complete research paper about abortion in the philippines

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

Opportunities lost: Barriers to increasing the use of effective contraception in the Philippines

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Writing – original draft

* E-mail: [email protected]

Affiliation Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan

Roles Data curation, Formal analysis, Methodology, Writing – original draft

Affiliation Partnership for Maternal, Newborn and Child Health, Geneva, Switzerland

Roles Conceptualization, Methodology, Writing – original draft, Writing – review & editing

Affiliation Independent consultant, maternal and child health, Iowa City, United States of America

Roles Conceptualization, Methodology, Validation, Writing – review & editing

Affiliation World Health Organization Philippines Country Office, Manila, Philippines

Affiliation Responsible Parenthood and Reproductive Health National Implementation Team (RP-RH NIT), Department of Health, Manila, Philippines

Roles Conceptualization, Funding acquisition, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliation Division of NCD and Health through Life-Course, Reproductive, Maternal, Newborn, Child and Adolescent Health, World Health Organization Regional Office of the Western Pacific, Manila, Philippines

• Mari Nagai, 
• Saverio Bellizzi, 
• John Murray, 
• Jacqueline Kitong, 
• Esperanza I. Cabral, 
• Howard L. Sobel

• Published: July 25, 2019
• https://doi.org/10.1371/journal.pone.0218187
• Reader Comments

In the Philippines, one in four pregnancies are unintended and 610 000 unsafe abortions are performed each year. This study explored the association between missed opportunities to provide family planning counseling, quality of counseling and its impact on utilization of effective contraception in the Philippines.

One-hundred-one nationally representative health facilities were randomly selected from five levels of the health system. Sexually-active women 18–49 years old, wanting to delay or limit childbearing, attending primary care clinics between April 24 and August 8, 2017 were included. Data on contraceptive use, counseling and availability were collected using interviews and facility assessments. Effective contraceptive methods were defined as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use.

849 women were recruited of whom 51.1% currently used effective contraceptive methods, 20.6% were former effective method users and 28.3% had never used an effective method. Of 1664 cumulative clinic visits reported by women in the previous year, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility, with 83.7% having a missed counseling opportunity on the day of the interview. Most women (55.9%) reported health concerns about modern contraception, with 2.9% receiving counseling addressing their concerns. Only 0.6% of former users and 2.1% never-users said they would consider starting a modern contraceptive in the future. Short and long acting reversible contraceptive methods were available in 93% and 68% of facilities respectively.

Conclusions

Missed opportunities to provide family planning counseling are widespread in the Philippines. Delivery of effective contraceptive methods requires that wider legal, policy, social, cultural, and structural barriers are addressed, coupled with systems approaches for improving availability and quality of counseling at all primary health care contacts.

Citation: Nagai M, Bellizzi S, Murray J, Kitong J, Cabral EI, Sobel HL (2019) Opportunities lost: Barriers to increasing the use of effective contraception in the Philippines. PLoS ONE 14(7): e0218187. https://doi.org/10.1371/journal.pone.0218187

Editor: Elizabeth Ann Micks, University of Washington, UNITED STATES

Received: January 12, 2019; Accepted: May 28, 2019; Published: July 25, 2019

Copyright: © 2019 Nagai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: Data collection was funded by World Health Organization (WHO) Regional Office of the Western Pacific. The funder was involved with study design, data analysis, and preparation of the manuscript. SB, JK, and HS are affiliated with WHO. The specific role of these authors is articulated in the 'author contributions' section.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Unintended pregnancies remain an important public health problem worldwide. Between 2010 and 2014, there were an estimated 62 unintended pregnancies per 1000 women aged 15–44 years each year, with rates ranging from 112 in East Africa to 28 in Western Europe [ 1 ]. In Philippines, 54% of all pregnancies (1.9 million pregnancies) are reported to be unintended and around 610 000 unsafe abortions are performed each year [ 2 ]. Nine percent of women 15 to 19 years of age have begun child bearing [ 3 ].

In 2017, the modern contraceptive prevalence rate (CPR) in the Philippines was estimated to be 40% among married women of reproductive age and 17% among unmarried sexually active women [ 3 ]. The modern CPR increased only 2% between 2013 and 2017, with rates being much lower in some populations. Forty-six percent of married women used no contraceptive method in 2017 and 14% a traditional method, a decline from 16.7% in 2008; only 10% of women used long acting reversible contraceptives (LARCs) such as IUDs and implants [ 3 ]. Among sexually active unmarried women, traditional methods were used by 15% [ 3 ].

Women who are fecund, sexually active and who want no more children or to delay the next child, but are not using any method of contraception, are defined as having an “unmet need for family planning”. The unmet need for family planning among married women of reproductive age in Philippines was 17% in 2017, with the demand met by modern methods estimated to be 57%. Among unmarried sexually active women the unmet need increases to 49% and the demand met by modern methods falls to 22% [ 3 ]. As a consequence of the low contraceptive met need, 68% of unintended pregnancies occur in women not using any method and 24% in those using traditional methods [ 4 ]. Those using LARCs rarely have unintended pregnancies [ 5 ].

Several barriers to accessing family planning services have been observed in the Philippines. A 2013 survey found that maintenance of virginity until marriage was important for 83% of women aged 15–24, even though 14% of 15–19 year-olds and 49% of those aged 20–24 years experienced first sexual intercourse before marriage [ 6 ]. This social norm paradoxically discourages use of contraception by unmarried women. In addition, infrequent sex was commonly stated as a reason why women with an unintended pregnancy did not use modern methods. Among married women with an unmet need, half cite inappropriate health concerns as a reason not using modern methods including weight loss, chemical toxicity due to prolonged use, excessive bleeding, the buildup of blood if menstruation stops, loss of physical strength, debilitating headaches or stomach aches, and fears that devices that get lost inside the body [ 7 ]. Religion-based opposition to contraception was reported as a barrier by only 3%-6% of women and accessibility of methods by 2% to 7% [ 7 ].

Although the family planning program in the Philippines began in 1971 and was one of the strongest in Asia, religious concerns, rapid decentralization and various legal interventions have restricted implementation. The Responsible Parenthood and Reproductive Health Act of 2012, designed to re-vitalize family planning service provision, was not put into place until 2017 when legal and programmatic barriers had been overcome [ 8 ].

In response, the Department of Health in Philippines sought to identify strategies to improve family planning programming. Improvement of uptake of modern methods of contraception, especially LARCs, became an important public health priority. Experience from other countries in Asia has shown that facility-based contraceptive counseling is often poor [ 9 , 10 ]. Women are often dissatisfied with clinic visits, because they are unable to discuss their concerns and receive insufficient information about their options. Additionally, providers frequently have inaccurate knowledge about contraceptive methods, including out-of-date information [ 11 , 12 , 13 , 14 ]. For these reasons, this study was designed to review current counseling practices as a key barrier to uptake of contraception. Since the government health insurance provider (Philhealth) provides coverage for 66% of the population, with 56% of women currently obtaining contraception at public health facilities [ 3 ], the study was designed to focus on practices in the public sector. The objectives were to identify the extent of missed opportunities to provide family planning counselling at primary care visits, whether effective counselling was provided and its impact on women’s concerns and decision making to begin use of modern contraceptives. The goal was to identify systems factors that could be targeted to improve the quality of care and to reduce unintended pregnancies.

Study design

A nationally representative cross-sectional survey design was used. One hundred one health facilities (11 national hospitals, 13 regional hospitals, 23 provincial hospitals, 27 main health centers, and 27 barangay health centers) were selected. In first stage sampling, 23 provinces were randomly selected using probability proportionate to size based on the estimated number of sexually active women with unmet need [ 15 ]. Within the sampled provinces, the provincial hospital, 1 main health center and 1 Barangay health center of the most populated Barangay were selected. Regional and national hospitals within the province were also included. The number of facilities sampled was based on estimated participants sample size (n = 820) required to allow comparisons of the proportion women using modern methods of contraception by socio-economic factors with 80% power.

At each facility, women aged 18–49 years of age, who were not currently pregnant or within 6 weeks of delivery, wanting to delay or limit childbearing on the day of the visit were eligible to for the study, to avoid confounding by stage of pregnancy, place of delivery or the early post-pregnancy period on the likelihood and quality of counseling. Questions about missed opportunities to provide family planning counseling were asked about all clinic visits in the previous year. Individual interviews using structured questionnaires were conducted with 10 women per hospital and 6 per health center. Sampled women were divided into equal groups of those currently using and not using effective contraceptive methods. We defined effective contraceptive methods as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use (i.e., patch, oral pills, injectables, IUDs, implants and sterilization) [ 5 ]. We excluded lactational amenorrhea to focus on non-transient modern methods. Less effective contraceptive methods were defined as condoms, fertility self-monitoring (i.e, standard days method, basal body temperature) and traditional methods (i.e., withdrawal, calendar or rhythm method). Where multiple methods were used, subjects were categorized according to the most effective method used.

Data were collected from women attending the outpatient primary care clinic on the day of the survey. Primary care clinics included postnatal care, reproductive health, well child, and primary care. If more than the required number of women were in attendance, systematic sampling method was used. At five sampled health facilities, the minimum number of women were not available on the day of the survey. At these facilities, 24 (2.8%) women meeting eligibility requirements for the study and living within 1 hour of the facility were identified from clinic registers for the previous days and interviewed at their homes to obtain the minimum sample size.

A closed-ended questionnaire for women, interview guide and health facility assessment checklist were developed referring to previous research. These were finalized after two field pilot tests. To those women who preferred local dialects, the questionnaires and consent forms were translated into one of eight local dialects (Tagalog, Ilocano, Bicolano, Visayan, Ilonggo, Chavacano, Tausug, and Meranao) then validated by back-translation. Eight teams consisting of one team leader and one enumerator collected data from April 24 to August 8, 2017 using paper-based questionnaires. Enumerators near selected facilities were identified to minimize language differences across study sites. Data were collected using: 1) interviews with women on current, former and never use of effective contraceptive methods, concerns and attitudes towards contraception, and management of concerns at outpatient primary care clinics of health facilities; 2) facility assessments of the availability of family planning commodities and policies including hospital accreditation status for use of LARCs.

Study outcomes

Counseling was defined as any information or advice given about any contraceptive method during the woman's clinic visit. A missed opportunity was defined as a woman’s clinic visit at which a staff member at the health facility did not provide any counseling. When counseling was provided, quality of counseling was measured by asking the woman whether health staff asked about her concerns on family planning, helped her to find solutions to her concerns, offered her information about how different family planning methods work, or explained side-effects or problems she might have with any method. A health concern about a family planning method was defined as any perceived undesirable health effect. Accumulated facility visits were defined as the number of visits to health facilities made by interviewed women between January 1 and December 31, 2016. Accumulated missed opportunities were defined as the total number of accumulated facility visits at which health staff did not provide any family planning counseling on the day of that visit.

Data management and analysis

The team leader checked completeness and accuracy of completed paper-based questionnaires on the day of interview. Two data managers independently entered the questionnaire data into identical Excel sheets and compared using STATA version 13.1. Inconsistencies were validated with the original paper and corrected. Statistical analysis was also done using STATA.

Ethical considerations

Ethical clearance was obtained by the WHO Regional Office for the Western Pacific Ethics Review Committee on 12 January 2017, and the National Ethics Committee in the Philippine Council for Health Research and Development of the Department of Science and Technology on 1 February 2017. All women were asked for informed consent. Participants were informed of their right to refuse participation in the study, or not answer specific questions should they assent to participation and were assured of the confidentiality of the collected information. All interviews were conducted in private settings and unique identifiers were used to maintain anonymity. All paper copies are maintained in a locked file cabinet.

A total of 849 non-pregnant sexually active women, 18–49 years of age, wanting to delay or limit childbearing were included in the study. Only one woman meeting the entry criteria refused to be interviewed. Of sampled women, 51.1% (434) were currently using an effective contraceptive method, 16.5% (140) a less effective contraceptive method and 32.4% (275) no contraceptive method. Of all women, 36.7% (312) were currently using short-acting effective methods (pills, patches or injectables), 8.9% (76) LARCs (IUD or implants) and 5.5% (46) female sterilization. An additional 18.2% (155/849) of women had used short-acting effective methods in the past and 2.4% (20) had used LARCs in the past. An effective method had never been used by 28.3% (240) of women ( Fig 1 ).

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0218187.g001

Demographic characteristics of sampled current, former and never users were similar ( Table 1 ). Respondents were predominantly urban, aged 30 years, married or living together, with at least a high school education and 2 living children. They reported an average of 1.9 health facility visits in the past year. Philhealth insurance coverage in our sample was 71.3% with 24.7% having no health insurance. Women who had never used contraception were more likely than current users to have not graduated high school.

https://doi.org/10.1371/journal.pone.0218187.t001

Of all women, 83.7% (711/849) reported a missed opportunity for family planning counseling on the day of the interview. Missed opportunities were high regardless of contraceptive method used, residence, age group, marital status, education, number of children, or financial protection status, but highest among those younger than 21 years old, and women living together or not married ( Fig 2 ). Missed opportunities remained high across all levels of health facility and facility accreditation or certification status.

https://doi.org/10.1371/journal.pone.0218187.g002

The 849 women interviewed reported 1664 accumulated primary health care facility visits including antenatal care and postnatal care before discharge, between January 1 and December 31, 2016, not including the day of the interview. Of the 1664 accumulated health facility visits, 72.6% (1211) were missed opportunities to provide family planning counseling. Missed opportunities were found for 68.6% (587/856) of visits by current effective contraceptive method users, 73.4% (235/320) by former users and 78.9% (385/488) by never users. Overall, women not currently using any effective contraceptive method had a missed opportunity in 76.7% (620/808) of all clinic visits in 2016. Missed opportunities to provide family planning counseling were reported for 85.8% (241/281) of reproductive health clinic visits, 76.8% (182/237) of antenatal care visits, 74.7% (198/265) of postnatal care before discharge contacts, 73.7% (73/99) of postnatal care visits after discharge, 71.9% (264/367) of well-child visits, 70.7% (162/229) of sick child visits and 57.1% (68/119) of primary care visits for herself. Missed opportunities were lowest for contraceptive clinic visits, at which 32.8% (23/70) women reported that family planning counseling about any method was not provided ( Fig 3 ).

https://doi.org/10.1371/journal.pone.0218187.g003

Sixteen percent (138/849) of women received family planning counseling on the day of the interview. Of the 138 women receiving counseling, 67.4% (93) were asked if they had concerns about contraceptives, 59.4% (82) received information about how different contraceptives work and 44.9% (62) were told about possible contraceptive side-effects during the counseling. Current effective contraceptive users were more likely to receive information than former or never users. Of the 80 current users receiving family planning counseling, 75.0% (60) were asked about concerns, 66.3% (53) were given explanations about how different methods work, and 55.0% (44) were given advice about side-effects. In contrast, the same information was given less frequently to the 24 former users receiving counseling (50%, 41.6% and 37.5%, respectively) and the 34 never users receiving counseling (62.9%, 55.9% and 23.5%, respectively).

Overall, 55.9% (481/849) of women reported a total of 567 concerns about any effective contraceptive method on the day of the interview. The prevalence of concerns was 72.6% (126/175) among former users, 56.0% (242/434) among current users, and 47.5% (113/240) among never users. Only two women reported concerns that were not related to health: one woman who had never used effective contraception stated that it was illegal to use sterilization and IUDs; and another currently using injectables stated that the church did not allow the use contraception. Of all 567 concerns, 64.9% (368) were medically known side effects such as changes in bleeding patterns, irritability (mood changes), headaches and weight gain 4 , while 35.1% (199) were misperceptions. The latter included the belief that contraceptives caused uterine cancer, cysts, fetal malformations, varicose veins, and dry skin. Misperceptions accounted for 33.6% (38/113) of all concerns among current, 25.7% (44/171) former and 41.3% (117/ 283) never users. Misperceptions were particularly high about female sterilization (87.0% or 20/23 of concerns such as frequent bleeding or cause uterine cancer) and IUDs (67.6% or 50/74 of concerns were misperceptions such as movement to other organs inside the body). Misperceptions were a low proportion of concerns for implants (37.5% or 9/24 of concerns), pill (27.9% or 79/283 of concerns) and injectables (25.1% or 41/163 of concerns).

Of the 481 women with a health concern about effective contraceptive methods, 16.3% (79/481) received family planning counseling on the day of interview. Regardless of contraceptive usage status, information given to women with concerns was limited, with only 2.9% (14/481) of women reporting that their concern about a specific method(s) had been addressed by the health worker during counseling ( Fig 4 ). Only 0.6% (1/175) of former users and 2.1% (5/240) never users with concerns said they would consider starting a modern contraceptive method at the time of the interview.

https://doi.org/10.1371/journal.pone.0218187.g004

A stock of non-expired effective short-acting contraceptive methods was available at 87.5% (42/47) of government hospitals, 95.7 (45/47) of health centers, and 100% (7/7) of barangay health stations. LARCs were available in 85.1% (40/47) of government hospitals, 60% (28/47) (61%) of health centers and 1/7 (14.3%) of barangay health stations.

Of 1664 cumulative total clinic visits reported by the women wanting to delay or limit childbearing in 2016, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility or socio-economic indicators. On the day of the interview in 2017, 83.7% of women had a missed opportunity. Although 55.9% of women reported health concerns about effective contraceptives on the day of the interview, 16% with a concern received family planning counseling and only 2.9% received counseling addressing her specific concerns. Only 0.6% of former effective contraceptive method users and 2.1% never-users said they would consider starting effective contraceptive method in the future. As relatively few facilities had stock-outs, most women in our study could have received an effective contraceptive on the day of the visit, if they had received high quality of counseling, been offered a method and had decided to use it.

These findings suggest that the quantity and quality of family planning counseling provided at primary care clinic contacts in Philippines to women who wish to delay or limit childbearing is inadequate and unlikely to significantly increase the use of effective contraceptive methods. Around 20% of women attending clinics in this study had previously used an effective contraceptive method, but had discontinued use, highlighting that contraceptive services must focus not only on attracting new users but also on improving continuation rates [ 16 ]. To do this, current users should receive continued counseling at every contact, to address the emerging or ongoing concerns about methods; and past users who have stopped use targeted, where appropriate, to resume use by identifying reasons for discontinuation.

The high prevalence of missed opportunities to provide family planning counseling found in this study is consistent with other studies in both developed and developing country settings [ 17 – 19 ].

The World Health Organization recommends providing routine family planning counseling at antenatal care, postnatal care, and other contact points [ 20 – 23 ]. However, experience with integration of family planning counseling into routine primary care is mixed. Significant improvements in family planning outcomes have been seen when improved counseling or referral is integrated into both immunization clinics and general primary care clinic settings [ 24 – 26 ]. In other settings limited improvements in contraceptive use are seen with integration into other services [ 27 – 30 ]. These studies suggest that integrating family planning counseling into routine practice cannot be effective unless systems barriers at primary care clinics are addressed, including the availability of staff, patient numbers and flow, space for adequate one-on-one counseling and availability of low-risk contraceptive methods.

Client-centered counseling approaches are associated with improved method continuation. Women who report experiencing higher quality care have higher rates of contraceptive continuation and contraceptive use [ 31 – 33 ]. In reality, interactions between clients and providers are often provider-dominated, with minimal engagement with women in the process of method selection and with frequent failure of providers to deliver personalized counseling tailored to the individual women's needs and preferences [ 34 – 36 ].

Most counseling in primary care clinics in Philippines is provided by doctors, nurses and midwives. Although family planning counseling at both antenatal and postnatal care contacts is included in national policies and guidelines in Philippines [ 37 ], our findings indicate they are rarely translated into practice. Improving delivery of effective contraceptive methods requires addressing wider legal, policy, social, cultural, and structural barriers which prevent individuals from accessing and using contraception and influence the quality of counseling provided. Some recent policy initiatives in Philippines may promote improved family planning counseling. The Universal Health Coverage Act (RA11223) signed into law in Philippines in February 2019, requires that FP counseling should offered at all primary care contacts, along with a package of essential services. The Expanded Maternity Leave Act (RA11210) also signed in February 2019, increases paid maternity leave from 60 to 105 days and is designed to improve opportunities for postpartum care, including improve family planning counseling and method provision. In 2012, the Responsible Parenthood and Reproductive Health Act (RPRHA) passed, which guarantees universal and free access to modern contraceptives, in particular for poor women [ 8 ].

However, the RPRHA imposes a ban on the purchase of dedicated emergency contraceptives by national hospitals, and requires parental consent for minors to access contraceptives. These restrictions directly impose barriers to contraceptive use on poorer women and adolescent girls [ 38 ].

Although many Philippine-governmental norms and standards are in agreement with adolescents’ human rights to contraceptive information and services recommended by the WHO, a significant number are restrictive, reflecting the strong influence of conservative religious beliefs [ 39 ]. In addition, decentralization of the health system, gives local chief executives the power to ignore national health policies and programs. For example, the mayor of Manila banned contraceptive services in local health facilities in 2000 because of his own religious objections [ 40 ]. In Philippines, staff report that providers who are members of the church often face pressure not to distribute contraception and sometimes pressure from anti-reproductive health groups. Religious beliefs are not cited as important barriers among women of reproductive age, however, suggesting that if appropriate information and counseling was provided, many women would consider adopting modern methods.

There are also a number of provider perceptions that may limit counseling provision, including lack of knowledge, training, and comfort, assumptions about patient pregnancy risk, negative beliefs about contraceptive methods, a reliance on patients to initiate discussions; and limited communication with other primary care staff [ 41 , 42 , 43 ]. Our finding of 32% missed opportunities at contraception clinics suggests that provider-related perceptions and skills continue to play a role in limiting the quality of counseling in the Philippines.

Social norms are believed to be particularly important barriers in Philippines. These norms prevent women, especially adolescents and unmarried women, from accessing services and using methods effectively. The high value placed on virginity at marriage discourages women from admitting sexual activity and inappropriate health concerns [ 6 ].Women frequently do not use any contraceptive method, despite wanting to avoid pregnancy, because they do not perceive themselves to be at risk of pregnancy or they have concerns about the methods, perceptions that are reinforced by families and communities where they live [ 44 ]. In some cases, health-provider or community assumptions about needs may conflict with the women’s own assessment, especially in contexts where there has been a history of contraceptive coercion or discrimination. Providers often offer less-effective methods such as condoms to adolescents believing that LARCs are inappropriate for women who have never had a child. This is despite the fact there is no medical reason to withhold LARCs from adolescents and young women [ 45 ].

This study confirms that LARCs such as IUDs and implants are used less frequently than short acting methods in the Philippines despite being far more effective [ 5 ]. Although previous studies have shown that cost and availability are minor contributors to stoppage or non-use of family planning in general, long-acting methods require specially trained workers and upfront payments which may present barriers to use [ 46 ]. In the Philippines, the national policy allowing only accredited facilities, mostly hospitals, to administrator LARCs results in lower availability at peripheral level facilities. Alternative models, which provide on-site family planning counseling and services, have been shown to increase uptake of LARCs [ 23 ].

In summary, improving family planning counseling at all clinic contacts in the Philippines will require actions at several levels. Recognizing the role of effective contraception to improve the health and economic development of the country is the first step and should be reflected in national laws and policies. Legal barriers such as limitations on the availability of emergency contraception and requiring parental consent can be carefully re-considered and removed. National policies and guidelines should be reinforced at all levels to ensure they are consistent with WHO recommendations and to remove abstinence-centered and sex-negative content. Mechanisms to avoid local adaptations which bypass national policies and guidelines should be explored. Availability of LARCs can be increased by expanding the range of facilities where they can be provided and the number and categories of staff trained in their use. National policies, guidelines and standard operating procedures for primary care services can emphasize integrating family planning counseling at all contacts. Health worker awareness and counseling skills can be strengthened by incorporating skills into professional medical, nursing and midwifery pre-service training curricula and by providing on-the-job coaching of doctors, nurses and midwives; client-centered counseling approaches can address both relational and task-based communication focusing on common obstacles to use [ 47 ]. Development of simple screening tools may allow many counseling tasks to be done by under-employed staff at facilities, removing pressure on those providing clinical services. This approach may be particularly useful for screening current users about concerns; and for identifying and improving support for past users who have stopped use. Systems barriers to counseling need to be identified and addressed in all primary care settings. These include organization of clinic space, patient flow and time to allow counseling to take place, making adequate human resources available, task shifting to improve quality and making LARCs more widely available in primary care settings. Facility accreditation, professional licensure and performance-based financing can help to maintain the motivation of health professionals and provide incentives for prioritizing uptake of effective contraceptive methods.

This study aimed to select a nationally representative sample, based on unmet need for family planning. Since the 2014 Philippine Demographic and Health Survey calculated population-based estimates of unmet need only at the regional level, provinces within a region with higher than average unmet need may be under-represented [ 15 ]. Philhealth insurance coverage in the study population was 71.3% compared to 65.8%, in the general population; 24.7% of the sample had no health insurance compared to 9.9% in the general population [ 3 ]. Higher uninsured rates suggest that the study population may be poorer and less educated, which puts them at higher risk of not using modern methods of contraception. The sample was not weighted for different outpatient clinic attendance rates, which may differ by clinic level and could not be determined in advance. At the clinic level women were selected by order of attendance until the required number was obtained; if more than the required number was present, they were selected by systematic random sampling ordered by time of arrival. In 24 cases home visits were made to interview women who had attended on the previous day. If the characteristics of women or of counseling provided differed by time of attendance, then the sampling of women at clinics could introduce bias. In addition, the study could not control for the clinic type from which women were sampled, since various clinics often fell on certain days of the week. To mitigate these limitations of sampling, we also analyzed the data from the accumulated visits of interviewed women for previous 12 months. The universal presence of missed opportunities across all clinic types at all levels, and the consistency of findings by demographic characteristics, suggests that these factors are unlikely to produce significant biases.

Since our sample was facility-based, findings may not reflect the practices of those who have less access to public clinics or seek care less regularly. In addition, adolescents under 18 years of age were excluded, because their inclusion would have required a lengthy institutional review process which could not be completed within financial deadlines. Given the high missed opportunities among adult women, omission of these groups likely meant that our findings underestimate the extent of the problem.

We asked respondents about family planning services received on the day of the interview and at all clinic visits in 2016. A maximum period of 6 months has been suggested for the recall of non-significant events [ 48 ]. However, rates of missed opportunities did not change significantly between the day of interview and one-year accumulated visits across all demographic categories. To limit the influence of recall bias, detailed data on quality of counseling were collected only for counseling conducted on the day of interview.

Conclusions and broader implications

As in other low- and middle-income countries, the Philippines faces substantial barriers to improving reproductive health services. This study showed that the vast majority of women who wish to delay pregnancy, attending public health clinics, did not receive family planning counseling regardless of their current status of contraceptive use or clinic attended. Over half of these women had health concerns about effective contraceptive methods which were not addressed. This striking finding means that many women in contact with the health system continue to use no contraception, use traditional and other less-effective methods or stop using contraception altogether. As a consequence, many women are put at unnecessary risk of short-spaced high-risk pregnancies and cycles of high fertility, lower educational and employment potential and poverty [ 49 – 51 ]. The study shows that effective contraceptive methods are generally available and that out-of-pocket expenditure was not a major barrier. Systems approaches for improving availability and quality of contraceptive counseling at all primary health care contacts are now needed. Since similar systems problems exist across low and middle-income countries, better quantification of missed opportunities to provide contraceptive counseling and barriers to use is an urgent priority [ 52 ].

Supporting information

S1 questionnaire. questionnaire to women in english..

https://doi.org/10.1371/journal.pone.0218187.s001

S2 Questionnaire. Questionnaire to women in Bicol.

https://doi.org/10.1371/journal.pone.0218187.s002

S3 Questionnaire. Questionnaire to women in Chavacano.

https://doi.org/10.1371/journal.pone.0218187.s003

S4 Questionnaire. Questionnaire to women in Ilocano.

https://doi.org/10.1371/journal.pone.0218187.s004

S5 Questionnaire. Questionnaire to women in Ilonggo.

https://doi.org/10.1371/journal.pone.0218187.s005

S6 Questionnaire. Questionnaire to women in Meranao.

https://doi.org/10.1371/journal.pone.0218187.s006

S7 Questionnaire. Questionnaire to women in Tagalog.

https://doi.org/10.1371/journal.pone.0218187.s007

S8 Questionnaire. Questionnaire to women in Tausug.

https://doi.org/10.1371/journal.pone.0218187.s008

S9 Questionnaire. Questionnaire to women in Visaya.

https://doi.org/10.1371/journal.pone.0218187.s009

S10 Questionnaire. Facility assessment checklist.

https://doi.org/10.1371/journal.pone.0218187.s010

S1 Minimal Dataset. 1:Response of 860 women in Excel.

https://doi.org/10.1371/journal.pone.0218187.s011

S2 Minimal Dataset. 2:Response of 860 women in STATA.

https://doi.org/10.1371/journal.pone.0218187.s012

S3 Minimal Dataset. 3:Values used to build graphs.

https://doi.org/10.1371/journal.pone.0218187.s013

Acknowledgments

We are grateful for the data collection conducted by Asian Institute of Development Studies, INC, Philippines. We thank all health facilities and women who visited those facilities voluntarily participated to this study.

• View Article
• PubMed/NCBI
• Google Scholar
• 3. Philippine Statistics Authority (PSA) and ICF. 2018. Philippines National Demographic and Health Survey 2017: Key Indicators. Quezon City, Philippines, and Rockville, Maryland, USA: PSA and ICF.
• 5. World Health Organization Department of Reproductive Health and Research (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP), Knowledge for Health Project. Family Planning: A Global Handbook for Providers (2018 update). Baltimore and Geneva: CCP and WHO, 2018.
• 6. Demographic Research and Development Foundation, Inc. and University of the Philippines Population Institute (2016). The 2013 young adult fertility and sexuality study in the Philippines. Quezon City: Demographic Research and Development Foundation, Inc. and University of the Philippines Population Institute.
• 8. Congress of the Philippines. The Responsible Parenthood and Reproductive Health Act of 2012: Section 7: 4.06,4.07. Manila. 2012.
• 9. Cambodia: Identifying actions for scaling up long-acting reversible contraceptives. World Health Organization Regional Office for the Western Pacific; 2017.
• 10. Papua New Guinea: Actions for scaling up long-acting reversible contraception. World Health Organization Regional Office for the Western Pacific; 2017.
• 15. Philippine Statistics Authority (PSA) [Philippines], and ICF International. 2014. Philippines National Demographic and Health Survey 2013. Manila, Philippines, and Rockville, Maryland, USA: PSA and ICF International.
• 20. WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization. 2016
• 21. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice –3rd ed. 2015
• 22. WHO recommendations on postnatal care of the mother and newborn. World Health Organization, 2013
• 23. Programming strategies for postpartum family planning. World Health Organization, 2013
• 38. UN DESA, Population Division. World population policies database. New York, NY: United Nations Department of Economic and Social Affairs, 2015. https://esa.un.org/poppolicy/cprofile_report.aspx
• 40. Convention on the Elimination of All Forms of Discrimination against Women. Committee on the Elimination of Discrimination Against Women (CEDAW). Summary of the inquiry concerning the Philippines under article 8 of the Optional Protocol to the Convention on the Elimination of All Forms of Discrimination a Summary of against women. 2015. https://www.escr-net.org/sites/default/files/CEDAW_C_OP-8_PHL_1_7679_E_0.pdf
• 44. Sedgh G, Ashford LS, Hussain R. Unmet need for contraception in developing countries: examining women’s reasons for not using a method. New York, NY: The Guttmacher Institute, 2016.
• 45. WHO, Department of Reproductive Health and Research. Global consensus statement for expanding contraceptive choice for adolescents and youth to include long-acting reversible contraception. Geneva: World Health Organization, 2015.
• 48. Bowling A. Bowling A, Ebrahim S. Techniques of questionnaire design. Handbook of health research methods: investigation, measurement and analysis. Maidenhead:Open University Press; 2006. 422.
• 50. Bongaarts J. How exceptional is the pattern of the fertility decline in sub-Saharan Africa? UN Population Division, Expert Paper No. 2013/4. 2014; New York: United Nations.

In Brief: Unveiling the Realities of Laws on Abortion in the Philippines

This brief outlines the impact of the philippines’ abortion laws and advocates for the decriminalization of abortion in the country..

Developed by the Center for Reproductive Rights and its regional partner, Philippine Safe Abortion Advocacy Network (PINSAN), this brief outlines the impact of abortion laws on Filipinos and advocates for the decriminalization of abortion in the Philippines.

The brief will serve as a crucial tool for building human rights-based advocacy around abortion, demystify the national law and its impact on women and girls, and empower the civil society, media, legal professionals and the public in demanding for a long overdue national law reform in the Philippines that aligns with international human rights standards.

• Download In Brief: Unveiling the Realities of Laws on Abortion in the Philippines here.

Tags: Philippines , Abortion decriminalization , Abortion in the Philippines , Philippines abortion laws , PINSAN , Philippine Safe Abortion Advocacy Network , Philippines abortion reform

Related Posts

Center and partners promote strategies to expand abortion access at “safe abortion dialogue-asia” conference.

The Center for Reproductive Rights Asia team is playing a significant role this month at Safe Abortion Dialogue-Asia, a virtual...

Virtual Event: Global Reproductive Politics, Reproductive Justice, and Limits of Law

Register for this May 11 symposium featuring global experts, academics and activists.

In Op-Ed, the Center’s Jihan Jacob Argues for the Philippines to Follow WHO’s New Guideline and Ensure Abortion Access

“For Filipinos to fully exercise their human rights, they must be able to make free and informed decisions and have...

Sign up for email updates.

The most up-to-date news on reproductive rights, delivered straight to you.

Privacy Overview

Abortion in the Philippines: a study of clients and practitioners

• PMID: 7147312
• Abortion Applicants / psychology
• Abortion, Criminal*
• Catheterization
• Dilatation and Curettage
• Health Knowledge, Attitudes, Practice
• Middle Aged
• Philippines
• Socioeconomic Factors
• Statistics as Topic

• Privacy Notice
• Authors Database
• AV Materials
• Partner-Institutions
• Site Statistics
• Events and Announcements
• Socioeconomic Issue on Spotlight
• Featured Researcher
• Featured Partner Institution
• About SERP-P
• Objectives of SERP-P
• Terms and License Statement
• How to become a partner institutiion?

Estimating the Level of Abortion in the Philippines and Bangladesh

This publication has been cited time(s).

In other Publication

Since Jul 03, 2013

Download Publication

Please let us know your reason for downloading this publication. May we also ask you to provide additional information that will help us serve you better? Rest assured that your answers will not be shared with any outside parties. It will take you only two minutes to complete the survey. Thank you.

• Partner Login

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Rom J Morphol Embryol
• v.61(1); Jan-Mar 2020

A research on abortion: ethics, legislation and socio-medical outcomes. Case study: Romania

Andreea mihaela niţă.

1 Faculty of Social Sciences, University of Craiova, Romania

Cristina Ilie Goga

This article presents a research study on abortion from a theoretical and empirical point of view. The theoretical part is based on the method of social documents analysis, and presents a complex perspective on abortion, highlighting items of medical, ethical, moral, religious, social, economic and legal elements. The empirical part presents the results of a sociological survey, based on the opinion survey method through the application of the enquiry technique, conducted in Romania, on a sample of 1260 women. The purpose of the survey is to identify Romanians perception on the decision to voluntary interrupt pregnancy, and to determine the core reasons in carrying out an abortion.

The analysis of abortion by means of medical and social documents

Abortion means a pregnancy interruption “before the fetus is viable” [ 1 ] or “before the fetus is able to live independently in the extrauterine environment, usually before the 20 th week of pregnancy” [ 2 ]. “Clinical miscarriage is both a common and distressing complication of early pregnancy with many etiological factors like genetic factors, immune factors, infection factors but also psychological factors” [ 3 ]. Induced abortion is a practice found in all countries, but the decision to interrupt the pregnancy involves a multitude of aspects of medical, ethical, moral, religious, social, economic, and legal order.

In a more simplistic manner, Winston Nagan has classified opinions which have as central element “abortion”, in two major categories: the opinion that the priority element is represented by fetus and his entitlement to life and the second opinion, which focuses around women’s rights [ 4 ].

From the medical point of view, since ancient times there have been four moments, generally accepted, which determine the embryo’s life: ( i ) conception; ( ii ) period of formation; ( iii ) detection moment of fetal movement; ( iv ) time of birth [ 5 ]. Contemporary medicine found the following moments in the evolution of intrauterine fetal: “ 1 . At 18 days of pregnancy, the fetal heartbeat can be perceived and it starts running the circulatory system; 2 . At 5 weeks, they become more clear: the nose, cheeks and fingers of the fetus; 3 . At 6 weeks, they start to function: the nervous system, stomach, kidneys and liver of the fetus, and its skeleton is clearly distinguished; 4 . At 7 weeks (50 days), brain waves are felt. The fetus has all the internal and external organs definitively outlined. 5 . At 10 weeks (70 days), the unborn child has all the features clearly defined as a child after birth (9 months); 6 . At 12 weeks (92 days, 3 months), the fetus has all organs definitely shaped, managing to move, lacking only the breath” [ 6 ]. Even if most of the laws that allow abortion consider the period up to 12 weeks acceptable for such an intervention, according to the above-mentioned steps, there can be defined different moments, which can represent the beginning of life. Nowadays, “abortion is one of the most common gynecological experiences and perhaps the majority of women will undergo an abortion in their lifetimes” [ 7 ]. “Safe abortions carry few health risks, but « every year, close to 20 million women risk their lives and health by undergoing unsafe abortions » and 25% will face a complication with permanent consequences” [ 8 , 9 ].

From the ethical point of view, most of the times, the interruption of pregnancy is on the border between woman’s right over her own body and the child’s (fetus) entitlement to life. Judith Jarvis Thomson supported the supremacy of woman’s right over her own body as a premise of freedom, arguing that we cannot force a person to bear in her womb and give birth to an unwanted child, if for different circumstances, she does not want to do this [ 10 ]. To support his position, the author uses an imaginary experiment, that of a violinist to which we are connected for nine months, in order to save his life. However, Thomson debates the problem of the differentiation between the fetus and the human being, by carrying out a debate on the timing which makes this difference (period of conception, 10 weeks of pregnancy, etc.) and highlighting that for people who support abortion, the fetus is not an alive human being [ 10 ].

Carol Gilligan noted that women undergo a true “moral dilemma”, a “moral conflict” with regards to voluntary interruption of pregnancy, such a decision often takes into account the human relationships, the possibility of not hurting the others, the responsibility towards others [ 11 ]. Gilligan applied qualitative interviews to a number of 29 women from different social classes, which were put in a position to decide whether or not to commit abortion. The interview focused on the woman’s choice, on alternative options, on individuals and existing conflicts. The conclusion was that the central moral issue was the conflict between the self (the pregnant woman) and others who may be hurt as a result of the potential pregnancy [ 12 ].

From the religious point of view, abortion is unacceptable for all religions and a small number of abortions can be seen in deeply religious societies and families. Christianity considers the beginning of human life from conception, and abortion is considered to be a form of homicide [ 13 ]. For Christians, “at the same time, abortion is giving up their faith”, riot and murder, which means that by an abortion we attack Jesus Christ himself and God [ 14 ]. Islam does not approve abortion, relying on the sacral life belief as specified in Chapter 6, Verse 151 of the Koran: “Do not kill a soul which Allah has made sacred (inviolable)” [ 15 ]. Buddhism considers abortion as a negative act, but nevertheless supports for medical reasons [ 16 ]. Judaism disapproves abortion, Tanah considering it to be a mortal sin. Hinduism considers abortion as a crime and also the greatest sin [ 17 ].

From the socio-economic point of view, the decision to carry out an abortion is many times determined by the relations within the social, family or financial frame. Moreover, studies have been conducted, which have linked the legalization of abortions and the decrease of the crime rate: “legalized abortion may lead to reduced crime either through reductions in cohort sizes or through lower per capita offending rates for affected cohorts” [ 18 ].

Legal regulation on abortion establishes conditions of the abortion in every state. In Europe and America, only in the XVIIth century abortion was incriminated and was considered an insignificant misdemeanor or a felony, depending on when was happening. Due to the large number of illegal abortions and deaths, two centuries later, many states have changed legislation within the meaning of legalizing voluntary interruption of pregnancy [ 6 ]. In contemporary society, international organizations like the United Nations or the European Union consider sexual and reproductive rights as fundamental rights [ 19 , 20 ], and promotes the acceptance of abortion as part of those rights. However, not all states have developed permissive legislation in the field of voluntary interruption of pregnancy.

Currently, at national level were established four categories of legislation on pregnancy interruption area:

( i )  Prohibitive legislations , ones that do not allow abortion, most often outlining exceptions in abortion in cases where the pregnant woman’s life is endangered. In some countries, there is a prohibition of abortion in all circumstances, however, resorting to an abortion in the case of an imminent threat to the mother’s life. Same regulation is also found in some countries where abortion is allowed in cases like rape, incest, fetal problems, etc. In this category are 66 states, with 25.5% of world population [ 21 ].

( ii )  Restrictive legislation that allow abortion in cases of health preservation . Loosely, the term “health” should be interpreted according to the World Health Organization (WHO) definition as: “health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” [ 22 ]. This type of legislation is adopted in 59 states populated by 13.8% of the world population [ 21 ].

( iii )  Legislation allowing abortion on a socio-economic motivation . This category includes items such as the woman’s age or ability to care for a child, fetal problems, cases of rape or incest, etc. In this category are 13 countries, where we have 21.3% of the world population [ 21 ].

( iv )  Legislation which do not impose restrictions on abortion . In the case of this legislation, abortion is permitted for any reason up to 12 weeks of pregnancy, with some exceptions (Romania – 14 weeks, Slovenia – 10 weeks, Sweden – 18 weeks), the interruption of pregnancy after this period has some restrictions. This type of legislation is adopted in 61 countries with 39.5% of the world population [21].

The Centre for Reproductive Rights has carried out from 1998 a map of the world’s states, based on the legislation typology of each country (Figure ​ (Figure1 1 ).

The analysis of states according to the legislation regarding abortion. Source: Centre for Reproductive Rights. The World’s Abortion Laws, 2018 [ 23 ]

An unplanned pregnancy, socio-economic context or various medical problems [ 24 ], lead many times to the decision of interrupting pregnancy, regardless the legislative restrictions. In the study “Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008” issued in 2011 by the WHO , it was determined that within the states with restrictive legislation on abortion, we may also encounter a large number of illegal abortions. The illegal abortions may also be resulting in an increased risk of woman’s health and life considering that most of the times inappropriate techniques are being used, the hygienic conditions are precarious and the medical treatments are incorrectly administered [ 25 ]. Although abortions done according to medical guidelines carry very low risk of complications, 1–3 unsafe abortions contribute substantially to maternal morbidity and death worldwide [ 26 ].

WHO has estimated for the year 2008, the fact that worldwide women between the ages of 15 and 44 years carried out 21.6 million “unsafe” abortions, which involved a high degree of risk and were distributed as follows: 0.4 million in the developed regions and a number of 21.2 million in the states in course of development [ 25 ].

Case study: Romania

Legal perspective on abortion

In Romania, abortion was brought under regulation by the first Criminal Code of the United Principalities, from 1864.

The Criminal Code from 1864, provided the abortion infringement in Article 246, on which was regulated as follows: “Any person, who, using means such as food, drinks, pills or any other means, which will consciously help a pregnant woman to commit abortion, will be punished to a minimum reclusion (three years).

The woman who by herself shall use the means of abortion, or would accept to use means of abortion which were shown or given to her for this purpose, will be punished with imprisonment from six months to two years, if the result would be an abortion. In a situation where abortion was carried out on an illegitimate baby by his mother, the punishment will be imprisonment from six months to one year.

Doctors, surgeons, health officers, pharmacists (apothecary) and midwives who will indicate, will give or will facilitate these means, shall be punished with reclusion of at least four years, if the abortion took place. If abortion will cause the death of the mother, the punishment will be much austere of four years” (Art. 246) [ 27 ].

The Criminal Code from 1864, reissued in 1912, amended in part the Article 246 for the purposes of eliminating the abortion of an illegitimate baby case. Furthermore, it was no longer specified the minimum of four years of reclusion, in case of abortion carried out with the help of the medical staff, leaving the punishment to the discretion of the Court (Art. 246) [ 28 ].

The Criminal Code from 1936 regulated abortion in the Articles 482–485. Abortion was defined as an interruption of the normal course of pregnancy, being punished as follows:

“ 1 . When the crime is committed without the consent of the pregnant woman, the punishment was reformatory imprisonment from 2 to 5 years. If it caused the pregnant woman any health injury or a serious infirmity, the punishment was reformatory imprisonment from 3 to 6 years, and if it has caused her death, reformatory imprisonment from 7 to 10 years;

2 . When the crime was committed by the unmarried pregnant woman by herself, or when she agreed that someone else should provoke the abortion, the punishment is reformatory imprisonment from 3 to 6 months, and if the woman is married, the punishment is reformatory imprisonment from 6 months to one year. Same penalty applies also to the person who commits the crime with the woman’s consent. If abortion was committed for the purpose of obtaining a benefit, the punishment increases with another 2 years of reformatory imprisonment.

If it caused the pregnant woman any health injuries or a severe disablement, the punishment will be reformatory imprisonment from one to 3 years, and if it has caused her death, the punishment is reformatory imprisonment from 3 to 5 years” (Art. 482) [ 29 ].

The criminal legislation from 1936 specifies that it is not considered as an abortion the interruption from the normal course of pregnancy, if it was carried out by a doctor “when woman’s life was in imminent danger or when the pregnancy aggravates a woman’s disease, putting her life in danger, which could not be removed by other means and it is obvious that the intervention wasn’t performed with another purpose than that of saving the woman’s life” and “when one of the parents has reached a permanent alienation and it is certain that the child will bear serious mental flaws” (Art. 484, Par. 1 and Par. 2) [ 29 ].

In the event of an imminent danger, the doctor was obliged to notify prosecutor’s office in writing, within 48 hours after the intervention, on the performance of the abortion. “In the other cases, the doctor was able to intervene only with the authorization of the prosecutor’s office, given on the basis of a medical certificate from hospital or a notice given as a result of a consultation between the doctor who will intervene and at least a professor doctor in the disease which caused the intervention. General’s Office Prosecutor, in all cases provided by this Article, shall be obliged to maintain the confidentiality of all communications or authorizations, up to the intercession of any possible complaints” (Art. 484) [ 29 ].

The legislation of 1936 provided a reformatory injunction from one to three years for the abortions committed by doctors, sanitary agents, pharmacists, apothecary or midwives (Art. 485) [ 29 ].

Abortion on demand has been legalized for the first time in Romania in the year 1957 by the Decree No. 463, under the condition that it had to be carried out in a hospital and to be carried out in the first quarter of the pregnancy [ 30 ]. In the year 1966, demographic policy of Romania has dramatically changed by introducing the Decree No. 770 from September 29 th , which prohibited abortion. Thus, the voluntary interruption of pregnancy became a crime, with certain exceptions, namely: endangering the mother’s life, physical or mental serious disability; serious or heritable illness, mother’s age over 45 years, if the pregnancy was a result of rape or incest or if the woman gave birth to at least four children who were still in her care (Art. 2) [ 31 ].

In the Criminal Code from 1968, the abortion crime was governed by Articles 185–188.

The Article 185, “the illegal induced abortion”, stipulated that “the interruption of pregnancy by any means, outside the conditions permitted by law, with the consent of the pregnant woman will be punished with imprisonment from one to 3 years”. The act referred to above, without the prior consent from the pregnant woman, was punished with prison from two to five years. If the abortion carried out with the consent of the pregnant woman caused any serious body injury, the punishment was imprisonment from two to five years, and when it caused the death of the woman, the prison sentence was from five to 10 years. When abortion was carried out without the prior consent of the woman, if it caused her a serious physical injury, the punishment was imprisonment from three to six years, and if it caused the woman’s death, the punishment was imprisonment from seven to 12 years (Art. 185) [ 32 ].

“When abortion was carried out in order to obtain a material benefit, the maximum punishment was increased by two years, and if the abortion was made by a doctor, in addition to the prison punishment could also be applied the prohibition to no longer practice the profession of doctor”.

Article 186, “abortion caused by the woman”, stipulated that “the interruption of the pregnancy course, committed by the pregnant woman, was punished with imprisonment from 6 months to 2 years”, quoting the fact that by the same punishment was also sanctioned “the pregnant woman’s act to consent in interrupting the pregnancy course made out by another person” (Art. 186) [ 26 ].

The Regulations of the Criminal Code in 1968, also provided the crime of “ownership of tools or materials that can cause abortion”, the conditions of this holding being met when these types of instruments were held outside the hospital’s specialized institutions, the infringement shall be punished with imprisonment from three months to one year (Art. 187) [ 32 ].

Furthermore, the doctors who performed an abortion in the event of extreme urgency, without prior legal authorization and if they did not announce the competent authority within the legal deadline, they were punished by imprisonment from one month to three months (Art. 188) [ 32 ].

In the year 1985, it has been issued the Decree No. 411 of December 26 th , by which the conditions imposed by the Decree No. 770 of 1966 have been hardened, meaning that it has increased the number of children, that a woman could have in order to request an abortion, from four to five children [ 33 ].

The Articles 185–188 of the Criminal Code and the Decree No. 770/1966 on the interruption of the pregnancy course have been abrogated by Decree-Law No. 1 from December 26 th , 1989, which was published in the Official Gazette No. 4 of December 27 th , 1989 (Par. 8 and Par. 12) [ 34 ].

The Criminal Code from 1968, reissued in 1997, maintained Article 185 about “the illegal induced abortion”, but drastically modified. Thus, in this case of the Criminal Code, we identify abortion as “the interruption of pregnancy course, by any means, committed in any of the following circumstances: ( a ) outside medical institutions or authorized medical practices for this purpose; ( b ) by a person who does not have the capacity of specialized doctor; ( c ) if age pregnancy has exceeded 14 weeks”, the punishment laid down was the imprisonment from 6 months to 3 years” (Art. 185, Par. 1) [ 35 ]. For the abortion committed without the prior consent of the pregnant woman, the punishment consisted in strict prison conditions from two to seven years and with the prohibition of certain rights (Art. 185, Par. 2) [ 35 ].

For the situation of causing serious physical injury to the pregnant woman, the punishment was strict prison from three to 10 years and the removal of certain rights, and if it had as a result the death of the pregnant woman, the punishment was strict prison from five to 15 years and the prohibition of certain rights (Art. 185, Par. 3) [ 35 ].

The attempt was punished for the crimes specified in the various cases of abortion.

Consideration should also be given in the Criminal Code reissued in 1997 for not punishing the interruption of the pregnancy course carried out by the doctor, if this interruption “was necessary to save the life, health or the physical integrity of the pregnant woman from a grave and imminent danger and that it could not be removed otherwise; in the case of a over fourteen weeks pregnancy, when the interruption of the pregnancy course should take place from therapeutic reasons” and even in a situation of a woman’s lack of consent, when it has not been given the opportunity to express her will, and abortion “was imposed by therapeutic reasons” (Art. 185, Par. 4) [ 35 ].

Criminal Code from 2004 covers abortion in Article 190, defined in the same way as in the prior Criminal Code, with the difference that it affects the limits of the punishment. So, in the event of pregnancy interruption, in accordance with the conditions specified in Paragraph 1, “the penalty provided was prison time from 6 months to one year or days-fine” (Art. 190, Par. 1) [ 36 ].

Nowadays, in Romania, abortion is governed by the criminal law of 2009, which entered into force in 2014, by the section called “aggression against an unborn child”. It should be specified that current criminal law does not punish the woman responsible for carrying out abortion, but only the person who is involved in carrying out the abortion. There is no punishment for the pregnant woman who injures her fetus during pregnancy.

In Article 201, we can find the details on the pregnancy interruption infringement. Thus, the pregnancy interruption can be performed in one of the following circumstances: “outside of medical institutions or medical practices authorized for this purpose; by a person who does not have the capacity of specialist doctor in Obstetrics and Gynecology and the right of free medical practice in this specialty; if gestational age has exceeded 14 weeks”, the punishment is the imprisonment for six months to three years, or fine and the prohibition to exercise certain rights (Art. 201, Par. 1) [ 37 ].

Article 201, Paragraph 2 specifies that “the interruption of the pregnancy committed under any circumstances, without the prior consent of the pregnant woman, can be punished with imprisonment from 2 to 7 years and with the prohibition to exercise some rights” (Art. 201, Par. 1) [ 37 ].

If by facts referred to above (Art. 201, Par. 1 and Par. 2) [ 37 ] “it has caused the pregnant woman’s physical injury, the punishment is the imprisonment from 3 to 10 years and the prohibition to exercise some rights, and if it has had as a result the pregnant woman’s death, the punishment is the imprisonment from 6 to 12 years and the prohibition to exercise some rights” (Art. 201, Par. 3) [ 37 ]. When the facts have been committed by a doctor, “in addition to the imprisonment punishment, it will also be applied the prohibition to exercise the profession of doctor (Art. 201, Par. 4) [ 37 ].

Criminal legislation specifies that “the interruption of pregnancy does not constitute an infringement with the purpose of a treatment carried out by a specialist doctor in Obstetrics and Gynecology, until the pregnancy age of twenty-four weeks is reached, or the subsequent pregnancy interruption, for the purpose of treatment, is in the interests of the mother or the fetus” (Art. 201, Par. 6) [ 37 ]. However, it can all be found in the phrases “therapeutic purposes” and “the interest of the mother and of the unborn child”, which predisposes the text of law to an interpretation, finally the doctors are the only ones in the position to decide what should be done in such cases, assuming direct responsibility [ 38 ].

Article 202 of the Criminal Code defines the crime of harming an unborn child, pointing out the punishments for the various types of injuries that can occur during pregnancy or in the childbirth period and which can be caused by the mother or by the persons who assist the birth, with the specification that the mother who harms her fetus during pregnancy is not punished and does not constitute an infringement if the injury has been committed during pregnancy or during childbirth period if the facts have been “committed by a doctor or by an authorized person to assist the birth or to follow the pregnancy, if they have been committed in the course of the medical act, complying with the specific provisions of his profession and have been made in the interest of the pregnant woman or fetus, as a result of the exercise of an inherent risk in the medical act” (Art. 202, Par. 6) [ 37 ].

The fact situation in Romania

During the period 1948–1955, called “the small baby boom” [ 39 ], Romania registered an average fertility rate of 3.23 children for a woman. Between 1955 and 1962, the fertility rate has been less than three children for a woman, and in 1962, fertility has reached an average of two children for a woman. This phenomenon occurred because of the Decree No. 463/1957 on liberalization of abortion. After the liberalization from 1957, the abortion rate has increased from 220 abortions per 100 born-alive children in the year 1960, to 400 abortions per 100 born-alive children, in the year 1965 [ 40 ].

The application of provisions of Decrees No. 770 of 1966 and No. 411 of 1985 has led to an increase of the birth rate in the first three years (an average of 3.7 children in 1967, and 3.6 children in 1968), followed by a regression until 1989, when it was recorded an average of 2.2 children, but also a maternal death rate caused by illegal abortions, raising up to 85 deaths of 100 000 births in the year of 1965, and 170 deaths in 1983. It was estimated that more than 80% of maternal deaths between 1980–1989 was caused by legal constraints [ 30 ].

After the Romanian Revolution in December 1989 and after the communism fall, with the abrogation of Articles 185–188 of the Criminal Code and of the Decree No. 770/1966, by the Decree of Law No. 1 of December 26 th , 1989, abortion has become legal in Romania and so, in the following years, it has reached the highest rate of abortion in Europe. Subsequently, the number of abortion has dropped gradually, with increasing use of birth control [ 41 ].

Statistical data issued by the Ministry of Health and by the National Institute of Statistics (INS) in Romania show corresponding figures to a legally carried out abortion. The abortion number is much higher, if it would take into account the number of illegal abortion, especially those carried out before 1989, and those carried out in private clinics, after the year 1990. Summing the declared abortions in the period 1958–2014, it is to be noted the number of them, 22 037 747 exceeds the current Romanian population. A detailed statistical research of abortion rate, in terms of years we have exposed in Table ​ Table1 1 .

The number of abortions declared in Romania in the period 1958–2016

Source: Pro Vita Association (Bucharest, Romania), National Institute of Statistics (INS – Romania), EUROSTAT [ 42 , 43 , 44 ]

Data issued by the United Nations International Children’s Emergency Fund (UNICEF) in June 2016, for the period 1989–2014, in matters of reproductive behavior, indicates a fertility rate for Romania with a continuous decrease, in proportion to the decrease of the number of births, but also a lower number of abortion rate reported to 100 deliveries (Table ​ (Table2 2 ).

Reproductive behavior in Romania in 1989–2014

Source: United Nations International Children’s Emergency Fund (UNICEF), Transformative Monitoring for Enhanced Equity (TransMonEE) Data. Country profiles: Romania, 1989–2015 [ 45 ].

By analyzing data issued for the period 1990–2015 by the International Organization of Health , UNICEF , United Nations Fund for Population Activity (UNFPA), The World Bank and the United Nations Population Division, it is noticed that maternal mortality rate has currently dropped as compared with 1990 (Table ​ (Table3 3 ).

Maternal mortality estimation in Romania in 1990–2015

Source: World Health Organization (WHO), Global Health Observatory Data. Maternal mortality country profiles: Romania, 2015 [ 46 ].

Opinion survey: women’s opinion on abortion

Argument for choosing the research theme

Although the problematic on abortion in Romania has been extensively investigated and debated, it has not been carried out in an ample sociological study, covering Romanian women’s perception on abortion. We have assumed making a study at national level, in order to identify the opinion on abortion, on the motivation to carry out an abortion, and to identify the correlation between religious convictions and the attitude toward abortion.

Examining the literature field of study

In the conceptual register of the research, we have highlighted items, such as the specialized literature, legislation, statistical documents.

Formulation of hypotheses and objectives

The first hypothesis was that Romanian women accept abortion, having an open attitude towards this act. Thus, the first objective of the research was to identify Romanian women’s attitude towards abortion.

The second hypothesis, from which we started, was that high religious beliefs generate a lower tolerance towards abortion. Thus, the second objective of our research has been to identify the correlation between the religious beliefs and the attitude towards abortion.

The third hypothesis of the survey was that, the main motivation in carrying out an abortion is the fact that a woman does not want a baby, and the main motivation for keeping the pregnancy is that the person wants a baby. In this context, the third objective of the research was to identify main motivation in carrying out an abortion and in maintaining a pregnancy.

Another hypothesis was that modern Romanian legislation on the abortion is considered fair. Based on this hypothesis, we have assumed the fourth objective, which is to identify the degree of satisfaction towards the current regulatory provisions governing the abortion.

Research methodology

The research method is that of a sociological survey by the application of the questionnaire technique. We used the sampling by age and residence looking at representative numbers of population from more developed as well as underdeveloped areas.

Determination of the sample to be studied

Because abortion is a typical women’s experience, we have chosen to make the quantitative research only among women. We have constructed the sample by selecting a number of 1260 women between the ages of 15 and 44 years (the most frequently encountered age among women who give birth to a child). We also used the quota sampling techniques, taking into account the following variables: age group and the residence (urban/rural), so that the persons included in the sample could retain characteristic of the general population.

By the sample of 1260 women, we have made a percentage of investigation of 0.03% of the total population.

The Questionnaires number applied was distributed as follows (Table ​ (Table4 4 ).

The sampling rates based on the age, and the region of residence

Source: Sample built, based on the population data issued by the National Institute of Statistics (INS – Romania) based on population census conducted in 2011 [ 47 ].

Data collection

Data collection was carried out by questionnaires administered by 32 field operators between May 1 st –May 31 st , 2018.

The analysis of the research results

In the next section, we will present the main results of the quantitative research carried out at national level.

Almost three-quarters of women included in the sample agree with carrying out an abortion in certain circumstances (70%) and only 24% have chosen to support the answer “ No, never ”. In modern contemporary society, abortion is the first solution of women for which a pregnancy is not desired. Even if advanced medical techniques are a lot safer, an abortion still carries a health risk. However, 6% of respondents agree with carrying out abortion regardless of circumstances (Table ​ (Table5 5 ).

Opinion on the possibility of carrying out an abortion

Although abortions carried out after 14 weeks are illegal, except for medical reasons, more than half of the surveyed women stated they would agree with abortion in certain circumstances. At the opposite pole, 31% have mentioned they would never agree on abortions after 14 weeks. Five percent were totally accepting the idea of abortion made to a pregnancy that has exceeded 14 weeks (Table ​ (Table6 6 ).

Opinion on the possibility of carrying out an abortion after the period of 14 weeks of pregnancy

For 53% of respondents, abortion is considered a crime as well as the right of a women. On the other hand, 28% of the women considered abortion as a crime and 16% associate abortion with a woman’s right (Table ​ (Table7 7 ).

Opinion on abortion: at the border between crime and a woman’s right

Opinions on what women abort at the time of the voluntary pregnancy interruption are split in two: 59% consider that it depends on the time of the abortion, and more specifically on the pregnancy development stage, 24% consider that regardless of the period in which it is carried out, women abort a child, and 14% have opted a fetus (Table ​ (Table8 8 ).

Abortion of a child vs. abortion of a fetus

Among respondents who consider that women abort a child or a fetus related to the time of abortion, 37.5% have considered that the difference between a baby and a fetus appears after 14 weeks of pregnancy (the period legally accepted for abortion). Thirty-three percent of them have mentioned that the distinction should be performed at the first few heartbeats; 18.1% think it is about when the child has all the features definitively outlined and can move by himself; 2.8% consider that the difference appears when the first encephalopathy traces are being felt and the child has formed all internal and external organs. A percentage of 1.7% of respondents consider that this difference occurs at the beginning of the central nervous system, and 1.4% when the unborn child has all the features that we can clearly see to a newborn child (Table ​ (Table9 9 ).

The opinion on the moment that makes the difference between a fetus and a child

We noticed that highly religious people make a clear association between abortion and crime. They also consider that at the time of pregnancy interruption it is aborted a child and not a fetus. However, unexpectedly, we noticed that 27% of the women, who declare themselves to be very religious, have also stated that they see abortion as a crime but also as a woman’s right. Thirty-one percent of the women, who also claimed profound religious beliefs, consider that abortion may be associated with the abortion of a child but also of a fetus, this depending on the time of abortion (Tables ​ (Tables10 10 and ​ and11 11 ).

The correlation between the level of religious beliefs and the perspective on abortion seen as a crime or a right

The correlation between the level of religious beliefs and the perspective on abortion procedure conducted on a fetus or a child

More than half of the respondents have opted for the main reason for abortion the appearance of medical problems to the child. Baby’s health represents the main concern of future mothers, and of each parent, and the birth of a child with serious health issues, is a factor which frightens any future parent, being many times, at least theoretically, one good reason for opting for abortion. At the opposite side, 12% of respondents would not choose abortion under any circumstances. Other reasons for which women would opt for an abortion are: if the woman would have a medical problem (22%) or would not want the child (10%) (Table ​ (Table12 12 ).

Potential reasons for carrying out an abortion

Most of the women want to give birth to a child, 56% of the respondents, representing also the reason that would determine them to keep the child. Morality (26%), faith (10%) or legal restrictions (4%), are the three other reasons for which women would not interrupt a pregnancy. Only 2% of the respondents have mentioned other reasons such as health or age.

A percentage of 23% of the surveyed people said that they have done an abortion so far, and 77% did not opted for a surgical intervention either because there was no need, or because they have kept the pregnancy (Table ​ (Table13 13 ).

Rate of abortion among women in the sample

Most respondents, 87% specified that they have carried out an abortion during the first 14 weeks – legally accepted limit for abortion: 43.6% have made abortion in the first four weeks, 39.1% between weeks 4–8, and 4.3% between weeks 8–14. It should be noted that 8.7% could not appreciate the pregnancy period in which they carried out abortion, by opting to answer with the option “ I don’t know ”, and a percentage of 4.3% refused to answer to this question.

Performing an abortion is based on many reasons, but the fact that the women have not wanted a child is the main reason mentioned by 47.8% of people surveyed, who have done minimum an abortion so far. Among the reasons for the interruption of pregnancy, it is also included: women with medical problems (13.3%), not the right time to be a mother (10.7%), age motivation (8.7%), due to medical problems of the child (4.3%), the lack of money (4.3%), family pressure (4.3%), partner/spouse did not wanted. A percentage of 3.3% of women had different reasons for abortion, as follows: age difference too large between children, career, marital status, etc. Asked later whether they regretted the abortion, a rate of 69.6% of women who said they had at least one abortion regret it (34.8% opted for “ Yes ”, and 34.8% said “ Yes, partially ”). 26.1% of surveyed women do not regret the choice to interrupted the pregnancy, and 4.3% chose to not answer this question. We noted that, for women who have already experienced abortion, the causes were more diverse than the grounds on which the previous question was asked: “What are the reasons that determined you to have an abortion?” (Table ​ (Table14 14 ).

The reasons that led the women in the sample to have an abortion

The majority of the respondents (37.5%) considered that “nervous depression” is the main consequence of abortion, followed by “insomnia and nightmares” (24.6%), “disorders in alimentation” and “affective disorders” (each for 7.7% of respondents), “deterioration of interpersonal relationships” and “the feeling of guilt”(for 6.3% of the respondents), “sexual disorders” and “panic attacks” (for 6.3% of the respondents) (Table ​ (Table15 15 ).

Opinion on the consequences of abortion

Over half of the respondents believe that abortion should be legal in certain circumstances, as currently provided by law, 39% say it should be always legal, and only 6% opted for the illegal option (Table ​ (Table16 16 ).

Opinion on the legal regulation of abortion

Although the current legislation does not punish pregnant women who interrupt pregnancy or intentionally injured their fetus, survey results indicate that 61% of women surveyed believe that the national law should punish the woman and only 28% agree with the current legislation (Table ​ (Table17 17 ).

Opinion on the possibility of punishing the woman who interrupts the course of pregnancy or injures the fetus

For the majority of the respondents (40.6%), the penalty provided by the current legislation, the imprisonment between six months and three years or a fine and deprivation of certain rights for the illegal abortion is considered fair, for a percentage of 39.6% the punishment is too small for 9.5% of the respondents is too high. Imprisonment between two and seven years and deprivation of certain rights for an abortion performed without the consent of the pregnant woman is considered too small for 65% of interviewees. Fourteen percent of them think it is fair and only 19% of respondents consider that Romanian legislation is too severe with people who commit such an act considering the punishment as too much. The imprisonment from three to 10 years and deprivation of certain rights for the facts described above, if an injury was caused to the woman, is considered to be too small for more than half of those included in the survey, 64% and almost 22% for nearly a quarter of them. Only 9% of the respondents mentioned that this legislative measure is too severe for such actions (Table ​ (Table18 18 ).

Opinion on the regulation of abortion of the Romanian Criminal Code (Art. 201)

Conclusions

After analyzing the results of the sociological research regarding abortion undertaken at national level, we see that 76% of the Romanian women accept abortion, indicating that the majority accepts only certain circumstances (a certain period after conception, for medical reasons, etc.). A percentage of 64% of the respondents indicated that they accept the idea of abortion after 14 weeks of pregnancy (for solid reasons or regardless the reason). This study shows that over 50% of Romanian women see abortion as a right of women but also a woman’s crime and believe that in the moment of interruption of a pregnancy, a fetus is aborted. Mostly, the association of abortion with crime and with the idea that a child is aborted is frequently found within very religious people. The main motivation for Romanian women in taking the decision not to perform an abortion is that they would want the child, and the main reason to perform an abortion is the child’s medical problems. However, it is noted that, in real situations, in which women have already done at least one abortion, most women resort to abortion because they did not want the child towards the hypothetical situation in which women felt that the main reason of abortion is a medical problem. Regarding the satisfaction with the current national legislation of the abortion, the situation is rather surprising. A significant percentage (61%) of respondents felt as necessary to punish the woman who performs an illegal abortion, although the legislation does not provide a punishment. On the other hand, satisfaction level to the penalties provided by law for various violations of the legal conditions for conducting abortion is low, on average only 25.5% of respondents are being satisfied with these, the majority (average 56.2%) considering the penalties as unsatisfactory. Understood as a social phenomenon, intensified by human vulnerabilities, of which the most obvious is accepting the comfort [ 48 ], abortion today is no longer, in Romanian society, from a legal or religious perspective, a problem. Perceptions on the legislative sanction, moral and religious will perpetual vary depending on beliefs, environment, education, etc. The only and the biggest social problem of Romania is truly represented by the steadily falling birth rate.

Conflict of interests

The authors declare that they have no conflict of interests.

Cultural Relativity and Acceptance of Embryonic Stem Cell Research

Article sidebar.

Main Article Content

There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

[1] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk ; Kimmelman, J., Hyun, I., Benvenisty, N.  et al.  Policy: Global standards for stem-cell research.  Nature   533 , 311–313 (2016). https://doi.org/10.1038/533311a

[4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk

[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research.  The New England journal of medicine ,  351 (3), 207–209. https://doi.org/10.1056/NEJMp048145 ; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos . The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos ; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy , 38 (2/3), 264–284. http://www.jstor.org/stable/24439776 ; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells.  The New England journal of medicine ,  351 (3), 209–211. https://doi.org/10.1056/NEJMp048147 ; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality.  Bosnian journal of basic medical sciences ,  4 (1), 5–14. https://doi.org/10.17305/bjbms.2004.3453

[6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review.  Restorative neurology and neuroscience ,  28 (4), 589–603. https://doi.org/10.3233/RNN-2010-0543

[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa.  Stem Cell Res Ther   4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction.  Frontiers in pharmacology ,  13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

[25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech.

[26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan.  Curr Stem Cell Rep   1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned.  Accountability in research ,  13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

[66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet) . Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en

[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979).  The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services.  https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes.  Journal of assisted reproduction and genetics ,  35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

[71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA.  Reproductive biomedicine online ,  18 (5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8

[72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa.  Clinical trials (London, England) ,  3 (3), 306–313. https://doi.org/10.1191/1740774506cn150oa

[73] Veatch, Robert M.  Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict . Georgetown University Press, 2012.

[74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity.  Research Ethics ,  14 (3), 1-17.  https://doi.org/10.1177/1747016117739939

[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry.  Voices in Bioethics ,  8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis.  Voices in Bioethics ,  3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation,  New Genetics and Society , 30:2, 141-153, DOI:  10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

[80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier . Stanford University Press.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

Article Details

This work is licensed under a Creative Commons Attribution 4.0 International License .