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This chapter reviews the evolving consensus in international human rights law, first supporting the liberalization of criminal abortion laws to improve access to care and now supporting their repeal or decriminalization as a human rights imperative to protect the health, equality, and dignity of people. This consensus is based on human rights standards or the authoritative interpretations of U.N. and regional human rights treaties in general comments and recommendations, individual communications and inquiry reports of treaty monitoring bodies, and in the thematic reports of special rapporteurs and working groups of the U.N. and regional human rights systems. This chapter explores the reach and influence of human rights standards, especially how high courts in many countries reference these standards to hold governments accountable for the reform and repeal of criminal abortion laws.

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The February 2016 WHO declaration that congenital Zika virus syndrome constitutes a Public Health Emergency of International Concern reacted to the outbreak of the syndrome in Brazil. Public health emergencies can justify a spectrum of human rights responses, but in Brazil, the emergency exposed prevailing inequities in the national healthcare system. The government's urging to contain the syndrome, which is associated with microcephaly among newborns, is confounded by lack of reproductive health services. Women with low incomes in particular have little access to such health services. The emergency also illuminates the harm of restrictive abortion legislation, and the potential violation of human rights regarding women's health and under the UN Conventions on the Rights of the Child and on the Rights of Persons with Disabilities. Suggestions have been proposed by which the government can remedy the widespread healthcare inequities among the national population that are instructive for other countries where congenital Zika virus syndrome is prevalent.

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When patients require information to decide whether to accept recommended treatments, a question in both law and ethics is whether the same information is adequate whether they consent or refuse, or whether refusal requires more or repeated information. Refusals of recommended treatment can carry increased risks for patients' well-being and so require more emphatic disclosure without imposing pressure. A related question is whether guardians of dependents who would decline recommended treatment for themselves--for instance on religious grounds--can similarly decline it for their dependents. When pregnant women, children, and adolescents are able to give consent for recommended treatment, the question arises whether they are equally competent to refuse it and prevent their decisions being overridden by guardians or courts. Consenting to and refusing medical treatments recommended in one's own or dependents' best interests might not be the same sorts of decisions and could require different levels of disclosure and capacity.

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Healthcare providers require prior consent to treat patients. Consent can be different for legal purposes, and be expressed in different ways. Simple consent affords providers protection from liability for assault, but negligence can arise if the consent is inadequately informed. Providers cannot coerce or improperly induce consent; patients' agreement that a provider wrongly influences is compliance, not true consent. Attempts to rescue patients in peril may be lawful on the presumption of their implied consent, unless patients negate the presumption. In special cases, laws may require that consent be written, but generally consent can be given by speech or conduct. Informed consent depends on patients' comprehension, but consent for treatment of uncomprehending patients may come from third parties, including legally recognized substitutes or judges. There may be legal limits to reproductive procedures to which patients may consent, under laws that can be respectfully tested, but have to be obeyed.

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Stigmatization marks individuals for disgrace, shame, and even disgust-spoiling or tarnishing their social identities. It can be imposed accidentally by thoughtlessness or insensitivity; incidentally to another purpose; or deliberately to deter or punish conduct considered harmful to actors themselves, others, society, or moral values. Stigma has permeated attitudes toward recipients of sexual and reproductive health services, and at times to service providers. Resort to contraceptive products, to voluntary sterilization and abortion, and now to medically assisted reproductive care to overcome infertility has attracted stigma. Unmarried motherhood has a long history of shame, projected onto the "illegitimate" (bastard) child. The stigma of contracting sexually transmitted infections has been reinvigorated with HIV infection. Gynecologists and their professional associations, ethically committed to uphold human dignity and equality, especially for vulnerable women for whom they care, should be active to guard against, counteract, and relieve stigmatization of their patients and of related service providers.

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This article explores the effectiveness of the decision of the Committee on the Elimination of Discrimination against Women in the case of Alyne da Silva Pimentel Teixeira (deceased) v. Brazil, concerning a poor, Afro-Brazilian woman. This is the first decision of an international human rights treaty body to hold a state accountable for its failure to prevent an avoidable death in childbirth. Assessing the future effectiveness of this decision might be undertaken concretely by determining the degree of Brazil's actual compliance with the Committee's recommendations, and how this decision influences pending domestic litigation arising from the maternal death. Alternative approaches include: determining whether, over time, the decision leads to the elimination of discrimination against women of poor, minority racial status in the health sector, and if it narrows the wide gap between rates of maternal mortality of poor, Afro-Brazilian women and the country's general female population. Determining the effectiveness of this decision will guide whether to pursue a more general strategy of judicializing maternal mortality.

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Universal access to reproductive health is a target of Millennium Development Goal (MDG) 5B, and along with MDG 5A to reduce maternal mortality by three-quarters, progress is currently too slow for most countries to achieve these targets by 2015. Critical to success are increased and sustainable numbers of skilled healthcare workers and financing of essential medicines by governments, who have made political commitments in United Nations forums to renew their efforts to reduce maternal mortality. National essential medicine lists are not reflective of medicines available free or at cost in facilities or in the community. The WHO Essential Medicines List indicates medicines required for maternal and newborn health including the full range of contraceptives and emergency contraception, but there is no consistent monitoring of implementation of national lists through procurement and supply even for basic essential drugs. Health advocates are using human rights mechanisms to ensure governments honor their legal commitments to ensure access to services essential for reproductive health. Maternal mortality is recognized as a human rights violation by the United Nations and constitutional and human rights are being used, and could be used more effectively, to improve maternity services and to ensure access to drugs essential for reproductive health.

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Recent decisions of the Committee on the Elimination of Discrimination against Women (CEDAW), the Inter-American Court of Human Rights, and the High Court of Delhi have shown how the pregnancy-related deaths of individual women have been bases on which these authoritative tribunals have held Brazil, Paraguay, and India respectively accountable for avoidable maternal mortality not only in these cases, but also among their populations more generally. The right to life is the most fundamental of women's human rights, recognized in international human rights treaties and national laws. Failure of governments to apply their resources adequately to address, respect, and protect this right violates the law of human rights. These cases show, however, that governments may fail to allocate adequate resources to women's survival of pregnancy. Tribunals can build on the failures in individual cases to set standards of performance to which governments will legally be held to achieve safe motherhood.

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Recent research in the USA has shown the advantages for children's welfare of open fetal surgery over postnatal treatment for myelomeningocele. However, a balance must be struck between complications of premature birth risked by prenatal surgery and the long-term advantages for affected children's health, including mobility and neurologic capacity. Risks for women are repeated surgery for intervention and delivery. The research raises legal and ethical questions about how fetal interests should influence women's choices, and whether women may decline interventions in their pregnancies that offer their children lifelong advantages. Beyond fetal interests and women's preferences are state interests in fetal life, which in the USA and elsewhere have been expressed in judicially authorized cesarean deliveries. Underlying issues are the nature of fetal interests; contrasting entitlements to care from their mothers of fetuses and born children; healthcare providers' responsibilities toward fetuses; and duties of care, information, and advice to pregnant women.

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Conscientious commitment, the reverse of conscientious objection, inspires healthcare providers to overcome barriers to delivery of reproductive services to protect and advance women's health. History shows social reformers experiencing religious condemnation and imprisonment for promoting means of birth control, until access became popularly accepted. Voluntary sterilization generally followed this pattern to acceptance, but overcoming resistance to voluntary abortion calls for courage and remains challenging. The challenge is aggravated by religious doctrines that view treatment of ectopic pregnancy, spontaneous abortion, and emergency contraception not by reference to women's healthcare needs, but through the lens of abortion. However, modern legal systems increasingly reject this myopic approach. Providers' conscientious commitment is to deliver treatments directed to women's healthcare needs, giving priority to patient care over adherence to conservative religious doctrines or religious self-interest. The development of in vitro fertilization to address childlessness further illustrates the inspiration of conscientious commitment over conservative objections.

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Judicial approaches to stored (cryopreserved) human embryos, in western jurisprudence, tend not to reflect approaches within systems of moral ordering or particular religious traditions, which differ among themselves. The emerging judicial approach is pragmatic, protecting individuals' rights of control and their interests in parenthood. Embryos are approached instrumentally, not by reference to any inherent characteristics that may be attributed to them outside the law. Political legislatures may adopt religious approaches, such as by prohibiting embryo preservation and limiting how many may be created in an IVF treatment cycle. Legislatures may alternatively set time limits on embryo preservation, however, on expiry of which they must be left to natural degeneration. In treating human embryos as property, courts recognize owners' powers of voluntary disposition, for instance by gift, but have held back from making financial assessments of their value, for instance on loss, consistently with legislation prohibiting their exchange for payment.

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Stereotypes are generalized preconceptions defining individuals by group categories into which they are placed. Women have become stereotyped as homemakers and mothers, with the negative effect of precluding them from other roles and functions. Legislation and judicial constructions show a history, and often a continuing practice, of confining women to these stereotypical functions. In access to reproductive and sexual health care, for instance, women's requests have been professionally subject to approval of their husbands, fathers or comparable males. Choice of abortion is particularly significant, because it embeds moral values. Women's capacity to act as responsible moral agents is denied by stereotypical attitudes shown by legislators, judges, heads of religious denominations, and healthcare providers who consider women incapable of exercising responsible moral choice. These attitudes violate ethical requirements of treating patients with respect and equal justice. They can also result in violations of human rights laws that prohibit discrimination against women.

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Policy on reinfibulation exposes the interface between individual or micro-ethics and population-wide or macro-ethics. If, following childbirth, an infibulated woman requests reinfibulation, a gynecologist may respectfully advise her of its negative implications, but would not act in breach of ethical or usually legal requirements in undertaking the procedure. However, as a matter of health policy and professional responsibility, physicians should refuse to initiate infibulation, and advise their patients and communities that the procedure is harmful, not required by religious or other ordinance, and frequently if not always unlawful. Reinfibulation is not genital cutting (or "mutilation") in itself, but when undertaken by a physician may appear to condone infibulation. This is contrary to medical professional ethics, which condemn medicalization of infibulation and generally of reinfibulation, even as a harm-reduction strategy to spare women the risks of injury and infection from unskilled interventions.

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The new American College of Obstetricians and Gynecologists' (ACOG) monitoring guidelines introduce a new category of interpretation of fetal heart rate tracings between reassuring and nonreassuring, namely intermediate. The purpose is to reduce unnecessary cesarean deliveries. The legal role of medical guidelines is ambivalent. Providers are expected to be familiar with such guidelines, but also to exercise clinical judgment in their patients' interests. Practice departing from guidelines requires justification, but simple compliance without regard to patients' circumstances may constitute negligence. Some courts defer to medical professional guidelines, but others hold that professional standards are set as a matter of law, not by the profession itself. Unlike conclusions in medical science, which are open to continuing review, courts determine facts in a case only once, at trial. Litigation to compel patients' compliance with medical advice based on guidelines may fail, as may prosecutions, more common in the US, of patients who defy such advice.

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A hymen may be ruptured by sexual intercourse and several other means. In cultures prizing unmarried women's virginity, premarital rupture may shame a woman, and her family. Women, including brides whose virginity is not proven at marriage, face humiliation, ostracism, divorce, and violence-at the extreme, "honor" killing. Nevertheless, gynecologists may oppose hymen reconstruction on grounds that it is deceptive, not medically required, or that the requirement of evidence of virginity discriminates against women and the procedure supports holding them to higher standards of virtue than are required of men. Gynecologists may justify the procedure, however, as serving health, which includes patients' mental and social well-being and women's human rights to control their own bodies. Further, many adolescents lose their virginity innocently, by rape or coercion, and, without hymen reconstruction, women may face violence and even death. The procedure is usually lawful, and distinguishable from female genital cutting or mutilation.

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Since the 1994 Cairo Conference on Population and Development, the human rights movement has embraced the concept of reproductive rights. These are often pursued, however, by means to which objection is taken. Some conservative political and religious forces continue to resist implementation of several means of protecting and advancing reproductive rights. Individuals' rights to grant and to deny consent to medical procedures affecting their reproductive health and confidentiality have been progressively advanced. However, access to contraceptive services, while not necessarily opposed, is unjustifiably obstructed in some settings. Rights to lawful abortion have been considerably liberalized by legislative and judicial decisions, although resistance remains. Courts are increasingly requiring that lawful services be accommodated under transparent conditions of access and of legal protection. The conflict between rights of resort to lawful reproductive health services and to conscientious objection to participation is resolved by legal duties to refer patients to non-objecting providers.

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Intimate partner violence (IPV), usually men's violence against women, appears universal. It may be associated with pregnancy, but this may be because pregnant women receive more medical attention. Violence may cause bruises, abrasions, and cuts, but its extremes include hospitalization, death, and suicide. IPV is often disclosed when women are asked why they feel in poor health or depressed. A legal dilemma arises when healthcare providers consider that intervention such as law-enforcement is appropriate, but patients refuse approval. Patients may fatalistically accept violence, or fear loss of support for their children and themselves if their partners are held in custody. Legal reforms, such as punishing spousal rape, may provide some protection of women's autonomy. Ethical dilemmas concern intervention without patients' approval, and whether treating violent injuries without taking preventive action breaches the principle to Do No Harm. Professional advocacy and social action have been urged to expose and reduce IPV.

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