From consent to choice in family planning: application of an international framework to the United States.

Building on the broad agenda set forth at the 1994 International Conference on Population and Development, this article articulates similarly broad expectations for informed choice in family planning service delivery. A framework developed by a Global Working Group in 1998 sets forth various issues into a single analysis of informed choice. In an effort to bring international perspectives to bear on the articulation of new objectives for the home front, the article applies this framework to the US research literature in family planning. Review of the literature indicates a heartening degree of attention to issues of access and choice, but it also uncovers challenges faced by clients and providers and gaps in what is known. Few studies look beyond access to how providers actually do or could better facilitate informed decision making within the family planning setting. Such studies could help improve innovative and ambitious service delivery approaches that go beyond meeting the reproductive health needs of clients to ensure rights, improve choice, and empower individuals.

Opening a door to safe abortion: international perspectives on medical abortifacient use.

International experience compels us to revisit how we define and assess the safety and efficacy of medical abortifacients such as misoprostol. In some countries where safe abortion is neither accessible nor legal, even unsupervised, off-protocol use of misoprostol can provide women with a means to safely terminate pregnancy. This is due primarily to misoprostol-induced uterine contractions that cause bleeding, which in turn provides access to existing reasonable quality health services that would otherwise be unavailable. Several studies have suggested that an increase in the underground use of misoprostol in Brazil has already reduced serious complications from unsafe abortion. Thus, the availability of medical abortifacients combined with strengthened postabortion care services can legitimately be considered a public health success in countries in which safe abortion services do not exist and law reform is unlikely.

Maintaining a focus on informed choice.

PIP: Informed choice refers to the process by which a person arrives at a decision about health care. It must be based upon access to, and full understanding of, all necessary information from the client's perspective. Much has been done over the past 20 years to build a strong global policy consensus for informed choice in family planning. That consensus rests upon a commitment to the health and rights of individuals, combined with the knowledge that family planning services do not meet clients' family planning needs when individual choice is not respected. However, despite this consensus, there remains a wide gap between policy objectives and the realities of informed choice at the service delivery level. There were widely published accounts in 1998 of people who have been forced to accept family planning, including sexual sterilization. Two particular reports referred to coercion in China and Peru. Informed choice remains a major concern. Interaction between clients and providers, providing information, informed consent protocols, targets and other evaluation measures, eligibility criteria for receiving services, and provider bias are discussed.^ieng

Congress again attacks international family planning.

PIP: The US Congress passed a spending bill in September for fiscal year 1997 which continues the restrictions for international family planning programs applied in fiscal year 1996. In addition to imposing funding cuts greater than any proposed for other development assistance programs, the bill prevents the funds from being released until July 1, 1997, 9 months into the fiscal year, and then only in small monthly installments. The final bill set the spending level for the program at $385 million. A chance does, however, exist that some of the restrictions can be loosened. The bill provides that the US President can determine that the restrictions are having a serious negative impact upon the proper functioning of the population program. If Congress approves such a finding, it can allow the funds to be released beginning March 1. The authors describe the individual suffering caused by the program funding problems, with particular note of the deleterious effects upon medical quality, counseling, and informed choice.^ieng

Seeking a stable future: perspectives on population policy. The legal approach: women's rights as human rights.

PIP: As it has grappled with issues of population policy, the international community has emphasized that women's reproductive rights are human rights. Scholars have also acknowledged that the right to reproductive health care exists within the scope of international human rights treaties and conventions and that gender equality, nondiscrimination, and freedom from government interference in marriage and family life are also guaranteed. Further protections extend to counseling and health information and referral. The Programme of Action of the 1994 International Conference on Population and Development continues this trend by emphasizing the importance of human rights for attaining population and development objectives, calling on governments to focus their efforts on improving the quality of life for individuals, and endorsing the notion that reproductive rights are universal human rights. Reproductive health care options are also influenced by sovereign laws that restrict availability of contraception, sterilization, or abortion. However, universal rights and unrestricted access must be complemented by other factors controlled by domestic laws to guarantee reproductive choice. Such laws cover issues like marriage age, divorce, marital property, child support, maternity benefits, day care, sex discrimination, eligibility for insurance, confidentiality, spousal consent, rape, and sexual abuse. Countries must modify restrictive national laws and promote laws protecting women's rights.^ieng

Benten v. Kessler: the RU 486 import case.

PIP: On July 1, 1992, the case of Benten v. Kessler was filed in the US District Court in New York. The case arose out of an attempt by abortion rights activist Lawrence Lader to call public attention to the US Food and Drug Administration's (FDA) ban on importation of the abortifacient drug mifepristone known as RU-486. The ban expresses the anti abortion stance of the Reagan and Bush administrations and creates a hostile climate for the development of new drugs related to reproductive health and reproductive choice. Plaintiffs in the Benten case sought public accountability by the FDA for its adoption of a ban of a safe and effective drug for unwanted pregnancy. Although the case did not succeed in retrieving the confiscated RU-486 pills for Leona Benten, in its opinion issued on July 14, 1992, the New York district court judge concluded that the import ban did not appear to be based on concern with the safety or effectiveness of RU-486, describing the FDA's process of adopting the import ban as a sink of illegality. On July 17, 1992, 7 Justices of the Supreme Court, with justices Blackmun and Stevens dissenting, joined in a per curiam opinion denying the application and foreclosing further personal relief for Leona Benten. This was the best result possible short of an all out victory for Leona Benten. The Court ruled against plaintiffs in their argument that notice and comment were required, but left entirely open plaintiffs' claims that the import ban is arbitrary and capricious under the Administrative Procedure Act and that the ban is unconstitutional in that it unduly burdens the right to terminate pregnancy. This backdrop creates a healthy skepticism about the prospects for the introduction of RU-486 into the US in the near future as well as about the fairness of government processes in areas of concern to women. Public health considerations, not politics, should determine access to health care.^ieng