Reproductive Services and Conscience-Based Refusals in Obstetrics and Gynecology Training

Purpose: Professional bodies such as the American College of Obstetrics and Gynecology recognize the impact of conscience-based decisions. The first time such decisions affect patients and providers is in residency. Our study sought to determine the attitudes of program directors towards various conscience-based refusals in potential applicants to obstetrics and gynecology programs. Method: An eight-question survey was sent to 279 directors of U.S. obstetrics and gynecology residencies in 2019. The survey proposed hypothetical conscientious refusals of common aspects of obstetric and gynecology practice. The survey asked respondents to categorize their reaction to these choices and choose from a list of factors which could modify their reaction. Univariate analysis and multivariate logistic regression were performed. Results: 97 program directors (35%) responded. A majority of PDs reported that the inability to prescribe or counsel on birth control, to provide methotrexate, to counsel on abortion, or to clearly enumerate refusals was impossible to work around, likely to lower an applicant’s rank, not compatible with training, or not good for patients; collectively, these responses were grouped as “negative reactions” (73–99%). Female program directors had more negative reactions to applicants who refused to prescribe birth control (aOR 15.8, 95% CI 1.7–99.5) and counsel on abortion (aOR 3.6, 95% CI 1.2–10.8). Directors from different locations and program types did not have significantly different responses. A few program directors identified that academic strength could mitigate otherwise negatively-viewed choices. Illustrative comments of directors’ attitudes are provided. Conclusions: Program directors agree that conscientious refusal to participate in certain activities is problematic for obstetrics and gynecology residency. There are very few subjective or regional differences on this stance, and few aspects of an application modify directors’ reactions.

Ethics in canine reproduction – a survey among veterinarians who provide canine reproductive services

Objective Several dog breeds suffer from health and welfare problems due to unfavorable anatomies and high prevalence of inherited diseases. Veterinarians should care for animal health and welfare but they may also be involved in breeding management including the use of reproductive techniques. Material and methods An online survey was conducted to find out how veterinarians who are involved in small animal reproduction regard ethical issues, which services they provide, how they discuss and handle ethical concerns and talk about them with breeders. Results In total, 83 participants mainly from Europe completed the online survey. Opinions on which interventions are ethical or not were heterogeneous. Most respondents (79.2 %) found it ethical to perform artificial insemination (AI) in dogs which did not reproduce naturally before. However, 62.7 % of participants stated that surgical insemination is not ethical. Elective cesarean sections are considered not ethical by approximately half of the participants. A closer look at responses to the questions of whether AI is ethical under specific conse quences suggests that most veterinarians are making ethical and value judgments in terms of what is justifiable or not. However, more than 80 % feel at least sometimes compromised by ethical conflicts. Clinical relevance This research intended to foster discussion of this topic. International strategies should be developed to support solving conflicts and dilemmas related to ethical issues in dog breeding and assisted reproduction, as well as diminishing physical disabilities and heritable diseases.

Reprowebs: a conceptual approach to elasticity and change in the global assisted reproduction industry

In the last few decades, assisted reproductive technologies (ARTs) have become increasingly transregional and transnational, often involving travel within or between countries or even continents. Until recently, the global ART industry was marked by so-called ‘reprohubs’—places (such as southern California, Dubai, Anand, and Mumbai) specializing in the provision of reproductive services. While reprohubs continue to exist, in the last few years, many have splayed out, transforming into something more akin to webs that encompass, but go beyond these hubs. These webs show a unique dynamic capability to tighten, entangle, or extend in reaction to local and global changes, a characteristic which became particularly obvious during the global Covid-19 pandemic. In this paper, we propose conceptualizing this new dynamic capability as ‘reprowebs’—an approach that adds a new dimension to the existing conceptualization of reproductive travel and helps us to better understand current developments in the global ART industry.

Prevalence of asymptomatic SARS-CoV-2 Infection in couples seeking in vitro fertilization treatment in Riyadh, July–November, 2020

Background: After the start of the coronavirus disease (COVID-19) pandemic, assisted reproductive services were suspended and restarted in in vitro fertilization (IVF) clinics worldwide. In our center we implemented screening of all couples for COVID-19 the day before starting the ovulation cycle and before the ovum pick-up (OPU) procedure. Objectives: Assess the prevalence of asymptomatic COVID-19 among couples undergoing in vitro fertilization (IVF). Design: Cross-sectional and retrospective cohort study. Setting: An IVF unit in Riyadh from July to November 2020. Patients and methods: Patients and their partners were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection 24-48 hours before their initial visit to initiate the fertility cycle and again prior to the ovum pick-up visit. Main outcome measures: Prevalence of asymptomatic SARS-CoV-2 infection. Sample size: 508 couples. Results: A total of 508 couples were tested. Of the 508 cycles of therapy, 24 (4.7%) were cancelled, 16 (3.14%) before the start of the cycle, and 8 (1.66%) before ovum pick-up, because one or both partners in the couple tested SARS-CoV-2 positive. Before the start of the cycle, 3 patients and their partners both tested positive; 7 patients tested positive and their partners tested negative; and 6 partners tested positive and the patient testing negative. In addition, on retesting 481 couples before OPU 3 patients and their partners both tested positive; 3 patients tested positive, and their partners tested negative; and 2 partners tested positive and the patients tested negative. Conclusion: The prevalence of asymptomatic SARS-CoV-2 infection in couples seeking IVF was higher than that in the general population. Implementing a policy of screening couples for SARS-CoV-2 prior to IVF treatment, minimized the possibility of transmission of SARS-CoV-2 from patients to healthcare workers.

Girl Champ in eSwatini: A Strategic Marketing Campaign to Promote Demand for Sexual and Reproductive Health Services Among Young Women

Efforts to engage adolescent girls and young women (AGYW) in HIV services have struggled, in part, due to limited awareness of services and stigma. Strategic marketing is a promising approach, but the impact on youth behavior change is unclear. We report findings from a mixed methods evaluation of the Girl Champ campaign, designed to generate demand for sexual and reproductive services among AGYW, and piloted in three clinics in the Manzini region of eSwatini. We analyzed and integrated data from longitudinal, clinic-level databases on health service utilization among AGYW before and after the pilot, qualitative interviews with stakeholders responsible for the implementation of the pilot, and participant feedback surveys from attendees of Girl Champ events. Girl Champ was well received by most stakeholders based on event attendance and participant feedback, and associated with longitudinal improvements in demand for HIV services. Findings can inform future HIV demand creation interventions for youth.

Utilization of Reproductive Health Services among Youths in Owerri, Southeastern Nigeria

Youths are faced with immense reproductive health problems and they have limited access to reproductive health services. This study was carried out to investigate the utilization of reproductive health services among youths in Owerri, Southeastern Nigeria. The study was a descriptive cross sectional study and the multistage sampling technique was adopted to select samples for the study. A well-structured questionnaire was used to interview the subjects and obtain data for the study which was uploaded into the SPSS version 21 software and the Chi-square was used to test for association at 5% level of significance. A total of 424 people were studied comprising of 276 (65.1%) males and 148 (34.9%) females. Results showed that only 106 (25%) showing good knowledge of reproductive health services while 318 (75%) showed poor knowledge. Among the 148 that have used reproductive services, 56.8% responded that they seek reproductive services in the home of a health worker, 29.1% seek reproductive health services through public health facilities such as health centers, clinic or NGO, and 14.2% obtain their reproductive health services through drug shops such as a pharmacy or chemist. SPSS analysis using the Chi-square showed that the male gender showed poorer knowledge of RHS than the female gender but gender was not found to be significant (p=0.098, χ2=1.993). Other significant socio-demographic factors include marital status (p=0.0001, χ2= 46.29), living pattern (p=0.005, χ2=6.93) and education (p=0.0001, χ2= 17.8). In conclusion, the study showed that the knowledge and the level of utilization RHS is still low among youths in the study area. It was recommended that stakeholders sensitize the public on the importance of youth reproductive health services and strengthen the idea of youth friendly reproductive health services. Keywords: Youth, Utilization, Knowledge, Reproductive Health Services, Youth Friendly Services.

Towards Comprehensive Guidance for States in the African Region to respond to Children’s Rights in Emergencies, Disasters and Pandemics

The covid-19 pandemic spread has it impacted health systems, economies and communities across the African continent. It has also exacerbated risks already faced by children: limiting access to education, reducing protection from sexual and gender-based violence, harmful traditional and cultural practices including child, early or forced marriage (cefm), female genital-mutilation (fgm); and further limiting access to reproductive services and food insecurity. This article illustrates that because demonstrably different considerations arise by comparison to children’s experiences in the global north, it would be a valuable contribution for the African Committee of Experts on the Rights and Welfare of the Child to develop a General Comment on state responses to upholding children’s rights in the context of epidemics, pandemics and emergencies, tailored to the specificities of the region.

MEĐUNARODNOPRAVNI MATERIJALNI ELEMENTI VLADAVINE PRAVA I OBIM REPRODUKTIVNIH USLUGA

Starting from the position that the basic purpose of the concept of rule of law is the protection of the individuals from the power of the State, the aim of this research is to examine if the principle of rule of law contains an element that could legitimize the restrictions of the scope of services in the field of reproductive medicine by the State. In particular, the object of this research is the question whether the right to life, as a substantive element of the rule of law encompassing negative as well as positive guarantees, can be used as an excuse for restrictive regulation of medical service of artificial gestation (ectogenesis). In a broader sense, it was examined if there was introduced any binding regional standards in Europe that would require from the Member State of Council of Europe to regulate service of artificial gestation as if it was an irrevocable process. If so, it would imply inability of progenitors – consumers, to withdraw from the process and suspend consumption of the service. Necessarily, the analysis also referred to the guarantees from the ambit of Article 8 of the European Convention as another substantive international legal element of the rule of law. The research was conducted using a descriptive method that describes the content of the right to life. Further, relevant guarantees and practices of the right to life protection were synthesized into possible claims - premises, which could amount potential basis for building a restrictive syllogism as a legal framework for the State intrusion in this area. These claims are the claim of the intentionality, the claim for equality, the claim of the conflict exclusion, the claim for viability. The conclusions of this research are that presumptive claims cannot provide excuses for the extension of the right to life to an ectoagent (an embryo that develops through ectogenesis) for the reasons explained below. With regard to the guarantees contained in Article 8 of the European Convention, above all autonomy, it has double effect. First, it disconnects ultimate demands of the progenitors from the Convention; second, it confers conditional right to life eligibility to ecto-agent. This research considered second stage of ectogenesis which commence with implantation. The intended originality of the analysis is to examine if the substantive elements of the rule of law from the scope of international human rights law, can be obstacles to the development of reproductive services.

Gender-based disparities on health indices during COVID-19 crisis: a nationwide cross-sectional study in Jordan

Background COVID-19 has an inevitable burden on public health, potentially widening the gender gap in healthcare and the economy. We aimed to assess gender-based desparities during COVID-19 in Jordan in terms of health indices, mental well-being and economic burden. Methods A nationally representative sample of 1300 participants ≥18 years living in Jordan were selected using stratified random sampling. Data were collected via telephone interviews in this cross-sectional study. Chi-square was used to test age and gender differences according to demographics, economic burden, and health indices (access to healthcare, health insurance, antenatal and reproductive services). A multivariable logistic regression analysis was used to estimate the beta-coefficient (β) and 95% confidence interval (CI) of factors correlated with mental well-being, assessed by patients’ health questionnaire 4 (PHQ-4). Results 656 (50.5%) men and 644 (49.5%) women completed the interview. Three-fourths of the participants had health insurance during the COVID-19 crisis. There was no significant difference in healthcare coverage or access between women and men (p > 0.05). Half of pregnant women were unable to access antenatal care. Gender was a significant predictor of higher PHQ-4 scores (women vs. men: β: 0.88, 95% CI: 0.54–1.22). Among women, age ≥ 60 years and being married were associated with significantly lower PHQ-4 scores. Only 0.38% of the overall participants lost their jobs; however, 8.3% reported a reduced payment. More women (13.89%) were not paid during the crisis as compared with men (6.92%) (P = 0.01). Conclusions Our results showed no gender differences in healthcare coverage or access during the COVID-19 crisis generally. Women in Jordan are experiencing worse outcomes in terms of mental well-being and economic burden. Policymakers should give priority to women’s mental health and antenatal and reproductive services. Financial security should be addressed in all Jordanian COVID-19 national plans because the crisis appears widening the gender gap in the economy.

The Scenario of Adoption and Foster Care in Relation to the Reproductive Medicine Practice in Asia

In vitro fertilization (IVF) is a hallmark of reproductive medicine. However, the inconclusive outcome leads to marital disharmonies; thus, the choices of gamete donation and surrogacy (GD/S) are often offered. In restricted countries, the child-rearing choice through foster/adoption care is promising, but the uptake remains low. We explore the current reproductive services and adoption scenarios in Asian countries to delineate this issue. The web and literature search using PubMed and Ichushi was conducted in Japanese and English using the keywords “adoption”, “foster care”, “reproductive medicine”, including the interview with the respective Asian clinicians. We found that an established adoption system was seen in China, Malaysia, and the Philippines, mainly due to the restriction of GD/S. Although GD/S were allowed in Thailand, Singapore, and India, the different local affordability of IVF cost led to various adoption system scenarios. Nevertheless, the country’s economic aspect does influence the establishment of adoption care, mainly due to financial support from local government. Otherwise, the significant barrier was the cultural/religious background leading to low adoption rates. We concluded that the adoption option should always be highlighted as an alternative strategy as it synergistically contributes to children’s and infertile couples’ welfare.