by Sanjay Suri
Ten years after 179 countries embarked on a 20-year plan to improve reproductive health and other population and development services around the world, analysts are divided in seeing the glass half empty or half full.
The plan, agreed to at the 1994 International Conference on Population and Development (ICPD) in Cairo, called for integrating family planning—once the main focus of population programs—into a wider package of reproductive health services to improve maternal and child health, enhance women's status and rights, and prevent HIV and other sexually transmitted infections (STIs).
Today, halfway to the 2015 mark for achieving the plan's goals, the reviews are mixed. Many people enjoy better reproductive health, but many services remain unaffordable to the poor. There is greater focus on maternity care but no corresponding decline in maternal deaths in the poorest countries. More infants survive the first years of life, but more lose their parents to HIV/AIDS. More girls are going to school but still more are kept out by rising school costs.
According to the State of World Population 2004, released by the United Nations Population Fund (UNFPA), inadequate resources, persistent inequalities between women and men, and gaps in serving the poor and adolescents are undermining progress in developing countries.
New Policies in Place
There is some good news. Most countries have established or broadened reproductive health policies and programs. Many have also reshaped maternal and child health and family planning services to improve the quality of those services and meet clients' needs. In addition, reproductive rights—including a woman's right to choose the number and spacing of her births—have received greater attention in laws and policies.
The State of World Population 2004 shows that, since 1994, 46 countries have passed laws to increase women's and men's access to reproductive health care and to ensure that adolescents and pregnant women do not face discrimination in school and employment. Some of smallest countries have adopted new policies:
- In Papua New Guinea, women no longer need their husbands' consent to use contraceptives, and adolescents over age 16 no longer need parental permission to access reproductive health services.
- In a reversal of its pronatalist policy, Laos now provides free contraception to couples.
- Belize's national health policy includes voluntary counseling and testing for HIV, and tax exemption for nongovernmental organizations providing health services.
- Pregnant students in the Pacific islands of Micronesia can continue school, and adolescents do not need parental consent for contraception.
Limited Access to Contraceptives for the Poor
Despite such gains in the policy arena, large disparities remain in couples’ ability to access reproductive health services and information. An estimated 53 percent of married women worldwide use modern contraceptive methods (Population Reference Bureau’s 2004 World Population Data Sheet).
However, use varies among regions. Only an estimated 14 percent of married women use modern methods in sub-Saharan Africa, compared with around 43 percent in Asia (excluding China, with its large population and high contraceptive prevalence).
Of great concern are the estimated 201 million women—many concentrated in the poorest countries—who are not using a method but say they would prefer to space or limit their births. While the Cairo conference gave priority to reducing the unmet need for contraceptives, shortfalls in funding remain a major obstacle to fulfilling that goal. Meeting this need would cost some $3.9 billion a year, says the State of World Population report.
This unmet need partly results from problems in delivering services, a lack of support from spouses and communities, a lack of information, financial constraints, and growing demand. Between 2000 and 2015, contraceptive users in developing countries are expected to increase by 40 percent as the number of reproductive-age couples grows by 23 percent.
NGOs Try to Fill the Breach
Nongovernmental organizations (NGOs) are increasingly involved in providing contraceptives and other reproductive health services in developing countries. "Governments find it difficult to provide services in this field because it’s about people’s sex lives," says Patricia Hindmarsh, external relations director for Marie Stopes International, which provides sexual and reproductive health information and services worldwide.
Some agencies say restrictions in U.S. population funds since 2001 have created funding gaps for such services. No U.S. family planning assistance can be provided to foreign NGOs that use other funds to provide abortion-related information, referrals, and other services in their country, except in cases when a woman experiences rape, incest, or a threat to her life. The restrictions have affected organizations such as UNFPA and the International Planned Parenthood Federation (IPPF).
Views differ on the impact of these restrictions. U.S. officials say the money has been redirected to other programs. Others, such as IPPF president Steven Sinding, say the restrictions have meant "closed clinics, contraceptives not purchased, a rise in unwanted pregnancies and consequently, unsafe abortions."
On the other hand, UNFPA executive president Thoraya Ahmed Obaid says the declining trend in donor funding could change and that money from other countries has closed UNFPA's own funding gap.
"In 2004, UNFPA will have the highest budget since it was established," Obaid told PRB. "If this is an indication of future trends, then we are on the correct track. Over the next 10 years, the main thing is to strengthen national responses so that they are built into the budgets of those countries."
Maternal Deaths Plague the Poor
One area that requires more investments worldwide is maternal health. Despite progress in some countries, death from obstetric complications remains an intractable problem. Roughly half a million women died of risks associated with pregnancy and childbirth in 2000, with some 95 percent of the deaths occurring in Asia (253,000) and sub-Saharan Africa (251,000), according to estimates by the World Health Organization, the UN Children’s Fund, and UNFPA. Millions more women survive but suffer from pregnancy-related illness and disability.
The ICPD set a goal for cutting maternal deaths to one-half of 1990 levels by 2000 and for a further one-half reduction by 2015. The Millennium Development Goals (MDGs) set by world leaders in 2000 call for a 75 percent reduction between 1990 and 2015 in the maternal mortality ratio—the number of maternal deaths for every 100,000 births.
Reducing these deaths will present a major challenge. State of World Population says that while some gains in reducing maternal deaths and illnesses are expected in the next 10 years, current approaches will need more resources and will have to be scaled up to more fully protect women’s lives and health.
The report adds that reducing these deaths would require expanded access to emergency obstetric care for women who experience complications, skilled attendance at delivery, and referrals and transportation so women can receive care quickly. According to UNFPA, skilled personnel assist slightly more than half of all deliveries in the developing world, but just 35 percent in South Asia and 41 percent in sub-Saharan Africa.
The UNFPA report also shows that all the countries that managed to reduce maternal deaths—countries as varied as China, Egypt, Honduras, Indonesia, Jamaica, Jordan, and Mexico—addressed issues surrounding available and accessible skilled birth attendants, referral systems, and emergency obstetric services.
Looking Ahead: The Next 10 Years
The State of the World Population report says that policy priorities in the next 10 years should include broadening programs to meet the needs of the poorest, strengthening urban planning to provide services in marginal communities, investing in rural development, and reforming laws and policies to end discrimination against women.
However, 10 years after the ICPD conference in Cairo, just how to measure progress toward meeting the Cairo goals remains a major question. The Cairo plan lacks indicators to identify progress on a range of health and development issues. For this reason, supporters of reproductive health and rights are working for a broader networking with the Millennium Development Goals.
Fortunately, say many, the 20-year target set in Cairo dovetails with the 2015 target date for most of the eight MDGs. The goals include ending extreme poverty and hunger, promoting gender equality and universal primary education, reducing maternal and child deaths, combating HIV/AIDS, and preserving the environment.
"Progress in reproductive health should be closely tied to progress toward the eight Millennium Development Goals, especially in terms of poverty reduction, as it influences the achievement of most, if not all, of the eight goals," says Amy Tsui, professor of population and family health sciences at Johns Hopkins Bloomberg School of Public Health.
Sanjay Suri is the London correspondent for the Inter Press Service news agency.
References
Carl Haub, 2004 World Population Data Sheet (Washington, DC: Population Reference Bureau, 2004).
United Nations Population Fund (UNFPA), State of the World Population 2004 (New York: UNFPA, 2004).
World Health Organization (WHO), Maternal Mortality in 2000: Estimates Developed by WHO, UNICEF, and UNFPA (Geneva: WHO, 2003), accessed online at www.who.int/reproductive-health/publications/maternal_mortality_2000, on Sep. 15, 2004.