Sexual and Reproductive Health and Rights- An Essential Component of the Priority Health Agenda for 2015-2030. Ipas, December 2012.

Sexual and reproductive health and rights – an essential component of the priority health agenda for 2015-2030 Ipas December 2012 Paper submitted for Health priorities for the post-2015: What is the priority health agenda for the 15 years after 2015? Abstract While the proposed post-2015 development framework will be broader in scope than the Millennium Development Goals (MDGs), it should give priority to including those focus areas that received the least attention in implementation of the MDG framework. Within an overarching health goal, sub-goals and targets related to sexual and reproductive health and rights should be incorporated so that governments and other stakeholders continue addressing the most neglected MDGs, including those related to maternal, newborn and child/adolescent health, as well as gender equality, gender equity and women’s empowerment as core foundations of human development. The principles of the human rights-based approach should underlie all goals, targets and indicators formulated within the post-2015 development agenda: accountability, participation, transparency, empowerment, sustainability, non-discrimination and international cooperation. Any targets or indicators proposed under an overarching health goal should include measures of access to all essential reproductive health services including: comprehensive sexuality education; noncoercive sexual and reproductive health counseling; a wide range of short- and longer-term modern contraceptives that are available without requirements for spousal or parental consent; assisted conception measures; prevention of sexually transmitted infections and diseases that can affect healthy pregnancies (e.g., malaria); adequate and accessible antenatal, delivery and post-natal care; and prevention and management of unwanted pregnancies through easily accessible and legal emergency contraception and safe abortion care. In addition, targets and indicators should be formulated regarding the implementation of laws and policies and fulfillment of obligations assumed with the ratification of international treaties that promote access to all evidence-based reproductive health services. Introduction The post-2015 development framework will provide an opportunity at the international, regional and national levels to continue addressing issues covered by the Millennium Development Goals (MDGs). While the proposed post-2015 framework will be broader in scope than the MDGs, it should give priority to including those focus areas that have received the least attention in implementation of the MDG framework.

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For example, in 2012, only four countries were on track to meet the targets established for MDG 5 on improving maternal health: China, Egypt, Morocco, and Peru.1 The Independent Expert Review Group (iERG) for the UN Secretary General’s Strategy on Women’s and Children’s Health noted: “Among women, to achieve MDG-5, the annual rate of maternal mortality decline must be 5.5%. But worldwide, the decline has been only 1.9% since 1990. The predicament for adolescent girls is especially acute: one in 8 births in low-income settings is in girls aged 15-19 years old; in sub-Saharan Africa, girls aged 15-19 years account for a quarter of unsafe abortions.”1 One lesson that can be drawn from implementation of the MDGs is that the post-2015 development framework must address the high incidence of unsafe abortions as a leading cause of maternal mortality and morbidity that affects vulnerable women in developing countries. Governments should decriminalize abortion and implement policies and programs to ensure that women, especially adolescents and young women, have access to safe and legal abortions without mandatory waiting periods or requirements for parental and spousal notification and/or consent based on the woman’s age, as well as adequate, pre- and postabortion services including contraceptive counseling and information on HIV and sexually transmitted infections (STIs). Sexual and reproductive health and rights are an essential health priority Sexual and reproductive health and rights comprise an area of governmental policy that facilitate addressing the neglected and unfulfilled needs of society’s most vulnerable and neglected groups, as well as bolstering efforts to tackle other social welfare issues including poverty alleviation, promotion of gender-equitable access to education and employment and agricultural development. For sustainable development to occur, societies must enable and empower all social groups to participate fully (taking into account that all individuals belong to multiple social groups and have varying identities, roles and responsibilities). Promotion of sexual and reproductive health rights necessarily encompasses promotion of gender equality and equity and measures to combat gender-based violence and violence against women, which assists in facilitating the social inclusion of vulnerable groups in development efforts. When laws and policies are in place to further gender equality, including regulations to ensure that girls are not forced into early marriages and that women and girls can inherit and own land and property, provide food for their families by growing and selling food, attend educational institutions of their choice, and control their own fertility, their participation in social development is enhanced. Women and girls must be enabled to take voluntary, autonomous decisions about whether and when to have children so that they can take full advantage of educational and employment opportunities and be able to participate in community and civic decisionmaking and activities. The Guttmacher Institute has reported, for example, that ensuring 2

access to contraceptives for all women who need them would prevent an additional 54 million unintended pregnancies, 26 million abortions (of which 16 million would be unsafe) and 7 million miscarriages, as well as 79,000 maternal deaths and 1.1 million infant deaths.2 Measures must also be taken to prevent and treat pregnancy-related injuries and illnesses that interfere with women’s and girls’ life plans and which can lead to social exclusion due to stigma, such as fistulas3 and unsafe abortions, which lead one in four women who suffer complications to develop temporary or lifelong disabilities requiring medical care and which cost individuals and societies US$ 930 million annually in lost income.4 Essential sexual and reproductive health services include: comprehensive sexuality education; non-coercive sexual and reproductive health counseling; a wide range of shortand longer-term modern contraceptives that are available without requirements for spousal or parental consent; assisted conception measures; prevention of STIs and diseases that can affect healthy pregnancies (e.g., malaria); adequate and accessible antenatal, delivery and post-natal care; and prevention and management of unwanted pregnancies through easily accessible and legal emergency contraception and safe abortion care. Underlying principles for addressing sexual and reproductive health The human rights-based approach to addressing maternal mortality and morbidity, endorsed by the Human Rights Council in several resolutions,5-8 provides a set of principles that should underlie all goals, targets and indicators formulated within the post-2015 development agenda: accountability, participation, transparency, empowerment, sustainability, nondiscrimination and international cooperation. The Office of the High Commissioner on Human Rights (OHCHR) has issued guidance for UN Member States and other stakeholders on application of this approach to maternal mortality and morbidity which can easily be applied to all areas of sexual and reproductive health.9 Accountability implies that essential interventions and services must be defined in accordance with a government’s core obligations under international law and that they must be consistent with the best available public health research evidence, as reiterated by the African Union’s Commission on Maternal, Newborn and Child Health.10 States should protect against interference with sexual and reproductive health rights by third parties (e.g., attempts to prevent women from accessing legal abortions11) by adopting and enforcing appropriate laws, policies, regulations and guidelines,12 and by rescinding laws and policies that criminalize sexual and reproductive health prevention and treatment measures, as recommended by the UN Special Rapporteur on the right to health.13-14 Participation implies that people must be active agents who are entitled to participate in decisions that affect their lives, including their sexual and reproductive health. For example, WHO recommends that adolescents be approached as full partners in the design, implementation and monitoring of programs for contraceptive information and service provision,15 experience that can stand them in good stead for engagement in other community development efforts. 3

Transparency implies that government spending on specific sectors and programs should be clearly identifiable in overall budgets and be made available in a format readily accessible to the general public. This facilitates budgetary monitoring by civil society and other groups and can help identify where changes in health systems are needed. For example, WHO points out that the costs to health systems of managing the complications of unsafe abortions are high (US$ 114 per case for Africa and US$ 130 per case for Latin America);4 if safe abortion were available, these expenditures could go to covering other health or social needs. When rights-holders (e.g., women, youth, disabled persons, health-care providers, etc.) and their entitlements are specifically identified in policies along with governmental obligations to fulfill these, steps are taken towards empowerment. The iERG has commented that a post-2015 framework must place women and children in a central position, for example, by addressing issues such as women’s empowerment, girls’ education, and reproductive health as vital elements of development.1 Sustainability requires governments to balance expenditures and income in a way that avoids making cuts to programs and services designed to meet the needs of vulnerable population groups. The resolution adopted by UN Member States at the 2012 Commission on Population and Development (CPD) urged governments and development partners to improve maternal health, reduce maternal and child morbidity and mortality, and prevent and respond to HIV and AIDS by, inter alia, strengthening health systems and ensuring that they prioritize universal access to sexual and reproductive information and health-care services, including family planning, antenatal care, safe delivery and postnatal care, especially breastfeeding and infant and women’s health care, emergency obstetric care, prevention and appropriate treatment of infertility, quality services for the management of abortion complications, training and equipping health-service providers and taking other measures to ensure that legal abortion is safe and accessible, especially taking into account the particular needs of persons in vulnerable situations. The resolution further called upon governments to make every effort to mobilize the required resources to ensure that the health, development and human rights-related objectives of the ICPD Programme of Action are met.16 Non-discrimination must ensure that all people, regardless of their social identities based on race, gender identity, sex, sexual orientation, age, ethnicity, residence, etc., have access to needed to social and health services. The 2012 CPD resolution agreed, for example, that governments should meet the reproductive health-service, information and educational needs of young people, including evidence-based comprehensive education on human sexuality, sexual and reproductive health, human rights and gender equality, with full respect for their privacy and confidentiality and free of discrimination.16 Finally, international cooperation requires States to seek outside resources when they have demonstrated an inability to cover basic population needs, while donors must commit to providing resources in a way that strengthens governmental and community structures. The 4

Center for Strategic and International Studies recently recommended, for example, that the US government focus on providing recipient countries with support to improve maternal health-related data collection at individual health facilities and in communities.17 Targets and indicators Targets and indicators for a sub-goal on sexual and reproductive health and rights under an overarching health goal should include measures of access to all reproductive health services included in The Partnership for Maternal, Newborn and Child Health’s guidance on Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health.18 As noted in this reference document, “When linked together and included as integrated programmes, these interventions can lower costs, promote greater efficiencies and reduce duplication of resources,” which can allow governments to devote more resources to other areas. A particular concrete focus can be placed on indicators to monitor improvements achieved in data collection systems regarding access to reproductive health services, such as contraceptive use, skilled birth attendance, postabortion care and safe abortion, disaggregated by age, residence and socioeconomic status. Guidance issued by OHCHR on the use of human rights indicators provides concrete examples of such indicators.19 Another focus should be on the implementation of laws and policies and fulfillment of obligations assumed with the ratification of international treaties that promote access to all evidence-based reproductive health services. This would include revision of laws that criminalize or impede access to comprehensive sexuality education, modern contraceptives including emergency contraception, and safe abortion care. In this context, attention should also be given to monitoring mechanisms at the community level,20 as well as the implementation of national human rights bodies, such as human rights commissions and ombudspersons, and redress mechanisms for persons denied sexual and reproductive rights. Concluding remarks The post-2015 development framework provides an opportunity to ensure that sexual and reproductive health, based on principles of gender equity and human rights, are addressed as a health priority. During formulation of the MDGs, this was not adequately incorporated until a target on achieving universal access to reproductive health was added in 2007. However, the indicators did not address reproductive rights, which can be rectified in the post-2015 agenda by including sexual and reproductive health and rights as a sub-goal of the overarching goal on health. WHO has proposed that an overarching health goal could possibly focus on universal health coverage and/or healthy life expectancy.21 Within such an overarching health goal, sub-goals and targets related to sexual and reproductive health and rights should be incorporated so that governments and other stakeholders continue addressing the most neglected MDGs, 5

including maternal, newborn and child/adolescent health, as well as gender equality, gender equity and women’s empowerment as core foundations of human development. References 1. World Health Organization. Every woman, every child: from commitments to action: the first report of the independent Expert Review Group (iERG) on Information and Accountability for Women’s and Children’s Health; 2012. Geneva:, WHO. Available from: http://www.who.int/woman_child_accountability/ierg/reports/2012/IERG_report_low_res olution.pdf 2. Singh S, Darroch JE. Adding it up: costs and benefits of contraceptive services. Estimates for 2012; June 2012. New York: Guttmacher Institute and UNFPA. Available from: http://www.guttmacher.org/pubs/AIU-2012-estimates.pdf 3. UN General Assembly. Supporting efforts to end obstetric fistula. Report of the SecretaryGeneral. A/67/258; 6 August 2012. New York: United Nations. Available from: http://www.endfistula.org/webdav/site/endfistula/shared/documents/reports/67th%20U NGA%20-%20Report%20of%20the%20SecretaryGeneral%20on%20Supporting%20efforts%20to%20end%20obstetric%20fistula.pdf 4. World Health Organization. Safe abortion: technical and policy guidance for health systems. Second edition; 2012. Geneva: WHO. 5. Human Rights Council. Resolution 11/8. Preventable maternal mortality and morbidity and human rights; 2009. Geneva: Human Rights Council. 6. Human Rights Council. Resolution 15/17. Preventable maternal mortality and morbidity and human rights: follow-up to Council resolution 11/8. A/HRC/RES/15/17; 7 October 2010. Geneva: Human Rights Council. 7. Human Rights Council. Resolution on Preventable maternal mortality and morbidity and human rights. A/HRC/18/L.8; 23 September 2011. Geneva,: Human Rights Council. 8. Human Rights Council. Resolution on Preventable maternal mortality and morbidity and human rights. A/HRC/21/L.10; 21 September 2012. Geneva: Human Rights Council. 9. Office of the High Commissioner on Human Rights. Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality. A/HRC/21/22; 2 July 2012. Geneva: OHCHR. Available from: http://www2.ohchr.org/english/issues/women/docs/A.HRC.21.22_en.pdf 10. Commission on Maternal, Newborn and Child Health. Progress report of the Commission on Maternal, Newborn and Child Health. EX.CL/737(XXI); July 2012. Addis Ababa: African Union. 11. Guttmacher Institute. Making abortion services accessible in the wake of legal reforms: a framework and six case studies; 2012. New York: Guttmacher Institute. Available from: www.guttmacher.org/pubs/abortionservices-laws.pdf 12. Uberoi D, de Bruyn M, Galli B. Using human rights to address consequences of criminal laws on sexuality and reproductive autonomy, The International Journal of Human Rights, 2012, 16/7: 1023-1039.

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13. Human Rights Council. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Anand Grover. A/HRC/14/; 2027 April 2010. Geneva: Human Rights Council. 14. UN General Assembly. Interim report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. A/66/254; 3 August 2011. New York: United Nations. 15. World Health Organization. From evidence to policy: expanding access to family planning. Expanding access to contraceptive services for adolescents. Policy brief; 2012. Geneva: WHO. Available from: http://apps.who.int/iris/bitstream/10665/75160/1/WHO_RHR_HRP_12.21_eng.pdf 16. Commission on Population and Development. Resolution 2012/1. Adolescents and youth. Report on the forty-fifth session (15 April 2011 and 23-27 April 2012). E/2012/25 andE/CN.9/2012/8; 2012. New York: United Nations. 17. Nieburg P. Improving maternal mortality and other aspects of women’s health. The United States’ global role; October 2012. Washington, DC: Center for Strategic and International Studies. Available from: http://csis.org/files/publication/121003_Nieburg_MaternalMortality_Web.pdf 18. The Partnership for Maternal, Newborn & Child Health. A global review of the key interventions related to reproductive, maternal, newborn and child health; 2011. Geneva: PMNCH. Available from: http://www.who.int/pmnch/topics/part_publications/essential_interventions_18_01_20 19. Office of the High Commissioner on Human Rights. Human rights indicators. A guide to measurement and Implementation. HR/PUB/12/5; 2012. Geneva: OHCHR. Available from: http://www.ohchr.org/EN/Issues/Indicators/Pages/HRIndicatorsIndex.aspx 20. Yamin AE, Falb KL. Counting what we know; knowing what to count. Sexual and reproductive rights, maternal health, and the Millennium Development Goals. NJHR 2012, 30/3: 350–371. 21. World Health Organization. Positioning health in the post-2015 development agenda. WHO discussion paper; October 2012. Geneva: WHO.

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