Reproductive Health Care, a Fundamental Human Right

Reproductive health is a fundamental human right recognized by international frameworks like the Committee on the Elimination of Discrimination against Women (CEDAW). Women’s sexual and reproductive health is intrinsically linked to multiple human rights, such as the right to life, freedom from torture, health, privacy, education, and non-discrimination. Both the Committee on Economic, Social, and Cultural Rights (CESCR) and the CEDAW have explicitly stated that women’s right to health encompasses their sexual and reproductive health (CESCR General Comment No. 14; CEDAW General Recommendation No. 24). Violations of women’s sexual and reproductive health (SRH) and rights often stem from deeply in-built patriarchal beliefs that value women primarily for their reproductive abilities. These beliefs lead to early and closely spaced pregnancies, often to produce male offspring, causing severe health consequences; women who are infertile frequently face ostracism and human rights violations (WHO, 2020).

Reproductive health directly impacts individuals’ autonomy over their bodies and life choices and intersects with various forms of gender violence (GV), significantly affecting overall physical health and social, economic, and psychological well-being. Moreover, cultural norms and societal expectations around reproduction often perpetuate harmful practices and stigmas, making official policies and legal backing for reproductive rights essential. It is accepted globally that access to comprehensive reproductive health services empowers women; specifically, to pursue education, careers, and personal goals, contributing to gender equality. The Beijing Platform for Action asserts that “the human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence” (United Nations, 1995). Hence, reproductive health is a central issue for gender justice, and addressing reproductive health is crucial not only for providing necessary services but also for dismantling structural inequalities that perpetuate GV; justifying its own chapter in discussions on gender justice.

What is Reproductive Justice?

Reproductive justice rights are the right to have a child, the right not to have a child, and the right to parent a child or children in safe and healthy environments. Reproductive justice is the human right to maintain personal bodily autonomy, have or not have children as desired, and parent the children we have in safe and sustainable communities. But pandemics often lead to breakdowns of social infrastructures, compounding existing weaknesses and conflicts. Existing gender inequalities are worsened by pandemic situations; for example, increasing the exposure of children and women to harassment and sexual violence when they attempt to procure necessities such as water, food, and firewood (UNFPA, 2020b).

Access to Reproductive Health Care Services During the Pandemic and Measures Taken

The COVID-19 pandemic intensified the prevalence of gender violence and emerged with a long-standing impact on women. According to VanBenschoten et al. (2022), reproductive health services, including contraception, abortion, support for gender and intimate partner violence, and the treatment and prevention of sexually transmitted infections (STIs), were significantly disrupted due to the COVID-19 pandemic.

In the United States, during the COVID-19 period, patients faced ongoing challenges related to sexual and reproductive health. Millions of patients relied on preventive services like STI and cancer screenings, as well as HPV vaccinations. However, the pandemic resulted in significant delays in accessing essential reproductive health care, exacerbating existing health disparities, and impacting overall health outcomes (American College of Obstetricians and Gynaecologists, 2020).

Increased Vulnerability of Women During the Pandemic

UN Women (2024) emphasizes the harmful impact of violence against women on various aspects of health, including increased rates of depression, anxiety disorders, unplanned pregnancies, sexually transmitted infections (STIs), and HIV, compared to those not experiencing violence. This statistic highlights the pervasive nature of gender violence and the urgent need for collective action in a post-pandemic world. Despite the Centers for Disease Control and Prevention’s removal of language suggesting delays in non-urgent visits and “elective” procedures, there was a dramatic decline in patients seeking reproductive healthcare (Kaiser Family Foundation, 2020). Disruptions in supply chains contributed to an estimated 2.7 million unplanned pregnancies and 1.2 million unsafe abortions in the pandemic’s first year. Moreover, 35% and 21% of sexual and reproductive health (SRH) clinics closed in the U.S. South and Midwest, respectively. A decrease in STI testing was reported across multiple countries, including Jordan, Thailand, and Uganda, with 95% of community STI testing clinics in Central Asia and Europe reducing testing. In the US, prescriptions for pre-exposure prophylaxis (PrEP) dropped by 80%, while follow-up care for vulnerable women in South Africa also declined (VanBenschoten et al., 2022; Singh et al., 2023).

Lockdowns, social distancing, clinic closures, and quarantine measures during the pandemic confined individuals to their homes, often trapping women with their abusers. This isolation hindered victims’ ability to seek support or escape abusive situations, leading to a significant increase in the risk of serious psychological consequences, such as post-traumatic stress disorder (PTSD) (Brooks et al., 2020; Hawryluck et al., 2004; Reynolds et al., 2008). Furthermore, quarantine measures coincided with a surge in cases of gender violence, which often went unaddressed (Usher et al., 2020). GV encompasses sexual, physical, and emotional violence, as well as neglect or deprivation, targeting individuals based on their gender (UN Women, 2020).

Research indicates that instances of family and sexual violence tend to rise during and after large crises or disasters (Sinha, 2020; Parkinson & Zara, 2013; Peterman et al., 2020). The pandemic exacerbated financial hardships and intensified existing household tensions, leading to increased violence against women. Job loss and financial stress made women more vulnerable, with the National Commission for Women (NCW) in India reporting a twofold increase in gender violence cases (Chandra, 2020). Lockdowns disrupted access to essential support services, including hotlines, shelters, and counselling, making it difficult for women to seek help or prompting fears about leaving their homes.

Numerous factors contributed to the increase in gender violence during the COVID-19 pandemic. Quarantine, social distancing, limited access to social support, unemployment, the patriarchal nature of society, and inequality in access to digital devices and services made women vulnerable. This heightened their susceptibility to gender violence. Alcohol and substance abuse by partners, societal tolerance of violence, previous abusive relationships, threats of harm, and the lack of essential health services, including contraception and abortion, further intensified the incidence of gender violence during the pandemic (Ostadtaghizadeh et al., 2023). Women from marginalized communities, including those with disabilities, LGBTQIA+ individuals, refugees, and migrants, faced heightened vulnerabilities in accessing support services. The multifaceted barriers to contraceptive care during the pandemic severely impacted reproductive autonomy and raised concerns about potential increases in unintended pregnancies (Diamond-Smith et al., 2021).

Barriers to Reproductive Healthcare Access During the COVID-19 Pandemic

The COVID-19 pandemic worsened existing disparities in reproductive healthcare, underscoring the critical need for reproductive justice. Disruptions in services, economic instability, and social distancing measures significantly restricted access to reproductive healthcare when they needed it most (Chandra, 2020). Tam et al. (2024) found that essential services, including antepartum, intrapartum (care during delivery), postpartum care, abortion, and sexual health services, were severely impacted, even in nations with universal healthcare systems.

Financial hardships compounded these issues, as many women struggled to afford maternal care, worsened by poverty and food insecurity (Adelekan et al., 2024). Additionally, law enforcement harassment and transportation challenges further hindered access to health facilities, with some women even arrested while trying to seek care (Adolescent Group, Lagos State as cited in Adelekan et al., 2024).

These barriers highlight the systemic inequities in reproductive healthcare during crises, necessitating urgent action to ensure reproductive justice (Adelekan et al., 2024; Tam et al., 2024).

Disparities in Access to Contraceptives

The COVID-19 pandemic severely disrupted access to essential reproductive health services, including contraception and abortion care, leaving many without critical healthcare. Lockdown measures halted manufacturing processes, causing contraceptive shortages (IPPF, 2020). The Guttmacher Institute’s analysis revealed the far-reaching consequences: a 10% reduction in sexual and reproductive health services could result in an additional 15.4 million unintended pregnancies, over 3.3 million unsafe abortions, and 28,000 maternal deaths globally (Krishna, 2021). The Foundation for Reproductive Health Services India (FRHS India, 2020) forecasted significant setbacks in contraceptive access, predicting negative outcomes such as unintended pregnancies, unsafe abortions, and maternal deaths. They outlined three scenarios to assess the pandemic’s impact: the Best Case projected that 24.55 million couples would struggle to access contraceptives by mid-2020 if services resumed quickly; the Likely Case anticipated 25.63 million couples would be affected by September 2020, and the Worst Case estimated that 27.18 million couples would face challenges due to the slow resumption of services. These figures underscore the importance of maintaining uninterrupted access to family planning during crises (FRHS India, 2020).

The pandemic also intensified issues of gender violence, particularly intimate partner violence. Many women faced reproductive coercion, where partners refused or sabotaged contraception, limiting women’s reproductive autonomy. Over 23% of women reported being unable to refuse sex (UNFPA, 2020a; Kumler, 2022). Additionally, Padez Vieira et al. (2022) found that pregnant women in Portugal experienced heightened depression during the lockdown, reflecting the broader mental health impact of restricted reproductive services. The barriers to contraception and reproductive health services during the pandemic highlight the urgent need for flexible, accessible options during crises. The denial of reproductive rights underscores the importance of proactive policies that protect women’s health and autonomy in future emergencies.

Increasing Maternal Mortality in the Wake of Health Service Disruptions

The COVID-19 pandemic exposed deep gaps in maternal health outcomes, disproportionately affecting marginalized communities. Systemic inequities, such as racism and inadequate healthcare access, contributed to higher rates of maternal mortality and morbidity. Lockdown restrictions, economic hardships, and travel bans disrupted the distribution of reproductive health products and contraceptive services (Church et al., 2020). In India, these interruptions severely impacted institutional deliveries, with media reports from states like Uttar Pradesh and Bihar showing a reduction in institutional deliveries, forcing many women to opt for home births (Motihar, 2020).

Mathematical models from the Global Financing Facility (GFF) indicated that disruptions caused by the COVID-19 pandemic could lead to a 40% increase in child mortality and a 52% rise in maternal mortality (Motihar, 2020). A scoping review by Kotlar et al. (2021) highlights increased risks for pregnant individuals, such as mental health challenges and socioeconomic disparities. The fear of contracting the virus discouraged women from seeking maternal care, leading to decreased institutional deliveries, which are crucial for reducing maternal mortality. The authors emphasized the need for stronger healthcare infrastructure and targeted resources to address these disparities. Addressing these issues is vital for advancing reproductive justice and ensuring equitable access to maternal health services during public health crises.

Intersection of Gender Violence and Abortion Rights: A Fight for Reproductive Autonomy

The connection between gender violence and abortion access reveals significant challenges in safeguarding women’s reproductive rights. Gender violence, including intimate partner violence and sexual assault, often leads to unintended pregnancies, compelling survivors to seek abortions. However, restrictive laws, stigma, and insufficient healthcare services frequently hinder access to safe and legal abortion services, pushing women toward unsafe alternatives that jeopardize their health and well-being.

The right to abortion is intertwined with several fundamental human rights, including the right not to be subjected to cruel, inhuman, or degrading treatment (UN General Assembly, 1984). Additionally, access to abortion is vital to the broader framework of sexual and reproductive health, education, and information (UNFPA, 1994). The CEDAW Committee recognizes the criminalization of abortions and forced continuation of pregnancies as forms of gender violence and discrimination, highlighting how these violations infringe upon women’s rights under CEDAW. Such restrictions force women into unsafe abortions and restrict their autonomy over their physical and mental health, further contributing to the underreporting of sexual violence.

In 2017, the Supreme Court of India affirmed that “[t]he intersection between one’s mental integrity and privacy entitles the individual to freedom of self-determination,” particularly regarding gender identity, reproduction, and procreation. Similarly, the Bombay High Court emphasized that forcing a woman to continue an unwanted pregnancy “represents a violation of the woman’s bodily integrity and aggravates her mental trauma” (Reproductive Rights Alliance Advocacy of India, 2020). Restrictions on abortion access, exacerbated during the COVID-19 pandemic, heightened these inequities, with many governments exploiting public health measures to further limit services, forcing women to seek unsafe alternatives and undermining their reproductive autonomy.

Disruptions in Abortion Services During COVID-19

The COVID-19 lockdown in India severely impacted access to safe abortions, as illustrated by the story of Kiran, a 20-year-old college student in Delhi. Kiran, who found out she was pregnant in May 2020, initially tried to terminate the pregnancy using abortion pills, but they were ineffective. As her only option was a surgical abortion, Kiran faced significant challenges due to the lockdown, which restricted travel and limited hospital services to essential care only. Despite contraception and abortion being classified as essential, many hospitals shut down outpatient departments and cancelled elective surgeries, complicating access to reproductive health services.

Kiran’s struggle is part of a broader issue, as research indicates that the lockdown compromised an estimated 1.85 million abortions in India. Women were pushed towards unsafe abortions or surgical procedures due to delayed access to medical abortions. Public health advocates and doctors reported an increase in calls from women seeking help for abortions but being turned away from hospitals or facing delays, particularly affecting poorer women and those in rural areas. Kiran’s case was eventually resolved with the help of the Medical Support Group, a team of public health professionals who assisted her in finding a doctor for a safe abortion. This case highlights the urgent need for policy changes, such as allowing medical abortions via telemedicine and strengthening referral systems for abortion services, to ensure women’s reproductive health needs are met during crises (Rao, 2020).

During India’s lockdown, despite abortion being classified as an essential service, many women struggled to access safe medical care due to restricted transportation, limited healthcare services, and movement restrictions. Experts warned that this could lead women to use unsafe methods or continue with unwanted pregnancies. The stigma surrounding abortion further complicated the access.

A comprehensive review by Ochola et al. (2023) highlighted the significant interruptions in access to sexual and reproductive health (SRH) services and the harmful impact on the well-being of women of reproductive age during the pandemic. Loss of income and employment opportunities resulted in the inability to afford healthcare costs, further reducing access to maternal healthcare services. Additionally, de-prioritization of services during the pandemic limited access to maternal healthcare, particularly among women from neighbouring communities, due to entry restrictions and limited public transport. While some areas with unrestricted access to reproductive health services observed an increase in family planning uptake among adolescents, travel restrictions and lockdown measures have likely contributed to the reduction in attendance at post-abortion care services. Adolescents emerge as a vulnerable group, with higher maternal death rates and limited access to abortion care. The increase in gender violence has been attributed to economic stressors, lack of privacy, and movement restrictions during the lockdown. Stay-at-home orders exacerbated the situation, leading to increased reports of gender violence cases.

Reproductive Healthcare Inequities for Marginalized Communities: Addressing Gaps for Transgender and Queer Individuals

The COVID-19 pandemic exacerbated existing barriers to reproductive healthcare, affecting contraception, prenatal care, abortion, and STI testing, with marginalized populations like LGBTQIA+ individuals, low-income groups, lower caste people, people of color, and rural communities facing the brunt of these challenges (Diamond-Smith et al., 2021; John et al., 2020). Lockdowns and healthcare interruptions further deepened disparities, although telemedicine emerged as a solution to provide reproductive healthcare services remotely. However, this method remained inaccessible to many due to the digital divide (lack of access to technology and its advantages), which disproportionately affected marginalized communities (MacLean, 2021).

While women’s reproductive rights have gained increasing attention globally, including in India and the USA, transgender reproductive rights remain largely overlooked.

Raj Yadav and Aditi Jain (2021) analyze the Medical Termination of Pregnancy (MTP) Act of 1971, emphasizing its exclusion of transgender individuals, especially transgender men, from abortion rights. The paper critiques India’s abortion laws for catering only to cisgender women, ignoring the unique reproductive needs of transgender people. The authors highlight legal conflicts between the MTP Act and other laws like the PCPNDT Act (Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994) and POCSO Act (Protection of Children from Sexual Offences Act, 2012) while also discussing economic barriers. They advocate for legal reform to include transgender rights in reproductive healthcare, addressing both social and medical challenges.

A literature review on transgender men’s reproductive health by MacLean (2021) reveals feelings of invisibility and isolation during pregnancy due to gendered perinatal care. The lack of gender-affirming environments and experienced providers contributes to care avoidance and discrimination. The reproductive rights of transgender individuals remain overlooked in medical curricula and legal frameworks, particularly in India, where LGBTQIA+ communities are ostracized and invisibilized (erased) (MacLean, 2021). More research is essential to improve their reproductive healthcare experiences. Similarly, Lunde et al. (2021) found that transgender and non-binary individuals globally face barriers when seeking healthcare services, due to practitioners’ lack of knowledge. Rodriguez-Wallberg (2023) stressed the importance of researching fertility preservation and family planning options for the transgender community.

This review investigates the barriers faced by LGBTQIA+ individuals in accessing abortion care and pregnancy options counseling. The study reveals significant discrimination and healthcare avoidance, leading to unsafe abortions and adverse health outcomes. The authors advocate for gender-inclusive healthcare services and further research to address the unique needs of this marginalized community (Bowler et al., 2023). The entrenched legal frameworks defining reproductive rights through a cisgender lens underscore the need for more inclusive policies. To address these issues, documenting the lived experiences of marginalized communities is essential to sensitizing the medical field and advancing reproductive justice (Stephenson et al., 2017).

Essential Reproductive Health Care Services to Resist Gender Violence

The World Bank (2020) emphasizes the importance of maintaining essential health services during the pandemic. The pandemic presented not only a direct threat to health but also significant risks of indirect morbidity (increased proportion of sickness) and mortality when essential health services were disrupted. Supply-side challenges included the diversion of medical personnel to COVID-19 response, overwhelmed health facilities, and disruptions in global supply chains for essential supplies. Demand-side factors included reduced use of essential services due to lockdowns, financial constraints, and fear of COVID-19 exposure. Past epidemics like Ebola and SARS have also shown declines in healthcare utilization, particularly for maternal and child health services, during crises. Preserving essential health services is crucial for safeguarding the health and well-being of mothers and children, especially during economic downturns and pandemics like COVID-19. Policymakers must incorporate sexual and reproductive health into emergency preparedness and response planning to mitigate indirect impacts in future outbreaks (Singh et al., 2023).

References

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Further Learning

Center for Reproductive Rights. (n.d.) Asia. Asia – Center for Reproductive Rights. Includes an interactive map of “the World’s Abortion Laws.”

Guttmacher Institute. (2022, November 17). Pandemic-Related Changes to Sexual and Reproductive Health Services in the United States Offer Lessons for Innovation. News Release. Pandemic-Related Changes to Sexual and Reproductive Health Services in the United States Offer Lessons for Innovation | Guttmacher Institute

YWCA. (n.d.). Strengthen maternal health services and safe, legal abortion care. Reproductive Justice and Abortion Access. Reproductive Justice and Abortion Access — YWCA — YWCA