UNFPAState of World Population 2002
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Report 1997
THE RIGHT TO CHOOSE:

Reproductive Rights and Reproductive Health
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Summary

Denial of Reproductive Rights Kills or Harms Millions of Women and Impedes Progress Towards Equality and Development

UNITED NATIONS, New York, 28 May 1997—Gaps and failures in reproductive health care, combined with widespread discrimination and violence against women, amount to a massive violation of human rights. Denial of sexual and reproductive rights–including free choice with regard to pregnancy and childbearing–causes millions of deaths every year, and much more illness and disability. Most of those affected are women, the vast majority in developing countries.

These human rights violations, and efforts to end them, are the focus of The State of World Population 1997 report by the United Nations Population Fund (UNFPA). The report, titled “The Right to Choose: Reproductive Rights and Reproductive Health”, summarizes the international understandings that define sexual and reproductive rights, presents evidence on progress and problems in attaining and protecting those rights, and examines the effects of denying them to millions of women and men.

To enable individuals to exercise their sexual and reproductive rights, the report stresses the need for gender equality and increased investment in education and primary health care. Specific recommendations focus on improving the availability and quality of information and services that meet a broad range of sexual and reproductive health needs.

At the International Conference on Population and Development (ICPD) in 1994, 180 nations agreed that quality reproductive health information and services should be available to everyone by the year 2015. The UNFPA report reviews the considerable progress countries have made in implementing the conference recommendations, and presents statistical indicators describing the current situation.

“The international community has agreed repeatedly that reproductive health is a right for both women and men,” said Dr. Nafis Sadik, Executive Director of UNFPA. “The challenge now is to make this right a reality for every individual.”

The ICPD estimated that providing better reproductive health care worldwide will cost $17 billion annually by the year 2000–less than the world currently spends each week on armaments. But while many governments have increased their allocations for population programmes since 1994, annual global expenditures are only slightly above half the $17 billion mark.

Building on human rights treaties, the ICPD recognized a core set of sexual and reproductive rights: the right to reproductive and sexual health, throughout the life cycle; reproductive self-determination, including the rights to voluntary choice in marriage, and to have the information and means to determine the number, timing and spacing of one’s children; equality and equity for men and women in all spheres of life; and sexual and reproductive security, including freedom from sexual violence and coercion.

The State of World Population 1997 documents the effects of denying these sexual and reproductive rights:

  • 585,000 women–one every minute–die each year from pregnancy-related causes, nearly all in developing countries. Many times this number are disabled as the result of childbirth. Much of this death and suffering could be averted with relatively low-cost improvements in health care systems.

  • About 200,000 maternal deaths per year result from the lack or failure of contraceptive services.

  • 120-150 million women who want to limit or space their pregnancies are still without the means to do so effectively. Altogether 350 million couples lack information about and access to a range of contraceptive services.

  • At least 75 million pregnancies each year (out of about 175 million) are unwanted; they result in 45 million abortions, 20 million of which are unsafe.

  • 70,000 women die each year as a result of unsafe abortion, and an unknown number suffer infection and other health consequences. Many unsafe abortions could be avoided if safe and effective means of contraception were freely available.

  • 3.1 million people were infected last year by the human immunodeficiency virus (HIV) which leads to AIDS; 1.5 million died from HIV/AIDS-related causes in 1996; 22.6 million people are living with HIV/AIDS.

  • 1 million people die each year from reproductive tract infections including sexually transmitted diseases (STDs) other than HIV/AIDS. More than half of the 333 million new cases of STDs per year are among teenagers.

  • 120 million women have undergone some form of female genital mutilation; another 2 million are at risk each year.

  • Rape and other forms of sexual violence are rampant, though many rapes are unreported because of the stigma and trauma associated with rape and the lack of sympathetic treatment from legal systems.

  • At least 60 million girls who would otherwise be expected to be alive are “missing” from various populations as a result of sex-selective abortions or neglect.

  • 2 million girls between ages 5 and 15 are introduced into the commercial sex market each year.

The UNFPA report stresses that sexual and reproductive rights are key to women’s empowerment and gender equality, and are also critical to the economic and social life of communities, nations and the world. Global and national needs coincide with personal rights and interests. Given the choice, most women would have fewer children than their parents’ generation. Ensuring that women and their partners have the right to choose will support a global trend towards smaller families, and help countries find a balance between their populations and resources. Successful development efforts will in turn bring sexual and reproductive health to more people.

The Legal Framework for Sexual and Reproductive Rights
Reproductive and sexual rights are implied by long-established human rights: to life and survival; liberty and personal security; equal treatment; education; information; development; and the highest attainable standard of health. The State of World Population report highlights the relevant guarantees in the United Nations Charter, the Universal Declaration of Human Rights, the two human rights covenants (on civil and political rights, and on economic, social and cultural rights), and the conventions on the rights of children and on eliminating discrimination against women.

These international instruments forbid states to interfere with individual freedoms, and obligate them to actively promote the exercise of rights. United Nations’ mechanisms for monitoring national compliance with human rights treaties therefore offer powerful support for legal, political and social actions intended to ensure reproductive and sexual health and rights.

Agreements reached at the ICPD and the Fourth World Conference on Women (FWCW) in 1995 also protect reproductive and sexual health. These international consensus documents, while not legally binding, can influence national lawmaking and policies, and can help the human rights treaty monitoring bodies to set standards and make recommendations. The FWCW Platform for Action, for example, calls on governments to protect women’s “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”.

A growing number of countries are incorporating sexual and reproductive rights into their constitutions, legal codes and institutional procedures. Many national population and development strategies now focus on meeting individuals’ reproductive health needs instead of on fertility reduction.

Rights for Sexual and Reproductive Health
In most societies, women’s social status and economic opportunities are largely determined by their reproductive role, which has been simultaneously over-valued and under-supported. Enabling women to control the timing and frequency of pregnancy has made it possible to discuss reproductive roles in terms of rights. Nearly 60 per cent of couples in the developing world use contraception, up from 15 per cent 30 years ago. While the right to health is recognized almost universally, women carry a heavy and largely avoidable burden of poor health related to reproduction and sexuality:

Malnutrition and anaemia—caused by poverty and aggravated by gender inequality—contribute to many of the problems found in pregnancy and delivery, and play a part in many maternal deaths.

Complications of pregnancy—obstructed labour, haemorrhage and post-partum infection— could be reduced dramatically by prenatal examinations, wider availability of trained birth attendants, and prompt referral to emergency obstetric care. Many lives could be saved if more women were able to avoid pregnancy as teenagers or after age 35, or too soon after having given birth.

Sexually transmitted diseases disproportionately afflict women, particularly young women. Women’s biological susceptibility to STDs is aggravated by social realities; young women especially may be forced into sex or have little power to negotiate condom use with older sexual partners. Sexually active adolescents are especially vulnerable to STDs, but most know very little about them.

The HIV/AIDS pandemic continues to destroy families and communities in Africa and elsewhere, and is spreading rapidly in much of Asia and countries of the former Soviet Union. About 42 per cent of infected adults are women, and the proportion is growing; most newly infected adults are between ages 15 and 24. Men’s concern about contracting HIV has led to increasing sexual exploitation of girls.

Abortion done under unsafe conditions is a significant public health risk. In Latin America, one in five clandestine abortions leads to complications and subsequent hospitalization. Many women who resort to abortion would use contraception if given a choice.

Female genital mutilation (FGM) has horrific short- and long-term effects on the health of girls and women; it is often carried out under unhygienic conditions. The international community has condemned the practice, yet it remains widespread in some 28 countries. Several non-governmental organizations are working to eliminate FGM, and to show that traditional practices can change without compromising values.

Reproductive Health Services
The right to health and the right to determine the number and spacing of one’s children imply a right to reproductive health services that respect and promote clients’ rights, respond to their needs and desires, and facilitate individual choice and informed consent. Despite considerable progress over the last two decades, this right remains far from realization in most countries.

Population growth and “structural adjustment” programmes have lowered per capita allocations for primary health care, reducing the availability and quality of services and lowering life expectancy, particularly in sub-Saharan Africa. Public health reforms–to provide a range of services under one roof, emphasize training, and make the most of limited staff and funds–have only just begun, supported by non-governmental organizations.

Since the ICPD, many reproductive health programmes have put more emphasis on the quality of care offered to clients. This involves offering a full range of services, including a choice among contraceptive methods, sensitive counselling and complete and accurate information. Various barriers (formal and informal) impede access to reproductive health information and services– particularly to adolescents, both married and unmarried; spousal consent requirements in many countries effectively deny contraceptive services to many women. The ICPD emphasized that programmes must fully respect the right to informed reproductive choice; coercion in any form is unacceptable. National targets for limiting population growth are ineffective and may lead to coercive practices.

Adolescent Sexuality
Teenage mothers face a higher-than-average risk of maternal death, and their children have higher levels of morbidity and mortality. Early marriage and childbearing also impede young women’s educational and employment opportunities. Both premarital sexual activity among teenagers and the average age at which young women marry have increased in many societies in recent decades, particularly in industrialized countries. In many places, however, early marriage and childbearing are still the norm. High levels of adolescent pregnancy, childbearing and unsafe abortion reflect a lack of educational and economic opportunities.

Young people are typically poorly informed about how to protect against unwanted pregnancy and STDs including HIV/AIDS. Parents are often uncomfortable talking to children about sexual matters, and young people get information (much of it incorrect) from their peers. Contrary to the myth that sex education leads to promiscuity, experience indicates that it encourages responsible sexual behaviour.

Worldwide, there is increasing agreement that adolescents need unrestricted access to information, and to private and confidential reproductive health services.

Choice in Marriage and Forming Families
Age and educational differences between husbands and wives, while narrowing in many countries, continue to reinforce stereotypes of female dependency. Laws defining a minimum age of marriage are not always enforced, and typically apply only when parental consent is lacking; young people often lack legal protection from forced marriages. Young couples often face strong pressure to begin childbearing immediately after marriage, and to go on having children until they produce sons.

In some countries, sons are often better fed and receive more medical attention than daughters. As fertility levels have fallen, notably in parts of Asia, son preference has led to sex-selective abortion, resulting in an abnormal excess of boys born compared to girls, especially after the first birth. Surveys show that men and women generally know how many children they would like to have, and increasingly know about modern contraceptives and where to find them. But spouses often fail to discuss family size desires, limiting the practice of family planning.

Violence Against Women
Violence against women may be the most pervasive yet least recognized human rights abuse in the world. Gender violence, physical or emotional, perpetuates male power and control. Studies link violence against women to male socialization and peer pressure, rather than biology or sexuality. Eighty per cent of women raped already know their attackers. The majority of sexual assault victims are young. Women subjected to rape and assault face numerous health risks, including severe injuries, mental illness, sexually transmitted diseases and unwanted pregnancy.

Rape in time of war and other emergency situations is still common. In the former Yugoslavia, Rwanda and elsewhere, it has been used systematically as an instrument of torture or ethnic domination.

Sexual exploitation and trafficking in children affects tens of millions of children worldwide. In developing countries, the sex industry draws girls from poor rural families to cities. Many commercial sex workers in developed countries are from poorer countries. Sex workers are particularly at risk from STDs and HIV infection.

Gender Equality and Male Involvement
Women’s social empowerment and economic security clearly contribute to, and depend on, good reproductive health. But their access to reproductive health services is constrained by their lack of resources, restrictions on social participation, and limited access to information due to illiteracy. Men are frequently insensitive to women’s reproductive and sexual health needs. Boys and men need to learn to be responsible in sexuality and parenthood, and to understand the risks women face from harmful traditional practices, sexual initiation too early in life, and when they or their spouses have multiple partners. Because men dominate positions of power, they have a key role to play in eliminating gender inequality.

Education of girls is a key factor in improving family health, reducing infant mortality and changing reproductive behaviour. Globally, nearly 600 million women remain illiterate, compared with about 320 million men.

Recommendations
The State of World Population 1997 report calls for greater attention to human rights, especially the promotion of gender equality and women’s empowerment. This requires legal reforms, better enforcement of existing laws, new procedures to document violations, education about human rights, and alliances among institutions concerned with rights. International assistance programmes should give greater priority to human rights goals. To combat the poverty that prevents the exercise of sexual and reproductive rights, the report advocates increasing women’s access to credit and economic resources. It stresses the value of both general education and specific education on sexual and reproductive health.

The report calls for greater investment in primary health care, particularly for sexual and reproductive health. Health services should be restructured to focus on the reproductive and sexual health needs of clients, including underserved groups, using new guidelines, standards of conduct and evaluation methods. Non-governmental organizations and the private sector must help design, implement and monitor programmes.

Implementing the ICPD Programme of Action
A special section, based on reports from UNFPA field offices, describes national implementation of the ICPD Programme of Action: revisions of population and development policies and related institutions; legal and constitutional reforms to protect women’s rights and promote gender equality; and reorganization of health services to reduce maternal mortality and address the full range of reproductive health concerns. The report notes that while many developing countries have made important progress, many others suffer from a shortage of funds and trained personnel.

The ICPD Programme of Action estimates that a basic package of population and reproductive health programmes for developing countries will require some $17 billion annually by the year 2000, and $21.7 billion by 2015; about two thirds of these global costs will have to come from domestic resources, and about one third from the donor community.

For further information:
Information and External Relations Division
United Nations Population Fund
220 E. 42nd Street
New York, NY 10017, USA
Telephone: (212) 297-5020
Fax: (212) 557-6416
Email: ryanw@unfpa.org

The State of World Population 1997

Editor: Alex Marshall
Research and Writing: Stan Bernstein
Managing Editor: William A. Ryan
Editorial Assistant: Phyllis Brachman

Last modified: 24 April 2001