For, against, and beyond: healthcare professionals' positions on Medical Assistance in Dying in Spain.

BACKGROUND: In 2021, Spain became the first Southern European country to grant and provide the right to euthanasia and medically assisted suicide. According to the law, the State has the obligation to ensure its access through the health services, which means that healthcare professionals' participation is crucial. Nevertheless, its implementation has been uneven. Our research focuses on understanding possible ethical conflicts that shape different positions towards the practice of Medical Assistance in Dying, on identifying which core ideas may be underlying them, and on suggesting possible reasons for this disparity. The knowledge acquired contributes to understanding its complexity, shedding light into ambivalent profiles and creating strategies to increase their participation. METHODS: We conducted an exploratory qualitative research study by means of semi-structured interviews (1 h) with 25 physicians and nurses from primary care (12), hospital care (7), and palliative care (6), 17 women and 8 men, recruited from Madrid, Catalonia, and Andalusia between March and May 2023. Interviews were recorded, transcribed, and coded in Atlas.ti software by means of thematic and interpretative methods to develop a conceptual model. RESULTS: We identified four approaches to MAiD: Full Support (FS), Conditioned Support (CS), Conditioned Rejection (CR), and Full Rejection (FR). Full Support and Full Rejection fitted the traditional for and against positions on MAiD. Nevertheless, there was a gray area in between represented by conditioned profiles, whose participation cannot be predicted beforehand. The profiles were differentiated considering their different interpretations of four core ideas: end-of-life care, religion, professional duty/deontology, and patient autonomy. These ideas can intersect, which means that participants' positions are multicausal and complex. Divergences between profiles can be explained by different sources of moral authority used in their moral reasoning and their individualistic or relational approach to autonomy. CONCLUSIONS: There is ultimately no agreement but rather a coexistence of plural moral perspectives regarding MAiD among healthcare professionals. Comprehending which cases are especially difficult to evaluate or which aspects of the law are not easy to interpret will help in developing new strategies, clarifying the legal framework, or guiding moral reasoning and education with the aim of reducing unpredictable non-participations in MAID.

"It's like crystal gazing": The Lived Experience of Anticipating End-of-Life Choices in Older Adults and Their Close Ones.

BACKGROUND AND OBJECTIVES: Nowadays people increasingly try to take control over the end of their lives by anticipating end-of-life choices. Explication of these choices is encouraged using advance care planning (ACP). We aim to deepen our understanding of how choice-making processes are lived in real life, exploring the experience of community-dwelling older adults and their close ones over time. RESEARCH DESIGN AND METHODS: A multiperspective and longitudinal approach grounded in phenomenology was chosen. Ten triads consisting of an older adult (75+) and 2 close ones (n = 30) were interviewed, twice individually and once as a group, over 20 months (=70 interviews). Data were thematically analyzed both longitudinally and from all 3 perspectives. RESULTS: The essential meaning of anticipatory choice-making processes was described as a dynamic and relationally entangled decisional process, to navigate between paradoxical choices for an opaque future. Three fields of tension were created due to ambivalence in these choice-making processes: navigation between having and losing control, between taking away and burdening with responsibility, and between expressing and holding back oneself. DISCUSSION AND IMPLICATIONS: Anticipation of choices for hypothetical end-of-life scenarios turned out to be complex and ambivalent. Most older adults resisted ambivalence and ignored complexity in an attempt to stay in control over their end of life. The burdening impact of choices on close ones illuminated the relationality of choice-making processes. These aspects of end-of-life choice-making processes should be integrated into ACP in order to better understand and care for people and their close ones faced with these choices.

An "ethics of strangers"? On knowing the patient in clinical ethics.

The shape and function of ethical imperatives may vary if the context is an interaction between strangers, or those who are well acquainted. This idea, taken up from Stephen Toulmin's distinction between an "ethics of strangers" and an "ethics of intimacy", can be applied to encounters in healthcare. There are situations where healthcare personnel (HCP) know their patients (corresponding to an "ethics of intimacy") and situations where HCP do not know their patients (corresponding to "an ethics of strangers"). Does it make a difference for normative imperatives that follow from central concepts and principles in medical ethics whether HCP know their patients or not? In our view, this question has not yet been answered satisfactorily. Once we have clarified what is meant by "knowing the patient", we will show that the distinction is particularly relevant with regard to some thorny questions of autonomy in healthcare (e.g., regarding advance directives or paternalism in the name of autonomy), whereas the differences with regard to imperatives following from the principles of justice and beneficence seem to be smaller. We provide a detailed argument for why knowing the patient is ethically valuable in encounters in healthcare. Consequently, healthcare systems should provide fertile ground for HCP to get to know their patients, and structures that foster therapeutic continuity. For this to succeed, a number of questions still need to be clarified, which is an important task for medical ethics.

Decision-making experiences of patients and partners opting for active surveillance in esophageal cancer treatment.

OBJECTIVES: This study explored the decision-making experiences of patients and their partners or primary caregiver who opted for experimental active surveillance (instead of standard surgery) for the treatment of esophageal cancer. METHODS: Seventeen couples participated. Semi-structured interviews were conducted on couples' joint experiences as well as their individual experiences. Preferred and perceived role in the treatment decision-making process was assessed using the adjusted version of the Control Preferences Scale, and perceived influence on the treatment decision was measured using a visual analog scale. RESULTS: Couples reflected on the decision-making process as a positive collaboration, where patients retain their autonomy by making the final decision, and partners offer emotional support. Couples reported about an overwhelming amount and sometimes conflicting information about treatments among different hospitals and healthcare providers. CONCLUSIONS: Patients often involve their partner in decision-making, which they report to have enhanced their ability to cope with the disease. The amount and sometimes conflicting information during the decision-making process provide opportunities for improvement. PRACTICE IMPLICATIONS: Couples can benefit from an overview of what they can expect during treatment course. If active surveillance becomes an established treatment option in the future, provision of such overviews and consistent information should become more streamlined.

Fostering relational autonomy in end-of-life care: a procedural approach and three-dimensional decision-making model.

Respect for patient autonomy is paramount in resolving ethical tensions in end-of-life care. The concept of relational autonomy has contributed to this debate; however, scholars often use this concept in a fragmented manner. This leads to partial answers on ascertaining patients' true wishes, meaningfully engaging patients' significant others, balancing interests among patients and significant others, and determining clinicians' obligations to change patients' unconventional convictions to enhance patient autonomy. A satisfactory solution based on relational autonomy must incorporate patients' competence (apart from decisional capacity), authenticity (their true desires or beliefs) and the involvement level of their significant others. To that end, we argue that John Christman's procedural approach to relational autonomy provides critical insights, such as the diachronic or socio-historical personhood, sustained critical reflection and his recent explication of the nature of asymmetrical relationships and helpful interlocutors. This study reviews Christman's account, proposes minor modifications and advocates for an integrated three-dimensional model for medical decision-making. Clarifying the relationship among the three elements promotes an ethical framework with a coherent understanding of relational autonomy. This model not only provides a descriptive and normative framework for end-of-life care practice but also reconsiders the nature of the clinician-patient relationship and its normative implications. We further present a case study to illustrate the merits of our proposed model. Altogether, our proposal will help navigate complex medical decision-making, foster trust and negotiate shared values between patients and their significant others, particularly in end-of-life care.

Factors Contributing to Non-Concordance Between End-of-Life Care and Advance Care Planning.

CONTEXT: Despite making do-not-resuscitate or comfort care decisions during advance care planning, terminally ill patients sometimes receive life-sustaining treatments as they approach end of life. OBJECTIVES: To examine factors contributing to nonconcordance between end-of-life care and advance care planning. METHODS: In this longitudinal retrospective cohort study, terminally ill patients with a life expectancy shorter than six months, who had previously expressed a preference for do-not-resuscitate or comfort care, were followed up after palliative shared care intervention. An instrument with eight items contributing to non-concordant care, developed through literature review and experts' consensus, was employed. An expert panel reviewed electronic medical records to determine factors associated with non-concordant care for each patient. Statistical analysis, including descriptive statistics and the chi-square test, examines demographic characteristics, and associations. RESULTS: Among the enrolled 7871 patients, 97 (1.2%) received non-concordant care. The most prevalent factor was "families being too distressed about the patient's deteriorating condition and therefore being unable to let go" (84.5%) followed by "limited understanding of medical interventions among patients and surrogates" (38.1%), and "lack of patient participation in the decision-making process" (25.8%). CONCLUSIONS: This study reveals that factors related to relational autonomy, emotional support, and health literacy may contribute to non-concordance between advance care planning and end-of-life care. In the future, developing an advance care planning model emphasizes respecting relational autonomy, providing emotional support, and enhancing health literacy could help patients receiving a goal concordant and holistic end-of-life care.

"The Patient Is Being Pressured!" Coercion Versus Relational Autonomy.

Relational autonomy is a concept that describes the interdependent nature of decision making by individuals. Relational autonomy is distinct from the traditional concept of autonomy, which asserts the need for each individual to make choices based on their own values and without influence by others. We present a case in which a patient made decisions that appeared contrary to his own desires. The case raises questions about the line between appropriate and coercive family influence. We also explore the moral distress generated by the attempt to reconcile his expressed desires and the decisions he made. We propose that examining the case with a relational autonomy lens may have helped clinical staff understand his decision and thus mitigate moral distress.

Parental agency in pediatric palliative care.

The study discusses a new approach to parental agency in pediatric palliative care based on an active form of caregiving. It also explores the possibility of a positive conceptualization of parental agency in its relational context. The paper begins with an illustrative case study based on a clinical situation. This is followed by an analysis of various aspects of parental agency based on empirical studies that disclose the insufficiencies of the traditional approach to parental agency. In the next step, parental agency is analyzed from a reality-based perspective as an activity focused on relationships and the cognitive capacity of parents vis-a-vis their seriously ill children. The paper also considers the importance of the cultural and social contexts in which parental agency and decision-making take place. This agency is addressed not as individualistic in form, and nor is it exercised in terms of fixed choices. Rather, the focus is on its dynamic and future-oriented aspects. Consequently, parental agency should be comprehended not only as a form of proxy agency representing the child's best interests but also as a complex decision-making process in which the parents learn from their child how to become good, compassionate caregivers and at the same time good parents.

"Existe o espaço, mas ao mesmo tempo não existe": análise do processo de cuidado no tratamento psicofarmacológico na saúde mental / "Existe el espacio, pero al mismo tiempo no existe": análisis del proceso de cuidado en el tratamiento psicofarmacéutico en la salud mental / "There is space, but at the same time there isn't": the care process analysis in psychopharmacological treatment in mental health

Considerando os desafios à reabilitação psicossocial, objetivou-se compreender a perspectiva de usuários e trabalhadores no tratamento psicofarmacológico. Trata-se de um estudo qualitativo que entrevistou seis profissionais e dez usuários do Centro de Atenção Psicossocial de um município da região norte de Minas Gerais. As transcrições foram tratadas em Ciclos de Codificação e examinadas pela Análise de Discurso. Definiram-se três categorias relativas à dimensão micropolítica do cuidado: o fluxograma institucional, os espaços intercessores e a produção subjetiva dos agentes. Revelaram-se dissonâncias entre enunciados alusivos à política da atenção psicossocial, com a concorrência de concepções e tecnologias de cuidado emancipatórias e restritivas. Constatou-se a importância da análise micropolítica do cuidado no tratamento psicofarmacológico, favorecendo os processos de contratualidade, protagonismo e autonomia do usuário.

Considerando los desafíos para la rehabilitación psicosocial, el objetivo fue comprender la perspectiva de usuarios y trabajadores en el tratamiento psicofarmacéutico. Se trata de un estudio cualitativo que entrevistó a seis profesionales y a diez usuarios del Centro de Atención Psicosocial de un municipio de la región norte de Minas Gerais. Las transcripciones fueron tratadas en Ciclos de Codificación y examinadas por el Análisis del Discurso. Se definieron tres categorías relativas a la dimensión micropolítica del cuidado: el diagrama de flujo institucional, los espacios intercesores y la producción subjetiva de los agentes. Se revelaron disonancias entre enunciados alusivos a la política de la atención psicosocial, con la concurrencia de concepciones y tecnologías de cuidado emancipatorias y restrictivas. Se constató la importancia del análisis micropolítico del cuidado en el tratamiento psicofarmacéutico, favoreciendo los procesos de contractualidad, protagonismo y autonomía del usuario.

Considering the challenges to psychosocial rehabilitation, this study was aimed at understanding the perspective of users and workers regarding psychopharmacological treatment. This is a qualitative study, which interviewed six providers and ten users of the Psychosocial Care Center of a municipality in the north of Minas Gerais. The transcripts were treated in Coding Cycles and examined by Discourse Analysis. Three categories related to the micropolitical dimension of care were defined: the institutional flowchart; the intercessory spaces; and the subjective production of the agents. Dissonances were revealed between statements alluding to the psychosocial care policy, with the competition of emancipatory and restrictive conceptions and technologies of care. The importance of the micropolitical analysis of care in psychopharmacological treatment was verified, favoring the processes of contractuality, protagonism, and user autonomy.

Factors impacting the demonstration of relational autonomy in medical decision-making: A meta-synthesis.

BACKGROUND: Relational autonomy is an alternative concept of autonomy in which an individual is recognized as embedded into society and influenced by relational factors. Social context, including social location, political structure, and social forces, significantly influence an agent to develop and exercise autonomy skills. The relational approach has been applied in clinical practice to identify relational factors impacting patient autonomy and decision-making, yet there is a knowledge gap in how these factors influence the demonstration of relational autonomy in the context of medical decisions of adults. OBJECTIVE: The present study targeted the existing knowledge of what and how relational factors impact individuals making medical decisions using the theoretical framework of relational autonomy. METHODS: A meta-synthesis study was utilized. Four electronic databases, including Embase, OVID Medline, CINAHL, and PubMed, were searched, along with gray literature and reference lists, to identify relevant studies. RESULTS: 23 studies reporting 21 qualitative and two mixed-method studies were reviewed. Four themes emerged from the qualitative findings: (1) supportive relationships facilitate an individual's relational autonomy; (2) obtaining comprehensive information from broader sources helps individuals exercise relational autonomy; (3) undue family pressure impedes the exercising of patient relational autonomy; and (4) healthcare providers' dominant voice hampers the demonstration of relational autonomy. CONCLUSIONS: Applying relational autonomy to assist adults in making well-considered decisions is essential. The meta-synthesis suggests establishing a supportive relationship between individuals, healthcare providers, and family. A supportive relationship will allow healthcare providers to make judgments in line with an individual's values and wishes with the aim of promoting relational autonomy. Advance care planning was proposed as the effective solution to obtain a consensus between individuals and their families while respecting an individual's values and preferences. Furthermore, it is considered crucial for healthcare providers to appreciate an individual's values and incorporate their preferences into recommendations.

Ethics Guideline Development for Neuroscience Research involving Patients with Mental Illness in Japan.

This study aims to develop guidelines of key concepts and specific considerations to make the research more ethical when conducting neurological examinations and treatment interventions in mentally ill patients. We analyzed guideline development theory and literature, previous issues, and discussions with specialists of philosophy, medicine, sociology, and bioethics. The selection of research participants, drafting of intervention plans, and informed consent process were examined with reference to the dual burden; the minimal risk as a general rule of ethical allowance levels, assent and dissent to assess the individual's judgment capacity for consent, relational autonomy for personal consent with assistance by the proxy, and risk/benefit assessments. When conducting studies, this guideline requires that these three processes be set up appropriately on a case-by-case basis. Supplementary Information: The online version contains supplementary material available at 10.1007/s41649-023-00240-x.

Providing Emotional Support and Physical Comfort During a Time of Social Distancing: A Thematic Analysis of Doulas' Experiences During the Coronavirus Pandemic.

Doulas are trained, non-clinical professionals that provide a continuum of support for mothers. An interpretive phenomenological approach was used to explore the professional experiences of doulas (n = 17) during the COVID-19 pandemic in the US. Data were collected using brief intake surveys, in-depth semi-structured interviews, and an online discussion group. After a list of significant statements was created and grouped during emergent themes analysis, the reflections were summarized into three themes, (1) Doula Resilience, (2) Experiencing Vulnerability, and (3) Concern for Client Vulnerability that encapsulate the experiences of doulas during the COVID-19 pandemic. We conclude that as part of the COVID-19 recovery process, policy makers should look to non-clinical interventions for improving maternal health, such as promoting and supporting synergy between doulas and other maternal health service providers.

Relational approaches in bioethics: A guide to their differences.

Contemporary critical approaches to bioethics increasingly present themselves as "relational," though the meaning of relationality and its implications for bioethics seem to be many and varying. I argue that this confusion is due to a multiplicity of relational approaches originating from distinct theoretical lineages. In this article, I identify four key differences among commonly referenced relational approaches: the scope and nature of relationships considered, the extent of the determining influence on individual selfhood, and the integrity of individual selfhood. Importantly, these four differences carry consequences for the usage of relational approaches within academic and clinical bioethics. I show that these differences attach to multiple objects of critique within mainstream bioethics and imply distinct metaethical commitments. Although I issue a cautionary note about combining relational approaches from distinct lineages, I close by suggesting that many such approaches may have their use, drawing on Susan Sherwin's sense of bioethical theories as lenses.

Advance Care Planning in Spain.

In the last decade in Spain, an important push has been given to the development of health policies that define the framework of action in the care of people with advanced chronic diseases. Respect for the autonomy of the patient, shared decision-making processes and advance care planning (ACP) are recognized into health plans as a key aspect in chronic care, frailty, and palliative care. A few but significant number of institutions, local governments, and healthcare professionals from different regions of Spain have started a rationale and roadmap for a new twist in Spain's theoretical, ethical and policy development, promoting ACP implementation into public health care systems. In 2020, a working group founded in 2017, evolved into the "Spanish Association of Shared Care Planning" (AEPCA). The Shared Care Planning (SCP) concept grows up after the two international consensus Delphi studies in 2017 and pretends to shift from the framework of ACP programs to a person-centred care approach. In the last years, several experiences show how professionals are more sensible and interested on the ACP process, but it cannot be said, for now, that it has taken effect in the global Spanish health system. Even both ACP and SCP are being used simultaneously in Spain, each day more people and autonomous communities embrace renewed concept and foundations of SCP, supporting the work of AEPCA on spreading the value of this process into the care of people who are coping with chronic diseases, vulnerability, and frailty.

Real-world experience implementing Advance Care Planning in the Asia-Pacific: ACP in Japan.

Promoting Advance Care Planning (ACP) in the super-aged society of Japan has become increasingly important for supporting older adults to continue to live in the community until the end of life. To promote ACP further in Japan, Japanese family-centered decision-making and high-context culture need to be taken into account. Therefore, we describe the environmental and historical backgrounds surrounding ACP in Japan, and based on the results, introduce research and education programs regarding its implementation.

Women's autonomy for managing labour pain in a relational context: An interpretive description study.

AIM: To describe how women perceived relational autonomy for decision-making during childbirth pain and illuminate influencing factors. BACKGROUND: Most women report challenging pain during birth. Circumstances can affect their ability to engage in pain management decisions. DESIGN: We used an interpretative description approach to conduct this study. METHOD: A purposive sample of ten women who reported pain during childbirth participated in semi-structured interviews. The study was conducted between July 2019 and November 2020 and reported according to the COREQ checklist. RESULTS: Circumstances during childbirth, such as women's expectations and relationships, influenced their efforts to engage in relational autonomy. Care providers dealt with the unpredictability of childbirth and challenges with pain management using decision-making practices that could disrupt women's expectations, undermine women's trust, demonstrate disrespect for women and rely on inadequate communication. Women who felt dependent on others were less likely to participate in decision-making. When care providers' perceptions about pain differed from women's reports of pain, participants became distressed because care providers did not acknowledge their subjective pain experiences. CONCLUSIONS: Women regarded their relationships and communication with care providers as foundational to relational autonomy in decision-making about pain management during childbirth. RELEVANCE TO CLINICAL PRACTICE: Study findings can support care providers' considerations of the complexity of childbirth pain and factors affecting women's relational autonomy in decision-making about pain. In particular, the findings highlight the importance of women's expectations and care providers' recognition of women's experiences of pain. PATIENT OR PUBLIC CONTRIBUTION: Women who shared their stories of childbirth pain contributed to the data collected. The chief nursing officers in the data collection setting facilitated the recruitment and data collection.

Patient and therapist perspectives on physical therapy outcome measures and engagement after stroke: A case study.

BACKGROUND: Outcome measures are highly recommended in stroke physical therapy, however, most of the existing research has been performed from the provider perspective. Understanding the patient perspective of outcome measures in conjunction with the therapist perspective may help to better support patient engagement and autonomy. PURPOSE: The purpose of this study was to explore patient and therapist perspectives on physical therapy outcome measures post-stroke. METHODS: This qualitative case study of a Canadian rehabilitation facility is based on patient-oriented research principles, with three patient partners embedded in the research team. Data collection included chart reviews, observations of physical therapy sessions, patient interviews, and therapist interviews. Field notes of observations and interview transcripts were analyzed using thematic analysis. RESULTS: Ten patients and seven therapists participated. Analysis revealed the following two themes: 1) tracking progress; and 2) partnership. Tracking progress included the expectations patients had for improvement, the importance of objectively measuring change and the functional improvement observed day by day. Partnership described the relationship between therapist and patient including communication, encouragement and affirmation, the therapist as expert and the gradual shift in autonomy from therapist to patient. CONCLUSION: Patients valued the objective results of outcome measures and were encouraged by measurable changes. Maximizing the use of physical therapy outcome measures may improve patient engagement and support relational autonomy.

Is the Cure Worse than the Disease? The Ethics of Imposing Risk in Public Health.

Efforts to improve public health, both in the context of infectious diseases and non-communicable diseases, will often consist of measures that confer risk on some persons to bring about benefits to those same people or others. Still, it is unclear what exactly justifies implementing such measures that impose risk on some people and not others in the context of public health. Herein, we build on existing autonomy-based accounts of ethical risk imposition by arguing that considerations of imposing risk in public health should be centered on a relational autonomy and relational justice approach. Doing so better captures what makes some risk permissible and others not by exploring the importance of power and context in such deliberations. We conclude the paper by applying a relational account of risk imposition in the cases of (a) COVID-19 measures and (b) the regulation of sugar-sweetened beverages to illustrate its explanatory power.

Toma de decisión compartida en la asesoría preprueba de la ecografía de las 11 a las 13 semanas de gestación: revisión bibliográfica / Shared decision making in pretest counseling at the 11 to 13 weeks ultrasound scan: bibliographic review

Resumen ANTECEDENTES: En el diagnóstico prenatal confluye un grupo de tecnologías enfocadas a la detección de defectos o anomalías congénitas de origen genético y multifactorial. Con independencia del tipo de prueba de que se trate, cualquier tecnología de diagnóstico prenatal debe ir acompañada de asesorías pre y posprueba. La sustentación ética de estas asesorías es de primordial interés para la Medicina prenatal y ha sido tarea de diversas organizaciones. METODOLOGÍA: Estudio retrospectivo, de búsqueda en las bases de datos PubMed, Web of Science y Google Scholar, con los términos MeSH: "Pregnancy", "Prenatal Diagnosis", "Genetic Conuseling", "Relational Autonomy" y "Decision Making". RESULTADOS: Se encontraron 909 referencias de las que se eliminaron las de más de 20 años de publicación, las que no contaban con textos completos y las duplicadas por la búsqueda en distintas bases de datos. Al final se analizaron 25 artículos en texto completo que sirvieron de base para la revisión bibliográfica. CONCLUSIONES: En la actualidad, el ultrasonido es la principal puerta de entrada al mundo del diagnóstico prenatal. Aludir a la indicación y uso éticos de cualquier tecnología de diagnóstico prenatal previene daño al embarazo en su conjunto y desincentiva la necesidad de una normatividad jurídica detallada que, por el momento, no existe en muchos países, incluido el nuestro. Hoy en día se dispone de lineamientos éticos claros para la asesoría de la ecografía como técnica de diagnóstico prenatal.

Abstract BACKGROUND: Prenatal diagnosis brings together a group of technologies that focus on the detection of congenital defects or anomalies of genetic and multifactorial origin. Irrespective of the type of test, any prenatal diagnostic technology must be accompanied by pre- and post-test counselling. The ethical underpinning of such counselling is of paramount interest to prenatal medicine and has been the task of several organisations. METHODOLOGY: Retrospective study, searching PubMed, Web of Science and Google Scholar databases using the MeSH terms: "pregnancy", "prenatal diagnosis", "genetic counselling", "relational autonomy" and "decision making". RESULTS: We found 909 references from which we eliminated those older than 20 years of publication, those without full text and those duplicated by searching in different databases. In the end, 25 full-text articles were analysed and served as the basis for the literature review. CONCLUSIONS: Ultrasound is currently the main gateway to the world of prenatal diagnosis. The ethical indication and use of any prenatal diagnostic technology prevents harm to the pregnancy as a whole and avoids the need for detailed legal regulation, which currently does not exist in many countries, including our own. Clear ethical guidelines are now available for advice on ultrasound as a prenatal diagnostic technique.

Reproductive autonomy associated with the use of contraceptive methods among reproductive aged women / Autonomía reproductiva asociada al uso de métodos anticonceptivos en mujeres en edad reproductiva / Autonomia reprodutiva associada ao uso de métodos contraceptivos entre mulheres em idade reprodutiva

ABSTRACT Objective: To assess the sociodemographic aspects associated with reproductive autonomy among urban women, with special regard to the relationship with the use of contraceptive methods. Method: Cross-sectional study with 1252 women, conducted between April and June 2021, using the Brazilian version of the Reproductive Autonomy Scale. Data were analyzed using multiple linear regression. Results: Mean scores for the subscales were 2.5 (SD=0.3) (Decision-making), 3.8 (SD=0.3) (Absence of Coercion) and 3.6 (SD=0.4) (Communication). Compared to women who reported no use of contraceptive methods, women using barrier or behavioral methods and those using LARC had higher level of reproductive autonomy on all dimensions of the Scale (p<0.001). Other aspects associated with reproductive autonomy were education, race/ethnicity, religion, socioeconomic status and cohabitation living with a partner, depending on each subscale. Conclusion: The type of contraceptive method used was statistically associated with reproductive autonomy in all subscales.

RESUMEN Objetivo: Verificar los aspectos sociodemográficos asociados a la autonomía reproductiva entre mujeres urbanas, especialmente en relación al uso de métodos anticonceptivos. Método: Estudio transversal realizado con 1252 mujeres, entre abril y junio de 2021, utilizando la versión brasileña de la Escala de Autonomía Reproductiva. Los datos se analizaron mediante regresión lineal múltiple. Resultados: Las puntuaciones medias de las subescalas fueron 2,5 (DE=0,3) (Toma de decisiones), 3,8 (DE=0,3) (Ausencia de coerción) y 3,6 (DE=0,4) (Comunicación). En comparación con las mujeres que informaron no usar métodos anticonceptivos, las mujeres que usaron métodos de barrera o conductuales y las que usaron LARC mostraron un mayor nivel de autonomía reproductiva en todas las dimensiones de la Escala (p<0,001). Otros aspectos asociados a la autonomía reproductiva fueron la educación, la raza/color, la religión, el grupo socioeconómico y la convivencia, según cada subescala. Conclusión: El tipo de método anticonceptivo utilizado se asoció estadísticamente con la autonomía reproductiva en todas las subescalas.

RESUMO Objetivo: Verificar os aspectos sociodemográficos associados à autonomia reprodutiva entre mulheres urbanas, em especial na relação com o uso de métodos contraceptivos. Método: Estudo transversal realizado com 1252 mulheres, entre abril e junho de 2021, utilizando a versão brasileira da Escala de Autonomia Reprodutiva. Os dados foram analisados por meio de regressão linear múltipla. Resultados: Os escores médios das subesacalas foram 2,5 (dp=0,3) (Tomada de decisão), 3,8 (dp=0,3) (Ausência de Coerção) e 3,6 (dp=0,4) (Comunicação). Comparadas às mulheres que relataram não usar métodos contraceptivos, mulheres que usavam métodos de barreira ou comportamentais e as que usavam LARC mostraram maior nível de autonomia reprodutiva em todas as dimensões da Escala (p<0,001). Outros aspectos associados à autonomia reprodutiva foram a escolaridade, raça/cor, religião, grupo socioeconômico e morar com o parceiro,a depender de cada subescala. Conclusão: O tipo de método contraceptivo utilizado foi estatisticamente associado à autonomia reprodutiva em todas as subescalas.