State of the World Population report 2024 - Interwoven lives, threads of hope

Publication date: 2024

ISSN 1020-5195 ISBN 9789210031318 Sales No. E.24.III.H.1 E/700/2024 United Nations Population Fund 605 Third Avenue New York, NY 10158 Tel. +1 212-297-5000 @UNFPA state of w orld population 2024 Interw oven Lives, T hreads of H ope Ensuring rights and choices for all Printed on recycled paper Ending inequalities in sexual and reproductive health and rights INTERWOVEN LIVES, THREADS OF HOPE Ensuring rights and choices for all State of World Population report 2024 This report was developed under the auspices of the UNFPA Division for Communications and Strategic Partnerships. EDITOR-IN-CHIEF Ian McFarlane EDITORIAL TEAM Senior editor: Rebecca Zerzan Production editor/creative direction: Katherine Black Features editor: Richard Kollodge Features writers: Katherine Black, Richard Kollodge, Dalia Rabie, Lisa Ratcliffe, Catherine Trautwein, Rebecca Zerzan Editorial support and guidance: Jacqueline Daldin, Lisa Ratcliffe, Catherine Trautwein Digital edition manager: Katherine Black Digital edition adviser: Enes Champo Fact checker: Ralph Hakkert SENIOR RESEARCH ADVISER Dr. Gita Sen RESEARCHERS AND WRITERS Daniel Baker, Ann Garbett, Gretchen Luchsinger, Dr. Tlaleng Mofokeng, Letlhogonolo Mokgoroane, Gilda Sedgh, Claire Thomas UNFPA LEAD TECHNICAL ADVISERS Emilie Filmer-Wilson, Mengjia Liang ARTISTS AND ART ADVISERS Bayombe Endani, Philip Fimmano, Higinia Gonzáles, Iain Guest at the Advocacy Project, Nadia Hamid at the International Folk Art Market, Rosie James, Nneka Jones, Cristin Knight-Sethi, Rosalia Sciortino, Pankaja Sethi, The Sussex Archaeological Society (, Tally Assuit Women’s Collective, Woza Moya MAPS AND DESIGNATIONS The designations employed and the presentation of material in maps do not imply the expression of any opinion whatsoever on the part of UNFPA concerning the legal status of any country, territory, city or area or its authorities, or concerning the delimitation of its frontiers or boundaries. Timeline art: American Association of University Women, United Nations Conference on Population and Development/Robert Rauschenberg Front cover: Nneka Jones (@artyouhungry) All other artwork by Rosie James (@rosiejamestextileartist) unless otherwise credited ACKNOWLEDGEMENTS UNFPA thanks the following people for sharing glimpses of their lives and work for this report: Alia, Turkmenistan; Ellen Amster, Canada; Adel Botros, Egypt; Eira Carrera, Panama; Isaac Chirwa, Malawi; Francisca Córdoba, Colombia; Carolyn DeFord, United States of America; Maïmouna Déné, Burkina Faso; Duha, Syrian Arab Republic; Eneida, Panama; Dr. Eda Gülüm, Türkiye; Ceylan Güzey, Türkiye; Sharron Hinchliff, United Kingdom; Seif Kuchengo, United Republic of Tanzania; Jonas Lubago, United Republic of Tanzania; Shirley Maturana Obregón, Colombia; Thivya Rakini, India; Rama, Syrian Arab Republic; Humberto Rodríguez, Panama; Syrah Sy Savané, Côte d’Ivoire; Nandita Shivakumar, India; Gertrudis Sire, Panama; Audrey Tang, United Kingdom; Luhui Whitebear, United States of America; Jose Luis Wilches Gutiérrez, Colombia. Chief of the UNFPA Media and Communications Branch, Selinde Dulckeit, provided invaluable insights to the draft, as did members of the UNFPA Technical Division, including Michael Herrmann, Priscilla Idele, Dr. Julitta Onabanjo, Leyla Sharafi and Dr. Willibald Zeck. Support also came from Arthur Erken and Dr. Nkeiruka Didigu in the UNFPA Policy and Strategy Division, and from members of the Office of the Executive Director, including Teresa Buerkle, Samuel Choritz, Dr. Nigina Muntean, Alana Ngoh and Horst Rutsch. Members of the offices of Deputy Executive Director Diene Keita and Deputy Executive Director Andrew Saberton contributed, as did colleagues from UNFPA SWEDD, including Moussa Bagayoko, Nafissatou Diop, Emmanuelle Landais Lopez and Waly Sene. UNFPA colleagues and others around the world supported the development of feature stories and other content or provided technical guidance: Samir Aldarabi, Vannie Arrocha, Zeynep Atilgan, Adolfo Ballina, Ana De Obaldia, Jens-Hagen Eschenbaecher, Rose Marie Gad, Eren Korkmaz, Lilian Landau, Daisy Leoncio, Nouran Makhlouf, Julia Novichenok, Demetra Pollinari, Norha Restrepo, and Siaka Traore. Author Ann Garbett led the analysis of Demographic and Health Survey data to examine access to sexual and reproductive health services and information by ethnicity and socioeconomic categories. Print and interactive design: Prographics, Inc. The editors are grateful for the contributions of partners, including researchers at the Guttmacher Institute, particularly Jacqueline Darroch and Elizabeth Sully; experts at the Population Division of the United Nations Department of Economic and Social Affairs, in particular Giulia Gonnella, Yumiko Kamiya, Vladimíra Kantorová and Karoline Schmid; experts at the Office of the United Nations High Commissioner for Human Rights (OHCHR), in particular Nicolas Fasel and Yekaterina Spassova; experts at the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), in particular Lilian Barajas, Jaspreet Kindra, April Pham and Barbara Wachter; the UN Independent Expert on Protection against violence and discrimination based on sexual orientation and gender identity Victor Madrigal-Borloz; and experts at the Asian-Pacific Resource and Research Centre for Women (ARROW), in particular Sivananthi Thanenthiran. A NOTE ON LANGUAGE In this report, “Black” is capitalized when referring to groups or individuals in racial, ethnic or cultural terms. The term “Black” is often used to convey a shared sense of history and identity, while “white” is less commonly used this way. As the term “indigenous” can be used to refer generally to peoples of many cultures and traditions, the term is not capitalized in this report unless it is used to refer to a specific group or nation. This report also tends to refer to women and girls when discussing issues such as sexual violence and pregnancy; the data for these issues broadly come from surveys and studies that identify participants as women or girls. It is important to note that transgender men and non-binary people also experience pregnancy, and that gender-diverse people experience sexual violence and barriers to sexual and reproductive health care in disproportionate and unacceptable numbers. A NOTE ON ART For thousands of years, women and indigenous communities have used weaving and embroidery to blur the boundaries between art and function, practicality and beauty. Yet their work has long been dismissed as craft rather than fine art, and excluded from formal art institutions and markets. For this reason, women’s movements and indigenous peoples have embraced this art form to draw attention to issues related to their exclusion, like gender-based violence, reproductive justice and systemic racism — and also to call for solidarity across communities. The artists and textile collectives featured in this report continue that tradition, expressing contemporary concerns with skills passed down by generations of women. Together, their art shows how each woman’s rights, dignity and future are woven together with those of her sisters, daughters, mothers and friends. Ending inequalities in sexual and reproductive health and rights INTERWOVEN LIVES, THREADS OF HOPE CHAPTER 1 CHAPTER 2 CONTENTS A work in progress page 6 FEATURE: When crises cut off health care, community members fill the gaps ����������������������������������������������������� �16 FEATURE: Women garment workers organize against gender- based violence ���������������������������������������������� �22 IN FOCUS: Self-reported problems in accessing health care, over time, by socioeconomic status and ethnicity ������ �28 TIMELINE ��������������������������������������������������� 34–39 Unravelling inequality page 32 FEATURE: Safe, culturally sensitive, empowering childbirth for Colombia’s Afrodescendent women ����������������������������46 FEATURE: Grass-roots activists raise visibility for missing and murdered indigenous women ������������������������������������� �52 IN FOCUS: Decolonizing sexual and gender norms ������������������������������������������������60 FOREWORD ����������������������4 CHAPTER 4 CHAPTER 5 INDICATORS ������������������������������������133 TECHNICAL NOTES ����������������������152 REFERENCES ����������������������������������156 Weaving a collective future page 110 FEATURE: Sexual health of older adults emerging from the shadows������������������������������������ �118 FEATURE: Ngäbe women spark a revolution in women’s health and equality������������������������124 CHAPTER 3 Counting every stitch page 62 FEATURE: Women with disabilities in Turkmenistan claim their rights ������������������������� �70 FEATURE: African censuses strive to count everyone ����������� �76 IN FOCUS: Who matters enough to measure? The case of adolescent mothers ��������������� �82 Women are the thread page 86 FEATURE: Syphilis highlights threat to health and human rights: stigma��������������������������������� 92� FEATURE: Local leadership reaches girls most in need������ �104 Thirty years ago, governments around the world agreed that reproductive health and rights are foundation stones of global development – a groundbreaking consensus that paved the way for decades of progress. Since then, the global rate of unintended pregnancies has fallen by nearly 20 per cent globally. The number of women using modern contraceptive methods has doubled. Today at least 162 countries have adopted laws against domestic violence, and maternal deaths have decreased by 34 per cent since 2000. Yet that progress has not been fast enough, nor far-reaching enough. Gender-based violence remains rampant in practically every country and community. There has been zero reduction in maternal mortality since 2016, and in an alarming number of countries the rates are rising. Nearly half of women still are unable to make decisions about their own bodies — unable to exercise their sexual and reproductive health and rights. One important reason is inequality. New evidence in this report shows that although women across socioeconomic classes and ethnicities say barriers to health care have come down over time, the women most marginalized have experienced the least improvement. In other words, while the world has focused on serving the easiest to reach, we have neglected to confront the inequalities and disparities within our systems and societies, which has allowed gaps to widen into chasms. Everywhere, people seeking essential sexual and reproductive health care are forced to navigate overlapping hurdles because of their gender, economic status, ethnicity, sexual orientation, disability and more. In the few places where data are collected, women of African descent are found to be more vulnerable to obstetric mistreatment and negative maternal health outcomes. Indigenous women are often denied culturally appropriate maternal health care, and their own childbirth practices may be criminalized, resulting in significantly higher risk of death in pregnancy and childbirth. Gender-unequal norms remain embedded in health-care infrastructure, including persistent underinvestment in the world’s largely female midwifery workforce. Women and girls with disabilities face up to 10 times more gender-based violence 4 Foreword while also facing higher barriers to sexual and reproductive information and care. LGBTQIA+ people face serious health disparities in addition to – and as a result of – discrimination and stigma. The path forward to fulfill the Cairo International Conference on Population and Development promise of universal sexual and reproductive health and rights is clear: To achieve it we must root out inequalities from our health systems and policies and focus as a priority on those women and young people who are most marginalized and excluded. We need comprehensive, universal and inclusive health care grounded in human rights and evidence of what works. This work is vitally important, it is just, and it is possible. This report contains many examples of programmes and efforts that have expanded access to, and uptake of, quality care, usually with interventions tailored by and for those most in need. To accelerate success, we will require more and better data, disaggregated to understand exactly who is being left behind, and collected with their input and safety assured. A diverse cross-section of people, from feminists to indigenous groups to climate and youth activists, are already pointing the way forward towards a fairer, shared future. In the end, ensuring equitable progress will benefit all of society. That is important in its own right, and the dividends of achieving a more just and gender-equal world could also add trillions of dollars to the global economy. The fabric of humanity is rich and beautiful, a tapestry composed of 8 billion threads and counting, each one of us unique. Our resilience comes not from any individual strand but emanates from the collective, interwoven whole. That is our strength, and it is how we will proceed and succeed — by working together. Dr. Natalia Kanem Executive Director United Nations Population Fund 5STATE OF WORLD POPULATION 2024 7 CHAPTER 1 CHAPTER 1 A work in STATE OF WORLD POPULATION 2024 7 A safe birth. A choice of contraceptives. Protection from gender-based violence. More people than ever before have realized these essential, life-sustaining rights. But the number of people denied these rights has not yet reached zero – as it can and as it must. Overall, people today live longer, healthier lives. Still, millions remain far behind on the trajectory of progress, trapped by multiple, compounding forms of marginalization and discrimination. In a world of tremendous wealth and proven solutions in sexual and reproductive health care, such disparity suggests a lack of will, not a shortfall of ideas or resources. This is important to keep in mind because it means that much faster progress in ending marginalization and discrimination is not just desirable but possible, starting right now. In 2024, the world marks the thirtieth anniversary of the 1994 International Conference on Population and Development (ICPD) in Cairo. That conference produced a watershed global agreement putting people at the centre of development, one that committed to realizing better health, rights and choices for all. It affirmed a vision of human potential that has inspired significant progress ever since, echoed and amplified by the global 2030 Agenda for Sustainable Development agreed in 2015. Yet the ICPD agenda remains only partially realized, for the most marginalized people most of all. Disparities cut through every society, depriving some human beings of fundamental sexual and reproductive health and rights. Differences in power and opportunity related to gender, race and ethnicity, among many other factors, both alone and in combination, still largely constrain people’s choices and access. These dynamics manifest when a woman with a disability is refused sexual health information or when a girl in an impoverished village is married as a child. They arise when a pregnant woman or person from an ethnic minority encounters abusive practices that go unquestioned in health systems. Moving faster to bring the promise of ICPD alive for people who have been pushed behind is one of the world’s most urgent priorities. It’s a priority because, for each individual, bodily autonomy – the power and agency to make choices over one’s body and future, without violence or coercion (UNFPA, 2021) – depends on realizing sexual and reproductive health and rights. This determines the gains individuals can experience across their life course, in health but also in education, employment and political participation. In turn, peaceful, resilient and just societies depend on healthy and empowered people, without exclusions. A strong foundation is in place to realize ICPD commitments for everyone. The world’s understanding of how to dismantle remaining barriers and types of discrimination is greater than ever before. The international community has agreed for decades that people-centred development requires universal access to quality sexual and reproductive health care, and it is moving ever closer to the holistic goals of the reproductive justice movement (McGovern and others, 2022). This report argues that the thirtieth anniversary of the ICPD is an opportunity to pivot health and social systems towards providing services that empower all people, respect their diversity, uphold their dignity, and support them to realize their rights and bodily autonomy. It also calls for renewed CHAPTER 1: A work in progress8 commitments to unwind the disparities and inequities that still divide societies. These inequities create and reinforce systemic, structural barriers that chronically marginalize women and other groups in nearly every aspect of life, from labour markets to education to political participation. Now is the moment to take decisive action towards dismantling these barriers. Political and social polarization, often linked to economic disparities, is driving insecurity around the world (United Nations, 2018), with reproductive rights issues – including comprehensive sexuality education, LGBTQIA+ rights, access to contraception, abortion and gender equality – increasingly caught in the crossfire (Kanem, 2023). Yet reducing inequalities in sexual and reproductive health and rights could help lessen economic disparities (UNFPA, 2017), thereby contributing to stability, preventing conflict (Nyård, 2018) and accelerating development. And in many ways, the opportunity to mobilize support for gender equality and reproductive rights is at hand: This year could herald the largest cumulative act of participatory democracy in history, with more than 50 countries holding major elections that will affect the fates of billions of people (Harbath, 2023; IFES, n.d.) – among them billions of women and girls, and countless marginalized communities. The opportunity to mobilize support for gender equality and reproductive rights is at hand. STATE OF WORLD POPULATION 2024 9 Progress – but not for all Since the ICPD, remarkable progress has been made in core areas of sexual and reproductive health, driven by social mobilization, leadership, partnership and the commitment of people from remote health service delivery points to the highest echelons of government, business and philanthropy. The relentless advocacy of civil society and grass-roots movements has been instrumental in securing these impressive gains (see timeline on pages 34–39). Between 2000 and 2020, global maternal mortality declined by 34 per cent (WHO and others, 2023), a success story that can be credited largely to better access to skilled and emergency obstetric care. From 1990 to 2021, the number of women using modern contraception doubled (UN DESA, 2022). There has been a 19 per cent decline in the unintended pregnancy rate between 1990–1994 and 2015–2019 (Bearak and others, 2018). Births among girls aged 15 to 19 years have fallen by around one third since 2000 (UNFPA, 2023). HIV infection rates have dropped significantly. The number of new infections in 2021 was almost one third fewer than in 2010 (United Nations, 2023). The proportion of girls subjected to female genital mutilation has decreased significantly as well, due to shifting attitudes towards the practice (UNICEF, 2022). As women’s status has increased – evidenced, for example, by slow but steady gains in leadership roles (United Nations, 2023) – so has recognition of the importance of bodily autonomy as a human right (OHCHR, 2017). With the 2015 adoption of the Sustainable Development Goals (SDGs), the international community sought, through indicator 5.6.1, to measure women’s ability to exercise bodily autonomy, a groundbreaking global affirmation that bodily autonomy is a human rights imperative. Governments around the world have also sought to protect women and girls through legislation: A historic 162 countries have passed laws against domestic violence (World Bank, n.d.). As a further advancement of bodily autonomy, the world is increasingly rejecting the criminalization of LGBTQIA+ sexuality. At the start of the AIDS pandemic, most countries criminalized same-sex sexuality, while today two thirds of countries do not – and this progress may be accelerating, with more countries eliminating punitive laws in 2022 than in any single year in the past 25 years (HIV Policy Lab and others, 2023). Other hopeful signs come from new models of health care backed by sound evidence and recognition of human rights. These are reaching more people, and are more responsive to diverse contexts and human needs. For example, self-care models of health care have been endorsed by UNFPA, the World Health Organization (WHO) and other public health organizations, following rapid advancements in new technologies that enable users to promote and maintain their own health, and cope with illness and disability, without the direct intervention of a health worker. Such developments could greatly expand access to sexual and reproductive health (UNFPA, 2024). Also promising is the growing acknowledgement that health care delivered by skilled midwives – whose ancient profession has long been sidelined within modern medicine (see Chapter 2) – is both life-saving and cost-saving (UNFPA and others, 2021). CHAPTER 1: A work in progress10 Gender equality is increasingly understood as one of the smartest development investments, generating enormous social and economic gains (UNFPA, 2023a), while the economic returns on investment in sexual and reproductive health are compelling too. According to a UNFPA calculation, spending an additional US$79 billion in low- and middle-income countries by 2030, for example, would avert 400 million unplanned pregnancies, save the lives of 1 million mothers and 4 million newborns, and generate $660 billion in economic benefits (UNFPA, 2022). Yet with all that has been achieved, millions of people still see little difference in their daily lives and continue to struggle to realize their rights, largely because the roots of gender discrimination and other forms of marginalization run deep. The latest data show that, in 69 countries, one quarter of women still cannot make their own health care decisions. One quarter cannot say no to sex with their husband or partner. Nearly 1 in 10 have no choice in using contraception (UNFPA, 2024a). But these data have yet to motivate significant improvements in women’s bodily autonomy. Only about a third of countries even report these data. And for the first time, trend data on SDG indicator 5.6.1 are available for more than 30 countries, and while 19 countries have seen a positive trend in women’s ability to exercise decision-making over their own sexual and reproductive health, 13 countries have seen a negative trend in this same measurement (UNFPA, n.d.). Once promising progress in reducing preventable maternal deaths has largely stalled: Between 2016 and 2020, the global annual reduction in maternal deaths was effectively zero (WHO and others, 2023). That means around 800 women still die every day while giving birth, and nearly every one of those deaths is preventable. As Dr. Mahmoud Fathalla, former Director of the United Nations Special Programme on Human Reproduction, powerfully stated, “Mothers are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving” (Fathalla, 2012). And maternal deaths are a telling microcosm of the inequalities that plague all aspects of sexual and reproductive health because of how blatant the disparities are – between countries and within them. The difference between living and dying can depend on where a woman gives birth, as the vast majority of maternal deaths, over 70 per cent, take place in sub-Saharan Africa, home to many of the world’s least developed countries and most fragile health systems. A woman in this region who experiences pregnancy and childbirth complications is around 130 times more likely to die from them than a woman in Europe or North America. Inequities within regions and countries are also wide and deep. In Madagascar, for example, the richest women are five times more likely than the poorest to have skilled assistance when giving birth (UN Women and others, 2023); and across the Americas, people of African descent are more likely to experience obstetric mistreatment (UNFPA and others, 2023). Inequities are also seen in access to modern contraceptives, including disparities based on race and ethnicity (Jackson and others, 2017), refugee and migration status STATE OF WORLD POPULATION 2024 11 (Raben and van den Muijsenbergh, 2018), education, socioeconomic status, and rural versus urban location (Makumbi and others, 2023). And while gender-based violence is both pervasive and underreported, there are signs of inequities here, too – including disparities based on age (Decker and others, 2015) and sexuality (Evens and others, 2019), as well as racial, ethnic and gender-based disparities in years of life lost due to intimate partner violence (Graham and others, 2021). Despite these inequalities – or perhaps because of them – too few countries are collecting data on sexual and reproductive health needs and barriers; fewer still are disaggregating these data by factors known to contribute to neglect, discrimination and marginalization, factors including culture, ethnicity, race, caste, language and religion, disability status, HIV/AIDS status, migration status, sexual orientation and gender identity. At the same time, new challenges are arriving quickly in the digital realm. Health-care technologies are evolving rapidly and offer tremendous promise in improving information, easing bureaucracy and extending access to care. Yet millions of people remain stranded on the wrong side of a digital divide. Technologies such as artificial intelligence can replicate existing biases and discriminatory norms, potentially worsening inequalities. Some computer- assisted diagnostic systems, for instance, are shown to be more accurate for white men than people of other races and genders (Muro and Egbokhare, 2023). New research also highlights how technology offers a dangerous new avenue for gender-based exploitation and abuse (UNFPA, 2024b). Gender inequity can be 12 baked into the very design of technologies, with women underrepresented in training algorithm decisions. Gender-biased health technology can be especially problematic, leading to delayed or incorrect diagnoses and treatments. Women’s representation in early phase clinical trials is as low as 22 per cent, and pregnant and breastfeeding women continue to be excluded from even postmarket stage clinical trials (Ravindran, 2020; Shields and Lyerly, 2013). Pushing back – and pushing forward The ICPD agenda was born from the commitment of people from all walks of life to come together and find solutions to common concerns about population and development, reflecting “major shifts in attitude among the world’s people and their leaders in regard to reproductive health, family planning and population growth” (UNFPA, 1994). The powerful momentum it unleashed has since sustained and renewed progress on sexual and reproductive health and rights. Although no country can yet claim it has reached everyone, almost every country can celebrate significant advances. Many have committed to accelerating progress, recognizing it is integral to the 2030 Agenda for Sustainable Development and its 17 SDGs. Multiple crises, however, including conflict, climate fallout and the COVID-19 pandemic, have put decades of gains at risk and threaten future progress. Further, a relentless, well- organized effort to push back against human rights and gender equality is under way. While opposition to sexual and reproductive health and rights is often rationalized in the name of tradition and cloaked in nostalgia, it contradicts long-agreed consensus and core human rights agreements, denies well-established scientific and medical knowledge, and contributes to political division and instability (Kanem, 2023; Guttmacher Institute, 2017). Resistance to sexual and reproductive health and rights is resulting in greater marginalization for communities already left – or pushed – behind. Efforts to control fertility and restrict bodily autonomy disproportionately affect migrants, people with disabilities, and minority and indigenous communities, among many others. A lack of comprehensive sexuality education limits rights to information and education, and may be more likely to derail opportunities for young people with fewer resources to seek accurate answers to their questions. The stark denial of the rights of people with diverse sexual orientations and gender identities has escalated (El Chamaa, 2023). Amid the global trend towards decriminalizing LGBTQIA+ sexuality and identity, there has been an intensification of penalties within those countries that continue to criminalize LGBTQIA+ persons – including punishments as severe as the death penalty – despite clear evidence that criminalization not only increases HIV rates and leads to human rights violations, but also negatively impacts economies (HIV Policy Lab and others, 2023). Regression and polarization leave societies less stable and trusting than they otherwise might be, and more prone to disinformation and falsehoods (Gupta and others, 2023; Osmundsen and others, 2021). To move forward, we can start with what we agree upon: that no woman should die while giving life; that STATE OF WORLD POPULATION 2024 13 every individual has the right to decide when, whether and with whom to start a family; that every person should be able to make choices about their bodies without violence or coercion; that when women and girls can chart their own destiny, they and their societies prosper. Further, as the ICPD implicitly acknowledges, the rights and well-being of any one person are inextricably linked to the rights and well-being of others. Where rights are at risk for one person, they are effectively at risk for us all (United Nations, 2020). This principle was well understood by the feminist and other movements that came together with Member States to forge the ICPD agenda: In the lead-up to the September 1994 conference in Cairo, a broad cross-section of women came together from around the world. They mobilized to make sexual and reproductive health and rights a cornerstone of women’s rights activism and central to poverty eradication, sustainable development and the realization of human rights as a whole (Corrêa and others, 2015). Nine months before the ICPD, women from 79 countries took part in a global preparatory conference in Rio de Janeiro, where they took a strong stand against coercive population policies and pointed to inherent structural inequities as the “underlying basis of increasing poverty and marginalization of women, environmental degradation, growing numbers of migrants and refugees, and the rise of fundamentalism everywhere” (Anon, 1994). Four months before the ICPD, a collective of Black feminists in the United States responded to international momentum by launching a call for reproductive justice – a concept that goes beyond access to reproductive health care to tackle multiple forms of economic, social, political and environmental injustice, all of which impact sexual and reproductive health and rights and must be addressed to yield holistic results for the most marginalized (Ross, 2017). Today, a wide range of people’s movements is reiterating these ideas in a renewed call for justice and development. Diverse constituencies, often led by marginalized peoples, are coalescing and linking concerns that are converging around the world, from the right to bodily autonomy to the desire for a liveable planet. Their shared reach is powerful and promising, with research suggesting that large-scale social change can take off as soon as about 25 per cent of people stand in favour of it (Sloane, 2018). Many points of light include the increasing alignment of diverse grass-roots movements and civil society organizations with efforts to secure reproductive health and rights, and vice versa. Indigenous women are mobilizing to end the destruction of environmental resources, for example, because it threatens not just their culture and their sense of connection to the land but also their health and choices to bear children. Young activists are campaigning for climate justice with growing recognition that climate justice is also reproductive justice (McGovern and others, 2022). They have stressed that poor communities hardest hit by climate change are also those falsely blamed for worsening the crisis because of their high fertility rates – even as most greenhouse gas emissions still emerge from wealthier, lower-fertility countries. In India, Dalit activists have argued for legal protections for women facing caste-based discrimination in workplaces and education. Many will otherwise remain too poor to support CHAPTER 1: A work in progress14 their families and give their children a dignified life, contributing to a cycle that perpetuates poor sexual and reproductive health (McGovern and others, 2022). Cases where women’s rights have been largely obliterated, as in Afghanistan, have unified women’s activists, human rights defenders, politicians and prominent jurists behind a move to define gender apartheid and make it a crime against humanity (Bahous, 2023; Nia, 2023). The Green Wave movement sweeping across Latin America, which emerged from protests against shockingly high rates of femicide, has transformed activism as well as abortion laws in a region once known for some of the strictest limitations (Carpenter, 2019). As one activist said, “The cries of anger, pain, joy and sisterhood on the streets have certainly placed the feminist movement at the centre of public attention as a strong and necessary movement that is requesting radical changes in life as we know it” (Kharas and others, 2019). Rollback as a response to progress After decades of progress, there has also been a recent rollback in sexual and reproductive health and rights. Comprehensive sexuality education, once the subject of near-universal agreement, has been increasingly contested in international negotiations, for example (United Nations, 2023a). Advocacy organizations are reporting that abortion restrictions in one country are having a ripple effect in others (Fòs Feminista, 2023), with medical professionals increasingly uncertain about the legality of basic sexual and reproductive health services (Kanem, 2023). But pushback can be a common response to progress. As the United Nations Office of the High Commissioner for Human Rights notes, “In several countries, the authorities have noted a dramatic spike in homophobic and transphobic violence in the immediate aftermath of high-profile legislative advances aimed at better protecting the rights of LGBT people. It is a phenomenon with historic parallels: past attempts to eradicate racial segregation and discrimination reportedly triggered a similar backlash directed at members of racial minorities” (OHCHR, n.d.). The challenge, therefore, is to sustain hope and momentum in the face of opposition. STATE OF WORLD POPULATION 2024 15 FEATURE Duha, a 28-year-old single mother, was already a refugee from the war in the Syrian Arab Republic, living in Türkiye’s Hatay Province, when two powerful earthquakes struck in February 2023. The disaster forced her and her three young children from their former precarious housing and into a makeshift tent. Duha became pregnant in the aftermath of the crisis, and suffered for months from a painful urinary tract infection; she says this is common among the earthquake survivors, given the unsanitary washing facilities. “The lack of clean water has led to many kinds of infections.” One of her biggest concerns was the scarce access to health care: Regulations under Turkish law allow registered Syrian refugees with temporary protection status to visit family and migrant health centres without paying. But in Hatay, near the epicentre of the quakes, many services were incapacitated, and others were at risk of buckling under the increased demand. Fortunately, Duha was able to receive treatment from Dr. Eda Gülüm, a doctor working with HASUDER, the Turkish Association of Public Health Specialists, members of which have paid frequent visits to women and girls in the earthquake-affected areas. Mobile units with HASUDER, supported by UNFPA, provide prenatal and postnatal consultations, as well as family planning advice and treatment for common conditions such as cystitis, vaginitis and urinary tract infections. They also deliver group information sessions on breast cancer awareness, personal hygiene, family planning and preventing sexually transmitted infections. “We performed an abdominal examination and checked her vital signs,” Dr. Gülüm says. “We also made sure she wouldn’t miss her routine prenatal visits and gave her a ‘maternity kit’, which includes baby clothes, a blanket and toiletries.” Duha began organizing others to seek care. “Duha was fl uent in Turkish and very eager to help the health staff communicate with more women, contacting doctors and gynaecologists whenever a woman in her neighbourhood needed them,” Dr. Gülüm says. Globally, the human right to health is articulated in many international agreements, but in displacement, confl ict and other crisis settings, this right is often threatened or violated. Existing health systems can be compromised, patient populations may be uprooted and emergency responses may fail to prioritize sexual and reproductive health services – with consequences falling disproportionately on women and girls. Dr. Gülüm and HASUDER are trying to bridge these gaps. Dr. Gülüm is fl uent in Arabic and English as well as Turkish. Since August 2023, she has been serving quake-affected communities, typically seeing 10 to 30 women each day. When she’s with the mobile unit, she can visit up to 80. When crises cut off health care, community members fi ll the gaps CHAPTER 1: A work in progress16 “The nearest hospital is about 20 minutes away by car,” she explains. “With no public transport in the area, the mobile unit also supports patients in urgent need.” It’s a situation 22-year-old Rama (name changed), from the Syrian Arab Republic, faced. She has also been living in a tent since the earthquake. She reached out to HASUDER when she discovered she had miscarried early in her pregnancy, putting her at risk of life- threatening sepsis. The mobile team helped her gain access to a public hospital where she was treated. A few days later, she called the mobile team: “I just want to let you know I got through it,” she said. For those not intending to become pregnant, being displaced and losing access to basic health facilities also poses critical risks. “The most common conditions I see are sexually transmitted infections, urinary tract infections and unintended pregnancies,” says Ceylan Güzey, a nurse and health trainer with the UNFPA- supported Youth Approaches to Health Association (Y-Peer Türkiye) in Hatay. “I also do training and awareness-raising on these, and on family planning.” Since May 2023, Ms. Güzey has been working chiefl y with people displaced by the disaster; she explains that the team often discovers other underlying issues. While distributing maternity kits, for example, staff may identify untreated sexually transmitted infections, or violence or coercion. “We’ve seen child and unintended pregnancies rise since the crisis, as well as reports of sexual abuse, coercion and traffi cking… there’s been a very visible increase.” To address the prevalence of unintended pregnancies, Ms. Güzey is liaising with men much more than before. “I work mainly with women, but we’ve seen more couples asking for advice together – it’s unusual, normally men don’t want to go and ask for contraceptives.” Although the disruption in services is leading to harmful outcomes, Ms. Güzey has seen a surprising upside to bringing support directly to those displaced. “Before the earthquake, sexual and reproductive health work was more hidden, it was a kind of secret – now men are more understanding about these issues. They thought contraceptives were somehow against them, so it’s become less of a threat.” Nurse Ceylan Güzey says there’s been an increase in child and unintended pregnancies since the 2023 earthquakes, as well as reports of sexual abuse, coercion and traffi cking. © UNFPA Türkiye STATE OF WORLD POPULATION 2024 17 The language of inequality The language we use to address inequality matters. It is crucial that we avoid depicting any individual or community as powerless or peripheral. While there has been a tendency to describe entire groups as marginalized or oppressed, efforts are increasingly being made to name the specific conditions that can impede access to rights and choices. For these reasons, UNFPA has shifted from a focus on furthest-behind groups to furthest-behind factors. Some experts and organizations now refer to those “pushed behind” (Kharas and others, 2019) rather than “left behind”, avoiding the implication that marginalization is the result of a community’s own failures or inadequacies. Many use the phrases “leave no one behind” and “reach the furthest behind first”; both principles are central to the 2030 Agenda for Sustainable Development (UNFPA, 2021a). The report uses many of these terms, not to reflect a preference for one or another but to adhere to the source material and/or to bring research together into a cohesive and comprehensible text. The authors recognize that overall, the language of inequality is ever-changing. We must commit to listening to and learning from all members of our societies on a continuous basis. This report uses the following terms with the following definitions: Leave no one behind – from the 2030 Agenda for Sustainable Development (United Nations, 2015). Leaving no one behind represents the commitment of all United Nations Member States to eradicate poverty in all its forms, reduce inequalities, and end all types of discrimination and exclusion. Left behind/pushed behind – individuals who, due to systemic inequalities, face barriers to accessing their rights and choices. Both “left behind” and “pushed behind” are used in this report. Furthest behind – individuals who are the most excluded from access to their rights and choices. Those furthest behind often face intersecting disadvantages that combine to produce extreme hardship or ostracization. Importantly, this is context-specific; the circumstances that lead individuals to fall behind are determined by larger social, political and cultural factors, which can differ substantially from one place to another. Equality – the state of being equal, particularly in value, status, rights or treatment under the law. Equity – fairness; the term “equity” is often used to highlight that an equal distribution of resources or opportunities can still result in unjust or unfair outcomes because of existing privileges and disadvantages. Inequality – the state of lacking equality, particularly in status, rights or treatment under the law. Inequity – the state of lacking equity. Marginalized – a person or group treated as insignificant, lesser or peripheral by virtue of their identity. A person can be marginalized because of their sexual identity, race, ethnic identity, religious identity, class, caste, level of education or economic status, or disability, among other things. Vulnerable – susceptible to exploitation, abuse or other forms of harm; this term is widely used but can be problematic if the factors that lead to vulnerability, such as denial of opportunities or barriers to services, are not acknowledged. CHAPTER 1: A work in progress18 Factors, in addition to gender, that push people behind FIGURE 1 Source: Adapted from UNFPA, 2021a. Young undocumented domestic worker at risk of sexual exploitation by her employer Out-of-school girl with a hearing disability living in a remote community Transgender sex worker at risk of HIV working in a poor community Gay man living in a refugee camp HIV status Sexual and gender identity Culture, ethnicity, race, language, religion Income Location Migratory status Age Disability Children (under 18); Adolescents (10-25); Young adults (18-25); Older adults (over 60) Hearing or vision impairment, mobility, mental health Indigenous peoples, people of African descent, religious minorities, disadvantaged castes Remote, informal settlements, disputed territories Lowest wealth quintile Refugees, migrants, domestic workers, people in transit Sexual orientation, gender identity, sex traits Men who have sex with men, sex workers, people who inject drugs, people in detention Many factors interact with gender to marginalize people and communities. These include, but are not limited to, ethnicity, race, caste, language, religion, disability status, HIV/AIDS status, migration status, sexual orientation and gender identity. Gender (in the centre of the illustration) and these marginalizing factors (the middle ring) can find many different forms of expression (examples given in the outer ring). In the real world, individuals may experience many overlapping identities and circumstances (bottom of the illustration) that negatively impact their sexual and reproductive health and rights. STATE OF WORLD POPULATION 2024 19 We know more than ever about the levers of change If some people are still pushed behind, there is scope – and hope – for rapid progress based on global agreements to achieve equity, notably a core theme of the 2030 Agenda (United Nations System Chief Executives Board for Coordination, 2017). Among the reasons for optimism is research showing that improvements in reproductive and maternal health coverage have advanced faster among the poorest populations in recent years (Ghebreyesus and others, 2020), though progress has been uneven, with well-off groups continuing to maintain substantially higher levels of health coverage (Amouzou and others, 2020). Also encouraging is the mounting body of knowledge about who remains pushed behind and why, and what to do about it. Poverty is increasingly seen as only one driver of inequalities. Progress also diverges significantly (Ghebreyesus and others, 2020) when considering other factors that create barriers to services, lead to poorer health outcomes or otherwise limit fulfilment of sexual and reproductive health and rights. These factors include gender as well as age; culture, ethnicity, race, language and religion; disability status; HIV/AIDS status; location of residence; migration, asylum and displacement status; and sexual orientation and gender identity. This list is not exhaustive – and even among people who share a disadvantage, complex and diverse circumstances can abrogate their right to sexual and reproductive health in varying ways (UNFPA, 2021a). In all cases, a core human rights principle remains: Wherever and however discrimination, bias, vulnerability and inequality arise, they always warrant corrective action. Since 1994, major international agreements have clearly defined responsibilities and obligations to close disparities in sexual and reproductive health and rights. They have codified the rights of people with disabilities and of indigenous peoples, adding to existing conventions on women’s rights and the elimination of racial discrimination. Forward-looking regional agreements include the Montevideo Consensus on Population and Development, with its commitment to promote and protect sexual and reproductive health and rights as essential to social justice and sustainable development. The groundbreaking Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, better known as the Maputo Protocol, has led to the removal of abortion restrictions in over half a dozen countries, including colonial-era prohibitions linked directly to high levels of maternal mortality (see page 60 on colonial history) (McGovern and others, 2022). Understanding and agreeing to redress the factors that push people and communities behind can propel new choices – and with the right choices, the race to reach all people can begin, at the pace and scale required. Many levers of change are well known and well demonstrated. These start with redressing the power imbalances embedded in societies, laws, economies and health care, because it will be difficult if not impossible to achieve inclusion in systems that remain intrinsically discriminatory. A deliberate rebalancing of gendered power relations is required on all levels, for instance, from families to parliaments, alongside efforts CHAPTER 1: A work in progress20 Humanitarian crises drive marginalization Humanitarian emergencies disproportionately affect women and girls, persons with disabilities, indigenous persons, persons with diverse gender identity and sexual orientation, older persons and adolescents. Pre-existing gender inequalities and discrimination against marginalized groups are exacerbated during crises. Gender-based violence also spikes, yet the prevention, mitigation and response to gender-based violence remains one of the most underfunded and least prioritized humanitarian sectors (OCHA, n.d.). Insufficient funding in a crisis increases vulnerabilities for those at risk: Survivors can be left without access to vital care, for instance, and cuts to food aid and other assistance are closely linked with increases in gender-based violence. In Chad, when two new refugee sites could not be established, many displaced women and girls were left living in an overcrowded camp with insufficient protection from violence (OCHA, 2023). Meagre resources also limit health-care access for people in hard-to-reach areas. In Ethiopia, this meant mobile health teams could reach only 36 per cent of targeted people, with many remote communities going underserved. And in Afghanistan, around 170 static and mobile health facilities had to be discontinued, limiting primary health care for 1 million people, including pregnant women, children and persons with disabilities (OCHA, 2023). However vulnerability is only half the story. Local women and women-led organizations on the frontline of emergencies are key actors in ensuring the needs of marginalized communities are met. Their full, equal and meaningful participation must be ensured and their leadership strengthened. While these organizations continue to be underfunded and underrepresented, progress is taking place. In 2023, 10 humanitarian country teams had at least one local women-led organization as a member. In Yemen, the humanitarian country team included two local women-led organizations and a local organization for persons with disabilities. Thirteen of 19 advisory boards for country-based pooled funds, which allocate funding to humanitarian actors, had representation of at least one local women-led organization. These are promising steps, but many more are needed. This text was contributed by the United Nations Office for the Coordination of Humanitarian Affairs. STATE OF WORLD POPULATION 2024 21 FEATURE Women garment workers organize against gender-based violence “Garment workers can raise their voices against workplace violence without the threat of retribution,” says Thivya Rakini. This represents a sea change for thousands of the garment industry’s predominantly young female workforce, explains Ms. Rakini, president of the Tamil Nadu Textile and Common Labour Union (TTCU). With over 2,000 mills employing 280,000 workers, Tamil Nadu is India’s largest producer of cotton yarn, supplying both domestic and international markets, including well-known fashion brands. Most of these employees are young women, while management and supervisors are mostly male. This uneven power dynamic is exacerbated by the garment workers’ caste and migrant status, and by corporate efforts to avoid accountability for wrongdoing. Existing unions were reluctant to address issues such as gender- based violence and harassment. “In Tamil Nadu, the garment industry is dominated by male-led trade unions, and the management and senior leadership are also men. Women’s issues never really had space,” says Nandita Shivakumar, an adviser with the TTCU. “What women workers wanted was for the labour movement to ensure gender-related issues are part of the core agenda; it’s not just about wages.” “The workforce is 80 per cent women, 60 per cent of whom are from the Dalit community” – a marginalized caste in India, explains Ms. Rakini. “But the management and line leaders are men of the upper castes. It is not easy for them to listen when a Dalit worker says, ‘You are doing this wrong.’ That is something they fi nd really hard.” Frustrated, women garment workers made the decision to begin organizing themselves, and the TTCU was born. It is one of the fi rst women-led labour unions in Tamil Nadu, and it is also Dalit- led. Membership grew quickly; it now represents more than 11,000 workers. Trust between its leadership and members enabled the union to act decisively when tragedy struck: In January 2021, Jeyasre Kathiravel, a Dalit woman and member of the TTCU, was murdered by her supervisor at a Dindigul garment mill owned by Eastman Exports, following months of sexual harassment. Her death marked a breaking point; her colleagues wanted not just justice for Kathiravel but systemic change to protect all women garment workers. “What was different in Jeyasre’s case was that this was a village where the TTCU had a very strong union presence,” says Ms. Shivakumar. “The women had been in the union for a very long time. Jeyasre’s mother was in the union, and Jeyasre was in the union. So because it was such a village and such circumstances, there was strong solidarity and the general tendency to fall back to self-blame was not there[.] It was like whatever happens, we don’t care, we’re going to fi ght. It was that ‘Me Too’ moment, you know, for factory workers.” Their grief and frustration fuelled a global campaign, “Justice for Jeyasre”. It culminated in the April 2022 signing of the Dindigul CHAPTER 1: A work in progress22 Agreement to Eliminate Gender- Based Violence and Harassment, a historic deal that enshrines multiple layers of protection in the workplace through a set of supply chain agreements with a system of checks and balances intended to ensure accountability for gender- based violence and harassment at all levels. If management does not adhere to the stipulations of the agreement, brand signatories are legally required to impose business consequences on Eastman Exports to ensure compliance. Signatories include the supplier, the TTCU and the union’s allies, including the Asia Floor Wage Alliance and the Global Labor Justice — International Labor Rights Forum. The agreement was also signed by international fashion brands that purchase garments from the factories, including the H&M Group and Gap Inc. Today, Ms. Shivakumar explains, “There are women leaders in each production line acting as shop fl oor monitors. They have a lot of power to raise issues and they will not face retaliation.” And the impacts extend beyond the workplace, too. Many garment workers in Tamil Nadu are domestic migrants who stay in factory- arranged hostels and use factory- arranged buses; both were sites of exploitation. “Drivers harass women, saying ‘If you give me a sexual favour, even if you come late I’ll wait for fi ve minutes,’” says Ms. Shivakumar. Business owners used to shrug off any responsibility. “They used to say, ‘These are contracted services. It’s not our responsibility.’” The Dindigul Agreement addresses this. “We’ve tried to cover not just the workplaces but buses that transport workers and hostels, because a lot of the issues happen on buses… Now we’ve got monitors on the buses.” One year on, the results of the agreement have exceeded the expectations even of its founders. Ninety-eight per cent of total grievances have been resolved (Asia Floor Wage Alliance and others, 2023), including 100 per cent of complaints related to gender-based violence and harassment. Over 2,000 workers have received training on identifying and preventing abuse, including senior management, support staff and external contractors. The agreement has also had positive results for the manufacturer. In September 2022, the Dindigul garment factory was removed from a list of manufacturers banned by the United States for suspicion of forced labour; the Dindigul Agreement was credited in the decision. “In one year, we have made the workers understand that we are for them,” says Ms. Rakini. “But now the top management also understands that we are not for the workers alone, just protesting against management. We are also for the business.” Now, the TTCU is negotiating for these protections to be expanded to other suppliers – but it is determined that each new agreement must be tailored to the needs of the workers it covers. “Wherever it goes, the agreement should speak to the local issues of women workers. That’s the lesson that we learned,” says Ms. Shivakumar. “Now what we need is to expand the agreement to more places so that these protections are available in every factory and this becomes the norm. That’s what we need to do.” Members of the TTCU celebrate the signing of the Dindigul Agreement. © TTCU STATE OF WORLD POPULATION 2024 23 to extend and improve the quality of services and to shift norms and behaviours (George and others, 2020; Herten-Crabb and Davies, 2020). Concepts such as sexual and reproductive justice have been developed to acknowledge and act on the multiple drivers of discrimination and inequity, including through a deliberate call for people themselves to define what equity looks like and requires (McGovern and others, 2022). Examples of how structural shifts can happen include the decline in child marriage in South Asia, which has emerged through more education for girls as well as changes in economies that opened options for women’s employment (Herten-Crabb and Davies, 2020). A recent pledge to end child marriage by four countries that are home to one fifth of all child brides drew on emerging evidence of an integrated package of solutions that comprise gender-responsive social assistance, inclusive labour-market policies and universal secondary school education, among others (Indira and others, 2023). Much better data have been collected since the ICPD, helping to steer new programmes and investments. In 1994, we knew little about the scale of maternal mortality, for example; data were often unreliable or uncollected. Today, the figures are largely in place on an aggregate level. Further, population and health CHAPTER 1: A work in progress24 data collected by international institutions and national governments are now commonly disaggregated by sex, income, location and age. Data are increasing rapidly on disability. More now remains to be done to capture a full picture of all forms of marginalization. Data on ethnicity, race, language, religion, indigeneity, migration status and LGBTQIA+ identity remain scarce. More is possible, with the right commitments, including through the continued harnessing of new technologies. There is a nascent but growing understanding of how health services can help dismantle discrimination and structural barriers for those who have been pushed behind. Midwives have shown promise in both providing services and empowering women in marginalized communities. Growing evidence indicates that sex-positive sexual health interventions can reduce stigma; draw marginalized people to use services, including for sexually transmitted infections and HIV; and increase contraceptive use (Ford and others, 2022; Zaneva and others, 2022; Starrs and others, 2018). Women’s self-help groups in poor communities have demonstrated merit in providing both information on health care and microfinance to respond to economic needs, resulting in significant improvements in antenatal care and family planning indicators. A critical component of these groups is that women members determine, on a local level, the terms on which they operate – a lesson that should be applied broadly, ensuring participation in decision-making over one’s future is the norm, not the exception. Population and health data collected by international institutions and national governments are now commonly disaggregated by sex, income, location and age. STATE OF WORLD POPULATION 2024 25 Our past, our present, our future No one wants a world where half of all pregnancies are unintended, where women are battered in their homes or die from preventable causes in childbirth. We all want a future where girls and women know they can complete their schooling, pursue decent jobs, start families if they wish to do so and become part of and contribute meaningfully to a healthy, thriving society. This is people-centred development – robust, just and resilient to crisis. Original research in this report (page 28) will highlight how barriers to health-care access have fallen more quickly for women who are more socioeconomically privileged and for those belonging to ethnic groups that already had fewer barriers to care. This research also shows that disparities within countries are greater than disparities across countries – implicating every society in the perpetuation of these injustices and calling for redress at levels both low and high. Chapter 2 of the report highlights why this is so. Despite 30 years of consensus about the emancipatory power of sexual and reproductive health, the systems that deliver this health care remain contaminated by deep legacies of gender inequality, racial discrimination and misinformation. Yet the process of exposing these injustices offers opportunities to develop systems and practices rooted in the common dignity of all people. The third chapter explores the world’s data revolution – sparked in some ways by the ICPD itself, which called for disaggregating data to identify where, and for whom, unmet sexual and reproductive health needs are most dire. This directive has gone largely unfulfilled. If the world is to achieve universal sexual and reproductive health and rights, the data element of the ICPD cannot continue to go overlooked. Chapter 4 highlights the societal, health and productivity gains that still need to be made and the investments that can take gains to scale. The case for contraception is by now incontrovertible. Economists and advocates, and women themselves, have established that human capital development is greatly accelerated when individuals are able to plan their families. But investments in contraception alone are insufficient. This chapter elaborates on the benefits unleashed by reproductive autonomy more broadly. The final chapter looks ahead, using analyses from a consortium of experts and thought leaders across the fields of demography, climate change, health and technology, to anticipate some of the greatest challenges to both the ICPD agenda and the world more generally. This chapter shows that, even amid the looming storm clouds of populism, disinformation, climate catastrophe and large-scale displacement, universal and inclusive sexual and reproductive health care and rights will remain as crucial, or indeed become more crucial, to securing a sustainable and rights-based future for all. Each chapter begins with a reflection on the past 30 years of progress, a critical reminder that, despite current and imminent challenges, the broader trajectory is towards the fulfilment of human rights and gender equality. The chapters then aim to establish a basis of shared CHAPTER 1: A work in progress26 understanding about the importance of addressing discrimination before pointing to paths forward. The struggle for health is a struggle for equality and bodily autonomy (Ghebreyesus and others, 2020), for justice and for people- centred development. It should lift people and societies up, not push them behind, through choices that all people deserve to have about their bodies and their lives. To do this, we must grapple with complexity. We will have to move beyond measuring human experience in broad averages that obscure the experiences of marginalized groups. And we will have to advance beyond a zero-sum accounting, where some people always win and others always lose. We can look to the geometry of weaving as inspiration for an alternative vision of human potential. In weaving – which is inherent to cultures and communities everywhere – the strength of any single thread is vastly multiplied by braiding. Similarly, the education, autonomy, health and potential of every individual is tenuous alone but vastly strengthened when woven together with the rights, health and well-being of others. Indeed, 30 years ago, the ICPD Programme of Action affirmed by consensus that sexual and reproductive health and reproductive rights are enmeshed with, and inseparable from, the broader aims of sustainable development. This is both a new and an ancient way of understanding our world, in which diverse strands come together in a holistic tapestry, in which every life adds to the fabric of our collective humanity, beautifying and fortifying the whole. The Boruca are an indigenous people living in Costa Rica. They collect seeds, flowers, tree bark, sea snails and other items from the natural world to create the dyes for their fabric, but first ask permission from Mother Nature to ensure that their practices and traditions remain sustainable. © Christian Moon/UNFPA Costa Rica STATE OF WORLD POPULATION 2024 27 Recent years have brought a proliferation of ways to track and measure progress towards the global expansion of accessible and affordable health care (WHO and others, 2023). Notably, the reporting for SDG target 3.8.1, coverage of essential health services, gives critical insight into the percentage of individuals receiving essential care, the number of health facilities and personnel per capita, and other internationally comparable measures. Yet, as this report shows, it is also important to let people speak for themselves. The original analysis elaborated here highlights how change in health-care access has been experienced by women from different socioeconomic and ethnic backgrounds, as they themselves report. In 69 countries around the world, Demographic and Health Surveys have done precisely that. The surveys ask women to report on whether they have serious problems in accessing health care for themselves when they are sick. Among a larger list of various types of problems, there are four specific issues that have been asked across all country contexts, namely, whether women have a serious problem: (1) with the distance to a health facility; (2) with getting money needed for treatment; (3) with not wanting to go alone; or (4) with getting permission to go. In only 25 of the 69 countries – about one third of the total – have the questions been asked in more than one survey while also identifying a woman’s ethnicity. This data set offers an opportunity to examine women’s self-reported problems accessing health care, looking both across time, by socioeconomic factors (wealth quintile, level of schooling and urban or rural residence) and by ethnicity. Together, these 25 countries represent about one third of the global female population, and identify nearly 300 different ethnic groups. It is worth emphasizing that these self-reported answers to health- access questions are very different from measures of universal health coverage (WHO and others, 2023a), and, importantly, the levels and trends of both can sometimes be in conflict with one another. Demographic and Health Surveys are among a variety of studies and surveys being used to evaluate health access, which can together bring nuance to this important topic. Overall improvement, unequal pace The findings show a promising overall trend of reduction in problems accessing health care. According to the most recent surveys (which took place between 2012 and 2022, depending on the country), 61 per cent of women reported one or more serious problems in accessing health care for themselves when they were sick – improvement over the first survey period (2000–2018), when 67 per cent of women reported serious problems accessing health care. Nevertheless, the analysis also finds considerable inequalities across countries. For example, in the most recent survey period, 43 per cent of women in Gambia had serious problems obtaining health care while 95 per cent of women in Peru did. And while most countries have seen women report improved access between the first and second surveys, a handful of countries saw little change (Gabon, Gambia, Malawi, Nigeria, Peru and Sierra Leone) or showed evidence Self-reported problems in accessing health care, over time, by socioeconomic status and ethnicity IN FOCUS CHAPTER 1: A work in progress28 Source: Demographic Health Survey Note: There is an overall positive trend of reduction in problems accessing health care. (For the case of Malawi, which shows little change over time, the margins of error are large enough to make this uncertain.) Proportion of women with serious problems in accessing health care for themselves when they are sick, by country �������������� �������������� �������������� �������������� ������������ ������������ ������������������� ������������������� ��������������� ��������������� ���� ���� ��� ���� � � ������������� ���� ���� ��� ���� � � ������������� �������������������� �������������������� ����� ��������� ����� ���������� ������������ �������������������������� ������������ ������������ ������������� ������������� ������������ ������������ ������������ ������������ �������������� ������������� ������������ ����������� ����������� �� ��������� �� ��������� ����������������������������  ��������������  ��������������  ����������  ���� �����������  ���� ����������� ­������������� ­������������� ­������������������­������������������ ������������� ������������� ������������� ������������� ��� ��� ��� ��� ��� ��� ���� �������������� ������� ����������  ���������� FIGURE 2 of regression (Kenya, Pakistan and Senegal). Furthermore, inequalities within countries are often greater than the difference across countries. That is, the differences that appear across socioeconomic groups and ethnicities within the same country usually exceed the gap seen in the averages between countries (i.e., Gambia compared to Peru). For example, in 2017 in Albania, 91 per cent of Roma women with the most marginalized socioeconomic status – urban women with no education and in the poorest wealth quintile – had serious problems in accessing health care while only 5 per cent of ethnic Albanian women from the most privileged socioeconomic status – rural women with higher education and in the richest wealth quintile – had serious problems. Likewise, while 18 per cent of urban Senoufo women with higher education and in the richest wealth quintile had serious problems in accessing health care in Burkina Faso in 2021, 95 per cent of rural Touareg/Bella women with no education and in the poorest wealth quintile did so. Wealth, education, residence contribute to widening gaps Women with the most marginalized socioeconomic status, who started out in the first survey with a higher prevalence of serious problems accessing health care, saw the least change over time on average. Those with the least marginalized socioeconomic status, who reported the lowest prevalence of serious STATE OF WORLD POPULATION 2024 29 problems with access, generally saw the most improvement over time, a finding highly reminiscent of other health research revealing similar patterns of inverse equity (Victora and others, 2018). These socioeconomic designations – which look at wealth, education and residence – are all country-specific, with some countries seeing more advantage among rural residents and others seeing more advantage among urban residents, for example, (see technical note 154). On average, the most marginalized socioeconomic groups saw a 5 percentage point decline in the proportion of women with serious problems in health-care access between the earlier and later surveys. By contrast, in the least socioeconomically marginalized group, the proportion of women with serious problems in health care access declined by 8 percentage points. Ethnicity plays a persistent role in inequality Health disparities occur across a broad range of dimensions, including ethnicity. This research looked at how ethnic groups fared over time in access to health care; groups with higher proportions of women experiencing serious problems were considered to be more marginalized, and those with lower proportions facing access problems were considered less marginalized. Ethnicity-based differences persist even after accounting for different levels of education, wealth and urban/ rural residence. In plain language, women with the same levels of education, wealth and place of residence, but different ethnicities, often report vastly different realities when it comes to accessing health care. Across all countries, 43 per cent of women from their country’s most disadvantaged socioeconomic profile and least marginalized ethnicity faced serious problems accessing health care; for women from their country’s most disadvantaged socioeconomic profile and most marginalized ethnicity this percentage was 83 – a 40 percentage point span among women who shared the same socioeconomic challenges and only differed by their ethnicity. Furthermore, despite most countries seeing overall improvements in access, more than half of countries analysed saw ethnic disparities widen between the two survey periods. In the 14 countries with a widening ethnic gap, the earlier surveys showed a 41 percentage point gap between socioeconomically disadvantaged women from the most versus the least marginalized ethnic groups, while in the more recent surveys, the gap increased to 48 percentage points. The trends among all the ethnic groups identified across the 25 countries are diverse, but the overarching tendency is clear: Ethnic disparities in self-reported problems accessing health care exist in almost every country and society where data are disaggregated for ethnicity. That is, when we listen to women’s own reports about problems accessing health care when they are sick – using surveys representing one third of the female population of the planet – we see that ethnic disparities in health- care access are pervasive and, in a number of cases, widening. Narrowing the gap is possible However, there is some good news. Ethnic differences are not extreme everywhere, and there are promising signs that narrowing the gap is possible. In Guinea, the poorest rural Guerzé women with no education saw the highest proportion with health-care access problems of any ethnic group, 96 per cent, in the earlier survey, but by the most recent survey the proportion with serious problems had declined to 72 per cent – better than rural women from all other ethnic groups with similar levels of poverty and schooling. In the earlier Nigerian survey, among the poorest rural women with no education, 87 per cent of Ekoi women reported serious problems in health-care access. By the most recent survey, that proportion had fallen to 64 per cent, nearly the same as poor rural Hausa women, the ethnic group reporting the best access. (Still, these improvements were not shared universally among all ethnic groups within these countries.) One particular bright spot was Ghana, where there was only a CHAPTER 1: A work in progress30 3 percentage point difference in the proportion of Akan women with the most marginalized socioeconomic profile facing serious problems in accessing health care compared with Ga and Dangme women, whereas in the earlier survey it was a 16 percentage point difference. In fact, inequality across several other ethnic and socioeconomic groups in Ghana also diminished between the earlier and later surveys, a sign of not just improved access to health care but also improved equity. Why was Ghana so successful in closing equity gaps compared to other countries? One possible explanation relates to the expansion of access to health care in Ghana over the period covered by these surveys, including the introduction of a free maternal health-care policy and the continued roll-out of a national health insurance scheme (Aikins and Koram, 2017; Blanchet and others, 2012). Many other countries have also adopted national health insurance schemes, but in Ghana equity seems to have been a deliberate tenet of health-care access efforts – not just in how initiatives were designed but also in the prioritization of evidence-driven evaluation and reform (Phillips and others, 2020). For example, where other countries with national health insurance schemes might rely heavily on private out-of-pocket expenditures, Ghana dramatically increased the portion of health financing from public funds (Odeyemi and Nixon, 2013). Insisting upon progress for all Overall, the analysis from these 25 countries offers important lessons to all nations and communities. Namely, global progress in improving access to health care has been uneven and, by many measures, those who are furthest behind remain among the last to be reached. Additionally, ethnic disparities are not limited to certain countries but rather are identifiable everywhere adequate ethnicity data are collected. Highlighting the existence of ethnic and socioeconomic disparities in health-care access should therefore not be regarded as an accusation of bias or an appeal to politics. Rather, ethnic and socioeconomic disparities are seemingly universal – while progress towards eliminating these disparities is not. But progress is possible. And it starts by giving people the opportunity to identify their experience of inequality in the first place. FIGURE 3 Source: UNFPA Note: Only two ethnic groups (Ga/Dangme and Mole-Dagbani) were found to experience changes in health-care access different from the largest ethnic group (the Akan). For both of these groups, women reported health-care access improved over time, erasing gaps seen in the earlier survey. Ghana. Proportion of women with one or more serious problems accessing health care: socioeconomic extremes, by ethnicity � ��� ��� ��� ��� ��� ��� ��� ��� ��� ���� ���� ������������������������������� ����������� � ������������������������������� ����������� �������������������������� ����������� ��������������� �������������� ����������� � ��������������� �������������� ����������� ���������� �������������� ����������� STATE OF WORLD POPULATION 2024 31 CHAPTER 2: Unravelling in- equality CHAPTER 2STATE OF WORLD POPULATION 2024 CHAPTER 2STATE OF WORLD POPULATION 2024 33 THIRD WORLD POPULATION CONFERENCE, BUCHAREST Following a decade of economic growth, population came to be seen as less of a ‘problem’. Governments here agreed on the need for a new paradigm around population and development. 1954 1974 1975 FIRST WORLD POPULATION CONFERENCE, ROME This largely academic conference focused on demography in developing countries; conversations at the time were dominated by fears over population growth and resource scarcity. THE UNITED NATIONS DECADE FOR WOMEN BEGINS International women’s movements were growing and mobilizing around social, economic and political issues. ���������������������� ����������������������� ����� ������� ������������ ������������� ������ �� ��� ������������� �������������� � ������� ��������������� ��������������� ���� ����� � ����������This timeline illustrates how the ICPD ��� �� �� �� ���� ������������� ����������������� ����� ���������������������� to consolidate support for sexual and reproductive health and rights globally. Feminist researchers used human rights frameworks to carve a role for themselves. The ICPD Programme of Action emerged in the aftermath of the Cold War, a time of upheaval and uncertainty. That year, 1994, saw both the end of apartheid in South Africa, which held its first multiracial democratic election in April, and the eruption of genocide in Rwanda that same month. Sweden legalized civil unions between same-sex partners – making it the third country ever to do so – as the global rate of new HIV infections was reaching its highest-ever peak (UNAIDS, n.d.). The promise of collective action, and the perils of failing to take such action, could not have been more prominent in the minds of ICPD attendees in Cairo. And indeed a central achievement of the ICPD, the paradigm shift in the world’s understanding of population and development issues, did result from the collective efforts of the Member States and grass-roots movements. The Programme of 34 CHAPTER 2: Unravelling inequality Action introduced the concepts of reproductive health and reproductive rights – both terms already in use by the women’s movement and public health advocates – to the broader international community (Berro Pizzarossa, 2018), and situated these within “human rights that are already recognized in national laws, international human rights documents and other consensus documents” (UNFPA, 1994). By invoking the wisdom of grass-roots advocates and drawing on the existing human right to health, the Programme of Action was able to secure, by consensus, recognition that States and health systems are obligated to uphold the sexual and reproductive health and reproductive rights and well-being of all people. This role for health systems as an enabler of human rights – not only the right to the highest attainable standard of health but a suite of other rights – was 1977 1979 19811976 FIRST INTERNATIONAL WOMEN AND HEALTH MEETING (IWHM), ROME The international women’s health movement emerged. CEDAW ADOPTED BY THE GENERAL ASSEMBLY CONVENTION ON THE ELIMINATION OF ALL FORMS OF DISCRIMINATION AGAINST WOMEN (CEDAW) was drafted and approved by the Commission on the Status of Women. THIRD INTERNATIONAL WOMEN AND HEALTH MEETING, GENEVA Activists from the Global North and Global South united on reproductive rights and access to health care. STATE OF WORLD POPULATION 2024 35 Preparatory committees and the ICPD Secretariat at UNFPA began working towards the 1994 ICPD in Cairo. Simultaneously, women’s organizations and networks mobilized to influence the existing population agenda. 1990 1992 WOMEN’S DECLARATION ON POPULATION POLICIES Signed by 2,539 individuals and organizations from over 110 countries, calling for population discussions to reorient around reproductive health and rights. 1984 FOURTH INTERNATIONAL WOMEN AND HEALTH MEETING, AMSTERDAM The term ‘reproductive rights’ was officially embraced by the international women’s health movement. INTERNATIONAL CONFERENCE ON POPULATION, MEXICO Here discussions broadened to include both technical and political demands. by this point well understood, but in the contested arena of sexual and reproductive health this recognition was groundbreaking. The Programme of Action even achieved agreement on the hotly disputed issue of abortion, determining that “in circumstances where abortion is not against the law, such abortion should be safe” and that “in all cases, women should have access to quality services for the management of complications arising from abortion”. The final text showed that a woman’s “health and personal development are crucially dependent on the quality of the services she is offered, and the choices available”, as then- UNFPA Executive Director Nafis Sadik described the following year in Beijing, at the Fourth World Conference on Women, highlighting the role of health systems, doctors, contraception and information in “liberating women from a system of values which insists that reproduction is their only function”. 36 CHAPTER 2: Unravelling inequality 1999 ICPD+5 Youth movements were engaged to help advance the ICPD agenda among a new generation. INTERNATIONAL CONFERENCE ON POPULATION AND DEVELOPMENT (ICPD), CAIRO This was a rare opportunity for political agreement among governments, held at a unique time in global politics: amid the end of the Cold War, on the heels of the Oslo Accords, and as views on population issues shifted at the highest levels. NGO representation was unmatched, with 4,000 representatives from over 1,500 civil society organizations from 113 countries. Representatives of the women’s movement were also part of national delegations, advocating for their realities and rights to be included in the ICPD Programme of Action. PREPARATORY CONFERENCE, RIO DE JANEIRO Hundreds of women released a statement outlining principles and conditions needed to ensure a woman- centred, rights-focused approach to population.  FOURTH WORLD CONFERENCE ON WOMEN, BEIJING This culminated in the Beijing Declaration and Platform for Action and is recognized alongside the 1994 Cairo conference as a seminal moment in the international women’s movement. 1994 1995 And in the 30 years since the Cairo conference, health systems, education systems and governments – and the civil society groups that hold them accountable – have delivered. When laws are assessed by whether they sufficiently guarantee full and equal access to sexual and reproductive health care, information and education — including maternity care, abortion, contraception, comprehensive sexuality education, HPV vaccination, and HIV testing, counselling and treatment — 76 per cent of such laws are found to be in place across 115 countries, as measured in SDG indicator 5.6.2 (UNFPA, 2024a). Additionally, since 1994, abortion rights have been recognized for millions of people worldwide, as more than 60 countries have revised their abortion laws to remove restrictions (Center for Reproductive Rights, n.d.), compared to just four that have rolled back the legality of abortion. STATE OF WORLD POPULATION 2024 37 The 2030 Agenda for Sustainable Development was adopted, leading to the Sustainable Development Goals. Thanks to advocacy, Goal 3 on health and Goal 5 on gender equality both included targets on sexual and reproductive health and rights. The #NiUnaMenos movement calling for an end to femicide emerged in Argentina, uniting women’s groups across Latin America and ultimately leading to the Green Wave. ICPD+20 Once more, experts, feminists, youth, NGOs and governments mobilized around the ICPD agenda, resulting in a bold Framework of Actions for the Follow-up to the ICPD Programme of Action Beyond 2014. The ICPD was also re-endorsed at the United Nations General Assembly Special Session on the ICPD. MDGS + 5 Advocates succeeded in having universal access to reproductive health included in the Millennium Development Goals. The Millennium Declaration was adopted by the United Nations General Assembly, followed by the Millennium Development Goals. But civil society called for amendments: The initial goal on improving maternal health, for example, did not contain any targets on reproductive health. 2014 201520052000 The SheDecides movement was launched in support of reproductive health and rights. The #MeToo movement also erupted, reviving a 2006 campaign, in response to millions of women decrying sexual abuse and harassment. NAIROBI SUMMIT ON ICPD25 Civil society, youth leaders and government representatives turned out in force for sexual and reproductive health and rights. The Summit resulted in nearly 1,300 commitments and the forward-looking Nairobi Statement. GENERATION EQUALITY Due to the global COVID-19 pandemic, the review took place a year late. The Generation Equality Forums saw an emboldened international women’s movement and reignited support from governments and partners; this included an action coalition dedicated to bodily autonomy and sexual and reproductive health and rights. 2017 2021 ICPD30 The thirtieth anniversary of the groundbreaking Cairo conference. Feminist and reproductive rights movements have grown in numbers and in strength and many gains have been made – but our work is far from over. New organizations and members have mobilized, including on intersectional issues such as caste, disability, indigeneity, sexual orientation and gender identity. These are creating space for multiple voices and stakeholders, and social media is drawing more people, and perspectives, to the cause. ������������������������������������������������������������ �� ��������������������� ��� ������������� �� ��� ���� �� �������������� �� ���������������������������������������������������� �������� ����������������������� �������������������������������������������� � ���� ������ ������������ �� ��������������������������������� ��������������������������������� ��������� ��� ���������� ��������������� ���������� ���� 20242019 The ICPD also called for youth to have access to, and participate in the development of, “information, education and communication activities and services concerning reproductive and sexual health” – acknowledgement that this information would help to empower current and future generations to fulfil their potential. Since then, international standards have been developed and today two thirds of reporting countries state 76 per cent or more of their schools provide some form of sexuality education (UNESCO and others, 2021). Assisted reproductive technologies have become almost ubiquitous, enabling more people to realize their fertility aspirations and expanding opportunities for more diverse families. But much more remains to be done. Bodily autonomy is a reality for too few women globally. Today, just over half 38 CHAPTER 2 The SheDecides movement was launched in support of reproductive health and rights. The #MeToo movement also erupted, reviving a 2006 campaign, in response to millions of women decrying sexual abuse and harassment. NAIROBI SUMMIT ON ICPD25 Civil society, youth leaders and government representatives turned out in force for sexual and reproductive health and rights. The Summit resulted in nearly 1,300 commitments and the forward-looking Nairobi Statement. GENERATION EQUALITY Due to the global COVID-19 pandemic, the review took place a year late. The Generation Equality Forums saw an emboldened international women’s movement and reignited support from governments and partners; this included an action coalition dedicated to bodily autonomy and sexual and reproductive health and rights. 2017 2021 ICPD30 The thirtieth anniversary of the groundbreaking Cairo conference. Feminist and reproductive rights movements have grown in numbers and in strength and many gains have been made – but our work is far from over. New organizations and members have mobilized, including on intersectional issues such as caste, disability, indigeneity, sexual orientation and gender identity. These are creating space for multiple voices and stakeholders, and social media is drawing more people, and perspectives, to the cause. ������������������������������������������������������������ �� ��������������������� ��� ������������� �� ��� ���� �� �������������� �� ���������������������������������������������������� �������� ����������������������� �������������������������������������������� � ���� ������ ������������ �� ��������������������������������� ��������������������������������� ��������� ��� ���������� ��������������� ���������� ���� 20242019 (56 per cent) of the world’s women were able to make their own informed decisions about sex and reproduction. This means the freedom to make choices about health care and the use of contraceptives as well as to say no to sex with a husband or partner, information collected in countries’ reporting for SDG indicator 5.6.1 (UNFPA, 2024a). And while data are limited (explored further in Chapter 3), a growing body of evidence indicates that bodily autonomy and reproductive health are more frequently, and more severely, undermined among those facing one or more forms of oppression, such as those enduring ethnic or racial discrimination, persecution over HIV status or disability, or discrimination over their sexual orientation or gender identity. There is increasing recognition that the capacity to determine one’s reproductive future – including access to modern contraception, safe abortion where legal, prenatal medical care and childcare – is unequally distributed across race, sexual STATE OF WORLD POPULATION 2024 39 orientation, gender identity, sex characteristics, class and socioeconomic status. In fact, the world is only just beginning to grapple with the legacy of multiple forms of discrimination in medicine and health systems. As this legacy is unearthed, questions are being asked about the people who have been marginalized, the mechanisms of that marginalization and the persistence of its consequences. Experts are drawing attention to the structures that perpetuate discrimination, sometimes invisibly – a contrast to earlier efforts that tended to focus on individual behaviours (OHCHR, 2021). As a result, discrimination is increasingly being identified through unequal outcomes rather than requiring proof that these outcomes were motivated by individual animus. The human right to sexual and reproductive health Sexual and reproductive health and rights are now widely understood, and acknowledged in a number of human rights frameworks (Organization of African Unity, 1981; OHCHR, 1966), to be grounded in the right to life, to dignity, to education and information, to equality before the law and to non-discrimination; the right to decide on the number and spacing of children; the right to privacy; the right to health; the right to freedom of opinion and expression; the right to consent to marriage and to equality in marriage; and the right to be free from gender-based violence, harmful practices, torture and ill treatment, as well as the right to an effective remedy for violations of fundamental rights. It is also well accepted (OHCHR, 2019; UNFPA, 2019; Shalev, 1998) that the key principles that shape human rights – especially non-discrimination, equality and privacy, the right to information, as well as the integrity, autonomy, dignity and well-being of individuals, particularly in relation to sexual and reproductive health and rights – are integral to the realization of the right to health. 40 CHAPTER 2: Unravelling inequality This reckoning has been most prominent in justice systems. The Ni Una Menos movement in Latin America, for example, highlighted the passivity of authorities in cases of femicide and other forms of gender-based violence. The Black Lives Matter movement brought attention to the disproportionate experience of police violence among Black people globally (OHCHR, 2023). Other sectors have been affected as well: Within education, the Rhodes Must Fall protest movement drew attention to inequities in higher education, first in South Africa and then internationally (Knudsen and Andersen, 2019). This kind of reckoning is just as relevant for health systems, a fact deeply underscored during the COVID-19 pandemic. In many parts of the world, pandemic emergency measures were not in conformity with human rights law (OHCHR, 2020). Already marginalized populations experienced higher rates of COVID-19 pandemic-related illness and death and greater disruptions of other health services, including for sexual and reproductive health (WHO, 2020). Contemporary discourse around gender, social and racial justice movements might suggest these issues are controversial or political, but it is a mistake to see this process only through the lens of politics. We can recognize that the history of reproductive health includes regrettable tragedies and missteps without diminishing the many advances that have been made in science and technology. Rather, it allows us to learn from the past, creating opportunities for knowledge and progress – for all people. Health systems must be enablers of human rights Reproductive health systems have not always been health- and rights-affirming. At least not for all women. “A major shortcoming in reproductive health care within the health-care system was the philosophy with which services were provided,” experts have commented. “Women were considered as means in the process of reproduction, and as targets in the process of fertility control. Services were not provided to women as ends in themselves. Women benefited from the process, but were not at its centre. They were objects, and not subjects” (Cook and others, 2003). Systems and structures to control sexuality, especially (but not exclusively) the sexuality of women, have been universal, permeating all societies around the globe. The bodies of women, girls and gender-diverse people were often subject to discrimination, harmful practices, control, exploitation, violence and oppression – human rights violations that historically have been abetted by health systems (OHCHR, 2021a). And these issues are all too persistent today. Many obstacles continue to stand between individuals and their enjoyment of sexual and reproductive health and rights, operating at different levels: in clinical care, at the level of health systems and in the context of the underlying determinants of health. And they operate differently for those experiencing different forms of marginalization. Health workers are, today, among those best placed to identify the transformative value of sexual and reproductive health and rights, as they STATE OF WORLD POPULATION 2024 41 see first-hand how family planning, protection from violence, safety from disease and access to maternal health care result in healthier and better-educated families and communities. Many contemporary reproductive health workers embrace their role in upholding the rights of their patients (and the topic of patients’ rights is, in fact, a staple in the education of health professionals globally [Rostami-Moez and others, 2021; Karakuş and others, 2015; Lewkonia, 2011]). Through the provision of contraception, information and care, reproductive health practitioners often stand on the front lines of individuals’ efforts to secure bodily autonomy (see feature on page 16) (Kalra and others, 2021). Yet they can be subjected to abuse for doing so. New research shows that, “as [sexual and reproductive health and rights] workers Health workers as champions of bodily autonomy A reciprocal relationship exists between the receipt of dignified, quality sexual and reproductive health care and the experience of economic, social and personal empowerment. Health workers, in particular, observe directly how reproductive autonomy – the ability to choose whether, when and with whom to have sex or become pregnant, the ability to live free of violence and preventable sexually transmitted infections, etc. – enables individuals to pursue their education, delay or start their family, build their career and/or contribute to their community. And they see first-hand how empowered individuals – those able to pursue education, careers and/or families – are better able to access reproductive health services. The virtuous cycle is an uncontested truth for those who witness it. “We teach them to expect respect,” says Víctor Cazorla, a male midwife working in the Andes mountains of Peru, who sensitizes his mostly indigenous patients about their rights (UNFPA, 2021). “Nobody has a right to touch their bodies: not me, not their aunts, not their fathers, not their mothers, not staff, not police, nobody.” seek to fulfil the human rights of others, their own human rights are put at risk”, as they face “ostracization and harassment in the workplace”, “verbal threats and physical violence” and hostilities in their personal lives (Boydell and others, 2023). The following sections illustrate how sex discrimination, racial and ethnic discrimination, and misinformation continue to impact health services and information today, making the case that both human rights and public health require reconciliation with this history. In order for health workers to become enablers of human rights, the health systems that employ them – which have historically been so complicit in exploitation and abuse, and which today leave many sexual and reproductive health workers 42 CHAPTER 2: Unravelling inequality vulnerable to mistreatment – can and should be reformed to realize their original and more noble purpose, for individuals, health professionals and society as a whole: healing. The legacy of sex discrimination in reproductive health care Understanding the legacy of sexism within sexual and reproductive health care can actually help to identify solutions – including cost- effective and readily achievable solutions – to persistent problems. One important example is the history of childbirth care, which, for centuries, was largely considered the domain of women. Women midwives managed childbirth while physicians, a profession restricted to men, generally avoided it. Childbirth was long considered a female mystery, and women alone had special knowledge and understanding of it, including the use of herbs as drugs. Over time, male doctors did begin to assist birthing women, initially only in complicated and high-risk deliveries (Litoff, 1982). Eventually, doctors and other male-dominated institutions assumed authority over midwives. In precolonial Indonesia, for example, women relied on traditional midwives, or birth attendants, known as dukun, who provided contraception, delivery care and abortion. When Indonesia became a colony in the 1800s, authorities sought to replace dukun with midwives trained under the male leadership of the Dutch medical service (Adnani and others, 2023). Around the same time, male physicians in India proposed the provision of formal training to traditional midwives known as dai, efforts that ultimately led to dai being replaced by trained midwives and doctors working under the medical establishment (Samanta, 2016). Midwives were also brought under the jurisdiction of male leaders in Europe in the 16th and 17th Centuries, when they were licensed by male-dominated church authorities and, in some cases, compelled to serve as expert witnesses in cases of “infanticide, contested virginity, abortion and sterility” (Sprecher and Karras, 2011). It was during this period that “accoucheurs” (male midwives) became fashionable in France, creating competition with the so-called “natural practising” female midwives and popularizing the use of instruments such as forceps. The gender and status of men established their authority in the field despite having little or no practical experience (Martucci, 2017). At the time, men training to be doctors were largely influenced by writings about birth, written by practitioners who may never have seen labour or birth (Hobby, 1999), rather than practical knowledge (Thomas, 2016). The emerging “science of nature” gave rise to a view of medicine as being objective, part of a universal system of knowledge, one from which female midwives were largely excluded (Shiva, 1996). Unlike male doctors, they were neither educated nor involved in the investigative and experimental scientific methods. By the 18th Century, the medical profession mostly consisted of men, and midwives were accused of using ancient, dangerous and outdated practices. Research on colonial-era South Africa, for example, shows that the real-world experience STATE OF WORLD POPULATION 2024 43 and knowledge of midwives – especially Black midwives – was largely omitted from the historical record (Deacon, 1998). Men’s contributions to the field, by contrast, were better documented, enabling male-dominated views of childbirth to prevail. New birthing theories likened the body to a machine and childbirth to a mechanical process, a view that further alienated midwives as practitioners, since women were seen as lacking the knowledge and ability to understand the mechanisms of birth (Murphy-Lawless, 1998). Birthing bodies were increasingly viewed as uncontrollable, uncontained, unbounded, unruly, leaky and wayward (Carter, 2010). In 1915, Dr. Joseph DeLee, author of the most important obstetric textbook of that period, described childbirth as a pathological process that damaged both mothers and babies. “If the profession (obstetrics) would realize that parturition viewed with modern eyes is no longer a normal function… the midwife would be impossible even of mention,” he wrote (DeLee, 1915). Dr. DeLee would later propose interventions, including routine use of sedatives, ether, episiotomies and forceps – all of which are now known to be harmful when used routinely – to save women from the “evils” natural to labour (Leavitt, 1988). The sidelining of midwives within obstetric medicine was a global phenomenon, but today the consequences are most severe in low- and middle-income countries. WHO has identified Africa and South-east Asia as the regions with proportionally fewest countries recognizing midwifery as a distinct profession. Midwifery educators in these regions persistently report lacking access to toilet facilities, and in French- speaking West Africa, three quarters of midwifery educators lack access to clean water at least some of the time. Furthermore, WHO’s Africa region accounts for 56 per cent of the global shortage in health professionals dedicated to providing sexual, reproductive, maternal, newborn and adolescent health care (UNFPA and others, 2021). And although midwifery today is widely understood to be a modern, regulated, technical profession well integrated into the health- care infrastructure, it remains predominantly female in most places. Research shows the midwifery workforce suffers under serious occupational segregation, gender pay gaps, lack of leadership opportunities and multiple forms of discrimination and harassment, including sexual harassment (UNFPA and others, 2021). A 2019 WHO report found the gender pay gap in health care was larger than that in other sectors, with female health workers earning, on average, 28 per cent less than male health workers – and an 11 per cent gender pay gap persisted among nurses and midwives even after adjusting for occupational segregation (Boniol and others, 2019). The undervaluing of midwifery “results in restriction of choices and job opportunities for midwives and reinforces unequal power structures within society”, including a lack of professional autonomy (UNFPA and others, 2021), which midwives themselves identify as a barrier to providing high-quality care (International Confederation of Midwives and others, 2016). The 2021 State of the World’s Midwifery report noted that, in low- and middle-income countries, many midwives struggle or fail to be reimbursed by government insurance programmes, leaving them to absorb financial losses or prioritize care for more affluent patients. 44 CHAPTER 2: Unravelling inequality Yet researchers have long noted that investments in midwifery training and care would yield significant dividends for maternal and neonatal health, with lower costs and better outcomes than more medicalized models of care (UNFPA and others, 2021). A 2021 Lancet Global Health study, supported by UNFPA, found that substantially increasing coverage of midwife- delivered interventions could avert 41 per cent of maternal deaths, 39 per cent of neonatal deaths and 26 per cent of stillbirths – equalling 2.2 million deaths averted annually by 2035, and most of them in low- and middle-income countries (Nove and others, 2021). In view of the historical marginalization of women within obstetrics and midwifery, it is worth examining the role of gender discrimination in the world’s continued underinvestment in midwifery. It is also worth examining the consequences of these gendered hierarchies in medicine, which affect not only health practitioners but also the people receiving health services (and, in the case of neglect and exclusion, those not receiving those services). Obstetric and gynaecological violence, broadly described as mistreatment and violence experienced during reproductive health care, including during childbirth, is a matter of growing concern to the international community (OHCHR, 2019a). The concept is expansive, including verbal and physical abuse – examples are mockery, threats, punching, kicking, gagging and physical restraint (Downe and others, 2023) – as well as over-intervention such as medically unnecessary episiotomy, lack of informed consent, denial of pain relief (UNFPA, 2019a) and forced sterilization. Research highlights that these forms of mistreatment tend to occur in “contexts where providers, primarily midwives, feel unsupported or even victimized within their professional hierarchies” (Schaaf and others, 2023). Mistreatment in reproductive health settings contributes significantly to maternal mortality and creates barriers to health services for marginalized women and girls (UNFPA and others, 2023). STATE OF WORLD POPULATION 2024 45 FEATURE Safe, culturally sensitive, empowering childbirth for Colombia’s Afrodescendent women More than two decades ago, 18-year- old Shirley Maturana Obregón visited a hospital in Chocó, in Colombia’s Pacifi c region, seeking care for a case of gastritis. Despite the fact that she was nine months pregnant at the time, Ms. Maturana Obregón never considered staying on and giving birth there. “It wasn’t the environment I wanted,” Ms. Maturana Obregón tells UNFPA. “I wanted my mum to be there, and what I heard [at the hospital] was that I was going to be alone.” So she returned home and soon went into labour. Her mother and sisters were there to support her throughout the delivery – as was a partera, a traditional birth attendant and practitioner of knowledge ancestral to Colombia’s Afrodescendent community. “It was beautiful and unforgettable,” she says. For Ms. Maturana Obregón, the decision to give birth with a partera refl ected her personal and cultural priorities. But home births also often refl ect a lack of other options. Chocó’s population – of which 80 per cent identifi es as Afrodescendent – is disproportionately poor and remains largely disconnected from Colombia’s formal health-care system. Getting to a doctor can require travel across hazardous, confl ict-affected terrain, or can simply cost too much. The consequences of not delivering safely can be deadly, particularly for Afrodescendent women and girls. In Colombia, they are at more than double the risk of dying due to pregnancy and childbirth than their non-Afrodescendent counterparts. Yet in seeking to improve maternal health outcomes, the Colombian health system has sometimes alienated parteras and the cultural values they represent. Parteras have been derided as witches and herbalists, or portrayed as unhygienic and unprofessional. Historically, Colombian laws required anyone attending childbirth to be offi cially licensed by a medical institution, rules that led to the erasure of the work parteras do, isolating them from the medical establishment. Yet along Colombia’s Pacifi c coast, parteras are often the only health provider on hand. In one town in Chocó in 2021, national statistics show every birth was supported by a traditional birth attendant (DANE and UNFPA, 2023). “Doctors treat us like everything [we do] is fi lthy,” says partera Francisca Córdoba, better known as Pacha Pasmo. “As I have told several doctors, you may have fi ve years of experience, but you do not have the experience I have – I started attending births before you were born.” But a new initiative is knitting health workers and parteras more closely together. In 2020, the Partera Vital project was launched, aiming to validate parteras’ often invisible work in providing culturally affi rming care to pregnant and post-partum women, while also providing parteras with tools and skills to deliver their services safely to their communities and in conjunction with the formal medical system. 46 CHAPTER 2: Unravelling inequality Through Partera Vital, Colombia’s national statistics agency worked together with UNFPA and local parteras associations to amend rules barring traditional birth attendants from registering newborns. Parteras received a mobile app allowing them to register births in the national birth registry; they also came together for training sessions aimed at improving risk identifi cation during pregnancy and childbirth. The project was fi rst rolled out to 30 traditional birth attendants in Chocó. The parteras also received scales for weighing newborns, safe delivery kits containing items like clean sheets and gloves, and blood pressure monitors, which can help them identify life-threatening pregnancy complications. “If a partera sees that a pregnant woman’s blood pressure is high, they run to refer her,” Ms. Pacha says. The project’s impact was immediately clear during the COVID-19 pandemic in 2020, when statistics showed 34 per cent of births in Chocó were supported by parteras – nearly 50 per cent more than had been recorded in the previous year. Parteras petitioned the Government to be recognized as essential workers amid the crisis, a change that led to parteras receiving resources and equipment to care for their communities. Most recently, UNESCO, the United Nations Educational, Scientifi c and Cultural Organization, designated midwifery in Colombia and other countries an integral part of humanity’s intangible cultural heritage. Partera Vital’s introduction to Chocó has also corresponded with a major health advancement in the region: reduced maternal deaths. “We don’t know yet to what extent the empowerment of parteras has contributed to the national efforts to reduce maternal mortality in Chocó, but in 2023, maternal deaths dropped by nearly 40 per cent,” says UNFPA Colombia sexual and reproductive health adviser Jose Luis Wilches Gutiérrez. Since delivering with a partera, Ms. Maturana Obregón has become one. “The people we serve – they want to experience having their children with a partera, because the partera puts her in the position she wants to give birth in,” she says. “We are there, making those women’s dreams come true.” UNFPA’s Partera Vital project seeks to empower traditional birth attendants like Shirley Maturana Obregón (left) and Pacha Pasmo (right) to support pregnant women across Chocó, Colombia. © UNFPA Colombia/Sara Chavarriaga STATE OF WORLD POPULATION 2024 47 The legacy of ethnic and racial discrimination One of the consequences of the COVID-19 pandemic has been a renewed awareness of the racial disparities that continue to persist within health systems, and a growing effort to understand these disparities within the context of historical inequities. While many conversations around racial inequity have been contentious, the advancement of equity and justice in health are in many cases yielding valuable and evidence-based solutions to these issues. In short, understanding the legacy of racial discrimination, and also the role of colonialism in exporting racial hierarchies, is revealing the many possibilities that exist for achieving equity and justice within medicine. Historically, many governments have seen reproduction primarily in instrumental terms. Childbearing has been promoted when it is deemed valuable for economic or political objectives (Juan Bautista Alberdi of Argentina famously said, “To govern is to populate”), and it has been discouraged (often selectively, among groups considered “inferior”) when deemed undesirable. During colonial regimes, and especially in the transatlantic slave trade, childbirth was seen both figuratively and literally as a form of asset production (UNFPA, 2023b). In Africa and the Caribbean in the early 20th Century, maternal health programmes were driven largely by a perceived shortage of labour needed to work on plantations and in export industries (De Barros, 2014; Thomas, 2003). Perspective shifted to promoting family planning in the mid-20th Century, as smaller families were seen as more conducive to national economic development and global security, and also as leaders and international organizations reacted to fears of an impending “population bomb” exploding in developing countries (UNFPA, 2023b; Bourbonnais, 2016; Solinger and Nakachi, 2016; Ahluwalia, 2008; Connelly, 2008; Klausen, 2004; Briggs, 2003; Hartmann, 1995). Notably, instrumentalist rhetoric around childbearing persists today, both in fears of “overpopulation” in a context of climate change, which can attribute environmental destruction to fertility rates among people in the Global South, and in fears of “underpopulation” when it comes to ageing societies (UNFPA, 2023b). For these reasons, the field of reproductive health bears particularly deep scars from the world’s racialized colonial history. Slavery institutionalized Black women’s loss of bodily and reproductive autonomy and incentivized control over enslaved people’s ability to reproduce (Johnson and others, 1999). For many Black women, reproduction was an area of control and exploitation, including rape, forced sterilization, medical experimentation and non-consented medical research and training. One of the most well-known examples is the case of J. Marion Sims, a gynaecologist who performed experimental surgeries on enslaved Black women without anaesthesia or their informed consent (Owens, 2017) – but in fact this was far from an isolated incident. Slave hospitals of the era primarily facilitated the production of biomedical knowledge about Blackness and normalized the idea that Black bodies were physiologically distinct, inferior and impervious to pain (Hogarth, 2017). 48 CHAPTER 2: Unravelling inequality In this way, advances in obstetric and gynaecological medicine have contained an inherent contradiction for some of the most marginalized women and girls – these fields of medicine are comprised, on the one hand, of knowledge and technologies that can save lives and alleviate suffering, while on the other hand emerging from, and even perpetuating, significant harms. This duality played out, as well, in the advent of modern contraception, which was revolutionary for women’s bodily and reproductive autonomy yet was also promoted as a tool for the application of eugenics theories. Modern fertility control was widely seen, including by its earliest proponents, as a means with which to curb the reproduction of “undesired” populations, particularly poor women, women with disabilities, Black women, women of marginalized ethnicities in the Global South, and indigenous people in the Global North (Ross and Solinger, 2017; Ginsburg and Rapp, 1995). The use of contraception as a tool STATE OF WORLD POPULATION 2024 49 for reproductive control persisted for decades. In apartheid-era South Africa, for example, Black women were often subject to aggressive contraception programmes, which were carried out under the guise of population control (Klugman, 1993). Black women living under South Africa’s apartheid regime were also more likely to experience obstetric violence and mistreatment in the health-care system. Non-consented care and obstetric violence were particularly noted in public hospitals serving predominantly low-income communities, where multiple marginalizing factors – gender, poverty, race – coalesced. These populations endured lack of informed consent, lack of awareness of patients’ rights, and lack of training for health-care providers on how to obtain informed consent and provide respectful care (Jewkes and others, 2015). Subpar treatment of Black people and other disadvantaged persons within the medical field continues to this day (UNFPA and others, 2023). For example, international human rights bodies have repeatedly expressed concern about the persistent discrimination and human rights violations facing Roma women, particularly in reproductive health care (Committee on the Elimination of Racial Discrimination, 2017; Human Rights Committee, 2016; Committee on the Elimination of Discrimination against Women, 2015). A 2020 report by the European Roma Rights Centre on reproductive rights of Roma women found that numerous interviewees had been immobilized during childbirth, subjected to physical abuse and denied anaesthesia (ERRC, 2020). This legacy also persists in ongoing health disparities among Black and ethnic minority women in the United Kingdom (MBRRACE-UK, 2020) and United States (Hoyert, 2023), and among migrants and members of certain castes in India (Allard and others, 2022) and other South Asian countries (Kapilashrami and John, 2023). But a positive development can be found in the increased attention, and growing body of evidence, on discrimination and harm in sexual and reproductive health settings (Downe and others, 2023). These findings note that discrimination is linked to the normalization of harm, and that it is often invisible to health practitioners, health systems and even patients themselves. “Where violence is an everyday, and even trivial, ‘fact of life’. it becomes expected, invisible, and, therefore, structurally embedded,” researchers note. Furthermore, efforts to 50 reduce or eliminate violence are ineffective when discrimination and stigma are not addressed (Bohren and others, 2022), an observation that can also be seen as a call to action to root out bias in health-care spaces. These findings can, and should, be applied in health systems writ large, where inequities in care are racialized or can be attributed to ethnicity, Forced sterilization – an ongoing violation While quality sexual and reproductive health care contributes to – and is supported by – individual empowerment, the reverse is also true. Substandard or poorly tailored sexual and reproductive health care, denial of services and violations of reproductive rights can result in a cascade of harms across one’s life, and disadvantages reciprocally contribute to vulnerability to substandard care, denial of care and rights violations. Perhaps nowhere is this more pronounced than in the case of coerced sterilization, one of the most extreme forms of control over a person’s reproductive autonomy. By permanently denying women the right to have children, non-consensual sterilization enforces society’s view that certain women do not deserve to be mothers. Black women, indigenous women, women from religious minorities, women living with a disability, institutionalized women, migrant women and impoverished women in rural settings have all been subjected to sterilization abuse (Roberts, 1991), both historically and today. In 2015, for example, a complaint was lodged with the Commission for Gender Equality on behalf of 48 South African women who had experienced forced or coerced sterilization in public hospitals. All were pregnant Black women, and most were HIV-positive. They described being coerced or forced to sign consent forms that allegedly permitted sterilization while they were in extreme pain or active labour. The Commission found that the complainants’ rights to equality, freedom from discrimination, dignity, bodily integrity, freedom and security over their bodies, and the highest attainable standards of health, including sexual and reproductive health and rights, had been violated (Commission for Gender Equality, 2020). In another example, a 2022 report to the Human Rights Council highlighted that forced sterilization is a common practice around the globe (United Nations General Assembly, 2022). cultural differences, migration status or forms of marginalization. To address disrespectful and abusive treatment of women during childbirth, for instance, WHO has called for action – including research, human rights alignment and greater participation by women from affected communities – to be taken by governments, health-care providers, professional associations and educational institutions (WHO, 2015). STATE OF WORLD POPULATION 2024 51 FEATURE Grass-roots activists raise visibility for missing and murdered indigenous women Although Carolyn DeFord’s mother disappeared in 1999, it wasn’t until 2011 that she fi nally learned the term to describe the complicated grief she had felt since that day: ambiguous loss. “You’re stuck, and you can’t move on, and there’s the constant wonder,” says Ms. DeFord, who is a member of the Puyallup Tribe in Washington State and board member of Missing and Murdered Indigenous Women USA (MMIWUSA). “I’ve imagined everything that could have happened to my mum, in every way, over and over again.” This lack of closure is experienced by thousands of indigenous people across the United States whose relatives are reported missing every year. The murder rate for Native American women living on reservations can be up to 10 times the national average (Urban Indian Health Institute, 2018), making murder the third leading cause of death for Native women. Though the statistics are stark, there are huge gaps in data, meaning that the numbers affected are likely underestimated. In 2016, the National Crime Information Center reported 5,712 cases of missing American Indian and Alaska Native women and girls; in the same year, the US Department of Justice recorded just 116 cases in its missing persons database. Underreporting of cases, racial misclassifi cation and poor relationships between law enforcement and Native communities all contribute to the lack of reliable data (Urban Indian Health Institute, 2018). A jurisdictional web exacerbates the problem. In 1978, the US Supreme Court ruled that tribal nations could no longer prosecute non-Natives who commit crimes against Native individuals on tribal lands. As a result, when an indigenous person is the victim of a violent crime, the Native or non-Native identities of the victim and perpetrator(s), the location of the crime either on or off the reservation, and the nature and severity of the act must all be established before it is even known which authorities should handle the case. Many believe perpetrators have been able to take advantage of the confusion to target indigenous women and girls. “We need to be able to have jurisdiction over crimes committed on our land. We’re nations within nations, sovereign nations within a nation, and we have the least ability to protect our people,” Ms. DeFord says. Families of missing persons and Native advocates say even when investigations are conducted, they are not afforded the rigour they deserve. “It feels like everybody’s trying to pass the buck so that nobody has to get their hands dirty,” says Ms. DeFord. “That’s probably not the case, but it’s what it feels like.” In 2013, the reauthorization of the Violence Against Women Act (VAWA) restored tribal criminal jurisdiction over non-Native individuals committing crimes of domestic violence on tribal lands. The most recent reauthorization, in 2022, expanded the list of crimes that could be prosecuted to include sexual violence, sex traffi cking 52 CHAPTER 2: Unravelling inequality and stalking, among others. Luhui Whitebear, a professor of Indigenous Studies at Oregon State University and board member with MMIWUSA, says tribal nations now have access to a new range of tools to protect their communities from harm. Still, she says, legal reforms only go so far. “People think ‘Yes, we did it!’ But that’s not always the end of the story.” Prof. Whitebear points out that the 2022 VAWA reauthorization doesn’t cover all tribal nations – only federally recognized ones. This means that nations like Prof. Whitebear’s own, the Coastal Band of the Chumash Nation, are not covered by the act. There is also the issue of resources, with tribes rarely having access to suffi cient funding or training to conduct thorough investigations. Grass-roots organizations like MMIWUSA are stepping in to help. Often, what families need most when a loved one goes missing are basic things – a plane ticket, feet on the ground to conduct a search, or money to hire a babysitter for children whose parent has disappeared. “I’m really thankful that there are people who are dedicating so much time to doing ground searches for people and creating missing fl iers, because sometimes families have to choose, ‘Do I eat dinner, or do I look for my missing person? Because I don’t have support for a search.’ And so for organizations to be able to provide resources for those searches is critical,” says Prof. Whitebear. Another crucial step is ending stereotypes of indigenous people and communities. “De-normalizing that exploitation of people’s bodies and the view of us as disposable would help immensely,” Prof. Whitebear says. “I would say that what helps to end violence against indigenous women is viewing it as not just an indigenous issue. This is everyone’s issue.” For Ms. DeFord, in the years since her mother disappeared, she has learned to take her grief and use it to help other families struggling for answers: “It’s been very healing to share my story, to be able to use my experience to help other people, like these other advocates are helping me,” she says. “Being able to do some of that footwork so that families can take care of themselves and be where they feel the most useful – that’s been helpful, really being able to feel like this horrible, traumatizing experience hasn’t been in vain. If I can use that to help other people, then it makes me feel like at least there’s a purpose.” Local advocates are also helping to reshape laws. “Some of the fi rst legislation in the country was passed here,” says Ms. DeFord, “and it was because of grass-roots voices, because of families going and testifying and sharing our stories and our frustrations and what we needed.” Carolyn DeFord, whose mother disappeared in 1999, works with MMIWUSA to advocate for the rights and well-being of indigenous women and girls in the United States. Image courtesy of Carolyn DeFord STATE OF WORLD POPULATION 2024 53 The legacy of misinformation Despite the progress seen within medical science and in international human rights agreements, falsehoods and assumptions remain widespread, permeating not only social norms and domestic laws but also health and education systems. As a result, these vestigial misconceptions continue to enact harm. Many of these misconceptions rely on an overly simple understanding of human sexual development. When sexual development, traits and identity are assumed to follow one standard pathway, natural variation in the human experience may seem wrong or disordered, and people who fail to conform to expectations may find themselves unserved or even harmed by policies and practices. As one example, menarche – the onset of menstruation – was once widely believed to be a biologically incontrovertible sign of a girl’s readiness for pregnancy. The ability to menstruate was assumed to indicate fertility and the ability to bear children. A girl’s marriageability could be socially or legally determined by whether or not she had menstruated. As recently as the 1970s, one internationally used gynaecology textbook taught that menstruation was “the weeping of a disappointed uterus” (Jeffcoate, 1975), implying that menstruation signals the failure of a female body to become pregnant. Perspectives about menarche have evolved over time, and contemporary views recognize a more comprehensive understanding of physical and emotional maturity. Today it is known that many early menstrual cycles are not accompanied by the release of an ovum, and therefore menarche does not necessarily signal that pregnancy is possible (Carlson and Shaw, 2019). Age of menarche also changes based on factors such as genetics, nutritional status and exposure to environmental pollutants (Forman and others, 2013), and mental and psychological maturity are now understood to take place years – even a decade – after the average age of menarche (Arain and others, 2013). Pregnancy and motherhood in early adolescence are now understood to pose life-threatening physiological and mental health risks. Yet rather than teach that menarche is one factor among many in the process of developing fertility, it continues to be taught as signifying one’s body is “prepared” for pregnancy. This oversimplification can be used to support incorrect beliefs, such as the notion that younger adolescents do not require education about menstruation or the presumption that pregnant adolescents are physiologically equipped for childbirth. Another oversimplification involves gender essentialism – the outdated idea that men and women are distinct biologically, physiologically and in their innate capacities, and that these differences are unchangeable (Meyer and Gelman, 2016). Researchers across multiple disciplines have discredited this notion: “[E]vidence include[s] neuroscience findings that refute sexual dimorphism”, i.e., the existence of two distinct and fixed categories, “suggesting that the tendency to view gender/sex as a meaningful, binary category is culturally determined and malleable” (Hyde and others, 2019). 54 CHAPTER 2: Unravelling inequality The reality is much more complicated, for both sex and gender, terms that are often conflated but that carry different meanings. Sex, referring to the biological and physiological characteristics of females and males, such as chromosomes, hormones and reproductive organs, is often seen as falling into only two categories. Yet studies estimate that roughly 2 per cent of people actually have intersex variations (with some figures as high as 4 per cent [Jones, 2018]), meaning they have anatomy, chromosomes, hormones or other physical traits that do not fall perfectly within the male-female dichotomy. Gender, on the other hand, can be described as the socially constructed characteristics of women, men, girls and boys, and the process of conforming to these social expectations through norms, behaviours, roles and other means (WHO, n.d.). Gender, too, defies duality – communities from countries around the globe (including Argentina, Australia, Bangladesh, Canada, Fiji, India, Mexico, Nepal, New Zealand, Pakistan, the Philippines, Samoa, Thailand, Tonga and the United States) recognize identities that do not correspond with the male/ female binary (OHCHR, 2023a). When gender expectations are a moving target While many people born with non-dimorphic sex traits are forced by legal, social and health systems to fit within the gender binary, those who do live within the gender binary often face scrutiny, stigma and exclusion for failing to embody those gender norms enough. Elite South African runner Caster Semenya was both assigned female at birth and has continuously identified as female, but her femaleness has been repeatedly questioned by athletic competitors and institutions, a situation common to women and girl athletes perceived to be too masculine. Ms. Semenya was coerced into undertaking hormone treatments to “correct” her natural body. She continued to win races during hormone treatment, but felt tired, nauseous and as though, she said, “I had been running in a body that wasn’t my own” (Semenya, 2023). She has also been subjected to repeated invasive sex testing, a violation of a range of internationally protected fundamental rights. The human rights court of Europe recently ruled that her right to freedom from discrimination and private life had been violated (European Court of Human Rights, 2023), yet she remains barred from participating in athletic events by the World Athletics governing body (Reid and Worden, 2023). And she is just one of a number of world-class women runners (many from developing countries) who have been banned from competition, pressured into surgeries and/or subjected to genital examinations, all because their naturally occurring sex traits are considered unacceptable by athletics authorities (Longman, 2024). STATE OF WORLD POPULATION 2024 55 human development – while others represented an “arrest in evolution from the ape form”. Today, researchers note, “There is good evidence that the shape of the birth canal is highly variable and tends to differ both within and among human populations, and that using the gynaecoid shape as a model for all women is empirically unsupported, factually inaccurate and potentially dangerous, especially for women of non-European ancestry” (Betti, 2021). Similar misconceptions affect access to pain relief and other care. One study from 2016 in the United States found that about half of participating medical students and medical residents endorsed at least one false belief about biological differences between Black and white people, such as that Black people have less sensitive nerve endings, thicker skin or higher fertility (Hoffman and others, 2016). As a final example, misconceptions about history are also pervasive, with ongoing consequences for access to services that should enable bodily autonomy and sexual and reproductive health. For instance, many popular narratives suggest that the advancement of sexual rights and abortion rights internationally are forms of Western influence (OHCHR, 2023a). In fact, a great deal of evidence points to colonial regimes enacting and enforcing homophobic norms and laws and restrictions on women’s bodily autonomy (see spread on page 60). Often, these norms and laws remain in force after countries achieve independence from colonial control, even in cases where precolonial cultures were comparatively open to diversity in gender expression and sexual orientation. There is nothing inherently political or ideological in acknowledging the existence of gender diversity, or in noting the prevalence of non-dimorphic sex traits. This complexity does not require eliminating the categories “men” and “women”. Indeed, the global consensus on achieving gender equality requires that harms overwhelmingly associated with men and boys or with women and girls be identified as such. But harms overwhelmingly associated with people who do not conform to sex or gender binaries must also be identified accurately, or else these harms will persist – and they are significant. The Office of the High Commissioner for Human Rights notes that intersex people are subjected to infanticide; forced and coercive medical interventions; discrimination in education, sport, employment and other services; and lack of access to justice and legal recognition (OHCHR, n.d.a). People of diverse sexual orientations and gender expressions, including lesbian, gay, bisexual and transgender people, also face rampant discrimination and violence, including violence both legalized and enforced by States (OHCHR, n.d.b). The non-recognition of sexual diversity – such as denials that sexual diversity exists and refusal to collect data on sexual minorities – does not, and cannot, eliminate this brutality and exclusion. Misinformation about anatomical differences based on race also remains deeply rooted in education systems, including medical education systems. For example, many contemporary midwifery and obstetrics textbooks continue to use the pelvic-shape classification proposed in 1938 by W.E. Caldwell and H.C. Moloy, doctors who believed certain pelvic shapes were “ultrahuman” – the perceived standard for 56 CHAPTER 2: Unravelling inequality New understandings embraced in health systems Health experts now widely accept that menarche is not the defining marker of womanhood, and that racial assumptions about pain and pelvises can cause harm. Health systems are also increasingly recognizing diverse gender identities, sexual orientations and sex characteristics as being within the spectrum of normal human development. For example, over the past three decades, many traits of sexual minorities once believed to be pathological have been recategorized as non-pathological or otherwise removed from diagnostic codes. This is not simply an effort to better realize human rights; it is also a reflection of the “poor-quality evidence and social rationales that justified” these diagnoses to begin with (Carpenter, 2018). This move is also coherent with global efforts to improve public health overall through destigmatization (UNAIDS, 2021) and through growing awareness that health services must be tailored to populations that are far more diverse than previously acknowledged. Still, some States are considering measures that entrench pathologization and intervene in rights-affirming health care. In 2021 in Guatemala, draft legislation, which ultimately did not pass, sought to protect children from the “disorder” and “trauma” of transgender identity, and policymakers in Ghana are considering drafting legislation that promotes practices of so-called “conversion therapy” by offering incentives to transgender persons who “recant” (OHCHR, 2022). In the United States, in 2023, 87 anti-trans bills were passed, out of some 600 proposed at the local, state and federal levels, including bills that penalize health-care workers for referring or providing gender-affirming care to transgender people (Trans Legislation Tracker, n.d.). STATE OF WORLD POPULATION 2024 57 A bridge to a better future Reconciling modern health systems with these legacies need not be painful or punitive. As the history of the ICPD shows, there is a globally agreed common agenda to secure gender equality and sexual and reproductive health and rights for all people. The benefits of this common agenda are felt individually, in human rights realized, higher standards of health attained and human potential expanded, and they are felt across communities, societies, nations and regions. To reach these agreed goals, a concerted and well- funded effort must be made, not to push down those who have already felt the gains of progress but to raise up those who have yet to access those gains. It should not be controversial to note that many medical and societal advances have been enabled by a long history of health-system mistreatment, from the invention of tools like the Sims speculum to eugenics motives that ultimately played a role in expanding access to family planning. And it should not be controversial to recognize that the descendents of those who were mistreated continue to endure some of the most attenuated access to these services, technologies and rights. Indeed, it is urgent that we learn from past mistakes. Reproductive health technologies continue to advance rapidly, creating opportunities both to benefit individuals and to perpetuate abuses (UNFPA, 2024b). Valuable diagnostic tools like prenatal testing are already commonly misused for gender-biased sex selection, for example. Users of powerful new digital technologies are already giving away access to deeply private data, often without knowing it. And on the horizon are artificial intelligence-boosted diagnostics, cytoplasmic transfers that could produce embryos with three parents, in-vitro gametogenesis that can produce sperm or egg cells from non-reproductive cells – innovations that could change the nature of reproduction, sex and family configuration – and many more advancements. The potential for serious harm, including issues of patient safety and privacy as well as “ethical and human rights concerns about the commodification of human reproduction”, exists, as always, alongside significant positive gains (UNFPA, 2024). As much as these technologies could be used to mistreat or exclude marginalized groups, they can also be tools of inclusion and empowerment, for example by expanding quality sexual and reproductive health services to those who are currently beyond reach, and by enabling gender- diverse individuals and people excluded from infertility treatment services (Perritt and Eugene, 2022) to create the families of their choosing. Movements around the world are helping us reconcile with the ills of the past, efforts that can – and should – inform our vision of the future. Global donors are targeting some of the most severely left-behind communities for investment in midwifery, gender equality and comprehensive sexuality education initiatives (see page 108). Increasing inclusivity in medicine and research is improving the quality of human knowledge. We have a much better understanding today of diversity in gender expression, how gender norms vary within and between countries and how complex and diverse sex traits are. We have a much better understanding of how women of colour, indigenous women and women in the Global South have been excluded from much 58 CHAPTER 2: Unravelling inequality of the progress seen in sexual and reproductive health and rights. This report’s analysis of barriers to health care, as reported by women themselves (page 28), finds that progress is indeed possible, and that while, in general, those groups of women who faced the highest prevalence of barriers to health care have experienced the least progress, they did experience progress. And in some countries, the strongest improvements in health-care access were among ethnic groups that had previously experienced the worst levels of self-reported barriers to care – heartening indications that progress can indeed be accelerated. And while much more evidence is needed to design policies and programmes that reach all people (see Chapter 3), the clarity of insight into inequity and, therefore, the possibility of achieving real justice has never been greater. Bilums are tote bags used in Papua New Guinea. People use them as baby carriers – “bilum” translates to “womb” in the Tok Pisin language – and for transporting goods to market, as well as in the funeral ceremonies of prominent community members. In this way, bilums accompany many Papua New Guineans throughout life. This pattern, the skin pig design, represents the struggle of women to be seen, heard and respected. © UNFPA Papua New Guinea/PidginProductions STATE OF WORLD POPULATION 2024 59 Decolonizing sexual and gender norms In July 2023, the United Nations Secretary-General released a report drawing attention to the role of colonialism in perpetuating violence and discrimination against gender-diverse populations (OHCHR, 2023a). The report, by the Independent Expert on Protection from violence and discrimination based on sexual orientation and gender identity, drew from hundreds of meetings, visits and exchanges with State and non-State actors from around the world. The cumulative evidence found that specific strategies to exercise control over colonized persons – employed by diverse colonial powers – resulted in the stigmatization, criminalization and pathologization of same-sex attraction, transgender identities and other forms of diverse gender expression. Precolonial diversity From the Filipino indigenous community’s babaylan spiritual protectors to ogbanje individuals in Nigeria, diversity in sexual orientations and gender identities has existed everywhere throughout recorded history. Individuals embodying gender-variant identities have been cherished and respected in many societies, such as the “two- spirit persons” in North America, the bonju in Europe, the muxes in Mexico, the hijra in India and Bangladesh, the takatāpui in New Zealand and the “sistergirls” of the Aboriginal and Torres Strait Islander peoples in Australia. Indeed, the social meaning attached to sex characteristics is as varied as cultures around the world. Patriarchal and heteronormative social structures certainly existed in many precolonial societies, but there is also ample evidence of normalized gender variation in others. Some communities even had dedicated roles for people with diverse sex and gender characteristics, including positions as advisers, military commanders, royal court members, healers and keepers of traditional practices. Colonial control strategies While recent colonial projects did not invent gender-binary norms, they did result in the systematic imposition of a gender binary through laws and practices that affected colonized people over centuries of control. Colonial strategies included the conversion of colonized people to religious institutions, the criminalization of gender and sexual nonconformity and the enforcement of rigid social hierarchies. Both religious and secular justifications were given for the moral codes enforced by colonial powers. Examples include “pecado nefando”, or the crime of “nefarious sin”, applied by Portuguese and Spanish inquisitorial courts; French laws criminalizing “lewd or unnatural acts”, which were intended to inculcate colonized people with Christian morals; and British colonial laws punishing “gross indecency” between two men. Other laws included “sodomy”, “buggery”, “carnal knowledge against the order of nature”, as well as offences such as “public indecency” and “encouraging debauchery”. There were also “vagrancy laws” that did not directly restrict sexual or gender-divergent conduct, but which had a disproportionate impact on people living in poverty, gender and sexual minorities and persons with disabilities. Notably, the same, or similar, laws were applied within the societies of colonial powers. Moments of “sex panic” or “moral panic” took place within European countries, for example, during which governments, medical authorities and the mainstream media identified groups who did not follow dominant “correct” sexual practices as deviants; the IN FOCUS 60 CHAPTER 2: Unravelling inequality enforcement of these laws within colonies was linked to policymakers’ perceptions – often based upon reports of explorers – that same-sex relations were pervasive across the colonized world (HRW, 2008). While the law was a principal means of enforcement, it also formed the basis for complex systems of socialization that included policing, medicine, literature and education. Black sexuality, for example, was regarded as “rampant and insatiable, and thus in need of regulation” (Westman, 2023). Indeed, in colonial settings the ability to thrive was heavily dependent on a person’s ability to assimilate to white, patriarchal and heteronormative customs. Lasting impact Colonial laws and norms have had an impact well beyond current and former colonies. In 1908, Thailand – which was never a European colony – adopted language from the Indian penal code to ban acts “against human nature”. In some cases, colonial dynamics have influenced law and policy reform processes even in post-colonial settings. For example, Cameroon and Senegal, both former French colonies, criminalized same-sex relations after gaining independence in 1960. Today, 64 countries still criminalize same-sex consensual acts, often referring explicitly to sexual intimacy between men; 41 countries criminalize sexual intimacy between women; and 20 countries explicitly criminalize and/or persecute transgender persons through laws targeting “cross-dressing”, “impersonation” and “disguise”. And although many of the world’s anti-LGBTQIA+ legal frameworks originate from colonial legislation and social mores, today it is advocacy of the human rights of LGBTQIA+ persons that is often portrayed as colonial or as a Western agenda (OHCHR, 2023a). One important step towards realizing the rights of all people, in all their diversities, is to reject the view that the Global West or North are archetypes of inevitable progress, while framing the Global South or East as backward. If anything, it is the persistence of colonial-era legal frameworks and social norms, inherited from the Global West and North, that continue to constrain the internationally agreed human rights of LGBTQIA+ persons, particularly those living in the Global South or East. Further avenues for research The above summary of the Independent Expert’s report necessarily excludes the impact of colonial laws and norms on aspects of sexual and reproductive health beyond gender and sexual diversity. However, the findings raise important related questions about the legacy of colonialism on gender equality and sexual and reproductive health and rights. For example, there is evidence that abortion was practised in many precolonial communities, but banned by colonial-era laws (OHCHR, 2021b; Malvern and Macleod, 2018). In fact, European colonial powers have been called “the most important sources” of laws restricting abortion; such laws were in place in almost every country in the world by the end of the 19th Century (Berer, 2017). Similarly, obscenity, vice and indecency laws – many dating from European colonial rule – were widely used to prohibit information about family planning from the start to the middle of the 20th Century (Stepan and Kellogg, 1974). These and other consequences of colonialism on women’s reproductive health and rights merit further exploration, especially given the persistence of reproductive health and rights violations around the world. This text was contributed by Victor Madrigal-Borloz, who from 2018 to 2023 served as the United Nations Independent Expert on Protection from violence and discrimination based on sexual orientation and gender identity. STATE OF WORLD POPULATION 2024 61 CHAPTER 3STATE OF WORLD POPULATION 2024 CHAPTER 3: Counting every stitch CHAPTER 3STATE OF WORLD POPULATION 2024 63 The 1994 ICPD, and its resulting Programme of Action, not only represented a moment of remarkable consensus around the value of universal sexual and reproductive health and reproductive rights (Brown and others, 2019; Sen and others, 2019; Corrêa and others, 2015), it also represented a powerful call for better and more transparent data – a contribution to global standards that has seldom been recognized. In fact, an entire chapter of the Programme of Action, Chapter XII (UNFPA, 1994), is devoted to the need for “valid, reliable, timely, culturally relevant, internationally comparable data”, including “gender and ethnicity-specific information”. It also called for research into the views of less-empowered groups of people and those in different cultural settings. This appeal for data took place at a time when little was actually known about men’s and women’s sexual and reproductive health or the realization of their rights. For example, reliable data – and in most cases any data – on maternal mortality for the vast majority of countries were non-existent in the 1990s (WHO and others, 2001). At the time of the ICPD, WHO’s most recent maternal mortality estimates (already more than half a decade old) were rough given that many country- level data were thorny with non-representative samples and problems of under-recording (WHO, 1991). Even without a globally agreed maternal mortality estimate for 1990, the ICPD Programme of Action called for a cumulative 75 per cent reduction in maternal deaths between 1990 and 2015, and committed to narrowing maternal mortality disparities “within countries and between geographical regions, socio-economic and ethnic groups” (UNFPA, 1994). These goals gave rise to a follow-up process that saw routine collaboration between population and health ministers, demographers, statisticians, epidemiologists and human rights experts, as well as the establishment of measurable health and rights indicators and subsequent collection of rigorous data to track progress towards achieving the goals of the Programme of Action (Snow and others, 2015; United Nations, 2014; UNFPA, 1998). Since 1994, the quality and quantity of maternal mortality data have vastly improved, as have the statistical methods used to estimate these data. By 2014, missing data had gone from being the norm to being the exception, even as the bar for what constitutes reliable data had been raised. Thirty years after the ICPD, the world is at another inflection point, with a similar goal required, one which again recognizes vast and unacceptable unmet needs, even as we lack the data to precisely define the scope of the problem: the ambition to meet the sexual and reproductive health and rights of those individuals who have been left – and pushed – behind, not only by advances in health and the expansion of health infrastructure, but also by the data revolution itself. This chapter explores most closely the issue of maternal mortality, for which numerous unanswered questions about levels and trends globally, regionally, nationally and subnationally remain, despite the steady advances in statistical prowess and data availability. But maternal death rates and ratios are only a starting point; beyond the issue of maternal mortality are many further, still unanswered, questions about the health and rights of women and girls who continue to see little of the progress experienced by their more privileged sisters. 64 CHAPTER 3: Counting every stitch A new inflection point Part of the story, and one that has been apparent for some time, are the vast and – in many cases – growing inequalities in sexual and reproductive health and rights. An expanding body of evidence makes clear that some individuals are pushed to the margins of societies and health systems – those facing discrimination in health systems, those with language barriers in clinical settings, those stigmatized for their HIV status, or unreachable because they lack the privileges of citizenship, as only a few examples. The available data strongly indicate these individuals are suffering and dying in far greater proportions than previously imagined (Khalil and others, 2023; Geller and others, 2018; Gon and others, 2018). Yet their deaths – and the morbidities and indignities that precede these deaths – are largely invisible (Creanga and others, 2014). Why? Deaths and injuries remain uncounted because of deficient data systems, infrequent surveys and other studies that are limited in scope or comparability. When their deaths and morbidities are counted, the underlying inequalities are often invisible because few efforts have been made to disaggregate data by the particularities of their exclusion. Their disproportionate experience of injury and death is absorbed into the vastness of statistical averages. When this veil is lifted, we see gaping inequalities both between and within countries. One common public health explanation is the inverse equity hypothesis, in which new health interventions are most immediately adopted by wealthier populations that have the lowest levels of need (Victora and others, 2018). Crying Women by Bayombe Endani, Democratic Republic of the Congo, 2010. Artwork contributed by the Advocacy Project, which helps marginalized communities use embroidery as a tool for therapy and advocacy. STATE OF WORLD POPULATION 2024 65 Health advancements can therefore give rise to an initial increase in overall inequality – with inequality declining if and when those advancements become accessible to those with greater needs. Yet by some measures, inequalities both between and within countries are growing. In 1990, for instance, a 15-year-old girl had on average a 1 in 12 chance of eventually dying from pregnancy or childbirth in the 10 per cent of countries with the highest risk, while a 15-year-old girl in the 10 per cent of countries with the lowest risk had a 1 in nearly 7,000 chance (see technical note). By 2020, girls in the countries with the highest risk had a 1 in 34 chance of dying, while girls in the countries with the lowest risk had a 1 in nearly 23,000 chance. This is a 2.8-fold change in the highest- risk countries, compared to a 3.3-fold change in the lowest-risk countries – a widening inequality. In other words, at the global extremes, progress was greater where maternal mortality was rarest and more limited where maternal mortality was highest. Such inequalities between countries are often attributed to disparities in resources – but this explanation falters when looking at the inequalities that exist within countries. These intranational discrepancies make clear that persistent forms of discrimination and exclusion, not just limited resources, play a significant role in many of the global inequalities in sexual and reproductive health and rights that we see today (UNSDG, n.d.). This is true both in countries where maternal mortality remains painfully high (Patel and others, 2018; Acharya and Patra, 2017) (see technical note on page 155) and also in high- income countries where maternal mortality is dramatically lower. Take the United States and the United Kingdom, for example – 2 of only 19 countries estimated to have a higher maternal mortality ratio in 2020 than in 1990. In both countries, the incidence of maternal death is multiple times higher for Black women than white women. The latest United Nations estimates, which differ slightly from each country’s national estimates, indicate the United States had a maternal mortality ratio of 21 per 100,000 live births in 2020 (WHO and others, 2023). According to official national statistics in the United States, in 2021, Black women faced a mortality ratio more than double the national average (Hoyert, 2023). Maternal mortality risk is also higher than the national average for the country’s Hispanic women (Hoyert, 2023). Still, these trends in the United States are part of a broader increase in maternal mortality across the board – meaning it has been increasing for most groups of women in the country, including high, middle and low socioeconomic classes; women of all age groups; and women of all races (Hoyert, 2023; Singh, 2021) (see technical note on page 154). By contrast, in the United Kingdom, where the United Nations estimates maternal mortality stood at 9.8 deaths per 100,000 live births in 2020 (WHO and others, 2023), researchers have shown that the rising maternal mortality ratio is largely attributable to increased death rates among certain ethnic minorities and socioeconomic classes. The highest levels of maternal death, and highest increases, have been among Black women as well as women who are the most socioeconomically deprived (Knight and others, 2022). 66 CHAPTER 3: Counting every stitch It would be all too easy to dismiss these findings as stand-alone results from just two countries. Yet these are among a very small number of nations worldwide that even have data systems in place to identify such differences (Small and others, 2017) – meaning they are among some of the only places in the world where such disparities are being made visible. In fact, the United States’ efforts to identify racial disadvantage in maternal mortality date back to the earliest WHO tabulations where it was the only country to have any type of racial or ethnic disaggregation (WHO, 1991). The United Kingdom has an impressive maternal mortality surveillance system, dating back to 1952 (making it the world’s oldest), but it only started identifying ethnicity in 1995 (Small and others, 2017). A UNFPA report released in 2023 examined, for the first time, indicators of maternal health among women and girls of African descent and those with other heritages across the small number of countries in the Americas where data make this possible. Only 4 of the 35 countries identify the race or ethnicity of the women who die in childbirth, and only 11 collect other maternal health data broken down by race (UNFPA and others, 2023). Canada, for example, joins the United States and United Kingdom as one of the few countries with worse maternal mortality ratios in 2020 than in 1990 (11 per 100,000 live births compared with 6.9) (WHO and others, 2023), but it does not collect racial data in maternal surveillance despite evidence of race-based barriers to access and utilization of maternal health care. It is therefore impossible to know whether increases in the country’s maternal mortality over time have been universal or concentrated among select subpopulations (Dayo and others, 2022). Where data do exist, they point squarely at persistent inequalities facing marginalized groups, not just among Black people and people of African descent but also among indigenous STATE OF WORLD POPULATION 2024 67 Confronting the confounders Evidence of racial inequities in health outcomes is often met with questions about possible confounding factors: Could these disparities be the result of levels of education? Income differences? What about employment factors or genetic predispositions towards ill health? The available research on indigenous women and women of African descent shows that, while these characteristics do matter for health outcomes, they do not explain all of the disparities observed, meaning some or many of these disparities are indeed linked to ethnicity (Australian Institute of Health and Welfare, 2023). “Maternal deaths persist regardless of income and education levels, with maternal deaths among African American college graduates still 1.6 times higher than among white women with less than a high school diploma,” recent UNFPA analysis found, as just one example (UNFPA and others, 2023). Indeed, a growing body of research explores how chronic exposure to systemic injustice is linked to accelerated declines in physical health – often called weathering – that underpin many racial disparities in maternal health (Geronimus, 2023; Forde and others, 2019). The analysis in this report (page 28) also supports this point: While there are significant socioeconomic factors contributing to self-reported disparities in health-care access, there are also considerable ethnic differences in the proportion of women who have serious problems accessing care when sick, even controlling for wealth, income, and urban or rural residence. antenatal care, less likely to give birth under the care of a skilled birth attendant, more likely to give birth as an adolescent, and significantly more likely to die of causes related to pregnancy and childbirth (UNFPA and others, 2018). Research from other countries – looking at indigenous women in Australia (Australian Indigenous HealthInfoNet, n.d.), India (Government of India, Ministry of Health and Family Welfare, 2016), Guatemala (ENSMI, 2015), Panama and Russia (Anderson and others, 2016) – shows the same disparities. people (Paradies, 2016). A 2018 paper by UNFPA, UNICEF and UN Women examined the limited data available on the maternal health of indigenous women and girls. Out of 80 countries examined, 16 had data, and across these 16 low- and middle-income countries (Belize, Costa Rica, Ethiopia, Gambia, Guyana, Indonesia, Kenya, Lao People’s Democratic Republic, Mexico, Namibia, Nepal, Pakistan, Senegal, Sierra Leone, Suriname and Viet Nam), women from indigenous ethnic groups were significantly less likely to benefit from 68 CHAPTER 3: Counting every stitch Serious inequities are also apparent when considering persons with disabilities. Women with disabilities are up to 10 times more likely to experience gender-based violence, including sexual violence. And though young persons with disabilities are just as likely to be sexually active as their peers without disabilities, this population faces significant barriers to accessing sexual and reproductive health information and services, including lack of accommodating services and discriminatory attitudes among health-care providers (UNFPA, 2018). Yet data collection about the needs of this community is also hindered by the stigma attached to disability, and by the lack of agreed definitions when it comes to identifying persons with disabilities and measuring their needs. These issues are particularly troublesome given that roughly 1 billion people, 15 per cent of the global population, are estimated to experience a disability within their lifetime. But important progress is taking place. In 2021, UNFPA found that the proportion of countries adopting standardized census questions from the international Washington Group on Disability Statistics “has increased from 33 per cent in 2018 to 73 per cent in 2020” (UNFPA, 2021b). Similarly, sexual and gender minorities also face serious health disparities, not just in issues of access to and quality of health care, but in both psychological and physical health outcomes (Tabaac and others, 2020; Matsick and others, 2020; Caceres and others, 2019; Gibson and others, 2018; Müller, 2016), yet data remain limited. There are positive signs that data collection on sexual and gender minorities is expanding, but where data do exist, they remain largely the product of ad hoc efforts rather than arising from regular, standardized national data systems such as censuses or large-scale social surveys (European Commission, Directorate-General for Justice and Consumers, 2017). Furthermore, data collection is hindered not just by stigma but by the criminalization of same-sex sexual activity and transgender identity and expression in dozens of countries around the world (Human Dignity Trust, n.d.). Finally, compounding factors of exclusion, such as age, can create extreme marginalization. For instance, recent research points to how hostile laws and social attitudes – including taboos against teenage sexuality – mean that sexual and reproductive health services and information (including from LGBTQIA+ organizations) are all but completely closed off to sexual- and gender- minority adolescents in southern Africa (Müller and others, 2018). 69 FEATURE Women with disabilities in Turkmenistan claim their rights Years ago, at a gynaecologist’s offi ce in Ashgabat, Turkmenistan, Alia (name changed) and her husband were advised that it was “undesirable” for them to have a child because they were both blind. “How will you be able to take care of a child? How will you raise them, watch them?” she recalls being asked. “They thought we wouldn’t be able to cope at all and suggested having an abortion,” Alia tells UNFPA. “But I disagreed. My mother is blind, too, and she raised all seven of us.” Alia’s experience is tragically familiar among the one in fi ve women globally living with a disability. Despite international agreements guaranteeing people the world over the freedom to make reproductive choices free from discrimination and coercion, women with disabilities often face a different reality, one in which prejudices drive health professionals, intimate partners and the public to question their capacity to make sexual and reproductive health decisions. Research shows women and girls with disabilities are frequently confronted with discrimination around reproductive choices, barred from health services by accessibility issues and excluded from comprehensive sexuality education, especially in special education settings. And for some, that discrimination can even translate into forced sterilizations. Like Alia, many have been judged as ill equipped for pregnancy and parenthood. UNFPA research in 2021 found that many people with disabilities in Turkmenistan were not able to access sexual and reproductive health services and information. To meet their needs, UNFPA and the Society of the Blind and Deaf of Turkmenistan created sexual and reproductive health videos accompanied by sign language interpretation. The videos, available online and via fl ash drives, cover topics such as puberty, family planning and safe motherhood. Plans for a mobile app are in the works. Women reported the resources taught them they could access contraceptives and pregnancy care free of charge. They also appreciated the materials’ inclusion of contact information for different clinics and service providers. These steps and others are making the country a more inclusive and just place to be a pregnant woman living with a disability. Still, Alia says more must be done: “It is necessary to increase the knowledge of medical staff so that we are accepted and treated like everyone else.” Meanwhile, she has embraced parenthood while living with a visual impairment, like her mother before her. “I knew I could do it,” she says. 70 CHAPTER 3: Counting every stitch Adopting a lens of equality One of the great developments to take place within the last 30 years has been an emerging consensus that factors like gender, race, ethnicity, disability status, sexual orientation and migration are not perks and penalties to be tallied with a simple score. Rather, they are dynamic factors at play within a complex web of advantages and disadvantages. The last 15 years alone have seen a significant shift in the world’s understanding of how structural and intersectional barriers are preventing certain people from realizing their health and rights. For example, where previous research might have focused solely on individual behaviours – such as delaying seeking treatment for an illness – that negatively affect health, researchers today more readily acknowledge that these behaviours are shaped by broader norms, systems and institutions, and also that multiple intersecting factors can intensify the challenges individuals face. One groundbreaking study from 2009, for example, compares the health-seeking behaviours of poor women, non-poor women, poor men and non-poor men in India. The study reveals that traditional methodologies would mistakenly conclude that poor men and poor women are equally disadvantaged, while a methodology specifically designed to identify the compounding influence of intersecting factors of disadvantage reveals that poor men were actually better off than all women – both poor and non-poor women. In essence, both gender and class mattered for health outcomes, but, in this case at least, men were able to leverage their gender advantage to such a degree that even poor men were actually better off than non-poor women (Sen and Iyer, 2012; Sen and others, 2009). The interplay between forms of advantage and forms of disadvantage greatly complicates the design of effective responses. A one-size- fits-all approach to policymaking simply does not work. The past 30 years have seen remarkable progress in part because policies and interventions have elevated the welfare of the people most easily reached, those with the least-complicated disadvantages, those best positioned to benefit. Reaching those who remain in need, those with intersecting vulnerabilities, will necessarily be harder and require more thoughtful interventions. To continue apace with current approaches creates the risks not only of inefficiency but also of waste and harm. Information circulated in languages that an intended target does not understand, campaigns that fail to account for cultural or religious requirements of intended users, or clinics inaccessible to people living with disabilities, as just a handful of examples, result in lost investments, continued exclusion and an erosion of trust between health providers and the populations they exist to serve. But these findings are not cause for despair. This new lens for understanding is something to commend, even as it draws our attention to uncomfortable facts about privilege and prejudice. Through this lens, we see more clearly where efforts and resources are needed in order to achieve our global goals. STATE OF WORLD POPULATION 2024 71 Inequalities between and within countries: the cases of India and Nigeria For as long as measurements have existed, India and Nigeria have been the two countries with the largest absolute numbers of maternal deaths. Both in 1990 and in 2020, the countries together accounted for more than one third of all global maternal mortality. India started the journey with many more deaths, accounting for 26 per cent of all maternal deaths in 1990, compared to Nigeria, which accounted for 10 per cent. But by 2020, the countries had switched places, with Nigeria accounting for 29 per cent of all estimated global maternal deaths, while deaths in India had fallen considerably – accounting for 8 per cent of all worldwide maternal deaths (WHO, n.d.a). While the pace of population growth plays a role in these trends (Nigeria’s population more than doubled between 1990 and 2020, while India’s grew by a factor of 1.6), the core issue is that maternal mortality ratios have declined steeply in India, but less so in Nigeria. India’s success is often attributed to improved access to affordable, quality maternal health services (Exemplars in Global Health, 2023; Singh, 2018), as well as efforts to address the impact of gender discrimination on health outcomes. For example, one study found that policies designed to address gender equality – such as increasing the number of female physicians, increasing institutional support and respect for nurses, and promoting women’s empowerment collectives — were associated with better health outcomes and increased health-care access for women (Hay and others, 2019). Another study points to how increases in the share of women in politics were linked to increased numbers of primary and community health centres, government dispensaries and hospitals (Heymann and others, 2019). Other effective programmes have promoted respectful care before, during and after delivery, and provided free antenatal care. But this case study – of widening maternal health inequalities between two countries – becomes much more complicated when looking at inequities within these same countries. In both places, certain groups of women are receiving the care they need while others are not. Dramatic differences in maternal mortality are linked to locality in Nigeria, for example, with significantly higher death rates among women in urban slums and rural locales, and higher maternal death ratios in the north compared to the south (Babajide and others, 2021; Gulumbe and others, 2018; Anastasi and others, 2017). When related vulnerabilities, such as child marriage and skilled birth attendance, are examined by ethnicity, location and income, even more inequities are revealed (UN Women, 2018). India, too, continues to see dramatic inequities in maternal death risk. Recent research into India’s 640 districts reveals that while nearly one third of districts have achieved the SDG goal of reducing maternal mortality ratio below 70 per 100,000 live births, 114 districts still have ratios of 210 or more deaths per 100,000 live births (Goli and others, 2022). The highest – 1,671 per 100,000 births – is seen in Tirap District of Arunachal Pradesh, a rural area with a high proportion of indigenous peoples. While disaggregating these figures by socioeconomic group, ethnicity, caste or religion is challenging, these factors clearly play a role in health outcomes. For example, despite the entitlement of all women to free maternal health care (Beckingham and others, 2022), women from the most disadvantaged castes and indigenous groups receive less antenatal, postnatal and obstetric care, or none at all (Raghavendra, 2020; Yadav and Jena, 2020; Saroha and others, 2008). A central lesson in these case studies is that all inequalities – including those across countries and within countries – require urgent attention, and that no one society or region has yet achieved the goals towards which we collectively aspire. 72 CHAPTER 3: Counting every stitch Acceleration needed The most recent 2023 estimates, using the best available data and practices, hold that the global maternal mortality ratio, as of 2020, had changed little over the preceding five years – and was tragically far from the goal set in 1994 (UNFPA, 1994). Critics might suggest this means the 1994 goal was simply unachievable, but evidence from a handful of countries today indicates that maternal mortality ratios of 1 or 2 deaths per 100,000 births are indeed reachable (WHO and others, 2023). What does this mean for the state of maternal mortality today? Unfortunately, a real-time view of progress in reducing maternal death is currently impossible – not only because of limited data but also because official updates only happen several years after the fact. As a result, there is considerable uncertainty about the current state of progress, especially in the wake of the global COVID-19 pandemic. The most recent estimates contain data inclusive of only the first year of the pandemic, a time in which experts struggled to understand what proportion of total COVID-19 deaths were also indirect obstetric deaths (WHO and others, 2023). At present, the full scale of the effects of the pandemic on maternal outcomes remains unknown. However, there are indications of distressing increases in maternal mortality ratios in parts of Europe, North America and Latin America and the Caribbean. These increases are substantial and widespread enough that they have offset declines elsewhere, leading to stagnation in global maternal mortality ratios since 2016. Without more recent data, it is not clear whether maternal deaths will rise further due to the impacts of the pandemic, or if the recent increases have abated (WHO and others, 2023). Despite these mixed signals, there is hope in the progress that has been achieved. First, the total number of annual maternal deaths has fallen considerably since 1994 – encouraging given that the global population has grown dramatically from 5.7 billion in 1994 to 8.1 billion in 2024 (UN DESA, 2022a). And second, the data are themselves a sign of progress as well. With each iterative improvement in data collection and analysis, solutions present themselves – and sometimes in unlikely places. For example, some estimates suggest that about one third of the total reduction in maternal mortality is attributable to declining fertility, with the greater uptake of contraception resulting in fewer pregnancies and safer spacing between pregnancies (Snow and others, 2015). Other research suggests that meeting the unmet need for contraception can avert more than half of maternal deaths simply because it will reduce pregnancies at old and young ages when risk is higher, increase the spacing between births and decrease the likelihood of unsafe abortions (Utomo and others, 2021; Chola and others, 2015; Ahmed and others, 2012). Meanwhile, the prevalence of unintended pregnancies and unmet need for contraception is plagued by inequalities across many factors, including age, socioeconomic status, race and ethnicity (Anik and others, 2022; Sully and others, 2020; Kim and others, 2016), pointing the world to the communities that need to be reached. Decades of data also underline the role of unsafe abortion in contributing to maternal mortality. This link was known as far back as 1987, when the Safe Motherhood Conference highlighted a finding from a study in Ethiopia where more than half of maternal deaths in Addis STATE OF WORLD POPULATION 2024 73 Measuring discrimination With the Sustainable Development Goals, the international community has sought to measure the proportion of people who have reported experiencing discrimination or harassment in the previous 12 months, looking at forms of discrimination prohibited under international human rights law. These data reveal that almost one in six individuals have encountered discrimination within the past 12 months – and in certain settings, the number is as high as one in three. The global prevalence of discrimination is typically higher for women, and in certain societal contexts women report discrimination up to three times more often than men. Similarly, individuals with disabilities face discrimination nearly twice as frequently as those without disabilities, with ratios as high as 6 to 1 in certain contexts. Forms of discrimination Racial discrimination*, rooted in factors such as ethnicity, colour or language, is the most common type of discrimination or harassment reported, with a median of 6 per cent of the global population reporting discrimination on these grounds within the past year. In extreme circumstances, this proportion can reach nearly 24 per cent. Intersectional discrimination compounds the challenges faced by vulnerable groups, notably women and persons with disabilities, who report heightened discrimination based on their ethnic origins, skin colour and linguistic affiliations. In some national contexts, up to four times as many women or six times as many individuals with disabilities experience discrimination compared to men or individuals without disabilities. Discrimination based on age and sex each affects a median of 4 per cent of the global population. In certain regions, discrimination based on sex impacts almost 19 per cent of the population, with significant disparities between men and women. For every man facing sex-based discrimination, four women are affected, and in specific country settings, this ratio can escalate to as high as 1 to 20. Age-related discrimination exhibits the highest inter-country variation, with rates reaching slightly above 34 per cent in some places. Limited evidence suggests that younger populations report disproportionately more age discrimination. Progress and room to improve Since 2023, there has been a 25 per cent increase in the number of countries measuring discrimination – a significant achievement. Still, there is much room to improve: fewer than half of all nations systematically capture and report the voices of those marginalized by discrimination. Current data collection practices also lack the granularity necessary for comprehensive, disaggregated analysis of discrimination. To address this challenge, the Praia Group is working to develop governance statistics, including statistics on non-discrimination and equality, and to promote a human rights-based approach to data. This text was contributed by UN Human Rights. � � � � ������������������������ �� � �� � ���� ��� ���������� �� ��� ����������� ����� ��� Proportion of people experiencing discrimination, by selected grounds, 2015‑2023 (percentage) FIGURE 4 Source: UN Human Rights, 2024 * The use of the term “race” here is consistent with international human rights treaties. It does not imply the acceptance of theories which attempt to determine the existence of separate human races. 74 CHAPTER 3: Counting every stitch Ababa were from infections following unsafe abortions (Cohen, 1987). Now, the association is well established: Unsafe abortion remains a leading cause of maternal death, accounting for an estimated 1 in 13 of all maternal deaths worldwide (Say and others, 2014). A growing body of evidence shows that legal restrictions do not lower the incidence of abortion and that legal access to safe abortion indeed reduces maternal mortality (Bearak and others, 2020; Latt and others, 2019; Haddad and Nour, 2009). Evidence also shows that restrictions in abortion access are likely to deepen existing inequalities in sexual and reproductive health and rights (Fuentes, 2023; Harned and Fuentes, 2023). The growing weight of these data may contribute to the fact that more than 60 countries have removed restrictions from their abortion laws in the last 30 years. Still, today, about one quarter of all women of reproductive age are living in places where abortion is fully prohibited or permitted only to save a woman’s life or under specific circumstances such as pregnancy resulting from rape (Center for Reproductive Rights, n.d.). Inclusive Data Charter In 2018, UNFPA joined a global network of governments, businesses, philanthropists and non-governmental organizations in launching the Inclusive Data Charter, a commitment to improve the quality, quantity, financing and availability of inclusive and disaggregated data. The charter is guided by five principles (Inclusive Data Charter and Global Partnership for Sustainable Development Data, 2018): All populations must be included in the data. We can only achieve the “leave no one behind” goal by empowering the furthest behind. This means ensuring their voices are heard and their experiences are represented through data and analytics. All data should, wherever possible, be disaggregated in order to accurately describe all populations. Data should be disaggregated by sex, age, geographical location and disability status and, where possible, by income, race, ethnicity, migratory status and other relevant characteristics. Data should be drawn from all available sources. High-quality, timely data from official and non-official sources should be accessible, and these should include new data sources, where consistent with internationally accepted statistical standards. Those responsible for the collection of data and production of statistics must be accountable. The principles of transparency, confidentiality and privacy must be balanced to ensure personal data are not abused or misused, in accordance with national laws and the Fundamental Principles of Official Statistics (United Nations Statistics Division, 2014). Human and technical capacity to collect, analyse and use disaggregated data must be improved, including through adequate and sustainable financing. Collecting and analysing disaggregated data requires specific skills and support. STATE OF WORLD POPULATION 2024 75 FEATURE African censuses strive to count everyone After starting his career as a schoolteacher in the United Republic of Tanzania, Jonas Lubago went to his local bank to open an account but was refused. The reason: He was blind. The bank had a policy of requiring any person with blindness or vision impairment to bring a designated proxy to sign for even the most basic transactions. That was neither practical nor fair, says Mr. Lubago. Becoming a schoolteacher was Mr. Lubago’s second choice. He entered university with the intention of studying law, but his academic adviser discouraged him from trying because none of the required reading existed in braille. “He told me I would fail,” Mr. Lubago says. That was two decades ago. While the situation has improved over the years, people with disabilities in the United Republic of Tanzania still face an array of obstacles when they go about their daily lives or need public services, such as health care and education. A clinic may be right around the corner from the home of someone in a wheelchair, but if it is accessible only by stairs, or if the consultation rooms are too small to allow the door to close for privacy, or if the washrooms are not properly equipped, that service is out of reach. “And that’s discrimination,” says Mr. Lubago, who is today the secretary-general of the Tanzanian Federation of Disabled Peoples’ Organizations. In 2012, the country began identifying people with disabilities in its census. Still, the exercise did not count a wide range of disability categories nor did it consider severity. “There was a demand for better data – both from the disabled community and from the Government,” says Principal Statistician and National Census Coordinator Seif Kuchengo. The information gathered through the census is critically important. As a State Party to the Convention on the Rights of Persons with Disabilities, the United Republic of Tanzania committed to ensuring and promoting “the full realization of all human rights and fundamental freedoms for all persons with disabilities”. Yet institutions require data in order to make services not only available, but also accessible. Mr. Kuchengo says offi cials sought early involvement of representatives from the disability community in the design of the most recent census, including in the planning and in the training of enumerators. Mr. Lubago, who left his teaching job, joined forces with government offi ces to have the census adopt a more expansive and diverse set of internationally standardized disability questions. In all, about 400 people with disabilities and impairments were involved. Some 17 different categories of disability or impairment were included, and levels of severity could also be specifi ed. Preliminary fi ndings from a 2022 national census show that about 11 per cent of the population has at least one type of physical or developmental disability or impairment, according to 76 CHAPTER 3: Counting every stitch Mr. Kuchengo. That level is about 2 percentage points higher than in 2012, but the increase is the result of the recent census’s more comprehensive approach to counting people with disabilities. Mr. Lubago hopes that new census data will show just how large and important the disabilities community is, and result in persons with disabilities participating in local and national decision-making. In addition to generating better data on persons with disabilities, the 2022 census also included an inn

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