State of World Population 2012 - UNFPA Haiti

OverviewOne hundred seventy-nine governments affirmed individuals’ right to familyplanning at the International Conference on Population and Development, ICPD, in1994, when signatories of the ICPD Programme of Action stated that, “the aim offamily planning programmes must be to enable couples and individuals to decidefreely and responsibly the number and spacing of their children and to have theinformation and means to do so.” This affirmation marked a paradigm shift inthe way governments and international organizations looked at developmentand population issues.Family planning is critical to individuals’ abilitiesto exercise their reproductive rights, and other basichuman rights. The international consensus aroundthe right to decide the timing and spacing of pregnanciesis the result of decades of research, advocacyand debate. Reflecting this consensus, there is nowa renewed focus in the development communityabout the need for more policy and programmaticaction to ensure that all people can equally exercisetheir right to access high-quality services, suppliesand information when they need them.A broad range of services must be provided toensure sexual and reproductive health. Familyplanning is just one such service, which shouldbe integrated with:• primary health care as well as antenatal care,safe delivery and post-natal care;• prevention and appropriate treatment ofinfertility;• management of the consequences of unsafeabortion;• treatment of reproductive tract infections;• prevention, care and treatment of sexuallytransmitted infections and HIV/AIDS;• information, education and counselling onhuman sexuality and reproductive health;• prevention and surveillance of violenceagainst women and care for survivors ofviolence; and• other actions to eliminate traditionalharmful practices, such as female genitalmutilation/cutting.This report focuses on family planning andrights because:• The basic right of all couples and individualsto decide freely and responsibly on the timingand number of their children is understood asa key dimension of reproductive rights, alongsidethe right to attain the highest standard ofsexual and reproductive health, and the rightof all to make decisions concerning reproductionfree of discrimination, coercionand violence.• A person’s ability to plan the timing and sizeof his or her family closely determines therealization of other rights.• And the right to family planning is one thatmany have had to fight for and still todayrequires advocacy, despite the strong globalrights and development frameworks thatsupport it.ivOVERVIEW

tWomen who are able toplan their families aremore likely to be ableto send their children toschool. And the longerchildren stay in schoolthe higher their lifetimeearnings will be, helpingthem to lift themselvesout of poverty.©Lindsay Mgbor/UKDepartment for InternationalDevelopmentThe shift towards a rights-basedapproach to family planningThe value of a rights-based approach to familyplanning is that it treats individuals as fullhuman beings in their own right, as activeagents, not as passive beneficiaries. Thisapproach is built upon the explicit identificationof rights-holders (individuals) and theduty-bearers (governments and others) that areresponsible for delivering on rights. Today, familyplanning is widely accepted as a foundationfor a range of rights.For this reason, a rights-based approachmay be the premise for the global sustainabledevelopment framework that will succeed theMillennium Development Goals, MDGs, whichwill conclude in 2015. In a recent essay aboutthe post-2015 agenda, the Office of the UnitedNations High Commissioner for Human Rightsstressed that the “increasing global embrace ofhuman-rights-based approaches to development,based on the principles of participation,accountability, non-discrimination, empowermentand the rule of law, offers hope that amore enlightened model of development isnow emerging.”Rights-based approaches—to family planningor other aspects of sustainable development—can lead to greater equity, equality and nondiscrimination.Children by choice, not by chanceThis State of World Population report explains whyfamily planning is a human right and what thatmeans for individuals in developing and developedcountries alike. The report synthesizes severalframeworks for health, reproductive health, andfamily planning, while also building upon themby: elevating the discussion about the importanceof engaging men in family planning as partnersin relationships and in life, and as beneficiaries ofservices; underscoring the need to collect moredata and devise programming that also reachesunmarried young and older people alike; drawingattention to the high rates of unintended andunwanted pregnancies in both developing anddeveloped countries; and showing how changingsexual behaviour in different social contexts andacross age groups is increasingly at variance withold patterns about sexuality, which represent abarrier to making family planning available andaccessible to all.THE STATE OF WORLD POPULATION 2012v

The report is structured to answer the following key questions:What is arights-basedapproach tofamily planning?Chapter 1 provides an overview of the international commitments to sexualand reproductive health, including family planning, with a particular emphasison the ICPD Programme of Action and the renewed international commitmentto invest in family planning in a post-MDG sustainable developmentagenda. The chapter outlines the freedoms and entitlements associated withreproductive rights, drawing from civil, political, economic, social and culturalrights. The chapter outlines States’ obligations to fulfil citizens’ right to familyplanning and an accountability framework to monitor implementation.Where have gainsbeen made andwho cannot yetfully exercise theirright to familyplanning?Chapters 2 and 3 draw on research and programmatic evidence to describe globaltrends and show disparities in enjoyment of the benefits of family planning.Chapter 2 calls attention to inequalities in several key family planning indicators.Inequalities in access to and use of family planning services are examined acrosslevels of wealth, education and place of residence. The chapter discusses whypeople use specific methods, the predominant use of female methods, and theimpact of family planning use on abortion. Chapter 3 discusses the relativelyhigh unmet needs of specific large—and largely neglected—sub-populations:young people, unmarried people of all ages, men and boys, the poor, and othersocially marginalized groups with restricted access to information and services.This chapter discusses how the dynamics of sexual activity and marriage patternsare changing and how those changes affect the need for family planning.viOVERVIEWtMaternal health in Tajikistan.©UNFPA/Natasha Warcholak

What are thesocial andeconomic benefitsof a rights-basedapproach tofamily planning?Chapter 4 summarizes the social and economic benefits of expanding accessto family planning, with an emphasis on underserved populations in greatestneed. Reductions in maternal mortality and morbidities, gains in women’seducation and improved life prospects for children are among the benefitsto individuals, with broad implications for families, communities and countries.When governments prioritize family planning as part of an integrateddevelopment strategy, they make a strategic investment that both fulfils theirobligation to protect citizens’ rights and helps alleviate poverty and stimulateeconomic growth.What are thecost implicationsof a rights-basedapproach to familyplanning?Government and development agencies have to invest more resources to realizethe individual and broader social and economic gains that can be achievedthrough a rights-based approach to family planning. Chapter 5 consolidatesthe latest research on costing, which finds that unmet need will continue torise as more young people enter their reproductive years. Research confirmsthat family planning is a cost-effective public health investment. Taking intoconsideration its contributions to the realization of human rights and itscost-effectiveness, family planning is a strategic investment.What shouldthe internationalcommunity do toimplement arights-basedapproach?Chapter 6 outlines recommendations to guide future investments, policies,and programmes. Key stakeholders must recognize systematic inequalities infamily planning as an infringement of human rights and a hindrance to directinformation and services for underserved populations. Families, communities,institutions, and governments will have to modify their strategies to ensure thatall people are able to realize their human right to family planning. This workwill expand conventional approaches to family planning programmes. Theadoption of post-MDG indicators that allow for nuanced assessments of sexualand reproductive health disparities is critical.THE STATE OF WORLD POPULATION 2012vii

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CHAPTERONEThe right tofamily planningA fundamental human rightPlanning the number and timing of one’s children is today largely taken forgranted by the millions of people who have the means and power to do so. Yeta large proportion of the world’s people do not enjoy the right to choose whenand how many children to have because they have no access to family planninginformation and services, or because the quality of services available to them is sopoor that they go without and are vulnerable to unintended pregnancy.tMothers ata women'sadvocacy centreattend a talk oncontraception inPakistan.©Panos/Peter BarkerThe international community agreed in 1994at the International Conference for Populationand Development, ICPD, that family planningshould be made available to everyone who wantsit, and that governments should create the conditionsthat support people’s right to plan theirfamilies. But recent research shows that 222million women in developing countries todaydo not have the means to delay pregnancies andchildbearing. Millions of women in developedcountries are also unable to plan their familiesbecause they lack access to information, education,and counselling on family planning, cannotaccess contraceptives and face social, economicor cultural barriers, including discrimination,coercion and violence in the context of theirsexual and reproductive lives.The number and spacing of children can havean impact on the schooling prospects, incomeand well-being of women and girls, and alsoof men and boys. The right to family planningtherefore permits the enjoyment of other rights,including the rights to health, education, and theachievement of a life with dignity. An informedrights-based approach to family planning is themost cost-effective intervention for addressingmaternal mortality and morbidity. Ensuring theright to family planning can ultimately acceleratea country’s progress towards reducing poverty andachieving development goals. Universal accessto reproductive health services, including familyplanning, is sufficiently important that it is partof the United Nations Millennium DevelopmentGoals. And it will be fundamental to achievingmany of the priority goals emerging from thepost-2015 sustainable development framework.Although family planning is a fundamentalright, it is met at times with ambivalence fromcommunities, health systems and governments.The commitment to family planning can beundermined by its association with sexual activityand its meaning in the context of social andcultural values. In practical terms, concernswith extending access to specific populationTHE STATE OF WORLD POPULATION 20121

“All human beings are born free and equal in dignityand rights… Everyone is entitled to all the rights andfreedoms set forth in this declaration, without distinctionof any kind, such as race, colour, sex, language, religion,political or other opinion, national or social origin,property, birth or other status… Everyone has theright to life, liberty and security of person.”— Universal Declaration of Human Rightsgroups can also weaken a broader commitmentto family planning.Many groups, including young people andunmarried people, have been excluded orhave not benefited from family planning programmes.Other groups, including persons withdisabilities or older people, have been deniedaccess to family planning programmes based onprevailing misconceptions that they do not havesexual needs.This report makes the case that the inabilityto determine when to have children and howlarge a family to have results from and furtherreinforces social injustice and a lack of freedom.This report promotes the right to family planningas an essential and sometimes neglectedfocus of the range of services required to supportsexual and reproductive health morebroadly. It also underscores that family planningis one of the most cost-effective public healthand sustainable development interventions everdeveloped (Levine, What Works Group andKinder, 2004).Family planning reinforces otherhuman rightsThe world has evolved a globally shared understandingabout sexual and reproductive healthand the institutional, social, political and economicfactors needed to support it. This sharedunderstanding was documented most fully atthe ICPD, which marked a profound changein the international community’s approach tosexual and reproductive health and shaped manypolicies in place today. The ICPD Programmeof Action formally recognized the rights ofindividuals to have children by choice, notby chance.Individuals have the right to determine theirfamily size, and the right to choose when tohave their children. Several features of theICPD Programme of Action have contributedto making it possible for more people to exercisetheir reproductive rights. First, the ICPDProgramme of Action contributed to advancingreproductive rights by defining the broadconcept of “sexual and reproductive health,”and by giving attention to the social conditionsthat shape it. It explicitly acknowledged theimportance of sexual and reproductive health inthe lives of women as well as the specific needsof adolescents and the roles of men and boys.It laid out a mandate for development programmesto take into account—and respondThe ICPD defines sexual andreproductive health as “a state ofcomplete physical, mental and socialwell-being…in all matters relating tothe reproductive system and to itsfunctions and processes. Reproductivehealth therefore implies that peopleare able to have a satisfying andsafe sex life and that they have thecapability to reproduce and thefreedom to decide if, when and howoften to do so.”— ICPD Programme of Action, paragraph 7.22 CHAPTER 1: THE RIGHT TO FAMILY PLANNING

to—the social, political and economic factorsthat affect people differently because of whothey are, where they live and what they do.One additional contribution of the ICPD:Whereas earlier programmes had treatedfamily planning as a standalone activity, theProgramme of Action situated family planningin the context of broader sexual and reproductivehealth programmes. Reproductive rightsrest not only on the recognition of the rightof couples and individuals to plan their family,but on “the right to attain the higheststandard of sexual and reproductive health. Italso includes their right to make decisions concerningreproduction free of discrimination,coercion and violence, as expressed in humanrights documents” (UNFPA, 1994).By reducing worry about unintendedpregnancy, family planning can contributeto building relationships between partnersand ensuring a satisfying and safe sex life.Respecting, protecting and fulfilling people’shuman rights make it easier for people toachieve the full benefit of investments infamily planning (Cottingham, Germainand Hunt 2012).International commitmentsSexual and reproductive health and reproductiverights do not represent a new set of rights butare rights already recognized implicitly or explicitlyin national laws, international human rightsdocuments and other relevant United Nationsconsensus documents. Some of these internationalnorms rest on broader human rights thatalso underpin the right to sexual and reproductivehealth, including family planning.Reproductive rights encompass both freedomsand entitlements involving civil, political, economic,social and cultural rights. The right todecide the number and spacing of children isintegral to the reproductive rights frameworkand is therefore directly related to other basichuman rights, including:• The right to life;• The right to liberty and security of person;• The right to health, including sexual and reproductive health;• The right to consent to marriage and to equality in marriage;• The right to privacy;• The right to equality and non-discrimination;• The right not to be subjected to torture or other cruel, inhuman, ordegrading treatment or punishment;• The right to education, including access to sexuality education;• The right to participate in the conduct of public affairs and the right tofree, active and meaningful participation;• The right to seek, impart and receive information and to have freedomof expression;• The right to benefit from scientific progress.(Center for Reproductive Rights, 2009; InternationalPlanned Parenthood Federation, 1996).These rights are derived from numerousinternational and regional treaties andconventions. As such they reflect a commonunderstanding of fundamental human rights.These and other human rights related to reproductiverights and their sources are laid outin Reproductive Rights are Human Rights, by theCenter for Reproductive Rights (2009).Responding to the realities of gender inequalitiesand the nature of reproductive physiology,a number of human rights documents referencethe special challenges and discriminationwomen and girls face. The human rights ofmost direct relevance to gender inequalityinclude the right to be free from discriminatorypractices that especially harm women and girls,and the right to be free from sexual coercionand gender-based violence.THE STATE OF WORLD POPULATION 20123

Treaties, conventions and agreements relevant to reproductive health and rights1948 Universal Declaration of Human Rights: A key document that has inspired the whole human rights discourseand many constitutions and national laws, and a source of international customary law.1968 Tehran Conference on Human Rights proclaims and declares the right of individuals and couples to information,access and choice to determine the number and spacing of their children.1969 Convention on the Elimination of all Forms of Racial Discrimination1969 United Nations General Assembly Declaration on Social Progress and Development, resolution 2542 (XXIV),Article 4: “Parents have the exclusive right to determine freely and responsibly the number and spacing of theirchildren.” The Assembly also resolved that the implementation of this right requires, “the provision to familiesof the knowledge and means necessary to enable them to exercise their right…”1974/1984 The World Population Plan of Action adopted at the 1974 World Population Conference in Bucharest, and the88 recommendations for its further implementation approved at the International Conference on Population inMexico City in 1984.1976 International Covenant on Civil and Political Rights, which is used by civil rights groups in their fight againstgovernment abuses of political power.1976 International Covenant on Economic, Social and Cultural Rights adopted in 1966 and entered into force in 1976.Article 12 of the Covenant recognized the right of everyone to the enjoyment of the highest attainable standardof physical and mental health.1979 The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) is the onlyinternational human rights document that specifically references family planning as key for ensuring the healthand well-being of families. CEDAW provides the basis for realizing equality between women and men byensuring women’s equal access to, and equal opportunities in, political and public life—including the right tovote and to stand for election—as well as education, health and employment.1986 Declaration on the Right to Development calls for development that aims at the well-being of the entirepopulation, free and meaningful participation and the fair distribution of the resulting benefits.1989 Convention on the Rights of the Child sets standards for the defense of a child against neglect and abuse incountries throughout the globe. In order to protect the best interests of the child, it aims to:• Protect children from harmful acts and practices, including commercial and sexual exploitation andphysical and mental abuse, and maintains that parents will be helped in their responsibilities of the positiveupbringing of a child where assistance is needed.• Ensure the right of children to have access to certain services, such as health care and information onsexuality and reproduction.• Guarantee the participation of the child in matters concerning his or her life as s/he gets older. This includesexercising the right of freedom of speech and opinion.1993 United Nations World Conference on Human Rights in Vienna affirmed women’s rights are human rights.4 CHAPTER:1: THE RIGHT TO FAMILY PLANNING

1994 At the International Conference on Population and Development (ICPD) in Cairo, 179 governments agreed thatpopulation and development are inextricably linked, and that empowering women and meeting people’s needs foreducation and health, including reproductive health, are necessary for both individual advancement and balanceddevelopment. The conference adopted a 20-year Programme of Action, which focused on individuals’ needs andrights, rather than on achieving demographic targets. Advancing gender equality, eliminating violence against womenand ensuring women’s ability to control their own fertility were acknowledged as cornerstones of population anddevelopment policies. Concrete goals of the ICPD centred on providing universal access to education, particularly forgirls; reducing infant, child and maternal deaths; and ensuring universal access by 2015 to reproductive health care,including family planning, assisted childbirth and prevention of sexually transmitted infections including HIV.1995 Beijing Declaration and Platform for Action, United Nations Fourth World Conference on Women Reiteratesbroad definition of right to family planning laid out in ICPD Programme of Action.1999 Key Actions for the Further Implementation of the ICPD Programme of ActionA gender perspective should be adopted in all processes of policy formulation and implementation and in thedelivery of services, especially in sexual and reproductive health, including family planning. Emphasized givingpriority to sexual and reproductive health in the context of broader health reform, with special attention to rightsand excluded groups.2000 The Millennium Declaration was drafted by 189 nations which promised to free people from extreme poverty by2015. The connections with reproductive health were initially understated.2001 The Millennium Development Goals (MDGs). The goals are a road map with measurable targets and cleardeadlines; the targets relevant to reproductive health include:• Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio (MDG-5).• Achieve, by 2015, universal access to reproductive health (MDG 5-B).2004 The 57th World Health Assembly adopted the World Health Organization’s first strategy on reproductive health,recognized the Programme of Action and urged countries to implement the new strategy as part of national effortsto achieve the MDGs.• Make reproductive and sexual health and integral part of planning, budgeting as well as monitoring andreporting on progress towards the MDGs.• Strengthen health systems to provide universal access to reproductive and sexual health care, with specialattention to the poor and other marginalized groups, including adolescents and men.2005 World Summit 2005, follow-up to the 2000 Millennium World Summit. World leaders committed to universalaccess to reproductive health by 2015, to promote gender equality and end discrimination against women.2006 Convention on the Rights of Persons with Disabilities2010 MDG/10 Review Summit. World leaders renewed their commitment to universal access to reproductive health by2015 and promote gender equality and end discrimination against women.2011 The Committee on the Elimination of Discrimination against Women issued a decision establishing that allStates have a human rights obligation to guarantee women of all racial and economic backgrounds timely andnon-discriminatory access to appropriate maternal health services.THE STATE OF WORLD POPULATION 20125

Health: a social and economic rightThe International Covenant on Civil andPolitical Rights, ICCPR and the InternationalCovenant on Economic, Social and CulturalRights, ICESCR, were developed during the1960s to ensure the principles referenced in theUniversal Declaration of Human Rights wouldbe implemented. Human rights activists haveensured that the ICCPR has played a key partin protecting people against government abusesof political power while today the ICESCR isinstrumental in activist efforts to persuade governmentsto place the right to a house or a mealon an equal footing with the right to vote (TheEconomist, 2001). Activists in and committedto some of the world’s poorest countries havedemanded that economic and social goods betreated as entitlements in places where access tofood and shelter is so lacking as to make evencivil and political rights seem like luxuries.Since 1998, the World Health Organizationhas been asking the international community toformally respect and uphold health as a humanright. The challenge has been to define whatthese social and economic rights—including theright to health—mean in specific and concreteterms that facilitate advocacy and implementation.In 2000, the United Nations Committeeon Economic, Social and Cultural Rightsdefined governments’ “core obligations” toinclude providing equal access to health services,sufficient food, potable water, sanitation andessential drugs.Accountability for rightsNo right exists without obligation, and no obligationis meaningful without accountability.United Nations treaty-monitoring bodies arecharged with tracking government compliancewith major human rights treaties and now routinelyrecommend that governments take actionto protect sexual and reproductive health andreproductive rights (Center for ReproductiveRights, 2009). Under the auspices of theHuman Rights Council of the United Nations,the Universal Periodic Review involves a Statedrivenreview of the human rights records of allUnited Nations Member States once every fouryears. Each State is given the opportunity todeclare the actions they have taken to improvethe human rights situations in their countriesand to fulfil their human rights obligations.The Committee on the Elimination ofDiscrimination Against Women reviews evidenceon the protection of human rightsaround the world and issues recommendations.In 2011, for example, the Committee issuedstrong recommendations to the Governmentsof Nepal, Zambia and Costa Rica to ensurethe sexual and reproductive rights of theircitizens (Center for Reproductive Rights,2011a). The independent Expert ReviewGroup was created in 2011 by the UnitedNations Secretary-General to track the GlobalStrategy for Women’s and Children’s Healthand the Commission on Information andAccountability (World Health Organization,2010a). With a special focus on ensuring thecommitment of resources to fulfil MillenniumDevelopment Goals 4 (to reduce child deathrates) and 5 (to reduce maternal death rates),the independent Expert Review Group willlast four years, delivering its first report tothe United Nations General Assembly inSeptember 2012.National human rights institutions and courtsof justice are directly responsible for ensuringthe realization of reproductive rights. The KenyaNational Commission on Human Rights, forexample, recently conducted an inquiry into arange of reproductive rights abuses in that country(Kenya National Commission on Human6 CHAPTER 1: THE RIGHT TO FAMILY PLANNING

Rights, 2012). The charges had been broughtin late 2009 by the Federation of WomenLawyers–Kenya and the Center for ReproductiveRights, alleging violations of reproductive rightsin Kenyan health facilities. The Commission’sassessment found that people’s rights had beenabused, largely as a consequence of the poorservice quality and called on the Governmentto make the needed improvements.The Colombian Constitutional Court haspassed important judgments ensuring accessto sexual and reproductive health services(Corte Constitucional de Colombia, 2012;Reprohealthlaw, 2012). In 2010, for example,it affirmed the legality of and ensured access toemergency contraception.In 2003 UNFPA conducted a global surveyof national experiences 10 years after theICPD (UNFPA, 2005a). Of the 151 countriessurveyed, 145 provided responses on theenforcement of reproductive rights. Of thosethat responded, 131 reported adopting newpolicies, national plans, programmes, strategiesor legislation on reproductive rights.Family planning and human rights:a frameworkAt the ICPD in 1994, the international communitytranslated its recognition of peoples’right to family planning into a commitment toa human rights-based approach to health, whichfocuses on building the capacity of States andindividuals to realize rights. Thus people notonly have rights, but States have the obligationto respect, protect and fulfil these rights (Centerfor Reproductive Rights and United NationsPopulation Fund, 2010).In their work to support human rights,United Nations agencies are guided by theUnited Nations Common Understandingon the Human Rights Based Approach toDevelopment Cooperation (2003): in the pursuitof the realization of human rights as laiddown in the Universal Declaration of HumanRights and other international human rightsagreements, “human rights standards andprinciples must guide all development cooperationand programming in all sectors andphases of the programming process” (WorldHealth Organization and Office of the HighCommissioner for Human Rights, 2010). Ahuman rights-based approach is operationallydirected towards developing the capacitiesof rights holders to claim their rights andthe capacities of duty-bearers to meet theirtGrace Matthews,a mother-of-two,walked and cycledfor three hours to getcontraceptives. Shedecided to have aninjection to delay hernext pregnancy.©Lindsay Mgbor/UK Department forInternational DevelopmentTHE STATE OF WORLD POPULATION 20127

“Everyone has the right to education, which shall be directedto the full development of human resources, and humandignity and potential, with particular attention to women andthe girl child. Education should be designed to strengthenrespect for human rights and fundamental freedoms,including those relating to population and development.”— ICPD Programme of Action, Principle 10.human rights, including the right to health, forall without discrimination. They achieve thisthrough strategies that contribute to removingobstacles and the adoption of positive measuresthat compensate for the factors that systematicallyprevent specific groups from accessingquality services.t Mother and child,Kiribati.©UNFPA/Ariela Zibiahobligations (United Nations Practitioner’sPortal on Human Rights Based Approaches toProgramming).The practical expressions of the right to familyplanning can be divided into freedoms and entitlementsto be enjoyed by individuals, and theobligations of the State (Center for ReproductiveRights and UNFPA, 2010). The freedoms andentitlements of individuals are strongly dependenton States’ obligations to ensure an equalopportunity and the progressive realization ofFreedoms and entitlements of individualsThe right to family planning entitles individualsand couples to access a range of quality familyplanning goods and services, including the fullrange of methods for men and women.The right to family planning informationand sexuality education is central to people’sentitlements. Individuals must have access tosexual and reproductive health-related information,whether through comprehensive sexualityeducation programmes in schools, campaigns,or counselling and training. This information“should be scientifically accurate, objective, andfree of prejudice and discrimination” (Center forReproductive Rights, 2008).The third element of the right to familyplanning is informed consent and freedom fromdiscrimination, coercion, or violence. Womenand men, girls and boys, must be able tomake informed choices that are free fromcoercion, discrimination, or violence (Centerfor Reproductive Rights and UNFPA 2010;International Federation of Gynecology andObstetrics Committee for the Study of EthicalAspects of Human Reproduction and Women’sHealth, 2009).Obligations of the StateThe Programme of Action of the ICPD affirmsthat “States should take all appropriate measuresto ensure, on the basis of equality of menand women, universal access to health-careservices, including those related to reproductive8 CHAPTER 1: THE RIGHT TO FAMILY PLANNING

t Women lining up forfree family planningservices. An estimated222 million womenin developingcountries lackaccess to moderncontraceptives.©Lindsay Mgbor/UK Department forInternational DevelopmentA set of “minimum core obligations” are independentof national resources and are thereforenot subject to progressive realization. Theseinclude providing access to family planninginformation and services on a non-discriminatorybasis, and providing essential drugs as definedunder the World Health Organization ActionProgramme on Essential Drugs, which includesthe full range of contraceptive methods. (Centerfor Reproductive Rights and UNFPA, 2010)A human rights-based approachto family planningHuman rights standards, as laid out in internationaltreaties and further developed in nationallaws and regulations provide the legal basis for10 CHAPTER 1: THE RIGHT TO FAMILY PLANNING

designing and delivering accessible, acceptableand high-quality family planning informationand services and for establishing the basis foradvocacy by individuals and communities whowant these services (Cottingham, Germain andHunt, 2010). Advocacy includes lobbying forthe translation of international commitmentsinto national laws, policies and regulations, andfor accountability in implementing these laws,policies and regulations.Human rights standards and the authoritativeinterpretation of the standards by the correspondingtreaty monitoring bodies (GeneralComments) provide an objective set of parametersand criteria that help translate the right tofamily planning at the abstract normative levelinto policies and programmes. As part of ensuringthis translation, development cooperationmust contribute to developing the capacities of“duty-bearers” (especially States) to meet theirobligations, and to “rights-holders” (individualsand communities) to claim their rights (WorldHealth Organization and Office of the HighCommissioner for Human Rights, 2010). Thecommittee on Economic Social and CulturalRights in its General Comment Number 14 onthe right to the highest attainable standard ofphysical and mental health has defined the followingnormative elements that apply to all theunderlying determinants of health:AvailabilityThe State’s obligation to ensure the availabilityof the full range of family planning methodsextends to offering services, to regulating conscientiousobjection and private service delivery,and to ensuring that providers are offeringthe full range of legally permissible services.The State’s role to protect and fulfil rightsincludes ensuring that the exercise of conscientiousobjection among healthcare providersUNFPA ensuring a reliable supply ofquality contraceptivesThrough its Global Programme to Enhance Reproductive HealthCommodity Security, UNFPA ensures access to a reliable supply of contraceptivesin 46 developing countries.Since the Programme’s inception in 2007, UNFPA has mobilized $450million for reproductive health commodities, including contraceptives. In2011 alone, the Programme provided $32 million for these commoditiesand $44 million for initiatives to strengthen national health care systemsand build their capacities to deliver reproductive health services.In 2011, the Programme funded about 15 million vials of injectablecontraceptives, 1.1 million intrauterine devices, 14 million cycles oforal contraception, 316,000 doses of emergency oral contraception,308,000 contraceptive implants, 253 million male condoms and 3.5million female condoms.does not result in unavailability of services.“Conscientious objection” occurs when healthcarepractitioners for reasons of their ownreligious or other beliefs do not want to providefull information on some alternatives. “[T]heyhave, as a matter of respect for their patient’shuman rights, an ethical obligation to disclosetheir objection, and to make an appropriatereferral so [the patient] may obtain the fullinformation necessary to make a valid choice”(International Federation of Gynecology andObstetrics Committee for the Study of EthicalAspects of Human Reproduction and Women’sHealth, 2009). The United States is respondingto conscientious objection in the contextof the Affordable Care Act. In January 2012,the U.S. Department of Health and HumanServices specified preventive health services thatnew insurance plans would be required to cover(Galston and Rogers, 2010). The list includedcontraceptives and sterilizations including emergencycontraception. Churches were narrowlyexempted from this rule, but religiously affiliatedhospitals and social service agencies were not.If they were not already providing these services,THE STATE OF WORLD POPULATION 201211

this latter group would have one year to complywith the new mandate. During this year, theywould be required to disclose the limitations totheir coverage and direct employees to affordablecontraceptive services elsewhere.“In order to effectively claim their rights, rights-holdersmust be able to access information, organize and participate,advocate for policy change and obtain redress.”— Office of the High Commissioner for Human Rights and theWorld Health OrganizationAccessibilityEven when services exist, social norms andpractices can limit individual access to them.The subordination of the rights of youngpeople to those of their parents, for example,can limit access to information and servicesand the capacity to act. The ICPD Programmeof Action recognized the need for parents toprioritize the best interest of their childern(based on the Convention on the Rights of theChild). Since then, other negotiations, notablythe 2009 and 2012 Commission on Populationand Development meetings, have emphasizedthe rights of the child and the “duties andresponsibilities” of parents, including their soleresponsibility for deciding on the number andspacing of their children.AcceptabilityInformation and services may exist, and they maybe readily available to individuals in a community.But if they are not acceptable for cultural,religious or other reasons, they will not be used.Research in one community in Mexico, forexample, found that married Catholic womenin their main childbearing years relied primarilyon withdrawal and periodic abstinence, as thewomen interviewed for this study said that moderncontraceptives, such as the pill or intrauterinedevices, were against their religious beliefs andwere therefore unacceptable to them (Hirsch,2008; Hirsch and Nathanson, 2001).UNFPA, rights and family planningUNFPA works for the realization of reproductive rights, including the right tothe highest attainable standard of sexual and reproductive health, throughthe application of the principles of a human rights-based approach, genderequality and cultural sensitivity to the sexual and reproductive health framework.In light of these principles, individuals are treated as active participantsin the policy process with the ability to hold governments accountable intheir obligations to respect, protect and fulfil human rights.As the lead United Nations agency working to improve sexual andreproductive health, UNFPA promotes legal, institutional and policychanges, and raises human rights awareness, empowering people toexercise control over their sexual and reproductive lives and to becomeactive participants in development. UNFPA promotes the development ofnational policy frameworks and accountability systems to ensure universalaccess to quality sexual and reproductive health information, goods andservices without discrimination or coercion on any grounds. At the sametime, UNFPA emphasizes the need to build cultural legitimacy for humanrights principles so that communities can make them their own.QualityTo be in line with fundamental rights, familyplanning services must meet certain qualitystandards. Considerable agreement has evolvedover the definition of “quality of care” sinceit was first defined in 1990 (Bruce, 1990). Itsfocus on service quality from the perspective ofindividuals has highlighted a number of specificelements: choice among contraceptive methods;accurate information on method effectiveness,risks and benefits; technical competenceof providers; provider–user relationships basedon respect for informed choice, privacy andconfidentiality; follow-up; and the appropriateconstellation of services. Providing good qualityservices meets human rights standards and alsoattracts more clients, increases family planning12 CHAPTER 1: THE RIGHT TO FAMILY PLANNING

use, and reduces unintended pregnancy (Creel,Sass and Yinger, 2002).In recent years, consensus has emerged onwhat ensuring quality means in the context offamily planning and human rights. It includes:• Providing family planning as part of otherreproductive health services, such as preventionand treatment of sexually transmittedinfections, and post-abortion care (Mora etal., 1993);• Disallowing family planning targets, incentivesand disincentives, such as providingmoney to women who undergo sterilizationor to health-care providers on the basis ofnumber of women “recruited” for familyplanning;• Including assessments of gender relations inplans and budgeting for family planningservices (AbouZahr et al., 1996);• Accounting for factors such as the distanceclients must travel, affordability andattitudes of providers.In settings as diverse as Senegal andBangladesh, women are more likely to usefamily planning where they are receiving goodcare (Sanogo et al., 2003; Koenig, Hossain andWhittaker, 1997). Among women not usingcontraception, their perceptions of the qualityof care significantly predicted the likelihoodthat they would start using a method; similarly,those currently using contraception were farmore likely to continue using their method. Byimproving the quality of services, programmeshave also created a greater sense of entitlement,leading clients to demand better quality inother parts of the health system (Creel, Sassand Yinger, 2002).A human rights-based approach to sustainabledevelopment gives equal importance to boththe outcomes and processes through which itis achieved. Human rights standards guide theformulation of development outcomes and thecontent of interventions, including meeting theunmet need for family planning. Human rightsprinciples lend quality and legitimacy to developmentprocesses. Processes have to be inclusive,participatory and transparent. Of critical importanceis the priority that must be given to therights and needs of those groups of populationleft behind and excluded as a result of persistentpatterns of discrimination and disempowerment.tWoman and child,Tanzania©UNFPA/Sawiche Wamunz“Ill health constitutes a human rights violation when it arises,in whole or in part, from the failure of a duty-bearer—typicallya State—to respect, protect or fulfil a human rights obligation.Obstacles stand between individuals and their enjoymentof sexual and reproductive health. From the human rightsperspective, a key question is: are human rights duty-bearersdoing all in their power to dismantle these barriers?”(Hunt and de Mesquita, 2007).THE STATE OF WORLD POPULATION 201213

t Viet Nam hasexpanded reproductivehealth services, whichinclude family planning,pre- and post-natal careand HIV prevention.©UNFPA/Doan Bau ChauThree cross-cutting principles contribute tobuilding strong, rights-based family planningprogrammes:• Participation —a commitment to engagingkey stakeholders, especially the most vulnerablebeneficiaries, at all stages of decisionmaking, from policies to programme implementationto monitoring (UNFPA, 2005).• Equality and non-discrimination—a commitmentto ensuring that all individualsenjoy their human rights independent ofsex, race, age, or any other status.• Accountability—mechanisms must be inplace for ensuring that governments are fulfillingtheir responsibilities with regard tofamily planning information and services.Accountability includes monitoring andevaluation systems, with clear benchmarksand targets in order to assess governmentpolicy efforts in meeting people’s rights.Monitoring and evaluation are essential forgiving governments the means to identifythe major barriers to family planning and thegroups that have the greatest difficulty withthese barriers. Monitoring and evaluationalso provide individuals—rights holders—and communities with information to holdgovernments to account when rights are notbeing upheld.ConclusionHundreds of millions of the world’s men andwomen wish to have children by choice and notby chance. Many of their fellow citizens—thosewho are wealthier and more educated—seemto be able to achieve this right (Foreit, Karra14 CHAPTER 1: THE RIGHT TO FAMILY PLANNING

16 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE needs

CHAPTERTWOAnalysing data and trends tounderstand the needsGlobal trends in fertilityLast year, the world’s population surpassed 7 billion and it is projected to reach9 billion by 2050. Population growth is generally highest in the poorest countries,where fertility preferences are the highest, where governments lack the resources tomeet the increasing demand for services and infrastructure, where jobs growth isnot keeping pace with the number of new entrants into the labour force, andwhere many population groups face great difficulty in accessing family planninginformation and services (Population Reference Bureau, 2011; UNFPA, 2011b).tIn Mali, a couplewith their sons.©Panos/GiacomoPirozziWorldwide, birth rates have continued to declineslowly. However, large disparities exist betweenmore developed and less developed regions. Thisis particularly true for sub-Saharan Africa, wherewomen give birth to three times as many childrenon average as womenin more developed regionsof the world (5.1 versus1.7 births per woman).A large part of this differencereflects a desirefor larger families in sub-Saharan Africa, but asmost women in this regionnow want to have fewerchildren (Westoff andBankole, 2002), fertilitydifferences increasinglyreveal limited and unequal access in thedeveloping world to the means to preventunintended pregnancy.Fertility ratesPoverty, gender inequality and socialpressures are all reasons for persistent highfertility. But in nearly all of the least-developedcountries, lack of access to voluntary familyplanning is a major contributing factor.Who is using familyplanning?The use of modern familyplanning methods as measuredby the contraceptive prevalencerate has increased globally ata very modest pace of 0.1 percent per year in recent years,more slowly than in the previousdecade (United Nations,Department of Economicand Social Affairs, 2011). Themodest increase is partially a function of thelarge increase in the numbers of married womenof reproductive age—a 25 per cent increaseTotal fertility rate(births per woman)World................................................ 2.5More Developed............................. 1.7Less Developed.............................. 2.8Least Developed............................ 4.5Sub-Saharan Africa....................... 5.1Source: United Nations, 2011a.THE STATE OF WORLD POPULATION 201217

Change in Age-Specific Fertility RatesOver Time(Births per 1,000 Women)1970-1975 2005-2010AgeWorldMore DevelopedLess DevelopedLeast Developed45-49 40-4435-3930-3425-2920-2415-19WorldMore DevelopedLess DevelopedLeast DevelopedWorldMore DevelopedLess DevelopedLeast DevelopedWorldMore DevelopedLess DevelopedLeast DevelopedWorldMore DevelopedLess DevelopedLeast DevelopedWorldMore DevelopedLess DevelopedLeast DevelopedWorldMore DevelopedLess DevelopedLeast DevelopedSource: United Nations, 2011a.0 50 100 150 200 250 300between 2000 and 2010 in 88 countries thatreceive donor support for contraception (Ross,Weissman and Stover, 2009). Due to earlierhigh fertility, many more people in developingcountries have now reached their reproductiveages, and meeting the contraceptive needs ofmany more women has contributed to only amarginal gain in the percentage covered.Globally, about three of every four sexuallyactive women of reproductive ages 15 to 49,who are able to become pregnant, but are notpregnant nor wanting to become pregnant,are currently using contraception (Singh andDarroch, 2012). In every country of the world,most women who are educated and well-offuse family planning. In East Asia, 83 per centof married women use contraception (UnitedNations, Department of Economic and SocialAffairs, 2011). Conversely, in the poorestregions of the world, contraceptive prevalencerates are lowest and have increased most slowly.Contraceptive use among women in sub-SaharanAfrica in 2010 was lower than use amongwomen in other regions in 1990.Family size and contraceptive use changed dramaticallyworldwide in the 1970s, when coupleshad an average of five children per family. Todaythey have an average of 2.5 (United NationsDepartment of Economic and Social Affairs,2010). Increased contraceptive use is largelyresponsible for fertility declines in developingcountries (Singh and Darroch, 2012). Thoughlevels of contraceptive prevalence have stabilizedsince 2000, the desire to have smaller familiesremains strong worldwide and is increasing indeveloping countries.Use varies according to income levelsMost surveys calculate national wealth scoresand disaggregate indicators by wealth quintile,from the poorest 20 per cent of the population18 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE needs

through the wealthiest 20 per cent. Quintileanalyses of population-based surveys can helpidentify inequalities and family planning needswithin countries, especially in combination withdata on urban-rural and other important dimensionsof access (Health Policy Initiative, TaskOrder 1, 2010).Because poverty takes on specific characteristicswithin a given setting, some researchersnow advocate for separate quintile rankings forurban and rural populations to paint a morecomplete picture of inequalities between povertyand wealth in both urban and rural areas.This approach makes it possible to compare thedifferent experiences of poor women in urbansettings and relatively wealthy women in ruralcommunities. Research from a 16-country studyacross Africa, Asia, and Latin America and theCaribbean finds strong relationships betweenfamily planning use, socioeconomic status,and place of residence (Foreit, Karra andPandit-Rajani, 2010).In countries such as Bangladesh, the prevalenceof modern contraceptive use is the sameacross wealth quintiles in urban and rural settings:there is a nominal difference betweencontraceptive use among rich and poor in urbancommunities, and between the wealthiest andpoorest within rural settings (Demographicand Health Surveys, 2007). In Bangladesh, theprevalence of contraceptive use is greater (by 6per cent) in urban areas. Similar findings, whichsupport pro-rural strategies, have been found inPeru, which would warrant pro-rural programming,as would Bolivia, Ethiopia, Madagascar,Tanzania and Zambia (Health Policy Initiative,Task Order 1, 2010). In some countries, such asNigeria (DHS, 2008), modern contraceptive useincreases with increasing wealth for people wholive in urban and rural areas. The key differenceis the rate of change: wealthier people in ruralsettings report higher use of contraceptives thanthe urban poor. These results would supportpolicies that focus on reaching the urban poor,especially if similar patterns of disparities existamong indicators that measure adverse sexualand reproductive health outcomes.Educational achievement influencesdesired family size, family planning useand fertilityLevel of schooling is associated with desiredfamily size, contraceptive use and fertility. Ananalysis of 24 sub-Saharan African countriesshowed that the adolescents most likely tobecome mothers are poor, uneducated and livein rural areas (Lloyd, 2009). Birth rates aremore than four times as high among uneducatedadolescent girls ages 15 to 19 as amonggirls who have at least secondary schooling. Asimilar gap exists based on wealth and residence.And in these countries, the gaps are widening:births among adolescent girls between the agesof 15 and 19 with no education have increasedtHigh school studentsin Bucharest, Romania,read a leaflet aboutcondoms.©Panos/Peter BarkerTHE STATE OF WORLD POPULATION 201219

Sexuality, sexual and gender stereotypesand limited use of vasectomyA lack of information and access to vasectomy services can compromisethe rights and health of men and women who, if they were appropriatelyinformed, might prefer this relatively safe, simple, permanent and noninvasiveprocedure over female sterilization. Men who choose vasectomiesdecide upon the long-term method after considering numerous physiological,psychological, social and cultural factors. In many places, malesterilization is not well understood and is viewed as a threat to male sexualityand sexual performance.When men and women have access to a full range of family planninginformation and services, more couples may choose vasectomy as theirpreferred method of contraception. The low uptake of vasectomies reflectslimited access to appropriate information about the procedure, institutionalbiases against the method, and individual concerns about the effectsof vasectomies on sexual performance and pleasure.Sources: Landry and Ward, 1997; Greene and Gold, n.d.; EngenderHealth, 2002.by about 7 per cent in the past decade, whilebirths among girls with secondary plus schoolinghave declined by about 14 per cent (Loaiza andBlake, 2010).The widening disparities in birth rates amongeducated and uneducated girls over time reflecta similar increasing gap in their use of contraception.In sub-Saharan African, girls withsecondary schooling were found to be more thanfour times more likely to use contraception thangirls with no education (Lloyd, 2009).Whereas contraceptive use among educatedadolescent girls has risen somewhat between thetwo surveys to 42 per cent overall, there wasno change among uneducated girls. No morethan one in 10 uneducated adolescents usescontraception, even though one in four girls inthese countries, independent of wealth, educationor residence, has an unmet need for familyplanning. These figures suggest that efforts toimprove access to reproductive health servicesamong youth by expanding youth-friendly serviceshave not benefited young women who arepoor, live in rural areas, and are poorly educated.Those most in need of these services lag thefurthest behind (Loaiza and Blake, 2010). Themost plausible explanations for the positive familyplanning outcomes associated with educationare that better-educated women marry later andless often, use contraception more effectively,have greater knowledge about and access tocontraception, exercise greater autonomy inreproductive decision-making, and are moreaware of the socioeconomic costs of unintendedchild-bearing (Bongaarts, 2010).Case studyCASE STUDYYouth-friendly services in MalawiThe sexual and reproductive health needs ofadolescents and young people were not wellserved in Malawi, as in many other parts ofAfrica. The lack of information, long distancesto services and unfriendly providers contributedto high rates of unintended pregnancy and HIV.UNFPA has partnered with the MalawianMinistry of Health and the Family PlanningAssociation of Malawi to provide integratedyouth-friendly sexual and reproductive healthservices through multi-purpose Youth LifeCentres as well as via community-based andmobile services; they have strengthened theirinfrastructure as part of improving quality ofcare for young people. Services include contraception,including emergency contraception,pregnancy testing, treatment of sexually transmittedinfections, HIV counselling and testing,antiretroviral therapy, treatment of opportunisticinfections, cervical cancer screening andtreatment, general sexual and reproductivehealth counselling, post-abortion care, andprenatal and postnatal care for teen mothers.The services are promoted through newspa-20 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE needs

pers, advertisements and by word of mouth.Improvements in service infrastructure, the participationof young people in service provision,the integration of sexual and reproductive healthand HIV services, and the frequent solicitationof input from young clients—all of these thingshave improved the quality of the sexual andreproductive health services and have significantlyincreased their use.The connections between schooling, familyplanning use and fertility are most readilyevident in adolescence. But the effects of educationon desired family size and contraceptiveuse persist into adulthood. The adjacent figureshows that women with secondary educationuse family planning at four times the rate ofwomen with no schooling in sub-SaharanAfrica. This effect reflects both preferences fornumber of children and access to family planning(UNFPA, 2010).Family planning use andplace of residenceContraceptive use in sub-Saharan Africais double in urban areas than what it is inrural areas. Many countries, especially theworld’s poorest, struggle to bring services torural areas. In addition, people in rural areastend to have less access to schooling, anotherimportant correlate of preferences for smallerfamilies and use of family planning.Family planning demand and use evolvethrough lifeA review of global data shows that sexualactivity evolves over a person’s lifetime.Women and men have sex for differentreasons and under different circumstancesat various times in their lives. Individualdecisions to initiate sex with a partner areThe poorest, least educatedand rural women have the lowest ratesof contraceptive use inSub-Saharan AfricaEDUCATIONWEALTHNo EducationPrimarySecondaryPoorest 20%SecondThirdFourthRichest 20%LOCATIONRuralUrban10%10%13%18%17%24%25%34%42%0 5 10 15 20 25 30 35 40 45PERCENTAGE OF USE38%Contraceptive prevalence by background characteristics from 24 sub-Saharan Africancountries at most recent survey, 1998-2008 (Percentage of women aged 1-49, marriedor in union, using any method of contraceptive).Source: Demographic and Health Surveys (calculated using data in Annex III).50THE STATE OF WORLD POPULATION 201221

not necessarily associated with a desire to havechildren. In many instances—absent coercion,exploitation, or violence—it is the humandesire for intimacy and relationships thatdrives sexual behaviour.Young peopleEven though most of young peoples’ sexualactivity takes place in marriage, many youngpeople are sexually active outside of marriage.Sexual initiation is increasingly taking placeoutside of marriage for adolescent girls, thoughoften with a future husband (McQueston,Silverman and Glassman, 2012; NationalResearch Council and Institute of Medicine,2005). Declines in age at menarche are likely tocontribute to increased reproductive health risksfor young women, increasing the number ofNumber of countries where at least10 per cent of women and men never marryNumber of countriesNever-Married,at Least 10% (1970)60504030201003341WomenNever-Married,at Least 10% (2000)31MenSource: United Nations, Department of Economic and Social Affairs, Population Division(2009). World Marriage Data 2008 (POP/DB/Marr/ Rev2008).49years between menarche and marriage. Very earlyintercourse (at age 14 or younger) continuesto occur among approximately a third of girlsin Bangladesh, Chad, Mali, and Niger (Dixon-Mueller, 2008). The proportion making thistransition varies very widely (between 40 and 80per cent) among sub-Saharan African countries,for example.Boys are much less likely than girls to have sexbefore age 15 where early, arranged marriage forgirls is common. Where it is less common, however,boys in many settings are more likely tobe sexually active than girls of the same age. Assome researchers have noted, “the shift over timefrom marital to non-marital sexual initiationmay be advantageous for girls’ sexual and reproductivehealth,” since non-marital sex generallyentails less frequent and more often protectedsex than occurs in marital relationships (Clark,Bruce and Dude, 2006).Young women and men face different challengesfrom early adolescence through youngadulthood. Most young people do not haveconsensual sex to prematurely become mothersand fathers. Globally, young people areincreasingly delaying marriage. For women, thesingulate mean age at marriage (only those whomarry before age 50) has increased in 100 of 114countries with available data since 1970 (UnitedNations, Department of Economic and SocialAffairs, 2011b).In many countries, however, earlier introductionto marriage and sex continues to set youngwomen down a path of greater risk for severaladverse outcomes. Across several regions, girlsremain significantly more likely than their malepeers to be married as children and to begin havingsex at a young age. While younger womenmay have sex earlier in their lives, research findsthat young men are more likely than their femalepeers to have sex with someone who is not a22 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE needs

cohabitating partner (UNICEF, Office of theDeputy Director, Policy and Practice, 2011).These details help contextualize family planningdata on young people, and tell a more completepicture of why young men are more likely thanyoung women to use condoms.AdultsEven though age at first marriage has risen, themajority of women and men eventually marryor live in consensual unions (United Nations,Department of Economic and Social Affairs,2009). As a result, childbearing remains commonplacewithin legally recognized unions—areality in alignment with social acceptability inmost countries where childbearing should occurbetween married couples. Recent data highlight,however, how adults’ need for family planningmay increasingly arise while they are single,separated, or divorced.Today, adults are spending more time out ofmarriage compared to previous generations, andtheir family planning needs reflect these realities.In developing as well as developed countries, theproportion of never-married adults is increasing.Over the last 40 years, the number of countrieswhere at least 10 per cent of women nevermarried (by age 50) has increased from 33 to 41;the number of countries where at least 10 percent of men do not marry before their 50thbirthday increased from 31 to 49.Consensual unions account for an increasingproportion of live-in partnerships, and thesepartnerships are less stable and more fluid thanformal marriages. In Latin America and theCaribbean, over a quarter of women betweenthe ages of 20 and 34 live in consensual unions(United Nations, Department of Economic andSocial Affairs, 2009). This arrangement is lesscommon in sub-Saharan Africa and Asia whereabout 10 per cent and 2 per cent of women,respectively, live in consensual unions. Globally,the proportion of adults (between the ages of 35and 39) who are divorced or separated has risenfrom 2 per cent to 4 per cent between 1970 and2000, a trend concentrated in developed countries(Organisation for Economic Co-operationand Development, 2010).Preferred methodsThe use of modern methods of family planninghas increased in recent years in Eastern Africa,particularly Ethiopia, Malawi and Rwanda,and in Southeast Asia, but there has been notA Cameroonianhome just visited bya community-basedfamily planningcounsellor.© UNFPA/Alain SibenalerTHE STATE OF WORLD POPULATION 201223

METHOD EFFECTIVENESSMethod, rankedfrom most toleast effectiveincrease in use of modern methods in Centraland Western Africa (Singh and Darroch, 2012).When women have access to a selection of contraceptivemethods, several factors influence theircontraceptive preference. Significant among thesefactors are health-related side effects, ease of use,and partner preference (Bradley, Schwandt andKhan, 2009; Darroch, Sedgh and Ball, 2011).For example, estimates suggest that 34 million ofthe 104 million women with method-related reasonsfor unmet need for modern contraceptiveswould like methods that do not cause, or seemPregnancies per100 women in firstyear of typical useImplant .05Vasectomy .15Female sterilization .5Intrauterine device (IUD) (Copper T) .8Levonorgestrel-releasing IUD .2Injectable – 3 month 6Vaginal ring 9Patch 9Pill, combined oral 9Diaphragm 12Male condom 18Female condom 21Sponge 12-24Withdrawal 22Fertility awareness methods: standard days,two-day, SymptothermalSpermicides 28No method 85Source: Guttmacher Institute, 2012. (Based on data from the United States)24to cause, health problems or side effects (Singhand Darroch, 2012). Long-term methods such asintrauterine devices and injectables require fewerclinical visits and rely less on users’ recall to consistentlyuse a method. Individuals and coupleswho use contraceptives also weigh methods’effectiveness and failure rates with its impact onsexual pleasure.In some cases, women are covertly using“invisible” methods such as injectables for fear oftheir husbands’ opposition. As women increasinglywant to control their own fertility or havewanted to and are now more aware that theycan, some women choose to thwart this oppositionby using contraceptives that cannot bedetected by their partners. A few studies andanecdotal evidence suggest that some of therapid rise in use of injectables (6 per cent to 20per cent) in sub-Saharan Africa and elsewhereis attributed to covert use by women who feelthey must conceal contraception from their husbands,families or communities (Biddlecom andFapohunda, 1998).Method effectivenessLong acting methods such as the implant andthe intrauterine device are highly effective atpreventing pregnancy, in large part because theydo not require a daily or periodic action, suchas taking a pill or getting another injection ontime. The pill, patch, vaginal ring, injectables,and barrier methods are all much more effectivein “perfect use” than they are in typical use,because people may forget to use the method oruse it incorrectly.Most modern methods are highly effectiveif used correctly and consistently. Fertilityawareness-related methods are also quite effectiveif used correctly, and are sometimes preferred bywomen who have religious objections to otherforms of contraception. Even the least effective24 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE needs

methods are several times more effective in preventingpregnancy than no method. About 85 ofevery 100 sexually active women who chose notto use a method will become pregnant withinthe first year (Guttmacher Insititute, 2012).Method effectiveness—measured in pregnanciesper 100 women in the first year of typicaluse—ranges from .05 for the implant, to 28 forspermicides, compared with 85 for no methodat all (Guttmacher Institute 2012). Worldwide,almost one in three women using contraceptionrelies on female sterilization. About one in fourrelies on an intrauterine device. More than onein 10 relies on a traditional method, predominantlywithdrawal and rhythm.Use depends on available options, easeof use and informationWomen may have unmet need or discontinuecontraceptive use because they are dissatisfiedwith current options (Frost and Darroch, 2008;Bradley, Schwandt and Khan, 2009). Most ofthe available options depend on technologiesdeveloped in the 1960s and 1970s, and there hassince been nominal investment into the discoveryand dissemination of new methods (Harper,2005; Darroch, 2007). In addition to strengtheningthe quality of information services aboutmodern methods, national efforts to fulfil therights of women and men may require investmentinto new contraceptive methods, includingmethods that do not cause systemic side effects,can be used on demand, and do not requirepartner participation or knowledge (Darroch,Sedgh and Ball, 2011).New methods alone would not eliminateunmet need. However, newer methods that governmentshave recently approved could enablewomen to exercise their right to more reliablyand safely prevent pregnancies. Studies findthat the leading causes of discontinuation —Global contraceptive use by method23%12%11%14%6%4%30%Source: United Nations. 2011 World Contraceptive Data Sheetside effects and fear of side effects —impedeefforts to meet unmet need (Cottingham,Germain and Hunt, 2012).Effectiveness and a full range of methods arepart of demand but also reflect supply. The qualityof services may be poor and the full rangeof methods is not available to most people; as aconsequence, family planning may not be attractiveto them even if they wish to postpone orend their childbearing.Family planning use and reliabilityof suppliesA growing number of contraceptive optionsare available, especially in developed countries.However, women in most developing countrieshave far fewer options, although the range ofmethods available is improving and now oftenincludes injectables and implants in additionto pills and condoms. Obtaining contraceptiveFemale SterilizationMale SterilizationInjectablesPillCondomIUDTraditionalImplant - Less than 1%Other barriermethods - Less than 1%THE STATE OF WORLD POPULATION 201225

tCouple visiting a ruralfamily planning clinic.Mindanao, Philippines.©Panos/Chris Stowersmethods is one challenge; distributing them isanother: The majority of international fundingfor condoms is spent on the procurement ofthe commodity with relatively little spent ondelivery, distribution and administration.CASE STUDYSupplies in SwazilandAccess to supplies and their reliable provision areessential to the realization of individuals’ rightto family planning. Like many other Africancountries, Swaziland has experienced stock-outs,making it difficult for people to choose and haveconfidence in relying on specific contraceptivemethods. Reproductive health commodity securityprogramming had focused mainly on theprocurement of contraceptives by the government,with poor results.As part of its effort to address high maternalmortality and adolescent pregnancy,Swaziland has invested in reproductive healthcommodity security. The Ministry of Healthstrengthened its relationship with civil societyand UNFPA by establishing a partnershipwith the Family Life Association of Swaziland,Management Sciences for Health and UNFPAin 2011 to strengthen programme delivery.Its overall objective was to increase the healthsystem’s effectiveness in ensuring reproductivehealth commodities through three strategies:National systems were strengthened forreproductive health and commodity security;human resources capacity was strengthenedfor implementation, monitoring and reporting;and political and financial commitment toreproductive health commodity security wereenhanced. By conventional standards, successwas achieved through an increase in contraceptiveprevalence. Just as important, however, wasthe increase in the number of facilities offeringfamily planning services and the reliability ofthose services.Traditional methods of family planningremain popularTraditional methods remain widely used,especially in developing countries. Surveydata do not often shed light on why peopleuse traditional rather than modern methodsof family planning.Traditional methods include periodic abstinence,withdrawal, lactational amenorrhea(extended breast-feeding) and “folk” practices;thus their effectiveness varies very significantly.Comparative studies across diverse settingsconfirm that women who use modern methodsare much less likely to become pregnantthan women who rely on a traditional method(Trussell, 2011).26 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE needs

Despite the tendency to consolidate all traditionalmethods into a singular category, notall traditional methods are the same. Severalcountries have good histories with non-modern,traditional methods. For example, withdrawalis a commonly used among educated couplesin Iran and Turkey and has been widely usedto prevent pregnancy in Sicily and Pakistan(Cottingham, Germain and Hunt, 2012; Erfani,2010). The Demographic and Health Surveyscategorize coitus interruptus as a “totally ineffectivefolk method,” even though this method isused extensively in a number of countries andis about as effective as condoms (Cottingham,Germain and Hunt, 2012).five married women. Nearly everywhere, womenare far more likely to undergo the sterilizationprocedure than men. In Colombia, for example,where 78 per cent of women are current contraceptiveusers, nearly a third of all women(31 per cent) have been sterilized, comparedwith just two per cent of men (United Nations,Department of Economic and Social Affairs,2011). Since desired fertility declines over time,couples married at young ages will stop havingchildren at earlier ages. After reaching theirdesired fertility, these younger couples may haveto avoid unintended pregnancy for up to 25years, making permanent methods attractiveto them.Female methods of family planning morewidely used than male methodsThe ICPD Programme of Action noted as a“high priority… the development of new methodsfor the regulation of fertility for men,” andcalled for the involvement of private industry.It urged countries to take special efforts toenhance male involvement and responsibilityin family planning (Paragraph 12.14.). Nearly20 years later, no new male methods have beenwidely introduced to the public. With few contraceptiveoptions for men, men’s use of familyplanning has been less than envisioned by theICPD. Today, even if all traditional methodsrequiring men’s cooperation (rhythm, withdrawaland others) are counted together withmale condoms, male methods account for about26 per cent of global contraceptive prevalence(United Nations, Department of Economic andSocial Affairs, 2011).Female sterilization rates far outnumber malerates. Although the decision to permanently endchildbearing can be difficult, sterilization is themost commonly used family planning methodin the world, relied upon by more than one in”Although the decision to permanently end childbearing canbe difficult, sterilization is the most commonly used familyplanning method in the world, relied upon by more than onein five married women.”While female sterilization rates are highest inLatin and Central America, ranging as high as47 per cent in the Dominican Republic, only 14countries in the world have at least 5 per centof men who have undergone vasectomy. Maleand female sterilization rates are most similar inAustralia and New Zealand, where about 15 percent of both men and women have been sterilized(United Nations, Department of Economicand Social Affairs, 2011). Male sterilizationexceeds female sterilization in only a handfulof countries, most notably in Canada and theUnited Kingdom, where men are about twice aslikely as women to be sterilized.One might infer from the mostly developedcountries that vasectomy rates primarily reflectwomen’s economic power and rights in thesecountries. Nepal is among the few developingcountries where vasectomy rates are aboveTHE STATE OF WORLD POPULATION 201227

Demand and supply over time5 per cent and equal a third or more of femalesterilizations, suggesting that increased femaleempowerment in Nepal may be having an effecton contraceptive choice (EngenderHealth, 2002).Female sterilization is a significantly moreinvasive, costly and risky procedure than malesterilization, and is somewhat less effective,Measures of contraceptive prevalence and unmet need are limited in theirability to capture the dynamic nature of individuals’ decisions regarding theirsexual activity, as well as the context in which these decisions take place. Forexample, contraceptive prevalence and unmet need are influenced by factorsthat women in need of contraceptives cannot control, including changingavailability and supply of contraceptives over a period of time. Furthermore,unmet need for family planning reflects both individuals’ demand for specificmethods and the supply. As more people learn about the benefits of exercisingtheir right to plan their families, the demand for services can potentiallyoutpace supply. This may occur in hard-to-reach regions and among populationswhose sexual activity defies commonly held beliefs about when sex isappropriate.While contraceptive prevalence and unmet need are important indicators,the limitations of contraceptive prevalence and unmet need callattention to the need for additional indicators that better capture the proportionof demand for contraceptives that health systems satisfy (UNFPA,2011). One such indicator is the “proportion of demand satisfied.” This indicatoris derived from current data collection methods and more accuratelymonitors whether women’s stated desires for family planning are beingmet. Additionally, more consistent use of adjusted urban vs. rural quintileanalyses can help policymakers and development practitioners designtailored need-based family planning strategies and programmes.WOMEN USING ANY METHODOF CONTRACEPTIONWOMENUSINGANY METHOD OFCONTRACEPTIONDIVIDED BY+WOMEN NOT USINGCONTRACEPTION ANDWANTING NO MORECHILDREN OR WANTING TODELAY THE NEXT BIRTHSource: United Nations Population Fund (2010). Sexual and Reproductive Health for All:Reducing poverty, advancing development and protecting human rights. New York: UNFPA=PROPORTIONOFDEMANDSATISFIEDyet its prevalence dramatically surpasses vasectomyeverywhere except in North Americaand Western Europe (Greene and Gold, n.d.;Shih, Turok and Parker, 2011). That femalesterilization has become the norm, while malesterilization remains rare, is a clarifying momentof gender inequality. The lack of access to andfailure to promote vasectomy compromises bothmen’s and women’s rights.Given these realities, what factors do couplestake into consideration, if indeed they discusswhich of them will be sterilized? One multicountrystudy showed that some men who chosevasectomy did so out of concern for their partners’health (Landry and Ward, 1997). Othermen were dissatisfied with the choice of methodsavailable, or their wives had discontinued othermethods due to side effects. In some poor families,vasectomy was chosen because women couldnot be spared from child and household care forthe time it would take them to recover. Somemen decided that they had enough children anddid not consult their wives before being sterilized.In the United States, prevalence of vasectomy ishighest among men with higher educations andincomes, whereas female sterilization is moreprevalent among women with lower incomesand education (Anderson et al., 2012).Vasectomy is uncommon in sub-SaharanAfrica, where rates are well below 1 per cent(Bunce et al., 2007). Few providers are trainedto perform vasectomies and many, if not mostmen and women, have not heard of the method.A study of the acceptability of vasectomy inTanzania found that both men and women hadconcerns about sexual side effects (Bunce et al.,2007). While some women feared their husbandswould become unfaithful, men had heard rumorsthat vasectomy caused impotence and fearedtheir wives might leave them if their sexualperformance suffered.28 CHAPTER:2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE needs

taken, the more effective it is. Emergency contraceptionis not effective once implantationhas begun and does not cause abortion. It isintended for emergency use only and is notappropriate for regular use. For longer-termprotection, a copper intrauterine device, wheninserted within five days of intercourse, alsoprevents implantation and can be left in placefor up to 10 years (Trussell and Raymond,2012). Emergency contraception plays a specialrole in instances of sexual violence, armedconflict, and humanitarian emergencies.Given the unpredictable and often unplannednature of young people’s sexual encounters,emergency contraception is especially importantin the range of services provided toadolescents and young adults.Rights and the unmet needfor family planningAccording to a 2012 report by the GuttmacherInstitute and UNFPA, there are 1.52 billionwomen of reproductive age in the developingworld. An estimated 867 million of themneed contraception, but only 645 million arecurrently using modern contraceptive methods.The remaining 222 million women have anunmet need for contraception.• An estimated 80 million unintended pregnancieswill occur in 2012 in the developingworld as a result of contraceptive failure andnon-use among women who do not want apregnancy soon.• Most—63 million—of the 80 million unintendedpregnancies in developing countriesin 2012 will occur among the 222 millionwomen with an unmet need for moderncontraception.• 18 per cent of unintended pregnancies occuramong the 603 million women who wereusing a modern contraceptive but haddifficulty using it consistently and correctly,or because of method failure.Why is unmet need for contraceptionstill so high?The 222 million women who want to avoidbecoming pregnant for at least the next twoyears but are not using a method actually reflecta slight decline in unmet need between 2008and 2012. During this time, the number ofwomen who wanted to avoid a pregnancy grewby nearly 40 million, and the biggest improvementsin reducing unmet need were made inSoutheast Asia. Despite the gains, there is asignificant need for targeted interventions thatreach underserved communities and marginalizedsub-populations, where unmet need remainsrelatively high.In the developing world as a whole, 18 percent of married women have an unmet need formodern contraception, yet in Western, Centraland Eastern Africa and Western Asia, 30 percent to 37 per cent of women have an unmetneed for contraception. In the Arab region, asignificant number of women have unmet needfor family planning—that is, they prefer to avoida pregnancy for at least two years but are notusing a family planning method. A survey collectedby the Pan-Arab Project for Family Healthfound that only four in 10 married women ofreproductive age living in the Arab countriesuse modern contraception (Roudi-Fahimi et al.,2012). In most Arab countries, women’s ambivalencetowards family planning results from arange of factors, including fear of side effects,concern with husbands’ reactions, conflictsabout family roles and cultural responsibility forbearing children. This ambivalence declines aswomen grow older.Particularly in Western and CentralAfrica, weak health systems and poor services30 CHAPTER:2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE NEEDS

contribute to high unmet need (Singh andDarroch, 2012). In virtually all developingcountries, poor women have more children andlower contraceptive use than wealthier women,underscoring the need for programming inresource-poor communities. In sub-SaharanAfrica, women in the top wealth quintile arethree times as likely to use contraception as thosein the lowest wealth quintile (Gwatkin et al.,2007). The major difference between users andnon-users is that some have access to information,have more choices as a consequence of theirgreater wealth and schooling, and can act ontheir desire to have fewer children.Women with unmet need for family planningaccount for nearly four out of every five unintendedpregnancies (Singh and Darroch, 2012).Other factors contributing to unintended pregnanciesinclude incorrect or inconsistent use ofa method of contraception, which may be dueto inadequate counselling or information, anddiscontinuation of a method without switchingto another method (Singh and Darroch, 2012).Use of modern methods among never-marriedwomen in the developing world as a wholeis much lower than among married women,except in sub-Saharan Africa, where womenhave a strong need for dual protection frompregnancy and sexually transmitted infections,including HIV, and condoms are the predominantmethod used by unmarried women (Singhand Darroch, 2012).Data also support the need for adolescentandyouth-friendly services. Pregnancies amongadolescents between the ages of 15 and 19 frompoor families are more than twice as commonthan they are among the same age group fromwealthy families (Gwatkin et al., 2007). Thesedisparities are compounded by the fact that poorgirls are more likely than wealthy girls to be married,to be uneducated and malnourished andto have preterm or underweight infants. Littleimprovement in access among adolescents overthe past 10 years can be observed in 22 sub-Saharan African countries where one in fouradolescent girls has unmet need for familyplanning (United Nations, 2011c). Marriedadolescents in all regions have greater difficultythan older women in meeting their need forcontraceptive services (Ortayli and Malarcher,2010). But young never-married women alsoface difficulties in obtaining contraceptives,largely because of the stigma attached to beingsexually active before marriage (Singh andDarroch, 2012).Contraceptive use lowersabortion ratesAccording to a recent Guttmacher Institutestudy (Singh and Darroch, 2012), an estimated80 million unintended pregnancies will takeplace in 2012 in the developing world, and40 million of them will likely end in abortion.tMobile health educatorin Gabarone, Botswanavisits home.©Panos/Giacomo PirozziTHE STATE OF WORLD POPULATION 201231

Most unintended pregnancies ending inabortion result from non-use of a contraceptivemethod or from method failure, particularlyof a traditional method such as withdrawal.Despite their lower rate of effectiveness, 11per cent of all contraceptive users globally(less than 7 per cent of all married women) relyon withdrawal, rhythm, and other traditionalmethods (Rogow, 1995). While lack of access tomodern methods is often a factor in this choice,many prefer so-called “natural” methods becauseof the absence of side effects, their lack of cost,and the fact that they can be used at home withno trip to a clinic.“All countries should, over the next several years, assessthe extent of national unmet need for good-quality familyplanning services and its integration in the reproductivehealth context, paying particular attention to the mostvulnerable and underserved groups in the population.”— ICPD Programme of Action 1994, Paragraph 7.16Addressing women’s concerns about modernmethods and helping women who stopusing one method to find a new and effectiveone could reduce unintended pregnancies insub-Saharan Africa, South Central Asia andSoutheast Asia by 60 per cent, and reduce abortionsin those regions by more than half (Cohen,2011). Addressing unmet need globally wouldavert 54 million unintended pregnancies andresult in 26 million fewer abortions—a declinefrom 40 million to 14 million abortions (Singhand Darroch, 2012).A study of abortion in 12 countries in CentralAsia and Eastern Europe found that manywomen had used modern contraceptives but haddiscontinued for a variety of reasons (Westoff,2005). The majority of pregnancies resultingfrom discontinuation of a modern methodended in abortions. This highlights the importanceof offering a range of methods from whichto choose, of providing high-quality counsellingand “accompaniment” to clients, and of providershelping women who are dissatisfied with amethod to switch to another method before anunintended pregnancy occurs.In the Ukraine, fertility rates have beendeclining as more women have an opportunityto have careers outside of the home, and morecouples are choosing to have fewer children.Immediately after the dissolution of the SovietUnion, couples relied on abortions as familyplanning. Today, however, because family planningis more readily available and understood,there are fewer unplanned pregnancies, andtherefore fewer abortions.In Latin America and the Caribbean, abortionrates have fallen from 37 per 1,000 womenbetween the ages of 15 and 44 in 1995 to 31 per1,000 in 2008 (Kulcycki, 2011), as use of moderncontraceptive methods has risen throughoutthe region to about 67 per cent among marriedwomen (United Nations, Department ofEconomic and Social Affairs, 2011). However,access to contraceptives remains difficult in someregions and for some groups, especially the poorand adolescents. High rates of unintended pregnancylead many women to seek abortion, whichis restricted in most countries in the region. In anumber of countries, abortion is permitted onlyto save a woman’s life. As a consequence, almostall of the 4.2 million abortions annually in theregion are performed clandestinely or underunsafe conditions; the rates of abortion and theproportion that are unsafe are the highest in theworld (United Nations, Economic Commissionfor Latin America and the Carribean, 2011).While wealthier women can seek private providers,poor women more often suffer the medicaland legal consequences of their limited choices(World Health Organization, 2011a). Unsafe32 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE needs

abortions in the region lead to more than 1,000deaths and 500,000 hospitalizations each year(Kulcycki, 2011).Women in developed and developing regionsof the world have abortions at similar rates:29 abortions per 1,000 women in developingcountries, compared with 26 per 1,000women in developed countries (World HealthOrganization, 2011). Though contraceptiveprevalence is higher in developed countries,some women may discontinue use or do nothave regular access to contraceptive methods.Unsafe abortions account for almost half of allabortions (Sedgh, Singh and Shah, 2012). Nearlyall (98 per cent) of unsafe abortions—among allage groups—take place in developing countries,with the greatest number occurring in sub-Saharan Africa. The World Health Organizationhas estimated that 21.6 million unsafe abortionsoccur each year (World Health Organization,2011). The number is steadily increasing as thenumber of women of reproductive age (15-44)increases worldwide.CASE STUDYUnsafe abortion in MozambiqueSome young women in Mozambique resortto dangerous and illegal practices to terminateunwanted pregnancies. The AssociaçãoMoçambicana para o Desenvolvimento daFamília (AMODEFA) and now other nongovernmentalorganizations have organized“Women’s Caucus” discussion groups that meetfor two hours each week to talk about thisand related issues (United Nations PopulationFund, 2011a). The members choose the topics,which revolve around contraception, partners,unsafe abortion, gender equality, small businessopportunities and violence against women.Young women from AMODEFA with trainingin human rights, sexual and reproductive healthand gender equality coordinate the forum. Youngwomen report greater confidence in reproductivehealth decision-making and more knowledgeof sexual and reproductive health services andwhere to find them.Greater contraceptive use,fewer abortionsThe evidence is strong that as modern contraceptionbecomes more widely used, abortion ratesfall (Westoff, 2008). For example, in Russia, asthe use of the intrauterine device and the pillincreased by 74 per cent between 1991 and2001, abortion, which had been the primarymeans of fertility control for decades, fell by 61per cent. Similar patterns are seen throughoutthe Eastern Europe and Central Asian countrieswhere women previously lacked access tomodern contraception (Westoff, 2005).tBy 2020, if anadditional 120 millionwomen who wantcontraceptives couldget them, this wouldmean 200,000 fewerwomen and girls dyingin pregnancy andchildbirth—that’s savinga woman’s life every20 minutes. Access tocontraceptives wouldmean nearly 3 millionfewer babies dying intheir first year of life.©Lindsay Mgbor/UKDepartment for InternationalDevelopmentTHE STATE OF WORLD POPULATION 201233

According to the most recent data, adolescentsand youth account for approximately 40per cent of unsafe abortions worldwide (Shahand Ahman, 2004). Adolescents may havehigher rates of death and disability than adultwomen due to delays in seeking abortion servicesand failure to seek care for complications.Abortion rates increase with limits to contraception,increased demand for smaller families ordelayed childbearing.Family planning aimed at young people canhelp prevent the leading causes of death amonggirls between the ages of 15 and 19: complicationsrelated to pregnancy, delivery and unsafeabortion (Patton et al., 2009). Almost all maternaldeaths occur in developing countries, withmore than half of these deaths occurring insub-Saharan Africa and almost one-third inSouth Asia (World Health Organization, 2012).A comparative study of hospitalizations across13 developing countries estimated that nearlyone-fourth of women (8.5 million) who have anTotal abortion rates and theprevalence of modern contraceptivemethods in 59 countriesTotal abortion rate432100 10 20 30 40 50 60 70 80Source: Westoff, 2005.Percent of married women using modern methodsabortion each year experience complications thatrequire medical attention, with about 3 millionof them unable to receive the care they need(Singh, 2006).Young girls face greater risks than adults ofcomplications and death as a result of pregnancy.Compared to adult women, younger mothers aretwo-to-five times more likely to die during childbirth,and the risk of maternal death is highestamong girls who have children before their fifteenthbirthdays (World Health Organization,2006). Pregnant girls age 18 or younger areat up to four times greater risk of maternaldeath than women who are at least 20 years old(Greene and Merrick, n.d.).Often overlooked, maternal morbidities arealso a concern for young people. Young motherswho survive childbirth are at greater risk ofsuffering from pregnancy-related injuries andinfections, including obstetric fistula. In sub-Saharan Africa and Asia, the United Nationsestimates that more than 2 million youngwomen live with untreated obstetric fistula, acondition associated with disability and socialexclusion (World Health Organization, 2010).In most settings, high levels of maternal deathand disability reflect inequalities in access tohealth services and the social disadvantage andexclusion that young people face—both a causeand consequence of health risk that young peopleface as a consequence of pregnancy (Swannet al., 2003; Greene and Merrick, n.d.).Nearly 95 per cent of births among adolescentstake place in developing countries, andin these countries, about 90 per cent of birthsto adolescents 15-19 occur within marriage(World Health Organization, 2008). Child marriage—marriagethat takes place before the ageof 18—is increasingly recognized as a violationof a girl’s human rights, including the right tobe protected from traditional harmful practices34 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE needs

(as stated in the Convention on the Rights ofthe Child), but it remains all too common,particularly in Africa and South Asia, whereapproximately half of all girls are marriedbefore age 18 (Hervish, 2011). Most marriedgirls become pregnant not long after marriage(Godha, Hotchkiss and Gage, 2011).Even though 75 per cent of all births amongadolescents are described as “intended,”(World Health Organization, 2008), suchintentions may be strongly influenced by socialpressures and cultural norms, for example, thata woman prove her fertility to her husbandand his family soon after marriage (Godha,Hotchkiss and Gage, 2011). For unmarriedgirls, pregnancy is far more likely to be unintendedand to end in abortion (World HealthOrganization, 2008).In Latin America, births among adolescentshave declined more rapidly, but remain high,averaging 80 births per 1,000 young womenper year. In a few countries, such as Ecuador,Honduras, Nicaragua, and Venezuela, adolescentbirth rates are above 100 births per 1,000women ages 15 to 19, approaching those ofmost sub-Saharan countries (UNFPA 2011).Adolescent pregnancy and childbearing areOthermuch higher among indigenous groups in thesecountries; these groups tend to be socioeconomicallyand educationally disadvantaged (Lewisand Lockheed, 2007). In the United States,birth rates among adolescents have recently40%declined among all ethnic groups to an historiclow level of 34 births per 1,000 women but are60%still higher than they are in Western Europe(UNFPA, 2010a).Births among adolescents are declining inmost regions, but the rate of decline has slowedin some parts of the world, even reversed insome countries in sub-Saharan Africa wherebirths among adolescents are the highest in theAdolescentsand youth (15-24)Unsafe abortionsamong adolescents and youthpercentage of total unsafe abortions in developingcountries and proportion as a percentage of unsafeabortion BY regionPercentage among adolescents and youth, as apercentage of total unsafe abortions worldwideAdolescentsand youth (15-24)60%40%OtherBreakdown, as a percentage of unsafeabortions (15-24 years) in their region605040302010020-24323125Africa15-19AsiaSource: Shah, I., Ahman, E (2004). “Age Patterns of Unsafe Abortionin Developing Country Regions. Reproductive Health Matters. 12(24Supplement):9–17.2392914Latin Americaand Caribbean654321THE STATE OF WORLD POPULATION 201235

world (United Nations Population Division,2012). In sub-Saharan Africa, adolescentsbetween the ages of 15 and 19 have, on average,120 births per 1,000 per year, ranging froma high of 199 per 1,000 girls in Niger to a lowof 43 per 1,000 girls in Rwanda. Over half ofyoung women give birth before age 20 (Godha,Hotchkiss and Gage, 2011), and adolescentfertility in most countries in sub-Saharan Africahas shown little decline since 1990 (Loaiza andBlake, 2010). In the Caucasus and Central Asia,fertility among adolescents has leveled off overthe past 10 years, perhaps because the regionhas achieved such high levels of girls’ schooling,with gender parity at the secondary level andmore girls studying at the tertiary level than boys(United Nations, 2012). The only region whereadolescent fertility increased between 2000 and2010 was Southeast Asia.The need for comprehensive dataProtecting the right to family planning firstrequires a baseline understanding of who currentlyhas access to family planning and whodoes not. Ensuring rights also requires anData-driven advocacy results inpolitical and financial support forfamily planning in EcuadorFertility rates in Ecuador vary among population groups. Women in thelowest income quintile, for example, have an average of five children,compared to women in the highest income quintile who have about two.These disparities reflect inequalities in access to sexual and reproductivehealth services. In response, UNFPA partnered with the Ministry ofHealth and other bilateral and multinational organizations to collect andanalyse data to document the disparities and to advocate for changesthat would rectify these inequalities. The data made the case in 2009 fora new strategy for family planning and for the prevention of adolescentpregnancy, and as a result, Ecuador stepped up its investments in reproductivehealth supplies, including contraceptives, by more than 700 percent between 2010 and 2012, to $57 million.understanding of how young people and adultsview sex, sexuality, and the decision to havechildren. New technologies make it possible forStates to gain a greater understanding of demographictrends and the environmental factorsthat motivate people to have sex and influencefertility rates. Digital and mobile communicationsmake it possible for people to more easilyaccess information about their rights and theirgovernments’ obligations to uphold them.An assessment of family planning trendsrequires a nuanced analysis of who is most vulnerable,whose needs have been neglected, andwhat factors contribute to peoples’ vulnerabilitiesand their inability to realize their rights to familyplanning throughout their lives (UNFPA, 2010).Good demographic measures tell a complexand evolving narrative. Stakeholders increasinglyneed to analyse these data in concert withinformation about the social, cultural, andpolitical conditions that shape health and causepatterns in health to evolve. The World HealthOrganization asserts that these social determinantsof health drive “most of the global burdenof disease and the bulk of health inequalities”(World Health Organization, 2005). At alllevels—individual, community, and national—social determinants of health establish conditionsthat influence the ability of women, men, andyoung people to access quality family planningwhen they want to prevent or delay pregnancy atdifferent stages of their lives.Policymakers must therefore use comprehensivedata across sectors on population dynamics,including age structures and the rate of urbanization,as well as other trends. Simply increasingthe availability of family planning may do littleto reduce unintended pregnancy without analysesof where unmet need is greatest, where effortsto uphold reproductive rights have been weak,or where cultural, social, economic or logistical36 CHAPTER 2: ANALYSING DATA AND TRENDS TO UNDERSTAND THE needs

arriers prevent individuals from accessing informationand high quality services.The Programme of Action highlights theinterrelation of human sexuality, age and genderrelations, and how they together affect the abilityof men and women to achieve and maintain sexualhealth and manage their reproductive lives.Family planning programmes must therefore bebased on an analysis of data in ways that takeinto account the continuum of sexual activity, aswell as the gender- and age-specific consequencesof sexual activity.ConclusionFertility, unmet need, rates of discontinuationamong those who are using contraceptionand levels of unsafe abortion are highest in thepoorest countries, and among disadvantagedpopulations within every country. Lingering highlevels of unintended pregnancy persist in somedeveloped countries. Persistent inequalities canbe seen in access to and use of family planningbetween the educated and wealthy elites andeveryone else. When it comes to using familyplanning, therefore, those who can, do, whilethose with more limited access experience unmetneed and unintended pregnancy.In contemplating the need around the worldfor family planning information and services,policymakers need access to comprehensive dataand should consider patterns of sexual activityand not just fertility rates.tA couple with theirbaby in Vulcan.Romania.©Panos/Petrut CalinescuTHE STATE OF WORLD POPULATION 201237

38 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

CHAPTERTHREEChallenges in extendingaccess to everyoneA large and unsatisfied desire exists for family planning around the world amongpeople of many ages, ethnic groups and places of residence. Nations vary greatlyin their ability to help their populations fulfil this desire and uphold individuals’rights. In many countries national legislation exists to translate international rightscommitments into reality (Robison and Ross, eds, 2007). But in far too manysettings, the rights of some—not all—are guaranteed only in principle.tBrenda, 16, (left)and her older sisterAtupele, 18, (right)had to drop outof school becausetheir family couldnot afford the fees.Both are now youngmothers.©Lindsay Mgbor/UK Departmentfor InternationalDevelopmentDespite a range of legal protections, barriers toaccess—and to rights—persist. Some barriersare related to costs and affordability. Others arerelated to difficulties in making quality suppliesand services reliably available in remoteareas or to the distances individuals must travelto obtain family planning. Other obstaclesare related to social norms, customs or genderinequality. And still others are related to policyor legislative environments.Many groups, therefore, are not able toexercise their right to decide whether, whenand under what conditions to have children.The challenge is often related to direct andindirect discrimination and the unequalimplementation of existing legislation, policiesand programming.Worldwide, specific sub-populations face thegreatest challenges in accessing the informationand services they need to plan their families. Asa result, access to family planning is more akinto a privilege enjoyed by some rather than auniversal right exercised by all.Confronting social and economicbarriers to family planningThe United Nations Common Understandingon a Human Rights-Based Approachemphasizes the importance of building thecapacities of individuals to claim their rightsas well as of duty-bearers to meet theirobligations, including service provision.Consequently increased access and use ofbasic family planning services require thedevelopment of capacities for empowerment,in particular of marginalized and discriminatedrights-holders, and capacities for duty-bearersresponsiveness and accountability. Many variedinstitutions can and do address these barriers tothe realization of the right to family planning.Social, cultural and economic factors canenable or impede the realization of rightsincluding access to and provision of familyplanning information and services. Thesefactors may mean that ethnicity, age, maritalstatus, refugee status, sex, disability, poverty,mental health and other characteristics areTHE STATE OF WORLD POPULATION 201239

all barriers to individuals’ access to familyplanning. However, in the sexual andreproductive health arena, gender inequality,gender-based discrimination and women’sdisempowerment stand out as posing obstaclesto women in particular as they pursue andclaim their health and rights.Achieving States’ family planningobligations requires a focus ongender equalityIn many settings, gender norms condone specificbeliefs, behaviours, and expectations of adultwomen and men, contributing to the healthrisks and vulnerabilities that affect women andmen throughout their lives. Relative to men,women and girls are often socialized to beAs part of the effort to meet unmet needs, all countriesshould seek to identify and remove all the major remainingbarriers to the utilization of family planning services.— Programme of Action of the International Conference on Populationand Development, ICPDpassive and under-educated about their sexualand reproductive health. Sexuality—a topic thatencompasses a diverse set of desires, experiences,and needs—is typically confined to notions ofpurity and virginity for women and girls. Womenlive with pressures to conform to social normsthat uniformly restrict their sexual activity withinthe context of marriage. They are often discouragedfrom taking the initiative to bring up topicsrelated to sexual relations, to refuse to have sex orto communicate about family planning.A dominant masculinity teaches boys and menthat sexuality and sexual performance are key tomasculinity. The enjoyment of sexual relations isviewed as their prerogative and they are taught totake the lead in their sexual relationships, creatingsignificant pressure (and insecurity). Traditionalviews of what it means to be a man can encouragemen to seek out multiple sexual partnershipsand to take sexual risks. Around the world, menare taught that they are not primarily responsiblefor family planning and are often not heldresponsible for pregnancies outside of marriage.The differing treatment of boys and girlsas they grow up begins early, and it continuesthroughout their lives. The result is that everyone—children,young people, adults—generallyabsorb messages about how they ought or oughtnot to behave or think, and early on, begin toestablish divergent expectations of themselvesand others as females and males. Often, theseexpectations unfortunately translate into practicesthat can harm sexual and reproductive health.Although women more consistently suffer thenegative effects of harmful gender norms acrosstheir lifetimes, societies also socialize their men,male adolescents, and boys in ways that drivepoor sexual and reproductive health outcomes.In many societies, men are encouraged to asserttheir manhood by taking risks, asserting theirtoughness, enduring pain, being independentproviders, and having multiple sex partners. Theroles and responsibilities of breadwinner andhead of the household are inculcated into boysand men; fulfilling these behaviours and roles aredominant ways to affirm one’s manhood.If gender norms simply dictated difference andnot hierarchy, we might not be talking aboutthem here. But gender norms as a rule establishand reinforce women’s subordination to menand drive poor sexual and reproductive healthoutcomes for both men and women. Women areoften prevented from learning about their rightsand from obtaining the resources that could helpthem plan their lives and families, sustain theiradvancement in school, and support their participationin the formal economy (Greene andLevack, 2010). Men are often not offered most40 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

sources of sexual and reproductive health informationand services and develop the sense thatplanning their childbearing is not their domain:it is women’s responsibility.Gender inequality in family planningprogrammesGender inequality is a profound obstacle towomen’s—and men’s—ability to realize theirright to family planning. It is also an impedimentto sustainable development. While genderequality refers to the overarching goal of equalrights, access, opportunities and lack of genderdiscrimination, gender equity refers to fairnessin the distribution of resources and services(UNFPA, 2012b; Caro, 2009). To ensure fairnessand justice, governments must pursuegender equality, adopting strategies and measuresto compensate for historical and social disadvantagesthat prevent women and men fromenjoying equal opportunities (UNICEF, 2010).The legal, economic, social and culturalbarriers to health and access to health servicesare reinforced by the physiological realities ofreproduction: women bear the consequencesof poor sexual and reproductive health choicesand pay for these consequences with theirhealth and sometimes their lives. Empoweredwith appropriate information, methods, andservices, vulnerable populations are in a betterposition to avoid many of the harmful sexualand reproductive health outcomes affectingthem. A focus on gender equality can makeit easier for both women and men of all agesacross diverse social settings to plan the timingand spacing of their children.The rigid ideals about appropriate attitudesand behaviours for men and women arelearned, socially constructed norms that varyacross local contexts and interact with socioculturalfactors such as class or caste (Barker,2005; Barker, Ricardo and Nascimento, 2007).These social and gender norms are carried outand reinforced on multiple levels, among individualsin peer groups and families, throughcommunity-wide attitudes and practices, andwithin institutions.CASE STUDYAddressing gender-based violencein TanzaniaThe Jijenge! programme in Tanzania recognizedthe harm gender inequality was causing towomen, including to their sexual and reproductivehealth (Michau, Naker and Swalehe, 2002).Going beyond a typically biomedical approachto sexual and reproductive health, thetCouple atantenatal careservice for couplesin Venezuela.©UNFPA/RaúlCorredorTHE STATE OF WORLD POPULATION 201241

Association of gender equitable attitudes and behavioursrelated to sexual and reproductive healthPercentage of men who say the following are importantScore on Genderequitable men scaleCouplecommunicationSexualsatisfactionAccompanied toprenatal visitGEtting anHIV TESTBrazil LOW 87 80 58 28MODERATE 84 91 68 31HIGH 87 95 87 38Chile LOW 50 50 27 21MODERATE 86 83 83 24HIGH 90 88 89 31Croatia LOW 70 61 69 5MODERATE 88 67 84 3HIGH 95 79 94 13India LOW 73 98 91 20MODERATE 65 98 91 12HIGH 64 98 93 6Mexico LOW 71 86 75 16MODERATE 85 91 87 15HIGH 91 96 94 31Rwanda LOW -- 83 -- 85MODERATE -- 85 -- 87HIGH -- 90 -- 89Source: International Center for Research on Women and Promundo, 2011.programme integrated gender equality into sexualand reproductive health via three strategies:• Providing information and clinical servicesfor women, information, services andcounselling that helped women identify theroot causes of the sexual health problems intheir communities;• Training community workers to create moregender-sensitive service agencies and providers,including teachers, police, judges, churchgroups and so on who could develop morewoman-friendly practices;• Changing gender attitudes in communitiesby stimulating public debate on the situationof women through brochures, street theatre,community meetings and other ways ofdisseminating information.The programme found that a specific focuson gender-based violence (particularly when42 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

messages were delivered via a number of routes)turned out to be more effective than a broaderapproach to gender inequality. Men’s involvementin discussions was key, as was the endorsement ofinfluential members of the community.If more traditional, dominant male genderattitudes are related to poorer health outcomes,it is logical that more gender equitable attitudescan lead to improvements in sexual and reproductivehealth-related attitudes and practices(Pulerwitz and Barker 2006; Barker, Ricardo andNascimento, 2007). The International Men andGender Equality Survey, for example, has shownmore healthful practices to be associated withhigher scores on the “gender equitable man” orGEM Scale for measuring attitudes towards genderequality (International Center for Research onWomen and Promundo, 2010).What these data tell us is that men with morerespectful attitudes are likely to have betterindividual and couple outcomes as reflected inimproved couple communication, more sexualsatisfaction, greater chances of accompanying theirfemale partners to antenatal visits, and greaterlikelihood of having sought an HIV test.In the past 15 years, non-governmentalorganizations, United Nations agencies andgovernments have invested in programmes thatbring together efforts to change gender normswith health interventions. Recent research hasshown that efforts to strengthen more genderequitable attitudes among men can influence sexualand reproductive health-related attitudes andpractices (Pulerwitz and Barker, 2006; Barker,Ricardo and Nascimento, 2007). Recent globalreviews of sexual and reproductive health programmeshave found that those that integratedgender considerations achieved better outcomes(Rottach, Schuler and Hardee, 2011; Barker,Ricardo and Nascimento, 2007).Prevention of mother-to-childtransmission of HIV/AIDSOlivia Adelaide,lab technician atMozambique's BoaneHealth Center, whichoffers primary care andsexual and reproductivehealth services, includingfamily planning andHIV testing.©UNFPA/Pedro Sá daBandeiraHIV status does not necessarily repress the desire to have children,and HIV-positive women may decide to have children in spite of theirHIV status, or they may decide not to have children (Rutenberg et al.,2006). Women living with HIV are unable to exercise their right todecide the number, timing and spacing of their children when discriminatorypractices deprive these women of the necessary means andservices to fulfil their decisions, such as accessing contraception, familyplanning, maternal health care, and drugs and services to preventmother-to-child transmission.The right to health and the right to sexual and reproductive health entitlewomen living with HIV to the treatment, care and services necessaryfor them to prevent mother-to-child transmission when they are pregnant.The risk of perinatal transmission of HIV is below 2 per cent whencoupled with antiretroviral treatments, safe delivery and safe infantfeeding. Absent these critical services, the risk ranges from 20 per centto 45 per cent (World Health Organization, 2004a).In low- and middle-income countries, an estimated 45 per centof HIV-positive pregnant women receive at least some antiretroviraldrugs to prevent mother-to-child transmission of HIV (World HealthOrganization, UNAIDS and UNICEF, 2010).tTHE STATE OF WORLD POPULATION 201243

Cultural attitudes and expectations regardingvirginity, marriage and family roles remain rigidin many places, reinforced by anxieties aboutfemale sexuality, power and independence andthe very real dangers girls may face (Greeneand Merrick, n.d.). As more girls stay in schoolfor longer, they are statistically more likely tomature sexually while they are enrolled; theyface risks that few schools address adequately,including sexual violence, exposure to sexuallytransmitted infections and HIV, early pregnancyand childbearing, and unsafe abortion (Lloyd2009). Of course not all of these risks are new,or occur just at school; out-of-school girls alsomarry, and continue to have children as teens ingreat number. What is new is the greater possibilityof friction between the parts of girls’ rolesthat remain stable (domestic chores, expectationsabout virginity, the management of theirsexuality, and aspirations for marriage) and thosethat are changing (schooling, exposure to peers,greater mobility in some cases).Unsafe abortion is “a procedure for terminating anunintended pregnancy that is carried out either by a personlacking the necessary skills or in an environment that doesnot conform to the minimal medical standards, or both.”— World Health Organization (1992).An analysis in five African countries of theexperience of 12-to-19 year-olds who were inschool at age 12 shows that girls are less likelythan boys at every age to continue in primaryor secondary school, and less likely than boysto make the transition from primary to secondaryschool (Biddlecom et al., 2008). Girls aremuch more vulnerable to dropping out oncethey are sexually mature and once they experiencepremarital sex; early pregnancy is evenmore disastrous for girls. Some recent researchsuggests that pregnancy and early marriage aremore likely consequences rather than causesof girls failing to complete their secondaryeducation (Biddlecom et al., 2008; Lloyd andMensch, 2008).Redefining what it means to be a“real man”Like women and girls, men and boys feel socialpressures to adopt rigid ideals about how theyshould behave, feel, and interact to be consideredreal men. These ideals are learned, nota result of simply their sex (Connell, 1987;Connell, 1998). When given the opportunity tocritically reflect on these ideals, men and boyscan often describe the pressures they feel to bereal men—a term usually ascribed to takingrisks, enduring pain, being tough, being aprovider, and having multiple sex partners(Flood, 2007).Real men usually refers to hegemonic masculinity—theprevailing measure of masculinityby which men assess themselves and others.Dominant concepts of masculinity are complexand different across societies, influenced by severalfactors including culture, race, social class,and sexuality (Kimmel, 2000). For example, agroup with one version of masculinity withina social class or ethnic group may exert greaterpower over another, just as heterosexual masculinityis often dominant over homosexualand bisexual masculinity (Marsiglio, 1998). Inmany societies, hegemonic masculinity is associatedwith heterosexuality, marriage, authority,professional success, ethnic dominance, and/or physical toughness (Barker, Ricardo andNascimento, 2007).Men and boys who deviate from dominantmale norms in their attitudes and behaviours aresusceptible to ridicule and criticism (Barker and44 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

Ricardo, 2005). Moreover, young and adult menwho adhere to these traditional views of manhoodare more likely to engage in riskier sexualpractices (Sonenstein, ed, 2000). Results fromthe Gender Equitable Men Scale have foundthat men who adhere to more rigid views aboutmasculinity are more likely to hold attitudes orpractice behaviours that compromise their sexualhealth and their partners’ health (Pulerwitz andBarker, 2008).Not all boys and men identify with dominantversions of masculinity within theircommunities. For example, young men ofhigher socioeconomic status often hold morepower and access to goods and opportunitiesthan young men of lower socioeconomicclasses (Barker, 2005). The evolution of whothey are within their peer groups, families, andcommunities is a dynamic process that changesover time (Connell, 1994). Men’s attitudes andexperiences, particularly the conclusions theydraw about what is socially acceptable behaviour,have implications for men’s and boys’willingness to access family planning servicesand to be active participants in planningfamilies with their partners.A global review conducted by the WorldHealth Organization found that culturally dominantforms of masculinity, which often urge mento practice strict emotional control and cultivatea sense of invulnerability, serve as barriers tohealth—and health-seeking behaviour: they discouragesome men and boys from visiting healthfacilities or from supporting their partners’ health(Barker, Ricardo and Nascimento, 2007).Men often have no opportunity to questionthese male norms or to reflect on how theirviews of manhood affect their health and theirpartner’s health. However, tailored programmeshave demonstrated that young and adult mencan adopt equitable attitudes and behaviours—attitudes associated with better sexual andreproductive health outcomes (InternationalCenter for Research on Women and Promundo,2010; UN Women, 2008).Prevailing attitudes and norms aboutsex impede access for young people,unmarried people of all ages, men andboys and marginalized groupsSocial and cultural norms dictate who, when,with whom, and for what purpose women andmen should have sex. Sexual activity is widelyviewed as acceptable only when the “right”people engage in it under the “right” conditions.The perspectives of excluded groups are notclosely reflected in the design, implementation,and evaluation of family planning policies andprogrammes. The impediments to their accesstYoung men in Cairo'sTahrir Square.©UNFPA/Matthew CasselTHE STATE OF WORLD POPULATION 201245

Relationship between adherence to dominantmasculinities and sexuality807060Men need more sexthan women doMen don’t talk about sex,they just do it57.1 58.161.2Men are always readyto have sex69.757.854.250.1 48.632.4% Agree50403025.234.326.530.741.7201000Brazil Croatia India Mexico RwandaSource: International Men and Gender Equality Survey, International Center for Research on Women & Instituto Promundo 2011are taken for granted following patterns of exclusionspecific to each setting.Across societies worldwide, expectationsdictate that sex should take place only amongmarried individuals who are healthy, heterosexual,monogamous, not too young, not tooold, and whose childbearing fulfils expectationsin their families and communities. When anyperson’s sexual activity violates any of these rigidrequirements, society makes it more difficult forthat person to access family planning education,methods and services.Human sexuality and gender relations are closely interrelatedand together affect the ability of men and women to achieveand maintain sexual health and manage their reproductive lives...Responsible sexual behaviour, sensitivity and equity in genderrelations, particularly when instilled during the formative years,enhance and promote respectful and harmonious partnershipsbetween men and women.— Programme of Action of the ICPD, paragraph 7.34Reinforced over time by longstanding culturalattitudes and practices, social norms underpinthe dialogue, or the absence thereof, aroundindividuals’ sexual desires, their motivations andreservations about accessing family planning, andthe stigma and discrimination they experience.To take the example of unmarried adolescents,despite copious evidence that many are sexuallyactive and that it makes complete public healthsense to prepare them to manage the experience,social norms preclude discussing sexual relationshipsor providing sexual and reproductive healthand family planning information to them.Social conditions under which sexual activity isdeemed “unacceptable” do not excuse States fromfulfilling their obligations and commitment topublic health. Governments alone cannot changediscriminatory attitudes and norms about sex.However, they can structure and coordinate processesthat mitigate social barriers to access, buildcapacities of marginalized groups to exercise theirrights and provide these persons with adequate46 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

per cent in Guatemala. Across all countries, thediscontinuation rates for adolescents are about25 per cent higher than those for older women,with regional variations (Blanc et al., 2009). Inall countries except Ethiopia, a greater proportionof adolescents than older women discontinuedmethod use while still wishing to avoid pregnancy.The same analysis noted higher rates ofcontraceptive failure among young people duringthe first year of contraceptive use.Very few young people are able to exploretheir sexuality in healthy environments alignedwith age-appropriate sexuality education andservices that empower them to make informeddecisions about their sexual behaviours andreproductive health. Family planning programmescan reflect the belief that young peopleare supposed to remain abstinent until marriage.This sociocultural standard no longer reflects thediverse realities of young peoples’ sex lives.Young people explore their sexuality andnegotiate their sex lives influenced by familymembers, religious practices, community leadersand their peers. Male and female adolescentseverywhere are exposed to gendered attitudesand behaviours that shape their perceptions ofsex, sexuality, and relationships, as well as theirbehaviour. The quality and content of the informationyoung people receive varies widely, andis strongly influenced by adolescent peer groups(Kinsman, Nyanzi and Pool, 2000; Jaccard,Blanton and Dodge, 2005). Where youngpeople are especially vulnerable to gender-basedviolence, adolescent girls in particular are atincreased risk that their first sexual experienceis coerced or forced. Coercion is common inDisparities in adolescent fertility rates:Education and household income matterAge-specific fertility rates (live births per 1,000 girls)for 15-19 year-olds by income quintile and regionRegionNo. ofsurveys percountries inthe regionRegionalaveragePoorestquintileRichest quintileRatio offertility ratesPoor-Rich% children of lowersecondary school ageout of school^East Asia 4 of 7 42.4 75.6 17.6 4.3 10.0Central and EasternEurope, Central AsiaLatin America,CaribbeanMiddle East,North Africa6 of 8 52.7 7.0 31.3 2.3 9.6, 4.9**9 of 17 95.7 169.5 39.2 4.3 5.54 of 6 57.8 68.2 35.1 1.9 19.5South Asia 4 of 8 107.0 142.0 57.9 2.5 27.3*Sub-Saharan Africa 29 of 49 129.7 168.1 75.4 2.2 36.8All country average 56 of 95 103.0 142.5 56.6 2.5 18.3Source of fertility data: Gwatkin et al 2007.Source of education data: UNESCO Institute for Statistics 2010.^ Includes children approximately ages 11-14, varies by country* Includes South and West Asia** Data on education presented separately for these two regions48 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

instances of early sexual initiation: more thana third of girls in some countries report thatcoercion was involved in their early sexual experiences(World Health Organization, 2012a).Recent analyses of data on sexual behaviouramong young people in 59 countries found nouniversal trend towards sex at younger ages;trends are complex and vary significantly byregion and marital status (Lloyd, 2005). At thesame time, global trends towards later marriagehave contributed to a diminishing proportion ofyoung women who report having had sex beforethe age of 15 (Lloyd, 2005; Greene and Merrick,n.d.). Notwithstanding, where child marriage isespecially prevalent—South Asia, and Central,West, and East Africa—the median age at firstintercourse for women is lower than in LatinAmerica and the Caribbean, for example. Foryoung men, age at first intercourse is not linkedto their marital status. These differences betweenyoung peoples’ experiences are most pronouncedin developing countries.Comparative assessments of adolescent sexualhealth between the United States and Europefind that young people begin to have sex atsimilar times, though with rather divergent outcomes.In the United States, 46 per cent of allhigh school age students have had sex (Centersfor Disease Control and Prevention, 2010).Despite similar levels of adolescent sexualactivity in several European countries, such asFrance, Germany and the Netherlands, sexuallyactive adolescents are significantly less likelyto experience pregnancy, birth, or abortion.Pregnancy, birth, and abortion rates among teenagegirls in the United States are approximatelythree, eight, and two times as high as theirEuropean peers (Advocates for Youth, 2011).The differences are attributable to Europeanpolicies that facilitate easier access to sexualhealth information and services for school-agedgirls and boys and that respect young peoples’rights and support their health: young peoplein Europe have greater access to comprehensivesexuality education and sexual health services,including family planning; there also tends tobe more open discussion of sexual activity withparents and in the society more broadly.Globally, marriage patterns are changing.Young women and men are marrying later, andthe number of countries where first sexual intercourseand marriage coincide for those undertJust-marriedcouple, Paris.©Panos/Martin RoemersTHE STATE OF WORLD POPULATION 201249

tTeenager inMadagascar listens toa talk about safe sex.©Panos/Piers Benatar25 has decreased compared to earlier generations(Lloyd, ed, 2005; Greene and Merrick,n.d.). These trends have led to an increase inthe prevalence of premarital sex among youngpeople. In developed countries, there has beena clear increase in the number of years betweenfirst intercourse and marriage (Mensch, Grantand Blanc, 2005). The time between first sexualintercourse and living with a partner is longer formen (three to six years) than for women (up totwo years).The increased time interval between age atfirst sex and age at first marriage have implicationsfor the sexual health risks and needs ofyoung people, particularly for school-aged girls.A recent cross-country analysis of 39 countriesfound that—with the exceptions of Benin andMali—unmarried girls (ages 15 to 17) whoattend school are considerably less likely to havehad premarital sex, as compared to their outof-schoolpeers (Biddlecom et al., 2008; Lloyd,2010). Even though individual, familial, andsocial factors influence sexual behaviour andschool participation, these findings underscorethe protective effects that an education confersagainst adolescent pregnancy and its adverseoutcomes. Evidence from five countries in WestAfrica suggests that pregnancy and early marriagemay be consequences, rather than causes, of girlsdropping out of school in some settings (Lloydand Mensch, 2008).Millions of young people have sex before theirparents acknowledge it or before institutionsrespond to their needs. These young people—married and unmarried—also need services toavoid unintended pregnancy and prevent sexuallytransmitted infections including HIV but oftendo not have access.Young people’s sexual activity challenges theemphasis on abstinence and the view that sexshould occur strictly for procreation. The realityis that many young people are not abstinent,and their sexual activity is not motivated by adesire to have children. Qualitative assessmentsin sub-Saharan Africa suggest that sexually activeunmarried young people are generally not seekingto become pregnant (Cleland, Ali and Shah,2006). Furthermore, married young people donot necessarily wish to become pregnant at ayoung age or, if they have already had a child,some wish to delay a second pregnancy.Given young people’s desire to delay childbearingand prevent disease, the term “familyplanning” may seem irrelevant to their needs.Recent research touches upon this key point:Many young people can be interested in contraceptionto prevent unwanted pregnancy and toprotect against sexually transmitted infections,50 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

ut conventional family planning messages aboutplanning their families are irrelevant. Addressingtheir needs and overcoming barriers to theiraccess to family planning requires emphasis oncontraception and disease prevention as wellas comprehensive sexuality education, which isgrounded in human rights including equality andnon-discrimination, reflection about gender roles,sexual attitudes and behaviour (Cottingham,Germain and Hunt, 2010).2 Unmarried people of all agesRelative to previous generations, greater numbersof young people and adults of reproductiveage are having sex outside of marriage, withno immediate desire to have children (Ortega,2012). Ensuring their access to family planningregardless of their marital status requires anacknowledgement of sexual activity for pleasureand intimacy before and after marriage as well aswithin it.Most people in the world marry, and mostsexual activity does take place within marriage(United Nations, Department of Economic andSocial Affairs, 2009). Yet many people who havenever married or whose marriages have endedare sexually active and wish to use family planning.Recent data highlight that interpersonalcommunication among adults about familyplanning—and actual family planning use—isincreasingly taking place while they are single,separated, widowed or divorced.When State family planning programmesexclude these non-married groups, family planningmarginalizes a growing portion of thepopulation. Though religious practices and socialnorms suggest that marriage is a pre-requisitefor sexual activity, the State has an obligation toensure access to family planning to all peopleirrespective of their religious beliefs and sexualpractices without discrimination.In some countries, the proportion of nevermarriedadults is increasing (United Nations,Department of Economic and Social Affairs,2009). Over the last 40 years, the number ofcountries where at least 10 per cent of womenhave never married by age 50 has increased from33 to 41. Larger proportions of men are also notmarrying. Between 1970 and 2000, the numberof countries where at least 10 per cent of men donot marry before their 50th birthday increasedfrom 31 to 49.Use and unmet need among adolescentswho wish to avoid pregnancy in thedeveloping world53%No method Traditional method Modern methodAdolescents who wantto avoid pregnancySub-Saharan AfricaUnintended pregnanciesamong adolescents32South Central and Southeast AsiaLatin America and the Caribbean81%15% 8%32%54%14%32%39%9%11%83%7%10%75%17%52% 8%Source: Guttmacher Institute and International Planned Parenthood Federation, 2010a.THE STATE OF WORLD POPULATION 201251

Consensual unions account for an increasingproportion of live-in partnerships, whichtend to be less stable than formal marriages. InLatin America and the Caribbean, more thanone in four women between the ages 20 and34 live in a consensual union (United Nations,Department of Economic and Social Affairs,2009). This arrangement is less common insub-Saharan Africa and Asia where about 10 percent and 2 per cent of women live in consensualunions, respectively. The percentage of womenin consensual unions ranges from nearly zeroto 30 in 16 developed countries. In a majorityof countries with available data, the percentageof women in consensual unions peaks betweenages 25-29 (United Nations, Department ofEconomic and Social Affairs, 2009).Globally, the proportion of adults who aredivorced or separated doubled (from 2 per centto 4 per cent) between 1970 and 2000. Divorceand separation are more common in developedcountries than in developing countries.According to the World Marriage Data for 2008,11 per cent of women were divorced or separatedin developed countries whereas only 2 per cent ofwomen of the same age were divorced or separatedfrom their husbands in developing countries(United Nations, Department of Economic andWe’re here! Per cent distribution of young people, as per cent ofworld population by region45%11%0-14 15-24 25-59 Over 6017%27%RegionsAfricaWorldLatin Americaand the CaribbeanAsiaOceaniaNorth AmericaEurope0 10 20 30 40 50 60 70 80 90 100Source: United Nations, Department of Economic and Social Affairs, Population Division (2011).52 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

Social Affairs, 2009). Data from 15 industrializedcountries between 2006 and 2008 suggest theaverage duration of marriage ranges from 10 to17 years. Additionally, approximately one in fourregistered marriages in countries belonging to theOrganisation for Economic Co-operation andDevelopment is a remarriage.Adults are entering, staying, and endingpartnerships very differently from previousgenerations, and their needs for familyplanning education and services have takenon new characteristics. Family planning policiesand programmes have an opportunity torethink their focus so as not to exclude unmarriedpeople, whether they are never-married,divorced, separated—temporarily or permanently—orwidowed.In both developed and developing countries,social norms—to varying degrees—promoteabstaining from sexual activity until marriage.Despite broader support for comprehensivesex education in many settings, the abstinenceuntil-marriageapproach to family planning cancompromise the effectiveness of in-school sexualityeducation programmes and neglects the sexualhealth needs of single, sexually active adolescentsand young adults. Evidence shows that theabstinence-only-until-marriage style of sexualityeducation is not effective (Kirby, 2008).“Family planning” usually focuses on theneeds of younger married persons, generally themost fertile. Yet a growing number of olderwomen and men have to negotiate contraceptiveuse and protect themselves from sexually transmittedinfections later in life, often after marriage(Organisation for Economic Co-operation andDevelopment, 2010). The desire for sexualrelationships among older people (over age 49)is largely overlooked in policy and programmedesign. This omission compromises the rightsof sexually active elders who wish to protectthemselves from harmful sexual and reproductivehealth outcomes, including higher-risk unintendedpregnancies and protection from sexuallytransmitted infections, including HIV. Meetingtheir family planning needs requires challengingthe pervasive assumption that older people arenot sexually active and do not need to exercisethe right to family planning.Greater numbers of older women and menare entering their late reproductive years assingle, divorced, or widowed, creating a largepopulation of people who are “post-marriage.”Research in Thailand has described the vulnerabilityof older men to HIV (Van Landinghamand Knodel, 2007), but family planning researchhas not touched on this area. The sexual healthneeds of older women and men are oftenneglected because, like adolescence, sex outsidemarriage for pleasure and intimacy challengessocial norms about who should have sex andtContraceptives atthe Egyptian FamilyPlanning Association inAbo Attwa town, nearIsmailiyah.©UNFPA/Matthew CasselTHE STATE OF WORLD POPULATION 201253

when. The proportion of never-married adults issteadily increasing in all parts of the world, placingnew obligations on States to meet the familyplanning needs of older people (United Nations,Department of Economic and Social Affairs,2009). In their older years, women and menhave unmet need for “mature-friendly” services.Male fertility declines very gradually over aperiod of many years (Guttmacher Institute,2003, cited in Barker and Pawlak, 2011). Fertilelong after females, older men often lack supportfor preventing high-risk pregnancies in theirrelationships, many of which occur with youngerwomen. With greater numbers of single men andwomen having sex after marriage and marital dissolution,a complementary focus on educatingolder men about the benefits and availability ofall methods, including condoms and no-scalpelvasectomy, could empower elders with resourcesto prevent unintended, high-risk pregnancies inolder age, thereby protecting older women’sright to health.Low rates of unintended pregnancyand abortion among young peoplein the netherlandsThe Netherlands has addressed the obstacles to young people’s accessin a variety of ways (Greene, Rasekh and Amen, 2002). Among thechanges of note were: Comprehensive sex education in primary andsecondary schools that includes instruction on relationships, valuesclarification, sexual development, skills for managing healthy sexuality,and tolerance for diversity, for which teachers receive regular trainingin content and instructional approaches; the provision of qualityinformation to parents, family doctors, youth-friendly clinics and themedia; patient-doctor confidentiality, even among young adolescents;and explicit and humorous national campaigns on sexual health. Thetheme running through the policy commitment to youth sexual andreproductive health in the Netherlands is that laws should addressreality, not ideology (Ketting, 1994). In short, the government respondedto the needs and rights of young people with policies that ensure theiraccess to information and services. The Netherlands now has among thelowest rates of unintended pregnancy and abortion in the world.3 MalesMen and women in heterosexual relationshipscan be partners in discussing the timing andspacing of children. Nonetheless, the needsand participation of men and boys in familyplanning has received little attention relative totheir roles as supportive partners for women’shealth (Barker and Pawlak, 2011). Consideringthe evidence and the increased awareness aboutthe importance of engaging men and boys inhealth and gender equality, national responsesto the interlinked family planning needs of bothwomen and men remain limited in scale and inscope (Barker et al., 2010).A growing body of evidence over the last 20years has demonstrated that harmful gendernorms influence attitudes and behaviours amongboys and men, with negative consequences forwomen and girls and men and boys themselves(Barker, Ricardo and Nascimento, 2007; Barkeret al., 2011). This same programme researchacross diverse settings has noted that boys andmen can and often do adopt gender-equitableattitudes and behaviours that support improvedhealth for themselves, their partners, and theirfamilies. This insight is increasingly informingfamily planning policies and programmes.In addition, several international conventionsand agreements including the Programmeof Action of the ICPD affirm the importanceof men’s participation in family life, includingsexual and reproductive health and familyplanning. More governments now engage inpolicy dialogue around men’s roles in sexual andreproductive health, and greater numbers ofdevelopment practitioners integrate gender intoprogramme designs.The international community has acknowledgedthat male partners can exert considerableinfluence in couples’ fertility preferences(UNFPA, 1994; Bankole and Singh, 1998).54 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

Many institutions, providers, and civil societyorganizations must, however, still overcome thepersistent, common perception that boys andmen are merely disinterested in family planning.Men and boys are often trained from anearly age to view fertility matters as women’sresponsibility. And even when men do want toplay more of a role, they are often sidelined byservices. Research into the ways gender normsinfluence boys and men has challenged stereotypesabout their attitudes and behaviours,highlighting opportunities for health promotionand efforts to achieve gender equality.Men’s sexual behaviours vary considerablyacross regions. For example, men vary in thetiming of their sexual activity. The latest availabledemographic and household survey datafrom 30 countries suggest that young men continueto have sex years before they marry (IFCMacro DHS Statcompiler). The gaps betweenage at first intercourse and age at marriage rangefrom 1.1 years in South and Southeast Asia to6.8 years in Latin America and the Caribbean.In sub-Saharan Africa, young men marry4.8 years after they first have sex.When adolescents and male youth are notreached with appropriate information andservices during this interval between first intercourseand when they enter a formal union,they—like their partners—are at increased riskof sexually transmitted infections and unintendedpregnancy. Couples-based family planningprogrammes that heavily rely on links to maternalhealth are less likely to reach these men.Partly because of HIV prevention efforts,young men have become increasingly awareof contraceptive methods available to them(Abraham, Adamu and Deresse, 2010). Menin unions are more likely to know about thecontraceptive methods available to them; inrecent years they have become more aware ofcondoms, while vasectomy remains relativelyunknown.Even though men are increasingly aware ofmale methods of contraception, women stillaccount for 75 per cent of global contraceptiveuse (United Nations, 2011). In 2009, theUnited Nations reported that only 9 per centof married women in developing regions reliedon methods of contraception that required maleparticipation, such as condoms and male sterilization(United Nations, 2009).Men’s fertility preferences have changed overtime. Today, young men generally wish to havesmaller families. As a result, young and adult menmay have an increasing desire for information andservices that help them choose when to havechildren (Guttmacher Institute, 2003).Contraceptive use among young men (ages15 to 24) worldwide varies significantly, withtMan in Kinaaba,Uganda holds his childwhile his wife receivesinjection of long-actingcontraceptive.©UNFPA/OmarGharzeddineTHE STATE OF WORLD POPULATION 201255

63 per cent to 93 per cent of young men reportingusing contraception in parts of NorthAmerica, Europe, and Latin America and theCaribbean (United Nations, 2007). These figuresstand in stark contrast with most sub-SaharanAfrican countries, where less than 50 per centof young, sexually active men used a condom atlast sex. Globally, female sterilization remains themost commonly used method, chosen by 20 percent of married women (United Nations, 2011).The figure is much higher in some countriesdepending on fertility patterns and the rangeof reversible methods available to women.Countries, with the support of the international community,should protect and promote the rights of adolescents toreproductive health education, information and care andgreatly reduce the number of adolescent pregnancies …Governments, in collaboration with non-governmentalorganizations, are urged to meet the special needs ofadolescents and to establish appropriate programmes torespond to those needs. Such programmes should includesupport mechanisms for the education and counseling ofadolescents in the areas of gender relations and equality,violence against adolescents, responsible sexual behaviour,responsible family-planning practice, family life, reproductivehealth, sexually transmitted diseases, HIV infection andAIDS prevention.— ICPD Programme of Action, paragraphs 7.46 and 7.47.The international community has morethoroughly cultivated men’s engagement in thecontext of HIV prevention, and communitybasedprevention efforts have contributed toincreased uptake of male condoms. Yet theWorld Health Organization reports that lessthan a third (31 per cent) of young men indeveloping countries have a “thorough andaccurate” understanding of HIV, suggesting thatmore support for men’s sexual and reproductivehealth, including sexuality education and contraceptives,is needed (United Nations, 2009b).Men are increasingly expressing a desire tobe more engaged in planning their families,including reducing the number of unplannedpregnancies (Barker and Pawlak, 2011). Up to50 per cent of men in some countries—Brazil,Germany, Mexico, Spain, and the UnitedStates—would consider hormone-based contraceptionif such male methods became available(Glasier, 2010). Involving men of reproductiveage in family planning programmes from anearly age can promote more constructive communicationbetween couples about the timingand spacing of children.4 Other marginalized groupsIndigenous people and ethnic minorities.Indigenous peoples and ethnic minorities oftenlack access to family planning. Results fromqualitative interviews find that providers themselvesexpress difficulties assisting ethnic andindigenous women, often because of an inabilityto adequately communicate or understandtheir cultural practices (Silva and Batista, 2010;Cooper, 2005). Prejudice against these groupscan lead to lower levels of investment in theirsexual and reproductive health (United NationsEconomic and Social Council, 2009).The harmful consequences of governmentunder-investment are reflected in large disparitiesbetween indigenous and non-indigenous womenon key reproductive and maternal health indicators.These include maternal mortality rates,total fertility rates and unmet need for familyplanning (Silva and Batista, 2010).Significant health-related inequalities existbetween indigenous and non-indigenousgroups in several countries around the world.In Guatemala, for example, where indigenous56 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

groups (Maya, Xinka, and Garifuna) account fornearly 40 per cent of the total population and75 per cent of its poor, 39 per cent of marriedindigenous women ages 15–49 have an unmetneed for family planning and are thereforeunable to exercise their right to family planning(Guatemala Ministry of Public Health andSocial Assistance, 2003). In contrast, 22 per centof non-indigenous women have an unmet needfor family planning. These disparities in accessto services contribute to the high fertility rate(6.1) among indigenous women who are also atgreater risk of maternal death compared to nonindigenouswomen.CASE STUDYUNFPA and indigenous groups inLatin AmericaIn order to address the high maternal and infantmortality among indigenous women, youth andadolescent girls, UNFPA has been working toincrease their access to quality, safe and culturallyacceptable maternal, newborn and reproductivehealth services, including family planning(UNFPA, 2012d). In so doing, UNFPA hasbeen promoting intercultural dialogue amongtraditional health systems with national, predominantlyWestern allopathic health systems,Need for family planning reflected in multi-year gap between men’s age atfirst intercourse and age at marriageMean age at first intercourseMean age at marriageSub-Saharan Africa18.923.7Latin Americaand the Caribbean1723.8South andSoutheast Asia22.323.50 10 20 30Age• In sub-Saharan Africa, young men have sex approximately five years before they marry• In Latin America and the Caribbean, young men on average have sex before their 18th birthday, and then wait nearlyseven years before marrying• In South and Southeast Asia, the gap (1.1 years) between men’s self-reported age at first intercourse and their age atmarriage is significantly less compared to other regions.Source: Select countries with latest available demographic and health survey data, data: IFC Macro DHS StatcompilerTHE STATE OF WORLD POPULATION 201257

Family planning in humanitariansettings: SomaliaWomen in Somalia have the highest fertility rates in the world, averagingmore than six children each (United Nations Population Fund, 2012b). Inspite of conflict, famine and high maternal, infant and child mortality rates,the country’s population has nearly tripled in the past 50 years. In thispastoralist society, where so many have been lost to war, children haveenormous value.Throughout the past two decades of conflict in Somalia and the lack ofa functioning central government since 1991, international attention hascentred on resolving the political crisis and delivering emergency relief.In this context, developing the programmes and healthcare infrastructurenecessary to generate and fulfil a demand for family planning has not beena priority.Some believe that the only way to effectively communicate aboutfamily planning to Somalis, most of them devout sunni Muslims, is throughreligion. Partnering with faith-based organizations can alleviate the religiousand social pressures on women who practice child spacing. Traditionalmethods such as withdrawal and exclusive breastfeeding are most easilyaccepted in Somali society. UNFPA is collaborating with non-governmentaland governmental organizations to deliver essential reproductive healthsupplies and services. With the worst of the famine now over, Somaliafaces an opportunity to focus on family planning programmes as a way tosafeguard the well-being of future generations.while also supporting community-basedinterventions that mobilize communities tosave women’s lives. The “cultural brokerage”roles that indigenous authorities and leaders,including traditional birth attendants, play arefundamental in this process.UNFPA has also contributed to advancingknowledge on indigenous peoples at theregional and country level through qualitativeand quantitative studies, advocating for theinclusion of indigenous peoples issues in populationand housing censuses, and assisting inthe improvement of health registries and otheradministrative records.Persons with disabilities. The Conventionon the Rights of Persons with Disabilitiesrecognizes their specific rights and outlines correspondingState obligations. The Conventionspecifies that persons with disabilities enjoy legalcapacity on an equal basis with others (Article12), have the right to marry and found a familyand retain their fertility (Article 23), and haveaccess to sexual and reproductive health care(Article 25).Research finds that persons with disabilitiesexperience discrimination that violatestheir rights and social biases that restrict theirabilities to academically, professionally, andpersonally excel (World Health Organization,2011). Furthermore, disabled persons experiencepoorer socioeconomic outcomesand poverty (Scheer et al., 2003; EuropeanCommission, 2008).Worldwide, the belief that disabled personsare asexual or should have their sexuality andfertility controlled is commonplace (WorldHealth Organization, 2009). But persons withdisabilities are sexually active, and studies havedocumented significant other unmet needsfor family planning (Maart and Jelsma, 2010;World Health Organization, 2009). Despitelegal prohibitions that grant disabled personsthe right to plan and time pregnancies, disabledpersons are more likely to be excluded fromsex education programmes (Rohleder et al.,2009; Tanzanian Commission for AIDS, 2009).Studies have also documented cases of involuntarysterilizations of disabled women (Servais,2006; Grover, 2002). Non-consensual sterilizationis against international human rightsstandards.People living with HIV. Research in bothdeveloped and developing countries suggeststhat HIV status does not repress the desire tohave children (Rutenberg et al., 2006). Thespecific considerations of women and men58 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

who are living with HIV and are consideringpregnancy remain linked to the stigma anddiscrimination they encounter from their families,community or health system (Oosterhoffet al., 2008).For women and men with access to antiretroviraltreatment, a diagnosis of HIV can nowbe managed largely as a chronic disease. Eventhough universal access to life-saving treatmentshas not been achieved in all parts of the world,the international community has made considerableprogress towards expanding access. Inlow- and middle-income countries, the numberof people receiving treatment has reached 6.65million, representing a 16-fold increase withinseven years (World Health Organization, 2011).As progress towards universal access to antiretroviraltreatment continues, more people who liveYoung men are more likely than young women to have high-risk sexwith a non-marital, non-cohabiting partner in the last 12 months(PER CENT of young people 15-24)Implications for family planning: married and unmarried people need access to contraceptionto prevent unintended pregnanciesYoung womenYoung menViet NamIndiaCambodiaMalawiUgandaCentral African RepublicZambiaZimbabweUnited Rep. of TanzaniaGuyanaRepublic of MoldovaKenyaUkraineDominican RepublicNamibiaHaiti11114162126272428363240363338465557656972788081838376878790950 20 40 60 80100Source: AIS, DHS, MICS and other national household surveys, 2005-2009. For each country, data refer to the most recent yearavailable in the specified period. THE STATE OF WORLD POPULATION 201259

Studies suggest that HIV may have adverseeffects on both male and female fertility (Lyerly,Drapkin and Anderson, 2001). Moreover,among discordant couples—relationships inwhich one person is HIV positive and theother is not—the ways to safely pursue havingchildren vary. Artificial insemination canreduce the risk of infection when the woman isHIV-positive. When the male partner lives withHIV, pursuing pregnancy can be more complicated,problematic, and costly (Semprini, Fioreand Pardi, 1997).The poor. Although sexual and reproductivehealth outcomes have improved over thelast 20 years, they vary according to incomelevels (UNFPA, 2010). This widening gaphas increased the number of people who areunable to exercise the right to family planning.Moreover, research finds that a disproportionateamount of public spending on health andeducation is allocated towards wealthier sectorsof society, thereby exacerbating the likelihoodthat present-day inequalities will continue towiden among and within countries (Gwatkin,Wagstaff and Yazbeck, 2005).Demographic and Health Surveys from 24sub-Saharan African countries find that thepoorest and least educated women have “lostground,” with poor adolescent girls having thelowest levels of sustained contraceptive use andthe highest unmet need for family planning(UNFPA, 2010). For example, only 10 per centof those belonging to the poorest householdsuse contraception, compared to 38 per cent ofwomen belonging to the wealthiest households.Social exclusion makes it harder for poorpeople to access family planning informationand services, compared to individuals of highersocioeconomic status. These disparities compromisewomen’s health, men’s and women’s“Reproductive health eludes many of the world’s people becauseof such factors as: inadequate levels of knowledge abouthuman sexuality and inappropriate or poor-quality reproductivehealth information and services; the prevalence of high-risksexual behaviour; discriminatory social practices; negativeattitudes towards women and girls; and the limited power manywomen and girls have over their sexual and reproductive lives.Adolescents are particularly vulnerable because of their lack ofinformation and access to relevant services in most countries.Older women and men have distinct reproductive and sexualhealth issues which are often inadequately addressed.”— ICPD Programme of Action, 1994, paragraph 7.3rights, and undermine poverty reduction efforts(Greene and Merrick, 2005). For example,research finds that birth rates have increasedamong the least educated, poor adolescent girlswho often live in rural communities (UNFPA,2010). In contrast, more educated adolescentgirls who live in the wealthiest 60 per cent ofhouseholds in urban areas have experienced lowand declining birth rates since 2000.Hard-to-reach persons in rural or urbancommunities. In most developing countries,national measures of poverty are highly correlatedwith place of residence; urban householdstend to be weathier than rural households(Bloom and Canning, 2003a). Hard-to-reachcommunities vary across countries, but wherepeople live influences their ability to accessfamily planning.In some settings, women and men in ruralareas are unable to routinely access qualityfamily planning information and services. Onaverage, for example, poor women in ruralsub-Saharan Africa have a contraceptive prevalencerate of 17 per cent, compared to 34per cent for their urban peers (United NationsPopulation Fund, 2010). Relative differencesTHE STATE OF WORLD POPULATION 201261

“… culture influences the status of women’s reproductive healththrough determination of the age and modalities of sexuality,marriage patterns, the spacing and number of children,puberty rites, decision-making mechanisms and their ability tocontrol resources, among others. Societal and cultural genderstereotypes and roles also explain why so many adolescent boysand men remain on the fringes of sexual and reproductive healthpolicies and programmes, despite their key role in this realm andtheir own needs for information and services.”— UNFPA Family Planning Strategy, 2012also exist within rural communities, andnational income quintile assessments can maskthe relative disparities within rural and urbancommunities. For example, research from LatinAmerica and sub-Saharan Africa finds thatwhen adjusted quintiles for rural communitiesare used to examine family planning indicators,women from the wealthiest quintiles withintheir rural communities are more able to accessfamily planning services (Foreit, 2012).In other settings, the rapid expansion ofurban areas has also outpaced governments’abilities to develop the infrastructure to providethe urban poor with quality family planning.More than half of the world’s populationStrengthening integration of HIVand sexual and reproductive healthin ZimbabweWomen and girls of reproductive age have been hardest hit by the HIVepidemic in Zimbabwe: prevalence among pregnant women is high, andHIV and AIDS are responsible for about one in four maternal deaths. In2010, an assessment of sexual and reproductive health and HIV/AIDSpolicies and programmes found that inadequate integration of sexual andreproductive health and HIV programmes diminished health providers’capacities to respond to women’s and girls’ unmet need for familyplanning. In collaboration with UNFPA, the World Health Organizationand UNICEF, the Ministry of Health and Child Welfare is closing the gapby developing new integrated service-delivery guidelines and trainingservice providers.now lives in urban areas, and in the comingdecades, almost all global population growthwill occur in towns and cities, with most urbangrowth concentrated in Africa and Asia (UnitedNations Population Fund, 2007). Two-thirds ofAfrica’s urban population lives in informal settlements,where a lack of infrastructure and thethreat of violence impede women’s use of transportationand health services (UN Habitat,2003; Taylor, 2011). Many urban pregnanciesin developing countries are unintended; thereis a 30 per cent to 40 per cent difference incontraceptive prevalence between women in therichest and poorest urban households (Ezeh,Kodzi and Emina, 2010).Stock-outs, disruptions in supply chains,and costs contribute to unmet need in hardto-reach,underserved communities in bothurban and rural settings. Additionally, a lackof targeted information relating to the needsof people who live in isolated rural areas anddensely populated urban communities areamong key factors contributing to lower levelsof contraceptive use and higher unmet need(Ezeh, Kodzi and Emina, 2010).Migrants, refugees and displaced people.Migration and displacement, the movement ofpersons from one area to another has becomeincreasingly commonplace. The total numberof international migrants has increased overthe last eight years from an estimated 150 millionin 2000 to 214 million persons in 2008(UN Department of Economic and SocialAffairs, 2008a). The reasons for migration anddisplacement within and across borders vary,but whether forced or voluntary, for political,economic, social or environmental reasons, theWorld Health Organization notes that the largenumbers of people whose place of residence hasshifted present the international community62 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

with a public health challenge (World HealthOrganization, 2003).International human rights instrumentsexplicitly recognize that human rights, includingthe right to health and family planning,apply to all persons including migrants, refugeesand other non-nationals (World HealthOrganization, 2003). The denial of theserights for socially excluded migrants and displacedpersons makes them unable to fullybenefit from health services, including familyplanning. Women (and men, as evidence isstarting to show) are also vulnerable to sexualviolence from soldiers, guards, recipient communitymembers and other refugees andare therefore at risk of unwanted pregnancy(United Nation's High Commissioner forRefugees and Women’s Refugee Commission,2011).According to migrants and displaced personsin developed and developing countries,a lack of information about their rightsand available services is among the key reasonsgiven for not accessing health services(Braunschweig and Carballo, 2001). Forexample, a national review of several WesternEuropean countries noted that the rates ofmaternal mortality and morbidity are higheramong immigrant women—outcomes areassociated with lower levels of access to contraceptives(Kamphausen, 2000).A study by the United Nations HighCommissioner for Refugees and the Women’sRefugee Commission in Djibouti, Jordan,Kenya, Malaysia and Uganda in 2011 foundthat people who live in refugee settingsreport lower contraceptive use and greaterdifficulty accessing information and services,especially adolescent girls and boys (UnitedNations High Commissioner for Refugees andWomen’s Refugee Commission, 2011).Family planning and a satisfying sex lifeAccording to paragraph 7.2 of the Programme of Action of the InternationalConference on Population and Development, reproductive health implies“that people are able to have a satisfying and safe sex life… It also includessexual health, the purpose of which is the enhancement of life and personalrelations, and not merely counseling and care related to reproduction andsexually transmitted diseases.” This comprehensive notion of reproductivehealth—one that includes a satisfying and safe sex life—has been taken intoaccount in a number of family planning programmes.CASE STUDYFamily planning classes in IranThe Islamic Republic of Iran has required that all couples intending to marryattend a pre-marital counselling course and undergo medical examinations.In order for couples to obtain the results of these exams and register theirmarriages, couples must attend a two-hour class that covers issues of familyplanning, disease prevention and most importantly, the emotional and socialrelationships involved in marriage. The Islamic Republic of Iran has prioritizeddiscussion of “sexual and emotional issues,” in part as a consequence ofhaving observed high divorce rates. Since its inception, the family planningprogramme in the Islamic Republic of Iran has been one of the most successfulin the world, achieving a contraceptive prevalence rate of about 81.6 per cent.CASE STUDYFear of unintended pregnancy in MexicoAccording to a 2008 study of one traditional community in Mexico (Hirsch2008: 101), women’s religious beliefs prevented them from using familyplanning (sterilization was the main method available to them) for most oftheir reproductive lives. These women were therefore often worried aboutunintended pregnancies. Only late in life, after their reproductive years, didthe women have the “possibility of enjoying sexual intimacy free from theworry of an unintended or unwanted pregnancy.”CASE STUDYHIV, sex and condom useSome men's resistance to using condoms has been recognized as an obstacleto use of this method of contraception and HIV prevention (UNAIDS2000). But the approach to encouraging women to use the method hasshifted considerably since the beginning of the HIV/AIDS epidemic (Higginsand Hirsch 2007). Many programmes emphasize building women’s negotiationskills, in recognition of men’s resistance. But we know little aboutwomen’s sexual resistance to male condoms. Research in the United States,however, found that more women than men disliked the feeling of male condoms(Higgins and Hirsch 2008).THE STATE OF WORLD POPULATION 201263

CASE STUDYExpanding family planning inhumanitarian settingsAs part of the emergency response in SouthSudan, UNFPA delivered supplies for oraland injectable contraception and insertion ofintrauterine devices and other family planningcommodities (United Nations PopulationFund, 2011a). And in collaboration withthe American Refugee Committee, UNFPAcontributed to training health care workers,community distribution workers and peereducators on family planning.Strategies and programmes often fail to fulfilthe family planning needs of refugees and internallydisplaced populations who take refuge awayfrom home for varying lengths of time. A focuson the emergency provision of shelter, food, andbasic health services has not always includedtargeted programming to deliver essential reproductivehealth information and services. In recentyears however, humanitarian inter-agencyworking groups have developed resources andtools to help humanitarian personnel generatedemand for family planning and ensure refugees’right to family planning is met.Sex workers. Sex workers not only have a rightto time and space their children, but also to relyon condoms as a means of protecting themselvesfrom sexually transmitted infections includingHIV. However, sex workers often face socialstigma and discrimination, which subsequentlyinhibit them from accessing family planninginformation and services (Lin, 2007).Social norms often classify sex work as beingimmoral, and the institutions and individualsresponsible for law enforcement and healthmay reinforce discriminatory attitudes and practices,with harmful effects on sex workers. Forexample, in some countries such as Lebanonand the Philippines, stigma against sex work andnon-marital sex has been used to pass legislationthat prevents people from freely possessingcondoms (Human Rights Watch, 2004; WorldHealth Organization, 2005). As a result, sexworkers often perceive that health systemsare non-responsive to their needs, includingdenying them access to the full range ofavailable contraceptives.Studies affirm that when sex workers accessfamily planning services, they often do so reluctantlyand fall victim to the biases of health-careworkers who neglect their sexual and reproductivehealth needs, focusing primarily on the riskof HIV and sexually transmitted infections (Lin,2007; Human Rights Watch, 2004). There aredocumented cases of providers in South Asia andSouth East Asia being accused of exposing HIVstatuses and threatening to report those withHIV to the authorities (Mgbako et al., 2008).The consequences of the stigmatization ofsex workers violate universal human rights.According to the World Health Organization,“interventions to promote safer sex among sexworkers must be part of an overall effort toensure their safety, promote their health andwell-being more broadly and protect their humanrights” (World Health Organization, 2005).Lesbian, gay, bisexual and transgenderedpeople. State-run family planning programmeslargely neglect the needs of those who identifythemselves as lesbian, gay, bisexual andtransgendered. The United Nations HighCommissioner for Human Rights has affirmedthat, “discrimination on the basis of sexualorientation is contrary to international humanrights law” (United Nations High Commissionerfor Human Rights, 2008). However, in mostplaces it is heterosexuals who are privileged in64 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

State-run family planning programmes. Some ofthese individuals may seek to prevent unintendedpregnancies. For example, men who have sexwith men and bisexuals may choose to engagein heterosexual sex without wishing to havechildren. In other situations, lesbians and gaymen may wish to plan families. Sexual violenceagainst people based on their perceived or actualsexual orientation makes women vulnerable tounintended pregnancy as a result of rape, requiringaccess to emergency contraception.Child brides. Despite declines in rates of earlymarriage, the practice of marrying girls beforethe age of 18—the internationally agreed age ofadulthood—remains widespread sub-SaharanAfrica and South Asia. It remains relativelyuncommon for young men. Estimates suggestthat 34 per cent of women between the ages of20 and 24 in developing countries were marriedor in a union before their eighteenth birthday.In 2010, this was equivalent to almost 67 millionwomen. Social expectations, including theexpectation that girls will marry early, shape girls’sexual behaviour, compromising their schoolperformance, and making them vulnerable toearly marriage.Child marriage leads to the initiation of sexualactivity during a period when girls know littleabout their bodies, their sexual and reproductivehealth, and their right to family planning. Childwives are also under intense social pressure toprove their fertility, which makes them more likelyto have early and closely-spaced pregnancies.Even when child wives have accurate, comprehensiveknowledge about how to prevent earlytNujoud, Sana'a,Yemen, was marriedto her husband, morethan 20 years hersenior, when she wasonly 10 years old. Theyare now divorced.©VII/Stephanie SinclairTHE STATE OF WORLD POPULATION 201265

pregnancy, their inability to negotiate contraceptiveuse with their (usually older) husbands, orto access services contribute to high levels ofchildbearing in adolescence.Few family planning programmes includestrategies for reaching child brides who are oftenisolated, without well-developed social networks,and vulnerable to many adverse maternal healthoutcomes associated with early pregnancy andchildbirth. This is another important area forinvestment. (Malhotra et al., 2011; Bruce andClark, 2003; UNFPA, 2009; Lloyd, 2009;Countries with the highestrates of child marriageCountryPer cent girlsmarried beforeage 18Niger 75%Chad 72%Bangladesh 66%Guinea 63%Central African Republic 61%Mali 55%Mozambique 52%Malawi 50%Madagascar 48%Sierra Leone 48%Burkina Faso 48%India 47%Eritrea 47%Uganda 46%Somalia 45%Nicaragua 43%Zambia 42%Ethiopia 41%Nepal 41%Dominican Republic 40%Source: UNFPA, 2012World Health Organization, 2008; Lam,Marteleto and Ranchhod, 2009; Levine et al,2008; Mensch, Bruce and Greene, 1999.)Poor quality as an obstacle to familyplanning useWhen services are unreliable or delivered byuntrained personnel, or when a full range ofcontraceptives and information is unavailable,people with unmet need may choose not to takeadvantage of family planning and are thereforeunable to exercise their right to it.Health systems in many countries struggle tomeet the challenge of managing their humanresources effectively, making sure that infrastructureis adequate to the task of providing servicesand ensuring the supply of adequate materialsand equipment of all kinds. People living inrural areas are especially vulnerable to weaknessesin the health system that can leave them beyondthe reach of services available to people in townsand cities.One consequence of poor guidance on a rightsbasedapproach to health and weak managementof staff can be the biased and discriminatoryattitudes of health workers. Some providers internalizesocial biases towards minority populations.Health workers’ attitudes can affect the quality ofinformation given to specific clients, resulting ina lack of informed choice and options.A lack of privacy and inability to communicateare barriers to service delivery for somegroups. A recent multi-country study found thathealth programmes in refugee camps did notensure the right to privacy, confidentiality, andnon-discrimination to all, particularly for adolescentsand unmarried persons (United NationsHigh Commissioner for Refugees, 2011). Insome settings, internally displaced persons orrefugees are often unable to access quality servicesdue to limited commitment to helping66 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

people in mobile, temporary, and resource-poorsettings manage their fertility (United NationsHigh Commissioner for Refugees, 2011).Potential beneficiaries of family planningservices may feel alienated by their providersat moments that compromise their long-termhealth. For example, in communities with highlevels of HIV, alienating experiences amongyoung people from select castes or ethnic groupscan dissuade them from accessing services atcritical moments in their sexual and reproductivelives (United Nations, Economic and SocialCouncil, 2009a). Ethnic minorities, people fromlower castes, and sex workers who may spendconsiderable portions of their lives in poor,hard-to-reach, or other stigmatized communitiesdo not always benefit from the full range ofapproaches to distribution (UNHCR, 2011).These include the safe, community-based provisionof injectables and intrauterine devices thatthe World Health Organization has approved foruse (World Health Organization, USAID andFamily Health International, 2009).CASE STUDYTajikistanTajikistan has worked to overcome a lack ofinformation and services, particularly in ruralareas. Through the joint efforts of UNFPA andthe Ministry of Health, Tajikistan has improvedthe access of vulnerable populations to familyplanning. Family planning information andservices are being provided in the context ofcomprehensive and quality reproductive healthservices and information, a key stipulation ofthe ICPD Programme of Action. Tajikistan hasaccomplished this shift through building capacity,conducting awareness-raising campaigns, providingcontraceptives and ensuring there is adequateequipment to support quality services.CASE STUDYIndiaIn keeping with its demographic goals, India’sfamily planning programme had in the 1970sestablished targets for a narrow range of methodsand relied on health workers to promotethese methods. Many people were pressured oreven coerced into using long-term or permanentmethods of family planning, and the approachrestricted access to the full range of methods.Evidence existed, however, that unmet needcould be addressed without resorting to targetsby making supply respond more effectively tolocal needs. In response, the Government developeda new framework that provided familyplanning in the context of broader reproductiveand child health services, and that built on planningat the local level based on an assessment ofwomen’s need for services (Murthy et al., 2002).Though shifting a massive national programmeis a slow process, increasing the range of methods,managing health workers in a less directiveway, and making the programme more responsiveto local needs has contributed to increasingdemand for family planning.tHealth extensionworker dispensesfamily planning in anEthiopian village.©UNFPA/Antonio FiorenteTHE STATE OF WORLD POPULATION 201267

Laws that block family planning cancompromise rights and healthLaws and policies that restrict peoples’ accessand prohibit health professionals from providingsexual and reproductive health services, includingfamily planning, can compromise women’s rightto health and institutionalize cycles of stigmaand discrimination according to Anand Grover,the Human Rights Council's Special Rapporteuron the Right of Everyone to the Enjoyment ofthe Highest Attainable Standard of Physical andMental Health. A State that uses laws to regulateExpanding access throughculturally appropriate, local servicesin Lao People’s Democratic RepublicThe Lao People’s Democratic Republic is a culturally and ethnically diversecountry. Its indigenous communities, which speak four unique languages,account for 40 per cent of the country’s total population. The unmet needfor family planning among these indigenous populations is significant.With support from UNFPA, the Mother and Child Health Center within theMinistry of Health launched an initiative to provide culturally appropriateand client-friendly family planning services in 2006. The programme hastrained villagers to serve as community-based family planning serviceproviders who work with adolescents, young people and married couples.In these communities, contraception use increased from 12 per cent of thepopulation in 2007 to 45 per cent in 2011.Training for pharmacistsresults in more reliable supplyof contraceptives in MongoliaA lack of specialized training for pharmacists had been a major constraintto reliable supplies of contraceptives and other reproductivehealth supplies in Mongolia until UNFPA began collaborating with theMinistry of Health and the School of Pharmacy at the Health SciencesUniversity of Mongolia in revising the training curriculum for youngpharmacists. Today, more than 350 pharmacists graduate each yearwith skills needed to dispense contraceptives and help reduce unmetneed for family planning.peoples’ family planning options “coercivelysubstitutes its will for that of the individual.”In the Interim report of the Special Rapporteuron the right of everyone to the enjoyment of thehighest attainable standard of physical and mentalhealth, Grover called on States to, amongother things, remove criminal and other lawsrestricting access to comprehensive educationand information on sexual and reproductivehealth. He also said that laws and other legalrestrictions that reduced or denied access tofamily planning goods and services, includingemergency contraception, violated the right tohealth and reflected discriminatory notions ofwomen's roles in the family and society.ConclusionA number of important population groups areneglected by family planning systems or facesometimes insurmountable barriers: youngpeople, unmarried adults in their central reproductiveyears, people who are separated fromtheir partners, older men, people with disabilities,refugees, people living with HIV/AIDS,ethnic minorities and other disadvantagedgroups. An enormous need exists to providemore systematically and more generously themeans to delay and prevent unintendedpregnancy.A human rights-based approach to healthand to family planning points to this reorientation.A human-rights framework for policyand programming calls for a focus on fairnessand non-discrimination to achieve equality; onreaching the most neglected, often marginalizedand vulnerable groups; and on buildingmechanisms that strengthen monitoring andaccountability (UNFPA, 2010). Applying ahuman rights-based approach requires notonly having laws and policies that prohibit andsanction discriminatory practices, but also the68 CHAPTER 3: CHALLENGES IN EXTENDING ACCESS TO EVERYONE

systems and civic participation to implementthem and to ensure accountability.Sexual activity is increasingly taking place inways that challenge social norms that dictateunder what circumstances sex should take place.Families, communities, institutions, and governmentswill have to modify their strategies toensure that all people, as entitled rights-holderswith the right to family planning under internationalconventions, are able to realize it.Adolescents, unmarried people of all ages, menand boys, and other socially marginalized groupswith restricted access to information and servicesare among key sub-populations that have notequally benefited from the recent gains in familyplanning. As a result, unmet need remains relativelyhigh among key populations, and access tofamily planning is still more akin to a privilegeenjoyed by some rather than a universal rightexercised by all.tBritish Prime MinisterDavid Cameronand Melinda Gatestalk about familyplanning issues andvolunteering withyoung people at theLondon Summit onFamily Planning.©Russell Watkins/UK Department forInternational DevelopmentTHE STATE OF WORLD POPULATION 201269

70 CHAPTER 4: THE SOCIAL AND ECONOMIC IMPACT OF FAMILY PLANNING

CHAPTERFOURThe social and economicimpact of family planningBeing able to exercise the right to family planning—and more broadly theright to sexual and reproductive health—is instrumental for the realization ofother rights and also yields many economic benefits to individuals, households,communities and whole countries. Better reproductive health, including familyplanning, affects the economy—and therefore sustainable development—innumerous ways. Women who have fewer risky births, healthier pregnancies andtEduardo MondlaneUniversity.Geography class.©UNFPA/Pedro Sá daBandeirasafer deliveries face lower risks of mortalityand improved overall health.Their babies areborn healthier and their children’s health isbetter early in life. These improvements inhealth produce an array of economic benefits:greater investments in schooling, greater productivity,greater labour force participationand eventually increased income, savings,investment and asset accumulation. Thereis little evidence, however, about the impacton the lives of men.Researchers attempting to document themagnitude of these relationships face severalhurdles, partly because the use of family planningdepends on a variety of other variables,including income, education (particularlyfemale education), opportunities for femaleemployment, the pace of industrialization andurbanization, cultural and social norms andthe cost of raising children. These variables aredifficult to measure and have strong effects oneach other.Family planning and the well-beingof womenHealth impactThe economic impact of improved reproductivehealth on women’s lives begins with improvementsin their own health, in which accessto family planning plays a key role. Access tofamily planning reduces overall fertility, thenumbers of unintended pregnancies as well asthe number of risky pregnancies, which thenreduces the risks of maternal mortality andlong-term morbidity (Maine et al., 1996).Access to family planning can also lead to moreoptimal birth spacing, which in turn improvesoverall maternal health by lowering maternaldepletion syndrome and the risks of prematuredelivery and complications (Conde-Agudelo,Rosas-Bermudez and Kafury-Goeta, 2007).In Sri Lanka for example, the sharpestdeclines in maternal mortality occurred duringits period of fertility decline. Today, Sri Lankahas one of the highest contraceptive prevalenceTHE STATE OF WORLD POPULATION 201271

ates, lowest fertility rates, lowest maternal mortalityrates and some of the best maternal andchild health indicators in the world (Seneviratneand Rajapaksa, 2000).Some of the most rigorous evidence of theeffect of fertility decline on improvements inwomen’s health comes from Matlab, Bangladesh,where a long-term maternal and child-healthprogramme provided doorstep-delivery ofcontraceptives, pre-natal care, vaccinations, safedeliverykits and a variety of other health servicesto women in their homes. Over the course of 30years, the programme not only reduced fertilityby about 15 per cent and improved maternaland child mortality rates, but also had a varietyof spillover effects on women’s health. Womenwho were exposed to the programme throughouttheir reproductive lives experienced increases intheir weight, body mass and general health status(Phillips et al., 1988; Muhuri and Preston, 1991;Muhuri, 1995; Muhuri, 1996; Ronsmans andKhlat, 1999; Chowdhury et al., 2007). Studiesfound that the body-mass index of womenwho participated in the programme crossed athreshold of 18.5, which is associated with lowermortality risks (World Health Organization,1995). A recent study argues that a one-pointincrease in body mass index around this value of18.5 lowers the hazard of death by 17 per cent(Joshi and Schultz, 2007).Linkages between reproductive health and economic outcomesWOMENFewer BirthsFewer RiskyBirthsLower Risksof MortalityReproductivehealthservicesHealthyPregnancySafeDeliveryCHILDRENImprovedOverallHealthIncreasedLifeExpectancyIncreasedProductivityHOUSEHOLDIncreasedSchoolingIncreasedIncomeImproved FoetalHealthImprovedChildhoodHealthFewerChildhoodInfectionsVaccinationsLower Risksof MortalityImprovedCognitionLower Risksof Life-timeIllnessLowerDependencyRatioIncreasedLabour ForceParticipation72 CHAPTER 4: THE SOCIAL AND ECONOMIC IMPACT OF FAMILY PLANNING

tCommunityeducation inCaracas, Venezuela.©Panos/Dermot TatlowThe health benefits of family planning areparticularly significant for younger women andadolescents. Women ages 15 to 19 are twiceas likely to die from maternal causes as olderwomen as a consequence of their physicalimmaturity and increased risk of obstetric complicationssuch as obstetric fistula (Miller et al.,2005; Raj et al., 2009).By averting early pregnancies, reducing riskypregnancies and reducing the risks of prematuremortality or long-term morbidity, improvedaccess to family planning can extend life spans,increase the time horizons for the returns tohuman capital investments and also enablewomen to reallocate their time towards othereconomic activities. One research study foundthat women in Europe and North America havegone from spending 70 per cent of their adultlives bearing and rearing children before thedemographic transition, to spending about14 per cent of it more recently (Lee, 2003).Impact on schoolingIn Colombia, the drop in fertility induced by theProfamilia family planning programme was associatedwith nearly 0.15 more years of schooling(Miller, 2009). In Sri Lanka, the reduction inmaternal mortality risk between 1946 and 1953increased female life expectancy by 1.5 years(approximately 4 per cent), and this increasedfemale literacy among the affected cohorts by 2.5per cent (one percentage point) and increasedyears of schooling by 4 per cent (0.17 years)(Jayachandran and Lleras-Muney, 2009).The trade-off between schooling and childbearingis particularly important for adolescents,since childbearing can disrupt education andpreparation for the labour force. The relationshipTHE STATE OF WORLD POPULATION 201273

tReturning from the field,Kiribati.©UNFPA/Ariela Zibiahbetween marriage and childbearing differsdepending on the setting or country, and thecausal relationship between adolescent pregnanciesand early school dropout can be difficultto disentangle.Research using the United States NationalLongitudinal Survey of Youth found that earlysexual intercourse had detrimental effects ongirls’ performance in school and educationalattainment, even when socioeconomic backgroundvariables were controlled (Steward,Farkas and Bingenheimer, 2009). Another studyin the United States confirms that motherhoodduring adolescence reduces a girl’s chances ofobtaining a high school diploma by up to 10 percent, reduces annual income as a young adult by$1,000 to $2,400, and decreases years of schooling(Fletcher and Wolfe, 2008).Adolescent pregnancy also obstructs girls’educational achievement in developing countries.Lloyd and Mensch (2008) calculated thecumulative risks in five West African countriesof girls’ dropping out of school before completingtheir secondary education. They estimatethe cumulative risks of dropping out as a resultof adolescent pregnancy (or marriage) to rangebetween 20 per cent in Burkina Faso, Côted’Ivoire, Guinea and Togo to nearly 40 per centin Cameroon. One analysis of the impact ofadolescent motherhood on high school attendanceand completion in Chile finds that beinga mother reduces girls’ likelihood of attendingand completing high school by between 24 percent and 37 per cent (Kruger et al., 2009).While some studies find that girls appearmore vulnerable to leaving school once theybecome sexually mature and once they engagein premarital sex, others have concluded thatgirls are more likely to drop out for reasonsother than pregnancy (Biddlecom et al., 2008).In some cases, pregnancy is more likely to bethe consequence of early school exit. Evidencefrom South Africa for example, suggests thatpoor performance in school is associated with aheightened risk of pregnancy and then a higherrisk of dropping out of school. This leads tolong-term negative impacts on a woman’s education,skills, employment and income (Grant andHallman, 2006).Impact on women’s labour forceparticipationAccess to reproductive health services, includingfamily planning, also improves women’s opportunitiesto enter the labour force. First, accessallows women to control the timing of birthsand thus expand their participation in labourmarkets. This is illustrated by the release ofEnovid, the first birth control pill, in the United74 CHAPTER 4: THE SOCIAL AND ECONOMIC IMPACT OF FAMILY PLANNING

Estimates of Total Fertility2010-2015 median projectionRegion Total fertility (children per woman), 2010-2015World 2.45More developed regions 1.71Less developed regions 2.57Least developed countries 4.10Less developed regions, excluding least developed countries 2.31Less developed regions, excluding China 2.86Africa 4.37Eastern Africa 4.74Middle Africa 5.16Northern Africa 2.75Southern Africa 2.46Western Africa 5.22Asia 2.18Eastern Asia 1.56South-Central Asia 2.56Central Asia 2.46Southern Asia 2.57South-Eastern Asia 2.13Western Asia 2.85Europe 1.59Eastern Europe 1.49Northern Europe 1.86Southern Europe 1.49Western Europe 1.69Latin America and the Caribbean 2.17Caribbean 2.25Central America 2.41South America 2.06Northern America 2.04Oceania 2.45United Nations data estimate that the total fertility rate has fallenbelow replacement level (2.1 children per woman) in more than 83countries. Some governments in countries where each generation isnow smaller than the one before it are concerned about having fewerworkers to tax and greater numbers of elders to support. As greaternumbers of individuals and families are able to exercise their rightto family planning, national dialogue about family policy, includingparental leave, support for care-giving services, and the eliminationof discriminatory employment practices against people with youngchildren may be productive. Any adjustments to public policy, however,should not dilute governments’ financial and political commitmentto ensuring that women and men of all ages have reliable access toquality family planning information and services.In societies where total fertility has dipped to below replacementlevels, individuals and families are not refraining from having childrenbecause they merely have access to family planning. Rather, they areachieving their desired small family sizes because they have the meansof doing so. Access to family planning has increasingly empoweredwomen in particular with the information and services to assert theirrights and to carry out their fertility preferences.THE STATE OF WORLD POPULATION 201275

States in 1960. The pill afforded Americanwomen unprecedented freedom to make simultaneousdecisions about childbearing as well astheir careers. A causal analysis of the impact ofthe pill on the timing of first births and women’slabour force participation suggests that legalaccess to the pill before age 21 significantlyreduced the likelihood of a first birth before age22, increased the number of women in the paidlabour force, and raised the number of annualhours worked. The effects are significant: from1970 to 1990 early access to the pill accountedfor three of the 20 percentage-point increase (14per cent) in labour force participation rates and67 of the 450 increase in annual hours worked(15 per cent) among women between the agesof 16 and 30 (Bailey, 2006).Access to family planning services also affectslabour market participation through the reductionof morbidity and improvement in overallhealth. Family planning contributes to thereduction of risky and complicated births, andthis reduces the risk of maternal morbidity andincreases women’s productivity.There are some exceptions to these patterns.In some contexts, female labour force participationcan decrease as fertility declines or aseducational attainment and socioeconomic statusincrease. In the Matlab project in Bangladesh,for example, the provision of family planningand reproductive health services to adult womenin their homes for a period of 20 years resultedin significant improvements in well-being,but female participation in wage employmentactually declined. Researchers attribute thisphenomenon to strong patriarchal mores andrestrictions on female mobility, particularly forwealthy and high-status women, causing somewomen to work at home instead of performingmanual or wage labour outside the home.Estimates indicated, however, that womenwho did work in paid jobs received wages thatwere more than one-third higher than theircounterparts who had not received programmeservices. These wage gains were largely driven bythe higher returns women received from theirschooling in villages covered by the programme(Schultz, 2009a).Health and income benefits from familyplanning also bolster women’s rightsDeclines in fertility, improvements in health andincreased incomes can improve women’s rightsat home and in their communities. A recentstudy illustrates that when fertility declinesand the importance of human capital in theeconomy increases, men start to be willing toshare power with women to ensure that childrenget better educated, since women invest morein children’s human capital and their bargainingpower matters for household decisions (Doepkeand Tertlit, 2009). Men face a tradeoff betweentheir own utility and the utility of their children,grandchildren, and future generations. This tiltstheir preferences towards ceding women greaterrights. The evidence for this argument is historical:using parliamentary debates and newspapereditorials, the authors document that in bothEngland and the United States there was agradual shift during the nineteenth century fromarguments that concentrated on the rights ofmen towards a view that gave first priority tothe needs of children.Family planning and the well-beingof childrenImproved reproductive health services influencechild health in several ways. First, the use offamily planning services to achieve a reductionin the number of pregnancies and the betterspacing of births create positive spilloversbecause healthier women give birth to healthier76 CHAPTER 4: THE SOCIAL AND ECONOMIC IMPACT OF FAMILY PLANNING

children, and healthier women also have moreresources to invest in the well-being of theirchildren (Alderman et al., 2001).Impact on infant and child healthand survivalMany cross-national studies have found apositive relationship between family planningand child survival: users of family planningprogrammes are more likely to experiencelower mortality risks for themselves and theirchildren (Bongaarts, 1987). The relationshipshowever, cannot be interpreted as causal due toconfounding factors such as length and intensityof breastfeeding, prematurity, and as yetunspecified biological, behavioural, environmental,socioeconomic, or health-care effectsthat are known to cause large infant mortalitydifferences between families. A recent studycontrolled for many of these factors, however,and found that increasing birth intervals canreduce neonatal mortality, infant mortality andchild mortality (Rustein, 2005). This study concludedthat birth spacing of three to five yearsalone could prevent up to 46 per cent of infantmortality in developing countries.Evidence from country-specific programmesconfirms this finding. A study from Colombia,for example, illustrates that the local availabilityof clinics and hospital beds and increased familyplanning expenditures per capita are associatedwith lower child mortality as well as lower fertilityacross women in urban areas (Rosenzweigand Schultz, 1982). In the Philippines, the presenceof a family planning programme had directeffects on children’s health (Rosenzweig andWolpin, 1986). Improved access to reproductivehealth, improved spacing of pregnancies, anda reduction in the number of risky pregnanciesin Bangladesh all combined to reduce childmortality and improve child survival (Phillips etal., 1998; Muhuri and Preston, 1991; Muhuri,1995; Muhuri, 1996; Joshi and Schultz, 2007).Similar impact was seen in a programme inNavrongo, Ghana (Binka, Nazzar and Phillips,1995; Pence et al., 2001; Phillips et al., 2006;Pence, Nyarko and Phillips, 2007).Recent research has used anthropometricmeasures of lifetime health as a measure ofearly-childhood health. An individual’s heightis a particularly interesting example of this.Adult height is considered as a latent indicatorof early nutrition and lifetime health status:children with low birth-weights, for example,achieve lower heights even if they receive additionalnutrition in childhood. Though height isdetermined by genetic makeup, it is realized inpart through satisfactory nutrition and healthrelatedcare and conditions, particularly in earlytAt a family planningworkshop in Costa Rica.©UNFPA/Alvaro MongeTHE STATE OF WORLD POPULATION 201277

childhood. It has increased in recent decades inpopulations where per capita national incomehas increased and public health activities havegrown. A study from the Laguna province ofthe Philippines that collected information onheights, weights and exposure to family planningprogrammes between 1975 and 1979 foundthat exposure to health programmes and familyplanning programmes improved children’sheight-for-age as well as weight-for-age. Theirestimates indicate that the height of a childfor whom no health clinic existed would be5 per cent below that for a child always exposedto a clinic, while exposure to a family planningclinic increases height by 7 per cent.Another important mechanism linkingimproved family planning services and earlychildhoodhealth is the improvement inmaternal nutrition that occurs as a result ofbetter-spaced and fewer overall pregnancies.A vast literature in medicine, public health andthe social sciences now argues that improvedmaternal nutrition plays a critical role in childdevelopment. Many studies show that maternalunder-nutrition—as measured by stunting,wasting, chronic energy deficiencies, essentialmicronutrient deficiencies and body massindexes below 18.5 are associated with increasedrisk of intrauterine growth retardation as well ascomplications at birth and birth defects (Bhuttaet al., 2008). Poor foetal growth can contributeindirectly to neonatal deaths, particularly thosedue to birth asphyxia and infections (sepsis,pneumonia, and diarrhoea), which togetheraccount for more than half of neonatal deathsin the world today.Declines in fertility and improvements inmaternal health are known to be associated withhealthier babies with higher birth weights andlower risks of neonatal death. This was seen incommunity-sampled prospective birth cohortsin Nepal, India, Pakistan and Brazil. The studyfound that infants born at term weighing 1500–1999 grams were 8.1 times more likely to die,while those weighing 2000–2499 grams were2.8 times more likely to die from all causesduring the neonatal period than were thoseweighing more than 2499 grams at birth(Bhutta et al., 2008).Children’s schoolingImproved reproductive health and access to familyplanning can also affect investment in humancapital in children. This occurs through severalchannels. Increases in life expectancy create newincentives and opportunities for investmentsin schooling. Moreover, improved reproductivehealth improves overall health of mothers duringpregnancy, which has favourable impacts on children’scognitive development. Finally, declinesin fertility free up women’s resources and allowthem to increase investments in schooling fortheir children.The best evidence for the relationship betweenfertility decline, improved reproductive healthand children’s schooling again comes fromMatlab, Bangladesh. Declines in fertility andimproved maternal health not only increasedinvestment in the schooling of children butalso impacted the trade-offs between children’sschooling and labour (Sinha, 2003; Joshi andSchultz, 2007; Schultz, 2010). There is alsoevidence that the programme also positivelyimpacted children’s test scores and cognitivedevelopment (Barham, 2009).Children’s future labour force participationDeclines in a mother’s fertility, improvements inher health and greater investments in children’shuman capital should ultimately impact theirparticipation in the labour force. While thislink is intuitive and appears to be obvious,78 CHAPTER 4: THE SOCIAL AND ECONOMIC IMPACT OF FAMILY PLANNING

empirical evidence supporting this theory hasso far proved to be elusive, largely because of thelong time lags between the times that these outcomesare observed.Further evidence in support of the relationshipbetween mother’s health, a child’s health and hisor her participation in the labour force comesfrom the studies of maternal nutrition. Thesestudies demonstrate that declines in fertility andimprovements in maternal health are associatedwith not only improved child health, improvedcognitive test scores and schooling attainmentbut also improved occupational status and earnings,reduced non-participation in the labourforce, reduced chronic disease and disabilitybefore the age of 50, and more notably thereafter(Miguel and Kremer, 2004; Almond 2006;Almond, Edlund, et al., 2007; Almond andMazumder, 2008; Almond and Currie, 2011).One recent study used data on monozygotictwins to estimate the effect of intrauterinenutrient intake on adult health and earningsfound that health conditions play a majorrole in determining the world distribution ofincome (Behrman and Rosenzweig, 2004).The study showed considerable variation in theincidence of low birth weight across countries,and that there are real payoffs to increasingbody weight at birth. Increasing birth weightincreases adult schooling attainment and adultheight for babies at most levels of birth weight.They also find evidence that augmenting birthweight among lower-birth weight babies, butnot among higher-birth weight babies, hassignificant labour market payoffs.Reproductive health and the wealth andwell-being of householdsThere are several routes through which fertilitydecline and improved health may be translatedinto better household social and economicwell-being (Bloom and Canning, 2000;Birdsall, Kelley and Sinding, 2001; Schultz,2008; Sinding, 2009). First, as documentedearlier, healthier people work more and arephysically and cognitively stronger, and, thusmore productive and earn higher incomesand accumulate more assets. Second, healthierpeople enjoy a longer life expectancy, and thushave greater opportunities to invest in, andreap returns from, their schooling and humancapital more broadly. This positive relationshipbetween health and wealth is further reinforcedby low fertility and the quantity-qualitytMobile health clinic inSri Lanka.©UNFPA/FPASLTHE STATE OF WORLD POPULATION 201279

tradeoff that induces parents to invest moreresources into each child when the number ofchildren falls.Household savings, income and assetsImproved health and longer life-expectanciesthat can result from better access to reproductivehealth services, including family planning,alter decisions not only about education, butalso about expenditures and savings over anindividual’s lifetime. With declines in fertility,individuals are less likely to rely on childrenfor old age-support and insurance. They arethus more inclined to save for their ownretirement. The impetus to save is furtherreinforced by improved health and increasedlife expectancy since retirement becomes areasonable prospect, and the length of retirementalso increases. There is ample evidenceto support this relationship between fertilitydecline and savings rates (Bloom and Canning,2008). Many studies find a positive correlationbetween declines in fertility or increases in lifeexpectancy on the one hand, and savings rateson the other.In Taiwan, Province of China, for example,the private savings rate rose from 5 per centin the 1950s to over 20 per cent in the 1980s,almost synchronously with improvements in lifeexpectancy (Tsai, Chu and Chung, 2000). Thiseffect is amplified with the adoption of welfareand social security systems.Some of the best micro-level evidence of therelationship between lower fertility, improvedreproductive health, and income comes againfrom Matlab, Bangladesh (Joshi and Schultz,2007; Schultz, 2008; Barham, 2009; Schultz,2009). The overall evidence suggests thatdeclines in fertility and child mortality contributedto poverty alleviation: sons receivedsignificantly more schooling, daughters had abetter nutritional status, and better educatedwomen had proportionately higher wage ratesand lived in households with proportionatelygreater assets. Households in villages coveredby the programme reported 25 per cent moreassets per adult, and held smaller shares ofhousehold assets in forms which complementchild labour, such as livestock and fishingor even land for agricultural annual cultivation.They held a larger share of their assets infinancial savings, jewelry, orchards and ponds,housing, and consumer durables, which may beassets that are better substitutes for old age supportprovided traditionally by children.Improved access to family planning, declinesin fertility, the reduction of maternal mortalityand maternal morbidity and the improvementof child health also increase savings and incomethrough the reduction of spending to copewith “health shocks,” such as a sudden loss ofearnings, the dissolution of households and areduction in the health of surviving householdmembers, particularly children. Improved healthalso contributes to economic productivity.Shifts in intra-household decision-makingThe availability of reproductive health services,particularly family planning, also alters powerstructures within households. In contexts wheremen and women differ in their fertility preferences,and where family planning services areaccessible to women independently, greatercontrol over their fertility translates into greaterbargaining power, autonomy and decisionmakingcapacity within the family.An example of this at the country level comesfrom Bangladesh. The rapid decline in fertility,from approximately six children per woman inthe 1970s to under three children per woman80 CHAPTER 4: THE SOCIAL AND ECONOMIC IMPACT OF FAMILY PLANNING

tRicardo and Sarain Mexico City saythey have decided towait until they finishschool and find jobsbefore they marryand have children.©UNFPA/RicardoRamirez Arriolaelderly, as was documented in another studyfrom Matlab, Bangladesh (Chaudhuri, 2005;Chaudhuri, 2009).Family planning and the well-being ofboys and menThe impact of family planning on men’s physicalhealth is likely not significant. However, delayingand preventing unintended pregnancies andbirths can have an impact on their schooling andemployment opportunities (Montgomery, 1996).Where a man is obliged to take responsibilityfor a woman’s pregnancy, he may be forced toleave school (though without facing the samesocial stigma a woman would) in order to workand support the woman. Like most mothers, aresponsible father may have to give up opportunitiesfor lucrative employment, accept jobs thatare less than ideal, and give up opportunities forcareer growth and development.Outside or within marriage, an unintendedpregnancy can have an effect on the mentalhealth of both parents, particularly whenpartners differ in their commitment towards apregnancy (Leathers and Kelley, 2000). Evidenceindicates that the incidence of depression, physicalabuse, and other mental health problems areall higher among those who experience unintendedpregnancies than where pregnancies areintended. These issues affect not only the menand women concerned, but their children andfamilies (Korenman et al., 2002).Evidence also suggests that unwantedpregnancies are often associated with higherlevels of marital dissolution, lower householdincomes, and a variety of negative psychosocialeffects on child-development (McLanahan andSandefur, 1994).Health, demographic change, thewealth of nations and sustainabledevelopmentThe impact of improved sexual and reproductivehealth, including family planning, and82 CHAPTER:4: THE SOCIAL AND ECONOMIC IMPACT OF FAMILY PLANNING

gender equality is much stronger and moredirect at the household level than the microeconomiclevel or the macroeconomic level.But the individual and household impactsof family planning services—lower fertility,improved health, decreased mortality, greaterinvestment in human capital, greater participationin the labour force and increasedincome and savings—also scale up at the moreaggregate levels of communities and countries.These macro-level effects are sometimes difficultto identify because these variables areinterrelated and are influenced by an enormousnumber of additional variables such asthe institutional environment, the influence ofpolicy, wars and other major social, economicand political events. Though conclusive evidenceof the magnitude of the relationshipsdoes not yet exist, some areas of consensushave emerged.One such area of consensus among economists,demographers and policymakers isrecognition of the role of population age structuresin economic development. Declines infertility initially reduce the share of a country’spopulation that is young. For some time, theinitial decline in the youth population that isdependent others for their basic needs is notoffset by increases in the share of the populationthat is older and dependent on others. Atthis point in the demographic transition, therelative size of a country’s working-age populationincreases. This one-time increase in theproportion of the working-age population thatcoincides with a one-time decrease in “dependencyratios” creates favorable conditionsfor economic development and is called the“demographic dividend.”At the macroeconomic level, the demographictransition reduces a number of challengesin countries that cannot easily keep up withinvesting in health and education of a large andrapidly growing youth population, and managingan essentially unlimited supply of labour.The demographic dividend also provides countrieswith opportunities to increase labour forceparticipation, income, saving, investment, andsocial change, if policies are in place to investin the human capital of this young group (viahigher per-capita spending on health andeducation, greater investment in physicalinfrastructure and institutional development,and support for civic participation, amongother things).“After fertility rates steadily decline over the course of20 or 30 years, the number of income-generating adultsgrows relative to the number people who depend on themfor support, thus creating more favourable conditions foreconomic growth and sustainable development.”Demographic dividends have been observedin East and Southeast Asia, Latin America, theMiddle East and North Africa, and the PacificIslands (Lee et al., 2010; Lee, 2003; Lee et al.,2001; Mason and Lee, 2004; Lee and Mason,2006; Bloom et al., 2009; Schultz, 2009). Thedividend began in East Asia in the 1970s, inSouth Asia in the 1980s and in sub-SaharanAfrica in the new millennium.Macro-level impact of family planning onsavings, investment and growthDependency ratios and the demographicdividend can affect economies and societies innumerous ways. In early stages of the demographictransition—when the share of thepopulation that is young starts to grow—countriesmay be required to spend more on schools,health clinics, housing, and other infrastructureTHE STATE OF WORLD POPULATION 201283

to secure the future population’s well-beingand productivity. This relocation of resourcestowards the young, who consume but do notproduce, may not be conducive to immediateimprovements in economic growth rates(Coale and Hoover, 1958). But after fertilityrates steadily decline over the course of 20 or30 years, the number of income-generatingadults grows relative to the number people whodepend on them for support, thus creating morefavourable conditions for economic growth andsustainable development.One of the key drivers of improved economicgrowth during the demographic transition is theincrease in the level of savings and investment inthe economy. Adults with fewer children may beable to reallocate more of their resources towardssaving for their own retirement. This increasesthe amount of capital available for investment.Improvements in general health and reductionin the burden of disease also increase theattractiveness of investment opportunities.Declines in dependency ratios in East Asia sincethe 1960s, for example, increased savings ratesRatio of Working Age to Dependent PopulationSub-Saharan AfricaEast AsiaSouth Asia3Ratio of working age to dependents2101950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 2060 2070 2080 2090 2110YearSource: United Nations World Population Prospects 2010 Medium Fertility Variant84 CHAPTER:4: THE SOCIAL AND ECONOMIC IMPACT OF FAMILY PLANNING

substantially, created new opportunities forinvestment and helped Asian countries reducetheir reliance on foreign capital (Higgins andWilliamson 1996; Higgins and Williamson,1997). The rise in savings rates also contributedto the establishment of pension systems andsocial welfare systems: ever-increasing populationsof working-age adults were able to financethe benefits of a relatively small group of elderlycitizens (Reher, 2011).Improved health, improved investments inschooling, higher savings rates and more investmentultimately translate into economic growth.The rapid growth of East Asian economies since1975 has been shown to be related to its demographicdividend. One study finds that changesin age structure account for as much as one-thirdof the Asian “tiger” economies (Bloom, Canningand Malaney, 2000; Williamson, 2001).Research also shows that the initial healthof a population is one of the most robust andpotent drivers of economic growth. One studyfound that one extra year of life expectancyraises GDP per capita by about 4 per cent(Bloom, Canning and Silva, 2001; Bloom,Canning and Silva, 2003).ConclusionGreater access to family planning can improvethe well-being of women, men, children, theirhouseholds and communities by increasing lifeexpectancy, decreasing morbidity and improvinghealth more broadly. It increases opportunitiesto invest in schooling and other forms of humancapital and to participate in labour markets,increasing productivity and raising incomes,savings, investment and asset accumulation.Declines in mortality, followed by declinesin fertility, lead to changes in the age-structureof the population and also produces anaggregate “demographic dividend” at the levelof countries. This leads to improvements ineconomic growth and development.Three main conclusions emerge from thisliterature. First, improvements in reproductivehealth not only ensure rights and improvethe lives of women and children, but alsoalleviate poverty and promote economicgrowth. Second, integrated programmesaimed at improving reproductive health—maternal health, child health, nutrition, andfamily planning programmes—can resultin demographic change as well as economicchange. Third, these programmes shouldnot be regarded as substitutes for any othertype of policy aimed at increasing growth orsustainable development in a society. Rather,family planning should be regarded as onecomponent of broader strategies to invest inhuman capital, particularly for women.tYouth-friendly servicesin Egypt.© UNFPA/Matthew CasselTHE STATE OF WORLD POPULATION 201285

86 CHAPTER 5: THE COSTS AND SAVINGS OF UPHOLDING THE RIGHT TO FAMILY PLANNING

CHAPTERFIVEThe costs and savingsof upholding the rightto family planningTo uphold human rights and to reap the benefits of family planning for theeconomic and social well-being of individuals, households, communities andnations, expanding access to family planning is essential. But how much will thiscost? Treating family planning as a right has important implications for developmentpolicy and for the sustainable development framework that will in 2015 succeed theMillennium Development Goals. The normative dimension of human rightstMwanasha, along withnearly 200 women,gather under theshade of a Balboabtree. They’ve comefor contraceptives,which for many ofthem can save theirlives and transformtheir families' futures.In Malawi, one in 36women die in childbirthcompared to one in4,600 in the UK.©Lindsay Mgbor/UK Department forInternational Developmentbrings about a radical shift by moving familyplanning strategies from the realm of policycommitment and economic pragmatism to therealm of obligations and the setting of red flagsin dealing with complex policy tradeoffs.On the pragmatic economic side, however,it requires a look at the economic and budgetaryimplications of the obligation of equalityand non-discrimination in fiscal and budgetarypolicies, for example, the impact of user fees ortaxes on the affordability on contraceptive services.It also requires a focus on the obligationof progressive realization over time in relationto budgetary allocations across sectors as part ofthe national budget.Estimates of the costs have not generally takenthis rights perspective, though they are certainlynot in conflict with it. They have tended tofocus on the demographic characteristics of thepopulation, its age structure and how this incombination with unmet need generates numbersof potential family planning clients.Growing needThe need for family planning will grow as thenumber of people entering their reproductiveyears increases in the near future, especiallyin the poorest countries. About 15 per centof women of reproductive age in developingcountries wish to delay their next birth or ceasechildbearing but are not currently using modernmethods of contraception (Singh and Darroch,2012). Their right to family planning is thereforeat risk.“Unmet need,” according to the widelyaccepted definition, is not as high in richercountries. Yet “unintendedness” is a term thatapplies to a significant proportion of births inrich and poor countries alike. The lowest rateof unintendedness is 30 per cent in WesternTHE STATE OF WORLD POPULATION 201287

Unintended Pregnancies and outcomes, 2008Total numberof pregnancies(millions)Per cent ofpregnancies thatwere unintendedPercentage distribution of unintended pregnancyoutcomes (as % of all pregnancies)Births Abortions MiscarriagesWorld 208.2 41 16 20 5More developed regions 22.8 47 15 25 6Less developed regions 185.4 40 16 19 5Africa 49.1 39 21 13 5Eastern 17.4 46 25 14 6Middle 6.9 36 22 8 5Northern 7.4 38 15 18 5Southern 2.0 59 34 20 8Western 15.5 30 16 10 4Asia 118.8 38 12 21 5Eastern 31.7 33 4 25 3South-Central 60.4 38 15 18 5Southeastern 19.2 48 14 28 6Western 7.5 44 24 15 6Europe 13.2 44 11 28 5Eastern 6.4 48 5 38 5Northern 1.8 41 17 18 5Western 2.4 42 17 20 5Southern 2.7 39 18 16 5Latin America andCaribbean17.1 58 28 22 8Caribbean 1.2 63 31 23 9Central America 4.6 43 20 17 6South America 11.3 64 31 24 9North America 7.2 48 23 18 7Oceania 0.9 37 16 16 5Source: Singh, S. et al.. 2010: 244.88 CHAPTER 5: THE COSTS AND SAVINGS OF UPHOLDING THE RIGHT TO FAMILY PLANNING

Europe; the highest is 64 per cent in SouthAmerica (Singh, Sedgh and Hussain, 2010).In the United States, an estimated 49 per centof pregnancies are unintended, a figure thatremained unchanged between 1994 and 2001(Finer and Henshaw, 2006).Unintended pregnancies in the UnitedStates occur most frequently among youngwomen 18 to 24 who are unmarried, poor,black or Hispanic. Forty-eight per cent ofunintended conceptions in 2001 occurredduring a month when contraceptives wereused (Finer and Henshaw, 2006). This isbecause some women are more likely to haveunprotected sex, even when they are at othertimes using contraception. In addition, theymay be using less effective methods. Finally,women who are cohabiting are more likely toexperience unintended pregnancies, in partbecause they may be ambivalent about usingcontraception, which may be the preference oftheir partners, not their own. People of lowersocioeconomic status are more likely to experiencecontraceptive failure, in part because theyare more likely to use less effective methods.Changes in contraceptive use, currentlevels of use and unmet needAs described in Chapters 2 and 3, there isa strong and growing need for sexual andreproductive health services that includefamily planning among unmarried people,since age at first marriage has increased ashas sexual activity among unmarried people.Unmarried, sexually active women are atgreater risk of unintended pregnancy thanmarried women. Cohabiting women are usingcontraception at rates like those of marriedwomen, but tend to have higher levels ofsexual activity, being younger; in addition,they may be more fecund.Contraceptive use by married women indeveloping and developed countries betweenthe ages of 15 and 49 rose from near zero inthe 1960s to approximately 47 per cent in 1990and to 55 per cent in 2000 and has leveled offsince (United Nations Department of Economicand Social Affairs, 2004 and 2011). In EastAfrica, the rate increased from 20 per cent inLarge Variations in married women'slevel of unmet need for and use ofmodern contraception among subregionsof the developing world in 2012Subregions of the developing worldDeveloping worldWestern AfricaMiddle AfricaEastern AfricaNorthern AfricaSouthern AfricaWestern AsiaSouth AsiaCentral AsiaSoutheast AsiaEastern AsiaCaribbeanCentral AmericaSouth AmericaSource: Singh & Darroch 2012Modern contraceptive useUnmet need for modern contraceptives9 307 3727 3257 1845 2158 1634 3546 2452 1956 2056 2264 1870 170 10 20 30 40 50 60 70 80 90 100% of married women 15-4988 3THE STATE OF WORLD POPULATION 201289

tDonor Commitmentspanel at the LondonSummit on FamilyPlanning.©Russell Watkins/UK Department forInternationalDevelopment2008 to 27 per cent today. In Southeast Asia,the rate rose from 50 per cent to 56 per centover the same period. Between 2008 and 2012,an average annual increase of 1.7 per cent inmodern-method users translated into 42 millionadditional married women using family planning.Singh and Darroch (2012), with their newmeasures of unmet need, recalibrated to includeestimates of sexually active never-marriedwomen, calculate that of the 1.52 billion womenof reproductive age in developing countries, 867million have a need for family planning in 2012.The needs of about three in four of thosewomen are being met. The needs of one in fourof them, however, are not.Funding fails to keep pace with needDonor and government support for sexual andreproductive health, especially family planning,has been shrinking at a critical time, whennearly 2 billion young people are entering theirreproductive years. Meanwhile, many developingcountries have not made sexual and reproductivehealth a priority in their health sectors(Population Council, 2007; Birungi et al., 2006).At the same time, sexual and reproductive healthhas lost ground to “competing” health issues,such as infectious diseases, because the field hasfailed to persuade power brokers—such as policymakersand donors—to increase funds.The Programme of Action of the InternationalConference on Population and Development,ICPD, called on international donors to coverone-third of the costs for sexual and reproductivehealth, including family planning, and developingcountries themselves to contribute two-thirdsof the total.Both developing countries and donorcountries have fallen short of this target. Forexample, to meet the family planning needsof current users of modern contraception in2010, donors had been expected to contributeabout $1.32 billion but actually contributed$822 million—about one-third less thanthe target amount.The shortfall may be attributed to budget cutsin some donor countries but also to changes inthe way a country decides to allocate resources.The United States, for example, a major contributorto international family planning, has placeda growing number of countries on a “graduation”list. As countries “graduate,” they are seen as nolonger requiring the same level of support theyonce enjoyed. Countries slated for graduationare those with a total fertility rate of 3.0 or lessand a modern contraceptive prevalence rate of 55per cent or more (Bertrand, 2011). Countries inLatin America have been especially affected bythe graduation process, since some of the region’sministries of health have not filled the void asUnited States funding ends or is phased out.90 CHAPTER 5: THE COSTS AND SAVINGS OF UPHOLDING THE RIGHT TO FAMILY PLANNING

Extending access to meetthe unmet needProviding contraceptives to the current 645million users in the developing world costs $4billion a year. Improving the quality of theseservices would cost an additional $1.1 billiona year, according to the recent GuttmacherInstitute estimates. Providing modern methodsof contraception, with improved services, to the222 million women with unmet need wouldraise costs an additional $3 billion a year. Thus,the cost of fully meeting the needs of all womenin developing countries and improving the qualityof services would together total $8.1 billion ayear. Meeting all need for modern contraception,coupled with improving the quality of services,would raise the average annual cost per userin the developing world from $6.15 to $9.31(Singh and Darroch, 2012).The cost of meeting unmet need is highestin sub-Saharan Africa and the poorest countriesof other regions where capacities for deliveringservices are weakest. Committing to meeting theunmet need would therefore require a shift inthe allocation of donor resources. The 69 poorestcountries now receive about 36 per cent ofdonor resources for family planning. That sharewould need to increase to about 51 per cent.Providing modern contraceptives toall who need them in 2012would meanincreasing current costs by $4.1 billionDirect costsContraceptive commodities and suppliesHealth worker salariesProgramme and system costs (P&S)U.S. dollars (billions)Current level of P&S costAdded P&S cost for current usersP&S for serving women with unmet need10864$4.0BillionTO MEET100%OF THENEED FORMODERNMETHODSWOULDINCREASECOSTS$4.1BILLION$8.1BillionCASE STUDYAccountability in Sierra LeoneCorruption is enormously costly to any healthsystem. Before and after the end of Sierra Leone’scivil war, more than 50 per cent of drugs andmedical supplies destined for public health facilitieswent unaccounted for (UNFPA, 2011a).The supply chain faced a lack of transparency,poor record keeping, poor management ofdrugs and theft of drugs from the public systemthat were then resold to private pharmacies.20Current levelof careSource: Singh & Darroch 2012To meet 100%of the need forfamily planningTHE STATE OF WORLD POPULATION 201291

UNFPA supports the Health for All coalition,a civil society organization that works towardsthe establishment of a strong and independentmonitoring and evaluation system. The drugmonitors now working in the health systemhave reduced the theft of drugs and dramaticallyincreased accountability with direct effects onpeople’s access to family planning methods.The savings realized from meetingunmet needBy investing an additional $4.1 billion inmodern contraceptive services in developingcountries, the world would save approximately$5.7 billion in maternal and newbornhealth services as a consequence of preventingunintended pregnancies and unsafe abortions(Singh and Darroch, 2012). Family planningis a cost-saving intervention at the individual,household/family and national levels (Clelandet al., 2011; Greene and Merrick, 2005). Recentresearch estimates that increased contraceptiveuse over the past two decades has reduced thenumber of maternal deaths by 40 per cent byreducing unintended pregnancies (Cleland etal., 2012). Thirty per cent more maternal deathscould be prevented simply by fulfilling unmetneed for family planning.The role of “unsafe sex”—a range of sexualand reproductive health-related conditionsincluding HIV—in the global burden of diseaseis enormous (Ezzati et al., 2002). Sexualand reproductive ill health is the fifth-leadingcause of death around the world, and the secondcontributor to the global burden of diseaseas measured by disability-adjusted life years(DALYs); the proportion of disability-adjustedlife years lost due to “unsafe sex” is much higherfor women than for men.Committing to the right to familyplanning: cost implicationsCosting family planning is challenging becausethe modes of service delivery are varied, andFamily planningservices offer a rangeof options in Guinea.© UNFPA/Mariama SireKaba.t92 CHAPTER 5: THE COSTS AND SAVINGS OF UPHOLDING THE RIGHT TO FAMILY PLANNING

“family planning” services often offer morethan methods of family planning (Janowitz andBratt, 1994). In addition, the costs associatedwith an unintended pregnancy or the benefits ofavoiding one extend beyond the individual andinclude the impact on families, communitiesand nations.In addition, some costs of family planningare borne by health services; others are borneby individuals. In some settings, specific groupsare more or less disadvantaged by having to bearthese costs. In general, the costs of providinginformation are not included in most estimates,which focus more on the delivery of suppliesand services.Programmes that have provided family planningto the initial “easy to reach” groups mayfind that the costs of reaching the next tier ofclients are much greater (Janowitz and Bratt,1994). For one thing, it may be necessary toreach out to people who are more geographicallyremote or socially isolated. The services mayneed to be extended or improved to address therights of marginalized groups.A commitment to fulfil the right to familyplanning requires a complete understanding ofall costs involved in reaching every individual.Is outreach needed to increase the access of disadvantagedgroups? How does a State meet itsobligation to prioritize the hardest to reach evenwhen it does not make full economic sense? Arethere programmatic components beyond theclinic that will need to be included so thatbarriers to access are overcome?The Programme of Action of the ICPDacknowledged social and cultural constraints tohealth and established a rationale for addressingsome of those constraints as part of familyplanning programmes. Yet these sorts of programmesthat go “beyond family planning”can seem removed from services yet have broadhealth and development consequences (Singhand Darroch, 2012). An example would beefforts to work with men and boys to encouragemore equitable gender norms and relationships,including supporting their own or partners’ useof family planning.Activities that support family planningare also essential to rightsCosting has most often focused on healthservices and on generating the of suppliesand services to respond to unmet need.Often neglected is the need to influence theunderlying conditions that shape people’sperspectives on childbearing and permit themto use family planning.A human rights-based approach to sustainabledevelopment can guide policies and programmesin identifying and addressing the inter-relatedweb of factors that lead to unmet need in a given"A commitment to fulfil the right to family planning requiresa complete understanding of all costs involved in reachingevery individual."country or local context. The application of ahuman rights-based approach as a continuumfrom situation analysis, to policy formulationand then to programme costing can help ensurethat public budgets are more sensitive to variousforms of discrimination, and are supportive ofhuman rights.The Guttmacher Institute’s recent costinganalysis notes that, “‘beyond family planning’interventions are needed to address social factorsthat inhibit the use of contraception….Addressing these types of barriers requires commitmentto long-term, extensive interventions,such as providing comprehensive sex educationand well-designed large-scale public educationefforts” (Singh and Darroch, 2012).THE STATE OF WORLD POPULATION 201293

tDr. BabatundeOsotimehin, ExecutiveDirector of UNFPA,speaking at theLondon Summit onFamily Planning.©Russell Watkins/UK Department forInternational DevelopmentActivities that support the right to familyplanning may include:• Changing norms to generate long-termchange in demand, for example, workingwith men and boys to delay marriage andsupport female partners;• Mobilizing people to demand their rightsand to hold providers accountable for thequality of services;• Overcoming obstacles to access; for example,helping develop community transportationsystems.Some activities aimed at increasing demandfor family planning, such as encouraging malesto be more supportive of their female partners’family planning use and raising awareness ofthe health and economic benefits of being ableto space and time pregnancies are sometimesincluded in cost estimates because they aredirectly related to use of family planning.Efforts to change gender and other normsultimately related to sexual and reproductivehealth outcomes can be costed, but the “credit”they can take for increasing contraceptive use isdifficult to measure. This makes it hard to assesstheir cost in relation to family planning, eventhough they may ultimately have effects not onlyon family planning and other aspects of sexualand reproductive health but on other areas ofhealth and development. One example of anorm change intervention with concrete effectson clinical outcomes is the “Stepping Stones”curriculum, developed in sub-Saharan Africaand now adapted for use in dozens of countriesaround the world (Welbourn, 2003). The curriculumworks to alter the balance of power asit plays out in relationships between and amongmen and women in the community in waysthat impact health. Stepping Stones affectedgender-related attitudes in ways that reducedHIV incidence and increased condom use,among other outcomes, even measured a yearafter the intervention.There has so far been little rights discourse indiscussions about how much it costs to providefamily planning to all who want it. There have,however, been some instances in other fieldswhere the costs of ensuring human rights arefactored in to overall costs. A recent study ofcosts associated with treating HIV, for example,included estimates for supporting activities thatwould ensure the effectiveness of investment inproviding antiretroviral therapies. These activitiesincluded actions to protect the human rights ofpeople receiving treatment (Jones et al., 2011).A recent study attempts to calculate thehuman rights costs of offering antiretroviral94 CHAPTER 5: THE COSTS AND SAVINGS OF UPHOLDING THE RIGHT TO FAMILY PLANNING:

therapy as an inexpensive preventive intervention(Granich et al., 2012).The study finds that without engaging andsupporting the community, the programme willbe unlikely to achieve its goals. This model supportsthe importance of ensuring “communityengagement in the planning and implementationof the programme so that there is no coercionto be HIV tested or take antiretroviral therapies,and that there is adequate support for individualswith questions and concerns. Contrary tomany other similar studies, we included thecost of ensuring many components of a stronghuman rights framework” (Granich, 2012).The total cost of including these human rightscomponents in the programme overall is 1.4per cent, a small investment in the long-termsuccess of the programme and its contribution tothe achievement of rights.ConclusionRecent estimates of unmet need indicate thesignificant levels of investment necessary touphold the right of the world’s people to familyplanning. High levels of unmet need for familyplanning will be increased in the coming yearsby the large generation of young people enteringtheir reproductive years. Family planning hasbeen shown to be one of the most cost-effectivepublic health interventions ever developed. Thusany decision regarding how to invest in familyplanning must counterpose its costs againstthe range of benefits it brings to individuals,households and nations.Average costs Associated with treatment for hiv by category withbreakdown of human rights and community-support component(Costs shown in US$)Care$2 billion66%Human rights$37 million1.4%Transport $9.1 million, 23%Adherence $12.9 million, 32%Monitoring and evaluation $1.6 million, 4%Supervision $2.1 million, 5%Training $9.7 million, 24%Education $4.6, 11%Outreach$255 million8%Nutrition$45 million1.5%Antiretroviral Therapy$694 million23%Source: Granich et al, 2012THE STATE OF WORLD POPULATION 201295

96 CHAPTER 6: MAKING THE RIGHT TO FAMILY PLANNING UNIVERSAL

CHAPTERSIXMaking the right tofamily planning universalAlmost 20 years have passed since the 179 governments represented at theInternational Conference on Population and Development, ICPD, transformedthe way the world approaches sexual and reproductive health, including familyplanning. While some progress has been made, there is still much work to bedone to realize the rights-oriented vision of the ICPD.tA couple with theirbaby in Brazil.©Panos/Adam HintonThe ICPD Programme of Action defined sexualand reproductive health and located family planningamong a broader interrelated set of rights.It pointed beyond programmes to the social andeconomic circumstances that shape people’s decisionsabout their sexual and reproductive lives anddetermine their ability to act on those decisions. Ithighlighted the roles and needs of adolescents, menand other groups not previously addressed. And itemphasized the need for services to respect individualrights and respond to individual preferencesin offering family planning.For policymakers, international organizations,governments and civil society, this new rightsbasedapproach was seen as revolutionary, partlybecause it created obligations for governments tomake reproductive health services and suppliesavailable to all. But was the shift experienced asrevolutionary by ordinary people, the individualwomen, men, girls and boys the ICPD wasintended to help?Where the right to family planning has beenupheld and access to it increased, people havebenefited—through better health, higher incomes,reductions in poverty and greater gender equality.But the ICPD has not yet changed daily realitiesfor the hundreds of millions of people who want toavoid or delay pregnancy but are unable to eitherbecause they still have no reliable access to qualitycontraception, information and services or becausethey face insurmountable social, economic andlogistical obstacles.These individuals have missed out on theimprovements in health, empowerment andenjoyment of a range of other rights that familyplanning can facilitate or catalyse. The challengesare most acute in developing countries but existalso in developed countries, where many womenand men are unable to access family planning, arepoorly served or are dissatisfied with the methodsthey use.The vision of the ICPD has yet to be translatedfully into a rights-based approach to sexual andreproductive health policies and programmes,with quality and access for all.As a consequence, too many individuals still lackthe power to make decisions about family size andthe timing of their pregnancies.THE STATE OF WORLD POPULATION 201297

When individuals are able to exercise the right to familyplanning, they are able to make decisions about the timingand spacing of their pregnancies and are also able toexercise—and benefit from—many other rightsThe governments that endorsed the ICPDProgramme of Action committed to ensuringthat individuals have the information, educationand means to freely and responsibly decidewhether and when to have children and agreedthat family planning is a right.The right to family planning is also explicitlystated in the Convention on the Eliminationof All Forms ofDiscriminationAgainst Women.And, familyplanning is includedin MillenniumDevelopment Goal5, especially target5-B, which aims foruniversal access toreproductive healthby 2015. But progresswithin our grasp.towards achievingthis goal lags behindprogress towards the other MillenniumDevelopment Goals.So what happens after 2015, after thedeadline for achieving the MillenniumDevelopment Goals has passed?The values and principles affirmed in theMillennium Declaration provide a solidfoundation for addressing global developmentchallenges. The post-2015 sustainabledevelopment agenda will likely be based onthe fundamental principles of human rights,equality and sustainability. In the context ofthese principles, development goals would bePlanning one’s family isa fundamental humanright, and something thatwomen and men of allages everywhere in theworld yearn to achieve. In2012, realizing this rightfor all seems increasinglypursued along four interdependent dimensions:inclusive social development, environmentalsustainability, inclusive economic developmentand peace and security.The vision for the post-2015 developmentagenda is holistic and global and rests on coreprinciples, values and standards that derive frominternationally agreed-upon frameworks. Theseprinciples will contribute to policy coherence atthe global, regional, national and sub-nationallevels, and ensure that development activitiesare mutually reinforcing.Family planning is one such activity. Whenindividuals are able to exercise the right tofamily planning, they areable to make decisions aboutthe timing and spacing oftheir pregnancies and arealso able to exercise—andbenefit from—many otherrights, such as rights toeducation, health anddevelopment.The ability to determineif and when to have childrenand how many to have reflectsthe realization of equal rightsand opportunities. Familyplanning is therefore a matter of equity andsocial justice.Four broad recommendations forrecognizing family planning as a matter ofcore rights and sustainable development—and specific strategies for achieving theserecommendations—are outlined here. Theypoint to the need to 1) take or reinforce arights-based approach; 2) secure an emphasis onfamily planning in the post-2015 sustainabledevelopment framework; 3) ensure equality byfocusing on specific excluded groups; 4) raise thefunds to invest fully in family planning.98 CHAPTER 6: MAKING THE RIGHT TO FAMILY PLANNING UNIVERSAL

1 Expand the reach of familyplanning and improve servicesby adopting a humanrights-based approach to healthFamily planning must be grounded incomprehensive sexual and reproductivehealth programmes. A human rights-basedapproach to family planning entails farmore than solely protecting the right toaccess family planning services. The closerelationship between the right to chooseif, when and how many children to haveand other aspects of people’s sexual andreproductive lives requires a broad approachto services.Governments should monitor for andeliminate any use of incentives, targetsor fee structures that incentivize healthcare providers to advocate for adoption ofspecific methods, or for incentives to usecontraception. Service delivery itself mustmeet human rights standards, and barriers touse must be acknowledged as human rightsviolations. Poor people with limited schoolingare most vulnerable to misunderstandingsand misinformation about how contraceptiveswork and how their choices may be directed.these constraints directly as part of their effortto ensure the right to family planning.Recognize that men and boys are pivotal torealizing women’s right to family planningand their own rights as well. As a humanright, family planning is relevant to every personand all potential parents, both female andmale. Family planning is especially importantto women and their health and well-being,and it is also of great interest and value tomen. The sexual and reproductive health fieldhas an opportunity to encourage men’s fullerengagement in family planning. Men andboys can help ensure women’s right to familyplanning by being supportive partners, usingcontraception, avoiding violence and promotinggender equality. They have important roles toplay in transforming gender roles and norms inways that make it easier for everyone to achievetheir rights.tA bus stop in Mumbai,India.©Panos/Mark HenleyGo “beyond family planning” to addressthe social and economic obstacles tosexual and reproductive health. Womenand sometimes men must often overcomeentrenched gender norms in order to exercisetheir right to family planning. Ensuringwomen’s access to family planning shouldbe supported by activities that address theirsocial circumstances directly and enhance theirdecision-making, mobility, autonomy andaccess to resources. Programmes must addressTHE STATE OF WORLD POPULATION 201299

Family planning programmes must reflect thereality that contraceptive use occurs in thecontext of sexual relationships. The familyplanning field has readily acknowledged theconnections between sexual and reproductivehealth, reproductive rights and sexuality.Research is needed to examine how the desirefor a satisfying sex life plays a part in shapingwomen’s and men’s views of family planning,their preferences for specific methods, and theirability to negotiate that use. Family planningprogrammes could more systematically recognizeand support their desire to maintain healthy,enjoyable sexual relationships.Family planning should be made availablewith abortion services where they are notagainst the law. Family planning shouldbe readily available to women who haverecently had abortions to enable them toavoid unplanned pregnancies in the future.Yet, family planning has often been separatedfrom abortion services where they are legal.The world is united in its concern aboutunsafe abortion, an important cause ofmaternal morbidity and mortality. Familyplanning makes a fundamental contributionto addressing this important public healthproblem by reducing unintended pregnancy.Ensuring access to emergency contraceptionis an essential part of fulfilling the right tofamily planning. The international communityneeds to emphasize the importance of accessto emergency contraception in cases of sexualviolence, as well as in contexts of armed conflictand humanitarian emergencies.Governments, international organizationsand civil society should track levels ofsatisfaction with the quality of availablecontraceptive methods and services, theimpact on health outcomes and the incidenceof adolescent pregnancy and the costsof unintended pregnancy. Internationaland non-governmental organizations andgovernments should consider adopting morerefined indicators of unmet need, such as the“proportion of demand satisfied,” which showsthe share of total demand for contraceptives thatis being fulfilled. Taken together, contraceptiveuse and unmet need only define the total levelof demand for family planning. Measuring“demand satisfied” serves as a proxy for whethera person’s stated desires regarding contraceptionare being fulfilled and is a more sensitivemeasure of the extent to which individuals,communities, and health systems supportpeople’s right to use family planning.2 Secure a central place forfamily planning in the post-2015 sustainable developmentframework, one that recognizes itscontributions to development andto breaking the cycle of povertyand inequality.Treat family planning not as a “specialty”topic within the health sector, but as one ofseveral key investments that contribute todevelopment. Family planning is a proven,sound economic investment that yieldsreturns to the individual, the household, thecommunity and the nation. The breadth andscale of the benefits to upholding the right tofamily planning suggest that family planningmay be among the most effective—and costeffective—interventionsfor human capitalaccumulation and poverty alleviation. Whengovernments ratify human rights treaties theyassume certain obligations to protect a wide100 CHAPTER 6: MAKING THE RIGHT TO FAMILY PLANNING UNIVERSAL

ange of rights. Meeting those obligations willoften be facilitated through fulfilling the rightto family planning.Family planning plays a central role in theachievement of a broad range of developmentgoals. With its special focus on disparitiesand inequalities, the post-2015 sustainabledevelopment framework will likely be composedof mutually reinforcing elements. Familyplanning reinforces at least four priorities thatreflect the emerging human rights orientation ofthis new post-2015 development framework:• Poverty reduction: Family planning permitspeople to prevent unplanned, unwanted,unhealthy pregnancies and helps reducepoverty by creating conditions that make itpossible for people to take better advantageof other social sector investments and toinvest more in their children.• Gender equality: How can women plantheir lives if they are unable to makedecisions about childbearing? Developmentefforts must put women in particular in theposition of implementing their life choices.And gender equality calls for men to play acentral role in planning their families andsupporting women and girls.• Health: family planning is fundamentalto women’s health as it delays earlypregnancies, allows spacing of pregnancies,and reduces high fertility.Improved access to family planning extendslife expectancy for both mothers and children,increases incentives to invest in schoolingand other forms of human capital, createsopportunities for participation in labourmarkets, raises the return to participation inlabour markets and results in higher incomesand levels of asset accumulation. These add upto significant benefits, particularly if declinesin fertility occur quickly enough to generate ademographic dividend. In addition, almost allstudies on this topic confirm that the magnitudeof the demographic dividend depends not onlyon the pace of mortality and fertility decline,but also on the policy environment, particularlyin the areas of sexual and reproductive healthand family planning, education, labour‐marketflexibility and openness to trade and savings.tDr. Awa MarieColl-Seck, Ministerof Health, Senegal,speaking at the LondonSummit on FamilyPlanning.©Russell Watkins/UKDepartment for InternationalDevelopment• Youth empowerment: Family planningcontributes to opening up opportunities foryouth and highlights planning for their lives.Preventing unintended pregnancy protectsadolescent girls and boys from being hijackedfrom their life opportunities. Learning toplan one’s family is a skill that is neededfor decades of a person’s reproductive life.Planning a family contributes to planningmany other aspects of one’s life: schooling,work, family formation, and other aspects.THE STATE OF WORLD POPULATION 2012101

Family planning programmes reinforce thepositive impacts of other programmes thatinvest in human capital. By reducing maternalmortality and increasing life expectancy, suchprogrammes raise the return to schooling andthus increase the returns to investment ineducation, particularly for girls. Governmentsshould regard family planning in the sameway they view and prioritize other humancapitalinvestments in education, labour forceparticipation and political participation.By reducing maternal mortality and increasing life expectancy,such programmes raise the return to schooling and thusincrease the returns to investment in education, particularly forgirls. Governments should regard family planning in the sameway they view and prioritize other human-capital investments ineducation, labour force participation and political participation.The close relationship between declines infertility and improvements in women’s rightssuggests that governments and multilateralinstitutions should not only focus on promotingdirect legislative changes for women’s rights butshould also invest in family planning and otherprogrammes that invest in human capital. Thisis one more way of improving the bargainingposition of women in society.Family planning programmes are not,however, a substitute for other types ofinvestments in human capital. In fact, familyplanning programmes and declines in fertilityhave their maximum impact in societies thatare making complementary investments inincreasing female schooling, expanding labourmarket opportunities, and experiencingeconomic changes that fundamentally changethe cost-benefit tradeoff of high fertility.Programmes have often been most effectivewhen coupled with other types of maternaland child health inputs.3 Ensure the right to family planningof specific excluded groupsAs an essential part of governments’ commitmentsto rectifying inequalities in health,programmes must address the financial,physical, legal, social and cultural factors thatmake it difficult for so many people to seekhealth services and overcome the intersectingforms of discrimination they may face.Poor women who have no access to familyplanning have more children than they intend.Meanwhile, wealthy and educated elites,wherever they are, tend to have access to familyplanning, independent of whether policies orprogrammes support it. In many countries, eventhough efforts have been made to overcomehealth inequities by targeting services for thepoor, the benefits are often accrued mainlyby those who are already better off (Gwatkinand others, 2007). To improve access tocontraceptive information and services for thepoor, programmes must often address not justthe financial obstacles but also the physicalobstacles (such as distance to health facilitiesand the opportunity costs of lost work timeto visit family planning providers) and socialand cultural factors (including disrespectful orjudgmental treatment by health workers, lackof autonomy in making decisions about healthservices or family or community opposition tocontraceptive use).In countries where it is needed, new legislationshould be introduced to ensure universalaccess to family planning; in others, stepsmust be taken to ensure the equitableimplementation of existing legislation, policiesand programming. Government support forfamily planning should include actions thatmake services available to marginalized groups,102 CHAPTER 6: MAKING THE RIGHT TO FAMILY PLANNING UNIVERSAL

including indigenous and ethnic minorities andpersons who live in hard-to-reach urban andrural communities (United Nations Economicand Social Council, 2009).Family planning policies and programmesmust respond to the needs of unmarriedpersons of all ages whose numbers are growingworldwide. Young people and adults areentering, staying, and ending partnerships inways different from previous generations, andeducation and services must respond to thesechanges. Young people need services betweentheir first sexual experiences and when theymarry. Expanding access to meet young peoples’sexual and reproductive health needs will requireadvocacy and other actions that shift attitudesabout young peoples’ sexual and reproductiveexperiences. Services and information should bemade available to adults who are separated fromtheir partners or in new partnerships later in life.As people grow older, they face shifting pressuresto fulfil community and familial expectationsrelated to sex, marriage, and childbearing. Astheir roles evolve, their need for family planningoften recedes from the view of policymakers andprogramme designers.Family planning programmes should beexpanded so that services are available toyoung, married women and their husbands.Married adolescents face great difficulties inaccessing family planning services, and aretherefore vulnerable to unintended or unwantedpregnancies and their negative health effects(Ortayli and Malarcher, 2010; Godha, HotchkisstA couple in Botswanalearns about contraceptiveoptions.© Panos/Giacomo PirozziTHE STATE OF WORLD POPULATION 2012103

tPresident of NigeriaGoodluck Jonathanannounces plan inSeptember to increaseaccess to life-savingsupplies, includingfamily planning.Jonathan co-chairsthe UN Commissionon Life-SavingCommodities.©United Nations/J. Carrierand Gage, 2011). The younger a girl is at thetime of marriage, the greater the challengesshe faces in controlling her own fertility, andthe more subject she is to closely spaced andrepeated pregnancies (Rutstein 2008).Adequately meeting the family planningneeds of older people requires challenging thepervasive assumption that these individualsdo not need to exercise their right to familyplanning. Often overlooked in the design offamily planning policies and programmes aremen over the age of 49 whose fertility declinesonly gradually as they age. This omissioncompromises the rights of sexually activeolder people who wish to protect themselvesfrom harmful sexual and reproductive healthoutcomes. As was affirmed by the Commissionon Population and Development in 2012,services and information should be madeavailable to adults who are separated from theirpartners or in new partnerships later in life.States and the international communityshould strengthen efforts to collect dataabout all groups who may face difficultiesin accessing family planning: adolescents—including 10-to-14-year-olds—young people,boys and men, married adolescents, unmarriedpeople, older people, ethnic minorities, refugeesand migrants, sex workers, people living withHIV/AIDS and women and girls vulnerableto sexual violence in conflict zones or in areaswhere there have been natural disasters orhumanitarian crises. Data should routinely bedisaggregated by sex, age and ethnicity, andanalysed by wealth quintiles and should showdifferences between people living in rural andurban areas to shed light on how access varieswithin and across populations.Measurement and monitoring of access mustreflect everyone’s needs and experiences. Acombination of indicators would yield greaterinsights into inequalities in access by populationgroups. An analysis of the social equalitydimensions of health, for example, would helpto focus efforts where they are needed (Austveg,2011). A human rights focus to family planningrequires costing of demand-side programming.Singh and Darroch (2012) recommendsystematic data collection at the provider andfacility level to include indicators such as thenumber and training of staff, the range ofmethods offered, the consistency with which arange of contraceptive commodities is suppliedand the quality of care.104 CHAPTER 6: MAKING THE RIGHT TO FAMILY PLANNING UNIVERSAL

Monitoring ICPD goals:selected indicatorsMonitoring ICPD Goals – Selected IndicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfantmortalityTotal per1,000 livebirthsLife expectancyM/FMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FSecondaryenrolment(gross) M/F% Illiterate(>15 years)M/FBirths per1,000womenaged15-19ContraceptivePrevalenceAnymethodModernmethodsHIVprevalencerate (%)(15-49)M/FCountry,territory orother areaMaternal and Newborn Health Sexual and Reproductive Health EducationMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolmortality ratio attended by birth rate per mortality rate, prevalence prevalence family planning, net per cent of school-age enrolment, net per cent(deaths per skilled health 1,000 women, per 1,000 rate, women rate, women per cent, children, 1999/2011of school-age children,100,000 live personnel, % aged 15-19, live births, aged 15-49, aged 15-49, 1988/20111999/2011births), 2010 2000/2010 1991/2010 2010-2015 any method, modern method,1990/2011 1990/2011male female male femaleAfghanistan 460 34 90 184 22 16 34 13Albania 27 99 11 19 69 10 13 80 80 75 73Algeria 97 95 4 27 61 52 98 96 65 69Angola 450 49 165 156 6 5 93 78 12 11Antigua and Barbuda 67 91 84 85 85Argentina 77 98 68 14 79 70 100 99 78 87Armenia 30 100 28 27 55 27 19 95 98 85 88Australia 1 7 99 16 5 72 68 97 98 85 86Austria 4 99 10 5 51 47Azerbaijan 43 88 41 43 51 13 15 85 84 81 78Bahamas 47 99 41 18 94 96 82 88Bahrain 20 97 12 9 62 31 99 100 92 97Bangladesh 240 27 133 51 56 48 17 45 50Barbados 51 100 50 14 90 97 81 88Belarus 4 100 21 9 73 56Belgium 8 99 11 5 75 73 3 99 99 90 87Belize 53 88 90 21 34 31 21 100 91 64 65Benin 350 74 114 121 17 6 27 27 13Bhutan 180 58 59 52 66 65 12 88 91 50 57Bolivia (Plurinational State of) 190 71 89 54 61 34 20 95 96 68 69Bosnia and Herzegovina 8 99 17 16 36 11Botswana 160 95 51 46 53 51 27 87 88 57 65Brazil 56 99 71 24 80 77 6 95 97Brunei Darussalam 24 100 18 6 95 99Bulgaria 11 99 48 11 63 40 30 99 100 84 82Burkina Faso 300 67 130 147 16 15 30 65 61 19 16Burundi 800 60 65 152 22 18 29 91 89 18 15Cambodia 250 71 48 69 51 35 24 96 95 37 33Cameroon, Republic of 690 64 127 136 23 14 21Canada 12 99 14 6 74 72 100 100Cape Verde 79 76 92 22 61 57 17 95 92 61 71Central African Republic 890 41 133 155 19 9 19 78 60 18 10Chad 1100 14 193 195 3 2 21 74 51 16 5Chile 25 100 54 8 64 94 94 81 84China 37 96 6 24 85 84 2Colombia 92 95 85 23 79 73 8 92 91 72 77106 INDICATORS

Monitoring Monitoring ICPD ICPD Goals goals: – Selected selected Indicators indicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfant Maternal Life and expectancy Newborn Health Maternal Primary enrolment Sexual Proportion and Reproductive Secondary Health% Illiterate Education Births per Contraceptive HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 PrevalenceprevalenceMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolTotal perratioM/F(gross) M/F M/Fwomenrate (%)mortality ratio attended by birth rate per mortality rate, prevalence prevalence family planning, net per cent of school-age1,000 liveagedAny enrolment, Modern net per cent(15-49)(deaths per skilled health 1,000 women, per 1,000 rate, women rate, women per cent, children, 1999/2011births15-19methodof school-age methods children,M/F100,000 live personnel, % aged 15-19, live births, aged 15-49, aged 15-49, 1988/20111999/2011Country, territorybirths), 2010 2000/2010 1991/2010 2010-2015 any method, modern method,or other area1990/2011 1990/2011male femalemale femaleComoros 280 47 95 86 26 19 36 81 75Congo, Democratic Republic of the 2 540 80 135 180 18 6 24 34 32Congo, Republic of the 560 83 132 104 44 13 20 92 89Costa Rica 40 95 67 11 82 80 5Côte d'Ivoire 400 57 111 107 13 8 29 67 56Croatia 17 100 13 7 95 97 88 94Cuba 73 100 51 6 73 72 100 99 87 87Cyprus 10 98 4 5 99 99 96 96Czech Republic 5 100 11 4 72 63 11 96 96Denmark 12 98 6 5 95 97 88 91Djibouti 200 78 27 104 18 17 47 42 28 20Dominica 48 95 96 84 93Dominican Republic 150 94 98 28 73 70 11 96 90 58 67Ecuador 110 89 100 23 73 59 7 99 100 58 59Egypt 66 79 50 25 60 58 12 100 96 71 69El Salvador 81 85 65 23 73 66 9 95 95 57 59Equatorial Guinea 240 65 128 151 10 6 29 57 56Eritrea 240 28 85 62 8 5 37 33 32 25Estonia 2 99 21 7 70 56 25 96 96 91 93Ethiopia 350 10 79 96 29 27 85 80 17 11Fiji 26 100 31 22 99 99 79 88Finland 5 99 8 3 98 98 94 94France 8 98 12 4 77 75 2 99 99 98 99Gabon 230 86 144 64 33 12 28Gambia 360 52 104 93 18 13 68 70Georgia 67 100 44 27 47 27 16 96 94 84 80Germany 7 99 9 4 70 66Ghana 350 55 70 63 24 17 36 84 85 51 47Greece 3 12 5 76 46 98 99 91 90Grenada 24 100 53 15 54 52 96 99 95 86Guatemala 120 51 92 34 43 34 28 100 98 43 40Guinea 610 46 153 134 9 4 22 83 70 36 22Guinea-Bissau 790 44 137 181 14 77 73 12 7Guyana 280 87 97 46 43 40 29 82 86 78 83Haiti 350 26 69 76 32 24 37Honduras 100 66 108 33 65 56 17 95 97Hungary 21 100 19 7 81 71 7 98 98 91 91Iceland 5 15 3 99 100 87 89India 200 58 39 65 55 48 21 99 98Indonesia 220 77 52 31 61 57 13 97 93 68 67THE STATE OF WORLD POPULATION 2012107

Monitoring ICPD Goals goals: – selected Selected indicators IndicatorsInfant Maternal Life and expectancy Newborn Health Maternal Primary enrolment Sexual Proportion and Reproductive Secondary Health% Illiterate Education Births per Contraceptive HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 PrevalenceprevalenceMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolTotal perratioM/F(gross) M/F M/Fwomenrate (%)mortality ratio attended by birth rate per mortality rate, prevalence prevalence family planning, net per cent of school-age1,000 liveagedAny enrolment, Modern net per cent(15-49)(deaths per skilled health 1,000 women, per 1,000 rate, women rate, women per cent, children, 1999/2011births15-19methodof school-age methods children,M/F100,000 live personnel, % aged 15-19, live births, aged 15-49, aged 15-49, 1988/20111999/2011Country, territorybirths), 2010 2000/2010 1991/2010 2010-2015 any method, modern method,or other area 1990/2011 1990/2011male femalemale femaleIran (Islamic Republic of) 21 99 31 31 73 59 98 96108 INDICATORSIndicators of Mortality Indicators of Education Reproductive Health IndicatorsIraq 63 80 68 41 50 33 94 84 49 39Ireland 6 100 16 4 65 61 99 100 98 100Israel 7 14 4 97 97 97 100Italy 4 100 7 4 63 41 12 100 99 94 94Jamaica 110 98 72 26 69 66 12 83 81 80 87Japan 5 100 5 3 54 44 99 100Jordan 63 99 32 22 59 41 13 91 91 83 88Kazakhstan 51 99 31 29 51 49 12 99 100 90 89Kenya 360 44 106 89 46 39 26 84 85 52 48Kiribati 39 44 36 31 12 65 72Korea, Democratic People'sRepublic of 81 100 1 32 69 58Korea, Republic of 16 100 2 5 80 70 99 98 96 95Kuwait 14 99 14 10 52 39 97 100 86 93Kyrgyzstan 71 97 31 42 48 46 95 95 79 79Lao People's Democratic Republic 470 37 110 46 38 35 27 98 95 42 38Latvia 34 99 15 8 68 56 17 95 97 83 84Lebanon 25 97 18 24 58 34 94 93 71 79Lesotho 620 62 92 89 47 46 23 72 75 23 37Liberia 770 46 177 107 11 10 36 52 41Libya 58 100 4 15 45 26Lithuania 8 100 17 9 51 33 18 96 96 91 91Luxembourg 20 100 7 3 96 98 84 86Madagascar 240 44 147 58 40 28 19 79 80 23 24Malawi 460 71 157 119 46 42 26 91 98 28 27Malaysia 29 99 14 9 49 32 96 96 65 71Maldives 60 95 19 12 35 27 29 97 97 46 52Mali 540 49 190 173 8 6 28 72 63 36 25Malta 8 100 20 7 86 46 93 94 82 80Martinique 20 8Mauritania 510 57 88 106 9 8 32 73 76 17 15Mauritius 3 60 100 31 15 76 39 4 92 94 74 74Mexico 50 95 87 17 71 67 12 99 100 70 73Micronesia (Federated States of) 100 100 52 38Moldova, Republic of 41 100 26 19 68 43 11 90 90 78 79Mongolia 63 99 20 37 55 50 14 100 99 77 85Montenegro 8 100 24 9 39 17Morocco 100 74 18 31 63 52 12 97 96 38 32Mozambique 490 55 193 123 16 12 19 92 88 18 17Myanmar 200 71 17 57 41 38 19 49 52

Monitoring Monitoring ICPD ICPD Goals goals: – Selected selected Indicators indicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfant Maternal Life and expectancy Newborn Health Maternal Primary enrolment Sexual Proportion and Reproductive Secondary Health% Illiterate Education Births per Contraceptive HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 PrevalenceprevalenceMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolTotal perratioM/F(gross) M/F M/Fwomenrate (%)mortality ratio attended by birth rate per mortality rate, prevalence prevalence family planning, net per cent of school-age1,000 liveagedAny enrolment, Modern net per cent(15-49)(deaths per skilled health 1,000 women, per 1,000 rate, women rate, women per cent, children, 1999/2011births15-19methodof school-age methods children,M/F100,000 live personnel, % aged 15-19, live births, aged 15-49, aged 15-49, 1988/20111999/2011Country, territorybirths), 2010 2000/2010 1991/2010 2010-2015 any method, modern method,or other area 1990/2011 1990/2011male femalemale femaleNamibia 200 81 74 39 55 54 21 84 89 44 57Nepal 170 36 81 39 50 43 25 78 64Netherlands 6 5 5 69 67 100 99 87 88New Zealand 15 96 29 6 75 72 99 100 94 95Nicaragua 95 74 109 22 72 69 8 93 95 43 49Niger 590 18 199 144 11 5 16 68 57 13 8Nigeria 630 34 123 141 14 9 19 60 55Norway 7 99 10 4 88 82 99 99 94 94Occupied Palestinian Territory 64 60 22 50 39 90 88 81 87Oman 32 99 12 11 32 25 100 97Pakistan 260 45 16 86 27 19 25 81 67 38 29Panama 92 89 88 21 99 98 66 72Papua New Guinea 230 40 70 58 36Paraguay 99 85 63 33 79 70 5 86 86 58 62Peru 67 84 72 28 74 50 7 98 98 77 78Philippines 99 62 53 27 51 34 22 88 90 56 67Poland 5 100 16 7 73 28 96 96 90 92Portugal 8 16 5 87 83 99 100 78 86Qatar 7 100 15 10 43 32 96 97 76 93Romania 27 99 41 15 70 38 12 88 87 82 83Russian Federation 34 100 30 16 80 65 95 96Rwanda 340 69 41 114 52 44 19 89 92Saint Kitts and Nevis 67 86 86 89 88Saint Lucia 35 100 49 16 90 89 85 85Saint Vincent and the Grenadines 48 98 70 25 100 97 85 96Samoa 29 24 29 27 48 93 97 73 83São Tomé and Príncipe 70 81 110 69 38 33 38 97 98 44 52Saudi Arabia 24 100 7 19 24 90 89 78 83Senegal 370 65 93 85 13 12 29 76 80 24 19Serbia 12 100 22 13 61 22 7 95 94 89 91Seychelles 62 96 94 92 100Sierra Leone 890 31 98 157 8 6 28Singapore 3 100 6 2 62 55Slovakia 6 100 21 7 80 66Slovenia 12 100 5 4 79 63 9 97 97 91 92Solomon Islands 93 70 70 43 35 27 11 83 81 32 29Somalia 1000 9 123 162 15 1South Africa 300 91 54 64 60 60 14 90 91 59 65Spain 6 13 4 66 62 12 100 100 94 96Sri Lanka 35 99 24 13 68 53 7 94 94THE STATE OF WORLD POPULATION 2012109

Monitoring ICPD Goals goals: – selected Selected indicators IndicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfant Maternal Life and expectancy Newborn Health Maternal Primary enrolment Sexual Proportion and Reproductive Secondary Health% Illiterate Education Births per Contraceptive HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 PrevalenceprevalenceMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolTotal perratioM/F(gross) M/F M/Fwomenrate (%)mortality ratio attended by birth rate per mortality rate, prevalence prevalence family planning, net per cent of school-age1,000 liveagedAny enrolment, Modern net per cent(15-49)(deaths per skilled health 1,000 women, per 1,000 rate, women rate, women per cent, children, 1999/2011births15-19methodof school-age methods children,M/F100,000 live personnel, % aged 15-19, live births, aged 15-49, aged 15-49, 1988/20111999/2011Country, territorybirths), 2010 2000/2010 1991/2010 2010-2015 any method, modern method,or other area 1990/2011 1990/2011male femalemale femaleSudan 4 730 23 70 87 9 29Suriname 130 87 66 27 46 45 91 91 46 55Swaziland 320 82 111 92 65 63 13 86 85 29 37Sweden 4 6 3 75 65 100 99 94 94Switzerland 8 100 4 5 82 78 99 99 84 82Syrian Arab Republic 70 96 75 16 58 43 100 98 67 67Tajikistan 65 88 27 65 37 32 99 96 90 80Tanzania, the United Republic of 460 49 128 81 34 26 25 98 98Thailand 48 99 47 13 80 78 3 90 89 70 78The former Yugoslav Republicof Macedonia 10 100 20 15 97 99 82 81Timor-Leste, the DemocraticRepublic of 300 30 54 76 22 21 32 86 86 34 39Togo 300 60 89 104 15 13 31 33 16Tonga 110 98 16 25 94 89 67 80Trinidad and Tobago 46 97 33 31 43 38 98 97 66 70Tunisia 56 95 6 23 60 52 12 99 96 64 66Turkey 20 91 38 23 73 46 6 98 97 77 71Turkmenistan 67 100 21 62 62 45 10Turks and Caicos Islands 26 31 22 77 84 72 69Tuvalu 28 24Uganda 310 42 159 114 24 18 38 90 92 17 15Ukraine 32 99 30 15 67 48 10 91 91 86 86United Arab Emirates 12 100 34 8 28 24 94 98 80 82United Kingdom 12 25 6 84 84 100 100 95 97United States of America 21 99 39 8 79 73 7 95 96 89 90Uruguay 29 100 60 15 77 75 100 99 66 73Uzbekistan 28 100 26 53 65 59 14 94 91 93 91Vanuatu 110 74 92 29 38 37 98 97 46 49Venezuela (Bolivarian Republic of) 92 95 101 20 70 62 19 95 95 68 76Viet Nam 59 84 35 23 78 60 4Yemen 200 36 80 57 28 19 39 86 70 49 31Zambia 440 47 151 130 41 27 27 91 94Zimbabwe 570 66 115 71 59 57 16110 INDICATORS

Monitoring Monitoring ICPD ICPD Goals goals: – Selected selected Indicators indicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfant Maternal Life and expectancy Newborn Health Maternal Primary enrolment Sexual Proportion and Reproductive Secondary Health% Illiterate Education Births per Contraceptive HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 PrevalenceprevalenceMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolTotal perratioM/F(gross) M/F M/Fwomenrate (%)mortality ratio attended by birth rate per mortality rate, prevalence prevalence family planning, net per cent of school-age1,000 liveagedAny enrolment, Modern net per cent(15-49)(deaths per skilled health 1,000 women, per 1,000 rate, women rate, women per cent, children, 1999/2011births15-19methodof school-age methods children,M/F100,000 live personnel, % aged 15-19, live births, aged 15-49, aged 15-49, 1988/20111999/2011births), 2010 2000/2010 1991/2010 2010-2015 any method, modern method,1990/2011 1990/2011male femaleWorld 210 70 49 60.0 63 57 12 92 90 64 61World andregional data 14 male femaleMore developed regions 6 26 23 7.7 72 62 97 97 90 91Less developed regions 7 240 65 52 66.1 62 56 13 91 89 60 57Least developed countries 8 430 42 116 112.0 35 28 24 82 78 35 29Arab States 9 140 76 43 49.1 51 42 18 89 82 61 58Asia and the Pacific 10 160 69 33 51.4 67 62 11 95 94 63 60Eastern Europe andCentral Asia 11 32 97 30 26.1 70 54 10 94 94 85 85Latin America andthe Caribbean 12 81 91 79 23.9 73 67 10 96 95 71 76Sub-Saharan Africa 13 500 47 120 122.6 25 20 25 79 76 33 26THE STATE OF WORLD POPULATION 2012111

Monitoring ICPD Goals – Selected IndicatorsDemographic indicatorsMaleFemaleCountry,territory orother areaTotalpopulationin millions,2012Averageannual rateof populationchange,per cent,2010-2015Lifeexpectancyat birth,2010-2015Totalfertilityrate, perwoman,2010-2015Afghanistan 33.4 3.1 49 49 6.0Albania 3.2 0.3 74 80 1.5Algeria 36.5 1.4 72 75 2.1Angola 20.2 2.7 50 53 5.1Antigua and Barbuda 0.1 1.0Argentina 41.1 0.9 72 80 2.2Armenia 3.1 0.3 71 77 1.7Australia 1 22.9 1.3 80 84 1.9Austria 8.4 0.2 78 84 1.3Azerbaijan 9.4 1.2 68 74 2.1Bahamas 0.4 1.1 73 79 1.9Bahrain 1.4 2.1 75 76 2.4Bangladesh 152.4 1.3 69 70 2.2Barbados 0.3 0.2 74 80 1.6Belarus 9.5 -0.3 65 76 1.5Belgium 10.8 0.3 77 83 1.8Belize 0.3 2.0 75 78 2.7Benin 9.4 2.7 55 59 5.1Bhutan 0.8 1.5 66 70 2.3Bolivia (Plurinational State of) 10.2 1.6 65 69 3.2Bosnia and Herzegovina 3.7 -0.2 73 78 1.1Botswana 2.1 1.1 54 51 2.6Brazil 198.4 0.8 71 77 1.8Brunei Darussalam 0.4 1.7 76 81 2.0Bulgaria 7.4 -0.7 70 77 1.5Burkina Faso 17.5 3.0 55 57 5.8Burundi 8.7 1.9 50 53 4.1Cambodia 14.5 1.2 62 65 2.4Cameroon, Republic of 20.5 2.1 51 54 4.3Canada 34.7 0.9 79 83 1.7Cape Verde 0.5 0.9 71 78 2.3Central African Republic 4.6 2.0 48 51 4.4Chad 11.8 2.6 49 52 5.7Chile 17.4 0.9 76 82 1.8China 1,353.6 0.4 72 76 1.6Colombia 47.6 1.3 70 78 2.3Comoros 0.8 2.5 60 63 4.7Congo, DemocraticRepublic of the 2 69.6 2.6 47 51 5.5Congo, Republic of the 4.2 2.2 57 59 4.4Country, territoryor other areaTotalpopulationin millions,2012Averageannual rateof populationchange,per cent,2010-2015Lifeexpectancyat birth,2010-2015Totalfertilityrate, perwoman,2010-2015Costa Rica 4.8 1.4 77 82 1.8Côte d'Ivoire 20.6 2.2 55 58 4.2Croatia 4.4 -0.2 73 80 1.5Cuba 11.2 0.0 77 81 1.5Cyprus 1.1 1.1 78 82 1.5Czech Republic 10.6 0.3 75 81 1.5Denmark 5.6 0.3 77 81 1.9Djibouti 0.9 1.9 57 60 3.6Dominica 0.1 0.0Dominican Republic 10.2 1.2 71 77 2.5Ecuador 14.9 1.3 73 79 2.42Egypt 84.0 1.7 72 76 2.6El Salvador 6.3 0.6 68 77 2.2Equatorial Guinea 0.7 2.7 50 53 5.0Eritrea 5.6 2.9 60 64 4.2Estonia 1.3 -0.1 70 80 1.7Ethiopia 86.5 2.1 58 62 3.8Fiji 0.9 0.8 67 72 2.6Finland 5.4 0.3 77 83 1.9France 63.5 0.5 78 85 2.0Gabon 1.6 1.9 62 64 3.2Gambia 1.8 2.7 58 60 4.7Georgia 4.3 -0.6 71 77 1.5Germany 82.0 -0.2 78 83 1.5Ghana 25.5 2.3 64 66 4.0Greece 11.4 0.2 78 83 1.5Grenada 0.1 0.4 74 78 2.2Guatemala 15.1 2.5 68 75 3.8Guinea 10.5 2.5 53 56 5.0Guinea-Bissau 1.6 2.1 47 50 4.9Guyana 0.8 0.2 67 73 2.2Haiti 10.3 1.3 61 64 3.2Honduras 7.9 2.0 71 76 3.0Hungary 9.9 -0.2 71 78 1.4Iceland 0.3 1.2 80 84 2.1India 1,258.4 1.3 64 68 2.5Indonesia 244.8 1.0 68 72 2.1Iran (IslamicRepublic of) 75.6 1.0 72 75 1.6Iraq 33.7 3.1 68 73 4.5112 INDICATORS

Monitoring ICPD Goals Demographic – Selected Indicators indicatorsMaleFemaleCountry, territoryor other areaTotalpopulationin millions,2012Averageannual rateof populationchange,per cent,2010-2015Lifeexpectancyat birth,2010-2015Totalfertilityrate, perwoman,2010-2015Ireland 4.6 1.1 78 83 2.1Israel 7.7 1.7 80 84 2.9Italy 61.0 0.2 79 85 1.5Jamaica 2.8 0.4 71 76 2.3Japan 126.4 -0.1 80 87 1.4Jordan 6.5 1.9 72 75 2.9Kazakhstan 16.4 1.0 62 73 2.5Kenya 42.7 2.7 57 59 4.6Kiribati 0.1 1.5 66 71 2.9Korea, DemocraticPeople's Republic of 24.6 0.4 66 72 2.0Korea, Republic of 48.6 0.4 77 84 1.4Kuwait 2.9 2.4 74 76 2.3Kyrgyzstan 5.4 1.1 64 72 2.6Lao People'sDemocratic Republic 6.4 1.3 66 69 2.5Latvia 2.2 -0.4 69 79 1.5Lebanon 4.3 0.7 71 75 1.8Lesotho 2.2 1.0 50 48 3.1Liberia 4.2 2.6 56 59 5.0Libya 6.5 0.8 73 78 2.4Lithuania 3.3 -0.4 67 78 1.5Luxembourg 0.5 1.4 78 83 1.7Madagascar 21.9 2.8 65 69 4.5Malawi 15.9 3.2 55 55 6.0Malaysia 29.3 1.6 73 77 2.6Maldives 0.3 1.3 76 79 1.7Mali 16.3 3.0 51 53 6.1Malta 0.4 0.3 78 82 1.3Martinique 0.4 0.3 77 84 1.8Mauritania 3.6 2.2 57 61 4.4Mauritius 3 1.3 0.5 70 77 1.6Mexico 116.1 1.1 75 80 2.2Micronesia (Federated States of) 0.1 0.5 68 70 3.3Moldova, Republic of 3.5 -0.7 66 73 1.4Mongolia 2.8 1.5 65 73 2.4Montenegro 0.6 0.1 73 77 1.6Morocco 32.6 1.0 70 75 2.2Mozambique 24.5 2.2 50 52 4.7Myanmar 48.7 0.8 64 68 1.9Namibia 2.4 1.7 62 63 3.1Country, territoryor other areaTotalpopulationin millions,2012Averageannual rateof populationchange,per cent,2010-2015Lifeexpectancyat birth,2010-2015Totalfertilityrate, perwoman,2010-2015Nepal 31.0 1.7 68 70 2.6Netherlands 16.7 0.3 79 83 1.8New Zealand 4.5 1.0 79 83 2.1Nicaragua 6.0 1.4 71 77 2.5Niger 16.6 3.5 55 56 6.9Nigeria 166.6 2.5 52 53 5.4Norway 5.0 0.7 79 83 1.9Occupied PalestinianTerritory 4.3 2.8 72 75 4.3Oman 2.9 1.9 71 76 2.1Pakistan 180.0 1.8 65 67 3.2Panama 3.6 1.5 74 79 2.4Papua New Guinea 7.2 2.2 61 66 3.8Paraguay 6.7 1.7 71 75 2.9Peru 29.7 1.1 72 77 2.4Philippines 96.5 1.7 66 73 3.1Poland 38.3 0.0 72 81 1.4Portugal 10.7 0.0 77 83 1.3Qatar 1.9 2.9 79 78 2.2Romania 21.4 -0.2 71 78 1.4Russian Federation 142.7 -0.1 63 75 1.5Rwanda 11.3 2.9 54 57 5.3Saint Kitts and Nevis 0.1 1.2Saint Lucia 0.2 1.0 72 78 1.9St. Vincent and theGrenadines 0.1 0.0 70 75 2.0Samoa 0.2 0.5 70 76 3.8São Tomé and Príncipe 0.2 2.0 64 66 3.5Saudi Arabia 28.7 2.1 73 76 2.6Senegal 13.1 2.6 59 61 4.6Serbia 9.8 -0.1 72 77 1.6Seychelles 0.1 0.3Sierra Leone 6.1 2.1 48 49 4.7Singapore 5.3 1.1 79 84 1.4Slovakia 5.5 0.2 72 80 1.4Slovenia 2.0 0.2 76 83 1.5Solomon Islands 0.6 2.5 67 70 4.0Somalia 9.8 2.6 50 53 6.3South Africa 50.7 0.5 53 54 2.4South Sudan 10.7 3.2Spain 46.8 0.6 79 85 1.5THE STATE OF WORLD POPULATION 2012113

Monitoring Demographic ICPD indicators Goals – Selected IndicatorsMaleFemaleCountry, territoryor other areaTotalpopulationin millions,2012Averageannual rateof populationchange,per cent,2010-2015Lifeexpectancyat birth,2010-2015Totalfertilityrate, perwoman,2010-2015Sri Lanka 21.2 0.8 72 78 2.2Sudan 5 35.0 2.2Suriname 0.5 0.9 68 74 2.3Swaziland 1.2 1.4 50 49 3.2Sweden 9.5 0.6 80 84 1.9Switzerland 7.7 0.4 80 85 1.5Syrian Arab Republic 21.1 1.7 74 78 2.8Tajikistan 7.1 1.5 65 71 3.2Tanzania, United Republic of 47.7 3.1 58 60 5.5Thailand 69.9 0.5 71 78 1.5The former Yugoslav Republicof Macedonia 2.1 0.1 73 77 1.4World andregional data 14Totalpopulationin millions,2012Averageannual rateof populationchange,per cent,2010-2015Lifeexpectancyat birth,2010-2015Totalfertilityrate, perwoman,2010-2015World 7,052.1 1.1 67 72 2More developed regions 6 1,244.6 0.3 75 81 2Less developed regions 7 5,807.6 1.3 66 69 3Least developed countries 8 870.4 2.2 58 60 4Arab States 9 318.5 1.9 68 72 3Asia and the Pacific 10 3,744.5 1.0 68 71 2Eastern Europe andCentral Asia 11 401.9 0.3 66 75 2Latin America andthe Caribbean 12 598.3 1.1 72 78 2Sub-Saharan Africa 13 841.8 2.4 54 56 5Timor-Leste, DemocraticRepublic of 1.2 2.9 62 64 5.9Togo 6.3 2.0 56 59 3.9Tonga 0.1 0.4 70 75 3.8Trinidad and Tobago 1.4 0.3 67 74 1.6Tunisia 10.7 1.0 73 77 1.9Turkey 74.5 1.1 72 77 2.0Turkmenistan 5.2 1.2 61 69 2.3Turks and Caicos Islands 0.0 1.2Tuvalu 0.0 0.2Uganda 35.6 3.1 54 55 5.9Ukraine 44.9 -0.5 64 75 1.5United Arab Emirates 8.1 2.2 76 78 1.7United Kingdom 62.8 0.6 78 82 1.9United States of America 315.8 0.9 76 81 2.1Uruguay 3.4 0.3 74 81 2.0Uzbekistan 28.1 1.1 66 72 2.3Vanuatu 0.3 2.4 70 74 3.7Venezuela (BolivarianRepublic of) 29.9 1.5 72 78 2.4Viet Nam 89.7 1.0 73 77 1.7Yemen 25.6 3.0 65 68 4.9Zambia 13.9 3.0 49 50 6.3Zimbabwe 13.0 2.2 54 53 3.1114 INDICATORS

Monitoring ICPD Goals – Selected IndicatorsNotes for indicators* Most recent data available used for each country inthe period specified.1 Including Christmas Island, Cocos (Keeling) Islandsand Norfolk Island.2 Formerly Zaire.3 Including Agalesa, Rodrigues and St. Brandon.4 Due to the formation in July 2011 of the Republicof South Sudan and its subsequent admission tothe United Nations on 14 July 2011, disaggregateddata for Sudan and South Sudan as separateStates are not yet available for most indicators.Aggregated data presented are for Sudan prior tothe independence of South Sudan.5 Does not include South Sudan6 More-developed regions comprise North America,Japan, Europe and Australia-New Zealand.7 Less-developed regions comprise all regionsof Africa, Latin America and Caribbean, Asia(excluding Japan), and Melanesia, Micronesia andPolynesia.8 Least-developed countries according to standardUnited Nations designation.9 Comprising Algeria, Bahrain, Djibouti, Egypt, Iraq,Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya,Morocco, Occupied Palestinian Territory, Oman,Qatar, Saudi Arabia, Somalia, Sudan, Syrian ArabRepublic, Tunisia, United Arab Emirates and Yemen.10 Includes only UNFPA programme countries,territories or other areas: Afghanistan, Bangladesh,Bhutan, Cambodia, China, Cook Islands,Democratic People's Republic of Korea, Fiji, India,Indonesia, Iran (Islamic Republic of), Kiribati, LaoPeople's Democratic Republic, Malaysia, Maldives,Marshall Islands, Micronesia, Mongolia, Myanmar,Nauru, Nepal, Niue, Pakistan, Palau, Papua NewGuinea, Philippines, Samoa, Solomon Islands,Sri Lanka, Thailand, Timor-Leste, Tokelau, Tonga,Tuvalu, Vanuatu, Viet Nam.11 Includes only UNFPA programme countries,territories or other areas: Albania, Armenia,Azerbaijan, Belarus, Bosnia and Herzegovina,Bulgaria, Georgia, Kazakhstan, Kyrgyzstan,Republic of Moldova, Romania, Russian Federation,Serbia, Tajikistan, the former Yugoslav Republic ofMacedonia, Turkmenistan, Ukraine, Uzbekistan.12 Includes only UNFPA programme countries,territories or other areas: Anguilla, Antiguaand Barbuda, Argentina, Bahamas, Barbados,Belize, Bermuda, Bolivia (Plurinational State of),Brazil, British Virgin Islands, Cayman Islands,Chile, Colombia, Costa Rica, Cuba, Dominica,Dominican Republic, Ecuador, El Salvador,Grenada, Guatemala, Guyana, Haiti, Honduras,Jamaica, Mexico, Montserrat, Netherlands Antilles,Nicaragua, Panama, Paraguay, Peru, Saint Kitts andNevis, Saint Lucia, St. Vincent and the Grenadines,Suriname, Trinidad and Tobago, Turks and Caicos,Uruguay, Venezuela (Bolivarian Republic of).13 Includes only UNFPA programme countries,territories or other areas: Angola, Benin, Botswana,Burkina Faso, Burundi, Cameroon, Cape Verde,Central African Republic, Chad, Comoros, Congo,Côte d'Ivoire, Democratic Republic of the Congo,Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia,Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho,Liberia, Madagascar, Malawi, Mali, Mauritania,Mauritius, Mozambique, Namibia, Niger, Nigeria,Rwanda, Senegal, Seychelles, Sierra Leone, SouthAfrica, South Sudan, Swaziland, Togo, Uganda,United Republic of Tanzania, Zambia, Zimbabwe.14 Regional aggregations are weighted averagesbased on countries with available data.Technical notes:Data sources and definitionsThe statistical tables in The State of World Population 2012 includeindicators that track progress toward the goals of the Programme ofAction of the International Conference on Population and Development(ICPD) and the Millennium Development Goals (MDGs) in the areas ofmaternal health, access to education, reproductive and sexual health. Inaddition, these tables include a variety of demographic indicators.Different national authorities and international organizations mayemploy different methodologies in gathering, extrapolating or analyzingdata. To facilitate the international comparability of data, UNFPA relieson the standard methodologies employed by the main sources of data,especially the Population Division of the United Nations Department ofEconomic and Social Affairs. In some instances, therefore, the data inthese tables differ from those generated by national authorities.Regional averages are based on data about countries and territorieswhere UNFPA works, rather than on strict geographical definitionsemployed by the Population Division of the United Nations Departmentof Economic and Social Affairs. For a list of countries included in eachregional category in this report, see the “Notes for indicators.”Monitoring ICPD GoalsMaternal and Newborn HealthMaternal mortality ratio, per 100,000 live births. Source: WorldHealth Organization (WHO), UNICEF, UNFPA and World Bank. 2010.Trends in maternal mortality: 1990 to 2010: WHO. This indicator presentsthe number of deaths to women per 100,000 live births which resultfrom conditions related to pregnancy, delivery, the postpartum period,and related complications. Estimates between 100-999 are rounded tothe nearest 10, and above 1,000 to the nearest 100. Several of the estimatesdiffer from official government figures. The estimates are basedon reported figures wherever possible, using approaches that improvethe comparability of information from different sources. See the sourcefor details on the origin of particular national estimates. Estimates andmethodologies are reviewed regularly by WHO, UNICEF, UNFPA, academicinstitutions and other agencies and are revised where necessary,as part of the ongoing process of improving maternal mortality data.Because of changes in methods, prior estimates for 1995 and 2000may not be strictly comparable with these estimates. Maternal mortalityestimates reported here are based on the global database on maternalmortality, which is updated periodically.Births attended by skilled health personnel, per cent, 2000/2010Source: WHO global database on maternal health indicators, 2012 update.Geneva, World Health Organization (http://www.who.int/gho). Percentageof births attended by skilled health personnel (doctors, nurses or midwives)is the percentage of deliveries attended by health personneltrained in providing life-saving obstetric care, including giving the necessarysupervision, care and advice to women during pregnancy, labourand the post-partum period; conducting deliveries on their own; andcaring for newborns. Traditional birth attendants, even if they receive ashort training course, are not included.Adolescent birth rate, per 1,000 women aged 15-19, 1991/2010Source: United Nations, Department of Economic and Social Affairs,Population Division (2012). 2012 Update for the MDG Database:Adolescent Birth Rate (POP/DB/Fert/A/MDG2012). The adolescentTHE STATE OF WORLD POPULATION 2012115

Monitoring ICPD Goals – Selected IndicatorsIndicators of Mortality Indicators of Education Reproductive Health Indicatorsbirth rate measures the annual Infant number Life of expectancy births to women Maternal 15 to 19 Primary enrolment union. Proportion For further Secondary analysis, see % Illiterate also Adding it Births Up: per Cost Contraceptive and Benefits of HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 Prevalenceprevalenceyears of age per 1,000 women in that age group. It represents the risk Contraceptive Services: Estimates for 2012. Guttmacher InstituteTotal perratioM/F(gross) M/F M/Fwomenrate (%)1,000 liveagedAny Modernof childbearing among adolescent women 15 to 19 years of age. For civil and UNFPA.(15-49)births15-19method methodsM/Fregistration, rates are subject to limitations which depend on the completenessof birth registration, the treatment of infants born alive butdead before registration or within the first 24 hours of life, the quality ofthe reported information relating to age of the mother, and the inclusionof births from previous periods. The population estimates may sufferfrom limitations connected to age misreporting and coverage. For surveyand census data, both the numerator and denominator come from thesame population. The main limitations concern age misreporting, birthomissions, misreporting the date of birth of the child, and samplingvariability in the case of surveys.Under age 5 mortality, per 1,000 live births. Source: United Nations,EducationMale and female net enrolment rate in primary education (adjusted),male and female net enrolment rate in secondary education, 2010 orlatest year. Source: UNESCO Institute for Statistics, data release of May2012. Accessible through: stats.uis.unesco.org. The net enrolment ratesindicate the enrolment of the official age group for a given level of educationexpressed as a percentage of the corresponding population. Theadjusted net enrolment rate in primary also includes children of officialprimary school age enrolled in secondary education. Data presented arethe most recent year estimates available for the period 1999-2011.Department of Economic and Social Affairs, Population Division (2011).World Population Prospects: The 2010 Revision. DVD Edition - ExtendedDataset in Excel and ASCII formats (United Nations publication, ST/ESA/SER.A/306). Under age 5 mortality is the probability (expressed as arate per 1,000 live births) of a child born in a specified year dying beforereaching the age of five if subject to current age-specific mortality rates.Demographic indicatorsTotal population, 2012. Source: United Nations, Department ofEconomic and Social Affairs, Population Division (2011). World PopulationProspects: The 2010 Revision. DVD Edition - Extended Dataset in Excel andASCII formats (United Nations publication, ST/ESA/SER.A/306) Theseindicators present the estimated size of national populations at mid-year.Sexual and reproductive healthContraceptive prevalence. Source: United Nations, Department ofEconomic and Social Affairs, Population Division (2012). 2012 Update forthe MDG Database: Contraceptive Prevalence (POP/DB/CP/A/MDG2012).These data are derived from sample survey reports and estimate theproportion of married women (including women in consensual unions)currently using, respectively, any method or modern methods of contraception.Modern or clinic and supply methods include male and femalesterilization, IUD, the pill, injectables, hormonal implants, condoms andfemale barrier methods. These numbers are roughly but not completelycomparable across countries due to variation in the timing of the surveysand in the details of the questions. All country and regional data referto women aged 15-49. The most recent survey data available are cited,ranging from 1990-2011.Unmet need for family planning. Source: United Nations, Departmentof Economic and Social Affairs, Population Division (2012). 2012Update for the MDG Database: Unmet Need for Family Planning (POP/DB/CP/B/MDG2012). Women with unmet need for spacing births arethose who are fecund and sexually active but are not using any methodof contraception, and report wanting to delay the next child. This isa subcategory of total unmet need for family planning, which alsoincludes unmet need for limiting births. The concept of unmet needpoints to the gap between women's reproductive intentions and theircontraceptive behavior. For MDG monitoring, unmet need is expressedas a percentage based on women who are married or in a consensualAverage annual rate of population change (%) Source: UnitedNations, Department of Economic and Social Affairs, Population Division(2011). World Population Prospects: The 2010 Revision. DVD Edition -Extended Dataset in Excel and ASCII formats (United Nations publication,ST/ESA/SER.A/306). Average annual rate of population change is theaverage exponential rate of growth of the population over a given period.It is based on a medium variant projection.Male and female life expectancy at birth. Source: United Nations,Department of Economic and Social Affairs, Population Division (2011). WorldPopulation Prospects: The 2010 Revision. DVD Edition - Extended Dataset inExcel and ASCII formats (United Nations publication, ST/ESA/SER.A/306).These indicators are measures of mortality levels, respectively, andrepresent the average number of years of life expected by a hypotheticalcohort of individuals who would be subject during all their lives to themortality rates of a given period. Data are for the period 2010-2015 andare expressed as years.Total fertility rate. Source: United Nations, Department of Economicand Social Affairs, Population Division (2011). World PopulationProspects: The 2010 Revision. DVD Edition - Extended Dataset in Excel andASCII formats (United Nations publication, ST/ESA/SER.A/306). Themeasure indicates the number of children a woman would have duringher reproductive years if she bore children at the rate estimated for differentage groups in the specified time period. Countries may reach theprojected level at different points within the period. Estimates are forthe period 2010-2015.116 INDICATORS

BibliographyAbbasi-Shavazi, Mohammad Jalal, PeterMcDonald, and Meimanat Hosseini-Chavoshi.2011. “The Fertility Transition in Iran:Revolution and Reproduction.” Studies inFamily Planning 42(3): 233-235.Abdel-Tawab, Nahla, Dale Huntington, EzzeldinOsman, Hala Youssef and Laila Nawar. 2002.“Recovery from Abortion and Miscarriage inEgypt: Does Counseling Husbands Help?” In,Haberland, Nicole and Diana Measham, eds.,Responding to Cairo: Case Studies of ChangingPractice in Reproductive Health and FamilyPlanning. New York: Population Council.Abma, Joyce C., Gladys Martinez, and CaseyE. Copen. 2010. “Teenagers in the UnitedStates: Sexual Activity, Contraceptive Use,and Childbearing, National Survey of FamilyGrowth 2006-2008.” Vital and HealthStatistics. 23(30): 1-47.AbouZahr, Carla and others. 1996. “QualityHealth Care for Women: A Global Challenge.”Health Care for Women International. 17(5):449-467.Abraham, W., A. Adamu, and D. Deresse.2010. “The Involvement of Men in FamilyPlanning An Application of TranstheoreticalModel in Wolaita Soddo Town SouthEhtiopia.” Asian Journal of Medical Sciences.2(2): 44-50.Advocates for Youth. 2011. “Adolescent SexualHealth in Europe and the United States: TheCase for a Rights. Respect. Responsibility.Approach.” Fact Sheet. Washington, DC:Advocates for Youth.Aka-Dago-Akribi, H, A. Desgrees Du Lou,Phillippe Msellati, and others. 1999. “IssuesSurrounding Reproductive Choice for WomenLiving with HIV in Abidjan, Cote d’Ivoire.”Reproductive Health Matters. 7(13): 20-29.Alderman, Harold, Jere. R. Behrman, VictorLavy, and others. 2001. “Child Health andSchool Enrollment: A Longitudinal Analysis.”The Journal of Human Resources. 36(1):185-205.Almond, Douglas. 2006. “Is the 1918Influenza Pandemic Over? Long-Term Effectsof In Utero Influenza Exposure in the Post-1940 U.S. Population.” Journal of PoliticalEconomy. 114(4): 672-712.Almond, Douglas and Janet Currie. 2011.“Killing Me Softly: The Fetal OriginsHypothesis.” Journal of Economic Perspectives.25(3): 153-172.Almond, Douglas, Lena Edlund, Hongbin Li,and others. 2007. “Long-Term Effects of the1959-1961 China Famine: Mainland Chinaand Hong Kong.” National Bureau of EconomicResearch Working Paper Series. No. 13384.Almond, Douglas and Bhashkar Mazumder.2008. “Health Capital and the PrenatalEnvironment: The Effect of Maternal FastingDuring Pregnancy.” National Bureau ofEconomic Research Working Paper Series.No. 14428.Anderson, John E., Denise J. Jamieson, LeeWarner, and others. 2012. “ContraceptiveSterilization Among Married Adults: NationalData on Who Chooses Vasectomy and TubalSterilization.” Contraception. 85(6): 552-557.Angusto E. Semprini, Simona Fiore, GioigioPardi. 1997. “Reproductive Counseling for HIV-Discordant Couples.” The Lancet. 349(9062):1401-1402.Austveg, Berit. 2011. "Perpetuating power:some reasons why reproductive healthhas stalled." Reproductive Health Matters.19(38):26-34.Bailey, Martha J. 2006. “More Power to thePill: The Impact of Contraceptive Freedomon Women’s Life Cycle Labor Supply.” TheQuarterly Journal of Economics. 121(1):289-320.Bankole A and Singh S. 1998. Couples’fertility and contraceptive decision-makingin developing countries: hearing the man’svoice, International Family Planning Perspectives,1998, 24(1): 15–24.Barham, Tania. 2009. “Effects of EarlyChildhood Health and Family PlanningInterventions on Adolescent CognitiveFunctioning: Evidence from Matlab inBangladesh.” Working Paper.Barker, Gary T. 2005. Dying to Be Men: Youth,Masculinity, and Social Exclusion. Abingdon:Routledge.Barker, Gary, Margaret E. Greene, EveGoldstein Siegel, and others. 2010. What MenHave to Do With It: Public Policies to PromoteGender Equality. Washington, DC: InternationalCenter for Research on Women.Barker, Gary and Peter Pawlak. 2011. “EvolvingMen? Men, Families, Gender Equality andCare.” In Men in Families and Family Policy ina Changing World. New York: The Divisionfor Social Policy and Development of theUnited Nations Department of Economicand Social Affairs.Barker, Gary and Christine Ricardo. 2005.Young Men and the Construction of Masculinityin Sub-Saharan Africa: Implication for HIV/AIDS, Conflict, and Violence. Social DevelopmentPapers: Conflict Prevention and Reconstruction.Paper No. 26.Barker, Gary, Christine Ricardo, and MarcosNascimento. 2007. Engaging Men and Boysin Changing Gender-Based Inequity in Health:Evidence from Programme Interventions. Geneva:World Health Organization.Batini, Nicoletta, Tim Callen, and WarwickMcKibbin. 2006. The Global Impact ofDemographic Change. International MonetaryFund Working Paper. Washington, DC: IMF.Behrman, Jere R. and Mark R. Rosenzweig.2004. “Returns to Birthweight.” The Review ofEconomics and Statistics. 86(2): 586-601.Bertrand, Jane T. 2011. USAID Graduation fromFamily Planning Assistance: Implications for LatinAmerica. Washington, DC: Population Instituteand Tulane University School of Public Healthand Tropical Medicine.Bertrand, Jane T., Karen Hardee, Robert J.Magnani, and others. 1995. “Access, Qualityof Care and Medical Barriers in FamilyPlanning Programs.” International FamilyPlanning Services. 21(2): 64-69, 74.Bhutta, Zulfiqar A., Tahmeed Ahmed,Robert E. Black, and others. 2008. “WhatWorks? Interventions for Maternal and ChildUndernutrition and Survival.” The Lancet.371(9610): 417-440.Biddlecom, Ann E., and Bolaji M. Fapohunda.1998. “Covert Contraceptive Use: Prevalence,Motivations, and Consequences.” Studies inFamily Planning. 29(4): 360-372.THE STATE OF WORLD POPULATION 2012117

Monitoring ICPD Goals – Selected IndicatorsInfantmortalityTotal per1,000 liveLife expectancyM/FBiddlecom, Ann E., Richard Gregory, CynthiaB. Lloyd, and Barbara S. Mensch. births 2008.“Associations between Premarital Sex andLeaving School in Four Sub-Saharan AfricanCountries.” Studies in Family Planning. 39(4):337-350.Binka, Fred N., Alex Nazzar, and James F.Phillips. 1995. “The Navrongo CommunityHealth and Family Planning Project.” Studiesin Family Planning. 26(3): 121-139.Birdsall, Nancy, Allen Kelley, and StephenSinding. 2001. Population Matters: DemographicChange, Economic Growth, and Poverty in theDeveloping World. New York: OxfordUniversity Press.Birungi, Harriet, Philomena Nyarko, Ian Askew,and others. 2006. Priority Setting for ReproductiveHealth at the District Level in the context of HealthSector Reforms in Ghana. Washington, DC:Population Council.Blanc, Ann K., Amy O. Tsui, Trevor N. Croft,and Jamie L. Trevitt. 2009. “Patterns andTrends in Adolescents’ Contraceptive Useand Discontinuation in Developing Countriesand Comparisons with Adult Women.”International Perspectives on Sexual andReproductive Health. 35(2): 63-71.Bloom, David E. and David Canning. 2008.“Global Demographic Change: Dimensionsand Economic Significance.” Population andDevelopment Review. 34:17-51.Bloom, David E. and David Canning. 2003.“The Health and Poverty of Nations: fromTheory to Practice.” Journal of HumanDevelopment. 4(1): 47-71.Bloom, David E. and David Canning. 2000.“The Health and Wealth of Nations.” Science.287(5456): 1207-1209.Bloom, David E., David Canning, Gunther Fink,and others. 2009. “Fertility, Female LaborForce Participation, and the DemographicDividend.” Journal of Economic Growth. 1492):79-101.Bloom, David E., David Canning, and PiaN. Malaney. 2000. “Population Dynamicsand Economic Growth in Asia.” Populationand Development Review. 26(Supplement:Population and Economic Change in EastAsia): 257-290.Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FBloom, David E., David Canning, JaypeeSilva. 2001. “Economic Growth and theDemographic Transition.” National Bureauof Economic Research Working Paper Series.No. 8685.Bloom, David E., David Canning, and JaypeeSilva. 2003. “The Effect of Health onEconomic Growth: A Production FunctionApproach.” World Development. 32(1): 1-13.Bongaarts, John. 2010. The Causesof Educational Difference in Fertility insub-Saharan Africa. New York: ThePopulation Council.Secondaryenrolment(gross) M/FBongaarts, John. 1987. “Does Family PlanningReduce Infant Mortality Rates?” Population andDevelopment Review. 13(2): 323-334.Bongaarts, John, W. Parker Mauldin, andJames F. Phillips. 1990. “The DemographicImpact of Family Planning Programs.” Studiesin Family Planning. 21(6): 299-310.Bradley, Sarah E.K., Hilary M. Schwandt,and Shane Khan. 2009. Levels, Trends, andReason for Contraceptive Discontinuation. DHSAnalytical Studies No. 20. Calverton, Maryland:ICF Macro.Braunschweig, Scott and Manuel Carballo.2001. Health and Human Rights of Migrants.Geneva: International Centre for Migrationand Health.Bruce, Judith. 1990. “Fundamental Elementsof the Quality of Care: A Simple Framework.”Studies in Family Planning. 21 (2): 61-91.Bruce, Judith, and Shelley Clark. 2003.Including Married Adolescents in AdolescentReproductive Health and HIV/AIDS Policy. Paperprepared for the WHO/UNFPA/PopulationCouncil Technical Consultation on MarriedAdolescents, WHO, Geneva, 9-12December 2003.Bunce, Arwen, Greg Guest, Hannah Searing,and others. 2007. “Factors AffectingVasectomy Acceptability in Tanzania.”International Family Planning Perspectives.33 (1):13-21.Canning, David, Jocelyn E. Finlay, and EmreOzaltin. 2009. Adolescent Girls Health Agenda:Study on Intergenerational Health Impacts.Boston: Harvard School of Public Health.% Illiterate(>15 years)Births per1,000ContraceptivePrevalenceHIVprevalenceM/Fwomenrate (%)Caro, Deborah, for aged the Interagency Any Modern Gender (15-49)15-19method methodsM/FWorking Group. 2009. A Manual forIntegrating Gender Into Reproductive Healthand HIV Programs: From Commitment to Action(2nd Edition). Washington, DC: PopulationReference BureauCenters for Disease Control and Prevention.2010. Youth Risk Behavior Surveillance:United States, 2009. Surveillance Summaries.MMWR 2010; 59 (No. SS-5).Center for Reproductive Law and Policy. 1998.Silence and Complicity: Violence Against Womenin Peruvian Public Health Facilities. New York:CRLP.Center for Reproductive Rights. 2009.Reproductive Rights are Human Rights.New York: CRR.Center for Reproductive Rights. 2010.“Facts on Abortion in the Philippines:Criminalization and a General Ban onAbortion.” New York: CRR.Center for Reproductive Rights. 2011.Calculated Injustice—The Slovak Republic’sFailure to Ensure Access to Contraceptives.New York: CRR.Center for Reproductive Rights. 2011a.The CEDAW Committee Urges States toProtect and Promote Sexual and ReproductiveRights. July 2011. Available from: http://reproductiverights.org/en/feature/the-cedaw-committee-urges-states-to-protectand-promote-sexual-and-reproductive-rights(Accessed 30 August 2012).Center for Reproductive Rights. 2008. AnInternational Human Right: Sexuality Educationfor Adolescents in Schools. New York: CRR.Center for Reproductive Rights. 2012. “Over700,000 Petitioners Demand HonduranCongress Reject Law Criminalizing EmergencyContraception.” Press Release. 16 May 2012.Center for Reproductive Rights and UnitedNations Population Fund. 2010. The Rightto Contraceptive Information and Services forWomen and Adolescents. New York: CRR.Chaudhuri, Anoshua. 2005. “Direct andIndirect Effects of a Maternal and ChildHealth Program in Rural Bangladesh.” Journalof Developing Societies. 21(1-2): 143-173.118 INDICATORSBIBLIOGRAPHY

Monitoring ICPD Goals – Selected IndicatorsInfantmortalityTotal per1,000 liveLife expectancyM/FChaudhuri, Anoshua. 2009. “Spillover Impactsof a Reproductive Health Program births on ElderlyWomen in Rural Bangladesh.” Journal of Familyand Economic Issues. 30(2): 113-125.Chowdhury, M.E., R. Botlero, M. Koblinsky,and others. 2007. “Determinants of Reductionin Maternal Mortality in Matlab, Bangladesh:a 30-year march.” The Lancet. 370(9595):1320-1328.Chun, Hyunbae and Jeungil Oh. 2002. “AnInstrumental Variable Estimate of the Effectof Fertility on the Labour Force Participationof Married Women.” Applied Economics Letters.9(10): 631-634.Clark, Shelley, Judith Bruce, and Annie Dude.2006. “Protecting Young Women from HIV/AIDS: The Case Against Child and AdolescentMarriage.” International Family PlanningPerspectives. 32(2): 79-88.Cleland, John, Mohamed M. Ali, and IqbalShah. 2006. “Trends in Protective BehaviorAmong Single Versus Married Young Womenin sub-Saharan Africa.” Reproductive HealthMatters. 14(28): 17-22.Cleland, John, Agustin Conde-Agudelo,Herbert Peterson, and Others. 2012.“Contraception and Health.” The Lancet.380(9837): 149-156.Cleland, Kelly, Jeffrey F. Peipert, CarolynWestoff, and others. 2011. “Family Planning asa Cost-Saving Preventive Health Service.” TheNew England Journal of Medicine. 364(18):e37.Coale, Ansley J. and Edgar M. Hoover. 1958.Population Growth and Economic Developmentin Low-Income Countries: A Case Study of India’sProspects. Princeton, New Jersey: PrincetonUniversity Press.Cohen, Susan A. 2011. “The World at SevenBillion: Global Milestone A Reflection ofIndividual Needs.” Guttmacher Policy Review.14(3): 2-5.Conde-Agudelo, A., A. Rosas-Bermudez, A.C.Kafury-Goeta. 2007. “Effects of Birth Spacingon Maternal Health: A Systematic Review.”American Journal of Obstetrics and Gynecology.196(4): 297-308.Connell, Robert W. 1987. Gender and Power:Society, the Person, and Sexual Politics. Stanford:Stanford University Press.Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FConnell, Robert W. 1994. Masculinities.Berkeley: University of California Press.Connell, Robert W. 1998. “Masculinitiesand Globalization.” Men and Masculinities.1(1): 3-23.Secondaryenrolment(gross) M/F“Convention on the Elimination of All Formsof Discrimination against Women (CEDAW).”UN News Center. UN. Web. 30 May. 2012.Accessible at: http://www.un.org/womenwatch/daw/cedaw/Cooper, Diane, Hillary Bracken, Landon Myer,and others. 2005. Reproductive Intentionsand Choices among HIV-infected individualsin Cape Town, South Africa: Lessons forReproductive Policy and Service Provisionfrom a qualitative Study (Policy Brief).New York: Population Council.Cooper, D., J. Harries, L. Myer, and others.2007. “Life is Still Going on”: ReproductiveIntentions Among HIV-Positive Womenand Men in South Africa.” Social ScienceMedicine. 65(2): 274-283.Corte Constitucional de Colombia. SentenciaT-841/2011. 10 May 2012. Available from:http://www.promsex.org/docs/varios/Sentencia_T-841_de_2011.pdf (Accessed30 August 2012).Cottingham, Jane, Adrienne Germain,and Paul Hunt. 2012. “Use of Human Rightsto Meet the Unmet Need for Family Planning.”The Lancet 380 (9837): 172-180.Craft, Shonda M., Robin O. Delaney, DianneT. Bautista, and others. 2007. “PregnancyDecisions among Women with HIV.” AIDSand Behavior. 11(6): 927-935.Creanga, Andreea A., Duff Gillespie, SabrinaKarklins, and Amy O. Tsui. 2011. “Low Use ofContraception Among Poor Women in Africa:An Equity Issue.” Bulletin of the World HealthOrganization. 89(4): 241-316.Creel, Liz C., Justine C. Sass, and Nancy V.Yinger. 2002. Overview of Quality of Carein Reproductive Health: Definitions andMeasurements of Quality. Washington, DC:Population Council and Population ReferenceBureau.% Illiterate(>15 years)Births per1,000ContraceptivePrevalenceHIVprevalenceM/Fwomenrate (%)Darroch, Jacqueline. aged 2007. Any Family Planning:Modern(15-49)15-19method methodsM/FOverview of Epidemiologic and MedicalEvents. In: JW Ward and C Warren, eds.,Silent Victories: The History and Practiceof Public Health in Twentieth CenturyAmerica. New York: Oxford UniversityPress. pp. 253-278.Darroch, Jacqueline E., Gilda Sedgh, andHaley Ball. 2011. Contraceptive Technologies:Responding to Women’s Needs. New York:The Guttmacher Institute.Dixon-Mueller, Ruth. 2008. “How Young is“Too Young”? Comparative Perspectives onAdolescent Sexual, Marital, and ReproductiveTransitions.” Studies in Family Planning. 39 (4):247-262.Doepke, Matthias and Michele Tertlit. 2009.“Women’s Liberation: What’s in It for Men?”The Quarterly Journal of Economics. 11(92):379-420.Donohue, John J. and Steven D. Levitt. 2001.“The Impact of Legalized Abortion on Crime.”The Quarterly Journal of Economics. 116(2):379-420.Eaton, Danice K., Laura Kann, Steve Kinchen,and others. 2012. “Youth Risk BehaviorSurveillance—United States, 2011.” Morbidityand Mortality Weekly Report SurveillanceSummaries. 61(4): 1-164.The Economist. 2001. “Righting Wrongs—Human Rights.” New York: The Economist.EngenderHealth. 2002. ContraceptiveSterilization: Global Issues and Trends. NewYork: EngenderHealth.EnGendeRights. 2009. Advancing reproductiverights using the inquiry procedure of theOP CEDAW and the UN special procedures:the Philippine experience. Manila:EnGendeRights, Inc.Erfani, Amir. 2010. The Use of Withdrawalamong Birth Limiters in Iran and Turkey. DHSWorking Papers No. 71. Calverton, Maryland:ICF Macro.Erulkar, Annabel S. and Eunice Muthengi.2007. Evaluation of Berhane Hewan: A PilotProgram to Promote Education and DelayMarriage in Rural Ethiopia. New York:Population Council.THE STATE OF WORLD POPULATION 2012119

Monitoring ICPD Goals – Selected IndicatorsInfantmortalityTotal per1,000 liveLife expectancyM/FEuropean Commission. 2008. Quality inand Equality of Access to Healthcare births Services.Brussels: Directorate-General for Employment,Social Affairs and Equal Opportunities.Ezeh, Alex C., Ivy Kodzi, Jacques Emina.2010. “Reaching the Urban Poor with FamilyPlanning Services.” Studies in Family Planning.41(2): 109-116.Ezzati, Majid, AD Lopez, A Rodgers, S VanderHoorn, CJ Murray and Comparative RiskAssessment Collaborating Group. 2002.“Selected Major Risk Factors and Global andRegional Burden of Disease.” Lancet Nov 2;360(9343): 1347-60. Lancet. 2002Nov 2;360(9343): 1347-60.Fahimi-Roudi, Farzaneh, Ahmed AbdulMonem, Lori Ashford, and Maha El-Adawy.2012. Women’s Need for Family Planning inArab Countries. Cairo: UNFPA Arab StatesRegional Office and the Pan Arab Project forFamily Health. Washington DC: PopulationReference Bureau.Feldman, R. and C. Maposhere. 2003. “SaferSex and Reproductive Choice: Findings from“Positive Women: Voices and Choices” inZimbabwe.” Reproductive Health Matters.11(22): 162-173.Finer, Lawrence B. and Stanley K. Henshaw.2006. “Disparities in Rates of UnintendedPregnancy in the United States, 1994 and2001.” Perspectives on Sexual and ReproductiveHealth. 38(2): 90-96.Fletcher, Jason M. and Barbara L. Wolfe.2008. “Education and Labor MarketConsequences of Teenage Childbearing.” TheJournal of Human Resources. 44(2): 303-325.Flood, Michael. 2007. “Involving Men inGender Policy and Practice.” Critical Half.5(1): 9-13.Foreit, Karen G. 2012. Addressing Poverty: AGuide for Considering Poverty-Related and OtherInequities in Health. Washington, DC: USAIDand MEASURE Evaluation.Foreit, Karen, M. Karra, and T. Pandit-Rajani.2010. Disentangling the Effects of Povertyand Place of Residence for Strategic Planning.Washington, DC: Futures Group, Health PolicyInitiative, Task Order 1.Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FSecondaryenrolment(gross) M/FFrost, Jennifer J. and Jacqueline E. Darroch.2008. “Factors Associated with ContraceptiveChoice and Inconsistent Method Use.”Perspectives on Sexual and Reproductive Health.40(2): 94-104.Galston, William A. and Melissa Rogers. 2012.Health Care Providers’ Consciences and Patients’Needs: The Quest for Balance. Washington, DC:The Brookings Institution.Glasier, Anna. 2010. Acceptability ofcontraception for men: a review.Contraception. 82 (5): 453-456.Glasier, Anna, A. Metin Gulmezoglu,George P. Schmid, and others. “Sexual andReproductive Health.” The Lancet. 368(9547):1595-1607.Godha, Deepali, David Hotchkiss, andAnastasia Gage. 2011. The Influence of ChildMarriage on Fertility, Fertility-Control, andMaternal Health Care Utilization: A MulticountryStudy from South Asia. MEASUREEvaluation PRH Working Paper Series. Tulane:Tulane University School of Public Healthand Tropical Medicine.Granich, Reuben, James G. Kahn, RodBennett, and others. 2012. “Expanding ARTfor Treatment and Prevention of HIV in SouthAfrica: Estimated Cost and Cost-Effectiveness2011-2050.” PLoS ONE. 7(2): e30216.Grant, Monica and Kelly Hallman. 2006.Pregnancy-related School Dropout and PriorSchool Performance in South Africa. New York:Population Council.Greene, Margaret E. and Alison M. Gold. N.d.“Gender and Sterilization in InternationalReproductive Health Programs.” Unpublishedmanuscript.Greene, Margaret E., and Andrew Levack.2010. Synchronizing Gender Strategies: ACooperative Model for Improving ReproductiveHealth and Transforming Gender Relations.Washington, DC: Population Reference Bureaufor the Interagency Gender Working Groupof USAID.Greene, Margaret E., Manisha Mehta,Julie Pulerwitz, and others. N.d. InvolvingMen in Reproductive Health: Contributionsto Development. New York: United NationsMillennium Project.% Illiterate(>15 years)M/FBirths per1,000womenagedContraceptivePrevalenceGreene, Margaret E. and Thomas Any W. Modern15-19method methodsMerrick. n.d. “Adolescent Sexual Activityand Childbearing in Developing Countries:Challenges and Support for Girls (Draft).”Washington, DC: World Bank.Greene, Margaret E, Omar J Robles, andKrista Stout. 2012. A Girl’s Right to LearnWithout Fear: Working to End Gender-BasedViolence at School. Toronto: Plan Canada.HIVprevalencerate (%)(15-49)M/FGreene, Margaret E. and Thomas W. Merrick.2005. Poverty Reduction: Does ReproductiveHealth Matter? In HNP Discussion Paper Series.Washington, DC: The World Bank.Greene, Margaret E., Zohra Rasekh, and Kali-Ahset Amen. 2002. In this Generation: Sexualand Reproductive Health Policies for a YouthfulWorld. Washington, DC: Population ActionInternational.Grover S.R. 2002. “Menstrual andContraceptive Management in Women with anIntellectual Disability.” The Medical Journal ofAustralia. 176(3): 108-110.Guatemala Ministry of Public Health andSocial Assistance. 2003. Encuesta Nacionalde Salud Materno Infantil (National Maternaland Child Health Survey). Guatemala City:MSPAS.aThe Guttmacher Institute. 2003. In Their OwnRight: Addressing the Sexual and ReproductiveHealth Needs of Men Worldwide. New York:The Guttmacher Institute.The Guttmacher Institute. 2012. “Are you inthe know?” New York: Guttmacher Insitute.Website: http://www.guttmacher.org/in-theknow/contraceptive-use.html.Accessed 25July 2012.The Guttmacher Institute and theInternational Planned Parenthood Federation.2010. Facts on Satisfying the Need forContraception in Developing Countries. New Yorkand London: The Guttmacher Institute andIPPF. Accessible at: http://www.guttmacher.org/pubs/FB-Unmet-Need-Intl.pdf.The Guttmacher Institute and theInternational Planned Parenthood Federation.2010a. In Brief: Facts on the Sexual andReproductive Health of Adolescent Women inthe Developing World. New York: GuttmacherInstitute and IPPF.120 INDICATORSBIBLIOGRAPHY

Monitoring ICPD Goals – Selected IndicatorsInfantmortalityTotal per1,000 liveLife expectancyM/FGwatkin, Davidson R., Shea Rutstein, KierstenJohnson, and others. 2007. births Socio-EconomicDifferences in Health, Nutrition, and PopulationWithin Developing Countries: An Overview.Country Reports on Health, Nutrition, andPopulation and Poverty. Washington, DC:World Bank.Gwatkin, Davidson R., Adam Wagstaff,Abdo S. Yazbeck. 2005. Reaching the Poorwith Health, Nutrition, and Population Services:What Works, What Doesn’t, and Why.Washington, D.C.: The International Bankfor Reconstruction and Development andThe World Bank.Haberland, Nicole and Diana Measham.2002. Responding to Cairo: Case Studiesof Changing Practice in ReproductiveHealth and Family Planning. New York:Population Council.Hamilton, Brady E., and Stephanie J. Ventura.2012. Birth Rates for U.S. Teenagers ReachHistoric Lows for All Age and Ethnic Groups.NCHS Data Brief, No. 89. Hyattsville, MD:National Center for Health Statistics.Hardon, Anita. 2001. Monitoring FamilyPlanning and Reproductive Rights. New York:Zed Books.Harper, Michael J.K. 2005. “In Search of aSecond Contraceptive Revolution.” Sexuality,Reproduction, and Menopause. 3(2): 59-67.Haupt, A., T.T. Kane, and C. Haub. 2011.PRB’s Population Handbook. A Quick Guideto Population Dynamics for Journalists,Policymakers, Teachers, Students, and otherPeople Interested in Demographics. Washington,DC: Population Reference Bureau.Health Policy Initiative, Task Order 1. 2010.“Quantify Inequalities in Access to HealthServices and Health Status.” Washington, DC:Futures Group, Health Policy Initiative, TaskOrder 1.Hervish, Alexandra Charlotte Feldman-Jacobs. 2011. Who Speaks for Me?: EndingChild Marriage. Policy Brief. Washington, DC:Population Reference Bureau.Higgins JA and HS Hirsch JS. 2008. “Pleasureand power: incorporating sexuality, agency,and inequality into research on contraceptiveuse and unintended pregnancy.” AmericanJournal of Public Health. 98(10): 1803-1813.Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FHiggins, Jenny A. and Jennifer S. Hirsch.2007. “The Pleasure Deficit: Revisiting the“Sexuality Connection” in ReproductiveHealth.” International Family PlanningPerspectives. 33(3): 133-139.Higgins, Matthew and Jeffrey G. Williamson.1997. “Age Structure Dynamics in Asia andDependence on Foreign Capital.” Populationand Development Review. 23(2):261-293.Secondaryenrolment(gross) M/FHiggins, Matthew and Jeffrey G. Williamson.1996. “Asian Demography and Foreign CapitalDependence.” National Bureau of EconomicResearch Working Paper Series.No. 5560.Hirsch, Jennifer S. 2008. “Catholics UsingContraceptives: Religion, Family Planning, andInterpretive Agency in Rural Mexico.” Studiesin Family Planning. 39(2): 93-104.Hirsch, Jennifer S. and Nathonson, ConstanceA. 2001. “Some Traditional Methodsare More Modern than Others: Rhythm,Withdrawal and the Changing Meanings ofSexual Intimacy in Mexican CompanionateMarriage.” Culture, Health, and Sexuality. 3 (4):413-428.Hobcraft, J. 1991. Child Spacing and ChildMortality. Columbia, MD: MacroInternational, Inc.Human Rights Watch. 2004. “Testimoniesfrom “Unprotected: Sex, Condoms,and the Human Right to Health in thePhilippines.” Accessible at: http://www.hrw.org/news/2004/05/04/testimonies-unprotected-sex-condomsand-human-right-health-philippines.Human Rights Watch. 2011. “Landmark UNVote on Sexual Orientation.” Available athttp://www.hrw.org/news/2011/06/17/landmark-un-vote-sexual-orientation.(Accessed 30 August 2012).Hunt, Paul and Judith Bueno de Mesquita.2007. The Rights to Sexual and ReproductiveHealth. Essex: University of Essex HumanRights Centre.ICF Macro and Uganda Bureau of Statistics.2007. Uganda Demographic and Health Survey2006. Calverton, Maryland: ICF Macro.% Illiterate(>15 years)Births per1,000ContraceptivePrevalenceHIVprevalenceM/Fwomenrate (%)ICF Macro and Uganda aged Bureau Any of Statistics.Modern(15-49)15-19method methodsM/F2012. Uganda Demographic and Health Survey2011. Calverton, Maryland: ICF Macro.International Center for Research on Womenand Promundo. 2011. Evolving Men: InitialResults from the International Men and GenderEquality Survey. Washington, DC: ICRW andPromundo.International Consortium for EmergencyContraception. 2012. “What is EmergencyContraception?” New York: ICEC. Accessibleat: http://www.cecinfo.org/what/index.htm.Accessed 25 June 2012.International Federation of Gynecologyand Obstetrics Committee for the Studyof Ethical Aspects of Human Reproductionand Women’s Health. 2009. Ethical Issuesin Obstetrics and Gynecology. London:International Federation of Gynecologyand Obstetrics.International Planned Parenthood Federation,European Network. 2006. Sexuality Educationin Europe: a Reference Guide to Policies andPractices. Brussels: The SAFE Project: AEuropean partnership to promote thesexual and reproductive health and rightsof young people.International Planned Parenthood Federation.2005. Fulfilling Fatherhood: Experiences fromHIV-Positive Fathers. London: IPPF.International Planned Parenthood Federation.1996. IPPF Charter on Sexual and ReproductiveRights. London: IPPF.Jaccard, James; Blanton, Hart; Dodge, Tonya(2005). Developmental Psychology, Vol.41(1). 135-147.Janowitz, Barbara and John H. Bratt. 1994.Methods for Costing Family Planning Services.New York: United Nations Population Fund andFamily Health International.Jayachandran, Seema, and Adriana Lleras-Muney. 2009. “Life Expectancy and HumanCapital Investments: Evidence from MaternalMortality Declines.” The Quarterly Journal ofEconomics. 124(1): 349-397.Jewkes, R. and H. Rees. 2005. “DramaticDecline in Abortion Mortality Due to theChoice on Termination of Pregnancy Act.”South African Medical Journal. 95(4): 250.THE STATE OF WORLD POPULATION 2012121

Monitoring ICPD Goals – Selected IndicatorsInfantmortalityTotal per1,000 liveLife expectancyM/FJones, Louisa, Paula Akugizibwe, MichaelaClayton, and others. 2011. “Costing births HumanRights and Community Support Interventionsas a Part of Universal Access to HIVTreatment and Care in a Southern AfricanSetting.” Current HIV Research. 9(6):416-428.Jones, Rachel K. and Joerg Dreweke. 2011.Countering Conventional Wisdom: New Evidenceon Religion and Contraceptive Use. New York:Guttmacher Institute.Joshi, Shareen, T. Paul Schultz. 2007. FamilyPlanning as an Investment in Development:Evaluation of a Program’s Consequences inMatlab, Bangladesh. New Haven, CT: YaleUniversity.Kabeer, Naila. 2000. Bangladeshi Women andLabour Market Decisions in London and Dhaka.London: Verso.Kabeer, Naila. 1997. “Women, Wages, andIntra-Household Power Relations in UrbanBangladesh.” Development and Change.28(2):261-302.Kamphausen, W. 2000. Health Status ofMinority Women Living in Europe. Report of ameeting in Gothenburg, Sweden, November2000. Brussels: European Commission.Karki, Yagya B. and Radha Krishna. 2008.Factors Responsible for the Rapid Decline ofFertility in Nepal—An Interpretation: FurtherAnalysis of the 2006 Nepal Demographic andHealth Survey. Calverton, Maryland: MacroInternational.Ketting, Evert and Visser, Adriaan P. 1994.“Contraception in the Netherlands: The LowAbortion Rate Explained.” Patient Educationand Counseling. 23 (3): 161-171.Kim, Young Mi, Caroline Marangwanda, andAdrienne Kols. 1996. Involving Men in FamilyPlanning: The Zimbabwe Male Motivation andFamily Planning Method Expansion Project,1993-1994. Baltimore: Johns HopkinsSchool of Public Health, Center forCommunication Programs.Kimmel, Michael S. 2000. The GenderedSociety. New York: Oxford University Press.Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FSecondaryenrolment(gross) M/FKinsman, John; Nyanzi, Stella; Pool, Robert(2000). Socializing Influences and the Valueof Sex: The Experience of Adolescent SchoolGirls in Rural Masaka, Uganda Culture, Health& Sexuality. Vol. 2, No. 2 (Apr. - Jun., 2000):151-166.Kirby, Douglas. 2008. “The Impact ofAbstinence and Comprehensive Sex andSTD/HIV Education Programs on AdolescentSexual Behavior.” Sexuality Research and SocialPolicy. 5(3): 18-27.Koenig, Michael A., Mian Bazle Hossain, andMaxine Whittaker. 1997. “The Influence ofQuality of Care upon Contraceptive Use inRural Bangladesh.” Studies in Family Planning.28 (4): 278-289.Korenman, Sanders, Robert Kaestner andTed Joyce. 2002. “Consequences for Infantsof Parental Disagreement In PregnancyIntention.” Perspectives on Sexual andReproductive Health Volume 34, Number 4,July/August.Kruger, Diana, Matias Berthelon, and RodrigoNavia. 2009. Adolescent Motherhood andSecondary Schooling in Chile. IZA DiscussionPaper Series Paper No. 4552.Kulcycki, Andrzej. 2011. “Abortion in LatinAmerica: Changes in Practice, GrowingConflict, and Recent Policy Developments.”Studies in Family Planning. 42(3): 199-220.Lam, David, Leticia Marteleto, and VimalRanchhod. 2009. Schooling and SexualBehavior in South Africa: The Role of Peer Effects.Presentation to the XXVI IUSSP InternationalPopulation Conference, Marrakech, Morocco,September 2009.Landry, Evelyn, and Victoria Ward. 1997.“Perspectives from Couples on the VasectomyDecision.” Reproductive Health Matters.London: Reproductive Health Matters.Leathers, Sonya J. and Michele A. Kelley.2000. “Unintended Pregnancy and DepressiveSymptoms Among First-Time Mothers andFathers.” American Journal of Orthopsychiatry.70(4): 523-531.Lee, Ronald. 2003. “The DemographicTransition: Three Centuries of FundamentalChange.” Journal of Economic Perspectives.17(4): 167-190.% Illiterate(>15 years)Births per1,000ContraceptivePrevalenceHIVprevalenceM/Fwomenrate (%)Lee, Ronald and Andrew aged Mason. Any 2006. Modern “What (15-49)15-19method methodsM/Fis the Demographic Dividend?” Finance andDevelopment. 43(3): 16.Lee, Ronald, Andrew Mason, andTimothy Miller. 2000. “Life Cycle andthe Demographic Transition: The Case ofTaiwan.” Population and Development Review.26 (Supplement: Population and EconomicChange in East Asia): 194-219.Lee, Ronald, Andrew Mason, and TimothyMiller. 1997. Saving, Wealth, and theDemographic Transition in East Asia. Honolulu:East-West Center.Levine, Ruth, The What Works WorkingGroup, with Molly Kinder. 2004. MillionsSaved: Proven Successes in Global Health.Washington, DC: Center for GlobalDevelopment.Levine, Ruth, Cynthia B. Lloyd, MargaretGreene, and others. 2008. Girls Count:A Global Investment and Action Agenda.Washington, DC: Center for GlobalDevelopment.Lewis, Maureen, and Marlaine Lockheed.2007. Inexcusable Absence: Why 60 MillionGirls Aren’t in School and What to Do AboutIt. Washington, DC: Center for GlobalDevelopment.Lin, Yim Yuet. 2007. “Working from a Rights-Based Approach to Health Service Delivery toSex Workers.” Exchange. Accessible at: http://www.kit.nl/net/KIT_Publicaties_output/ShowFile2.aspx?e=1277.Lloyd, Cynthia B., ed. 2005. GrowingUp Global: The Changing Transitionsto Adulthood in Developing Countries.Washington, DC: National Academyof Sciences.Lloyd, Cynthia B. 2009. New Lessons: ThePower of Educating Adolescent Girls-A GirlsCount Report on Educating Adolescent Girls.New York: The Population Council.Lloyd, Cynthia B. 2007. The Role of Schoolsin Promoting Sexual and Reproductive HealthAmong Adolescents in Developing Countries.Poverty, Gender, and Youth Working PaperNo. 6. New York: Population Council.122 INDICATORSBIBLIOGRAPHY

Monitoring ICPD Goals – Selected IndicatorsInfantmortalityTotal per1,000 liveLife expectancyM/FLloyd, Cynthia B. and Barbara S. Mensch.2008. Marriage and childbirth birthsas factorsin dropping out from school: an analysis ofDHS data from sub-Saharan Africa. PopulationStudies Mar; 62(1):1-13.Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FSecondaryenrolment(gross) M/FMcQueston, Kate, Rachel Silverman, andAmanda Glassman. 2012. Adolescent Fertility inLow- and Middle-Income Countries: Effects andSolutions. Working Paper 295. Washington,DC: Center for Global Development.% Illiterate(>15 years)Births per1,000ContraceptivePrevalenceHIVprevalenceM/Fwomenrate (%)Montgomery, Mark aged R. 1996. Any “Comments Modern on (15-49)15-19method methodsM/FMen, Women, and Unintended Pregnancy.”Population and Development Review. 22(Supplement: Fertility in the United States:New Patterns, New Theories): 100-106.Loaiza, Edilberto, and Sarah Blake. 2010. HowUniversal is Access to Reproductive Health?:A Review of the Evidence. New York: UnitedNations Population Fund.Lyerly, Anne Drapkin and Jean Anderson.2001. “Human Immunodeficiency Virusand Assisted Reproduction: ReconsideringEvidence, Reframing Ethics.” Fertility andSterility. 75(5): 843-858.Maart, S and J Jelsma. 2010. “The SexualBehaviour of Physically Disabled Adolescents.”Disability and Rehabilitation. 32(6):438-443.Maine, Deborah, Murat Z. Akalin, JyotsnamoyChakraborty, and others. 1996. “Why didMaternal Mortality Decline in Matlab.” Studiesin Family Planning. 27(4): 179-187.Malhotra, Anju, Ann Warner, AliisonMcGonagle, and others. 2011. Solutions toEnd Child Marriage: What the Evidence Shows.Washington, DC: International Center forResearch on Women.Mason, Andrew and Sang-Hyop Lee. 2004.The Demographic Dividend and PovertyReduction. Presentation to Seminar on theRelevance of Population Aspects for theAchievement of the Millenium DevelopmentGoals New York NY, November 17-19, 2004.Honolulu: East-West Center.Marsiglio, William. 1988. “Adolescent MaleSexuality and Heterosexual Masculinity: AConceptual Model and Review.” Journal ofAdolescent Research. 3 (3-4): 285-303.McCleary-Sills, Jennifer, Allison McGonagle,and Anju Malhotra. 2012. Women’s Demandfor Reproductive Control: Understanding andAddressing Gender Barriers. Washington, DC:International Center for Research on Women.McLanahan, Sara and Gary Sandefur. 1994.Growing Up With a Single Parent: WhatHurts, What Helps. Cambridge, MA: HarvardUniversity Press.Meekers, Dominique. 1994. “Sexual Initiationand Premarital Childbearing in Sub-SaharanAfrica.” Population Studies. 48 (1): 47-67.Mensch, Barbara S., Judith Bruce, MargaretE. Greene. 1999. The Uncharted Passage: Girls’Adolescence in the Developing World. New York:Population Council.Mensch, Barbara S., Monica J. Grant, and AnnK. Blanc. 2005. The Changing Context of SexualInitiation in Sub-Saharan Africa. New York:Population Council.Mgbako, Chi, Meghan Gabriel, Laura Garr,and others. 2008. Rights-Based Sex WorkerEmpowerment Guidelines: An Alternative HIV/AIDS Intervention Approach to the 100%Condom Use Programme. Maharashta: Centerfor Advocacy on Stigma and Marginalization.Michau, Lori, Dipak Naker and ZaharaSwalehe. 2002. “Mobilizing Communities toEnd Violence Against Women in Tanzania.”In Responding to Cairo: Case Studies ofChanging Practice in Reproductive Health andFamily Planning, Nicole Haberland and DianaMeasham, eds. New York: Population Council.Miguel, Edward and Michael Kremer. 2004.“Worms: Identifying Impacts on Educationand Health in the Presence of TreatmentExternalities.” Econometrica. 72(1): 159-217.Miller, Grant. 2009. “Contraception asDevelopment? New Evidence from FamilyPlanning in Colombia.” The Economic Journal.120(545):709-736.Miller, S., F. Lester, M. Webster, B. Cowan.“Obstetric Fistula: A Preventable Tragedy.”Journal of Midwifery and Women’s Health.50(4): 286-294.“Monitoring MDG Target 5B”. MDG5at 10. Commonwealth Medical Trust, 01January 2010. Web. 10 July. 2012. http://mdg5at10.org/index.php?option=com_content&view=category&id=3:mdg-target-5b&layout=blog&Itemid=4.Mora G., C. Betts, J. Gay, and others. 1993.Quality of Care in Women’s ReproductiveHealth: A Framework for Latin America and theCaribbean. Washington, DC: Pan AmericanHealth Organization.Muhuri, Pradip K. 1996. “EstimatingSeasonality Effects on Child Mortalityin Matlab, Bangladesh.” Demography.33(1): 98-110.Muhuri, Pradip K. 1995. “Health Programs,Maternal Education, and Differential ChildMortality in Matlab, Bangladesh.” Populationand Development Review. 21(4): 813-834.Muhuri, Pradip K. and Samuel H. Preston.1991. “Effects of Family Composition onMortality Differentials by Sex Among Childrenin Matlab, Bangladesh. “ Population andDevelopment Review. 17(3): 415-434.Murthy, Nirmala, Lakshmi Ramachandar,Pertti Pelto and Akhila Vasan. 2002.“Dismantling India’s Contraceptive TargetSystem: An Overview and Three CaseStudies.” In Responding to Cairo: Case Studiesof Changing Practice in Reproductive Health andFamily Planning, Nicole Haberland and DianaMeasham, eds. New York: Population Council.“Namibia: Women Take Legal Action OverAlleged Sterilisations.” Irin Plus News. 25 June2009. Accessible at: http://www.irinnews.org/Report/85012/NAMIBIA-Women-takelegal-action-over-alleged-sterilisations.National Research Council and Institute ofMedicine, panel on Transitions to Adulthoodin Developing Countries, Cynthia B. Lloyd(ed.). 2005. Growing up Global: The ChangingTransitions to Adulthood in Developing Countries.Washington, DC: National Academies Press.Office of the High Commissioner for HumanRights. Convention on the Rights of the Child.3 June 2012.THE STATE OF WORLD POPULATION 2012123

Monitoring ICPD Goals – Selected IndicatorsInfantmortalityTotal per1,000 liveLife expectancyM/FOosterhoff, P., NT Anh, NT, Hanh, and others.2008. “Holding the Line: Family births Responsesto Pregnancy and the Desire for a Child in theContext of HIV in Vietnam. “ Culture, Health,and Sexuality. 10(4): 403-416.Organisation for Economic Co-Operation andDevelopment. 2011. Doing Better for Families.Presentation to OECD Ministerial Meetingon Social Policy Paris, May 2-3, 2011.Paris: OECD.Organisation for Economic Co-Operationand Development. 2010. “Marriage andDivorce Rates.” OECD Family Database. Paris:OECD, Social Policy Division-Directorateof Employment, Labour, and Social Affairs.Accessible at: http://www.oecd.org/els/familiesandchildren/40321815.pdf.Ortayli, Nuriye, and Shawn Malarcher. 2010.“Equity Analysis: Identifying Who Benefitsfrom Family Planning Programs”. Studies inFamily Planning. 41(2): 101-108.Ortega, José Antonio. 2012. “ACharacterization of World Union Patternsat the National and Regional Level.” Paperpresented at the International Union for theScientific Study of Population seminar on FirstUnion Patterns around the World, Madrid,Spain, 20-22 June.PATH. 2012. “Sharing Experiences andChanging Lives—Communication InfluencesInformed Choice for Nepali Women.” Seattle:PATH. Website: http://www.path.org/projects/safe_abortion_nepal.php.Accessed 14 July 2012.Patton, George C., Carolyn Coffey, Susan M.Sawyer, and others. 2009. “Global Patternsof Mortality in Young People: A SystematicAnalysis of Population Health Data.” TheLancet. 374(9693): 881-892.Pence, Brian, Philomena Nyarko, CorneliusDebpuur, and others. 2001. The Impactof the Navrongo Community Health and FamilyPlanning Project on Child Mortality, 1993-2000.Pence, Brian W., Philomena Nyarko, andJames F. Phillips. 2007. “The Effect ofCommunity Nurses and Health Volunteers onChild Mortality: The Navrongo CommunityHealth and Family Planning Project.”Scandinavian Journal of Public Health.35(6): 599-608.Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FSecondaryenrolment(gross) M/FPenteado, Luis Guilherme, Francisco Cabral,Margarita Diaz, and others. 2001. “Organizinga Public-sector Vasectomy Program in Brazil.”Studies in Family Planning. 32(4):315-328.Perper K, Peterson K, Manlove J. 2010.Diploma Attainment Among Teen Mothers. ChildTrends, Fact Sheet Publication #2010-01:Washington, DC: Child Trends.Phillips, James F., Ayaga A. Bawah, and FredN. Binka. 2006. “Accelerating Reproductiveand Child Health Programme Impact withCommunity-Based Services: the NavrongoExperiment in Ghana.” Bulletin of the WorldHealth Organization. 84: 949-955.Phillips, James F., Ruth Simmons, Michael A.Koening, and others. 1988. “Determinants ofReproductive Change in a Traditional Society:Evidence from Matlab, Bangladesh.” Studies inFamily Planning. 19(6): 313-334.Philpott, Anne, Wendy Knerr and DermotMaher. 2006. “Promoting protection andpleasure: amplifying the effectiveness ofbarriers against sexually transmittedinfections and pregnancy.” The Lancet.368(9551): 2028–2031.Planned Parenthood Federation of America.2012. “Fertility Awareness-Based Methods.”New York: Planned Parenthood Federationof America. Website: http://www.plannedparenthood.org/healthtopics/birth-control/fertility-awareness-4217.htm. Accessed 25 July 2012.Population Action International. 2003.Emergency Contraception and the Global GagRule: An Unofficial Guide. New York: PopulationAction International.Population Council. 2007. “FinancialSustainability of Reproductive HealthServices.” Frontiers in Reproductive Health(Legacy Series). Washington, DC: PopulationCouncil.Population Reference Bureau. 2011.2011 World Population Datasheet.Washington, DC: PRB.Population Reference Bureau. 2011.Population Bulletin: The World at 7 Billion.Washington, DC: PRB.% Illiterate(>15 years)M/FBirths per1,000womenagedContraceptivePrevalenceHIVprevalencerate (%)(15-49)M/FPradhan Ajit, Subedi Bal Krishna, Any Barnett Modern15-19method methodsSarah, Sharma Sharad Kumar, Puri Mahesh,Poudel Pradeep, Rai Shovana, KC NareshPratap, Hulton Louise. 2010. Nepal MaternalMortality and Morbidity Study 2008/2009.Family Health Division, Department of HealthServices, Ministry of health and Population,Government of Nepal: Kathmandu, Nepal.Pulerwitz, Julie, and Gary Barker. 2006.“Promoting More Gender-equitable Normsand Behaviors Among Young Men as an HIV/AIDS Prevention Strategy.” Horizons FinalReport. Washington, DC: Population Council.Pulerwitz, Julie and Gary Barker. 2008.“Measuring Attitudes toward Gender Normsamong Young Men in Brazil.” Men andMasculinities. 10(3): 322-338.Raj, Anita, Niranjan Saggurti, Donta Balaiah,and others. 2009. “Prevalence of ChildMarriage and its Effect on Fertility andFertility-Control Outcomes of Young Womenin India: A Cross-Sectional, ObservationalStudy.” The Lancet. 373(9678):1883-1889.Ravindran, TK Sundari. 1995. A Study of UserPerspectives on the Diaphragm in an UrbanIndian Setting. New York: Population Council.Reher, David S. 2011. “Economic and SocialImplications of the Demographic Transition.”Population and Development Review. 37(Supplement s1): 11-33.Reprohealthlaw. 2012. Colombia: ConstitutionalCourt Upholds Abortion Rights, 23 Feb 2012.Available from: http://reprohealthlaw.wordpress.com.(Accessed 30 August 2012).Ringheim, Karin. 2007. “Ethical and HumanRights Perspectives on Providers’ Obligationto Ensure Adolescents’ Rights to Privacy.”Ethical Issues in Reproductive Health. 38(4):245-252.Rogow, Deborah. 1995. “Withdrawal: AReview of the Literature and an Agenda forResearch.” Studies in Family Planning. 26(3):140-153.Rohleder P., SH Braathen, LSwartz, AH Eide.2009. “HIV/AIDS and Disability in SouthernAfrica: A Review of Relevant Literature.”Disability and Rehabilitation. 31(1): 51-59.124 INDICATORSBIBLIOGRAPHY

Monitoring ICPD Goals – Selected IndicatorsInfantmortalityTotal per1,000 liveLife expectancyM/FRonsmans, Carine and Myriam Khlat. 1999.“Adolescence and Risk of Violent births Death duringPregnancy in Matlab, Bangladesh.” The Lancet.354(9188): 1448.Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FSecondaryenrolment(gross) M/FSchalet, Amy. 2010. “Sexual SubjectivityRevisited: The Significance of Relationshipsin Dutch and American Girls’ Experiences ofSexuality.” Gender and Society. 24(3):304-329.% Illiterate(>15 years)Births per1,000ContraceptivePrevalenceHIVprevalenceM/Fwomenrate (%)Seneviratne, H.R. and aged L.C. Rajapaksa. Any Modern 2000. (15-49)15-19method methodsM/F“Safe Motherhood in Sri Lanka: a 100 yearmarch.” International Journal of Gynecology andObstetrics. 70(1): 113-124.Rosenzweig, Mark R. and T. Paul Schultz. 1982“Child Mortality and Fertility in Colombia:Individual and Community Effects.” HealthPolicy and Education. 2(3-4):305-348.Rosenzweig, Mark R. and Kenneth I. Wolpin.1986. “Evaluating the Effects of OptimallyDistributed Public Programs: Child Health andFamily Planning Interventions.” The AmericanEconomic Review. 76(3):470-482.Ross, John, Eva Weissman, and John Stover.2009. Contraceptive Projections and the DonorGap: Meeting the Challenge. Washington, DC:Reproductive Health Supplies Coalition.Rottach, Elisabeth, Sidney Schuler, and KarenHardee. 2009. Gender Perspectives ImproveReproductive Health Outcomes: New Evidence.Washington, DC: Population Reference Bureau.Rutenberg, Naomi, Duff Gillespie, ElizabethFlanagan, and others. 2006. HIV Status,Fertility Intentions, and the Demand forContraception: Assessing the Current Researchto Improve the Integration of ReproductiveHealth and HIV Programs. Presentation toPopulation Association of America MeetingsLos Angeles CA, March 30, 2006. Princeton:Princeton University.Rutstein, Shea. 2000. “Effects of BirthIntervals on Mortality and Health: MultivariateCross-Country Analyses.” Power PointPresentation. Washington DC: United StatesAgency for International Development.Rutstein, Shea. 2005. “Effects of PrecedingBirth Intervals on Neonatal, Infant andUnder-five years Mortality and NutritionalStatus in Developing Countries: Evidencefrom the Demographic and Health Surveys.”International Journal of Gynecology andObstetrics. 89: S7-S24.Sanogo, Diouratie, Saumya RamaRao, HeidiJones, Penda N’diaye, Bineta M’bow, andCheikh Bamba Diop. 2003. “ImprovingQuality of Care and Use of Contraceptivesin Senegal.” African Journal of ReproductiveHealth. 7 (2): 57-73.Schalet, Amy. 2004. “Must We FearAdolescent Sexuality?” MedGenMed. 6(4):44.Scheer, Jessica, Thilo Kroll, Melinda T. Neri,Phillip Beatty. 2003. “Access Barriers forPersons with Disabilities: The Consumer’sPerspective.” Journal of Disability Policy Studies.14(4):221-230.Schmidt, Brita. 1998. “Forced Sterilization inPeru.” Political Environments. 6. Accessible at:http://cwpe.org/node/49.Schultz, Paul T. 2009. “The Gender andIntergenerational Consequences of theDemographic Dividend: An Assessmentof the Micro- and Macrolinkages betweenthe Demographic Transition and EconomicDevelopment.” The World Bank EconomicReview. 23(3): 427-442.Schultz, Paul T. 2008. “Health Disabilities andLabor Productivity in Russia in 2004: HealthConsequences beyond Premature Death.” InEconomic Implications of Chronic Illness andDisability in Eastern Europe and the FormerSoviet Union, edited by C. Mete. Washington,DC: The World Bank.Schultz, Paul T. 2010. “Health Human Capitaland Economic Development.” Journal ofAfrican Economies. 19(3): iii12-iii80.Schultz, Paul T. 2009a. How Does FamilyPlanning Promote Development? Evidence from aSocial Experiment in Matlab, Bangladesh, 1977-1996. Presentation to Population Associationof America meetings Detroit MI, April 20,2009. New Haven: Yale University.Schultz, Paul T. 2003. “Human Capital,Schooling and Health.” Economics and HumanBiology. 1(2):207-221.Schultz, Paul T. 1997. “Wage and Labor SupplyEffects of Illness in Cote d’Ivoire and Ghana:Instrumental Variable Estimates for DaysDisabled.” Journal of Development Economics.53(2): 251-286.Sedgh, Gilda, Susheela Singh, and Iqbal H.Shah. 2012. “Induced Abortion: Incidenceand Trends Worldwide from 1995 to 2008.”The Lancet. 379(9816): 625-632.Servais, L. 2006. “Sexual Health Care inPersons with Intellectual Disabilities.” MentalRetardation and Developmental DisabilitiesResearch Reviews. 12(1): 48-56.Shah, Iqbal and Elisabeth Ahman. 2010.“Unsafe Abortion in 2008: Global andRegional Levels and Trends.” ReproductiveHealth Matters. 18(36): 90-101.Sharma, Sudha. 2003. “Legalization ofAbortion in Nepal: The Way Forward.”Kathmandu University Medical Journal.2(3): 177-178.Shih, Grace, David Turok, and Willie Parker.2011. “Vasectomy: the Other (Better)Form of Sterilization.” Contraception.83(4): 310-315.Silva, Erika and Ricardo Batista. 2010.Bolivian Maternal and Child Health Policies:Successes and Failures (Policy Paper). Ottawa,ON: FOCAL (Canadian Foundation for theAmericas).Simmons, Ruth. 1996. “Women’s Lives inTransition: A Qualitative Analysis of theFertility Decline in Bangladesh.” Studies inFamily Planning. 27(5):251-268.Sinding, Steven W. 2009. “Population,Poverty, and Economic Development.”Philosophical Transactions of the Royal Society B:Biological Sciences. 364(1532): 3023-3030.Singh, Susheela. 2006. “Hospital AdmissionsResulting from Unsafe Abortion: Estimatesfrom 13 Developing Countries.” The Lancet.368(9550):1887-92.Singh, Susheela and others. 2009. AddingIt Up: The Costs and Benefits of Investing inFamily Planning and Maternal and NewbornHealth, New York: Guttmacher Institute andUNFPA.Singh, Susheela and Jacqueline E. Darroch.2012. Adding it Up: Costs and Benefits ofContraceptive Services-Estimates for 2012.New York: Guttmacher Institute and UnitedNations Population Fund.THE STATE OF WORLD POPULATION 2012125

Monitoring ICPD Goals – Selected Indicators126 INDICATORSBIBLIOGRAPHYInfantmortalityTotal per1,000 liveLife expectancyM/FSingh, Susheela, Gilda Sedgh, and RubinaHussain. 2010. “Unintended births Pregnancy:Worldwide Levels, Trends, and Outcomes.”Studies in Family Planning. 41(4): 241-250.Sinha, Nistha. 2003. “Fertility, Child Work andSchooling Consequences of Family PlanningPrograms: Evidence from an Experiment inRural Bangladesh.” Economic Development andCultural Change. 54(1): 97-128.Sonenstein, Freya L. (ed). Young Men’s Sexualand Reproductive Health: Toward a NationalStrategy-Framework and Recommendations.Washington, DC: Urban Institute.Statement by Dr. Kisamba Mugerwa,Chairperson of the National PlanningAuthority at the 45th Session of theCommission on Population and Developmenton Agenda Item 4 “Adolescents and Youth”.Accessible at: http://www.un.org/esa/population/cpd/cpd2012/Agenda%20item%204/Country%20statements/Uganda_Item4.pdf.Steward N.R., G. Farkas, and J.B.Bingenheimer. 2009. “Detailed EducationalPathways Among Females After Very EarlySexual Intercourse.” Perspectives on Sexual andReproductive Health. 41(4):244-252.Suvedi, Bal Krishna, Ajit Pradhan, SarahBarnett, and others. 2009. Nepal MaternalMortality and Morbidity Study 2008/2009:Summary of Preliminary Findings. Kathmandu,Nepal: Family Health Division, Departmentof Health Services, Ministry of Health,Government of Nepal.Swann C., K. Bowe, G. McCormick, M.Kosmin. 2003. Teenage Pregnancy andParenthood: A Review of Reviews. London:Health Development Agency.Taylor, Joan. 2008. Revitalizing UnderutilizedFamily Planning Methods Using Communicationand Community Engagement to StimulateDemand for the IUD in Uganda. New York:The ACQUIRE Project and Engender Health.Tanzania Commission for AIDS. 2009. TheForgotten: HIV and Disability in Tanzania. Dar esSalaam, Tanzania: Tanzania Commission forAIDS. Available from: http://www.gtz.de/de/dokumente/gtz2009-en-hiv-and-disabilitytanzania.pdf(accessed 14 June 2012).Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FTensou, Biruk, and Michelle J. Hindin. 2010.Covert Contraceptive Use and DiscordantFertility Preferences among Ethiopian Couples.Presentation to Population Association ofAmerica Dallas TX, April 17, 2010. Princeton,New Jersey: Princeton University.Secondaryenrolment(gross) M/FTrussell, James. 2011. “Contraceptive Efficacy.”In Hatcher R.A., J. Trussell, A.L. Nelson,W. Cates, D. Kowal, and M. Policar (eds).Contraceptive Technology: Twentieth RevisedEdition. New York: Ardent Media.Trussell, James, and Elizabeth G. Raymond.2012. Emergency Contraception: A Last Chanceto Prevent Unintended Pregnancy. Princeton,New Jersey: Princeton University Office ofPopulation Research.Tsai, I-Ju, C. Y. Cyrus Chu and Ching-FanChung. 2000. “Demographic Transition andHousehold Saving in Taiwan.” Populationand Development Review. 26 (Supplement:Population and Economic Change in EastAsia): 174-193.UNAIDS. 2000. Men and AIDS—A GenderedApproach. Geneva: UNAIDS.UNFPA. 1994. International Conference onPopulation and Development Programme ofAction. New York: UNFPA.UNFPA. 2003. Enlisting the Armed Forces toProtect Reproductive Health and Rights: LessonsLearned from Nine Countries-Technical Report.New York: UNFPA.UNFPA. 2005. Rights into Action: UNFPAImplements Human Rights-Based Approach.New York: UNFPA.UNFPA. 2005a. ICPD at Ten – The WorldReaffirms Cairo: Official Outcomes of the ICPDat Ten Review. New York: UNFPA.UNFPA. 2007. “RHIYA Programme OfficiallyEnds, But Its Legacy Continues-Making aDecade of Investment in the Youth in Asia.”Brussels: UNFPA. Website: http://www.unfpa.org/news/news.cfm?ID=1038&Language=1.Accessed 25 July 2012.UNFPA. 2007a. The State of the WorldPopulation Report. New York: UNFPA.% Illiterate(>15 years)Births per1,000ContraceptivePrevalenceHIVprevalenceM/Fwomenrate (%)UNFPA. 2009. Do all aged pregnant Any women Modern have (15-49) the15-19method methodsM/Fright to live? Retrieved June 8, from Fact Sheet:Motherhood and Human Rights: http://www.unfpa.org/public/cache/offonce/home/factsheets/pid/3851.UNFPA. 2010. Sexual and ReproductiveHealth for All: Reducing Poverty, AdvancingDevelopment and Protecting Human Rights.New York: UNFPA.UNFPA. 2010a. Monitoring ICPD Goals:Select Indicators. New York: UNFPA. http://www.unfpa.org/swp/2010/web/en/pdf/EN_SOWP10_ICPD.pdf United NationsPopulation Fund. 2011. “Issues Brief:Comprehensive Condom Programming.”New York: UNFPA.UNFPA. 2011. The State of the World PopulationReport. New York: UNFPA.UNFPA. 2011a. The Global Programme toEnhance Reproductive Health CommoditySecurity: Annual Report 2011. New York:UNFPA.UNFPA. 2011b. Population Dynamics in theLeast Developed Countries: Challenges andOpportunities for Development and PovertyReduction. New York: UNFPA.UNFPA. 2012. Marrying Too Young: End ChildMarriage. New York: UNFPA.UNFPA. 2012a. The Family Planning Programmein the Islamic Republic of Iran. Tehran: UNFPA.UNFPA. 2012b. “Promoting Gender Equality-Frequently Asked Questions about Gender.”New York: UNFPA. Website: http://www.unfpa.org/gender/resources_faq.htm.Accessed 12 July 2012.UNFPA. 2012c. “So Many Mouths to Feed:Addressing High Fertility in Famine-StrickenSomalia.” Retrieved 30 August from http://www.unfpa.org/public/home/news/pid/10333.UNFPA. 2012d. “Statement of UNFPA for theEleventh Session of the Permanent Forum onIndigenous Peoples Issues,” May 9 th , 2012.UNFPA. N.d. “Young People and Times ofChange.” Fact Sheet. New York: UNFPA.Accessible at: http://www.unfpa.org/public/home/factsheets/young_people, Accessed4/12/11.

Monitoring ICPD Goals – Selected IndicatorsInfant Life expectancymortality M/FTotal perUN-Habitat. 2003. The Challenge 1,000 live of Slums—Global Report on Human Settlements.birthsVirginia: Earthscan.UNICEF. 2011. Boys and Girls in the Life Cycle:Sex Disaggregated data on a selection of wellbeingindicators, from early childhood to youngadulthood. New York: UNICEF, Division ofPolicy and Practice.UNICEF. 2010. Progress for Children: Achievingthe MDGs with Equity. New York: UNICEF.UNICEF, with UNAIDS, United NationsEducational Scientific and CulturalOrganization, United Nations Population Fund,International Labour Organization, WorldHealth Organization, and the World Bank.2011a. Opportunity in Crisis: Preventing HIVfrom Early Adolescence to Early Adulthood.New York: UNICEF.United Nations. 2006. Levels and Trends inContraceptive Use as Assessed in 2002.New York: Department of Economic andSocial Affairs.United Nations. 2007. World Youth Report.New York: Department of Economic andSocial Affairs.United Nations. 2008. Official List ofMillennium Development Goals Indicators.New York: Statistics Division, Department ofEconomic and Social Affairs. Accessible at:http://mdgs.un.org/ (Accessed 30August 2012).United Nations. 2008a. Trends in InternationalMigrant Stock: The 2008 Revision. New York:Population Division of the Department ofEconomic and Social Affairs.United Nations. 2009. World Marriage Data2008. New York: Population Division of theDepartment of Economic and Social Affairs.Accessible at: http://www.un.org/esa/population/publications/WMD2008/WP_WMD_2008/Documentation.html.United Nations. 2009a. Analysis preparedby the secretariat of the Permanent Forumon Indigenous Issues: indigenous women.E/C.19/2009/8. New York: Economic andSocial Council.United Nations. 2009b. “The MillenniumDevelopment Goals Report 2009.”New York: UN.Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FUnited Nations. 2010. World Fertility Report2007. New York: Population Division ofDepartment of Economic and Social Affairs.United Nations. 2011. “World Contraceptiveuse.” Wall Chart. New York: The PopulationDivision of the Department of Economic andSocial Affairs. Accessible at: http://www.un.org/esa/population/publications/contraceptive2011/wallchart_front.pdfUnited Nations. 2011a. World PopulationProspects: The 2010 Revision, Highlights andAdvance Tables. New York: The PopulationDivision of the Department of Economic andSocial Affairs.Secondaryenrolment(gross) M/FUnited Nations. 2011b. “World MarriagePatterns.” Population Facts. No. 2011/1. NewYork: Population Division of the Departmentof Economic and Social Affairs. Accessible at:http://www.un.org/esa/population/publications/popfacts/PopFacts_2011-1.pdf.United Nations. 2011c. “The MillenniumDevelopment Goals Report 2011.”New York: UN.United Nations. 2011d. Social Panorama ofLatin America 2011. Santiago: UN EconomicCommission for Latin America.United Nations. 2012. Millennium DevelopmentGoals: 2012 Progress Chart. New York: StatisticsDivisions, Department of Economic andSocial Affairs.United Nations General Assembly. 1999.Report of the Ad Hoc Committee of the Wholeof the Twenty-First Special Session of the GeneralAssembly. Key Actions for Further Implementationof the ICPD Programme of Action. New York:United Nations.United Nations General Assembly SpecialSession (2010). UNGASS Report on HIVand AIDS - Zimbabwe. Harare: NationalAIDS CouncilUnited Nations High Commissioner forRefugees. 2011. Refocusing Family Planning inRefugee Settings: Findings and Recommendationsfrom a Multi-Country Baseline Study. Geneva:UNHCR.% Illiterate(>15 years)M/FBirths per1,000womenagedContraceptivePrevalenceHIVprevalencerate (%)(15-49)M/FUnited Nations High Commissioner Any Modern for15-19method methodsHuman Rights. 2008. Ms. Navanetham Pillay,Statement to the UN General Assembly(New York, N.Y., 18 Dec 2008). Availablefrom: http://www.unhcr.org/refworld/docid/49997ae312.html (accessed 30August 2012).United Nations Population Division. 2012.Unpublished data on regional averages.United Nations Practitioner’s Portal on HumanRights Based Approaches to Programming.The Human Rights Based Approach toDevelopment Cooperation: Towards a CommonUnderstanding Among UN Agencies. Availablefrom: http://hrbaportal.org/ (Accessed 30August 2012).UN System Task Force Team on the Post-2015UN Development Agenda. 2012. Realizing theFuture We Want for All: Report to the Secretary-General (New York, United Nations).UN Women. 2008. The Role of Men andBoys in Achieving Gender Equality. New York:The Division for the Advancement ofWomen of the Department of Economicand Social Affairs.VanLandingham, Mark, and John E. Knodel.2007. “Sex and the Single (Older) Guy:Sexual Lives of Older Unmarried Thai MenDuring the AIDS Era.” Journal of Cross-CulturalGerontology, 22(4): 375-388.Ventura, Stephanie J. , Joyce A. Martin, SallyC. Curtin, and T.J. Mathews. 1997. “Reportof Final Natality Statistics.” Monthly VitalStatistics Report. 45(11):1-84.Welbourn, Alice. 2003. Stepping Stones.Oxford, UK: Strategies for Hope Trust.Westoff, Charles F. 2008. A New Approachto Estimating Abortion Rates. DHS AnalyticalStudies No. 13. Calverton, Maryland: MacroInternational, Inc.Westoff, Charles F. 2005. Recent Trends inAbortion and Contraception in Twelve Countries.DHS Analytical Studies No. 8. Calverton,Maryland: ORC Macro.Westoff, Charles F., and Akinrinola Bankole.2002. Reproductive Preferences in DevelopingCountries at the Turn of the Century. DHSComparative Reports No. 2. Calverton,Maryland: ORC Macro.THE STATE OF WORLD POPULATION 2012127

Monitoring ICPD Goals – Selected IndicatorsInfantmortalityTotal per1,000 liveLife expectancyM/FWilliamson, Jeffrey G. 2001. “DemographicChange, Economic Growth and births Inequality.”Population Matters. 1(9): 106-137.World Health Organization. 1995. PhysicalStatus: The Use and Interpretation ofAnthropometry—Report of a WHO ExpertCommittee. Geneva: WHO.World Health Organization. 2003.International Migration, Health, and HumanRights. Geneva: WHO.World Health Organization. 2004. BasicIndicators: Health Situation in South-East Asia.Geneva: WHO.World Health Organization. 2004a.Antiretroviral drugs for treating pregnantwomen and preventing HIV infection in infants:Guidelines on care, treatment and support forwomen living with HIV/AIDS and their childrenin resource-constrained settings. Geneva: WorldHealth Organization.Indicators of Mortality Indicators of Education Reproductive Health IndicatorsMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FSecondaryenrolment(gross) M/FWorld Health Organization. 2009. Strategy forIntegrating Gender Analysis and Actions into thework of WHO. Geneva: WHO.World Health Organization. 2010. “10 Factson Obstetric Fistula.” Geneva: WHO. Availablefrom: http://www.who.int/features/factfiles/obstetric_fistula/en/.World Health Organization. 2010a.Accountability for Women’s and Children’sHealth. Geneva: WHO. Available from: http://www.who.int/woman_child_accountability/about/en/ (Accessed 30 August 2012).World Health Organization. 2011. Global HIV/AIDS Response: Epidemic Update and HealthSector Progress Towards Universal Access:Progress Report 2011. Geneva: WHO.World Health Organization. 2011a. UnsafeAbortion: Global and Regional Estimates of theIncidence of Unsafe Abortion and AssociatedMortality in 2008. Geneva: WHO.% Illiterate(>15 years)Births per1,000ContraceptivePrevalenceHIVprevalenceM/Fwomenrate (%)World Health Organization, agedAny UNAIDS, Modern UNICEF. (15-49)15-19method methodsM/F2010. Scaling up priority HIV/AIDS interventionsin the health sector: Progress Report 2010.Geneva: World Health Organization.World Health Organization and UNFPA.2009. Promoting Sexual and ReproductiveHealth for Persons with Disabilities. Geneva:WHO and UNFPA.World Health Organization, U.S. Agency forInternational Development, Family HealthInternational. 2009. Community-Based HealthWorkers Can Safely and Effectively AdministerInjectable Contraceptives: Conclusions from aTechnical Consultation. Research Triangle Park,North Carolina: FHI.World Health Organization. 2005. Actionon the Social Determinants of Health: Learningfrom Previous Experience (Background Paper).Geneva: Commission on Social Determinantsof Health.World Health Organization. 2005a.“Emergency Contraception.” Fact SheetNo. 244. Geneva: WHO.World Health Organization. 2005b. Violenceagainst Sex Workers and HIV Prevention.Information Bulletin Series, Number 3.Geneva: WHO.World Health Organization. 2006.International Covenant on Economic, Social,and Cultural Rights. Geneva: WHO.World Health Organization. 2006a. PregnantAdolescents: Delivering on Global Promises ofHope. Geneva: WHO.World Health Organization. 2008.“Adolescent Pregnancy.” Making PregnancySafer (MPS) Notes. 1(1). Geneva: WHO.World Health Organization. 2008a. “Whyis Giving Special Attention to AdolescentsImportant for Achieving MillenniumDevelopment Goal 5?” Fact Sheet.Geneva: WHO.World Health Organization. 2011b.“Reproductive Health at a Glance:Uganda.” Accessible at: http://siteresources.worldbank.org/INTPRH/Resources/376374-1303736328719/Uganda42111WEB.pdf, accessed15 July 2012.World Health Organization. 2011c. WorldReport on Disability. Geneva: WHO.World Health Organization. 2012.“WHO Upholds Guidance on HormonalContraceptive Use and HIV: Women Livingwith HIV or at Risk of HIV can safely continueto use Hormonal Contraceptives to PreventPregnancy.” Note for the Media. 16 February2012. Geneva: WHO.World Health Organization. 2012a. EarlyMarriages, Adolescent and Young Pregnancies.Geneva: WHO.World Health Organization. 2012b. “MaternalMortality.” Fact Sheet No. 348. Geneva:WHO. Accessible at: http://www.who.int/mediacentre/factsheets/fs348/en/index.html.World Health Organization and Office of theHigh Commissioner for Human Rights. 2010.A Human Rights-Based Approach to Health.Geneva: WHO and OHCHR.128 INDICATORSBIBLIOGRAPHY

Delivering a world where every pregnancy is wanted,every childbirth is safe and every young person's potential is fulfilled.United Nations Population Fund605 Third AvenueNew York, NY 10158 USATel. +1-212 297-5000www.unfpa.org©UNFPA 2012USD $24.00ISBN 978-1-61800-009-5sales no. E.12.III.H.1E/11,000/2012524009 781618 000095Printed on recycled paper.