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NOTES

Introduction

1. A basic set of reproductive rights, including rights to reproductive and sexual health, is implied by the rights recognized in international human rights instruments, and has been recognized by the ICPD and other international conferences; Chapter 1. Paragraph 96 of the Platform for Action of the Fourth World Conference on Women affirms, "The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence." (United Nations. 1996. The Beijing Declaration and the Platform for Action: Fourth World Conference on Women: Beijing, China: 4-15 September 1995 (DPI/1766/Wom). New York: Department of Public Information, United Nations.) This report uses the term "sexual and reproductive rights" to encompass these concepts.

2. United Nations. 1995. Population and Development, vol. 1: Programme of Action adopted at the International Conference on Population and Development: Cairo: 5-13 September 1994 (Sales No. E.95.XIII.7), Ch. 2, Principle 1, p. 9. New York: Department for Economic and Social Information and Policy Analysis, United Nations.

Chapter 1

1. This section relies heavily on the analyses of Rebecca Cook and her colleagues; see: Cook, Rebecca J., and Mahmoud F. Fathalla. 1996. "Advancing Reproductive Rights Beyond Cairo and Beijing." Studies in Family Planning 22(3): 115-121. New York: The Population Council.

2. United Nations. "Charter of the United Nations: Signed 26 June 1945," Article 1. These sections and many other relevant instruments are reproduced in The United Nations and the Advancement of Women 1945-1996, The United Nations Blue Book Series, vol. 6 (Sales No. E. 96.1.9), by the United Nations. 1996a. New York: Department of Public Information, United Nations.

3. United Nations. "The Universal Declaration of Human Rights: Adopted by the General Assembly in its Resolution 217A (III) of 10 December 1948," Preamble. In United Nations 1996a, Document 14. (See note 2.)

4. United Nations. 1967. International Covenant on Economic, Social and Cultural Rights and International Covenant on Civil and Political Rights, General Assembly Resolution 2200 (XXI): 21st Session: Supplement No. 16 (A/6316). These entered into force 3 January and 23 March 1976, respectively.

5. European Convention for the Protection of Human Rights and Fundamental Freedoms. 4 November 1950. (Europ. T.S. No. 5, 213 U.N.T.S. 221) (entered into force Sept. 3, 1953); and European Social Charter (529 U.N.T.S. 89). 18 October 1961(entered into force 26 February 1965).

6. Formally: Organization of American States. 1970. American Convention on Human Rights, O.A.S. Treaty Series. No. 36 (Rec. OEA/Ser.L/V/II.23 doc. 21, rev 6, 9 I.L.M. 673); entered into force 18 July 1978.

7. Formally: Organization of African Unity. 1982. The African Charter on Human and People's Rights (CAB/LEG/67/3 rev. 5, reprinted in 21. I.L.M. 58); entered into force 21 October 1986.

8. Formally: United Nations. 1980. Convention on the Elimination of All Forms of Discrimination Against Women: General Assembly Resolution 34/180: 34th Session: Supplement No. 46. (A/34/46, reprinted in I.L.M. 33); entered into force 3 September 1981.

9. "Gender" refers to the socially constructed roles ascribed to males and females. These roles, while based on biological differences, are learned; they change over time and vary widely within and between cultures. Gender issues, therefore, have to do with differences in what men and women do, and to the ways their socially defined roles benefit or harm them. They also relate to access to resources and to autonomy and control resulting from specific rights, roles, power relationships, responsibilities and expectations assigned to women and men. Source: Adapted from the UNFPA Thematic Workshop on Gender, Population and Development, The Population Council, New York, 30 September-3 October 1996.

10. United Nations. 1989. Convention on the Rights of the Child: General Assembly Resolution 25(XLIV): 44th Session: Supplement No. 49 (A/RES/44/25, reprinted in 28 I.L.M. 1448); opened for signature 26 January 1990.

11. As of February 1997, only four countries of the 189 member states of the United Nations had not ratified the convention.

12. This point was made eloquently by Mr. Stephen Lewis, Deputy Executive Director of UNICEF, at the 2nd International Seminar on Health and Human Rights, François-Xavier Bagnoud Center for Health and Human Rights, Harvard University, School of Public Health, 4-7 October 1996. The François-Xavier Bagnoud Center and this seminar series are helping advance the development of policy studies and practical applications at the intersection of public health and human rights concerns. Papers from the 2nd International Seminar will appear in the journal Health and Human Rights.

13. The other treaty monitoring bodies are the Committee on Economic, Social and Cultural Rights (which reports to ECOSOC); the Committee on the Rights of the Child; the Committee on the Elimination of All Forms of Racial Discrimination Aganist Women; and the Committee Against Torture.

14. See especially: United Nations 1996b. CEDAW General Recommendations 12, 19 and 21 found in: United Nations. 1996c. Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies: Note by the Secretariat: 29 March 1996 (Human Rights Instruments, Doc. HRI/GEN/1/Rev. 2). New York: United Nations.

15. Reproductive rights were addressed at the International Conference on Human Rights in 1968, the World Population Conference in 1974, the International Conference on Primary Health Care in 1978, the International Conference on Population in 1984, the women's conference in Nairobi in 1985, the International Conference on Population and Development in 1994, in the World Summit on Social Development and the Fourth World Conference on Women in 1995, and the Second UN Conference on Human Settlements and the World Food Summit of 1996.

16. United Nations. 1993. Vienna Declaration and Programme of Action, World Conference on Human Rights (A/CONF.157/24). New York: United Nations.

17. Ibid., part II, sections 38, 40.

18. The ICPD Programme of Action states that implementation efforts will be guided by, among others, the following principle: "All human beings are born free and equal in dignity and rights. Everyone is entitled to all the rights and freedoms set forth in the Universal Declaration of Human Rights, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Everyone has the right to life, liberty and security of person." See: United Nations. 1995. Population and Development, vol. 1: Programme of Action adopted at the International Conference on Population and Development: Cairo: 5-13 September 1994 (Sales No. E.95.XIII.7), Ch. 2, Principle 1, p. 9. New York: Department for Economic and Social Information and Policy Analysis, United Nations.

19. Ibid., Principle 3, p. 9.

20. Ibid., Principle 4, p. 9.

21. United Nations. 1996d. The Beijing Declaration and The Platform for Action: Fourth World Conference on Women: Beijing, China: 4-15 September 1995 (DPI/1766/Wom). New York: Department of Public Information, United Nations.

22. Ibid., Paragraph 232 (f).

23. The fundamental work of Rebecca J. Cook is a cornerstone of these analyses (see especially: "Human Rights and Reproductive Self-determination." Keynote speech at the Conference on the International Protection of Reproductive Rights. 1995. In The American University Law Review 44[4]: 975- 1016). Ms. Cook and her colleagues in a broad international network of human rights and reproductive health activists have provided invaluable insights through their writings, conference presentations and, at times, personal discussions. Space limitations did not allow this report to fully display the impressive efforts of this growing community, including many not cited elsewhere in the report. Without intending to slight others not enumerated, special mention is made here of the work of Sajeda Amin, Chaloka Beyani, Reed Boland, Sandra Coliver, Rhonda Copelon, Sonia Corrêa, Lynn Freedman, Sofia Gruskin, Sara Hossain, Deborah Maine, Jonathan Mann, Rosalind Petchevsky, Rachel N. Pine, María Isabel Plata, Anika Rahman, Donna Sullivan and Katrina Tomasùevski.

24. See particularly: World Health Organization. 1993. Human Rights in relation to Women's Health: The Promotion and Protection of Women's Health through International Human Rights Law. Document prepared by Rebecca J. Cook in the context of the Global Commission on Women's Health for the World Conference on Human Rights. Geneva: World Health Organization; and Cook, Rebecca J. 1994. Women's Health and Human Rights. Geneva: World Health Organization.

25. International Planned Parenthood Federation (IPPF). 1996. IPPF Charter on Sexual and Reproductive Rights. London: International Planned Parenthood Federation.

26. Universal Declaration, Article 3; Political Covenant, Article 6; Children's Convention, Article 6.

27. Universal Declaration, Article 25; International Covenant on Economic, Social and Cultural Rights, Article 12; Convention on the Elimination of All Forms of Discrimination Against Women, Articles 11(1) (f), 12 and 14(2) (b).

28. International Planned Parenthood Federation 1996. (See note 25.)

29. Austria, France, Italy, Canada and the Netherlands have ruled on the applicability of the principle in abortion cases. Cited in Cook and Fathalla 1996. (See note 1.)

30. United Nations 1996d, para 135. (See note 21.)

31. United Nations 1995, Para. 4.10, p. 18. (See note 18.)

32. Universal Declaration, Article 16; Political Covenant, Article 23; Economic Rights Covenant, Article 10; Women's Convention, Article 16; Children's Convention, Articles 8 and 9.

33. Universal Declaration, Article 12; Political Covenant, Article 17; Economic Rights Covenant, Article 10; Women's Convention, Article 16; Children's Convention, Article 16.

34. Universal Declaration, Article 27(2); Economic Rights Covenant, Article 15(1) (b) and (3).

35. Universal Declaration, Article 19; Political Covenant, Article 19; Women's Convention, Articles 10(e), 14(b) and 16(e); Children's Convention, Articles 12, 13 and 17.

36. Universal Declaration, Article 26; Economic Rights Covenant, Articles 13 and 14; Women's Convention, Articles 10 and 14(d); Children's Convention, Articles 28 and 29.

37. Universal Declaration, Articles 1, 2 and 6; Political Covenant, Articles 2(1) and 3; Economic Rights Covenant, Articles 2(2) and 3; Women's Convention, Articles 1-5; Children's Convention, Article 2(1).

38. Universal Declaration, Articles 1, 2 and 6; Political Covenant, Article 2(1); Economic Rights Covenant, Article 2(2); Children's Convention, Article 2(2).

Chapter 2

1. Murray, Christopher J. L., and Alan D. Lopez. 1996. The Global Burden of Disease. Cambridge, Massachusetts: The Harvard School of Public Health. Measurements are in disability adjusted life years (DALYs) a measure of loss of life through death or disability attributable to disease or injury. One DALY is one lost year of healthy life. Morbidity contributions are weighted according to the severity of the ailment or injury (e.g., highest weight is given to conditions like quadriplegia, dementia and active psychosis; moderate weight, to deafness and below-the-knee amputation; lowest weight to vitiligo on the face, weight-for-height less than two standard deviations low). Weights are also assigned to the value of healthy life at different periods in the life span; the procedure assumes that the relative value of a healthy year of life rises from birth to a peak in the early 20s and then steadily declines. Other technical adjustments include discounting of future impacts of current conditions.

2. Leary, Warren E. 1996. "Childbearing Deaths Underreported." The New York Times, 31 July 1996.

3. Examples cited in: Timyan, Judith, et al. 1993. "Access to Care: More than a Problem of Distance." In The Health of Women: A Global Perspective, edited by Marge Koblinsky, Judith Timyan and Jill Gay. Boulder, Colorado: Westview Press.

4. United Nations. 1996. World Population Monitoring 1996: Selected Aspects of Reproductive Rights and Reproductive Health (ESA/P/WP.131), p. 234. New York: Population Division, Department for Economic and Social Information and Policy Analysis, United Nations.

5. McCauley, Ann P., and Cynthia Salter. 1995. Meeting the Needs of Young Adults. Population Reports, Series J, No. 41. Baltimore: Population Information Program, Johns Hopkins School of Public Health.

6. See the following articles in: Germain, A., et al., (eds.) 1992. Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health. New York: Plenum Press: Maggwa, A.B.N., and E.N. Ngugi. "Reproductive Tract Infections in Kenya: Insights for Action from Research"; and Adekunle, A.O., and O.A. Ladipo, "Reproductive Tract Infections in Nigeria: Challenges for a Fragile Health Infrastructure."

7. These differences are documented in McCauley and Salter 1995, p. 13. (See note 5.)

8. The descriptive material in this section is from United Nations 1996, p. 234. (See note 4.)

9. Panos. 1996. "The Silent Pandemic: Reproductive Tract Infections." Panos Briefing, Panos Media Briefing No. 21, p. 1. London: Panos.

10. UNAIDS and World Health Organization. 1996. "UNAIDS: The Global Epidemic: December 1996," 28 November 1996.

11. These figures are given as ranges because existing data are not precise.

12. Mann, J., and D. Tarantola (eds.). 1996. AIDS in the World II. New York: Oxford University Press.

13. The literature on the need for HIV/AIDS prevention programmes to deal with the social context of men's sexual contacts and women's relative powerlessness is growing rapidly. A useful analysis of the special risks faced by women in high risk occupations can be found in: Heise, Lori L., and Christopher Elias. 1995. "Transforming AIDS Prevention to Meet Women's Needs: A Focus on Developing Countries." Social Science and Medicine 40(7): 931-943. Great Britain: Elsevier Science Ltd. An example of similar findings in a developed country can be found in: Worth, Dooley. 1989. "Sexual Decision-Making and AIDS: Why Condom Promotion among Vulnerable Women is Likely to Fail." Studies in Family Planning 20(6): 297-307. New York: The Population Council.

14. WHO defines an unsafe abortion as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both. (See: United Nations. 1995. Population and Development, vol. I: Programme of Action adopted at the International Conference on Population and Development: Cairo: 5-13 September 1994 [Sales. No. E.95.XIII.7]. New York: Department for Economic and Social Information and Policy Analysis, United Nations.) As WHO notes "the legality or illegality of the services may not be the defining factor of their safety" (World Health Organization. 1994. Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion, Second Edition. Geneva: World Health Organization.)

15. United Nations 1996, p. 161. (See note 4.)

16. The Alan Guttmacher Institute. 1994. Clandestine Abortion: A Latin American Reality. New York and Washington: The Alan Guttmacher Institute. Cited in United Nations 1996, p. 164. (See note 4.)

17. The reduction in observed fertility from the maximum level without the limiting effects of the proximate determinants was 26.5 per cent from contraception and 17.5 per cent from abortion (unweighted average over the 42 surveys).

18. A study of contraception and abortion in Latin America by Susheela Singh and Gilda Sedgh (1996. "Abortion, Contraception and Fertility in Latin America." Chapel Hill, North Carolina: The Evaluation Project, Carolina Population Center. Cited in "Understanding How Family Planning Programs Work: Findings from Five Years of Evaluation Research," draft project document by Renee Samara, Bates Buckner and Amy Tsui. 1996. Chapel Hill, North Carolina: The Evaluation Project, Carolina Population Center) using a different methodology for estimating induced abortion levels demonstrated that in Mexico and Colombia the impact of both contraception and abortion increased between the mid-1970s and mid-1980s but the effect of contraception grew at a much more rapid rate as these programmes became more accessible.

19. Studies cited in: Robey, Bryant, John Ross and Indu Bhushan. 1996. Meeting Unmet Need: New Strategies. Population Reports, Series J, No. 43. Baltimore, Maryland: Population Information Program, Johns Hopkins School of Public Health.

20. Removal of the clitoral hood only has been referred to by some as "true circumcision" as it is most closely analgous to male circumcision. Removal of the clitoris is referred to in some communities as "mild circumcision" or "Sunna circumcision" (WHO discourages the use of this term as it could reinforce the incorrect idea that any form of FGM is recommended in the Koran). Infibulation is referred to variously as "severe circumcision", "Pharaonic circumcision" (in Sudan) and "Sudanese circumcision" (in Egypt). The WHO classification presented in the text relies on medical description and seeks to avoid terminology which attributes any cultural or geographical origin or basis of legitimation.

21. World Health Organization. 1996a. Female Genital Mutilation: A Joint WHO/UNICEF/UNFPA Statement. Geneva: World Health Organization.

22. The health rights violation has been central to the criticism of FGM from medical institutions. Women's rights groups have also given prominence to women's right to security of person, including control over what is done to their bodies. The former view has the advantage of indicating rights violation concerns even when the procedure is voluntarily undertaken; the latter view appropriately emphasizes women's autonomy, albeit in situations where extended socialization, immediate social pressures and incentives or outright coercion might be involved.

23. World Health Organization. 1996b. Female Genital Mutilation: Report of a WHO Technical Working Group Meeting: Geneva: 17-19 July 1995. Geneva: World Health Organization.

24. Toubia, N. 1995. Female Genital Mutilation: A Call for Global Action, Second Edition. Lexington: Women Ink. Cited in "Female Genital Mutilation: A Reproductive Health Concern." Supplement to Population Reports Series J, No. 41, by Kurungari Kiragu. 1995. Baltimore, Maryland: Population Information Program, Johns Hopkins School of Public Health.

25. World Health Organization 1996a and 1996b. (See notes 21 and 22.)

26. Moderate responses to some more extreme international criticism of the practice are offered by three African scholars active in American universities in the newsletter of an African Studies Programme (Iweriebor, Ifeyinwa. 1996. "Brief Reflections on Clitoridectomy"; Matias, Aisha Samad. "Female Circumcision in Africa"; and Apena, Adeline. 1996. "Female Circumcision in Africa and the Problem of Cross-cultural Perspectives." In Africa Update 3[2]. The Chief Editor of the newsletter, Professor Gloria T. Emeagwali, appropriately notes in an introduction to the papers: "none of the accounts constitutes a blind defence of this social practice, all three emphasize the need for a holistic perspective that brings into the discourse the rich, complex and diversified nature of African civilization–in its patriarchal and matrifocal dimensions, its strength and weakness, its glory and pain."

27. Williams, Lindy, and Teresa Sobieszczyk. 1996. "Attitudes Surrounding the Continuation of Female Circumcision in the Sudan: Passing the Tradition to the Next Generation." University of Michigan Population Studies Center Research Report No. 96-366. Ann Arbor, Michigan: Population Studies Center, University of Michigan.

28. This list is based on the pioneering work being done by the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC), Geneva, Switzerland, and the Maendeleo ya Wanawake Organization (MYWO), Nairobi, Kenya.

29. WHO compilations provided by the Division of Family and Reproductive Health.

30. United Nations. (Forthcoming.) World Population Prospects: The 1996 Revision. New York: Population Division, Department for Economic and Social Information and Policy Analysis, United Nations.

31. This is the major theme of the analyses and recommendations in: The World Bank. 1993. World Development Report: Investing in Health. Oxford and London: Oxford University Press.

32. Michaud, C., and C. Murray. 1994. "External Assistance to the Health Sector in Developing Countries: A Detailed Analysis: 1972-1990." Bulletin of the World Health Organization 72(4): 639-651.

33. Inter-American Development Bank. 1996. Annual Report. Washington, D.C.: Inter-American Development Bank.

34. Magnani, Robert J., et al. 1995. "Does Utilization of Maternal and Child Health Services Influence Contraceptive Use: Evidence from Morocco." Revised version of paper presented at the Annual Meeting of the Population Association of America, San Francisco, California, 6-8 April 1995.

35. Timyan, Judith, et al. 1993. (See note 3.)

36. Pillsbury, Barbara, Ann Brownlee and Judith Timyan. 1990. Understanding and Evaluating Traditional Practices: A Guide for Improving Maternal Care. Washington, D.C.: Maternal Nutrition and Health Care Program, International Center for Research on Women.

37. Information on trained birth attendance has been compiled in various sources including: World Health Organization. 1993. Coverage of Maternity Care: A Tabulation of Available Information. Geneva: World Health Organization; United Nations 1996, pp. 93ff (See note 4.); and International Planned Parenthood Federation. 1996. Reproductive Rights, wallchart. London: International Planned Parenthood Federation.

38. Generally above 80 per cent except: 73 per cent in Brazil and Nicaragua, 69 per cent in Mexico, 66 per cent in Paraguay, 55 per cent in Bolivia and 50 per cent in Peru.

39. The lowest percentages of trained birth attendance are in Somalia (2), Ethiopia (14), Chad, Angola and Niger (15), Mali (18), Burundi (19) and Rwanda (26); the highest in Mauritius (85), Gabon (80), Botswana (77), Zimbabwe (70), Sudan (69) and Namibia (68).

40. The highest percentages are observed in Kuwait and Israel, where trained birth attendance is almost universal. Other relatively high percentages are observed in Saudi Arabia (90), Jordan (87), Algeria (77), Libyan Arab Jamahiriya and Turkey (76) and Tunisia (69). Lower percentages are observed in Morocco (32) and Yemen (16).

41. Nearly universal attendance except for China (94) and the Republic of Korea (89).

42. The concept of "access with quality" is derived from the work of Anrudh Jain and Judith Bruce. See: Jain, Anrudh K. (ed.). 1992. Managing Quality of Care in Population Programs. West Hartford, Connecticut: Kumarian Press; Bongaarts, John, and Judith Bruce. 1995. "The Causes of Unmet Need for Contraception and the Social Content of Services." Studies in Family Planning 26(2). New York: The Population Council.

43. See Thaddeus, Sereen, and Deborah Maine. 1994. "Too Far to Walk: Maternal Mortality in Context." Social Science and Medicine 38(8): 1091-1110. Great Britain: Elsevier Science Ltd.

44. National Family Planning Coordinating Board (BKKBN). 1994. A Situation Analysis of the Government Run Service Delivery Points for Family Planning in Indonesia (Report copy). Jakarta: Training and Development Center for Biomedical and Human Reproduction.

45. Cernada, George P., et al. 1993. A Situation Analysis of Family Welfare Centres in Pakistan. Operations Research Working Paper Series, No. 4. New York: The Population Council.

46. Handouts provided for the Workshop on Quality of Care, UNFPA and the Population Council, New York, 21-25 October 1996.

47. Cernada et. al. 1993. (See note 45.)

48. Stein, Karen. 1996. "The Differing Perceptions of Women Seeking Maternal and Child Health and Family Planning Services in Three African Countries." Presentation at the Workshop on Quality of Care, UNFPA and the Population Council, New York, 21-25 October 1996.

49. Miller, Robert. 1996. Personal communication; and presentation at the Workshop on Quality of Care, UNFPA and the Population Council, New York, 21- 25 October 1996.

50. Krieger, Laurie. 1991. "Male Doctor, Female Patient: Access to Health Care in Egypt"; and Alexander, Marie. 1991. "The Role of Gender, Socio-Economic, Cultural, and Religious Pressure on the Health of Women in Cameroon." Papers presented at the 18th Annual National Council for International Health (NCIH) Conference, Arlington, Virginia. Cited in Timyan, et al. 1993. (See note 3.)

51. Reported average client contacts have been reported as short as four minutes in Bangladesh. See, for example: Janowitz, B., and D. Hubacher. 1996. Productivity and Costs for Family Planning Service Delivery in Bangladesh: The Government Program. Technical Report. Research Triangle Park, North Carolina: Family Health International; and National Family Planning Coordinating Board (BKKBN) 1994. (See note 44.) Additional data were presented at the Workshop on Quality of Care, sponsored by UNFPA and the Population Council, 21-25 October 1996, New York.

52. Helzner, J. (Forthcoming.) What Does Sex Have to Do with It? Challenges for Incorporating Sexuality into Family Planning (Draft). London and New York: International Planned Parenthood Federation and the Population Council.

53. National Family Planning Coordinating Board (BKKBN) 1994. (See note 44.)

54. Some clients may not have been asked since they came to the clinic with young children and their behaviour may have been directly observed. The frequency of such events was not tabulated.

55. Robey, Ross and Bhushan. 1996. (See note 19.); and Bhushan, Indu. 1996. Understanding Unmet Need, Center for Communications Programs Working Paper (Draft). Baltimore, Maryland: Center for Communications Programs, Johns Hopkins University.

56. In Botswana, about 23 per cent of SDPs had run out of condoms at least once during the six months preceding the study. Lower proportions were observed in Kenya (12 per cent) and Senegal (5 per cent). The higher incidence of HIV/AIDS in Botswana is probably responsible for escalating demand and supply shortages.

57. Miller, Robert. 1996. Presentation and handout at Workshop on Quality of Care, UNFPA and the Population Council, New York, 21-25 October 1996. In Tanzania, 41 per cent of SDPs lacked oral contraceptives on the day they were visited; in Zaire, 20 per cent had this difficulty; in other settings studied (Kenya, Zimbabwe and Burkina Faso) either an insignificant portion or no SDPs lacked supplies when visited.

58. According to the data compiled by Miller, Nairobi city had no stock problems on the day visited but in rural Kenya 40 per cent of centres lacked IUD supplies. In other countries studied, between roughly one third (Burkina Faso and Tanzania) and four fifths (Zimbabwe) of delivery sites lacked IUD supplies. In Asia, a study in Indonesia also identified supply difficulties for selected IUDs (copper Ts in particular; National Family Planning Coordination Board (BKKBN) 1994. [See note 44.])

59. Mauldin, W. Parker, and John A. Ross. 1991. "Family Planning Programs: Efforts and Results: 1982-1989." Studies in Family Planning 22(6): 350-367; Ross, John A., et al. 1992. Family Planning and Child Survival Programme: As Assessed in 1991. New York: The Population Council; and Ross, John A., and W. Parker Mauldin. 1996. "Family Planning Programs: Efforts and Results: 1972-94." Studies in Family Planning 27(3). New York: The Population Council.

60. United Nations 1996. (See note 4.) Estimates are for couples with women in the reproductive ages.

61. Ibid. A substantial portion of the difference in reliance on non-modern methods is due to greater reliance in the more developed regions on withdrawal (17 per cent of users vs. 4 per cent) and rhythm (9 per cent vs. 4 per cent). Other significant differences are observed in choice among modern methods as indicated in the text.

62. United Nations 1995, Paragraph 7.13, p. 32. (See note 14.)

63. Estimates of unmet need among women who are married (or in consensual unions) range from 120 million to 150 million, depending on the definitions used. For recent estimates and references to the evolution of the concept see: Westoff, Charles F., and Akinrinola Bandole. 1995. Unmet Need: 1990-1994, Demographic and Health Surveys Comparative Studies No. 16. Calverton, Maryland: Macro International Inc. For a discussion of the conceptual difficulties of the original concept, see: Dixon-Mueller, Ruth, and Adrienne Germain. 1992. "Stalking the ‘Unmet Need' for Family Planning." Studies in Family Planning 23(5): 330-335. New York: The Population Council. A useful discussion is found in: Aitken, Iain, and Laura Reichenbach. 1994. "Reproductive and Sexual Health Services: Expanding Access and Enhancing Quality." In Population Policies Reconsidered: Health, Empowerment and Rights, edited by Gita Sen, Adrienne Germain and Lincoln C. Chen. 1994. Cambridge, Massachusetts: Harvard University Press. The definitions used by Dixon-Mueller and Germain result in even higher estimates of unmet need.

64. Mauldin, W. Parker, and Vincent C. Miller, 1994. Contraceptive Use and Commodity Costs in Developing Countries: 1994-2005, UNFPA Technical Report No. 18. New York: UNFPA.

65. A comparison of preference-based and health-based approaches to measurement of unmet need in Sri Lanka can be found in: DeGraff, Deborah S., and Victor de Silva. 1996. "A New Perspective on the Definition and Measurement of Unmet Need for Contraception." International Family Planning Perspectives 22(4): 140-147.

66. 70,000 deaths are due to complications of unsafe abortions; 128,000 of the 513,000 annual maternal deaths not due to unsafe abortion would have been averted if unwanted pregnancies had been avoided through use of safe and effective methods of family planning, since conservative estimates suggest at least a quarter of all unaborted pregnancies are unwanted. (Bongaarts, John. 21 February 1997. Personal communication.)

67. Information on formal access barriers are from the wallchart, Reproductive Rights, compiled by IPPF and the International Women's Rights Action Watch. (See note 36.)

Chapter 3

1. Article 2 of General Assembly Resolution 48/104. Declaration on the Elimination of Violence Against Women (20 December 1993, A/48/629) states that: Violence against women shall be understood to encompass, but not be limited to, the following:

(a) Physical, sexual and psychological violence occurring in the family, including battering, sexual abuse of female children in the household, dowry-related violence, marital rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation;

(b) Physical, sexual and psychological violence occurring within the general community, including rape, sexual abuse, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women and forced prostitution;

(c) Physical, sexual and psychological violence perpetrated or condoned by the State, wherever it occurs.

2. United Nations. 1996. World Population Monitoring 1996: Selected Aspects of Reproductive Rights and Reproductive Health (ESA/P/WP.131), pp. 14ff. New York: Population Division, Department for Economic and Social Information and Policy Analysis, United Nations.

3. Senderowitz, J., and J. Paxman. 1985. "Adolescent Fertility: Worldwide Concerns." Population Bulletin 40(2). Washington D.C.: Population Reference Bureau; Senanayake, P. 1996. "Adolescent Fertility." In Health Care of Women and Children in Developing Countries, edited by H. Wallace and K. Giri. Oakland, California: Third Party Publishing. Cited in United Nations 1996, p.29. (See note 2.) See also: Senderowitz, J. 1995. Adolescent Health: Reassessing the Passage to Adulthood, World Bank Discussion Paper 272. Washington D.C.: The World Bank.

4. This pattern has been observed even in countries where induced abortion is legal and available. It is also increasing worldwide (See: The Alan Guttmacher Institute. 1995. Women, Families and the Future: Sexual Relationships and Marriage Worldwide. (Fact sheet.) Washington, D.C.: The Alan Guttmacher Institute.).

5. The proportion of women sexually active under age 20 has fallen in Colombia, the Dominican Republic, Mexico, Peru and Trinidad and Tobago and has remained relatively stable in Brazil, Ecuador, El Salvador and Guatemala. (See United Nations 1996 (See note 2.).

6. The findings of 13 country studies have been summarized in: Weiss, Ellen, Daniel Whelan and Geeta Rao Gupta. 1996. Vulnerability and Opportunity: Adolescents and HIV/AIDS in the Developing World: Findings from the Women and AIDS Research Program. Washington D.C.: International Center for Research on Women.

7. Meekers, Dominique. 1993. Sexual Initiation and Premarital Childbearing in Sub-Saharan Africa, Demographic and Health Survey Working Paper No. 5. Columbia, Maryland: Macro System, Inc. Cited in United Nations 1996. (See note 2.)

8. K. Welling, et al. 1994. Sexual Behaviour in Britain. Harmondsworth, United Kingdom: Penguin Books. Cited in United Nations 1996, p. 31. (See note 2.)

9. United Nations 1996, pp. 29ff. (See note 2.) See also: United Nations. 1989a. Adolescent Reproductive Behaviour, vol. 1: Evidence from Developed Countries, Population Studies No. 109 (Sales No. E.86.XIII.5). New York: United Nations.

10. McCauley, Ann P., and Cynthia Salter. 1995. Meeting the Needs of Young Adults, Population Reports, Series J, No. 41. Baltimore, Maryland: Population Information Program, Johns Hopkins School of Public Health.

11. Qualitative studies have documented this as a common theme in focus group discussions.

12. Weiss, Whelan and Gupta 1996. (See note 6.) The individual country studies are particularly revealing of the unease in communications between parents and children of both sexes about sexual matters.

13. United Nations 1996, Box II.1 (See note 2.); and United Nations. 1995. Women’s Education and Fertility Behaviour: Recent Evidence from the Demographic and Health Surveys (Sales No. E.95.XIII.23). New York: United Nations.

14. McCauley and Salter 1995. (See note 10.)

15. Among other particulars, see Article 3: "In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration."; and Article 18: "State Parties shall use their best efforts to ensure recognition that both parents have common responsibilities for the upbringing and development of the child. Parents or, as the case may be, legal guardians, have the primary responsibility for the upbringing and development of the child. . . . The best interest of the child will be their basic concern." (Emphasis added.) (See: United Nations. 1989b. Convention on the Rights of the Child: General Assembly Resolution 25[XLIV]: 44th Session: Supplement No. 49 [A/RES/44/25, reprinted in 28 I.L.M. 1448]; opened for signature 26 January 1990.)

16. For one example which shows how the relatively insensitive measurement tool of social surveys can inform understanding of the marriage process, see: Meekers, Dominique. 1992. "The Process of Marriage in African Societies: A Multiple Indicator Approach." Population and Development Review 18(1): 61-78, 205, 207. This work presents the marriage ceremony in the context of a variety of socially prescribed rites and practices related to formalizing a couple’s relationship. Additional insights emerge from integrated quantitative and qualitative research. See: Meekers, Dominique. 1994. "Combining Ethnographic and Survey Methods: A Study of the Nuptiality Patterns of the Shona of Zimbabwe." Journal of Comparative Family Studies 25(3): 313-328.

17. A consanguineous marriage is one where the husband and wife are related to each other at the level of second cousin or closer.

18. Polygynous unions (multiple wives of a single husband) are far more common than polyandrous unions (multiple husbands of a single wife). The discussion here does not consider any marriage system as inherently posing human rights concerns. Adherence to principles of non-coercion determine the relevance of rights arguments.

19. This section is based on: United Nations. (Forthcoming.) World Population Prospects: The 1996 Revision. New York: Population Division, Department for Economic and Social Information and Policy Analysis, United Nations.

20. These findings are based on formal marriage registration data, not, as in developing regions, on survey reports. Some of the increases in formal marriage age in Northern Europe and North America are offset by increases in premarital cohabitation, either as prelude or alternative to marriage, in those areas.

21. Data presented in: McCauley and Salter 1995. (See note 10.) Note that in regions where marriage age remains low, fewer than 50 per cent of the women were not married by age 20.

22. United Nations 1996. (See note 2.) Based on United Nations. 1990. Patterns of First Marriage: Timing and Prevalence (Sales No. E.91.XIII.6). New York: United Nations.

23. Gage-Brandon, Anastasia J., and Dominique Meekers. 1993. "The Changing Dynamics of Family Formation: Women’s Status and Nuptiality in Togo," Population Research Institute Working Paper No. 1993-02. University Park, Pennsylvania: Population Research Institute, Pennsylvania State University.

24. International Planned Parenthood Federation. 1996. Reproductive Rights, wallchart. London: International Planned Parenthood Federation.

25. Meekers, Dominique, and Nadra Franklin. 1994. "Women’s Perceptions of Polygyny among the Kaguru of Tanzania," Population Research Institute Working Paper in African Demography, No. AD95-01. University Park, Pennsylvania: Population Research Institute, Pennsylvania State University.

26. McCauley, et al. 1994. Opportunities for Women Through Reproductive Choice, Population Reports, Series M, No. 12, pp. 18ff, 27. Baltimore, Maryland: Population Information Program, Johns Hopkins School of Public Health.

27. Information for this section is from: Korea Institute for Health and Social Affairs (KIHASA) and United Nations Population Fund. 1996. Sex Preference for Children and Gender Discrimination in Asia. Seoul: Korea Institute for Health and Social Affairs; see particularly the following sections: Nizamuddin, M., and Iqbal Alam, "Nature of Sex Preference for Children and Gender Discrimination in Asia"; Chang, Gu Bao, and Li Yong Ping, "Sex Ratio at Birth and Son Preference in China"; Cho, Nam-Hoon and Moon-Sik Hong, "Effects of Induced Abortion and Son Preference on Korea’s Imbalanced Sex Ratio at Birth"; Das Gupta, Monica, and Leela Visaria, "Son Preference and Excess Female Mortality in India’s Demographic Transition"; and Leete, Richard, "Son Preference in Asia: Issues and Considerations."

28. Infanticide was considerably more prevalent and accepted historically than it is today. For example, it was part of Western traditions under various institutional frameworks from ancient times through at least the seventeenth century. Information from East Asia suggests very significant declines over the last century. It is currently found largely in remote and rural areas.

29. Comparative under-registration of girl children, also a reflection of their lower valuation, and other technical issues complicate precise estimation.

30. Isaacs, Stephen L. 1995. "Incentives, Population Policy and Reproductive Rights: Ethical Issues." Studies in Family Planning 26(6): 363-367. New York: The Population Council.

31. Ross, John A., and W. Parker Mauldin. 1996. "Family Planning Programs: Efforts and Results: 1972-94." Studies in Family Planning 27(3). New York: The Population Council; and the database provided by the authors. Reliance on incentives either to various providers and/or clients varied from: highest levels, China, India, the Republic of Korea, Singapore and Vietnam; more limited use, Bangladesh, Taiwan (Province of China). Indonesia and the Democratic People’s Republic of Korea; more moderate use, Egypt, Nepal, Sri Lanka, Malaysia, Mexico, the Philippines, the United Republic of Tanzania and Thailand; and lower levels in Brazil, Colombia, the Dominican Republic, El Salvador, Honduras, Pakistan, Somalia, Tunisia, Liberia and Ecuador. Many of these countries are reassessing their practices in the light of the international consensus achieved at the ICPD.

32. Some writers have noted the pronatalist biases inherent in many social systems, and the impact of rapid population growth on prospects for development in poor countries, as justifying the principled offering of non-coercive incentives to families to limit their fertility (see, for example: Hollingsworth, William G. 1996. Ending the Explosion: Population Policies and Ethics for a Humane Future. Santa Ana, California: Seven Locks Press. Mr. Hollingsworth presents complex and nuanced arguments in favor of specific incentive schemes for multisectoral population and development programmes and offers his views on how these would address various ethical concerns.). The international community, in part because of recognition of potentials for abuse of rights, stressed voluntary approaches and urged priority, particularly, to education.

33. Heise, Lori. 1993. "Violence Against Women: The Missing Agenda." In The Health of Women: A Global Perspective, p. 171, edited by Marge Koblinsky, Judith Timyan and Jill Gay. 1993. Boulder, Colorado: Westview Press. The following discussion is indebted to this and other work of Ms. Heise and her colleagues.

34. This is an adaptation of the definition offered by Heise 1993 (see note 33) itself based on a definition of domestic violence offered by: Antony, Carmen, and Gladys Miller. 1986. "Estudio Exploratorio Sobre el Maltrato Físico de que es Víctima la Mujer Panameña." Panama City: ICRUP/Ministerio de Trabajo y Bienestar Social.

35. Engle, Patrice. 1994. Men in Families: Report of a Consultation on the Role of Men and Fathers in Achieving Gender Equity. New York: UNICEF.

36. Heise 1993 (see note 33) cites surveys of anthropological data sources which document physical violence against women in over 70 of 90 studied societies or groups, including: Levinson, David. 1989. Violence in Cross-Cultural Perspective. Newbury Park: Sage Publications; and Counts, Dorothy Ayers, Judith K. Brown and Jaquelyn C. Campbell. 1992. Sanctions and Sanctuary: Cultural Perspectives on the Beating of Wives. Boulder, Colorado: Westview Press.

37. This section uses materials presented in: Heise, Lori, Kirsten Moore and Nahid Toubia. 1995. Sexual Coercion and Reproductive Health: A Focus on Research. New York: The Population Council.

38. United Nations. 1995. Violence against Women. New York: Department of Public Information, United Nations; also, American Medical Association, "Sexual Assault in America." 6 November 1995.

39. In the United States, women who have been raped or beaten have medical costs in that year two and a half times greater than other women. This makes a history of rape or assault a stronger predictor of physician visits or outpatient costs than any other variable, including age and health risks like smoking. (See: World Health Organization. 1996. Presentation by Dr. Liljestrand to UNFPA, November 1996; and Schwartz, I.L. 1991. "Sexual Violence against Women: Prevalence, Consequences, Societal Factors and Prevention." American Journal of Preventive Medicine 7[6]: 363-373.)

40. This figure was for the period 1987-89, the latest available. "U.S. Women at Higher Risk of Rape than European Women, U.N. Says," Associated Press (Report on an Economic Commission for Europe publication), Geneva, 12 December 1995.

41. Lederer, Edith M. 1996. "Sexual Exploitation of Women," AP Worldstream, 6 June 1996. (Report on panel discussion in Istanbul related to the World Congress on the Sexual Exploitation of Children, prior to Habitat II Conference.)

42. "China Police Nab 61 for Kidnapping Women, Children," Reuters World Service, 26 November 1996. (Report from Beijing disseminating China News Service story.)

43. McEvoy, Janet. 1996. "EU to Tackle Smuggling of Women from Eastern Europe," Reuters World Service, 6 June 1996.

Chapter 4

1. Adair, Linda, David Guilkey, and Elizabeth Bisgrove. 1996. "Effects of Childbearing on Filipino Women’s Labour Force Participation and Earnings." Paper presented at the Annual Meeting of the Population Association of America, New Orleans, Louisiana, 6-11 May 1996.

2. Jejeebhoy, Shireen J. 1995. Women’s Education, Autonomy, and Reproductive Behaviour: Experience from Developing Countries, International Studies in Demography Series. New York: Oxford University Press.

3. Simmons, Ruth. 1996. "Women’s Lives in Transition: A Qualitative Analysis of the Fertility Decline in Bangladesh." Studies in Family Planning 27(5). New York: The Population Council.

4. See: Schuler, Sidney Ruth, Syed M. Hashemi and Ann P. Riley. 1996. "Credit Programs and Women’s Empowerment in Bangladesh." Paper presented at the 1996 Annual Meeting of the Population Association of America, New Orleans, Louisiana, 9-11 May 1996; and Dixon-Mueller, Ruth. 1993. Population Policy and Women’s Rights: Transforming Reproductive Choice, Chapters 5 and 6. Westport, Connecticut: Praeger. Further studies being conducted under the Women’s Study Project of Family Health International directed by Nancy Williamson were reported at these meetings.

5. Gage, Anastasia J. 1995. "Women’s Socioeconomic Position and Contraceptive Behavior in Togo." Studies in Family Planning 26(5). New York: The Population Council.

6. Economic power was indicated by, in decreasing order: works for cash and participates in rotating credit and savings schemes; works for cash but does not invest; and does not work for cash.

7. Control over selection of spouse was indicated by, in decreasing order: women who selected their partners without the advice of their family; women who acted with family advice; and women whose partner was selected (arranged) by the family.

Chapter 5

1. See particularly: United Nations. 1995. World’s Women 1995: Trends and Statistics: Social Statistics and Indicators (ST/ESA/STAT/SER.K/12). New York: United Nations.

2. Project activities in Ghana, Egypt and Indonesia were described at the UNFPA Thematic Workshop on Gender, Population and Development, UNFPA, New York, 30 September-3 October 1996.

3. During 1994-1995 the USAID-funded Evaluation Project produced a series of volumes of indicators for assessing family planning programmes (Bertrand J., R. Magnani and J. Knowles (eds.). 1994. Handbook of Indicators for Family Planning Program Evaluation [Supported by USAID contract DPE-3060-C-00- 1054-00]. Chapel Hill, North Carolina: The Evaluation Project, Carolina Population Center; and the series Indicators for Reproductive Health Program Evaluation, December 1995, including: Galloway, Rae, and Allison Cohn (eds.). Final Report of the Subcommittee on Women’s Nutrition; O’Gara, Chloe, Martha Holley Newsome and Claire Viadro (eds.). Final Report of the Subcommittee on Breastfeeding; and Koblinsky, Marge, et al. (eds.). Final Report of the Subcommittee on Safe Pregnancy.) This series has been extended to include other components of comprehensive reproductive health programmes. WHO has been working on guidelines, standards and indicators for reproductive health programmes. UNFPA has also initiated consultations to further develop, compare and disseminate indicators within the UN system. In February 1997, participants from national programmes, specialized agencies, bilateral assistance organizations and international financial institutions met to seek consensus on a set of reproductive health indicators. Continued collaboration is expected to forge agreements on a common framework for assessing and improving programme performance.

4. See especially: Amnesty International. 1995. Human Rights are Women’s Rights. New York: Amnesty International; the publications of Human Rights Watch/Women’s Rights Group, including: The Human Rights Watch Global Report on Women’s Human Rights. 1995. New York: Human Rights Watch; and the bibliographies and databases of Human Rights Internet (e.g., 1995. The Human Rights Internet Reporter 15[2], an issue devoted to "Women’s Rights as Human Rights").

5. For example, the World Congress Against Commercial Sexual Exploitation of Children, Stockholm, August 1996.

6. An accessible international database of these materials is being compiled by Human Rights Internet on the World Wide Web (http://www.hri.ca).

7. United Nations. 1995. Population and Development, vol. 1: Programme of Action adopted at the International Conference on Population and Development: Cairo: 5-13 September 1994 (Sales No. E.95.XIII.7), Paragraphs 7.19- 7.20. New York: Department for Economic and Social Information and Policy Analysis, United Nations.

8. See: Lynam, Pamela, Leslie McNeil Rabinowitz and Mofoluke Shobowale. 1993. "Using Self-assessment to Improve the Quality of Family Planning Services." Studies in Family Planning 24(4): 252-260. New York: The Population Council.

9. UNFPA. 1997. "Rapid Assessment Procedures for Reproductive Health" (Draft Technical Paper). New York: UNFPA.

Special Report

1. UNFPA. 1996. Report of the Second Annual Meeting of the Non-governmental Organization Advisory Committee to UNFPA, 16-17 May 1996. New York: UNFPA

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