The Challenges of Reproductive and Sexual Rights

There is continuing historical and social ambivalence about whether human reproduction and indulgence of human sexuality are primarily private rights or public concerns. Family creation is essentially a private matter, involving the most personal, intimate motivations and occasions. However, when medical science replaced herbal medicine for the artificial regulation of fertility it was fiercely opposed for violation of alleged public values, often drawn from publicly proclaimed religious perceptions embodied in laws. For instance, in the 1820s, a young John Stuart Mill, the English philosopher and social reformer, was imprisoned for advocating means of birth control, and, until as recently as 1969, the Canadian criminal code condemned spreading knowledge and means of contraception as a crime against morality.

There has been similar public challenge, particularly by conservative religious hierarchies, to the concept of rights to reproductive health. Modeled on the World Health Organization's description of “health” as a state of physical, mental, and social well-being, this concept was advanced at the 1994 UN International Conference on Population and Development, held in Cairo, and reaffirmed at the 1995 UN Fourth World Conference on Women, held in Beijing. The concept is based on the conviction that reproductive health “is a state of complete physical, mental and social well-being … in all matters relating to the reproductive system and to its functions and processes.”^1(para94) The Programme of Action developed at the Cairo conference went on to explain that “reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.”^1(para94) In 2005, the World Summit of the UN General Assembly renewed its commitment to the Cairo goal of achieving universal access to reproductive health by 2015.²

Key elements of the safety of reproductive health are targets of three of the eight UN 2001 Millennium Development Goals: namely, improving maternal health, reducing child mortality, and combating HIV/AIDS. The continuing gravity of maternal mortality worldwide is shown in the latest annual estimate (for 2005). This shows that about 535 900 women died that year, for the most part avoidably, from pregnancy-related causes.³ Because 50% of these deaths were in sub-Saharan Africa and 45% were in Asia, the figure has had little impact in North America and Europe. It amounts to the equivalent, however, of four 367-seat jumbo jets full of pregnant women crashing, with no survivors, every day of the year. Traffic safety in general, and road-traffic safety in particular, are considered legitimate public health concerns. By this measure, reproductive health in general, and maternal health and mortality in particular, also should be regarded as legitimate public health concerns.

Seconds after birth, a physician reaches into the warm water for the newborn child. Photographer: Floris Leeuwenberg. Printed with permission of Corbis.

Separate features of reproductive health have equally been found to warrant attention within the public health framework. For instance, the 1995 UN Fourth World Conference on Women urged all countries to “deal with the health impact of unsafe abortion as a major public health concern.”^4(para8.25) Data on maternal mortality show that, in many regions of the world, women's alternative to unsafe abortion is not safe gestation and childbirth, but maternal death or serious illness and disability. The effect of maternal mortality and morbidity on women, their dependent children, the aged relatives who depend on them for care, and on their partners and wider families justify a public health approach.

Reflecting on the 12 years that had passed since representatives of the 184 governments at the 1994 Cairo conference had reached agreement on its Programme of Action, the Global Forum for Health Research and the World Health Organization noted that

[s]eeking new ways to balance population and development processes, the Cairo consensus represented a paradigm shift from a focus on controlling excessive population growth through vertically structured family planning programs to a focus on promoting sexual and reproductive health for all through horizontally integrated primary health-care and family planning services.^5(p8)

This shift underscored the 1994 observation that advance in population health requires

parallel efforts to be directed towards achieving poverty eradication, sustainable economic development, education (especially for girls), gender equity and equality, food security, human resources development, and guarantees of fundamental human rights.^5(p8)

The move from top-down, directive population-control programs to the promotion of individuals' rights of reproductive choice and self-determination through their access to appropriate services fits within an enlightened vision of public health ethics.⁶

The challenges to be met and some of the progress achieved in the promotion of rights to sexual and reproductive health are reflected in this month's Journal. Management of HIV/AIDS, which in many regions of the world is transmitted primarily by sexual relations, is an inescapable contemporary concern, particularly when women have little regulation of their sexual availability to men outside, or within, familial relationships. Making services responsive to women's needs for accessible, affordable, and culturally acceptable care to reduce the risks and manage the effects of infection raises a range of public health challenges. Younger women and girls are frequently particularly vulnerable to infection, but the protection and care of men are no less concerns and challenges.

Medical, ethical, and legal issues in prevention, reduction, and treatment of HIV/AIDS abound. Infection may be stigmatizing, even in generally nonjudgmental environments, and where sufferers face social, legal, and other punitive sanctions in response to their presumed behavior, public knowledge of their need of care can endanger them. Training and equipping health care providers to preserve confidentiality and supply relevant services, under conditions that reduce risks of infection to others and themselves, require devotion of often scarce clinical and public health resources.

Visions of desirable sexual and reproductive health policy seen through the lens of sin raise further challenges. Education is an important weapon in the public health armory. However, doctrinally driven, abstinence-only sexual education programs in schools pose challenges on grounds of educational ethics, because their purpose is to withhold aspects of relevant knowledge, and on grounds of their demonstrable effectiveness in protecting against pregnancy and sexually transmitted infections, including HIV/AIDS. Similarly, some hospitals may delay urgent care indicated for women who have suffered late-term miscarriage if fetal heart tones are present. The priority they afford potential fetal viability risks patient infection and heavy blood loss or patients' trauma in emergency transportation to an alternative hospital.

Doctrinal hostility to rights to reproductive health care covers the full spectrum of services and can compromise public health interests in the effectiveness of services. For instance, physicians, hospitals, clinics, and pharmacists may decline to deliver contraceptive care, or in defiance of medical professional understanding, equate postcoital or emergency contraception with abortion and deny it on that ground, thus prejudicing women's reproductive health care. Paradoxically, this may condition induced abortion, procured by skillful or unsafe means, by obstructing pregnancy prevention. At the other end of the reproductive spectrum, in which medically assisted pregnancy offers means to overcome the effects of infertility, restrictive laws may both reduce pregnancy rates and compel risks of multiple pregnancy and its related premature deliveries and ill health of neonates.

For instance, the law introduced in Italy in June 2004, known as Law 40, prohibits creation of more than three embryos in a treatment cycle and requires implantation in that cycle of every embryo created, by prohibiting both the discarding and preservation (cryopreservation) of embryos. The first official evaluation of that law has shown a decline in pregnancy rates of assisted reproductive technologies and an increase in multiple deliveries.⁷ These consequences contradict the policies of assisted reproduction programs in other countries, both in Europe and beyond, which, on public health and clinical grounds, are moving toward implantation of a selected single embryo in a treatment cycle.

Public health interests in reproductive and sexual health have been directed, in more recent history, toward prevention, notification, and management of sexually transmitted infections. This was the background against which early responses to HIV/AIDS were framed. The more ancient public health response of quarantine, the period of 40 days (quarantina in Italian) for which ships arriving in Genoa in the 14th century were isolated to determine if they carried plague, was inapplicable to HIV/AIDS because of its uncertain incubation period and chronic nature. In modern times, however, public health implications have come to attach to the full spectrum of reproductive and sexual health services, including their availability, affordability, and acceptability.

It may be anticipated that there will be evolving public health dimensions to future scientific advances in reproductive health care, such as in long-term preservation and in vitro maturation of reproductive tissues, preservation of reproductive organs, such as the uterus, for transplantation, and postmenopausal pregnancy. Future public health services will have to react to practices perceived as bizarre or outrageous, but it would be wise to recall the prescient observation in a 1966 study of artificial insemination:

Any change in custom or practice in this emotionally charged area has always elicited a response from established custom and law of horrified negation at first; then negation without horror; then slow and gradual curiosity, study, evaluation, and finally a very slow but steady acceptance.^8(p178)