledge of and ability to prescribe medication abortion. Taken together, these findings suggest that pharmacies may be a feasible channel for the provision of medication abortion.

Despite high levels of pharmacist support for pharmacist-prescribed hormonal birth control observed in this study—consistent with past studies 23 —slightly less than half of licensed, community pharmacists (46.8%) reported that the pharmacy in which they work provided prescriptions for self-administered hormonal contraception (eg, birth control pills, patch, ring, or injection). In this study, we observed that more chain pharmacies offered pharmacist-provided hormonal contraception than independent pharmacies. Prior studies 24 - 27 have similarly found that chain pharmacies are more likely to provide emergency contraception without restrictions (over-the-counter and without security barriers). This suggests that chain pharmacies are more experienced in providing reproductive health care medications directly to clients. Furthermore, the corporate structure behind chain pharmacies may be responsible for reducing barriers, as policies can be set at the corporate level to facilitate access, and greater financial resources could enable stocking of over-the-counter medications. 28

In this study, we also observed that emergency contraception was far more available than pharmacist-prescribed hormonal birth control; however, nearly one-fifth of community pharmacists indicated that emergency contraception was not available where they worked without an outside clinician’s prescription, despite its availability as an over-the-counter product. This finding is consistent with those from a 2017 secret shopper study conducted in Los Angeles County 29 that found that over-the-counter emergency contraception was not available at approximately 23% of pharmacies. Recent studies suggest that the availability of over-the-counter emergency contraception may be even more limited elsewhere in the US. 24 , 28 , 30 - 32

California was one of the first states to expand pharmacist scope of practice to include furnishing contraception, which is now permitted in 27 states plus the District of Columbia. 21 Although California was an early pioneer in this area, implementation lagged behind policy change: 1 year after implementation, only 5.1% of California pharmacists reported furnishing hormonal contraception 33 ; 3 years in, 11% of Los Angeles County pharmacies reported implementation. 29 Levels of implementation have varied between states (eg, 19% in New Mexico 2 years after the change in law, and 31% in Hawaii and 46% in Oregon 3 years post expansion) 34 , 35 indicating that significant opportunities to expand access to contraception remain. Across states, consistent with our findings, pharmacists reported barriers to incorporating hormonal contraception into their practice, including training needs, payment for pharmacist services, time and staff constraints, and liability concerns. 23 , 36 , 37

In this study, we observed that slightly fewer Asian pharmacists than White pharmacists indicated a willingness to prescribe abortion medication. Given that the race and ethnicity of pharmacists may be correlated with the demographic composition of pharmacist catchment areas, future efforts to ensure access to reproductive health services should be attentive to area sociodemographic composition. Lessons learned in Oregon suggest that state efforts to support implementation can increase access to contraception beyond the passage of laws and across the state. 38 Before the law took effect, the state convened a task force to identify potential barriers and to guide implementation. Within 12 months of expanded pharmacist practice, 63% of zip codes in Oregon had a pharmacist who prescribed contraception.

A strength of this study is that the involvement of pharmacists in the study design and implementation increases confidence that the data gathered have the potential to inform pharmacy practice. Additionally, the survey was implemented using rigorous, best-practice procedures to ensure data integrity for internet research.

This study also has some limitations. We relied on pharmacist reports of pharmacy practice to ascertain the availability of pharmacist-prescribed hormonal birth control, which renders the study vulnerable to information bias. 39 Pharmacists who themselves provide a service may be more likely to report that the pharmacy offers the service than those who have not provided the service themselves (but may lack information about store practice). Another consideration is the possibility that pharmacists were clustered within pharmacies, which, if present, could affect tests of statistical significance. Detailed workplace information (ie, name and street address) was not collected. However, 243 of 313 participants (77.6%) who reported a zip code for their pharmacy did not share it with any other participant working in the same type of pharmacy (eg, chain, independent). Thus, our analyses suggest that most participants were the only respondent from their pharmacy.

The use of nonprobability methods to gather data, and the associated risk of selection bias, 39 is another study limitation. It is possible that our results may not be representative of the attitudes and perspectives of the larger population of licensed community pharmacists in California. However, the age, gender, and racial and ethnic distribution of the sample is similar to that of California pharmacists more broadly (eTable 1 in Supplement 1 ), and the geographic distribution of participants’ pharmacies mirrors the population distribution of California, 40 providing some evidence in support of the demographic representativeness of our sample.

The findings of this cross-sectional survey study suggest that most pharmacists in California would be willing to prescribe medication abortion in the future, were they legally permitted to do so. However, efforts to expand provider scope of practice to increase abortion access would likely need to address moderate levels of confidence in, knowledge of, and ability to prescribe medication abortion. Furthermore, legislative efforts to expand abortion access through an expanded scope of practice for pharmacists should be informed by experience with California law SB 493, which has allowed them to prescribe hormonal birth control since 2016. Although most pharmacists held favorable attitudes toward pharmacist-provided hormonal contraception, just under half of participants (46.8%) report that the community-based pharmacies in which they work offer this service.

Implementation barriers identified through this study, and prior research, including lack of pharmacist knowledge, insufficient staff to add new services, and lack of insurance coverage for service provision, can be addressed through the development of sexual and reproductive health service training plans and expanded insurance payment for pharmacist-provided services. Findings also suggest that pharmacies and pharmacists who are already prescribing birth control are likely to be early adopters of pharmacist-prescribed medication abortion and could be prioritized in any future rollout. Finally, studies that draw large probability samples of community pharmacists and include embedded validation studies (eg, secret shopper, interviews with pharmacy owners or chain managers) are recommended. Such surveys could be part of a system to monitor reproductive health service and product availability in the state.

Accepted for Publication: February 13, 2024.

Published: April 10, 2024. doi:10.1001/jamanetworkopen.2024.6018

Corresponding Author: Kerith J. Conron, ScD, Williams Institute, UCLA School of Law, 1060 Veteran Ave, Ste 134, Los Angeles, CA 90024 ( [email protected] ).

Author Contributions: Dr Hunter had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr Beltran and Ms Serpico contributed equally.

Concept and design: Hunter, Beltran, Packel, Ochoa, McCoy, Conron.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Cohen, Hunter, Beltran, Serpico, Ochoa, Conron.

Critical review of the manuscript for important intellectual content: Hunter, Beltran, Serpico, Packel, Ochoa, McCoy, Conron.

Statistical analysis: Hunter.

Obtained funding: Ochoa.

Administrative, technical, or material support: Cohen, Hunter, Beltran, Serpico, Packel, Ochoa, McCoy.

Supervision: Cohen, Packel, Ochoa, McCoy, Conron.

Conflict of Interest Disclosures: Ms Ochoa reported receiving grant funding from the Williams Institute, UCLA School of Law, during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was conducted by the California HIV/AIDS Policy Research Centers with faculty from University of California, Berkeley, and UCLA and supported by the California HIV/AIDS Research Program, grants H21PC3466 and H21PC3238 from the University of California Office of the President, and the UCLA Center on Reproductive Health, Law, and Policy, with additional support by grant T32MH080634 from the National Institute of Mental Health (Dr Beltran).

Role of the Funder/Sponsor: The University of California Office of the President and the National Institute of Mental Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Employees of the the UCLA Center on Reproductive Health, Law, and Policy participated in study design and implementation and manuscript development.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: This study would not have been possible without the recruitment support of the California Society of Health-System Pharmacists and California Pharmacists Association. We are grateful for the thoughtful leadership of Ian W. Holloway, PhD (Luskin School of Public Affairs, University of California, Los Angeles) (salary support), California Pharmacist Study Co-Principal Investigator, and for the contributions of Orlando Harris, PhD (School of Nursing, University of California, San Francisco), Loriann De Martini, PharmD (California Society of Health-System Pharmacists), Sally Rafie, PharmD (Birth Control Pharmacist, San Diego, California, University of California San Diego Health) (paid consultant), Pooja Chitle, MPH (School of Public Health, University of California Berkeley) (salary support), Donald Kishi, PharmD (School of Pharmacy, University of California, San Francisco), Craig Pulsipher, MPP, MSW (formerly of APLA Health, Los Angeles, CA, currently at Equality California), Dorie Apollonio, PhD (School of Pharmacy, University of California, San Francisco), Betty Dong, PharmD (School of Pharmacy, University of California, San Francisco), Jerika Lam, PharmD (School of Pharmacy, Chapman University), Kim Koester, PhD (Department of Medicine, University of California, San Francisco), Tam Phan, PharmD (Alfred E. Mann School of Pharmacy & Pharmaceutical Sciences, University of Southern California), Robert Gamboa, MPP (Los Angeles LGBT Center), Richard Salazar, MPH (Los Angeles County Department of Public Health), and Amanda Mazur, MS (School of Public Health, University of California Berkeley) (salary support) to survey development and input on recruitment strategies. Amanda Mazur also assisted with survey implementation and monitoring. Unless otherwise indicated, these contributors did not receive additional compensation for this work.

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A global review on the abundance and threats of microplastics in soils to terrestrial ecosystem and human health

Shi, Wenshan
Zhang, Zengli
Liu, Yuting
Chen, Jingsi

Soil is the source and sink of microplastics (MPs), which is more polluted than water and air. In this paper, the pollution levels of MPs in the agriculture, roadside, urban and landfill soils were reviewed, and the influence of MPs on soil ecosystem, including soil properties, microorganisms, animals and plants, was discussed. According to the results of in vivo and in vitro experiments, the possible risks of MPs to soil ecosystem and human health were predicted. Finally, in light of the current status of MPs research, several prospects are provided for future research directions to better evaluate the ecological risk and human health risk of MPs. MPs concentrations in global agricultural soils, roadside soils, urban soils and landfill soils had a great variance in different studies and locations. The participation of MPs has an impact on all aspects of terrestrial ecosystems. For soil properties, pH value, bulk density, pore space and evapotranspiration can be changed by MPs. For microorganisms, MPs can alter the diversity and abundance of microbiome, and different MPs have different effects on bacteria and fungi differently. For plants, MPs may interfere with their biochemical and physiological conditions and produce a wide range of toxic effects, such as inhibiting plant growth, delaying or reducing seed germination, reducing biological and fruit yield, and interfering with photosynthesis. For soil animals, MPs can affect their mobility, growth rate and reproductive capacity. At present epidemiological evidences regarding MPs exposure and negative human health effects are unavailable, but in vitro and in vivo data suggest that they pose various threats to human health, including respiratory system, digestive system, urinary system, endocrine system, nervous system, and circulation system. In conclusion, the existence and danger of MPs cannot be ignored and requires a global effort.

Microplastics;
Terrestrial ecosystem;
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J Family Reprod Health
v.9(1); 2015 Mar

A Comparative Study on Knowledge about Reproductive Health among Urban and Rural Women of Bangladesh

Monoarul haque.

1 Department of Community Nutrition, Faculty of Public Health, Bangladesh University of Health Sciences (BUHS) Dhaka, Bangladesh

Sharmin Hossain

2 Department of Health Promotion & Health Education, Bangladesh University of Health Science (BUHS), Dhaka, Bangladesh

Kazi Rumana Ahmed

Taslima sultana.

3 Department of Public Health, State University of Bangladesh, Dhaka, Bangladesh

Hasina Akhter Chowdhury

4 Department of Biostatistics, Bangladesh University of Health Sciences (BUHS), Dhaka, Bangladesh

Jesmin Akter

5 Department of Reproductive and Child Health, Bangladesh University of Health Sciences (BUHS), Dhaka, Bangladesh

Objective: To compare the level of knowledge on reproductive health among urban and rural women of selected area of Bangladesh.

Materials and methods: A descriptive cross-sectional study was undertaken among 200 women selected purposively from different rural and urban areas of Bangladesh. Data were collected using a semi-structured interviewer-administered questionnaire by face to face interview. Knowledge level was analyzed according to poor, moderate and good knowledge by pre-defined knowledge scoring.

Results: Mean age of the respondents was 26 years and majority (66%) of them was housewives. Most of them (61%) had completed their primary level education. Around three-fourth of them belongs to lower-middle income group. Overall level of reproductive health knowledge was more evident among urban reproductive aged women than rural counterparts (p < 0.001). Moreover, significant knowledge gap was found regarding family planning (p = 0.005), care during pregnancy (p < 0.001), safe motherhood (p = 0.002), newborn care (p = 0.009) and birth spacing (p <0.001) between urban and rural women. Family members were the major source of information in both groups.

Conclusion: A wide knowledge gap was found between Bangladeshi urban and rural respondents regarding their reproductive behaviors. Government and concerned organizations should promote and strengthen various health education programs to focus on reproductive health, especially among reproductive aged women in rural area.

Introduction

Reproductive health has been a great concern for every woman. It is a crucial part of general health and a central feature of human development. Reproductive ill-health have been a apprehension to many stakeholders as maternal mortality and morbidity are very high in developing countries, especially in Bangladesh compared to developed world. In the past few years, the issues of Reproductive Health/Rights (RH/RR) have been increasingly perceived as social problems; they have emerged as a matter of increasing concern throughout the developed and developing countries. Bangladesh has achieved remarkable progress in important aspects of health and family welfare since Independence. However, the overall health status, particularly the status of reproductive health, still remains unsatisfactory ( 1 ). The insufficient health services available to women and children are evident from high infant and maternal mortality rates ( 2 , 3 ).

The common health problems faced by both rural and urban women of Bangladesh are lower abdominal pain accompanied by heavy bleeding, white discharge and irregularity of the menstrual cycle ( 4 , 5 ). The major concern, though, is that they do not discuss these since they do not consider these normal illnesses. Although urban educated women sometimes visit doctors, but women in rural areas are taken to some traditional healers, like Kabiraj/Hakim, who prescribes Tabij and herbal medicines, Pir (saints), Fakir (religious persons) or Huzurs (mullah), who prescribes Panipora (sanctiﬁed water) ( 5 ). Family planning helps women to protect from unwanted pregnancies, thereby saving them from high risk pregnancies or unsafe abortions.

Health knowledge is considered as one of the key factors that enable women to be aware of their rights and health status in order to seek appropriate health services. It is very important to study the overall situation and to know the differences between rural and urban Bangladeshi women in order to focus on reproductive health issues. The results could be used as an important guide to assist policymakers and administrators in evaluating and designing the programs and strategies for improving reproductive health services with a special consideration for rural women.

Modern facilities, such as TV, radio, newspaper, etc., have played a vital role to ensure the reproductive health of the respondents. Possession of modern facilities is a very important issue for a society, and a society with enough modern facilities is more developed, while people enjoy their reproductive health. Consequently, mass media such as radio and television can create awareness about issues affecting the daily life, family planning programs, poverty alleviation programs, gender issues, human rights issues, etc.

The focus of this study, therefore, was to find out the level of knowledge regarding reproductive health among rural and urban women of Bangladesh.

Materials and methods

A cross sectional study was conducted among 200 reproductive age group women (15-49 years), whereas 100 respondents were randomly selected from urban community of Dhaka and rest of 100 were selected from rural community of Sirajgonj. This area was selected purposively to get adequate sample. The study subjects were included women who sought reproductive health services in the health facilities like antenatal care, self immunization during pregnancy, child immunization, choice of family planning methods and safe abortions, and who were willing to participate and to provide required information. Physical and mental retarded people and very sick were excluded from the study. The study consisted of both data gathered by structured and semi structured questionnaires and in depth interviews with Bangladeshi women. The field work was conducted from April to July 2013 in four clinics/hospitals providing reproductive health care for women from the two districts: Dhaka and Sirajgonj. Out of the four hospitals, two were selected from urban areas in Dhaka City Corporation (Marie Stopes Clinic and Dhaka Medical College Hospital, Dhaka), and other two hospitals were selected from rural community of Sirajgonj (Kamarkhando and Belkuchi Upazilla Health Complex, Sirajgonj), which was about eighty kilometers away from Dhaka. The socioeconomic scenario of rural areas of Bangladesh were almost same all over the country with lack of roads, transportations, sanitary facilities, electric supply, women education, and women empowerment, while they have less access to mass media, newspapers, health service facilities and so forth. The clinics/hospitals were selected purposively, and from one clinic/hospital, fifty respondents were interviewed. The respondents were selected consecutively who meet the inclusion and exclusion criteria. Data were collected by interviewer-administered questionnaires. The socio-economic classification in this study was made according to 2006 Gross National Income (GNI) per capita using the calculation of World Bank (WB) ( 6 ) [The groups were: low-income $75.41 or less (BDT ≤ 5360), lower middle-income $75.5 - $299.58 (BDT 5361-21270), upper middle-income $299.68 - $926.25 (BDT 21271-65761) and high-income $926.33 or more (BDT ≥ 65762)]. It is noteworthy that scores 0 and 1 were allocated to each of the questions of reproductive knowledge. Three categories were defined on the basis of the score obtained by each participant: poor (<50% of the total score), moderate (50%-70% of the total score), and good (>70% of the total score). After collection, data were checked thoroughly for consistency and completeness, and all analysis was done by appropriate statistical methods using Statistical Package for Social Sciences (SPSS ; SPSS Inc., Chicago, IL, USA) software for Windows version 16.0. Univariate and bivariate analysis were done as appropriate to show results.

The study results revealed that among the 200 respondents, mean (± SD) age of them was 26±5 years. Among the respondents, 50% belonged to urban and another 50% were from rural areas. Most of them (61%) had primary education; this was followed by those who (9%) had higher secondary level of education. Preponderance of housewives (66%) was observed, whereas rest of them was involved with NGO job, garments work and student. Majority of the respondents belonged to lower middle income family (77%), and only 1% was from high income family ( Table 1 ).

Socio-demographic information of the respondents (n = 200)

Results are expressed as number (%) and Mean ±SD

The figure shows the proportion of poor knowledge regarding reproductive health was more (84%) among rural women, but good knowledge was more rampant (75%) among urban women. The overall knowledge difference between urban and rural women regarding reproductive health were highly significant (p < 0.001) ( Figure 1 ).

An external file that holds a picture, illustration, etc.
Object name is JFRH-9-35-g001.jpg

Overall Level of Knowledge on reproductive

health among urban and rural women (χ2 = 41.737; p < 0.001)

The extent of respondent’s knowledge on different components of reproductive health showed that rural women had less knowledge on family planning than urban women. Family planning refers to deliberate efforts of couples or individuals to regulate fertility by delaying or spacing births or limiting the number of their children. Significant association was found between location of respondents and knowledge on family planning (p = 0.005). Knowledge regarding contraceptive method use reveals that everybody had better knowledge on contraceptive use. Around 88% rural women had moderate knowledge on contraception. But in terms of good knowledge, urban women went ahead than rural women. Overall Level of Knowledge score did not differ between groups (p = 0.542) ( Table 2 ).

Level of Knowledge on different components of reproductive health among urban and rural women (n = 200)

Results were expressed as frequency percentage; χ2 test was performed and p < 0.05 was level of significance.

Moreover, table 2 indicates that urban women had (56%) good knowledge on care during pregnancy. But in case of safe motherhood, both urban (96%) and rural (83%) women had good knowledge (p = 0.002). Urban women (40%) had good knowledge on new born care where 18% rural women had no knowledge regarding it, and the difference was significant (p = 0.009). Around 72% and 70% urban and rural women had good knowledge on safe abortion, respectively. However, it is cheering that a total of 90% urban women had good knowledge on birth spacing and family size, but around one-third (36%) of rural women did not have any knowledge on birth spacing and family size ( Table 2 ).

In respect to the source of information regarding reproductive health and reproductive rights, 55% urban and 63% rural women revealed that the most important source of information was their family members such as their spouse, parents, siblings, cousins, etc. In urban area, only 8% women gathered information from television or radio, while the corresponding value for rural women was 19%. The responds also congregated information from newspaper or magazine (11% vs. 5%), other educational materials (12% vs. 10%) and friends or peers (14% vs. 3%), respectively ( Figure 2 ).

An external file that holds a picture, illustration, etc.
Object name is JFRH-9-35-g002.jpg

Source of information on reproductive health among urban and rural women

(*multiple responses)

Reproductive health knowledge is important for women as woman's health and well-being, contraception, as well as those of her family may depend on her being able to delay the birth of her first child or space the birth of her children ( 7 , 8 ).

Women started antenatal care at a relatively early stage of their pregnancy (before 4-month pregnancy), and 78.2% of women made six or more antenatal care visits during their entire pregnancy, but present study found that most of the respondents made three or four antenatal care visits during their entire pregnancy which was not similar to Palestine study ( 9 ). On the other hand, our study found that poor knowledge on reproductive health was more among rural women (84%). Urban women were more knowledgeable about reproductive health than rural women. Thus overall knowledge on reproductive health among urban women was better than rural women.

Women are often aware of benefits of family planning. Women's decision about use, non-use, or discontinuation of family planning methods can be affected by their perceptions of contraceptive risks and benefits, concerns about how side effects may influence their daily lives and assessment of how particular methods may affect relationships with partners or other family members ( 10 , 11 ). A study was done to understand the family planning (FP) knowledge and current use of contraception and its predictors among women of the Mru people – the most underprivileged indigenous community in Bangladesh ( 12 ). Only about 40% of respondents had ever heard FP messages or about FP methods – two-fifths of the national figure (99.9%). The current use of contraception was much lower (25.1%) among the Mru people than at the national level (55.8%) ( 12 ). But our study found that 58% rural women had good knowledge on family planning, whereas 68% urban women showed good knowledge on family planning.

Safe motherhood has evolved from a neglected component in maternal and child health programs to an essential and integrated element of women’s sexual and reproductive health. A comparative case study was done in Nepal on safe motherhood practice and they showed that more than a half have knowledge about safe motherhood, but practice is found lower as compared to the magnitude of known. Antenatal care is found better in comparison about safe motherhood which is found some increased now than before. Family planning knowledge is found better as compared to antenatal, safe delivery and postnatal cares among this caste ( 13 ). Present study found that most of the study subjects both urban and rural had good knowledge on safe motherhood.

Unsafe abortions still contribute to 13-50 % of the maternal mortality in some of these countries. Only three respondents have actually dealt with abortion related cases. A few respondents said that they have dealt with issues like adultery, extra marital relations, etc. but not with abortions. The source of their information on abortion was, therefore, media or other reports and TV as like my study subjects. However, seventeen of them were interested in knowing more about abortion and abortion laws ( 14 ).

A study aimed at identifying the effect of birth spacing on maternal health among 324 married women at the fertile age period and revealed that women practicing birth spacing were 33.3% of the studied sample. Good knowledge and favorable attitude were 88% and 100% of properly birth spaced women, respectively. Rural origin women were less practicing birth spacing ( 15 ). The present study found that 90% urban women had good knowledge on birth spacing and family size, but 64% rural women had knowledge on birth spacing and family size.

On the basis of this study, knowledge on reproductive rights was more pronounced among urban reproductive women than rural. The present study found that family planning and contraceptive knowledge factors were less among rural reproductive women. Out of 200 study subjects, nearly half had knowledge about care during pregnancy, but knowledge on safe motherhood was satisfactory in both urban and rural area. Knowledge on safe abortion is found less good in comparison about safe motherhood. Besides 90% urban women had good knowledge on birth spacing and family size, but 64% rural women had knowledge on birth spacing and family size.

A wide gap was found between urban and rural respondents in Bangladesh regarding their reproductive behaviors and exercising their reproductive rights.

Acknowledgements

The authors express their sincere thanks to all the participants of this study. There is no conflict of interest in this study.

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A comprehensive interventional program to improve the sexual function of women with endometriosis: a mixed-methods protocol study

Ranking the dietary interventions by their effectiveness in the management of polycystic ovary syndrome: a systematic review and network meta-analysis

To what extent did implementing a community-embedded intervention align with the goals and roles of stakeholders in adolescent sexual and reproductive health?

The psychosocial impact of male infertility on men undergoing ICSI treatment: a qualitative study

Influence of menstrual pain and symptoms on activities of daily living and work absenteeism: a cross-sectional study

Development, implementation, and evaluation of the effectiveness of an intervention program to improve the sexual competence of young adult women about to get married: a protocol study

Documentation of prenatal contraceptive counseling and fulfillment of permanent contraception: a retrospective cohort study

Acceptability of IV iron treatment for iron deficiency anaemia in pregnancy in Nigeria: a qualitative study with pregnant women, domestic decision-makers, and health care providers

“They call me the ‘Great Queen’”: implementing the Malkia Klabu program to improve access to HIV self-testing and contraception for adolescent girls and young women in Tanzania

Reproductive autonomy and the experience of later-than-desired pregnancy: results from a cross-sectional survey of reproductive-aged women in Uganda

Explaining the experience of breastfeeding in women with gestational diabetes and designing and implementing an educational program based on planned behavior theory: a combined exploratory study protocol

A loss-of-function variant in ZCWPW1 causes human male infertility with sperm head defect and high DNA fragmentation

Menarche and reproductive health in Spanish Roma women from a reproductive justice perspective: a qualitative study

Women's voices and meanings of empowerment for reproductive decisions: a qualitative study in Mozambique

Weight development from childhood to motherhood—embodied experiences in women with pre-pregnancy obesity: a qualitative study

Exploring women’s interpretations of survey questions on pregnancy and pregnancy outcomes: cognitive interviews in Iganga Mayuge, Uganda

What is the impact of endometriosis and the AFS stage on cumulative pregnancy rates in IVF programs?

Efficacy and safety of a novel pain management device, AT-04, for endometriosis-related pain: study protocol for a phase III randomized controlled trial

Non-pharmacological labor pain relive methods: utilization and associated factors among midwives and maternity nurses in Najran, Saudi Arabia

Attitude towards assisted reproductive technology: acceptance of donors eggs, sperms, and embryos as treatment of human infertility: a systematic review and meta-analysis

Designing, validation and evaluation of the expert system of “Healthy Menopause” and assessing its effect on the management of menopause symptoms: an exploratory mixed method study protocol

Maternal and fetal/neonatal outcomes in pregnancy, delivery and postpartum following bariatric surgery and comparison with pregnant women with obesity: a study protocol for a prospective cohort

Barriers and delays in access to abortion care: a cross-sectional study of people traveling to obtain care in England and the Netherlands from European countries where abortion is legal on broad grounds

The effectiveness of an m-Health intervention on the sexual and reproductive health of in-school adolescents: a cluster randomized controlled trial in Nigeria

A qualitative assessment of the impact of a community-embedded intervention on beneficiaries' attitudes and beliefs about adolescent sexual reproductive health in Ebonyi State, Southeast, Nigeria

The effects of reproductive variables on child mortality in Ethiopia: evidence from demographic and health surveys from 2000 to 2016

Determinants of preventive sexual behaviours among first year university students in Beira city, central Mozambique: a cross-sectional study

Identifying opportunities for prevention of adverse outcomes following female genital fistula repair: protocol for a mixed-methods study in Uganda

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Reaction to the 2024 Alabama Supreme Court ruling on IVF

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32 An Overview of Sexual and Reproductive Health in the Context of Public Health Ethics

Introduction

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