Dr. Gill Greer's speech at the UN General Assembly informal session in preparation of the 2010 MDG Summit
Ambassador Staur, Ambassador Badji, I would like to begin by thanking you, and your colleagues, for this opportunity to speak with you, with members of delegations, UN agencies and members of civil society on this important occasion in the lead up to the 2010 MDG Review and Summit.
The MDGs have been described as ‘the world's biggest promise’, and I have the privilege of representing civil society, which plays an invaluable and diverse role in delivering that promise, across the globe, although I cannot speak for them all. In particular, I have the privilege to represent 148 indigenous, Non-Governmental Organisations (NGOs) that are voluntary members of the International Planned Parenthood Federation (IPPF), delivering some 66 million health services a year in 170 countries. These right-based services include family planning, maternal health, sexual health, HIV/AIDS prevention, treatment and care, child and adolescent health. They are combined with evidence based advocacy, education and information, and are provided at the national and community level. Together these 148 diverse organisations make up the world’s leading provider of sexual and reproductive health services, education and information. They have a common mission, to serve the marginalised, poor and underserved, and a shared vision of a better, brighter world in which all people, wherever they may be, are able to realise their rights to the highest attainable standard of health, to education and to development.
I have been asked to speak about the importance of reproductive health, maternal health, gender, and education, to comment on gains made and existing challenges, and most importantly on opportunities and strategies to accelerate the health MDGs which, of course, will in turn accelerate the realisation of all the MDGs.
Regrettably, the central goal of the landmark 1994 International Conference on Population and Development (ICPD), was originally omitted from the world’s MDG development framework, and what is invisible is inevitably overlooked and underfunded. In reviewing the progress of the MDGs at the World Summit in September 2005, however, Heads of State and governments committed to 'achieving universal access to reproductive health by 2015, as set out in the ICPD and integrating this goal in strategies to attain the internationally agreed development goals, including those included in the Millenium Declaration' (i).
Subsequently, in October 2007, the GA noted the Secretary General's Report, integrating the new target ‘achieve by 2015, universal access to reproductive health’, which became MDG5B. Its indicators are contraceptive prevalence rate, adolescent birth rate, antenatal care coverage, and unmet need for family planning, so complementing the critical MDG target 5A, ‘reducing maternal mortality by three quarters by 2015’.
This belatedly recognised what the evidence continues to show us - that family planning saves lives. At the centre of comprehensive reproductive health, family planning saves women's lives by preventing at least 1 in 3 maternal deaths, it saves children's lives, as mothers and their babies are healthier when births are more widely spaced, and contributes to the fight against HIV/AIDS, and helps governments and communities achieve sustainable social and economic development. Indeed, in the words of Professor Jeffrey Sachs, 'Family planning is one of the great success stories of modern times' (ii).
Yet despite that long standing evidence, reproductive health has only been formally included in the MDG Framework for 3 years, not 10. And now we must make up for lost time and opportunities. And again, despite that evidence, the global investment for family planning has nearly halved between 1997 and 2006, from $653m to $394m (iii). And now we must make up for that lost investment. And in just those countries where USAID supports family planning programmes the number of women of reproductive age doubled between the 1970s and to-day, from 680 million to 1.4 billion (iv).
The world's 'biggest promise' has failed women and their children, and continues to do so. It is time for a new compact for women, children and young people, with MDG5B at the heart of that compact.
In sub-Saharan Africa a woman has a 1 in 22 risk of dying from childbirth and pregnancy related causes, in the developed world that risk is a mere 1 in 7,300. Surely there is no greater inequity or injustice? MDG5, the goal of improving maternal health, remains the most off-track of all the MDGs. Every year an estimated 536,000 women die as a result of complications during pregnancy and child birth. Ninety-nine percent of these needless deaths are in developing countries. And when mothers die their families are at even greater risk.
Globally, maternal mortality decreased by less than one percent per year between 1990 and 2005. To reach MDG target 5A, a 'three quarters reduction in maternal mortality’, an annual improvement of 5.5 percent will be needed. Although sub-Saharan Africa's annual decline in maternal mortality is currently only 0.1 percent (v), this goal is undeniably achievable if there is renewed political will and investment. This is at the centre of the African Maputo Plan of Action and the African Union's new CARMMA initiative. New and bold initiatives such as these should be supported with renewed determination and funding to match, in order to become not only words but reality. Professor Mahmoud Fathallah, recipient of the UN Population award last year, has said that women are not dying because we don't know how to save them, but because societies are yet to decide that their lives are worth saving. Not to achieve this goal of reducing maternal mortality and morbidity would be a continued denial of human rights as the UN recognised so clearly last year in the Human Rights Council’s resolution, ‘Preventable maternal mortality and morbidity and human rights’. It is a moral and public health imperative.
Last year too governments widely endorsed the Consensus on Maternal New Born and Child Health, emanating from the High Level Task Force on Innovative Financing. This consensus document shows clearly what can and must be achieved, as does the newly published Guttmacher/UNFPA report 'Adding it Up'. And there are many countries represented in this room who have shown what can be achieved when countries invest in women’s health, and in comprehensive sexual and reproductive health with family planning at its centre.
Anywhere in our world, pregnancy should be cause for celebration, not despair, disability or death. Yet pregnancy and childbirth related causes, including unsafe abortion, are the major cause of death for girls aged 15 - 19. These are young women robbed of their potential, and their right to 'hold up half the sky', alongside their brothers, partners, and husbands because all too often their value is not recognised by their families, their communities, their governments: they are denied the same chance to be educated, and to be employed, denied the same chance to choose whether or not to have sex, or to have sex safely and be free from sexual violence, to choose to marry or not, to choose whether or not to have a child. They are denied the chance to decide. Just one indicator for 5B, 'adolescent fertility rates' will indicate much more than the statistics alone. The girls represented in those country reports statistics are more likely to be poor, to be unable to continue their education or to receive information about sex or reproduction, or access to health services. They are more likely to have been coerced into their first sexual experience or marriage, to be unemployed or earn the lowest wage, to have more children more closely spaced, to have less chance of feeding their children well, of investing in their health or education, of lifting them out of poverty. They are more likely to be ill, and to die young.
But when girls do complete their education, and can become women who have the means and the understanding to plan the number and spacing of their children, they are more likely to choose more for their children rather than more children. Their children are more likely to be healthy, better fed and educated, and the women themselves are more likely to be employed, and to participate fully in their community, in society and in governance, and to become the drivers of development and agents of change that they have the potential to be.
We have seen this demonstrated in many countries and this success is well documented. Empowering women and men to take personal control over their fertility and choose the number and spacing of their children is, in itself, a powerful development tool in the fight to halve poverty by 2015. The demographic transition of Brazil in the last 50 years has been equivalent to up to a half a per cent increase in national economic growth each year (vi). In Bangladesh, an investment of $50m in family planning will save $327m expenditure on meeting the other MDGs (vii).
In a report undertaken by the Human Development Research Centre, meeting the unmet need for family planning in Bangladesh would contribute nearly $1 billion to the national economy in increased output (viii). As also highlighted in the Millennium Project’s Quick Wins, access to family planning services is a key action that will rapidly allow the saving of millions of lives and promote economic growth (ix).
When the poorest and most marginalised people are able to access comprehensive family planning services, the impact on their families’ lives is even more noticeable. The health benefits are also compelling, particularly in high fertility countries, where investment in family planning can reduce hunger and prevent nearly a third of all maternal and ten percent of child deaths (x). When children’s deaths decrease their parents are likely to choose to have fewer children –if they have the means to do so. Furthermore, meeting the unmet need for voluntary family planning will help to enable many of the world’s poorest people and communities to be more resilient as climate change further erodes scarce resources.
We have seen the global use of voluntary family planning (excluding China) increase from 10 percent in 1965 to 53 percent in 2005, from 30 million women to 430 million (xi), and this has been reflected in improved health and well being of individuals, families and communities, and sustainable development. However in spite of increased global contraceptive prevalence from 59 per cent in 1990-1995 to 63 percent in 2000-2006, 1 in 4 women in Sub-Saharan Africa who wish to delay, space or finish child bearing cannot do so. Globally 215 million women have an unmet need for family planning, 45 percent of them in Southern and Central Asia, 22 percent of them in Sub-Saharan Africa where the percentage of unmet need is highest. This level of unmet need will be multiplied as the world's largest generation ever of young people enter their reproductive lives, increasing demand for contraception by 40 percent by 2050 (xii). This represents a crisis for health, human rights, and development. How can we hope for national or global sustainability and resilience unless we invest now in young people, in their education, health-especially their sexual and reproductive health, and their employment?
Each year 8 million women and girls require treatment for serious complications from unsafe abortion, which 3 million never receive. When contraceptive prevalence increases, as in Turkey between 1988 and 1998, the rate of unsafe abortion can drop by a third. Similarly, the passing of more liberal legislation to address the tragic impact of unsafe illegal abortion on girls and women's lives, in countries such as Nepal has contributed to dramatic reductions in maternal mortality and morbidity.
Family planning is one of the most cost effective interventions in health and development. World Bank studies show that investing in family planning can reduce maternal mortality by at least 35 percent. However, ’Adding it Up’ demonstrates that investing in both family planning AND maternal new born heath, would cost less than providing these separately, and could reduce unintended pregnancies by two thirds from 75 million in 2008 to 22 million, seventy percent of maternal deaths would be averted, and forty four percent of newborn deaths - a decline from 3,5 million to 1.9 million (xiii). Over 30 percent of the burden of disease for women of reproductive age results from poor sexual and reproductive health, and investing in family planning and comprehensive reproductive health would reduce the healthy years of lives lost due to disability and premature death (DALYS) by 60 per cent. Various estimates have been made for the size of investment that would be required, and donor funding for reproductive health commodities alone is urgently needed, but what is clear is that the direct and indirect benefits combine to make this a sound economic investment.
Furthermore, investment in comprehensive sexual and reproductive health would contribute to reducing the 250,000 deaths a year from cervical cancer, and prevent HIV infection. Denying young people the knowledge and understanding they need to lead their lives in the 21st century is not only wrong, it makes no sense. Comprehensive sexuality education, both in and out of school, would improve individual health and well being and contribute to changing gender stereotypes that are barriers to women's rights, health and development, and to reducing endemic levels of violence against women. Globally, tens of millions of children are abused and neglected each year. In addition, rape and domestic violence (including during pregnancy) account for 5-16 per cent of healthy years of life lost by women of reproductive age (xiv).
Research has shown that linkages between sexual and reproductive health and HIV-related policies and programmes can lead to a number of benefits. Integrated clinics such as those provided by a number of IPPF's members like the Family Planning Association of Swaziland, bring together family planning, antenatal care, maternal and child health services, prevention of mother-to-child transmission of HIV services and HIV counselling and testing, along with access to antiretroviral therapy (xv).
So what do we need to do?
Health, education and human rights are central to development and women are the drivers of development; yet so many attempts to make progress fail or only partially succeed because they not take these fundamental elements into account. The impact of this omission from many health and development policies, plans and priorities, is felt directly at the individual, community and national levels, it affects health, wellbeing, productivity and sustainable economic and social development. Poor sexual and reproductive health perpetuates poverty by affecting those in the prime of their economically productive lives and that it has a disproportionate effect on the most vulnerable. Every year, 250 million years of productive life are lost due to death or disability related to poor sexual and reproductive health. Furthermore, as climate change moves inexorably to influence our lives, it is the poorest women and children who again will pay the highest price. It is also women who can lead the changes required for increased resilience in the face of climate change and to enable them to do this we must meet their unmet need for health and education.
The gains that contraception has made possible in women’s health make family planning one of the most successful international development stories. Family planning is vital to improving maternal health because it gives women the power to control their own bodies and manage their lives, in the words of Nafis Sadik “it is the freedom from which other freedoms flow”.
The high level meeting of Ministers on maternal health in Addis-Ababa in November 2009, an initiative of the Government of the Netherlands and UNFPA, called for investment in three key actions – prioritisation of family planning, young people’s health education and livelihood, and the strengthening of health systems-in which civil society has a vital role to play-your promise is our goal.
Too much time has been lost. It is now time to deliver ‘the world’s biggest promise’ – time to make up for lost opportunities, time for a new agenda of investment in women, children and young people, with sexual and reproductive health and rights at its centre.
It is time to deliver MDG5B, universal access to reproductive health. Only then can we achieve the MDGs for all. Ambassador Staur, Ambassador Badji, thank you again, I wish you and your colleagues well in this important process.
Dr Gill Greer
International Planned Parenthood Federation
13 April 2010.
(i) Outcome document, paragraph 57g.
(ii) Sachs, ‘Commonwealth’, p185.
(iii) Guttmacher/UNFPA (2009). Adding it Up, cited by DFID, March 2010
(iv) ‘Making the Case’, p 2.
(v) WHO Briefing Note, 2010.
(vi) Birdsall, N. Kelly, A. C. Sinding, S.W (2001) Population Matters: Demographic
Change, Economic Growth, and Poverty in the Developing World.
(vii)Achieving the MDGs: The Contribution of Family Planning: Bangladesh, USAID/HPI.
(viii) Barkat, A. Majid, M. Karim, A. Hossain, S. Mahmud, M. N. (2009), Human Development Research Centre, DRAFT Report on Human and National Impact of Reproductive Health Commodity Shortage /Stock-outs in Bangladesh.
(ix) Quick Wins, http://www.unmillenniumproject.org/documents/4-MP-QuickWins-E.pdf.
(x) Department of Reproductive Health and Research, World Health Organization. Briefing Note on Achieving Millennium Development Goal 5.
(xi) Making the Case, p4.
(xii) Making the Case, p2.
(xiii) Guttmacher/ UNFPA 'Adding it Up', p2.
(xiv) WHO ‘Preventing Violence’ p2.
(xv) Michel Sidibe UNAIDS letter to Partners, February 2010.