By Choice, Not by Chance: Family Planning, Human Rights, and Development (2012)

Publication date: 2012

state of w orld population 20 12 By choice, not by chance: fam ily planning, hum an rights and developm ent United Nations Population Fund 605 Third Avenue New York, NY 10158 USA Tel. +1-212 297-5000 ©UNFPA 2012 USD $24.00 ISBN 978-1-61800-009-5 sales no. E.12.III.H.1 E/11,000/2012 Printed on recycled paper. state of world population 2012 FAMILY PLANNING, HUMAN RIGHTS AND DEVELOPMENT BY CHOICE, NOT BY CHANCE Delivering a world where every pregnancy is wanted, every childbirth is safe and every young person's potential is fulfilled. 9 7 8 1 6 1 8 0 0 0 0 9 5 52400 14 November 2012 All countries should take steps to meet the family-planning needs of their populations as soon as possible and should, in all cases by the year 2015, seek to provide universal access to a full range of safe and reliable family-planning methods and to related reproductive health services which are not against the law. The aim should be to assist couples and individuals to achieve their reproductive goals and give them the full opportunity to exercise the right to have children by choice. —Programme of Action of the International Conference on Population and Development, paragraph 7.16 The State of World Population 2012 This report was produced by the Information and External Relations Division of UNFPA, the United Nations Population Fund EDiTorial TEam Editor: Richard Kollodge Editorial associate: Robert Puchalik Editorial and administrative associate: Mirey Chaljub Distribution manager: Jayesh Gulrajani ackNoWlEDgEmENTS The editorial team is grateful to the report's advisory group at UNFPA for guiding the conceptualization, direction and development of the report and for providing invaluable feedback on drafts. The group included: Alfonso Barragues, Beatriz de la Mora, Abubakar Dungus, Werner Haug, Michael Herrmann, Mona Kaidbey, Laura Laski, Edilberto Loaiza, Kechi Ogbuagu, Niyi Ojuolape, Nuriye Ortayli and Jagdish Upadhyay. Drafts were also reviewed by Anne-Birgitte Albrectsen, Klaus Beck, Ysabel Blanco, Delia Barcelona, Saturnin Epie, François Farah, Kate Gilmore, Elena Pirondini and Ziad Rifai. Hafedh Chekir, Thea Fierens, Nobuko Horibe, Bunmi Makinwa, Marcela Suazo also contributed to the substantive development of the report. Additional advisory support was provided by Mohamed Afifi, Monique Clesca, Jorge Cordoba, Adebayo Fayoyin, Sonia Heckadon, Gabriela Iancu, Yanmin Lin, Suzanne Mandong, William Ryan and Sherin Saadallah. The editorial team is also grateful to Marisabel Agosto for her sustained involvement with the report through development, writing and editing. Many thanks also to Karin Ringheim and David Levinger for their contributions to the report. aboUT ThE aUThorS margaret greene Margaret Greene (lead writer-researcher) has worked for nearly 20 years on the social and cultural determinants of health, adolescent reproductive health, development policy and gender. She is widely known for her research and advocacy on the conditions faced by girls and women in poor countries and on engaging men and boys for gender equality. She currently directs GreeneWorks, a consulting group working to promote social change for health and development. She is Chair of the Board of Promundo-USA and of the Willows Foundation, which provides reproductive health services in Turkey. Dr. Greene received her doctorate and master of philosophy degrees in demography from the University of Pennsylvania, and a bachelor of arts in linguistics from Yale University. Shareen Joshi Shareen Joshi (researcher-writer for Chapter 4) is a visiting professor of international development at Georgetown University’s School of Foreign Service in Washington, DC and teaches courses in economics and political development; poverty, gender and politics; and integrated approaches to sustainable development. At Yale University, she received her doctorate in economics, a master of philosophy in economics, and a master of arts in economics. She holds a bachelor’s degree in mathematics from Reed College in Portland, Oregon. omar robles Omar Robles works as a consultant on health, gender and development. He has led training in gender-sensitive programming for UNFPA in Indonesia and is currently a gender advisor on CARE International’s emergency deployment roster. Prior to consulting, Omar was a gender and health policy advisor on the global USAID Health Policy Initiative, implemented by Futures Group. He holds a master of science degree in public health, health policy and management from the University of North Carolina’s Gillings School of Global Public Health and a bachelor’s degree in journalism and mass communication, also from the University of North Carolina. Cover photo: Mother and child, Pakistan. ©Panos/Peter Barker state of world population 2012 The right to family planning1 page 1 Analysing data and trends to understand the needs2 Foreword page ii page 17 Challenges in extending access to everyone3 The social and economic impact of family planning4 page 39 page 71 The costs and savings of upholding the right to family planning5 page 87 Making the right to family planning universal 6 page 97 Bibliography page 117 Indicators page 106 Overview page iv BY CHOICE, NOT BY CHANCE FAMILY PLANNING, HUMAN RIGHTS AND DEVELOPMENT Teenage girl attends informational meeting about family planning in Dominica. ©Panos/Philip Wolmuth t ii FOREWORD The ICPD marked a great paradigm shift in the field of population and development, replac- ing a demographically driven approach to family planning with one that is based on human rights and the needs, aspirations, and circumstances of each woman. The impact of this milestone has been nothing short of revolutionary for the hundreds of mil- lions of women and young people who have over the past 18 years gained the power and the means to avoid or delay pregnancy. The results of the rights-based approach to sex- ual and reproductive health and family planning have been extraordinary. Millions more women have become empowered to have fewer children and to start their families later in life, giving them an opportunity to complete their schooling, earn a better living and escape the trap of poverty. Countless studies have shown that women who use family planning are generally healthier, better educated, more empowered in their households and communities and are more economically productive. And in homes where parents have the power and the means to decide on the number and spacing of pregnancies, their children tend to be healthier, do better in school and grow up to earn higher incomes. And now there is indisputable evidence that when family planning is integrated into broader economic and social development initiatives, it can have a positive multiplier effect on human development and the well-being of entire nations. The visionaries who forged the ICPD Programme of Action in 1994 have much to be proud of; the progress made since then has been remarkable. Still, wherever I travel, I continue to meet women and girls who tell me they are unable to exercise their right to family planning and end up having more children than they intend, burden- ing them economically, harming their health, and undermining opportunities for a better life for themselves and their families. Recent statistics show that 867 million women of childbearing age in developing countries have a need for modern contraceptives. Of that total, 645 million have access to them. But a stagger- ing 222 million still do not. This is inexcusable. Family planning is a human right. It must there- fore be available to all who want it. But clearly this right has not yet been extended to all, especially in the poorest countries. Obstacles remain. Some have to do with the quality and availability of supplies and services, Foreword The right of the individual to freely and responsibly decide how many children to have and when to have them has been the guiding principle in sexual and reproductive health, including family planning for decades, but especially since 1994, when 179 governments came together and adopted the groundbreaking Programme of Action of the International Conference on Population and Development, the ICPD. iiiTHE STATE OF WORLD POPULATION 2012 but many others have to do with economic circumstances and social constraints. Regardless of the type of obstacle, it must be removed. Recognizing the urgent need to address this lingering and massive unmet need for fam- ily planning, UNFPA, the United Kingdom Department for International Development, the Bill and Melinda Gates Foundation and other partners organized a summit in July 2012 that garnered $2 billion in funding commitments from developing countries and $2.6 billion from donor nations. This new funding aims to make voluntary family planning available to an addi- tional 120 million women and adolescent girls in developing countries by 2020. But additional resources and political commitments are needed to meet the entire unmet need. Family planning is central to many of the international community’s goals—to improve the health of mothers and children, to promote gender equality, to increase access to education, to enable young people to fully participate in their economies and communities, and to reduce poverty. It must therefore be fully integrated into all current and future development initiatives, including the global sustainable development framework that will build on the Millennium Development Goals after 2015. The international community made a com- mitment in 1994 to all women, men and young people to protect their rights as individuals to make one of life’s most fundamental decisions. It is high time we lived up to that commitment and made voluntary family planning available to all. Dr. Babatunde Osotimehin United Nations Under-Secretary-General and Executive Director UNFPA, the United Nations Population Fund UNFPA Executive Director Babatunde Osotimehin pledging continued assistance for reproductive health and voluntary family planning in the Philippines. ©UNFPA t iv OVERVIEW Family planning is critical to individuals’ abilities to exercise their reproductive rights, and other basic human rights. The international consensus around the right to decide the timing and spacing of preg- nancies is the result of decades of research, advocacy and debate. Reflecting this consensus, there is now a renewed focus in the development community about the need for more policy and programmatic action to ensure that all people can equally exercise their right to access high-quality services, supplies and information when they need them. A broad range of services must be provided to ensure sexual and reproductive health. Family planning is just one such service, which should be integrated with: • primary health care as well as antenatal care, safe delivery and post-natal care; • prevention and appropriate treatment of infertility; • management of the consequences of unsafe abortion; • treatment of reproductive tract infections; • prevention, care and treatment of sexually transmitted infections and HIV/AIDS; • information, education and counselling on human sexuality and reproductive health; • prevention and surveillance of violence against women and care for survivors of violence; and • other actions to eliminate traditional harmful practices, such as female genital mutilation/cutting. This report focuses on family planning and rights because: • The basic right of all couples and individuals to decide freely and responsibly on the timing and number of their children is understood as a key dimension of reproductive rights, along- side the right to attain the highest standard of sexual and reproductive health, and the right of all to make decisions concerning reproduc- tion free of discrimination, coercion and violence. • A person’s ability to plan the timing and size of his or her family closely determines the realization of other rights. • And the right to family planning is one that many have had to fight for and still today requires advocacy, despite the strong global rights and development frameworks that support it. Overview One hundred seventy-nine governments affirmed individuals’ right to family planning at the International Conference on Population and Development, ICPD, in 1994, when signatories of the ICPD Programme of Action stated that, “the aim of family planning programmes must be to enable couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so.” This affirmation marked a paradigm shift in the way governments and international organizations looked at development and population issues. vTHE STATE OF WORLD POPULATION 2012 The shift towards a rights-based approach to family planning The value of a rights-based approach to fam- ily planning is that it treats individuals as full human beings in their own right, as active agents, not as passive beneficiaries. This approach is built upon the explicit identifica- tion of rights-holders (individuals) and the duty-bearers (governments and others) that are responsible for delivering on rights. Today, fam- ily planning is widely accepted as a foundation for a range of rights. For this reason, a rights-based approach may be the premise for the global sustainable development framework that will succeed the Millennium Development Goals, MDGs, which will conclude in 2015. In a recent essay about the post-2015 agenda, the Office of the United Nations High Commissioner for Human Rights stressed that the “increasing global embrace of human-rights-based approaches to develop- ment, based on the principles of participation, accountability, non-discrimination, empower- ment and the rule of law, offers hope that a more enlightened model of development is now emerging.” Rights-based approaches—to family planning or other aspects of sustainable development— can lead to greater equity, equality and non- discrimination. Children by choice, not by chance This State of World Population report explains why family planning is a human right and what that means for individuals in developing and developed countries alike. The report synthesizes several frameworks for health, reproductive health, and family planning, while also building upon them by: elevating the discussion about the importance of engaging men in family planning as partners in relationships and in life, and as beneficiaries of services; underscoring the need to collect more data and devise programming that also reaches unmarried young and older people alike; draw- ing attention to the high rates of unintended and unwanted pregnancies in both developing and developed countries; and showing how changing sexual behaviour in different social contexts and across age groups is increasingly at variance with old patterns about sexuality, which represent a barrier to making family planning available and accessible to all. Women who are able to plan their families are more likely to be able to send their children to school. And the longer children stay in school the higher their lifetime earnings will be, helping them to lift themselves out of poverty. ©Lindsay Mgbor/UK Department for International Development t vi OVERVIEW Chapter 1 provides an overview of the international commitments to sexual and reproductive health, including family planning, with a particular emphasis on the ICPD Programme of Action and the renewed international commit- ment to invest in family planning in a post-MDG sustainable development agenda. The chapter outlines the freedoms and entitlements associated with reproductive rights, drawing from civil, political, economic, social and cultural rights. The chapter outlines States’ obligations to fulfil citizens’ right to family planning and an accountability framework to monitor implementation. Chapters 2 and 3 draw on research and programmatic evidence to describe global trends and show disparities in enjoyment of the benefits of family planning. Chapter 2 calls attention to inequalities in several key family planning indicators. Inequalities in access to and use of family planning services are examined across levels of wealth, education and place of residence. The chapter discusses why people use specific methods, the predominant use of female methods, and the impact of family planning use on abortion. Chapter 3 discusses the relatively high unmet needs of specific large—and largely neglected—sub-populations: young people, unmarried people of all ages, men and boys, the poor, and other socially marginalized groups with restricted access to information and services. This chapter discusses how the dynamics of sexual activity and marriage patterns are changing and how those changes affect the need for family planning. What is a rights-based approach to family planning? Where have gains been made and who cannot yet fully exercise their right to family planning? The report is structured to answer the following key questions: Maternal health in Tajikistan. ©UNFPA/Natasha Warcholak t viiTHE STATE OF WORLD POPULATION 2012 Chapter 4 summarizes the social and economic benefits of expanding access to family planning, with an emphasis on underserved populations in greatest need. Reductions in maternal mortality and morbidities, gains in women’s education and improved life prospects for children are among the benefits to individuals, with broad implications for families, communities and coun- tries. When governments prioritize family planning as part of an integrated development strategy, they make a strategic investment that both fulfils their obligation to protect citizens’ rights and helps alleviate poverty and stimulate economic growth. Government and development agencies have to invest more resources to real- ize the individual and broader social and economic gains that can be achieved through a rights-based approach to family planning. Chapter 5 consolidates the latest research on costing, which finds that unmet need will continue to rise as more young people enter their reproductive years. Research confirms that family planning is a cost-effective public health investment. Taking into consideration its contributions to the realization of human rights and its cost-effectiveness, family planning is a strategic investment. Chapter 6 outlines recommendations to guide future investments, policies, and programmes. Key stakeholders must recognize systematic inequalities in family planning as an infringement of human rights and a hindrance to direct information and services for underserved populations. Families, communities, institutions, and governments will have to modify their strategies to ensure that all people are able to realize their human right to family planning. This work will expand conventional approaches to family planning programmes. The adoption of post-MDG indicators that allow for nuanced assessments of sexual and reproductive health disparities is critical. What are the social and economic benefits of a rights-based approach to family planning? What are the cost implications of a rights-based approach to family planning? What should the international community do to implement a rights-based approach? viii CHAPTER ONE CHAPTER 1: THE RIGHT TO FAMILY PLANNING 1THE STATE OF WORLD POPULATION 2012 Planning the number and timing of one’s children is today largely taken for granted by the millions of people who have the means and power to do so. Yet a large proportion of the world’s people do not enjoy the right to choose when and how many children to have because they have no access to family planning information and services, or because the quality of services available to them is so poor that they go without and are vulnerable to unintended pregnancy. Mothers at a women's advocacy centre attend a talk on contraception in Pakistan. ©Panos/Peter Barker t The international community agreed in 1994 at the International Conference for Population and Development, ICPD, that family planning should be made available to everyone who wants it, and that governments should create the con- ditions that support people’s right to plan their families. But recent research shows that 222 million women in developing countries today do not have the means to delay pregnancies and childbearing. Millions of women in developed countries are also unable to plan their families because they lack access to information, educa- tion, and counselling on family planning, cannot access contraceptives and face social, economic or cultural barriers, including discrimination, coercion and violence in the context of their sexual and reproductive lives. The number and spacing of children can have an impact on the schooling prospects, income and well-being of women and girls, and also of men and boys. The right to family planning therefore permits the enjoyment of other rights, including the rights to health, education, and the achievement of a life with dignity. An informed rights-based approach to family planning is the most cost-effective intervention for addressing maternal mortality and morbidity. Ensuring the right to family planning can ultimately accelerate a country’s progress towards reducing poverty and achieving development goals. Universal access to reproductive health services, including family planning, is sufficiently important that it is part of the United Nations Millennium Development Goals. And it will be fundamental to achieving many of the priority goals emerging from the post-2015 sustainable development framework. Although family planning is a fundamental right, it is met at times with ambivalence from communities, health systems and governments. The commitment to family planning can be undermined by its association with sexual activ- ity and its meaning in the context of social and cultural values. In practical terms, concerns with extending access to specific population The right to family planning CHAPTER ONE A fundamental human right 2 CHAPTER 1: THE RIGHT TO FAMILY PLANNING2 groups can also weaken a broader commitment to family planning. Many groups, including young people and unmarried people, have been excluded or have not benefited from family planning pro- grammes. Other groups, including persons with disabilities or older people, have been denied access to family planning programmes based on prevailing misconceptions that they do not have sexual needs. This report makes the case that the inability to determine when to have children and how large a family to have results from and further reinforces social injustice and a lack of freedom. This report promotes the right to family plan- ning as an essential and sometimes neglected focus of the range of services required to sup- port sexual and reproductive health more broadly. It also underscores that family planning is one of the most cost-effective public health and sustainable development interventions ever developed (Levine, What Works Group and Kinder, 2004). Family planning reinforces other human rights The world has evolved a globally shared under- standing about sexual and reproductive health and the institutional, social, political and eco- nomic factors needed to support it. This shared “All human beings are born free and equal in dignity and rights… Everyone is entitled to all the rights and freedoms set forth in this declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status… Everyone has the right to life, liberty and security of person.” — Universal Declaration of Human Rights The ICPD defines sexual and reproductive health as “a state of complete physical, mental and social well-being…in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so.” — ICPD Programme of Action, paragraph 7.2 understanding was documented most fully at the ICPD, which marked a profound change in the international community’s approach to sexual and reproductive health and shaped many policies in place today. The ICPD Programme of Action formally recognized the rights of individuals to have children by choice, not by chance. Individuals have the right to determine their family size, and the right to choose when to have their children. Several features of the ICPD Programme of Action have contributed to making it possible for more people to exer- cise their reproductive rights. First, the ICPD Programme of Action contributed to advanc- ing reproductive rights by defining the broad concept of “sexual and reproductive health,” and by giving attention to the social conditions that shape it. It explicitly acknowledged the importance of sexual and reproductive health in the lives of women as well as the specific needs of adolescents and the roles of men and boys. It laid out a mandate for development pro- grammes to take into account—and respond 3THE STATE OF WORLD POPULATION 2012 to—the social, political and economic factors that affect people differently because of who they are, where they live and what they do. One additional contribution of the ICPD: Whereas earlier programmes had treated family planning as a standalone activity, the Programme of Action situated family planning in the context of broader sexual and reproduc- tive health programmes. Reproductive rights rest not only on the recognition of the right of couples and individuals to plan their fam- ily, but on “the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions con- cerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents” (UNFPA, 1994). By reducing worry about unintended pregnancy, family planning can contribute to building relationships between partners and ensuring a satisfying and safe sex life. Respecting, protecting and fulfilling people’s human rights make it easier for people to achieve the full benefit of investments in family planning (Cottingham, Germain and Hunt 2012). International commitments Sexual and reproductive health and reproductive rights do not represent a new set of rights but are rights already recognized implicitly or explic- itly in national laws, international human rights documents and other relevant United Nations consensus documents. Some of these interna- tional norms rest on broader human rights that also underpin the right to sexual and reproduc- tive health, including family planning. Reproductive rights encompass both freedoms and entitlements involving civil, political, eco- nomic, social and cultural rights. The right to decide the number and spacing of children is integral to the reproductive rights framework and is therefore directly related to other basic human rights, including: These rights are derived from numer- ous international and regional treaties and conventions. As such they reflect a common understanding of fundamental human rights. These and other human rights related to repro- ductive rights and their sources are laid out in Reproductive Rights are Human Rights, by the Center for Reproductive Rights (2009). Responding to the realities of gender inequali- ties and the nature of reproductive physiology, a number of human rights documents refer- ence the special challenges and discrimination women and girls face. The human rights of most direct relevance to gender inequality include the right to be free from discriminatory practices that especially harm women and girls, and the right to be free from sexual coercion and gender-based violence. • The right to life; • The right to liberty and security of person; • The right to health, including sexual and reproductive health; • The right to consent to marriage and to equality in marriage; • The right to privacy; • The right to equality and non-discrimination; • The right not to be subjected to torture or other cruel, inhuman, or degrading treatment or punishment; • The right to education, including access to sexuality education; • The right to participate in the conduct of public affairs and the right to free, active and meaningful participation; • The right to seek, impart and receive information and to have freedom of expression; • The right to benefit from scientific progress. (Center for Reproductive Rights, 2009; International Planned Parenthood Federation, 1996). 4 CHAPTER:4 CHAPTER 1: THE RIGHT TO FAMILY PLANNING Treaties, conventions and agreements relevant to reproductive health and rights 1948 Universal Declaration of Human Rights: A key document that has inspired the whole human rights discourse and many constitutions and national laws, and a source of international customary law. 1968 Tehran Conference on Human Rights proclaims and declares the right of individuals and couples to information, access and choice to determine the number and spacing of their children. 1969 Convention on the Elimination of all Forms of Racial Discrimination 1969 United Nations General Assembly Declaration on Social Progress and Development, resolution 2542 (XXIV), Article 4: “Parents have the exclusive right to determine freely and responsibly the number and spacing of their children.” The Assembly also resolved that the implementation of this right requires, “the provision to families of the knowledge and means necessary to enable them to exercise their right…” 1974/1984 The World Population Plan of Action adopted at the 1974 World Population Conference in Bucharest, and the 88 recommendations for its further implementation approved at the International Conference on Population in Mexico City in 1984. 1976 International Covenant on Civil and Political Rights, which is used by civil rights groups in their fight against government abuses of political power. 1976 International Covenant on Economic, Social and Cultural Rights adopted in 1966 and entered into force in 1976. Article 12 of the Covenant recognized the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 1979 The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) is the only international human rights document that specifically references family planning as key for ensuring the health and well-being of families. CEDAW provides the basis for realizing equality between women and men by ensuring women’s equal access to, and equal opportunities in, political and public life—including the right to vote and to stand for election—as well as education, health and employment. 1986 Declaration on the Right to Development calls for development that aims at the well-being of the entire population, free and meaningful participation and the fair distribution of the resulting benefits. 1989 Convention on the Rights of the Child sets standards for the defense of a child against neglect and abuse in countries throughout the globe. In order to protect the best interests of the child, it aims to: • Protect children from harmful acts and practices, including commercial and sexual exploitation and physical and mental abuse, and maintains that parents will be helped in their responsibilities of the positive upbringing of a child where assistance is needed. • Ensure the right of children to have access to certain services, such as health care and information on sexuality and reproduction. • Guarantee the participation of the child in matters concerning his or her life as s/he gets older. This includes exercising the right of freedom of speech and opinion. 1993 United Nations World Conference on Human Rights in Vienna affirmed women’s rights are human rights. 5THE STATE OF WORLD POPULATION 2012 5THE STATE OF WORLD POPULATION 2012 1994 At the International Conference on Population and Development (ICPD) in Cairo, 179 governments agreed that population and development are inextricably linked, and that empowering women and meeting people’s needs for education and health, including reproductive health, are necessary for both individual advancement and balanced development. The conference adopted a 20-year Programme of Action, which focused on individuals’ needs and rights, rather than on achieving demographic targets. Advancing gender equality, eliminating violence against women and ensuring women’s ability to control their own fertility were acknowledged as cornerstones of population and development policies. Concrete goals of the ICPD centred on providing universal access to education, particularly for girls; reducing infant, child and maternal deaths; and ensuring universal access by 2015 to reproductive health care, including family planning, assisted childbirth and prevention of sexually transmitted infections including HIV. 1995 Beijing Declaration and Platform for Action, United Nations Fourth World Conference on Women Reiterates broad definition of right to family planning laid out in ICPD Programme of Action. 1999 Key Actions for the Further Implementation of the ICPD Programme of Action A gender perspective should be adopted in all processes of policy formulation and implementation and in the delivery of services, especially in sexual and reproductive health, including family planning. Emphasized giving priority to sexual and reproductive health in the context of broader health reform, with special attention to rights and excluded groups. 2000 The Millennium Declaration was drafted by 189 nations which promised to free people from extreme poverty by 2015. The connections with reproductive health were initially understated. 2001 The Millennium Development Goals (MDGs). The goals are a road map with measurable targets and clear deadlines; the targets relevant to reproductive health include: • Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio (MDG-5). • Achieve, by 2015, universal access to reproductive health (MDG 5-B). 2004 The 57th World Health Assembly adopted the World Health Organization’s first strategy on reproductive health, recognized the Programme of Action and urged countries to implement the new strategy as part of national efforts to achieve the MDGs. • Make reproductive and sexual health and integral part of planning, budgeting as well as monitoring and reporting on progress towards the MDGs. • Strengthen health systems to provide universal access to reproductive and sexual health care, with special attention to the poor and other marginalized groups, including adolescents and men. 2005 World Summit 2005, follow-up to the 2000 Millennium World Summit. World leaders committed to universal access to reproductive health by 2015, to promote gender equality and end discrimination against women. 2006 Convention on the Rights of Persons with Disabilities 2010 MDG/10 Review Summit. World leaders renewed their commitment to universal access to reproductive health by 2015 and promote gender equality and end discrimination against women. 2011 The Committee on the Elimination of Discrimination against Women issued a decision establishing that all States have a human rights obligation to guarantee women of all racial and economic backgrounds timely and non-discriminatory access to appropriate maternal health services. 6 CHAPTER 1: THE RIGHT TO FAMILY PLANNING Health: a social and economic right The International Covenant on Civil and Political Rights, ICCPR and the International Covenant on Economic, Social and Cultural Rights, ICESCR, were developed during the 1960s to ensure the principles referenced in the Universal Declaration of Human Rights would be implemented. Human rights activists have ensured that the ICCPR has played a key part in protecting people against government abuses of political power while today the ICESCR is instrumental in activist efforts to persuade gov- ernments to place the right to a house or a meal on an equal footing with the right to vote (The Economist, 2001). Activists in and committed to some of the world’s poorest countries have demanded that economic and social goods be treated as entitlements in places where access to food and shelter is so lacking as to make even civil and political rights seem like luxuries. Since 1998, the World Health Organization has been asking the international community to formally respect and uphold health as a human right. The challenge has been to define what these social and economic rights—including the right to health—mean in specific and concrete terms that facilitate advocacy and implementa- tion. In 2000, the United Nations Committee on Economic, Social and Cultural Rights defined governments’ “core obligations” to include providing equal access to health services, sufficient food, potable water, sanitation and essential drugs. Accountability for rights No right exists without obligation, and no obli- gation is meaningful without accountability. United Nations treaty-monitoring bodies are charged with tracking government compliance with major human rights treaties and now rou- tinely recommend that governments take action to protect sexual and reproductive health and reproductive rights (Center for Reproductive Rights, 2009). Under the auspices of the Human Rights Council of the United Nations, the Universal Periodic Review involves a State- driven review of the human rights records of all United Nations Member States once every four years. Each State is given the opportunity to declare the actions they have taken to improve the human rights situations in their countries and to fulfil their human rights obligations. The Committee on the Elimination of Discrimination Against Women reviews evi- dence on the protection of human rights around the world and issues recommendations. In 2011, for example, the Committee issued strong recommendations to the Governments of Nepal, Zambia and Costa Rica to ensure the sexual and reproductive rights of their citizens (Center for Reproductive Rights, 2011a). The independent Expert Review Group was created in 2011 by the United Nations Secretary-General to track the Global Strategy for Women’s and Children’s Health and the Commission on Information and Accountability (World Health Organization, 2010a). With a special focus on ensuring the commitment of resources to fulfil Millennium Development Goals 4 (to reduce child death rates) and 5 (to reduce maternal death rates), the independent Expert Review Group will last four years, delivering its first report to the United Nations General Assembly in September 2012. National human rights institutions and courts of justice are directly responsible for ensuring the realization of reproductive rights. The Kenya National Commission on Human Rights, for example, recently conducted an inquiry into a range of reproductive rights abuses in that coun- try (Kenya National Commission on Human 7THE STATE OF WORLD POPULATION 2012 Rights, 2012). The charges had been brought in late 2009 by the Federation of Women Lawyers–Kenya and the Center for Reproductive Rights, alleging violations of reproductive rights in Kenyan health facilities. The Commission’s assessment found that people’s rights had been abused, largely as a consequence of the poor service quality and called on the Government to make the needed improvements. The Colombian Constitutional Court has passed important judgments ensuring access to sexual and reproductive health services (Corte Constitucional de Colombia, 2012; Reprohealthlaw, 2012). In 2010, for example, it affirmed the legality of and ensured access to emergency contraception. In 2003 UNFPA conducted a global sur- vey of national experiences 10 years after the ICPD (UNFPA, 2005a). Of the 151 coun- tries surveyed, 145 provided responses on the enforcement of reproductive rights. Of those that responded, 131 reported adopting new policies, national plans, programmes, strategies or legislation on reproductive rights. Family planning and human rights: a framework At the ICPD in 1994, the international com- munity translated its recognition of peoples’ right to family planning into a commitment to a human rights-based approach to health, which focuses on building the capacity of States and individuals to realize rights. Thus people not only have rights, but States have the obligation to respect, protect and fulfil these rights (Center for Reproductive Rights and United Nations Population Fund, 2010). In their work to support human rights, United Nations agencies are guided by the United Nations Common Understanding on the Human Rights Based Approach to Development Cooperation (2003): in the pur- suit of the realization of human rights as laid down in the Universal Declaration of Human Rights and other international human rights agreements, “human rights standards and principles must guide all development coop- eration and programming in all sectors and phases of the programming process” (World Health Organization and Office of the High Commissioner for Human Rights, 2010). A human rights-based approach is operation- ally directed towards developing the capacities of rights holders to claim their rights and the capacities of duty-bearers to meet their Grace Matthews, a mother-of-two, walked and cycled for three hours to get contraceptives. She decided to have an injection to delay her next pregnancy. ©Lindsay Mgbor/ UK Department for International Development t 8 CHAPTER 1: THE RIGHT TO FAMILY PLANNING obligations (United Nations Practitioner’s Portal on Human Rights Based Approaches to Programming). The practical expressions of the right to family planning can be divided into freedoms and enti- tlements to be enjoyed by individuals, and the obligations of the State (Center for Reproductive Rights and UNFPA, 2010). The freedoms and entitlements of individuals are strongly depen- dent on States’ obligations to ensure an equal opportunity and the progressive realization of human rights, including the right to health, for all without discrimination. They achieve this through strategies that contribute to removing obstacles and the adoption of positive measures that compensate for the factors that system- atically prevent specific groups from accessing quality services. Freedoms and entitlements of individuals The right to family planning entitles individuals and couples to access a range of quality family planning goods and services, including the full range of methods for men and women. The right to family planning information and sexuality education is central to people’s entitlements. Individuals must have access to sexual and reproductive health-related informa- tion, whether through comprehensive sexuality education programmes in schools, campaigns, or counselling and training. This information “should be scientifically accurate, objective, and free of prejudice and discrimination” (Center for Reproductive Rights, 2008). The third element of the right to family planning is informed consent and freedom from discrimination, coercion, or violence. Women and men, girls and boys, must be able to make informed choices that are free from coercion, discrimination, or violence (Center for Reproductive Rights and UNFPA 2010; International Federation of Gynecology and Obstetrics Committee for the Study of Ethical Aspects of Human Reproduction and Women’s Health, 2009). Obligations of the State The Programme of Action of the ICPD affirms that “States should take all appropriate mea- sures to ensure, on the basis of equality of men and women, universal access to health-care services, including those related to reproductive “Everyone has the right to education, which shall be directed to the full development of human resources, and human dignity and potential, with particular attention to women and the girl child. Education should be designed to strengthen respect for human rights and fundamental freedoms, including those relating to population and development.” — ICPD Programme of Action, Principle 10. Mother and child, Kiribati. ©UNFPA/Ariela Zibiah t 9THE STATE OF WORLD POPULATION 2012 health care, which includes family planning and sexual health. Reproductive health-care programmes should provide the widest range of services without any form of coercion.” (UNFPA, 1994) The State’s obligations to respect, protect and fulfil the right to contraceptive information and services include both limitations on its actions and proactive obligations it must undertake (Center for Reproductive Rights and UNFPA, 2010; Hunt and de Mesquita, 2007). • Respect: States must refrain from interfer- ing in the enjoyment of the right to family planning by, for example, restricting access through spousal or parental consent laws or and by prohibiting a particular family planning method. • Protect: States must also prevent third parties from infringing people’s access to family plan- ning information and services, for example, in instances of refusal by a pharmacist to provide legally available contraceptive methods. • Fulfil: States are required to adopt legislative, budgetary, judicial, and/or administrative measures to achieve people’s full right to family planning, which may, for example, require subsidizing goods and services. Governments may be prevented by their limited resources from immediately fulfilling certain economic, social, and cultural rights underpinning individuals’ right to family plan- ning information and services. This is where the principle of “progressive realization” comes in: In recognition of these realities, human rights law permits States to demonstrate they are taking steps “with a view to achieving progressively the full realization” of these rights, to the extent of their maximum available resources (International Covenant on Economic, Social and Cultural Rights, 1966). Goal: to deliver access to family planning for 120 million additional women in 69 countries by 2020. The UNFPA family planning strategy is founded on key principles: a rights-based approach including a commitment to gender equal- ity; geographical, social and economic equity in services; a focus on innovation and efficiency; sustainable results, and integration with national priorities. UNFPA’s commitment to the integration of human rights in family planning policies and programmes emphasizes two essential actions. All policies, services, information and communications must meet human rights standards for voluntary use of contraception and quality of care in service delivery. And actions must be taken to reduce the poverty, marginalization and gender inequalities that are often the root causes of violations of the right to family planning and of people’s inability to enjoy their right to family planning (Cottingham, Germain and Hunt, 2012; Center for Reproductive Rights and UNFPA, 2010). In focusing on rights, UNFPA commits in particular to: • Ensuring that the contraceptives procured respond to gender- specific needs; • Informing men, women and young people about the availability of contraceptives and where they can access them—and supporting them as they exercise their rights to family planning; • Supporting both men and women to transform gender attitudes and cultural barriers that impede access to and use of family planning. UNFPA focuses on: • strengthening political and financial commitment to family planning; • Increasing demand for family planning; • Improving national supply chain management; • Improving availability and quality of family planning services; • Improving knowledge management on family planning. UNFPA FAMILY PLANNING STRATEGY 2012-2020 In addition to allocating resources, States must take steps towards incorporating family planning into national public health policies and programmes, and establish measures of reproductive health that assist in monitoring national progress towards family planning goals. 10 CHAPTER 1: THE RIGHT TO FAMILY PLANNING A set of “minimum core obligations” are inde- pendent of national resources and are therefore not subject to progressive realization. These include providing access to family planning information and services on a non-discriminatory basis, and providing essential drugs as defined under the World Health Organization Action Programme on Essential Drugs, which includes the full range of contraceptive methods. (Center for Reproductive Rights and UNFPA, 2010) A human rights-based approach to family planning Human rights standards, as laid out in interna- tional treaties and further developed in national laws and regulations provide the legal basis for Women lining up for free family planning services. An estimated 222 million women in developing countries lack access to modern contraceptives. ©Lindsay Mgbor/ UK Department for International Development t 11THE STATE OF WORLD POPULATION 2012 designing and delivering accessible, acceptable and high-quality family planning information and services and for establishing the basis for advocacy by individuals and communities who want these services (Cottingham, Germain and Hunt, 2010). Advocacy includes lobbying for the translation of international commitments into national laws, policies and regulations, and for accountability in implementing these laws, policies and regulations. Human rights standards and the authoritative interpretation of the standards by the corre- sponding treaty monitoring bodies (General Comments) provide an objective set of param- eters and criteria that help translate the right to family planning at the abstract normative level into policies and programmes. As part of ensur- ing this translation, development cooperation must contribute to developing the capacities of “duty-bearers” (especially States) to meet their obligations, and to “rights-holders” (individuals and communities) to claim their rights (World Health Organization and Office of the High Commissioner for Human Rights, 2010). The committee on Economic Social and Cultural Rights in its General Comment Number 14 on the right to the highest attainable standard of physical and mental health has defined the fol- lowing normative elements that apply to all the underlying determinants of health: Availability The State’s obligation to ensure the availability of the full range of family planning methods extends to offering services, to regulating con- scientious objection and private service delivery, and to ensuring that providers are offering the full range of legally permissible services. The State’s role to protect and fulfil rights includes ensuring that the exercise of conscien- tious objection among healthcare providers does not result in unavailability of services. “Conscientious objection” occurs when health- care practitioners for reasons of their own religious or other beliefs do not want to provide full information on some alternatives. “[T]hey have, as a matter of respect for their patient’s human rights, an ethical obligation to disclose their objection, and to make an appropriate referral so [the patient] may obtain the full information necessary to make a valid choice” (International Federation of Gynecology and Obstetrics Committee for the Study of Ethical Aspects of Human Reproduction and Women’s Health, 2009). The United States is respond- ing to conscientious objection in the context of the Affordable Care Act. In January 2012, the U.S. Department of Health and Human Services specified preventive health services that new insurance plans would be required to cover (Galston and Rogers, 2010). The list included contraceptives and sterilizations including emer- gency contraception. Churches were narrowly exempted from this rule, but religiously affiliat- ed hospitals and social service agencies were not. If they were not already providing these services, Through its Global Programme to Enhance Reproductive Health Commodity Security, UNFPA ensures access to a reliable supply of con- traceptives in 46 developing countries. Since the Programme’s inception in 2007, UNFPA has mobilized $450 million for reproductive health commodities, including contraceptives. In 2011 alone, the Programme provided $32 million for these commodities and $44 million for initiatives to strengthen national health care systems and build their capacities to deliver reproductive health services. In 2011, the Programme funded about 15 million vials of injectable contraceptives, 1.1 million intrauterine devices, 14 million cycles of oral contraception, 316,000 doses of emergency oral contraception, 308,000 contraceptive implants, 253 million male condoms and 3.5 million female condoms. UNFPA ENSURING A RELIABLE SUPPLY OF qUALITY CONTRACEPTIvES 12 CHAPTER 1: THE RIGHT TO FAMILY PLANNING this latter group would have one year to comply with the new mandate. During this year, they would be required to disclose the limitations to their coverage and direct employees to afford- able contraceptive services elsewhere. Accessibility Even when services exist, social norms and practices can limit individual access to them. The subordination of the rights of young people to those of their parents, for example, can limit access to information and services and the capacity to act. The ICPD Programme of Action recognized the need for parents to prioritize the best interest of their childern (based on the Convention on the Rights of the Child). Since then, other negotiations, notably the 2009 and 2012 Commission on Population and Development meetings, have emphasized the rights of the child and the “duties and responsibilities” of parents, including their sole responsibility for deciding on the number and spacing of their children. Acceptability Information and services may exist, and they may be readily available to individuals in a commu- nity. But if they are not acceptable for cultural, religious or other reasons, they will not be used. Research in one community in Mexico, for example, found that married Catholic women in their main childbearing years relied primarily on withdrawal and periodic abstinence, as the women interviewed for this study said that mod- ern contraceptives, such as the pill or intrauterine devices, were against their religious beliefs and were therefore unacceptable to them (Hirsch, 2008; Hirsch and Nathanson, 2001). Quality To be in line with fundamental rights, fam- ily planning services must meet certain quality standards. Considerable agreement has evolved over the definition of “quality of care” since it was first defined in 1990 (Bruce, 1990). Its focus on service quality from the perspective of individuals has highlighted a number of specific elements: choice among contraceptive methods; accurate information on method effective- ness, risks and benefits; technical competence of providers; provider–user relationships based on respect for informed choice, privacy and confidentiality; follow-up; and the appropriate constellation of services. Providing good quality services meets human rights standards and also attracts more clients, increases family planning UNFPA works for the realization of reproductive rights, including the right to the highest attainable standard of sexual and reproductive health, through the application of the principles of a human rights-based approach, gender equality and cultural sensitivity to the sexual and reproductive health frame- work. In light of these principles, individuals are treated as active participants in the policy process with the ability to hold governments accountable in their obligations to respect, protect and fulfil human rights. As the lead United Nations agency working to improve sexual and reproductive health, UNFPA promotes legal, institutional and policy changes, and raises human rights awareness, empowering people to exercise control over their sexual and reproductive lives and to become active participants in development. UNFPA promotes the development of national policy frameworks and accountability systems to ensure universal access to quality sexual and reproductive health information, goods and services without discrimination or coercion on any grounds. At the same time, UNFPA emphasizes the need to build cultural legitimacy for human rights principles so that communities can make them their own. UNFPA, RIGHTS AND FAMILY PLANNING “In order to effectively claim their rights, rights-holders must be able to access information, organize and participate, advocate for policy change and obtain redress.” — Office of the High Commissioner for Human Rights and the World Health Organization 13THE STATE OF WORLD POPULATION 2012 use, and reduces unintended pregnancy (Creel, Sass and Yinger, 2002). In recent years, consensus has emerged on what ensuring quality means in the context of family planning and human rights. It includes: • Providing family planning as part of other reproductive health services, such as preven- tion and treatment of sexually transmitted infections, and post-abortion care (Mora et al., 1993); • Disallowing family planning targets, incen- tives and disincentives, such as providing money to women who undergo sterilization or to health-care providers on the basis of number of women “recruited” for family planning; • Including assessments of gender relations in plans and budgeting for family planning services (AbouZahr et al., 1996); • Accounting for factors such as the distance clients must travel, affordability and attitudes of providers. In settings as diverse as Senegal and Bangladesh, women are more likely to use family planning where they are receiving good care (Sanogo et al., 2003; Koenig, Hossain and Whittaker, 1997). Among women not using contraception, their perceptions of the quality of care significantly predicted the likelihood that they would start using a method; similarly, those currently using contraception were far more likely to continue using their method. By improving the quality of services, programmes have also created a greater sense of entitlement, leading clients to demand better quality in other parts of the health system (Creel, Sass and Yinger, 2002). A human rights-based approach to sustainable development gives equal importance to both the outcomes and processes through which it is achieved. Human rights standards guide the formulation of development outcomes and the content of interventions, including meeting the unmet need for family planning. Human rights principles lend quality and legitimacy to develop- ment processes. Processes have to be inclusive, participatory and transparent. Of critical impor- tance is the priority that must be given to the rights and needs of those groups of population left behind and excluded as a result of persistent patterns of discrimination and disempowerment. Woman and child, Tanzania ©UNFPA/Sawiche Wamunz t “Ill health constitutes a human rights violation when it arises, in whole or in part, from the failure of a duty-bearer—typically a State—to respect, protect or fulfil a human rights obligation. Obstacles stand between individuals and their enjoyment of sexual and reproductive health. From the human rights perspective, a key question is: are human rights duty-bearers doing all in their power to dismantle these barriers?” (Hunt and de Mesquita, 2007). 14 CHAPTER 1: THE RIGHT TO FAMILY PLANNING Three cross-cutting principles contribute to building strong, rights-based family planning programmes: • Participation —a commitment to engaging key stakeholders, especially the most vulner- able beneficiaries, at all stages of decision making, from policies to programme imple- mentation to monitoring (UNFPA, 2005). • Equality and non-discrimination—a com- mitment to ensuring that all individuals enjoy their human rights independent of sex, race, age, or any other status. • Accountability—mechanisms must be in place for ensuring that governments are ful- filling their responsibilities with regard to family planning information and services. Accountability includes monitoring and evaluation systems, with clear benchmarks and targets in order to assess government policy efforts in meeting people’s rights. Monitoring and evaluation are essential for giving governments the means to identify the major barriers to family planning and the groups that have the greatest difficulty with these barriers. Monitoring and evaluation also provide individuals—rights holders— and communities with information to hold governments to account when rights are not being upheld. Conclusion Hundreds of millions of the world’s men and women wish to have children by choice and not by chance. Many of their fellow citizens—those who are wealthier and more educated—seem to be able to achieve this right (Foreit, Karra Viet Nam has expanded reproductive health services, which include family planning, pre- and post-natal care and HIV prevention. ©UNFPA/Doan Bau Chau t 15THE STATE OF WORLD POPULATION 2012 and Pandit-Rajani, 2010; Loaiza and Blake, 2010; World Heath Organization, 2011). The Programme of Action of the ICPD framed this right to family planning in the context of the right to sexual and reproductive health and reproductive rights, paying special attention to the needs of specific excluded populations and to gender equality. This year’s State of World Population Report builds on an earlier human rights and health framework developed by UNFPA and the Center for Reproductive Rights to include boys and men, many of whom also want to use fam- ily planning but who have typically been left out of the discussion. It also emphasizes the context of the sexual relationships within which individuals and couples elect to use family planning. And it advocates for a focus on extending access to family planning more equi- tably across population groups, particularly with reference to the socioeconomic differentials that exist in virtually every country of the world. The right to family planning has been strongly upheld and reinforced by a series of international treaties and conventions, endorsed by the inter- national community and is firmly grounded in human rights. The right to family planning is also a gateway to the achievement of other rights. “A human rights-based approach to sustainable development gives equal importance to both the outcomes and processes through which it is achieved.” For UNFPA, the key benefits to implementing a human rights-based approach to sexual and reproductive health programming, including family planning, are that doing so: • Promotes realization of human rights and helps government partners to achieve their human rights commitments; • Increases and strengthens the participation of the local community; • Improves transparency; • Promotes results (and aligns with results based management); • Increases accountability; • Reduces vulnerabilities by focusing on the most marginalized and excluded in society; and • Leads to sustained change as human rights-based programmes have greater impact on norms and values, structures, policy and practice. 16 CHAPTER TWO CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS 17THE STATE OF WORLD POPULATION 2012 Last year, the world’s population surpassed 7 billion and it is projected to reach 9 billion by 2050. Population growth is generally highest in the poorest countries, where fertility preferences are the highest, where governments lack the resources to meet the increasing demand for services and infrastructure, where jobs growth is not keeping pace with the number of new entrants into the labour force, and where many population groups face great difficulty in accessing family planning information and services (Population Reference Bureau, 2011; UNFPA, 2011b). Worldwide, birth rates have continued to decline slowly. However, large disparities exist between more developed and less developed regions. This is particularly true for sub-Saharan Africa, where women give birth to three times as many chil- dren on average as women in more developed regions of the world (5.1 versus 1.7 births per woman). A large part of this dif- ference reflects a desire for larger families in sub- Saharan Africa, but as most women in this region now want to have fewer children (Westoff and Bankole, 2002), fertility differences increasingly reveal limited and unequal access in the developing world to the means to prevent unintended pregnancy. Poverty, gender inequality and social pressures are all reasons for persistent high fertility. But in nearly all of the least-developed countries, lack of access to voluntary family planning is a major contributing factor. Who is using family planning? The use of modern family planning methods as measured by the contraceptive prevalence rate has increased globally at a very modest pace of 0.1 per cent per year in recent years, more slowly than in the previ- ous decade (United Nations, Department of Economic and Social Affairs, 2011). The modest increase is partially a function of the large increase in the numbers of married women of reproductive age—a 25 per cent increase t Analysing data and trends to understand the needs CHAPTER TWO Fertility rates Total fertility rate (births per woman) World . 2.5 More Developed . 1.7 Less Developed . 2.8 Least Developed .4.5 Sub-Saharan Africa . 5.1 Source: United Nations, 2011a. Global trends in fertility In Mali, a couple with their sons. ©Panos/Giacomo Pirozzi 18 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS Source: United Nations, 2011a. CHANGE IN AGE-SPECIFIC FERTILITY RATES OvER TIME (BIRTHS PER 1,000 WOMEN) between 2000 and 2010 in 88 countries that receive donor support for contraception (Ross, Weissman and Stover, 2009). Due to earlier high fertility, many more people in developing countries have now reached their reproductive ages, and meeting the contraceptive needs of many more women has contributed to only a marginal gain in the percentage covered. Globally, about three of every four sexually active women of reproductive ages 15 to 49, who are able to become pregnant, but are not pregnant nor wanting to become pregnant, are currently using contraception (Singh and Darroch, 2012). In every country of the world, most women who are educated and well-off use family planning. In East Asia, 83 per cent of married women use contraception (United Nations, Department of Economic and Social Affairs, 2011). Conversely, in the poorest regions of the world, contraceptive prevalence rates are lowest and have increased most slowly. Contraceptive use among women in sub-Saharan Africa in 2010 was lower than use among women in other regions in 1990. Family size and contraceptive use changed dra- matically worldwide in the 1970s, when couples had an average of five children per family. Today they have an average of 2.5 (United Nations Department of Economic and Social Affairs, 2010). Increased contraceptive use is largely responsible for fertility declines in developing countries (Singh and Darroch, 2012). Though levels of contraceptive prevalence have stabilized since 2000, the desire to have smaller families remains strong worldwide and is increasing in developing countries. Use varies according to income levels Most surveys calculate national wealth scores and disaggregate indicators by wealth quintile, from the poorest 20 per cent of the population 1970-1975 2005-2010 0 50 100 150 200 250 300 World More Developed Less Developed Least Developed World More Developed Less Developed Least Developed World More Developed Less Developed Least Developed World More Developed Less Developed Least Developed World More Developed Less Developed Least Developed World More Developed Less Developed Least Developed World More Developed Less Developed Least Developed Age 20 -2 4 25 -2 9 30 -3 4 35 -3 9 4 0 -4 4 4 5- 4 9 15 -1 9 19THE STATE OF WORLD POPULATION 2012 through the wealthiest 20 per cent. Quintile analyses of population-based surveys can help identify inequalities and family planning needs within countries, especially in combination with data on urban-rural and other important dimen- sions of access (Health Policy Initiative, Task Order 1, 2010). Because poverty takes on specific character- istics within a given setting, some researchers now advocate for separate quintile rankings for urban and rural populations to paint a more complete picture of inequalities between pov- erty and wealth in both urban and rural areas. This approach makes it possible to compare the different experiences of poor women in urban settings and relatively wealthy women in rural communities. Research from a 16-country study across Africa, Asia, and Latin America and the Caribbean finds strong relationships between family planning use, socioeconomic status, and place of residence (Foreit, Karra and Pandit-Rajani, 2010). In countries such as Bangladesh, the preva- lence of modern contraceptive use is the same across wealth quintiles in urban and rural set- tings: there is a nominal difference between contraceptive use among rich and poor in urban communities, and between the wealthiest and poorest within rural settings (Demographic and Health Surveys, 2007). In Bangladesh, the prevalence of contraceptive use is greater (by 6 per cent) in urban areas. Similar findings, which support pro-rural strategies, have been found in Peru, which would warrant pro-rural program- ming, as would Bolivia, Ethiopia, Madagascar, Tanzania and Zambia (Health Policy Initiative, Task Order 1, 2010). In some countries, such as Nigeria (DHS, 2008), modern contraceptive use increases with increasing wealth for people who live in urban and rural areas. The key difference is the rate of change: wealthier people in rural settings report higher use of contraceptives than the urban poor. These results would support policies that focus on reaching the urban poor, especially if similar patterns of disparities exist among indicators that measure adverse sexual and reproductive health outcomes. Educational achievement influences desired family size, family planning use and fertility Level of schooling is associated with desired family size, contraceptive use and fertility. An analysis of 24 sub-Saharan African countries showed that the adolescents most likely to become mothers are poor, uneducated and live in rural areas (Lloyd, 2009). Birth rates are more than four times as high among unedu- cated adolescent girls ages 15 to 19 as among girls who have at least secondary schooling. A similar gap exists based on wealth and residence. And in these countries, the gaps are widening: births among adolescent girls between the ages of 15 and 19 with no education have increased High school students in Bucharest, Romania, read a leaflet about condoms. ©Panos/Peter Barker t 20 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS by about 7 per cent in the past decade, while births among girls with secondary plus schooling have declined by about 14 per cent (Loaiza and Blake, 2010). The widening disparities in birth rates among educated and uneducated girls over time reflect a similar increasing gap in their use of con- traception. In sub-Saharan African, girls with secondary schooling were found to be more than four times more likely to use contraception than girls with no education (Lloyd, 2009). Whereas contraceptive use among educated adolescent girls has risen somewhat between the two surveys to 42 per cent overall, there was no change among uneducated girls. No more than one in 10 uneducated adolescents uses contraception, even though one in four girls in these countries, independent of wealth, educa- tion or residence, has an unmet need for family planning. These figures suggest that efforts to improve access to reproductive health services among youth by expanding youth-friendly ser- vices have not benefited young women who are poor, live in rural areas, and are poorly educated. Those most in need of these services lag the furthest behind (Loaiza and Blake, 2010). The most plausible explanations for the positive fam- ily planning outcomes associated with education are that better-educated women marry later and less often, use contraception more effectively, have greater knowledge about and access to contraception, exercise greater autonomy in reproductive decision-making, and are more aware of the socioeconomic costs of unintended child-bearing (Bongaarts, 2010). Case study CASE STUDY Youth-friendly services in Malawi The sexual and reproductive health needs of adolescents and young people were not well served in Malawi, as in many other parts of Africa. The lack of information, long distances to services and unfriendly providers contributed to high rates of unintended pregnancy and HIV. UNFPA has partnered with the Malawian Ministry of Health and the Family Planning Association of Malawi to provide integrated youth-friendly sexual and reproductive health services through multi-purpose Youth Life Centres as well as via community-based and mobile services; they have strengthened their infrastructure as part of improving quality of care for young people. Services include contra- ception, including emergency contraception, pregnancy testing, treatment of sexually trans- mitted infections, HIV counselling and testing, antiretroviral therapy, treatment of opportu- nistic infections, cervical cancer screening and treatment, general sexual and reproductive health counselling, post-abortion care, and prenatal and postnatal care for teen mothers. The services are promoted through newspa- A lack of information and access to vasectomy services can compromise the rights and health of men and women who, if they were appropriately informed, might prefer this relatively safe, simple, permanent and non- invasive procedure over female sterilization. Men who choose vasectomies decide upon the long-term method after considering numerous physi- ological, psychological, social and cultural factors. In many places, male sterilization is not well understood and is viewed as a threat to male sexu- ality and sexual performance. When men and women have access to a full range of family planning information and services, more couples may choose vasectomy as their preferred method of contraception. The low uptake of vasectomies reflects limited access to appropriate information about the procedure, institu- tional biases against the method, and individual concerns about the effects of vasectomies on sexual performance and pleasure. Sources: Landry and Ward, 1997; Greene and Gold, n.d.; EngenderHealth, 2002. SExUALITY, SExUAL AND GENDER STEREOTYPES AND LIMITED USE OF vASECTOMY 21THE STATE OF WORLD POPULATION 2012 pers, advertisements and by word of mouth. Improvements in service infrastructure, the par- ticipation of young people in service provision, the integration of sexual and reproductive health and HIV services, and the frequent solicitation of input from young clients—all of these things have improved the quality of the sexual and reproductive health services and have signifi- cantly increased their use. The connections between schooling, fam- ily planning use and fertility are most readily evident in adolescence. But the effects of edu- cation on desired family size and contraceptive use persist into adulthood. The adjacent figure shows that women with secondary education use family planning at four times the rate of women with no schooling in sub-Saharan Africa. This effect reflects both preferences for number of children and access to family plan- ning (UNFPA, 2010). Family planning use and place of residence Contraceptive use in sub-Saharan Africa is double in urban areas than what it is in rural areas. Many countries, especially the world’s poorest, struggle to bring services to rural areas. In addition, people in rural areas tend to have less access to schooling, another important correlate of preferences for smaller families and use of family planning. Family planning demand and use evolve through life A review of global data shows that sexual activity evolves over a person’s lifetime. Women and men have sex for different reasons and under different circumstances at various times in their lives. Individual decisions to initiate sex with a partner are Contraceptive prevalence by background characteristics from 24 sub-Saharan African countries at most recent survey, 1998-2008 (Percentage of women aged 1-49, married or in union, using any method of contraceptive). Source: Demographic and Health Surveys (calculated using data in Annex III). THE POOREST, LEAST EDUCATED AND RURAL WOMEN HAvE THE LOWEST RATES OF CONTRACEPTIvE USE IN SUB-SAHARAN AFRICA 0 5 10 15 20 25 30 35 40 45 42% 13% Rural Urban No Education Primary Poorest 20% Second Third Fourth Secondary Richest 20% 50 PERCENTAGE OF USE 38% 34% 25% 18% 10% 24% 10% 17% EDUCATION WEALTH LOCATION 22 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS not necessarily associated with a desire to have children. In many instances—absent coercion, exploitation, or violence—it is the human desire for intimacy and relationships that drives sexual behaviour. Young people Even though most of young peoples’ sexual activity takes place in marriage, many young people are sexually active outside of marriage. Sexual initiation is increasingly taking place outside of marriage for adolescent girls, though often with a future husband (McQueston, Silverman and Glassman, 2012; National Research Council and Institute of Medicine, 2005). Declines in age at menarche are likely to contribute to increased reproductive health risks for young women, increasing the number of years between menarche and marriage. Very early intercourse (at age 14 or younger) continues to occur among approximately a third of girls in Bangladesh, Chad, Mali, and Niger (Dixon- Mueller, 2008). The proportion making this transition varies very widely (between 40 and 80 per cent) among sub-Saharan African countries, for example. Boys are much less likely than girls to have sex before age 15 where early, arranged marriage for girls is common. Where it is less common, how- ever, boys in many settings are more likely to be sexually active than girls of the same age. As some researchers have noted, “the shift over time from marital to non-marital sexual initiation may be advantageous for girls’ sexual and repro- ductive health,” since non-marital sex generally entails less frequent and more often protected sex than occurs in marital relationships (Clark, Bruce and Dude, 2006). Young women and men face different chal- lenges from early adolescence through young adulthood. Most young people do not have consensual sex to prematurely become moth- ers and fathers. Globally, young people are increasingly delaying marriage. For women, the singulate mean age at marriage (only those who marry before age 50) has increased in 100 of 114 countries with available data since 1970 (United Nations, Department of Economic and Social Affairs, 2011b). In many countries, however, earlier introduc- tion to marriage and sex continues to set young women down a path of greater risk for several adverse outcomes. Across several regions, girls remain significantly more likely than their male peers to be married as children and to begin hav- ing sex at a young age. While younger women may have sex earlier in their lives, research finds that young men are more likely than their female peers to have sex with someone who is not a 41 33 31 49 Never-Married, at Least 10% (2000) 0 10 20 30 40 50 60 Women Men Never-Married, at Least 10% (1970) N um be r of c ou nt ri es Source: United Nations, Department of Economic and Social Affairs, Population Division (2009). World Marriage Data 2008 (POP/DB/Marr/ Rev2008). NUMBER OF COUNTRIES WHERE AT LEAST 10 PER CENT OF WOMEN AND MEN NEvER MARRY 23THE STATE OF WORLD POPULATION 2012 cohabitating partner (UNICEF, Office of the Deputy Director, Policy and Practice, 2011). These details help contextualize family planning data on young people, and tell a more complete picture of why young men are more likely than young women to use condoms. Adults Even though age at first marriage has risen, the majority of women and men eventually marry or live in consensual unions (United Nations, Department of Economic and Social Affairs, 2009). As a result, childbearing remains com- monplace within legally recognized unions—a reality in alignment with social acceptability in most countries where childbearing should occur between married couples. Recent data highlight, however, how adults’ need for family planning may increasingly arise while they are single, separated, or divorced. Today, adults are spending more time out of marriage compared to previous generations, and their family planning needs reflect these realities. In developing as well as developed countries, the proportion of never-married adults is increasing. Over the last 40 years, the number of countries where at least 10 per cent of women never married (by age 50) has increased from 33 to 41; the number of countries where at least 10 per cent of men do not marry before their 50th birthday increased from 31 to 49. Consensual unions account for an increasing proportion of live-in partnerships, and these partnerships are less stable and more fluid than formal marriages. In Latin America and the Caribbean, over a quarter of women between the ages of 20 and 34 live in consensual unions (United Nations, Department of Economic and Social Affairs, 2009). This arrangement is less common in sub-Saharan Africa and Asia where about 10 per cent and 2 per cent of women, respectively, live in consensual unions. Globally, the proportion of adults (between the ages of 35 and 39) who are divorced or separated has risen from 2 per cent to 4 per cent between 1970 and 2000, a trend concentrated in developed coun- tries (Organisation for Economic Co-operation and Development, 2010). Preferred methods The use of modern methods of family planning has increased in recent years in Eastern Africa, particularly Ethiopia, Malawi and Rwanda, and in Southeast Asia, but there has been no A Cameroonian home just visited by a community-based family planning counsellor. © UNFPA/Alain Sibenaler t 24 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS increase in use of modern methods in Central and Western Africa (Singh and Darroch, 2012). When women have access to a selection of con- traceptive methods, several factors influence their contraceptive preference. Significant among these factors are health-related side effects, ease of use, and partner preference (Bradley, Schwandt and Khan, 2009; Darroch, Sedgh and Ball, 2011). For example, estimates suggest that 34 million of the 104 million women with method-related rea- sons for unmet need for modern contraceptives would like methods that do not cause, or seem to cause, health problems or side effects (Singh and Darroch, 2012). Long-term methods such as intrauterine devices and injectables require fewer clinical visits and rely less on users’ recall to con- sistently use a method. Individuals and couples who use contraceptives also weigh methods’ effectiveness and failure rates with its impact on sexual pleasure. In some cases, women are covertly using “invisible” methods such as injectables for fear of their husbands’ opposition. As women increas- ingly want to control their own fertility or have wanted to and are now more aware that they can, some women choose to thwart this oppo- sition by using contraceptives that cannot be detected by their partners. A few studies and anecdotal evidence suggest that some of the rapid rise in use of injectables (6 per cent to 20 per cent) in sub-Saharan Africa and elsewhere is attributed to covert use by women who feel they must conceal contraception from their hus- bands, families or communities (Biddlecom and Fapohunda, 1998). Method effectiveness Long acting methods such as the implant and the intrauterine device are highly effective at preventing pregnancy, in large part because they do not require a daily or periodic action, such as taking a pill or getting another injection on time. The pill, patch, vaginal ring, injectables, and barrier methods are all much more effec- tive in “perfect use” than they are in typical use, because people may forget to use the method or use it incorrectly. Most modern methods are highly effective if used correctly and consistently. Fertility awareness-related methods are also quite effective if used correctly, and are sometimes preferred by women who have religious objections to other forms of contraception. Even the least effective Method, ranked from most to least effective Pregnancies per 100 women in first year of typical use Implant .05 Vasectomy .15 Female sterilization .5 Intrauterine device (IUD) (Copper T) .8 Levonorgestrel-releasing IUD .2 Injectable – 3 month 6 Vaginal ring 9 Patch 9 Pill, combined oral 9 Diaphragm 12 Male condom 18 Female condom 21 Sponge 12-24 Withdrawal 22 Fertility awareness methods: standard days, two-day, Symptothermal 24 Spermicides 28 No method 85 METHOD EFFECTIvENESS Source: Guttmacher Institute, 2012. (Based on data from the United States) 25THE STATE OF WORLD POPULATION 2012 methods are several times more effective in pre- venting pregnancy than no method. About 85 of every 100 sexually active women who chose not to use a method will become pregnant within the first year (Guttmacher Insititute, 2012). Method effectiveness—measured in pregnan- cies per 100 women in the first year of typical use—ranges from .05 for the implant, to 28 for spermicides, compared with 85 for no method at all (Guttmacher Institute 2012). Worldwide, almost one in three women using contraception relies on female sterilization. About one in four relies on an intrauterine device. More than one in 10 relies on a traditional method, predomi- nantly withdrawal and rhythm. Use depends on available options, ease of use and information Women may have unmet need or discontinue contraceptive use because they are dissatisfied with current options (Frost and Darroch, 2008; Bradley, Schwandt and Khan, 2009). Most of the available options depend on technologies developed in the 1960s and 1970s, and there has since been nominal investment into the discov- ery and dissemination of new methods (Harper, 2005; Darroch, 2007). In addition to strength- ening the quality of information services about modern methods, national efforts to fulfil the rights of women and men may require invest- ment into new contraceptive methods, including methods that do not cause systemic side effects, can be used on demand, and do not require partner participation or knowledge (Darroch, Sedgh and Ball, 2011). New methods alone would not eliminate unmet need. However, newer methods that gov- ernments have recently approved could enable women to exercise their right to more reliably and safely prevent pregnancies. Studies find that the leading causes of discontinuation — side effects and fear of side effects —impede efforts to meet unmet need (Cottingham, Germain and Hunt, 2012). Effectiveness and a full range of methods are part of demand but also reflect supply. The qual- ity of services may be poor and the full range of methods is not available to most people; as a consequence, family planning may not be attrac- tive to them even if they wish to postpone or end their childbearing. Family planning use and reliability of supplies A growing number of contraceptive options are available, especially in developed countries. However, women in most developing countries have far fewer options, although the range of methods available is improving and now often includes injectables and implants in addition to pills and condoms. Obtaining contraceptive Source: United Nations. 2011 World Contraceptive Data Sheet 11% 30% 4% 6% Female Sterilization Male Sterilization Injectables Pill Condom IUD Traditional 14% 12% 23% 11% 30% 4% 6% 14% 12% 23% 0% 0% Implant - Less than 1% Other barrier methods - Less than 1% GLOBAL CONTRACEPTIvE USE BY METHOD 26 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS methods is one challenge; distributing them is another: The majority of international funding for condoms is spent on the procurement of the commodity with relatively little spent on delivery, distribution and administration. CASE STUDY Supplies in Swaziland Access to supplies and their reliable provision are essential to the realization of individuals’ right to family planning. Like many other African countries, Swaziland has experienced stock-outs, making it difficult for people to choose and have confidence in relying on specific contraceptive methods. Reproductive health commodity secu- rity programming had focused mainly on the procurement of contraceptives by the govern- ment, with poor results. As part of its effort to address high mater- nal mortality and adolescent pregnancy, Swaziland has invested in reproductive health commodity security. The Ministry of Health strengthened its relationship with civil soci- ety and UNFPA by establishing a partnership with the Family Life Association of Swaziland, Management Sciences for Health and UNFPA in 2011 to strengthen programme delivery. Its overall objective was to increase the health system’s effectiveness in ensuring reproductive health commodities through three strate- gies: National systems were strengthened for reproductive health and commodity security; human resources capacity was strengthened for implementation, monitoring and report- ing; and political and financial commitment to reproductive health commodity security were enhanced. By conventional standards, success was achieved through an increase in contracep- tive prevalence. Just as important, however, was the increase in the number of facilities offering family planning services and the reliability of those services. Traditional methods of family planning remain popular Traditional methods remain widely used, especially in developing countries. Survey data do not often shed light on why people use traditional rather than modern methods of family planning. Traditional methods include periodic absti- nence, withdrawal, lactational amenorrhea (extended breast-feeding) and “folk” practices; thus their effectiveness varies very significantly. Comparative studies across diverse settings confirm that women who use modern meth- ods are much less likely to become pregnant than women who rely on a traditional method (Trussell, 2011). t Couple visiting a rural family planning clinic. Mindanao, Philippines. ©Panos/Chris Stowers 27THE STATE OF WORLD POPULATION 2012 Despite the tendency to consolidate all tra- ditional methods into a singular category, not all traditional methods are the same. Several countries have good histories with non-modern, traditional methods. For example, withdrawal is a commonly used among educated couples in Iran and Turkey and has been widely used to prevent pregnancy in Sicily and Pakistan (Cottingham, Germain and Hunt, 2012; Erfani, 2010). The Demographic and Health Surveys categorize coitus interruptus as a “totally ineffec- tive folk method,” even though this method is used extensively in a number of countries and is about as effective as condoms (Cottingham, Germain and Hunt, 2012). Female methods of family planning more widely used than male methods The ICPD Programme of Action noted as a “high priority… the development of new meth- ods for the regulation of fertility for men,” and called for the involvement of private industry. It urged countries to take special efforts to enhance male involvement and responsibility in family planning (Paragraph 12.14.). Nearly 20 years later, no new male methods have been widely introduced to the public. With few con- traceptive options for men, men’s use of family planning has been less than envisioned by the ICPD. Today, even if all traditional methods requiring men’s cooperation (rhythm, with- drawal and others) are counted together with male condoms, male methods account for about 26 per cent of global contraceptive prevalence (United Nations, Department of Economic and Social Affairs, 2011). Female sterilization rates far outnumber male rates. Although the decision to permanently end childbearing can be difficult, sterilization is the most commonly used family planning method in the world, relied upon by more than one in five married women. Nearly everywhere, women are far more likely to undergo the sterilization procedure than men. In Colombia, for example, where 78 per cent of women are current con- traceptive users, nearly a third of all women (31 per cent) have been sterilized, compared with just two per cent of men (United Nations, Department of Economic and Social Affairs, 2011). Since desired fertility declines over time, couples married at young ages will stop hav- ing children at earlier ages. After reaching their desired fertility, these younger couples may have to avoid unintended pregnancy for up to 25 years, making permanent methods attractive to them. While female sterilization rates are highest in Latin and Central America, ranging as high as 47 per cent in the Dominican Republic, only 14 countries in the world have at least 5 per cent of men who have undergone vasectomy. Male and female sterilization rates are most similar in Australia and New Zealand, where about 15 per cent of both men and women have been steril- ized (United Nations, Department of Economic and Social Affairs, 2011). Male sterilization exceeds female sterilization in only a handful of countries, most notably in Canada and the United Kingdom, where men are about twice as likely as women to be sterilized. One might infer from the mostly developed countries that vasectomy rates primarily reflect women’s economic power and rights in these countries. Nepal is among the few develop- ing countries where vasectomy rates are above ”Although the decision to permanently end childbearing can be difficult, sterilization is the most commonly used family planning method in the world, relied upon by more than one in five married women.” 28 CHAPTER:CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS 5 per cent and equal a third or more of female sterilizations, suggesting that increased female empowerment in Nepal may be having an effect on contraceptive choice (EngenderHealth, 2002). Female sterilization is a significantly more invasive, costly and risky procedure than male sterilization, and is somewhat less effective, yet its prevalence dramatically surpasses vasec- tomy everywhere except in North America and Western Europe (Greene and Gold, n.d.; Shih, Turok and Parker, 2011). That female sterilization has become the norm, while male sterilization remains rare, is a clarifying moment of gender inequality. The lack of access to and failure to promote vasectomy compromises both men’s and women’s rights. Given these realities, what factors do couples take into consideration, if indeed they discuss which of them will be sterilized? One multi- country study showed that some men who chose vasectomy did so out of concern for their part- ners’ health (Landry and Ward, 1997). Other men were dissatisfied with the choice of methods available, or their wives had discontinued other methods due to side effects. In some poor fami- lies, vasectomy was chosen because women could not be spared from child and household care for the time it would take them to recover. Some men decided that they had enough children and did not consult their wives before being sterilized. In the United States, prevalence of vasectomy is highest among men with higher educations and incomes, whereas female sterilization is more prevalent among women with lower incomes and education (Anderson et al., 2012). Vasectomy is uncommon in sub-Saharan Africa, where rates are well below 1 per cent (Bunce et al., 2007). Few providers are trained to perform vasectomies and many, if not most men and women, have not heard of the method. A study of the acceptability of vasectomy in Tanzania found that both men and women had concerns about sexual side effects (Bunce et al., 2007). While some women feared their husbands would become unfaithful, men had heard rumors that vasectomy caused impotence and feared their wives might leave them if their sexual performance suffered. Measures of contraceptive prevalence and unmet need are limited in their ability to capture the dynamic nature of individuals’ decisions regarding their sexual activity, as well as the context in which these decisions take place. For example, contraceptive prevalence and unmet need are influenced by factors that women in need of contraceptives cannot control, including changing availability and supply of contraceptives over a period of time. Furthermore, unmet need for family planning reflects both individuals’ demand for specific methods and the supply. As more people learn about the benefits of exercis- ing their right to plan their families, the demand for services can potentially outpace supply. This may occur in hard-to-reach regions and among popula- tions whose sexual activity defies commonly held beliefs about when sex is appropriate. While contraceptive prevalence and unmet need are important indi- cators, the limitations of contraceptive prevalence and unmet need call attention to the need for additional indicators that better capture the pro- portion of demand for contraceptives that health systems satisfy (UNFPA, 2011). One such indicator is the “proportion of demand satisfied.” This indi- cator is derived from current data collection methods and more accurately monitors whether women’s stated desires for family planning are being met. Additionally, more consistent use of adjusted urban vs. rural quintile analyses can help policymakers and development practitioners design tailored need-based family planning strategies and programmes. DEMAND AND SUPPLY OvER TIME Source: United Nations Population Fund (2010). Sexual and Reproductive Health for All: Reducing poverty, advancing development and protecting human rights. New York: UNFPA WOMEN NOT USING CONTRACEPTION AND WANTING NO MORE CHILDREN OR WANTING TO DELAY THE NExT BIRTH + = PROPORTION OF DEMAND SATISFIEDWOMEN USING ANY METHOD OF CONTRACEPTION DIvIDED BY WOMEN USING ANY METHOD OF CONTRACEPTION 29THE STATE OF WORLD POPULATION 2012 CASE STUDY No-scalpel vasectomy in the Solomon Islands After the ICPD, family planning programmes in the Solomon Islands became more rights-based. New population policy provisions reflected an emphasis on rights, with the government explicitly committing to “…encouraging and supporting parental efforts to make responsible decisions regarding family size…” Family plan- ning was reinvigorated in 2003-2004 with the updating of national guidelines and extensive training of health care workers on various topics, including informed choice and a broader meth- od mix. Contraceptive prevalence rose from 11 per cent to 29 per cent. No-scalpel vasectomy has been an especially popular method. Success in offering this method has been attributed in part to men being invited for the first time to be more engaged in family planning. In addition, no-scalpel vasectomy is very economical and could take place locally, while tubal ligation required travel to a referral clinic. An additional factor that seems to have made a difference in cultivating men’s engage- ment is that men have been invited to be present during their wives’ labour and delivery, building their appreciation for their wives and what is involved in giving birth. Emergency contraception Emergency contraception is a method to prevent pregnancy within five days of unpro- tected intercourse, failure or misuse of a contraceptive (such as a forgotten pill), rape or coerced sex. It disrupts ovulation and reduces the likelihood of pregnancy by up to 90 per cent. It cannot prevent implantation of a fertilized egg, harm a developing embryo or end a pregnancy. The sooner the pill is 8% 42% Already uses modern methods Has unmet need for modern methods Unmarried and not sexually active Wants a child soon or is pregnant/postpartum with intended pregnancy Infecund 15% 24% 11% IN NEED NOT IN NEED More than half of all reproductive-age woMen in developing countries are in need of Modern contraceptives Source: Singh, S and JE Darroch, 2012. Sources: Singh S and J Darroch, 2012, and special tabulations of data for Singh S et al., 2009. 26% No method or traditional method Modern methods 74% 82% 18% 38% 62% 13% 87% 818 million 75 million 388 million 49 million Women who want to avoid a pregnancy Unintended pregnancies All developing countries Sub-Saharan Africa, South Central Asia and Southeast Asia 26% No method or traditional method Modern methods 74% 82% 18% 8% 62% 13% 87% 818 million 75 million 388 million 49 million Women who want to avoid a pregnancy Unintended pregnancies All developing countries Sub-Saharan Africa, South Central Asia and Southeast Asia woMen who want to avoid pregnancy but do not use a Modern Method account for a disproportionate Majority of unintended pregnancies 30 CHAPTER:CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS taken, the more effective it is. Emergency con- traception is not effective once implantation has begun and does not cause abortion. It is intended for emergency use only and is not appropriate for regular use. For longer-term protection, a copper intrauterine device, when inserted within five days of intercourse, also prevents implantation and can be left in place for up to 10 years (Trussell and Raymond, 2012). Emergency contraception plays a spe- cial role in instances of sexual violence, armed conflict, and humanitarian emergencies. Given the unpredictable and often unplanned nature of young people’s sexual encounters, emergency contraception is especially impor- tant in the range of services provided to adolescents and young adults. Rights and the unmet need for family planning According to a 2012 report by the Guttmacher Institute and UNFPA, there are 1.52 billion women of reproductive age in the developing world. An estimated 867 million of them need contraception, but only 645 million are currently using modern contraceptive methods. The remaining 222 million women have an unmet need for contraception. • An estimated 80 million unintended preg- nancies will occur in 2012 in the developing world as a result of contraceptive failure and non-use among women who do not want a pregnancy soon. • Most—63 million—of the 80 million unin- tended pregnancies in developing countries in 2012 will occur among the 222 million women with an unmet need for modern contraception. • 18 per cent of unintended pregnancies occur among the 603 million women who were using a modern contraceptive but had difficulty using it consistently and correctly, or because of method failure. Why is unmet need for contraception still so high? The 222 million women who want to avoid becoming pregnant for at least the next two years but are not using a method actually reflect a slight decline in unmet need between 2008 and 2012. During this time, the number of women who wanted to avoid a pregnancy grew by nearly 40 million, and the biggest improve- ments in reducing unmet need were made in Southeast Asia. Despite the gains, there is a significant need for targeted interventions that reach underserved communities and marginal- ized sub-populations, where unmet need remains relatively high. In the developing world as a whole, 18 per cent of married women have an unmet need for modern contraception, yet in Western, Central and Eastern Africa and Western Asia, 30 per cent to 37 per cent of women have an unmet need for contraception. In the Arab region, a significant number of women have unmet need for family planning—that is, they prefer to avoid a pregnancy for at least two years but are not using a family planning method. A survey col- lected by the Pan-Arab Project for Family Health found that only four in 10 married women of reproductive age living in the Arab countries use modern contraception (Roudi-Fahimi et al., 2012). In most Arab countries, women’s ambiva- lence towards family planning results from a range of factors, including fear of side effects, concern with husbands’ reactions, conflicts about family roles and cultural responsibility for bearing children. This ambivalence declines as women grow older. Particularly in Western and Central Africa, weak health systems and poor services 31THE STATE OF WORLD POPULATION 2012 contribute to high unmet need (Singh and Darroch, 2012). In virtually all developing countries, poor women have more children and lower contraceptive use than wealthier women, underscoring the need for programming in resource-poor communities. In sub-Saharan Africa, women in the top wealth quintile are three times as likely to use contraception as those in the lowest wealth quintile (Gwatkin et al., 2007). The major difference between users and non-users is that some have access to informa- tion, have more choices as a consequence of their greater wealth and schooling, and can act on their desire to have fewer children. Women with unmet need for family planning account for nearly four out of every five unin- tended pregnancies (Singh and Darroch, 2012). Other factors contributing to unintended preg- nancies include incorrect or inconsistent use of a method of contraception, which may be due to inadequate counselling or information, and discontinuation of a method without switching to another method (Singh and Darroch, 2012). Use of modern methods among never-married women in the developing world as a whole is much lower than among married women, except in sub-Saharan Africa, where women have a strong need for dual protection from pregnancy and sexually transmitted infections, including HIV, and condoms are the predomi- nant method used by unmarried women (Singh and Darroch, 2012). Data also support the need for adolescent- and youth-friendly services. Pregnancies among adolescents between the ages of 15 and 19 from poor families are more than twice as common than they are among the same age group from wealthy families (Gwatkin et al., 2007). These disparities are compounded by the fact that poor girls are more likely than wealthy girls to be mar- ried, to be uneducated and malnourished and to have preterm or underweight infants. Little improvement in access among adolescents over the past 10 years can be observed in 22 sub- Saharan African countries where one in four adolescent girls has unmet need for family planning (United Nations, 2011c). Married adolescents in all regions have greater difficulty than older women in meeting their need for contraceptive services (Ortayli and Malarcher, 2010). But young never-married women also face difficulties in obtaining contraceptives, largely because of the stigma attached to being sexually active before marriage (Singh and Darroch, 2012). Contraceptive use lowers abortion rates According to a recent Guttmacher Institute study (Singh and Darroch, 2012), an estimated 80 million unintended pregnancies will take place in 2012 in the developing world, and 40 million of them will likely end in abortion. Mobile health educator in Gabarone, Botswana visits home. ©Panos/Giacomo Pirozzi t 32 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS Most unintended pregnancies ending in abortion result from non-use of a contraceptive method or from method failure, particularly of a traditional method such as withdrawal. Despite their lower rate of effectiveness, 11 per cent of all contraceptive users globally (less than 7 per cent of all married women) rely on withdrawal, rhythm, and other traditional methods (Rogow, 1995). While lack of access to modern methods is often a factor in this choice, many prefer so-called “natural” methods because of the absence of side effects, their lack of cost, and the fact that they can be used at home with no trip to a clinic. Addressing women’s concerns about mod- ern methods and helping women who stop using one method to find a new and effective one could reduce unintended pregnancies in sub-Saharan Africa, South Central Asia and Southeast Asia by 60 per cent, and reduce abor- tions in those regions by more than half (Cohen, 2011). Addressing unmet need globally would avert 54 million unintended pregnancies and result in 26 million fewer abortions—a decline from 40 million to 14 million abortions (Singh and Darroch, 2012). A study of abortion in 12 countries in Central Asia and Eastern Europe found that many women had used modern contraceptives but had discontinued for a variety of reasons (Westoff, 2005). The majority of pregnancies resulting from discontinuation of a modern method ended in abortions. This highlights the impor- tance of offering a range of methods from which to choose, of providing high-quality counselling and “accompaniment” to clients, and of provid- ers helping women who are dissatisfied with a method to switch to another method before an unintended pregnancy occurs. In the Ukraine, fertility rates have been declining as more women have an opportunity to have careers outside of the home, and more couples are choosing to have fewer children. Immediately after the dissolution of the Soviet Union, couples relied on abortions as family planning. Today, however, because family plan- ning is more readily available and understood, there are fewer unplanned pregnancies, and therefore fewer abortions. In Latin America and the Caribbean, abor- tion rates have fallen from 37 per 1,000 women between the ages of 15 and 44 in 1995 to 31 per 1,000 in 2008 (Kulcycki, 2011), as use of mod- ern contraceptive methods has risen throughout the region to about 67 per cent among mar- ried women (United Nations, Department of Economic and Social Affairs, 2011). However, access to contraceptives remains difficult in some regions and for some groups, especially the poor and adolescents. High rates of unintended preg- nancy lead many women to seek abortion, which is restricted in most countries in the region. In a number of countries, abortion is permitted only to save a woman’s life. As a consequence, almost all of the 4.2 million abortions annually in the region are performed clandestinely or under unsafe conditions; the rates of abortion and the proportion that are unsafe are the highest in the world (United Nations, Economic Commission for Latin America and the Carribean, 2011). While wealthier women can seek private provid- ers, poor women more often suffer the medical and legal consequences of their limited choices (World Health Organization, 2011a). Unsafe “All countries should, over the next several years, assess the extent of national unmet need for good-quality family planning services and its integration in the reproductive health context, paying particular attention to the most vulnerable and underserved groups in the population.” — ICPD Programme of Action 1994, Paragraph 7.16 33THE STATE OF WORLD POPULATION 2012 abortions in the region lead to more than 1,000 deaths and 500,000 hospitalizations each year (Kulcycki, 2011). Women in developed and developing regions of the world have abortions at similar rates: 29 abortions per 1,000 women in develop- ing countries, compared with 26 per 1,000 women in developed countries (World Health Organization, 2011). Though contraceptive prevalence is higher in developed countries, some women may discontinue use or do not have regular access to contraceptive methods. Unsafe abortions account for almost half of all abortions (Sedgh, Singh and Shah, 2012). Nearly all (98 per cent) of unsafe abortions—among all age groups—take place in developing countries, with the greatest number occurring in sub- Saharan Africa. The World Health Organization has estimated that 21.6 million unsafe abortions occur each year (World Health Organization, 2011). The number is steadily increasing as the number of women of reproductive age (15-44) increases worldwide. CASE STUDY Unsafe abortion in Mozambique Some young women in Mozambique resort to dangerous and illegal practices to termi- nate unwanted pregnancies. The Associação Moçambicana para o Desenvolvimento da Família (AMODEFA) and now other non- governmental organizations have organized “Women’s Caucus” discussion groups that meet for two hours each week to talk about this and related issues (United Nations Population Fund, 2011a). The members choose the topics, which revolve around contraception, partners, unsafe abortion, gender equality, small business opportunities and violence against women. Young women from AMODEFA with training in human rights, sexual and reproductive health and gender equality coordinate the forum. Young women report greater confidence in reproduc- tive health decision-making and more knowledge of sexual and reproductive health services and where to find them. Greater contraceptive use, fewer abortions The evidence is strong that as modern contracep- tion becomes more widely used, abortion rates fall (Westoff, 2008). For example, in Russia, as the use of the intrauterine device and the pill increased by 74 per cent between 1991 and 2001, abortion, which had been the primary means of fertility control for decades, fell by 61 per cent. Similar patterns are seen throughout the Eastern Europe and Central Asian countries where women previously lacked access to modern contraception (Westoff, 2005). By 2020, if an additional 120 million women who want contraceptives could get them, this would mean 200,000 fewer women and girls dying in pregnancy and childbirth—that’s saving a woman’s life every 20 minutes. Access to contraceptives would mean nearly 3 million fewer babies dying in their first year of life. ©Lindsay Mgbor/UK Department for International Development t 34 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS According to the most recent data, adoles- cents and youth account for approximately 40 per cent of unsafe abortions worldwide (Shah and Ahman, 2004). Adolescents may have higher rates of death and disability than adult women due to delays in seeking abortion ser- vices and failure to seek care for complications. Abortion rates increase with limits to contracep- tion, increased demand for smaller families or delayed childbearing. Family planning aimed at young people can help prevent the leading causes of death among girls between the ages of 15 and 19: complica- tions related to pregnancy, delivery and unsafe abortion (Patton et al., 2009). Almost all mater- nal deaths occur in developing countries, with more than half of these deaths occurring in sub-Saharan Africa and almost one-third in South Asia (World Health Organization, 2012). A comparative study of hospitalizations across 13 developing countries estimated that nearly one-fourth of women (8.5 million) who have an abortion each year experience complications that require medical attention, with about 3 million of them unable to receive the care they need (Singh, 2006). Young girls face greater risks than adults of complications and death as a result of pregnancy. Compared to adult women, younger mothers are two-to-five times more likely to die during child- birth, and the risk of maternal death is highest among girls who have children before their fif- teenth birthdays (World Health Organization, 2006). Pregnant girls age 18 or younger are at up to four times greater risk of maternal death than women who are at least 20 years old (Greene and Merrick, n.d.). Often overlooked, maternal morbidities are also a concern for young people. Young moth- ers who survive childbirth are at greater risk of suffering from pregnancy-related injuries and infections, including obstetric fistula. In sub- Saharan Africa and Asia, the United Nations estimates that more than 2 million young women live with untreated obstetric fistula, a condition associated with disability and social exclusion (World Health Organization, 2010). In most settings, high levels of maternal death and disability reflect inequalities in access to health services and the social disadvantage and exclusion that young people face—both a cause and consequence of health risk that young peo- ple face as a consequence of pregnancy (Swann et al., 2003; Greene and Merrick, n.d.). Nearly 95 per cent of births among adoles- cents take place in developing countries, and in these countries, about 90 per cent of births to adolescents 15-19 occur within marriage (World Health Organization, 2008). Child mar- riage—marriage that takes place before the age of 18—is increasingly recognized as a violation of a girl’s human rights, including the right to be protected from traditional harmful practices TOTAL ABORTION RATES AND THE PREvALENCE OF MODERN CONTRACEPTIvE METHODS IN 59 COUNTRIES Source: Westoff, 2005. Percent of married women using modern methods 3 2 1 0 4 0 10 20 30 40 50 60 70 80 To ta l a bo rt io n ra te 35THE STATE OF WORLD POPULATION 2012 (as stated in the Convention on the Rights of the Child), but it remains all too common, particularly in Africa and South Asia, where approximately half of all girls are married before age 18 (Hervish, 2011). Most married girls become pregnant not long after marriage (Godha, Hotchkiss and Gage, 2011). Even though 75 per cent of all births among adolescents are described as “intended,” (World Health Organization, 2008), such intentions may be strongly influenced by social pressures and cultural norms, for example, that a woman prove her fertility to her husband and his family soon after marriage (Godha, Hotchkiss and Gage, 2011). For unmarried girls, pregnancy is far more likely to be unin- tended and to end in abortion (World Health Organization, 2008). In Latin America, births among adolescents have declined more rapidly, but remain high, averaging 80 births per 1,000 young women per year. In a few countries, such as Ecuador, Honduras, Nicaragua, and Venezuela, adoles- cent birth rates are above 100 births per 1,000 women ages 15 to 19, approaching those of most sub-Saharan countries (UNFPA 2011). Adolescent pregnancy and childbearing are much higher among indigenous groups in these countries; these groups tend to be socioeconom- ically and educationally disadvantaged (Lewis and Lockheed, 2007). In the United States, birth rates among adolescents have recently declined among all ethnic groups to an historic low level of 34 births per 1,000 women but are still higher than they are in Western Europe (UNFPA, 2010a). Births among adolescents are declining in most regions, but the rate of decline has slowed in some parts of the world, even reversed in some countries in sub-Saharan Africa where births among adolescents are the highest in the UNSAFE ABORTIONS AMONG ADOLESCENTS AND YOUTH PERCENTAGE OF TOTAL UNSAFE ABORTIONS IN DEvELOPING COUNTRIES AND PROPORTION AS A PERCENTAGE OF UNSAFE ABORTION BY REGION Source: Shah, I., Ahman, E (2004). “Age Patterns of Unsafe Abortion in Developing Country Regions. Reproductive Health Matters. 12(24 Supplement):9–17. 15-19 31 Adolescents and youth (15-24) 0 10 20 30 40 50 60 Africa Asia 25 32 9 23 29 14 Latin America and Caribbean 40% 60% 20-24Other 15-19 31 0 10 20 30 40 50 60 Africa Asia 25 32 9 23 29 14 LAC 20-24 Percentage among adolescents and youth, as a percentage of total unsafe abortions worldwide Breakdown, as a percentage of unsafe abortions (15-24 years) in their region 15-19 31 Adolescents and youth (15-24) 0 10 20 30 40 50 60 Africa Asia 25 32 9 23 29 14 Latin America and Caribbean 40% 60% 20-24Other 15-19 31 0 10 20 30 40 50 60 Africa Asia 25 32 9 23 29 14 LAC 20-24 36 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS world (United Nations Population Division, 2012). In sub-Saharan Africa, adolescents between the ages of 15 and 19 have, on aver- age, 120 births per 1,000 per year, ranging from a high of 199 per 1,000 girls in Niger to a low of 43 per 1,000 girls in Rwanda. Over half of young women give birth before age 20 (Godha, Hotchkiss and Gage, 2011), and adolescent fertility in most countries in sub-Saharan Africa has shown little decline since 1990 (Loaiza and Blake, 2010). In the Caucasus and Central Asia, fertility among adolescents has leveled off over the past 10 years, perhaps because the region has achieved such high levels of girls’ schooling, with gender parity at the secondary level and more girls studying at the tertiary level than boys (United Nations, 2012). The only region where adolescent fertility increased between 2000 and 2010 was Southeast Asia. The need for comprehensive data Protecting the right to family planning first requires a baseline understanding of who cur- rently has access to family planning and who does not. Ensuring rights also requires an understanding of how young people and adults view sex, sexuality, and the decision to have children. New technologies make it possible for States to gain a greater understanding of demo- graphic trends and the environmental factors that motivate people to have sex and influence fertility rates. Digital and mobile communica- tions make it possible for people to more easily access information about their rights and their governments’ obligations to uphold them. An assessment of family planning trends requires a nuanced analysis of who is most vul- nerable, whose needs have been neglected, and what factors contribute to peoples’ vulnerabilities and their inability to realize their rights to family planning throughout their lives (UNFPA, 2010). Good demographic measures tell a complex and evolving narrative. Stakeholders increas- ingly need to analyse these data in concert with information about the social, cultural, and political conditions that shape health and cause patterns in health to evolve. The World Health Organization asserts that these social determi- nants of health drive “most of the global burden of disease and the bulk of health inequalities” (World Health Organization, 2005). At all levels—individual, community, and national— social determinants of health establish conditions that influence the ability of women, men, and young people to access quality family planning when they want to prevent or delay pregnancy at different stages of their lives. Policymakers must therefore use comprehen- sive data across sectors on population dynamics, including age structures and the rate of urbaniza- tion, as well as other trends. Simply increasing the availability of family planning may do little to reduce unintended pregnancy without analy- ses of where unmet need is greatest, where efforts to uphold reproductive rights have been weak, or where cultural, social, economic or logistical Fertility rates in Ecuador vary among population groups. Women in the lowest income quintile, for example, have an average of five children, compared to women in the highest income quintile who have about two. These disparities reflect inequalities in access to sexual and reproduc- tive health services. In response, UNFPA partnered with the Ministry of Health and other bilateral and multinational organizations to collect and analyse data to document the disparities and to advocate for changes that would rectify these inequalities. The data made the case in 2009 for a new strategy for family planning and for the prevention of adolescent pregnancy, and as a result, Ecuador stepped up its investments in repro- ductive health supplies, including contraceptives, by more than 700 per cent between 2010 and 2012, to $57 million. DATA-DRIvEN ADvOCACY RESULTS IN POLITICAL AND FINANCIAL SUPPORT FOR FAMILY PLANNING IN ECUADOR 37THE STATE OF WORLD POPULATION 2012 barriers prevent individuals from accessing infor- mation and high quality services. The Programme of Action highlights the interrelation of human sexuality, age and gender relations, and how they together affect the ability of men and women to achieve and maintain sex- ual health and manage their reproductive lives. Family planning programmes must therefore be based on an analysis of data in ways that take into account the continuum of sexual activity, as well as the gender- and age-specific consequences of sexual activity. Conclusion Fertility, unmet need, rates of discontinua- tion among those who are using contraception and levels of unsafe abortion are highest in the poorest countries, and among disadvantaged populations within every country. Lingering high levels of unintended pregnancy persist in some developed countries. Persistent inequalities can be seen in access to and use of family planning between the educated and wealthy elites and everyone else. When it comes to using family planning, therefore, those who can, do, while those with more limited access experience unmet need and unintended pregnancy. In contemplating the need around the world for family planning information and services, policymakers need access to comprehensive data and should consider patterns of sexual activity and not just fertility rates. A couple with their baby in Vulcan. Romania. ©Panos/Petrut Calinescu t 38 CHAPTER THREE CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE 39THE STATE OF WORLD POPULATION 2012 A large and unsatisfied desire exists for family planning around the world among people of many ages, ethnic groups and places of residence. Nations vary greatly in their ability to help their populations fulfil this desire and uphold individuals’ rights. In many countries national legislation exists to translate international rights commitments into reality (Robison and Ross, eds, 2007). But in far too many settings, the rights of some—not all—are guaranteed only in principle. Despite a range of legal protections, barriers to access—and to rights—persist. Some barriers are related to costs and affordability. Others are related to difficulties in making quality sup- plies and services reliably available in remote areas or to the distances individuals must travel to obtain family planning. Other obstacles are related to social norms, customs or gender inequality. And still others are related to policy or legislative environments. Many groups, therefore, are not able to exercise their right to decide whether, when and under what conditions to have children. The challenge is often related to direct and indirect discrimination and the unequal implementation of existing legislation, policies and programming. Worldwide, specific sub-populations face the greatest challenges in accessing the information and services they need to plan their families. As a result, access to family planning is more akin to a privilege enjoyed by some rather than a universal right exercised by all. Confronting social and economic barriers to family planning The United Nations Common Understanding on a Human Rights-Based Approach emphasizes the importance of building the capacities of individuals to claim their rights as well as of duty-bearers to meet their obligations, including service provision. Consequently increased access and use of basic family planning services require the development of capacities for empowerment, in particular of marginalized and discriminated rights-holders, and capacities for duty-bearers responsiveness and accountability. Many varied institutions can and do address these barriers to the realization of the right to family planning. Social, cultural and economic factors can enable or impede the realization of rights including access to and provision of family planning information and services. These factors may mean that ethnicity, age, marital status, refugee status, sex, disability, poverty, mental health and other characteristics are Challenges in extending access to everyone CHAPTER THREE t Brenda, 16, (left) and her older sister Atupele, 18, (right) had to drop out of school because their family could not afford the fees. Both are now young mothers. ©Lindsay Mgbor/ UK Department for International Development 40 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE all barriers to individuals’ access to family planning. However, in the sexual and reproductive health arena, gender inequality, gender-based discrimination and women’s disempowerment stand out as posing obstacles to women in particular as they pursue and claim their health and rights. Achieving States’ family planning obligations requires a focus on gender equality In many settings, gender norms condone specific beliefs, behaviours, and expectations of adult women and men, contributing to the health risks and vulnerabilities that affect women and men throughout their lives. Relative to men, women and girls are often socialized to be passive and under-educated about their sexual and reproductive health. Sexuality—a topic that encompasses a diverse set of desires, experiences, and needs—is typically confined to notions of purity and virginity for women and girls. Women live with pressures to conform to social norms that uniformly restrict their sexual activity within the context of marriage. They are often discour- aged from taking the initiative to bring up topics related to sexual relations, to refuse to have sex or to communicate about family planning. A dominant masculinity teaches boys and men that sexuality and sexual performance are key to masculinity. The enjoyment of sexual relations is viewed as their prerogative and they are taught to take the lead in their sexual relationships, creating significant pressure (and insecurity). Traditional views of what it means to be a man can encour- age men to seek out multiple sexual partnerships and to take sexual risks. Around the world, men are taught that they are not primarily respon- sible for family planning and are often not held responsible for pregnancies outside of marriage. The differing treatment of boys and girls as they grow up begins early, and it continues throughout their lives. The result is that every- one—children, young people, adults—generally absorb messages about how they ought or ought not to behave or think, and early on, begin to establish divergent expectations of themselves and others as females and males. Often, these expectations unfortunately translate into practic- es that can harm sexual and reproductive health. Although women more consistently suffer the negative effects of harmful gender norms across their lifetimes, societies also socialize their men, male adolescents, and boys in ways that drive poor sexual and reproductive health outcomes. In many societies, men are encouraged to assert their manhood by taking risks, asserting their toughness, enduring pain, being independent providers, and having multiple sex partners. The roles and responsibilities of breadwinner and head of the household are inculcated into boys and men; fulfilling these behaviours and roles are dominant ways to affirm one’s manhood. If gender norms simply dictated difference and not hierarchy, we might not be talking about them here. But gender norms as a rule establish and reinforce women’s subordination to men and drive poor sexual and reproductive health outcomes for both men and women. Women are often prevented from learning about their rights and from obtaining the resources that could help them plan their lives and families, sustain their advancement in school, and support their par- ticipation in the formal economy (Greene and Levack, 2010). Men are often not offered most As part of the effort to meet unmet needs, all countries should seek to identify and remove all the major remaining barriers to the utilization of family planning services. — Programme of Action of the International Conference on Population and Development, ICPD 41THE STATE OF WORLD POPULATION 2012 sources of sexual and reproductive health infor- mation and services and develop the sense that planning their childbearing is not their domain: it is women’s responsibility. Gender inequality in family planning programmes Gender inequality is a profound obstacle to women’s—and men’s—ability to realize their right to family planning. It is also an impedi- ment to sustainable development. While gender equality refers to the overarching goal of equal rights, access, opportunities and lack of gender discrimination, gender equity refers to fairness in the distribution of resources and services (UNFPA, 2012b; Caro, 2009). To ensure fair- ness and justice, governments must pursue gender equality, adopting strategies and measures to compensate for historical and social disad- vantages that prevent women and men from enjoying equal opportunities (UNICEF, 2010). The legal, economic, social and cultural barriers to health and access to health services are reinforced by the physiological realities of reproduction: women bear the consequences of poor sexual and reproductive health choices and pay for these consequences with their health and sometimes their lives. Empowered with appropriate information, methods, and services, vulnerable populations are in a better position to avoid many of the harmful sexual and reproductive health outcomes affecting them. A focus on gender equality can make it easier for both women and men of all ages across diverse social settings to plan the timing and spacing of their children. The rigid ideals about appropriate atti- tudes and behaviours for men and women are learned, socially constructed norms that vary across local contexts and interact with socio- cultural factors such as class or caste (Barker, 2005; Barker, Ricardo and Nascimento, 2007). These social and gender norms are carried out and reinforced on multiple levels, among indi- viduals in peer groups and families, through community-wide attitudes and practices, and within institutions. CASE STUDY Addressing gender-based violence in Tanzania The Jijenge! programme in Tanzania recognized the harm gender inequality was causing to women, including to their sexual and reproduc- tive health (Michau, Naker and Swalehe, 2002). Going beyond a typically biomedical approach to sexual and reproductive health, the Couple at antenatal care service for couples in Venezuela. ©UNFPA/Raúl Corredor t 42 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE programme integrated gender equality into sexu- al and reproductive health via three strategies: • Providing information and clinical services for women, information, services and counselling that helped women identify the root causes of the sexual health problems in their communities; • Training community workers to create more gender-sensitive service agencies and provid- ers, including teachers, police, judges, church groups and so on who could develop more woman-friendly practices; • Changing gender attitudes in communities by stimulating public debate on the situation of women through brochures, street theatre, community meetings and other ways of disseminating information. The programme found that a specific focus on gender-based violence (particularly when Percentage of men who say the following are important SCORE ON GENDER EqUITABLE MEN SCALE COUPLE COMMUNICATION SExUAL SATISFACTION ACCOMPANIED TO PRENATAL VISIT GETTING AN HIV TEST BRAzIL LOW 87 80 58 28 MODERATE 84 91 68 31 HIGH 87 95 87 38 CHILE LOW 50 50 27 21 MODERATE 86 83 83 24 HIGH 90 88 89 31 CROATIA LOW 70 61 69 5 MODERATE 88 67 84 3 HIGH 95 79 94 13 INDIA LOW 73 98 91 20 MODERATE 65 98 91 12 HIGH 64 98 93 6 MExICO LOW 71 86 75 16 MODERATE 85 91 87 15 HIGH 91 96 94 31 RWANDA LOW -- 83 -- 85 MODERATE -- 85 -- 87 HIGH -- 90 -- 89 ASSOCIATION OF GENDER EqUITABLE ATTITUDES AND BEHAvIOURS RELATED TO SExUAL AND REPRODUCTIvE HEALTH Source: International Center for Research on Women and Promundo, 2011. 43THE STATE OF WORLD POPULATION 2012 messages were delivered via a number of routes) turned out to be more effective than a broader approach to gender inequality. Men’s involvement in discussions was key, as was the endorsement of influential members of the community. If more traditional, dominant male gender attitudes are related to poorer health outcomes, it is logical that more gender equitable attitudes can lead to improvements in sexual and repro- ductive health-related attitudes and practices (Pulerwitz and Barker 2006; Barker, Ricardo and Nascimento, 2007). The International Men and Gender Equality Survey, for example, has shown more healthful practices to be associated with higher scores on the “gender equitable man” or GEM Scale for measuring attitudes towards gen- der equality (International Center for Research on Women and Promundo, 2010). What these data tell us is that men with more respectful attitudes are likely to have better individual and couple outcomes as reflected in improved couple communication, more sexual satisfaction, greater chances of accompanying their female partners to antenatal visits, and greater likelihood of having sought an HIV test. In the past 15 years, non-governmental organizations, United Nations agencies and governments have invested in programmes that bring together efforts to change gender norms with health interventions. Recent research has shown that efforts to strengthen more gender equitable attitudes among men can influence sex- ual and reproductive health-related attitudes and practices (Pulerwitz and Barker, 2006; Barker, Ricardo and Nascimento, 2007). Recent global reviews of sexual and reproductive health pro- grammes have found that those that integrated gender considerations achieved better outcomes (Rottach, Schuler and Hardee, 2011; Barker, Ricardo and Nascimento, 2007). HIV status does not necessarily repress the desire to have children, and HIV-positive women may decide to have children in spite of their HIV status, or they may decide not to have children (Rutenberg et al., 2006). Women living with HIV are unable to exercise their right to decide the number, timing and spacing of their children when discrimi- natory practices deprive these women of the necessary means and services to fulfil their decisions, such as accessing contraception, fam- ily planning, maternal health care, and drugs and services to prevent mother-to-child transmission. The right to health and the right to sexual and reproductive health entitle women living with HIV to the treatment, care and services necessary for them to prevent mother-to-child transmission when they are preg- nant. The risk of perinatal transmission of HIV is below 2 per cent when coupled with antiretroviral treatments, safe delivery and safe infant feeding. Absent these critical services, the risk ranges from 20 per cent to 45 per cent (World Health Organization, 2004a). In low- and middle-income countries, an estimated 45 per cent of HIV-positive pregnant women receive at least some antiretroviral drugs to prevent mother-to-child transmission of HIV (World Health Organization, UNAIDS and UNICEF, 2010). PREvENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIv/AIDS Olivia Adelaide, lab technician at Mozambique's Boane Health Center, which offers primary care and sexual and reproductive health services, including family planning and HIV testing. ©UNFPA/Pedro Sá da Bandeira t 44 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE Cultural attitudes and expectations regarding virginity, marriage and family roles remain rigid in many places, reinforced by anxieties about female sexuality, power and independence and the very real dangers girls may face (Greene and Merrick, n.d.). As more girls stay in school for longer, they are statistically more likely to mature sexually while they are enrolled; they face risks that few schools address adequately, including sexual violence, exposure to sexually transmitted infections and HIV, early pregnancy and childbearing, and unsafe abortion (Lloyd 2009). Of course not all of these risks are new, or occur just at school; out-of-school girls also marry, and continue to have children as teens in great number. What is new is the greater possi- bility of friction between the parts of girls’ roles that remain stable (domestic chores, expecta- tions about virginity, the management of their sexuality, and aspirations for marriage) and those that are changing (schooling, exposure to peers, greater mobility in some cases). An analysis in five African countries of the experience of 12-to-19 year-olds who were in school at age 12 shows that girls are less likely than boys at every age to continue in primary or secondary school, and less likely than boys to make the transition from primary to second- ary school (Biddlecom et al., 2008). Girls are much more vulnerable to dropping out once they are sexually mature and once they experi- ence premarital sex; early pregnancy is even more disastrous for girls. Some recent research suggests that pregnancy and early marriage are more likely consequences rather than causes of girls failing to complete their secondary education (Biddlecom et al., 2008; Lloyd and Mensch, 2008). Redefining what it means to be a “real man” Like women and girls, men and boys feel social pressures to adopt rigid ideals about how they should behave, feel, and interact to be con- sidered real men. These ideals are learned, not a result of simply their sex (Connell, 1987; Connell, 1998). When given the opportunity to critically reflect on these ideals, men and boys can often describe the pressures they feel to be real men—a term usually ascribed to taking risks, enduring pain, being tough, being a provider, and having multiple sex partners (Flood, 2007). Real men usually refers to hegemonic mascu- linity—the prevailing measure of masculinity by which men assess themselves and others. Dominant concepts of masculinity are complex and different across societies, influenced by sev- eral factors including culture, race, social class, and sexuality (Kimmel, 2000). For example, a group with one version of masculinity within a social class or ethnic group may exert greater power over another, just as heterosexual mas- culinity is often dominant over homosexual and bisexual masculinity (Marsiglio, 1998). In many societies, hegemonic masculinity is associ- ated with heterosexuality, marriage, authority, professional success, ethnic dominance, and/ or physical toughness (Barker, Ricardo and Nascimento, 2007). Men and boys who deviate from dominant male norms in their attitudes and behaviours are susceptible to ridicule and criticism (Barker and Unsafe abortion is “a procedure for terminating an unintended pregnancy that is carried out either by a person lacking the necessary skills or in an environment that does not conform to the minimal medical standards, or both.” — World Health Organization (1992). 45THE STATE OF WORLD POPULATION 2012 Ricardo, 2005). Moreover, young and adult men who adhere to these traditional views of man- hood are more likely to engage in riskier sexual practices (Sonenstein, ed, 2000). Results from the Gender Equitable Men Scale have found that men who adhere to more rigid views about masculinity are more likely to hold attitudes or practice behaviours that compromise their sexual health and their partners’ health (Pulerwitz and Barker, 2008). Not all boys and men identify with domi- nant versions of masculinity within their communities. For example, young men of higher socioeconomic status often hold more power and access to goods and opportuni- ties than young men of lower socioeconomic classes (Barker, 2005). The evolution of who they are within their peer groups, families, and communities is a dynamic process that changes over time (Connell, 1994). Men’s attitudes and experiences, particularly the conclusions they draw about what is socially acceptable behav- iour, have implications for men’s and boys’ willingness to access family planning services and to be active participants in planning families with their partners. A global review conducted by the World Health Organization found that culturally domi- nant forms of masculinity, which often urge men to practice strict emotional control and cultivate a sense of invulnerability, serve as barriers to health—and health-seeking behaviour: they dis- courage some men and boys from visiting health facilities or from supporting their partners’ health (Barker, Ricardo and Nascimento, 2007). Men often have no opportunity to question these male norms or to reflect on how their views of manhood affect their health and their partner’s health. However, tailored programmes have demonstrated that young and adult men can adopt equitable attitudes and behaviours— attitudes associated with better sexual and reproductive health outcomes (International Center for Research on Women and Promundo, 2010; UN Women, 2008). Prevailing attitudes and norms about sex impede access for young people, unmarried people of all ages, men and boys and marginalized groups Social and cultural norms dictate who, when, with whom, and for what purpose women and men should have sex. Sexual activity is widely viewed as acceptable only when the “right” people engage in it under the “right” conditions. The perspectives of excluded groups are not closely reflected in the design, implementation, and evaluation of family planning policies and programmes. The impediments to their access Young men in Cairo's Tahrir Square. ©UNFPA/Matthew Cassel t 46 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE are taken for granted following patterns of exclu- sion specific to each setting. Across societies worldwide, expectations dictate that sex should take place only among married individuals who are healthy, hetero- sexual, monogamous, not too young, not too old, and whose childbearing fulfils expectations in their families and communities. When any person’s sexual activity violates any of these rigid requirements, society makes it more difficult for that person to access family planning education, methods and services. Reinforced over time by longstanding cultural attitudes and practices, social norms underpin the dialogue, or the absence thereof, around individuals’ sexual desires, their motivations and reservations about accessing family planning, and the stigma and discrimination they experience. To take the example of unmarried adolescents, despite copious evidence that many are sexually active and that it makes complete public health sense to prepare them to manage the experience, social norms preclude discussing sexual relation- ships or providing sexual and reproductive health and family planning information to them. Social conditions under which sexual activity is deemed “unacceptable” do not excuse States from fulfilling their obligations and commitment to public health. Governments alone cannot change discriminatory attitudes and norms about sex. However, they can structure and coordinate pro- cesses that mitigate social barriers to access, build capacities of marginalized groups to exercise their rights and provide these persons with adequate Human sexuality and gender relations are closely interrelated and together affect the ability of men and women to achieve and maintain sexual health and manage their reproductive lives. Responsible sexual behaviour, sensitivity and equity in gender relations, particularly when instilled during the formative years, enhance and promote respectful and harmonious partnerships between men and women. — Programme of Action of the ICPD, paragraph 7.34 0 10 20 30 40 50 60 70 80 50.1 48.6 32.4 0 25.2 34.3 57.1 58.1 26.5 61.2 Brazil Croatia India Mexico Rwanda 30.7 41.7 69.7 57.8 54.2 Men need more sex than women do % A gr ee Men don’t talk about sex, they just do it Men are always ready to have sex RELATIONSHIP BETWEEN ADHERENCE TO DOMINANT MASCULINITIES AND SExUALITY Source: International Men and Gender Equality Survey, International Center for Research on Women & Instituto Promundo 2011 47THE STATE OF WORLD POPULATION 2012 information and services, including comprehen- sive and objective sexuality education. Marginalizing the rights of a number of popu- lations undermines national development goals. These population groups are often the most vulnerable to neglect and discrimination, and in many countries, are those with greatest unmet need. Those whose sexual activity may challenge prevailing social norms and whose access to reli- able, quality family planning may be impeded include 1) young people, 2) unmarried people of all ages, 3) males and 4) other marginalized or discriminated against groups. Without integrating family planning policies that promote social inclusion and applying a rights-based framework, institutions responsible for equitable delivery of information and services may systematically neglect the needs of entire segments of their population. 1 Young people Despite the international commitments to remove barriers to family planning for all popu- lation groups, research finds that young people’s needs remain largely neglected. The consequence is that the largest generation of young people in history is unable to fully exercise their reproduc- tive rights and prevent unintended pregnancies, mitigate the risks of school dropout, or protect themselves from sexually transmitted infections, including HIV. This reality and its harmful con- sequences are largely preventable. People younger than 25 years now account for 44 per cent of the world’s total population, and in developing countries, the numbers of children and youth are at all-time highs— 1.6 billion and 1 billion, respectively. Girls aged 10 to 19 alone account for nearly one-fifth of all women of reproductive age (Guttmacher Institute and International Planned Parenthood Federation, 2010; Guttmacher Institute and International Planned Parenthood Federation, 2010a). As these young people mature into adulthood, their political, economic, and sociocultural realities will shape the oppor- tunities and risks they face in planning their childbearing. In many societies, these factors continue to reinforce attitudes and practices that restrict or deter young people from access- ing education and services, resources that would empower them with information to choose when they want to become parents. Unmet need is highest among the 300 million adolescent women between the ages of 15 and 19. The risks of childbearing for both mother and infant are highest for adolescent mothers, and intensive efforts are needed to ensure that adolescent rights to sexual and reproductive health information and services, including for protection against sexually transmitted infections and HIV, are respected (UNICEF et al., 2011a). Each day, 2,500 youth, the majority of them female, become newly infected with HIV. Young women, whether married or unmarried, often need the dual protection of a condom plus a modern contraceptive to protect them from both pregnancy and disease. In sub-Saharan Africa and South Central and Southeast Asia, more than 60 per cent of ado- lescents who wish to avoid a pregnancy have an unmet need for modern contraception. These adolescents who do not use modern contracep- tion or rely on a traditional method account for more than 80 per cent of unintended pregnan- cies in this age group. A comparative analysis of Demographic and Health Survey data from 40 countries by the Guttmacher Institute found that the proportion of adolescent women who reported discontinuing their method while still in need of contraception ranged from 4 per cent in Morocco to 28 Source: International Men and Gender Equality Survey, International Center for Research on Women & Instituto Promundo 2011 48 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE per cent in Guatemala. Across all countries, the discontinuation rates for adolescents are about 25 per cent higher than those for older women, with regional variations (Blanc et al., 2009). In all countries except Ethiopia, a greater proportion of adolescents than older women discontinued method use while still wishing to avoid preg- nancy. The same analysis noted higher rates of contraceptive failure among young people during the first year of contraceptive use. Very few young people are able to explore their sexuality in healthy environments aligned with age-appropriate sexuality education and services that empower them to make informed decisions about their sexual behaviours and reproductive health. Family planning pro- grammes can reflect the belief that young people are supposed to remain abstinent until marriage. This sociocultural standard no longer reflects the diverse realities of young peoples’ sex lives. Young people explore their sexuality and negotiate their sex lives influenced by family members, religious practices, community lead- ers and their peers. Male and female adolescents everywhere are exposed to gendered attitudes and behaviours that shape their perceptions of sex, sexuality, and relationships, as well as their behaviour. The quality and content of the infor- mation young people receive varies widely, and is strongly influenced by adolescent peer groups (Kinsman, Nyanzi and Pool, 2000; Jaccard, Blanton and Dodge, 2005). Where young people are especially vulnerable to gender-based violence, adolescent girls in particular are at increased risk that their first sexual experience is coerced or forced. Coercion is common in Disparities in aDolescent fertility rates: eDucation anD householD income matter Age-specific fertility rates (live births per 1,000 girls) for 15-19 year-olds by income quintile and region Region No. of surveys per countries in the region Regional average Poorest quintile Richest quintile Ratio of fertility rates Poor-Rich % children of lower secondary school age out of school^ East Asia 4 of 7 42.4 75.6 17.6 4.3 10.0 Central and Eastern Europe, Central Asia 6 of 8 52.7 7.0 31.3 2.3 9.6, 4.9** Latin America, Caribbean 9 of 17 95.7 169.5 39.2 4.3 5.5 Middle East, North Africa 4 of 6 57.8 68.2 35.1 1.9 19.5 South Asia 4 of 8 107.0 142.0 57.9 2.5 27.3* Sub-Saharan Africa 29 of 49 129.7 168.1 75.4 2.2 36.8 All country average 56 of 95 103.0 142.5 56.6 2.5 18.3 Source of fertility data: Gwatkin et al 2007. Source of education data: UNESCO Institute for Statistics 2010. ^ Includes children approximately ages 11-14, varies by country * Includes South and West Asia ** Data on education presented separately for these two regions 49THE STATE OF WORLD POPULATION 2012 instances of early sexual initiation: more than a third of girls in some countries report that coercion was involved in their early sexual expe- riences (World Health Organization, 2012a). Recent analyses of data on sexual behaviour among young people in 59 countries found no universal trend towards sex at younger ages; trends are complex and vary significantly by region and marital status (Lloyd, 2005). At the same time, global trends towards later marriage have contributed to a diminishing proportion of young women who report having had sex before the age of 15 (Lloyd, 2005; Greene and Merrick, n.d.). Notwithstanding, where child marriage is especially prevalent—South Asia, and Central, West, and East Africa—the median age at first intercourse for women is lower than in Latin America and the Caribbean, for example. For young men, age at first intercourse is not linked to their marital status. These differences between young peoples’ experiences are most pronounced in developing countries. Comparative assessments of adolescent sexual health between the United States and Europe find that young people begin to have sex at similar times, though with rather divergent out- comes. In the United States, 46 per cent of all high school age students have had sex (Centers for Disease Control and Prevention, 2010). Despite similar levels of adolescent sexual activity in several European countries, such as France, Germany and the Netherlands, sexu- ally active adolescents are significantly less likely to experience pregnancy, birth, or abortion. Pregnancy, birth, and abortion rates among teen- age girls in the United States are approximately three, eight, and two times as high as their European peers (Advocates for Youth, 2011). The differences are attributable to European policies that facilitate easier access to sexual health information and services for school-aged girls and boys and that respect young peoples’ rights and support their health: young people in Europe have greater access to comprehensive sexuality education and sexual health services, including family planning; there also tends to be more open discussion of sexual activity with parents and in the society more broadly. Globally, marriage patterns are changing. Young women and men are marrying later, and the number of countries where first sexual inter- course and marriage coincide for those under Just-married couple, Paris. ©Panos/Martin Roemers t 50 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE 25 has decreased compared to earlier genera- tions (Lloyd, ed, 2005; Greene and Merrick, n.d.). These trends have led to an increase in the prevalence of premarital sex among young people. In developed countries, there has been a clear increase in the number of years between first intercourse and marriage (Mensch, Grant and Blanc, 2005). The time between first sexual intercourse and living with a partner is longer for men (three to six years) than for women (up to two years). The increased time interval between age at first sex and age at first marriage have implica- tions for the sexual health risks and needs of young people, particularly for school-aged girls. A recent cross-country analysis of 39 countries found that—with the exceptions of Benin and Mali—unmarried girls (ages 15 to 17) who attend school are considerably less likely to have had premarital sex, as compared to their out- of-school peers (Biddlecom et al., 2008; Lloyd, 2010). Even though individual, familial, and social factors influence sexual behaviour and school participation, these findings underscore the protective effects that an education confers against adolescent pregnancy and its adverse outcomes. Evidence from five countries in West Africa suggests that pregnancy and early marriage may be consequences, rather than causes, of girls dropping out of school in some settings (Lloyd and Mensch, 2008). Millions of young people have sex before their parents acknowledge it or before institutions respond to their needs. These young people— married and unmarried—also need services to avoid unintended pregnancy and prevent sexually transmitted infections including HIV but often do not have access. Young people’s sexual activity challenges the emphasis on abstinence and the view that sex should occur strictly for procreation. The real- ity is that many young people are not abstinent, and their sexual activity is not motivated by a desire to have children. Qualitative assessments in sub-Saharan Africa suggest that sexually active unmarried young people are generally not seek- ing to become pregnant (Cleland, Ali and Shah, 2006). Furthermore, married young people do not necessarily wish to become pregnant at a young age or, if they have already had a child, some wish to delay a second pregnancy. Given young people’s desire to delay child- bearing and prevent disease, the term “family planning” may seem irrelevant to their needs. Recent research touches upon this key point: Many young people can be interested in contra- ception to prevent unwanted pregnancy and to protect against sexually transmitted infections, Teenager in Madagascar listens to a talk about safe sex. ©Panos/Piers Benatar t 51THE STATE OF WORLD POPULATION 2012 but conventional family planning messages about planning their families are irrelevant. Addressing their needs and overcoming barriers to their access to family planning requires emphasis on contraception and disease prevention as well as comprehensive sexuality education, which is grounded in human rights including equality and non-discrimination, reflection about gender roles, sexual attitudes and behaviour (Cottingham, Germain and Hunt, 2010). 2 Unmarried people of all ages Relative to previous generations, greater num- bers of young people and adults of reproductive age are having sex outside of marriage, with no immediate desire to have children (Ortega, 2012). Ensuring their access to family planning regardless of their marital status requires an acknowledgement of sexual activity for pleasure and intimacy before and after marriage as well as within it. Most people in the world marry, and most sexual activity does take place within marriage (United Nations, Department of Economic and Social Affairs, 2009). Yet many people who have never married or whose marriages have ended are sexually active and wish to use family plan- ning. Recent data highlight that interpersonal communication among adults about family planning—and actual family planning use—is increasingly taking place while they are single, separated, widowed or divorced. When State family planning programmes exclude these non-married groups, family plan- ning marginalizes a growing portion of the population. Though religious practices and social norms suggest that marriage is a pre-requisite for sexual activity, the State has an obligation to ensure access to family planning to all people irrespective of their religious beliefs and sexual practices without discrimination. In some countries, the proportion of never- married adults is increasing (United Nations, Department of Economic and Social Affairs, 2009). Over the last 40 years, the number of countries where at least 10 per cent of women have never married by age 50 has increased from 33 to 41. Larger proportions of men are also not marrying. Between 1970 and 2000, the number of countries where at least 10 per cent of men do not marry before their 50th birthday increased from 31 to 49. Sub-Saharan Africa Adolescents who want to avoid pregnancy South Central and Southeast Asia Latin America and the Caribbean Unintended pregnancies among adolescents No method Traditional method Modern method 32 81%53% 11% 17% 52% 8% 15% 8% 75% 9% 32% 39% 32% 14% 54% 7% 10% 83% USE AND UNMET NEED AMONG ADOLESCENTS WHO WISH TO AvOID PREGNANCY IN THE DEvELOPING WORLD Source: Guttmacher Institute and International Planned Parenthood Federation, 2010a. 52 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE Consensual unions account for an increas- ing proportion of live-in partnerships, which tend to be less stable than formal marriages. In Latin America and the Caribbean, more than one in four women between the ages 20 and 34 live in a consensual union (United Nations, Department of Economic and Social Affairs, 2009). This arrangement is less common in sub-Saharan Africa and Asia where about 10 per cent and 2 per cent of women live in consensual unions, respectively. The percentage of women in consensual unions ranges from nearly zero to 30 in 16 developed countries. In a majority of countries with available data, the percentage of women in consensual unions peaks between ages 25-29 (United Nations, Department of Economic and Social Affairs, 2009). Globally, the proportion of adults who are divorced or separated doubled (from 2 per cent to 4 per cent) between 1970 and 2000. Divorce and separation are more common in devel- oped countries than in developing countries. According to the World Marriage Data for 2008, 11 per cent of women were divorced or separated in developed countries whereas only 2 per cent of women of the same age were divorced or separat- ed from their husbands in developing countries (United Nations, Department of Economic and 45% 27% 17% 0 10 20 30 40 50 60 70 80 90 100 11% Africa Asia Oceania North America Europe World Latin America and the Caribbean 0-14 15-24 25-59 Over 60 Regions Source: United Nations, Department of Economic and Social Affairs, Population Division (2011). WE’RE HERE! PER CENT DISTRIBUTION OF YOUNG PEOPLE, AS PER CENT OF WORLD POPULATION BY REGION 53THE STATE OF WORLD POPULATION 2012 Social Affairs, 2009). Data from 15 industrialized countries between 2006 and 2008 suggest the average duration of marriage ranges from 10 to 17 years. Additionally, approximately one in four registered marriages in countries belonging to the Organisation for Economic Co-operation and Development is a remarriage. Adults are entering, staying, and ending partnerships very differently from previous generations, and their needs for family planning education and services have taken on new characteristics. Family planning poli- cies and programmes have an opportunity to rethink their focus so as not to exclude unmar- ried people, whether they are never-married, divorced, separated—temporarily or perma- nently—or widowed. In both developed and developing countries, social norms—to varying degrees—promote abstaining from sexual activity until marriage. Despite broader support for comprehensive sex education in many settings, the abstinence- until-marriage approach to family planning can compromise the effectiveness of in-school sexual- ity education programmes and neglects the sexual health needs of single, sexually active adolescents and young adults. Evidence shows that the abstinence-only-until-marriage style of sexuality education is not effective (Kirby, 2008). “Family planning” usually focuses on the needs of younger married persons, generally the most fertile. Yet a growing number of older women and men have to negotiate contraceptive use and protect themselves from sexually trans- mitted infections later in life, often after marriage (Organisation for Economic Co-operation and Development, 2010). The desire for sexual relationships among older people (over age 49) is largely overlooked in policy and programme design. This omission compromises the rights of sexually active elders who wish to protect themselves from harmful sexual and reproductive health outcomes, including higher-risk unin- tended pregnancies and protection from sexually transmitted infections, including HIV. Meeting their family planning needs requires challenging the pervasive assumption that older people are not sexually active and do not need to exercise the right to family planning. Greater numbers of older women and men are entering their late reproductive years as single, divorced, or widowed, creating a large population of people who are “post-marriage.” Research in Thailand has described the vulner- ability of older men to HIV (Van Landingham and Knodel, 2007), but family planning research has not touched on this area. The sexual health needs of older women and men are often neglected because, like adolescence, sex outside marriage for pleasure and intimacy challenges social norms about who should have sex and Contraceptives at the Egyptian Family Planning Association in Abo Attwa town, near Ismailiyah. ©UNFPA/Matthew Cassel t 45% 27% 17% 0 10 20 30 40 50 60 70 80 90 100 11% Africa Asia Oceania North America Europe World Latin America and the Caribbean 0-14 15-24 25-59 Over 60 Regions 54 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE when. The proportion of never-married adults is steadily increasing in all parts of the world, plac- ing new obligations on States to meet the family planning needs of older people (United Nations, Department of Economic and Social Affairs, 2009). In their older years, women and men have unmet need for “mature-friendly” services. Male fertility declines very gradually over a period of many years (Guttmacher Institute, 2003, cited in Barker and Pawlak, 2011). Fertile long after females, older men often lack support for preventing high-risk pregnancies in their relationships, many of which occur with younger women. With greater numbers of single men and women having sex after marriage and marital dis- solution, a complementary focus on educating older men about the benefits and availability of all methods, including condoms and no-scalpel vasectomy, could empower elders with resources to prevent unintended, high-risk pregnancies in older age, thereby protecting older women’s right to health. The Netherlands has addressed the obstacles to young people’s access in a variety of ways (Greene, Rasekh and Amen, 2002). Among the changes of note were: Comprehensive sex education in primary and secondary schools that includes instruction on relationships, values clarification, sexual development, skills for managing healthy sexuality, and tolerance for diversity, for which teachers receive regular training in content and instructional approaches; the provision of quality information to parents, family doctors, youth-friendly clinics and the media; patient-doctor confidentiality, even among young adolescents; and explicit and humorous national campaigns on sexual health. The theme running through the policy commitment to youth sexual and reproductive health in the Netherlands is that laws should address reality, not ideology (Ketting, 1994). In short, the government responded to the needs and rights of young people with policies that ensure their access to information and services. The Netherlands now has among the lowest rates of unintended pregnancy and abortion in the world. LOW RATES OF UNINTENDED PREGNANCY AND ABORTION AMONG YOUNG PEOPLE IN THE NETHERLANDS 3 Males Men and women in heterosexual relationships can be partners in discussing the timing and spacing of children. Nonetheless, the needs and participation of men and boys in family planning has received little attention relative to their roles as supportive partners for women’s health (Barker and Pawlak, 2011). Considering the evidence and the increased awareness about the importance of engaging men and boys in health and gender equality, national responses to the interlinked family planning needs of both women and men remain limited in scale and in scope (Barker et al., 2010). A growing body of evidence over the last 20 years has demonstrated that harmful gender norms influence attitudes and behaviours among boys and men, with negative consequences for women and girls and men and boys themselves (Barker, Ricardo and Nascimento, 2007; Barker et al., 2011). This same programme research across diverse settings has noted that boys and men can and often do adopt gender-equitable attitudes and behaviours that support improved health for themselves, their partners, and their families. This insight is increasingly informing family planning policies and programmes. In addition, several international conven- tions and agreements including the Programme of Action of the ICPD affirm the importance of men’s participation in family life, includ- ing sexual and reproductive health and family planning. More governments now engage in policy dialogue around men’s roles in sexual and reproductive health, and greater numbers of development practitioners integrate gender into programme designs. The international community has acknowl- edged that male partners can exert considerable influence in couples’ fertility preferences (UNFPA, 1994; Bankole and Singh, 1998). 55THE STATE OF WORLD POPULATION 2012 Many institutions, providers, and civil society organizations must, however, still overcome the persistent, common perception that boys and men are merely disinterested in family plan- ning. Men and boys are often trained from an early age to view fertility matters as women’s responsibility. And even when men do want to play more of a role, they are often sidelined by services. Research into the ways gender norms influence boys and men has challenged ste- reotypes about their attitudes and behaviours, highlighting opportunities for health promotion and efforts to achieve gender equality. Men’s sexual behaviours vary considerably across regions. For example, men vary in the timing of their sexual activity. The latest avail- able demographic and household survey data from 30 countries suggest that young men con- tinue to have sex years before they marry (IFC Macro DHS Statcompiler). The gaps between age at first intercourse and age at marriage range from 1.1 years in South and Southeast Asia to 6.8 years in Latin America and the Caribbean. In sub-Saharan Africa, young men marry 4.8 years after they first have sex. When adolescents and male youth are not reached with appropriate information and services during this interval between first inter- course and when they enter a formal union, they—like their partners—are at increased risk of sexually transmitted infections and unintend- ed pregnancy. Couples-based family planning programmes that heavily rely on links to mater- nal health are less likely to reach these men. Partly because of HIV prevention efforts, young men have become increasingly aware of contraceptive methods available to them (Abraham, Adamu and Deresse, 2010). Men in unions are more likely to know about the contraceptive methods available to them; in recent years they have become more aware of condoms, while vasectomy remains relatively unknown. Even though men are increasingly aware of male methods of contraception, women still account for 75 per cent of global contracep- tive use (United Nations, 2011). In 2009, the United Nations reported that only 9 per cent of married women in developing regions relied on methods of contraception that required male participation, such as condoms and male steril- ization (United Nations, 2009). Men’s fertility preferences have changed over time. Today, young men generally wish to have smaller families. As a result, young and adult men may have an increasing desire for information and services that help them choose when to have children (Guttmacher Institute, 2003). Contraceptive use among young men (ages 15 to 24) worldwide varies significantly, with Man in Kinaaba, Uganda holds his child while his wife receives injection of long-acting contraceptive. ©UNFPA/Omar Gharzeddine t 56 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE 63 per cent to 93 per cent of young men report- ing using contraception in parts of North America, Europe, and Latin America and the Caribbean (United Nations, 2007). These figures stand in stark contrast with most sub-Saharan African countries, where less than 50 per cent of young, sexually active men used a condom at last sex. Globally, female sterilization remains the most commonly used method, chosen by 20 per cent of married women (United Nations, 2011). The figure is much higher in some countries depending on fertility patterns and the range of reversible methods available to women. The international community has more thoroughly cultivated men’s engagement in the context of HIV prevention, and community- based prevention efforts have contributed to increased uptake of male condoms. Yet the World Health Organization reports that less than a third (31 per cent) of young men in developing countries have a “thorough and accurate” understanding of HIV, suggesting that more support for men’s sexual and reproductive health, including sexuality education and con- traceptives, is needed (United Nations, 2009b). Men are increasingly expressing a desire to be more engaged in planning their families, including reducing the number of unplanned pregnancies (Barker and Pawlak, 2011). Up to 50 per cent of men in some countries—Brazil, Germany, Mexico, Spain, and the United States—would consider hormone-based contra- ception if such male methods became available (Glasier, 2010). Involving men of reproductive age in family planning programmes from an early age can promote more constructive com- munication between couples about the timing and spacing of children. 4 Other marginalized groups Indigenous people and ethnic minorities. Indigenous peoples and ethnic minorities often lack access to family planning. Results from qualitative interviews find that providers them- selves express difficulties assisting ethnic and indigenous women, often because of an inabil- ity to adequately communicate or understand their cultural practices (Silva and Batista, 2010; Cooper, 2005). Prejudice against these groups can lead to lower levels of investment in their sexual and reproductive health (United Nations Economic and Social Council, 2009). The harmful consequences of government under-investment are reflected in large disparities between indigenous and non-indigenous women on key reproductive and maternal health indi- cators. These include maternal mortality rates, total fertility rates and unmet need for family planning (Silva and Batista, 2010). Significant health-related inequalities exist between indigenous and non-indigenous groups in several countries around the world. In Guatemala, for example, where indigenous Countries, with the support of the international community, should protect and promote the rights of adolescents to reproductive health education, information and care and greatly reduce the number of adolescent pregnancies … Governments, in collaboration with non-governmental organizations, are urged to meet the special needs of adolescents and to establish appropriate programmes to respond to those needs. Such programmes should include support mechanisms for the education and counseling of adolescents in the areas of gender relations and equality, violence against adolescents, responsible sexual behaviour, responsible family-planning practice, family life, reproductive health, sexually transmitted diseases, HIV infection and AIDS prevention. — ICPD Programme of Action, paragraphs 7.46 and 7.47. 57THE STATE OF WORLD POPULATION 2012 groups (Maya, Xinka, and Garifuna) account for nearly 40 per cent of the total population and 75 per cent of its poor, 39 per cent of married indigenous women ages 15–49 have an unmet need for family planning and are therefore unable to exercise their right to family plan- ning (Guatemala Ministry of Public Health and Social Assistance, 2003). In contrast, 22 per cent of non-indigenous women have an unmet need for family planning. These disparities in access to services contribute to the high fertility rate (6.1) among indigenous women who are also at greater risk of maternal death compared to non- indigenous women. CASE STUDY UNFPA and indigenous groups in Latin America In order to address the high maternal and infant mortality among indigenous women, youth and adolescent girls, UNFPA has been working to increase their access to quality, safe and culturally acceptable maternal, newborn and reproduc- tive health services, including family planning (UNFPA, 2012d). In so doing, UNFPA has been promoting intercultural dialogue among traditional health systems with national, pre- dominantly Western allopathic health systems, 17 23.8 23.7 18.9 Mean age at first intercourse 0 10 20 30 Age 22.3 23.5 Sub-Saharan Africa Latin America and the Caribbean South and Southeast Asia Mean age at marriage NEED FOR FAMILY PLANNING REFLECTED IN MULTI-YEAR GAP BETWEEN MEN’S AGE AT FIRST INTERCOURSE AND AGE AT MARRIAGE • In sub-Saharan Africa, young men have sex approximately five years before they marry • In Latin America and the Caribbean, young men on average have sex before their 18th birthday, and then wait nearly seven years before marrying • In South and Southeast Asia, the gap (1.1 years) between men’s self-reported age at first intercourse and their age at marriage is significantly less compared to other regions. Source: Select countries with latest available demographic and health survey data, data: IFC Macro DHS Statcompiler 58 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE while also supporting community-based interventions that mobilize communities to save women’s lives. The “cultural brokerage” roles that indigenous authorities and leaders, including traditional birth attendants, play are fundamental in this process. UNFPA has also contributed to advanc- ing knowledge on indigenous peoples at the regional and country level through qualitative and quantitative studies, advocating for the inclusion of indigenous peoples issues in popu- lation and housing censuses, and assisting in the improvement of health registries and other administrative records. Persons with disabilities. The Convention on the Rights of Persons with Disabilities recognizes their specific rights and outlines cor- responding State obligations. The Convention specifies that persons with disabilities enjoy legal capacity on an equal basis with others (Article 12), have the right to marry and found a family and retain their fertility (Article 23), and have access to sexual and reproductive health care (Article 25). Research finds that persons with disabili- ties experience discrimination that violates their rights and social biases that restrict their abilities to academically, professionally, and personally excel (World Health Organization, 2011). Furthermore, disabled persons expe- rience poorer socioeconomic outcomes and poverty (Scheer et al., 2003; European Commission, 2008). Worldwide, the belief that disabled persons are asexual or should have their sexuality and fertility controlled is commonplace (World Health Organization, 2009). But persons with disabilities are sexually active, and studies have documented significant other unmet needs for family planning (Maart and Jelsma, 2010; World Health Organization, 2009). Despite legal prohibitions that grant disabled persons the right to plan and time pregnancies, disabled persons are more likely to be excluded from sex education programmes (Rohleder et al., 2009; Tanzanian Commission for AIDS, 2009). Studies have also documented cases of involun- tary sterilizations of disabled women (Servais, 2006; Grover, 2002). Non-consensual steril- ization is against international human rights standards. People living with HIV. Research in both developed and developing countries suggests that HIV status does not repress the desire to have children (Rutenberg et al., 2006). The specific considerations of women and men Women in Somalia have the highest fertility rates in the world, averaging more than six children each (United Nations Population Fund, 2012b). In spite of conflict, famine and high maternal, infant and child mortality rates, the country’s population has nearly tripled in the past 50 years. In this pastoralist society, where so many have been lost to war, children have enormous value. Throughout the past two decades of conflict in Somalia and the lack of a functioning central government since 1991, international attention has centred on resolving the political crisis and delivering emergency relief. In this context, developing the programmes and healthcare infrastructure necessary to generate and fulfil a demand for family planning has not been a priority. Some believe that the only way to effectively communicate about family planning to Somalis, most of them devout sunni Muslims, is through religion. Partnering with faith-based organizations can alleviate the religious and social pressures on women who practice child spacing. Traditional methods such as withdrawal and exclusive breastfeeding are most easily accepted in Somali society. UNFPA is collaborating with non-governmental and governmental organizations to deliver essential reproductive health supplies and services. With the worst of the famine now over, Somalia faces an opportunity to focus on family planning programmes as a way to safeguard the well-being of future generations. FAMILY PLANNING IN HUMANITARIAN SETTINGS: SOMALIA 59THE STATE OF WORLD POPULATION 2012 who are living with HIV and are considering pregnancy remain linked to the stigma and discrimination they encounter from their fami- lies, community or health system (Oosterhoff et al., 2008). For women and men with access to antiret- roviral treatment, a diagnosis of HIV can now be managed largely as a chronic disease. Even though universal access to life-saving treatments has not been achieved in all parts of the world, the international community has made consid- erable progress towards expanding access. In low- and middle-income countries, the number of people receiving treatment has reached 6.65 million, representing a 16-fold increase within seven years (World Health Organization, 2011). As progress towards universal access to antiretro- viral treatment continues, more people who live Young women Young men 0 20 40 60 80 1 21 1 26 1 36 14 57 27 65 24 69 28 72 32 78 80 40 81 36 83 33 83 46 87 87 38 76 90 95 55 16 100 Viet Nam India Cambodia Malawi Uganda Central African Republic Zambia Zimbabwe United Rep. of Tanzania Guyana Republic of Moldova Kenya Ukraine Dominican Republic Namibia Haiti YOUNG MEN ARE MORE LIkELY THAN YOUNG WOMEN TO HAvE HIGH-RISk SEx WITH A NON-MARITAL, NON-COHABITING PARTNER IN THE LAST 12 MONTHS (PER CENT OF YOUNG PEOPLE 15-24) Implications for family planning: married and unmarried people need access to contraception to prevent unintended pregnancies Source: AIS, DHS, MICS and other national household surveys, 2005-2009. For each country, data refer to the most recent year available in the specified period. 60 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE with HIV will seek ways to express their sexual- ity and to plan their families. Women and men who live with HIV report intense pressure from family, community lead- ers, and health providers to abandon their desire to have children. Most justifications for this pressure are related to concerns about the risk of perinatal HIV transmission or about the welfare of children, whose parents may prematurely die of AIDS (Cooper et al., 2005; IPPF, 2005). As people with HIV increasingly live longer lives, more are considering becom- ing parents. In most societies, childbearing is a pivotal component of social identity for women and men; “healthy people” are often expected to have children as part of familial or commu- nity pressures. Stigma about the pregnancy intentions of HIV-positive people varies in different contexts. Studies in Zimbabwe, for example, find that women may want children but do not feel safe enough to realize their desires, fearing potential backlash from the community in particular because of potential transmission of HIV to their children (Feldman and Maposhere, 2003; Craft et al., 2007). Other studies from Côte d’Ivoire and South Africa have shown that some women want to become pregnant precisely to avoid the stigma of childlessness, based not only on social expectations that women should become mothers, but also because avoiding pregnancy is often interpreted as a sign of HIV- positive status (Aka-Dago-Akribi et al., 1999). Because condoms are the most widely avail- able contraceptive method that also protects against HIV transmission, the World Health Organization recommends that men and women with HIV who are seeking to avoid pregnancy use condoms, with or without another contraceptive method (World Health Organization, 2012; Cooper et al., 2007). Honduras bans access to emergency contraception On 24 October 2009, the Ministry of Health of Honduras announced in the country's official press, La Gaceta, a ban on the promotion, sale, purchase, distribution and marketing of emergency contraception in pharmacies or any other locale. Since then, access to and use of this product is not permit- ted, even in cases of rape. Restrictions on family planning in Manila City For over 10 years, a ban on modern contraception in the city of Manila, the Philippines, denied women access to family planning. The mayor of Manila passed an executive order in 2000 discouraging the use of artificial meth- ods of contraception like condoms, pills, intrauterine devices, surgical sterilization, and other methods. Health care centres that receive funding from the city are prohibited from providing modern contraception. In 2008, plaintiffs brought a case against the city, challenging the consti- tutionality of the ban and arguing that it violates the Philippines’ obligations under international law. The case was dismissed, appealed and then dis- missed again by the Supreme Court. The case was re-filed in April 2009 at the Regional Trial Court in Manila City. Sources: International Consortium for Emergency Contraception, 2012; Center for Reproductive Rights, 2012; Center for Reproductive Rights, 2010; EnGendeRights, 2009. policies limiting family planning Patience Mapfumo, 37, from Zimbabwe, with her five-year-old son Josphat who was born HIV free. © Elizabeth Glaser Pediatric AIDS Foundation t 61THE STATE OF WORLD POPULATION 2012 Studies suggest that HIV may have adverse effects on both male and female fertility (Lyerly, Drapkin and Anderson, 2001). Moreover, among discordant couples—relationships in which one person is HIV positive and the other is not—the ways to safely pursue hav- ing children vary. Artificial insemination can reduce the risk of infection when the woman is HIV-positive. When the male partner lives with HIV, pursuing pregnancy can be more compli- cated, problematic, and costly (Semprini, Fiore and Pardi, 1997). The poor. Although sexual and reproduc- tive health outcomes have improved over the last 20 years, they vary according to income levels (UNFPA, 2010). This widening gap has increased the number of people who are unable to exercise the right to family planning. Moreover, research finds that a disproportion- ate amount of public spending on health and education is allocated towards wealthier sectors of society, thereby exacerbating the likelihood that present-day inequalities will continue to widen among and within countries (Gwatkin, Wagstaff and Yazbeck, 2005). Demographic and Health Surveys from 24 sub-Saharan African countries find that the poorest and least educated women have “lost ground,” with poor adolescent girls having the lowest levels of sustained contraceptive use and the highest unmet need for family planning (UNFPA, 2010). For example, only 10 per cent of those belonging to the poorest households use contraception, compared to 38 per cent of women belonging to the wealthiest households. Social exclusion makes it harder for poor people to access family planning information and services, compared to individuals of higher socioeconomic status. These disparities com- promise women’s health, men’s and women’s rights, and undermine poverty reduction efforts (Greene and Merrick, 2005). For example, research finds that birth rates have increased among the least educated, poor adolescent girls who often live in rural communities (UNFPA, 2010). In contrast, more educated adolescent girls who live in the wealthiest 60 per cent of households in urban areas have experienced low and declining birth rates since 2000. Hard-to-reach persons in rural or urban communities. In most developing countries, national measures of poverty are highly corre- lated with place of residence; urban households tend to be weathier than rural households (Bloom and Canning, 2003a). Hard-to-reach communities vary across countries, but where people live influences their ability to access family planning. In some settings, women and men in rural areas are unable to routinely access quality family planning information and services. On average, for example, poor women in rural sub-Saharan Africa have a contraceptive preva- lence rate of 17 per cent, compared to 34 per cent for their urban peers (United Nations Population Fund, 2010). Relative differences “Reproductive health eludes many of the world’s people because of such factors as: inadequate levels of knowledge about human sexuality and inappropriate or poor-quality reproductive health information and services; the prevalence of high-risk sexual behaviour; discriminatory social practices; negative attitudes towards women and girls; and the limited power many women and girls have over their sexual and reproductive lives. Adolescents are particularly vulnerable because of their lack of information and access to relevant services in most countries. Older women and men have distinct reproductive and sexual health issues which are often inadequately addressed.” — ICPD Programme of Action, 1994, paragraph 7.3 62 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE also exist within rural communities, and national income quintile assessments can mask the relative disparities within rural and urban communities. For example, research from Latin America and sub-Saharan Africa finds that when adjusted quintiles for rural communities are used to examine family planning indicators, women from the wealthiest quintiles within their rural communities are more able to access family planning services (Foreit, 2012). In other settings, the rapid expansion of urban areas has also outpaced governments’ abilities to develop the infrastructure to provide the urban poor with quality family planning. More than half of the world’s population now lives in urban areas, and in the coming decades, almost all global population growth will occur in towns and cities, with most urban growth concentrated in Africa and Asia (United Nations Population Fund, 2007). Two-thirds of Africa’s urban population lives in informal set- tlements, where a lack of infrastructure and the threat of violence impede women’s use of trans- portation and health services (UN Habitat, 2003; Taylor, 2011). Many urban pregnancies in developing countries are unintended; there is a 30 per cent to 40 per cent difference in contraceptive prevalence between women in the richest and poorest urban households (Ezeh, Kodzi and Emina, 2010). Stock-outs, disruptions in supply chains, and costs contribute to unmet need in hard- to-reach, underserved communities in both urban and rural settings. Additionally, a lack of targeted information relating to the needs of people who live in isolated rural areas and densely populated urban communities are among key factors contributing to lower levels of contraceptive use and higher unmet need (Ezeh, Kodzi and Emina, 2010). Migrants, refugees and displaced people. Migration and displacement, the movement of persons from one area to another has become increasingly commonplace. The total number of international migrants has increased over the last eight years from an estimated 150 mil- lion in 2000 to 214 million persons in 2008 (UN Department of Economic and Social Affairs, 2008a). The reasons for migration and displacement within and across borders vary, but whether forced or voluntary, for political, economic, social or environmental reasons, the World Health Organization notes that the large numbers of people whose place of residence has shifted present the international community “… culture influences the status of women’s reproductive health through determination of the age and modalities of sexuality, marriage patterns, the spacing and number of children, puberty rites, decision-making mechanisms and their ability to control resources, among others. Societal and cultural gender stereotypes and roles also explain why so many adolescent boys and men remain on the fringes of sexual and reproductive health policies and programmes, despite their key role in this realm and their own needs for information and services.” — UNFPA Family Planning Strategy, 2012 Women and girls of reproductive age have been hardest hit by the HIV epidemic in Zimbabwe: prevalence among pregnant women is high, and HIV and AIDS are responsible for about one in four maternal deaths. In 2010, an assessment of sexual and reproductive health and HIV/AIDS policies and programmes found that inadequate integration of sexual and reproductive health and HIV programmes diminished health providers’ capacities to respond to women’s and girls’ unmet need for family planning. In collaboration with UNFPA, the World Health Organization and UNICEF, the Ministry of Health and Child Welfare is closing the gap by developing new integrated service-delivery guidelines and training service providers. STRENGTHENING INTEGRATION OF HIv AND SExUAL AND REPRODUCTIvE HEALTH IN ZIMBABWE 63THE STATE OF WORLD POPULATION 2012 with a public health challenge (World Health Organization, 2003). International human rights instruments explicitly recognize that human rights, includ- ing the right to health and family planning, apply to all persons including migrants, refu- gees and other non-nationals (World Health Organization, 2003). The denial of these rights for socially excluded migrants and dis- placed persons makes them unable to fully benefit from health services, including family planning. Women (and men, as evidence is starting to show) are also vulnerable to sexual violence from soldiers, guards, recipient com- munity members and other refugees and are therefore at risk of unwanted pregnancy (United Nation's High Commissioner for Refugees and Women’s Refugee Commission, 2011). According to migrants and displaced per- sons in developed and developing countries, a lack of information about their rights and available services is among the key rea- sons given for not accessing health services (Braunschweig and Carballo, 2001). For example, a national review of several Western European countries noted that the rates of maternal mortality and morbidity are higher among immigrant women—outcomes are associated with lower levels of access to con- traceptives (Kamphausen, 2000). A study by the United Nations High Commissioner for Refugees and the Women’s Refugee Commission in Djibouti, Jordan, Kenya, Malaysia and Uganda in 2011 found that people who live in refugee settings report lower contraceptive use and greater difficulty accessing information and services, especially adolescent girls and boys (United Nations High Commissioner for Refugees and Women’s Refugee Commission, 2011). According to paragraph 7.2 of the Programme of Action of the International Conference on Population and Development, reproductive health implies “that people are able to have a satisfying and safe sex life… It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases.” This comprehensive notion of reproductive health—one that includes a satisfying and safe sex life—has been taken into account in a number of family planning programmes. CASE STUDY Family planning classes in Iran The Islamic Republic of Iran has required that all couples intending to marry attend a pre-marital counselling course and undergo medical examinations. In order for couples to obtain the results of these exams and register their marriages, couples must attend a two-hour class that covers issues of family planning, disease prevention and most importantly, the emotional and social relationships involved in marriage. The Islamic Republic of Iran has prioritized discussion of “sexual and emotional issues,” in part as a consequence of having observed high divorce rates. Since its inception, the family planning programme in the Islamic Republic of Iran has been one of the most successful in t

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