Politics, power, and sexual and reproductive health and rights: impacts and opportunities

For many, the very word “politics” has taken on a negative hue, imbued with connotations of misused power, corruption, electioneering, and populism. But politics is much more than this. The study of politics is, in many respects, the study of power, who is able to exercise power, under what circumstances and to what ends.

The capacity of people to access and realise their sexual and reproductive health and rights (SRHR) has long been influenced by the shifting tides of politics and the various configurations of political power that hold sway in specific times and specific places. As the articles in this issue make clear, pronounced shifts towards far right-wing and conservative politics are threatening hard-won progress in SRHR. This is happening globally, regionally, nationally and locally, affecting progress in many areas, such as access to safe abortion, access to contraception, the protection of the sexual and reproductive rights of migrants and refugees including those in humanitarian settings, and the advancement of the rights of LGBTI+ individuals. Taken together, the articles paint a compelling picture of how governments, political leaders, activists, non-governmental organisations (NGOs), lawyers, and others are all engaging in the politics of SRHR, with profound impacts, both positive and negative, on the everyday lived realities of people around the world. As these articles illustrate, the impacts of politics on SRHR are often the greatest for the most vulnerable or marginalised populations, who themselves may have limited opportunity to influence political outcomes on their own behalf.

The embodied consequences of SRHR politics

Political decisions have embodied consequences. Decisions made in the corridors of power in one part of the world can reverberate across the globe, with very real implications for the lives and health of individuals in other parts of the world. It is the bodies and lives of women and girls that are most often impacted by domestic and international political decisions related to SRHR. For example, in the 2017 reinstatement and expansion of the Mexico City Policy, or Global Gag Rule, under US President Trump, we are witness to the devastating international impacts of a political decision taken in the US to prohibit any foreign NGO that receives US global health funds from engaging in “certain abortion-related activities, including providing abortion services, information, counselling and referrals, and advocating to expand access to safe abortion services.”¹ Against public health evidence, such politics and politically-driven decisions restrict the life choices and undermine the fundamental human rights of some of the most marginalised people in the world. For many women, such as those forced in the circumstances to seek unsafe abortions, they are also a matter of life and death.

The embodied consequences of political decisions may be intentional or unintentional, and indeed policies (which give form to political decisions) often do have unintended consequences – positive or negative. In her nuanced contribution to this issue, based on data from 122 police files related to criminal investigations of cases or suspected cases of Female Genital Mutilation (FGM) in Sweden, Johnsdotter² highlights the ways in which even those criminal laws and policies that are meant to protect girls and women may have unintended and potentially negative consequences for the very people they are designed to protect. Johnsdotter’s exploration of the impacts of compulsory genital examinations of Swedish African girls during suspected cases of FGM raises important questions about the impact of such policies on girls’ bodily integrity, human dignity, and privacy and the consequences of such prosecutions on their families. It also draws attention to the problematic assumptions around ethnicity and culture that may underly some decisions around reporting suspecting cases of FGM, and of conducting compulsory genital examinations within the context of criminal investigations.² The article is also illustrative of the importance of understanding policy-making as an iterative process, requiring close monitoring of intended and unintended consequences and adaptability, to avoid, mitigate, or rectify any harm that may be caused. SRHM’s publication of this important research by Johnsdotter has already advanced the conversation in Sweden, with the article having received robust coverage from major media outlets in the country.

Political decisions and associated policies that undermine or intentionally attack SRHR are often driven by the political priorities of those in power, underwritten by the incentive of politicians and decision-makers to gain or retain political power. They can also be shaped by the social norms and cultural beliefs of decision-makers and the embedded cultures within institutions of the state. In their review article, Yasmine and Sukkar trace the ways in which the political agenda of the Lebanese state influences laws and policies that either restrict or encourage women’s procreation, “depending on their nationality, sect, marital and legal status.”³ In her article focused on South Korea, Kim⁴ also demonstrates how the political imperatives of a state or a government, in relation to shaping its preferred demographic outcomes, can undermine women’s reproductive health and rights, including their reproductive choices. Kim argues that demographic changes have spurred different government responses to the regulation and promotion of reproductive technologies, which are conceptualised and used as tools of population control “rather than a means by which to pursue and uphold reproductive health and rights.”⁴

Some of the most dramatic and direct illustrations of the impact of politics on SRHR and the embodied consequences of those politics can be found in conflict zones and humanitarian settings. Morris et al.⁵ and Parmar et al.⁶ explore two very different settings in which the politics of conflict have undermined and violated women’s SRHR. Morris et al.⁵ show how, in Yemen, health facilities have become a primary target for airstrikes and bombing, while the delivery of essential medicines and supplies have been disrupted by blockades. They trace the work of Save the Children to continue with the provision of family planning and post-abortion care programmes within two governorates heavily impacted by the conflict, demonstrating that demand for quality services has continued amidst the crisis.⁵ Further, their article shows that with adaptable and innovative programming (alongside adequate funding), such demand can be met. In their review, Parmar et al.⁶ draw attention to the issue of maternal death in the Rohingya refugee camps in Ukhia and Teknaf Upazilas, Cox’s Bazar District, Bangladesh. They argue that attempts to reduce maternal mortality within the camps need to take into account the complex historical, social and political factors that, taken together, provide the context within which reproductive health programming amongst Rohingya women in the camps takes place.

In pursuit of change: setting agendas, seizing opportunity, challenging norms

In robust literature on “agenda-setting,” political scientists have long recognised that it is often no accident that specific issues or problems are considered by decision-makers and governments at a given time.^7,8 Rather, the way that policy problems or issues are defined and recognised, along with the timing of their rise to prominence as a public or media issue, is often politically shaped and defined. In the field of SRHR, “agenda-setting” strategies are used by progressive activists and practitioners, who wish to the see the protection and expansion of SRHR, as well as by conservative forces working to limit, restrict and retract the rights of women and girls in various global settings. Activists on both sides also work carefully to consider how issues are framed and presented to the media and the public, as well as to decision-makers. They take advantage of, or help bring about, political opportunities (for example, the rise of a political party or government supportive of their perspective) to advance their work.

In her “spotlight” article in this issue, Vida⁹ shows how opponents of SRHR in Hungary are using carefully crafted and emotive arguments, symbols and rhetoric to frame their arguments against gender equality and SRHR. Vida highlights contemporary attacks on SRHR in the context of the European Union (EU), calling attention to the failure of the EU to demand compliance amongst Member States in upholding EU commitments to gender equality and democracy. To build her case, Vida offers a glimpse into anti-gender discourse, ideology, and politics in Hungary, which has experienced a significant backlash against women’s rights and SRHR since 2010, under the government of the conservative, right-wing Fidesz and Christian Democratic Party (KDNP) coalition. She notes the rhetorical tactics of the anti-gender movements, who have worked to frame progressive ideas about gender values, equality, and human rights as a threat to institutions and individuals who may be threatened by the transformative agendas of those seeking gender equality and associated rights. The anti-gender backlashes within Hungary, as Vida notes, are far from isolated, but have spread across Europe and globally, as a fight against progressive, gender-inclusive social policies and protections, and which are framed as a fight against “gender ideology.”⁹

In their contribution to this issue, Undurraga and Sadler¹⁰ unpack key legal debates regarding the scope and eligibility for abortion-related conscientious objection in Chile, at both an individual and an institutional basis. The authors demonstrate how these debates intersect with the complicated politics of private medicine, and political and economic shifts towards a market-oriented logic of health provision in Chile. They highlight some emerging arguments being advanced to support conscientious objection in debates in Chile and draw attention to the ways in which these arguments can hold sway beyond the borders of Chile, potentially influencing SRH policies in the rest of Latin America.

The commentary by Gressick et al.¹¹ highlights how the Zika epidemic opened a debate in Brazil about expanding legal provisions for abortion to include cases of microcephaly secondary to Zika virus infection. Particularly through coverage in two top-circulating Brazilian newspapers, the debate on abortion in the case of microcephaly also shone a light on existing health disparities in Brazil, which were magnified by the Zika virus. This provided an important political opportunity to renew debates about health inequities and access to abortion more broadly. Gressick et al.¹¹ further note the importance within these debates of how the issues were framed by opponents and proponents of expanding legal provisions for abortion.

In their contribution, Sharma et al.¹² present an example of how political norms around abortion have been recently challenged in Pakistan, despite the government having long relied on restrictive colonial-era abortion laws through political inaction. The lack of political priority attached to abortion law was challenged, in this case, by concerted attempts to shift norms amongst decision-makers, ahead of any attempts to formally change the law. This was done through building the political will of key government stakeholders (including champion policy-makers and influencers) to first address maternal mortality by improving access to safe abortion within the parameters of existing law, through a health-oriented, pragmatic approach. In this case, the issue was framed within a shared civil society and government goal of reducing maternal mortality, using the terminology of “uterine evacuation,” in order to open dialogue with government stakeholders and clinical advisors who may otherwise have been reluctant to engage.¹² While the end goal remains essential changes in abortion law through formal political processes, this case highlights avenues for change within existing legal frameworks that can “soften the ground” for future legal reform efforts.

Another article in this issue explores not how to change social norms, but rather how best to scale up programming that has already been shown to be effective in one context, or level of engagement, towards changing norms related to gender equality, the prevention of violence against women and girls, and advances in SRHR. Goldmann et al.¹³ draw on lessons and experiences from a group of nine organisations, the Community for Understanding Scale Up (CUSP), which works across four regions towards the development of evidence-based, social norms change methodologies, and towards supporting scale-up efforts. Their recommendations suggest that the effective and ethical scale up of social norms change initiatives requires a careful rethinking of current donor and implementation practices, including (amongst other key points) decisions around the duration of programme funding and who receives such funding, how to ensure accountability to communities, and the need to rethink evaluation approaches and practices to produce evidence that can guide processes of scale up, and which represents the voices of activists and communities from within the Global South.¹³

Holding power to account

Political support, as well as policy or legal decisions that uphold and protect SRHR, are critical starting points in the advancement of SRHR in any context. They are, however, not enough. A key component of ensuring that SRHR are truly accessible and protected not just on paper, but in the everyday lives of women and girls globally, is the ability to hold political power to account for delivering on the provision of services and the realisation of rights. Accountability is a cornerstone of democratic governance, but it is seldom easy to achieve. In particular, holding policy-makers, decision-makers, politicians, managers, health care providers, and others accountable in the area of SRHR can be a challenging and complex undertaking.

Boydell et al.¹⁴ build on a recent systematic review of the published evidence on SRHR and accountability, going beyond the parameters of the initial review to ask what specific factors and dynamics shape and constrain the opportunities for accountability efforts in the area of SRHR. While various global normative frameworks, standards and guidelines are designed to enhance and protect individuals’ access to SRHR, the authors note that there are often substantial gaps between these frameworks, standards and guidelines, and the lived realities of millions of people globally. The authors highlight some specific themes in the literature that may offer a signpost for further research into accountability efforts in the area of SRHR, and in work towards improved accountability. These include understanding the political and ideological context of SRHR, enhancing community voice and health system responsiveness, and recognising the complexity of health systems. In all of these areas, the authors find space for leveraging opportunities for improved financial, performance and political/democratic accountability for SRHR, yet they note that there are characteristics specific to SRHR which need to be considered in accountability efforts, as they “colour the capabilities and conditions in which accountability efforts occur.”¹⁴

In some contexts, legal challenges can represent an important tool in the accountability toolkit, with civil society organisations, human rights organisations, and others using litigation, including public interest and strategic litigation, to hold power to account. However, legal decisions can also work to undermine SRHR. In this issue, Molina et al.¹⁵ explore the potentially dangerous implications for women of US Attorney General Jeff Sessions’ reversal of a decision (Matter of A-R-C-G) in June 2018, in which domestic violence was the basis for asylum. The authors warn that, amidst a global epidemic of gender-based violence, this reversal could set a perilous international precedent, with possible impacts on women and survivors of violence globally. Legal decisions, they write, “not only provide mechanisms for individuals to pursue justice, but they also serve as symbols of what is considered to be acceptable or not acceptable in a society.”¹⁵ They note that this decision also illustrates the need for improved collaboration between legal and health professionals to “go beyond their traditional roles to advocate for the people they serve and to partner in holding political and legal authorities accountable for their decisions.”¹⁵

Engaging with politics towards change

Globally, we are in a period of widespread populist politics, replete with propaganda and lies, the promulgation of hatred and fear, and regressive SRHR policies. Decades of public health evidence demonstrates, inarguably, that sexual and reproductive rights are fundamental to the health and well-being of all. Yet, sexual and reproductive rights are in the cross-hairs in many corners of the world, including within countries and regions which, by their own accounts of themselves, ought to be leading the way in the protection of promotion of human rights. The enactment of the so-called fetal heartbeat laws in four states this year in the US, and the backlashes against women’s rights and SRHR in Brazil under President Bolsanaro, for example, are stark reminders of the potential for politics and ideology to outweigh evidence when it comes to the protection of women’s reproductive health and rights.

With the forthcoming ICPD25 Summit in Nairobi in November, and the 25th Anniversary of the Beijing Declaration and Platform for Action in 2020, it is an opportune time for activists, practitioners, researchers, policy-makers and others engaged in promoting and protecting SRHR, to reflect on the various impacts that politics, in its various guises, continues to have in this field. As the articles in this issue demonstrate, we need to pay careful attention to the ways in which political debates around SRHR are created and advanced, how policies are developed and implemented, how to create and take advantage of political opportunities for change, how to create and maintain coalitions across disciplines and across issues, and how to work to change social, cultural and political norms that continue to deny or restrict access to SRHR, particularly for women and girls. We also need to work towards improved strategies and mechanisms of holding power to account. And, in the midst of very trying political times, we need to continue to work with passion and without relent towards the realisation of SRHR for all.