BMJ

Advocates must use history, evidence, and multilateral leverage to protect sexual and reproductive health from attempts to erode rights, write Terry McGovern and colleagues Anti-rights forces—whether religious-conservative, nationalist, or far right—are increasingly gaining political power by challenging the multilateral system and the international human rights framework that safeguard gender equality, sexual and reproductive health, and LGBTQ+ rights. These political actors and alliances reject and distort settled international norms to obstruct inclusive development efforts, with disastrous effects on health outcomes. These trends erode the quality of patient care, restrict access to essential services, and hinder the implementation of evidence based care. Progressive civil societies are devising creative transnational and multilateral strategies to resist these forces. This paper, part of a collection of articles on the impacts of shifts in the multilateral system on sexual and reproductive health and rights (SRHR), spotlights jurisdiction specific examples of how anti-rights actors are targeting this arena and how SRHR advocates and progressive civil society can respond. The multilateral dimensions of this work are examined in depth elsewhere in the collection. 1 This landscape is complex. Anti-rights actors range from religious communities acting on religious beliefs to well funded transnational political networks (box 1). SRHR advocates also do not speak with one voice: civil society encompasses organisations with differing priorities, resources, and relationships to the communities they serve. Funding for such work is at an all-time low and is an ongoing problem. 1 Acknowledging this complexity is a precondition for strategies that are durable and context sensitive. Box 1 ### Terminology For the purposes of this article:RETURN TO TEXT

Decades of progress risk being undone unless the UN prioritises its commitments to human rights, says Terry McGovern The 1945 charter that created the United Nations begins with a promise to save future generations from war, reaffirm human rights, and promote social progress.1 Eighty years later, this pledge is languishing: global conflict, waning financial and political commitments to international cooperation, and a growing anti-rights movement have put the multilateralism at the core of the UN’s mandate in grave danger.2 All of these forces threaten the health of the world’s population, in particular those affected by devastating backsliding on sexual and reproductive health and rights (SRHR). The gathering of 193 country representatives in New York for the 2026 UN General Assembly (UNGA) this September sees several major political and institutional developments converging: the election of the next UN secretary general, the ongoing policy impact of Donald Trump’s second US presidency, and the UN80 reform initiative that is proposing to merge institutions dedicated to SRHR. The 2026 General Assembly is hugely consequential: member states need to stand up and defend SRHR, as a new BMJ Collection argues (bmj/collections/SRHR). The election of the next secretary general is an important part of defending SRHR. Advocates are strongly invested in securing the election of …

As anti-rights actors have consolidated political power in the US, restrictions on sexual and reproductive health and rights have expanded through judicial, legislative, legal, and fiscal mechanisms. Greene and colleagues examine how New York’s experience illustrates both the potential and the limits of state level resistance For nearly a quarter of a century, anti-rights forces in the US have consolidated national and local power with the goal of undermining sexual and reproductive health and rights (SRHR). These efforts (in the form of executive orders, Supreme Court decisions, national and local legislation, and discontinuation of funding) restrict access to care, individual choice, bodily autonomy, and quality of care and disrupt the overall public health system nationally and locally. Recently, US health policies have sharply diverged from the scientific evidence supporting SRHR. Across the US, SRHR advocates and progressive states have initiated local efforts of resistance, including changes to state constitutions and passage of protective state level and local level legislation, defeated referendums proposing SRHR restrictions, and targeted local funding allocations. This paper is part of a collection of articles on the impacts of shifts in the multilateral system on SRHR. Building on the descriptions of anti-rights ideology and the impact on global multilateral governance that this collection offers, we assess changes in US SRHR policy and the mitigation response in New York State. Although New York may be more liberal, better funded, and more organised than other localities experiencing similar threats, the strategies it has used may inform and inspire local efforts elsewhere. The federalist structure of the US government relies on a capitalist approach to social welfare. The US provides a safety net, not a baseline, to pay for healthcare, food, housing assistance, and/or income support for specific vulnerable populations (that is, people who are living with disabilities or severe …

Delivering sexual and reproductive health justice requires a new independent and neutral global body where global rights obligations are prioritised, write Attiya Waris and colleagues The freefall in development assistance for health has captured most of the attention of the global health community and could indeed lead to “tens of millions of excess deaths” in low and middle income countries (LMICs). Reductions in development assistance will contribute to reversing progress on achieving the sustainable development goals (SDGs), particularly SDG 3.1 (reduce the global maternal mortality ratio) and SDG 3.2 (end preventable deaths of newborns and children under 5 years).1 Cuts in US funding alone are predicted to contribute to “40-55 million additional unplanned pregnancies and 12-16 million unsafe abortions across 51 countries, and 2.5 million (1.3-4.5) additional child deaths from causes other than HIV and tuberculosis across 24 countries.”2 Preventing these avoidable deaths will require countries dependent on development assistance to increase domestic government spending on sexual and reproductive health and rights (SRHR) to compensate for the funding shortfall.3 LMICs are diverse, but many have tighter fiscal constraints and weaker regulatory and industrial capacity than high income countries, largely because of external factors, including the international fiscal architecture (box 1). This article, part of a BMJ Collection examining the effects of shifts in the multilateral system on SRHR, considers how broader macroeconomic and fiscal trends will constrain LMICs’ capacity to increase government expenditure on health systems and will contribute to increases in avoidable morbidity and mortality, especially among women and children, undermining progress on SRHR. Box 1 ### Definition of financial termsRETURN TO TEXT

Protecting meaningful participation, feminist leadership, and rights based governance amid growing political and financial pressures is essential to sustain gains in sexual and reproductive health, write Jaime M Gher and colleagues Many of the advances made in sexual and reproductive health and rights (SRHR) and justice were not simply granted by states or multilateral institutions. They were built through decades of feminist organising, advocacy, knowledge production, and movement building. Feminist civil society (box 1) helped secure the recognition of sexual and reproductive health as human rights, brought the experiences of affected communities into policymaking spaces, and created mechanisms through which states and institutions could be held accountable for their commitments. These gains are now under growing pressure. Rising authoritarianism, declining confidence in multilateralism, and weakening political commitments to human rights and international cooperation are reshaping the global environment in which SRHR and justice are advanced and protected. While the United Nations (UN) has long provided a critical space for civil society and marginalised communities to promote human rights norms and support accountability, the institution is facing a crisis of confidence and credibility.1 Combined with a $2.4bn funding shortfall,2 this has led to calls for drastic reform to ensure that the UN is “agile, integrated, and better equipped to respond to contemporary global challenges.”3 As the UN system reconfigures, largely through closed door discussions, concerns are mounting that core programming around human rights, gender equality, and SRHR and justice may be deprioritised.4 The UN80 initiative, a system-wide reform process reviewing the UN’s structures, mandates, and use of resources, has included an assessment of a possible merger between UN Women and UN Population Fund (UNFPA).5 Women’s rights and SRHR advocates have warned that such a merger could weaken the visibility and institutional protection of both mandates.6 …

Health and political leaders must seize the opportunity to build lasting systems for governance, financing, and delivery of sexual and reproductive health, rights, and justice Recent cuts to foreign aid1 are hitting sexual and reproductive health particularly hard. Right wing political movements are pressing governments and multilateral institutions to restrict reproductive rights, exacerbating the general retrenchment in bilateral and multilateral health funding.2 Institutions that finance sexual and reproductive health commodities, set standards, and defend related rights are losing money and political support at the same time.3 The BMJ Collection on protecting global sexual and reproductive health and rights is therefore welcome and timely (www.bmj/collections/SRHR). It examines how these disruptions are rolling back decades of progress and identifies new opportunities to mobilise support for sexual and reproductive rights, health, and justice (SRHRJ). Meaningful advances have been made in SRHRJ over recent decades, many of which were enabled by global coordination, including through formal governance mechanisms, donor funding, and sustained civil society action. From 2000 to 2023, global maternal mortality fell 40%.4 Millions more women around the world have access to contraception than they did a decade ago, especially in low and middle income countries,5 partly because of coordinated global financing and market shaping work that …

Amid proposals to restructure the UN and merge UNFPA and UN Women, Clarisa Bencomo and colleagues argue that strong specialised multilateral institutions remain essential for advancing gender equality and sexual and reproductive health and rights For 80 years the United Nations (UN) system has been a venue for advancing the rights of women, girls, and, over time, LGBTQ+ individuals.12 Its support for laws, norms, policies, and programmes to improve gender equality and sexual and reproductive health and rights (SRHR, box 1) directly contributed to global decreases in maternal mortality (40%, 2000-23) and women’s and girls’ AIDS related mortality (58%, 2010-24), and halved the lifetime risk of maternal related death (2020-23).34 The features that helped the UN make progress on SRHR—specialised gender equality and SRHR agencies with complementary mandates; civil society contributions to knowledge production, norm setting, and accountability; and consensus based decision making—are being undermined and those gains reversed. Today’s the UN faces unprecedented crises. Member states owed a record $1.6bn in regular budget dues at the end of 2025, and by May 2026, the UN projected it would run out of money in August if member states didn’t pay up.5 Voluntary development funding is shrinking, and 2026 bilateral aid for health is projected to reach its lowest level in almost two decades, with reproductive and population health hardest hit.6 Anti-rights agendas are gaining ground.7891011 Imposed austerity measures, illicit financial flows, and an emerging debt crisis make women and girls in low and middle income countries especially vulnerable.12 The UN secretary general’s solution to this moment is UN80, a rushed package of restructuring and programmatic cuts. Within UN80, the merger of the UN’s lead gender equality and SRHR agencies, UN Women and the UN Population Fund (UNFPA), promises …

UK maternity care is at a turning point after successive reviews into services locally and nationally. It has the opportunity to tackle the underlying drivers of failures and poor care. Many of these were identified in the recent review of Nottingham University Hospitals NHS Trust.1 They are systemic in nature—racism, lack of governance, failures in leadership, underresourcing, toxic workplace culture—but also clinical. In Nottingham, factors contributing to …

Helen Jones talks to Anand Srivastava, a nephrologist combining medicine, research, and artificial intelligence “At medical school, I was probably one of the few people that really enjoyed learning about fluids and electrolytes,” says Anand Srivastava, associate professor of medicine in the division of nephrology at the University of Illinois Chicago. That interest led him into nephrology, a specialty he was drawn to because of the way kidney disease affects multiple organs. “I really enjoy the complexity of caring for patients that unfortunately have kidney disease,” he says. Srivastava always knew that he wanted to become a doctor. Growing up in north Texas, he developed a love of maths and science and was fascinated by how the body works. “I always felt great empathy for those who were not well, and I just wished that I knew how to make them feel better,” he says. After completing medical school at Saint Louis University in Missouri, he returned to Texas to undertake …

### What you need to know A 71 year old woman presents to the emergency department with 48 hours of pain, erythema, and swelling of the right lower leg. She appears comfortable, is alert and oriented, and can walk independently. Her temperature is 38.3ºC and her other vital signs are normal. She has a history of type 2 diabetes mellitus, hypertension, and venous stasis dermatitis. Her medications include metformin and ramipril. She has no allergies. Cellulitis is a bacterial infection of the skin and subcutaneous tissue.1 The Global Burden of Disease database estimated a global incidence of 54.8 million cases in 2019.2 Between 2016 and 2023, emergency department visits for cellulitis in the US remained stable but admission rates rose from 11.2% to 13.3%.3 Between 1999 and 2020, hospital admissions for skin and soft tissue infections in England and Wales rose by 145%, from 183 to 449 per 100 000 population.4 In this Practice Pointer, we cover the diagnostic approach, differential diagnosis, treatment, and indications for emergency or specialist referral in adults with lower limb cellulitis. Cellulitis is typically a clinical diagnosis. Presentation ranges from uncomplicated (ie, without signs of systemic illness in an immunocompetent patient) to complicated (eg, systemically unwell with fever, persistent tachycardia, tachypnoea, hypotension; or immunosuppressed). ### History Ask about