State of World Population 2019 - Unfinished business: the pursuit of rights and choices FOR ALL

Publication date: 2019

UNFINISHED BUSINESS the pursuit of rights and choices FOR ALL state of w orld population 20 19 U N FIN ISH ED BU SIN ESS: the pursuit of rights and choices for all Ensuring rights and choices for all since 1969 United Nations Population Fund 605 Third Avenue New York, NY 10158 +1 (212) 297-5000 www.unfpa.org @UNFPA Printed on recycled paper. Sales No. E.19.III.H.1 E/4,221/2019 ISSN 1020-5195 ISBN 978-0-89714-029-4 Ensuring rights and choices for all since 1969 State of World Population 2019 This report was developed under the auspices of the UNFPA Division of Communications and Strategic Partnerships. EDITOR-IN-CHIEF Arthur Erken, Director, Division of Communications and Strategic Partnerships EDITORIAL TEAM Editor: Richard Kollodge Editorial associate: Katie Madonia Digital edition manager: Katie Madonia Digital edition advisers: Hanno Ranck, Katheline Ruiz Publication and web design: Prographics, Inc. RESEARCH ADVISER AND WRITER Stan Bernstein UNFPA TECHNICAL ADVISERS Elizabeth Benomar Daniel Schensul LEAD RESEARCHER AND WRITER Kathleen Mogelgaard CHAPTER RESEARCHERS AND WRITERS Jeffrey Edmeades Gretchen Luchsinger William A. Ryan Ann M. Starrs FEATURE WRITERS Janet Jensen Gretchen Luchsinger © UNFPA 2019 ACKNOWLEDGMENTS UNFPA thanks the following women for sharing glimpses of their lives for this report: Tefta Shakaj, ALBANIA Mediha Besic, BOSNIA AND HERZEGOVINA Tsitsina Xavante, BRAZIL Say Yang, CAMBODIA Dahab Elsayed and Um Ahmed, EGYPT Alma Odette Chacón, GUATEMALA Marta Paula Sanca, GUINEA-BISSAU Fanie Derismé, HAITI Rajeshwari Mahalingam, INDIA Shara Ranasinghe, SRI LANKA Rasamee, THAILAND Josephine Kasya, UGANDA The editors are grateful to William McGreevey for research on institutional and financing obstacles to sexual and reproductive health and to Christopher Hook for other research assistance. The Population and Development Branch of UNFPA aggregated regional data in the indicators section of this report. Source data for the report’s indicators were provided by the Population Division of the United Nations Department of Economic and Social Affairs, the United Nations Educational, Scientific and Cultural Organization and the World Health Organization. Rachel Snow, Sara Reis and Marielle Sander-Lindstrom from UNFPA also contributed to the shaping of this year’s report. Erin Anastasi, Emilie Filmer-Wilson, Anneka Knutsson and Leyla Sharafi reviewed and commented on drafts. MAPS AND DESIGNATIONS The designations employed and the presentation of material in maps in this report do not imply the expression of any opinion whatsoever on the part of UNFPA concerning the legal status of any country, territory, city or area or its authorities, or concerning the delimitation of its frontiers or boundaries. A dotted line approximately represents the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not been agreed upon by the parties. PHOTOGRAPHY Front cover: © Steve McCurry/Magnum Photos Timeline: © Alamy Stock Photos, Getty Images, Jangbu Sherpa, Warren K. Leffler, NASA, UN/UNFPA UNFINISHED BUSINESS the pursuit of rights and choices FOR ALL 2 Six women, six decades, six journeys Available but inaccessible4 5 The obstacle underlying all others 1 Rights at risk in times of population growth3 6 When services collapse The struggle for rights and choices is an ongoing one Institutions and funding to ensure rights and choices7 8 Realizing rights and choices for all: If not now, when? 9 More than my mother, less than my daughter page 7 page 23 page 37 page 53 page 73 page 87 page 101 page 117 page 137 © Cristina Garcia Rodero/Magnum Photos Remarkable gains have been made in sexual and reproductive health and rights since 1969, when UNFPA was established. But despite progress, hundreds of millions of women today still face economic, social, institutional and other barriers that prevent them from making their own decisions about whether, when, how often and with whom to become pregnant. The pursuit of rights and choices is an ongoing one, with new challenges emerging all the time. FOREWORD Make rights and choices a reality for all It was 1969. World population reached 3.6 billion, up about 1 billion from only 17 years earlier. Fertility rates worldwide then were about double what they are today. In the least developed countries, fertility was about six births per woman. Paul Ehrlich’s The Population Bomb, released the year before, had incited a global panic about “overpopulation,” which the author predicted would lead to mass starvation on a “dying planet.” It was in that context that UNFPA was established to advise developing countries about the social and economic implications of population growth and to support national population programmes, which began dispensing contraceptives on an unprecedented scale. Through these programmes, real reproductive choices became a reality for more and more women in developing countries. And as a result, women started having fewer children. Millions were finally gaining the power to control their own fertility. Despite the increasing availability of contraceptives over the years, hundreds of millions of women today still have no access to them—and to the reproductive choices that come with them. Without access, they lack the power to make decisions about their own bodies, including whether or when to become pregnant. The lack of this power—which influences so many other facets of life, from education to income to safety—leaves women unable to shape their own futures. Since its creation in 1969, UNFPA has led a multilateral effort to help women in developing countries navigate through an ever-changing landscape of barriers to their reproductive rights. This effort gained new momentum and inspiration in 1994, when 179 governments gathered in Cairo for the International Conference on Population and Development and forged a plan for sustainable development grounded in individual rights and choices and the achievement of sexual and reproductive health for all. That plan, embodied in a Programme of Action, not only re-energized the global reproductive rights movement but also positioned UNFPA as the movement’s custodian. The combined actions of civil society, governments, development institutions and UNFPA over the past 50 years have unlocked opportunities and possibilities for women and girls across the globe. Yet, we still have a long way to go before all women and girls have the power and the means to govern their own bodies and make informed decisions about their sexual and reproductive health. At the same time, we must push back against forces that would see us return to a time when women had little say in reproductive decisions or, for that matter, in any area of their lives. The fight for rights and choices must continue until they are a reality for all. Dr. Natalia Kanem United Nations Under-Secretary-General and Executive Director of UNFPA, the United Nations Population Fund 4 © Digby Oldridge/PR Eye Bespoke Photography 1969 1 970 1 9 7 1 1 97 2 1 97 3 1 974 1 97 5 1 976 1 97 7 1 978 1 979 1980 1 9 8 1 1982 1983 1984 1985 1986 1987 1988 1989 1990 1 9 9 1 1 992 1 993 1994 1 995 1996 1 997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2 0 1 1 20 12 20 13 2014 20 15 2016 20 17 2018 2019 © Gilles Peress/Magnum Photos THE STRUGGLE FOR RIGHTS AND CHOICES IS AN ONGOING ONE The year 2019 marks two important milestones in the field of reproductive health: 50 years since UNFPA began operations, and 25 years since the landmark International Conference on Population and Development (ICPD) in Cairo. These two events—the launch of the first United Nations agency dedicat- ed to addressing population growth and the reproductive health needs of the world’s people, and the dec- laration of a global commitment to sexual and reproductive health and reproductive rights—have funda- mentally shaped the lives of women and families, and the societies in which they live, in ways measurable and immeasurable, profound and trivial, permanent and fleeting. Activists, advocates, public health specialists and many others have pushed relentlessly for the trans- formations we see around us today, but much remains to be done. What the future holds in terms of changes in population growth, contraceptive use and sexual and reproductive health and rights will both determine and be determined by the ability of women and girls to achieve their full potential as mem- bers of their societies. And this will be determined, in no small part, by CHAPTER 1 7STATE OF WORLD POPULATION 2019 THE UNITED NATIONS FUND FOR POPULATION ACTIVITIES STARTS OPERATIONS Nuclear Non-Proliferation Treaty goes into force GENERAL ASSEMBLY DESIGNATES UNFPA AS LEAD IN POPULATION PROGRAMMES The United States and Soviet Union join 70 other nations in signing an agreement to ban biological warfare The bridge in Istanbul that crosses the Bosphorus is completed, connecting the continents of Europe and Asia WORLD POPULATION CONFERENCE, BUCHAREST UNITED NATIONS DECLARES OPENING OF DECADE FOR WOMEN ▲ ▲ ▲ ▲ ▲ ▲ ▲ 1969 1970 1971 1972 1973 1974 1975 ▼ ▼ ▼ ▼ ▼ ▼ ▼ The Stonewall riots in New York City mark the start of the modern gay rights movement in the United States First message sent through ARPANET, a precursor to the Internet Neil Armstrong takes his historic first steps on the Moon Biologist Robert Geoffrey Edwards reports having fertilized human oocytes in a Petri dish for the first time USAID Office of Population established Population Council establishes the International Committee for Contraception Research Dalkon Shield IUD goes on the market Sierra Leone becomes a republic Club of Rome releases Limits to Growth THE UNITED NATIONS PROCLAIMS 8 DECEMBER INTERNATIONAL HUMAN RIGHTS DAY The American Psychiatric Association removes homosexuality from its DSM-II Abortion legalized in the United States WORLD POPULATION 4 BILLION India successfully conducts an underground nuclear test Mozambique and Suriname become independent Scientist Andrei Sakharov, creator of Soviet Union’s hydrogen bomb, is awarded Nobel Peace Prize how the world takes forward the achievements and addresses the shortfalls of the ICPD to date. The world in 1969 Fifty years ago around the world, the average woman had 4.9 chil- dren, and 35 per cent of married women were using some form of contraceptive method to delay or prevent pregnancy; in the least developed countries, however, the average woman had 6.7 chil- dren, and about 2 per cent were using a method of contraception. Abortion was illegal in much of the world, and the women’s lib- eration movement was fighting for equality in access to educa- tion, employment opportunities and pay, marriage and divorce, property ownership, and on a range of other fronts. In 1969, the Stonewall Riots in New York 1969 TO2019 ▲ ▲RAFAEL SALAS NAMED UNFPA EXECUTIVE DIRECTOR U N M IL ES TO N ES an d W or ld e ve nt s City marked the start of the global gay rights movement; the United States Agency for International Development established an Office of Population; and Ghana adopted its policy for Population Planning for National Progress and Prosperity. A year earlier, at the first United Nations International Conference on Human Rights, in Tehran, delegates had affirmed, for the first time in a global declara- tion, the basic right of parents “to determine freely and responsibly the number and the spacing of their children” (United Nations, 1968). By 1969, as a result of public health interventions that were reducing infant and child mortality and prolonging life expectancy, birth rates had outstripped mortality rates in much of the developing world. Concerns that the resulting population THE UNITED NATIONS FUND FOR POPULATION ACTIVITIES STARTS OPERATIONS Nuclear Non-Proliferation Treaty goes into force GENERAL ASSEMBLY DESIGNATES UNFPA AS LEAD IN POPULATION PROGRAMMES The United States and Soviet Union join 70 other nations in signing an agreement to ban biological warfare The bridge in Istanbul that crosses the Bosphorus is completed, connecting the continents of Europe and Asia WORLD POPULATION CONFERENCE, BUCHAREST UNITED NATIONS DECLARES OPENING OF DECADE FOR WOMEN ▲ ▲ ▲ ▲ ▲ ▲ ▲ 1969 1970 1971 1972 1973 1974 1975 ▼ ▼ ▼ ▼ ▼ ▼ ▼ The Stonewall riots in New York City mark the start of the modern gay rights movement in the United States First message sent through ARPANET, a precursor to the Internet Neil Armstrong takes his historic first steps on the Moon Biologist Robert Geoffrey Edwards reports having fertilized human oocytes in a Petri dish for the first time USAID Office of Population established Population Council establishes the International Committee for Contraception Research Dalkon Shield IUD goes on the market Sierra Leone becomes a republic Club of Rome releases Limits to Growth THE UNITED NATIONS PROCLAIMS 10 DECEMBER INTERNATIONAL HUMAN RIGHTS DAY The American Psychiatric Association removes homosexuality from its DSM-II Abortion legalized in the United States WORLD POPULATION 4 BILLION India successfully conducts an underground nuclear test Mozambique and Suriname become independent Scientist Andrei Sakharov, creator of Soviet Union’s hydrogen bomb, is awarded Nobel Peace Prize ▲ ▲ 9STATE OF WORLD POPULATION 2019 First known outbreak of Ebola virus UNFPA ISSUES FIRST STATE OF WORLD POPULATION REPORT THE CONVENTION ON THE ELIMINATION OF ALL FORMS OF DISCRIMINATION AGAINST WOMEN (CEDAW) IS ADOPTED UNITED NATIONS ESTABLISHES POPULATION AWARD Sally Ride becomes the first woman in space aboard Space Shuttle Challenger ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ 1976 1977 1978 1979 1980 1981 1982 1983 ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ Egyptian President Anwar Sadat makes an official visit to Israel First test tube baby born First International Year of the Child Global eradication of smallpox certified by the World Health Organization Sandra Day O'Connor takes her seat as the first female justice of the US Supreme Court China's population tops 1 billion IBM puts its first personal computer on the market, launching operating systems by Microsoft Doctors perform the first implant of a permanent artificial heart designed by Robert Jarvik Time magazine's Man of the Year is given for the first time to a non-human, the computer Retrovirus that causes AIDS discovered Famine in Ethiopia growth could harm economic progress and the environment contributed to the desire to better understand and manage human fertility. The establishment of the United Nations Fund for Population Activities, renamed the United Nations Population Fund in 1987, reflected a growing interest in understanding how population dynamics affected social and economic development, and a desire on the part of the United Nations to support action programmes aimed at stabilizing the world’s population. The expanding availability of relatively new and effective contra- ceptive methods during the 1960s was transformational for women, offering them, for the first time, the ability to reliably prevent unin- tended pregnancy and new choices in controlling their reproductive THE STATE OF THE WORLD POPULATION 1978 ▲ ▲ 10 CHAPTER 1 First known outbreak of Ebola virus UNFPA ISSUES FIRST STATE OF WORLD POPULATION REPORT THE CONVENTION ON THE ELIMINATION OF ALL FORMS OF DISCRIMINATION AGAINST WOMEN (CEDAW) IS ADOPTED UNITED NATIONS ESTABLISHES POPULATION AWARD Sally Ride becomes the first woman in space aboard Space Shuttle Challenger ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ 1976 1977 1978 1979 1980 1981 1982 1983 ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ Egyptian President Anwar Sadat makes an official visit to Israel First test tube baby born First International Year of the Child Global eradication of smallpox certified by the World Health Organization Sandra Day O'Connor takes her seat as the first female justice of the US Supreme Court China's population tops 1 billion IBM puts its first personal computer on the market, launching operating systems by Microsoft Doctors perform the first implant of a permanent artificial heart designed by Robert Jarvik Time magazine's Man of the Year is given for the first time to a non-human, the computer Retrovirus that causes AIDS discovered Famine in Ethiopia lives. But the implications of con- traception and fertility regulation for the health, well-being and eco- nomic and social lives of individual women and girls were only begin- ning to be understood. A fuller realization of what they would mean was still to come. The world in 1994 Twenty-five years ago, when the ICPD was held in Cairo, the aver- age global fertility rate was about three births per woman, and 58.8 per cent of women worldwide were using contraception; in the least developed countries, fertility was about 5.6 children, and 20.2 per cent of married women were using contraception. South Africa held its first multiracial elections and elect- ed Nelson Mandela as President; the Rwandan genocide resulted in the deaths of more than 800,000 men, women and children; civil 11STATE OF WORLD POPULATION 2019 INTERNATIONAL POPULATION CONFERENCE, MEXICO CITY Schengen Agreement reached by five member States of the European Economic Community Space Shuttle Challenger disintegrates, killing its crew of seven DR. NAFIS SADIK NAMED UNFPA EXECUTIVE DIRECTOR UNFPA NAME CHANGES TO UNITED NATIONS POPULATION FUND First World AIDS Day marked on 1 December Nelson Mandela is released from Victor Verster Prison Democratic People’s Republic of Korea and the Republic of Korea, Estonia, Latvia, Lithuania, the Marshall Islands and Micronesia join the United Nations ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ 1984 1985 1986 1987 1988 1989 1990 1991 1992 ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ First embryo transfer from one woman to another, resulting in a live birth The US Food and Drug Administration approves a blood test for HIV South Africa ends its ban on interracial marriages Corazon Aquino becomes the first Filipina woman president First child born to a non-related surrogate mother Black Monday—stock markets plunge on Wall Street and around the world WORLD POPULATION 5 BILLION Safe Motherhood Initiative launched Berlin Wall is opened Namibia becomes independent Destruction of Berlin Wall begins Croatia and Slovenia declare independence from Yugoslavia; the Balkans war begins The Soviet Union dissolves Peace accord in Mozambique unions between same-sex partners were legalized in Sweden; and the launch of America Online, or AOL, marked the beginning of easy access to the Internet. The years preceding the ICPD saw a gradual and accelerating shift: from a primary focus on population issues and fertility reduction to one grounded in the rights of individuals and couples to prevent or delay pregnancy and attain sexual and reproductive health. This shift was largely driven by fem- inists and advocates for sexual and reproductive health and rights, and was, in part, a response to the abus- es that resulted from target-driven “population control” policies of the past. In the 1970s and 1980s, with funding and encouragement from wealthy donor countries and foun- dations, some countries had rolled out programmes that coerced or forced couples to use contraception ▲ ▲ INTERNATIONAL POPULATION CONFERENCE, MEXICO CITY Schengen Agreement reached by five member States of the European Economic Community Space Shuttle Challenger disintegrates, killing its crew of seven DR. NAFIS SADIK NAMED UNFPA EXECUTIVE DIRECTOR UNFPA NAME CHANGES TO UNITED NATIONS POPULATION FUND First World AIDS Day marked on 1 December Nelson Mandela is released from Victor Verster Prison Democratic People’s Republic of Korea and the Republic of Korea, Estonia, Latvia, Lithuania, the Marshall Islands and Micronesia join the United Nations ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ 1984 1985 1986 1987 1988 1989 1990 1991 1992 ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ First embryo transfer from one woman to another, resulting in a live birth The US Food and Drug Administration approves a blood test for HIV South Africa ends its ban on interracial marriages Corazon Aquino becomes the first Filipina woman president First child born to a non-related surrogate mother Black Monday—stock markets plunge on Wall Street and around the world WORLD POPULATION 5 BILLION Safe Motherhood Initiative launched Berlin Wall is opened Namibia becomes independent Destruction of Berlin Wall begins Croatia and Slovenia declare independence from Yugoslavia; the Balkans war begins The Soviet Union dissolves Peace accord in Mozambique or limit their family size, or provid- ed monetary or other incentives to convince them to do so. The ICPD Programme of Action adopted by 179 governments called explicitly for dropping demographic and fertility-control targets from national population and family planning programmes. While still acknowledging that population dynamics merited consideration in policymaking, the Programme of Action issued a clarion call to place women’s needs and rights at the centre of population and development policies. What the world needed, governments agreed, was to provide women, couples and families with access to a range of sexual and reproductive health interventions, and to realize social and economic changes that would empower women, respect their rights, and 13STATE OF WORLD POPULATION 2019 help move the world towards gender equality. Advances and setbacks since 1994 The ICPD consensus was a turning point, and a transformative victory for the reproductive rights movement. By placing individual rights and well-being at the centre of the reproductive health agenda, it set in motion a number of shifts: in research, to explore the factors that influence individual choices and behaviour in relation to contraceptive use or non-use and fertility; in communication, to inform and educate women, men and decision makers about the health, economic and social benefits of reducing fertility and preventing unintended pregnancies; and in service delivery, to underscore the importance of providing a full range of contraceptive methods and ensuring choices for all women. UNITED NATIONS WORLD CONFERENCE ON HUMAN RIGHTS INTERNATIONAL CONFERENCE ON POPULATION AND DEVELOPMENT, CAIRO THE UNITED NATIONS FOURTH WORLD CONFERENCE ON WOMEN Ghanaian diplomat Kofi Annan is elected as Secretary-General of the United Nations Divorce becomes legal in the Republic of Ireland Cathy O’Dowd, a South African mountaineer, becomes the first woman to summit Mount Everest from both the north and south sides MILLENNIUM DEVELOPMENT GOALS ADOPTED THORAYA AHMED OBAID NAMED UNFPA EXECUTIVE DIRECTOR ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ 1993 1994 1995 1996 1997 1998 1999 2000 2001 ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ The World Health Organization declares tuberculosis a global emergency The Rwandan genocide In South Africa, Nelson Mandela is inaugurated president More than 170 countries agree to extend the Nuclear Non-Proliferation Treaty indefinitely and without conditions The Dayton Agreement is signed in Paris to end war in Bosnia The Ebola virus kills 244 in Zaire The Bosnian government declares the end of the Siege of Sarajevo Dolly the sheep, the first mammal to be successfully cloned from an adult cell, is born The US House of Representatives forwards articles of impeachment against President Clinton to the US Senate WORLD POPULATION 6 BILLION Historic summit of leaders of the Republic of Korea and the Democratic People’s Republic of Korea The world's first self- contained artificial heart is implanted in Robert Tools in the United States September 11 attacks at the World Trade Center in New York City ▲▲▲ 14 CHAPTER 1 The ICPD also recognized that a woman’s sexual and reproductive health and well-being encompass not only her access to, and use of, contraception, but many other factors as well: her ability to prevent and manage the complications of unsafe abortion; her capacity to avoid or treat sexually transmitted infections, including HIV; and the care she receives during pregnancy and childbirth. Prevention and management of infertility and reproductive tract cancers were also defined as part of sexual and reproductive health. The reproductive health needs of adolescents, the ICPD Programme of Action acknowledged, had been largely ignored by existing services. While the ICPD consensus called for special efforts to address these needs, opposition to the provision of comprehensive sexuality education and reproductive health services to adolescents, and disagreements on the issue of parental approval, UNITED NATIONS WORLD CONFERENCE ON HUMAN RIGHTS INTERNATIONAL CONFERENCE ON POPULATION AND DEVELOPMENT, CAIRO THE UNITED NATIONS FOURTH WORLD CONFERENCE ON WOMEN Ghanaian diplomat Kofi Annan is elected as Secretary-General of the United Nations Divorce becomes legal in the Republic of Ireland Cathy O’Dowd, a South African mountaineer, becomes the first woman to summit Mount Everest from both the north and south sides MILLENNIUM DEVELOPMENT GOALS ADOPTED THORAYA AHMED OBAID NAMED UNFPA EXECUTIVE DIRECTOR ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ 1993 1994 1995 1996 1997 1998 1999 2000 2001 ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ The World Health Organization declares tuberculosis a global emergency The Rwandan genocide In South Africa, Nelson Mandela is inaugurated president More than 170 countries agree to extend the Nuclear Non-Proliferation Treaty indefinitely and without conditions The Dayton Agreement is signed in Paris to end war in Bosnia The Ebola virus kills 244 in Zaire The Bosnian government declares the end of the Siege of Sarajevo Dolly the sheep, the first mammal to be successfully cloned from an adult cell, is born The US House of Representatives forwards articles of impeachment against President Clinton to the US Senate WORLD POPULATION 6 BILLION Historic summit of leaders of the Republic of Korea and the Democratic People’s Republic of Korea The world's first self- contained artificial heart is implanted in Robert Tools in the United States September 11 attacks at the World Trade Center in New York City ▲ ▲ ▲ led to convoluted language in the document and, in some cases, to convoluted policies on the ground. The ICPD coincided with the crest of another public health and rights crisis: the HIV/AIDS epidemic. As concern and activism about the enormous implications of HIV and AIDS ballooned, some donors increased attention and funding to addressing the pandemic and its impact on people, communities and nations, while funding for other aspects of sexual and reproductive health remained mostly stagnant. Some observers feared that the ICPD’s emphasis on individual choice and women’s empowerment would not resonate with donors and governments, and that by moving away from a focus on population growth, the community was compromising its ability to mobilize resources and political commitment. Despite such concerns, the ICPD framework held. The commitment The Organisation of African Unity is disbanded and replaced by the African Union Brazil launches its first rocket into space TARGET TO ACHIEVE UNIVERSAL ACCESS TO REPRODUCTIVE HEALTH APPROVED FOR INCLUSION IN MILLENNIUM DEVELOPMENT GOALS UNITED NATIONS GENERAL ASSEMBLY VOTES TO ESTABLISH THE UNITED NATIONS HUMAN RIGHTS COUNCIL UNFPA LAUNCHES GLOBAL PROGRAMME TO ENHANCE REPRODUCTIVE HEALTH COMMODITY SECURITY Surgeons at London’s Moorfields Eye Hospital perform the first successful operations using bionic eyes, implanting them into two blind patients Bolivia declares the right of indigenous people to govern themselves ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ 2002 2003 2004 2005 2006 2007 2008 2009 ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ The Euro is officially introduced in Eurozone countries EARTH SUMMIT 2002 The Human Genome Project is completed, with 99 per cent of the human genome sequenced to 99.9 per cent accuracy European heads of State sign the Treaty and Final Act, establishing the first European Constitution Angela Merkel, 51, becomes Germany's first female chancellor, and its youngest Ellen Johnson Sirleaf becomes first democratically elected female head of State in Africa Michelle Bachelet is sworn in as Chile's first female president South Africa's parliament passes a law that legalizes same-sex marriage UNITED NATIONS GENERAL ASSEMBLY ADOPTS THE DECLARATION ON THE RIGHTS OF INDIGENOUS PEOPLES The morning-after pill approved by US Food and Drug Administration for use by 17-year-olds 16 CHAPTER 1 to universal access to sexual and reproductive health was reaffirmed in 1999 at the ICPD five-year review meeting, where supporters eked out advances on a few key elements, including adolescent sexual and reproductive health, and access to safe abortion where legal, in the face of fierce opposition. In 2000, however, when the United Nations adopted the Millennium Development Goals (MDGs) setting out global aims and targets for the next 15 years, reproductive health was nowhere to be seen. Perhaps responding to the length and contentiousness of the negotiations at the Fourth World Conference for Women in 1995 and at the ICPD five-year review meeting in 1999, the officials in charge of writing the MDGs opted instead to define a goal on “improving maternal health.” Not until 2005 did the sexual and reproductive health community succeed in its quest to add universal The Organisation of African Unity is disbanded and replaced by the African Union Brazil launches its first rocket into space TARGET TO ACHIEVE UNIVERSAL ACCESS TO REPRODUCTIVE HEALTH APPROVED FOR INCLUSION IN MILLENNIUM DEVELOPMENT GOALS UNITED NATIONS GENERAL ASSEMBLY VOTES TO ESTABLISH THE UNITED NATIONS HUMAN RIGHTS COUNCIL UNFPA LAUNCHES GLOBAL PROGRAMME TO ENHANCE REPRODUCTIVE HEALTH COMMODITY SECURITY Surgeons at London’s Moorfields Eye Hospital perform the first successful operations using bionic eyes, implanting them into two blind patients Bolivia declares the right of indigenous people to govern themselves ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ 2002 2003 2004 2005 2006 2007 2008 2009 ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ The Euro is officially introduced in Eurozone countries EARTH SUMMIT 2002 The Human Genome Project is completed, with 99 per cent of the human genome sequenced to 99.9 per cent accuracy European heads of State sign the Treaty and Final Act, establishing the first European Constitution Angela Merkel, 51, becomes Germany's first female chancellor, and its youngest Ellen Johnson Sirleaf becomes first democratically elected female head of State in Africa Michelle Bachelet is sworn in as Chile's first female president South Africa's parliament passes a law that legalizes same-sex marriage UNITED NATIONS GENERAL ASSEMBLY ADOPTS THE DECLARATION ON THE RIGHTS OF INDIGENOUS PEOPLES The morning-after pill approved by US Food and Drug Administration for use by 17-year-olds 1 The Global Programme to Enhance Reproductive Health Commodity Security 17STATE OF WORLD POPULATION 2019 access to sexual and reproductive health as a target under the maternal health goal. The initial omission of sexu- al and reproductive health from the MDGs contributed to the perception that the issue was con- tentious and problematic, and therefore easier to ignore, at least in global discussions and negoti- ations. Despite frequently being set aside by the global community, funding and visibility for family planning continued, and at times surged, receiving a strong boost in July 2012 from a global Family Planning Summit, which mobilized major new donor and political commitments and reinvigorated the family planning community. A new paradigm: 2015 and the Sustainable Development Goals In September 2015, 193 gov- ernments adopted a new global framework to succeed the MDGs. DR. BABATUNDE OSOTIMEHIN NAMED UNFPA EXECUTIVE DIRECTOR GENERAL ASSEMBLY ADOPTS RESOLUTION ON PREVENTING FEMALE GENITAL MUTILATION COMMISSION ON THE STATUS OF WOMEN CALLS ON STATES TO END THE PRACTICE OF CHILD, EARLY AND FORCED MARRIAGE 20-YEAR REVIEW OF PROGRESS IMPLEMENTING ICPD PROGRAMME OF ACTION SUSTAINABLE DEVELOPMENT GOALS ADOPTED, INCLUDING UNIVERSAL ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH CARE AND SERVICES World Health Organization announces an outbreak of the Zika virus ▲ ▲ ▲ ▲ ▲ ▲ ▲ 2010 2011 2012 2013 2014 2015 2016 ▼ ▼ ▼ ▼ ▼ ▼ ▼ World Health Organization declares the H1N1 influenza pandemic over WORLD POPULATION 7 BILLION The Syrian civil war begins Typhoon Bopha hits the Philippines Beijing’s level of air pollution is declared to be hazardous to human health Ebola epidemic in West Africa infects at least 28,616 people and kills at least 11,310 people 276 girls and women in Nigeria are abducted and held hostage World leaders gather in Paris for historic climate change talks 18 CHAPTER 1 Reflecting the expanded scope of the agenda and the growing complexity of the challenges to be addressed, the 2030 Agenda for Sustainable Development includes 17 Sustainable Development Goals (SDGs) with 169 targets. While the number and proportion of people living in poverty declined between 2000 and 2015, eliminating poverty remains the over- riding aim of the new global agenda. But there are new aspects to old challenges, as well as new challeng- es, that are explicitly acknowledged and targeted in the SDGs. These include climate change and envi- ronmental fragility; a growing number of intractable humanitarian and political crises, and a conse- quent increase in the number of people living in fragile and unstable settings; and a greater emphasis on the need for domestic financing as well as development aid to build resilience, expand capacity and establish the basis for sustainable economic and social progress. DR. BABATUNDE OSOTIMEHIN NAMED UNFPA EXECUTIVE DIRECTOR GENERAL ASSEMBLY ADOPTS RESOLUTION ON PREVENTING FEMALE GENITAL MUTILATION COMMISSION ON THE STATUS OF WOMEN CALLS ON STATES TO END THE PRACTICE OF CHILD, EARLY AND FORCED MARRIAGE 20-YEAR REVIEW OF PROGRESS IMPLEMENTING ICPD PROGRAMME OF ACTION SUSTAINABLE DEVELOPMENT GOALS ADOPTED, INCLUDING UNIVERSAL ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH CARE AND SERVICES World Health Organization announces an outbreak of the Zika virus ▲ ▲ ▲ ▲ ▲ ▲ ▲ 2010 2011 2012 2013 2014 2015 2016 ▼ ▼ ▼ ▼ ▼ ▼ ▼ World Health Organization declares the H1N1 influenza pandemic over WORLD POPULATION 7 BILLION The Syrian civil war begins Typhoon Bopha hits the Philippines Beijing’s level of air pollution is declared to be hazardous to human health Ebola epidemic in West Africa infects at least 28,616 people and kills at least 11,310 people 276 girls and women in Nigeria are abducted and held hostage World leaders gather in Paris for historic climate change talks 19STATE OF WORLD POPULATION 2019 Unlike the MDGs, the SDGs explicitly recognize sexual and reproductive health as essential to equitable development and women’s empowerment, referencing sexual and reproductive health under SDG 3, for health, and again under SDG 5, for gender equality, which also references reproductive rights. As was the case with the ICPD and the MDGs, however, the SDGs do not acknowledge sexual rights. Other central elements of sexual and reproductive health, including maternal and newborn mortality and HIV, were addressed under targets for SDG 3, and gender-based violence and harmful practices under targets for SDG 5. The SDGs also call for achieving universal health coverage, specifically by ensuring access to quality essential health-care services and to safe, effective and affordable medicines and vaccines for all. Overall, the SDGs advance an agenda for all people, as the ICPD continues to do, while emphasizing DR. NATALIA KANEM APPOINTED UNFPA EXECUTIVE DIRECTOR UNFPA TURNS 50 ▲ ▲ ▲ 2017 2018 2019 ▼ ▼ ▼ Millions of people in 168 countries join the Women's March The United Nations warns that 20 million people are at risk of starvation and famine in Yemen, Somalia, South Sudan and Nigeria Global Conference on Primary Health Care declares central role for sexual and reproductive health 25TH ANNIVERSARY OF THE ICPD 25 International Conference on Population and Development ICPD 20 CHAPTER 1 the importance of equity and addressing the needs of the most vulnerable. Over the past 25 years, in various review meetings and processes related to the ICPD, some regions of the world have called for recognition of sexual rights. A number of current definitions of sexual rights, including those presented in the 2018 report of the Guttmacher-Lancet Commission on sexual and reproductive health and rights, and by the World Health Organization, encompass the rights of people to express their individual sexuality; the rights of adolescents to receive comprehensive sexuality education and sexual and reproductive health services; and the rights of women and girls to be free of gender- based violence and coercion. These rights have been recognized and endorsed by civil society organizations around the world, and acknowledged in various regional documents negotiated and endorsed by governments. No consensus on these rights, however, has been reached by all the Member States of the United Nations in any globally negotiated document. 2019 and beyond UNFPA’s 50th anniversary and ICPD’s 25th anniversary present a unique opportunity for the global community to build on the ICPD framework and fully commit to realizing a visionary agenda for Millions of women in India join hands to form a 385-mile wall to protest inequality, 2019. © Babus Panachmoodu sexual and reproductive health and rights, and to reaching those who have been left behind. This agenda must pay attention to population dynamics, recognize the diverse challenges faced by different countries at various stages of development, and ground policies and programmes in respect for, and fulfilment of, human rights and the dignity of the individual. There is enormous momentum around efforts to achieve the SDGs, including a renewed commitment to “health for all,” explicitly recognizing that every human being has a fundamental right to the enjoyment of the highest attainable standard of health, without distinction. The Every Woman Every Child movement, launched by former United Nations Secretary-General Ban Ki-moon in 2010 and now led by Secretary- General António Guterres, brings concerted attention and effort to the SDGs and universal health coverage as they relate to women, girls and adolescents, with sexual and reproductive health and rights as one of its key focus areas. The pursuit of rights and choices for all is an ongoing one, with new challenges emerging all the time. Over the years, the nature and scope of these obstacles may have changed, but the international community’s commitment to overcoming them remains strong. 21STATE OF WORLD POPULATION 2019 © UNFPA/R. Anis SIX WOMEN, SIX DECADES, SIX JOURNEYS Six women who were 10 years old in 1969, when UNFPA was established, and 35 at the time of the International Conference on Population and Development, reflect on marriage, work and family. Did they have the freedom to choose their own paths and shape their own futures? CHAPTER 2 23STATE OF WORLD POPULATION 2019 Choices were limited Dahab Elsayed, 60, lives in a marginal neighbourhood of Cairo. She vaguely remembers the excitement in her city when the International Conference on Population and Development (ICPD) took place. But because she was busy working and caring for her family back then, details about the conference and its impact eluded her. But some of the shifts in attitudes about women and girls she witnessed later in life can be traced to the ICPD, which acknowledged that fulfilling the rights of girls and women, especially their sexual and reproductive choices, is central to development. As a girl, growing up in a poor rural family of 15, Dahab’s choices were limited, and even an education was out of reach. “There were no opportunities other than marriage—it was the only future I could foresee,” she says. Dahab recalls the day that a woman came to her house and cut her genitals. Dahab had no idea what was happening, but recalls the pain, the blood, and the powder that was applied © UNFPA/R. Anis “There were no opportunities other than marriage—it was the only future I could foresee.” Dahab 24 CHAPTER 2 to staunch the bleeding. She remembers staying in bed for 15 days to heal. But when she grew older and started a family of her own, she had her own daughter’s genitals cut. “It [female genital mutilation] was a must,” Dahab says. Her in-laws insisted on it. Marriage prospects depended on it. All the girls were cut back then. She now believes it is wrong to be subjected to this practice, and her granddaughter has been spared. “Now it is not preferable,” says Dahab, who learned from a television campaign about the harm female genital mutilation causes, and the fact that the procedure is now illegal. Dahab had four children in quick succession soon after her marriage. Faced with poverty, and her husband’s declining health, the couple decided they had enough children. Because she always did odd jobs—cleaning, laundry, caretaking—she never had health insurance to pay for contraception. But intrauterine devices were subsidized in Egypt, so she started using one. Her husband, an upholsterer, died 20 years ago. Since then, it has been increasingly difficult for her to make ends meet. Three of her children have medical conditions that prevent them from working. To help support them, and herself, she works at two jobs during the day and cares for an older person at night. She rarely even goes home. Much as she would like to learn to read and write, if she had more time, she would probably use it to earn more money. Soon she will receive a small government pension, but it will not be enough to support her, so she will continue to work. “Women are the ones that work and get the money for the family,” she says matter-of-factly. As Dahab and other 60-year- olds share glimpses of their lives, their dreams and struggles, it becomes apparent how deeply the political and economic circumstances they were born into delineated the course of their lives. Although real choices and options were limited, most of the women found ways to navigate within them, carving out meaningful lives. © UNFPA/R. Anis After giving birth to two children through caesarean sections, she was told that future deliveries would have to be caesareans as well, and the cost would have been more than her family could have afforded, so she decided to have a tubal ligation. She had already had CHAPTER 2 The lives and experiences of the women turned out to be very different from what each had envisioned for herself at age 10. Sometimes aspirations were circumscribed by the limited roles that seemed available to females at the time. Other times, they were thwarted by social upheaval. Some lives took unexpected turns, and were successful in ways their 10-year-old selves could not have imagined. But across their disparate journeys, common threads emerge, many of them directly related to the mandate and work of UNFPA. Facing a world of limited horizons Rajeshwari Mahalingam recalls enjoying school in the Indian State of Tamil Nadu, where she was known for her beautiful long curly hair and her participation in dance performances. But no one ever asked her about her dreams or what she would like to do in the future. When she did think about it, her possible roles seemed limited: homemaker, medical worker, teacher. She entered into an arranged marriage at age 25. She was obliged to wait until all seven of her older siblings were married and her parents were able to find an appropriate match, one that did not require an exorbitant dowry. © UNFPA/S. Clicks 26 “I enjoyed motherhood more than anything else.” Rajeshwari to sell some of her gold jewellery to pay for the delivery of her second child, a daughter. Most of her friends at that time were having smaller families. They were influenced by family planning campaigns, Rajeshwari says, recalling the popular slogan: “A planned family is a happy family.” She devoted most of her life to caring for her family, although she did take in and care for other children for extra money when times were tough. She invested most of her energy and her dreams in her two children, who are now both college- educated and successful. “I told © UNFPA/S. Clicks © UNFPA/Stormy Clicks them stories and read books with emphasis on service and being honest human beings. I longed to see them grow and reach higher,” she says. “I enjoyed motherhood more than anything else. A woman is the light of the house,” Rajeshwari says. “A woman contributes to the family, in that way, to the community, country and world.” Over her lifetime, Rajeshwari witnessed big changes in the expectations and possibilities for young women. Before she was married, she was afraid to do much outside the home—her parents did not approve. But her sister, just five years her junior, enjoyed a © UNFPA/Stormy Clicks greater sense of personal freedom, which allowed her to become a social activist, achieve a master’s degree, and work professionally on women’s issues. From deprivation to political action As a 10-year-old in Uganda, Josephine Kasya admired her teachers: “They were the smartest people—and I said I will become a teacher. Also my dad was a teacher, and I liked him so much. I said, ‘I want to be like my dad.’” But when Josephine was 12, Idi Amin seized power in her country, and years of instability, deprivation and violence followed. Her dream of becoming a teacher never materialized. After a civil war that ended in 1986, so much of her community was destroyed or lost that she and her new husband, a social worker, moved to his somewhat remote homeland in a verdant, southern part of the country. While less affected by the war, her new community lacked the social infrastructure she was used to. “Life became very different and difficult,” she says of that period © UNFPA/M. Mugisha early in her marriage, during which she raised six children, fetched water from a source a kilometre and a half away, and tended her cows. “I managed to sell some milk to get a little money to buy a few things at home.” But she does not regret those early struggles, she says, because they galvanized her into action. “It is out of that rural set-up that I started convincing women to come together and pool their resources.” There too she learned how to partner with other organizations to get things done. Her leadership skills were noticed, and she was elected to lead, first at a more local level, and later, in 2001, as the Chairperson of “I demystified the idea that the position was entirely for males and paved the way for other women to take on similar positions in other districts.” Josephine © UNFPA/M. Mugisha 28 CHAPTER 2 a district comprising 250,000 people. Throughout her political career, she has championed community development, education for girls and gender equality, focusing on being a voice for rural women. She became the first woman District Chairperson in Uganda. “I demystified the idea that the position was entirely for males and paved the way for other women to take on similar positions in other districts,” she says proudly, adding that in her district a number of other women have taken on decision-making roles. When war subverts choices Say Yang dreamed of going to a good school, studying hard to fulfil her wish to become a teacher. But her dream evaporated when she was 16: soldiers appeared in her community, firing in the air and shouting. She was separated from her family and forced to do backbreaking work. “War destroyed everything,” she says. “Even my dreams. Indeed, I didn’t dare make a dream. During a war, people don’t have to marry someone whose name she did not even know in a large collective ceremony. As their names were called out, each couple came forward. They held even a choice to choose. They do whatever they can to survive.” In Cambodia, when personal freedoms were curtailed under the Khmer Rouge, Yang was forced “During a war, people don’t have even a choice to choose. They do whatever they can to survive.” Yang © UNFPA/M. Kasztelan 29STATE OF WORLD POPULATION 2019 hands and promised to live as husband and wife. Initially, and for several months, she and her husband were so shy that they rarely dared to look directly at or talk to each other. When rule by the Khmer Rouge ended, Yang and her husband travelled back to her home town to live with her mother. Between 1981 and 1988, she delivered five children, with one dying in infancy and another at age 13. After learning from a neighbour that the hospital in the next town would perform a tubal ligation, she made the arduous and somewhat perilous journey to take advantage of it. One day in Cambodia, Yang got the good news that she was invited to enrol in teacher training. “However, I just could not make it. I had a child to look after and housework to handle from day to day. I let my husband go instead. We had to balance between family and society.” Championing the rights of women Until Alma Odette Chacón was 14 years old, she led a relatively uneventful, happy life as the eldest of six children in a family in Guatemala City. Her parents prized education and sent the children to a Jesuit school. When she thought about the future, Alma imagined being a teacher like her mother, or an accountant like her father. What she knew for sure was that she wanted to help others. Her life changed abruptly the night her mother went to the hospital to deliver her seventh child. She never returned. Even though all her mother’s prior deliveries had been normal, this time something went wrong. Alma’s world fell apart. “It was very difficult,” she says. “Suddenly you are missing the key piece of the family, with each person going his or her own way.” Before her mother’s death, Alma had always been at the top of her class, but now couldn’t keep up her good grades. Her father was absent much of the time, and eventually her © UNFPA/M. Kasztelan 30 CHAPTER 2 stepmother threw her out of the house. A year after Alma’s mother died, a 7.5 magnitude earthquake killed or injured 100,000 people near Guatemala City and displaced more than 1 million. Sensitive to “Women now clearly know they have rights and they should be able to decide what goes on with their bodies.” Alma © UNFPA/Rizzo Producciones the plight of the dislocated, Alma found herself helping survivors. Soon after, she was sponsored by her school to spend a month teaching in an indigenous Quiché community. Those two experiences dealing with marginalized and suffering people—mostly indigenous women—were central to her lifelong commitment to social justice, she says. In her 20s, fearing arrest for her involvement in politics, she left Guatemala for Mexico, where she sought training in communications. There, she saw a freer way of living and was exposed to feminist ideas. To support herself, she worked in a variety of jobs: cleaning, production assistant and secretary to a centre for human rights, among other things. 31STATE OF WORLD POPULATION 2019 In the mid-1990s, Alma travelled around Central America and helped organize a regional meeting on the rights of women. This work galvanized her engagement in the women’s movement and her understanding of sexual and reproductive health and rights as a central lever to broader development. She is again living in Guatemala and has worked for several decades now with Terra Viva, a non-profit organization that addresses these issues. Through this lens, she sees big changes in the attitudes of women, especially in indigenous communities: “Women now clearly know they have rights and they should be able to decide what goes on with their bodies.” A lifetime of helping others Tefta Shakaj always wanted to study at university to become a doctor, but that was not an option for her in Albania when she was a teenager. “We were obliged to do what we were told,” she says. After completing secondary school, however, she did get an opportunity that changed the course of her life: a one-year study programme to become a nurse midwife. After her training, Tefta was assigned to a remote village that lacked medical facilities, personnel and supplies. Life there was tough on many levels. But she loved caring for newborns and mothers and served with passion— delivering babies, providing antenatal care, attending to young children in a paediatric ward. “I have helped a lot because many deliveries took place at home— there were not many centres. I am happy I helped so many women.” In the early 1990s, following the fall of Albania’s communist regime, she lived through chaos and shortages of everything, she says. She married and had two children, but would have had more if there had not been so much economic uncertainty at the time. Then, too, her husband got sick, and they © UNFPA/Rizzo Producciones © UNFPA/G. Banaj CHAPTER 232 needed money for medical services. Unable to access contraceptives, she became pregnant, and like many women of that era in Eastern Europe, she had an abortion. There was a positive side to the turmoil of the early 1990s, she says: it spurred an exodus of Albanians to Italy and Greece, exposing people to new ideas and ways of doing things. From those who left Albania, “we started to see another world and other perspectives,” she says. “Before that we had only heard that everything outside Albania was bad.” “I am happy I helped so many women.” Tefta © UNFPA/G. Banaj Life is improving in Albania, Tefta says, and she believes that her own daughters and grandchildren will have more choices and opportunities than she had. For one thing, contraceptives are now widely available and free. And for another, her younger daughter has chosen to become a police officer—a sign that old notions of gender equality are changing. The lives they lived All six women are remarkable in the impact they have had on others, whether in their own families or in a wider sphere. But when their lives are viewed across a span of six decades it is also clear the extent to which the women, several of them powerful agents of change in their own families or communities, were also very much affected by larger social, political and economic forces. Compromises were made; aspirations thwarted. Dahab continues to toil at three jobs, but she says she has accepted her life, and feels content. Rajeshwari’s early love of dance has transformed into her training in a rigorous form of yoga. Her unlived dreams for education are being fulfilled through her children. Although Yang says her dreams died with the violence she endured during wartime, her close family relationships are central to her life. In addition to caring for her four grandchildren and, from time to time, her ageing mother, © UNFPA/M. Kasztelan© UNFPA/R. Anis © UNFPA/Stormy Clicks 34 CHAPTER 2 she recently started up a family laundry business. Alma continues to find meaning and purpose in her work on women’s empowerment, with no plans to retire soon. “There is more to come,” she says. Tefta, who has been struggling with cancer, is determined to see her granddaughter grow up and to stay engaged in life. “I won’t let the tumour get the best of me,” she says. “I’ll continue to help as long as I have energy.” And Josephine in Uganda intends to run for one more term—her fifth—before retiring from public office. But she is not planning to stop doing what she loves. “As years go by, I’m not as strong as I used to be. But I’m very passionate about baking and am planning to train a group of women so they can bake and sell bread.” © UNFPA/Rizzo Producciones © UNFPA/G. Banaj © UNFPA/M. Mugisha Upbeat population image still searching © UNFPA/Photographer © UN Photo/ILO 37STATE OF WORLD POPULATION 2019 CHAPTER 3 And by 1969, earlier advances in medical technology, along with stronger public health systems, better nutrition and sanitation, and a global commitment to ending the scourge of infant and child mortality, had started paying off. Worldwide, child death rates plummeted from 215 deaths per 1,000 live births in 1950 to under 160 per 1,000 just 19 years later (United Nations, 2017). Other medical advances were helping people to live longer. Worldwide, life expectancy in 1969 was about 55 years, up from 47 years in 1950. Improved child survival rates and longer lives transformed the human condition. But when combined with a global average fertility rate of about five births per woman, they also changed the world’s population trajectory. The world’s population in 1969 was growing at about 2 per cent a year. At that rate, world population would double in just 35 years. Never before had population grown so rapidly. From celebration to concern Global celebration of public health successes soon gave way to fears of a dystopian future in which too many people competed for ever-dwindling resources. What would such growth mean for global challenges like hunger? What would it mean for areas that were torn by conflict? How could efforts to RIGHTS AT RISK IN TIMES OF POPULATION GROWTH It was an era of extraordinary technological advances. Neil A. Armstrong and Edwin Aldrin, Jr., took the first walk on the moon in 1969. Also that year, for the first time, doctors replaced a dying man’s heart with a mechanical one. And a human egg was fertilized in a test tube (Edwards and others, 1969). grow economies and bring people out of poverty keep up when human numbers were expanding so dramatically? And what could be done about it? To some, population growth was seen not as a reflection of human progress but as a threat to humanity, a problem that required an urgent solution. Fears of the consequences of rapid population growth gripped the security community as early as the 1950s. In the United States, President Dwight D. Eisenhower designated retired general William H. Draper to lead a committee to devise coherent strategies for development assistance. Draper’s committee flagged what it saw as major concerns related to population growth in various parts of the developing world, primarily linked to food production. “Problems connected with world population growth will be among the most serious to be faced by the younger generation of today,” the committee’s 1959 report read. “Unless the relationship between the present trends of population growth and food production is reversed, the already difficult task of economic development will become a practical impossibility” (Draper and others, 1959). To address this challenge, the committee recommended that the United States and other advanced economies provide information and technical assistance to developing countries, at their request, “in the formulation of their plans to deal with the problem of rapid population growth.” It also recommended that the United States “increase its assistance to local programs relating to maternal and child welfare.” Several years later, Paul Ehrlich opined in The Population Bomb that “Whatever problem you’re interested in, you’re not going to solve it unless you also solve the population problem. Whatever your cause, it’s a lost cause without population control” (Ehrlich, Worldwide, child death rates plummeted from 215 deaths per 1,000 live births in 1950 to under 160 per 1,000 just 19 years later 1950 1969 Draper Committee “Problems connected with world population growth will be among the most serious to be faced by the younger generation of today.” 215 160 38 CHAPTER 3 Technology further heightened concerns about what continued rapid population growth could mean for society. In their study, The Limits to Growth, the researchers elaborated future scenarios based on differing assumptions related to population growth, food production, industrialization, pollution and consumption of non-renewable natural resources (Meadows and others, 1972). The “standard run” model, which was based on a continuation of historic trends from 1900 to 1970, led to “overshoot and collapse,” 1968). Ehrlich was interviewed numerous times by Johnny Carson, the host of the popular American late-night television programme The Tonight Show. The book became a bestseller, and soon the notion of “overpopulation” and questions about what, if anything, should be done about it were being debated in living rooms, lecture halls and the halls of government worldwide. A 1972 study commissioned by international think tank the Club of Rome and carried out by researchers at the Massachusetts Institute of © Mark Tuschman stemming from resource depletion, the collapse of the industrial base (and with it agricultural systems, which have become dependent on industrial inputs), and population growth that is eventually reversed due to increasing death rates from lack of food and health services. Other scenarios based on tweaked assumptions about one or more variables also led to eventual overshoot and collapse. Only one scenario, in which population and industrial capital growth rates stabilize and technological advances support pollution control and 39STATE OF WORLD POPULATION 2019 efficient food production, achieved a state of equilibrium that resulted in a “stabilized world.” “If the present growth trends in world population, industrialization, pollution, food production and resource depletion continue unchanged,” the researchers concluded, “the limits to growth on this planet will be reached sometime within the next 100 years. The most probable result will be a rather sudden and uncontrollable decline in both population and industrial capacity.” The methods and results of the study were widely discussed and debated, spawning further interest in examining the interactions between population growth and other human and natural systems (Nørgård and others, 2010). From concern to control Fearing that rapid population growth would reverse development gains, spawn famines, or worse, international and non-governmen- tal organizations and individual governments began to take action. In many places, this action was in the form of examining population trends and seeking to better understand their implications for other societal goals. In other places, action took the form of launching family planning programmes. In some places, action resulted in steps to encourage—or even force— couples and individuals to have fewer or no children, sometimes infringing on rights and choices along the way. Family planning mural: “Second child after three years,” India, 1988. © Raghu Rai/Magnum Photos Throughout the 1970s and 1980s, many countries adopted population or family planning policies. Often, such policies contained goals or targets linked to demographic outcomes—a target date for achieving population stabilization, for example, or goals related to reduction in fertility rates or increase in the proportion of the population using a modern method of contraception. Demographic objectives, however, sometimes took precedence over individual rights and choices. Family planning programmes that were voluntary, where individuals had the power to make their own decisions about contraception, were seen by some as inadequate to reduce fertility. “The conditions that cause births to be wanted or unwanted are beyond the control of family planning, hence beyond the control of any nation that relies on family planning alone as its population policy,” wrote American sociologist Kingsley Davis in an influential article in 1967 (Davis, 1967). He argued that if population policy were meant to control population growth to the benefit of society, then new directions in population policy— beyond simply providing family planning—would be needed. Among Davis’ recommendations: the postponement of marriage, as well as interventions to encourage the limitation of births within marriage. Such interventions had the potential to erode the protection and promotion of individual rights. For example, financial incentives—such as cash payments, food or household items—were incorporated into some population policies as a strategy to persuade couples to adopt particular family planning methods or limit childbearing (Heil and others, 2012); some population policies also offered housing and lending preferences to families with fewer children (Ross and Isaacs, 1988). Goals to reduce fertility and slow population growth, were, in a number of cases, not aligned with the Programme of Action of the International Conference on Population and Development (ICPD). Demographic concerns drove many of the innovations in contraceptive technologies in Free child care service offered by family planning programme. India, 1972. © UN Photo/ILO 41STATE OF WORLD POPULATION 2019 the 1950s and 1960s, leading to modern methods including oral contraceptives, intrauterine devices and injectables. But in some cases, demographically motivated population policies led to approaches that limited quality of care and jeopardized the health and rights of individuals. The first large-scale test of oral contraceptives, for example, took place in 1956 among 200 women living in a housing project in Puerto Rico. The women were given little information about safety and potential side effects, as little was known at the time (Liao and Dollin, 2012). Over time, other concerns have been raised about the practices of agencies, private companies and governments responsible for developing and evaluating contraceptive technologies— including concerns about lack of informed consent, adequate counselling and medical follow-up (United Nations, 2014). Expanding understanding of trends, enhancing options for individuals While population growth fears led in a number of cases to policies and programmes that limited or even trampled on rights and choices, the demographic shifts of the twentieth century also inspired new waves of scholarship and global discourse on the ways in which population dynamics influence and are influenced by socioeconomic trends, and how these trends intersected with an emerging human rights agenda. New institutions emerged to investigate the implications of population growth and potential policy and programmatic responses. In 1952, John D. Rockefeller III convened a meeting under the auspices of the United States National Academy of Sciences to investigate questions related to demographic trends and their consequences. Not long after, he established the Population Council to continue this work. From its early days, the Population Council engaged in pursuits related to building understanding of population trends and their relation to societal goals: one of its first programmes provided support to graduate students for advanced training in demography. The early work of the Population Council was not purely demographic, however; it A young woman examines the “loop” at a family planning centre. East Africa, 1973. © UN Photo/FAO 42 CHAPTER 3 After an initial grounding in ideological debates, evidence—not political power and support— would be brought to bear on the question of how economic and population growth were related. An important paper by Coale and Hoover (1958) demonstrated that across countries where population growth was very high, economic growth lagged. This correlation did not demonstrate causality, but it was nevertheless used by some to buttress fears of high population growth rates’ negative impact on economies. Later studies debunked that notion, however. For example, in 1984, shortly before the International Population Conference in Mexico City, a study commissioned by the United States National Academy of Sciences concluded that population growth was a neutral factor in economic growth. This conclusion came from a comparison of growth rates in population with growth rates in the economy (not in levels of the two). There seemed to be no relation (National Research Council, 1986). This uncertain conclusion and other research reinforced resistance to family planning efforts, at the 1984 conference and beyond. Since the late 1990s, there has been growing recognition that total aggregate population levels and change do not provide an explanation of the relationship. What is critical is the change in the age structure of populations as births are fewer, later and safer (Bloom and others, 2000 and 2007; Bloom and Canning, 2004), together with the attributes and opportunities of the population, specifically around education (Lutz and others, 2008), health and employment (Joshi and Schultz, 2007). As fertility declines, the proportion of the population that is of working age increases relative to the proportion of the population that is very old and very young. If this period coincides with a broad-based and significant investment in human capital concentrated from youth to adulthood, along with opportunities in the labour market, the result is a boost in economic growth and prosperity for the population. This effect, referred to as the “demographic dividend” or “demographic bonus,” does not last indefinitely. As mortality continues to fall, including at older ages, elder dependents become an increasing proportion of the population and the opportunity for a dividend may be attenuated. With growing scholarship on the demographic dividend, population dynamics has re-earned its place in economic policy discussions. This re-emergence has not been free of additional caveats and misunderstandings. The phenomenon is associated with a larger population of youth and adults relative to children and older people, not a raw increase in this working age population—so it requires a decline in fertility to reduce the size of following cohorts. Gender issues also need to be included. Working populations increase when women can productively enter the labour force (the same is true of marginalized and excluded populations). Further, ageing is not always associated with a lost window of opportunity. People are born without resources but enter old-age “dependency” with accumulated resources, unless they have been perennially poor. The window of opportunity is also often wrongly assumed to dissipate quickly when dependency reaches its minimum, even though it will still be more favourable than the initial starting point for additional years. This fact reinforces the need for supportive investments over time, initially facilitating and then maintaining the dividend. This effect, referred to as the “demographic dividend” or “demographic bonus,“ does not last indefinitely Population growth and economic growth 43STATE OF WORLD POPULATION 2019 The Draper Committee’s 1959 report was influential in the eventual establishment of the Office of Population at the United States Agency for International Development in 1969, and other developed countries began to establish population programmes as part of their foreign aid strategies. The key feature of these programmes was the provision of family planning information and services. The United States and Sweden soon became leading bilateral donors for family planning programmes throughout the developing world (Robinson and Ross, 2007). Concerns about rapid population growth also found their way into the United Nations General Assembly, which in 1966 passed resolution 2211 (XXI), titled Population growth and economic development. This resolution called on the United Nations “to assist, when requested, in further developing and strengthening national and regional facilities for training, research, information and advisory services in the field of population, bearing in mind the different character of the population problem in each country and region and the needs arising therefrom” (Singh, 2002). The next year, Secretary-General U Thant established a trust fund with a broad mandate to support the development of population policy in countries around the world, and in 1969, that trust fund became UNFPA, with Rafael Salas as its first Executive Director. UNFPA, along with its peer institutions of that era, helped to launch deeper inquiry into the causes and consequences of population trends. In partnership with the United States Agency for International Development, UNFPA launched the World Fertility Survey to gather and synthesize robust population data. This survey, for the first time, helped to shed light on important questions related to women’s lives— including their preferences, choices and needs related to fertility and childbearing. The Population Council, International Planned Parenthood Federation, United States Agency for International Development and others were founding members of a new population movement, which brought new energy, political will and resources into the exploration of population questions, resulting in the expansion of family planning programmes in the developing world that helped empower individuals to make choices about their reproductive lives. There was, however, growing tension within the movement about whether population growth, at its root, was a problem; and if it was, whether family planning programmes were an appropriate or sufficient solution. This tension came to the fore at the World Population Conference in Bucharest in 1974. By that time, also reflected an understanding that demographic trends had individual lives at their foundation. Population Council programmes in social and biomedical research sought to illuminate the context in which individuals made decisions about their reproductive lives, and to investigate contraceptive technologies that could help to expand individuals’ options related to sex and childbearing. These issues were of central concern to those working to expand women’s options and choices within what was known at the time as the “birth control” movement; indeed, the International Planned Parenthood Federation was established in the same year, under the joint presidency of birth control pioneer Margaret Sanger of the United States and Lady Rama Rau of India (Claeys, 2010). © Pictorial Press Ltd/Alamy Stock Photo Margaret Sanger 44 CHAPTER 3 CHAMPION OF CHANGE Rafael Salas Known affectionately as “Mr. Population,” Rafael Salas oversaw the birth of UNFPA as its first Executive Director in 1969. Under his leadership, UNFPA grew from a minor body to the world’s largest multilateral provider of population assistance. Along the way, global consensus emerged around the integral links between population and development and people’s sexual, reproductive and health rights, culminating in the Programme of Action of the International Conference on Population and Development. “Parents have a basic human right to determine freely and responsibly the number and the spacing of their children,” he told participants in the 1968 International Conference on Human Rights. It was a novel statement for the time, especially in Salas’ role as conference vice-president. Salas was widely known for bringing together people who might otherwise remain apart, helping them move past fixed positions of ideology and agree on common concerns. Always, the focus was on realizing the greater good. He led the 1984 International Population Conference in Mexico City and pioneered the work of the United Nations with parliamentarians and religious leaders. He persuaded people at all levels of government to introduce population and poverty links into national development plans. A man of many talents, Salas was at different points a professor and a poet, the Executive Director of the National Economic Council in his native Philippines, and the general manager of The Manila Chronicle. As national coordinator of the Philippine National Rice and Corn Sufficiency Program, he jump-started a “green revolution” that for the first time made the Philippines self-sufficient in rice production. In 1987, after his tenure as Executive Director of UNFPA was cut short by his untimely death, friends and colleagues gathered from all corners of the globe to say goodbye. As his many achievements were lauded, they agreed they had lost a great man, yet one who had always carried himself as a humble public servant. For his humanity and years of service, he would be remembered as dearly loved. © UN Photo/Milton Grant “ Parents have a basic human right to determine freely and responsibly the number and the spacing of their children.” 45STATE OF WORLD POPULATION 2019 developed countries had already been supporting family planning efforts in developing countries and assisting governments in establishing population policies. However, not all developing countries welcomed that support; some, in fact, did not see population growth as a challenge in their countries, and were frustrated that the developed world was, by their way of thinking, unduly distracted by the issue. For those whose views were influenced by a Marxist labour theory of value, a larger population meant more labourers and therefore the generation of greater wealth—and attempts to blunt that growth were met with suspicion and resistance. Others believed that more labourers would improve conditions only if the market generated enough employment. As population growth rates often exceeded economic growth rates, the gap would lead to under- and unemployment, with social turmoil as a result. “Is it owing to overpopulation that unemployment and poverty exist in many countries of the world today? No, absolutely not. It is mainly due to aggression, plunder and exploitation by the imperialists, particularly the superpowers,” said Huang Shu-tse, head of the Chinese delegation in Bucharest (Potts and others, 2018). Karan Singh, the Indian Minister of Health and Family Planning, argued that broader social and economic conditions were chiefly As an observant adolescent, Judith Bruce realized that unless aggressively challenged, the conventional process of “becoming a woman” meant not only bodily changes but also a loss of freedoms. Young females’ choices about sexuality and fertility were constrained not only by insensitive health care but just as forcefully by a lack of an independent “voice” and income. Even as her generation welcomed modern contraceptives, Bruce questioned the heavy reliance on technical fixes. In her early 20s, she joined a class action case to support a woman’s right to choice, and studied how girls’ adolescence shaped their ability to lead dignified lives of their choosing. Her intellectual path followed her lived experience, as she published almost simultaneously on women’s social and economic bargaining power in households and on client- centred care. Her “quality of care” framework Judith Bruce CHAMPION OF CHANGE underpinned a global shift in family planning programmes from stressing numerical targets as the success metric to promoting sustainable and safe use by responding to girls’ and women’s priorities. This framework contained six elements: ensuring that clients have a choice of among a range of different contraceptive methods appropriate to their needs; exchanging information with clients to ensure informed choices; technical competence of providers; respectful and supportive interpersonal relations; follow- up and continuity mechanisms to address discontinuation rates; and an appropriate constellation of services to ensure that clients receive the range of services they need to address both health needs and their wider social setting. This framework provided a basis for reorienting a number of planning programmes around the world. Bruce was an architect of the 1994 International Conference on Population and Development’s recognition that client-centred reproductive health services and female empowerment strategies were coequal, not competing, goals. 46 CHAPTER 3 responsible for high fertility, and therefore greater development assistance, not family planning assistance, should be the priority. “Development,” he said, “is the best contraceptive” (Potts, 1992). These conversations contributed to an overall sense of ambivalence about the efficacy of nascent family planning programmes and the relationship between population growth and economic growth more broadly. Indeed, numerous voices raised questions about factors that Today she calls for using the Sustainable Development Goals to drive investment to hotspots where child marriage, sexual coercion, unmet need, resource scarcity and intergenerational poverty overlap. “Girls at the highest risk of the worst outcomes are most likely to become single mothers and sole household supporters,” she says. These girls then become even more marginalized because their household responsibilities exclude them from seizing opportunities for learning, employment and participating in their communities. Meanwhile, their male counterparts are able to benefit from new, technologically driven economies. “Without aggressive investment in girls aged 10 to 14, countries cannot count on reaping a demographic dividend,” she says. Not making these investments, she says, amounts to planned poverty. And she predicts “increasing pressures on young females to trade sexuality and fertility for survival in the face of increasing climate emergencies, conflict, displacement, scarcity and stress.” Bruce calls for reversing this planned poverty and the poor reproductive health that accompanies it by implementing age-, gender-, and place-specific plans for those most likely to be left behind. The starting point for change: the 50 million 10-year-old girls in the poorest countries today. © Nadia Todres contribute to fertility decline and hasten the demographic transition in developing countries. In Bucharest in 1974, John D. Rockefeller III expressed “disappointment at the results of the family planning approach,” and urged reappraisal that would move beyond the simple provision of family planning. “In my opinion, if we are to make genuine progress in economic and social development, if we are to make progress in achieving population goals, women increasingly must have greater freedom of choice in determining their roles in society” (Rockefeller, 1978). Pushback on narrowly defined population policies As national population policies continued to expand through the 1980s, fear and mistrust of those promoting demographic goals continued to mount. A growing international women’s health movement began to advocate for programmes that ensured not just access to family planning, but a more holistic approach to women’s reproductive health, including attention to issues of sexuality and gender relations. While diverse in many ways, a fundamental message united the women’s health movement: the design, implementation and evalua- tion of women’s health programmes should be shaped by a concern for reproductive health and rights, and not by demographic objectives. Women’s groups from around the world increasingly called for policies and programmes that treated women as subjects, with their own needs and rights, and not merely as objects to achieve broader societal goals. A growing number of voices began calling for new research and data about women’s needs and preferences related to fertility and family planning, and many argued that these needs and preferences, rather than demographic targets, should serve as the primary guide to population policies and family planning programmes. Indeed, influential research carried out by Sinding and others (1994) showed that in the majority of countries analysed, existing demand for family planning exceeded national targets for contraceptive prevalence rates set by governments; therefore, they argued, population policies with demographic targets should be replaced with objectives expressed in terms of the stated desires of the people served. Pitching a big tent: the lead-up to the ICPD Individual and collective goals can be reconciled within the broad umbrella of population policy: this message became the global rallying cry in the preparations for the ICPD, to be held in Cairo in 1994. As a central organizing institution along with the United Nations Population Division, UNFPA sought to build bridges within a movement that had become increasingly divided. The institutions sought to build on the early foundations of the global population movement, acknowledging that an understanding of population trends is critical to achieving lasting development outcomes, while simultaneously embracing an understanding of the central role of women’s lives—and promoting their rights and choices as a basic tenet of population policy. Under the leadership of UNFPA Executive Director Dr. Nafis Sadik, the ICPD Secretariat guided a process that resulted in a consensus- driven Programme of Action that radically transformed views on how population policies should be developed and implemented in xthe future. The road to Cairo was long and deliberate. The first preparatory meeting was held in 1991, where, for the first time, “development” became part of the title of an international conference on population, and a draft programme CHAMPION OF CHANGE Nafis Sadik Born in 1929, Nafis Sadik grew up in a tumultuous time in history, one that in 1947 saw the birth of her country, Pakistan. It was not a particularly favourable moment to be a girl. But Sadik had a vision that she could change the world for the better. And this she did, by galvanizing people to come together around a wholly new understanding of population and development in 1994. She challenged convention from the start. She completed a medical degree in obstetrics, served poor rural women and men, and helped shape the first national population policy for Pakistan. When she joined UNFPA and rose through its ranks to become its second Executive Director in 1987, it marked the first time that a woman headed one of the major voluntarily funded United Nations programmes. She quickly became a passionate advocate for giving women the tools, from information to contraception, to manage their reproductive lives. Travelling the world, she heard women’s stories and made them into a relentless crusade for their rights to be healthy and live free from violence. In the early 1990s, the Secretary-General of the United Nations chose Sadik to lead preparations for the International Conference on Population and Development. It became the largest gathering of governments on the subject in history, and revolutionized the approach to sexual and reproductive health and rights. Under Sadik’s persuasive influence, civil society groups took prominent roles at all stages of the process, setting a new norm for activist engagement in international political talks. As the conference began, Sadik stood before delegates and said with typical forthrightness, “Any form of coercion in population policies and programmes is unacceptable. Women and men have the right to choose the size and spacing of their families, and to the information and the means to do so.” “People are at the heart of the process, as agents and beneficiaries,” she declared. “We have it in our power to lighten their burdens, remove obstacles in their path and permit them the full flowering of their potential as human beings.” © ZUMA Press, Inc./Alamy Stock Photo “People are at the heart of the process, as agents and beneficiaries.” of action was reviewed, debated and accepted by States in subsequent “preparatory committee” meetings. Alongside the preparatory meetings, the ICPD Secretariat organized expert group meetings to tackle thorny issues like population growth, migration, family planning and health, and population and environment. It organized five regional meetings to ensure broad geographic input and buy-in and, critically, organized numerous formal and informal gatherings of non-governmental organizations, enabling diverse and robust participation from a wide spectrum of interest areas. The numerous consultations, multiple meetings, and strategic advocacy and engagement of stakeholders paid off. In the final Programme of Action, governments agreed, for the first time, that population policies should include a broad swath of social development considerations. They arrived at a consensus that family planning should be delivered in the context of comprehensive reproductive health care, incorporating efforts to ensure healthy and safe childbearing, prevent sexually transmitted infections, and address related reproductive and sexual health concerns, including gender- based violence and other harmful practices. Women’s empowerment and gender equality were lifted up as fundamental elements of population and development policy. 48 CHAPTER 3 CHAMPION OF CHANGE Nafis Sadik Born in 1929, Nafis Sadik grew up in a tumultuous time in history, one that in 1947 saw the birth of her country, Pakistan. It was not a particularly favourable moment to be a girl. But Sadik had a vision that she could change the world for the better. And this she did, by galvanizing people to come together around a wholly new understanding of population and development in 1994. She challenged convention from the start. She completed a medical degree in obstetrics, served poor rural women and men, and helped shape the first national population policy for Pakistan. When she joined UNFPA and rose through its ranks to become its second Executive Director in 1987, it marked the first time that a woman headed one of the major voluntarily funded United Nations programmes. She quickly became a passionate advocate for giving women the tools, from information to contraception, to manage their reproductive lives. Travelling the world, she heard women’s stories and made them into a relentless crusade for their rights to be healthy and live free from violence. In the early 1990s, the Secretary-General of the United Nations chose Sadik to lead preparations for the International Conference on Population and Development. It became the largest gathering of governments on the subject in history, and revolutionized the approach to sexual and reproductive health and rights. Under Sadik’s persuasive influence, civil society groups took prominent roles at all stages of the process, setting a new norm for activist engagement in international political talks. As the conference began, Sadik stood before delegates and said with typical forthrightness, “Any form of coercion in population policies and programmes is unacceptable. Women and men have the right to choose the size and spacing of their families, and to the information and the means to do so.” “People are at the heart of the process, as agents and beneficiaries,” she declared. “We have it in our power to lighten their burdens, remove obstacles in their path and permit them the full flowering of their potential as human beings.” © ZUMA Press, Inc./Alamy Stock Photo “People are at the heart of the process, as agents and beneficiaries.” 49STATE OF WORLD POPULATION 2019 Underlying this emphasis was a shared understanding that enhanc- ing individual health and rights would contribute to lower fertility and slower population growth. By placing the causes and effects of rapid population growth in the context of human development and social progress, governments and civil society from multiple political, cultural and scholarly viewpoints could join in support of the recom- mendations (Ashford, 2001). Unlike outcome documents from previous international population conferences, the Programme of Action contained an openness and sensitivity in its treatment of issues related to sexuality, reproduction and gender relations. It emphasized the crucial links between sexual and reproductive health and rights with almost every other aspect of population and development: urbanization, migration, ageing, changing family structures and the rights of young people. By way of comparison, neither the World Population Plan of Action resulting from the 1974 Bucharest conference nor the recommendations from the 1984 Mexico City conference included the terms “sexual” or “sexuality” (United Nations, 1995). Taking the lessons forward The results of the consensus achieved at the ICPD were profound and enduring. Gone were the top-down, demographic targets of the past; today’s notions of “population policy” reflect the broad consensus that women’s education, empowerment and equality are paramount. The importance of providing family © Mark Tuschman 50 CHAPTER 3 planning in the context of full sexual and reproductive health care is fully embraced. That said, many continue to draw attention to the ways in which demographic trends may hinder the achievement of development outcomes. For example, rates of population growth remain high in many areas that are steeped in poverty and conflict, or vulnerable to climate change or natural disaster. At the other end of the spectrum, persistent low fertility and population ageing have raised concerns about economic health and society’s ability to provide adequate social safety nets. Undeniably, population dynamics shape and are shaped by societal conditions. The relationships are complex, multivariate and multidirectional. The lessons of the past have shown that top-down, State-sponsored efforts to engineer or alter demographic trends are a fool’s errand: they are instruments too blunt to achieve intended outcomes, they place undue limitations on individual choice, and they risk egregious violation of human rights. But greater understanding of demographic trends and their relationship to development objectives is needed. The international community has a responsibility to gather and communicate data that shed light on those relationships, while continuing to highlight the primacy of rights and choices in all aspects of life, but particularly in accessing sexual and reproductive health information and services. 51STATE OF WORLD POPULATION 2019 CHAPTER HIGHLIGHTS • The United Nations established UNFPA in 1969, at a time of rapid population growth, to help countries analyse demographic trends and their relationship to economic and social development. • In the 1970s, governments, non-governmental organizations and development institutions supplied an increasing quantity of reliable, modern contraceptives to empower women to manage their own fertility. • Achieving demographic targets was the main goal of some early family planning programmes, sometimes compromising the quality of reproductive health services. • By 1994, when the International Conference on Population and Development (ICPD) took place, a global consensus had emerged that women have a right to make their own decisions about whether, when and how often to become pregnant. The Programme of Action from the ICPD showed that reproductive rights and sustainable development are mutually reinforcing. • The achievement of rights and choices for all will depend on a continued partnership among civil society, governments, academia and international institutions. • The success of the United Nations Sustainable Development Goals depends in part on achieving universal access to sexual and reproductive health. © James Blair/National Geographic Image Collection The International Planned Parenthood Federation, too, was giving voice to women around the world who were demanding information and services that would enable them to exercise control of their fertility. Top among the goals of the Federation was expanding options for preventing pregnancy. In the 1950s, the most common contraceptive methods were largely controlled by men: the male condom, withdrawal and periodic abstinence. Margaret Sanger, one of the founders of Planned Parenthood, was particularly interested in developing a pill, as easy to take as aspirin, that would enable women to prevent pregnancy. In 1953, she introduced American feminist philanthropist Katharine Dexter McCormick to Dr. Gregory Pincus. McCormick provided financing for Pincus’ research into a hormonal oral contraceptive, and by 1960, “the pill” was on the market. In 1970, the Population Council established the International Committee for Contraception Research to further expand availability of contraceptive options, including long-acting ones, such as implants and injectables. By 1976, more than 100 governments were providing contraceptive information and services, either directly through government clinics or through non-governmental organizations. The number of countries making modern contraception available had grown to nearly 140 by 1986 and to 160 by 1996 (United Nations, 2013). By 2015, only 6 per cent of governments provided no support for family planning: these governments, however, allowed the private sector to provide family planning services without giving them any material AVAILABLE BUT INACCESSIBLE The growth of national population programmes and donor funding for them exponentially increased the availability of contraceptives in developing countries in the 1970s and beyond. CHAPTER 4 53STATE OF WORLD POPULATION 2019 or financial support (United Nations, 2017a). As government support for family planning and the number of methods grew, so too did the number of people availing themselves of contraception. Worldwide, the proportion of married or in-union women who reported using a contraceptive almost doubled between 1970 and 2015, from 36 per cent to 64 per cent (United Nations, 2015). Over the past half century, governments and the international donor community expanded the availability of multiple methods to people everywhere, leading to a broad method mix that is evident today. More than family planning As efforts to expand family planning programmes rolled out across the globe, women’s issues were moving to centre stage. In 1975, for example, the United Nations declared the opening of the Decade for Women, and multiple international conferences and regional gatherings enabled women across the world to meet, share information and advocate for change. More and more women were demanding agency in their reproductive lives, and such agency, they asserted, extended beyond the simple availability of family planning. For example, in response to sobering new evidence of hundreds of thousands of women dying during pregnancy or childbirth every year, the women’s health movement fuelled the launch of the global Safe Motherhood Initiative in 1987. The Initiative aimed to reduce maternal mortality by 50 per cent by 2000 through strengthening community-based health care and developing alarm and transport systems to enable at-risk pregnant women to reach life-saving maternal health services. Meanwhile, civil society organizations were calling for replacing narrowly focused family planning programmes that prioritized dispensing contraceptives with broader reproductive health care. They argued that the availability of family planning was only one part of the picture—that to ensure rights and choices in people’s lives, all people needed and deserved a comprehensive suite of information and services related to sexuality and reproductive health. So close yet so far In 1994, the Programme of Action resulting from the International Conference on Population and Development not only acknowledged that family planning and sexual and reproductive health and reproductive rights were intertwined, but also called on States to provide access to: antenatal care; safe delivery and postnatal care; treatment of infertility; safe abortion where legal, and management of the consequences of unsafe abortion; treatment of reproductive tract infections and sexually transmitted infections; and information, education and counselling on sexuality, reproductive health and responsible parenthood. The Programme of Action also affirmed that referral for these services, and for breast cancer and cancers of the reproductive system, should always be available; and that discouragement of harmful practices, such as female genital mutilation, should be an integral component of primary health care (United Nations, 2014a). The term “access” underscored the point that making reproductive health services available was insufficient to enable everyone to enjoy their reproductive rights. Rights are universal, which means that everyone has them. A woman who, for example, is unable to avail herself of family planning services, even when they are available, is denied her right to plan her family. Social, economic and other barriers to access would therefore have to be removed for rights to be fulfilled. One of the simplest and most basic definitions of “access” is geographic proximity to service- delivery points. Great distances can hamper access, either because affordable transportation options are limited or because the 54 CHAPTER 4 opportunity costs for poor women leaving their homes or livelihoods are too high. But distance is only part of the challenge. Sometimes services are available literally around the corner, but they are still inaccessible. A nearby family planning clinic, for example, may offer services, but a judgemental service provider may refuse to dispense contraceptives to a young person or an unmarried woman. That same clinic may also offer only one or two modern methods of contraception, but not the method preferred by some women. Supplies of contraceptives may be unreliable. There may be laws that block access to services by certain groups, or husbands may forbid their wives from using any form of contraception. Over time, researchers and practitioners have helped to articulate concepts of access that are multidimensional, recognizing that access is affected by factors at the levels of the individual, community, provider and service- delivery points. Enhanced concepts of access acknowledge the many barriers to individuals’ abilities to avail themselves of information and services that enable health, well-being and the realization of rights and choices in their sexual and reproductive lives. Overcoming barriers to access In the past half century, great progress has been made in extending access to sexual and reproductive health services and information to people everywhere. But this progress © Patrick Zachmann/Magnum Photos 55STATE OF WORLD POPULATION 2019 has been uneven and inequalities persist, both within and between countries—not only for traditional concerns around family planning and maternal health, but for information and services that can enable the realization of the full range of sexual and reproductive health and rights. Multiple social, institutional, political, geographic and economic forces are at play. Sexual and reproductive health inequalities are deeply affected by income inequality, the quality and reach of health systems, laws and policies, social and cultural norms, and people’s exposure to sexuality education. Income inequality Within most developing countries today, access to critical sexual and reproductive health care is generally lowest among the poorest 20 per cent of households and highest among the richest 20 per cent (UNFPA, 2017). The relationship between poverty and lack of access is complex: while financial costs of health services and supplies can be a barrier to access in some cases, income is linked to numerous social, institutional, political, geographic and economic forces that can also affect an individual’s access. Women in the poorest households may find themselves with little or no access to sexual and reproductive health care, leading to unintended pregnancies, higher risk of illness or death from pregnancy or childbirth, and the need to give birth on their own, without the assistance of a doctor, nurse or midwife. For these women, their poor sexual and reproductive health can block opportunities, blunt their potential, and solidify their position at the bottom rung of the economic ladder. Indicators paint a picture of vast differences among wealth quintiles for many critical sexual and reproductive health services (UNFPA, 2017). For example, in the majority of developing countries, the proportion of the demand for family planning that is met through modern contraception, the access to adequate antenatal care, and the likelihood of giving birth with assistance is dramatically lower among the poor than it is among wealthier households (Figures 4.1, 4.2, 4.3). Over the past 50 years, great strides have been made in © Giacomo Pirozzi/Panos Pictures 0 10 20 30 40 50 60 70 80 90 100 URBAN RURAL BOTTOM SECOND THIRD FOURTH TOP WEALTH QUINTILE Least developed (33 countries) Less developed (41 countries) Pe rc en ta ge o f f am ily p la nn in g de m an d sa tis fie d 50 64 39 59 34 55 38 59 41 61 46 64 51 66 Least developed (35 countries) 0 10 20 30 40 50 60 70 80 90 100 BOTTOM SECOND THIRD FOURTH TOP WEALTH QUINTILE Pe rc en ta ge o f w om en r ec ei vi ng fo ur o r m or e an te na ta l v is its More developed (10 countries)Less developed (41 countries) 37 63 78 41 72 82 47 75 85 54 81 89 67 86 90 WEALTH QUINTILE Pe rc en ta ge o f c hi ld bi rt hs w ith s ki lle d at te nd an t 0 10 20 30 40 50 60 70 80 90 100 URBAN RURAL BOTTOM SECOND THIRD FOURTH TOP Least developed (35 countries) More developed (10 countries)Less developed (46 countries) 81 94 99 48 79 99 98 70 36 45 82 55 88 100 69 93 100 86 9799 99 FIGURE 4.1 Proportion of demand for family planning met with modern contraception, by development level, place of residence and wealth quintile, latest year available FIGURE 4.2 Proportion of women having four or more antenatal visits, by development level and wealth quintile, latest year available FIGURE 4.3 Proportion of births with skilled attendants, by development level, place of residence and wealth quintile, latest year available 57STATE OF WORLD POPULATION 2019 reaching new populations with sexual and reproductive health information and services. Figure 4.4 shows that in many countries, remarkable progress has been made in expanding access to services that have dramatically decreased maternal mortality: globally, the maternal mortality ratio has experienced a decline of nearly 44 per cent, with progress seen in every region (Alkema and others, 2016). But in many other places, the poorest populations have not yet shared equally in this progress. The vast majority of maternal deaths, for instance, occur in low-resource settings, and poor women with limited access to prenatal care, skilled birth attendance, and emergency obstetric care are more likely to suffer debilitating health impacts and pregnancy-related injury, such as obstetric fistula. Greater effort is needed to advance information and services designed to prioritize the poor and hard to reach. Examples of such efforts offer hope. In Bangladesh, Bhutan, Cambodia and Thailand, for example, contraceptive prevalence rates are higher among the poorest 20 per cent of the population than they are among the richest 20 per cent. In these and several other countries, concerted efforts to expand family planning coverage to the hardest to reach have led to near-universal access to modern contraception, and near-equitable rates of contraceptive prevalence among rich and poor households alike (UNFPA, 2017). Innovative service-delivery models have helped expand access to the poorest populations. Community-based distribution systems initiated in the 1970s, for example, helped to extend access to poor and rural communities through trained members of the community. While traditionally these efforts were focused on expanding access to contraceptives such as pills and condoms, efforts have been made to expand the service mix to include emergency contraception, birthing kits and misoprostol for the prevention of post-partum haemorrhage (Bongaarts and others, 2012). More recently, demand-side financing strategies, such as vouchers, have been introduced as a way of giving more decision- making ability to poor clients. In this model, clients can purchase vouchers for specific reproductive products at a subsidized price. The vouchers can be exchanged for services—including services as diverse as information about long-term family planning, and information and services for safe delivery and gender-based violence recovery—at qualified outlets (Bongaarts and others, 2012). Conditional cash transfers have also been introduced as a strategy to incentivize actions and behaviours that contribute to critical health outcomes, such as antenatal health visits, keeping girls in school, or delaying marriage (Bongaarts and others, 2012). Insufficient facilities, providers and supplies A woman who seeks sexual and reproductive health information and services may find no provider in her community. If she has the means to cover the cost of transportation to a clinic in a neighbouring community, she may arrive only to find that it lacks the proper equipment or supplies for the services she needs. There may be no health service provider, or not enough providers, to see everyone who has turned up that day. If there are enough providers, they may not have the training to offer appropriate information or services, or perhaps Contraceptive prevalence rates are generally lower among the poorest 20% of the population and highest among the richest 20% UNFPA, 2017 20 40 60 80 58 CHAPTER 4 1990 1995 2000 2005 2010 2015 Year 0 100 200 300 400 500 600 Southern Asia Southeastern Asia Western Asia Eastern Asia 1990 1995 2000 2005 2010 2015 Year 0 50 100 150 200 250 300 350 Caribbean Latin America Year 0 100 200 300 400 Worldwide 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 Year 0 500 1000 Sub-Saharan Africa 1990 1995 2000 2005 2010 2015 Year 0 100 200 300 400 500 600 700 Oceania Year 0 50 100 150 200 1990 1995 2000 2005 2010 2015 Northern Africa Caucasus and central Asia Developed regions FIGURE 4.4 Global and regional estimates of maternal mortality ratio, 1990–2015 Maternal deaths per 100,000 live births. Shaded areas are 80 per cent uncertainty intervals. Shaded areas in background are comparable. Source: Alkema and others, 2016 Worldwide, there has been remarkable progress in addressing maternal mortality, with a decline of nearly 44 per cent in the maternal mortality ratio since 1990. Such progress, however, differs greatly between regions. 59STATE OF WORLD POPULATION 2019 Quality is a critical dimension of access to services. Judith Bruce’s seminal work in defining a framework for quality of care outlined six elements that deserve attention from the perspective of a family planning client: choice of methods; information given to clients; technical competence; interpersonal relations; follow- up and continuity mechanisms; and the appropriate constellation of services (Bruce, 1990). Recognizing that too many women were not benefiting from actions to improve reproductive health, international institutions and nine countries launched the Network for Improving Quality of Care for Maternal, Newborn and Child Health, or the “Quality of Care Network,” in 2017. Network members agreed on a vision that every pregnant woman and newborn receives high-quality care throughout pregnancy, childbirth and the postnatal period, a vision that is underpinned by the core values of quality, equity and dignity (WHO, 2018). The element of quality in all dimensions of sexual and reproductive health is supported by the broad health-care framework known as AAAQ, for availability, access, acceptability and quality, which has been advanced as a key component of rights in health care by the United Nations Committee on Economic, Social and Cultural Rights (UNCESCR, 2000). In 1992, the International Planned Parenthood Federation had advanced a “bill of rights” for family planning clients that outlined what individuals seeking family planning should be able to demand if they are receiving high-quality care from providers. These include rights to information, access to services and choice, as well as safety and the right to privacy, confidentiality, maintenance of dignity, comfort, continuity and expression of opinion. While responsibilities for quality of care are, in principle, distributed through the entirety of a family planning programme, those who are seen as most responsible for ensuring those rights are the individuals who are in direct contact with clients: the providers. Therefore, strategies for quality of care must also recognize that service providers have their own needs, and should be able to expect training, supplies, guidance, back-up, respect, encouragement, feedback and self-expression (Huezo and Diaz, 1993). The relationship between clients’ rights and providers’ needs is central to any effort to remove obstacles to quality of care. Promising interventions include those that facilitate a better interaction between clients and providers through means such as training providers in interpersonal communication. Resulting improvements in these dimensions of quality of care are possible without the need for large investments in staff, equipment or supplies (RamaRao and Mohanam, 2003). Limitations on quality of care can have significant implications for maternal health. While more and more women are giving birth in health facilities rather than at home, a lack of adequate staffing, training, infrastructure and commodities can result in poor quality care, known as “too little, too late” or TLTL. The converse also poses challenges: in some regions the rapid increase in the use of facilities for childbirth has been accompanied by widespread over-medicalization of birth, resulting in, for example, overused or unnecessary caesarean sections, or caesarean sections that are provided in unsafe or low- quality conditions, resulting in injury to mother and baby. This phenomenon, known as “too much, too soon” or TMTS, can have the effect of offsetting gains in maternal and perinatal health. For both TLTL and TMTS, improved provider training in respectful care and adherence to best practices can help to strengthen maternal and perinatal outcomes, avoid harm, and reduce health-care costs and inequities (Miller and others, 2016). The importance of quality “too little, too late” or “too much, too soon” 60 CHAPTER 4 may not be able to offer privacy or other measures that would enable her to feel safe and respected. Research, anecdotal information and reports by civil society have long confirmed the shortcomings of services. A recent review of health facilities in 10 African countries, for example, found overall low levels of readiness when assessing the availability of key supplies and services, including family planning guidelines, staff trained in family planning, blood pressure apparatus, combined oral contraceptives, injectable contraceptives and male condoms (Ali and others, 2018). More systematic attempts to quantify and monitor overall readiness remain under development. The World Health Organization, in partnership with other organizations, regularly releases guidance notes on standards of good practice for a variety of reproductive health interventions. A 2017 assessment of 24 countries indicated that family planning services run out of stock of some methods of contraception about three quarters of the time. An average of 78 per cent of primary- level facilities offering three or more methods of contraception had them in stock on the day of assessment; 79 per cent of secondary and tertiary facilities (regional and larger hospitals) offering five or more methods had them in stock (FP2020, 2018). These averages, however, mask wide variations within and between countries. “Reproductive health commodity security” is achieved when all individuals can have access to affordable, quality supplies, including the contraceptive method of their choice, whenever they © B. Sokol/Panos Pictures need them. Towards this goal, a partnership with the Bill & Melinda Gates Foundation and the United Kingdom Department for International Development is expediting the delivery of reproductive health commodities to countries to avoid stock-outs (UNFPA, 2018). In many places, the number of trained providers is simply insufficient to ensure adequate access to a full range of sexual and reproductive health information and services. The Global Health Workforce Alliance has cited a need for increasing the number of health workers, particularly skilled birth attendants, in developing countries (Campbell and others, 2013). Over all categories of health workers, there was an estimated global shortage of 7.2 million health workers earlier this decade. The need for trained professionals who can deliver essential sexual and reproductive health services is particularly acute. A recent analysis of 73 low- and middle-income countries found that while more than 92 per cent of the world’s maternal and newborn deaths and stillbirths occur within those countries, they are home to only 42 per cent of the world’s medical, midwifery and nursing personnel (UNFPA, 2014). Estimates of outlays for personnel needed to achieve universal coverage levels for key reproductive, maternal, neonatal and child interventions suggest that substantial increases will be needed. To attain levels to meet all unmet need for reproductive, maternal and newborn health worldwide, for example, an estimated 37 per cent increase in funding for personnel to dispense contraception would be required; maternal and newborn health would require increases of about 20 per cent above current levels (Guttmacher Institute, 2017). These global averages hide significant regional disparities. In the least developed countries, for example, outlays for personnel to address unmet need for contraception alone would need to be 96 per cent higher, and for full maternal and neonatal services coverage, 84 per cent higher. The payoff for such investment would be high: estimates suggest that maternal mortality and recourse to abortion would be reduced by as much as three quarters with full staffing, equipment and system maintenance (Guttmacher Institute, 2017). The preparedness of providers to offer adequate care has been long appreciated regarding family planning. Insufficient counselling (that which fails to address questions about proper use; to offer advisories about contraindications, side effects and appropriate follow- up, including method switching; or to help in addressing the context of use, including partner concerns) can be an obstacle to contraceptive access, adoption and continuation. Findings from studies of reasons for unmet need for family planning suggest that the provision of a range of methods and information and counselling to help women select and effectively © UNFPA/M. Bradley 62 CHAPTER 4 use an appropriate method can be critical in overcoming obstacles to contraceptive use. The most commonly reported reasons for non-use include infrequent sex and concerns about side effects or health risks (Sedgh and Hussain, 2014). Contraception discontinuation is an often ill-addressed dimension of unmet need. A recent analysis of 32 countries indicates that, on average, more than one fifth of episodes of short-term methods (condoms and pills) are stopped within 12 months, despite the user still wanting to prevent pregnancy (FP2020, 2018). Discontinuation rates within one year are lower for long-acting methods: 12 per cent with intrauterine devices and 8 per cent with implants. Legal barriers Even in places where there are well-trained providers and facilities are well-stocked and equipped, individuals may face legal barriers that limit their access to information and services. In some places, laws require third- party authorization for women or adolescents to access health services. Elsewhere, laws that criminalize same-sex relationships, sex work and drug use can force people into hiding and prevent them from seeking or receiving the information and services they need. While intended to protect minors, age-of-consent laws for medical services can discourage adolescents from accessing needed services related to their sexual and reproductive health. This can be particularly harmful for adolescent girls, who bear disproportionate social and physical consequences of unintended pregnancies. In 2017, 68 of 108 countries reporting data to the Joint United Nations Programme on HIV/AIDS (UNAIDS) indicated that they require parental consent for a child under 18 years to access sexual and reproductive health services (Figure 4.5; UNAIDS, 2018). In some settings, health-care providers are legally required to report underage sex or other illegal activities among adolescents (Delany-Moretlwe and others, 2015). Legislation that bans intercourse between consenting adults of the same sex can interfere with efforts to provide access to services to Asia and the Pacific Western and central Europe and North America Eastern and southern Africa Eastern Europe and central Asia Latin America Caribbean Middle East and North Africa Western and central Africa 52% 53% 92% 59% 90% 58% 61% 57% Reporting countries Countries with laws requiring parental consent for adolescents to access sexual and reproductive health services Source: 2017 and 2018 National Commitments and Policy Instrument. Countries with age of consent laws to access sexual and reproductive health services, 2018 FIGURE 4.5 Discouraging adolescents from accessing services Countries with age of consent laws to access sexual and reproductive health services, 2018 Source: UNAIDS, 2018 63STATE OF WORLD POPULATION 2019 CHAMPION OF CHANGE Mechai Viravaidya Mechai Viravaidya has galvanized a no-holds-barred revolution in Thailand, one fired by the belief that everyone should know how to plan their family and protect their health. A communications mastermind, Mechai has since the 1960s reached people with messages about condom use through schools and gas stations, in offices and villages, through pig-breeding contests and visits by Avon ladies and ceremonies by Buddhist monks. It was all part of a drive to make contraception an accepted, non-embarrassing feature of everyday life. “Say the word ‘condom.’ Make it available. Talk about it,” Mechai says. “In fact, what we’re teaching is … the right for you to choose the number of children you want.” While condoms offered a tactile and at times humorous entry point for education, Mechai’s aim was always having a wide variety of contraceptives found as easily as “vegetables in the villages.” Within a few decades, Thailand had moved a long way towards these goals, and the size of the average Thai family plummeted from 7 children to 1.6. In the early 1990s, when HIV prevalence was predicted to spike, Mechai persuaded the Government to boost the budget for prevention 50-fold and enlist people from all parts of public service, business and communities to speak out about protection and condom use. Thailand subsequently warded off an estimated 3 million HIV infections, and Viravaidya became known as the “Condom King.” Today, “mechai” is slang for condoms. Viravaidya still leads the largest Thai non-governmental organization, the Population and Community Development Association, which since 1973 has championed rural development and health. Its activities include the Mechai Pattana schools, which embrace principles of equity and fairness in bringing high-quality education—including comprehensive sexuality education—to otherwise marginalized communities. Gender equality is integral to the curriculum. “Women are very, very important in the development process,” Mechai says, adding, with a typically memorable flourish, “When you have two brilliant arms, why use only one?” “Say the word ‘condom.’ Make it available. Talk about it.” © Bangkok Post prevent or treat sexually transmitted infections, including HIV. As of 2017, more than 40 countries reporting to UNAIDS stated they have laws specifically criminalizing same-sex sexual intercourse. Among these, two apply the death penalty, and some others may imprison people for life (UNAIDS, 2018). As a consequence, many people fear seeking critical services such as HIV testing. Laws regarding access to abortion fall along a continuum, from total prohibition to no restrictions. As of 2017, 42 per cent of women of reproductive age live in the 125 countries where access to safe abortion is highly restricted. Of all abortions worldwide, only 55 per cent are safe, relying on a recommended method and administered by a trained provider (Singh and others, 2018). Evidence suggests that the frequency of abortion is not significantly impacted by legal restrictions: abortion rates in countries with the most restrictive abortion laws are roughly the same as abortion rates in countries with the least restrictive abortion laws. However, the more restrictive the legal setting, the higher the proportion of abortions that are unsafe—ranging from less than 1 per cent in the least restrictive countries to 31 per cent in the most restrictive countries (Singh and others, 2018). In developing regions combined, except East Asia, an estimated 6.9 million women are treated annually for complications related to abortion. Many more require post-abortion care but are unable to access it (Singh and others, 2018). Norms, attitudes and practices Across societies worldwide, expectations dictate that sexual activity and reproduction should take place only among groups with certain characteristics; those characteristics often include individuals who are heterosexual, married, monogamous, able- bodied, not too young, and not too old. In many places, childbearing practices are expected to adhere not to the interests of the individual, but to prevailing norms in families and communities. Such expectations may result from long-standing attitudes and practices, or prevailing religious beliefs. When a person’s sexual and reproductive activities fall outside these expectations, it is likely that it will be more difficult for that person to access information and services to meet their needs. Adolescents face particular challenges. Despite widespread evidence that many unmarried adolescents are sexually active (Starrs and others, 2018), social norms may preclude or outright prohibit discussions of sexual and reproductive health or sexuality. In addition to legal barriers, challenges to access may come in the form of insufficient sexuality education in schools, or in providers’ attitudes and beliefs about the appropriateness of interventions in the context of age or marital status. Ethnic minorities, indigenous people, sex workers, people with disabilities, the poorest women and girls, and the lesbian, gay, bisexual, transgender and intersex © Giacomo Pirozzi/Panos Pictures 64 CHAPTER 4 CHAMPION OF CHANGE Mechai Viravaidya Mechai Viravaidya has galvanized a no-holds-barred revolution in Thailand, one fired by the belief that everyone should know how to plan their family and protect their health. A communications mastermind, Mechai has since the 1960s reached people with messages about condom use through schools and gas stations, in offices and villages, through pig-breeding contests and visits by Avon ladies and ceremonies by Buddhist monks. It was all part of a drive to make contraception an accepted, non-embarrassing feature of everyday life. “Say the word ‘condom.’ Make it available. Talk about it,” Mechai says. “In fact, what we’re teaching is … the right for you to choose the number of children you want.” While condoms offered a tactile and at times humorous entry point for education, Mechai’s aim was always having a wide variety of contraceptives found as easily as “vegetables in the villages.” Within a few decades, Thailand had moved a long way towards these goals, and the size of the average Thai family plummeted from 7 children to 1.6. In the early 1990s, when HIV prevalence was predicted to spike, Mechai persuaded the Government to boost the budget for prevention 50-fold and enlist people from all parts of public service, business and communities to speak out about protection and condom use. Thailand subsequently warded off an estimated 3 million HIV infections, and Viravaidya became known as the “Condom King.” Today, “mechai” is slang for condoms. Viravaidya still leads the largest Thai non-governmental organization, the Population and Community Development Association, which since 1973 has championed rural development and health. Its activities include the Mechai Pattana schools, which embrace principles of equity and fairness in bringing high-quality education—including comprehensive sexuality education—to otherwise marginalized communities. Gender equality is integral to the curriculum. “Women are very, very important in the development process,” Mechai says, adding, with a typically memorable flourish, “When you have two brilliant arms, why use only one?” “Say the word ‘condom.’ Make it available. Talk about it.” © Bangkok Post CHAMPION OF CHANGE Lebogang Motsumi When Lebogang Motsumi speaks to other young people about HIV and AIDS, she does so from her own experience. In telling her story, she hopes to inspire other young women and girls to stay in school, stay healthy and make positive choices. A typical bold Facebook post: “Good morning, my name is Lebogang Brenda Motsumi aka African Queen. I am NOT HIV, I am LIVING with HIV. I am not the virus, the virus lives in me. I am not defined by HIV, but I define HIV.” Almost a decade has passed since Motsumi learned she was HIV-positive. She was only 17 when she was infected by her boyfriend, a well-known singer who later died. Motsumi did not go for testing until a later partner insisted on doing so. A few days after learning she was positive, she made a suicide attempt. A month after that, she found she was pregnant and started taking medication to protect her child. She also began a remarkable journey, on social media, as an inspirational speaker, and as an HIV activist and coach speaking especially to young people. “My HIV infection helped me find my purpose in life. I realized that I can turn my mess into a message, and use my pain to empower other people.” The African Union has honoured her as a youth hero, and she sits on youth advisory boards for both the Union and UNFPA. She also rallies people as an ambassador for Zazi, a campaign encouraging South African women and girls to “know your strength.” “We will find the cure to HIV,” Motsumi declares. “While we try to find a cure, the education and empowerment of people living with HIV is our cure. And prevention for those who are HIV-negative.” “I am not defined by HIV, but I define HIV.” © OneTwo Photography (LGBTI) community face marginalization and stigma that can result in significant barriers to sexual and reproductive health and the realization of rights and choices. Girls and young women with disabilities, for example, are frequently denied the right to make decisions for themselves about their reproductive and sexual health, increasing their risk of sexual violence, unplanned pregnancy and sexually transmitted infections. They may not be seen as needing information about their sexual and reproductive health and rights, and therefore have little knowledge about them, leading to outcomes that further limit their choices and exacerbate marginalization. In one study in Ethiopia, for example, just 35 per cent of young people with disabilities used contraceptives during their first sexual encounter, and 63 per cent had had an unplanned pregnancy (UNFPA, 2018a). Stigmatization can prevent individuals from seeking services they need and are entitled to. Unmarried women, for example, may be hesitant to seek sexual and reproductive health care, particularly services such as contraception and safe abortion. Levels of unmet need for modern family planning are much higher among single, sexually active women than among married women due to such stigma (Singh and others, 2018). Stigma not only impacts the choices and decisions of individuals in need of information and services, but can also affect the actions of providers. In places where abortion is broadly legal, for example, persistent stigma about the procedure can affect the willingness of providers to counsel or offer abortions. A recent review found that some providers held negative attitudes towards abortion in most countries in South-East Asia and sub-Saharan Africa, for example, and providers also reported being stigmatized Women Enabled International helped develop guidelines for governments, service providers and other stakeholders to meet the sexual and reproductive health needs of young people with disabilities. The guidelines include actions to ensure availability, accessibility, acceptability and quality services, as well as services to prevent or address the impact of gender-based violence: • Establish disability-sensitive protocols and guidelines for follow-up visits with health-care providers, management of side effects of medication or treatments, and referral guidelines for further assistance when necessary. • Create accessible informational materials tailored for young people with different types of disabilities and appropriate at different ages that address the types of contraceptive and sexual and reproductive health services available and consider subsidizing such services for low-income young people with disabilities. • Develop awareness-raising campaigns and educational materials for caregivers and family members of young people with disabilities on sexuality, contraceptive use and the availability of services. • Ensure that contraceptive information, goods and services are available to young women and men with disabilities. Men and boys should also receive information to help them understand the rights of young women and adolescent girls to use contraceptives. Access to services for young people with disabilities 67STATE OF WORLD POPULATION 2019 68 CHAPTER 4 Sexual and reproductive health in general, and family planning in particular, were for decades sidelined in global arenas that took up issues of primary health care. In 1978, for example, government representatives converged in Kazakhstan for the International Conference on Primary Health Care. The event concluded with the Alma-Ata Declaration, which identified primary health care as the key to attainment of health for all around the globe. But some governments said the goals outlined in the declaration were too broad and therefore unattainable. A year later, at a gathering of health and policy experts, a consensus emerged on the need to focus on simple but high-impact primary health-care interventions that promised to save lives in developing countries. These interventions, referred to as GOBI, for growth monitoring of children, oral rehydration, breastfeeding and immunizations, again failed to address fundamental sexual and reproductive health issues as part of primary health care. But the global health community eventually recognized the importance of other essential primary care interventions, and agreed that family planning should be a priority (as well as female education and food supplementation). The addition of family planning to the global primary health agenda foreshadowed the Millennium Development Goals (MDGs), which included an objective to reduce maternal mortality worldwide by 75 per cent between 2000 and 2015. In 2005, five years into efforts to achieve the MDGs, the United Nations agreed to add a target to achieve universal access to reproductive health. Health targets were scattered throughout four of the eight MDGs. But starting in 2015, with the new 2030 Agenda for Sustainable Development and its accompanying 17 Sustainable Development Goals (SDGs), all health-related targets, including ones related to sexual and reproductive health, were included in one Goal. Having all health-related targets in one place reinforced the notion of a continuum of care that includes sex and reproduction—from prevention of pregnancy, to pregnancy, birth, infancy, postnatal care and childhood—and critical water and sanitation factors. Under this Goal 3—to ensure healthy lives and promote well-being for all at all ages by 2030— Target 3.7 aims for universal access to sexual and reproductive health care and services, including family planning, information and education, and the integration of reproductive health into national strategies and programmes. Figure 4.6, which shows coverage of health interventions across the continuum of care in the world’s poorest countries with the greatest needs, reveals uneven progress in some sexual and reproductive health areas. Coverage, while still suboptimal, is highest around delivery and for schedulable immunizations (UNICEF and WHO, 2017). The times before pregnancy and after a recent birth, prime times for deciding on future pregnancy intentions, remain underserved. In October 2018, 40 years after the Alma-Ata Declaration, delegates participating in the latest Global Conference on Primary Health Care finally acknowledged the centrality of sexual and reproductive health in primary health care. The declaration from that gathering stated that primary health care “will provide a comprehensive range of services and care, including but not limited to … services that promote, maintain and improve maternal, newborn, child and adolescent health, and mental health and sexual and reproductive health.” The SDG target of universal health coverage includes family planning as a core indicator along with antenatal and delivery care and cervical cancer screening. In recent years, sexual and reproductive health has been consistently included in indicators in global health policymaking. Sexual and reproductive health and the advent of universal health care 68 CHAPTER 4 FIGURE 4.6 Major gaps in coverage Median national coverage of interventions across the continuum of care among countries, with available data from 2012, from the Countdown to 2030 initiative, which tracks progress in the 81 countries that account for more than 90 per cent of under-five child deaths and 95 per cent of maternal deaths in the world. a Refers to the prevention and planning of pregnancy and includes the time period prior to a first pregnancy and interpregnancy intervals as well as decision making on whether to ever have a pregnancy. b Infant and young child feeding indicators serve as a proxy for programme coverage for which measures are not available. Note: Includes only interventions of relevance to all Countdown countries. Malaria-related indicators that Countdown tracks are not shown. Source: Immunization rates, World Health Organization (WHO) and United Nations Children’s Fund (UNICEF); population using basic drinking-water services and sanitation services, WHO and UNICEF Joint Monitoring Programme for Water Supply and Sanitation; antiretroviral treatment of pregnant women with HIV, UNICEF global database, July 2017, based on 2017 estimates from the Joint United Nations Programme on HIV/AIDS; all other indicators, UNICEF global database, July 2017, based on Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other national surveys. Population using basic sanitation services Population using basic drinking-water services Oral rehydration salts treatment for diarrhoea Careseeking for symptoms of pneumonia Vitamin A supplementation (two doses) Rotavirus immunization Measles immunization (first dose) Diphtheria-tetanus-pertussis immunization (three doses) Continued breastfeeding (year 1)b Exclusive breastfeeding (< 6 months)b Postnatal care for babies Early initiation of breastfeedingb Postnatal care for mothers Skilled birth attendant Neonatal tetanus protection Pregnant women living with HIV receiving antiretroviral treatment Antenatal care (at least four visits) Demand for family planning satisfied with modern methods (among married or in-union women) Country reporting data Percentage 25 50 75 1000 PREGNANCY BIRTH POSTNATAL INFANCY CHILDHOOD ENVIRONMENT PRE-PREGNANCYa 69STATE OF WORLD POPULATION 2019 by their families, communities, colleagues and policymakers for providing abortions (Rehnström Loi and others, 2015). Insufficient education about sexuality Individuals’ lack of knowledge can be a barrier to accessing services. Misperceptions or a lack of understanding about sexuality, the human body and development, rights and gender, and power in relationships can stand in the way of people’s rights and choices. Comprehensive sexuality education is a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality. It aims to equip children and young people with knowledge, skills, attitudes and values that will empower them to: realize their health, well-being and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and understand and ensure the protection of their rights throughout their lives (UNESCO, 2018). Initiating age-appropriate comprehensive sexuality education in primary school offers numerous benefits, including helping children to identify and report inappropriate behaviour such as child abuse, and supporting the development of healthy attitudes about their own body and relationships. Comprehensive sexuality education should also be available to those who are not enrolled in school. © UNFPA 70 CHAPTER 4 Evidence confirms that sexuality education does not hasten sexual activity, but rather has a positive impact on safer sexual behaviours and can delay sexual debut. A UNESCO review for the devel- opment of technical guidance on comprehensive sexuality education found that curriculum-based pro- grammes contribute to delayed initiation of sexual intercourse, decreased frequency of sexual intercourse, decreased number of sexual partners, reduced risk-taking, and increased use of condoms and other forms of contraception (UNESCO, 2018). As with all curricula, comprehensive sexuality education must be delivered in accordance with national laws and policies (UNFPA, 2016a). About 80 per cent of 48 countries covered in a recent study have policies or strategies that support comprehensive sexuality education (UNESCO, 2015). Towards access for all Ensuring access to information and services is a priority for the international community. Over time, policymakers, practitioners and advocates have helped to answer the important questions of “access to what?” and “access for whom?” and “what does access really mean in practice?” Today, there is a consensus around the objective that everyone, everywhere should have access to high-quality information and services for the full range of their sexual and reproductive health needs over the course of their lives. While remarkable progress towards this objective is evident, its full realization remains elusive for many, due to lack of awareness, scant resources, insufficient political will, or underlying gender inequality. CHAPTER HIGHLIGHTS • To ensure rights and choices in people’s lives, all people need and deserve a comprehensive suite of information and services related to sexual and reproductive health. • While early programmes focused on expanding the availability of contraceptives to women around the world, over time, the concept of access has evolved. Advocates, practitioners and policymakers helped to answer important questions of “access to what?” and “access for whom?” and “what does access really mean in practice?” As our understanding of barriers to access grows, and as new challenges emerge, there is an ongoing need to raise these questions. • Enhanced concepts of access acknowledge the many barriers to individuals’ abilities to avail themselves of information and services that enable health, well-being, and the realization of rights and choices in their sexual and reproductive lives. • While significant progress has been made in extending access to services and information that enable the realization of the full range of sexual and reproductive health and rights, this progress has been uneven, and inequalities persist. Sexual and reproductive health inequalities are deeply affected by income inequality, the quality and reach of health systems, laws and policies, social and cultural norms, and people’s exposure to sexuality education. 71STATE OF WORLD POPULATION 2019 © Abbas/Magnum Photos for MFA Italy These changes included shifts in attitudes about what men and women could and should be doing in their lives. At the same time, Ela Bhatt, Sonia Montaño, Gloria Steinem and other feminists around the world were raising awareness about gender inequality and its connection to sexuality, inequality in the family, reproductive rights and sexual violence. This broader vision of gender inequality continues to play a central role in discussions around reproductive rights today. Of all the obstacles to the achievement and exercise of human rights, including reproductive rights, few have proven to be as challenging to overcome as those based on gender. Gender, the web of expectations and norms within a society that together define what are appropriate male and female behaviours, roles and characteristics, is learned, internalized and reinforced through social interactions with others, thus having a profound influence on every domain of life. While the expression of gender varies across contexts, in virtually all societies gender has been defined in ways that subordinate women (and those who are gender non-conforming) to men, imbuing definitions of masculinity and femininity with different levels of power and social authority. The net result of these differences in most societies has been a systematic disempowerment of women and non-gender-conforming groups, who find their autonomy and ability to freely make decisions THE OBSTACLE UNDERLYING ALL OTHERS The sexual revolution, fuelled in large part by the advent of reliable and safe contraceptive methods, was well under way in wealthier countries in the 1960s. At that same time, developing countries were undergoing dramatic economic and social changes that fundamentally transformed their societies. CHAPTER 5 73STATE OF WORLD POPULATION 2019 Source: MacQuarrie and Edmeades, 2015. FIGURE 5.1 The disproportionate burden of child marriage on girls for themselves limited across almost every aspect of life. Gender norms wield a particularly large influence in reproductive matters. Gender influences and is influenced by reproductive rights Gender inequality limits the ability of women to freely make fundamental decisions about when and with whom to have sex, about the use of contraception or health care, and about whether and when to seek employment or whether to seek higher education. Gender- unequal norms and expectations magnify the negative effects of other impediments to rights and choices. One example is with child marriage, which is overwhelmingly more common for girls than boys (Figure 5.1). When a girl is married, she is less likely to go to, or complete, school or travel freely outside of her home alone; more likely to be subjected to gender- based violence; and less likely to know about her body and rights. Her limited mobility, schooling and knowledge in turn reinforce and perpetuate gender inequality. Gaining the power to choose Overall, women today have more control over their reproductive lives than at any point in human history, with profound implications for individuals and societies. For women in particular, being able 74 Female 0 20 40 60 80 100 Bangladesh Burkina Faso Cameroon Chad Comoros Dominican Republic Ethiopia Guinea Honduras India Madagascar Malawi Mali Proportion of ever-married age 20–59 married before age 18 Male 74 CHAPTER 5 to choose how many children to have, and when to have them, has opened the doors to lives not dominated by childbearing and child-rearing and has helped reduce gender inequality. As levels of reproductive choices have expanded over time around the world, women in most parts of the world have started having fewer children. This trend towards fewer children has had a number of benefits for women in particular, including better health for both themselves and their children, greater educational attainment, increased participation in paid employment, and improvements in how women and girls themselves are viewed and valued by society and within their households (Stoebenau and others, 2013). In many settings, this has formed part of a virtuous circle of empowerment, where greater access to reliable ways of controlling fertility has enabled an expansion of rights in other areas, which in turn has further contributed to their ability to fully exercise their reproductive rights. The right of both women and men to freely choose the number, timing and spacing of children is now almost universally acknowledged. Ultimately, almost all of the 4.3 billion people of reproductive age around the world today will have had inadequate access to sexual and reproductive health services at some point in their lives (Starrs and others, 2018). And that access is heavily dependent on prevailing gender norms. Power, voice and choice In all societies, reproduction is imbued with deep social significance and cultural meaning, playing a critical role in marking the transitions between the stages of life and in building social status and identity. As a result, behaviours associated with reproduction, including the manner in which families are formed and sexual behaviour, are regulated through norms, particularly those related to gender. Such gender norms shape and reinforce social, legal and economic systems. Patriarchal societies are often characterized by strong and pervasive sexual double standards (Heise and others, forthcoming), where masculinity is defined in ways that reward sexual prowess and where women are rewarded for purity and chastity. These gender-unequal norms and attitudes are often used to rationalize control over women’s sexuality and reproduction. A UN film-maker, editor-and mother-to-be checks her film at UN Headquarters. The symbol for international Women’s Year can be seen in the background and on the speaker to the right. New York, 1974. © UN Photo/M. Faust 75STATE OF WORLD POPULATION 2019 Concerns over maintaining women’s sexual purity underpin a range of harmful practices, such as child marriage and female genital mutilation, and are often used by men as a justification for gender-based violence. The harmful practices that result from unequal gender norms can further impede access to sexual and reproductive health services and limit a woman’s rights and choices in all areas of her life. Gender-based violence: Violence against women and girls is a human rights violation and public health concern across all countries. One in three women worldwide will experience physical or sexual violence at some point in her lifetime (García-Moreno and others, 2013). The existence and even threat of violence creates an environment where women are subjugated by men in sexual and reproductive health matters and are at increased risk of sexually transmitted infections and unwanted pregnancies. Child marriage: An estimated 650 million women alive today were married when they were children. Child marriage denies a girl agency and autonomy in her home and in sexual and reproductive decisions, reduces her chance of being educated, undermines her future and blocks her from realizing her full potential in life. Married girls are less likely than adult women to receive adequate medical care during pregnancy, and that lack of care, coupled with the fact that many married girls are not yet physically ready to give birth, presents risks for both mothers and babies. The lack of autonomy that child brides have in terms of being able to make reproductive decisions, combined with the restrictions on mobility that many child brides have, restricts their ability to make reproductive choices freely and their ability to act on those choices by visiting health providers. Fertility pressure and son preference: Because reproduction is seen as a fundamental part of social ideals of both masculinity and femininity, both men and women can face considerable pressure to prove their fertility early in marital relationships. A similar pattern is also seen in contexts where there is a strong preference for sons, itself a reflection of deeply held and inequitable views of the intrinsic value of men and women. In these contexts, women face extreme pressure to bear sons and may encounter violence, abandonment or stigma for birthing girls instead of boys. Under these circumstances, women have little power, voice or choice and therefore little autonomy. Gender inequality in law and practice: Laws and policies often reflect broader societal values around gender and can interfere with autonomous decisions about sexual and reproductive health matters. For example, a service provider may be prohibited from dispensing contraception to adolescent girls or unmarried women, or the criminalization of same-sex relations may lead members of the lesbian, gay, bisexual, transgender and intersex (LGBTI) community to avoid seeking sexual and reproductive health services. Inherently relational Sexual and reproductive decisions and the role gender plays in making them are inherently relational in that they involve interactions with others, particularly sexual or romantic partners but also extended family members, community members, or institutions such as clinics and hospitals. Agency is experienced by individuals within these relationships (Figure 5.2). In particular, three gender- dependent aspects of relationships are important in sexuality and reproductive decisions: the power of the individual; voice, or the degree to which individuals are able to articulate and advocate for their needs and desires; and the extent to which individuals have real choices. Together, power, voice and choice shape the degree of agency an individual has within a relationship, whether interpersonal or with an 76 CHAPTER 5 FIGURE 5.2 Agency depends on relations to individuals, communities and institutions CHOICE VO ICE PO W ER INDIVIDUAL AGENCY INDIVIDUAL SRH RESOURCES: • Comprehensive knowledge • Physical and mental health • Self-efficiency • Critical consciousness IMMEDIATE RELATIONAL AGENCY IMMEDIATE RELATIONAL SRH RESOURCES: Characteristics of relationship(s) • Emotional intimacy • Communication quality • Respect for bodily integrity • Social support DISTANT RELATIONAL AGENCY DISTANT RELATIONAL SRH RESOURCES: • Political, legal, and policy environment • Health system culture • Gender and reproductive norms • Physical, cultural and economic environment LI FE C O U R SE LIFEC O U R SE Source: Edmeades and others, 2018. © Mark Tuschman institution or society. For example, a woman may have considerable agency in her immediate relationship with her husband, but have far less in her relationship with her health provider or even her mother-in-law. Agency is also determined at different levels within each relationship. For example, at the individual level, agency is influenced by factors such as knowledge about sexual and reproductive health and rights, which can enable a person to more effectively advocate for themself and make informed choices. On another level, agency is dependent on factors such as the degree to which a partner respects the other’s bodily integrity or the degree to which there is freedom to express views about contraception. At a more distant level, where relationships are with institutions such as health systems or even the economy, agency depends on the responsiveness to individual needs. Within all these relationships, gender norms are key. They can build—or undermine—agency in all aspects of life, but especially in making sexual and reproductive health decisions. Efforts to expand access to sexual and reproductive health care and empower individuals to exercise their reproductive rights can benefit from an approach that does not just anticipate what women need, but that also takes into account that sexual and reproductive health decisions are influenced by gender and the way it plays out in relationships, including those with health care systems. Insights into these dynamics can help service providers better respond to the unique needs of each client. The evolution of gender in family planning The urgency with which policymakers and donors viewed the question of population growth in the late 1960s meant that many early family planning programmes were mainly about reducing fertility, not about enabling women to realize their right to make decisions about the timing and spacing of pregnancies. Programmes in the 1960s and 1970s therefore mostly focused on providing contraceptives to women, with little attention paid to the needs or desires of the women and men who might actually use them or to the social and gendered contexts within which reproductive decisions take place. Some of these early programmes were, at best, blind to gender, and at worst, partly responsible for perpetuating gender inequalities in the name of achieving greater use of contraception and lower fertility. The focus on women, and particularly married women, as the primary targets of family planning programmes served to reinforce existing gender norms that assumed the primary roles of women to be as wives and mothers. Programmes usually reflected the patriarchal societies in which they operated, with little attention paid to the gender dynamics around reproductive © Michele Crowe 78 CHAPTER 5 CHAMPION OF CHANGE Gita Sen For 35 years, Indian economist Gita Sen has pushed for feminist thinking to play its rightful role at the centre of national and international commitments to reproductive and sexual health and rights. As a leader of the feminist network Development Alternatives with Women for a New Era, known as DAWN, Sen joins scholars and gender equality advocates in deploying the tools of research and activism to push for gender justice. “We have to make development work for women and girls,” Sen says. “And fight for women’s human rights in every way we can.” Sen was prominent in mobilizing the global groundswell of civil society that forever shifted understanding of population and development at the 1994 International Conference on Population and Development (ICPD). Before that point, population conferences mostly involved men deliberating population targets. Words like “sex” and “reproduction” were rarely heard. But at the ICPD, they met what Sen calls the “irresistible force of the women’s movement.” With thousands of activists participating from the global South and North, women’s reproductive and sexual health and rights became the agenda. “Twenty-five years later, the world is a much more difficult place for human rights. The backlash against women and feminism has been huge,” Sen reflects. “But the fact that the ICPD agenda is still going tells us about the strength of what we achieved.” Sen has long argued that real change for women will only come when women mobilize to break down existing power structures and shift models of development. Among other issues, that means reorienting economies so that they no longer depend on women’s unpaid care work or segregation into the worst low-wage jobs. The goal should be much more than an equal share of a “poisoned” pie. About her lifetime commitment to gender equality, she muses, “I think living the life of a woman drives me. I was aware of gender inequality even as a girl, when a lot was about controlling what girls could be and do. The same did not apply to boys. Later, when I could see how the structures of power and inequality work in entire societies and economies—well, there was no going back.” “We have to make development work for women and girls, and fight for women’s human rights in every way we can.” © Suzanne Camarata decision-making or the general well-being of women. Meanwhile, little programming was directed towards men, aside from efforts to increase condom use. By the time of the 1974 World Conference on Population, governments, feminists and others had begun to express frustration with the demographic objectives that had been driving much of the international family planning movement up to that point. The growing evidence of violations of reproductive and human rights, the lack of input from those most directly affected by family planning programmes, as well as the lack of recognition of broader issues of social and economic world conferences on women (in 1975, 1980 and 1985), the establishment of the United Nations Development Fund for Women (UNIFEM), and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). The networks formed along the way provided a foundation for a strong feminist alliance that influenced the direction of the family planning movement for the subsequent two decades. At the International Conference on Population and Development (ICPD) in 1994, the reproductive rights movement took a great leap forward. The agenda was led by advocates for individual choices and development in some family planning programmes contributed to significant scepticism in developing countries about the intentions of the international family planning movement. This scepticism resulted in a concerted push by developing countries to adopt a more comprehensive approach to development that included measures to empower women to make their own decisions about the number, timing and spacing of births. This push gained momentum in the years that followed. The United Nations Decade for Women (1976–1985), for example, coincided broadly with three United Nations 80 CHAPTER 5 © UN Photo/Milton Grant The effect of gendered norms is most directly felt by those groups for whom either control over sexuality and reproductive behaviour is seen as particularly important or those whose behaviour does not conform to prevailing social expectations. The effect on sexual and reproductive health and rights can be profound, with real consequences for their health. Adolescents Adolescence is a time of life when the forces of gender socialization, where boys and girls learn how to behave in gendered ways that are acceptable to society, are particularly strong (John and others, 2017). However, it is also a time when individuals have particularly low levels of power, voice and choice in their lives, posing unique challenges to their access to services (Patton and others, 2016). This is particularly true for girls. Adolescents have special sexual and reproductive health needs. They may lack knowledge about health matters and how to access health care, restricting their ability to prevent both pregnancy and sexually transmitted infections. Social proscriptions against sexual activity among adolescents, particularly for those that are unmarried, increase the social costs and stigma associated with seeking services, heighten fears about loss of confidentiality while accessing services, and place legal restrictions on free access to services. Finally, many adolescents are married as children, a fundamental violation of their rights. These girls, even more than adolescents as a group, have been overlooked for much of the history of the family planning movement, despite their obvious levels of need and relevance to the broader goals of the movement. People with disabilities Women and young people with disabilities face multiple forms of discrimination including gender- based discrimination. Data disaggregated by disability, sex and age remain scarce but are indispensable for understanding the situation of people with disabilities and informing policies. Evidence from around the world on sexual and gender-based violence and the sexual and reproductive health and rights of women and young people with disabilities reveals that their rights are at serious risk. Young people with disabilities under the age of 18 are almost four times more likely than their peers without disabilities to be victims of abuse, with young people with intellectual disabilities, especially girls, at greatest risk. Girls and young women with disabilities are more likely to experience violence than either their male peers with disabilities or girls and young women without disabilities. Sexual minorities LGBTI individuals face additional barriers to sexual and reproductive health information and services. In most societies, where sexual norms dictate heterosexual behaviour with an emphasis on reproduction, these individuals face pervasive stigma and discrimination, often find their sexual practices criminalized, and face high levels of sexual violence (Starrs and others, 2018). As a result, members of LGBTI communities are often reluctant to disclose their sexual orientation or activities to health providers, inhibiting their ability to receive quality care that is reflective of their needs. This population continues to be marginalized within the family planning movement, reflecting both direct prejudice and the perception that reproduction and reproductive matters are not relevant to them. Women and young people with disabilities face multiple forms of discrimination including gender-based discrimination. Gender and vulnerability: adolescents, sexual minorities and people with disabilities 81STATE OF WORLD POPULATION 2019 the full consideration of gender in exercising reproductive rights. In 2010, the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) was established to help realize the global objective of achieving gender equality and women’s empowerment. In 2012, the World Bank focused its annual World Development Report specifically on gender inequality, declaring gender to be at the heart of development, and gender equality to have an intrinsic value rather than being a tool to achieve economic growth or other goals (World Bank, 2012). And in 2015, the United Nations endorsed the 2030 Agenda for Sustainable Development and its accompanying 17 Sustainable Development Goals, which include a target for “universal access to sexual and reproductive health and reproductive rights” and greatly expand the number of gender-related indicators used to monitor progress. Goal 5 aims broadly to achieve gender equality and to empower women and girls. It calls for, among other things, the integration of the recommendations of the ICPD Programme of Action in national plans, policies and programmes. Challenging the status quo: moving towards gender-transformational programmes Sexual and reproductive health programmes that take into account how gender influences agency in the context of relationships may be better equipped to help women and men exercise their reproductive rights (Edmeades and others, 2018). Tremendous progress has been made in upholding reproductive rights since 1969. Achieving future success, however, requires directly challenging the linkages between gender and reproduction and the patriarchal social norms that reinforce them. Family planning programmes, for example, have the power to become agents of gender transformation by building understanding around gender in ways that promote greater equality and allow greater freedom in sexual and reproductive choices. A number of promising approaches have been developed that point the way towards achieving these goals. Achieving full equality must involve engaging directly with men as full, equitable partners in ways that enable them to be both invested in their own health and supportive of women’s autonomy (Hook and others, 2018). Initiatives that have taken this approach include the Mobilizing Men programme, which was shown to reduce violence against women in India, Kenya and Uganda (Greig and Jerker, 2012). Another example is MenCare, a programme developed by Promundo and Sonke Gender Justice. It aims to challenge traditional norms around caregiving, encouraging and enabling men to take on roles that are not traditionally considered masculine, with the goal of achieving greater overall well-being, gender equality and health. In a similar vein, the Ecole des maris, or husbands’ schools, in Niger have found considerable success in encouraging husbands to engage in questions around sexual and reproductive health, both for themselves and for their wives. While engaging men in the process of gender transformation is critical to the long-term goals of enhancing reproductive rights, it is equally critical to continue empowering women and girls to reach their full potential. Of the changes seen in the past two decades in this regard, perhaps none will have as much impact on gender norms in the long run as the sharp increase in girls who are attending and staying in school. The experience and content of schooling can be a transformative experience for girls in particular, enhancing their understanding of their place in society and how this is shaped; providing them with the skills and information to exercise voice in their relationships with others and negotiate for their own 82 CHAPTER 5 CHAMPION OF CHANGE Lise-Marie Dejean Her voice animated, she continues: “We had to deconstruct the myths and mentalities. We had to help women take care of their bodies and their health.” Widely renowned in Haiti as a defender of women’s rights, Dejean, 75, was born not long after the 1934 founding of the country’s first feminist organization, which fought for women’s rights to education and political participation, including to vote. Dejean remembers going to women’s meetings with her mother. But it was not until she became a doctor and started looking at the extremely high maternal mortality rates in Haiti that she fully grasped the magnitude of gender discrimination and the lack of reproductive rights. Dejean decided to take her medical skills to some of the poorest and most remote regions of Haiti, seeing individual patients and educating midwives to extend available medical services. Later, as the head of a major Haitian women’s organization—Solidarite Fanm Ayisyèn or SOFA—she helped open women’s clinics in crowded urban slums. An ongoing advocacy plank has been a push to remove criminal penalties for abortion. Illegal, unsafe abortion, Dejean points out, accounts for about a third of the maternal mortality rate. “This is a fight for women’s lives,” she stresses. For Haitian women, the 1994 International Conference on Population and Development was a watershed moment. One key outcome was the creation of the first national women’s affairs ministry, led by Dejean. She had to overcome death threats and demonstrations to get it running, and even now, constant vigilance is required in the face of regular suggestions to shut it down. Dejean is undaunted. “Women are beginning to represent themselves as people with rights,” she says. “It’s a beautiful gain. When a person is psychologically ready to defend herself as a human being, that’s a big victory. She won’t get lost. She won’t allow anyone to walk over her.” “It’s a beautiful gain. When a person is psychologically ready to defend herself as a human being, that’s a big victory. She won’t get lost. She won’t allow anyone to walk over her.” © UNFPA/M. Bradley “I grew up in an atmosphere where women’s lives were always put aside,” Lise-Marie Dejean remembers. “Women were constantly reminded by men and tended to believe that their bodies did not belong to them.” CHAMPION OF CHANGE Sivananthi Thanenthiran As a younger feminist activist, Sivananthi Thanenthiran used to think that reproductive rights battles had mostly been won in the 1960s. Enough focus had been put on women and their bodies. She chose instead to take part in seminal initiatives like the Women’s Candidacy Initiative in her native Malaysia. It backed political candidates running on women’s rights issues. But in 2006, as she worked on a book on reproductive health in Asia, she began looking at numbers and speaking to people, and became outraged. “It was really shocking to me that these battles were still very alive and present. I needed to do something about it.” Thanenthiran joined activists at the Asian-Pacific Resource and Research Centre for Women (ARROW), eventually becoming the organization’s Executive Director. Active in 17 countries, ARROW advocates for the full realization of women’s sexual and reproductive health and rights so that they can be equal citizens in all aspects of life. From social media to the halls of international political talks, Thanenthiran has become a prominent voice in systematically tracking gaps in sexual and reproductive rights as well as making links to issues that worsen the shortfalls, such as poverty and climate change. In a fragmented and deeply unequal world, she mobilizes people and policymakers to push back against what she calls the “bargaining” away of social rights amid a struggle over increasingly scarce economic and other resources. Thanenthiran is proud of young feminists now stepping up to take on the mantle of the movement, including at ARROW. They have inherited a world where gender equality is more widely recognized than it ever has been. But the battle is far from over, she cautions. Much depends on being bold while remaining united. “You only get what you fight for. We need to put our perspectives out there and forge ahead, fearlessly.” “You only get what you fight for. We need to put our perspectives out there and forge ahead, fearlessly.” © The Asian-Pacific Resource & Research Centre for Women (ARROW) CHAPTER HIGHLIGHTS • Of all the obstacles to the achievement and exercise of human rights, including reproductive rights, few have proven to be as challenging to overcome as those based on gender. • Gender, the web of expectations and norms within a society that together define what are appropriate male and female behaviours, roles and characteristics, is learned, internalized and reinforced through social interactions with others, thus having a profound influence on every domain of life. • Gender inequality limits the ability of women to freely make fundamental decisions about when and with whom to have sex, about the use of contraception or health care, and about whether and when to seek employment or whether to seek higher education. • Gender norms constrain the reproductive rights of men by creating strong social pressures to prove fertility, engage in risky behaviours, and have many children. • Gender-unequal norms and expectations magnify the negative effects of other impediments to rights and choices. • Sexual and reproductive decisions and the role gender plays in making them are inherently relational in that they involve interactions with others, particularly sexual or romantic partners but also extended family members, community members, or institutions such as clinics and hospitals. • Reproductive rights cannot be fully realized in the absence of greater gender equality. • Sexual and reproductive health programmes that take into account how gender influences agency in the context of relationships and seek to promote greater equality are better equipped to help both women and men exercise their reproductive rights. CHAMPION OF CHANGE Sivananthi Thanenthiran As a younger feminist activist, Sivananthi Thanenthiran used to think that reproductive rights battles had mostly been won in the 1960s. Enough focus had been put on women and their bodies. She chose instead to take part in seminal initiatives like the Women’s Candidacy Initiative in her native Malaysia. It backed political candidates running on women’s rights issues. But in 2006, as she worked on a book on reproductive health in Asia, she began looking at numbers and speaking to people, and became outraged. “It was really shocking to me that these battles were still very alive and present. I needed to do something about it.” Thanenthiran joined activists at the Asian-Pacific Resource and Research Centre for Women (ARROW), eventually becoming the organization’s Executive Director. Active in 17 countries, ARROW advocates for the full realization of women’s sexual and reproductive health and rights so that they can be equal citizens in all aspects of life. From social media to the halls of international political talks, Thanenthiran has become a prominent voice in systematically tracking gaps in sexual and reproductive rights as well as making links to issues that worsen the shortfalls, such as poverty and climate change. In a fragmented and deeply unequal world, she mobilizes people and policymakers to push back against what she calls the “bargaining” away of social rights amid a struggle over increasingly scarce economic and other resources. Thanenthiran is proud of young feminists now stepping up to take on the mantle of the movement, including at ARROW. They have inherited a world where gender equality is more widely recognized than it ever has been. But the battle is far from over, she cautions. Much depends on being bold while remaining united. “You only get what you fight for. We need to put our perspectives out there and forge ahead, fearlessly.” “You only get what you fight for. We need to put our perspectives out there and forge ahead, fearlessly.” © The Asian-Pacific Resource & Research Centre for Women (ARROW) interests; and protecting them from harmful practices such as child marriage. Other programmes, such as the Abriendo Oportunidades in Guatemala, implemented by the Population Council, have also found success in helping girls successfully navigate the transition to adulthood, thus literally opening up opportunities that may shape the remainder of their lives. Comprehensive sexuality education, too, is helping transform gender norms through age-appropriate curricula that provide information about sexuality and reproduction but that also focus on gender and power in relationships. UNESCO and UNFPA support comprehensive sexuality education in schools and through community organizations in dozens of developing countries (Haberland, 2015). Encouraging boys and girls to openly discuss questions around sexuality will result in more communicative partnerships where both partners feel free to share their desires and preferences in a mutually respectful manner, enhancing both the relationships of women and men and improving reproductive outcomes. Achieving the broader goal of empowerment for all will require the sexual and reproductive health community to make a renewed commitment to building a deeper understanding of the role of gender and how gendered roles and expectations shape social interactions in matters of sexual and reproductive health. Only by addressing these root causes will the field be able to finally claim to have effectively liberated humanity from what Goldberg (2009) describes as the “intertwined tyrannies of culture and biology,” an effort that remains one of the most ambitious undertaken in human history. 85STATE OF WORLD POPULATION 2019 © Brian Sokol/Panos Pictures In the twenty-first century, as long- running conflicts have proliferated and climate-related disasters have intensified, international consensus on this priority has deepened. States have approved successive commitments to address reproductive health concerns and gender-based violence in crisis settings, and responders have honed expertise on life-saving practices. A world of trouble The world today faces unprecedented levels of humanitarian need. Worldwide, some 136 million people were in need of humanitarian aid in 2018; 91 million received aid in 2017 (OCHA, 2018). Numbers of refugees, migrants and internally displaced people have mounted steadily in recent years. Factors driving the increase include long-running conflicts that stem from and exacerbate countries’ fragility; deadly storms related to climate change; and unpredictable events like earthquakes. The breakdown in security, loss of shelter and disruption of water, food, sanitation and health services all combine to create enduring hardship for people affected by crises. Many are compelled to move and undergo additional suffering during the journey. Others languish in refugee settlements, sometimes for decades. Every day, more than 500 women and girls in countries with emergency settings die during pregnancy and childbirth, due to the absence of skilled birth attendants or emergency obstetric procedures, and due to unsafe abortions (UNFPA, 2018b). Insecurity and dislocation increase vulnerabilities to rape, exploitation and HIV acquisition, including among women, adolescent girls and boys, disabled people and individuals identifying as lesbian, gay, bisexual, transgender or intersex. The causes and severity of displacement vary considerably between and within countries, but it is invariably the least advantaged who suffer hardest and longest. “Poverty WHEN SERVICES COLLAPSE Since the mid-1990s, governments, aid organizations and international institutions have increasingly delivered services to women and adolescent girls whose choices have been constrained by wars and natural disasters. CHAPTER 6 87STATE OF WORLD POPULATION 2019 and inequality, political instability and state fragility, water stress and food insecurity, climate change and environmental degradation, unsustainable development and poor urban planning combine in different ways in different countries to increase people’s exposure and vulnerability,” according to the Internal Displacement Monitoring Centre. Notably, it states, “low levels of human development correlate strongly with disaster displacement risk” (IDMC, 2018). Data consolidated by United Nations agencies, the European Commission, governments and non-governmental organizations show that the risk of humanitarian crises and disasters that could overwhelm national response capacities is high in at least 12 countries. (Figure 6.1; IASC and European Commission, 2019). Protracted crises: the new normal Wars have always impacted civilian populations and frequently produced mass displacements. In 1969, as UNFPA was coming into being, the Biafran War was precipitating a massive famine and humanitarian crisis. In 1994, the year of the International Conference on Population and Development (ICPD), conflict in the former Yugoslavia and civil war in Rwanda involved massive attacks on civilians. Today, “protracted crises are the new normal,” according to the © Ali Arkady/VII/Redux FIGURE 6.1 Humanitarian crises and disasters could overwhelm countries’ response capacity South Sudan Risk: 8.9 3-year trend: Hazard: 8.2 Vulnerability: 9.2 Lack of coping capacity: 9.3 Democratic Republic of Congo Risk: 7.6 3-year trend: Hazard: 7.1 Vulnerability: 7.6 Lack of coping capacity: 8.0 Yemen Risk: 7.8 3-year trend: Hazard: 8.1 Vulnerability: 7.5 Lack of coping capacity: 7.9 Somalia Risk: 9.1 3-year trend: Hazard: 9.0 Vulnerability: 9.2 Lack of coping capacity: 9.0 Central African Republic Risk: 8.5 3-year trend: Hazard: 7.9 Vulnerability: 8.8 Lack of coping capacity: 8.7 Nigeria Risk: 6.8 3-year trend: Hazard: 7.2 Vulnerability: 6.6 Lack of coping capacity: 6.6 Chad Risk: 7.2 3-year trend: Hazard: 5.5 Vulnerability: 7.6 Lack of coping capacity: 8.9 Syria Risk: 7.1 3-year trend: Hazard: 8.6 Vulnerability: 7.4 Lack of coping capacity: 5.7 Afghanistan Risk: 7.8 3-year trend: Hazard: 8.8 Vulnerability: 7.2 Lack of coping capacity: 7.5 Iraq Risk: 7.2 3-year trend: Hazard: 8.6 Vulnerability: 6.1 Lack of coping capacity: 7.0 Sudan Risk: 7.1 3-year trend: Hazard: 7.3 Vulnerability: 6.9 Lack of coping capacity: 7.0 Ethiopia Risk: 6.8 3-year trend: Hazard: 7.2 Vulnerability: 6.6 Lack of coping capacity: 6.6 INFORM RISK INDEX The 2019 INFORM Global Risk Index is made up of three dimensions—hazards and exposure, vulnerability and lack of coping capacity. This map shows details for the 12 countries with the highest overall risk. Legend is based on the INFORM 2019 Global Risk Index database. Low 2.1–3.5 Medium 3.6–5 Very high 6.6–10 High 5.1–6.5 Increasing risk Stable Decreasing risk Very low 0–2 KEY Not included in INFORM 89STATE OF WORLD POPULATION 2019 Global Humanitarian Overview 2018 of the United Nations Office for the Coordination of Humanitarian Affairs (OCHA, 2018). Long-term dislocation due to intractable conflicts has driven the unprecedented increase in internally displaced people, refugees and migrants in recent years, creating ever-growing needs for assistance and a mounting challenge for humanitarian actors. In eight years, the civil war in the Syrian Arab Republic has displaced more than half of the country’s population. At the end of 2017, there were 2.6 million refugees from Afghanistan, 2.4 million from South Sudan, and nearly 1 million from Somalia (UNHCR, 2018). The world’s largest humanitarian crisis today is in Yemen, where war has caused the economy, social services and livelihoods to collapse. Four out of five people, 22 million, are in need, many on the brink of famine (OCHA, 2018). Around the world, nearly 12 million people were newly displaced by armed conflict, terrorism and communal or political violence in 2017, up from 6.9 million the previous year; 18 million were uprooted by weather-related disasters (IDMC, 2018). At the start of 2018, there were 40.3 million people internally displaced by conflict and 22.5 million refugees—the highest numbers ever seen (IOM, 2017). Conflict was a major element in 19 of the 21 situations where the United Nations coordinated humanitarian response plans in 2018. Most of these crises have gone on for five years or more; three (in the Democratic Republic of the Congo, Somalia and Sudan) have persisted for over 18 years (OCHA, 2018). The number of forcibly displaced people has risen by over 50 per cent in the past decade. In 2017, ethnic violence forced 655,500 Rohingya people to flee Myanmar into Bangladesh. In the same year, 2.9 million Syrians, 2.2 million Congolese and 1.4 million Iraqis were newly displaced by conflict (IDMC, 2018). The effects of protracted internal or external conflict can © Lynsey Addario/Getty Images persist long after hostilities end. In 2017, the world’s largest displaced population— 7.7 million people— were living in Colombia, despite the achievement of a peace deal in 2016. Extensive conflict often results in a breakdown of authority and economic collapse, necessitating large-scale humanitarian assistance. Security threats to relief workers increase the challenges. Affected people in insecure places of refuge remain vulnerable to new outbreaks of violence and displacement, and each round makes them less resilient (IDMC, 2018). Those who flee violence are more likely to remain in their own countries than to cross borders. Many long-term displaced people settle among host communities, often in urban areas, straining services and complicating relief efforts. Climate-related disasters More people are displaced by floods, storms, droughts and wildfires than by conflict, though many of these evacuations are short term. Since 2008, new weather- related displacements worldwide have averaged around 25 million per year; typhoons and hurricanes are a leading cause (Figure 6.2). Small countries and island States in particular face increasing risks of economic and social devastation due to disasters (IOM, 2017). Poverty and hardship are expected to increase in some areas as global warming increases, contributing to further displacement. Indigenous peoples and local communities dependent on agricultural or coastal livelihoods, particularly in least developed regions, are especially vulnerable. Climate change is also believed to be a risk factor in outbreaks of infec- tious diseases like Ebola and Zika, through the spread of disease vectors and competition between humans and animals for dwindling habitat and resources (Deese and Klain, 2017). Epidemics in West Africa and more recently in the Democratic Republic of the Congo have had devastating impacts in communities already incapacitated by conflict. Flood N um be r of d is as te rs p er d is as te r ty pe DroughtStorm 0 20 40 60 80 100 120 140 160 180 200 220 240 Year 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 FIGURE 6.2 Disasters by type, 1969–2017 Source: EM-DAT: The Emergency Events Database – Unversité catholique de Louvain (UCL) – CRED, D. Guha-Sapir – www.emdat.be, Brussels, Belgium 91STATE OF WORLD POPULATION 2019 Millions on the move Displacement fuelled by conflict and desperation has contributed to a dramatic rise in international and internal migration in recent years. While refugees and internally displaced people are a relatively small percentage of all migrants, they frequently find themselves in highly vulnerable situations and most often need assistance and protection (IOM, 2017). Migrants displaced by conflict in the Middle East and Africa have endured particular hardship. Thousands have died attempting to cross the Mediterranean. The closure of transit routes in Europe and the resort to smugglers has exposed many migrants to risks of exploitation or human trafficking (IOM, 2017). Women and adolescents at risk Every humanitarian crisis— whether due to conflict or natural disaster—causes systems to break down, increasing multiple needs for protection and services. Especially in the initial rush to provide food and shelter, responders may overlook the particular ways a crisis can increase the vulnerability of women and girls and threaten their lives. Experiencing a natural disaster or fleeing violence can be extremely harrowing for pregnant women and mothers of small children. Trauma and malnutrition are dangerous during pregnancy, and during emergencies many women miscarry or deliver prematurely. The lack of even basic conditions for a clean delivery increases the risk of a fatal infection for both mother and child (UNFPA, 2004). Complications of childbirth in the absence of skilled birth attendants or emergency obstetric care often lead to death or serious injury such as obstetric fistula. In the world’s most densely populated refugee settlement at Cox’s Bazar in Bangladesh, only one in five Rohingya mothers gives birth at a health centre, although there are facilities staffed by dozens of trained midwives. Some women are reportedly prevented by their husbands from going outside their makeshift homes; others who have been raped are said to fear stigma and discrimination from the wider community (UNFPA Bangladesh, 2018). The disruption of family planning is also life-threatening. Sexually active women without access to contraceptives, due to a lack of services or legal restrictions, risk unintended pregnancy and sexually transmitted infections including HIV. Many who become pregnant resort to unsafe abortion, a leading cause of maternal death and injury. Safe abortion services are often minimal or non-existent in crisis settings, even where allowed under the law, and life- saving post-abortion care is often unavailable. Conditions of displacement and the disruption of families make women and girls susceptible to rape and assault. Adolescent girls, the disabled, and ethnic and sexual minorities may be especially at risk. Recent research indicates that at least one in five refugees or displaced women in complex humanitarian settings have experienced sexual violence, though it is often unreported (Vu and others, 2014). Survivors suffer psychological and physical trauma, as well as unwanted pregnancies and sexually transmitted infections, including HIV. People with disabilities are particularly vulnerable to sexual violence, and may have more difficulty accessing help after an attack. Men and boys are also at risk, and the norms that discourage women and girls from reporting assaults can be even more of a deterrent to coming forward in their case (IFRC, 2018). Fear of sexual assault or exploitation and abuse restrict the mobility of many refugee and displaced women. Some families in dire circumstances resort to child marriage, hoping that marrying their daughters off will protect the girls from violence. 92 CHAPTER 6 CHAMPION OF CHANGE Nadine Alhraki Newly married at the age of 21, Nadine Alhraki was studying geography in a university in Damascus, Syria, six years ago. Since then, she has been a refugee. As Syria descended into war and chaos, she and her husband joined 5 million people fleeing their country. Across the border in Jordan, they found safety in the sprawling Za’atari Refugee Camp. Three days after she arrived, despite wrenching personal upheaval, Alhraki signed on as a volunteer with Questscope, a humanitarian organization that serves young people. A workshop trained her to teach and mentor youth and adolescents on reproductive health. “These are important issues for all people, refugees or not,” Alhraki says. “In our own community, we know there is a gap in correct information and young people getting the services they need.” At a Questscope youth centre, Alhraki leads education sessions taking up issues such as safe motherhood for young men and women aged 18–24, and the stages of puberty for those under age 18. Maintaining a friendly atmosphere is part of encouraging interactive discussions around practical questions, such as what to do when your period starts. The sessions often mark the first time that younger camp residents have had any information about reproductive health. “When people realize they have had the wrong information, and hear the right information and how that can impact their life, it makes a huge change,” Alhraki says. Sessions empower youth to challenge stereotypes, including those related to gender, and to think up and act on their own ideas. In one activity that Alhraki remembers well, young people distributed baby slings to mothers and fathers, along with messages about how husbands can help their wives in caring for children. Now pregnant with her first child, Alhraki is determined to keep helping young residents of Za’atari. But her biggest dream is that her own child will not have to grow up as a refugee. And that he or she will enjoy full access to quality health services and education, and complete awareness of reproductive health. On the last, she laughs. “Of course, I will teach my child all I know, now that I’m an expert!” “When people realize they have had the wrong information, and hear the right information and how that can impact their life, it makes a huge change.” © Helal Khlaif Developing a response grounded in rights and choices In the humanitarian response to emergencies around the world, women’s needs and vulnerabilities have not always received the same level of attention as the need for food and shelter. It was only in the 1990s that humanitarian actors adopted a more consistent focus on the rights and needs of crisis-affected women and girls (Chynoweth, 2015). The first edition of the Handbook for Emergencies issued by the Office of the United Nations High Commissioner for Refugees (UNHCR) in 1982 had stipulated that primary health care for displaced communities should include “maternal and child care, including family planning.” In practice, however, contraceptive services were not typically included in refugee health care (Wulf, 1994). In 1991, UNHCR issued Guidelines on the Protection of Refugee Women, which framed pro- tection concerns within established international norms including the Universal Declaration on Human Rights and the Convention on the Elimination of All Forms of Discrimination Against Women. In addition to “protection against forced return to their countries of origin; security against armed attacks and other forms of violence; protection from unjustified and unduly prolonged detention; a legal status that accords adequate social and economic rights; and access to such basic items as food, shelter, clothing and medical care,” it noted, “refugee women and girls have special protection needs that reflect their gender: they need, for example, protection against manip- ulation, sexual and physical abuse and exploitation, and protection against sexual discrimination in the delivery of goods and services” (UNHCR, 1991). The Women’s Commission for Refugee Women and Children in 1994 published Refugee Women and Reproductive Health Care: Reassessing Priorities. This influential report identified critical gaps in care for women, including sex education, family planning, HIV education and prevention, supplies for menstruating women, and services to assist survivors of sexual abuse, rape and forced prostitution (Wulf, 1994). The transformational ICPD in 1994 elevated global recognition of women’s agency with regard to sex and reproduction. In its recommendations on realizing reproductive health and rights, the ICPD Programme of Action included displaced people, refugees and migrants affected by environmental degradation, natural disasters and internal conflicts, and called on States to address the root causes, “especially those related to poverty.” It called for protection of people who, “given the forced nature of their movement … often find themselves in particularly vulnerable situations, especially women, who may be subjected to rape and sexual assault in situations of armed conflict.” It urged governments “to ensure that internally displaced persons receive … basic health-care services, including reproductive health services and family planning” and to provide refugees with “health services including family planning” (United Nations, 2014a). In 1999, a five-year review of progress in implementing the Programme of Action elaborated on the need to address protection concerns and ensure the sexual and reproductive health of refugees and displaced people (United Nations, 1999). Setting standards for reproductive health care In 1995, some 40 intergovernmen- tal and government agencies and non-governmental organizations involved in relief work formed the Inter-Agency Working Group on Reproductive Health in Refugee Situations, now the Inter-Agency Working Group on Crises. The coalition, spearheaded by UNFPA and UNHCR, developed guide- lines for interventions at different phases of crises; on safe mother- hood; sexual and gender-based violence; sexually transmitted diseases, including HIV; and family planning. These were elaborated in Reproductive Health 94 CHAPTER 6 in Emergency Situations: An Inter-agency Field Manual (UNHCR, 1999). The stated cornerstone of the manual was the principle: “Reproductive health care should be available in all situations and be based on the needs and expressed demands of refugees, particularly women, with full respect for the various religious a

View the publication