This paper explores sexual and reproductive health and rights (SRHR) among young people, identifying intersecting factors that create inequities in access to services, health-seeking behaviour, and ultimately health outcomes. Based on qualitative interviews with young people in the Maldives, it demonstrates how these intersectional experiences are contrary to what is often assumed in official data, policies, and services. Three factors were found to shape young people's experiences: marital status, gender, and urban/rural differences. Non-marital sexual activity is illegal in the Maldives, but it is somewhat expected of unmarried men, while unmarried women are stigmatised for being sexually active. Although access to SRH services is restricted for all unmarried people, young women face additional difficulties, as the risk of being exposed is much greater in small island communities. Maldivian island communities are extremely small and characterised by an inward-looking culture that exerts considerable social pressure, particularly on unmarried women. For an unmarried woman, being known to be sexually active, or worse, pregnant outside of marriage, has severe social consequences including stigma and isolation from the community, and their own family. This concern is more prevalent among rural young women, as they live in smaller communities where stigma is inescapable. The need to avoid public scrutiny and humiliation contributes to making unsafe abortion a common solution for many unintended pregnancies. Failure to acknowledge these intersecting factors in SRHR experience and access has led to inequities among an already overlooked population, shaping their experiences, knowledge, health-seeking behaviour, and health outcomes.
Concerns about disrespect and abuse (D&A) experienced by women during institutional birth have become critical to the discourse on maternal health. The rapid growth of the field from diverse points of origin has given rise to multiple and, at times, confusing interpretations of D&A, pointing to the need for greater clarity in the concepts themselves. Furthermore, attention to measurement of the problem has been excessive when viewed in relation to the small amount of work on critical drivers of disrespect and abuse. This paper raises some key issues of conceptualisation and measurement for the field, puts forward a working definition, and explores two critical drivers of D&A - intersecting social and economic inequality, and the institutional structures and processes that frame the practice of obstetric care. By identifying gaps and raising questions about the deeper causes of D&A, we point to potentially fruitful directions for research and action.
Although abortion is now legal in Kenya under expanded circumstances, access is limited and many providers and individuals still believe it is illegal. This study aimed to characterise Kenyan women's perceptions and experiences with abortion and post-abortion care (PAC) services in Nairobi regarding barriers to care, beliefs about abortion, and perceived stigma. We conducted 15 semi-structured in-depth interviews with Kenyan women aged 18-24 years who recently received abortion and PAC services at four Marie Stopes Kenya clinic sites in Nairobi. The most significant psychosocial barrier respondents faced in promptly seeking abortion and PAC was perceived stigma. In response to stigma, participants developed a sense of agency and self-reliance, which allowed them to prioritise their own healthcare needs over the concerns of others. To adequately address perceived stigma as a barrier to abortion- and PAC-seeking, significant cultural norm shifting is required.
In March 2018, the Democratic Republic of Congo moved to enact the Maputo Protocol, under which signatory states agree to authorise legal access to abortion in a range of circumstances. Two months ...
Nepal has one of the highest maternal and neonatal mortality rates among low- and middle-income countries. Nepal's health system focuses on life-saving interventions provided during the antenatal to postpartum period. However, the inequality in the uptake of maternity services is of major concern. This study aimed to synthesise evidence from the literature regarding the social determinants of health on the use of maternity services in Nepal. We conducted a structured narrative review of studies published from 1994 to 2016. We searched five databases: PubMed; CINAHL; EMBASE; ProQuest and Global Index Medicus using search terms covering four domains: access and use; equity determinants; routine maternity services and Nepal. The findings of the studies were summarised using the World Health Organization's Social Determinants of Health framework. A total of 59 studies were reviewed. A range of socio-structural and intermediary-level determinants was identified, either as facilitating factors, or as barriers, to the uptake of maternity services. These determinants were higher socioeconomic status; education; privileged ethnicities such as Brahmins/Chhetris, people following the Hindu religion; accessible geography; access to transportation; family support; women's autonomy and empowerment; and a birth preparedness plan. Findings indicate the need for health and non-health sector interventions, including education linked to job opportunities; mainstreaming of marginalised communities in economic activities and provision of skilled providers, equipment and medicines. Interventions to improve maternal health should be viewed using a broad 'social determinants of health' framework.
The objective of this study is to measure the preliminary efficacy of a pilot intervention, grounded in behavioural economics, increasing adherence of dual protection (simultaneous use of effective modern contraception and a barrier method, such as a condom) to protect against HIV, other sexually transmitted infections, and unintended pregnancy. Between 2015 and 2016, 100 women aged 18–40 years, seeking post-abortion care in Cape Town, South Africa were recruited to Empower Nudge, a randomised controlled trial to test a lottery incentive intervention designed to increase dual protection. At baseline, the mean age of participants was 27 years; 82% of them were from South Africa; 58% self-identified as Black African; average education completed was 11.7 years. At three months, assignment to the lottery intervention was associated with higher odds of returning for study visits (OR: 6.0; 95%CI: 2.45 to 14.7, p < 0.01), higher condom use (OR: 4.5; 95%CI: 1.43 to 14.1; p < 0.05), and higher use of dual protection (OR: 3.16; 95%CI: 1.01 to 9.9; p < 0.05). Only 60% of the study population returned after three months and only 38% returned after six months. Women who receive post-abortion care represent a neglected population with an urgent need for HIV and pregnancy prevention. Dual protection is a critically important strategy for this population. Lottery-based behavioural economics strategies may offer possible ways to increase dual protection use in this population. Further research with larger samples, longer exposure time, and more sites is needed to establish fully powered efficacy of lottery incentives for dual protection; using objective verification for monitoring.
Baigas are a Particularly Vulnerable Tribal Group (PVTG), categorised as the most vulnerable amongst indigenous communities in India. As a strategy to stall their decreasing population, due mainly to high mortality, in 1979 the government restricted their access to permanent contraceptive methods, and this is enforced as a "ban". Using a case study design with mixed methods, this study aims to understand the experiences and perceptions of Baigas in Chhattisgarh in accessing contraceptive services. Data was collected through: a household survey (n = 289) in 13 habitations; individual interviews and group discussions with Baiga men and women and health service providers; and anthropometry. The Baiga suffer poor nutritional status and poverty, out of proportion with district and state averages. Of the women interviewed, 61.3% have had four or more pregnancies and 61.3% have experienced the loss of child at least once during pregnancy or later. Baiga women's forehead tattoo, a marker of their identity, is used to deny them contraceptive services. Baiga women either have to travel to the neighbouring state to avail themselves of services, or lie about their identity. They are usually unable to access even the temporary methods. This coercive policy has led to their further impoverishment. Baigas have been demanding the right to contraceptive services. Denying contraceptive services is a violation of reproductive and human rights and the right to self-determination and bodily autonomy.
Inadequate menstrual hygiene presents a barrier to women’s dignity and health. Recent attention to this marginalised challenge has resulted in the first national assessments of menstrual practices. Intuitively, surveys require women to have had a recent menses to be eligible. This study seeks to determine if there are demographic differences between women who are eligible and ineligible to answer questions about their menstrual hygiene during these assessments. Secondary analyses were undertaken on nationally or state representative data collected by the Performance Monitoring and Accountability 2020 survey programme across eight countries (Burkina Faso, Ethiopia, Ghana, India, Kenya, Niger, Nigeria, and Uganda). Female respondents were included in the study and compared on whether they had a menstrual period within the past three months and thus were eligible to answer questions regarding menstrual practices. On average, 29% of surveyed women across samples were ineligible to be asked menstrual hygiene questions. Higher levels of education, wealth, and urban residence were associated with higher odds of eligibility. Young and unmarried women were also more likely to be eligible. Demographic differences between eligible and ineligible women were consistent across all countries. Wealthy, urban, and educated women are more likely to be eligible to answer survey questions about menstrual hygiene. While population surveys may be representative of menstruating women, proportions of menstrual hygiene practices reported underrepresent the experiences of more vulnerable groups. These groups are likely to have greater struggles with menstrual hygiene when they are menstruating.
Criminal law is one of the most powerful tools that a State can use to exert control over individuals. It provides a means by which the State may legitimately restrict individual conduct, so as to prevent harm or address harms that have already occurred. In some areas, however, the criminal law itself can be harmful and, for this reason, must be carefully regarded to ensure that it is not employed in ways which are unjust or undermining of human rights, including the right to the highest attainable standard of health and sexual and reproductive health and rights (SRHR). In the areas of consensual sexual conduct, including adultery, sex work and samesex relations; drug use; HIV exposure and transmission; abortion and other sexual and reproductive health and rights, human rights bodies as well as international, regional and national courts have expressed concerns about the impact of criminal law on the enjoyment of human rights, including on gender equality and the right to health.
Limited research has examined lesbian and bisexual women's sexual health practices in the Caribbean, where lesbian and bisexual women experience sexual stigma that may reduce sexual healthcare utilisation. We conducted a sequential multi-method research study, including semi-structured individual interviews (n = 20) and a focus group (n = 5) followed by a cross-sectional survey (n = 205) with lesbian and bisexual women in Kingston, Montego Bay, and Ocho Rios, Jamaica. Binary logistic analyses and ordinal logistic regression were conducted to estimate the odds ratios for social-ecological factors associated with lifetime STI testing, sex work involvement, and the last time of STI testing. Over half of participants reported a lifetime STI test and of these, 6.1% reported an STI diagnosis. One-fifth of the sample reported ever selling sex. Directed content analysis of women's narratives highlighted that stigma and discrimination from healthcare providers, in combination with low perceived STI risk, limited STI testing access and safer sex practices. Participants described how safer sex self-efficacy increased their safer sex practices. Quantitative results revealed that a longer time since last STI test was positively associated with depression, sexual stigma, and forced sex, and negatively associated with residential location, perceived STI risk, safer sex self-efficacy, and LGBT connectedness. Selling sex was associated with perceived STI risk, relationship status, sexual stigma, food insecurity, and forced sex. Sexual health practices among lesbian and bisexual women in Jamaica are associated with intrapersonal, interpersonal, and structural factors, underscoring the urgent need for multi-level interventions to improve sexual health and advance sexual rights among lesbian and bisexual women in Jamaica.
Despite some international and national efforts in recent decades, Madagascar continues to make poor progress towards key sexual and reproductive health rights (SRHR) indicators. There are persistent cultural, social, political and economic barriers to accessing good quality SRHR knowledge and services globally, but particularly in regions with limited international geo-political influence, such as Madagascar. The political crisis in 2009 resulted in a stagnation and regression of SRHR services, due to the cessation of international funding, leaving youth-based services inadequate and insufficient. This paper aims to critically examine the social determinants and external factors that may influence and impact the roll-out of a national SRHR educational curriculum in Madagascar over the coming years. From the perspective of two SRHR specialists working in this context, this paper serves as a call for further action from the national and international community to address the still unmet SRHR needs of youth in Madagascar.
This paper comments on the views of the UN Human Rights Committee (hereafter the Committee) in the cases Mellet v. Ireland [1] and Whelan v. Ireland [2]. It focuses on the Committee's findings regarding a violation of the prohibition of discrimination. The interpretation presented by the Committee, although much welcomed and undeniably tackling reproductive health and rights in a progressive way, still leaves room for future improvements. It is argued herein that the Committee's reasoning is marked by some inaccuracies due to its inconsistent approach regarding gender equality. Whereas the Committee seems to have fully integrated a "substantive equality" approach when providing general interpretation of States' obligations under the International Covenant on Civil and Political Rights (hereafter the ICCPR), its assessment of individual cases remains to some extent influenced by the "formal equality" approach.
“No one left behind”, the mantra of the Sustainable Development Goals (SDGs),1 resonates in the global and development agenda and is being taken up by a myriad of organisations and agencies. It is ...
The 10th of December 2018 marks the 70th anniversary of the adoption of the Universal Declaration of Human Rights by the United Nations (UN) General Assembly. On the 20th November, the United Nations Convention on the Rights of the Child (CRC) reached its 29th anniversary. In September, 24 years had passed since the International Conference on Population and Development in Cairo introduced the term sexual and reproductive health and rights (SRHR) and declared SRHR as a fundamental human right, including for adolescents. Only three years ago, all UN Member States adopted the 2030 Agenda for Sustainable Development that included a specific target for achieving universal access to SRHR (Gender Equality Goal 5). Despite these important efforts to create consensus around human rights frameworks and steps to secure universal access to SRHR, the promise of child rights and adolescent girls’ and boys’ evolving capacities to claim SRH rights remains unrealised. For instance, a recent review of evidence on the SRHR of adolescent girls highlighted that many lowand middle-income countries have not yet made significant progress in delaying marriage and childbearing, reducing unwanted childbearing, or narrowing socioeconomic, health and gender gaps that could reduce girls’ risks of adverse adolescent sexual and reproductive health and rights (ASRHR) outcomes and related health effects over the life course. Multiple converging factors contribute to an ongoing lack of prioritisation of SRHR, which is defined, following the recent Guttmacher-Lancet report (see Panel 1), 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”. However, ASRHR is seemingly often relegated to a lower priority or is entirely absent from discussions on SRHR. Barriers to international and local prioritisation of (A)SRHR range from global political and economic trends, such as the shift towards farright and populist politics in high-income countries and in regions that push international health policy and aid investment toward the bottom of foreign policy agendas, to local inequitable social norms that define social expectations for adolescents boys’ and girls’ behaviours according to restrictive, binary gender roles and identities.
This year marks the 70th anniversary of the Universal Declaration of Human Rights (UDHR) and the bold acknowledgement by all the nations of the world that “the recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world”. As we celebrate the UDHR anniversary, we also need to take stock to reflect on humanity’s journey on this incredible path of realising human rights for all. In doing so, we must acknowledge that whilst the rhetoric has been on the inalienable rights of all members of the human family, the reality on the ground has been different, often characterised by the violation of rights of sexual minorities and other marginalised groups. Increasingly, humanity accepts the proposition that a fair, prosperous, secure and sustainable future is not possible if the rights of every person are not recognised in practice and in law. Perhaps no other public health epidemic has tried this assertion as well as the proclamation of “the equal and inalienable rights of all members of the human family” by the UDHR, as has HIV. HIV is not just a public health matter, it is also a human rights and social justice challenge perpetuated by stigma and discrimination and the failure to guarantee the rights of thosemost at risk of the disease. As a result, HIV continues to be a major global public health concern, having claimed more than 35 million lives so far. In 2017, 940,000 people died from HIV-related causes globally. Globally, there were approximately 36.9 million people living with HIV at the end of 2017, including 1.8 million people who became newly infected in 2017. Key populations are groups who are at increased risk of HIV infection, irrespective of epidemic type or local context. According to UNAIDS, key populations include gay, bisexual and other men who have sex with men, people who inject drugs, people in prisons and other closed settings, sex workers and their clients, and transgender people. They often have legal and social issues related to their behaviours that increase their vulnerability to HIV and reduce access to testing and treatment programmes. These behaviours are often criminalised, making it difficult for people to freely access health services for fear of arrests. Young people, due to specific higher risk behaviours, such as inconsistent use of condoms, are often regarded as part of key or vulnerable populations. What these populations have in common is that in many jurisdictions, they are marginalised, criminalised or in conflict with the criminal justice system, and subject to serious violations of the rights enshrined in the Universal Declaration of Human Rights – equality, dignity, non-discrimination, life, liberty, security of the persons, effective remedy, fair trial, freedom from torture, cruel, inhuman and degrading treatment and punishment, arbitrary arrest and detention, freedom of movement, expression, assembly and association, and so on. Key populations are “key” for a reason. Men who have sex with men, sex workers, transgender people, and people who inject drugs not only face HIV risks 14–50 times the general population but are often confronted with double, triple, or quadruple compounded stigma and discrimination, which severely affects their ability to access HIV prevention and treatment resources. The situation is perpetuated primarily by discriminatory and punitive legal and policy frameworks that undermine an effective HIV response for key COMMENTARY
