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Abstract
Laws and regulations provide the framework for implementing sexual and reproductive health and rights (SRHR)-related policies, programmes and services. They can promote the fulfilment of health and human rights; however, they may also limit the achievement of these goals. This study uses data collected under Sustainable Development Goal Indicator 5.6.2 to analyse SRHR-related laws and restrictions from 153 countries. Looking beyond the existence of supportive laws to assess the constellation of legal restrictions and contradictions such as criminalisation and plural legal systems provides a more nuanced understanding of factors involved in achieving full and equal access to SRHR.
The interaction between restrictions and contradictions within the law disproportionately impacts some populations’ health access and outcomes. Restrictions based on third-party authorisations and age are the most common restriction types, disproportionately impacting young women. Contraception, emergency contraception and abortion face the greatest number of restrictions, indicating a significant layering of barriers to family planning services. Further, plural legal systems commonly contradict guarantees of contraceptive services and emergency contraception. Our analyses suggest that one of the populations most affected by restrictions to SRH services as they appear in legal and regulatory frameworks is adolescent girls and young women in sub-Saharan Africa seeking abortion or contraceptive services.
Study findings provide a critical starting point for advocacy to address legal barriers to SRH services and evidence for future policy and programming. For individual countries, this study can serve as a model for analysis of their own legal and regulatory frameworks to identify priority areas for reform efforts.
- Public Health
- Health policy
- Maternal health
- HIV
Data availability statement
Data are available in a public, open access repository. Values for SDG 5.6.2 are available at the SDG Global Database: https://unstats.un.org/sdgs/metadata/?Text=&Goal=5&Target=5.6.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
National laws and policies can both enable and impose limitations on sexual and reproductive health and rights (SRHR).
WHAT THIS STUDY ADDS
Within existing legal guarantees, the greatest numbers of legal barriers exist in the areas of contraception, emergency contraception and abortion. This shows a layering of barriers to family planning services.
One of the populations most affected by legal restrictions to SRH services is adolescent girls and young women in sub-Saharan Africa who are seeking abortion or contraceptive services.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
These findings highlight nuances in legal environments that create barriers to accessing SRH services and can help inform targeted development of policy and programming. This paper can also inform approaches to further research on legal restrictions related to specific health topics, populations or geographies.
Introduction
Universal access to sexual and reproductive health (SRH) services is recognised as a global priority in Sustainable Development Goal (SDG) 3. SDG 5 aims to achieve gender equality and empower all women and girls. One of this goal’s indicators measures the sexual and reproductive health and rights (SRHR)-related legal environment, recognising this as a key facilitator or barrier to access to SRH services and to achieving gender equality.
The Programme of Action from the International Conference on Population and Development (ICPD), held in Cairo in 1994, recognised that the enjoyment of reproductive health was predicated on the enjoyment of certain human rights deemed to be ‘reproductive rights’. It also recognised ‘the basic right of all couples and individuals to decide freely and responsibly on the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of SRH’.1 At its 30-year anniversary, it is important to assess progress towards realising SRHR.
The human right to health includes the right to control one’s own health and body and to be free from interference2; state obligations to fulfil these rights include the obligation to ensure access to services and information and to remove medically unnecessary barriers that deny practical access. Other human rights standards complement this, including ‘the right of women to autonomous decision-making about their health’3 and ‘the right of women to SRH (as) indispensable to their autonomy and their right to make meaningful decisions about their lives and health’.4 International human rights standards proscribe certain restrictions to laws, designed to ensure non-discrimination in access to health services (table 1 provides some illustrative examples).
Restrictions in law proscribed within illustrative international human rights standards
Laws and regulations are key mechanisms for translating human rights into national frameworks. They provide the framework for implementing SRHR-related policies, programmes and services nationally. They can provide guarantees for the fulfilment of health-related human rights standards but may also limit individuals’ ability to achieve the highest attainable standard of health.
In this context, a supportive law refers to a specific law or regulation designed to ensure access to SRHR.5 For example, Zambia’s Bill of Rights includes a commitment that ‘the state shall ensure the availability to maternal healthcare’.6 However, even where a specific service is legally available, there may be restrictions in the law regarding who can access it that exclude, for example, minors or women who have not secured spousal consent.7–13 Some laws may also criminalise seeking, obtaining or providing certain SRH services, particularly abortion, further impeding an individual’s bodily autonomy and access to services.14 15 The WHO recommends the full decriminalisation of abortion as part of ensuring access to safe abortion.16 Human rights bodies have also stated their support for decriminalisation.17
Countries may have civil laws that reflect international human rights standards, however where plural legal systems such as customary and religious laws exist, they may create barriers to the practical implementation of civil law.18
The United Nations Population Fund (UNFPA) recently developed a composite indicator based on the ICPD programme of action and other international consensus documents and human rights standards to assess SRHR-related laws as part of the SDG monitoring framework (SDG Indicator 5.6.2).19 Indicator 5.6.2 covers four dimensions of SRHR: maternity care (maternity care, life-saving commodities, abortion and postabortion care), contraceptive services (family planning, consent and emergency contraceptives), sexuality education (topics and curriculum) and sexual health and well-being (HIV counselling, testing and treatment and human papillomavirus (HPV) vaccines). Country-level data are collected regularly via the United Nations (UN) Inquiry among Governments on Population and Development.20 Each topic (except life-saving commodities and sexuality education) consists of questions on supportive laws and legal barriers including restrictions and contradictory legal systems. Alongside questions about the existence of a supportive law, the survey asks whether a supportive law that is in place contains any exceptions or restrictions on the basis of age, sex, marital status or third-party authorisations; whether the country has a plural legal system that results in a contradiction to the guarantee in some way; and whether, in the case of abortion, the service is criminalised.
Existing literature on SRHR-related legal environments acknowledges that national laws and policies can both enable and impose limitations on SRH services. However, most prior research has focused primarily on country case studies, a single health topic or specific population groups. There is little analysis using country-level data to understand the interactions between supportive laws, associated restrictions and other barriers at a global scale.
This research uses the latest data from responses to the UN Inquiry in 2019 and 2021 from 153 countries.21 22 The data captured by the survey allow for an exploration of any patterns and overlap in restrictions at country, regional and global levels, providing insight into the populations and SRH services that are most impacted by legal barriers, even where supportive laws exist. This approach captures nuances in legal environments that create barriers to SRHR, thus contributing to an evidence base that can inform the targeted development of future law, policy and programming and support continued progress towards SDG 5. This approach also provides a useful starting point for future inquiry by pointing towards topics and geographies that might benefit from additional research either in relation to the broader legal and policy environment or to how identified restrictions are affecting SRH outcomes and experiences.
Methods
This research presents a descriptive quantitative analysis of the most recent data on legal restrictions within each component of indicator 5.6.2 as monitored and reported via the UN Inquiry, mandated by the UN General Assembly and conducted by the UN Secretary General. The survey asks about 11 possible supportive laws and a total of 28 possible restrictions that could be associated with them. The restrictions primarily focus on additional requirements in existing law. However, the survey does not ask all of the questions about every topic; table 2, column 1, lists the legal guarantees that the survey enquires about; the following columns indicate which particular legal barriers the survey asks about for each.
Overview of the restrictions and barriers asked about for each SRHR-related legal guarantee in the UN Inquiry among Governments on Population and Development
Data analysis is restricted to the 153 countries that responded to the UN Inquiry in either 2019 or 2021; if a country responded both years, the 2021 data were used as long as it was at least as complete as the 2019 data. The proportion of countries that responded to these questions varies by SDG region and subregion (range 4%–100%; see online supplemental table 1). Conducting analyses of data at the country level allowed for the identification of patterns in terms of which populations and SRH services are most affected by legal restrictions at the global, regional and country levels. This analysis of restrictions is contextualised within the reported legal protections of each country. Thus, it does not paint the full picture of the SRH-related legal environment. That has been previously published by UNFPA among others.23 The specific aim was to focus on existing legal protections to see how they might be maximised through the identification and potential removal of restrictions to these protections.
Supplemental material
Approach
To understand barriers in the SRHR-related legal environments of these countries as captured by SDG Indicator 5.6.2, for each country, we first conducted analyses of the presence or lack of a supportive law. Then, for each supportive law, we analysed the presence or lack of restrictions based on the population(s) affected; restrictions based on SRHR topics (as defined by each component of the survey, referred to here as component-based analysis); and, where relevant, geographical patterns using the SDG regional breakdown. Our underlying assumption is that the best possible scenario is a country with a supportive law and no associated restrictions, while a less desirable situation is where such a law exists but has associated restrictions. The least desirable scenario is where there is no supportive law in place.
Findings from the component-based analyses indicated that restrictions often overlap and intersect in ways that disproportionately impact certain populations and the accessibility of certain health services. These findings informed the design and inclusion of an additional cross-cutting analysis of survey data.
Lastly, in order to understand how legal barriers can overlap and intersect to influence access to SRHR, we also assessed how many countries reported the existence of a plural legal system that might act as a barrier to a reported supportive law. These differ from restrictions in that a contradiction arises as a result of a plural legal system that may not be clearly articulated in writing and may not explicitly refer to the supportive law in place or stipulate specific restriction types but may still impede the legal protection, either overall or for particular groups.
Because not all survey questions asked about each type of restriction, the analysis of each restriction type used a different denominator to calculate the percentage of reported restrictions (number of reported restrictions per type/possible number of restrictions per type). We excluded the requirement for medical authorisation for abortion from our primary analyses as the question is open to interpretation.
Patient and public involvement
The study is a secondary analysis of data that was collected by the UN. No patients or members of the public were involved in developing the research questions or data analysis.
Findings
This section provides an overview of study findings. A summary of findings on the number of supportive laws in countries that responded to the survey is presented. This contextualises the subsequent findings on patterns in restrictions within the laws, based on type and topic of restriction. A cross-cutting analysis of topically related restrictions is then presented. Findings conclude with an identification of the health topics impacted by contradictions to legal guarantees as a result of plural legal systems.
The existence of supportive laws
Of the 153 countries that responded at least once to the UN Inquiry in 2019 and 2021, 40 reported having all 11 listed supportive laws related to Indicator 5.6.2. These countries come from across geographical SDG regions and are somewhat representative of the geographical distribution of survey respondents, with the European subregion being the biggest exception. Forty-eight per cent (n=19) of the countries with all possible supportive laws were from Europe, despite only 22.2% of survey respondents being European countries, indicating that Europe generally tends towards having more supportive laws in place in comparison to other regions. One hundred and thirty-four of the 153 countries reported having at least 8 of the 11 listed supportive laws.
Eighteen countries reported lacking four or more of the listed supportive laws, including 18% of reporting countries in the Latin America and the Caribbean region, the highest proportion for all regions. The country with the lowest number of supportive laws was Trinidad and Tobago, where only 2 out of 11 supportive laws were reported to be in place (see online supplemental figure 3).
Supplemental material
Restriction types
Sixty-six countries responded to the nine questions about third-party authorisations, a number which excludes the question on medical authorisation requirements for abortion. Of these, 67% (n=44) reported having at least one restriction based on third-party authorisation requirements. The requirement for judicial consent for minors to access abortion services was the most common type of third-party restriction, reported by 24 countries that responded to all nine relevant questions.
The second most common restriction type was age. Of the 111 countries with all 7 supportive laws in place about which the survey asked about possible age-related restrictions, 42% (n=47) reported at least one age-based restriction.
Of the 110 countries that reported having all 7 supportive laws in place with possible restrictions based on marital status, at least 11% (n=12) have at least 1 of this type of restriction. Northern Africa and Western Asia are over-represented in this group with 20% (n=4) of reporting countries reporting this situation.
Of the 136 countries with all 4 supportive laws with possible sex-based restrictions, meaning the service is only available to females or males, only 2 countries reported 1 or more sex-based restrictions. Mali reported having one sex-based restriction associated with the legal guarantee to contraceptive services. South Sudan reported all four possible sex-based restrictions, which are associated with access to contraceptive services; voluntary HIV counselling and testing services; HIV treatment and care services; and the protection of confidentiality of people living with HIV. Irrespective of the number of supportive laws in place, only 3 other countries of all 153 respondents reported any sex-based restrictions (see online supplemental table 2).
Supplemental material
Restrictions on different SRHR topics
Component-based analyses of the survey data highlight patterns of restrictions for the various SRHR topics covered in indicator 5.6.2, providing a clearer understanding of which areas of SRHR are most impacted by restrictions where supportive laws exist.
Of these components and accounting for the appropriate denominators based on the number of restriction-based questions within each, restrictions are reported most in the survey section on contraceptive services, followed by maternity care and HIV and HPV (table 3).
Restrictions analysis, by component
In the maternity care section, 12.2% of all possible restrictions in countries with supportive laws were reported; the substantial majority of these restrictions are associated with abortion laws. Of the 81 countries that report abortion being legal on all four listed grounds (to save a woman’s life, to preserve a woman’s health, in cases of rape, in cases of fetal impairment), which is what we classify as a supportive law for this component, 37% (n=30) reported having one or more of the listed abortion-related restrictions. The component on postabortion care has a comparatively insignificant proportion of restrictions (the lowest of all components); 10 (8%) of the 125 countries with a supportive law reported one or more restrictions. However, another 28 countries report having no legal guarantees for postabortion care and 95 report that women can be criminally charged for obtaining an illegal abortion.
Intersecting and overlapping barriers: accessing family planning
The most restricted SRHR topics in the survey are access to contraception, access to emergency contraception and abortion, indicating substantial and overlapping barriers to accessing family planning services.
Figure 1 presents an analysis of supportive laws and restrictions on abortion, laws that criminalise abortion and the inclusion, or lack thereof, of emergency contraception and abortion medication on national essential medicines lists, disaggregated by whether or not emergency contraception is legally guaranteed.
Analysis of overlapping barriers to accessing family planning
Countries with a law that guarantees access to emergency contraception are more likely than those without to have laws that guarantee access to abortion. These countries are also much more likely to include emergency contraceptives (levonorgestrel) and misoprostol in their essential medicines list. Overall, countries with no legal guarantee of access to emergency contraception also have a comparatively less supportive legal environment for abortion care.
Eighty-one countries reported that abortion was legal on all four grounds listed, of which 30 had associated restrictions and 37 also reported that abortion was criminalised. Twenty-eight of these 37 (75.7%) countries reported a law that guarantees access to postabortion care. Of these 28 countries, 18 report having no associated restrictions. The other 10 countries did not respond to these questions.
Plural legal systems
Of the 153 countries, 36 (23.5%) reported at least 1 instance (out of a possible 10) of a plural legal system that may impede the effective implementation of relevant laws. Plural legal systems most commonly contradict guarantees for access to contraceptive services and emergency contraception (figure 2).
Number of countries with plural legal systems that may impede implementation of a law, by component. CSE, comprehensive sexuality education; HPV, human papillomavirus
In instances where there is more than one reported contradiction, it is common for the topics to be related. For example, a plural legal system may contradict some or all supportive laws relating to contraception. All three countries who reported three (out of a possible three) restrictions to the law guaranteeing access to emergency contraception also reported a plural legal system that might impede its effective implementation (Kenya, Mali, South Sudan). The same countries also reported three or four (out of a possible four) restrictions to the law guaranteeing access to contraceptive services.
It is most common for countries in sub-Saharan Africa to report plural legal systems that contradict legal guarantees for access to contraceptive services (24% of reporting countries in the region) and for access to emergency contraception (26% of reporting countries in the region).
Discussion
Understanding legal barriers to achieving ‘full and equal access’ to SRHR requires looking beyond just whether a supportive law exists. Data on other barriers such as restrictions in law, contradictory laws such as criminalisation and contradictions due to plural legal systems provide insight into whose access may still be legally curtailed and where advocacy and reform efforts are most needed. The coexistence of multiple legal barriers around interrelated SRHR topics can further hinder individuals’ decision-making ability and access to care for SRHR.
Moving forward, where there is no supportive law in place, advocacy might focus on the need to introduce new supportive legislation; there may also be cases that require the removal of obstructive legislation. Other settings may already have supportive legislation, and legal reform could more usefully focus on removing restrictions within said laws. In contexts that have a supportive law with no restrictions, efforts can focus on implementation and accountability, which are critical.5 24
While contraception, emergency contraception and abortion are very different forms of family planning, each of these should be available as options at different stages of the family planning process.25 26 Legal guarantees to any of these family planning-related services cannot be conflated with or substituted for one another, however, examining them together can illustrate where supportive laws are insufficient or where the combination of laws and restrictions compound barriers to care and exacerbate health inequities.27 28
Laws around postabortion care are also critical to understanding compound barriers to SRH services. International human rights standards state that postabortion care must always be available, regardless of whether abortion is legal.4 Even where there is a legal guarantee to postabortion care, a law that criminalises abortion may deter women and providers from seeking or providing not only safe abortion services but also postabortion care.29 30
The high percentage of third-party authorisation requirements indicates a widespread lack of legal autonomy over health and SRH-related decision-making. As has been found in other research,27 we found that the majority of third-party authorisation restrictions focus on maternity care, contraception or abortion, resulting in women being disproportionately impacted. Under the right to health, states’ obligation to ‘protect’ requires them to prevent third parties from interfering with the right to health.4 Efforts to remove third-party authorisation requirements may use this internationally accepted norm as a strong basis for countries to align their legislation with human rights standards.
More than half of the countries in Africa have a plural legal system,31 and many plural legal systems are grounded in patriarchy and thus have greater negative implications for women, particularly young women, than men.32 Further, a recent ecological analysis in Nigeria found that plural legal systems were associated with poorer SRH outcomes.33 In this study, plural legal system contradictions are most common within the topic of contraception, including access to contraceptive services and emergency contraception. This has implications for efforts to improve access to contraception, as efforts to remove restrictions in law may also need to be accompanied by work to understand and address the plural legal systems in place.
The confluence of legal barriers to accessing SRH services such as restrictions, criminalisation and contradictions caused by plural legal systems disproportionately impacts certain populations’ health and health outcomes. One of the populations most affected by restrictions to SRH services as they appear in legal and regulatory frameworks is adolescent girls and young women in sub-Saharan Africa seeking abortion or contraceptive services. From a global perspective, this provides a critical starting point for legal advocacy and reform; for individual countries, analysis of their own legal and regulatory frameworks can provide deeper insights into where the greatest needs for reform might exist.
Going forward, in-depth qualitative studies at both global and country levels would provide insights into the practical implications of the interactions and patterns of laws and restrictions highlighted by this research, which could further inform efforts from legal advocacy to programme design and implementation.
Limitations
This study focuses only on the data captured by the UN Inquiry on SDG Indicator 5.6.2. Focusing on this dataset results in only understanding the laws and restrictions reported by countries in response to this defined set of questions. Within each country, additional laws may contradict or create restrictions to the laws studied. For example, the survey does not include questions on legal provisions around conscientious objection, which has been recognised as a critical barrier to accessing SRH services.11 34 35 Additionally, missing data within the survey were not random; respondents most commonly skipped questions related to abortion restrictions. Survey respondents are government representatives, which could result in potential bias, or in other cases, a lack of comprehensive knowledge. There is thus opportunity for future research to combine the UN Inquiry data with other datasets to triangulate and explore the broader legal and policy environment.
Finally, the survey data only provide insight into the existence and partial content of laws, precluding any investigation of their implementation, which is essential for translating law to improved health outcomes.5 Future research could seek to combine information on legal guarantees and their associated restrictions with data on the implementation of these guarantees to better illustrate the impact of restrictions within law.
Conclusion
The ways in which SRHR outcomes are affected by laws and regulations are complex; studying the existence of a law is insufficient to paint the full picture. This study provides an evidence-based starting point for governments and civil society actors around the world to pursue advocacy and reform efforts to improve SRHR legal landscapes and, ultimately, outcomes.
Data availability statement
Data are available in a public, open access repository. Values for SDG 5.6.2 are available at the SDG Global Database: https://unstats.un.org/sdgs/metadata/?Text=&Goal=5&Target=5.6.
Ethics statements
Patient consent for publication
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Handling editor Vijay Kumar Chattu
Contributors LF and EF-W conceptualised this study. LF and MEA carried out data analysis and drafting of the manuscript. ML provided technical support with the data. All authors have read and approved the final manuscript. LF is the overall guarantor of this work.
Funding This project was funded with generous support from the United Nations Population Fund (N/A).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.