THE RELIGIOUS CONSULTATION
on population, reproductive health & ethics

The Economist (UK), September 2, 2004

Ten Years' Hard Labour

More money and less ideology could improve the reproductive health of millions

A DECADE ago, the world's leaders met in Cairo at the International Conference on Population and Development (ICPD). There, they crafted a plan to achieve “reproductive health and rights for all” by 2015. That plan was wide-ranging—from more contraception and fewer maternal deaths to better education for girls and greater equality for women. But more than just setting targets, the ICPD plan also aimed to change the way those at the sharp end of making policy and delivering services thought about reproduction. It wanted to move away from a focus on family planning (and, by extension, government policies on population control) towards a broader view of sexual health, and systems and services shaped by individual needs.

Over the past week, hundreds of government officials, public-health experts and activists met in London to mark the anniversary of the ICPD and to take stock of progress towards achieving its goals. On paper, that progress has been impressive. Governments around the world have introduced legislation that reflects the ICPD's aims. But when it comes to turning policy into practice, “mixed success” is the verdict of a report card just released by Countdown 2015, a coalition of voluntary bodies involved in the field.

Take contraception, for example. According to the United Nations' Population Fund (UNFPA), 61% of married couples now use contraception, an 11% increase since 1994. This has helped push global population growth down from 82m to 76m people a year over the past decade. But in some places—particularly in sub-Saharan Africa and parts of Asia—birth rates remain high (see chart). That has spurred some governments to offer incentives to those who have fewer children, and others to inflict penalties on those who do not.

Sometimes, a high birth rate is a result of people wanting large families. But often it is due to a lack of affordable contraception. UNFPA estimates that 137m women who want to use contraception cannot obtain it. As Amare Bedada, the head of the Family Guidance Association of Ethiopia, points out, “We don't need to tell our clients about contraception. They see their plots of land diminishing, and they tell us they want to limit their family size.”

Maternal health is another area where much more needs to be done. Poor women still die in huge numbers from the complications of pregnancy and childbirth. According to UNFPA, 920 women die for every 100,000 live births in sub-Saharan Africa. In Europe, by contrast, the figure is 24 (see chart). However, these numbers are, at best, only rough estimates gleaned from hospital statistics. Many women go uncounted because they never reach the health-care system for treatment in the first place.

Plenty of studies have shown what it takes to reduce maternal sickness and death. Good ante-natal health care is vital. So are cheap and simple drugs, such as oxytocin, to prevent haemorrhaging during birth. Trained midwives (or “birth attendants” as they are known in medical parlance) help, too. And so do local emergency obstetric centres that can handle complicated deliveries. Some countries, such as Sri Lanka, have managed to cut maternal mortality by careful spending on such measures. The challenge is to translate these successes to other places.

Yet another subject that needs to be tackled more effectively is youth sex. The largest generation of teenagers in history—a whopping 1.3 billion 10-19-year-olds—is now making its sexual debut. How it behaves, and what it learns, is crucial.

The ICPD plan was the first international agreement to acknowledge the sexual and reproductive rights of teenagers. A few countries, such as Panama, have introduced laws to safeguard some of these. In many others, youth-friendly programmes have sprung up to offer advice and assistance on thorny issues such as unwanted pregnancy and sexually transmitted diseases—now soaring worldwide at 340m infections a year.

Such programmes, of course, are complicated by fierce—if probably futile—battles in many countries over whether young people should be having sex at all. These play out in international skirmishes over abstinence versus condoms for the young, parental consent to contraception and abortion, and what, if any, sex education should be provided by the state.

Sex and money

One significant obstacle to tackling these problems is money, or rather the lack of it. Ten years ago, the ICPD estimated the cost of implementing its recommended programmes at $18.5 billion by 2005—or $23.7 billion in today's dollars. The goal was to mobilise one-third of that money from rich donors, and the rest from developing countries themselves. But current spending is well below the mark.

Few poor countries have earmarked enough of their budgets to meet their citizens' reproductive-health needs. Nor have donors lived up to expectations. In 2003, they spent an estimated $3.1 billion on reproductive health. Although contributions have increased over recent years, with a few European countries, such as the Netherlands, chipping in more, and private donors, such as the Gates Foundation, entering the field, this is still far off even the inflation-devalued $6.1 billion expected from donors by 2005.

Reproduction, it seems, is no longer a sexy subject. As Steve Sinding, the head of the International Planned Parenthood Federation (IPPF), points out, donor interest in the past was stimulated largely by fears of a population crisis. When the Cairo Conference reframed the issues in terms of women's health and reproductive rights, that demographic rationale was lost, taking funding with it.

Moreover, there are other causes competing for international funding, most notably AIDS. At the time of the Cairo Conference, 20m people were infected with HIV, the virus that causes AIDS. Today, that number has doubled. Indeed, AIDS threatens to derail the ICPD strategy. For, although billions of dollars are now pouring in to fight the disease, much of this money is going into AIDS-specific programmes that do not address reproductive health more broadly.

As Nafis Sadik, a former head of UNFPA and now the UN secretary-general's special envoy for HIV in Asia, observes, ten years ago those working in family planning shied away from the field of HIV, with its heavy burden of social stigma. Today, the roles are reversed, as reproductive health is engulfed in a storm of religious and political controversy. One consequence is that organisations concerned with fighting AIDS are failing to make use of valuable infrastructure and expertise already on the ground in places where the disease hits hardest. Given that more than half of HIV infections in sub-Saharan Africa are among women, and that for many African women family-planning services are their main contact with the formal health-care system, such services need to be drafted into the wider battle against HIV. Many family-planning clinics already offer HIV testing and counselling, as well as condoms (against the double whammy of unwanted pregnancy and HIV infection), and also a broad based message of sexual health.

What the field of reproductive health lacks in resources, however, it makes up in ideology. Over the past ten years, battles have broken out between contending views of sexuality, pitting religious conservatives—primus inter pares, the Vatican—against social liberals. The fight has become particularly fierce since the election of George W. Bush as America's president. Mr Bush's socially conservative views are reflected in the way America, the world's leading donor for reproductive health, spends its money at home and abroad.

Breeding trouble

The main battles are over abortion. Austin Ruse, the president of the Catholic Family and Human Rights Institute (C-FAM), an American Christian lobby group, argues that the shift in talk from fertility control to reproductive rights and services is just code for making abortion universally available. He regards this as wrong, and believes that the ICPD plan of action and those agencies which support it—particularly UNFPA—should be opposed at every turn by a growing coalition of “pro-family” groups worldwide. “Over the next five years, I see everything coming our way, especially on the question of abortion,” says Mr Ruse.

UNFPA, not surprisingly, has a different view. Thoraya Obaid, its head, reckons that those who oppose the ICPD plan of action are not just against legalising abortion, but are fighting against women's rights in general. She points to the text of the plan, which states that abortion should never be promoted as a form of family planning and that women should be helped to avoid abortion through better access to contraception. (It also says that those who have sought abortions are entitled to the best possible medical treatment to deal with the complications.)

All sound stuff, but trouble lies in the plan's statement that abortion policy should be up to national governments to decide. Since 1994, more than a dozen countries have liberalised their laws on abortion (with a couple of countries tightening them up). But none of this comes without a fight, often led by the Catholic Church. Kenya has seen a particularly nasty debate over the past six months. There have been street protests, graphic television “docudramas” showing the perils of abortion, and even the arrests of health-care workers who are alleged to have performed more than a dozen abortions whose fetuses recently ended up in a ditch outside Nairobi. The government, which was looking at its abortion laws as part of a broader constitutional review, has made no changes to the current provision, which bans abortion unless the mother's life is at stake.

In many developing countries, Christian anti-abortion groups such as America's Human Life International—a sister organisation to C-FAM—have been pitching in to help organise resistance to changes in abortion laws. But American officials have entered the fray as well. Delegates to regional meetings held in Latin America during the past year to re-affirm their commitment to the ICPD plan of action have complained about pressure from American officials to reject the plan's calls for broad-based reproductive rights and services.

While pressure by the Catholic Church and other opponents of legal abortion can shape official policy, Tim Black, the head of Marie Stopes International (MSI), a voluntary organisation providing reproductive services, argues it does little to stop women seeking abortions, legal or illegal. Surveys from hospitals in Ethiopia, Uganda and Kenya suggest that anywhere from 20-50% of maternal deaths are due to complications resulting from unsafe backstreet abortions. But these numbers are challenged by the opponents of abortion, who argue that it is a rare phenomenon in the developing world, and that legalising it will make it more common.

The American government's views on abortion are expressed in the Mexico City Policy, which was re-introduced by Mr Bush in 2001. This policy, first implemented by Ronald Reagan in 1984, forbids American government funding of foreign organisations which in any way promote, endorse or advocate abortion. American law has banned foreign assistance for the direct performance of abortions since 1973. But the Mexico City Policy, or “Global Gag Rule” as its critics often refer to it, means that groups which want to perform abortions with money from other sources must also toe the United States' line, or else forfeit American assistance.

Opponents of this policy argue that it imposes on foreigners restrictions which are unconstitutional in America. Indeed, Frances Kissling, the head of Catholics for a Free Choice, an American voluntary organisation which opposes banning abortion, argues that Mr Bush is flexing his conservative muscles abroad—and therefore appeasing his supporters at home—precisely because he cannot deliver a domestic anti-abortion agenda. Last week, for example, a court in New York declared unconstitutional a ban on so-called partial-birth abortion that Mr Bush signed into law in 2003.

Several prominent family-planning organisations, such as MSI and the IPPF, have refused to agree to the Mexico City Policy, saying it compromises their ability to offer women in poor countries the full range of services available in the rich world. In Ethiopia, for example, these groups have had to trim their services and shelve expansion plans as a result of losing both money and contraceptive supplies from the American government.

Such arguments, however, cut little ice with Jeanne Head, the United Nations representative for National Right to Life, an American anti-abortion group. As she puts it, “if they refuse these funds and they can't keep functioning, then they don't care about these women, they only care about abortion. I think the blame lies on the organisations, not on the US government.”

John Kerry has said he will rescind the Mexico City Policy if elected. The Democratic candidate has also promised to restore American funding to UNFPA. This has been withheld by the Bush administration for the past three years under a piece of legislation called the Kemp-Kasten amendment. This amendment authorises the president to restrict funding to any group that “supports or participates in the management of a programme of coercive abortion or involuntary sterilisation.”

The White House accuses UNFPA of abetting coercive reproductive practices in China—a claim that UNFPA denies. Several international delegations, including ones from Britain's parliament and the American State Department, have investigated UNFPA's activities in China and failed to find evidence to support such allegations. On the contrary, they argue that where UNFPA operates, policies in China are improving. But these findings are contested. The Bush administration says UNFPA has yet to mend its ways, and refuses to pay the $34m appropriated by Congress. The agency says it has managed to fill the gap this year, from big donors such as Britain, which is raising its annual contribution to £20m ($36m), and tiny ones such as Afghanistan, which chipped in $100.

But making up the money is the easy part. Today's battles over abortion, abstinence and condoms are casting a pall over the field, and complicating what is already a formidable task. Making sex safer and reproduction less risky in the 21st century requires all the tools to hand. Policies that restrict people's choices should not be a fact of life.

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