"Their body is their territory": Reproductive autonomy and governance by omission in Peru.

Abstract

Drawing on 22 in-depth interviews with government officials, civil society leaders, multilateral and community-based actors, we examine how reproductive autonomy is shaped, constrained, and contested within Peru's sexual and reproductive health (SRH) system. The findings point to a cascade of constraints across three levels. At the macro-level, political avoidance, conservative influence, and the enduring legacy of Fujimori-era forced sterilizations have produced sustained silence around SRH, limiting leadership, accountability, and investment. At the meso-level, this silence translates into institutional fragility, including supply shortages, uneven implementation, and weak oversight, which narrow contraceptive choice. At the micro-level, institutional weakness expands provider discretion, allowing moral reasoning, risk aversion, and gendered expectations to shape whether individuals can initiate, change, or discontinue contraception. These constraints are not experienced evenly: adolescents, rural populations, and low-income women are most affected, resulting in reproductive autonomy that is stratified. Participants described ongoing efforts to contest these constraints. Civil society organizations, youth networks, and community actors engage in rights-based education, institutional oversight, strategic litigation, and everyday advocacy. While these efforts do not resolve the underlying political and institutional conditions, they create spaces where reproductive rights can be asserted, defended, and monitored. We conceptualize these dynamics as governance by omission: a mode of reproductive governance in which reproductive autonomy is constrained and shaped through political silence, institutional drift, and expanded discretion, rather than through coercive policies, numerical targets, or formal prohibitions. This framework demonstrates how reproductive autonomy can be legally recognized yet unevenly realized. Furthermore, it highlights that without government presence, autonomy is fragile.