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Article

Lillian Abracinskas and Santiago Puyol

As time goes by, the world experiences advances and setbacks in the field of sexual and reproductive health and rights. But new challenges appear in terms of professional performance and implementation of services created by newer laws and policies. The development of new ethical frames in dialogue with disputed value systems is one of the main obstacles to ensuring universal access and comprehensive services to guarantee the exercise of these rights. Since 2002, Uruguay has been one of the few countries in Latin America and the Caribbean that has achieved significant advances regarding sexual and reproductive rights by recognizing them as human rights. The passage of several laws has resulted in the implementation of programs in SRHS and legal abortion as being considered mandatory for the National Health System. The follow-up and monitoring of this process by the Observatory of Mujer y Salud en Uruguay (MYSU) has demonstrated how changes in the legal framework led to a new stage for health-care providers, politicians, and decision makers and also for the social movement that has historically advocated for this agenda, all now facing new problems and challenges—some of which are completely unexpected. The high prevalence of conscientious objection exercised by physicians and OB/GYNs in refusing the provision of care in SRHS is one of the ethical dilemmas that needs to be discussed to innovate solutions to the problems and promote best practices from a gender equity and human rights paradigm.

Article

Ine Vanwesenbeeck

Comprehensive sexuality education (CSE) is increasingly accepted as the most preferred way of structurally enhancing young peoples’ sexual and reproductive well-being. A historical development can be seen from “conventional,” health-based programs to empowerment-directed, rights-based approaches. Notably the latter have an enormous potential to enable young people to develop accurate and age-appropriate sexual knowledge, attitudes, skills, intentions, and behaviors that contribute to safe, healthy, positive, and gender-equitable relationships. There is ample evidence of program effectiveness, provided basic principles are adhered to in terms of content (e.g., adoption of a broad curriculum, including gender and rights as core elements) and delivery (e.g., learner centeredness). Additional and crucial levers of success are appropriate teacher training, the availability of sexual health services and supplies, and an altogether enabling (school, cultural, and political) context. CSE’s potential extends far beyond individual sexual health outcomes toward, for instance, school social climates and countries’ socioeconomic development. CSE is gaining worldwide political commitment, but a huge gap remains between political frameworks and actual implementation. For CSE to reach scale and its full potential, multicomponent approaches are called for that also address social, ideological, and infrastructural barriers on international, national, and local levels. CSE is a work never done. Current unfinished business comprises, among others, fighting persevering opposition, advancing equitable international cooperation, and realizing ongoing innovation in specific content, delivery, and research-methodological areas.

Article

Shireen Jejeebhoy, K. G. Santhya, and A. J. Francis Zavier

India has demonstrated its commitment to improving the sexual and reproductive health of its population. Its policy and program environment has shifted from a narrow focus on family planning to a broader orientation that stresses sexual and reproductive health and the exercise of rights. Significant strides have been made. The total fertility rate is 2.2 (2015–2016) and has reached replacement level in 18 of its 29 states. The age structure places the country in the advantageous position of being able to reap the demographic dividend. Maternal, neonatal, and perinatal mortality have declined, child marriage has declined steeply, contraceptive use and skilled attendance at delivery have increased, and HIV prevalence estimates suggest that the situation is not as dire as assumed earlier. Yet there is a long way to go. Notwithstanding impressive improvements, pregnancy-related outcomes, both in terms of maternal and neonatal mortality and morbidity, remain unacceptably high. Postpartum care eludes many women. Contraceptive practice patterns reflect a continued focus on female sterilization, limited use of male methods, limited use of non-terminal methods, and persisting unmet need. The overwhelming majority of abortions take place outside of legally sanctioned provider and facility structures. Over one-quarter of young women continues to marry in childhood. Comprehensive sexuality education reaches few adolescents, and in general, sexual and reproductive health promoting information needs are poorly met. Access to and quality of services, as well as the exercise of informed choice are far from optimal. Inequities are widespread, and certain geographies, as well as the poor, the rural, the young, and the socially excluded are notably disadvantaged. Moving forward and, in particular, achieving national goals and SDGs 3 and 5 require multi-pronged efforts to accelerate the pace of change in all of these dimensions of health and rights.