The Lancet (UK), November 4, 2006
Cairo
after 12 years: successes, setbacks, and
challenges
By Ana Langer
In September, 1994, thousands of policymakers,
activists, health specialists, and members
of the donor community gathered in Cairo,
Egypt, for what turned out to be a unique
UN International Conference of Population
and Development (ICPD), a true turning
point. The Cairo conference put the ideas
of comprehensive sexual and reproductive
health and rights, choice, women's empowerment,
a life-cycle approach, and gender equity
at the centre of the international agenda,
and signalled the end of the so-called
population era. Instead of pursuing demographic
targets via family-planning programmes,
the goals of the ICPD Programme of Action
(signed by 179 countries) were to achieve
universal access to safe, affordable,
and effective reproductive health care
and services, including those for young
people, and promoted a gender perspective.1
The package of services incorporated family
planning information and contraceptives,
skilled care at pregnancy and childbirth,
safe abortion services where and when
abortion is legal, and treatment and management
of sexually transmitted infections and
HIV/AIDS. Governments set a realistic
timeframe of 20 years (ie, to 2015), to
accomplish the goals established in the
Programme of Action.1
Where are we now, 12 years after Cairo?
What have been the main successes and
where have we fallen short? This Comment
and other articles in The Lancet Sexual
and Reproductive Health Series describe
achievements and setbacks, as well as
the challenges that have been faced for
more than a decade.2,3
During the past 12 years, commitment to
the Cairo Programme of Action has been
reaffirmed in several follow-up conferences.
But despite the affirmations, the visibility
of sexual and reproductive health and
rights on the international development
and political landscape has decreased.
The most obvious evidence of a diminished
focus is probably the fact that the Millennium
Development Goals (MDGs), which provide
the current framework for development
efforts, did not include the attainment
of sexual and reproductive health and
rights as an explicit goal. But the accomplishment
of every MDG will be possible only if
gender inequities are overcome, and at
least three of the eight MDGs are at the
core of the Cairo agenda (numbers 4, 5,
and 6).4
During the past 5 years, this glaring omission
has been redressed to some extent. In
March, 2005, the fundamental role of sexual
and reproductive health and rights in
development was highlighted by the UN
Secretary-General Kofi Annan in what was
probably his most important speech so
far about achieving gender equity as part
of the MDGs.5 The UN Millennium Project
has since provided concrete recommendations
to move the agenda forward.6 Furthermore,
because of the advocacy efforts of national
and international non-governmental organisations,
universal access to sexual and reproductive
health and rights will probably be adopted
as an explicit target under the MDGs.3
For real change to benefit the sexual and
reproductive health and rights of billions
of people, it must take place and become
sustainable at the national level.2 Progress
in countries has been uneven and, in many
cases, not well documented. Among the
successes, most nations are giving far
more attention to sexual and reproductive
health and rights now than 12 years ago,
and have been working hard to create better
policies and improve access to information
and services. Data from demographic health
surveys and national health-information
systems show some improvement in the use
of key services, such as family planning
and skilled attendance at delivery.7 Access
to reproductive health services for all
individuals through primary health care
has not been simple, especially for the
most isolated, underserved, and poorest
communities.8The Lancet Sexual and Reproductive
Health Series provides an overview with
updated information and analysis about
specific topics within the broad specialty
of sexual and reproductive health.
Why is a straightforward picture of the
current status of sexual and reproductive
health and rights at the country level
so difficult to provide? First, the variety
of conditions that prevail in different
settings and population groups make summary
statements unreliable and unrealistic.
Moreover, average figures often hide huge
disparities between socioeconomic strata
or age cohorts.9 Second, the comprehensiveness
of the agenda for sexual and reproductive
health and rights poses serious methodological
challenges in terms of monitoring and
assessment. Indeed, to measure progress
of such a construct needs a large and
complex system of indicators. Unfortunately,
major stakeholders have achieved only
a small consensus on a core set of indicators
that have empirical coherence and that
can be communicated to the policymakers
and financial authorities who allocate
resources.10,11 In fact, no common data
system exists to ensure the calculation
of indicators at one point in time, and
even fewer data are available at many
points to show trends. Third, the societal
and cultural roots of many sexual and
reproductive health problems pose an additional
measurement challenge. Fourth, in many
cases large-scale national surveys are
the only source of data, because routine
national health-information systems are
weak or non-existent. Finally, in general,
we have few data about access to key reproductive
health services, such as postnatal care,
counselling and services for young people,
sexually transmitted infections, abortion,
and postabortion care.
What is undeniable is that problems in sexual
and reproductive health are still a high
priority for developing countries.12 Why
have we not moved forward as effectively
and quickly as was expected in 1994? Two
closely intertwined factors have contributed
to the persistence of these unmet needs:
reduced funding and ideological resistance
to the sexual and reproductive health
and rights paradigm in an increasingly
conservative environment.
As Anna Glasier and colleagues describe
in the first paper of this Series,2 sexual
and reproductive health, apart from HIV/AIDS,
has failed to attract the financial resources
that were expected from the donor community,
especially in the fields of family planning,
unsafe abortion, and sexually transmitted
infections. Insufficient international
support from donors is often attributed
to the incapacity of the sexual and reproductive
health community to sell such a complex
concept, and to show in a clear and compelling
way that improvement is achievable. Indeed,
the ICPD definition is too comprehensive
to measure, explain, or communicate easily.
The use of this broad model could have
diverted attention to the different components
of sexual and reproductive health and
rights. Moreover, the misperception that
the population crisis is over has further
reduced resources for family planning,
one of the pillars of reproductive health
and women's empowerment. Donor fatigue
and the financial downturn in the US economy
in the early years of this decade have
also limited the financial support to
sexual and reproductive health.
Resources from developing countries have
fallen short. Many of the promised changes
have remained at the stage of policy pronouncements
and have not reached implementation because
of a lack of political will (especially
on sensitive issues such as adolescent
sexuality and abortion), an absence of
financial commitment, little technical
expertise, and competing priorities.
Increased conservatism in some donor countries
has taken a heavy toll on the efforts
to advance the international agenda on
sexual and reproductive health and rights.
Indeed, contrary to scientific evidence,
conservative forces interpret the ICPD
Programme of Action's call for information
and services for young people as promoting
promiscuity and irresponsible behaviour.
This misconception has grave consequences
for all efforts to encourage the effective
and consistent use of condoms and contraceptives
in young people. Furthermore, constant
attacks by conservative forces on all
issues that relate to sexuality and abortion-as
discussed in The Lancet Sexual and Reproductive
Health Series-limit or prevent access
to several services and technologies that
should be used to improve sexual and reproductive
health and rights. This situation exposes
millions of women, men, and young people
to HIV/AIDS, unwanted pregnancies, and
unsafe and illegal abortions.
Despite these challenges, important new
technological instruments have been added
to the sexual and reproductive health
armamentarium over the past 12 years.
First, access to antiretroviral drugs
has substantially increased in dozens
of developing countries. Programmes have
been especially effective in preventing
the transmission of HIV from infected
mothers to fetuses and newborn babies.13
Second, a safe and effective vaccine against
human papillomavirus (and therefore cervical
cancer) was approved by the US Food and
Drug Administration only a few months
ago.14 This technology represents a very
promising opportunity to prevent one of
the primary causes of death in women of
reproductive age in developing countries.
In the past 12 years, the sexual and reproductive
health and rights community has come a
long way: the Cairo model is now a mainstream
notion among activists, programmers, policymakers,
and academics. We are now more aware of
the complex interactions between social,
political, cultural, and health factors
that shape reproduction and sexuality.
We have brought the movements for HIV/AIDS
and sexual and reproductive health and
rights closer together.15,16 We know our
challenges better, and have more evidence
about what works. Indeed, to achieve real
impact, a comprehensive approach that
improves access to services and their
quality, supports functional health systems,
community participation, and an enabling
environment is mandatory. Renewed efforts
building on lessons learned so far and
sustained commitment, both internationally
and nationally, will contribute to the
achievement of the ICPD goals 8 years
from now.
I declare that I have no conflict of interest.
________________________________________
Sexual
and reproductive health: a matter of life
and death
BYLINE: Anna Glasier a, * MD, Anna.Glasier@lpct.scot.nhs.uk;
A Metin Gülmezoglu b PhD; George
P Schmid c MD; Claudia Garcia Moreno d
MD; Paul FA Van Look b MD
Despite the call for universal access to
reproductive health at the 4th International
Conference on Population and Development
in Cairo in 1994, sexual and reproductive
health was omitted from the Millennium
Development Goals and remains neglected
(panel 1). Unsafe sex is the second most
important risk factor for disability and
death in the world's poorest communities
and the ninth most important in developed
countries. Cheap effective interventions
are available to prevent unintended pregnancy,
provide safe abortions, help women safely
through pregnancy and child birth, and
prevent and treat sexually transmitted
infections. Yet every year, more than
120 million couples have an unmet need
for contraception, 80 million women have
unintended pregnancies (45 million of
which end in abortion), more than half
a million women die from complications
associated with pregnancy, childbirth,
and the postpartum period, and 340 million
people acquire new gonorrhoea, syphilis,
chlamydia, or trichomonas infections.
Sexual and reproductive ill-health mostly
affects women and adolescents. Women are
disempowered in much of the developing
world and adolescents, arguably, are disempowered
everywhere. Sexual and reproductive health
services are absent or of poor quality
and underused in many countries because
discussion of issues such as sexual intercourse
and sexuality make people feel uncomfortable.
The increasing influence of conservative
political, religious, and cultural forces
around the world threatens to undermine
progress made since 1994, and arguably
provides the best example of the detrimental
intrusion of politics into public health.
This is the first in a Series of six
articles about sexual and reproductive
health
The international community has been concerned
about population growth for more than
a century. In 1994, at the most recent
of a series of UN conferences devoted
to population, delegates from the governments
of 179 countries and more than 1200 non-governmental
organisations (NGOs) met in Cairo at the
International Conference on Population
and Development (ICPD) and agreed a 20-year
programme of action to improve sexual
and reproductive health, foster reproductive
rights, and stabilise the world's population.1
Unlike previous population conferences,
the Cairo conference reflected the growing
awareness that population, poverty, health,
education, patterns of production and
consumption, and the environment are all
inextricably linked. Although these links
now seem obvious, at the time this awareness
represented a major shift in attitude
towards population growth. Another major
shift in attitudes was in the 15 guiding
principles underpinning the programme
of action, which incorporated several
universally recognised human rights. These
rights included the recognition that advancement
of gender equality and equity and the
empowerment of women, and the elimination
of all kinds of violence against women,
and ensuring women's ability to control
their own fertility, are cornerstones
of population and development-related
programmes.1
The link between fertility regulation and
development goals in the context of human
rights changed the focus of governments
and NGOs from classic population-control
policies and large-scale family planning
programmes to recognition of the needs
and rights of individuals. Through the
Cairo conference, the notions of reproductive
health and reproductive rights were defined
and universally applied. The Cairo definition
of reproductive health is long and includes
sexual health (panel 2). The emphasis
on sexual health as a separate public
health issue arose later as a result of,
inter alia, the HIV pandemic, increasing
global rates of sexually transmitted infections,
and the growing recognition of the public
health importance of issues such as violence
against women and girls (panel 3).
Sexual health and reproductive health overlap
and, in addition to supporting normal
physiological functions such as pregnancy
and childbirth, aim to reduce adverse
outcomes of sexual activity and reproduction.
They are also about enabling people of
all ages, including adolescents and those
older than the reproductive years, to
have safe and satisfying sexual relationships
by tackling obstacles such as gender discrimination,
inequalities in access to health services,
restrictive laws, sexual coercion, exploitation,
and gender-based violence.
Sexual and reproductive health services
are not only family planning clinics with
some treatment of sexually transmitted
infections. The five core components of
sexual and reproductive health care are:
improvement of antenatal, perinatal, postpartum,
and newborn care; provision of high-quality
services for family planning, including
infertility services; elimination of unsafe
abortions; prevention and treatment of
sexually transmitted infections, including
HIV, reproductive tract infections cervical
cancer, and other gynaecological morbidities;
and promotion of healthy sexuality.2
In 1994, at the ICPD, governments agreed
to provide "universal access"1
to reproductive health by 2015 as part
of a package for improvement of people's
health and wellbeing, reduction of population
growth, and promotion of sustainable development.
Practically, the burden of ill-health
can be reduced only if access to affordable
services that deliver high-quality sexual
and reproductive health care becomes universal.
The ICPD consensus was reaffirmed at the
UN General Assembly Special Session in
1999,3 yet the central ICPD goal of universal
access to reproductive health was excluded
from the 2000 Millennium Declaration4
and from the eight Millennium Development
Goals (MDGs) formulated in 2001.5 However,
this exclusion is becoming recognised
as a mistake since sexual and reproductive
health is now regarded as essential for
achievement of all MDGs.6 Accordingly,
at the World Summit in September, 2005,
governments re-committed themselves to
achieve universal access to reproductive
health by 2015.7
Sexual and reproductive health should not
be difficult to achieve. We have methods
of contraception (including reversible
ones) that prevent almost all unwanted
pregnancies.. Simple technologies that
have existed for decades make childbirth
in the 21st century very safe. People
can be taught skills that enhance safe-sex
practices and most sexually transmitted
infections are treatable; even HIV is
no longer the death sentence it once was.
Yet worldwide, the burden of sexual and
reproductive ill-health remains enormous.
WHO identified unsafe sex as the second
most important risk factor for disease,
disability, or death in the poorest communities
and the ninth in developed countries (table).8
Sexual and reproductive health statistics
make for sobering reading, although such
statistics are at best estimates (and
probably underestimates because of stigma
associated with sexual issues).
Every year, an estimated 210 million women
have life-threatening complications of
pregnancy, often leading to serious disability,
and a further half a million women die
in pregnancy, childbirth, and the puerperium
(more than 99 of these deaths are in developing
countries).9 Three million babies die
in the first week of life and about 3•3
million infants are stillborn every year.10,11
More than 120 million couples have an
unmet need for contraception12 and 80
million women each year have unwanted
or unintended pregnancies, 45 million
of which are terminated.13 Of these 45
million abortions, 19 million are unsafe,
40 of them are done on women aged under
25, and about 68000 women die every year
from complications of unsafe abortion.14
An estimated 340 million new cases of four
common sexually transmitted bacterial
and protozoal infections are acquired
every year, at least a third of which
affect people aged under 25.15 Such infections
contribute to the global problem of infertility,
which affects more than 180 million couples
in developing countries (excluding China).16
Nearly 5 million new HIV infections17
and 257000 deaths from cervical cancer
every year18 complete this long and dismal
record of sexual and reproductive ill-health.
Physical and sexual violence, reported
by between one in two and one in six women,
is an underlying risk factor for many
of these sexual and reproductive health
problems.19
Antenatal, perinatal, postpartum, and
newborn care
Despite some accomplishments, maternal mortality
rates in many countries have remained
more or less static in the past 15 years,
and more than half a million maternal
deaths take place each year. Yet, in the
21st century, no excuses can be made for
so many women dying in pregnancy and childbirth.
The burden of maternal morbidity and mortality
shows one of the largest differentials
between rich and poor countries.20 WHO's
systematic review of maternal mortality
and morbidity points to some important
regional differences in the contribution
of the major causes of deaths.21
The international emphasis on prevention
and treatment of postpartum haemorrhage
seems well justified in view of data from
Africa and Asia, where 33.9 and 30.8 of
maternal deaths, respectively, are attributable
to this complication. Additionally, anaemia
(12•8), infections or sepsis (11•6),
and obstructed labour (9•4) account
for substantial proportions of maternal
deaths in Asia (figure 1). Hypertensive
disorders continue to be a major cause
of mortality, especially in Latin America.
Unsurprisingly, HIV infection is emerging
as an important cause of maternal death
in Africa (6•2).
Maternal deaths from obstructed labour are
consigned to history in the developed
world, where cheap and effective interventions
to prevent and treat postpartum haemorrhage,
infection, and hypertensive disorders
of pregnancy have existed for many years.22
Yet, in the developing world, a third
of all pregnant women receive no health
care during pregnancy, 60 of deliveries
take place outside health facilities,
and only about 60 of all deliveries are
attended by trained staff.23,24 As long
as effective strategies to increase attendance
of skilled personnel at birth, provide
emergency obstetric care, and promote
institutional deliveries are not implemented
(and as long as practice remains poor),
to reduce maternal mortality and morbidity
will be difficult.
This scandal of millions of avoidable deaths
in children and newborn infants in the
developing world is familiar to health-care
providers in the developed world. The
Lancet recently devoted a series of papers
to these two topics.25,26 Arguably even
more neglected, and undoubtedly more challenging
for ensuring political commitment, are
the more uncomfortable parts of sexual
and reproductive health-ie, sexual intercourse
that is not for procreation and not only
within marriage.
Unsafe abortion
Many governments have concerns about rising
rates of unintended pregnancy and induced
abortion, perhaps especially in developed
countries. Although a concern, at least
abortion is safe in such places. However,
in many countries, access to safe abortion
is restricted and, in some of those, unsafe
abortion causes more than 30 of maternal
deaths. All but 3 of 19 million unsafe
abortions estimated to take place every
year happen in developing countries (figure
2).14 The estimated 68000 deaths from
unsafe abortion equate to the death of
every woman who will have an abortion
in a year in Sweden, the Netherlands,
and Scotland combined. Half the deaths
arise in Africa, where one in four unsafe
abortions are done in teenagers. Of all
deaths related to sexual and reproductive
health, those from abortion are most likely
to be underestimated and arguably the
most preventable.27
The frequency of unsafe abortion in a country
is affected by the effectiveness of its
family planning programmes (to prevent
unwanted pregnancies), the abortion legislation
and its implementation, and the availability
and quality of legal abortion services.
Legal obstacles to provision of safe abortion
services force women to resort to unsafe
abortion when faced with an unwanted pregnancy.28
Growing evidence suggests that, especially
in adolescent girls, unintended pregnancy
and unsafe abortion are associated with
violence and sexual coercion.29 At the
beginning of the 21st century, of 145
developing countries, abortion was not
permitted for rape or incest in 101 countries,
for fetal impairment in 108, and for economic
or social reasons in 118. In 65 countries
abortion was not allowed even to preserve
the physical health of the mother.14 Restrictive
legislation is usually associated with
a high incidence of unsafe abortion. In
Romania, for example, the introduction
of laws restricting access to abortion
in 1966 led to a five-fold increase in
maternal deaths from 20 in 100000 livebirths
to almost 100 in 1974, and the rate rose
further to 150 in 1983. After the restrictive
abortion law was revoked in 1989, maternal
deaths fell rapidly.14
Reproductive tract infections and morbidities
After pregnancy-related causes, sexually
transmitted infections are the second
most important cause of healthy life lost
in women. In 1990 the World Bank estimated
that sexually transmitted infections (excluding
HIV), accounted for 8.9 of all disease
burden in women aged 15-45 years, and
1•5 in similarly aged men.30 In the
same year, the Global Burden of Disease
and Injury report31 estimated that 18•6
million disability-adjusted life years
(DALYs) were lost from syphilis, gonorrhoea,
and chlamydia-ie, 1•5 of the total
calculated global burden of diseases and
injuries.31 However, if one includes sexually
transmitted HIV infection, sexually transmitted
infections and HIV easily become the leading
cause of healthy life lost in many countries.
In 1999, WHO estimated 340 million incident
cases of only four curable sexually transmitted
infections (gonorrhoea, syphilis, chlamydia,
trichomonas).15,32 Infection rates are
not evenly distributed, ranging from a
yearly incidence of 2•2 in east Asia
and the Pacific to 25•7 in sub-Saharan
Africa among the population aged 15-49
years (figure 3). Moreover, there are
at least 30 other bacterial, viral, and
parasitic sexually transmitted infections,
which raise these incidence figures substantially.33
Some infections, such as scabies or pubic
lice, are of low physical morbidity but
are distressing to the affected individual.
These, and other more physically damaging
infections, such as, human papilloma virus
(HPV), herpes simplex virus (HSV), and
sexually transmitted hepatitis B virus,
are far more widespread in the population
than the four common diseases modelled
in the WHO estimates (figure 4). Globally,
about 20 of women aged under 24 years
have a prevalent HPV infection,34 and
more than 25 in populations older than
40 years have been infected with HSV-2.35
Thus, the yearly number of sexually transmitted
infections acquired easily exceeds 1 billion
(more than one infection for every three
adults aged 15-49 years), which is probably
an underestimate.
Many sexually transmitted infections affect
the outcome of pregnancy and some are
passed to unborn and newborn babies.36
In sub-Saharan Africa alone, an estimated
1640000 pregnant women have undiagnosed
syphilis every year;17 almost all these
women remain undetected.37 Untreated early
syphilis results in a stillbirth rate
of 25 and a perinatal mortality of about
20. An effective screening and treatment
programme for syphilis in pregnancy in
that region could prevent close to half
a million fetal deaths a year, a figure
rivalling the number of infants infected
with HIV by mother-to-child transmission
of the virus, which receives much more
attention than does syphilis.38 Worldwide,
up to 4000 newborn babies go blind every
year because of maternal gonorrhoea; an
unknown number are affected by neonatal
herpes or chlamydial conjunctivitis; and
the list goes on and on...
Sexually transmitted diseases are to a large
extent infections of the young, mainly
because their sexual relations are often
unplanned, sometimes a result of pressure
or force, and typically happen before
they have the experience and skills to
protect themselves. Although compiled
data about sexually transmitted infection
acquisition by age are sparse, US data
show that young adults aged 15-24 years
acquired 48 of all such infections,39
even though not all young adults this
age are sexually active. Perversely, the
young have the most to lose from acquiring
sexually transmitted infections, since
they will suffer the consequences the
longest, and might not reach their full
reproductive potential.
Industrialised countries, where at one time
rates of sexually transmitted infections
rivalled those of the developing world
today, have much lower rates of bacterial
and parasitic sexually transmitted infections,
despite sexual behaviour similar to that
in the developing world.40 However, rates
of (frequently asymptomatic) viral sexually
transmitted diseases remain high in the
general population, for example, 22 of
American adults have genital herpes,41
and rates of bacterial and parasitic sexually
transmitted infections remain high in
specific groups, indicating the need for
further progress in the industrialised
world. In the developing world, success
in controlling sexually transmitted infections
can be achieved.42,43 A commitment to
enhanced health care services44 and preventive
measures for both women and men could
achieve notable success. In all countries,
enhanced efforts to bring services to
asymptomatic or mildly symptomatic individuals
are important to the success of further
efforts.45 We have only two approaches
to reach these people: screening and partner
notification. The first is practised poorly
in developing countries and the second
is practised poorly everywhere.
Other reproductive tract infections, and
a myriad of gynaecological problems, make
life a misery for many women. Infections
arising as a result of unsafe abortion
or as a complication of pregnancy and
childbirth not infrequently lead to chronic
disability and death in some places. The
cruel social consequences for women with
vesicovaginal fistula after obstructed
labour-divorce, exclusion from religious
activities, family separation, worsening
poverty, malnutrition and much suffering-are
well known. Less familiar are the social
repercussions of infertility in many Asian
and African societies.16 Even though the
infertility can be related to a problem
in the male partner, women might blame
themselves and are frequently blamed by
both the partner and his family. In a
survey of 400 women with secondary infertility
attending a hospital in Pakistan, more
than two-thirds of the women stated that
their inability to bear a child, or to
produce a son, had resulted in marital
difficulties including threatened divorce
(20), being returned to their parent's
home (26), or the husband remarrying (38).
10 were being physically and verbally
abused by their husbands-and 16 by their
in-laws-for being infertile.46
Although attention to major causes of maternal
death and to sexually transmitted infections
has increased somewhat, and unsafe abortion
is generally debated at political and
religious fora, a silent epidemic of gynaecological
morbidity is mostly unnoticed. A systematic
review47 reported dysmenorrhoea in 59
of women and chronic pelvic pain in 6•2
in the general population. Urinary incontinence
affects 10-40 of women and is regarded
as severe in around a quarter of them.48
An even more devastating and underreported
morbidity is fecal incontinence, affecting
a notable proportion of women after vaginal
delivery and associated procedures such
as episiotomy or vacuum extraction.49
Family planning
Investment in family planning services,
together with the development of modern
methods of contraception in the second
half of the 20th century led to a striking
increase in contraceptive use in many
countries.50 In the 1960s fewer than 10
of married women were using contraception,
in 2003 the proportion was 60. In 2003
the total fertility rate-the total number
of children a woman would have by the
end of her reproductive life if she met
the prevailing age-specific fertility
rates from age 15 to 49 years-was 2•6
in Asia (including China) thanks to contraceptive
use by 52 of married women.51 In Latin
America and the Caribbean where 71 of
married women use contraception, the total
fertility rate is 2•7 (figure 5).
The fall in total fertility rate in individual
countries has been spectacular. In Iran,
for example, the average number of lifetime
births fell from 6•8 in the early
1980s to slightly more than 2 in 2003.
Indeed in some places, especially in Europe
where the total fertility rate at 1•4
is well below the replacement rate of
2•1, the governments of 26 countries
(61) regard the birth rate as low. The
introduction of modern methods of contraception
in the 1960s has been important (figure
6). In Bulgaria, Kazakhstan, and Uzbekistan
the pronounced fall in abortion rates
has been attributed to the uptake of modern
contraceptives in the 1980s and 1990s.52
Ironically, this success has led to reduced
funding for contraceptive research and
most importantly, investment in family
planning services.53 The result of such
policies might be somewhat poorer sexual
and reproductive health in countries with
high contraceptive use, but the disinvestment
in contraception in other regions with
low contraceptive use rates, particularly
sub-Saharan Africa and for groups such
as adolescents could be disastrous. Fertility
remains high in most of Africa and high
population growth is one of the most important
factors contributing to economic, environmental,
social, and political strain in several
countries. In west Africa the average
total fertility rate is 5•9, in east
Africa 5•7, and in middle Africa
6•3. In 15 countries, the rate remains
above 6, and in Niger-one of the poorest
countries in the world-it is 8•0.51
In 18 African countries less than 10 of
married women use any contraception, and
in 22 countries less than 10 are using
modern methods.51 Family planning is key
to the reduction of maternal mortality,
not only in terms of prevention of unwanted
pregnancy and unsafe abortion, but also
through its effect on the composition
of childbearing (ie, age and parity of
pregnant women, and time between pregnancies).54
Most young women and men become sexually
active during their teenage years. In
many sub-Saharan African countries more
than 70 of young women begin sexual activity
at this time; these sexual relationships
typically lead to formal unions, and more
than 20 of adolescents have their first
child by the age of 18, usually soon after
marriage.55 In other places, apart from
some countries in Asia (eg, Bangladesh
and India), fewer teenage girls are married
or cohabiting and giving birth at such
a young age, and premarital sex is less
common than in Africa.55 Sexual activity
in the teenage years is generally unsafe.
Adolescents often face many obstacles
when seeking contraception. Little knowledge,
little access to services and inability
to negotiate contraceptive use all result
in low uptake and high rates of ineffective
use. Even when contraception is used it
is often a less effective method such
as condoms since they are easier to obtain.
In the developing world, girls aged under
15 years are more likely to have premature
labour and are four times more likely
to die from pregnancy-related causes than
are women older than 20 years. Young women
are less likely to receive antenatal care
and are more likely to undergo unsafe
abortion, especially in countries where
legislation is restrictive. Even if abortion
is legal young women can face an increased
risk of complications if they delay seeking
abortion.55
Even in the developed world, in which contraceptive
use is high, governments are concerned
about rates of teenage pregnancy. In many
developed countries teenage motherhood
means single motherhood, disrupted education,
social isolation, and repeat cycles of
unintended pregnancy.56 In these countries
uptake of contraception is not the problem,
rather it is the widespread failure to
use a method consistently and correctly.
Even in countries such as the UK, where
contraception is available free of charge,
at least a quarter of pregnancies ending
in abortion are conceived without contraception;
most of the rest are the result of incorrect
or inconsistent use, or use of less effective
methods.57 As the age of first sexual
intercourse becomes younger the age of
childbearing increases and desired family
size falls, and women (and it is mainly
women) spend most of their reproductive
lives trying to avoid pregnancy, but the
use of contraception consistently is not
easy, especially during adolescence.
The HIV epidemic has added further complexity
to the promotion of family planning and
contraceptive development. The male condom
only has been shown to reduce the risk
of HIV infection58 and initiatives to
encourage condom use are given high priority,
even in countries with a low HIV prevalence.
Condoms, unless used correctly and consistently,
have fairly high failure rates for pregnancy
prevention. Thus health professionals
wishing to prevent unintended pregnancies
are reluctant to promote their use as
the main method of contraception, even
though in some countries condoms are the
most used method. Dual protection-use
of a condom for sexually transmitted infection
prevention with a more effective method
of contraception for pregnancy prevention-is
even more difficult to promote than condom
use alone.
Although the HIV epidemic has led to renewed
interest in the development of improved
barrier methods and microbicides,59 which
could also have contraceptive properties,
all proposed methods rely on daily use,
if not use with every act of sex. On the
other hand, the development of new contraceptive
methods that do not simultaneously protect
against sexually transmitted infections,
especially HIV, is receiving diminishing
attention, yet hundreds of millions of
couples are at very low risk of infection.
This thinking, together with the widespread
view that the population problem has been
solved and that contraceptive use is widespread,
has led to family planning, and new contraceptive
methods development slipping down the
political, research, and public health
agendas. Although HIV prevention should
remain a global priority for public health,
especially in sub-Saharan Africa, and
safe motherhood should rightly attract
considerable funding, family planning
(which affects both strategies) must not
be neglected. Provision of effective contraception
for the 201 million women who have none
would prevent 23 million unplanned births,
22 million induced abortions and 14000
pregnancy-related deaths every year,53
and might be a much more cost-effective
way than drug treatment to prevent mother-to-child
transmission of HIV infection.60
Violence against women and girls
Violence against women is an important contributor
to ill-health of women, especially to
their sexual and reproductive health.
Such violence is a human rights abuse
and a consequence (and a cause) of gender
inequality.1 The most common and better
documented types of violence (physical,
sexual, and emotional), are intimate-partner
violence (domestic violence) and sexual
violence (rape, sexual coercion, and child
sexual abuse). Abuse by an intimate partner
is widespread and happens in both developed
and developing countries. Prevalence varies
widely between countries and between regions
within countries. Such abuse is accepted
as normal in many parts of the world,
with acts of violence often regarded by
families as a private matter and as an
inevitable fact of life by the victims.
WHO's Multi-country Study on Women's Health
and Domestic Violence,19 in which specially
trained teams obtained data from 24000
women in ten countries, reported that
between 13 and 61 of women who were or
had been married reported physical abuse
by an intimate partner in their lifetime,
and between 6 and 59 reported sexual violence.
In Brazil, Ethiopia, Peru, Samoa, and
Tanzania, at least one in five women reported
severe physical violence (hit with a fist;
kicked; dragged; threatened with or attacked
with a weapon). The prevalence of sexual
violence towards women older than 15 years
by perpetrators other than partners was
1-12, and sexual abuse before the age
of 15 (sexual child abuse) ranged was
1-21.19 In a review61 of publications
about non-consensual sex, 21 of people
aged 10-24 years in Kenya, 18 of 15-19-year-olds
in Nigeria, 16 in Thailand (mean age 20
years), and 16 of 15-19-year-olds in Haiti
and 14 of that age group in Colombia had
had non-consensual penetrative sex.61
In some cultures young men have a sense
of entitlement to sex. In many countries,
both developing and developed, premarital
or extra-marital sex is condoned for men
but stigmatises women who therefore cannot
seek help. In some places, transactional
sex (the exchange of material goods in
return for sex) has become the norm in
adolescent girls, is their main source
of income, and often pays for their education.
Sexual violence and harassment is also
reported in schools, especially in sub-Saharan
Africa, and is perpetrated by both peers
and teachers, including instances of male
teachers using their power to force sex
on female students in exchange for good
grades.62 In one Kenyan study,63 5 of
girls who reported non-consensual sex
named a teacher as the culprit.
Violence and the threat of violence affect
many aspects of women's health-in particular
their sexual and reproductive health.
Women living in violent relationships
are often unable to make sexual and reproductive
choices, putting them at great risk of
early and unwanted pregnancy and sexually
transmitted infections, including HIV.
This absence of choice is either through
direct exposure to forced or coerced sex
or because they are unable to control
or negotiate regular use of contraception
and condoms.64,65
Sexual abuse during childhood is associated
with high-risk behaviours later in life,
including alcohol and drug use, early
consensual sexual experience, and a high
number of partners.66 Elimination of intimate-partner
violence in Colombia would result in an
estimated 45000 fewer unintended pregnancies
in that country every year,67 In the USA
more than 32000 pregnancies yearly are
estimated to result from rape, mostly
in adolescents.68 Moreover, growing evidence
suggests that violence increases women's
vulnerability to HIV infection: studies
in Kenya, South Africa, and Tanzania found
that HIV-positive women were more likely
to report physical partner abuse than
their seronegative peers.69-71
Violence during pregnancy is common and
for some women, can be the first time
violence takes place. Violence is more
common than hypertension or pre-eclampsia,
for which pregnant women are routinely
assessed. In North America, most estimates
of prevalence of such violence fall between
4 and 8.72 In developing countries these
rates are estimated to be as high as 32.73
Violence during pregnancy has been associated
with adverse pregnancy outcomes, such
as low birthweight, premature labour,
preterm delivery, miscarriage, and fetal
injury.74 Such violence has also been
associated with increased rates of pregnancy
termination in both developed and developing
countries.75,76 Violence against women
is also a cause of maternal mortality.73
In the USA, several studies have suggested
that homicide is a leading cause of mortality
during pregnancy, with young age, black
race, and late or no prenatal care identified
as risk factors.77 A study in Mozambique
noted that violence was the fourth largest
cause of maternal death.78
Sadly, most women remain silent about violence
by an intimate partner and do not seek
help. They frequently think that this
violence is normal or even justified;
more than 20 of women in seven sites participating
in the WHO study19 thought that wife-beating
was justified if a wife disobeyed her
husband, and in five sites a wife's failure
to complete her housework was believed
to be justification for a beating.
Harmful traditional practices, such as female
genital mutilation (or cutting) are also
prevalent in countries, especially in
sub-Saharan Africa and some countries
in southeast Asia. Female genital mutilation
is generally done to girls before they
reach age 10 years. The procedure is often
done under unhygienic conditions and acute
haemorrhage and infection are common.
Many girls go on to have chronic morbidity,
including recurrent urinary tract infections,
reproductive tract infections, dyspareunia,
and sometimes vesicovaginal fistula, especially
with type II and type III mutilation.
A cohort study79 of more than 28000 women
attending for singleton delivery in six
African countries lent support to the
long-held suspicion that female genital
mutilation is associated with obstetric
morbidity, including perinatal problems.
Compared with women without genital mutilation,
women with type II and III (the most severe)
mutilation were significantly more likely
to have cesarean section, postpartum haemorrhage,
and long stay in hospital after delivery.
Women with both type II and type III genital
mutilation were also significantly more
likely to have babies needing resuscitation
or to have a stillbirth, or early neonatal
death.79 (figure 7)
Sexual and reproductive health and men
Much of sexual and reproductive health affects
women, and men tend to be seen only as
the perpetrators of acts leading to ill-health.
However, men are also subject to sexual
and reproductive ill-health; they also
aquire sexually transmitted infections,
including HIV. Male factors account for
at least a third of couples attending
for infertility treatment, and some young
men are victims of non-consensual sex
and of intimate partner violence.80 Men
who have sex with men, including those
who do not identify themselves as homosexual,
contribute to the spread of sexually transmitted
infections, including HIV, yet the health
needs of homosexual men (and women) are
especially neglected in countries where
homosexuality is taboo or illegal. An
eloquent personal view81 written by an
Indian medical student in 2005, describes
the pervasive attitude of the medical
profession to sexuality in general and
to homosexuality in particular in his
country.81
Men also contribute to family planning.82
Although to persuade men to use condoms
is difficult in many parts of the world,
in some countries-Japan, Hong Kong, and
Singapore, for example-condoms are the
main method of contraception.83 In the
UK, where about half the couples wishing
to avoid pregnancy are sterilised, more
than half those procedures are vasectomies.83
Nevertheless, to involve men rather than
women in improvement of sexual and reproductive
health is difficult. Much has been said
about the need to involve men (particularly
young men) in sexual and reproductive
health but little has been done to address
their needs and even less to assess the
effect of their involvement in, for example,
family planning.84
Why is sexual and reproductive health
neglected?
Despite the obvious fact that sexual and
reproductive illhealth is a major cause
of morbidity and mortality, with the exception
of HIV and AIDS, the subject has failed
to capture broad support from the donor
community. Some argue that the notion
of reproductive health that was promoted
in Cairo was too idealistic, that by emphasising
issues such as empowerment of women and
reproductive rights rather than the provision
of services and "by asking too much,
it ended up getting too little".85
Others make the point that in the current
climate of health sector reform, decisions
to use scarce funding are based on the
burden of death and disability attributable
to a particular disorder on the basis
of measures such as DALYs. Sexual and
reproductive health is not only about
disease, but also about a collection of
related health and human-rights issues
and many people are still confused about
what it consists of. Furthermore, use
of DALYs is not appropriate for quantification
of the full burden of sexual and reproductive
ill health. Pregnancy is not a disease,
and associated complications are poorly
counted unless they result in death; a
stillbirth does not contribute even one
DALY; reproductive morbidities are often
inadequately measured and are generally
under-reported because of associated stigma.
Moreover DALYs only measure death, disease,
and disability without assigning any value
to preventive interventions, such as family
planning, that avoid ill health and promote
wellbeing, including in sexual matters.
The first of the MDGs is the eradication
of extreme poverty and hunger. The view
that fertility control would reduce poverty
in developing countries has lost support
in the past 25 years, and the link between
sexual and reproductive health and poverty
reduction has been questioned.86 Nevertheless,
good evidence shows that poor women have
bad reproductive health outcomes and that
early and unintended childbearing-even
in developed countries-leads to poverty.86
Adolescent pregnancy can lead to reduced
educational opportunities for both mother
and child. Short intervals between births
are associated with prematurity, low birthweight,
and an increased risk of infant death.87
In some countries and settings, unwanted
children are more disadvantaged than wanted
ones. Children from large families might
also be disadvantaged in terms of nutrition,
healthcare, and education. Campaigners
for HIV and AIDS have been successful
in demonstrating links between HIV and
AIDS, and poverty. Unlike the ICPD goal
of universal access to reproductive health
services, halting the spread of HIV/AIDS
was adopted as one MDG. Funding for family
planning and reproductive health, which
represented 70 of total expenditures for
population and AIDS at the time of ICPD,
has shifted to control and treatment of
HIV/AIDS and sexually transmitted infections,
which in 2002 made up 43 of total population
and AIDS expenditures.88 Lastly but arguably
most importantly, sexual and reproductive
health issues frequently make people uncomfortable.
ICPD ended with statements in which several
government delegations voiced their reservations
with respect to specific aspects of the
Programme of Action. Areas of contention
included abortion, sexual health services
for adolescents, the idea of sexual activity
outside marriage and family-specifically,
union between a man and a woman from which
derives children and the rights of individuals
rather than couples. Despite these reservations
the Cairo ICPD generated excitement and
optimism in individuals and agencies working
in sexual and reproductive health. Unfortunately
the conservative forces that threatened
implementation of ICPD recommendations
have strengthened substantially since
that meeting and are continuously weakening
the international agreements about sexual
and reproductive health and rights reached
in 1994.
On his first day in office, US President
George W Bush reinstated the Mexico City
Policy of former President Ronald Reagan,
meaning that no US family-planning assistance
can be provided to foreign NGOs working
in abortion. The policy not only prohibits
the use of US funds by such NGOs for abortion,
but also bans the use of funding from
any other source to provide counselling
and referral for abortion; to do abortions
in cases other than those with threat
to the mother's life, rape, or incest;
or to lobby to legalise or increase availability
of abortion in their country. Similarly,
at the UN General Assembly special session
on children, held in May, 2002, some delegations
(Iran, Iraq, Libya, Sudan, the Vatican,
and the USA) wanted the phrase reproductive
health services redefined to exclude legal
abortion; the family characterised as
marriage only between a man and a woman;
and to include wording that would have
recognised a couple's right to information
about family planning but not access to
contraception.
Despite these attempts to roll back the
agreements reached at Cairo, not all the
news is bad. In May, 2004, at the 57th
World Health Assembly, all WHO member
states (except the USA) fully endorsed
the WHO global reproductive health strategy,
which had been designed to accelerate
progress towards international goals and
targets relating to reproductive health,
especially those set by ICPD in 1994.
Furthermore, a UN Millennium Project report6
identified 17 so-called quick wins, or
straightforward solutions to implement
immediately to help reach the goals. The
report noted that sexual and reproductive
health is essential not only for reaching
the three health-related goals, but also
for attainment of many other goals including
reduction of extreme poverty, ensuring
educational opportunities and gender equality,
and attainment of environmental sustainability.
In May, 2005, the EU stated "The
MDGs cannot be attained without progress
in achieving the Cairo goal of universal
access to sexual and reproductive health".89
Sexual and reproductive health is fundamental
to the social and economic development
of communities and nations, and a key
component of an equitable society. We
can bring sexual and reproductive health
care and choice to those who need it most,
which will be a vital contribution to
making the world a fairer place.
Conflict of interest statement
We declare that we have no conflict of interest.
Acknowledgments
We thank our colleagues Peter Fajans and
Dale Huntington for their contributions
to an earlier version of this paper and
to Hazel Ziaei, Irene McDonnell, and Svetlin
Kolev for secretarial and graphic assistance.
AM Gülmezoglu, PFA Van Look, GP Schmid,
and CG Moreno are staff members of WHO.
The views expressed in this paper are
those of the authors alone and do not
necessarily represent the decisions, policy,
or views of WHO.
CONTACT: *Correspondence to: Anna Glasier,
NHS Lothian Family Planning Service, 18
Dean Terrace, Edinburgh EH4 1NL, UK
<< The Lancet -- 11/4/06 >>
